Section 9: Nutrition and Blood

Section Description

BNF 9.1.1

Iron-deficiency anaemias

BNF 9.1.2

Drugs used in megaloblastic anaemias

BNF 9.1.3

Drugs used in hypoplastic, haemolytic, and renal anaemias

BNF 9.1.4

Drugs used in platelet disorders

BNF 9.1.6

Drugs used in neutropenia

BNF 9.2.1

Oral preparations for fluid and electrolyte imbalance

BNF 9.2.2

Parenteral preparations for fluid and electrolyte imbalance

BNF 9.2.2.2

Plasma and plasma substitutes

BNF 9.3

Intravenous nutrition

BNF 9.4.1

Foods for special diets

BNF 9.4.2

Enteral nutrition

BNF 9.5.1.1

Calcium supplements

BNF 9.5.1.2

Hypercalcaemia and hypercalciuria

BNF 9.5.1.3

Magnesium

BNF 9.5.2

Phosphorus

BNF 9.5.2.1

Phosphate supplements

BNF 9.5.2.2

Phosphate-binding agents

BNF 9.5.3

Fluoride

BNF 9.5.4

Zinc

BNF 9.5.5

Selenium

BNF 9.6.1

Vitamin A

BNF 9.6.2

Vitamin B group

BNF 9.6.3

Vitamin C

BNF 9.6.4

Vitamin D

BNF 9.6.5

Vitamin E

BNF 9.6.6

Vitamin K

BNF 9.6.7

Multivitamin preparations

BNF 9.7

Bitters and Tonics

BNF 9.8.1

Drugs used in metabolic disorders

BNF 9.8.2

Acute porphyrias

BNF 9.1.1 Iron-deficiency anaemias

Oral iron

Iron
per tablet

Cost
per tablet

Cost per 100mg iron

 

Ferrous fumarate 210mg

65mg

1.5p

2.5p

 

Ferrous sulphate 200mg

65mg

3.9p

6.0p

 

 

Oral iron (Liquids)

Ferrous fumarate (Fersamal®)

45mg iron in 5ml

21p per 100mg iron

Sodium feredetate (Sytron®)

27.5mg iron in 5ml

20p per 100mg iron

 

Iron and folic acid

Ferrograd Folic®

105mg iron (as sulphate)

350mcg folic acid

6.3p per tablet

Pregaday®

100mg iron (as fumarate)

350mcg folic acid

4.5p per tablet

 

Parenteral iron

Iron dextran

50mg iron in 1ml

Deep IM, slow IV injection or IV infusion (CosmoFer®)

Iron sucrose 20mg iron in 1ml

Specialist/ Hospital prescribing only

Slow IV injection or IV infusion (Venofer®)

Ferric carboxymaltose  50mg iron in 1ml

Specialist/ Hospital prescribing only

Slow IV injection or infusion (Ferinject®)

Iron isomaltoside 1000  100mg iron in 1ml 

Specialist/ Hospital prescribing only

Slow intravenous injection or intravenous infusion (Monofer®) RENAL use ONLY – for HOME  HAEMODIALYSIS PATIENTS

BNF 9.1.2 Drugs used in megaloblastic anaemias

Folic acid

Hydroxocobalamin injection 1mg

Hydroxocobalamin primary care information for testing, dosing and administration: patient specific direction template

Cyanocobalamin tablets 50mcg

BNF 9.1.3 Drugs used in hypoplastic, haemolytic, and renal anaemias

Please do not issue prescriptions for erythropoietin (darbepoetin or epoetin) for patients attending the Wolverhampton Renal Unit (New Cross Hospital and satellite units).  The prescribing budget has been top-sliced to pay for these supplies.

Darbepoetin alfa

 

Specialist/ Hospital prescribing only

Renal patients

NICE guidance (Epoeitin alfa, beta and darbopoetin alfa for cancer treatment-induced anaemia) NICE TA323

Epoetin alfa

Eprex®

Specialist/ Hospital prescribing only

Haematology patients

NICE guidance (Epoeitin alfa, beta and darbopoetin alfa for cancer treatment-induced anaemia) NICE TA323

Epoetin beta

NeoRecormon®

Specialist/ Hospital prescribing only

Renal patients

NICE guidance (Epoeitin alfa, beta and darbopoetin alfa for cancer treatment-induced anaemia) NICE TA323

Sickle-cell disease  
Hydroxycarbamide  Specialist/ Hospital prescribing only

Iron overload

 

Deferasirox

Specialist/ Hospital prescribing only

Deferiprone

Specialist/ Hospital prescribing only

Desferrioxamine mesilate

Specialist/ Hospital prescribing only

BNF 9.1.4 Drugs used in platelet disorders

Anagrelide

Specialist/ Hospital prescribing only

Essential thrombocythaemia

Eltrombopag

Specialist/ Hospital prescribing only

Idiopathic thrombocytopenic purpura NICE TA293

Romiplostim 

Specialist/ Hospital prescribing only

Idiopathic thrombocytopenic purpura NICE TA221

BNF 9.1.6 Drugs used in neutropenia

Filgrastim

Specialist/ Hospital prescribing only

Neupogen®

BNF 9.2.1 - Oral preparations for fluid and electrolyte imbalance

BNF 9.2.1.1 - Oral Potassium

Oral Potassium

 

Potassium effervescent (Sando-K®)

12 mmol of K+ per tablet

Potassium chloride SF syrup (Kay-Cee-L®)

1mmol of K+ in 1ml

Potassium chloride modified-release (m/r)

8 mmol of K+ per tablet

Potassium removal

 

Polystyrene sulphonate resins

Specialist/ Hospital prescribing only

Calcium Resonium® Powder

BNF 9.2.1.2 - Oral Sodium

UKMi nformation about the sodium content of medicines

Sodium chloride m/r tablets 600mg (Slow Sodium®)

10 mmol Na+ per tablet

BNF 9.2.1.3 - Oral bicarbonate

Sodium bicarbonate capsules 500mg

6 mmol of Na+ and 6 mmol of bicarbonate

 

Oral Rehydration Therapy

 

Dioralyte Relief® (apricot flavour packs)

35p per sachet

 

BNF 9.2.2  Parenteral preparations for fluid and electrolyte imbalance

Glucose 25% - 25ml

 

Glucose 5% - 500ml & 100ml

Specialist/ Hospital prescribing only

Glucose 50% - 25ml & 50ml

 

Potassium chloride 0.3% in glucose 5% - 500ml

Specialist/ Hospital prescribing only

Potassium chloride 0.3% in sodium chloride 0.9% - 500ml

Specialist/ Hospital prescribing only

Potassium chloride 0.3% in sodium chloride 0.18%  and glucose 4% - 500ml

Specialist/ Hospital prescribing only

Sodium bicarbonate 1.26% - 500ml

Specialist/ Hospital prescribing only

Sodium chloride 0.18% and glucose 4% - 500ml

Specialist/ Hospital prescribing only

Sodium chloride 0.45% and glucose 2.5% - 500ml

Specialist/ Hospital prescribing only

Sodium chloride 0.9% - 100ml, 500ml 1000ml

Specialist/ Hospital prescribing only

Sodium chloride 0.9% - 2ml,5ml,10ml, 20ml & 50ml

 

Sodium chloride 0.9% and glucose 5% - 500ml

Specialist/ Hospital prescribing only

Sodium Lactate (Hartmann’s solution) - 500ml & 1000ml

Specialist/ Hospital prescribing only

Water for injection – 2ml, 5ml, 10ml, 20ml, 50ml & 100ml

Specialist/ Hospital prescribing only

BNF 9.2.2.2 Plasma and plasma substitutes

Albumin

Specialist/ Hospital prescribing only

Not a pharmacy product but used within the hospital

Dextran 40

Specialist/ Hospital prescribing only

Dextran for use by Gynaecology, ENT and Vascular Surgery

Dextran 70

 

Gelatin

Gelofusine®

Esterified starch

Voluven® use on CCU

BNF 9.3  Intravenous nutrition

Refer to Nutrition Team – contact RWHT extension 8705

BNF 9.4.1 Foods for special diets

Products not stocked by Pharmacy at RWHT – contact dietician for advice

GLUTEN-FREE PRODUCTS

Gluten-free products can only be prescribed on FP10 for gluten-sensitive enteropathies including steatorrhoea due to gluten-sensitivity, coeliac disease and dermatitis herpetiformis. Prescriptions must be endorsed ACBS otherwise they may be investigated by Advisory Committee on Borderline Substances.

The Wolverhampton formulary only supports the prescribing of gluten free products listed in the Drug Tariff, Part XV – this list is known as the ABCS list. In England, only bread and flour mixes are available on prescription. For more information and guidance see: Coeliac UK.

FORMULA MILK ADVICE FOR GP PRACTICES

ALL CONDITIONS - How much powdered infant formula should I prescribe monthly?

Under 6 months 6-12 months Over 12 months

13 x 400g tins OR 6 x 900g tins

7-13 x 400g tins OR 3-6 900g tins

with dieticians's advice

For information about formula milk suitable for the child with symptoms suggestive of cow's milk protein allergy, prescribing for gastro-oesophageal reflux disease and pre-term formulas click here

BNF 9.4.2 Enteral nutrition

The West Midlands Alliance Enteral Feeds Contract covers both the Royal Wolverhampton Hospitals NHS Trust and Wolverhampton City PCT. The following products are those most used by RWHT and offer cost benefits for the NHS. All are ACBS approved. Other products are available at New Cross Hospital if clinically indicated.

Advice for managing undernutrition in the community (including Care Homes) can be found on the website for the British Association for Parenteral and Enteral Nutrition

Wolverhampton Nutrition Guidelines 2017

Patient Information Leaflet - Advice from RWT Nutrition and Dietetics Department on how patient/carers can increase calorie intake.

GUIDANCE FOR CHOICE OF SIP FEEDS

THICKENING AGENTS

Resource® ThickenUp™ Clear - guidance on product use

ADULT ENTERAL FEEDS

Kcal/ml

Presentation (sterile packs/ bottles)

Available at RWHT via Dietetics Dept

500ml

1000ml

1500ml

Nutrison Standard®

1.0

yes

yes

yes

yes (not 500mls)

Nutrison Multi-Fibre®

1.0

yes

yes

yes

yes (not 500mls)

Nutrison Energy®

1.5

yes

yes

yes

yes (not 500mls)

Nutrison Energy Multi-Fibre®

1.5

yes

yes

yes

yes (not 500mls)

Nutrison Concentrate®

2.0

yes

no

no

yes

Nutrison Low Sodium®

1.0

no

yes

no

yes

Nutrison Peptisorb®

1.0

no

 

yes

no

On request from a dietician

Nutrison Soya®

1.0

no

yes

 

On request from a dietician

Nutrison MCT® 1.0 no yes no On request from a dietitian
Nutrison 1000 Complete Multi-Fibre 1.0 no yes no On special request from a dietitian (not routinely stocked)
Nutrision 1200 Complete Multi-Fibre 1.2 no yes yes On special request from a dietitian (not routinely stocked)

Vital 1.5 RTH

1.5

no

yes

no

On special request from a dietitian (not routinely stocked)

 

PAEDIATRIC
ENTERAL FEEDS

Description

Available at RWHT via Dietetics Dept

Infantrini®

1.0 kcal/100ml infant feed for 0-12 months (<8kg)

yes

Nutrini®

1.0 kcal/100ml paediatric feed for 1 -6 years  (8-20kg)

yes

Nutrini Energy®

1.5 kcal/100ml paediatric feed for 1 -6 years  (8-20kg)

yes

Neocate®

Nutritionally complete elemental infant formula

yes

Nutriprem 2®

Nutritionally complete infant formula for premature infants on discharge from hospital

yes

 

 BNF 9.5.1.1 Calcium supplements

Calcium Replacement

 

 

Sandocal - 1000®

25 mmol calcium per effervescent tablet

 

Calcium gluconate injection 10%

220 micromole calcium in 1ml

 

Calcium chloride injection 75mg/ml

680 micromole calcium in 1ml

 

 

Calcium: Prevention & Treatment of Osteoporosis

See BNF Section 6.6.2

UKMi information on calcium and vitamin D products suitable for vegetarian or vegan

BNF 9.5.1.2 Hypercalcaemia and hypercalciuria

Cinacalcet

 

NICE Guidance (Hyperparathyroidism - cincalcet) NICE TA117 does not recommend use. RWHT Non-Formulary - only those patients already commenced on therapy will be supplied with cinacalcet.

BNF 9.5.1.3 Magnesium

Magnesium sulphate injection

 

 Specialist/ Hospital prescribing only

Magnaspartate® 243mg powder for oral solution  10mmol per sachet Licensed product, contains 2.706g sucrose per sachet 

Magnesium glycerophosphate

4mmol

Neomag® is the only licensed product. Brand prescribing is advised. Neomag® should be prescribed in preference to unlicensed products including Magnaphate, YourMag, Mag-4 and other presentations of magnesium glycerophosphate. 

BNF 9.5.2 Phosphorus

BNF 9.5.2.1 Phosphate supplements  

Phosphate-Sandoz® effervescent tablets

16.1 mmol phosphate per tablet

BNF 9.5.2.2 Phosphate-binding agent    

Calcium acetate (Renacet® or Phosex®)

Renacet® has cheaper acquisition cost

Sevelamer

Hospital/specialist only (no new shared care patients from May 2018)
3rd Line

Lanthanum

Hospital/specialist only (no new shared care patients from May 2018)

BNF 9.5.3 Fluoride

Not routinely stocked by RWHT

BNF 9.5.4 Zinc

Zinc sulphate monohydrate 125 mg effervescent tablets

Solvazinc®

Zinc sulphate 220 mg capsules

Specialist/ Hospital prescribing only

BNF 9.5.5 Selenium

Selenium 50 microgram/ml injection - Specialist/ Hospital prescribing only

BNF 9.6.1 Vitamin A

Vitamin A oral solution (Arovit®)

Available from special importing companies – see BNF for Children for further details.

Healthy Start Children’s Vitamin Drops

Available free of charge to children under 4 years through the Healthy Start Scheme; otherwise available direct to the public from maternity and child health clinics

Healthy Start Vitamins for women (containing ascorbic acid, vitamin D, and folic acid) are also available to women during pregnancy and until their baby is one year old, through the Healthy Start Scheme.

Information for health professionals

BNF 9.6.2 Vitamin B group

Pyridoxine (vitamin B6) tablets

 

Thiamine (vitamin B1) tablets

Alcohol withdrawl/ dependence
http://intranet.xrwh.nhs.uk/pdf/policies/AdultMedicalGuidelines/Alcohol_Withdrawal.pdfThiamine 50mg four times a day; continued until patient has stopped drinking and has a good diet i.e. regular meals and varied intake from all food groups. Longer courses of treatment may be required for specific indications e.g. Wernicke-Korsakoff encephalopathy, beriberi and thiamine deficiency related to chronic alcoholism.

Vitamin B compound strong

Hospital only. Re-feeding syndrome RWT guidance
Vitamin B Compound Strong 1-2 tablets three times a day immediately before and for the first 10 days of feeding if at high risk of re-feeding syndrome.

Pabrinex®

Specialist/ hospital prescribing only

BNF 9.6.3 Vitamin C

Ascorbic acid tablets

 

BNF 9.6.4 Vitamin D

Wolverhampton guidelines for vitamin D deficiency click here

There are two types of Vitamin D: ergocalciferol (vitamin D2) a plant product and colecalciferol (vitamin D3) which is a fish or mammal product; they are generally regarded as interchangeable in terms of efficacy. There is no vegan source of colecalciferol.

A dose of 10 micrograms of vitamin D = 400 units.

Vitamin D replacement in adults

Treatment based on serum 25-hydroxyvitamin D level. All patients to receive lifestyle and dietary advice 

Severe deficiency in adults
<10nmol/l

Product choice Licensed dose Duration

Other information

InVita D3® (colecalciferol) 50,000 unit capsule or 50,000units/ml oral solution   1 capsule once weekly or 1ml once weekly   6 weeks maximum Suitable for vegetarians but not vegans. Oral solution provided in 1ml plastic ampoules. 
Desunin® (colecalciferol) 4,000units tablets  One daily 10 weeks Suitable for vegetarians but not vegans
Fultium D3® (colecalciferol) 3,200units capsules One daily 12 weeks Not suitable for vegetarians or vegans
Fultium D3® (colecalciferol) 20,000units capsules Two capsules once a week 7 weeks Not suitable for vegetarians or vegans
InVita D3® (colecalciferol) 25,000units/ml oral solution 2ml once weekly 6 weeks Suitable for vegetarians but not vegans. Provided in 1ml plastic ampoules.
There are currently no ergocalciferol products with a UK marketing authorisation

If intolerant to oral treatment, refer to secondary care to consider IM injection

Colecalciferol 300,000unit injection [Focus Pharmaceuticals]
MONITORING: If 12 weeks after starting replacement therapy the patient has not made a clinical response, repeat levels and if still <50nmol/l, refer to appropriate specialist in secondary care. If there has been a clinical response, monitor patient every 12 months and re-inforce lifestyle and dietary advice.  

Deficiency(<25nmol/l) and Insufficiency (25-50nmol/l)

Lifestyle and dietary advice plus Colecalciferol 800units prescribed as one of the following:

  • InVita D3 800 unit capsule once daily
  • Desunin® 800unit tablets one daily
  • Fultium D3® 800unit capsules one daily

There are currently no ergocalciferol products with a UK marketing authorisation

If intolerant to oral treatment, refer to secondary care to consider IM injection Colecalciferol 300,000unit injection [Focus Pharmaceuticals]  

MONITORING:
If 12 weeks after starting replacement therapy the patient has not made a clinical response, repeat levels and if still <50nmol/l, refer to appropriate specialist in secondary care.

If there has been a clinical response, monitor patient every 12 months and re-inforce lifestyle and dietary advice.

Sufficient

>50nmol/l
Lifestyle and dietary advice only

Maintenance in deficient and insufficient adults

Monitor patient every 12 months and re-inforce lifestyle and diet advice
Colecalciferol prescribed as one of the following:

  • InVita D3® 800 units capsules one daily
  • Desunin® 800unit tablets one daily
  • Fultium D3® 800unit capsules one daily
  • InVita D3® 25,000units/ml oral solution 1ml once a month
There are currently no ergocalciferol products with a UK marketing authorisation
 

Vitamin D replacement in children and young adults

Royal Wolverhampton NHS Trust guidelines based on the guidelines of the Birmingham Children’s Hospital click here

Royal College of Paediatrics and Child Health Guide for vitamin D in childhood  click here

Treatment of deficiency <25nmol/l  0 - 18 years

1ml InVita D3® (colecalciferol) 25,000units/ml oral solution every 2 weeks for 6 weeks (total of 3 doses) then maintenance treatment of 400-1000 IU/day 

Suitable for vegetarians but not vegans. Provide in 1ml plastic ampoules. 
Insufficiency 25–50nmol/l   Lifestyle advice – safe sun and diet Multivitamins: long-term if no significant lifestyle change. Re-testing not routinely indicated  
1 month to 1 year  Healthy Start: 5 drops (300units colecalciferol) once daily  Available free of charge to some infants Healthy Start scheme
Dalivit® 0.3ml or 7 drops (200units ergocalciferol) once daily   
Abidec® 0.3ml or 7 drops (200units ergocalciferol) once daily  Contains peanut oil 
> 1 year  Dalivit® 0.6ml or 14 drops (400units ergocalciferol) once daily   
Abidec® 0.6ml or 14 drops (400units ergocalciferol) once daily  Contains peanut oil 
Prevention of deficiency in children and young adults  Preventing vitamin D deficiency in toddlers click here
1 -11 year olds: 1ml InVita D3® (colecalciferol) 25,000units/ml oral solution every 6 weeks
12 - 18 year olds: One Fultium D3® (colecalciferol) 20,000unit capsule every 6 weeks or 1ml InVita D3® (colecalciferol) 25,000units/ml oral solution every 6 weeks
There are currently no ergocalciferol products with a UK marketing authorisation 
 

Prevention & Treatment of Osteoporosis: Calcium and vitamin D products

  Calcium (mmol) Colecalciferol (units)  

Accrete D3 tablets
1 tablet twice a day

30 800 Unsuitable for vegetarians and vegans. Tablet can be broken across score-line (not crushed) to aid swallowing. 
Adcal-D3® chewable tablets
2 tablets daily (single or divided dose)  
30 800 Unsuitable for vegetarians and vegans. 
Adcal-D3® caplets
2 caplets twice a day  
30 800 Free of ingredients of animal origin but vitamin D3 is derived from the lanolin of sheep’s wool. Manufacturer states that may be suitable for vegetarians but not vegans. 
Calcichew-D3® chewable tablet
1 tablet twice a day  
25 400 Do not contain any ingredients from an animal source: suitable for vegetarians and vegans 
Calfovit D3® sachet
One daily  
30 800

Unsuitable for vegetarians and vegans 

Evacal D3® chewable tablets 30 800  
 

For details of non-formulary calcium and vitamin D products that may be suitable for vegetarians and vegans click here

Vitamin D derivatives

Please note calcitriol and alfacalcidol are ineffective in treating simple vitamin D deficiency and can cause severe adverse effects, particularly hypercalcaemia.

Alfacalcidol (1α-hydroxycholecalciferol)  

BNF 9.6.5 Vitamin E

Alpha tocopheryl acetate

 

500mg in 5ml suspension
100mg tablets available on a named patient basis

BNF 9.6.6 Vitamin K

Treatment of haemorrhage or threatened haemorrhage

Menadiol sodium phosphate tablets 10mg

Also for oral administration to prevent vitamin K deficiency in malabsorption syndromes.

Vitamin K deficiency bleeding in infants

 

Phytomenadione injection 10mg in 1ml

Specialist/ Hospital prescribing only

BNF 9.6.7 Multivitamin preparations

Vitamin BPC capsules

 

Forceval® capsules and soluble tablets 

Prescribing restricted to following situations:

  • supplement oral diets that provided adequate energy and protein but inadequate micronutrients eg. anorexia, food intolerance, autism
  • provide increased micronutrients where needs cannot be met through diet alone eg. pressure sores, cancer treatments
  • treat micronutrient deficiency eg. elderly, alcholic liver disease
  • provide micronutrients for patients at risk of re-feeding syndrome

Ketovite® tablets

 

Renavit® tablets

For renal patients only.
Listed in the Drug Tariff as a nutritional supplement for haemodialysis or continuous ambulatory peritoneal dialysis (CAPD) patients. Not a licensed medicine.

 

Multivitamin Liquid Preparations

Contents per 0.6ml

Abidec®

Dalivit®

Vitamin A         (Retinol)

1333 i.u.

5000 i.u.

Vitamin B         (Nicotinamide)

8mg

5mg

Vitamin B1       (Thiamine HCI)

0.4mg

1mg

Vitamin B2       (Riboflavine)

0.8mg

0.4mg

Vitamin B6       (Pyridoxine)

0.8mg

0.5mg

Vitamin C         (Ascorbic acid)

40mg

50mg

Vitamin D         (Ergocalciferol)

400 i.u.

400 i.u.

BNF 9.7 Bitters and Tonics

Gentian Alkaline mixture BP

 

BNF 9.8.1 Drugs used in metabolic disorders

Wilson’s disease

Penicillamine

 

Carnitine deficiency

Carnitine

 

BNF 9.8.2 Acute porphyrias

For information regarding the safety of drugs in acute porphyria please contact:

Welsh Drug Information Centre
University Hospital of Wales,
Cardiff
Tel: 029 2074 2979/ 3877

Haem arginate for intravenous infusion