Adult Prescribing Guidelines

Transcription

1 Prescribing Guidelines for the appropriate use of Oral Nutritional Supplements (ONS) in the Community (Adults) In recent years there has been a significant increase in the prescribing of ONS to treat malnutrition. A number of studies investigating prescribing practices have shown that many patients in primary care are prescribed ONS inappropriately with significant wastage. This has obvious cost implications. In NHS Fife the cost of prescribing oral nutritional supplements was in excess of 1million in 2010/11. ONS growth in Fife (12%, 2010) is significantly higher than the Scottish average (5%, 2010). The guideline is intended to give advice to prescribers regarding appropriate use of formulary ONS in adult Adult Prescribing Guidelines Page 1 Guidelines for patients presenting with weight loss Page 2 Guidelines for ONS in substance misuse Page 3 Guideline for ONS in palliative care Issue Food First dietary information pages: 4-6 If ONS prescribed: Issue Patient guide to ONS page: 7 Nb. max prescription period 3 /12 Once ONS discont issue High Calorie snack list page: 8 Adapted with kind permission of Prescribing Support Dietitians, Greater Glasgow & Clyde; Aug 2011

2 Prescribing Guidelines for the appropriate use of Oral Nutritional Supplements (ONS) in the Community (Adults) 1. Patient presents with recent weight loss &/or poor appetite Determine if patient is malnourished by selecting at least one of the following criteria: BMI < than 18.5kg/m 2 Unintentional weight loss of greater than 10% within 3-6 months BMI kg/m 2 & unintentional weight loss of 5-10% in 3-6 months 2. Address possible underlying causes & resolve where possible Are medical investigations / management necessary? Is weight loss linked to social issues If you consider nutritional problems to be linked to a medical condition or to be severe &/or long term please refer directly for dietetic intervention 3. Provide First Line Dietary Advice To maximise nutritional intake for a minimum period of 4 weeks provide Food First dietary information sheets to patient / carer 4. Review If weight loss occurs over 2 consecutive months, consider an ONS Set treatment goals prior to commencing ONS (e.g. weight gain / maintenance) ONS should not be prescribed for individuals who are underweight/low BMI where there is no underlying medical condition PRESCRIBING ONS: For first prescription, prescribe mixed flavours x 1 week to establish preference. Thereafter prescribe 1 month supply only Refer to formulary for dose. Advise patient to take ONS in between meals & avoid using as meal replacement. Provide Patient guide to nutritional supplements For Palliative Care / Substance Misuse see guidance sheets NHS FIFE FORMULARY: Effective dose is 1-2 bottles daily for max period of 2-3 months. ACBS guidelines apply Ensure Plus Milkshake style Milk-based supplement Ensure Plus Juce Juice based supplement Ensure Plus Fibre Milk-based + fibre supplement No other ONS should be prescribed without dietetic advice 5. Monitoring Monitor patient monthly for compliance and efficacy of ONS Once goals achieved gradually reduce ONS over one month. Once discontinued provide High calorie snack list to patient. Ensure ONS are removed from computer system. After 2-3 months, if no improvement or ongoing deterioration, refer to dietitian 2

3 Prescribing of Oral Nutrition Supplements (ONS) in Substance Misuse Supporting Notes ONS prescribing in substance misusers (alcohol and drug misuse) is an area of increasing concern, not only because of cost but also the question of appropriateness. **If the individual is insistent on using high energy supplements they should be encouraged to try an over the counter product such as Complan or Build-up ** Substance misusers may have a range of nutrition related problems such as:- Poor appetite and weight loss Nutritionally inadequate diet Constipation (drug misusers in particular) 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 misusers in particular) Chaotic lifestyles Lack of interest in food and eating Poor dental hygiene (drug misusers in particular) Irregular eating habits Poor nutrition knowledge and skills Low income and poor access to foods Homelessness / poor living conditions Infection with HIV or hepatitis B and C Potential problems created by prescribing ONS in Substance Misusers:- Once started it is difficult to persuade the individual to stop taking ONS They are often used as meal replacements They may be given to other members of the family / friends They may be sold and used as a source of income Drug misusers in particular are often poor clinic attendees, making it difficult to re-assess clinical need for ONS If BMI is > 18.5 and weight is stable ONS should not be prescribed ONS should NOT be prescribed in substances misusers unless the individual meets all the following criteria:- BMI <18.5 There is evidence of significant weight loss (>10%) within the last 3-6 months There is a co-existing medical condition which could affect weight or food intake Food First dietary advice has been advised and tried The patient is in a rehabilitation programme, e.g. methadone /alcohol programme or on waiting list If ONS are initiated:- Patient should be reviewed monthly. If they fail to attend on 2 consecutive occasions, ONS should be stopped Maximum prescription should be for 600kcal/day (2 bottles/day) They should be prescribed on a short term basis only (i.e. 1-3 months maximum). ONS SHOULD NOT be put on a repeat prescription If there is no change in weight after 3 months, ONS should be reduced and discontinued and patient encouraged with Food First Dietary Advice. 3

4 Prescribing of Oral Nutritional Supplements in Palliative Care Prescribing of ONS in early stages / later stages of palliative care In early stages of disease and during active treatment the aim of nutritional support remains that of restoring and maintaining nutritional and functional status, therefore ONS may be appropriate. However, in later stages the focus is on patient comfort and reducing patient and carer anxiety. Awareness is required that use of ONS at this stage, although intending to reduce pressure and alleviate anxiety, may in fact: - Increase pressure on the patient, Give false hope to carers Reduce any remaining enjoyment of food. ONS are, in general, poorly tolerated by this patient group & high levels of waste are experienced. Explanation/Reassurance Causes of Anorexia Management of Anorexia in Palliative Care Metabolic changes/increased requirements Symptom related problems nausea/vomiting Oral problems/constipation/depression (treat reversible symptoms) Effects of Anorexia physical chronic nausea/early satiety/fatigue psychological increased anxiety particularly in carers can increase tension around mealtimes social isolation/distress Practical advice about Nutrition Issue food first dietary advice/snack ideas leaflets Give patient permission to eat less offer attractively presented, small, portions of easily eaten foods throughout day. Encourage family/carers not to talk about food all the time if you have no appetite you don t fancy anything. Soup and pudding or cold food may be better tolerated and are just as nutritious as hot meals. Encourage participation in the social aspects of mealtimes if possible. Appetite may vary from day to day make use of times when appetite is best. 4

5 Food First Dietary Advice: Keeping up the Calories Your food intake may vary day to day so try not to worry if you have an off day. If there is a specific time of the day when you tend to eat better, try to make the most of that period. Guidance for increasing your calorie intake Little and often is the best way to increase your calories. Aim for 3 small meals and 3 snacks per day. (Aim to eat every 2-3 hours) Try to take a supper / snack before retiring to bed Use at least one pint of full cream milk per day Avoid low fat / sugar free or diet varieties of food & drink Ways to enrich your food:- Butter or margarine - 1 level teaspoon = 50 calories Add generously to vegetables and potatoes, butter toast and scones when hot Double Cream - 2 tablespoons = 130 calories Add generously to soups, sauces, desserts or porridge Sugar - 1 level teaspoon = 16 calories Add liberally to cereals, drinks or desserts. Spread marmalade, jam or honey on bread. Not suitable for diabetes Mayonnaise - 1 level tablespoon = 100 calories Add generously to salads, potatoes or sandwiches Cheese - matchbox size = 120 calories Use generously on bread, cracker, scones or toast. Grate over scrambled egg, vegetables or potatoes BREAKFAST If you are not managing a main meal try to have at least 2 snack meals as well as a breakfast. Cereals with full cream milk or fortified milk. For example, cornflakes, or weetabix with sugar and a glass of fresh fruit juice. Porridge made with milk and cream added prior to serving Toast with butter and jam or marmalade, peanut butter, scrambled egg or cheese. Rolls with bacon, sausage, egg, banana or cheese. Milk A full glass of fortified milk and two digestive biscuits with butter / spread. SNACK MEALS Ideas for snack meals: Toast with scrambled egg, cheese, spaghetti, beans or peanut butter. Sandwiches or a roll filled with cheese, egg, cold meat or tuna. Pasta, macaroni cheese or tinned ravioli. Soup, tinned, homemade, packet or cupa-soup with a roll or sandwich Omelette or quiche Pies, burgers, sausage roll, bridie or pizza Cheese and biscuits 5

6 Food First Dietary Advice: Keeping up the Calories Cont. SNACKS If you are only managing small meals it is important to try to take frequent snacks. Here are some suggestions: Glass of milk (full cream or fortified) with a biscuit, cake or Danish pastry Peanuts or mixed nuts with raisins PUDDINGS Aim to have at least 1 pudding every day with added double cream Tinned Custard or rice pudding Individual desserts such as trifle, mousse Cake, tart or sponge pudding with custard Ice Cream Fruit tinned or stewed fruit with custard, evaporated milk, cream or ice-cream Whole Milk or thick & creamy yoghurt Crisps with dips, crackers with spreading cheese or cream cheese Chocolate bar Drinks: hot or cold flavoured milk drinks - Aero, Mars, Milky Bar, Yazoo, Nesquick, Horlicks, Ovaltine, Hot Chocolate, cocoa or milky coffee Toast scone or pancake with butter, cream or jam FLUIDS Fortified Milk This may be used instead of full cream milk. It is rich and creamy and contains lots of calories. Add 4 tablespoons of dried milk powder to 1 pint of full cream milk. Fluids It is important your body has enough fluid to allow it to work properly. When appetite is poor it is better to take drinks after or between meals. Aim for about 8 cups of liquid (3pints) per day unless advised otherwise DON T FORGET YOUR VITAMINS When your appetite is poor it is still important to try to take some fruit and vegetables or fruit juices. Try the following. FRUIT JUICES - A small glass of fresh fruit juice or blackcurrant juice or a drink fortified with Vitamin C FRUIT - Fresh fruit, whole or chopped, dried fruit or tinned fruit as a snack. Chopped banana with cereal. Apple or grapes with cheese as a snack. Tinned/fresh fruit with pudding VEGETABLES - A portion of vegetables with your main meal. SOUP - Vegetable soup (added cream, grated cheese or full cream milk for extra calories) SALADS & DRESSINGS - Salad or tomato as part of a filling in a sandwich. Add mayonnaise or salad cream 6

7 Food First Dietary Advice: Nourishing Drinks FORTIFIED MILK 300 calories per serving 300ml or ½ pint of full cream milk 2 tablespoons dried milk powder (can be purchased in any supermarket in dairy aisle along side long life milk) Stir ingredients together. Fortified milk can be used as a drink, in tea/coffee, on cereals, in milk puddings or instead of full cream in any other foods including recipes below NOURISHING CUP-A-SOUP 270 calories per serving 200ml or 1/3 pint of full cream milk heated 1 heaped tablespoons milk powder 1 packet of Cup-a-soup Stir ingredients together and serve FRUITY FLOAT 200 calories per serving MILKSHAKE 230 calories per serving ½ glass fresh fruit juice ½ glass lemonade 1 tablespoon sugar 1 scoop ice cream Mix ingredients together and serve chilled. 200ml or 1/3 pint of full cream milk 2 tablespoons milk shakes syrup or powder 1 scoop ice cream Mix together and serve chilled PINEAPPLE & BANANA YOGHURT DRINK 450 calories per serving 300ml or 1/2 pint of full cream milk 1 tablespoons milk powder 1 pot (150g) thick and creamy yoghurt 3 pineapple rings or 1 banana Liquidise all the ingredients for 15 seconds, serve chilled GINGER LIME 215 calories per serving 1 glass ginger beer 1 small carton natural yoghurt 2 tablespoons lime syrup/cordial Mix lime syrup and yoghurt together. Top up with ginger beer and serve chilled. ICED COFFEE 230 calories per serving 200ml or 1/3 pint of full cream milk 2 tablespoons coffee powder 2 tablespoon sugar 1 scoop ice cream Dissolve the coffee in a little hot milk, then add rest of milk, sugar and ice cream. Whisk and chill thoroughly CINNAMON SPICE 180 calories per serving 200ml or 1/3 pint of full cream milk 1 tablespoons golden syrup Pinch mixed spice Pinch cinnamon Heat milk, add syrup, cinnamon and mixed spice and serve warm. CHOCOLATE DREAM 300 calories per serving 200ml or 1/3 pint of full cream milk 1 tablespoons drinking chocolate 1 teaspoons sugar Pinch cinnamon (optional) whipped cream Heat milk. Remove from heat and mix in chocolate powder and sugar. Top with cream and sprinkle chocolate powder and serve warm. 7

8 Patient Guide to Nutritional Supplements You have been advised to take nutritional supplements: SUPPLEMENT NAME: Amount.Daily These supplements are ready to use. Try to take your supplements at the following times Try to take these supplement drinks in the amounts advised, if you are struggling to do so, speak with your doctor or dietitian. HELPFUL HINTS CONT. Neutral flavoured supplement drinks can be used instead of milk in drinks Water, lemonade, soda water or other fizzy drinks can be used to dilute juice based supplement drinks, but still aim to take the full amount prescribed. Try adding ice if you like them really cold. Milk can be added to the milk based supplement drinks but still aim to take the full recommended amount. STORAGE: Prior to opening, your nutritional supplement drinks should be stored in a cool, dry place. Once open should be consumed within 4 hours or stored in the fridge (<5 C) for up to 24 hours) Supplement drinks should be taken in addition to meals and not instead of food. Also avoid taking them just before or at meal times. They are filling and can affect your appetite. It is best to take in-between meals or in the evening. HELPFUL HINTS It is best to sip your supplement slowly Sweet flavoured supplements are best served chilled/cold. As an alternative they can also be frozen to make ice cubes or lollipops or used in jelly or mousse. Small quantities of alcohol can be mixed with both milk and juice based supplement drinks check with your doctor or nurse first that alcohol may be taken. The decision whether you require ongoing prescriptions for supplement drinks will be made by your prescriber/dietitian. If you do need a further prescription from your GP, request in plenty of time so that you don t run out. If you feel you no longer require or are unable to take the supplement drinks, make sure you discuss this with your doctor and that the repeat prescription is cancelled. Remember good oral hygiene can help improve the taste of food and drinks, so brush your teeth regularly. 8

9 High Calorie Snack List 7 - High Calorie Snack List If you are reducing or stopping your supplement drinks, try to take at least 2 of the following snacks per day in addition to meals. Each snack is approximately 300 calories. SWEET SNACKS CAKES, PASTRIES & BISCUITS Scone with butter and jam with a milky coffee Milky coffee with cream cake, e.g. cream sponge, large piece of Swiss Roll A glass of full cream milk and 2 digestive biscuits with butter and cheese spread Flapjack or Danish pastry & a glass of full cream milk 1 croissant with butter or a buttery PUDDINGS Sponge with full fat custard Rice pudding with jam Carton of full fat or thick & creamy yoghurt with tinned fruit in syrup & a carton of Ribena Small individual dessert e.g. flake dessert, crunchy dessert, rich chocolate mousse DRINKS Hot chocolate made with full fat milk and 2 fingers of shortbread Milky coffee with full cream milk SWEETS Bar of chocolate with milky coffee SAVOURY SNACKS CEREAL Bowl of porridge made with full cream milk TOAST Slice of toast with butter and jam with a cup of hot chocolate made with full cream milk 1 slice of toast with peanut butter or melted cheese 2 slices of toast with beans or scrambled egg PASTRIES & OATCAKES 1 medium size sausage roll or a pork pie 1 toasted crumpet or 2 muffins with butter and a glass of full cream milk 4 oatcakes with butter and cheese Bagel and cream cheese Cheese scone with butter SANDWICHES Sandwich with egg or tuna mayonnaise Bacon sandwich SOUP Bowl of soup with 2 slices of bread and butter 9