| Formulary Chapter 9: Nutrition and blood - Full Chapter
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| Notes: |
This chapter of the formulary is under continual development, please let the team know if you have any comments about the contents: mlcsu.lscformulary@nhs.net.
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| Chapter Links... |
 LSCMMG: Bariatric surgery guidelines for prescribing of vitamins and nutritional supplements: Position Statement |
| LSCMMG: Gluten-Free food products: Position Statement |
| LSCMMG: Oral Nutritional Supplements in Primary Care |
| LSCMMG: PKU - Prescribing of Multivitamins & Phenylalanine-free amino acid substitutes for adults and children |
| NICE CG32: Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition |
| NICE NG20: Coeliac disease: recognition, assessment and management |
| NICE NG203: Chronic kidney disease: assessment and management |
| Details... |
| 09.06 |
Vitamins |
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To avoid potential toxicity, the content of all vitamin preparations, particularly vitamin A, should be considered when used together with other supplements. |
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Paravit CF®
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Formulary
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Capsules (vitamin A 4000 IU, vitamin D3 1500 IU, vitamin E 150 IU, vitamin K 5 mg)
Liquid (vitamins A, D, E and K)
Vitamin supplement in cystic fibrosis on the specific recommendation of a cystic fibrosis specialist.
Paravit CF liquid is only available as an option for patients with swallowing difficulties or young children.
Reimbursable on FP10.
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| 09.06.01 |
Vitamin A |
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| 09.06.02 |
Vitamin B group |
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Pyridoxine Hydrochloride
(Vitamin B6)
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Formulary
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Tablets 10mg, 50mg
Prolonged use of pyridoxine in a dose of 10 mg daily is considered safe but the long-term use of pyridoxine in a dose of 200 mg or more daily has been associated with neuropathy. The safety of long-term pyridoxine supplementation with doses above 10 mg daily has not been established.
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 NICE NG33: Tuberculosis
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Thiamine (Vitamin B1)
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Formulary
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Tablets 50mg, 100mg
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Thiamine with ascorbic acid (Vitamins B&C)
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Formulary
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Intravenous high potency concentrate for solution for infusion (5ml+5ml)
Intramuscular high potency solution for injection (5ml+2ml)
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MHRA: Pabrinex: allergic reactions
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| 09.06.02 |
Oral vitamin B complex preparations |
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Vitamin B complex
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Formulary
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 Re-feeding syndrome in line with NICE CG32
Post-gastric bypass
 All other indications
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NICE CG32: Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition
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| 09.06.02 |
Other compounds |
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| 09.06.03 |
Vitamin C |
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Ascorbic Acid (Vitamin C)
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Formulary
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Tablets 50mg, 100mg, 200mg & 500mg
Prevention and treatment of scurvy
All other indications |
LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy
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| 09.06.04 |
Vitamin D |
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Alfacalcidol (One-Alpha®)
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Formulary
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Capsules 250 nanograms, 500 nanograms, 1 microgram
Oral drops 2 micrograms/mL (1 drop contains approximately 100 nanograms alfacalcidol)
For patients with severe renal impairment requiring vitamin D therapy.
Secondary care prescribers initiating treatment should clearly outline monitoring requirements when transferring prescribing responsiblity to primary care.
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SPS - Alfacalcidol monitoring
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Colecalciferol
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Formulary
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Colecalciferol 400 units is equivalent to 10 micrograms.
For recommendations on the use of vitamin D please consult the LSCMMG Vitamin D position statement.
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Colecalciferol and Calcium Carbonate
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Formulary
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**Product choices to be confirmed with ICB. To be updated when resolved**
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Ergocalciferol
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Formulary
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Injection 300,000 units/1ml
For the correction of deficiency and insufficiency in high-risk, symptomatic patients as a short-course treatment.
Ergocalciferol 400 units is equivalent to 10 micrograms.
Plastic syringes can be used 'off label' providing the injection is administered immediately after being drawn up into the syringe.
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| 09.06.04 |
Vitamin D with Calcium |
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| 09.06.05 |
Vitamin E |
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| 09.06.06 |
Vitamin K |
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Menadiol Sodium Phosphate
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Formulary
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Tablets 10mg
Water soluble preparation for the prevention of vitamin K deficiency in malabsorption syndromes.
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| 09.06.07 |
Multivitamin preparations |
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Multivitamin (Renal - Renavit®)
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Formulary
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Tablets vitamins B and C
Dietary management of water-soluble vitamin deficiency in renal failure patients on dialysis. Not suitable for use in children.
Initiation by a renal consultant/SpR.
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LSCMMG: Renal Vitamins (Renavit®) NMR
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Multivitamin drops (Paediatrics - Abidec®, Dalivit®)
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Formulary
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Oral drops vitamins A, B group, C and D
The vitamin concentrations of Abidec® and Dalivit® vary, consult product literature for more information.
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Mutivitamin
(BPC capsules)
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Formulary
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Capsules
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LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy
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| 09.06.07 |
Vitamin and mineral supplements and adjuncts to synthetic diets |
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Taurine
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Formulary
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Taurine deficiency in CF liver disease
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Scottish Medicines Consortium |
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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Cancer Drugs Fund |
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NHS England |
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Homecare |
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ICB |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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| Status |
Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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