9.1. Anaemias and some other blood disorders
9.1.1. Iron-deficiency anaemias
For NHSGGC guidance on the Treatment of Iron Deficiency Anaemia (IDA) in Adults click here.
9.1.1.1. Oral iron
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 Medicines Update blog on oral iron therapy.
9.1.1.2. Parenteral iron
Should be reserved as a last resort in the treatment of IDA in a hospital setting.
With the exception of patients with severe renal failure receiving haemodialysis, parenteral iron does not produce a faster haemoglobin response than oral iron provided that the oral iron preparation is taken reliably and absorbed adequately.
Restrictions:
The treatment of iron deficiency anaemia (diagnosis based on laboratory tests) when oral iron preparations are ineffective or cannot be used is restricted to specialist use.
Prescribing Notes:
These preparations are more expensive than some other IV iron preparations. Use in patients on haemodialysis or use as a bolus injection was not recommended by SMC and remains non-Formulary.
For the relevant SMC advice click here
Restrictions:
Treatment of iron deficiency in adults with chronic kidney disease (CKD) on dialysis, when oral iron preparations are ineffective or cannot be used is restricted to specialist use only in adults with chronic kidney disease on dialysis.
Restrictions:
The treatment of iron deficiency anaemia (diagnosis based on laboratory tests) when oral iron preparations are ineffective or cannot be used is restricted to specialist use.
Prescribing Notes:
These preparations are more expensive than some other IV iron preparations. Use in patients on haemodialysis or use as a bolus injection was not recommended by SMC and remains non-Formulary.
For the relevant SMC advice click here
9.1.2. Drugs used in megaloblastic anaemias
Prescribing Notes:
Used for folate deficiency and prophylaxis for the prevention of neural tube defects in pregnancy. To prevent first occurrence of neural tube defects, women planning a pregnancy should take folic acid 400 micrograms daily before conception and during the first 12 weeks of pregnancy. Women, who suspect they are pregnant but have not been taking folic acid, should start at once and continue until the 12th week of pregnancy. Women with a previous pregnancy affected by a neural tube defect should take folic acid 5mg daily. Women taking antiepileptic drugs may also be advised to take higher doses of folic acid.
Restrictions:
Prescribing is restricted to a 4 week trial to establish whether vitamin B12 deficiency will respond to dietary adjustment.
Prescribing Notes:
The NHSGGC Guideline for Treatment of Vitamin B12 Deficiency can be found here.
Cyanocobalamin tablets should not be continued long-term for vitamin B12 replacement.
9.1.3. Drugs used in hypoplastic, haemolytic, and renal anaemias
Restrictions:
Restricted to specialist initiation. Approved in NHSGGC only for anaemia associated with renal failure. This is the preferred Formulary agent for this indication.
Restrictions:
Restricted to specialist use only in accordance with the Prescribing Notes below.
Prescribing Notes:
Formulary indications:
- Treatment of chronic iron overload associated with the treatment of rare acquired or inherited anaemias requiring recurrent blood transfusions when deferoxamine therapy is contraindicated or inadequate
- Treatment of myeloplastic syndrome (MDS) in patients with an International Prognostic Scoring System (IPSS) score of low or intermediate -1 risk when deferoxamine therapy is contraindicated or inadequate in accordance with regional protocol (in development)
It is not recommended by SMC for:
- Treatment of patients with chronic iron overload requiring chelation therapy when deferoxamine therapy is contraindicated or inadequate in patients with non-transfusion-dependent thalassaemia syndromes and is non-Formulary for these indications.
Restrictions:
Restricted to specialist initiation. Approved in NHSGGC only for anaemia associated with renal failure.
Prescribing Notes:
- Prescribe by brand name.
- The treatment of symptomatic anaemia in adults with low or intermediate-1-risk primary myelodysplastic syndromes (MDS) who have low serum erythropoetin is not recommended for use by the SMC and is non-Formulary.
Restrictions:
Restricted to specialist initiation. Approved in NHSGGC only for anaemia associated with renal failure.
Prescribing Notes:
Prescribe by brand name.
Restrictions:
Restricted to specialist initiation. Approved in NHSGGC only for anaemia associated with renal failure.
Restrictions:
The treatment of symptomatic anaemia associated with chronic kidney disease (CKD) is restricted to specialist use in patients who are non-dialysis dependent (NDD) at the time of treatment initiation.
9.1.4. Drugs used in platelet disorders
Restrictions:
Restricted to specialist use only for the reduction of elevated platelet counts in at-risk patients with essential thrombocythaemia who are intolerant of their current therapy or whose elevated platelet counts are not reduced to an acceptable level by their current therapy.
Restrictions:
Restricted to specialist use for the following indications:
- The treatment of severe thrombocytopenia in adults with chronic liver disease who are scheduled to undergo an invasive procedure
- The treatment of primary chronic thrombocytopenia (ITP) refractory to other treatments (e.g. corticosteroids or immunoglobulins) where patients have severe symptomatic ITP or a high risk of bleeding in accordance with local protocol (in development).
Restrictions:
The treatment of adults experiencing an episode of acquired thrombotic thrombocytopenic purpura (aTTP), in conjunction with plasma exchange and immunosuppression is restricted to specialist use in accordance with regional protocol.
Restrictions:
Restricted to use as detailed in Prescribing Notes section below.
Prescribing Notes:
Formulary indications:
- Adult chronic immune (idiopathic) thrombocytopenic purpura (ITP) is restricted to specialist use in accordance with local protocol.
- Treatment of thrombocytopenia in adults with chronic hepatitis C is restricted to specialist use.
Non-formulary indications:
- Treatment in adult patients with acquired severe aplastic anaemia (SAA) who were either refractory to prior immunosuppressive therapy or heavily pretreated and are unsuitable for haematopoietic stem cell transplantation.
Restrictions:
Treatment of chronic immune thrombocytopenia (ITP) in adult patients who are refractory to other treatments is restricted to specialist use.
Restrictions:
Restricted to specialist use for the treatment of severe thrombocytopenia in adults patients with chronic liver disease undergoing invasive procedures.
Restrictions:
Restricted to specialist use only. Restricted to use in patients with severe symptomatic immune (idiopathic) thrombocytopenia purpura (ITP) or patients with a high risk of bleeding.
9.1.5. G6PD deficiency
9.1.6. Drugs used in neutropenia
Restrictions:
Restricted to specialist use only. Restricted to prescribing in accordance with local protocol.
Prescribing Notes:
The BNF recommends that it is good practice to prescribe biosimilar preparations by brand name.
Restrictions:
Restricted to specialist use only. Restricted to prescribing in accordance with local protocol.
Restrictions:
Restricted to specialist use in accordance with regional protocol
Prescribing Notes:
The preferred brand is Pelgraz®.
Restrictions:
Restricted to specialist use only. Restricted to specialist use in accor-dance with local protocol in patients who would otherwise receive 5 days or more filgrastim or lenograstim.
9.1.7. Drugs used to mobilise stem cells
9.1.8. Drugs for other blood disorders
Restrictions:
Restricted to specialist use for the following indications:
- Treatment of adults with paroxysmal nocturnal haemoglobinuria (PNH) on the advice of the national PNH service:
- in patients with haemolysis with clinical symptom(s) indicative of high disease activity
- in patients who are clinically stable after having been treated with eculizumab for at least the past 6 months
- Treatment of patients with atypical haemolytic uremic syndrome (aHUS) under the advice of the National Renal Complement Therapeutics Service (based in Newcastle) who are complement inhibitor treatment-naïve or have received eculizumab for at least 3 months and have evidence of response to eculizumab.
Prescribing Notes:
Non-formulary indications as not recommended by SMC (non-submission):
- Treatment of adult patients with neuromyelitis optica spectrum disorder (NMOSD) who are anti-aquaporin 4 (AQP4) antibody-positive
- Add-on to standard therapy for the treatment of adult patients with generalized myasthenia gravis (gMG) who are antiacetylcholine receptor (AChR) antibody-positive
Restrictions:
Restricted to specialist use under the advice of the national PNH Service for patients with paroxysmal nocturnal haemoglobinuria (PNH) who are anaemic after treatment with a C5 inhibitor for at least 3 months.