1.1 Atypical haemolytic uraemia syndrome and paroxysmal nocturnal haemaglobinuria

• Ravulizumab – as per local guidance – ✓ Specialist Use Only

1.2 Iron deficiency anaemia

Oral treatment

• Ferrous Fumarate 305mg tablets ✓ First Choice

Parenteral treatment*

• Iron Dextran (Cosmofer®) ✓ First Choice
• Iron isomaltoside 1000 (Monofer®) – IV infusion only as per SMC

Please refer to https://www.nhsdghandbook.co.uk/medical-handbook/parenteral-iron-in-adults-18-years/?handbook=medical

MHRA Drug safety update Dec 2014: Intravenous iron and serious hypersensitivity reactions strengthened recommendations

MHRA Drug Safety UpdateDec 2014: Intravenous iron and serious hypersensitivity reactions

1.3 Megaloblastic anaemia

• Folic acid 5mg tablets

• Hydroxocobalamin injection for the treatment of vitamin B12 deficiency (see CKS)

For people with neurological involvement seek urgent specialist advice from a haematologist who will advise on treatment frequency.

For people with no neurological involvement

• Initially administer hydroxocobalamin 1 mg intramuscularly three times a week for 2 weeks.
• The maintenance dose depends on whether the deficiency is diet related or not. For people with B12 deficiency that is:
  • Not thought to be diet related — administer hydroxocobalamin 1 mg intramuscularly every 2–3 months for life.
  • Thought to be diet related — consider oral cyanocobalamin tablets prescribing guidance under review
  • In vegans, treatment may need to be life-long, whereas in other people with dietary deficiency replacement treatment can be stopped once the vitamin B12 levels have been corrected and the diet has improved.
• Give dietary advice about foods that are a good source of vitamin B12 — good sources of vitamin B12 include:
  • Eggs.
  • Foods which have been fortified with vitamin B12 (for example some soy products, and some breakfast cereals and breads) are good alternative sources to meat, eggs, and dairy products.
  • Meat.
  • Milk and other dairy products
  • Salmon and cod

Oral Bicarbonate – chronic acidotic states

Sodium bicarbonate capsules

Hypokalaemia

Sando-K® effervescent tablets

Kay-Cee-L® syrup

Hyponatraemia

Sodium chloride M/R tablets

Hypocalcaemia

Adcal® chewable tablet

Calvive® 1000 effervescent tablets

Hypomagnesaemia

Magnaspartate® sachets

Magnesium glycerphosphate chewable tablets (Neomag®)

Hypophosphataemia

Phosphate Sandoz® effervescent tablets

Hyperkalaemia (mild to moderate)

Calcium polystyrene sulphonate (Calcium resonium®)

Oral Rehydration Salts

Dioralyte® sachets

Low blood volume

Albumin/Gelaspan

See gluten-free formulary GFF-update-2022-1.pdf

Vitamin B group

• B6 – Pyridoxine tablets
• B1- Thiamine 50mg tablets
• Pabrinex® injection/infusion
• Vitamin B Co strong – in re-feeding syndrome for 10 days (See NICE guidance)

MHRA Drug Safety Update Dec 2014: Pabrinex Allergic reactions

Vitamin C

non formulary. Patients requiring vitamin C should be encouraged to eat vitamin c rich foods due to the high cost of this product

Vitamin D

• Alfacalcidol (renal patients)
• Stexerol-D3® (2x 25,000iu) for 6 weeks then maintenance
• Value Pack Vitamin D3 1,000 IU daily for treatment of deficiency
• If swallowing difficulties: InVita D3 oral drops 25,000IU
• Ergocalciferol 300,000 IU/ml intramuscular injection – to be supplied by clinic. If necessary can also be obtained as single ampoule from DGRI pharmacy.

Vitamin K

• Malabsorption syndromes (water-soluble preparation required): Menadiol sodium phosphate
• Fat soluble formula (not malabsorption): Phytomenadione

Multivitamins

• Abidec ®drops

Neural tube defects (prevention in pregnancy)

• Folic acid 400micrograms daily should be recommended for all women attempting to conceive and until 12th week of pregnancy.
• Advise women who are obese (BMI of 30 kg/m2 or more) to take folic acid 5 mg daily starting at least one month before conception and continuing during the first trimester
• Women at high risk (those with epilepsy, or those with previously affected pregnancy) should be advised to take 5mg folic acid.

Oral Nutritional Supplements (ONS) should not be used as first line treatment for malnutrition. Food fortification via dietary measures should be encouraged first. ONS should ideally be prescribed on the recommendation of a Registered Dietitian and should always have an ACBS indication.

Standard ACBS indications:

• Disease-related malnutrition.
• Short bowel syndrome.
• Intractable malabsorption.
• Pre-operative preparation of patients who are malnourished.
• Proven inflammatory bowel disease (IBD).
• Following total gastrectomy.
• Bowel fistula.

Other products may be prescribed as advised by Dietitian

Oral Nutritional Supplements (for use in adults)

First Line Product:

• Complan Shake (57g sachet reconstitute with 200ml whole milk, 1.6kcal/ml)

Second Line Products:

• Milk based:
  • Fortisip® Compact (low volume,125ml bottle, 2.4kcal/ml)
  • Fortisip® Bottle (200ml bottle, 1.5kcal/ml) Ensure Plus® Milkshake Style (220ml bottle, 1.5kcal/ml)
• Juice based:
  • Fortijuce® (200ml bottle)
  • Ensure Plus® Juce (220ml bottle, 1.5kcal/ml)
• Yogurt Style:
  • Fortisip® Yogurt Style (200ml bottle, 1.5kcal/ml))
  • Ensure Plus® Yogurt Style (220ml bottle, 1.5kcal/ml)

Thickeners

• Nutilis clear®, (not suitable for children <1yr except for failure to thrive)
• Carobel Instant®

For more information on managing malnutrition, including patient and carer information leaflets, please see: http://malnutritionpathway.co.uk or visit the Nutrition and Dietetic Patient and Carer Information Leaflets page on Beacon: http://hippo.citrix.dghealth.scot.nhs.uk/sorce/beacon/singlepageview.aspx?pii=589&row=76 9&SPVPrimaryMenu=5&SPVReferrer=Patient_and_Carer_Information_Leaflets