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... |
09.01 |
Anaemias and some other blood disorders |
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09.01.01 |
Iron-deficiency anaemias |
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Roxadustat (Evrenzo®)
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Formulary
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Tablets 20mg, 50mg, 70mg, 100mg, 150mg
Females of childbearing potential should use highly effective contraception during treatment and for at least 1 week after last treatment.
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NICE TA807: Roxadustat for treating symptomatic anaemia in chronic kidney disease
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09.01.01.01 |
Oral iron |
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Ferrous Sulphate
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First Choice
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Tablets 200mg (equivalent to 65 mg elemental iron)
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Ferrous Fumarate
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Formulary
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Tablets 210mg (equivalent to 69 mg elemental iron), 322mg (equivalent to 106 mg elemental iron) Oral solution 140mg/5ml (equivalent to 9 mg/mL elemental iron)
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Sodium Feredetate
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Formulary
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Sytron® oral solution contains sodium feredetate trihydrate 41.5 mg/mL equivalent to 5.5 mg/mL elemental iron.
Sodifer® oral solution contains sodium feredetate 38 mg/mL equivalent to 5.5 mg/mL elemental iron.
Sodifer® is not suitable for babies under 28 days.
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Medicines for children: Sodium feredetate for the prevention of anaemia
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Ferric maltol
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Formulary
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Iron Deficiency Anaemia in Adult Patients with Inflammatory Bowel Disease.
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LSCMMG: Ferric Maltol NMR
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09.01.01.01 |
Iron and folic acid |
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Iron and Folic Acid (Pregaday®)
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Formulary
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Tablets ferrous fumarate 322 mg (equivalent to 106 mg elemental iron) and folic acid 350 microgram
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09.01.01.01 |
Compound iron preparations |
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09.01.01.02 |
Parenteral iron |
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Prescribe parenteral iron products by brand name - important differences between formulations. |
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Ferric Carboxymaltose (Ferinject®)
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Formulary
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Injection 50mg/mL First line choice For use in patients with asthma or eczema For use when total dose infusion is needed
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MHRA: Ferric carboxymaltose (Ferinject▼): risk of symptomatic hypophosphataemia leading to osteomalacia and fractures
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Ferric Derisomaltose (Diafer®)
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Formulary
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Injection 50mg/mL (2mL ampoule) For use by renal unit only - preferred iron parenteral iron preparation for use by renal unit
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MHRA: Monofer 100mg/ml solution for injection/infusion▼ and Diafer 50mg/ml solution for injection▼: name change from iron isomaltoside to ferric derisomaltose
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Iron Sucrose (Venofer®)
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Formulary
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Injection 100mg/5mL
Second line after Ferinject
For intravenous use only Do not use in patients with asthma or eczema
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09.01.02 |
Drugs used in megaloblastic anaemias |
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Hydroxocobalamin
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Formulary
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Injection 1mg/1mL
1st line treatment in vitamin B12 deficiency.
Following gastric bypass or sleeve gastrectomy.
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MHRA: Vitamin B12 (hydroxocobalamin, cyanocobalamin): advise patients with known cobalt allergy to be vigilant for sensitivity reactions
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Cyanocobalamin
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Formulary
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Tablets 1mg
Treatment of non-dietary vitamin B12 deficiency when hydroxocobalamin injection is inappropriate or cannot be administered, and in dietary related deficiency only until B12 levels are replete, at which point patients are encouraged to self-care with 50-150mcg tablets daily purchased over the counter.
Maintenance therapy of dietary related insufficiency. Patients are advised to self-care by purchase of 50mcg tablets over the counter.
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LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy
MHRA: Vitamin B12 (hydroxocobalamin, cyanocobalamin): advise patients with known cobalt allergy to be vigilant for sensitivity reactions
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Folic Acid
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Formulary
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Tablets 400 microgram, 5mg Liquid 2.5mg/5mL
Should never be given alone for pernicious anaemia or other megaloblastic anaemias caused by vitamin B12 deficiency (may precipitate subacute combined degeneration of the spinal cord).
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Medicines for children: Folic acid for megaloblastic anaemia caused by folate deficiency and haemolytic anaemia
MHRA: Medicines in pregnancy and breastfeeding: new initiative for consistent guidance; report on optimising data for medicines used during pregnancy
NICE NG247: Maternal and child nutrition: nutrition and weight management in pregnancy, and nutrition in children up to 5 years
UK Chief Medical Officers Chief Nursing Officers and Chief Midwifery Officers - Folic Acid
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09.01.03 |
Drugs used in hypoplastic, haemolytic, and renal anaemias |
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Crovalimab (Piasky®)
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Formulary

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Solution for injection 340mg/2ml
Specialist initiation only.
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NICE TA1019: Crovalimab for treating paroxysmal nocturnal haemoglobinuria in people 12 years and over
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Danicopan
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Formulary

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Tablets 50mg, 100mg
Specialist initiation only.
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NICE TA1010: Danicopan with ravulizumab or eculizumab for treating paroxysmal nocturnal haemoglobinuria
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Iptacopan (Fabhalta®)
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Formulary

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Capsules 200mg
Specialist initiation only.
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NICE TA1000: Iptacopan for treating paroxysmal nocturnal haemoglobinuria
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Ravulizumab (Ultomiris®)
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Formulary

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Concentrate for solution for infusion 300mg/3mL, 1,100mg/11mL
Tertiary centre use only for treating paroxysmal nocturnal haemoglobinuria.
Specialist initiation only.
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NICE TA698: Ravulizumab for treating paroxysmal nocturnal haemoglobinuria
NICE TA710: Ravulizumab for treating atypical haemolytic uraemic syndrome
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Vadadustat (Vafseo®)
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Formulary

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Capsules 150mg, 300mg
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NICE TA1035: Vadadustat for treating symptomatic anaemia in adults having dialysis for chronic kidney disease
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09.01.03 |
Erythropoietin |
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Darbepoetin Alfa (Aranesp®)
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Formulary
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Injection prefilled syringe 10micrograms, 30micrograms, 50micrograms Injection prefilled syringe and SureClick 20micrograms, 40micrograms, 60micrograms, 80micrograms, 100micrograms. Consultant initiation only
Dialysis-induced anaemia.
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MHRA: Recombinant human erythropoietins: new advice for prescribing
MHRA: Recombinant human erythropoietins: treating anaemia in cancer
MHRA: Recombinant human erythropoietins: very rare risk of severe cutaneous adverse reactions (SCARs)
NICE TA323: Erythropoiesis‑stimulating agents (epoetin and darbepoetin) for treating anaemia in people with cancer having chemotherapy
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Epoetin alfa (Eprex®)
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Formulary
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Injection prefilled syringe 10,000units, 40,000units Consultant initiation only.
Dialysis-induced anaemia.
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MHRA: Recombinant human erythropoietins: new advice for prescribing
MHRA: Recombinant human erythropoietins: treating anaemia in cancer
MHRA: Recombinant human erythropoietins: very rare risk of severe cutaneous adverse reactions (SCARs)
NICE TA323: Erythropoiesis‑stimulating agents (epoetin and darbepoetin) for treating anaemia in people with cancer having chemotherapy
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09.01.03 |
Iron overload |
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09.01.04 |
Drugs used in autoimmune thrombocytopenic purpura |
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Anagrelide
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Formulary
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Capsules 500 micrograms Specialist initiation only.
Effective contraception required during treatment.
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MHRA: Xagrid (anagrelide hydrochloride): Risk of thrombosis, including cerebral infarction, if treatment discontinued abruptly. [also applicable to generic forms]
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Avatrombopag (Doptelet®)
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Formulary
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Tablets 20mg
Specialist initiation only.
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NICE TA626: Avatrombopag for treating thrombocytopenia in people with chronic liver disease needing a planned invasive procedure
NICE TA853: Avatrombopag for treating primary chronic immune thrombocytopenia
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Caplacizumab (Cablivi ®)
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Formulary

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Solution for injection 10mg
Specialist initiation only.
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NICE TA667: Caplacizumab with plasma exchange and immunosuppression for treating acute acquired thrombotic thrombocytopenic purpura
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Eltrombopag (Revolade®)
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Formulary

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Tablets 25mg, 50mg Specialist initiation only.
Ensure effective contraception during treatment.
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MHRA: Eltrombopag (Revolade): reports of interference with bilirubin and creatinine test results
NICE TA293: Eltrombopag for treating chronic immune thrombocytopenia
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Fostamatinib (TAVLESSE ®)
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Formulary

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Film coated tablets, 100mg, 150mg
Specialist initiation only.
Manufacturer advises effective contraception during and for at least 1 month after stopping treatment in females of childbearing potential.
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NICE TA835: Fostamatinib for treating refractory chronic immune thrombocytopenia
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Lusutrombopag (Mulpleo®)
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Formulary
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Film coated tablets 3mg
Specialist initiation only.
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NICE TA617: Lusutrombopag for treating thrombocytopenia in people with chronic liver disease needing a planned invasive procedure
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Romiplostim (Nplate®)
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Formulary

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Injection 250 micrograms Specialist initiation only.
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NICE TA221: Romiplostim for the treatment of chronic immune thrombocytopenia
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09.01.05 |
G6PD deficiency |
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09.01.06 |
Drugs used in neutropenia |
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Filgrastim
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Formulary
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Injection 12 million units in 0.2mL prefilled syringe, 30 million units & 48 million units in 0.5mL prefilled syringe
Specialist initiation only.
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MHRA: Filgrastim and pegfilgrastim: risk of capillary leak syndrome
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Pegfilgrastim
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Formulary
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Injection 6mg in 0.6mL prefilled syringe
Specialist initiation only.
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MHRA: Filgrastim and pegfilgrastim: risk of capillary leak syndrome
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09.01.07 |
Drugs used to mobilise stem cells |
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09.02 |
Fluids and electrolytes |
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09.02.01 |
Oral preparations for fluid and electrolyte imbalance |
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09.02.01.01 |
Oral potassium |
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Potassium chloride with potassium bicarbonate (Sando-K®)
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First Choice
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Effervescent tablets potassium 470 mg (12 mmol of K+) and chloride 285mg (8 mmol of Cl-)
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Potassium Chloride
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Second Choice
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m/r tablets 600mg (potassium 8 mmol)
Avoid unless effervescent tablets or liquid preparations inappropriate.
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Potassium Chloride oral liquid
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Second Choice
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Unlicensed potassium chloride oral solutions manufactured within the UK are available via Specials manufacturers, lead times vary.
Care is needed to ensure selection of the most appropriate oral potassium supplement and delivery of the correct dosage.
This National Patient Safety Alert provides further background, clinical information and actions for providers.
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CAS: UPDATE: Discontinuation of Kay-Cee-L (potassium chloride 375mg/ml) (potassium chloride 5mmol/5ml) syrup
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09.02.01.01 |
Potassium removal |
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Calcium polystyrene sulfonate (Calcium Resonium®)
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Formulary
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Powder for oral or rectal suspension 99.934% w/w calcium polystyrene sulfonate
In East Lancashire
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Patiromer calcium
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Formulary
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Oral powder sachets 8.4g, 16.8g
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NICE TA623: Patiromer for treating hyperkalaemia
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Sodium zirconium cyclosilicate
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Formulary
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Oral powder sachets 5g, 10g
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NICE TA599: Sodium zirconium cyclosilicate for treating hyperkalaemia
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09.02.01.02 |
Oral sodium and water |
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Sodium Chloride (Slow Sodium®)
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Formulary
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Modified release tablets 600mg (10mmol)
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Medicines for children: Sodium chloride for hyponatraemia (low levels of sodium in the blood)
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09.02.01.02 |
Oral rehydration therapy (ORT) |
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Oral Rehydration Salts
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Formulary
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Dioralyte® sachets ORS Hydration tablets
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LSCMMG: Over The Counter (OTC) Items That Should Not Be Routinely Prescribed In Primary Care Policy
Medicines for children: Oral rehydration salts
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09.02.01.03 |
Oral bicarbonate |
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Sodium Bicarbonate
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Formulary
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Capsules 500mg (approx 6 mmol each of Na+ and HCO3-)
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09.02.02 |
Parenteral preparations for fluid and electrolyte imbalance |
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09.02.02.01 |
Electrolytes and water |
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09.02.02.01 |
Intravenous sodium |
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09.02.02.01 |
Intravenous glucose |
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09.02.02.01 |
Intravenous potassium |
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09.02.02.01 |
Bicarbonate and lactate |
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09.02.02.01 |
Water |
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09.02.02.02 |
Plasma and plasma substitutes |
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09.02.02.02 |
Plasma substitutes |
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09.03 |
Intravenous nutrition |
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09.03 |
Supplementary preparations |
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09.04 |
Oral nutrition |
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09.04.01 |
Foods for special diets |
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09.04.02 |
Enteral nutrition |
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09.05 |
Minerals |
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09.05.01 |
Calcium and magnesium |
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09.05.01.01 |
Calcium supplements |
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Calcium Carbonate
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Formulary
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Chewable tablets calcium carbonate 1.25 g (calcium 500 mg or Ca2+ 12.5 mmol)
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Calcium carbonate with calcium lactate gluconate (Calvive 1000® Effervescent Tablets)
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Formulary
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Effervescent tablets calcium 1000mg (25mmol)
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Calcium Gluconate
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Formulary
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Injection 10% (calcium 2.25mmol/10mL)10mL amp Injection 10% 50mL vial
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MHRA: Calcium chloride, calcium gluconate: potential risk of underdosing with calcium gluconate in severe hyperkalaemia
MHRA: Calcium gluconate injection in small-volume glass containers: new contraindications due to aluminium exposure risk
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09.05.01.02 |
Hypercalcaemia and hypercalciuria |
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Cinacalcet
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Formulary
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Tablets 30mg, 60mg Consultant endocrinologist initiation only.
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NICE TA117: Cinacalcet for the treatment of secondary hyperparathyroidism in patients with end-stage renal disease on maintenance dialysis therapy
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Etelcalcetide (Parsabiv®)
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Formulary
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Injection
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NICE TA448: Etelcalcetide for treating secondary hyperparathyroidism
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09.05.01.03 |
Magnesium |
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Magnesium preparations may not be interchangeable due to differences in bioavailability, therefore caution should be exercised when switching preparations to ensure tolerability and to maintain therapeutic effect. |
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Magnesium Aspartate
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Formulary
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Oral powder sachets 10mmol
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Magnesium citrate
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Formulary
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Tablets 4mmol
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Magnesium Glycerophosphate
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Formulary
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Tablets 4mmol Oral solution 1mmol/1ml -Unlicensed
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NICE: Preventing recurrent hypomagnesaemia: oral magnesium glycerophosphate
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Magnesium Sulfate
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Formulary
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Injection 50% (magnesium 2mmol/mL)
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MHRA: Magnesium sulfate: risk of skeletal adverse effects in the neonate following prolonged or repeated use in pregnancy
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09.05.02 |
Phosphorus |
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09.05.02.01 |
Phosphate supplements |
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Phosphate oral (Phosphate-Sandoz®)
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First Choice
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Effervescent tablets sodium dihydrogen phosphate anhydrous (anhydrous sodium acid phosphate) 1.936 g, sodium bicarbonate 350 mg, potassium bicarbonate 315 mg, equivalent to phosphorus 500 mg (phosphate 16.1 mmol), sodium 468.8 mg (Na+ 20.4 mmol), potassium 123 mg (K+ 3.1 mmol)
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Phosphate infusion
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Formulary
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Intravenous infusion (phosphate 50mmol/500mL) 500mL
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09.05.02.02 |
Phosphate-binding agents |
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Calcium Acetate
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Formulary
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Phosex® tablets contain calcium acetate 1 g (equivalent to calcium 250 mg or Ca2+ 6.2 mmol). Renacet® tablets contain calcium acetate 475 mg (equivalent to calcium 120.25 mg or Ca2+ 3 mmol).
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Calcium acetate with magnesium carbonate (Osvaren®)
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Formulary
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Calcium acetate 435mg (equivalent to 110 mg calcium), Magnesium carbonate heavy 235mg (equivalent to 60 mg magnesium)
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Lanthanum
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Formulary
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Chewable tablets 500mg, 750mg, 1000mg
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Sevelamer Carbonate
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Formulary
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Tablets 800mg Oral powder sachets 2.4g
Caution when prescribing - Do not confuse with sevelamer hydrochloride 
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Switching patients from sevelamer hydrochloride (Renagel®) tablets to the generic sevelamer carbonate
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09.05.03 |
Fluoride |
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Sodium fluoride (Duraphat® (Toothpaste))
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Formulary
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Toothpaste 5000ppm (Duraphat®)
On the advice of a secondary care specialist, in patients who have had surgery, radiotherapy and/or chemotherapy, who are unable to access a primary care dentist.
Prophylaxis of dental caries. clinicians other than dentists working in primary care should not prescribe high strength fluoride toothpaste where dentists could reasonably treat the patient.
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LSCMMG: Fluoride High Strength Toothpastes: Position Statement
LSCMMG: Sodium fluoride toothpaste NMR
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09.05.04 |
Zinc |
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Zinc Sulfate
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Formulary
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Effervescent tablets 125mg
Zinc inhibits the absorption of copper, thereby reducing copper levels and potentially causing copper deficiency. The risk of copper deficiency is greater with higher doses of zinc and with long-term treatment, particularly if zinc deficiency is no longer present. Signs of copper deficiency include neurological and haematological symptoms.
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09.05.05 |
Selenium |
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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
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LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy
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09.06.04 |
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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09.07 |
Bitters and tonics |
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09.08 |
Metabolic disorders |
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Contact pharmacy for advice |
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09.08.01 |
Drugs used in metabolic disorders |
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Asfotase alfa (Strensiq® )
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Formulary

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Solution for injection
Tertiary Centre Only.
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NICE: Asfotase alfa for treating paediatric-onset hypophosphatasia
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Avalglucosidase alfa (Nexviadyme ®)
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Formulary

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Powder for concentrate for solution for infusion 100mg
Under expert supervision.
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NICE TA821: Avalglucosidase alfa for treating Pompe disease
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Eladocagene exuparvovec (Upstaza®)
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Formulary

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Solution for infusion 2.8 × 1011 vector genomes (vg)/0.5 mL
Tertiary Centre Only.
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Eplontersen (Wainzua®)
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Formulary

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Solution for injection 45 mg/0.8 ml
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NICE TA1020: Eplontersen for treating hereditary transthyretin-related amyloidosis
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Pegunigalsidase alfa (Elafbrio®)
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Formulary
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Concentrate for solution for infusion 20mg/10ml, 5mg/2.5ml
Under expert supervision.
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NICE TA915: Pegunigalsidase alfa for treating Fabry disease
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Vutrisiran (Amvuttra ®)
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Formulary

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Under expert supervision.
Females of childbearing potential should use effective contraception during treatment; if conception is planned, vutrisiran and vitamin A supplementation should be stopped and vitamin A levels monitored - consult product literature.
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NICE TA868: Vutrisiran for treating hereditary transthyretin-related amyloidosis
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09.08.01 |
Wilsons disease |
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Penicillamine
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Formulary
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Tablets 125mg, 250mg
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LSCMMG: Penicillamine shared care guideline
|
09.08.01 |
Carnitine deficiency |
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09.08.01 |
Fabry's disease |
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09.08.01 |
Gaucher's disease |
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09.08.01 |
Mucopolysaccharidosis I |
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09.08.01 |
Pompe disease |
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09.08.01 |
Nephropathic cystinosis |
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09.08.01 |
Urea cycle disorders |
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09.08.02 |
Acute porphyrias |
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09.08.02 |
Drugs unsafe for use in acute porphyrias |
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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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