9.0 Nutrition and blood

 9.1.1 Iron-deficiency anaemias

RED           Ferric Carboxymaltose (Ferinject®) 50mg/mL *       

* Can be considered as a cost effective option where IV iron is required - shorter infusion time , reduced adverse effects 

9.1.2 Drugs used in megaloblastic anaemias

Megaloblastic anaemia is usually due to vitamin B12 or folate deficiency; the specific deficiency and underlying cause must be identified. Treatment is usually only begun once a firm diagnosis is made. In emergencies, where delayed treatment may be dangerous, both folate and vitamin B12 may be required initially, until assay results are known. Folate must not be used alone in undiagnosed megaloblastic anaemia due to the risk of B12 deficiency leading to peripheral neuropathy.

During pregnancy the prevention of a first occurrence of neural tube defects is with 400 microgram/day. A higher dose of folic acid at 5mg/day is used for folate deficiency and prevention of recurrence of neural tube defects.  Both should be continued for the first twelve weeks of pregnancy.

9.1.3 Drugs used in hypoplastic, haemolytic, and renal anaemias

Iron Overload 

Iron overload is the result of many disorders and can lead per se to the development of organ damage and increased mortality. In humans total body iron stores is maintained within the range of 200-1500 mg by adequate adjustment of intestinal iron absorption, since no excretory mechanisms exist.   

Frequent blood transfusions lead to excessive accumulation of iron with a toxic accumulation in 3 to 10 years. The toxicity of iron results from two related events:

1. excess iron deposits in various tissues of the body, particularly in liver, heart and endocrine organs with the consequence of liver diseases, diabetes mellitus and other complications, and

2. free iron that catalyzes the formation of highly reactive hydroxyl radicals which lead to membrane damage and denaturation of proteins.

Once iron exceeds a certain level, these effects lead to significant morbidity and mortality. Without specific chelation therapy to remove the iron, in 3 to 10 years almost all regularly transfused patients will have acquired a toxic accumulation of iron. The main cause of death is due to cardiac complications.

The management of established iron overload also involves venesection which is not always possible.  The subsequent aim is to make the iron as safe as possible by binding the toxic iron pools responsible for causing tissue damage. Iron chelation therapy reduces iron-related morbidity, reduces and retards liver diseases, diabetes and other endocrine failures, normalizes growth and sexual development, prevents, and in some cases reverses, cardiac insufficiency and improves quality of life. Consequently iron chelation therapy dramatically reduces mortality.

Deferasirox

Deferasirox should only be initiated and prescribed by a haematologist or paediatrician for the management of patients with chronic iron overload.  It can be used as a first line therapy for all beta thalassaemia patients aged 6yrs and older requiring frequent blood transfusions (>7 ml/kg/month packed red blood cells).  

It should be used as a second or third line therapy in the following groups: 

• patients with beta thalassemia major 2-5 yrs, patients with beta thalassemia requiring infrequent blood transfusions, or
  
• those patients with other rare anaemias where desferrioxamine (DFO) and/or deferiprone are contra-indicated, not tolerated or insufficiently effective.

Deferasirox should only be used in those patients with myelodyslplastic syndrome (MDS) requiring long term blood transfusions such as those with sideroblastic anaemia or 5q-- syndrome where concurrent immunosuppression prevents the use of DFO.  Treatment should be regularly monitored by the specialist according to the SPC.  Desferasirox should be funded by the patients PCT under ‘pass through’ funding.  Deferasirox requires intensive monitoring - consult the SPC.  A new drug review is available online - click here to access it.

RED           Deferasirox dispersible tablets 125mg, 250mg, 500mg (Exjade®)

9.1.4 Drugs used in platelet disorders

9.1.6 Drugs used in neutropenia

                  Prefilled syringes 300microgram, 480microgram 

 9.2.1 Oral preparations for fluid and electrolyte imbalance

9.2.2 Parenteral preparations for fluid and electrolyte imbalance

CONTACT PHARMACY.

Prescribing Oral Nutrition Supplements

 (sip feeds) for Care Home Residents

9.5.1 Calcium & Magnesium 

9.5.1.1 Calcium supplements

Supplements are usually only needed when dietary intake is deficient. In osteoporosis/osteopenia calcium and vitamin D supplementation are required.  See section 9.6.4 for such preparations.

                    treatment, including dose escalation as appropriate.

RED           Cinacalcet f/c tablets 30mg, 60mg, 90mg                                                            (NHS England Commissioned)

Secondary Hyperparathyroidism in adults withChronic Kidney Disease on haemodialysis -NICE TA448 

Magnesium Aspartate (Magnaspartate®)

This product is a ‘food for special medical purposes’ and is indicated for the management of magnesium deficiency.  It is available as an oral powder, containing magnesium-L-aspartate 6.5 g (10 mmol Mg2+)/sachet, at a net price 10-sachet pack = £7.95.  It can be prescribed on FP10 prescriptions in primary care, and is now available from Alliance Healthcare, or directly from KoRa Healthcare, Co Dublin, Ireland, UK Tel: 0845-3038631.  It will be used where there is intolerance or poor response to other oral magnesium products, to prevent use of intravenous magnesium where appropriate

AMBER     Magnesium Aspartate sachets (Magnaspartate®)

9.5.2 Phosphorus

9.5.2.1 Phosphate supplements

9.5.2.2 Phosphate binding agents

9.6.1 Vitamin A group

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

RED           Vitamin A Palmitate 100000 units per 2mL injections [unlicensed medication]

9.6.2 Vitamin B group

9.6.3     Vitamin C

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

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

9.6.4 Vitamin D 

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

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.  Evacal D3®, 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.

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.

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.

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 Neokay® may be offered as an alternative.

Dose 1mg on day 1 and also day 7 & day 28 for breast fed babies.

AMBER     Phytomenadione capsules 1mg (Neokay®)

9.6.7  Multivitamin preparations

Dietary management of water-soluble vitamin deficiency in adults with renal failure on dialysis

AMBER     Renavit® tablets 

This a Borderline substance: To be initiated by renal consultant/SpR.

9.8.1  Drugs used in metabolic disorders

9.8.2 Acute porphyrias

For use as haem replacement in moderate, severe or unremitting acute porphyria crises.

RED           Haem arginate (Normosang®) injection 25mg/mL