netFormulary
Data extracted : 22/09/2017
 Formulary Section 9: Nutrition and blood
 Details...
09.01 Anaemias and some other blood disorders
09.01.01 Iron-deficiency anaemias
09.01.01.01 Oral iron
  • Iron supplements are indicated for proven iron-deficiency anaemia. A daily dosage of 100-120mg/day of elemental iron is usually appropriate in uncomplicated cases.

  • Treatment should be continued for 3 months after a normal haemoglobin concentration is restored, in order to replace iron stores.

  • At equivalent dosage there is little to choose between the different iron preparations.

  • All iron preparations may cause nausea and epigastric pain, which may subside if the dose is reduced. The astringent action of iron may cause diarrhoea and exacerbate symptoms in patients with inflammatory bowel disease.

First Choice:
Ferrous Fumarate 
210mg (68mg Fe) usual prophylactic dose i daily, treatment dose i 2-3 times daily
322mg (100mg Fe) usual prophylactic dose i daily, treatment dose i twice daily
Second Choice:
Ferrous Sulphate 
200mg (65mg iron)
Second Choice:
Ferrous Fumarate Syrup  (Fersamal®)
140mg (45mg iron) /5ml
Second Choice:
Sodium Feredetate Syrup  (Sytron®)
190mg (27.5mg iron)/5ml
Restricted Drug  Iron and Folic Acid SR  (Pregaday®)
For anaemia associated with pregnancy. Routine iron supplementation in pregnancy is no longer considered appropriate; the decision to prescribe should be based on full blood count results. The dose of folic acid in ‘Pregaday’ is insufficient if there is associated megaloblastic anaemia due to folate deficiency.
09.01.01.02 Parenteral iron

  • Parenteral iron therapy is not without risk. It should only be given in cases of proven iron deficiency where oral iron is ineffective or cannot be used because of malabsorption or serious non-compliance. It should be avoided in patients with a history of allergy/ anaphylaxis.

  • Parenteral iron does not produce a significantly faster haematological response than oral iron.

  • IV administration is not recommended in primary care.

  • Oral iron therapy should not be given until 5 days after the last injection.

  • Parenterally administered iron preparations can cause allergic or anaphylactoid reactions, which may be potentially fatal. Therefore, treatment for serious allergic reactions and facilities with the established cardio-pulmonary resuscitation procedures should be available
Link   MHRA Advice: Intravenous iron and serious hypersensitivity reactions: Clarification of advice on new recommendations regarding initial test dose.
Link   UHL Guideline: Iron Therapy For Anaemia Of Chronic Kidney Disease
First Choice:
Iron Isomaltoside  (Monofer®)
For IM or IV administration
Non-dialysis patients
IV Monograph available through ’Injectable Medicines Guide’ link available through INsite.
Restricted Drug  Iron Isomaltoside 1000  (Diafer®)
For anaemia of chronic kidney disease only
Restricted Drug  Iron Sucrose  (Venofer®)
This is administered by slow intravenous injection or intravenous infusion.
The BNF recommends a test dose before the first dose.
IV Monograph available through ’Injectable Medicines Guide’ link on front page of INsite.
For home dialysis patients or as an alternative if other choices not appropriate
09.01.02 Drugs used in megaloblastic anaemias

  • Megaloblastic anaemia is usually due to malabsorption of vitamin B12 or lack of folate. In established B12 deficiency initial injections are given more frequently to replenish body stores.

  • Oral vitamin B12 is only available as cyanocobalamin. A daily dose of 35-50micrograms may be used as an alternative to injections to prevent dietary deficiency in strict vegetarians (for example some members of the Hindu community).
First Choice:
Folic Acid 
Used to correct folate deficiency and to prevent neural tube defects in early pregnancy (in low doses). It should never be given alone in the presence of vitamin B12 deficiency as the anaemia may respond but neuropathy could be precipitated.
First Choice:
Hydroxocobalamin Injection 
This has now replaced cyanocobalamin as the usual source of B12 as it is excreted much less rapidly allowing maintenance doses to be given at 3-monthly intervals.
09.01.03 Drugs used in hypoplastic, haemolytic, and renal anaemias
Restricted Drug  Antilymphocyte immunoglobulin (rabbit) 
High cost drug excluded to tariff commissioned by NHSE in line with BCSH guidelines only
09.01.03 Erythropoietin
Restricted Drug  Darbepoetin Alfa   (Aranesp®)
Specialist prescribing only
High cost drug excluded to tariff commissioned by NHSE for renal dialysis only, including via outpatients, and only as per NICE NG8
Restricted Drug  Epoetin alfa 
Binocrit® and Eprex®
Specialist prescribing
High cost drug excluded to tariff commissioned by NHSE for renal dialysis only, including via outpatients, and only as per NICE NG8
Restricted Drug  Epoetin beta 
Specialist prescribing
High cost drug excluded to tariff commissioned by NHSE for renal dialysis only, including via outpatients, and only as per NICE NG8
09.01.03 Iron overload
Restricted Drug  Deferasirox  (Exjade®)
Specialist use
High cost drug excluded to tariff. Commissioned by NHSE for iron chelation in thalassaemia, sickle cell and Myelodysplastic Syndrome (MDS)
Restricted Drug  Deferiprone  (Ferriprox®)
Specialist use
High cost drug excluded to tariff. Commissioned by NHSE for iron chelation in thalassaemia, sickle cell and MDS
Restricted Drug  Desferrioxamine mesilate 
Specialist use
High cost drug excluded to tariff. Commissioned by NHSE for iron chelation in thalassaemia, sickle cell and MDS
09.01.04 Drugs used in autoimmune thrombocytopenic purpura
Restricted Drug  Eltrombopag 
Specialist haematology initiation only

Date of entry of decision to Formulary: October 2013
Restricted Drug  Romiplostim 
Specialist haematology initiation only
09.01.05 G6PD deficiency
Anagrelide 
09.01.06 Drugs used in neutropenia
Restricted Drug  Filgrastim  
Specialist use only
High cost drug excluded to tariff commissioned by NHSE
Restricted Drug  Lenograstim 
Specialist use only
High cost drug excluded to tariff commissioned by NHSE
09.01.07 Drugs used to mobilise stem cells
Restricted Drug  Plerixafor  
Specialist haematology use only
High cost drug excluded to tariff. Commissioned by NHSE in line with policy below only
09.02 Fluids and electrolytes
09.02.01 Oral preparations for fluid and electrolyte imbalance
09.02.01.01 Oral potassium

  • The cause of potassium depletion should be identified where possible and corrected.

  • Potassium supplements should be given orally whenever possible. Liquid or effervescent preparations are preferable to slow-release tablets.

  • To avoid ambiguity oral potassium supplements should be prescribed by brand name.

  • Supplements should not normally be given with potassium-sparing diuretics or angiotensin-converting enzyme (ACE) inhibitors unless serum potassium is closely monitored. For hypokalaemia associated with diuretic use a potassium-sparing diuretic (e.g. amiloride) is generally more effective and convenient than potassium chloride supplements. 

  • Refractory hypokalaemia due to diuretic use may be due to accompanying hypomagnesaemia which should be corrected. See also intravenous potassium.
First Choice:
Potassium Chloride  (Sando-K®)
Effervescent tablets. 12mmol K+ and 8mmol Cl-per tablet.
Second Choice:
Potassium Chloride  (Slow-K®)
Slow-release tablets 600mg. 8mmol K+ and Cl- per tablet.
These should be taken while sitting or standing with fluid during meals. Avoid in patients that may have an oesophageal or intestinal stricture as they can cause local ulceration.
Second Choice:
Potassium Chloride Syrup  (Kay-Cee-L®)
1mmol K+ and Cl- per mL
Restricted Drug  Potassium Bicarbonate  (Potassium effervescent tablets)
For hyperchloraemic acidosis only e.g. in renal tubular acidosis. They do not contain chloride and are not suitable for routine treatment of hypokalaemia.
09.02.01.01 Potassium removal

  • These resins are not absorbed but exchange potassium for calcium or sodium within the gastro-intestinal tract. The choice of sodium or calcium salt depends on their relative contra-indications, such as if sodium and fluid overload (use calcium resin) or in hypercalcaemia (use sodium resin).

  • Urgent reduction of hyperkalaemia must also involve a more rapidly acting treatment such as injection of glucose and insulin and/or sodium bicarbonate initially. Calcium gluconate injection may be given in severe hyperkalaemia to reduce the risk of cardiac arrhythmias.

  • To avoid overdose, therapy should be discontinued when serum potassium falls to 5mmol/L.

  • Both products may be given orally or by rectum as an enema (latter available from pharmacy on request).
Link   UHL Guidelines: Management of Acute Hyperkalaemia (Acute division)
First Choice:
Calcium Polystyrene Sulphonate  (Calcium Resonium®)
Monitor serum-calcium as patients with chronic renal failure may experience a sudden rise in serum-calcium.
First Choice:
Sodium Polystyrene Sulphonate  (Resonium A®)
09.02.01.02 Oral sodium and water

  • Oral sodium supplementation is indicated in chronic deficiency states. Severe hyponatraemia associated with volume depletion usually requires intravenous infusion of isotonic saline (0.9% sodium chloride which contains 150mmol/litre) but clinical assessment is important in view of the many possible causes of hyponatraemia. Water restriction is important in treatment of dilutional hyponatraemia.

  • Gastroenteritis: a rehydration solution such as Dioralyte® is recommended. The volumes should be dictated by the volume of losses. It is better to sip frequent small volumes as less likely to vomit.

  • High output diarrhoea ileostomy or jejunostomy: a solution containing extra sodium e.g. St Mark’s Electrolyte Mix (WHO) rehydration solution is recommended. See UHL Guidelines High Output Stoma Patients.
First Choice:
Sodium Chloride  (Slow Sodium®)
Slow-release tablets 600mg. Approximately 10 mmol Na+ and Cl- per tablet.
Restricted Drug  Glucodrate 
For initiation by the Leicestershire Intestinal Failure Team only. Second line treatment for patients who cannot tolerate St Mark’s solution.
09.02.02 Parenteral preparations for fluid and electrolyte imbalance
09.02.02.01 Electrolytes and water
09.02.02.01 Intravenous potassium

  • The cause of potassium depletion should be identified where possible and corrected. Oral potassium supplements should be given whenever possible.

  • For infusion ready-prepared solutions (which contain up to 40mmol/litre KCl) should normally be used. Solutions containing more than 40mmol/L potassium should be administered with ECG monitoring. The rate of administration should not exceed about 30mmol/hour and if given peripherally should be sufficiently slow to avoid pain along the vein (use large vein where possible). It is important to avoid extravasation as the solution is highly irritant.

  • The NPSA issued an Update on the implementation of recommended safety controls for potassium chloride in the NHS in November 2003.
First Choice:
Ready-diluted potassium in IV fluid 
0.15% contains 20mmol in 1L
0.3% contains 40mmol in 1L
Restricted Drug  Concentrated Potassium Chloride in ampoules 
Restricted in availability to intensive care areas, as it is a high-risk product. It should never be given undiluted. If it is added to IV fluids, thorough mixing is essential to avoid inadvertent administration of high concentrations.
09.02.02.02 Plasma and plasma substitutes

Please note section under development.  Currently includes only products supported by TAS since 2000, not historically used products

Tetraspan 
For treatment of imminent or manifest hypovolaemia and shock
09.04 Oral nutrition
Link   Leicestershire Guidelines: Managing Adult Malnutrition in Primary Care
Link   Leicestershire Statement: Low Priority Prescribing
09.05.01.01 Calcium supplements

  • Recommendations for daily calcium intake vary according to age, physiological status and conditions such as osteoporosis. The recommended daily intake of calcium as recommended by COMA (Committee on the Medical Aspects of Food and Nutrition) are available in a leaflet prepared by the National Osteoporosis Society available here

  • If long-term supplementation is being considered, a target calcium-level should be set and dietary assessment is advisable. A lactose-free calcium supplement (e.g. Sandocal®) may be used in patients on a milk free diet. Oral calcium supplements alone are indicated for correction of dietary deficiency. Supplements with added vitamin D are used in the replacement phase of ’privational’ osteomalacia or rickets.

  • Hypercalcaemia increases the effect of digoxin and may precipitate toxicity.

  • See also calcium with ergocalciferol (Vitamin D) tablets.
First Choice:
Sandocal-400® 
Effervescent tablets. 10mmol/400mg calcium per tablet
First Choice:
Sandocal-1000® 
Effervescent tablets. 25mmol/1000mg calcium per tablet.
Second Choice:
Calcium-Sandoz® 
Syrup 2.7mmol/108mg calcium in 5mL
Second Choice:
Calcium Gluconate Tablets 
1.35mmol/54mg calcium per tablet.
Restricted Drug  Calcium Gluconate Injection 
For acute hypocalcaemia with tetany.
Monitor serum-calcium level if more than 10mL is given. Monitor ECG. Do not administer calcium salts in the same intravenous line as bicarbonate solutions.
09.05.01.02 Hypercalcaemia and hypercalciuria
Link   UHL Guidelines: Management of Hypercalcaemia of Malignancy in Adults
First Choice:
Intravenous saline (0.9%) 
See UHL guidelines below
First Choice:
Disodium Pamidronate 
Non malignancy
Restricted Drug  Cinacalcet  
Cinacalcet is used for the treatment of secondary hyperparathyroidism in patients with end stage renal disease on maintenance dialysis therapy in line with NICE TA 117 only. It is restricted to initiation by a specialist nephrologist.
High cost drug excluded to tariff for this indication only, commissioned by NHSE

Restricted Drug  Cinacalcet  
For complex primary hyperparathyroidism in adults in line with NHSE policy only.
High cost drug excluded to tariff for this indication, commissioned by NHSE.

09.05.01.03 Magnesium

  • Symptomatic hypomagnesaemia may indicate a deficit of 0.5-1mmol/kg and requires parenteral therapy, as oral absorption is poor. Large doses should be given slowly, preferably by infusion. Causes of hypomagnesaemia include excessive loss e.g. high output ileostomy or chronic diarrhoea, renal wasting, some endocrine disorders and dietary deficiency. Hypokalaemia which is resistant to treatment may sometimes be caused by hypomagnesaemia; hypocalcaemia can also sometimes occur.

  • Oral therapy with magnesium hydroxide mixture may be adequate in mild deficiency, but may cause diarrhoea.
Link   UHL Guidelines: Acute Hypomagnesaemia
First Choice:
Magnesium Sulphate Injection 
IV Monograph available through ’Injectable Medicines Guide’ link on front page of INsite.
Second Choice:
Magnesium Hydroxide Mixture 
14mmol Mg2+/10mL
Magnesium Aspartate Dihydrate (Magnaspartate®) 
Contains 10 mmols (243 mg) of magnesium per sachet. Each sachet of Magnaspartate can be dissolved in 50-200mL water, tea or orange juice. For those on fluid restriction / St Marks’ regime mix in less than 100ml.

This is equivalent to 2.5 of the unlicensed Magnesium glycerophosphate 4mmol tablets. These will be restricted to use by the specialist nutrition team at UHL on request for named patients who are not responding to Magnaspartate.
09.05.02.01 Phosphate supplements

  • Hypophosphataemia can result from increased renal loss (usually due to secondary or primary hyperparathyroidism), inadequate dietary intake, or rapid utilisation, such as occurs at the start of parenteral nutrition. In re-feeding syndrome, profound hypophosphataemia is most likely to occur within 4 days of starting to re-feed a malnourished patient.

  • Low serum phosphate may cause muscle weakness resulting in respiratory or cardiac failure as well as neurological problems. The likely cause of the low phosphate should be established before starting treatment with phosphate supplements.

  • Hypophosphataemia may also result from an intracellular shift of the ion, (e.g. caused by respiratory alkalosis). This should not generally be treated with phosphate supplements.

  • Patients who are hypercalaemic should not be treated with intravenous phosphate either, due to the risk of metastatic calcification.

  • Mild hypophosphataemia may be treated with oral phosphate supplements. More severe hypophosphataemia may require treatment with phosphate infusion.

  • Intravenous infusion of phosphates is appropriate in malnourished patients with serum phosphate below 0.6mmol/L, or nourished adults with serum phosphate below 0.5mmol/L. Low serum magnesium and potassium are common in patients who are hypophosphataemic, these should be monitored closely during treatment. Phosphate supplementation using infusion should cease once serum phosphate reaches 0.8mmol/L. Consider oral treatment after this, if necessary.
First Choice:
Phosphate-Sandoz® 
Effervescent tablets. 16.1 mmol phosphate, 20.4 mmol sodium and 3.1 mmol potassium per tablet
First Choice:
Phosphate Polyfusor 
Infusion contains 50 mmol phosphate in 500 ml, also 81 mmol sodium and 9.5 mmol potassium.
Restricted Drug  Potassium Phosphate Injection 
Ampoules restricted to Intensive Care areas due to the risks associated with concentrated potassium solutions.
09.05.02.02 Phosphate-binding agents

  • Calcium-containing antacids are used to bind phosphate in the management of hyperphosphatemia secondary to renal failure and are preferable to phosphate binders containing aluminium.
Link   NICE CG 157: Hyperphosphataemia in chronic kidney disease
First Choice:
Phosex® 
Calcium Acetate
Second Choice:
Calcichew® 
Calcium carbonate
Restricted Drug  Sucroferric oxyhydroxide  (Velphoro®)
For treatment/prevention of hyperphosphataemia of chronic kidney disease. Restricted to initiation by Specialist nephrologists.
High Cost Therapy excluded to tariff for this indication, commissioned by NHSE
Adcal® 
3rd Choice
Restricted Drug  Sevelamer Carbonate  (Renvela®)
For treatment/prevention of hyperphosphataemia of chronic kidney disease. Restricted to initiation by Specialist nephrologists.
High Cost Therapy excluded to tariff for this indication, commissioned by NHSE
Restricted Drug  Lanthanum  
For treatment/prevention of hyperphosphataemia of chronic kidney disease. Restricted to initiation by Specialist nephrologists.
High Cost Therapy excluded to tariff for this indication, commissioned by NHSE
Restricted Drug  Osvaren®  
Calcium acetate 435mg (equivalent to 110 mg calcium)
Magnesium carbonate 235mg (equivalent to 60 mg magnesium)
09.05.03 Fluoride

  • Fluoride helps to reduce tooth decay. Where the level of fluoride in the drinking water is less than 700 micrograms per litre (0.7 ppm) – as is the current situation in Leicestershire – then the daily administration of fluoride drops or tablets may be considered from 6 months of age during the period of tooth development.

  • Children who benefit most from fluoride supplementation are those who have special needs.

  • The risk of a child developing tooth decay may change and the need for fluoride supplements should be reviewed by the dentist when the child attends for their regular check-up. The use of fluoride toothpaste is a convenient method of increasing fluoride availability and is recommended for everyone. It is important to use the correct strength and method of use depending on age.

  • Fluoride availability can be increased further in order to improve oral health by use of fluoride supplements, gels and rinses. These are best taken at a different time from brushing with fluoride toothpaste so as to increase the frequency of exposure of teeth to fluoride.

  • Fluoride gels and rinses are recommended for individuals who are particularly prone to developing caries or those who are medically compromised.

  • Excessive ingestion of fluoride may lead to fluorosis (mottling and discolouration) of permanent teeth.

  • Fluoride supplements are not recommended during pregnancy in the UK.
Fluoride 
09.05.04 Zinc

  • The only definite indication for zinc supplementation is zinc deficiency. This may result from inadequate diet, malabsorption or loss due to trauma, burns or protein-losing conditions. There is some evidence to suggest that zinc supplements may be useful in the prevention and treatment of pressure sores and management of burns.
First Choice:
Zinc Sulphate 
Each tablet contains 45mg Zn2+
Second Choice:
Zinc sulphate mixture LPS 
105mg/5mL Zn2+
09.06 Vitamins
  • The majority of the population consume a diet which provides adequate amounts of vitamins. Vitamin supplements should therefore only be prescribed in line with ACBS guidance on vitamins and mineral preperations:-

    Only in the management of actual or potential vitamin or mineral deficiency; not to be prescribed as dietary supplements or ’pick-me-ups’


  • Blood levels in very sick patients are sometimes difficult to interpret e.g. zinc levels are often low due to acute phase response.

    • Link   Leicestershire Statement: Low Priority Prescribing
      09.06.01 Vitamin A
      Vitamin A deficiency is rare in Britain but may be a problem in some patients with primary biliary cirrhosis or malabsorption from other causes. Vitamins A and D capsules contain a prophylactic dose of both vitamins.
      First Choice:
      Vitamins A and D Capsules BPC 
      09.06.02 Vitamin B group

      • Deficiency of B group vitamins is generally rare in Britain but thiamine deficiency is common in alcoholic liver disease and may be present in re-feeding syndrome (seek advice from a dietician).

      • High dose Vitamin B and C injection should only be used when considered essential e.g. in patients where Wernicke’s encephalopathy is a real possibility due to thiamine deficiency including alcoholics and those who are severely malnourished. Likely symptoms include lethargy inattentiveness confusion or an altered level of consciousness. Several days of parenteral treatment may be given initially followed if necessary by oral thiamine supplements. Thiamine contained in the injection may cause anaphylaxis which may become more likely with repeated doses.

      • Non-specific B group deficiencies should be treated with vitamin B Compound Strong tablets which contain thiamine riboflavin, nicotinamide and pyridoxine.

      • See also vitamin B12, folic acid and multivitamins.

       

      First Choice:
      Pyridoxine Hydrochloride Tablets 
      Vitamin B6
      First Choice:
      Thiamine 
      Vitamin B1
      First Choice:
      Vitamin B Tablets (Compound Strong) 
      Restricted Drug  Pabrinex® IM 
      High dose Vitamin B and C intramuscular injection.
      Restricted Drug  Pabrinex® IV 
      High dose Vitamin B and C intravenous injection
      IV Monograph available through ’Injectable Medicines Guide’ link on front page of INsite
      09.06.03 Vitamin C

      • The elderly can be prone to the development of subclinical scurvy because of poor diet prophylactic doses of vitamin C are recommended for patients at risk.

      • Although vitamin C has been promoted for wound healing there is little evidence to support this.

      • Other uses for vitamin C where there is no deficiency remain unproven.

      • Ascorbic acid 1g effervescent tablets are not prescribable on FP10 by GPs.
      First Choice:
      Ascorbic Acid Tablets 
      09.06.04 Vitamin D

      • Vitamin D deficiency has recently become a common diagnosis.

      • Vitamin D preparations are required for both treatment and maintenance prophylaxis of deficiency.

      • Local guidelines on the Diagnosis and Management of Vitamin D Deficiency in Adults and Diagnosis and Management of Vitamin D Deficiency in Children are available. 

      • Vitamin D with calcium supplementation is also recommended for those with osteoporosis receiving treatment, for example with bisphosphonates. All the major trials ensured adequate calcium and vitamin D intake, most frequently with concomitant supplementation

      • All inpatients with a Fractured Neck of Femur resulting from a fall from standing height or less should be prescribed Calcium and Vitamin D (Adcal D3® or Calceos®) unless osteoporosis has been excluded or some other cause for fragility fracture has been identified. Exception: patients with hypercalcaemia or hypocalcaemia.

      • Calcium and Vitamin D supplementation in elderly ambulatory patients in nursing and residential care homes has been shown to reduce the incidence of hip fracture (Local guidance recommends 1000 to 1200mg of Calcium and 800iu units Vitamin D3) Supplementation is also recommended for patients who have received oral corticosteroids for longer than 3 months

      • Vitamin D with calcium supplementation is also recommended for those who have undergone bariatric surgery. Calcium citrate may be better absorbed than calcium carbonate in the presence of reduced gastric acid. Hence for those who have undergone sleeve gastrectomy or gastric bypass procedures Cacit D3® is available under restriction.

       

      Link    Leicestershire Guidelines: Diagnosis and Management of Vitamin D Deficiency in Adults
      Link   Leicestershire Guidelines: Diagnosis and Management of Vitamin D Deficiency in Children
      Link   Leicestershire Guidelines: Vitamin D patient information leaflet
      Link   NICE TA 160: Osteoporosis - primary prevention
      Link   NICE TA 161: Osteoporosis – secondary prevention
      First Choice:
      Colecalciferol 
      Colecalciferol (vitamin D3) preparations are normally first choice, if oral treatment / supplementation is required for deficiency or insufficiency. Some of these preparations hold a UK marketing license e.g. Fultium-D3, however a number of products are unlicensed.
      Take care when prescribing twice weekly preparations as there have been reports locally of patients taking these daily despite being informed of correct dosage frequency
      First Choice:
      Restricted Drug  Ergocalciferol injection 
      Ergocalciferol injection is restricted for patients unable to tolerate or absorb oral colecalciferol.
      First Choice:
      Theical-D3® 
      NB Once daily dosing

      Each tablet contains 1000mg elemental calcium plus 880iu of vitamin D3
      Lower cost choice
      First Choice:
      Adcal-D3® 
      Use if both calcium and vitamin D supplementation is required.
      Each chewable tablet contains 600mg elemental calcium plus 400iu of vitamin D3 with a dose of one twice a day.
      Also available as a caplet which contains 300mg elemental calcium plus 200iu of vitamin D3 with a dose of two caplets morning and evening.
      First Choice:
      Calceos® 
      Each tablet contains 500mg elemental calcium plus 400iu of vitamin D3 Alternative choice if both calcium and vitamin D supplementation is required.
      First Choice:
      Calcium and Ergocalciferol Tablets 
      Each tablet contains 97mg elemental calcium plus 400iu of vitamin D2
      Can be used if low dose vitamin D only required. Calcium content low.
      Restricted Drug  Adcal-D3 Dissolve® 
      Each tablet contains 600mg elemental calcium plus 400iu of vitamin D3
      Soluble preparation if both calcium and vitamin D supplementation is required. Reserve for those not able to take chewable preparations as more costly.
      Restricted Drug  Alfacalcidol 
      Capsules, oral drops.
      For treatment of osteodystrophy resulting from renal failure; more potent than calciferol and has a shorter onset and offset of action, making it useful for acute deficiencies.
      Prescribe as One-Alpha® as non-proprietary capsules more costly.
      Restricted Drug  Cacit D3® 
      Each sachet of granules contains 500mg elemental calcium plus 440iu colecalciferol. Restricted for those who have had sleeve gastrectomy or gastric bypass bariatric procedures.
      09.06.06 Vitamin K

      • Vitamin K deficiency may arise from malabsorption or reduced gut synthesis; dietary deficiency is rare. A single IV dose is recommended routinely prior to operation for biliary obstruction.

      • Vitamin K is an antidote to warfarin but not heparin.

      • Avoid intramuscular injections in patients at risk of haemorrhage.
      Link   UHL Guidance: Management of warfarin overdose
      First Choice:
      Phytomenadione (Vitamin K1)  (Konakion®)
      Injection
      For reversal of warfarin overdose, the oral and IV forms are very similar in onset and magnitude of effect. If oral route use required use paediatric vitamin K injection (Konakion MM Paediatric 2mg/0.2ml)NB:unlicensed use
      IV Monograph available through ’Injectable Medicines Guide’ link on front page of INsite.
      RED TL status

      For newborn Green status
      Restricted Drug  Menadiol Sodium Phosphate 
      Tablets. Water soluble vitamin K derivative, which is preferable to oral phytomenadione in the presence of fat malabsorption, for example in cholestasis.
      09.06.07 Multivitamin preparations

      • Vitamins capsules BPC and multi-vitamin drops contain physiological doses of vitamins A B complex C and D.

      • See sections 9.6.2 and 9.6.3 for higher doses of individual vitamins (B and C) in acute deficiency.

      • Various nutrients and multivitamin preparations are required for patients who have undergone bariatric surgery. 
      First Choice:
      Multi-vitamin Drops 
      First Choice:
      Vitamin Capsules BPC 
      Or equivalent
      Restricted Drug  Multivitamin and mineral supplement  (Forceval®)
      For use in gastric bypass / BPD/DS bariatric surgery on the recommendation of a dietician, please see link below. (BPD = biliopancreatic diversion; DS = sleeve gastrectomy with duodenal switch).

      Forceval soluble is recommended for 8 weeks post surgery. One pack will be supplied on discharge from UHL with the second pack supplied by the GP as an acute prescription. This should be reviewed at 8 weeks and switched to the capsule formulation which has a lower cost. Only patients who are unable to tolerate capsules should be prescribed the soluble preparation after 8 weeks.

      Forceval and Forceval Soluble can be used in inpatients in line with the out of hours enteral feeding tube guidelines only (see below).
      09.08.01 Drugs used in metabolic disorders
      09.08.01 Wilsons disease
      Restricted Drug  Trientine  
      Wilson’s disease in patients intolerant of penicillamine
       ....