|Therapeutic Area||Formulary Choices||Cost for 28|
(unless otherwise stated)
|Rationale for decision / comments|
|Multivitamins which are considered for supplementation as an alternative to healthy diet should be considered a self-care issue.|
|Vitamin B||Vitamin B supplements should be considered as self-care except in disease related deficiency such as alcoholic liver disease.|
|Vitamin B compound strong||Tablets £1.51||Note that standard strength Vitamin B compound tablets are expensive at £26.63 for 28|
|Vitamin D PAMM approves prescribing of vitamin D for patients with active disease eg rickets or osteomalacia in the acute phase with patients then being advised to self-care with daily vitamin D supplements.
Public Health England issued advice in July 2016 on Vitamin D supplementation suggesting that some people may become deficient when exposure to sunlight is reduced between September and late March/early April.
PAMM recommends that Vit D prescribing is reviewed and deprescribing takes place when at maintenance dose for patients (including care home residents) who should be given advice to self-care.
1) Vitamins (including vitamin D) fall under the CCG self-care and patient activation guidance, it is primarily not a prescribing issue.
2) Self-care and patient activation does apply to residents in care homes
3) Vitamin D supplements cost ~1p per day to buy
4) Any patients prescribed a bisphosphonate/denosumab and just plain Vit D should have it switched to formulary calcium and D3 (unless when contraindicated when prescribing of plain vitamin D can continue)
5) Patients prescribed Sip feeds probably do not require additional Vit D as most contain more than the daily requirement eg Fresubin powder contains 5mcg per serving.
Please prescribe by brand to avoid unlicensed products being supplied
|800IU capsules: £2.34 (30)|
|as Fultium D3®||800IU capsules: £3.60 (30)|
|as Desunin®||800IU tablets: £ 3.60 (30)||Tablet version of colecalciferol – included for option to capsules which may be crushed for patients wih swallowing problems.
Dose equivalent to 20microgram vitamin D3
|as Fultium D3®||2740IU/ml oral drops £10.70 (25ml)|
3200IU capsules £13.32 (30)
20000IU capsules £17.04(15)
|Fultium D3 3200IU is included in formulary for Vitamin D deficiency in adults and the elderly (serum levels <25 nmol/l (<10 ng/ml)) for up to 12 weeks. For higher doses see below.
Treatment, 40,000iu weekly for 7 weeks, preferably with food, then reduce to maintenance dose equiv to 1400—2000iu/day (2—3 caps per month).
Prevention, 20,000iu every 4 weeks.
|as Avitcol®||20000IU capsules £29.00 (30)|
|as Stexerol-D3®||25000IU tablets £17.00 (12) and 1000IU tablets £2.95 (28)||Approved by PAMM Jan 16|
|as InVita D3®||2400IU/ml oral drops £3.60 (10ml)|
25,000IU Oral solution 3x1ml ampoule: £4.45
|Agreed as an option when recommended and initiated by a consultant|
|High dose unlicensed Vitamin D (e.g. 20,000IU Dekristol® Capsules) remain non-formulary.
Higher doses may be necessary for severe deficiency.If recommended by secondary care there is an agreement that they will be responsible for supplying the supplement for its whole duration (i.e. considered RED under the TLG)and primary care should not be asked to prescribe.
When concordance is an issue there should be no restriction of choice
|Vitamin D supplements with Calcium||Calcium and vitamin D should be considered as an intervention to reduce fracture risk for all women over 75 years.|
|Calcium and Vitamin D:||Calcium & Ergocalciferol tablets BP are non formulary as they provide an inadequate dosage for most patients.|
|Although the formulary only highlights first line cost effective calcium and colecalciferol preparations, all other licensed makes remain on formulary as options where the patient has specific taste or other formulation preferences which would increase patient concordance compared to the first line options.|
|First-line:||TheiCal D3® chewable tablets|
|£2.95 (30 tablets)||Once daily dose with or without food
|Accrete D3® 600mg/400IU||Tablets: £2.95 (60)||Twice daily dosage|
|Adcal D3® 300mg/200IU caplets||Tablets: £2.95 (112)||Take two caplets twice daily|
|Evacal D3® chewable tablets 600mg/400IU||Tablets: £5.84 (112)||Twice daily dosage|
|Calci-D® chewable tablets 1000mg/1000IU||Tablets: £2.25 (28)||Once daily dosage|
|Vitamin K1||Phytomenadione||10mg/ml ampoule: £3.78 (10)|
2mg/0.2ml ampoule: £4.71 (5)
|For use in the management of haemorrhage due to Warfarin, cross refer to anticoagulant section of formulary.|
|MultiVitamin Preparations||Dialyvit®||Approved at May-12 Prescribing Forum only for patients receiving renal dialysis.
Unlicensed in UK – order supplies from USA
|Renavit®||Tablets: £12.50 (100)||Preparation of Vitamins B1, B2, B6, B12, C, Biotin, Folic acid, Nicotinamide, and Pathothenic acid.
Approved at Nov-13 Prescribing Forum only for patients receiving renal dialysis.
|Vitamin E||Secondary or tertiary centres may recommend the use of vitamin E for children or adults with advanced liver fibrosis,taking into consideration any comorbidities. Offer to retest people after two years to assess whether treatment has been effective. If a patient's ELF test score has risen (adults or children) stop Vitamin D. NICE NG49 July 2016
“Valupak” Vitamin E Capsules 100iu and 400iu are a cost effective formulation with fixed NHS prices. Use these where possible–. Cost approx. 2p per capsule Liquid- Alpha tocopheryl acetate 500mg in 5ml oral suspension - Licensed but costs £53 per 100ml. Please avoid if possible.
Chewable tablets 100mg (Ephynal chewable tablets) are unlicensed and imported so are therefore expensive. Cost approx. £3 per tablet or more depending on the import process. Please avoid if possible