GP, Community Nurse and Specialist Nurse Oral Nutritional Supplement (ONS) Formulary for Adults
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1 GP, Community Nurse and Specialist Nurse Oral Nutritional Supplement (ONS) Formulary for Adults ALWAYS use the Food First approach before considering prescribing ONS (This includes over the counter ONS such as Complan, Aymes and Meritene Energis milkshakes or soups) Short term acute illness ONS prescription of Aymes Shake or Complan Shake, 57g sachet up to twice daily for up to 1 month. Long term chronic conditions refer to dietitian and commence Aymes Shake or Complan Shake, 57g sachet, up to twice daily for 2 months. Advise patient to consume ONS between meals to prevent spoiling appetite. Standard ACBS indications for the prescription of oral nutritional supplements: Disease-related malnutrition, intractable malabsorption, pre-operative preparation of malnourished patients, dysphagia, proven inflammatory bowel disease, following total gastrectomy, short-bowel syndrome, bowel fistula. For patients who do not meet ACBS criteria they can purchase over the counter ONS from community pharmacies or supermarkets. An Over the Counter Supplements leaflet is available along with other Food First supporting resources for clinicians, patients and carers at the Tayside Nutrition MCN website Dietitians may suggest different ONS as they use a formulary with more specialised products. Please note that not all supplements are nutritionally complete. Patients requiring complete nutrition should be referred to a dietitian without delay. The content of vitamin K is variable in ONS therefore increased monitoring is required for patients on warfarin. ONS guidance for palliative care and substance misuse (alcohol and drugs) is provided in Appendices 1 and 2 to aid prescribing practice for these patients. Version No 9 Date of Issue March 2017
2 Powdered ONS should be encouraged as FIRST LINE choice. Does the patient have the cognitive and functional ability to make up a shake, OR has access to a carer to mix a shake? Yes Aymes Shake Powder up to 2/day or Complan Shake Powder up to 2 /day (Always provide 1 x Sample/Starter pack initially to ensure patient receives the necessary Shaker) Aymes Complete Liquid up to 2/day or Ensure Plus milkshake style liquid up to 2/day No If patient is unable to tolerate twice daily ONS because the volume is too large, Aymes Shake can be mixed with 100ml full fat milk if a low volume compact style ONS is required. If the patient dislikes milk, encourage them to try mixing Aymes Shake powder or Complan Shake with 200ml fruit juice and look at Company Recipes. Powdered ONS - Vitamins K & A and Phosphate may exceed Dietary Reference Values, use with caution in pregnancy and patients with CKD 4. FIRST LINE Powdered Flavours PIP Codes Presentation Nutritionally kcal / Sachet Protein / Sachet ONS Complete Aymes Banana x 57g sachets No 389 Chocolate full Aymes Shake powder (flavour not specified) (Instructions advise to make up with milk or water but it is preferable if patients use full Strawberry Vanilla Neutral Chicken Sample pack x 57g sachets & shaker (Therefore not to be used as a sole source of nutrition) 250 water) 15g full fat milk) 9g water) Nutricia Complan Shake oral powder (flavour not specified) (Instructions advise to make up with milk or water but it is preferable if patients use full Banana x 57g sachets No Chocolate Original Strawberry Vanilla Starter Pack x 57g sachets & shaker (Therefore not to be used as a sole source of nutrition) 380 (with 200ml full fat milk) 253 water) 15.5g (with 200ml full 9g water)
3 Second Line Ready Made ONS 1.5 kcal/ml Aymes Aymes Complete Flavours PIP Codes Presentation Nutritionally kcal / Bottle Protein / Bottle Complete Banana ml bottle Yes g Chocolate Strawberry Vanilla Sample pack x 200ml bottles Abbott Ensure Plus milkshake style Banana ml bottle Yes g Peach Raspberry Strawberry Vanilla Neutral Chocolate Coffee Fruits of the forest Orange Ensure Plus Commence: Starter Pack x 220ml bottles Abbott Ensure style Plus yoghurt Orchard Peach Strawberry Swirl ml bottle Yes g
4 Appendix 1 :Substance Misuse (drugs and alcohol) ONS Guidance Substance misuse is NOT a specified ACBS indication for ONS prescription If ONS are initiated, the patient should be assessed and monitored by a dietitian. ONS should NOT be prescribed in those who misuse substances unless they meet ALL of the following criteria or on dietetic advice: Co existing medical condition which affects food and drink intake and meets ACBS criteria BMI 18.5kg/m 2 Significant weight loss ( >10%) in the past 3 to 6 months Patient is in rehabilitation / treatment programme e.g. methadone or alcohol programme or is on the waiting list to enter a programme. Have tried Food First dietary advice ONS prescribing in substances misuse (alcohol and drug misuse) is an area of increasing concern, not only because of cost but also the question of appropriateness Those who misuse substances may have a range of nutrition related problems such as: Poor appetite and weight loss Nutritionally inadequate diet Constipation (drug misuse in particular) Dental decay Possible aetiologies of nutrition related problems: Drugs themselves can cause poor appetite, reduce ph of saliva leading to dental problems, constipation, craving sweet foods (drug misuse in particular) Chaotic lifestyles Lack of interest in food and eating Poor dental hygiene (drug misuse in particular) Irregular eating habits Poor nutrition knowledge and skills Low income and poor access to foods, intensified by increased spending on drugs or alcohol Homelessness / poor living conditions Infection with HIV or hepatitis B and C Potential problems created by prescribing ONS in misuse of substances: Once started it is difficult to persuade the individual to stop taking ONS ONS are free and may be used to replace food. Money which should be used for food may be diverted to fund addiction They may be given to other members of the family / friends They may be sold and used as a source of income Those who misuse drugs in particular are often poor clinic attendees, making it difficult to reassess clinical need for ONS If ONS are to be initiated, as a short time measure whilst waiting for dietetic input, consider prescribing a maximum prescription of up to 2/day (Aymes Shake or Complan Shake) for 2 months (issued on a weekly basis). NOT on repeat prescription. Points to Consider When discussing diet and nutrition with those who misuse substances it should be explained that weight loss is caused by inadequate food intake, and that the only long term solution to this is to improve eating habits and food intake, which may take a considerable time. It should also be stressed that improving food intake doesn t have to be costly or time consuming. Why is their appetite poor? Are they still using any illicit drugs or alcohol to excess? How much do they smoke? Are they filling up on empty calories such as fizzy drinks, tea or coffee? What is their usual weight? Is there any evidence of weight loss or malnutrition? Foods to replace nutritional supplements which contain approximately the same calories as a standard, 1.5 kcal/ml supplement Sausage or bacon on a roll Slice of cheese on toast Packet of crisps and a carton of squash (not diet or sugar free unless patient has diabetes) Readymade milk shake and a biscuit Hot chocolate made with full fat milk and 2 biscuits Reproduced and adapted for NHS Tayside by kind permission of NHS Fife Scone with jam and butter or margarine Milky coffee and a piece of cake Glass of full fat milk and 2 biscuits Bar of chocolate with a milky coffee Individual dessert or custard and sponge
5 Appendix 2: Palliative Care ONS Guidance Consideration should be given to the patient s prognosis and their quality 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. Nutritional management in early palliative care In early palliative care, 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. As the patient progresses into the late palliative care stage, consider reducing the prescribing quantity. Nutritional management in late palliative care 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 and weighing at this stage is likely not appropriate and should be on an individual basis (see Tayside Food Fluid and Nutritional Care Policy). ONS may in fact reduce any remaining enjoyment for food, increase pressure and give false hope to carers. 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 Please see Management Guidelines for Nutritional problems in Palliative Care for more detailed guidance via the Palliative Care website:
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