9: Nutrition and blood
Please select a topic:
9.1 Anaemias and some other blood
9.2 Fluid and electrolytes
disorders
9.3 Intravenous nutrition
9.4 Oral nutrition
9.5 Minerals
9.6 Vitamins
9.8 Metabolic disorders
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 1 of 15
Date: 1.8.2012
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/medicinesinfo/chemotherapy-prescriptions.php#misc

A licensed intramuscular preparation of iron is no longer available.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
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Drug Formulary
Drug & Therapeutics Committee
Page 2 of 15
Date: 1.8.2012
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 B 12 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.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
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Drug Formulary
Drug & Therapeutics Committee
Page 3 of 15
Date: 1.8.2012
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
Dose
- as per NCN Chemotherapy Handbook and local protocols
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Drug & Therapeutics Committee
Page 4 of 15
Date: 1.8.2012
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.
Red = Hospital use only
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Amber 1 = Drugs with shared care agreement
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Drug Formulary
Drug & Therapeutics Committee
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Date: 1.8.2012
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 HCO 3-): 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.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
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Drug & Therapeutics Committee
Page 6 of 15
Date: 1.8.2012
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)

Compound sodium lactate 500ml and 1 litre intravenous infusion

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)
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Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
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Drug & Therapeutics Committee
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Date: 1.8.2012

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% 50ml minijet

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, 100ml and 500ml solutions

Human albumin 20% 50ml and 100ml solution

Geloflex 1 litre infusion (Theatres)

Dextran 40 10% in Sodium chloride 0.9% 500ml

Sodium lactate compound (Hartmans) 1 litre and 500ml infusion
 Volplex 500ml infusion
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Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
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Drug & Therapeutics Committee
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Date: 1.8.2012

Volulyte 6% infusion 500ml (to be replaced shortly by Volulyte)
9.3 Intravenous nutrition

Contact Pharmacy Aseptic Services for further information
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Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
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Drug & Therapeutics Committee
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Date: 1.8.2012
9.4 Oral nutrition
9.4 Oral nutrition
Contact Dieticians for further information

Aptamil

Carobel instant thickening powder

Duocal super soluble powder

Elemental 028 extra liquid – orange and summer fruits flavours

Fortijuice drink

Fortini Multifibre liquid (Paediatrics only)

Fortisip Bottle

Fortisip Multi Fibre liquid

Fortisip Compact

Fortisip Extra

Fortricreme

Gluten free digestive biscuits

Gluten free tea biscuits

Infatrini liquid

Gluten free fibre bread

Gluten free white sliced bread

Neocate LCP

Nutilis

Nutricia Preop

Nutrini Energy liquid (Paediatrics only)

Nutrini liquid (Paediatrics only)

Nutrini Energy Multifibre

Nutrini Multifibre liquid (Paediatrics only)

Nutrini Multifibre liquid (Paediatrics only)

Nutrison Standard liquid

Nutrison Energy liquid
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
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Drug & Therapeutics Committee
Page 10 of 15
Date: 1.8.2012

Nutrison Energy Multi Fibre liquid

Nutrison Multi Fibre liquid

Nutrison Protein Plus

Nutrison Protein Plus Multifibre

Nutrison Low Sodium

Pepti-junior

Polycal 200ml liquid

Scandishake mix
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
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Drug & Therapeutics Committee
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Date: 1.8.2012
9.5 Minerals
Calcium and magnesium

Calcium carbonate 1.25mg effervescent tablets (Cacit)

Calcium chloride 10mmol/10ml injection

Calcium chloride 1g/10ml minijet

Calcium gluconate 10% injection

Calcium-Sandoz Syrup (2.7mmol Calcium/5ml)

Magnesium sulphate 10% and 50% injection

Magnesium glycerophosphate 1g (4mmol) tablets (Unlicensed)
Phosphorus

Phosphate Sandoz
Zinc

Zinc sulphate 220mg capsules
Prescribing notes

Calcium supplements are only required if dietary calcium is deficient.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
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Drug & Therapeutics Committee
Page 12 of 15
Date: 1.8.2012
9.6 Vitamins
Vitamin B group

Thiamine 100mg tablets

Thiamine high potency IV injection (Pabrinex)

Pyridoxine 50mg tablets
Prescribing notes

Vitamin B deficiency, other than B12, is rare.

Pyridoxine (vitamin B6) deficiency may occur during isoniazid treatment. There is evidence to
suggest that pyridoxine in doses not exceeding 100mg daily may provide some benefit in
premenstrual syndrome.

Vitamin B complex preparations are no longer recommended for prescribing.
Vitamin C group

Ascorbic acid 50mg, 100mg, 200mg 500mg tablets
Dose
- Ascorbic acid tablets 50mg, 100mg, 200mg, 500mg: prevention of scurvy, 25-75mg daily;
treatment of scurvy, not less than 250mg daily in divided doses
Prescribing notes

Divided doses are necessary due to the low renal threshold of ascorbic acid
Vitamin D group

Calcium and ergocalciferol tablets (Adcal D3 or Calcichew D3 caplets)

Calfovit D3 sachets

Ergocalciferol 300 000 units/ml injection

Colecalciferol 20 000 unit capsules (Dekristol®) (unlicensed)

Alfacalcidol 250 nanograms, 1 microgram capsules

Alfacalcidol 2 micrograms/ml (1 drop=100 nanograms) oral drops
NB: 10 times stronger than former presentation
Dose
- Alfacalcidol capsules 250nanograms, 500nanograms, 1microgram; oral drops
2micrograms/mL: by mouth or intravenous injection, initially 1microgram daily (elderly,
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Date: 1.8.2012
500nanograms), adjusted to avoid hypercalcaemia; maintenance, usually 0.25-1microgram
daily.
Prescribing notes

Patients with severe renal impairment requiring vitamin D therapy should be prescribed
alfacalcidol. Note that AlfaD® capsules contain peanut oil and One-Alpha® capsules contain
sesame oil.
Vitamin E group

Alpha tocopheryl acetate 500mg/5ml suspension
Vitamin K group

Menadiol phosphate 10mg tablets

Phytomenadione 10mg tablets (unlicensed)

Phytomenadione 10mg/ml injection (Konakion MM)

Phytomenadione 2mg/0.2ml injection (Konakion MM Paediatric)
Prescribing notes


Menadiol is water soluble and suitable for malabsorption syndromes.
Phytomenadione is fat soluble and is not suitable for malabsorption syndromes.
Multivitamin preparations

Vitamin A, B, C and D drops (Abidec)

Vitamin A, B, C and D tablets(Multivitamins)
General notes

The use of vitamins as general "pick-me-ups" is of unproven value and, in the case of
preparations containing vitamin A or D, may be harmful if the prescribed dose is exceeded.

Mega-vitamin therapy with water-soluble vitamins, such as ascorbic acid and pyridoxine, is
unscientific and can be harmful.
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Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
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Drug & Therapeutics Committee
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Date: 1.8.2012
9.8 Metabolic disorders
Wilsons Disease

Penicillamine 125mg and 250mg tablets
Gauchers Disease
Imiglucerase 400 unit vial
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Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
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Drug & Therapeutics Committee
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Date: 1.8.2012