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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)       
                   RED           Vitamin A Palmitate 100000 units per 2mL injections [unlicensed medication]
        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 Group 
                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 Group
              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 in adults 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 prescribe on an FP10, it is recommended that only the following brands are used:
                  GREEN      Invita® 25,000 iu/ml oral solution [3 x 1ml amps] preferred choice for use in paediatrics
                  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
            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.  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.
           First Line: Evacal D3® is the preferred choice, most cost-effective option for use in Primary Care
           [Secondary care will continue to use Adcal D3 which can be changed to Evacal D3 in Primary Care]
                GREEN      Calcium carbonate tablets chewable 1500mg (15mmol Ca) & colecalciferol 10micrograms (Vitamin D 400units)   
                                   Evacal D3®Adcal D3®,  Accrete D3® (Give 1 tablet twice daily)
                GREEN      Calcium carbonate caplets 750mg (7.5mmol Ca) & colecalciferol 5micrograms (Vitamin D 200units)
                                   (Adcal D3®) (Give 4 caplets daily)   
           Second Line
                  GREEN      Calcium phosphate 1.5g (15mmol Ca) & colecalciferol 10mcg  effervescent tablets Vitamin D 400units)
                                    (Adcal D3 Dissolve®(Give 2 tablets daily) 
                 For swallowing difficulties       
                  GREEN      Calcium carbonate tablets chewable 1.25g (12.6mmol Ca) & colicalciferol 10 micrograms (Vitamin D3 400 units) 
                                    (Calcichew D3 Forte®) (Give 1 tablet twice daily) 
                                    If patient dislikes taste of chewable Evacal D3®, Adcal D3®, Accrete 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 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®)

9.6.5     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 
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
Indications for prescribing of forceval capsules post bariatric surgery:
Post-surgery if gastric bypass (Roux-en-Y)
AMBER   Forceval caps
Post-surgery if an adjustable gastric band fitted or sleeve gastrectomy
BLACK      Forceval® capsules
Patients should be directed to purchase nutritional supplements.  
NB: Patients that have proceeded with bariatric surgery privately and have subsequently opted to switch their care back to the NHS should be prescribed supplements equivalent
to that offered to NHS patients in accordance with the advice above and within the Policy
Guidance. [see below]

The full Guidance for the prescribing of nutritional supplements post bariatric surgery
 Is available here
For the prevention of re-feeding syndrome only
RED           Forceval® capsules

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