Vitamin deficiency

Prescribing Notes:

• If vitamin K is required, Paravit-CF reduces the pill burden and may be more cost-effective than separate combinations.
• Vitamin A and D can be toxic in overdose. Levels are monitored once per year, compliance checked and dose adjusted at the cystic fibrosis clinic.
• The usual maximum recommended dose of vitamin A is 10,000 units daily. This dose should not be exceeded in pregnancy.
• The Vita-E 200iu capsules are blacklisted so funding will not be reimbursed where this is prescribed or supplied. The maximum recommended dose of 400 units daily should not be exceeded.
• Vitamin E levels are monitored once per year, compliance checked and dose adjusted at the cystic fibrosis clinic.
• DEKAs Plus will be used where patient has high pill burden but high dose vitamin K is not required e.g. if they do not have CF liver disease. The usual dose is 1 or 2 capsules or tablets per day.

Prescribing Notes:

• Recommendations for Vitamin B supplementation for alcohol dependence are available within the Alcohol dependence section of the formulary.
• Pyridoxine (vitamin B₆) deficiency may occur during isoniazid treatment or penicillamine treatment in Wilson’s disease and is characterised by peripheral neuritis.
• Vitamin B complex preparations are not recommended for prescribing.
• The safety of long-term use of pyridoxine in doses above 10mg daily has not been established. Long-term use of doses above 200mg has been associated with neuropathy.

Prescribing Notes:

Refer to local guidelines on re-feeding syndrome in each Board.

• NHS Lothian intranet – Prevention of re-feeding syndrome guidelines

Prescribing Notes:

• Divided doses are necessary due to the low renal threshold of ascorbic acid.
• Vitamin C (ascorbic acid) is indicated in the treatment of scurvy. Scurvy is rare but less severe deficiency may be seen, especially in the elderly. Dietary advice is usually sufficient for prevention of scurvy.

Prescribing Notes:

• Treatment of vitamin D deficiency should follow local guidelines. In NHS Lothian Adult Vitamin D guideline via the Edinburgh Centre for Endocrinology Handbook recommends treatment in a three level step-wise approach. In NHS Borders Vitamin D deficiency guidance (intranet) and in NHS Fife Vitamin D guidance.
• Colecalciferol is indicated in adults and elderly for prevention and treatment of vitamin D deficiency who require level 2 treatment. This means there is a biochemical insufficiency but the benefit of treatment is unclear.
• Patients requiring level 3 treatment should receive colecalciferol oral solution (InVitaD3). Level 3 treatment is where there is osteomalacia, there are clear treatment benefits.
• InVitaD3 is presented as single dose oral ampoules, the contents of the ampoule should be emptied directly into the mouth and swallowed, or emptied on to a spoon and taken orally.
• Some colecalciferol tablets are dispersible which may aid administration and avoid need for liquid formulations.
• For prevention of vitamin d deficiency in the general population refer to Scottish Government vitamin D advice for all age groups.
• Do not routinely screen or test for vitamin D deficiency. Limit testing to patients showing clinical signs of vitamin D deficiency such as bone pain with muscle weakness or generalised muscular pain. Also consider testing those with bone diseases that may be improved with vitamin D treatment or to correct vitamin D prior to treatment with potent therapies for osteoporosis. For further information refer to the Royal Osteoporosis Society.
• Vitamin D supplements should only be prescribed for clinical need e.g. osteomalacia. For all other situations, patients should purchase an over-the-counter preparation.

Prescribing Notes:

• Treatment of vitamin D deficiency should follow local guidelines. In NHS Lothian Adult Vitamin D guideline via the Edinburgh Centre for Endocrinology Handbook recommends treatment in a three level step-wise approach. In NHS Borders Vitamin D deficiency guidance (intranet) and in NHS Fife Vitamin D guidance.
• Patients with severe renal impairment requiring vitamin D therapy should be prescribed alfacalcidol. Note One-Alpha capsules contain sesame oil. Check summary of product characteristics for excipients of generic products.
• For prevention of vitamin D deficiency in the general population refer to Scottish Government vitamin D advice for all age groups.
• Do not routinely screen or test for vitamin D deficiency. Limit testing to patients showing clinical signs of vitamin D deficiency such as bone pain with muscle weakness or generalised muscular pain. Also consider testing those with bone diseases that may be improved with vitamin D treatment or to correct vitamin D prior to treatment with potent therapies for osteoporosis. For further information refer to the Royal Osteoporosis Society.

Prescribing Notes:

• Accrete D3 One a day tablets may be prescribed for osteoporosis. See recommendations for the treatment of osteoporosis.
• Combination calcium and vitamin D products may be ineffective in moderate-severe renal disease; alfacalcidol may be a suitable alternative; see Vitamin D pathway above.
• Compliance with calcium and vitamin D preparations is often poor due to the unpleasant taste. This should be monitored and, if patients cannot tolerate the first choice LJF preparation, other products with the same calcium and vitamin D dose may be tried.
• Adcal D3 is available is several formulations e.g. caplets, chewable tablets, effervescent tablets. Caplets can be swallowed whole and are preferred but the formulation prescribed should be done in agreement with the patient to aid compliance.
  
  

Prescribing Notes:

• Used in non-alcoholic fatty liver disease in non-diabetetic and pre-cirrhotic patients.

Prescribing Notes:

• Menadiol sodium phosphate should be avoided in late pregnancy and labour unless benefit outweighs the risk of neonatal haemolytic anaemia, hyperbilirubinaemia and kerniticterus in neonate.
• See Anticoagulation for Atrial Fibrillation pathway in the Cardiovascular system chapter of the formulary for use of phytomenadione to reverse the effects of warfarin.
• Menadiol sodium phosphate is water-soluble and should be used to prevent vitamin K deficiency in malabsorption syndromes.
• Phytomenadione is a fat-soluble formulation used to prevent vitamin K deficiency bleeding in newborn babies, to reverse the anticoagulant effects of warfarin, in coagulopathy associated with liver disease and also to treat cystic fibrosis related liver disease.

Prescribing Notes:

• Zinc supplements should only be given in proven zinc deficiency and zinc-losing conditions such as burns.

Prescribing Notes:

• Forceval should be used as vitamin and mineral supplementation in complex patients with conditions causing malabsorption on the advice of dieticians. This shouldn’t be used where a general multi vitamin is required – if a general multi vitamin is required, they should be purchased over the counter.
• Specialist initiation for maldigestion following oesophagogastric surgery and micronutrient replacement in patients undergoing bariatric surgery.

Prescribing Notes:

• Renavit is a specific multivitamin preparation for use in dietary management of water-soluble vitamin deficiency in renal failure patients receiving dialysis. It is classed as a food for special medical purposes as approved by ACBS (Advisory Committee on Borderline Substances).

Prescribing 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.
• There are certain patient groups who require various vitamin supplementation including several metabolic and liver disorders.

Prescribing Notes:

• Oral solution should be given with or after food.

Prescribing Notes:

• Vitamin B deficiency, other than B₁₂, is rare. See megaloblastic anaemia recommendations.
• Pyridoxine (vitamin B₆) deficiency may occur during isoniazid treatment.
• Oral vitamin B₁₂ is only prescribable to treat or prevent Vitamin B₁₂ deficiency in a vegan patient or patient who has a proven deficiency of dietary origin. Prescriptions should be endorsed “SLS”.

Prescribing Notes:

• Ascorbic acid is used in certain metabolic disorders.

Prescribing Notes:

• High risk groups for Vitamin D deficiency are:
  • Northern UK abode.
  • Poor or 'faddy' eaters.
  • Restricted diet without meat or dairy products or exclusion diets.
  • Ethnic groups who have restricted diet for cultural or religious reasons.
  • Dark skin.
• Primary source of vitamin D is from sunlight, the amount of ultraviolet exposure depends on many factors not just time spent outdoors: skin pigmentation, latitude, season, air pollution and body mass. Much of the UK, but all of Scotland, is at a latitude such that there is no UV light of the appropriate wavelength during the winter months for adequate vitamin D production.
• Vitamin D supplementation is recommended for everyone in the UK particularly during the winter months (October - March). See Scottish Government Vitamin D recommendation for new parents 2017.
• The Scottish Government recommend that “Babies who are formula fed and having at least 500ml/day do not require vitamin D supplements as the formula milk will provide the required amount of vitamin D”. However it is the view of local public health specialists that the combined amount of vitamins from formula milk and the recommended dose of healthy start vitamins are within safe limits. This recommendation is consistent with the advice given in Lothian since April 2016.
• In NHS Lothian it is recommended that both formula fed and breastfed babies from birth up to one year of age should receive a vitamin D supplement beginning within the first two weeks of birth. Healthy Start vitamins drops are recommended. Some children age less than 4 years may be eligible for free vitamin supplements.
• More information on Healthy Start is available on the NHS Lothian intranet.
• From October 2018 a new vitamin preparation containing the recommended dose of 8.5 - 10 micrograms vitamin D will be available.
• Patients with severe renal and liver impairment requiring vitamin D therapy should be prescribed alfacalcidol. Alfacalcidol is not appropriate treatment for standard vitamin D deficiency. Alfacalcidol replaces the active form of vitamin D, it does not boost body stores.
• Alfacalcidol is also used in different doses for hypoparathyroidism and pseudohypoparathyroidism; see Parathyroid disease recommendations.
• Standard combination preparations of vitamins A and D may not be sufficient for cystic fibrosis patients. For patients requiring additional vitamin D supplementation, colecalciferol 800unit tablets can be used; the tablets can be crushed for those patients who cannot swallow whole tablets. CF patients with renal and liver impairment should receive a trial of daily alfacalcidol.
• Various products are available for children requiring vitamin D treatment and/or supplementation and should be chosen according to the child’s age and ability to take medicines. For further information see Vitamin D deficiency in Children and Young People.
• InVitaD3 oral solution 25000units/1ml 1ml single dose oral ampoule; the contents of the ampoule should be emptied directly into the mouth and swallowed, or emptied on to a spoon and taken orally. It can also be mixed with a small amount of children’s foods, yoghurt or milk. It should not be mixed into a bottle of milk or a whole container of food in case the child does not consume the whole portion.

Prescribing Notes:

• Calcichew-D3 Forte chewable tablets may be prescribed for osteoporosis.
• Calcichew-D3 Forte chewable tablets may be ineffective in moderate-severe renal disease; alfacalcidol may be a suitable alternative; see above.
• Select an appropriate preparation and dose according to the child’s age, ability to take the medication and individual calcium and vitamin D requirements.
• Compliance with calcium and vitamin D preparations is often poor due to the unpleasant taste. This should be monitored and, if patients cannot tolerate the first choice LJF preparation, other products which contain an appropriate dose of calcium and vitamin D may be tried.
• Calfovit D3 is a suitable second choice for patients with compliance problems or unable to chew tablets.

Prescribing Notes:

• 100mg of suspension is equivalent to 100 units Vitamin E, 50mg gel capsule is equivalent to 75 units Vitamin E.

Prescribing Notes:

• NHS Lothian Neonatal Services recommend that infants less than 35 weeks gestation or 1.8kg at birth should continue a vitamin supplement containing vitamin D from the time of discharge until the age of 5 years.
• Infants receiving breast milk fortifier do not require Abidec or Dalivit.
• If Abidec is not available neonates and infants less than 35 weeks gestation or 1.8kg at birth or with CF age 1 month to 1 year may be prescribed Dalivit 0.6ml daily in order to deliver an equivalent dose of vitamin D. The daily vitamin A dose in 0.6ml of Dalivit is higher than routinely required for this age group.
• For more information on multivitamins for premature and low birth weight infants see the NHS Lothian Neonatal Services Clinical Guidelines.
• The BNF dose of 0.3ml Abidec or Dalavit for neonates and children 1-11 months does not provide the recommended dose of 8.5-10micrograms vitamin D. For the prevention and treatment of vitamin deficiency in children with long-term conditions other than CF or a history of prematurity the appropriate vitamin preparation(s) and dose should be selected based on the patient’s individual requirements.
• See the child Vitamin D deficiency pathway above for prescribing notes on Healthy Start vitamins, which are the recommended multivitamin for all children in health.

Prescribing Notes:

• In cystic fibrosis the choice of multivitamin will depend on the patient’s pancreatic status. Additional vitamin D supplementation may be required in some individuals.