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9.1 Anaemias

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

1. Anaemias

1.1 Hypoplastic, haemolytic, and renal anaemias

 

Epoetins

 

NICE recommendations:

Use as per NICE TA 142: Epoetin alfa, beta and darbepoetin alfa for cancer treatment-induced anaemia (May 2008)

Use as per NICE TA 323: Erythropoiesis stimulating agents (epoetin and darbepoetin) for treating anaemia in people with cancer having chemotherapy (including review of TA 142) (November 2014)

 

Darbepoetin alfa (Amber 3)

  • Aranesp® Injection, prefilled syringes - 10, 20, 30, 40, 50, 60, 80, 100, 130, 150, 300, 500 micrograms
  • Aranesp® Injection, SureClick prefilled disposable pens 20, 40, 60, 80, 100, 150, 300, 500 micrograms       

 

Epoetin alfa

  • Eprex® Injection, prefilled syringes - 1000, 2000, 3000, 4000, 5000, 6000, 8000, 10 000,    20 000, 30 000, 40 000 units
  • Eprex® [3] Eprex can be prescribed by GPs after consultant initiation and stabilisation. However, renal patients remain under hospital prescribing and Eprex should NOT be prescribed by their GP

 

 

Epoetin beta  

  • NeoRecormon® Injection, prefilled syringes – 500, 2000, 3000, 4000, 5000, 6000, 10 000,  20 000, 30 000 units  

 

      

 

1.2 Iron deficiency anaemia

 

Iron (oral)

Warning – Iron tablets may be attractive to children and patients should be warned to store their iron tablets carefully to avoid accidental iron poisoning.

Notes:  

  • Patients should be advised to continue taking iron for 3 months after recovery of haemoglobin to allow replenishment of iron stores.
  • Maximum absorption of iron occurs with TDS dosing. Once or twice a day dosing of iron preparations may be effective for prophylaxis or mild iron deficiency.
  • Modified release preparations have not been included because they are likely to carry the iron past the first part of the duodenum into an area of the gut where conditions for iron absorption are poor. The low incidence of side effects may well be because of the small amounts of iron available under these conditions. The BNF recommends that these preparations have no therapeutic advantage and should not be used.
  • Pregaday®has not been included. It contains 350 microgram of folic acid, less than the 400 micrograms recommended for the prevention of neural tube defects in women planning a pregnancy and is inadequate for the treatment of megaloblastic anaemia.
  • A low Hb in pregnancy does not mean anaemia and iron should only be prescribed if the MCV and ferritin are low. 

 

Ferrous fumarate

  • Tablets 210mg (equivalent to 68mg ferrous iron per tablet) 
  • Syrup 140mg/5mL (equivalent to 45mg ferrous iron per 5mL)

 

Ferrous sulphate

  • Tablets 200mg (equivalent to 65mg ferrous iron per tablet)       

Note: Iron preparations differ in their iron content. As gastro-intestinal side effects are related to the iron content there is a lower incidence of side effects with preparations containing less iron.

 

Sodium feredetate (Sytron®)

  • ElixirSF 190mg in 5mL (equivalent to 27.5mg of ferrous iron per 5mL)

Note: Sodium feredetate is included as the liquid form of iron.   

 

Polysaccharide-iron complex (Niferex®) SLS

  • Elixir (equivalent to approximately 500 micrograms of ferrous iron per drop) - 30mL dropper bottle only.       

Note: 

  • Under part XVIIIB of the Drug Tariff, Niferex® can only be prescribed on FP10s to infants born prematurely for prophylaxis in treatment of iron deficiency.

 

 

  • Such prescriptions must be endorsed SLS.

 

 

Ferric Maltol

  • Feraccru® Capsules 30mg

Notes:

  • Place in therapy: second line for iron deficiency anaemia in adult with mild to moderate IBD who have failed 2 oral ferrous products.

 

  • To be considered prior to administration of IV options

 

  • Usual duration - 12 weeks

 

 

 

 

Iron (Parenteral)

    

Important Safety Information

MHRA/CHM advice: Serious hypersensitivity reactions with intravenous iron (August 2013)

Serious hypersensitivity reactions, including life-threatening and fatal anaphylactic reactions, have been reported in patients receiving intravenous iron. These reactions can occur even when a previous administration has been tolerated (including a negative test dose). Test doses are no longer recommended and caution is needed with every dose of intravenous iron.

Intravenous iron products should only be administered when appropriately trained staff and resuscitation facilities are immediately available; patients should be closely monitored for signs of hypersensitivity during and for at least 30 minutes after every administration. In the event of a hypersensitivity reaction, treatment should be stopped immediately and appropriate management initiated.

The risk of hypersensitivity is increased in patients with known allergies, immune or inflammatory conditions, or those with a history of severe asthma, eczema, or other atopic allergy; in these patients, intravenous iron should only be used if the benefits outweigh the risks.

Intravenous iron should be avoided in the first trimester of pregnancy and used in the second or third trimesters only if the benefit outweighs the potential risks for both mother and fetus

 

Ferric carboxymaltose (Ferinject®)

  • Injection 50mg/mL

Iron dextran (Cosmofer®)

  • Injection 50mg/mL

Iron sucrose (Venofer®)

  • Injection 20mg/mL        

    

 

1.3 Megaloblastic anaemia

 

 

 

Folic acid

  • Tablets 5mg
  • Tablets 400 microgram  
  • SyrupSF2.5mg in 5mL
  • SyrupSF 400 microgram in 5mL 
  • Folic Acid – injection 15mg/mL  U  

 

Note: 

  • Care should be taken in giving folic acid on its own in megalobastic anaemia. Patients given folic acid alone must have a proven high/normal B12 level before folic acid is started or else both must be given jointly until the level has come back, if there is urgency in starting treatment.

 

  • A ferritin level should also be done before treatment is given and one month after starting in case there is an occult iron deficiency which may become evident after B12 and folate replacement.

 

 

Hydroxocobalamin

  • Injection 1mg/mL 

 

Cyanocobalamin   SLS

  • Tablets 50 micrograms

Notes:

Hydroxocobalamin has completely replaced cyanocobalamin as the form of vitamin B12 of choice for therapy; it is retained in the body longer than cyanocobalamin and thus for maintenance therapy can be given at intervals of up to 3 months.

Neo-Cytamen®injection is blacklisted and prescriptions must be written for generic hydroxocobalamin to be allowable on FP10 prescription.

Folinic acid tablets (calcium folinate), used to counteract the folate-antagonistic action of methotrexate

 

       

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Return to Chapter: 9. Nutrition and Blood

Last updated by: Dupe Fagbenro on 12-03-2019 19:46