Oral Nutritional Supplement Formulary. January 2016

Transcription

1 Oral Nutritional Supplement Formulary January 2016 Contents Page Number Introduction and Dietetic Support 2 How to make a Dietetic Referral 2 Effective Prescribing Tips 3 Powdered Supplements 4 Milk Style Sip Feeds with/without Fibre 5 Compact Milk Style Sip Feeds 6 with/without Fibre Yoghurt Style Sip Feeds 7 Savoury Style Sip Feeds 7 Fruit / Juice Style Supplements 8 Thickened / Semi Solid Supplements 8 Malnutrition Universal Screening Tool 9 Malnutrition Care Plans 10 BMI Chart 11 Weight Loss Percentage Chart 12 MUST Alternative Measures 13 Page 1

2 Introduction This Formulary is intended to be a source of information for GPs and Health Care Professionals. Malnutrition is a common condition within the commy. Early detection and treatment will improve wellbeing, quality of life and clinical outcomes. It will also reduce demands on health care resources. Dietetic Support For any queries about food fortification, prescribing nutritional supplements, assessments or if you would like any training for your team or local Care Homes, please contact: Michelle Sutcliffe - Commy Dietitian Team Lead michelle.sutcliffe@nhs.net Sarah Dinenage - Commy Dietitian Sarah.dinenage@nhs.net Lisa Cartlidge Commy Dietitian Lisacartlidge@nhs.net It is strongly recommended that any products which are NOT included in this booklet should only be prescribed under dietetic supervision. Patients may be prescribed nutritional supplements in hospital whilst they are acutely unwell. These should not be added to their repeat prescription on discharge, unless they are specifically requested by a Dietitian. When clinical judgement indicates that supplements are required, regular monitoring is essential. Send a letter of referral to: Department of Nutrition and Dietetics Royal South Hants Hospital Brintons Terrace Southampton SO14 0YG Telephone: Fax: How to refer to the Dietitians Or the Prescribing Support Dietitians on: michelle.sutcliffe@nhs.net Page 2

3 Effective Prescribing Tips All patients should be weighed, and ideally screened using the Malnutrition Universal Screening Tool (MUST) (page 10). The appropriate care plan (page 11) should be followed Before starting supplements a food first approach should be followed and food fortification advice provided. Diet sheets How Can I Eat More? Nourishing Drinks and Build Yourself Up are available printed and electronically from the Dietitians. Patients can be advised to buy fortified drinks (e.g. Complan, Build Up, Meritene, Nurishment) if required. These are readily available from supermarkets/local chemist shops. Review after four weeks and commence supplements if indicated If supplements are indicated in the care plan, they should be prescribed within ACBS indications (refer to the BNF, MIMS or the Drug Tariff for indications) If patients have the dexterity to make up supplements, have carers or are in care homes, they should be prescribed powdered supplements first line (exceptions are patients with cows milk intolerance/allergy) Patients should be asked what type of supplement they prefer (juice style, savoury etc.) and be issued an assortment of flavours on an acute prescription The supplements in this booklet are listed in cost order (cheapest first), and prices have been taken from BNF January 2016 All supplements should be prescribed acutely It is essential that patients on supplements are reviewed monthly, by monitoring their weight or mid upper arm circumference (and BMI), changes in dietary intake, compliance and stock levels at home Page 3

4 Powdered Supplements These supplements are to be used first line in patients who have the dexterity to make them up, or who have carers or who are in care homes. Presentation Mix with Aymes Shake* Complan Shake* Ensure Shake Fresubin Powder Extra 7x57g sachets 4x57g sachets 7x57g sachets 7x62g sachets 57g sachet 57g sachet 57g sachet 62g sachet 100mls/ s Whole milk s Whole Milk s Whole Milk s Whole Milk Kcals / banana, chocolate, neutral, strawberry, vanilla banana, chocolate, original, strawberry, vanilla, Banana, chocolate, strawberry, vanilla chocolate, neutral, strawberry, vanilla, * These supplements are also available in a starter pack, with a selection of all the flavours and a shaker to aid mixing. They can be made up with chilled milk, gently heated for a warming drink, or used in place of milk (e.g. on cereal, in drinks, etc.). If a patient is struggling to tolerate the volume, they can be made up with less milk, or if the taste is too strong they can be diluted with extra milk. When made up they can be stored in the fridge, but must be consumed within 24 hours. If made with milk, 2 sachets will meet the majority of DRVs for vitamins and minerals, so additional vitamins and minerals will usually not be required. These can also be made up with water if a patient is struggling to tolerate the extra milk, however they will not be as complete in vitamins and minerals. All supplements should be used in between meals. Page 4

5 Milk Style Sip Feeds Milk shake style supplements tend to be more palatable when chilled. The chocolate and coffee flavoured ones can also be more palatable when warmed. If the supplements are too sweet, additional milk can be added to them to dilute them. Neutral flavours can be used in place of milk or in sweet/savoury recipes. They come in 2 main formats, regular or compact (i.e. concentrated). If a patient is experiencing gastro-intestinal symptoms with the compact versions, they may tolerate a regular version better. All supplements should be taken between meals. Regular Supplement - without fibre Aymes Complete Ensure Plus Milkshake Style Fortisip Bottle Fresubin Energy Resource Energy 220ml strawberry, vanilla, chocolate, banana chocolate, banana, strawberry, raspberry, orange, blackcurrant, peach, fruits of the forest, vanilla, coffee, neutral vanilla, banana, chocolate, tropical fruits, strawberry, toffee, orange, caramel, neutral vanilla, strawberry, banana, cappuccino, tropical fruits, chocolate, lemon, blackcurrant, neutral apricot, banana, coffee, chocolate, strawberry-raspberry, vanilla Standard Supplement - with fibre Ensure Plus Fibre 220ml Banana, chocolate, strawberry, raspberry, vanilla Fresubin Energy Fibre vanilla, strawberry, banana, caramel, cherry, chocolate, Fortisip Multifibre vanilla Page 5

6 Compact Supplement without fibre Ensure Plus Compact Fortisip Compact 125ml 125ml Banana, strawberry, vanilla vanilla, strawberry, mocha, banana Nutriplen 125ml vanilla, strawberry, banana, hazelchocolate Compact Supplement with fibre Fortisip Compact Fibre 125ml Mocha, strawberry, vanilla Some of the regular supplements also come as starter packs. Starter packs provide a mix of flavours and may be useful for patients who have not had supplements before and are unsure of flavours. They are a useful way to minimise wastage. Starter Packs Ensure plus Commence Fortisip Range 10x220ml s 10 x s ( 2.02 per ) ( 2.02 per ) 330kcals per 300kcals per Mixed milk shake style drinks Mixed milk shake style, yoghurt style and fruit juice style drinks Page 6

7 Yoghurt Style Sip Feeds without Fibre If patients are finding that the milk shake style supplements are too sweet, they may tolerate a yoghurt style sip feed better, as these tend to be less sweet. Again, these are all more palatable chilled. Ensure Plus Yoghurt Style Fortisip Yoghurt Style 220ml strawberry, peach raspberry, vanilla-lemon, peach-orange Savoury Supplements Savoury supplements can be used with people who struggle with the sweetness of the other supplements. They will generally be more palatable gently heated. They should not be boiled. Savoury supplements without fibre Ensure Plus Savoury 220ml Chicken, mushroom Savoury Supplements with fibre Vitasavoury 300* 50g sachet Chicken, leek & potato, mushroom, chicken *Need to be reconstituted with hot water Page 7

8 Juice Style Sip Feeds If a patient dislikes milky drinks, or is intolerant to milk, a juice style supplement may be more palatable. Again, these may be more palatable chilled and they should be taken in between meals. Fresubin Jucy Apple, blackcurrant, cherry, orange, pineapple Ensure Plus Juice Style 220ml Apple, fruit punch, lemon-lime, orange, peach, strawberry Fortijuce Apple, blackcurrant, forest fruits, lemon, tropical, strawberry, orange, Thickened/Semi-Solid Supplements Thickened supplements are ideal for people with dysphagia, and tend to be more palatable chilled. Nutricrem Resource Dessert Energy Forticreme Complete 125g pot 125g cup 125g pot Strawberry, vanilla, chocolate-orange Caramel, chocolate, vanilla Banana, chocolate, forest fruits, vanilla Fresubin YoCreme 125g pot Apricot-peach, biscuit, lemon, raspberry Page 8

9 Malnutrition Universal Screening Tool (MUST) STEP 1 BMI Score BMI >20.0 (>30 obese ) = 0 BMI = 1 BMI <18.5 = 2 (see page 11 for tables) STEP 2 Weight Loss Score (unplanned wt loss in 3-6 months) Wt loss <5% = 0 Wt loss 5-10% = 1 Wt loss >10% = 2 (see page 12 for tables) STEP 3 Acute Disease Score Add a score of 2 if there has been or is likely to be no nutritional intake for >5 days This step is unlikely to apply in a commy setting If unable to obtain height and weight, alternative measurements and subjective criteria are provided Add all scores In the obese, underlying acute conditions are generally controlled before the treatment of obesity STEP 4 Overall Risk of Malnutrition 0 LOW RISK 1 MEDIUM RISK 2 or more HIGH RISK No Care Plan required Go to Step 5 Go to Step 5 STEP 5 Start the Medium and High Malnutrition Risk: Care Plan (see page 10) The Malnutrition Universal Screening Tool ( MUST ) is adapted/reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition) January 2006 Version 2 For more information on MUST or alternative measures, visit Page 9

10 Care Plans Low Risk Care Plan Score 0 1. Screen as part of routine assessments, on a minimum of an annual basis 2. If BMI > 30kg/m 2 offer healthy eating or weight reducing advice as clinically appropriate Medium Risk Care Plan Score 1 1. Treat any underlying condition, e.g. nausea, constipation 2. Check if help is needed with eating and/or drinking e.g. adapted cutlery. Consider a referral to Occupational Therapy or Speech & Language Therapy if necessary 3. Give food fortification advice How Can I Eat More, Build Yourself Up Diet Booklet, Nourishing Drinks 4. Review after 4 6 weeks 5. If report to be eating better and weight stable/increasing encourage them to continue with dietary modifications until they reach their target/usual weight 6. If weight continuing to decrease follow High Risk Care Plan High Risk Care Plan (Score 2 or more) 1. Follow Medium Risk Care Plan steps If not eating and weight continuing to decrease after 4 weeks prescribe Aymes Shake (OD-BD) if in care home, or Aymes Complete (BD) if unable to make up powdered supplement 3. If MUST score decreases or weight remains stable/increases continue with supplements until target/usual weight reached. Monitor and rescreen frequently (ideally monthly) 4. If MUST increases consider referral to Dietitian (see page 2 for contact details) Page 10

11 BMI Chart Page 11

12 Weight Loss Charts Weight before weight loss SCORE 0 Wt Loss < 5% SCORE 1 Wt Loss 5-10% SCORE 2 Wt Loss > 10% Weight before weight loss SCORE 0 SCORE 1 SCORE 2 Wt Loss < Wt Loss 5-10% Wt Loss > 5% 10% 34 kg < >3.40 5st 4lb <4lb 4lb 7lb >7lb 36 kg < >3.60 5st 7lb <4lb 4lb 8lb >8lb 38 kg < >3.80 5st 11lb <4lb 4lb 8lb >8lb 40 kg < >4.00 6st <4lb 4lb 8lb >8lb 42 kg < >4.20 6st 4lb <4lb 4lb 9lb >9lb 44 kg < >4.40 6st 7lb <5lb 5lb 9lb >9lb 46 kg < >4.60 6st 11lb <5lb 5lb 10lb >10lb 48 kg < >4.80 7st <5lb 5lb 10lb >10lb 50 kg < >5.00 7st 4lb <5lb 5lb 10lb >10lb 52 kg < >5.20 7st 7lb <5lb 5lb 11lb >11lb 54 kg < >5.40 7st 11lb <5lb 5lb 11lb >11lb 56 kg < >5.60 8st <6lb 6lb 11lb >11lb 58 kg < >5.80 8st 4lb <6lb 6lb 12lb >12lb 60 kg < >6.00 8st 7lb <6lb 6lb 12lb >12lb 62 kg < >6.20 8st 11lb <6lb 6lb 12lb >12lb 64 kg < >6.40 9st <6lb 6lb 13lb >13lb 66 kg < >6.60 9st 4lb <7lb 7lb 13lb >13lb 68 kg < >6.80 9st 7lb <7lb 7lb 13lb >13lb 70 kg < >7.00 9st 11lb <7lb 7lb 1st 0lb >1st 0lb 72 kg < > st <7lb 7lb 1st 0lb >1st 0lb 74 kg < > st 4lb <7lb 7lb 1st 0lb >1st 0lb 76 kg < > st 7lb <7lb 7lb 1st 1lb >1st 1lb 78 kg < > st 11lb <8lb 8lb 1st 1lb >1st 1lb 80 kg < > st <8lb 8lb 1st 1lb >1st 1lb 82 kg < > st 4lb <8lb 8lb 1st 2lb >1st 2lb 84 kg < > st 7lb <8lb 8lb 1st 2lb >1st 2lb 86 kg < > st 11lb <8lb 8lb 1st 3lb >1st 3lb 88 kg < > st <8lb 8lb 1st 3lb >1st 3lb 90 kg < > st 4lb <9lb 9lb 1st 3lb >1st 3lb 92 kg < > st 7lb <9lb 9lb 1st 4lb >1st 4lb 94 kg < > st 11lb <9lb 9lb 1st 4lb >1st 4lb 96 kg < > st <9lb 9lb 1st 4lb >1st 4lb 98 kg < > st 4lb <9lb 9lb 1st 5lb >1st 5lb 100 kg < > st 7lb <9lb 9lb 1st 5lb >1st 5lb 102 kg < > st 11lb <10lb 10lb 1st 5lb >1st 5lb 104 kg < > st <10lb 10lb 1st 6lb >1st 6lb 106 kg < > st 4lb <10lb 10lb 1st 6lb >1st 6lb 108 kg < > st 7lb <10lb 10lb 1st 6lb >1st 6lb 110 kg < > st 11lb <10lb 10lb 1st 7lb >1st 7lb 112 kg < > st <11lb 11lb 1st 7lb >1st 7lb 114 kg < > st 4lb <11lb 11lb 1st 7lb >1st 7lb Page 12

13 Ulna Length MUST Alternative Measures If height cannot be measured or recalled by the patient, their ulna length can be used to estimate their height. MUAC can be used to estimate BMI when height and weight cannot be obtained. It is not designed to generate an actual score for use with MUST. For more information on MUST or alternative measures, visit Page 13