NHS England (NHSE) has published new prescribing guidance for items of limited clinical effectiveness that should not be routinely prescribed in primary care (quick reference guide). This included vitamins and minerals, unless there is a medically diagnosed deficiency, or when using calcium and vitamin D for osteoporosis, or for treating malnutrition including alcoholism. The guidance also excludes patients suitable to receive Healthy Start vitamins.

Many vitamin products are cheap to buy and are readily available over the counter along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

9.5.1.1 Calcium supplements

Patients should be encouraged to increase their dietary intake of calcium. Calcium supplements are usually only required where dietary calcium intake is deficient. Patients with coeliac disease are at increased risk of osteoporosis due to malabsorption of calcium, weight loss and low BMI. With a good response to a gluten free diet, bone mineral density increases. However, many coeliacs require supplementary calcium (see section 9.6 Vitamins)

Approximately 700mg of calcium is required per day. In osteoporosis, double the recommended daily amount reduces the risk of bone loss. For specific advice on the use of calcium in treatment and prophylaxis of osteoporosis see Chapter 6 section 6.6 Drugs affecting bone metabolism.

Calcium and vitamin D combination products are included in section 9.6.4 Vitamin D

Calcium carbonate

• Chewable tablets 1.5g (click here for preferred brands)
• Chewable tablets 1.25g, 2.5g (click here for preferred brands)

Indications

• Calcium deficiency
• Hyperphosphataemia (specialist)

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Calvive 1000

(Calcium carbonate with calcium lactate gluconate)

• Effervescent tablets 1000mg (£13.17 = one daily)

Indications

• Calcium deficiency

Notes

1. Each effervescent tablet contains 2,263mg of calcium lactate gluconate and 1,750mg of calcium carbonate (equivalent to 1000mg or 25mmol of calcium)
2. Formerly known as Sandocal 1000 Tablets

Calcium gluconate 10%

• 10ml ampoule
• Infusion 50ml

Notes

1. National Patient Safety Alert (27 June 2023): Potential risk of underdosing with calcium gluconate in severe hyperkalaemia
2. MHRA Drug Safety Update (June 2023): Calcium chloride, calcium gluconate: potential risk of underdosing with calcium gluconate in severe hyperkalaemia

Calcium chloride 10%

• Min-I-jet 10ml

Notes

1. National Patient Safety Alert (27 June 2023): Potential risk of underdosing with calcium gluconate in severe hyperkalaemia
2. MHRA Drug Safety Update (June 2023): Calcium chloride, calcium gluconate: potential risk of underdosing with calcium gluconate in severe hyperkalaemia

9.5.1.2 Hypercalcaemia and hypercalciuria

Bisphosphonates are usually used in the treatment of Hypercalaemia of Malignancy. Refer to section 6.6.2 Bisphosphonates and other drugs affecting bone metabolism

Cinacalcet

• Tablets 30mg, 60mg, 90mg (£25.53 = 60mg daily)

Notes

1. West Devon: refer to individual shared care guidelines
2. NICE TA117: Cinacalcet for the treatment of secondary hyperparathyroidism in patients with end-stage renal disease on maintenance dialysis therapy (January 2007):
   1. Cinacalcet is not recommended for the routine treatment of secondary hyperparathyroidism in patients with end-stage renal disease on maintenance dialysis therapy.
   2. Cinacalcet is recommended for the treatment of refractory secondary hyperparathyroidism in patients with end-stage renal disease (including those with calciphylaxis) only in those:
      1. who have 'very uncontrolled' plasma levels of intact parathyroid hormone (defined as greater than 85 pmol/litre [800 pg/ml]) that are refractory to standard therapy, and a normal or high adjusted serum calcium level, and
      2. in whom surgical parathyroidectomy is contraindicated, in that the risks of surgery are considered to outweigh the benefits.
   3. Refer to TA117 for treatment continuation criteria and other considerations.
3. NHS England (NHSE) will commission cinacalcet for complex primary hyperparathyroidism in adults (see NHSE Commissioning Policy for more details).

Etelcalcetide

• 5mg/ml solution for injection 0.5ml, 1ml, 2ml vial

Notes

1. NICE TA448: Etelcalcetide for treating secondary hyperparathyroidism (June 2017)

9.5.1.3 Magnesium

Magnaspartate and Neomag are licensed for treatment and prevention of magnesium deficiency. When Magnaspartate is not suitable/appropriate; Neomag may be considered as an alternative, for those patients who cannot tolerate high sugar content, or prefer a tablet formulation as opposed to drinking a solution.

No new patients should commence treatment with the unlicensed preparations.

Magnaspartate

(Magnesium aspartate dihydrate)

• Oral powder sachets (£9.45 = 10 sachets)

Indication

• treatment and prevention of magnesium deficiency

Notes

1. Renal patients: contraindicated in patients with severe renal impairment (eGFR less than 30); no dose adjustment necessary in mild to moderate renal impairment
2. Each 6.5g sachet of powder contains 243mg (10mmol) magnesium
3. Please be aware of the high sugar content, each sachet contains 2.706g sucrose

Neomag

(Magnesium glycerophosphate)

• Chewable tablets 4mmol (£22.77 = 50 chewable tablets)

Indication

• Treatment of chronic magnesium loss or hypomagnesaemia

Notes

1. Renal patients: contraindicated in patients with severe renal impairment; no dose adjustment necessary in mild to moderate renal impairment
2. Each chewable tablet contains 97mg (4mmol) magnesium
3. Tablets may be broken into quarters and chewed or swallowed with water
4. Neomag is not recommended for use in children under 4 years of age

Magnesium sulfate

• Injection 50% (approximately 2mmol magnesium per mL)
• Injection 1g in 10ml (10% W/V) – used in University Hospitals Plymouth NHS Trust

Notes

1. Magnesium sulfate may be used to treat pre-eclamptic arrhythmias
2. MHRA Drug Safety Update (May 2019): Magnesium sulfate: risk of skeletal adverse effects in the neonate following prolonged or repeated use in pregnancy