Hypercalcaemia and hypercalciuria

9.5.1.2 Hypercalcaemia and hypercalciuria

9.4.2 Enteral nutrition

9.5.1.3 Magnesium

The body’s reserves of protein rapidly become exhausted in severely ill patients, especially during

Calcium supplements

chronic illness or in those with severe burns, extensive

trauma, pancreatitis, or intestinal fistula. Much can be achieved by frequent meals and by persuading the

Calcium supplements are usually only required where patient to take supplementary snacks of ordinary food

dietary calcium intake is deficient. This dietary require- between the meals.

ment varies with age and is relatively greater in child- hood, pregnancy, and lactation, due to an increased

However, extra calories, protein, other nutrients, and demand, and in old age, due to impaired absorption. vitamins are often best given by supplementing ordinary

In osteoporosis, a calcium intake which is double the meals with sip or tube feeds of one of the nutritionally

recommended amount reduces the rate of bone loss. If complete foods.

the actual dietary intake is less than the recommended When patients cannot feed normally at all, for example,

amount, a supplement of as much as 40 mmol is appro- patients with severe facial injury, oesophageal obstruc-

priate, see also Osteoporosis, p. 414 and Vitamin D, tion, or coma, a diet composed solely of nutritionally

p. 541.

complete foods must be given. This is planned by a In severe acute hypocalcaemia or hypocalcaemic dietitian who will take into account the protein and total

tetany, an initial slow intravenous injection of 10– energy requirement of the patient and decide on the

20 mL of calcium gluconate injection 10% (providing

BNF 57

9.5.1 Calcium and magnesium 533

approximately 2.25–4.5 mmol of calcium) should be Calcium-500 (Martindale) given, with plasma-calcium and ECG monitoring (risk

Tablets , pink, f/c, calcium carbonate 1.25 g (calcium of arrhythmias if given too rapidly), and either repeated

12.5 mmol), net price 100-tab pack = as required or, if only temporary improvement, followed

500 mg or Ca

£9.46. Label: 25

by a continuous intravenous infusion to prevent recur- Calcium-Sandoz rence. For infusion, dilute 100 mL of calcium gluconate c (Alliance) 10% in 1 litre of glucose 5% or sodium chloride 0.9%

Syrup , orange flavour, calcium glubionate 1.09 g, and give at an initial rate of 50 mL/hour adjusted

calcium lactobionate 727 mg (calcium 108.3 mg or according to response. Oral supplements of calcium

Ca 2.7 mmol)/5 mL, net price 300 mL = £3.39 and vitamin D may also be required in persistent hypo-

Sandocal c (Novartis Consumer Health) calcaemia (see also section 9.6.4). Concurrent hypo-

Sandocal-400 tablets , effervescent, orange flavour, magnesaemia should be corrected with magnesium

calcium lactate gluconate 930 mg, calcium carbonate sulphate (section 9.5.1.3).

700 mg, anhydrous citric acid 1.189 g, providing cal- For the role of calcium gluconate in temporarily redu-

cium 400 mg (Ca

cing the toxic effects of hyperkalaemia, see p. 519. pack = £6.87. Label: 13 Excipients include aspartame (section 9.4.1)

Sandocal-1000 tablets , effervescent, orange flavour,

calcium lactate gluconate 2.263 g, calcium carbonate Indications

CALCIUM SALTS

1.75 g, anhydrous citric acid 2.973 g providing 1 g see notes above; calcium deficiency

calcium (Ca

Cautions renal impairment; sarcoidosis; history of

£6.17. Label: 13

nephrolithiasis; avoid calcium chloride in respiratory

Excipients include aspartame (section 9.4.1)

acidosis or respiratory failure; interactions: Appendix

1 (antacids, calcium salts) Parenteral preparations Contra-indications conditions associated with hyper-

Calcium Gluconate (Non-proprietary) A calcaemia and hypercalciuria (e.g. some forms of

Injection , calcium gluconate 10% (calcium 8.4 mg or malignant disease)

Ca 226 micromol/mL), net price 10-mL amp = 60p Side-effects gastro-intestinal disturbances; brady-

A Injection , calcium chloride dihydrate 10% (calcium latation, fall in blood pressure, injection-site reactions

Calcium Chloride (Non-proprietary) cardia, arrhythmias; with injection, peripheral vasodi-

680 micromol/mL), net price 10-mL Dose

27.3 mg or Ca

disposable syringe = £4.64 . By mouth , daily in divided doses, see notes above

Calcium Chloride 10% . By slow intravenous injection , acute hypocalc-

Brands include Minijet

Injection , calcium chloride dihydrate 13.4% (calcium aemia, calcium gluconate 1–2 g (Ca 2.25–

36 mg or Ca

910 micromol/mL), net price 10-mL

4.5 mmol); CHILD see BNF for Children

amp = £14.94

. By continuous intravenous infusion , acute hypo- calcaemia, see notes above

With vitamin D Section 9.6.4

Oral preparations Calcium Gluconate (Non-proprietary)

With disodium etidronate

Tablets , calcium gluconate 600 mg (calcium 53.4 mg

Section 6.6.2

Nutrition

or Ca

1.35 mmol), net price 20 = £1.43. Label: 24 Effervescent tablets , calcium gluconate 1 g (calcium

With risedronate sodium and colecalciferol

89 mg or Ca

2.23 mmol), net price 28-tab pack =

Section 6.6.2

and

£8.83. Label: 13

Note Each tablet usually contains 4.46 mmol Na

blood

Calcium Lactate (Non-proprietary) Tablets , calcium lactate 300 mg (calcium 39 mg or

9.5.1.2 Hypercalcaemia and

Ca 1 mmol), net price 84 = £3.01

hypercalciuria

Adcal c (ProStrakan) Chewable tablets , fruit flavour, calcium carbonate

Severe hypercalcaemia Severe hypercalcaemia calls 100-tab pack = £7.25. Label: 24

1.5 g (calcium 600 mg or Ca

15 mmol), net price

for urgent treatment before detailed investigation of the cause. Dehydration should be corrected first with intra-

Cacit c (Procter & Gamble Pharm.) venous infusion of sodium chloride 0.9%. Drugs (such Tablets , effervescent, pink, calcium carbonate 1.25 g,

as thiazides and vitamin D compounds) which promote providing calcium citrate when dispersed in water

hypercalcaemia, should be discontinued and dietary (calcium 500 mg or Ca

12.5 mmol), net price 76-tab calcium should be restricted. pack = £12.54. Label: 13

If severe hypercalcaemia persists drugs which inhibit Calcichew c (Shire)

mobilisation of calcium from the skeleton may be Tablets (chewable), orange flavour, calcium carb-

required. The bisphosphonates are useful and onate 1.25 g (calcium 500 mg or Ca

disodium pamidronate (section 6.6.2) is probably the price 100-tab pack = £9.33. Label: 24

12.5 mmol), net

most effective.

Forte tablets (chewable), orange flavour, scored, Corticosteroids (section 6.3) are widely given, but may calcium carbonate 2.5 g (calcium 1 g or Ca

only be useful where hypercalcaemia is due to sarcoi-

25 mmol), net price 60-tab pack = £13.16. Label: 24 dosis or vitamin D intoxication; they often take several

Excipients include aspartame (section 9.4.1)

days to achieve the desired effect.

9.5.1 Calcium and magnesium BNF 57 Calcitonin (section 6.6.1) is relatively non-toxic but its

CINACALCET

effect can wear off after a few days despite continued

use; it is rarely effective where bisphosphonates have Indications see under Dose and notes above failed to reduce serum calcium adequately.

Cautions measure serum-calcium concentration After treatment of severe hypercalcaemia the under-

before initiation of treatment and within 1 week after lying cause must be established. Further treatment is

starting treatment or adjusting dose, then monthly for governed by the same principles as for initial therapy.

secondary hyperparathyroidism and every 2–3 Salt and water depletion and drugs promoting hyper-

months for primary hyperparathyroidism and para- calcaemia should be avoided; oral administration of a

thyroid carcinoma; treatment should not be initiated bisphosphonate may be useful.

in patients with hypocalcaemia; in secondary hyper- parathyroidism measure parathyroid hormone con- centration 1–4 weeks after starting treatment or

Hyperparathyroidism Cinacalcet is licensed for the adjusting dose, then every 1–3 months; dose adjust- treatment of secondary hyperparathyroidism in dialysis

ment may be necessary if smoking started or stopped patients with end-stage renal disease (but see NICE

during treatment; hepatic impairment (Appendix 2); guidance below), for primary hyperparathyroidism in

pregnancy (Appendix 4); interactions: Appendix 1 patients where parathyroidectomy is inappropriate, and

(cinacalcet)

for the treatment of hypercalcaemia in parathyroid Contra-indications breast-feeding (Appendix 5) carcinoma. Cinacalcet reduces parathyroid hormone

Side-effects nausea, vomiting, anorexia; dizziness, which leads to a decrease in serum calcium concentra-

paraesthesia, asthenia; reduced testosterone concen- tions.

trations; myalgia; rash; less commonly dyspepsia, diarrhoea, and seizures; hypotension and heart failure

Paricalcitol (section 9.6.4) is also licensed for the pre-

also reported

vention and treatment of secondary hyperparathyroid- ism associated with chronic renal failure. Dose . Secondary hyperparathyroidism in patients with end-

Parathyroidectomy may be indicated for hyperparathyr- stage renal disease on dialysis (but see notes above), oidism.

ADULT over 18 years, initially 30 mg once daily, adjusted every 2–4 weeks to max. 180 mg daily

NICE guidance . Hypercalcaemia of primary hyperparathyroidism or Cinacalcet for the treatment of secondary

parathyroid carcinoma, ADULT ood over 18 years, initially bl

hyperparathyroidism in patients with end-

30 mg twice daily, adjusted every 2–4 weeks accord- stage renal disease on maintenance dialysis

ing to response up to max. 90 mg 4 times daily

and

therapy (January 2007) Mimpara c (Amgen)

Cinacalcet is not recommended for the routine treat- A

ment of secondary hyperparathyroidism in patients Tablets , green, f/c, cinacalcet (as hydrochloride)

30 mg, net price 28-tab pack = £126.28; 60 mg, 28-tab with end-stage renal disease on maintenance

pack = £232.96; 90 mg, 28-tab pack = £349.44.

Nutritio

dialysis therapy.

Label: 21

9 Cinacalcet is recommended for the treatment of

refractory secondary hyperparathyroidism

in

patients with end-stage renal disease (including those with calciphylaxis) only in those:

9.5.1.3 Magnesium

. who have ’very uncontrolled’ plasma concentra- tion of intact parathyroid hormone (defined as

Magnesium is an essential constituent of many enzyme greater than 85 picomol/litre) refractory to stan-

systems, particularly those involved in energy genera- dard therapy, and a normal or high adjusted

tion; the largest stores are in the skeleton. serum calcium concentration,

Magnesium salts are not well absorbed from the gastro- and

intestinal tract, which explains the use of magnesium .

in whom surgical parathyroidectomy is contra- sulphate (section 1.6.4) as an osmotic laxative. indicated, in that the risks of surgery outweigh

Magnesium is excreted mainly by the kidneys and is the benefits.

therefore retained in renal failure, but significant hyper- Response to treatment should be monitored regu-

magnesaemia (causing muscle weakness and arrhyth- larly and treatment should be continued only if a

mias) is rare.

reduction in the plasma concentration of intact parathyroid hormone of 30% or greater is seen

Hypomagnesaemia Since magnesium is secreted in within 4 months of treatment.

large amounts in the gastro-intestinal fluid, excessive losses in diarrhoea, stoma or fistula are the most com- mon causes of hypomagnesaemia; deficiency may also occur in alcoholism or as a result of treatment with certain drugs. Hypomagnesaemia often causes second-

Hypercalciuria Hypercalciuria should be investigated ary hypocalcaemia, and also hypokalaemia and hypo- for an underlying cause, which should be treated. Where

natraemia.

a cause is not identified (idiopathic hypercalciuria), the Symptomatic hypomagnesaemia is associated with a condition is managed by increasing fluid intake and

deficit of 0.5–1 mmol/kg; up to 160 mmol Mg over giving bendroflumethiazide in a dose of 2.5 mg daily

up to 5 days may be required to replace the deficit (a higher dose is not usually necessary). Reducing diet-

(allowing for urinary losses). Magnesium is given initi- ary calcium intake may be beneficial but severe restric-

ally by intravenous infusion or by intramuscular injec- tion of calcium intake has not proved beneficial and may

tion of magnesium sulphate; the intramuscular injec- even be harmful.

tion is painful. Plasma magnesium concentration should

BNF 57

9.5.2 Phosphorus 535

be measured to determine the rate and duration of least 24 hours after last seizure; if seizure recurs, infusion and the dose should be reduced in renal impair-

additional dose by intravenous injection , 2 g (4 g if ment. To prevent recurrence of the deficit, magnesium

body-weight over 70 kg) may be given by mouth in a dose of 24 mmol Mg daily

. Prevention of seizures in pre-eclampsia [unlicensed in divided doses; suitable preparations are magnesium

indication], initially by intravenous injection over 5– glycerophosphate tablets or liquid [unlicensed], avail-

15 minutes, 4 g followed by intravenous infusion , able from ‘special-order’ manufacturers or specialist

1 g/hour for 24 hours; if seizure occurs, additional importing companies, see p. 939. For maintenance

dose by intravenous injection ,2g (e.g. in intravenous nutrition), parenteral doses of

Intravenous administration For intravenous injection con- magnesium are of the order of 10–20 mmol Mg daily

centration of magnesium sulphate should not exceed 20% (often about 12 mmol Mg daily).

(dilute 1 part of magnesium sulphate injection 50% with at least 1.5 parts of water for injections)

Arrhythmias Magnesium sulphate has also been Note Magnesium sulphate 1 g equivalent to Mg approx. recommended for the emergency treatment of serious

4 mmol

arrhythmias , especially in the presence of hypokalaemia Magnesium Sulphate (Non-proprietary) A (when hypomagnesaemia may also be present) and

Injection , magnesium sulphate 20% (Mg approx. when salvos of rapid ventricular tachycardia show the

0.8 mmol/mL), net price 20-mL (4-g) amp = £2.75; characteristic twisting wave front known as torsade de

50% (Mg approx. 2 mmol/mL), 2-mL (1-g) amp = pointes (see also section 2.3.1). The usual dose of

£3.80, 4-mL (2-g) prefilled syringe = £6.40, 5-mL (2.5- magnesium sulphate by intravenous injection is 2 g

g) amp = £3.00, 10-mL (5-g) amp = £3.35; 10-mL (5-g) (8 mmol Mg ) over 10–15 minutes (repeated once if

prefilled syringe = £4.95 necessary).

Brands include Minijet

Magnesium Sulphate 50%

Myocardial infarction

Limited evidence that magnesium sulphate prevents arrhythmias and reperfu- sion injury in patients with suspected myocardial infarc- tion has not been confirmed by large studies. Routine use of magnesium sulphate for this purpose is not

9.5.2 Phosphorus

recommended. For the management of myocardial infarction, see section 2.10.1.

9.5.2.1 Phosphate supplements

9.5.2.2 Phosphate-binding agents

Eclampsia and pre-eclampsia Magnesium sulphate is the drug of choice for the prevention of recurrent seizures in eclampsia; see also Appendix 4. Regimens may vary between hospitals. Calcium gluconate injec- tion is used for the management of magnesium toxicity.

9.5.2.1 Phosphate supplements

Magnesium sulphate is also of benefit in women with Oral phosphate supplements may be required in addi- pre-eclampsia in whom there is concern about develop-

tion to vitamin D in a small minority of patients with ing eclampsia. The patient should be monitored care-

hypophosphataemic vitamin D-resistant rickets. Diarr- fully (see under Magnesium Sulphate).

Nutrition MAGNESIUM SULPHATE

hoea is a common side-effect and should prompt a reduction in dosage.

Phosphate infusion is occasionally needed in alcohol Indications see notes above; constipation (section

dependence or in phosphate deficiency arising from use 1.6.4); severe acute asthma (section 3.1); paste for

of parenteral nutrition deficient in phosphate supple- boils (section 13.10.5)

ments; phosphate depletion also occurs in severe dia-

and

Cautions betic ketoacidosis. For established hypophosphataemia, see notes above; hepatic impairment

blood

monobasic potassium phosphate may be infused at a

(Appendix 2); renal impairment (Appendix 3); in rate of 9 mmol every 12 hours. In critically ill patients, severe hypomagnesaemia administer initially via

the dose of phosphate can be increased up to 500 micro- controlled infusion device (preferably syringe pump);

mol/kg (approx. 30 mmol in adults, max. 50 mmol), monitor blood pressure, respiratory rate, urinary

infused over 6–12 hours, according to severity. Exces- output and for signs of overdosage (loss of patellar

sive doses of phosphates may cause hypocalcaemia and reflexes, weakness, nausea, sensation of warmth,

metastatic calcification; it is essential to monitor closely flushing, drowsiness, double vision, and slurred

plasma concentrations of calcium, phosphate, potas- speech); pregnancy (Appendix 4); interactions: Appendix 1 (magnesium, parenteral)

sium, and other electrolytes. Side-effects generally associated with hypermagne-

For phosphate requirements in total parenteral nutrition saemia, nausea, vomiting, thirst, flushing of skin,

regimens, see section 9.3. hypotension, arrhythmias, coma, respiratory depres-

Phosphates (Fresenius Kabi) A sion, drowsiness, confusion, loss of tendon reflexes,

Intravenous infusion + , phosphates (providing PO muscle weakness; colic and diarrhoea following oral

19 mmol, and Na + c 162 mmol/litre), net administration

100 mmol, K

price 500 mL (Polyfusor ) = £3.75. Dose

For the treatment of moderate to severe hypophosphatemia . Hypomagnesaemia, see notes above

Phosphate-Sandoz c (HK Pharma) . Arrhythmias, see notes above

Tablets , effervescent, anhydrous sodium acid phos- . Prevention of seizure recurrence in eclampsia, initially

phate 1.936 g, sodium bicarbonate 350 mg, potassium by intravenous injection over 5–15 minutes, 4 g,

bicarbonate 315 mg, equivalent to phosphorus 500 mg followed by intravenous infusion , 1 g/hour for at

(phosphate 16.1 mmol), sodium 468.8 mg (Na +

9.5.3 Fluoride BNF 57

breast-feeding (Appendix 5); interactions: Appendix price 20 = £3.29. Label: 13

20.4 mmol), potassium 123 mg (K +

3.1 mmol). Net

1 (lanthanum)

Dose vitamin D-resistant hypophosphataemic osteomalacia, 4–6 Contra-indications tablets daily; CHILD under 5 years 2–3 tablets daily

pregnancy (Appendix 4) Side-effects gastro-intestinal disturbances; hypocalc- aemia; less commonly anorexia, increased appetite, taste disturbances, dry mouth, thirst, stomatitis, chest

9.5.2.2 Phosphate-binding agents

pain, peripheral oedema, headache, dizziness, vertigo, asthenia, fatigue, malaise, hyperglycaemia, hyperpar-

Aluminium-containing and calcium-containing prepara- athyroidism, hypercalcaemia, hypophosphataemia, tions are used as phosphate-binding agents in the man-

eosinophilia, arthralgia, myalgia, osteoporosis, agement of hyperphosphataemia complicating renal

sweating, alopecia, pruritus, and erythematous rash; failure. Calcium-containing phosphate-binding agents

accumulation of lanthanum in bone, and transient are contra-indicated in hypercalcaemia or hypercalciur-

changes in QT interval also reported ia. Phosphate-binding agents which contain aluminium

Dose

may increase plasma aluminium in dialysis patients. . ADULT over 18 years, initially 750 mg daily in divided Sevelamer is licensed for the treatment of hyper-

doses chewed with or immediately after meals, phosphataemia in patients on haemodialysis or perito-

adjusted according to plasma-phosphate concentra- neal dialysis.

tion every 2–3 weeks (usual dose range 1.5–3 g daily The Scottish Medicines Consortium (p. 3) has advised

in divided doses)

Fosrenol c (Shire) TA recommended for use within NHS Scotland for the

(November 2007) that sevelamer (Renagel c ) is not

Tablets (chewable), lanthanum (as carbonate hydrate) control of hyperphosphataemia in adults receiving

500 mg, net price 90-tab pack = £114.13; 750 mg, 90- peritoneal dialysis.

tab pack = £152.17; 1 g, 90-tab pack = £161.33. Lanthanum is licensed for the control of hyperphospha-

Label: 21, counselling, to be chewed taemia in patients with chronic renal failure on haemo-

dialysis or continuous ambulatory peritoneal dialysis

SEVELAMER

(CAPD). Indications hyperphosphataemia in patients on haemodialysis or peritoneal dialysis

ood ALUMINIUM HYDROXIDE Cautions bl gastro-intestinal disorders; pregnancy

Indications hyperphosphataemia; dyspepsia (section (Appendix 4); breast-feeding (Appendix 5); interac- and tions: Appendix 1 (sevelamer) 1.1)

n Cautions hyperaluminaemia; see also notes above;

Contra-indications bowel obstruction renal impairment (Appendix 3); interactions:

Side-effects gastro-intestinal disturbances; very rarely Appendix 1 (antacids)

intestinal obstruction Nutritio Side-effects see section 1.1.1

Dose

. ADULT 9 over 18 years, initially 2.4–4.8 g daily in 3 Alu-Cap c (3M)

, green/red, dried aluminium hydroxide Capsules divided doses with meals, then adjusted according to 475 mg (low Na + ). Net price 120-cap pack = £3.75

plasma-phosphate concentration (usual dose range Dose phosphate-binding agent in renal failure, 4–20 capsules

2.4–12 g daily in 3 divided doses) daily in divided doses with meals

Renagel c (Genzyme) A Tablets , f/c, sevelamer 800 mg, net price 180-tab

pack = £122.76. Label: 25, counselling, with meals Indications hyperphosphataemia

CALCIUM SALTS

Cautions see notes above; interactions: Appendix 1 (antacids, calcium salts)

9.5.3 Fluoride

Side-effects hypercalcaemia

Adcal Availability of adequate fluoride confers significant

c section 9.5.1.1

resistance to dental caries. It is now considered that Calcichew c section 9.5.1.1

the topical action of fluoride on enamel and plaque is Calcium-500 section 9.5.1.1

more important than the systemic effect. Phosex c (Vitaline) Where the fluoride content of the drinking water is less than 700 micrograms per litre (0.7 parts per million),

Tablets , yellow, calcium acetate 1 g (calcium 250 mg daily administration of fluoride tablets or drops is a or Ca

6.2 mmol), net price 180-tab pack = £19.79. suitable means of supplementation. Systemic fluoride Label: 25, counselling, with meals

supplements should not be prescribed without reference Dose phosphate-binding agent (with meals) in renal failure, according to the requirements of the patient

to the fluoride content of the local water supply. Infants need not receive fluoride supplements until the age of 6 months.

Dentifrices which incorporate sodium fluoride or mono- Indications hyperphosphataemia in patients on

LANTHANUM

fluorophosphate are also a convenient source of fluo- haemodialysis or continuous ambulatory peritoneal

ride.

dialysis (CAPD) Individuals who are either particularly caries prone or Cautions acute peptic ulcer; ulcerative colitis; Crohn’s

medically compromised may be given additional pro- disease; bowel obstruction; hepatic impairment;

tection by use of fluoride rinses or by application of

BNF 57

9.5.3 Fluoride 537

fluoride gels. Rinses may be used daily or weekly; daily FluoriGard c (Colgate-Palmolive) use of a less concentrated rinse is more effective than

Tablets 0.5 , purple, grape-flavoured, scored, sodium weekly use of a more concentrated one. High-strength

fluoride 1.1 mg (F 500 micrograms). Net price 200- gels must be applied on a regular basis under profes-

tab pack = £1.91

sional supervision; extreme caution is necessary to Tablets 1.0 prevent children from swallowing any excess. Less con- , orange, orange-flavoured, scored, sod- ium fluoride 2.2 mg (F 1 mg). Net price 200-tab pack centrated gels are available for home use. Varnishes are

also available and are particularly valuable for young or Dental prescribing on NHS May be prescribed as Sodium disabled children since they adhere to the teeth and set

Fluoride Tablets

in the presence of moisture. Fluoride mouthwash, oral drops, tablets and tooth-

paste are prescribable on form FP10D (GP14 in

Oral drops

Scotland, WP10D in Wales; for details see prepara- Note Fluoride supplements not considered necessary below 6 months of age (see notes above)

tions, below). There are also arrangements for health authorities to supply fluoride tablets in the course of pre-school

En-De-Kay c (Manx)

dental schemes, and they may also be supplied in Fluodrops c (= paediatric drops), sugar-free, sodium school dental schemes.

fluoride 550 micrograms (F 250 micrograms)/ Fluoride gels are not prescribable on form FP10D

0.15 mL. Net price 60 mL = £2.38 (GP14 in Scotland, WP10D in Wales).

Dental prescribing on NHS Corresponds to Sodium Fluo- ride Oral Drops DPF 0.37% equivalent to sodium fluoride

80 micrograms (F 36 micrograms)/drop