BNF CHAPTER 9: NUTRITION & BLOOD 9.1 ANAEMIAS

Joint Formulary – Nutrition & Blood Uploaded by: Liz Kowlessar, February 2019 Approved by Area Prescribing Committee: n/a Review by: March 2020

BNF CHAPTER 9: NUTRITION & BLOOD 9.1 ANAEMIAS

9.1.1 IRON-DEFICIENCY ANAEMIAS

9.1.1.1 ORAL IRON

Use of modified release iron preparations is not recommended since these preparations release iron beyond the duodenum, an area where iron absorption is low. Ferrous gluconate should only be used if the patient has proven intolerant of ferrous sulphate; however any reduction in side effects is mainly due to the lower iron content of this preparation.

Ferrous sulphate 200mg tablets (equivalent to 60mg iron)

Ferrous fumarate 210mg tablets (equivalent to 68mg iron) (primary care only)

140mg/5mL syrup (equivalent 45mg/5mL iron)

Ferrous gluconate 300mg tablets (equivalent to 35mg iron)

9.1.1.2 PARENTERAL IRON

Iron sucrose

(Venofer)

100mg/2mL injection

Iron carboxymaltose 50mg/mL injection

(Ferinject) Limited indications

Contact the ward pharmacist or pharmacy department to determine the dose required to restore iron stores. Iron deficiency should have been established prior to this by checking serum ferritin. The patient’s most recent haemoglobin result will also be needed.

The calculated total required dose of iron sucrose is split into 200mg doses and given up to three times a week. Iron carboxymaltose may be given as a single dose of up to 1000mg.

MHRA safety advice: Anaphylaxis is uncommon but remains a possible adverse reaction to iron preparations. Resuscitation facilities must be available and patients must be observed for at least 30 minutes following every iron infusion.

https://www.gov.uk/drug-safety-update/intravenous-iron-and-serious-hypersensitivity-reactions


9.1.2 DRUGS USED IN MEGALOBLASTIC ANAEMIAS

Hydroxocobalamin 1mg/mL injection

Folic acid 5mg tablets

2.5mg/5mL syrup

Cyanocobalamin 50mcg tablets https://www.westcheshireccg.nhs.uk/document_uploads/Guidelines/B12guidelinev1_20170210.pdf

9.1.3 DRUGS USED IN HYPOPLASTIC, HAEMOLYTIC, AND RENAL ANAEMIAS

Erythropoietins

For use by Renal, Haematology & Oncology only

Oncology use, see NICE TA142 Erythropoietin (alfa and beta) and darbepoetin for the

treatment of cancer-treatment induced anaemia

Darbepoetin alfa

Epoetin alfa

9.1.4 DRUGS USED IN PLATELET DISORDERS

See haematology guidelines for regimes

Romiplostim available according to NICE TA221

Eltrombopag available according to NICE TA293

https://www.westcheshireccg.nhs.uk/document_uploads/Guidelines/B12guidelinev1_20170210.pdf

http://www.nice.org.uk/Guidance/TA142

http://www.nice.org.uk/TA221

https://www.nice.org.uk/guidance/ta293


9.2 FLUIDS AND ELECTROLYTES

9.2.1.1 ORAL POTASSIUM

Sando K 12mmol K+/tablet

Potassium chloride 1mmol/mL syrup SF

600mg m/r tablets (Slow K) (8mmol K+/tablet)

9.2.1.3 ORAL BICARBONATE

Sodium bicarbonate 500mg capsules

9.2.2 PARENTERAL PREPARATIONS FOR FLUID AND ELECTROLYTE IMBALANCE

9.2.2.1 ELECTROLYTES AND WATER

Intravenous sodium

Contact pharmacy for availability of preparations

Intravenous potassium

See COCH SharePoint for list of preparations and administration guidelines

Bicarbonate and lactate

Sodium bicarbonate 1.26% infusion (75mmol HCO3-/500mL)

8.4% injection (50mmol HCO3- / 50mL

Prescribing note Avoid modified release potassium preparations unless effervescent tablets or liquid preparations are inappropriate or not tolerated. Modified release potassium preparations must be taken sitting upright and with plenty of water to avoid oesophageal damage, which may occur if they become trapped in the oesophagus.


9.3 INTRAVENOUS NUTRITION Contact Nutrition Team

9.4 ENTERAL NUTRITION

See below for adult enteral product formulary. For paediatrics please refer to: Prescribing Guideline for Cow’s Milk Protein Allergy (CMPA),and information on infant formulas available for this.

https://staff.westcheshireccg.nhs.uk/document_uploads/Guidelines/prescribingguidelineforcmpav2_181123.pdf

https://staff.westcheshireccg.nhs.uk/document_uploads/Guidelines/prescribinginformationforinfantformulaev2_181213_37dac.pdf

https://staff.westcheshireccg.nhs.uk/document_uploads/Guidelines/prescribinginformationforinfantformulaev2_181213_37dac.pdf


Countess of Chester Hospital NHS Foundation Trust ADULT ENTERAL PRODUCT FORMULARY

Core feed - may be used prior to Dietetic referral when commencing the starter enteral feeding regimen.

Product Name Presentation Indications* Comments** Availability Jevity 1.0kcal/ml,

isonitrigenous, contains mixed fibre and FOS*** 500/1000/1500ml RTH****

To help maintain normal bowel function in patients requiring enteral feeds.

Core feed. Not suitable for low residue diets.

Regular stock item (see

key to availability below).

Core feeds – may NOT be used without Dietetic/Medical supervision.

Product Name Presentation Indications* Comments** Availability Jevity Plus 1.2 kcal/ml, high

nitrogen, contains mixed fibre and FOS, 500/1000/1500ml RTH.

Higher energy than standard feed. Nutritionally complete balanced feed.

Not suitable for low residue diets.

Regular stock item.

Jevity 1.5kcal 1.5 kcal/ml, high nitrogen, contains mixed fibre and FOS, 500/1000/1500ml RTH.

For increased energy requirements. Nutritionally complete balanced feed.

Not suitable for low residue diets or in hepatic or renal failure.

Regular stock item.

Jevity Promote 1.0kcal/ml, high nitrogen, contains mixed fibre and FOS, 1000ml RTH.

Nutritionally complete in 1000ml excluding potassium and chloride.

Not suitable for low residue diets or in hepatic or renal failure.

Regular stock item.

* All enteral feeds are indicated for patients with existing malnutrition or risk for malnutrition. ** Not suitable for intravenous administration; not suitable for infants under 1 year. *** FOS – Fruco-oligosaccharides. **** RTH – Ready-To-Hang container.


Countess of Chester Hospital NHS Foundation Trust ADULT ENTERAL PRODUCT FORMULARY Alternative/specialist feeds - must NOT be used without Dietetic/Medical supervision.

Product Name Presentation Indications Comments Availability Ensure Plus 1.5kcal/ml, high

nitrogen, complete balanced liquid, Non fibre, 500/1000/1500ml RTH.

As Jevity 1.5kcal. High energy and protein needs. Fluid restricted regimens.

May not be suitable for hepatic or renal failure.

Requires order request (see key to availability below).

Osmolite 1.0kcal/ml, non-fibre, isonitrogenous, 500/1000/1500ml RTH.

Standard feed for patients requiring enteral feeds.

May be suitable for patients requiring low residue feed.

Requires order request.

Osmolite Plus 1.2kcal/ml, non-fibre, isonitrogenous, 500/1000/1500ml RTH.

For patients with increased energy and protein needs.

May be suitable for patients requiring low residue feed.


Perative 1.3kcal/ml, semi elemental, non-fibre, 500/1000ml RTH.

Severe maldigestion/ malabsorption. Jejunostomy feeds.

Regular stock item.

Nepro 2.0kcal/ml, low electrolyte feed, nitrogen dense, low volume, 500ml RTH.

Electrolyte and fluid restrictions.

Regular stock item.


Countess of Chester Hospital NHS Foundation Trust ADULT ENTERAL PRODUCT FORMULARY Alternative/specialist enteral feeds continued.

Product Name Presentation Indications Comments Availability Modulen IBD 5kcal/g, elemental

powder feed to be made up to various concentrations with H2O, contains anti-inflammatory factors, 400g tin.

Exclusively designed for Crohn’s disease. Nutritionally complete in 400g.

Can be sole source of nutrition or used as a supplement to diet Can be given via oral route.

Regular stock item. .

Elemental 028 3.8kcal/g, elemental powder feed to be made up to various concentrations with H2O, 100g sachet.

IBD, short bowel syndrome, malabsorption.

Can be sole source of nutrition or used as a supplement to diet. Can be given via oral route.


Elemental 028 Extra 4.4kcal/g, elemental powder feed to be made up to various concentrations with H2O, 100g sachet.

IBD, short bowel syndrome, malabsorption.

Can be sole source of nutrition or used as a supplement to diet. Can be given via oral route.


Joint Formulary – Nutrition & Blood Uploaded by: Liz Kowlessar, February 2019 Approved by Area Prescribing Committee: 03-Jan-19 Review by: March 2020

Adult Oral Nutrition Supplement Formulary (GP Version)

Suitable for initiation by GP without dietetic input

Contents Powdered Milkshake Style (Not ready to drink) ......................................................................................................................................... 2

Ready to Drink - Milkshake Style ................................................................................................................................................................ 2

Ready to Drink - Savoury Styles .................................................................................................................................................................. 3

Ready to Drink - Juice Style ........................................................................................................................................................................ 3

Compact (Low Volume) Oral Nutrition Supplements ................................................................................................................................. 4

Ready to Eat – Yogurt/Dessert Style .......................................................................................................................................................... 4

Thickened Supplements ............................................................................................................................................................................. 4


POWDERED MILKSHAKE STYLE (NOT READY TO DRINK) *Please note: The suitability of food products for patients requiring a vegan, kosher, halal, or other compliant diet should be confirmed with individual manufacturers.*

Product Indications & Prescriber

Instructions

Available Flavours/ Presentation

Price (August 2018)

comments

Aymes Shake (Aymes International Ltd.)

Standard ACBS indications

57g sachets (7 x sachets per pack). Banana, Vanilla, Chocolate, Strawberry, Neutral.

Per sachet £0.60

To be mixed with full fat milk

Energy Shake Powder (Anaiah Healthcare)

Standard ACBS indications

57g sachets (4 x sachets per pack). Vanilla, Chocolate, Strawberry, Banana and Neutral flavours.

Per sachet £0.54


Complan Shake (Nutricia Ltd.)

Standard ACBS indications 57g sachet (4 x sachets per pack). Flavours: Banana, Chocolate, Milk, Strawberry, Vanilla.

Per sachet £0.70


Ensure Shake (Abbott Laboratories Ltd.)

Standard ACBS indications 57 g sachet (7 x 57 g per pack). Flavours: Banana, Chocolate, Strawberry, Vanilla.

Per sachet £0.60


READY TO DRINK - MILKSHAKE STYLE

*Please note: The suitability of food products for patients requiring a vegan, kosher, halal, or other compliant diet should be confirmed with individual manufacturers.*

Product Indication & Prescriber Instructions


Price (August 2018)

comments

Ensure Plus Milkshake Standard ACBS indications, 200 ml bottle. 200 ml bottle -


Style (Abbott Laboratories Ltd.)

CAPD, haemodialysis Flavours: Banana, Chocolate, Coffee, Fruits of the Forrest, Neutral, Orange, Peach, Raspberry, Vanilla

£1.11

Fortisip Bottle (Nutricia Ltd.)

Standard ACBS indications. 200ml bottle. Flavours: Banana, Caramel, Chocolate, Neutral, Orange, Strawberry, Tropical Fruit, Vanilla

200 ml bottle £1.12

-

READY TO DRINK - SAVOURY STYLES


Product Indications & Prescriber Instructions


Price (August 2018)

Comments

Powdered (Not ready to drink) VitaSavoury (Nestle Health Science Ltd.)

Standard ACBS indications. 50 g sachet (10 x 50 g sachets per pack). Flavour: Chicken, Golden Vegetable, Leek and Potato, Mushroom

50 g sachet £2.01

-

Ready to Drink

Ensure Plus Savoury (Abbott Laboratories Ltd.)

Standard ACBS indications, CAPD, haemodialysis

200 ml bottle. Flavours: Chicken, Mushroom

200 ml bottle £1.11 -


READY TO DRINK - JUICE STYLE




Price (August 2018)

Comments

Ensure Plus Juce Style (Abbott Laboratories Ltd.)

Standard ACBS indications.

220 ml bottle. Flavours: apple, fruit punch, lemon and lime, orange, peach and strawberry

220ml bottle £1.97

-

Fresubin Jucy (Fresenius Kabi Ltd)

Standard ACBS indications. Also CAPD, haemodialysis.

4 x 200 ml EasyBottle. Flavours: Apple, Orange, Pineapple, Blackcurrant, Cherry

200 ml bottle £2.01 -

Fortijuice (Nutricia Ltd)


200 ml bottle. Flavours: Lemon, Apple, Orange, Strawberry, Tropical, Forest Fruits, Blackcurrant


-

COMPACT (LOW VOLUME) ORAL NUTRITION SUPPLEMENTS


Product Indication & Prescriber Instructions


Price (August 2018)

Comments

Powdered

AYMES Shake Compact (Aymes International Ltd.)


57 g sachet (7 x 57 sachets in pack). Flavours: Vanilla, Strawberry, Chocolate, Banana and Neutral Can be added to food and fluid.

Per 57 g sachet £0.60 To be mixed with

full fat milk


READY TO EAT – YOGURT/DESSERT STYLE *Please note: The suitability of food products for patients requiring a vegan, kosher, halal, or other compliant diet should be confirmed with individual manufacturers.*



Price (August 2018)

comments

Ensure Plus Yogurt Style (Abbot Laboratories Ltd.)

Standard ACBS indications. Also CAPD, haemodialysis.

200 ml bottle. Orchard Peach, Strawberry Swirl

200 ml £1.11 -

THICKENED SUPPLEMENTS




Price (August

2018) Comments

Fresubin Thickened Stage 1 (Fresenius Kabi Ltd)*

Dysphagia or disease-related malnutrition.

200 ml bottle. Liquid/syrup thickness Flavours: Wild Strawberry, Vanilla

200ml Bottle £2.35

Consider dietetic referral for all patients on

thickened fluids

Fresubin Thickened Stage 2 (Fresenius Kabi Ltd)*

Dysphagia or disease-related malnutrition.

200 ml bottle. Liquid/syrup thickness Flavours: Wild Strawberry, Vanilla

200 ml Bottle £2.35

Consider dietetic referral for all patients on

thickened fluids

* Note: these supplements are not yet compliant with the IDDSI framework. This section will be updated in due course.


Adult Oral Nutrition Supplement Formulary Not suitable for GP initiation without dietetic review

Contents Powdered Milkshake Style Supplements (Not ready to drink) .............................................................................................. 14

Milkshake Style Supplements (Ready to Drink) .................................................................................................................... 15

Compact (Low Volume) Oral Nutrition Supplements ........................................................................................................... 16

Yogurt/Dessert Style Supplements (Ready to Eat) ............................................................................................................... 17

High Fat Supplements .......................................................................................................................................................... 17

High Protein Supplements ................................................................................................................................................... 19

High Fibre Supplements ....................................................................................................................................................... 20

Peptide-Based Supplements ................................................................................................................................................ 21

Oral nutrition Supplements for Specific Medical Conditions ................................................................................................ 22


POWDERED MILKSHAKE STYLE SUPPLEMENTS (NOT READY TO DRINK) *Please note: The suitability of food products for patients requiring a vegan, kosher, halal, or other compliant diet should be confirmed with individual manufacturers.*


Instructions


Price (August 2018)

Suitable for initiation by GP

without dietitian

involvement? Enshake (Abbott Laboratories Ltd.)

Standard ACBS indications. 96.5 g sachet (6 x 96.5 g per pack). Flavours: Banana, Chocolate, Strawberry, Vanilla.

Per sachet £2.45 No

Calshake (Fresenius Kabi Ltd)

Standard ACBS indications. 87 g sachet (7 x 87 g per pack). Flavours: Banana, Chocolate, Neutral, Strawberry, Vanilla.


Scandishake (Nutricia Ltd)

Standard ACBS indications. 85 g sachet (6 x 85 g per pack). Flavours: Banana, Caramel, Chocolate, Strawberry, Unflavoured, Vanilla.



MILKSHAKE STYLE SUPPLEMENTS (READY TO DRINK)




Price (August 2018)

Suitable for initiation by GP without dietitian

involvement? Ensure Plus Fibre (Abbott Laboratories Ltd.)


200 ml bottle. Flavours: Banana, Chocolate, Vanilla, Raspberry, Strawberry


No

Fresubin Protein Energy Drink (Fresenius Kabi Ltd)

Standards ACBS indications, CAPD, haemodialysis

200 ml bottle. Flavours: Cappuccino, Chocolate, Tropical Fruits, Vanilla, Wild Strawberry


No

Fresubin 2 kcal Drink (Fresenius Kabi Ltd)


200 ml bottle. Flavours: Apricot-Peach, Cappuccino, Fruits of the Forest, Neutral, Toffee, Vanilla


No

Ensure Twocal (Abbott Laboratories Ltd.)


200 ml bottle. Flavours: Banana, Neutral, Strawberry, Vanilla


No

Fresubin 3.2 kcal (Fresenius Kabi Ltd)

Standard ACBS indications. 125 ml EasyBottle. Flavours: Vanilla-Caramel, Hazelnut


No


COMPACT (LOW VOLUME) ORAL NUTRITION SUPPLEMENTS



Available Flavours/ Presentation Price (August 2018)


involvement? Ready to Drink Fresubin 2kcal Mini (Fresenius Kabi Ltd)


125 ml EastBottle (4 pack) Flavours: Vanilla, Fruits of the Forest, Apricot-Peach

125 ml Bottle £1.25

No

Altraplen Compact (Nualtra Ltd.)


125 ml bottle. Flavours: Hazel Chocolate, Vanilla, Strawberry, Banana


No

Ensure Compact (Abbott Laboratories Ltd.)

Standard ACBS Indications. 125 ml bottle Flavours: Banana, Strawberry, Vanilla


No

Fortisip Compact (Nutricia Ltd)


125 ml bottle Flavours: Apricot, Banana, Forest Fruit, Mocha, Strawberry, Vanilla


No

Fortisip Compact Fibre (Nutritica Ltd)

Standard ACBS indications. 125 ml bottle. Flavours: Mocha, Strawberry, Vanilla


No


YOGURT/DESSERT STYLE SUPPLEMENTS (READY TO EAT) *Please note: The suitability of food products for patients requiring a vegan, kosher, halal, or other compliant diet should be confirmed with individual manufacturers.*


Instructions


Price (August 2018)


involvement? Ensure Plus Crème (Abbott Laboratories Ltd)


Semi-solid in 125g pot. Flavours: Banana, Chocolate, Neutral, Vanilla

125 g pot £1.93 No

Fresubin Yocrème (Fresenius Kabi Ltd)


Semi-solid in 125 g pot. Flavours: Apricot-Peach, Biscuit, Lemon, Raspberry

125 g Pot £2.04 No

Fortisip Yogurt Style (Nutricia Ltd.)


200 ml bottle. Flavour: Vanilla & Lemon

200 ml £2.14

No

HIGH FAT SUPPLEMENTS




Price (August 2018)

Suitable for initiation by GP without

dietitian involvement?

Calogen (Nutricia Ltd.)


Calogen emulsion in 200 ml or 500 ml bottles. Flavours: Neutral, Banana or Strawberry

120 ml (4 x 30 ml)

£2.77 No

Calogen Extra Shot Standard ACBS indications. 40 ml shots (Pack of 6 x 40 120 ml (3 x 40 No


(Nutricia Ltd.) ml shots). Flavours: Neutral, Strawberry

ml) £2.88 (£0.96

per shot)

Fresubin 5 kcal shot (Fresenius Kabi Ltd.)


120 ml EasyBottle (4 x 120 ml per pack). Flavours: Neutral or Lemon

120 ml bottle £2.96 No

Pro-Cal Shot (Vitaflo International Ltd.)


120 ml bottles (6 x 120 ml per pack). Flavours: Neutral, Strawberry, Banana


No

Liquigen (Nutricia Ltd.)

Steatorrhoea associated with cystic fibrosis of the pancreas, intestinal lymphangiectasia, intestinal surgery, chronic liver disease, liver cirrhosis, other proven malabsorption syndromes, ketogenic diet in epilepsy, and in type 1 lipoproteinaemia.

250 ml bottle. Flavours: Neutral


No


HIGH PROTEIN SUPPLEMENTS *Please note: The suitability of food products for patients requiring a vegan, kosher, halal, or other compliant diet should be confirmed with individual manufacturers.*

Product

Indications & Prescriber

Instructions


Price (August 2018)


involvement? ProSource Liquid (Nutrinovo Ltd.)

Biochemically proven hypoproteinaemia.

30 ml sachet (ready to eat). Packs of 100. Flavours: Neutral, Lemon, Orange Crème, Citrus Berry.

Per 30 ml sachet £1.05

No

ProSource TF (Nutrinovo Ltd)

Hypoproteinaemia. 45 ml sachet (ready to eat). Packs of 100. Unflavoured.

Per 45 ml sachet £1.27 No

ProSource Jelly (Nutrinovo Ltd.)

Hypoproteinaemia. 118 ml jelly pot (ready to eat).Packs of 36. Cases of 36 jellies Flavours: Fruit Punch or orange

118 ml pot £1.94

No


HIGH FIBRE SUPPLEMENTS




Price (August 2018)


involvement? Fresubin 2 kcal Fibre Mini (Fresenius Kabi Ltd.)


125 ml bottle. Flavours: Chocolate, Vanilla

Per 125 ml bottle £1.25 No

Ensure Plus Fibre (Abbott Laboratories Ltd.)

Standard ACBS Indications. Also CAPD, haemodialysis.

200 ml bottle. Flavours: Banana, Chocolate, Vanilla, Raspberry, Strawberry


No

Fortisip Compact Fibre (Nutritica Ltd.)

Standard ACBS indications. 125 ml bottle. Flavours: Mocha, Strawberry, Vanilla


Fresubin 2 kcal Fibre Drink (Fresenius Kabi Ltd.)


200 ml bottle. Flavours: Apricot-Peach, Cappuccino, Chocolate, Lemon, Neutral


No

Nutrison Energy Multi Fibre (Nutricia Ltd.)


200 ml bottle. Flavours: Vanilla


No

Opti-fibre (Nestle Health Science Ltd.)

Standard ACBS indications. Dietary management for those with intestinal transit disorders.

16 x 5 g sachets or 250 g tin. Flavourless. 1 level tablespoon to be added to 200 ml liquid or 150 g food. Note: if on fluid restriction the minimum amount of fluid is 100 ml per 1 scoop.

5 g sachet £0.15

250 g tin £10.64 No


PEPTIDE-BASED SUPPLEMENTS *Please note: The suitability of food products for patients requiring a vegan, kosher, halal, or other compliant diet should be confirmed with individual manufacturers.*

Product

Indications & Prescriber

Instructions


Price (August 2018)


involvement? Ready to Drink

Vital 1.5 kcal (Abbott Laboratories Ltd)


200 ml bottle. Flavours: Café Latte, Mixed Berry, Vanilla


No

Peptamen (Nestle Health Sciences Ltd.)


200 ml bottle (prescribing unit 4 x 200 ml bottles). Flavours: Vanilla


No

Survimed OPD (Fresenius Kabi Ltd.)


200 ml EasyBottle. Flavours: Vanilla


No


ORAL NUTRITION SUPPLEMENTS FOR SPECIFIC MEDICAL CONDITIONS *Please note: The suitability of food products for patients requiring a vegan, kosher, halal, or other compliant diet should be confirmed with individual manufacturers.*



Price (August

2018)


involvement? Inflammatory Bowel Disease

Modulen IBD (Nestlè Health Science)

Crohn’s Disease active phase, and in remission if malnourished

400 g tin with 8.3 g scoop (12 x 400 g tins per case) . Flavour: Neutral (can be flavoured).

400 g tin

£15.06

No

Renal Failure

Nepro (Abbott Laboratories Ltd.)

Enteral feed or nutritional supplement in patients with chronic renal failure who are on haemodialysis or CAPD, or with cirrhosis, or other conditions requiring high energy, low fluid, low electrolyte diet.

220 ml bottle. Flavours: Strawberry, Vanilla


Nepro HP (Abbott Laboratories Ltd.)

Patient with chronic or acute kidney disease, on haemodialysis or continuous ambulatory peritoneal dialysis (CAPD). Cirrhosis. Other conditions requiring a high-energy, low electrolyte, low volume enteral feed.

220 ml bottle. Flavours: Strawberry, Vanilla


No

Joint Formulary – Nutrition & Blood Approved by Area Prescribing Committee: n/a Review by: March 2020

9.5 MINERALS

9.5.1 CALCIUM AND MAGNESIUM

9.5.1.1 Calcium supplements

Calcium carbonate 1.25g tablet (500mg, 12.6mmol Ca2+) (Calcichew®)

Sandocal-1000 25mmol Ca2+ (1g calcium)/ effervescent tablet

Calcium-Sandoz 2.7mmol Ca2+ (108.3mg calcium) / 5mL syrup

Calcium gluconate 10% injection (2.25mmoL Ca2+)

Calcium chloride

6.8mmol Ca2+ /10mL Injection (Min-I-Jet®) 10mmol Ca2+ /10mL ampoule

Management of symptomatic hypocalcaemia

Administer a dose of 10mL calcium gluconate 10% (2.25mmol) over 5 minutes into a large vein. If the injection is given too quickly, it may lead to a fall in blood pressure and heart rate. Alternatively, 10mL calcium gluconate 10% can be diluted in 100mL 0.9% sodium chloride and infused over 20 to 30 minutes. This may be followed by repeat injections every 6 to 8 hours or a continuous infusion of 40mL (9mmol) over 24 hours. If further calcium supplements are required give: 1. Alfacalcidol 1microgram orally daily. Adjust dose according to serum calcium. The

usual dose range is 1 to 3 micrograms daily. 2. Sandocal 1000 (1 tablet) daily only if diet is inadequate. Monitor calcium and phosphate closely.

9.5.1.2 Hypercalcaemia and hypercalciuria

Cinacalcet As per NICE TA117 guidance (renal only)

http://guidance.nice.org.uk/TA117


9.5.1.3 Magnesium

Magnesium sulphate

50% injection (2mmol /mL)

2mL, 5mL ampoules

Magnesium glycerphosphate

4mmol tablet (unlicensed) NB capsules are not prescribable on FP10

Magnesium-L-aspartate (Magnaspartate)

10mmol Mg2+/dissolvable sachet usual dose = one sachet once daily For long term oral replacement therapy, magnesium aspartate may be preferred to magnesium glycerophosphate (see above). It is a commercially available preparation and therefore more obtainable for FP10 prescribing and dispensing.

Management of hypomagnesaemia

Please refer to guidelines on Hypomagnesaemia Management

9.5.2 PHOSPHORUS

9.5.2.1 Phosphate Supplements

Phosphate-Sandoz 16.1mmol PO43- / tablet

Phosphates Intravenous infusion

9.5.2.2 Phosphate-Binding Agents

See Drug Management of Chronic Kidney Disease for preparations and doses

9.5.4 ZINC

Zinc sulphate 125mg Effervescent tablets (45mg zinc)

http://www.westcheshireccg.nhs.uk/document_uploads/Guidelines/hypomagnesaemiaguidelinesformanagement_29ce4.pdf

http://www.westcheshireccg.nhs.uk/document_uploads/Guidelines/chronickidneydisease(drugmanagement)krv1.115jun12_00502.pdf


9.6 VITAMINS

9.6.4 Vitamin D

See local guidelines: Vitamin D deficiency — clinical guidelines for adults

Aviticol® colecalciferol 20,000 IU capsules

(N.B. contains gelatin)

InVita D3® colecalciferol 25,000 IU/ml oral solution (suitable for vegetarians and patients with swallowing difficulties)

Desunin® colecalciferol 800 IU tablets (gelatin free)

Multivitamins for renal dialysis Renavit® 450mg tablets

http://www.westcheshireccg.nhs.uk/document_uploads/Guidelines/vitamindguideline_adultskrv2.0_15jun18_22154.pdf

Documents

BNF CHAPTER 9: NUTRITION & BLOOD 9.1 ANAEMIAS