Prescribing Guidance for Vitamins and Minerals in Primary Care
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Prescribing Guidance for Vitamins and
Minerals in Primary Care
Vitamins and Minerals Prescribing Guidance
V1.0 Approved November 2020
Review date: November 2022Review and Amendment Log / Version Control
Clinical Lead: Dr Shane Beggan, Medicines Optimisation Clinical Lead
Author: Susan Sheridan, Prescribing Support Dietitian, Medicines Optimisation
Team, NHS Bradford District and Craven Clinical Commissioning Group
(CCG) / Bradford Teaching Hospitals NHS Foundation Trust (BTHFT)
Date Approved: November 2020
Approving Body: Joint Formulary Group
Version: 1.0
Review Date: November 2022
Version History
V no. Date Author Description Circulation
Tracey Gaston, Claire
0.1 July 2020 Susan Sheridan Initial draft
Kilburn
0.2 27/08/2020 Susan Sheridan Comments: DH, AM, MS, IH secondary care
representatives
0.3 14/09/2020 Susan Sheridan Amendments following Joint Joint Formulary Group
Formulary Group meeting on
09/09/2020.
1.0 10/11/2020 As above Version approved by Joint CCG wide
Formulary Group
Vitamins and Minerals Prescribing Guidance
V1.0 Approved November 2020
Review date: November 2022Prescribing Guidance for Vitamins and Minerals in Primary Care
In line with NHS England’s guidance on conditions for which over-the-counter items should not be routinely
prescribed Bradford District and Craven CCG does not support the routine prescribing of vitamins and minerals on
prescription unless indicated for actual vitamin or mineral deficiency. Vitamins and minerals should not be prescribed
as a ‘general pick-me-up’ or as a dietary supplement.
Exceptions:
Medically diagnosed deficiency, including for those patients who may have a lifelong or chronic condition or
have undergone surgery that results in malabsorption. Continuing need should be reviewed on a regular
basis (NB maintenance or preventative treatment is not an exception).
Calcium and vitamin D for osteoporosis.
Malnutrition including alcoholism.
Vitamins and minerals are essential nutrients which most people should be able to get from eating a healthy, varied
and balanced diet. The Eatwell Guide https://www.nhs.uk/live-well/eat-well/the-eatwell-guide/ is a useful tool which
can be used to demonstrate to people how a healthy, varied and balanced diet can be achieved.
Many vitamin and mineral supplements are classified as foods, not medicines, and therefore do not have to
go through the strict criteria laid down by the Medicines and Healthcare products Regulatory Agency (MHRA)
to confirm their quality, safety and efficacy before reaching the market. It is therefore not deemed
appropriate for such preparations to be routinely funded on the NHS.
There is insufficient high quality evidence to demonstrate clinical effectiveness of vitamins and minerals.
Taking too many vitamins and minerals, or for too long could be harmful.
Recommendations for prescribers:
Discontinue prescribing vitamins and minerals on FP10 for patients where treatment is not in line with
recommendations.
If patients still want to take vitamins and minerals for dietary supplementation or as a ‘pick-me-up’, they
should be advised that these can be purchased as self-care over-the-counter with the support of the
community pharmacist. For information on daily amounts and dietary sources sign post patients to
https://www.nhs.uk/conditions/vitamins-and-minerals/
NHS Healthy Start vitamins are recommended for pregnant and breast-feeding women and children under 5,
as a preventative measure. These vitamins are not on prescription. In Bradford, Airedale and Wharfedale all
infants up to 6 months age receive free Healthy Start vitamin drops, after 6 months age infants and children
can receive the vitamins through either of the following ways:
1. Free vitamins via the Health Start scheme if eligible. Information can be found on the Healthy Start
website
2. Purchased at designated local health centres/community pharmacies
3. Health Visitors can issue free vitamins up to 2yrs age for children at high risk of deficiency.
In the Craven area, all Healthy Start vitamin drops need to be purchased or accessed via the Healthy Start scheme.
All pregnant women receive free NHS healthy Start vitamin tablets: Breast feeding women can purchase the vitamins
at designated local health centres/community pharmacies or via the Healthy Start scheme if eligible.
Vitamins and Minerals Prescribing Guidance
V1.0 Approved XXX 2020
Review date: XXX 2022Nutrient Indication Dose Review
Multivitamin and minerals - Adults
Forceval Medically diagnosed One capsule daily 3-6 months
deficiency Continued need should
be reviewed regularly
Malnutrition
If patients wish to have
Malabsorption multivitamins and
minerals in the absence
of proven deficiency
these should be
purchased OTC
Renavit
Water soluble vitamins Adults with renal failure Advised by secondary Monitored by secondary
on dialysis care care
Multivitamin and minerals - Paediatric
Abidec/Dalivit/Paediatric Metabolic conditions Advised by secondary Monitored by secondary
Seravit/Fruitivits/Phlexyvits/ Enteral tube feeds care care
Ketovite liquid and tablets Therapeutic restricted Annual review minimum
diets e.g. multiple allergy
A – Z Vitamins
Vitamin A (Retinol) Deficiency is associated Advised by secondary Monitored by secondary
with ocular defects and care care
an increased
susceptibility to infections,
but deficiency is rare in
the UK.
Thiamine (Vitamin B1) Deficiency related to 100mg three times daily Annually, based on
chronic alcoholism alcohol intake, continue
until 3 months abstinent /
varied diet.
Chronic alcohol
dependence may need to
be continued indefinitely.
If patients move into
care/nursing home and
are no longer drinking
alcohol, can be stopped.
Wernicke-Korsakoff 100mg three times daily With Wernicke-Korsakoff,
supplementation will
need to continue
Vitamins and Minerals Prescribing Guidance
V1.0 Approved XXX 2020
Review date: XXX 2022Vitamin B Compound Do NOT prescribe Vitamin B Compound or Vitamin B Compound Strong for
chronic alcoholism.
Vitamin B Compound If there is concern that diet is not adequate advise patients to purchase a complete
Strong multivitamin and mineral product or vitamin B complex.
Vitamin B6 (Pyridoxine) Prescribe for:
Isoniazid-induced neuropathy (prophylaxis/treatment).
Pyrodoxine responsive homocystinuria, advised and monitored by the metabolic team.
There is limited evidence to support the use of vitamin B6 for premenstrual syndrome, if
women wish to take vitamin B6 advise to purchase OTC.
Vitamin B12 See section on anaemias
Vitamin C (Ascorbic acid) Ascorbic acid should not be prescribed except for the treatment of scurvy. Advised by
secondary care.
Claims that vitamin C ameliorates colds or promotes wound healing have not been
proven.
Nutrient Indication Dose Review
Vitamin D Proven clinical deficiency See pathways ‘Treatment of Vitamin D
deficiency in adults/children’
For maintenance dose, advise patients to
purchase OTC.
Osteoporosis Calcium and vitamin D can be prescribed Annually
OR
Anticonvulsant Valupak vit D3 1,000 units can be
medication prescribed or purchased OTC as a
standalone treatment when there is
sufficient calcium in the diet.
Cystic fibrosis See section on cystic fibrosis Reviewed at regional
cystic fibrosis unit
Vitamin E Deficiency associated Advised by secondary care Monitored by secondary
with cholestasis, severe care
liver disease, cystic
fibrosis,
abetalipoproteinaemia
Vitamins and Minerals Prescribing Guidance
V1.0 Approved XXX 2020
Review date: XXX 2022Nutrient Indication Dose Review
Minerals
Magnesium Hypomagnesaemia, Magnesium aspartate (magnesium Monitored by secondary
prevent recurrence of 10mmol) oral powder sachet care.
magnesium deficit
Magnesium glycerophosphate
(magnesium 97.2mg (4 mmol)) chewable
tablets sugar free
Dose advised by secondary care
Selenium Only prescribe for Advised by secondary care Monitored by secondary
deficiency care
Zinc Only prescribe for Advised by secondary care Monitored by secondary
deficiency care
Vitamins and Minerals Prescribing Guidance
V1.0 Approved XXX 2020
Review date: XXX 2022Anaemias
Nutrient Indication Dose Review
Vitamin B12 Megaloblastic anaemia, most Hydroxocobalamin 1mg Lifelong treatment
common cause is pernicious intramuscular injection (IM)
anaemia. Other less common 3 x /week for 2 weeks,
causes include malabsorption, followed by
drugs (metformin, PPIs) hydroxocobalamin 1mg IM
every 2-3 months.
Dietary deficiency, e.g. vegan Hydroxocobalamin 1mg Vegan diet, maintenance oral
diet, restricted vegetarian diet intramuscular injection (IM) vitamin B12 may need to continue,
3 x /week for 2 weeks in other less restricted diets
followed by maintenance replacement treatment can be
oral vitamin B12 stopped once vitamin B12 levels are
(cyanocobalamin) 50-150 corrected and diet improved. Provide
micrograms. Advise dietary advice to patients
patients to purchase oral https://www.nhs.uk/conditions/vitami
vitamin B12 n-b12-or-folate-deficiency-anaemia/
(cyanocobalamin) OTC.
Folate Folate deficient megaloblastic Folic acid 5mg daily for 4 Provide dietary advice to patients to
anaemia months minimise risk of reoccurrence of
deficiency
Prevention of methotrexate- Folic acid 5mg daily except https://www.bda.uk.com/resourceDet
induced folate deficiency on methotrexate days ail/printPdf/?resource=folic-acid
For at least 3 months before Folic acid 5mg daily for at
and for the first trimester of least 3 months before and
pregnancy in the following for the first trimester of
women: pregnancy
Obese (BMI>30)
Diabetes
Woman or partner has neural
tube defect (NTD), previous
pregnancy affected by NTD,
family history of NTD.
Taking anti-epilepsy
medication
Coeliac disease or other
malabsorption states
For at least 3 months before
and throughout pregnancy in Folic acid 5mg daily for at
women with sickle cell least 3 months before and
disease, thalassaemia, throughout pregnancy
thalassaemia trait
Can also be used in the Advised by the metabolic Monitored by the metabolic team
management of team
Homocystinuria
Vitamins and Minerals Prescribing Guidance
V1.0 Approved XXX 2020
Review date: XXX 2022Iron Iron deficiency anaemia - Adults: 210mg ferrous Check Hb after 2-3 weeks to ensure
treatment fumarate (68 mg elemental adequate response. Treatment
iron), 200mg ferrous sulfate should continue for 3 months after
(65 mg elemental iron) iron deficiency is corrected to allow
once daily. stores to be replenished.
Monitor to ensure that there is an
Once daily elemental iron is adequate response to iron
effective and better treatment.
tolerated than 2–3 times Provide dietary advice to patients to
doses daily. minimise risk of reoccurrence of
deficiency
Children: sodium federate https://www.bda.uk.com/resourceDet
oral solution (Sytron) ail/printPdf/?resource=iron-rich-
foods-iron-deficiency
Tips to improve absorption:
Ensure not taking
at the same time as
a PPI, antacid
Take with a source
of vitamin C eg
orange juice
Iron deficiency anaemia – Advise patients to purchase
prophylaxis OTC.
Vitamins and Minerals Prescribing Guidance
V1.0 Approved XXX 2020
Review date: XXX 2022Bariatric surgery
Patients will be required to stay on lifelong nutritional supplements to counter the malabsorption effects of
bariatric surgery and have lifelong monitoring of their nutritional status.
It is recommended that patients purchase their multivitamin and mineral supplements OTC as agreed
before surgery. Existing patients may continue to receive their vitamin and mineral supplements on
prescription in exceptional circumstances.
Bradford Teaching Hospitals NHS Foundation Trust Bariatric Dietitians will provide patients with a list of
suitable preparations to self-purchase and advise on the appropriate dose to take depending on the type of
surgery the patient has undergone.
Type of bariatric surgery
Gastric Band Multivitamin and mineral supplement OTC
Gastric Bypass and Sleeve Multivitamin and mineral supplement OTC
Gastrectomy OR
Forceval one capsule daily
And
At least 800mg calcium and 800 IU vitamin D daily OTC (but may require
higher doses to maintain sufficient level of > 60nmol/L)
And
Additional iron supplements, 200mg ferrous sulfate, 210mg ferrous
fumarate or 300mg ferrous gluconate daily.
For menstruating women, 200mg ferrous sulfate or 210mg ferrous
fumarate twice daily
OTC if maintenance is required or NHS prescription if deficiency anaemia.
Vitamin B12, 1mg IM every 3 months.
Sufficient thiamine is contained within multivitamin and mineral supplement
If patient experiences prolonged vomiting, prescribe additional Thiamine
(thiamine 200-300mg daily, vitamin B Co Strong 1 or 2 tablets three times a
day) and urgent referral to bariatric centre. Those patients who are
symptomatic or where there is clinical suspicion of acute deficiency should
be admitted immediately for administration of IV thiamine.
Pregnancy:
Planning for and during pregnancy As above but ensure vitamin A in multivitamin & mineral supplement is in
(advise to plan pregnancy after 12-18 beta carotene form (Forceval capsules suitable).
months of operation - ideally wait Plus 5mg folic acid daily for at least 3 months before and for the first
until weight stable) trimester if BMI > 30kg/m2.
Vitamins and Minerals Prescribing Guidance
V1.0 Approved XXX 2020
Review date: XXX 2022Cystic fibrosis
Nutrient Dose Review
Abidec (vitamins A, D, E) Advised by secondary care/ regional Reviewed at regional cystic fibrosis
cystic fibrosis unit. unit
Dalivit (vitamins A, D, E)
Doses will change according to age
Vitamin A & D capsule and annual bloods.
Vitamin E suspension Additional vitamin D is often
prescribed such as cholecalciferol.
Vitamin K Phytomenadione Older children may need additional
vitamin D with calcium
Paravit-CF liquid (vitamins A, D,E,
K)
Paravit-CF capsule (vitamins A,
D,E,K)
Premature infant supplementation
Type of feed Breast milk Post discharge Term infant formula
Pre-term infant formula
Vitamins 0.6ml Abidec once daily 0.3ml Abidec once daily 0.3ml Abidec once daily
Folic acid 50 microgram once daily Nil Nil
when on full feeds until 6
weeks post EDD.
Only prescribed for infants
with anaemia following
haemolytic disease of the
new-born.
Not a routine premature
infant supplement.
Sytron 0.5ml twice daily. Start only Not routine. 0.5ml twice daily.
on day 28 for all infants Sometimes pre-term Start only on day 28.
bornTerm Infant - Low birth weight infant (
NICE CKS – Premenstrual syndrome, May 2019 https://cks.nice.org.uk/premenstrual-syndrome#!scenario
NICE, Anaemia – B12 and folate deficiency April 2018 https://cks.nice.org.uk/anaemia-b12-and-folate-deficiency
M. Muñoz et al, International consensus statement on the peri‐operative management of anaemia and iron deficiency.
Anaesthesia 2017, 72, 233 – 247
E Rimon et al, Are we giving too much iron? Low-dose iron therapy is effective in octogenarians. The American
Journal of Medicine (2005) 118, 1142 – 1147.
D Moretti et al, Iron supplements increase hepcidin and decrease iron absorption from daily or twice-daily doses in
iron-depleted young women. Blood, 22 October 2015, vol 126, number 17
British Obesity & Metabolic Surgery Society (BOMSS) Guidelines on peri-operative and postoperative biochemical
monitoring and micronutrient replacement for patients undergoing bariatric surgery, August 2020
https://www.bomss.org.uk/bomss-nutritional-guidance_2020/
Bradford Teaching Hospitals NHS Foundation Trust, Nutrition Policy for Adults: Appendix F Refeeding Syndrome
Sept.2019
British Dietetic Association Food Fact sheet: Supplements 2019 https://www.bda.uk.com/resource/supplements.html
Authors
Susan Sheridan, Prescribing Support Dietitian, Medicines Optimisation Team, NHS Bradford District and Craven
Clinical Commissioning Group (CCG) / Bradford Teaching Hospitals NHS Foundation Trust (BTHFT)
Tracey Gaston, Senior Head of Medicines Optimisation, NHS Bradford District & Craven CCG
Claire Kilburn, Senior Head of Medicines Optimisation, NHS Bradford District & Craven CCG
Acknowledgements
Amanda Musk, Neonatal & Paediatric Dietitian, BTHFT
Dalvinder Hellawell, Paediatric Dietitian, BTHFT
Inderdip Hunjan, Metabolic Dietitian, BTHFT
Michelle Soobayah, Bariatric Dietitian, BTHFT
Paul Bailey, Renal Dietitian, BTHFT
Dr Paul Southern, Consultant Hepatologist, BTHFT
Mr James Halstead, Consultant Surgeon, BTHFT
Dr Andrew Hanson, GP, Specialist Epilepsy Services, The Ridge Medical Practice, Bradford.
Nick Bergin, Specialist Nutrition Support Dietitian and Acute Team Leader, Airedale NHS Foundation Trust
Dr Nick Hayward, Associate Clinical Director for Quality Improvement, Bradford district & Craven CCG
Vitamins and Minerals Prescribing Guidance
V1.0 Approved XXX 2020
Review date: XXX 2022You can also read
