This page is a guide to help you understand some of the current treatments used to treat early inflammatory arthritis.

What is combination DMARD therapy?

On diagnosis with inflammatory arthritis, it is common practice to be started on some of the medications in this leaflet, either individually or in combination, to reduce pain, swelling and stiffness in your joints.

It may take 3 - 4 months before you start to feel the benefit of these medications (6 or more weeks for Leflunomide). Steroids should provide more immediate (but short term) relief.

Your doses may be increased or decreased gradually at clinic appointments or new drugs may be added or taken away from your regime.

You will be given the first prescription (for 1 month duration) from the hospital. Further supplies of your medicine should be obtained from your GP. It is important you do not run out of your medication.

Keep all medicine out of the reach of children.

If you buy medicines from your local pharmacy, tell the Pharmacist you are on this medication.

Methotrexate – Once a week only

• This is a weekly medication, which should be taken on the same day each week.
• You should only be given 2.5mg strength tablets to make up your dose (e.g. a dose of 15mg would be six x 2.5mg tablets taken together, once a week).
• You will be prescribed another tablet, folic acid, which you will be advised to take on a particular day or up to 6 out of 7 days, but it should NEVER be taken on the same day as your methotrexate.
• Report the onset of sore throat, bruising, mouth ulcers, nausea, vomiting, abdominal discomfort, dark urine or shortness of breath immediately.
• If you do not tolerate the tablets, your clinician may recommend switching to an injectable version.

Sulfasalazine

• This is a medication that is usually taken twice a day and may colour your urine orange.
• You may be given tablets with an enteric coating (which should be swallowed whole and not taken at the same time as indigestion remedies) or plain tablets.
• The dose will be increased gradually at the beginning. The usual starting regime is:

Sulfasalazine starting regime

500mg tablets	Morning	Evening
Week 1	One tablet
Week 2	One tablet	One tablet
Week 3	Two tablets	One tablet
Week 4 (onwards)	Two tablets	Two tablets

Hydroxychloroquine

• This medication is usually taken once or twice a day, with or after food; the dose depends on your body weight and disease activity.
• You will require baseline and ongoing annual eye checks at your high street optometrist. When you have been on treatment over 5 years (or earlier if you have additional risk factors) you will be referred to have an ophthalmic (eye) examination at a specialist hospital; your clinician will discuss this with you.

Leflunomide

• This is usually a once daily tablet.
• You will need to have your weight and blood pressure checked at each monitoring visit.

Corticosteroids

• You may be given prednisolone tablets; your dose will be made up of a combination of tablets which should be taken together in the morning as a single dose and should be taken with or after food. Do not stop taking prednisolone tablets suddenly, without advice from your clinician.
• You may be given a methylprednisolone depo injection (Depo-Medrone) which is a long acting injection into the bottom muscle. This can also be arranged to help with a flare up by calling our advice line service.
• You may be brought in to our medical day case unit to receive a methylprednisolone intravenous (drip) infusion.
• Your consultant may choose to inject your most affected joints with a steroid directly.
• If you are prescribed corticosteroids, you should usually be supplied with two different steroid cards: a ‘Steroid Treatment Card’ (blue) and a ‘Steroid Emergency Card’ (red). If you are not given these, it may be that you do not require both on this occasion but please check with your clinician.

Other advice

DMARD therapy should not routinely be stopped for surgery although individualised decisions may be made depending on the type of surgery.

During a serious infection (if you require hospital admission and / or antibiotics given via a drip infusion), your methotrexate, leflunomide or sulfasalazine should be temporarily discontinued until you have recovered from the infection.

More information about the drugs is available via www.versusarthritis.org/ and National Rheumatoid Arthritis Society (nras) leaflet Medicines in Rheumatoid Arthritis (including information about side effects).

Blood monitoring

These drugs will need regular blood monitoring as stated in your clinic letter. Your GP can also check the monitoring requirements on the BNSSG website.

Routine blood monitoring includes full blood count (FBC), renal function (SeCr / eGFR), and liver function tests (LFTs).

Frequency

For new treatment

Routine blood tests every 2 weeks until on stable dose for 6 weeks, then every month for 3 months, then every 12 weeks.

Following a dose increase

Routine blood tests every 2 weeks until on stable dose for 6 weeks, then revert to previous schedule.

Exceptions

Sulfasalazine – standard monitoring schedule for 12 months then no routine blood tests required (unless combined with other treatment).

Hydroxychloroquine – no blood tests required (unless combined with other treatment).

Methotrexate in combination with leflunomide – continue on monthly monitoring longer term.

Preparation for your appointments

We want you to be active in your healthcare. By telling us what is important to you and asking questions you can help with this. The three questions below may be useful:

1. What are my options?
2. What are the possible benefits and risks of those options?
3. What help do I need to make my decision?

References

Ledingham, J., Gullick, N., Irving, K. et al., on behalf of the BSR and BHPR Standards Guidelines and Audit Working Group, 2017. ‘BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs’, Rheumatology, 56 (6) p865–868. Available at: doi.org/10.1093/rheumatology/kew479.

National Rheumatoid Arthritis Society (NRAS) (2017). Medicines in Rheumatoid Arthritis. Available at: nras.org.uk/product/medicines-in-rheumatoid-arthritis/

Versus Arthritis. Treatments: Drugs. Available at: www.versusarthritis.org/about-arthritis/treatments/

Rheumatology DMARD medication record form

A Rheumatology DMARD medication record form (compliance chart) is available on the printed copy of this patient information leaflet (NBT003100). Please ask your clinician if you would like a paper copy to complete.

It is important that you update your medication record form regularly and after any medication changes (and specify the date it has been updated).

How to contact us

Rheumatology Advice Line

0117 414 0600

Ask three questions

Preparation for your appointments

We want you to be active in your healthcare. By telling us what is important to you and asking questions you can help with this. The three questions below may be useful:

1. What are my options?
2. What are the possible benefits and risks of those options?
3. What help do I need to make my decision?

If your arthritis is not well controlled on conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs), your treatment may be escalated to either a biologic disease modifying anti-rheumatic drug (bDMARD or biologic) or targeted synthetic disease modifying anti-rheumatic drug (tsDMARD) by your rheumatology clinician.

One of the Rheumatology Specialist Nurses or the Specialist Pharmacists will already have discussed with you which medicine you will be taking.

This page has been created to help you remember the important key information in relation to your medicine.

Contents

Section 1 - Choice of treatments

Section 2 - Monitoring

Section 3 - Infections

Section 4 - Vaccinations

Sections 5 - Pregnancy and breastfeeding

Section 6 - Surgery

Section 7 - Side effects

Section 8 - Dose reduction

Section 9 - Home delivery and self-administration

Section 10 - Travel

Section 11 - Contact information

1. Choice of treatment

What are bDMARDs?

bDMARDs are a group of medications that are used to treat arthritis (such as rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis).

These medicines can decrease the amount of inflammation you have and reduce the damaging effects of your arthritis on your joints.

There are now quite a few bDMARDs available to treat different types of arthritis; which medicine you have been prescribed may depend on the type of arthritis that you have or another medical condition at the same time as your arthritis that might make one treatment more appropriate than another.

At the time of writing, bDMARDs used for different conditions include:

• abatacept
• adalimumab
• anakinra
• belimumab
• certolizumab pegol
• etanercept
• golimumab
• guselkumab
• infliximab
• ixekizumab
• risankizumab
• rituximab
• sarilumab
• secukinumab
• tocilizumab
• ustekinumab

However more are becoming available very often.

bDMARDs can be given either as an injection into the layer of fat just underneath the surface of your skin (a subcutaneous injection) or by a drip into your vein (intravenous infusion).

If you have a subcutaneous injectable medication you can be taught how to do this yourself at home or someone can be taught to give you the injections, such as a family member.

If you are having an intravenous infusion you will need to come to the Medical Day Care Unit in Southmead Hospital which is located on Level 1 in Gate 5 of the Brunel building.

What are Biosimilar Medicines?

Some of the bDMARD medicines listed above are now available in the UK as similar versions made by different companies, because the patent (allowing one company to make the product exclusively) has expired.

These different versions of existing bDMARDs are known as ‘biosimilars’ because they are deemed to be sufficiently similar (in terms of safety and effectiveness) to the original product.

Switching between biosimilar brands should not affect the safety or the effectiveness of your medicine.

Switching patients to the most cost-effective version of bDMARD allows the NHS to treat more patients with these expensive therapies.

NHS England may ask us to change the brand of bDMARD medication you are prescribed from time to time and we will discuss this with you.

What are tsDMARDS?

tsDMARDs are targeted synthetic therapies.

Like biologic medicines, they target specific parts of the immune system, however they are not made from living cells. They are smaller chemical drugs and can usually be taken by mouth.

There are now quite a few tsDMARD medicines available to treat different types of arthritis; which medicine you have been prescribed may depend on the type of arthritis that you have or your other relevant medical conditions.

At the time of writing, this group of medicines include:

• apremilast
• baricitinib
• filgotinib
• tofacitinib
• upadacitinib

But others are going through approval steps so may be available soon.

How do we help you decide which b/tsDMARD is the best for you?

When your consultant or clinician decides it would be appropriate to start a b/tsDMARD therapy, we will usually invite you to a clinic appointment with the Rheumatology Specialist nurse or Rheumatology Specialist Pharmacist to carry out your baseline assessments (this usually includes a joint examination and blood tests) and talk to you about your new treatment options.

The Nurse or Pharmacist will complete some paperwork with you and discuss the main symptoms associated with your condition, your other medical problems, previously tried therapies and any patient preferences you might have.

Once we have discussed your condition and preferences, we will look at the most cost-effective treatment to suit your needs.

We will support you to make a shared, informed decision about the most appropriate treatment for you.

2. Monitoring

Will I need any special monitoring whilst taking a b/tsDMARD?

This depends on whether you take another medication, such as methotrexate, with the b/tsDMARD medicine.
If you are taking another medication with the b/tsDMARD medicine

If you are taking another medication with the b/tsDMARD medicine

You should be having regular blood tests via your GP to monitor this, and you will not need any different or additional blood tests (unless we tell you). You need to phone your GP surgery to arrange these blood tests.

If you take the b/tsDMARD medicine on its own (monotherapy)

• We usually ask you to have blood tests for full blood count, liver function and kidney function every 3 months for the first year and then every time you are seen for a review by the Rheumatology Team (usually every 6 months).
• For some b/tsDMARDs, the monitoring schedule might be different to this and we will tell you if this is the case.
• If you have a remote consultation (e.g. telephone or video review), we may arrange for you to have your blood sample taken at your GP surgery, but we tell you and advise how we will check the results.
• We may ask you to contact our rheumatology advice line (by email or telephone) to let us know you have had your blood sample taken so we can look out for the results.
• We need to review your blood test results before prescribing your medicines. We will not be able to prescribe your medicines if you have not had your routine blood test.

Will I need to be seen in the hospital clinic for regular reviews whilst taking a b/tsDMARD?

Once you have started treatment, we will usually give you a call after a couple of months to see how you are getting on with your new medication. We will then invite you to attend a face-to-face appointment to check your joints and see if you are responding to your new treatment. This appointment will be either 3, 4, 5 or 6 months after starting treatment, depending on which treatment you are on.

You will then be followed up routinely every 6 months.

Your review appointments may be face to face or in our Remote Therapy Clinic (RTC). This can be via telephone, video, or occasionally we may be able to complete a virtual review which means we have checked your hospital records and blood tests and have deemed it safe to prescribe further medication without speaking to you, but we will always write to you to let you know if this is the case.

If you feel you need to be seen sooner than your scheduled appointment or if you feel you need to be seen face-to-face rather than remotely, please contact us via the rheumatology advice line; you do not have to wait until your scheduled appointment.

It is very important that you do attend regularly for reviews with your Rheumatology Team as the prescriptions of the b/tsDMARD medicines are based on your hospital appointments – if we do not review you in clinic (face-to-face or remotely), we will not be able to prescribe more b/tsDMARD medicine until we have seen you.

It is really helpful for us to understand how you are responding to your b/tsDMARD medication.

Some patients are able to track their symptoms, disease activity and overall wellbeing on a disease activity tracking smartphone application. If you are not already using this but are keen to do so, please contact our rheumatology team so we can register you for this service (free of charge).

If you are expecting to be seen by the hospital but do not receive an appointment letter, please get in touch with us to check you have been booked into an appointment.

What happens if my new b/tsDMARD treatment doesn’t work?

It usually takes about 3-6 months for your b/tsDMARD to be fully effective, although some patients feel the benefit much sooner. We might prescribe you some other medication to help with symptoms whilst waiting for your b/tsDMARD to have an effect.

If your new medication doesn’t help improve your symptoms, we may need to stop your medication, allow for it to come out of your system and decide on an alternative treatment.

Sometimes, your medication will work very well at the beginning but might lose effect over time. If this happens, we may need to stop your medication, allow time for it to come out of your system and chose an alternative treatment.

It is important that you attend your follow up appointments so we can check how well your medication is working. Please always be honest with how your symptoms are feeling.

3. Infections

When not to have your b/tsDMARD and managing infections

You should not have your b/tsDMARD medicine if you are unwell in any way, if you are currently taking antibiotics or if you have just had or are having any surgery in the next few weeks.

You can use the checklist below to help you to decide if it is safe for you to give the injection or to help you decide if you should contact us for further advice before your infusion.

Do you have any of the following?

• Sore throat
• Cough / cold
• Diarrhoea and/or vomiting
• High temperature
• Burning or stinging when passing urine
• Wounds or cuts that could be infected
• Flu type symptoms
• Feeling out of breath
• Dental treatment such as a tooth extraction or a root canal filling.
• Having an operation – see surgery section below

If you say ‘yes’ to any of the above you should contact us on the rheumatology advice line for further advice before giving your injection or before attending your next appointment for an infusion.

After an infection

It is usually safe to restart your b/tsDMARD medication when you are feeling well and you do not have any signs of symptoms of an infection.

If you have had antibiotics

We recommend not starting treatment until at least 48hrs after completing the course of antibiotics as long as you are well.

If you restart your b/tsDMARD therapy on a different day to your usual injection day, this will become your new injection day and you need to count the dosing interval from this day. Never shorten the gap between doses.

If you develop chicken pox, shingles or come into contact with someone who has chicken pox or shingles (and you have not had it before), stop your b/tsDMARD and seek medical attention.

4. Vaccinations

Can I have any vaccinations whilst taking a b/tsDMARD?

• Whilst you are taking a b/tsDMARD medicine you cannot have any live vaccinations, such as the yellow fever vaccination.
• Your GP or practice nurse can discuss the possible risks and benefits of any vaccinations with you and advise which vaccinations are live.
• If you are in your 70s and are offered the shingles vaccination, please check with the GP surgery that they are offering the non-live shingles vaccine which is safe for you to have. You cannot have the live shingles vaccine.
• The yearly flu vaccination, 5 yearly pneumonia vaccination and Covid vaccinations are not live and do not interfere with b/tsDMARDs. We recommend you have these when offered.

5. Pregnancy and breastfeeding

Can I plan for pregnancy and can I breastfeed whilst taking a b/tsDMARD?

Although we have more information to suggest some bDMARD therapies are safe to use in specific trimesters of pregnancy, it is generally advisable that you do not become pregnant whilst on a b/tsDMARD medicine unless you have discussed this with your rheumatology consultant first and been told it is safe to continue taking your medicine.

• Your rheumatology consultant will be able to discuss which treatment is most recommended for your individual circumstances and when the treatment needs to be stopped (or whether you require it to continue).
• This will also impact whether or not your baby can have live vaccines between birth and 6 months old. Generally, you should make sure that you use reliable contraception whilst taking a b/tsDMARD medicine.
• If you unexpectedly become pregnant whilst taking a b/tsDMARD, please discuss this as soon as possible with your rheumatology consultant.
• Some of the established bDMARD therapies can be continued during breastfeeding, but again this needs to be discussed with your clinician.

Can I father children whilst on b/tsDMARDs?

Although it is thought that a number of therapies can be considered safe in men who wish to father children, it is advisable that you discuss this with your rheumatology consultant first and check it is safe to continue taking your medicine.

This decision is made on your personal needs and your thoughts and beliefs are taken into consideration before making the decision; this is to make sure that any decision made is the best one for you and your family.

You should make sure that you use reliable contraception whilst taking a b/tsDMARD medicine.

6. Surgery

What happens if I need surgery?

For planned surgery

You will need to come off your treatment for a certain amount of time beforehand to lower your infection risk with your surgery. Please contact us on the rheumatology advice line well in advance if your surgery so we can advise on the appropriate time to stop your b/tsDMARD.

For emergency surgery

It is important you let the surgical team know when you last had your dose of b/tsDMARD in case you need some preventative antibiotics.

You should also carry your b/tsDMARD alert card around with you.

Following surgery

You can usually restart your b/tsDMARD when your wound shows evidence of healing, any sutures/staples are out, there is no significant swelling, redness or drainage and there is no ongoing nonsurgical site infection, which is typically around 14 days.

7. Side effects

What should I do if I get side effects from my medication?

The information leaflet provided with your medication will list the potential side effects with your specific b/tsDMARD and some information on the likeliness of them occurring.

• Generally, the most common side effects are changes to your blood tests (which is why we monitor them) or increased frequency or severity of infections (which is why it is important that you don’t inject if you have an infection – see when to not have your injection section).
• There is no conclusive evidence to suggest an increased risk of cancer with bDMARDs, but data regarding risk of skin cancers are less clear and we recommend using a high SPF sun cream with UVA/B and 5* rating.
• If you are on a tsDMARD, it is important to report any signs or symptoms of a blood clot, for example chest pain, breathlessness, coughing up blood, leg pain, tenderness or swelling in your thigh or calf.
• You may experience injection site reactions to medicines you inject yourself. Applying a cold compress can help. Usually this reduces when you get more experienced at injecting. If you have a severe injection site reaction or a reaction hasn’t gone away when you are due to inject again, please get in touch with us as you may need to stop your treatment.
• Once you have had your first dose of b/tsDMARD, it is important that you let your GP surgery know you have started your treatment in case you have any reaction to your first or subsequent doses.
• It is important you let you Rheumatology Team know if you are suffering with side effects to your medication.
• If you develop any anaphylaxis or severe side effects, stop the medication and seek urgent medical attention (e.g. contact the usual out of hours emergency medical care).

8. Dose reduction

How long will I be on my b/tsDMARD medication?

• If you are responding to treatment with low disease activity or in remission after being on treatment for two years, we might look at reducing some of your medication.
• Firstly we would want to stop any remaining steroids and make sure you are on the optimal dose of csDMARD.
• We would then invite you to consider our dose reduction program known as Biologics Treatment Reduction by Interval Management (BTRIM). This is a step-wise dose reduction program.
• We will recommend slowly stretching out the gap between your injections in a very controlled way and allow you to decide when you are ready to stretch the gap out further or decide if you need to go back to the previous effective dose.
• We will provide you with written information about this and clears steps of action to take if your symptoms worsen.
• We will not supply you with less medication when you are trialling dose reduction so you will be able to return to standard dosing if preferred.
• Not all patients are able to come off treatment completely but many patients are able to stretch out the gap between their injections to reduce their overall dose.
• If you are keen to reduce the dose of your medication after 2 years on treatment and this hasn’t been discussed with you, please speak to your clinician at your appointment.

9. Home delivery and self-administration

Additional information for self-injectable bDMARDs and oral tsDMARDs, supplied by home delivery

The rest of this page focuses on the important parts to remember if you are taking an injectable form of bDMARD or oral tsDMARD medicine that is supplied via a home delivery provider.

How do I get supplies of my medicine?

Your b/tsDMARD medicine can only be prescribed by your Rheumatology team through the hospital. This means that you won’t be able to collect it with your usual medicines from your pharmacy, chemist or GP.

We use a Home Delivery Service who will deliver your medication to you at home. If you wish, you may arrange with them to deliver your medication to an alternative address (e.g. work address) if this would be more suitable (but this cannot be a local GP or community pharmacy).

Your Rheumatology Specialist Nurse or Specialist Pharmacist can give you details about which home delivery service will be delivering your medication.

Do my medicines need to be stored in the fridge?

• bDMARDs generally need to be kept in the fridge (between 2-8°C).
• Occasionally they can be kept out of the fridge for a short duration (depending on which injection you use).
• When you receive delivery of your first injections, they should be put in the fridge and until you are informed that a nurse is coming to show you how to inject your first dose.
• We recommend taking your injection out of the fridge 30 minutes before you inject it to reduce the change of it stinging when you inject it.
• tsDMARDs do not need to be kept in the fridge.

What happens if a bDMARD (biologic) medicine is left out of the fridge for too long or the fridge breaks down?

If this happens then you will need to contact the homecare delivery company who deliver your medicine and let them know so that they can arrange for the affected medication to be replaced.

You will also need to let the Rheumatology department know by calling the rheumatology advice line in case we need to provide the homecare delivery company with another prescription.

In some circumstances, we may advise that one or two injections can still be used, but we will provide personal instructions to you depending on your situation.

tsDMARD medicines do not need to be stored in the fridge.

What happens if I forget to give an injection or take a tablet?

If you forget to give an injection then you should give a dose as soon as you remember and then make sure that you take the next dose at the correct interval to make sure that you do not give the next dose too early.

For further advice on the specific medicine you are taking please contact the Rheumatology Advice Line.

If you forget to take a tablet (tsDMARD), do not take a double dose to make up for the forgotten dose. Take your next tablet at the usual time and continue as before.

What happens if something goes wrong when giving an injection (bDMARD)?

If the pen or syringe slips when you are giving your injection or if the device does not work properly for any reason please contact us on the Rheumatology Advice Line for more help on the particular problem you have experienced.

Do not try and inject another dose in case some of the first dose was given.

What should I do if the pen or syringe is faulty?

If you think that your pen or syringe is faulty for any reason please make a note of the batch number and expiry date (this information can be found on the box containing your medicine).

Please report any faulty pens or syringes to your home care delivery company.

How do I dispose of my injections?

You will be supplied with a sharps bin for disposing of your injections. When your sharps bin is full with used pens/syringes, contact your homecare company to arrange a collection for disposal.

10. Travel

Can I take my biologic/tsDMARD medicine on holiday with me?

It is possible to travel (either abroad or within the UK) with your b/tsDMARD medicine, but you will need to plan ahead.

• Airlines – ask your airline company in advance whether you can carry your medicine in your hand luggage (do not place your medicine in any checked in luggage as the baggage area is too cold).
• Carry documentation with you to explain why you need to take the medicine with you. You can ask the home delivery company to provide you with a letter for this purpose and we recommend taking your most recent clinic letter with you. You can also call us on the rheumatology advice line if you are struggling to get the suitable letter. Please make sure that you allow enough time between letting us know and us being able to post the letter to you before you travel.
• As a general rule, all biologic medicines should be stored in a refrigerator at temperatures between 2 and 8°C. Please contact us on the Rheumatology Advice Line for advice on how to safely transport your individual medicine.
• Please let us know in advance if you are planning to travel, so we can make sure you have sufficient supplies of medication.
• We can also provide extra advice about reducing the risk of infection when travelling.

11. Examples of who to contact

Contact your homecare provider

If you:

• have any problem with deliveries
• run out of supplies
• leave medication out of the fridge by mistake (you will also need to contact the rheumatology advice line)
• have a faulty pen or syringe
• have a full sharps bin that needs collecting
• need to change your delivery address

Contact the rheumatology advice line

If you:

• have any questions about your medication
• have any side effects
• have run out of medication and your homecare provider are telling you they do not have a prescription
• are unsure whether you should have your b/tsDMARD (e.g. if you feel unwell)
• feel you need to be seen sooner than your scheduled appointment or would like to change a remote consultation to be seen face-to-face
• leave medication out of the fridge by mistake (you will also need to contact the homecare provider)
• are expecting to be seen by the hospital but have not
• received an appointment letter
• want to plan a pregnancy
• feel your medicine has stopped working
• you are planning a holiday

Contact your GP

To arrange your blood tests and let them know once you’ve had your first dose of b/tsDMARD.

Contact emergency care (e.g. GP, 111, A&E)

If you have an allergic reaction to your medication or severe side effect.

Glossary of Terms

Subcutaneous injection

An injection using either a syringe or a pen injection device. The injection is given into the small layer of fat just underneath the surface of the skin.

Intravenous infusion

Medication which is given slowly through a needle in your vein.

Biosimilar medicines

These are different versions of existing biological medicines, thought to have similar effectiveness and safety, brought out because the patent (allowing one company to make the product exclusively) has expired.

Monotherapy

This is a term which is commonly used when patients have just one medicine to control their arthritis.

Dental extraction

Removal of a tooth, which would leave a hole in the gum and may become infected.

Root canal filling

Filling material is placed in the canals and the tooth is sealed with a temporary filling to protect it from infection. Then a crown is usually placed over the tooth to seal and protect it from recontamination and future damage.

References

www.medicines.org.uk

www.rheumatology.org.uk

www.versusarthritis.org/about-arthritis/

How to contact us

Rheumatology Advice Line

Telephone: 0117 414 0600

NHS Out of Hours Service

111 (Monday to Friday, 6.30pm - 8am, all day weekends and Bank Holidays)

Rheumatology Advice Line

rheumatologyadviceline@nbt.nhs.uk

Living With app

Contact the rheumatology advice line to sign up.

The FAST MRI research programme has been designed to find the most aggressive form of breast cancers sooner.

Early breast cancer detection and diagnosis saves lives. The NHS Breast Screening Programme offers women aged 50-70 years a mammogram every 3 years. By detecting breast cancers before they can be seen or felt, breast screening already saves about 1,300 lives each year in the UK. MRI scans can detect some aggressive breast cancers even earlier than mammograms.

Unfortunately, MRI scans are expensive, and so the NHS uses them only to screen women at a high risk of developing breast cancer. New evidence suggests that MRI scans can be abbreviated to reduce their cost to the NHS, without affecting their ability to accurately display breast cancers.

FAST MRI is an abbreviated form of MRI which takes less time to acquire (3 vs 20 mins on the scanner) and to interpret (1 vs 10 mins). Unlike mammograms, FAST MRI scans can identify aggressive cancers irrespective of breast density – a trait found more commonly in younger women. Therefore, we are developing FAST MRI for women who are having their first screening by the NHS Breast Screening Programme. We wish to find out if FAST MRI could find aggressive cancers even earlier and smaller for these women because early detection of breast cancer saves lives.

FAST MRI Studies:

DYAMOND

OPERA

ENAID

Mapping the learning curve of novice FAST MRI readers

Quality Assurance/Technical Development

Reader Training Programme: Multi-Centre Study

Reader Training Development: Single-Centre Study

Further Info:

If you would like more information about the FAST MRI research programme, or would like to find out how you can get involved, please contact FASTMRI@nbt.nhs.uk.

You can also get to know the researchers and support staff delivering this study by visiting the FAST MRI Research Team page.

The FAST MRI Programme has been developed by a multidisciplinary team of collaborating clinicians, academics and members of the public across the UK, led by North Bristol NHS Trust. Together the FAST MRI team bring a wealth of experience in imaging, research, science and breast cancer screening and treatment.

Early breast cancer detection and diagnosis saves lives. The NHS Breast Screening Programme offers women aged 50-70 years a mammogram every 3 years. By detecting breast cancers before they can be seen or felt, breast screening already saves about 1,300 lives each year in the UK. MRI scans can detect some aggressive breast cancers even earlier than mammograms.

Unfortunately, MRI scans are expensive, and so the NHS uses them only to screen women at a high risk of developing breast cancer. New evidence suggests that MRI scans can be abbreviated to reduce their cost to the NHS, without affecting their ability to accurately display breast cancers.

FAST MRI is an abbreviated form of MRI which takes less time to acquire (3 vs 20 mins on the scanner) and to interpret (1 vs 10 mins). Unlike mammograms, FAST MRI scans can identify aggressive cancers irrespective of breast density – a trait found more commonly in younger women. Therefore, we are developing FAST MRI for women who are having their first screening by the NHS Breast Screening Programme. We wish to find out if FAST MRI could find aggressive cancers even earlier and smaller for these women because early detection of breast cancer saves lives.

Meet the team:

Dr Lyn Jones

Dr Becky Geach

Dr Katherine Klimczak

Sadie Mckeown-Keegan

Dr Sam Harding

Professor Janet Dunn

Dr Andrea Marshall

Professor Sian Taylor-Phillips

Dr Sarah Vinnicombe

Dr Chris Foy

Professor Claire Hulme

Professor Mark Halling-Brown

Dr Elizabeth O’Flynn

Miss Shelley Potter

The BIRCH team

Public Involvement Members

Useful contacts

Pearce Brothers Mobility Services (Yate)

10-14 Stove Road

Bristol

BS37 5JN

0800 5420210

www.pearcebrosmobility.co.uk

Bristol Mobility Centre

423 Whitehall Road

St George

Bristol

BS5 7BP

0117 9515558 

0800 7834119

www.bristolsmobilitycentre.co.uk

Optimum Mobility

The Old Dairy

Pinkney Park

Near Sherston

Malmesbury

SN16 0NX

01666 840060

www.optimummobility.co.uk

Weston Mobility UK

234 High Street

Worle

North Somerset

BS22 6JE

01934 516896

https://wmukmobility.co.uk

Gooding Disability Service

29 Whitecross Road

Weston-super-Mare

North Somerset

BS23 1EN

01934 611304

Mark’s Mobility

52 Satchfield Cres

Henbury

Bristol

BS10 7BG

0117 915 5253

info@marksmobility.co.uk

www.marksmobility.co.uk

Bristol Community Transport

Email: bctoffice@hctgroup.org

Tel: 0117 902 0157

Swan Transport (Bath)

Tel: 01761 439548

Email: swan.transport@btconnect.com

Driving and Mobility Centre

The Vassall Centre

Gill Avenue

Fishponds

Bristol

BS16 2QQ

Tel: 0117 965 9353

Email: mobserv@drivingandmobility.org

Shopmobility

Bristol

Cabot Circus Car Park

0117 955 9083

Bath

One Stop Shop, 3-4 Manvers Street

01225 477111

Bridgwater

52 Clare Street

01278 434 254

Cardiff

St David’s Shopping Centre

02920 399 355

Cheltenham

30 St George’s Place

01242 255 333

Salisbury

3b Priory Square

01722 328 068

Swindon

Sanford Street

01793 512 621

Taunton

Orchard Car Park

01823 327 900

Yate

2 North Parade, Yate Shopping Centre

01454 868 718

Motability

City Gate House

22 Southwark Bridge Road

London

SE1 9HB

Tel: 0300 456 4566

Website: www.motability.co.uk

Disabled Motoring UK

National Headquarters

Ashwellthorpe

Norwich

NR16 1EX

Tel: 01508 489449

Website: www.disabledmotoring.org

Blue Badge Schemes

www.gov.uk (Supplies all information required)

Benefits Information

PIP helpline

0800 1214433

Disability Living Allowance Helpline

0800 1214600

The Pension Service

0800 7317898

DWP

0345 6088545

Website: www.gov.uk

Website: www.citizensadvice.org.uk/benefits

National Associations

Limbless Association

Unti 10, Water House, Business Centre

Chelmsford

Essex

CM1 2QE

Helpline: 0800 644 0185

Website: www.limbless-association.org

Disabled Living Foundation

4th Floor Jessica House

Red Lion Square

191 Wandsworth High Street

London

SW18 4LS

Tel: 0300 999 0004

Website: www.dlf.org.uk

Training and Equipment Demonstration Centre

Disabled Living Foundation

4a Buckhold Road

London

SW18 4GP

Email: training@dlf.org.uk

Training: 020 7432 8010

Disability Rights (Previously RADAR)

Plexal, 14 East Bay Lane

Here East

Queen Elizabeth Olympic Park

Stratford

London

E20 3BS

Tel: 0330 995 0400

Website: www.disabilityrightsuk.org

PHAB (Physically Disabled/ Able Bodied)

Summit House

50 Wandle Road

Croydon

Surrey

CR0 1DF

Tel: 020 8667 9443

Website: www.phab.org.uk

Email: info@phab.org.uk

REACH – The Arm Association for Children with Hand or Arm Deficiency

Pearl Assurance House

Brook Street

Tavistock

Devon

PL19 0BN

Tel: 0845 130 6225 or 020 3478 0100

Website: www.reach.org.uk

Activity Alliance

SportPark

Loughborough University

3 Oakwood Drive

Loughborough

Leicestershire

LE11 3QF

Tel: 01509 227750

Website: www.activityalliance.org.uk

Sport England

SportPark

3 Oakwood Drive

Loughborough

Leicestershire

LE11 3QF

Tel: 0345 8508 508

Website: www.sportengland.org

British Paralympic Association

101 New Cavendish Street

London

W1W 6XH

Tel: 020 7842 5789

BLESMA (British Limbless Ex-Service Men’s Association)

The Limbless Veterans

115 New London Road

Chelmsford

CM2 0QT

Website: www.blesma.org

Research Institute for Disabled Consumers (RiDC)

Ground Floor

Unit 10

Blenheim Court

26 Brewery Road

London

N7 9NY

Email: mail@ridc.org.uk

Limbpower

Whitecroft

Tangridge Lane

Lingfield

Surrey

RH7 6LL

Tel: 07502 276 858

Website: www.limbpower.com

Email: info@limbpower.com

Steps

The White House

Wilderspool Business Park

Greenall’s Ave

Warrington

Cheshire

WA4 6HL

Tel: 01925 750 271

Website: www.stepsworldwide.org

Email: info@steps-charity.org.uk

Infection Sciences Contacts

Clinical Lead Infection Sciences/Consultant in Infection (Medical Microbiology)
Dr Isabel Baker

UK Health Security Agency Regional Head of Operations 
Mr Jon Steer

Infection Sciences Quality Manager
Mrs Debbie Williams

For complaints or to raise any concerns/issues with services provided by the Infection Sciences laboratory please contact via the following:

Email: ISQuality@nbt.nhs.uk

This email can also be used for general enquiries but please note it is not for sample enquiries, e.g. clinical advice or results.

Address: Infection Sciences Laboratory
Pathology Sciences Building
Southmead Hospital
Westbury-on-Trym
Bristol
BS10 5NB

Bacteriology
Head of Bacteriology/Consultant in Infection
Dr Martin Williams

Bacteriology Laboratory Manager
Ms Nicola Childs

Virology
Head of Virology/Consultant Medical Virologist
Dr Matthew Donati

Virology Laboratory Manager
Mr Richard Hopes

Mycology Reference laboratory
Director of MRL/Consultant Clinical Scientist
Dr Elizabeth Johnson

MRL Laboratory Manager
Mr Michael Palmer

Anti-microbial Reference Laboratory
Principal Clinical Scientist
Mr Alan Noel

What is lactose intolerance?

Lactose intolerance means that your body cannot digest lactose. Milk is made up of fats, proteins and sugar (carbohydrate). Lactose is a type of sugar (carbohydrate) that is in milk and milk products.

What are the symptoms?

• Wind 
• Bloating
• Tummy ache
• Stomach cramps
• Tummy rumbling
• Nausea (feeling sick)
• Diarrhoea (loose stools)

What are the causes?

Lactose intolerance happens when your body does not make enough lactase.

Lactase is an enzyme that breaks down lactose; it is made in the lining of the small bowel. Enzymes break down sugars into smaller parts, so that they can pass from your gut into your body.

Types of lactose intolerance

There are two types of lactose intolerance: primary and secondary.

Primary lactase deficiency

Primary lactase deficiency is a lifelong genetic condition (runs in families). It is most common in people from Africa and Asia, but anyone can have it. 2 out of 3 people in the world have this. You may produce lactase as a child, but less lactase as you grow up.

Secondary lactase deficiency

Secondary lactase deficiency is usually short term. It is due to illnesses that affect your small bowel such as coeliac disease, inflammatory bowel disease (IBD), gastrointestinal infections and abdominal surgery.
Lactose cannot be broken down or absorbed without lactase. It will pass into the colon instead. In the colon it will be fermented which makes gas. Lactose also pulls water into the bowel, which is why it can also cause loose stools.

Lactose intolerance is not the same as an allergy. If you have lactose intolerance you may be able to manage some lactose in your diet in smaller amounts. However, if you have a milk protein allergy you need to strictly avoid all milk products.

Some people do not make the lactase enzyme but do not get bad symptoms. Other people can make the lactase enzyme but still have bad symptoms. Lactose may make you feel ill but it will not do any long-term harm or hurt your body. You need to work out how much lactose is right for you and your symptoms.

Diagnosis

Hydrogen Breath Test

In this test, you drink a special high lactose drink and they test how much hydrogen gas is in your breath. If your body does not break the lactose down, the bacteria that live in your colon will ferment it. This makes lots of hydrogen gas, so a high level of hydrogen in your breath means you have lactose intolerance.

The test results are not perfect. Some people have a positive breath test but no symptoms. Some people have a negative breath test but still have symptoms. Sometimes a lactose free trial is better.

Lactose free trial

This is a good choice instead of the breath test.

Stop having lactose for a short time (about 2-4 weeks). If you do not feel better, then you do not have lactose intolerance and you can start having lactose again. You can talk to your doctor or dietitian about what else could help your symptoms.

Which foods contain lactose?

Lactose is in milk, including breastmilk, cow’s milk, sheep’s milk and goat’s milk. All products containing milk or made from milk contain lactose.

Everyone will tolerate a different amount of lactose. Most people can have a low lactose diet, but some people will need to be stricter. For example, you might be able to have a splash of milk in tea, but you might have symptoms if you had a milky coffee.

• Start by strictly avoiding lactose.
• If your symptoms get better, you can slowly increase your lactose intake.
• Most people can have some lactose. Try to spread it out through the day.

The information below shows how much lactose is in different foods.

The amount of lactose in some foods can vary. There is not an exact amount of lactose in the table for these foods, but you can see which foods are lactose free, low in lactose or high in lactose.

Food groups

If you would like a printed copy of this information in a table format, please speak to your clinician.

Milk

High lactose (more than 2g /100g)

• Cow’s milk: 4.6 - 4.8g /100g
• Sheep’s milk: 5.1g /100g
• Goat’s milk: 4.4g /100g
• Condensed milk: 12.3g /100g
• Evaporated milk: 12.7g /100g
• Dried milk powder: 52.9g /100g
• Cream alternative (Elmlea): 4g /100g

Low lactose (up to 2g /100g)

• Creme Fraiche: 2g /100g
• Cream: 1.7 - 2.2g /100g
• Soured cream

Lactose free

• Oat milk
• Rice milk
• Soya milk
• Coconut milk
• Hazelnut milk
• Almond milk
• Tiger nut milk
• Lactose free milk
• Hemp milk

Other dairy

High lactose (more than 2g /100g)

• Yoghurts: 3.6 - 4.7g /100g
• Lassi: 8.6g /100g
• Fromage frais: 2.9 - 4.1g /100g
• Custard: 4.6 - 5.4g /100g
• Rice pudding: 3.9 - 4.9g /100g
• Mousse: 5.7g /100g

Low lactose (up to 2g /100g)

• Cheesecake

Lactose free

• Soya desserts / dairy free yoghurt style
• Lactose free yoghurts

Cheese

High lactose (more than 2g /100g)

• Cottage cheese: 3.5g /100g
• Processed cheese: 6.5g /100g
• Cheese spread, e.g. Philadelphia or supermarket own versions
• Ricotta
• Mascarpone: 4.5g /100g

Low lactose (up to 2g /100g)

• Hard cheese: 0.1g /100g
• Blue cheese: 1.0g /100g
• Ripe / rind cheeses: 0.9g /100g
• Mozzarella: <0.1g /100g
• Goat’s cheese: 0.9g /100g
• Feta: 1.4g /100g
• Halloumi: 1.5g /100g
• Lactose free cheese: <0.1g /100g
• Low / reduced fat cheese
• Brie: <0.1g /100g
• Cheddar: 0.1g /100g

Lactose free

• Dairy free cheese alternative

Cereals

High lactose (more than 2g /100g)

• Yoghurt coated cereal bars
• Porridge made with milk

Lactose free

• Breakfast cereals

Bread

Low lactose (up to 2g /100g)

• Milk bread
• Some gluten free bread contains milk

Lactose free

• All other breads

Rice

High lactose (more than 2g /100g)

• Rice pudding: 3.9 - 4.9g /100g

Low lactose (up to 2g /100g)

• Risotto

Lactose free

• Rice
• Rice cakes
• Sushi

Pasta

High lactose (more than 2g /100g)

• Macaroni cheese
• Ricotta ravioli
• Lasagne

Lactose free

• Pasta with tomato sauce
• Check free from section for dairy free white sauce, macaroni cheese or lasagne

Treats/snacks

High lactose (more than 2g /100g)

• Milk chocolate
• White chocolate
• Ice cream
• Chocolate cake bars

Low lactose (up to 2g /100g)

• Cheese and onion crisps
• Cheesy puffs / corn snacks
• Biscuits
• Chocolate coated / dipped biscuits
• Cake
• Cheese crackers: <0.3g /100g
• Fudge / toffee: <1.5g /100g
• Pastry made with butter: 3.3g /100g

Lactose free

• Most crisps
• Sorbet
• Dairy free ice cream
• Jelly

Fats

Low lactose (up to 2g /100g)

• Butter
• Ghee
• Reduced fat spreads
• Margarine

Lactose free

• Vegetable oils
• Coconut oil
• Lard
• Dairy free spreads

Meat, fish, eggs and alternatives

High lactose (more than 2g /100g)

• Omelette made with milk

Low lactose (up to 2g /100g)

• Scrambled egg made with butter / milk
• Battered fish (some does have milk in, some does not)

Lactose free

• Meat
• Fish
• Eggs
• Tofu
• Quorn
• Vegan meat alternatives

Sauces / condiments

High lactose (more than 2g /100g)

• White sauce
• Ready made custard

Lactose free

• Jam
• Marmite
• Peanut butter
• Mayonnaise (check as some brands contain milk or cream)
• Ketchup
• Vinegar
• Custard powder
• Gravy
• Spices / herbs
• Chutney / pickle

Fruit, veg, nuts, pulses

High lactose (more than 2g /100g)

• Yoghurt coated dried fruit / nuts

Low lactose (up to 2g /100g)

• Mashed potato made with butter / milk
• Instant mash
• Soup containing cream

Lactose free

• All fruit and vegetables
• Baked beans
• Pulses
• Chips, potato waffles, hash browns
• Nuts

Checking labels

It is the law that if a product contains milk products they will be listed in bold, underlined, or highlighted.

The ingredients list is in weight order, with the largest first. If it is near the bottom of the list then there is a smaller amount in the food. If milk is one of the last ingredients in a long list, it might be fine.

Vegan foods are lactose-free.

Check labels for:

• Milk
• Milk solid
• Skimmed milk powder
• Cream
• Butter
• Buttermilk
• Whey

“May contain”

Most people with lactose intolerance can have a food that says “may contain milk” or “made in a factory that handles milk” or “not suitable for people with a milk allergy”.

Confusing ingredients

Casein and milk protein are sometimes listed within the ingredients and are proteins found in milk; you can have both of these ingredients. Some people have an allergy to milk protein, but this is not the same as lactose intolerance.

Medications

Some tablets contain very small amounts of lactose. Do not worry unless you take lots of tablets.

You can talk to the pharmacist about changing to lactose free medicine. Do not stop taking a medication without speaking to your doctor or pharmacist first. Lactulose (a laxative) is not the same as lactose.

Nutrients

Dairy products provide some key nutrients. You need to make sure you get enough of these. Remember that most cheese is low in lactose so it may be okay for you.

Vitamin B12

You need vitamin B12 to help with energy release, healthy blood and the nervous system.

Non-dairy sources of vitamin B12:

• meat
• eggs
• fortified breakfast cereal
• yeast extract (marmite)
• salmon
• cod

Calcium

You need calcium for bone health. Milk and dairy products are the main sources of calcium.

• Lactose-free milk contains the same amount of calcium as cow’s milk.
• If you use a milk alternative (oat/soya/coconut/nut milk), make sure it has added calcium.
• Organic milk alternatives do not have calcium added to them.
• Tinned fish with bones (sardines, pilchards, salmon) are very high in calcium.
• Oranges, almonds, brazil nuts and tofu also contain calcium but it is not so easily absorbed.

You may need to take a calcium tablet if your bone health is high risk such as:

• Breastfeeding mothers
• Post-menopausal women
• Coeliac disease
• Inflammatory bowel disease

Vitamin D

You need vitamin D to use calcium.

The body makes vitamin D from sunlight on your skin. In the UK there is not enough sunshine in autumn or winter to make all the vitamin D that we need.

Consider taking a vitamin D supplement daily in autumn and winter.

Vitamin D is in oily fish, red meat, offal, and egg yolks. Some breakfast cereals, margarines and non-dairy milk alternatives have vitamin D added.

Protein

You need protein for growth and repair, and to keep you strong.

Some lactose free milks have more protein than others. Lactose free cow’s milk and soya milk contain the most protein; oat and nut milks contain the least protein.

Eat 2 - 3 portions of high protein foods daily.

Non-dairy sources of protein include meat, fish, eggs, beans/pulses, tofu and nuts.

Meal ideas

Breakfast

• Cereal with lactose free milk
• Toast with dairy free spread and jam

Lunch

• Sandwich with dairy free spread and tuna/ ham/ chicken/hard cheese and salad
• Homemade soup made without milk or cream
• Jacket potato with dairy free spread, tuna/baked beans/hard cheese and salad
• Eggs or baked beans on toast with dairy free spread

Evening meal

• Meat/chicken/fish with potatoes or rice and vegetables
• Omelette/frittata with side salad
• Spaghetti Bolognese
• Curry made without yoghurt, with rice and dahl

Snacks

• Fruit
• Nuts
• Crisps (not cheese and onion)
• Oat cakes/ rice cakes/ crackers with dairy-free spread
• Tea, coffee, squash, lactose free milk
• Dark chocolate
• Biscuits

Lactase enzymes

You can buy lactase enzymes from pharmacies, health food shops and online. They may reduce your symptoms if you do eat lactose by replacing the lactase that your gut does not make. There is not much research on how well they work.

Can I ever eat foods containing lactose?

Most people find that their symptoms get better after cutting out lactose for 4 weeks. If you have secondary lactose intolerance, it can take longer.

Once your symptoms get better, try to put some lactose back into your diet. Start with a very small amount and increase slowly. Most people can manage some lactose but everyone has a different limit.

• You should start by trying foods that are lower in lactose such as hard cheese.
• Try a small amount and increase it gradually until you find the level you can manage.
• Then you can try foods that are higher in lactose, like milk.
• Start with a splash of milk in your tea/coffee or on your cereal and build it up slowly.
• When you start to get symptoms, you have found your limit.

What if symptoms don’t improve?

If you are lactose intolerant then your symptoms should get better when you take lactose out of your diet.

If you do not feel better, then you do not have lactose intolerance and you can start having lactose again. You can talk to your doctor or dietitian about what else could help your symptoms.

Risk of anaphylaxis (serious allergic reaction) when reintroducing lactose

If you have ‘atopy’ (eczema, asthma, other allergies, hay fever), there is a very small risk that you can develop an allergy to milk protein if you completely avoid it for a long time.

To avoid this risk you should try to keep some low lactose dairy products in your diet such as hard cheese.

This page will provide you with information about longer term feeding tubes. The page will tell you what to expect before, during and after your operation. 

A member of the medical team, your dietitian or your speech and language therapist can answer any further questions you may have.

What is a feeding tube?

A feeding tube is a small tube that passes through the skin into your stomach. This allows special liquid feed, water and medicines to be passed into the stomach. It can help to meet your dietary needs.

The three different operations used in North Bristol Trust are:

• Percutaneous Endoscopic Gastrostomy (PEG) – uses a flexible camera (endoscope) that passes into your stomach.
• Per-oral Image Guided Gastrostomy (PIGG) – the tube is placed using x-ray.
• Radiologically Inserted Gastrostomy (RIG) – the tube is placed using x-ray.

The most common tube is the PEG. You may have a RIG or PIGG tube if you cannot have sedation or if the camera cannot access your stomach.  We will discuss with you which type is best. 

Why do I need a feeding tube?

There are many reasons why you may need a feeding tube. We will discuss this fully with you. You may consider a feeding tube when:

• You are losing weight.
• You cannot eat or drink enough.
• Eating and drinking leads to choking or discomfort.
• Your breathing function is reduced or you get chest infections.
• It takes a long time to eat and it is no longer enjoyable for you.
• You have been getting nutrition through a tube in your nose for many weeks (nasogastric tube (NG)).
• The feeding tube in your nose keeps coming out.
• It is unsafe for you to eat or drink.

Sometimes feeding tubes are placed if you have problems with swallowing.

Will a feeding tube stop me eating and drinking?

What are my other choices if I decide against having one?

How do I prepare for a feeding tube?

Are there any risks?

How is the tube placed?

If you are having a PEG

If you are having a PIGG

If you are having a RIG

What happens afterwards?

If there is:

• Leaking of fluid around the tube.
• Pain on feeding.
• Prolonged or severe pain after the operation.
• New bleeding. 

Stop feed immediately

Phone your community feeding team or visit your local accident and emergency department for urgent advice

How do I look after my feeding tube? 

PEG / PIGG

RIG

What help is available once I leave hospital?

Your ward dietitian will refer you to the community feeding team or an alternative service in your area. The community feeding team are known as the home management services (HMS).

The team comprises of dietitians, home enteral feeding nurses and a delivery company. They will contact you to arrange a monthly delivery of feeds and plastic equipment, such as syringes.

We may send you home from hospital with a small supply of feeds and equipment.

Your ward dietitian will explain your home feeding plan and provide contact details for the HMS team. Your GP may also be involved in the management of your tube.

What do I do if the tube becomes blocked?

How long will I need the tube?

What if the tube is accidentally removed? 
 

For PEG/PIGG tube

For RIG tube

Common questions

Further information

Nutricia website provides information on specialist feed and using a feeding pump. There is also information on the nursing team who help people with feeding tubes: 

• Nutricia Flocare - Infinity Training
• Nutricia UK | Homepage for Patients & Carers

PINNT helps people on enteral and parenteral nutrition providing advice and local help groups.

• Phone 020 3004 619
• PINNT: Advocacy & support for people on home artificial nutrition (HAN): parenteral, enteral & oral nutritional supplements. | PINNT

References

© North Bristol NHS Trust. This edition published October 2024. Review due October 2027. NBT002346. 

Forms, Booklets and Leaflets

You can get physical copies of these booklets and leaflets from the Macmillan Wellbeing Centre based at Southmead Hospital. Please come and visit.

Referral Forms:

Self-referral form

Professional referral form 

 

Eating well:

Healthy Eating and Cancer – Macmillan Healthy eating and cancer

Healthy Eating – British Dietetic Association Healthy eating 

Healthy Snacks – British Dietetic Association Healthy snacks

 

Difficulty with eating:

Eating Problems and Cancer – Macmillan Eating problems and cancer

Building Up Diet – Macmillan The build up diet

 

Weight management after cancer treatment:

Managing Weight Gain After Cancer Treatment – Macmillan  Managing weight gain

Weight loss - British Dietetic Association  Weight loss advice

Portion sizes - British Dietetic Association Portion sizes

Has the sample I sent recently arrived in the lab yet? How can I check?

Why has the sample I collected been rejected?

When will the results be available

When does the failsafe get updated?

Who do I contact for advice?

Can I arrange a visit to the laboratory?

Will the test show if a baby is a Cystic Fibrosis (CF) carrier?

Will the test show if a baby is a sickle cell carrier?

Will the test show if a baby has thalassaemia?

When did the Bristol Newborn Screening Laboratory start testing babies in the South West for each of the nine conditions?