A Guide to Prescribing Adult Oral Nutritional Supplements in West Kent CCG

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1 A Guide to Prescribing Adult Oral Nutritional Supplements in West Kent CCG Aim This guideline has been designed to support primary care prescribers initiating nutrition support for adults in West Kent. Introduction Malnutrition, in terms of undernourishment, is both a cause and consequence of disease in adults. It is common and affects over 3 million people in the UK with associated health costs exceeding 13 billion annually. Adverse effects include: Weight loss Muscle wasting and reduced strength Reduced respiratory muscle function - increasing the risk of chest infection and respiratory failure Reduced cardiac function Impaired immune function - increasing risk of infection Increased susceptibility to pressure ulcers Oedema Apathy, depression and self-neglect Increased mortality and morbidity There are also significant healthcare costs related to malnutrition. Malnourished people have more hospital admissions; longer length of stay and more readmissions; more GP visits and prescriptions. The overall healthcare cost is more than double that of a nonmalnourished individual. Therefore, it is important to identify and treat patients who are malnourished or at risk of becoming malnourished, as soon as possible. However, this does not mean that all such patients require oral nutritional supplements (ONS). The current cost of adult oral nutritional supplement prescribing in NHS West Kent is 1,117, (August July 2015), and without systems in place to monitor and review patients prescribed ONS, it is predicted that the expenditure will continue to rise. Individuals who are malnourished or at risk of malnutrition are best treated in the first instance with food - this is known as the food first approach. However all too often ONS are used as a first line treatment without individuals being advised to increase their energy and protein intakes from food first. This results in inappropriate use of ONS with increased prescribing costs. Due to increasing cost pressures faced by the CCG and local health economy it is essential to identify areas where savings can be made. There are a number of areas of prescribing in which cost effectiveness may be able to be further improved without impacting on the quality of prescribing and patient care. 1

2 Key messages The food first approach should always be used initially. Provide patient with a nutrition advice sheet Weigh the patient at their first appointment and thereafter at each review visit For initial ONS prescriptions use first line product Ensure shake Use starter packs for Ensure Shake using the direct to patient sampling service Set treatment goals with the patient, if viable, before initiating ONS, such as: o Prevent further weight loss/deterioration of nutritional status o Support recovery/weight gain/ achieve a healthy Body Mass Index (BMI) o Optimise nutritional status during illness Review patient monthly (weight, changes in dietary intake, compliance with ONS) Avoid prescribing 1 kcal/ml ONS products e.g. Ensure can or Fresubin original. They contain less nutritional benefit and are not as cost effective G.P should no longer initiate Calogen or Procal Shots prescriptions. These are expensive fat emulsion products. Double cream is an equivalent substitute. For example, 30ml double cream three times a day is equivalent to 30ml Calogen or Procal shot three times a day, both providing an equivalent of 405 kcals G.P to stop Calogen / Procal Shot prescriptions for patients in care homes. Double cream is an equivalent substitute Avoid Prescriptions of one ONS per day as there is no improved clinical outcome ONS should not be used to replace meals Patients in the final weeks of life are unlikely to benefit from an ONS prescription. There are over the counter products that could be suggested as alternatives e.g. Build up and Complan 2

3 Is the patient malnourished? The Malnutrition Universal Screening Tool (MUST) is the validated, NICE approved tool for identifying patients deemed to be at nutritional risk. It is recognised by West Kent CCG that due to a very limited dietetic service operating in West Kent, there are currently no dietetic resources to provide robust MUST training to all relevant staff involved within the service. However, the following criteria outlined by NICE used to identify those who are malnourished or nutritional at risk should be considered for adult patients can be defined by any of the following: Body mass index (BMI) of less than 18.5kg/m 2 Unintentional weight loss greater than 10% within the last 3-6 months BMI of less than 20kg/m 2 and unintentional weight loss greater than 5% within the last 3-6 months Eaten little or nothing for more than 5 days or unlikely to for the next 5 days Those who have poor absorptive capacity or high nutrient losses e.g. catabolism Re-feeding syndrome Be aware that some malnourished patients are at the risk of developing re-feeding syndrome. This causes a severe shift in electrolytes and fluid balance, associated with abnormalities in metabolism when individuals are treated nutritionally after a period of starvation. Patients who meet the following criteria outlined by NICE CG32 should be considered at high risk of developing re-feeding problems: Patient has 1 or more of the following: Or patient has 2 or more of the following: Body mass index (BMI) of 16.5kg/m 2 or less little or no nutritional intake for more than 10 days lost more than 15% of their body weight within the last 3-6 months (except patients at end of life) low levels of potassium, phosphate or magnesium prior to feeding BMI less than 18.5kg/m 2 unintentional weight loss greater than 10% within the last 3-6 months little or no nutritional intake for more than 5 days a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics Any G.P who has concerns that a patient may be at risk of re-feeding syndrome should contact the NHS West Kent CCG Medicines Optimisation Team for advice. 3

4 Food first approach West Kent CCG supports a Food first policy and patients should be provided with practical advice on ways to make meals and snacks more nutritious by increasing the protein and energy in their diets using everyday food. This should always be the first strategy for treating malnutrition. The nutrition sheet making the most of every mouthful should be provided to patients or carers Making the most of every mouthf First line ONS powder starter packs If food first has not improved nutritional intake, start ONS first line powder starter packs. This should be dispensed to avoid wastage, in case of product not being well tolerated Each sachet to be made up with 200ml of full fat milk Product Ensure Shake Starter pack Direct to patient sampling service: Abbott Direct-to-Patient samp Order samples via electronic version in the surgery and to abbott.hospital2home@nhs.net Directions: On the electronic sample document, select Ensure Shake samples with patient flavour/s choice (up to 2 weeks bd); enter patient name and address and to abbott.hospital2home@nhs.net The patient will then receive the samples at home within 48 hours. This can be done with the patient during the consultation. Free service 4

5 Appropriate prescribing first line ONS powder If following the starter pack the patient is willing to take the Ensure Shake, prescribe dosage in line with clinical judgement Product Unit Nutritional profile per serving Ensure Shake For initial prescriptions only 57g sachet to be mixed with 200ml of full fat milk Mixed using a fork method 389kcal 17g protein Contains lactose If the patient is non-compliant or non-tolerant to the first line ONS, prescribe alternative supplement options from borderline substances in the BNF. Suggested alternatives may include: Product 2.4 kcal/ml Unit Nutritional profile per serving Ensure Compact 125ml 300kcal 12.8g protein Fortisip Compact 125ml 300 kcal 12g protein Product 1.5 kcal/ml Unit Nutritional profile per serving Ensure Plus milkshake style Fortisip Fresubin Energy Product 1.5 kcal/ml Juice option Ensure Plus Juce Fortijuce Fresubin Jucy 220ml 200ml 200ml Unit 220ml 200ml 220ml 330 kcal 13.8g protein 300 kcal 11.8g protein 300 kcal 11.8g protein Nutritional profile per serving 330 kcal 10.6g protein 300 kcal 7.8g protein 300 kcal 8g protein Calogen and Procal Shots These are expensive fat emulsion products. Double cream is a suitable equivalent which can be used in the same way. G.P should no longer initiate Calogen or Procal Shots prescriptions. G.P to stop Calogen / Procal Shot prescriptions for patients in care homes. In care homes, double cream can be used as a replacement to Calogen or Procal Shots using the same dosage. For example, a patient currently on 30ml of Calogen or Procal Shot three times a day can be swapped to 30ml of double cream three times a day. Both these expensive products and double cream have similar taste and provide the same calories. 5

6 Mono caloric ONS Avoid initiating prescriptions for these products. They are 1kcal/ml ONS products e.g. Ensure Can, Fresubin Original. They contain less nutritional benefit and are not as cost effective as other more energy dense ONS products. The calorific value is equivalent to full fat milk and this should therefore be used instead of these ONS products. Contact details If you have any questions or require any further information regarding this document, please do not hesitate to contact the NHS West Kent Medicines Optimisation Team, via the generic account. References National Institute for Health and Clinical Excellence (NICECG32) Nutritional support in adults: oral nutritional support February Body Mass Index (BMI) patient weight (kg) Height 2 (m) 6