Greater Glasgow and Clyde Medicines

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Key Messages

• The GGC Adult Vancomycin Intermittent Infusion guideline and Prescribing, Administration and Monitoring chart (Vanc-PAM) have been updated.
• The GGC Adult Vancomycin dose calculator has been updated to use adjusted body weight (AdjBW) to calculate the creatinine clearance (CrCl) in patients weighing above their ideal body weight (IBW).

Prescribers should ensure that the Patient Information Leaflet (PIL) (attached to the PAM chart) is issued to the patient/carer as soon as possible. The gentamicin PIL now asks patients to report any pre-existing issues with hearing or balance as well as personal or familial history of mitochondrial disease and any previous hearing or balance issues relating to antibiotics.

Key messages:

• The GGC Creatinine Clearance (CrCl) calculator will now use Adjusted Body Weight (AdjBW) rather than Maximum Body Weight (MBW) to estimate renal function for patients who weigh more than their Ideal Body Weight (IBW).

• AdjBW provides a better estimate of renal function for patients who are overweight or obese.

• AdjBW is IBW plus 40% of the difference between ideal and actual body weight.

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The Emergency Care Summary (ECS) for patients with a diagnosis of schizophrenia may show no record of any antipsychotic prescription; this may indicate they are prescribed a specialist medicine such as clozapine or an antipsychotic depot.

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• Serum ferritin (SF) is the most useful test for iron deficiency.
• Serum iron, transferrin levels and transferrin saturation (TSAT) are labile measurements and not reliable indicators of low iron stores. Their role should be limited to investigation of high SF values and possible iron overload.
• Low SF (<15micrograms/L) provides absolute evidence of iron deficiency.
• Ferritin levels can be elevated by inflammatory processes and can mask iron deficiency.
• SF >100micrograms/L generally rules out IDA even in the presence of inflammatory disease.
• If SF results are equivocal, practitioners should consider monitoring the haemoglobin (Hb) concentration in response to a trial of oral iron.

• Patients diagnosed with clinically significant IDA should have iron replacement therapy to correct anaemia and replenish iron stores.
• Treatment should normally be conducted in parallel with investigations to determine the underlying cause. However, for some patients such as those with complex multi-morbidity or approaching end of life, such investigations may not be appropriate.
• Oral iron is the first line treatment of choice*.
• Prescribe ferrous fumarate 210mg or ferrous sulfate 200mg once a day as initial therapy (see below for information on dosing).
• Oral iron therapy should be continued for 3 months after haemoglobin (Hb) optimised and then stopped (consider ongoing prophylaxis in at risk patients).
• The irritant adverse effects of oral iron are related to the amount of elemental iron taken rather than the type of preparation.
• Iron preparations with a low content of elemental iron must be tried (with food) before acceptance of genuine intolerance to oral iron.

 * see inclusion criteria for IV iron therapy in full guideline, including use as first line agent in certain clinical settings.

IV iron:

• Should be reserved as a second line treatment choice in the management of IDA.*
• Does not produce a faster Hb response than oral iron (provided that the oral iron preparation is taken reliably and is absorbed adequately).
• Can cause hypersensitivity reactions which may be life-threatening or fatal (only administer during working hours when adequate supervision is available).
• Paravenous leakage may lead to permanent staining at the site of infusion.

 * see inclusion criteria for IV iron therapy in full guideline, including use as first line agent in certain clinical settings.