9: Nutrition and Blood

9: Nutrition and blood

Please select a topic:

9.1 Anaemias and some other blood disorders / 9.2 Fluid and electrolytes
9.3 Intravenous nutrition / 9.4 Oral nutrition
9.5 Minerals / 9.6 Vitamins
9.8 Metabolic disorders

Changes to the Formulary since previous version

(22.8.2013)

Section / Change / Reason for change
9.1 / ADDED: Filgrastim and pegfilgrastim: risk of potentially life-threatening capillary leak syndrome / MHRA Drug Safety Update

9.1 Anaemias and some other blood disorders

Iron deficiency anaemias

·  Ferrous sulphate 200mg tablets

·  Ferrous fumarate 210mg tablets

·  Ferrous fumarate 140mg/5ml syrup

·  Sodium Feredate elixir 190mg/5ml (Sytron)

·  Ferric carboxymaltose (Iron 500mg/10ml) injection (Ferinject®)

·  Iron sucrose 20mg/ml injection (Venofer)

Dose

- Ferrous sulphate tablets 200mg (65mg iron): therapeutic dose, 200mg three times daily. Prophylaxis, 200mg once daily.
- Ferrous fumarate tablets 210mg (68mg iron): therapeutic dose, 210mg three times daily. Prophylaxis, 210mg once daily.

- Ferrous fumarate syrup 140mg/5mL (45mg iron/5mL) (Fersamal®):10-20mL twice daily.

- Sodium feredate elixir 190mg/5ml (27.5mg iron/5ml) Sytron®:5 to 1oml three times daily.

- Ferric caboxymaltose injection : by slow intravenous injection or by intravenous infusion, calculated according to body-weight and iron deficit. Consult product literature. Facilities for cardiopulmonary resuscitation must be available.
- Iron sucrose injection providing iron 20mg/mL: by slow intravenous injection or infusion, calculated according to body- weight and haemoglobin. Consult product literature. Facilities for cardiopulmonary resuscitation must be at hand.

Prescribing notes

·  Iron salts should be given orally unless there are good reasons for using another route.

·  The haemoglobin should rise by approximately 1-2g/litre (100-200mg/100mL) per day or 20g/litre (2g/100mL) over 3-4 weeks. Once it has reached reference range, treatment should be continued for a further 3 months in order to replenish iron stores, and then stopped.

·  Gastro-intestinal side-effects are common. Therefore, although iron preparations are best absorbed on an empty stomach, they may be taken after food to reduce these side-effects. If side-effects are problematic the dose can be reduced or an alternative preparation prescribed.

·  Modified-release preparations have no therapeutic advantage and should not be used.

·  The only valid reason for administering iron parenterally is non-tolerance of oral therapy. If oral preparations are taken reliably and are absorbed, the haemoglobin response is not significantly faster with the parenteral route.

·  Ferinject® (iron injection providing iron 50mg/mL) and is the intravenous formulation of choice in Gateshead Health NHS Foundation Trust.

·  Ferinject® infusion is prepared on the wards. There is a prescription form on the intranet at:

http://staffzone/trust-documents/clinical-documents/by-department/medicines-info/chemotherapy-prescriptions.php#misc

·  A licensed intramuscular preparation of iron is no longer available.

MHRA Drug Safety Update

Intravenous iron and serious hypersensitivity reactions. New strengthened recommendations to manage and minimise risk

Article date: August 2013

Summary

A Europe-wide review of intravenous iron products for iron deficiency and anaemia has recommended strengthened measures are taken to manage and minimise the risk of hypersensitivity reactions, which may be life-threatening or fatal as outlined in this article.

Link: http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON300398

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.

·  Hydroxocobalamin 1mg injection

·  Folic acid 400 micrograms and 5mg tablets

·  Folic acid 2.5mg/5ml syrup

Dose

- Hydroxocobalamin injection 1mg/mL: by intramuscular injection, anaemia without neurological involvement, 1mg 3 times a week for 2 weeks then 1mg every 3 months. Anaemia with neurological involvement, 1mg on alternate days until no further improvement then 1mg every 2 months. Prophylaxis, 1mg every 3 months. Tobacco amblyopia and Leber's optic atrophy, 1mg daily for 2 weeks then 1mg twice weekly until no further improvement, thereafter 1mg every 1-3 months.

- Folic acid tablets 400micrograms, 5mg, 2.5mg/5ml syrup: folate deficient state (e.g. pregnancy, poor nutrition, antiepileptics), 5mg daily for 4 months to bring about haematological remission and replenish body stores. Malabsorption syndrome, up to 15mg daily. Prophylaxis in chronic haemolytic states and renal dialysis, 5mg daily (or once weekly depending on diet and rate of haemolysis).

Prescribing notes

·  Apart from dietary deficiency all other causes of vitamin B12 deficiency are attributable to malabsorption. Vitamin B12 should be given prophylactically after total gastrectomy or total ileal resection.

·  There is little place for use of low dose vitamin B12 orally. However, cyanocobalamin tablets can be used in doses of 50-150micrograms daily for vegans or patients who have proven dietary deficiency (prescription must be endorsed SLS).

·  There is no evidence that doses larger than those recommended provide any additional benefit in cases with neurological or ocular involvement.

·  There is no need to routinely prescribe a combined iron/folic acid preparation in pregnancy.

·  Folic acid has few indications for long-term therapy since most causes of folate deficiency are self-limiting or will yield to a short course of therapy.

·  Folic acid 400micrograms daily should be recommended for all women attempting to conceive, and continued until the 12th week of pregnancy to reduce the risk of a neural tube defect. Women at high risk (women with epilepsy, and those with a previous affected pregnancy) should take 5mg from pre-conception until 12 weeks.

Drugs used in neoplastic, haemolytic and renal anaemias

·  Epoetin beta (Neo-recormon) 500 to 10,000units syringes available

·  Darbepoetin alfa (Aranesp) 20 to 150 microgram syringes available

Dose

- Epoetin alfa (Eprex®) prefilled syringes 500units, 2000units, 3000units, 4000units, 5000units, 6000units, 7000units, 8000units, 9000units, 10,000units (packs of 6 syringes): see product information.
- Epoetin beta (NeoRecormon®) prefilled syringes 500units, 1000units, 2000units, 3000units, 4000units, 5000units, 6000units, 10,000units (packs of 6 syringes): see product information.

- Darbepoetin alfa (Aranesp®) prefilled syringes (packs of 4 syringes) : see product information

Iron overload

·  Desferrioxamine 500mg injection

·  Deferasirox 500mg dispersible tablets

Iron Overload
The management of established iron overload involves venesection. Desferrioxamine (deferoxamine) is used for prevention in patients receiving regular long-term blood transfusion: this type of management requires specialist input. Desferrioxamine and deferasirox are for hospital use only.

Drugs used in neutropenia

·  Lenogastrim 33.6 million unit (263 micrograms) injection

·  Lenogastrim 13.5 million unit (105 micrograms) injection

·  Pegfilgrastim 6mg pre-filled syringe

·  Filgrastim 30 & 48 million unit syringe (Zarzio® Brand)

Dose

- as per NCN Chemotherapy Handbook and local protocols

MHRA Drug Safety Update

Filgrastim and pegfilgrastim: risk of potentially life-threatening capillary leak syndrome

Article date: Sept 2013

Summary

Capillary leak syndrome (CLS) has been reported in recipients of filgrastim, including patients undergoing chemotherapy and a healthy donor undergoing peripheral blood progenitor-cell mobilisation; it has also been reported in recipients of pegfilgrastim undergoing chemotherapy. Episodes varied in severity and frequency. CLS is characterised by: hypotension and oedema; hypoalbuminaemia; and haemoconcentration, and may be fatal unless promptly diagnosed and managed.

Prescribers should monitor patients and healthy donors for signs and symptoms of CLS, and should give standard symptomatic treatment immediately if symptoms occur. Advise patients to seek medical attention immediately if they experience symptoms of CLS.

Link: http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON314895

9.2 Fluid and electrolytes

Oral preparations for fluid and electrolyte imbalance

9.2.1.1 Oral Potassium

·  Potassium chloride 600mg m/r tablets (Slow K)

·  Potassium chloride effervescent tablets (Sando-K)

·  Potassium chloride 1mmol/ml syrup (Kay-Cee-L)

Dose

- Sando-K® tablets effervescent containing potassium bicarbonate and chloride equivalent to potassium 470mg (12mmol of K+) and chloride 285mg (8mmol of Cl-): usually 2-4 tablets dispersed in water daily.
- Kay-Cee-L® syrup containing potassium chloride 7.5% (1mmol/mL each of K+ and Cl-): 25-50mL per day.

- Slow-K® tablets containing 600mg potassium chloride (8mmol each of K+ and Cl-): usual dosage is two to three tablets a day, but up to 12 tablets daily may be given.

Prescribing notes

·  Potassium-sparing diuretics are recommended instead of potassium supplements for prevention of hypokalaemia due to diuretics such as furosemide (frusemide) or thiazides when these are given to eliminate oedema.

·  Potassium levels should be monitored closely and dose of Sando-K® / Slow-K® reviewed or discontinued when potassium level in range

Potassium removal

·  Calcium polystyrene sulphonate powder (Calcium Resonium)

·  Calcium Resonium 30g in 100ml enema

Dose

- Calcium polystyrene sulphonate (Calcium Resonium®): orally, 15g 3-4 times daily in water (not fruit squash). (300g). As enema, 30g in methycellulose solution retained for 9 hours followed by irrigation to remove resin from colon.

Prescribing notes

·  Calcium polystyrene sulphonate may be used to remove excess potassium in mild hyperkalaemia or in moderate hyperkalaemia when there are not ECG changes. Intravenous therapy is required in emergencies; see BNF section 9.2.2.1 and local guidelines for advice.

9.2.1.1 Oral Sodium and water

·  Sodium chloride 600mg m/r tablets

·  Sodium chloride 1mmol/ml oral solution (unlicensed)

·  Oral rehydration salts (Dioralyte and Electrolade available)

Dose

- Sodium chloride tablets m/r 600mg containing approx 10mmol each of Na+ and Cl- (Slow Sodium®): prophylaxis of sodium chloride deficiency 4-8 tablets daily with water (max 20 tablets daily in severe depletion). Chronic renal salt wasting, up to 20 tablets daily with appropriate fluid intake.

- Dioralyte® and Electrolade®: see BNF

Prescribing notes

·  Any unused reconstituted solution of Electrolade® should be discarded after 1 hour unless stored in a fridge when it may be kept for up to 24 hours.

9.2.1.3 Oral bicarbonate

·  Sodium bicarbonate 500mg capsules

Dose

- Sodium bicarbonate capsules 500mg (approx 6mmol each of Na+ and HCO3-): 4.8g/day or more may be required.

Prescribing notes

·  Sodium bicarbonate is used for chronic acidotic states such as uraemic acidosis or renal tubular acidosis. It should be avoided in respiratory acidosis. The response is unpredictable and must be assessed.

Parenteral preparations for fluid and electrolyte imbalance

·  Sodium chloride 0.9% 5ml, 10ml, 20ml injection

·  Sodium chloride 0.9% 100ml, 250ml, 500ml and 1 litre intravenous infusion

·  Sodium chloride 0.9% 1litre and 3 litre irrigation

·  Sodium chloride 0.45% 500ml intravenous infusion (Steriflex 2)

·  Sodium chloride 1.8% 500ml intravenous infusion polyfusor

·  Sodium chloride 2.7% 500ml intravenous infusion polyfusor

·  Sodium chloride 5% 500ml intravenous infusion polyfusor

·  Sodium chloride 30% 10ml injection

·  Glucose 5% 100ml, 250ml, 500ml and 1 litre intravenous infusion (Steriflex 6)

·  Glucose 10% 500ml and 1 litre intravenous infusion (Steriflex 7)

·  Glucose 20% 500ml intravenous infusion (Steriflex 31)

·  Glucose 50% 50ml injection

·  Glucose 50% Sodium chloride 0.9% & Glucose 5% 500ml intravenous infusion (Steriflex 3)

·  Sodium chloride 0.18% & Glucose 4% 500ml and 1 litre intravenous infusion

·  Sodium chloride 0.18% & Glucose 10% 500ml intravenous infusion (Steriflex 19)

·  Sodium chloride 0.45% & Glucose 5% 500ml intravenous infusion (Steriflex 45)

·  Potassium chloride 0.15% in 1l sodium chloride 0.9% (20mmol) (Steriflex 12)

·  Potassium chloride 0.3% in 500ml sodium chloride 0.9% (20mmol) (Steriflex 15)

·  Potassium chloride 0.3% in 1l sodium chloride 0.9% (40mmol) (Steriflex 15)

·  Potassium chloride 0.15% in 1l glucose 5% (20mmol) (Steriflex 13)

·  Potassium chloride 0.3% in 1l glucose 5% (40mmol) (Steriflex 16)

·  Potassium chloride 0.15% in 500ml glucose 10% (10mmol) (Steriflex 106)

·  Potassium chloride 0.3% in 500ml glucose 10% (20mmol) (Steriflex 132)

·  Potassium chloride 0.15% in 500ml glucose 5% + sodium chloride 0.45% (10mmol) (Intraven GV332)

·  Potassium chloride 0.15% in 1l glucose 4% + sodium chloride 0.18% (20mmol) (Steriflex 14)

·  Potassium chloride 0.3% in 1l glucose 4% + sodium chloride 0.18% (40mmol) (Steriflex 17)

·  Potassium chloride 0.3% in 500ml glucose 5% + sodium chloride 0.45% (Paediatrics only)

·  Potassium chloride 0.45% in 1l sodium chloride 0.9% (60mmol) (High strength potassium bag – Restricted)

·  Potassium chloride 0.6% in 500ml sodium chloride 0.9% (80mmol) (High strength potassium bag – Restricted)

·  Potassium chloride 0.6% in 500ml dextrose 5% (80mmol) (High strength potassium bag – Restricted)

·  Potassium chloride 15% 10ml injection (20mmol) (Restricted)

·  Potassium phosphate 17.42% injection (Restricted)

·  Sodium bicarbonate 1.26% 500ml intravenous infusion polyfusor

·  Sodium bicarbonate 1.4% 500ml intravenous infusion polyfusor

·  Sodium bicarbonate 2.74% 500ml intravenous infusion polyfusor

·  Sodium bicarbonate 8.4% 10ml injection

·  Sodium bicarbonate 8.4% 200ml intravenous infusion polyfusor

·  Water for injection 2ml, 5ml, 10ml, 20ml, 100ml and 500ml

·  Water for irrigation 1L

·  Sterile oral water 100ml

Prescribing notes

·  High strength potassium bags are restricted use and are kept in pharmacy only. They are for use by on-call pharmacist out of hours only in conjunction with the strong potassium checklist.

·  Ready made potassium bags should be used where possible. In rare circumstances, a different bag may be required. During weekday pharmacy opening hours, this will be manufactured by the pharmacy aseptics department (ext 2316)

·  Potassium phosphate injection contains 20mmol potassium and 10mmol phosphate) in each 10ml and is generally restricted to Critical Care.

·  Potassium chloride 15% 10ml injection (20mmol) is restricted to Critical Care, Coronary Care, and SCBU.

Plasma and plasma substitutes

·  Human albumin 4.5% 50ml, and 500ml solutions

·  Human albumin 5%500ml solution

·  Human albumin 20% 50ml and 100ml solution

·  Geloflex 1 litre infusion (Theatres)

·  Sodium lactate compound (Hartmans) 1 litre and 500ml infusion

·  Volplex 500ml infusion

·  Volulyte 6% infusion 500ml

MHRA Drug Safety Update

Hydroxyethyl starch intravenous infusion: suspension of licenses

Article date: June 2013

Summary

Results from large randomised clinical trials have reported an increased risk of renal dysfunction and mortality in critically ill or septic patients who received hydroxyethyl starch (HES) compared with crystalloids. The risks of HES products for plasma volume expansion outweigh the benefits in all patient groups and clinical settings. The licences for all HES products have been suspended.