Guidelines for the Appropriate Use of Oral Nutritional Supplements (ONS) for Adults in Primary Care

Transcription

1 Guidelines for the Appropriate Use of Oral Nutritional Supplements (ONS) for Adults in Primary Care These guidelines are not applicable for patients who are under the care of the Nutrition and Dietetic Home Enteral Feeding Service. Home enterally tube fed patients will require the specific nutritional product prescription requested by their managing Dietitian. CONTENTS Page Aim, Introduction, Scope and Purpose of Guidelines 1-2 MUST Malnutrition Universal Screening Tool Steps to Appropriate Prescribing of ONS in Adults 4-9 Guide to Assessing Underlying Causes of Malnutrition and treatment options 5 Inappropriate Prescribing of ONS 10 ONS Care Pathway in Primary Care 11 ONS Product Choice Algorithm when initiating ONS in Primary Care 12 Over the Counter Supplements 13 1 st Line ONS: Powdered ONS 14 2 nd Line ONS: Ready to drink milkshake style ONS 15 Small Volume Compact Style ONS 16 Juice style ONS: for patients who dislike milky drinks 16 ONS that should not routinely be started in primary care Patient Groups for Special Consideration Further Reading, Resources and Acknowledgements 21 Supporting documents/resources Health and care professional resources - MUST Tool, Recording Sheets, Nutritional Support Pathway and Food Intake Chart Patient/carer resources - Food First - Eating Well for Small Appetites - Food first Quick guide - Food First - Fortifying Food for care homes - Food First - Homemade supplements - Eating and drinking at end of life Steps to the appropriate prescribing of Oral Nutritional Supplements in Primary Care West Hertfordshire Hospital Trust (WHHT) Dietitian ONS Prescription Request Letter Hertfordshire Community Trust (HCT) Dietitian ONS Prescription Request Letter Aim These guidelines aim to promote the appropriate, rational and cost effective prescribing of Oral Nutritional Supplements (ONS) in adults in primary care and support national guidance from National Institute for Health and Care Excellence (NICE) and other health professional organisations. Introduction Page 1 of 22

2 Malnutrition can refer to both under and over nutrition, but usually refers to under-nutrition - a deficiency of energy, protein and important micronutrients. These guidelines apply to undernutrition. Untreated malnutrition has many consequences other than weight loss and can result in: Reduced efficiency of the immune system resulting in increased risk of infection Reduced muscle mass and function which can affect respiratory muscles and respiratory function. Reduced muscle function can also lead to swallowing difficulties (dysphagia) Impaired thermoregulation resulting in a predisposition to hypothermia Impaired wound healing and delayed recovery from illness a detrimental effect on mental state, apathy, depression and self-neglect Increased risk of additional health care costs due to an increase in: GP visits (65%), hospital admissions (82%) and length of hospital stay (30%) Tackling malnutrition can improve nutrition status, clinical outcomes and reduce health care use. The National Institute for Health and Care Excellence (NICE) Nutrition Support in Adults Clinical Guidelines 2006 (NICE CG32) has shown substantial cost savings can result from identifying and treating malnutrition, CG32 is ranked in the top clinical guidelines shown to produce cost savings. ONS are nutritional supplements that are used for patients who have been identified as being nutritionally compromised. Use of nutritional supplements requires regular monitoring of the patient s progress and should be discontinued once treatment goals have been achieved. Alternative dietary approaches can be used to supplement dietary intake without or in addition to using ONS. Hertfordshire CCGs are committed to implementing a food first strategy and reserve the use of ONS for patients who have not responded to dietary measures alone as per NICE CG32, Scope and Purpose of Guidelines This guidance is intended for all qualified healthcare professionals working within Hertfordshire that recommend, prescribe, supply or administer ONS; specifically dietitians, GPs, care of the elderly doctors, nursing staff (practice nurses, community nurses, Macmillan and other specialist nurses), pharmacists and care home staff. The guidelines advise on: Who is at risk of malnutrition [STEP 1] Assessing underlying causes of malnutrition [STEP 2] Setting a treatment goal [STEP 3] Food First advice and over the counter products or homemade fortified drinks [STEP 4] Initiating prescribing of ONS [STEP 5] ensuring patients meet ACBS criteria, which products to prescribe, how much to prescribe Reviewing ONS prescriptions [STEP 6] Discontinuing ONS prescriptions [STEP 7] Advice is also offered for when prescribing is inappropriate, considerations for specific patient groups (palliative care, substance misusers, diabetic and renal patients) and when it is appropriate to refer to community dietetic services. MUST Malnutrition Universal Screening Tool MUST is a validated screening tool for adults and was specifically designed by a multi-disciplinary group of healthcare professionals to assess malnutrition risk in all care settings in a consistent way in order to facilitate continuity of care from one setting to another. It can be used by all types of care workers to identify malnutrition and is a 5-step screening tool that uses objective measurements when possible and subjective criteria when necessary. MUST is used throughout the NHS in primary and secondary care and includes an appropriate care plan linked to the risk of malnutrition (MUST score). An online MUST calculator can be accessed (on all mobile devices) at Although MUST is theoretically a simple tool, many people can find it difficult to use and therefore accessing training on MUST is always recommended. See page 3 and MUST, recording sheets and Nutritional Support Pathway Page 2 of 22

3 Hertfordshire Community and Primary Care Malnutrition Universal Screening Tool (MUST) and Nutritional Support Pathway for Treating Patients at Risk of Malnutrition (adapted for local use) BMI Score Weight Loss Score Acute Disease Effect Score BMI kg/m 2 Score >20 (>30 Obese) = = 1 <18.5 = 2 Unplanned weight loss in past 6 months % Score <5 = = 1 >10 = 2 If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days Please note: Acute disease effect is unlikely to apply outside hospital Score 2 Overall Risk of Malnutrition Add scores together to calculate overall risk of malnutrition Score 0: Low Risk Score 1: Medium Risk Score 2 or more: High Risk Management Guidelines Low Risk = 0 Routine Clinical Care Weigh: o Care Homes monthly Own home - opportunistic Repeat screening o Care Homes monthly o Own home - if there are changes that cause concern or new episode of care commenced Medium Risk = 1 Observe and Monitor Food Intake Complete detailed food & fluid record charts for 3 days then Look at the completed food record charts what do they tell you Set treatment goal Give & discuss most appropriate food first leaflet Repeat screening: o Monthly in care home o Monthly for 3 months in own home or in surgery High Risk = 2 or more Observe and Monitor Food Intake and Treat Set Measurable Treatment Goal Complete detailed food & fluid record charts for 3 days then Look at the completed food record charts what do they tell you Give & discuss most appropriate food first advice In care homes weigh weekly Re-screen after one month If deterioration or no improvement (eating < 50% of meals/ weight loss) Repeat screening every two weeks If further clinical concern follow high risk score box If improved or adequate intake and little clinical concern (eating >50% of meals) Monitor progress Repeat screening as above Continue treatment until appropriate to stop If no improvement Check that food first advice is being correctly followed If yes, consider whether ONS is more likely to be taken than homemade or OTC supplement If not, sip feed prescription is unlikely to be appropriate Review monthly against treatment goal If no progress or clinical concern REFER TO DIETITIAN If improving Repeat screening every 1-3 months until: Treatment goal met or BMI >20 and pt is gaining weight If improving Repeat screening every 1-3 months until: Treatment goal met or BMI >20 and pt is gaining weight or Pt is unable or unwilling to take sip feed in therapeutic dose (i.e. usually bd) (consider whether another product is suitable instead) Page 3 of 22

4 7 Steps to Appropriate Prescribing of ONS in Adults For any individual patient the following steps should apply. ONS should only be introduced after Steps 1 4 have been completed and if nutritional intake is still inadequate. STEP 1 Identification of Nutritional Risk Nutritional screening should be standard practice in all inpatient settings (hospitals) and community healthcare settings (GP clinics, care homes). Patients should be assessed using the Malnutrition Universal Screening Tool (MUST) or alternative validated screening tool (see page 3 MUST Tool, or use online MUST calculator). NICE Clinical Guideline 32, Nutritional Support in Adults 2006, suggests the following criteria are used to identify those who are malnourished or at nutritional risk: MUST score of 2 or more Body mass index BMI <18.5 kg/m 2 Unintentional weight loss >10% in the last 3-6 months BMI<20 kg/m 2 and unintentional weight loss >5% in the last 3-6 months Have eaten or likely to eat little or nothing for more than 5 days or longer Have poor absorptive capacity and/or high nutrient losses and/or increased nutritional need. REFERRAL TO THE DIETETIC SERVICE Patients who are likely to develop re-feeding syndrome cannot usually be managed in the community and will therefore require acute admission for re-feeding Also see page 9): Patients who may be at risk of refeeding syndrome include those who: Have a body mass index (BMI) <16 kg/m 2 OR Have had little or no nutritional intake for the last 10 days OR Have unintentionally lost >15% body weight within the last 3-6 months (except patients at the end of their lives) (see page 9 Inappropriate Prescribing of ONS, pages 19/20 Palliative Care and Carer Resource - Eating and drinking at end of life) *These patients may already be known to the dietetic service) All patients at high risk should be advised about food first (as outlined in STEP 4) and should also be assessed for underlying causes with onward referral as appropriate (as detailed in STEP 2). STEP 2 Assessment of causes of malnutrition (Global Nutritional Assessment) Once nutritional risk has been established, the underlying cause and treatment options should be assessed and appropriate action taken. Consider availability of adequate diet and identify problems with reduced or altered food intake relating to: Ability to feed using appropriate utensils Pressure sores Poor mental health eg. dementia/depression Substance or alcohol misuse Medication e.g. those that suppress appetite Social and environmental circumstances Ability to chew (consider whether dental assessment is available) and swallow (consider whether patient meets referral criteria for speech therapy assessment). Patients with dysphagia may require a modified consistency diet and are likely to require supplements for longer periods Physical symptoms e.g. pain, sore mouth, vomiting, constipation, diarrhoea Medical prognosis proactive nutritional support may not be appropriate at the very end of life (last few weeks of life) Review the treatment plan in respect of these issues and, if needed, make appropriate referrals. (See page 5 A Guide to Assessing Underlying Causes of Malnutrition and Treatment Options) Page 4 of 22

5 A GUIDE TO ASSESSING UNDERLYING CAUSES OF MALNUTRITION AND TREATMENT OPTIONS PROBLEM POSSIBLE SOLUTIONS Medical conditions causing poor appetite e.g. nausea, diarrhoea, constipation, cancer, COPD etc Poor emotional or mental health e.g. depression, isolation, bereavement Community Pharmacist/GP/ Community Matron/Community Nursing management (if available) & appropriate medication GP management, social clubs, day centres or if patient meets referral criteria counselling, Community Psychiatric Nursing management Poor dentition Refer to dentist (if available) and advise patient on appropriate diet (suggest soft diet only if necessary) Difficulties with swallowing or unable to swallow If patient meets referral criteria, refer to Speech and Language Therapy services Unable to do own shopping and/or cook and/or feed self Suggest home delivery of food, help from relative/friends or if patient meets referral criteria refer to Meals on Wheels, Social Services and/or Community Therapy team Experiencing financial difficulties If patient meets referral criteria, refer to Social Services benefits/ allowances review Alcohol or other substance misuse If patient meets referral criteria refer to community drug and alcohol services Adapted from Guidelines for Managing Adult Malnutrition and Prescribing Supplements Havering PCT 2006 and Oral Nutrition Support Pack Westminster PCT 2007 Page 5 of 22

6 STEP 3 Set Treatment Goals and Review Dates Clear treatment goals and a care plan should be agreed with patients. Patient expectations should be managed at this stage. Treatment goals should be documented on the patient record and should include the aim of the nutritional support, timescale, review period and be realistic and measurable. Suitable goals might consist of: Attaining a realistic target weight/ target BMI/ achieving weight gain over a specified period of time Weight maintenance where achieving weight gain is unrealistic or undesirable Slowing weight loss where, achieving weight maintenance is unlikely Completion of wound healing, if relevant STEP 4 Offer food first advice Oral nutritional supplements (ONS) should NOT be used as first line treatment. A food first approach should be used initially. Dietary counselling to encourage the use of energy and protein rich foods should be recommended as the initial intervention before prescribing ONS. This means offering advice on food fortification to increase calories and protein in everyday foods. Additional snacks will be needed to meet requirements of those with a small appetite. Patients may be reluctant to eat high fat / sugar foods, so it is important to reinforce the message that healthy eating for people who are malnourished is different to healthy eating for the rest of the population. Written information should be given to the patient/carer/care home to reinforce the advice: The following patient/carer resources are available: - Food First - Eating Well for Small Appetites - Food First - Fortifying Food for care homes - Food First - Quick guide - Food First - Homemade supplements - Eating and drinking at end of life Care homes should be able to provide adequately fortified foods and snacks and prepare homemade milkshakes and smoothies, which should negate the need to prescribe ONS in the majority of cases. In addition, for patients in care homes, food fortifying care plans can be inserted into individual patient s care plans to instruct care home staff regarding food fortification. If patients prefer, they can purchase over the counter products such as AYMES Retail milkshakes, Complan milkshakes or soups or Meritene milkshakes or soups. Please see page 13 for nutritional content and prices for these products. Patients who do not meet ACBS prescribing criteria (STEP 5) can also be advised to purchase over the counter supplements or prepare homemade nourishing drinks. Patients should be reviewed one month after being offered this advice to assess their progress with a food first approach. If there is a positive change towards meeting treatment goals, the changes should be encouraged and maintained and a further review arranged until goals are met. Page 6 of 22

7 STEP 5 Prescribing ONS ONS prescribing should only be initiated in primary care in addition to the food first changes which should be maintained: - 1. If first line dietary measures/ food first approach have failed to achieve a positive change towards meeting goals after one month. 2. Where there are clinical benefits to be realised and clear nutritional goals to work towards. Repeat prescriptions should only be issued if there is an explicit plan for continuation [Step 3]. Goals should be regularly reviewed and prescribing should cease when goals are achieved [Step 6] The main ACBS criteria to consider and evidence is Disease related malnutrition If the patient does not meet the ACBS criteria then over the counter nutritional supplements are recommended only (see page 13). ONS products will contain varying amounts of Vitamin K, alongside the Vitamin K already consumed within the diet. Possible interactions of ONS should be considered for Warfarin resistant patients. INR should be monitored and treatment altered accordingly especially if ONS is commenced or changed after Warfarin is started. Starting prescriptions To maximise their effectiveness and avoid spoiling appetite, patients should be advised to take ONS between meals and not before meals or as a meal replacement To be clinically effective, ONS should be prescribed twice daily (bd). This makes sure that calorie and protein intake is sufficient to achieve weight gain. If ONS prescribed and/or taken less than twice daily, food fortification should be used instead. Prescriptions should be clearly marked ACBS and give clear directions for use e.g. one to be taken twice daily between meals. As directed should not be used as this has been shown to cause patients / carers to use the wrong dose. A one week prescription or starter pack should always be prescribed initially to avoid wastage if products are not well accepted due to taste and palatability. Avoid prescribing starter packs except for an initial trial, as they are often more costly. Issue monthly prescriptions on acute for 1-2 months once the patient has informed the practice of their preferred flavour. Avoid adding prescriptions for ONS to the repeat medications list unless a short review date is included to make certain review against treatment goals occurs. Provide written information to patient and/or carer regarding their ONS (supplement drinks) to inform patient of why they are taking it and when they will stop. This will help manage patient expectation of duration of treatment. Prescribing choices should be in line with the primary care formulary. Page 7 of 22

8 1 st line ONS Powdered Shake: The preferred product in primary care is AYMES Shake. Alternatives are Foodlink Complete, Foodlink Complete With fibre, which can be prescribed for patient palatability or taste preferences. These should be mixed with 200ml full fat milk as per manufacturers instructions. Nutritional content and prices are shown on page nd line ONS Ready to Drink Liquid: Consider when a 1 st line powered ONS is not suitable i.e. patient is lactose intolerant or if patient has difficulties preparing the powdered shake. The preferred product in primary care is Aymes Complete. Alternatives for patient taste preferences are Ensure Plus Milkshake Style, Fortisip or Nutricomp Drink Plus. These are all clinically lactose free. Nutritional content and prices are shown on page 15. Small Volume Compact Style ONS Where volume is a problem, AYMES Shake and Foodlink Complete can be mixed with 100ml of full fat milk to make a compact style ONS. If patient/carer is unable to prepare powder ONS, then use Altraplen Compact (125ml). Nutritional content and prices are shown on page 16. Juice style drinks (for patients who do not like or are unable to take milky drinks): The preferred products in primary care are Ensure Plus Juce or Fresubin Jucy. Nutritional content and prices are shown on page 16. STEP 6 Reviewing ONS Patients on ONS should be reviewed regularly. It is the responsibility of the prescriber to make sure that patients are adequately monitored to assess progress towards treatment goals and whether there is a continued need for ONS on prescription. The following parameters should be monitored at least every 3 months: Weight/BMI/wound healing depending on goal set if unable to weigh patient, record other measures to assess if weight has changed e.g. mid-upper arm circumference, subjective measures (e.g. clothes/rings/watch looser or tighter, visual assessment) Changes in food intake Compliance with ONS and stock levels at home/ care home Prescription Requests from Care Homes Care Homes should not routinely request ONS prescriptions for residents because in most cases residents nutritional needs can and should be met using food and homemade supplements. Exceptions to this general rule are where residents are unable to manage 2 x 230ml homemade supplements per day (see Small Volume Compact Style ONS above) or where residents require thickened fluids due to diagnosed dysphagia. In these cases Care Homes must demonstrate that the resident meets criteria for prescription (i.e. that they are at high risk of malnutrition) and that the Home has also fully implemented food first strategies to treat malnutrition. Prescription Requests from Hospital and Community Dietitians Hospital and community dietitians requesting continuation of ONS post discharge or following a clinic appointment must clearly state the treatment goals, patient s current weight, BMI, % weight loss and MUST score on the discharge summary/ clinic appointment letter. The dietitian should also indicate the expected timescale for prescription and who is responsible for patient follow up. If the product requested is not 1 st or 2 nd line See West Hertfordshire Hospitals Trust (WHHT) Dietitian ONS Prescription Request Letter See Hertfordshire Community NHS Trust (HCT) Dietitian ONS Prescription Request Letter Patients discharged from hospital should not routinely be prescribed ONS as part of TTA medication unless a dietitian assessed the patient and approved the continued use. These patients may have been started on ONS products which are not the primary care preferred cost-effective choices. In these Page 8 of 22

9 cases, a switch to the preferred primary care ONS product is recommended. This switch in primary care is fully supported by the local hospital and community dietetic teams. Patients should have been informed of this likelihood prior to discharge. There will be instances where it would NOT be appropriate to switch to the preferred choice in primary care and the reason will be clearly stated in the communication letter from the hospital or community dietitian. STEP 7 Discontinuing ONS and follow up When treatment goals are met, discontinue treatment. Review one month after the discontinuation of ONS to make sure that there is no recurrence of the precipitating problem. Should the patient wish to continue with ONS and it is no longer indicated by ACBS criteria or treatment goals are met, the use of over the counter supplements (e.g. AYMES Retail, Complan, Meritene ) should be recommended. Nutritional content and prices are shown on page 13. Referral for specialist dietetic input (STEPS 4-7) Dietetic referral may be appropriate in any of the following circumstances: To advise on nutritional supplementation strategies and the appropriateness or otherwise of initiating oral nutritional supplements. To assist in appropriate planning and goal setting for nutritional support for individual patients. Deterioration in nutritional status despite supplementation after excluding other contributory pathology. Apparent requirement for ONS longer than 3 months. The presence of co-existing medical conditions such as diabetes, renal and liver disease, malabsorption, coeliac disease or high cardiovascular risk or any other condition which may indicate complex patient. Where swallowing difficulties or other indications for modified texture exist. Assessment by Speech and Language Therapist will be required before dietetic input. Page 9 of 22

10 Inappropriate Prescribing of ONS Care homes should provide adequate quantities of good quality food so that the use of unnecessary nutrition support is avoided. ONS should not be used as a substitute for the provision of food. Suitable snacks, food fortification as well as homemade milkshakes and smoothies and over the counter products can be used to improve the nutritional intake of those at risk of malnutrition (see Patient/carer resources: - Food First - Eating Well for Small Appetites - Food First - Fortifying Food for care homes - Food First Quick guide - Food First - Homemade supplements) Patients should not be routinely discharged from hospital on ONS without dietetic assessment and review process in place. These patients will not automatically require ONS on prescription once home. They may have required ONS whilst acutely unwell or recovering from surgery, but once home and eating normally the need is negated. Therefore, unless the request to prescribe ONS following hospital discharge is from the dietetic team, it is recommended that the GP does not prescribe without first assessing need in line with these 7 step guidelines. Where ONS are still required, a switch to the primary care cost-effective preferred product is recommended. Avoid prescribing less than the clinically effective dose of 2 sachets/bottles daily which will provide approximately 600kcal/day. Once daily prescribing provides amounts which can be met with food fortification alone. Patients with complex nutritional needs e.g. renal disease, liver disease, swallowing problems, poorly controlled diabetes and gastrointestinal disorders may require specialist products and should be referred to local community dietetic services, if not already known to the service. Patients with swallowing problems will require assessment by a Speech and Language Therapist (SLT) before ONS can be safely prescribed and before dietetic input. These patients may require ready thickened ONS or dessert/pudding style ONS to make sure that the required consistency is provided in the supplement. Only prescribe ONS on the recommendation of a dietitian following an SLT assessment (see page 17). Patients in the final days or weeks of life are unlikely to benefit from ONS. Focus at this time should be on enjoyment/quality of life, not on nutritional adequacy. See pages Palliative Care and ONS Prescribing and Eating and drinking at end of life). Diabetes UK is clear that for patients with diabetes, treating malnutrition takes priority over dietary management of blood glucose levels. If a patient with diabetes meets criteria for ONS prescription, the choice of product should be made as above. Any resulting impact on blood glucose control may need to be managed with medication. Patients who are substance misusers should not routinely be prescribed ONS. (See guidance on pages 18/19 - Substance Misusers). Do not initate ONS listed on pages ONS which should not be started in primary care unless a dietitian has requested and clinically justified the product Page 10 of 22

11 ONS CARE PATHWAY IN PRIMARY CARE STEP 1: Patient identified as requiring oral nutritional support Refer the following to community dietetic services: Without delay those at risk of re-feeding syndrome or who rely on ONS as sole source of nutrition STEP 2: Assess underlying causes of malnutrition and availability of adequate diet Make changes to treatment plan and refer to other services as needed STEP 3: Set a treatment goal (set target weight/weight gain or target BMI) STEP 4: Offer food first advice and suggest over the counter products (AYMES Retail, Complan or Meritene ) or homemade supplements Review after one month has there been progress toward treatment goal set? NO progress towards set goal STEP 5: Prescribe ONS Reinforce food first advice Reassess underlying problems and treat If ACBS criteria met, consider whether patient is more likely to take therapeutic dose (bd) of prescribed ONS compared with homemade or OTC supplements If yes, prescribe ONS as per guideline in addition to food first. Reassess after 1 week trial of ONS and prescribe preferred flavour twice daily for 1 month and then review Yes, there is progress towards set goal Reinforce advice. Reassess after 1-3 months until goal met If problems re-occur, return to start of ONS care pathway flowchart STEP 6: Reviewing ONS Continued improvement or progress Reinforce advice. Check compliance to ONS and any changes in food intake or other underlying cause Reassess after 1-3 months until goal met No progress or improvement Refer to community dietetic service Treatment goal met STEP 7: Discontinue ONS Review after 1-3 months. If patient still wishes to take ONS, suggest over the counter products (AYMES Retail, Complan, Meritene ) or homemade supplements If problems re-occur, return to start of ONS care pathway flowchart Page 11 of 22

12 ONS PRODUCT CHOICE ALGORITHM WHEN INITIATING ONS PRESCRIBING IN PRIMARY CARE Patient has been identified as requiring oral nutritional support (MUST score 2, BMI<18.5kg/m 2, weight loss) due to failure to improve nutritional status or functional status after one month of food first [i.e. STEPS 1-4 of appropriate prescribing of ONS in adults see pages 5-6 of guidelines]. Nutritional assessment undertaken and referral to appropriate local services considered; complex patients referred to dietetic services; treatment goal set (target weight/weight gain or target BMI) Does the patient meet ACBS criteria? YES NO Suggest patient/carer purchases over the counter supplements (AYMES Retail, Complan,Meritene ) Is patient or carer unable to make up a powder shake or is patient lactose intolerant? NO YES *1st LINE ONS POWDERED SHAKE AYMES Shake Mix the contents of one sachet with 200ml full fat milk drink this amount twice daily between meals Available as starter pack (box of 5x57g sachets of mixed flavours with a shaker) and a box of 7x57g sachets of one flavour: vanilla, banana, chocolate, strawberry & neutral. Alternative product for patient taste or palatability preferences: Foodlink Complete. Note: Do not use as sole source of nutrition or for patients with lactose intolerance Patient unable to tolerate twice daily ONS because the volume is too large, therefore non therapeutic dose taken and ONS wasted *2 ND LINE ONS READY TO DRINK MILKSHAKE STYLE LIQUID AYMES Complete Alternatives for patient palatability/taste- Ensure Plus Milkshake, Fortisip Bottle or Nutricomp Drink Plus One bottle twice daily between meals Note: Liquid ONS are nutritionally complete and lactose free Patient unable to tolerate twice daily ONS because the volume is too large, therefore non therapeutic dose taken and ONS wasted Low volume compact style milkshake 125ml bottles Altraplen Compact AYMES Shake mixed with 100ml full fat milk Alternatives for palatability and taste preference include Foodlink Complete *Refer to pages of guidelines for full details of ONS products Page 12 of 22

13 Over the Counter Supplements These products are available to buy at pharmacies and larger supermarkets. They are suitable for those who do not meet ACBS prescribing criteria and/or those who choose them instead of homemade fortified milkshakes. The nutritional content of these products is virtually identical to that of a homemade fortified milkshake so there is no nutritional advantage to using these products, and preparation time and effort is also almost identical. These products are not suitable as a sole source of nutrition and should not be used as tube feeds. These products should not be prescribed on the NHS. Powdered Products AYMES Retail sachets Complan Meritene Presentation 1 box of 4 x 38g sachets Vanilla, banana, strawberry and chocolate flavours 1 box of 4 x 57g sachets Vanilla, banana, strawberry, chocolate and neutral flavours 1 x 30g sachet of one flavour Vanilla, strawberry, and chocolate flavours Nutritional content per sachet mixed with 200mls full fat milk 265kcal 15.1g protein 387kcal 15.6g protein 247kcal* 16.6g protein* Approx. Retail Cost per sachet + milk 89p ## 93p # 1.07p # Soups Presentation Nutritional content per sachet mixed with 200mls water Complan soup 1 box of 4 x 55g sachets 243kcal chicken flavour 8.7g protein Meritene soup 1 x 50g sachet Chicken, and vegetable flavours 207kcal 7.0g protein Approx. Retail Cost per sachet # 82p 1.45 # costs accessed 05/03/18 ##costs accessed 05/03/18 ### costs accessed 05/03/18 Page 13 of 22

14 Alternatives for palatability and taste preference Preferred choice Powdered ONS to prescribe as 1 st line These products are not suitable as sole source of nutrition and should not be used as tube feeds Starter pack (shaker and mix of flavours) is available for AYMES Shake and Foodlink Complete. Powder shakes should be mixed with full fat milk (usual volume 200ml) as per manufacturer s instructions If patient cannot take the full volume, both AYMES Shake and Foodlink Complete can be mixed with 100ml of full fat milk to make a compact style ONS. Both these products are palatable when prepared in this way 1 st LINE ONS POWDER SHAKE ONS Powder Shake Product AYMES Shake AYMES Shake starter pack Foodlink Complete Foodlink Complete Starter Pack Foodlink Complete with Fibre Presentation 1 box of 7 x 57g sachets of one flavour. Vanilla, banana, strawberry, chocolate and neutral flavours 1 box of 5 x 57g sachets of mixed flavours with a shaker 1 box of 7 x 57g sachets of one flavour. Vanilla, banana, strawberry, chocolate and neutral flavours 1 box of 4 x 57g and 1x63g sachets of mixed flavours with a shaker 1 box of 7 x 63g sachets of one flavour. Vanilla, banana strawberry, chocolate and neutral flavours * Note: Increased protein content in comparison to alternative products. **Prices accessed 02/05/18 Nutritional Content per sachet mixed with 200ml full fat milk 388kcal 15.7g protein 385kcal 18.5g protein* 385kcal 18.5g protein* 420kcal 19.7g protein* 4.5g fibre Cost per sachet** 60p 96p 60p 62p 71p Page 14 of 22

15 Liquid ONS to prescribe as 2 nd line if powders not suitable Powdered ONS is the 1 st line ONS to be prescribed in primary care. Consider 2 nd line liquid ONS if one of the following applies*: - Patient is on a liquid only diet due to a (usually short term) inability to tolerate solid foods (e.g. inflammatory bowel disease, oesophageal stricture, neck/gi tumours requiring radiotherapy). These patients will require a liquid ONS which is nutritionally complete since this will be used as a sole source of nutrition. Ready to drink liquid ONS are nutritionally complete (contain a full range of vitamins and minerals) whereas powdered ONS are not. This is not an issue when powdered ONS are used to supplement oral nutrition in patients who are able to eat normal fortified meals. Patient requiring liquid ONS as part of an enteral feeding regimen administered via the enteral feeding route. Patient is on fluid restriction (e.g. refractory ascites, chronic heart failure). The patient will require referral to a Dietitian. Patient with renal impairment: - o Powdered ONS contains a higher potassium content which may cause hyperkalaemia. This may be potentiated if the patient is also taking a potassium sparing medication e.g. ACE-inhibitor. o Patient with chronic kidney disease taking phosphate binders. Milk based powdered ONS contains a higher phosphate content. Patient has diabetes - Diabetes UK is clear that for patients with diabetes, treating malnutrition takes priority over dietary management of blood glucose levels. If a patient with diabetes meets criteria for ONS prescription, the choice of product should be made as above. Any resulting impact on blood glucose control may need to be managed with medication. Patient has very limited dexterity (e.g. arthritis) or neuromuscular conditions (e.g. motor neurone disease) and does not have access to a carer to make up the powdered ONS shake. This should be assessed on an individual patient basis. Patient is intolerant to an ingredient in the powdered ONS e.g. lactose. Patients who dislike milky drinks see Juice style drinks. See (see Patient/carer resources: Food First - Eating Well for Small Appetites; Food First - Fortifying Food for care homes; Food First Quick guide; Food First - Homemade supplements) 2 nd line ONS (ready to drink liquid milkshake style) Preferred choice Alternatives for palatability/ taste preference AYMES Complete when patient is lactose intolerant or patient/carer cannot make up a shake Ensure Plus Milkshake when patient is lactose intolerant or patient/carer cannot make up a shake Nutricomp Drink Plus when patient is lactose intolerant or patient/carer cannot make up a shake Presentation 200ml bottle Vanilla, strawberry, banana and chocolate flavours 200ml bottle Strawberry, chocolate, fruit of forests, vanilla, banana, coffee, neutral, orange, peach, raspberry flavours 200ml bottle Vanilla, strawberry, banana and chocolate flavours Nutritional content per bottle 300kcal 12g protein 300kcal 12.5g protein 300kcal 12g protein Cost per bottle** Page 15 of 22

16 Fortisip bottle when patient is lactose intolerant or patient/carer cannot make up a shake **Prices accessed 02/05/ ml bottle Neutral, vanilla, banana chocolate, toffee/caramel, orange, strawberry, and tropical flavours 300kcal 12g protein 1.12 Small Volume Compact Style ONS If patient cannot take the full volume, then AYMES Shake or Foodlink Complete can be mixed with 100ml of full fat milk to make a compact style ONS. This will prevent wastage and improve compliance If powder is not suitable, then use Altraplen Compact (125ml) to prevent wastage and improve compliance. Small volume, compact style ready to drink liquid ONS Presentation Cost per 125ml bottle** Altraplen Compact when patient is lactose intolerant Ensure Compact 4 x 125ml bottles Strawberry, vanilla, banana & hazel chocolate flavours 4 x 125ml bottles Vanilla, strawberry, cafe latte or banana flavours Nutritional content per 125ml bottle 300kcal 12g protein 300kcal 12g protein Juice Style ONS for patients who dislike milky drinks These are fat free so can be used in patients requiring a low fat diet (e.g. pancreatitis) These are not nutritionally complete and should not be used as a sole source of nutrition Juice Style ONS Presentation Nutritional content Lactose Free Alternative for palatability/taste preference Ensure Plus Juce Fresubin Jucy 220ml bottle Orange, apple, lemon and lime, strawberry, peach, fr punch flavours 200ml bottle Orange, apple, pineapple, cherry and blackcurrant flavours per unit 300kcal 10.6g protein lactose free 300kcal 12g protein contains lactose Cost per unit** **Prices accessed 02/05/18 Page 16 of 22

17 ONS that should not routinely be initiated in primary care The ONS listed below should not routinely be initiated in primary care unless directed by a dietitian. These will sometimes be used by dietitians either alone or in conjunction with other ONS where first line products are not sufficient to meet individual patients nutritional needs or are not suitable. However these patients should always be under review of the dietitian. These include: Low calorie products i.e. 1kcal/ml since these are not cost effective Milkshake style ONS which are not first or second line products in primary care High energy/protein products Modular supplements which do not provide a balance of nutrients Specialist products which may be required for particular patient groups e.g. renal patients, or those with bowel disorders, those with pressure ulcers, or those with dysphagia Pre-thickened supplements may be required for patients who meet criteria for ONS prescription and who have a diagnosed swallowing difficulty (dysphagia) for which thickened fluids (stage 1 or 2 (UK guidance)/ Level 2 or 3 (IDDSI guidance from April 2018)) have been advised by a Speech and Language Therapist (SLT). Thickening either powder or liquid ONS to achieve a safe texture is difficult, therefore use of pre-thickened ONS is recommended to reduce risk of aspiration. Puddings/desserts should only be prescribed for patients who meet criteria for ONS prescription and who have a diagnosed swallowing difficulty (dysphagia) for which stage 3 thickened fluids (UK guidance)/level 4 (IDDSI guidance from April 2018) have been advised by an SLT. Yoghurt style ONS may be useful in patients who experience taste changes e.g. as a side-effect to cancer treatments This is not a comprehensive list. Please contact the dietitian or Pharmacy and Medicines Optimisation Team if you have queries about these or other supplements. ONS that should not routinely be initiated in primary care (this list is not exhaustive) Product Presentation Description of product Fresubin Original 200ml bottle 1kcal/ml ONS Ensure 250ml can 1kcal/ml ONS Resource Energy 200ml bottle Milkshake style ONS Fresubin Energy 200ml bottle Milkshake style ONS Fortisip Yogurt style 200ml bottle Yogurt style ONS Ensure Plus Savoury 220ml bottle Soup style ONS Vitasavoury 33g cups, 50g sachets Soup style ONS Ensure Plus Fibre 200ml bottle Milkshake style ONS with fibre Fresubin Energy Fibre 200ml bottle Milkshake style ONS with fibre Nutricomp Drink Plus Fibre 200ml bottle Milkshake style ONS with fibre Fortisip Compact Fibre 125ml bottle Low volume milkshake style ONS with fibre Altraplen Protein 200ml bottle Milkshake style ONS with high protein Fortisip 2kcal 200ml bottle Milkshake style ONS with high protein Fortisip Extra 200ml bottle Milkshake style ONS with high protein Ensure Twocal 200ml bottle Milkshake style ONS with high protein Fortijuce 200ml bottle Juice style ONS Altrashot 4 x 120ml bottle Modular supplement Calogen 200ml & 500ml bottle Modular supplement Calogen Extra 40ml shots & 200 ml Modular supplement bottle Page 17 of 22

18 Product Presentation Description of product Aymes 2.0kcal 200lml bottle High energy & protein Fresubin 2kcal Drink 200ml bottle High energy & protein Ensure Twocal 200ml bottle High energy & protein Fresubin 5kcal shot 4 x 120ml bottle Modular supplement Pro-Cal shot 6 x 250ml bottle, 60 x Modular supplement Pro-Cal powder 30ml shots, 510g tin Aymes Shake Extra 6 x 85g sachet Modular supplement Calshake 7 x 87g sachet Modular supplement Enshake 6 x 96.5g sachet Modular supplement Scandishake 6 x 85g sachet Modular supplement Aymes Creme 4 x 125g pots Dessert Ensure Plus Crème 4 x 125g pots Dessert Forticreme Complete 4 x 125g pots Dessert Fresubin 2 kcal Crème 4 x 125g pots Dessert Fresubin YoCreme 4 x 125g pots Dessert Nutilis Fruit Stage 3 3 x 150g pots Dessert Nutricrem 4 x 125g pots Dessert Fresubin Thickened Stage 1 4 x 200ml bottles Pre-thickened ONS Fresubin Thickened Stage 2 4 x 200ml bottles Pre-thickened ONS Nutilis Complete Stage 1 4 x 125ml bottles Pre-thickened ONS Nutilis Complete Stage 2 4 x 125ml bottles Pre-thickened ONS Vital 1.5kcal 200ml bottle Specialist product for bowel disorders Modulen IBD 400g tin Specialist product for bowel disorders Nepro 200ml bottle Specialist product for renal disease PATIENT GROUPS FOR SPECIAL CONSIDERATION Substance misusers Substance misuse (drug and alcohol misuse) is not a specified ACBS indication for ONS prescription. Substance misusers may have a range of nutritional problems such as: Poor appetite and weight loss Nutritionally inadequate diet Constipation (drug misusers in particular) Dental decay (drug misusers in particular) Problems created by prescribing ONS for Substance Misusers: Once started and established on ONS, it may be difficult to stop the individual taking them ONS may be taken instead of meals and therefore provide no benefit They may be given to others i.e. family / friends They may be sold and used as a source of income These patients can be poor clinic attendees, therefore making it difficult to monitor and reassess need for ONS ONS should not be prescribed for substance misusers unless all the following criteria are met: BMI < 18 kg/m 2 AND there is evidence of significant weight loss (>10%) in the past 3 to 6 months AND there is a co-existing medical condition that could affect weight or food intake AND once nutritional advice has been advised and tried AND the patient is in a rehabilitation programme e.g. methadone or alcohol programme or on the Page 18 of 22

19 waiting list to enter a programme Or they are within the ACBS categories If ONS is initiated: The patient should be assessed and monitored by a dietitian. If they fail to attend clinic appointment on two consecutive occasions ONS should be discontinued. Maximum prescription should be for approximately 600 kcal / day (300 kcal twice daily). Prescribed on a short term basis only (i.e. 1-3 months). If there is no change in weight after three months, ONS should be replaced with food. If weight gain occurs, continue until the treatment goals are met (e.g. usual or healthy weight/bmi) and then reduce and stop ONS. If the individual still wishes to continue using a supplement, recommend over the counter nutritional supplements (e.g. Complan or Mertitene ). See page 13 for nutritional content and prices. Palliative Care Consideration should be given to the patient s prognosis and their quality of life. ONS usage is common among palliative care patients, however the rationale and purpose of such a prescription needs to be carefully considered. See Eating and drinking at end of life Use of ONS in palliative care should be assessed on an individual basis. Appropriateness of ONS will be dependent upon the patient s health and their treatment plan. Emphasis should always be on the enjoyment of nourishing food and drinks and maximising quality of life. Management of palliative patients has been divided into three stages: early palliative care, late palliative care and the last days of life. Care aims will change through these stages. Loss of appetite is a complex phenomenon that affects both patients and carers. Health and social care professionals need to be aware of the potential tensions that may arise between patients and carers concerning a patient s loss of appetite. This is likely to become more significant through the palliative stages and patients and carers may require support with adjusting and coping. The patient should always remain the focus of care. Carers should be supported in consideration of the environment, social setting, food portion size, smell, presentation and their impact on appetite. ONS should not be prescribed just for the sake of doing something especially if other dietary treatments have failed. Nutritional management in early palliative care In early palliative care, the patient is diagnosed with a terminal disease but death is not imminent. Patients may have months or years to live and may be undergoing palliative treatment to improve quality of life. Nutrition screening and assessment in this patient group is a priority and appropriate early intervention could improve the patient s response to treatment and potentially reduce complications. However, if a patient is unlikely to consistently manage 2 servings of ONS per day, then they are unlikely to derive any significant benefit to well-being or nutritional status from the prescription. Following the 7 steps in this guideline is appropriate for this patient group. Particular attention should be paid to Step 2 Assessment of causes of malnutrition (see page 4). As the patient progresses into the late palliative care stage, consider reducing the prescribing quantity from monthly prescriptions to one or two weekly to avoid wastage. Nutritional management in late palliative care In late palliative care, the patient s condition is deteriorating and they may be experiencing Page 19 of 22

20 increased symptoms such as pain, nausea or reduced appetite. The nutritional content of the meal is no longer of prime importance and patients should be encouraged to eat and drink foods they enjoy. The main aim is to maximise quality of life including comfort, symptom relief and enjoyment of food. Aggressive feeding is unlikely to be appropriate especially if this can cause discomfort, as well as distress and anxiety to the patient, family and carers. The goal of nutritional management should NOT be weight gain or reversal of malnutrition, but quality of life. Nutrition screening, weighing and initiating prescribing of ONS at this stage is NOT recommended. Avoid prescribing ONS for the sake of doing something when other dietary advice has failed. Nutritional management in the last days of life In the last days of life, the patient is likely to be bed-bound, very weak and drowsy with little desire for food or fluid. The aim should be to provide comfort for the patient and offer mouth care and sips of fluid or mouthfuls of food as desired. Adapted from the Macmillan Durham Cachexia Pack 2007 and NHS Lothian guidance Diabetes Obtaining optimal blood glucose control may not be a priority over dietary measures to reduce malnutrition risk. This depends on the patient s diagnosis, prognosis and degree of malnutrition. The dietary treatment of malnutrition may require patients to have foods higher in fat and sugar than is usually recommended. For this reason tighter monitoring of blood glucose levels is recommended. Diabetes medications may need to be reviewed if oral intake has changed significantly. If ONS is indicated: - Milk based products should be chosen in preference to juice based products due to lower glycaemic index value. Diabetic patients requiring tight blood glucose control should be referred to a Dietitian.. Diabetes UK is clear that for patients with diabetes, treating malnutrition takes priority over dietary management of blood glucose levels. If a patient with diabetes meets criteria for ONS prescription, the choice of product should be made as above. Any resulting impact on blood glucose control may need to be managed with medication. Cardiovascular disease Patients with high cholesterol can be encouraged to choose foods with higher unsaturated fat (from plant origin) content in preference to those with a high saturated fat content. Healthier choices to increase the overall calorific value of the diet include using skimmed milk powder, margarine, nuts and seeds, and plant oils (with the exception of palm and coconut oil). However, food first treatment of malnutrition should focus on mainly nutrient dense foods (e.g. milk based foods, nuts) rather than mainly high fat foods (e.g. butter, cream). High cholesterol levels should not preclude food first treatment of malnutrition, not least because malnutrition is known to adversely affect heart health and diminish muscle (including cardiac muscle) mass. Renal disease The following should be considered in patients with renal disease: - Patients with chronic kidney disease requiring phosphate restriction (usually patient will be taking phosphate binder medication) are not suitable for milk based powder shakes due to the higher Page 20 of 22