Download Hypophosphataemia in Adults - Nottingham University Hospitals

Title of Guideline (must include the word “Guideline” (not
protocol, policy, procedure etc)
Contact Name and Job Title (author)
Directorate & Speciality
Date of submission
Date on which guideline must be reviewed (this should be one to
three years)
Explicit definition of patient group to which it applies (e.g.
inclusion and exclusion criteria, diagnosis)
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Abstract
Key Words
Statement of the evidence base of the guideline – has the
guideline been peer reviewed by colleagues?
Evidence base: (1-6)
1
NICE Guidance, Royal College Guideline, SIGN
(please state which source).
2a
meta analysis of randomised controlled trials
2b
at least one randomised controlled trial
3a
at least one well-designed controlled study without
randomisation
3b
at least one other type of well-designed quasiexperimental study
4
well –designed non-experimental descriptive studies
(i.e. comparative / correlation and case studies)
5
expert committee reports or opinions and / or clinical
experiences of respected authorities
6
recommended best practice based on the clinical
experience of the guideline developer
Consultation Process
Target audience
This guideline has been registered with the trust. However,
clinical guidelines are guidelines only. The interpretation
and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using
guidelines after the review date.
Guideline for the Treatment of
Hypophosphataemia in Adults
Dr Peter Prinsloo
Consultant Clinical Chemistry
Azma Malik
Senior Pharmacist
Diagnostics and Clinical Support
March 2016
March 2019
Guideline for Adult patients excluding
critical care and renal.
3
This guideline describes the
management of hyphosphataemia in
adult inpatients
Hypophosphataemia,
hypophosphatemia, Phosphate
5 expert committee reports or opinions
and / or clinical experiences of respected
authorities
Plus national advice in BNF
Drugs & Therapeutics Committee (DTC)
Consultant Clinical Chemistry
Senior Pharmacist
Critical Care Pharmacist
Nursing, pharmacy & medical staff
Guideline for the treatment of hypophosphataemia in adults. March 2016
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GUIDELINES FOR THE TREATMENT OF ACUTE
HYPOPHOSPHATAEMIA IN ADULTS
Clinical guidelines are guidelines only. These guidelines are not intended
to cover all factors relating to hypophosphataemia in critical care or the
renal unit, where specialist advice should be sought.
The interpretation and application of these guidelines remain the
responsibility of the clinician. If in doubt, a senior colleague should be
contacted.
Intravenous phosphate is potentially dangerous and can cause fatal
hypocalcaemia. This treatment must only be used within the
recommendations of this guideline.
Normal adult phosphate range = 0.8-1.45 mmol/L
Severity of
Hypophosphataemia
Mild
Moderate
Severe
Serum phosphate level
(mmol/L)
0.65 - 0.79
0.32 - 0.64
<0.32
Symptoms usually occur when serum phosphate falls below 0.32 mmol/L
Signs, symptoms and consequences of hypophosphatemia
 Generalised muscle
weakness, myopathy
 Confusion, irritability,
hallucinations, somnolence
 Paraesthesia
 Coma
 Hypotension
 Respiratory failure
 Rhabdomyolysis
 Decreased cardiac
contractility
 Abnormal LFTs
 Cardiomyopathy,
arrhythmias
 Seizures
Guideline for the treatment of hypophosphataemia in adults. March 2016
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Causes of hypophosphataemia
Internal distribution
*Refeeding syndrome, recovery from diabetic
ketoacidosis, alkalosis, sepsis, drugs (see below)
Decreased intestinal Vitamin D deficiency, diarrhoea, malabsorption,
absorption
vomiting, starvation
Increased urinary
Renal tubular defects, hyperparathyroidism,
excretion
disorders of vitamin D metabolism, diuretics,
renal treatment.
Dietary or internal
Chronic alcoholism
distribution
*See refeeding syndrome guideline.
http://nuhnet/nuh_documents/Guidelines/Trust%20Wide/Nutrition/1881.pdf
Drug induced hypophosphataemia
This is not an exhaustive list. Please contact Medicines Information, on
extension 64185 for more details.
Adrenaline
Aminophylline
Diuretics
Beta2-agonists
Insulin
Phosphate binders
Dopamine
Steroids
Sucralfate
Theophylline
Antacids
Cautions
 Phosphate supplements should be started only once a definitive
diagnosis is made.
 Intravenous phosphate should be used only when oral therapy has
failed or is inappropriate or on the advice of a specialist.
 Potassium dihydrogen phosphate 9mmol in 250ml sodium chloride
0.9% contains 9mmol of potassium (in addition to 9 mmol of
phosphate) per 250ml of solution. Caution should be used with
infusion rate and in patients with hyperkalaemia.
 Monitor the patient’s potassium.
 If patient is hyperkalaemic, intravenous phosphate may be
administered in the form of sodium glycerophosphate (see below).
Guideline for the treatment of hypophosphataemia in adults. March 2016
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 Intravenous and oral phosphate should be used with caution in
patients with severe renal impairment and dosage adjustment will be
required. Large doses can result in metabolic acidosis. If creatinine
clearance <15 ml/min, discuss with the renal team for specialist
advice.
 Patients on a restricted sodium diet should be monitored carefully on
both oral and intravenous therapy. Both serum phosphate level and
the patient’s clinical condition should guide treatment.
 Caution should be exercised with replacement in the elderly.
 Patients with hypocalcaemia should have their calcium corrected
before replacing phosphate to prevent further hypocalcaemia.
 Patients with severe hypercalcaemia who require phosphate
replacement should be discussed with clinical chemistry or the renal
team for specialist advice. Phosphate replacement in the presence
of hypercalcaemia may cause ectopic calcification.
The underlying cause of hypophosphataemia must be corrected.
Diet
Mild hypophosphataemia: phosphate may be replaced by increasing the
dietary intake of foods high in phosphate. Dairy products are high in
phosphate. Examples include: Milk, yoghurt and cheese.
Dairy products also contain calcium, so serum calcium should be checked.
Soft tissue calcification can occur if the patient suddenly develops
hyperphosphataemia with elevated calcium levels
Guideline for the treatment of hypophosphataemia in adults. March 2016
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Oral replacement therapy:
 Phosphate Sandoz® effervescent tablets (Sodium Dihydrogen
Phosphate anhydrous)
- 1 tablet contains 16.1mmol of phosphate, 20.4mmol of sodium
and 3.1mmol of potassium.
 Usual dose is one or two tablets three times a day adjusted
according to response.
 Serum phosphate levels should be checked daily.
 Treatment may be discontinued once the plasma level is above
0.8mmol/L
 Oral phosphate supplements are often poorly tolerated due to
diarrhoea. If this occurs, consider intravenous replacement.
 Administration of Phosphate-Sandoz® tablets at the same time as
calcium, aluminium or magnesium salts should be avoided as these
will bind phosphate and reduce its absorption.
 Phosphate Sandoz® effervescent tablets should be dissolved in 1/3
to 1/2 a tumblerful of water and taken orally.
For patients who are nil by mouth, have diarrhoea, ileostomy, at risk of
refeeding or a short bowel consider IV replacement.
If patient is at risk of refeeding refer to trust refeeding guideline
http://nuhnet/nuh_documents/Guidelines/Trust%20Wide/Nutrition/1881.pdf
For IV replacement therapy:
(Please note: Previously the product used for IV replacement was labelled
as potassium acid phosphate 13.6% 9mmol in 250ml bag. It is now
labelled as potassium dihydrogen phosphate 9mmol in 250ml)
 9-27 mmol Potassium Dihydrogen Phosphate in 250-750 ml sodium
chloride 0.9% should be infused over 12-24 hours
 The infusion should be repeated every 24 hours if needed until
phosphate level is above 0.8mmol/L.
 Consider changing to oral phosphate if appropriate
 Ready-made bags are available from pharmacy as
- 9mmol Potassium Dihydrogen Phosphate in 250mls sodium
chloride 0.9%.
Guideline for the treatment of hypophosphataemia in adults. March 2016
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- If 18mmols is required 2 bags of 9mmols in 250ml will be
prescribed, each bag should be given over 6 hours
- If 27mmols is required 3 bags of 9mmols in 250mls will be
prescribed each bag should be given over 4 - 8 hours (i.e. 27
mmols over 12- 24hrs)
 They are supplied from pharmacy in hours and via the on call
pharmacist out of hours
 These bags are held only on designated ward areas only. Under no
circumstances may wards borrow Potassium Dihydrogen Phosphate
9mmol bags from each other. All orders must be made through
pharmacy.
 Monitor phosphate levels daily.
 Please note potassium dihydrogen phosphate is unlicensed. Use
should be in accordance with the Trusts ULM policy
If patient is hyperkalaemic, Sodium glycerophosphate 9mmol can be used
instead of potassium dihydrogen phosphate 9mmol.
Please note sodium glycerophosphate is unlicensed. This is made up on
the ward. (Contact pharmacy for further advice)
Doses for intravenous phosphate vary in the literature and suggested
regimens have included 0.2-0.5mmol/kg/day up to a maximum of
50mmol/day.
Administration of IV Phosphate
The rate and concentration recommended for potassium infusions must
never be exceeded (see separate Potassium guideline)
Potassium dihydrogen phosphate should be administered using a
volumetric pump.
The dose and rate of phosphate infusion must be adhered to as stated in
this guideline. Any deviations may result in harm to the patient.
Guideline for the treatment of hypophosphataemia in adults. March 2016
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Summary of treatment
Phosphate level
0.32 - 0.6 mmol/L
Asymptomatic
<0.32 mmol/L
Symptomatic
*If refeeding risk see
refeeding guideline
Give oral Phosphate
Sandoz ® one or two
tablets three times a day.
Adjust according to
response
Check level daily.
Stop once level in
normal range i.e.
>0.8mmol/L
Poor oral absorption or
one of the below:
 Nil by mouth
 Short bowel
syndrome
 Diarrhoea
 Ileostomy
Give intravenous phosphate:
 Mild:
9mmol potassium dihydrogen phosphate
 Moderate:
18mmol potassium dihydrogen phosphate
 Severe:
27mmol potassium dihydrogen phosphate
Potassium dihydrogen phosphate contains 9 mmol
of phosphate in 250ml sodium chloride 0.9%. One,
two or three bags may be required over 12-24
hours (see text on prescribing and volumes)
Check phosphate and potassium levels daily
If phosphate >0.32mmol/L on more than two
occasions and patient is asymptomatic consider
changing to oral supplementation if appropriate.
Guideline for the treatment of hypophosphataemia in adults. March 2016
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Monitoring
 Daily serum phosphate, calcium, magnesium and potassium levels.
Excessive doses of phosphate may cause hyperkalaemia,
hypocalcaemia and metastatic calcification. Patients with
hypocalcaemia should have their calcium corrected before replacing
phosphate to prevent further hypocalcaemia.
 Daily renal function
 Veins should be monitored for thrombophlebitis, especially if IV
phosphate is given peripherally.
 The infusion must be stopped if patient develops adverse effects.
Special Precautions and Warnings for Use
 Phosphate is renally cleared and therefore should be used with caution
in patients with renal impairment.
 Insulin increases cell phosphate uptake and causes
hypophosphataemia during treatment of diabetic ketoacidosis (DKA).
An endocrinologist’s advice should be sought where appropriate.
 If the patient is receiving TPN, the potassium and phosphate content of
the prescription must be taken into account. Liaise with the nutrition
team.
Adverse Effects
Oral phosphate can cause diarrhoea and gastrointestinal upset. This is
usually dose related and may be reduced by dividing the doses.
Phosphate preparations are given as the potassium or sodium salts or
both and may be associated with hyperkalaemia, hypernatraemia and
dehydration. Sodium phosphate may cause hypokalaemia.
Management of adverse effects involves withdrawal of phosphate, general
supportive measures, and correction of serum electrolyte concentrations,
especially calcium.
Hazards of intravenous therapy include: hypotension, hyperkalaemia,
hypernatraemia, hypocalcaemia, hyperphosphataemia, tetany, cardiac
arrhythmias, metastatic calcification, and renal failure.
Guideline for the treatment of hypophosphataemia in adults. March 2016
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References
1. British National Formulary BNF
https://www.medicinescomplete.com/mc/bnf/current/ accessed April
2016
2. UKMi Q&A - How is acute hypophosphataemia treated in adults?
Accessed from:
http://www.medicinesresources.nhs.uk/upload/documents/Evidence/M
edicines%20Q%20&%20A/QA371_1_Hypophosphataemia.doc
accessed on 10/01/16
3. Phosphate Sandoz®.Summary of Product Characteristics. Available at
www.emc.medicines.org.uk.Updated 29/10/15. Accessed 18/01/16
4. R Edwards et al. Hypophosphataemia in the critically ill patientAetiology and management. Care of the critically ill.1998;14:8, 267-27
5. The Renal Drug Handbook,
https://www.medicinescomplete.com/mc/renalhandbook/current/
Accessed May 2016
6. Lederer E, Ouseph R.,Mittal D, Deo D. Hyperphosphataemia available
at www.emedicine.com/med/topic1135.htm#section~treatment/.
Updated March 31st 2015.
7. Worcester Acute Hospital NHS Trust. Acute Treatment of
Hypophosphateamia. March 2015
8. Uptodate. Updated 04th January 2016 Accessed 18/01/16
Guideline for the treatment of hypophosphataemia in adults. March 2016
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Equality Impact Assessment Report
1.
Name of Policy or Service
Trust wide clinical guidance
2.
Responsible Manager
Owen Bennett (Clinical Quality, Risk and Safety Manager)
3.
Name of person Completing EIA
Azma Malik
4.
Date EIA Completed
18/01/16
5.
Description and Aims of Policy/Service
This clinical guideline has been written to assist hospital staff in the
management of adult patients with hypophosphateamia
6.
Brief Summary of Research and Relevant Data
Full references provided on document which include British National
Formulary
7.
Methods and Outcome of Consultation
Drugs and Therapeutics Committee
8.
Results of Initial Screening or Full Equality Impact Assessment:
Equality Group
Assessment of Impact
Age
No Impact Identified
Gender
No Impact Identified
Race
No Impact Identified
Sexual Orientation
No Impact Identified
Religion or belief
No Impact Identified
Disability
No Impact Identified
Guideline for the treatment of hypophosphataemia in adults. March 2016
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Dignity and Human Rights No Impact Identified
Working Patterns
No Impact Identified
Social Deprivation
No Impact Identified
9.
Decisions and/or Recommendations (including supporting
rationale)
From the information contained in the procedure, and following the
initial screening, it is my decision that a full assessment is not
required at the present time.
10.
Equality Action Plan (if required)
N/A
11.
Monitoring and Review Arrangements
Review
Guideline for the treatment of hypophosphataemia in adults. March 2016
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