nhs forth valley formulary 11 - Community Pharmacy

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Forth Valley Formulary Eleventh Edition 2012/13Appendix 26FORTH VALLEY ACUTE HOSPITALSPRESCRIBING GUIDELINES PHARMACY DEPARTMENTHYPOPHOSPHATAEMIA in ADULTSRisk factors for hypophosphataemia include critical illness, a period of starvation prior to nutritional support,malnutrition, alcoholism, and respiratory alkalosis.Phosphate supplementation should be considered where there is evidence of phosphate deficiency. Serumphosphate does not always correlate to total body stores as most phosphate is stored intracellularly. Theonset and severity of symptoms will determine the need for and type of treatmentDrug Presentation:Addiphos® 20ml vial containing : phosphate 40 mmol (2mmol phosphate /ml)potassium 30 mmoland sodium 30 mmolNo other drugs should be added to a phosphate infusion.No other drugs should be co administered at a Y site with phosphate.Caution should be used if the patient has renal impairment.Mild to moderate deficiency : usually associated with levels of 0.3-0.6mmol/l and is usuallyasymptomaticSevere deficiency:usually associated with levels less than 0.3mmol/l, especially ifsymptomatic.Drugs and AdministrationINTRAVENOUS:In acute deficiency, or when a clinical difference to serum phosphate needs to be assuredquickly.• 20mmols phosphate (10mls Addiphos) over 6 hours in 100mls 0.9% N Saline through a central line, or20mmols phosphate (10mls Addiphos) in 500mls 0.9% N Saline over12 hours through a peripheral line.• In cases where the hypophosphataemia is symptomatic, or if prolonged phosphate wastage hasoccurred, then the dosage may be repeated within 12 hours and a level obtained several hours afterthe end of the infusionOral – see notes on diarrhoea before contemplating oral replacement• 1-2 Phosphate Sandoz ® tablets (see BNF) three times a day (provides 48 - 96mmol phosphate, 60-120mmol sodium and 9-18mmol potassium per day)• Continued therapy may be required depending on clinical response/adverse effects.• Oral phosphate is slow to effect and should be used in slow-losers of phosphate only, and not when arapid response is required.Page 98
Forth Valley Formulary Eleventh Edition 2012/13Appendix 26Important side effects²HyperphosphataemiaSymptoms may be those of resultant hypocalcaemianamely, muscle cramps, tetany and convulsion andmetastatic calcification.HyperkalaemiaHypernatraemiaandAs a result of infusion of these elements along withphosphateHyperphosphataemiaHypotensionHypocalcaemiaHigh dose rapid infusions of phosphate.Excessive doses of phosphates may causehypocalcaemia and metastatic calcification; it isessential to monitor closely plasma concentrations ofcalcium, phosphate, potassium and other electrolytes.Treatment of adverse effects involves withdrawal ofphosphate infusion, general supportive measures andcorrection of serum electrolyte concentrations,especially calcium.Diarrhoea with oraltherapyOral phosphate is poorly absorbed from the gut andmay cause diarrhoea, with the potential to exacerbatelosses of Magnesium, Sodium, Potassium and water..PrecautionsIn renal impairment, Addisons disease and where restricted sodium or potassium intake is required e.g..cardiac failure, hypertension, hyperkalaemia, severe oedema. Care should be taken when replacingphosphate to minimise electrolyte disturbances and the biochemist should be contacted for advice.MonitoringBlood pressure monitoring is advisedCalcium, magnesium, phosphate, potassium and other electrolyte monitoring is essential. Phosphate levelsshould be checked at least 6 hours after the end of the infusion 3AcknowledgementsJane SillarsMark HollidaySenior DietitianConsultant BiochemistReferences June 2012-1. Walmsley RN, Guerin MD. Disorders of fluid and electrolyte balance. Bristol 1984. Wrightpublishing2. Thatte L, Oster J et al. Review of literature: Severe Hyperphosphataemia. Am J Med Sciences1995; 310(4):167-1743. Bugg NC, Jones A Hypophosphataemia. Anaesthesia 1998;53:895-902Note: June 2012 This guideline is currently under reviewPharmacist Lead: Peter BucknerPage 99
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