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9.6 Vitamins

9.6 Vitamins

9.6.1 Vitamin A group

GREEN      Vitamin A and D capsules (vitamin A 4000units & vitamin D 400 units)

9.6.2 Vitamin B group

Deficiency of B vitamins is rare (except B12) and usually treated using a compound
preparation. Pyridoxine is used to protect against isoniazid neuropathy. Concerns over
toxicity from high dose pyridoxine are not yet resolved.
 
GREEN      Pyridoxine tablets 10mg, 50mg
GREEN      Thiamine tablets 50mg, 100mg
 
The BNF advises that oral vitamin B complex preparations are less suitable for prescribing,
and should not be considered drugs of first choice.
 
Intravenous/Intramuscular Vitamins B & C (High potency)
CSM advice – Since potentially serious allergic adverse reactions may occur during, or 
shortly after, parenteral administration, the CSM advises;
     >      Use to be restricted to patients in whom parenteral administration is essential
     >      Intravenous injections should be administered slowly (over 10mins)

     >      Facilities for treating anaphylaxis should be available when administered

AMBER     Vitamins B & C High potency IM injection 7ml (in 2 amps)
RED           Vitamins B & C High potency IV injection 10ml (in 2 amps)
 
For the prevention of re-feeding syndrome only 
RED            Vitamin B Co Strong
 
Vitamin B12 - see hydroxocobalamin Section 9.1.2

9.6.3     Vitamin C

Divided doses are necessary due to the low renal threshold of ascorbic acid.

Patients should be directed to purchase nutritional supplements.   
For further information please click here

GREEN      Ascorbic acid tablets 100mg, 200mg, 500mg

9.6.4 Vitamin D

Patients should be directed to purchase nutritional supplements (including calcium and vitamin D) over the counter post bariatric surgery. See Guideline 

Please Note: Treatment doses of Vitamin D for paediatrics should be prescribed by the GP on hospital request and the ongoing maintenance to be purchased over the counter (self-care)

Ergocalciferol/ Colecalciferol
Simple vitamin D deficiency can be prevented using 10 micrograms (400 units) daily of
ergocalciferol (calciferol, vitamin D2) or colecalciferol (vitamin D3). 
Vitamin D deficiency is not uncommon in Asians consuming unleavened bread and in the
elderly living alone, and can be prevented by giving an oral supplement of 20micrograms
(800units) of  colecalciferol (or ergocalciferol) daily. Patients are encouraged to buy their 
own supplements for vitamin D insufficiency, but where a clinician identifies a clinical need
guidelines have been developed to assist in treatment decisions.
 
For East Lancashire Health Economy Guideline Diagnosis and Management of Vitamin D 
Deficiency for Non-Specialists click here
The patient information leaflet is available to print off for use click here
If it is necessary for the clinician to precribe on an FP10, it is recommended that only  the
following brands are used:
 
GREEN      HuxD3® (Colecalciferol) capsules 20,000iu 1st line choice
GREEN      Osteocaps (Colecalciferol ) capsules 20,000iu
GREEN      SunVitD3 (Colecalciferol) tablets 20,000iu
GREEN      ProD3 ® (Colecalciferol)  liquid 2,000iu/ml 
GREEN      Aciferol® D3 (Colecalciferol) liquid 2,000units/mL, 3,000units/mL
 
Please note:       LIQUID "SPECIALS" MUST NOT BE PRESCRIBED

Preparations containing calcium and colecalciferol are available for the management of 
combined calcium and vitamin D deficiency (see below under prevention & treatment of 
osteoporosis).
 
Pharmacological strengths of ergocalciferol
AMBER      Ergocalciferol tablets 250microgram (10,000units) & 1.25mg (50,000units)
AMBER      Ergocalciferol injection 7.5mg (300,000 units)/ml - 1ml & 2ml ampoules
 
Prevention & treatment of osteoporosis
Those with, or at risk of, osteoporosis should maintain an adequate intake of calcium and
vitamin D. If deficiency is suspected, this should be corrected by increasing dietary intake
or taking supplements.  Calcium and vitamin D supplementation alone may reduce the risk
of fracture but it is less effective than other agents. The best evidence supports its use in
institutionalized or housebound elderly women.  Adcal D3® and Calcichew D3 Forte® 
should be given twice daily.  Calfovit D3® sachets should be given daily.  
For moderate to severe renal disease colicalciferol may not be metabolised to the active
metabolite of vitamin D. In these circumstances a suitable alternative would be alfacalcidol
 
First Line
GREEN     Calcium carbonate tablets chewable 1.5g (15mmol Ca) & colicalciferol
                 10micrograms (Vitamin D 400units) (Adcal D3®,  Accrete D3®, Evacal D3®)                                    (Give 1 tablet twice daily)       OR  
GREEN     Calcium carbonate caplets 750mg (7.5mmol Ca) & colicalciferol
                 5micrograms (Vitamin D 200units) (Adcal D3®) (Give 4 caplets daily)   
 
Second Line
GREEN      Calcium phosphate 1.2g (30mmol Ca) & colecalciferol 20microgram sachets
                   (Vitamin D 800units) (Calfovit D3®) (Give 1 sachet daily) 
                   - for swallowing difficulties                     
GREEN      Calcium carbonate tablets chewable 1.25g (12.6mmol Ca) & colicalciferol 
                   10 micrograms             
                    (Vitamin D 400 units) (Calcichew D3 Forte®) (Give 1 tablet twice daily) 
                  - if patient dislikes taste of chewable Adcal D3®

Alfacalcidol and Calcitriol
Patients with severe renal impairment requiring vitamin D therapy should be prescribed
alfacalcidol.
It is essential that healthcare professionals check that plasma calcium monitoring is 
undertaken.
Do NOT abbreviate nanograms or micrograms. Please see link.
 
Note that One-Alpha® capsules contain sesame.
AMBER      Alfacalcidol
                   capsules 250 nanograms, 1 microgram
                   oral drops 2 microgram/ml
AMBER      Calcitriol capsules 250nanograms 

9.6.5     Vitamin E

GREEN      Alpha Tocopheryl acetate suspension 500mg/5ml

9.6.6 Vitamin K

Essential for the production of blood clotting factors, antagonises effects of oral 
anticoagulants. Menadiol used when there are malabsorption syndromes, and in 
obstructive liver disease.
Malabsorption syndromes (water-soluble preparation required)
 
GREEN      Menadiol sodium phosphate tablets 10mg
                   Fat soluble formula (not malabsorption)
RED            Phytomenadione 10mg tablets (most cost effective option)
AMBER     Phytomenadione (vitamin K1) 2mg in 0.2ml amp (Konakion MM Paediatric®) *
RED           Phytomenadione 10mg in 1ml amp (Konakion MM®) **
 
*Note –   Konakion MM® Paediatric may be administered by mouth or by intramuscular 
                 injection or by intravenous injection.
**Note Konakion MM® may be administered by slow intravenous injection or by 
                 intravenous infusion in glucose 5%; not for intramuscular injection.

Haemorrhagic disease of the newborn
If parents do not want their baby to have the intramuscular injection of vitamin K, then
Konakion MM® orally or Orakay® may be offered as an alternative (although Orakay® is 
unlicensed for this indication).
Dose 1mg on day 1 and also day 7 & day 28 for breast fed babies.
 
AMBER     Phytomenadione capsules 1mg (Orakay®) (unlicensed)


9.6.7     Multivitamin preparations

Prescribing of Multivitamins and phenylalanine-free amino acid substitutes for adults and 
 
children with phenylketonuria (PKU). There is no requirement to use specific multivitamins for
people with PKU e.g Phlexy-Vit
  Please refer to Position Statement
AMBER     Multivitamins for adults and children with PKU (specialist initiation)
AMBER     Phenylalanine-free amino acid substitutes for adults with PKU (specialist 
                  initiation)
 
Dietary management of patients with Cystic Fibrosis Paravit-CF® capsules/liquid
Paravit-CF® is a 'Food for Special Medical Purposes' for the dietary management of
patients with cystic fibrosis, which offers patients a decreased oral medication load whilst 
also being a cost-effective option
AMBER     Paravit-CF® capsules (specialist initiation) one capsule contains:   : 
                  Vitamin A (retinyl palmitate)  1500 micrograms (=5000 IU)
                  Vitamin D3 (cholecalciferol)   37.5 micrograms  (=1500 IU)
                  Vitamin E (tochopheryl acetate) 100 milligrams (=150 IU)
                  Vitamin K1 (phytomenadione)  5000 micrograms
AMBER     Paravit-CF® liquid  (specialist initiation) - for use in young children or patients
                  with swallowing difficulties.
 NOTE:  The prescriber should ensure that when patients with cystic fibrosis are 
              initiated or switched to Paravit-CF® that existing prescriptions for individual 
              ingredients that are included in Paravit-CF ® are discontinued
 
GREEN      Dalivit® drops 25ml
GREEN      **Abidec® drops 25ml 
GREEN      Vitamin capsules/tablets
Vitamin and mineral supplements and adjuncts to synthetic diets
 
** ELHT neonatal formulary recommends that babies started on Sytron® and/or Abidec® 
     on the Neonatal Intensive Care Unit  (ELHT) should remain on the treatment for 1 year 
     post birth. GPs in Primary care are requested to continue to prescribe these products 
     for neonates until the age of 1 year old.
 
GREEN      Ketovite® tablets
GREEN      Ketovite® liquid
 
Forceval®
For vitamin and mineral supplementation and after gastric by-pass surgery.
Patients should be directed to purchase nutritional supplements.  
For further information please click here  
BLACK      Forceval® capsules

For the prevention of re-feeding syndrome only
RED           Forceval® capsules

Dietary management of water-soluble vitamin deficiency in adults with renal failure on  
dialysis
AMBER     Renavit® tablets 450mg
 
This a Borderline substance To be initiated by renal consultant/SpR.