Appropriate Use of Prescribed Oral Nutritional Supplement (ONS) in the Community

Appropriate Use of Prescribed Oral Nutritional Supplement (ONS) in the Community Aim This guideline sets out a recommended procedure for the identification and treatment of malnutrition to ensure Oral Nutritional Supplements (ONS) are prescribed appropriately in Coventry and Warwickshire. Audience All qualified community healthcare professionals who recommend, prescribe, supply or administer ONS to adult patients living in Coventry and Warwickshire care homes or in the community. This includes general practitioners (GPs), dietitians, nursing staff and pharmacists. Although the guideline is not applicable to the acute setting, it does give recommendations regarding the provision of ONS to patients upon discharge from hospital back into the community. Author Lisa-Jayne El-Sour, Medicines Management Dietitian (Warwickshire) Contributors SWFT Dietetic Department UHCW Dietetic Department Arden and GEM Medicines Management Team NHS Coventry and Rugby CCG Medicines Management Team Date February 2016 Review Date February 2019 1

Assessment and Dietary Treatment of Malnutrition The following steps should be taken before considering ONS on prescription: Step 1: Nutrition Screening Step 2: Assessment Step 3: Treatment Aims Step 4: Dietary Advice Step 5: Review Step 1: Nutrition Screening In the community, nutrition screening should be carried out on registration with GP practices, when there is clinical concern, and should also be considered at other opportunities, such as health checks (NICE, 2006). It is recommended that the Malnutrition Universal Screening Tool (MUST) is used to assess nutritional status. Use local documentation if available, otherwise a form is provided in Appendix A to help determine MUST score. For further details on how to use MUST, refer to www.bapen.org.uk. To ensure accurate assessment of weight and body mass index, calibrated weighing scales should be available in all GP practices (refer to NPSA Signal 1293 E). Community healthcare professionals should also have access to calibrated weighing scales to enable weighing of patients in their own home. When it is not possible to weigh the patient, subjective or alternative measures may be used. Refer to Appendix A and/ or www.bapen.org.uk for further details. Step 2: Assessment If a patient is found to be at either medium or high risk of malnutrition, their healthcare professional, such as their GP or nurse, should identify any underlying causes of malnutrition and ensure these are appropriately managed. Factors that may contribute to malnutrition include effects of disease, loss of appetite caused by symptoms such as nausea, vomiting, diarrhoea and constipation, mental health issues such as depression and dementia, poor dental health, dysphagia, or social issues such as inability to shop for or cook food. Step 3: Treatment Aims Treatment aims should be agreed with the patient, such as target weight. The patient should be consulted to determine their own personal aims and be advised whether these are suitable and achievable. Treatment aims can be agreed with the patient s relatives or carers where necessary. Step 4: Dietary Advice Patients found to be at medium or high risk of malnutrition should be provided with dietary advice as first line of treatment. This should be trialled for at least one month before considering ONS. Simple dietary changes such as including nourishing drinks and snacks can be advised. First line dietary advice leaflets have been produced by local Dietetic Departments and are available on the Area Prescribing Committee website. Over the counter (OTC) nutritional supplements, such as Meritene (previously Build Up), Aymes Retail, Complan and Nurishment, can be purchased from supermarkets and pharmacies. Patients may consider using these in addition to the dietary advice provided. These products are not meal 2

replacements and should be taken in addition to meals. OTC supplements are intended for short term use only and should not be used as a sole source of nutrition. Step 5: Review Aim to reweigh the patient after one month to determine whether nutritional status has improved. If convenient for both the patient and healthcare professional, the patient could monitor their weight at home and make contact if they continue to lose weight. If the patient s nutritional status has not improved, ONS and/ or referral to the Dietitian may be considered. Prescribing ONS Appendix B can be used to help ensure ONS is appropriate for the patient and, if so, which products should be considered. The following sections provide further detail regarding the prescribing of ONS. ACBS Indications The Advisory Committee on Borderline Substances (ACBS) is responsible for advising when nonmedicinal products such as foods (which are specially formulated for use by people with medical conditions) can be prescribed on the NHS. Standard ONS can be prescribed if the patient meets one or more of the approved ACBS indications: Disease related malnutrition (malnutrition identified using MUST, resulting from active disease, e.g. severe COPD, cancer, liver disease, renal disease). Intractable malabsorption Pre-operative preparation of malnourished (identified using MUST) patients Dysphagia Proven Inflammatory Bowel Disease Following total gastrectomy Short bowel syndrome Bowel fistula It should be noted that substance (drug and alcohol) misuse is not a specified ACBS indication. Specialist ONS required for specific clinical conditions (such as chronic liver disease, chronic renal failure and hypoproteinaemia) may only be prescribed if they meet the ACBS indication stated for that product in Appendix 2 of the BNF. These products should only be used under dietetic supervision and are outside the realms of this guidance. Palliative Care Prescribing ONS in palliative care requires consideration of the individual s health and treatment. Nutritional management may change depending upon the stage of treatment: If the patient is terminally ill but death is not imminent: Nutrition screening and assessment should be carried out at regular intervals. Encourage nourishing foods and drinks as first line advice. ONS may be indicated if the patient continues to lose weight following dietary advice. ONS will only be of benefit if taken daily. If the patient's condition is deteriorating and symptoms such as pain, nausea and poor appetite have worsened: 3

Encourage foods and drinks that the patient enjoys to maximise quality of life. Aggressive feeding may cause distress and anxiety. Nutrition screening and ONS will unlikely be of benefit. In the last days of life, the patient may be bedbound, weak, drowsy and have little desire for food or fluid. Aim to keep the patient comfortable by offering mouth care and sips of fluid and/ or small mouthfuls of food as wanted/ managed. Product and Dosage Refer to Appendix C to help choose a suitable product for the patient. Consider flavour preferences to ensure compliance with the prescription and reduce wastage. Sample packs are available for some products and may help determine preferences. ONS are only of nutritional benefit if taken regularly. Avoid PRN and As Required doses. Daily dosage will depend upon the patient s individual nutritional requirements and tolerance. Evidence suggests that supplementing the diet with an additional 250 to 600kcals/ day can improve nutritional status (Stratton and Elia, 2007). This can be achieved through providing a prescription of 1 to 2 supplements daily. Patients should be encouraged to use ONS in addition to meals. ONS should not be used as a sole source of nutrition unless under the supervision of a Dietitian. An acute prescription is recommended if ONS are unlikely to be required on a long term basis. ONS should not be used for multiple patient use in care homes, unless a bulk prescription system is in place. Dysphagia Refer patients with dysphagia/ difficulties swallowing to the Speech and Language Therapy (SALT) department for assessment following the local referral procedure. Dysphagic patients requiring thickened fluids should be prescribed pre-thickened ONS rather than thickening regular supplement drinks. The SALT and Dietitian can advise which product(s) are most appropriate for the patient. Enteral Feeding Patients receiving nutrition via a feeding tube may use ONS in addition to or instead of feed packs. Due to the risk of blocking the feeding tube, powdered ONS should not be used. Diabetes Patients with diabetes who are found to be at risk of malnutrition should be reviewed and monitored as their blood glucose control may change. Their diabetes medication may require review and dietary advice should be given, where possible, to increase energy intake from dietary source. If ONS are thought to be necessary, the patient s blood glucose control should be monitored. Referral to the Dietitian is recommended, particularly if the patient is unable to maintain control of their blood glucose levels. 4

Referral to the Dietitian Patients may be referred to the Dietitian if they are at high risk of malnutrition. Patients at medium risk of malnutrition who have followed dietary advice for at least one month but their nutritional status has not improved may also be referred. Patients can be referred to the Dietetic Services using the local Dietetic referral form or, where available, the electronic booking system. Requesting ONS on Prescription When requesting ONS prescriptions for patients, healthcare professionals must demonstrate that the guidance set out in this document has been followed. Written requests should include evidence of assessment of nutritional status, consideration of goals of treatment, outline of dietary advice provided (such as provision of dietary advice leaflet) and the review plan. An example dietetic letter template is included in Appendix D. Discharge from Hospital with ONS Need for ONS should be reassessed once the patient returns home by following the steps laid out in this guideline. Due to the different products available in hospital compared with community, it is advised that nutritional products included on TTOs are not automatically continued without consideration of suitable alternatives that may be preferred and are more cost effective. Appendix C can be used to check if alternatives are available. Patients advised by a hospital Dietitian to continue ONS in the community should be referred back to the GP for review. The GP must be informed that ONS are required as per the guidance set out in the Requesting ONS on Prescription section. Clear guidance should be provided to the GP regarding aims of treatment and when ONS can be discontinued. Consideration should be given to alternatives that are available in the community. Refer to Appendix C to select an appropriate product. If the patient was known to the Community Dietetic Services prior to hospital admission, the community Dietitian must be informed of any changes to the patient s dietetic treatment and ONS prescription. The GP should be informed that the patient is to be referred back to the community team. References BAPEN (2010) Malnutrition Matters, Meeting Quality Standards in Nutritional Care. British Association for Parenteral and Enteral Nutrition, Redditch. NICE (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. National Institute for Health and Clinical Excellence, London. Stratton and Elia (2007) A Review of Reviews: A New Look at the Evidence for Oral Nutritional Supplements in Clinical Practice. Clin Nutr Suppl., Vol 2, pp 5-23. Appendices Appendix A Malnutrition Universal Screening Tool (MUST) Record Sheet Appendix B Appropriate Prescribing of ONS Appendix C ONS Formulary Appendix D Example Dietitian letter to request ONS on prescription 5

Appendix A: Malnutrition Universal Screening Tool (MUST) Record Sheet Malnutrition Universal Screening Tool (MUST) Record Sheet Usual/ Pre illness weight (kg) Height (m) (actual/ recall/ ulna length) Date Weight (Kg) BMI (kg/m 2 ) If weight and height cannot be obtained, use subjective criteria to inform overall opinion of risk category STEP 1: BMI Score Body Mass Index (kg/m 2 ) (Circle one only) STEP 2: Weight Loss Score Unintentional weight loss in last 3 months (Circle one only) <18.5 = Very underweight 2 2 2 2 18.5 19.9 = Underweight 1 1 1 1 20 24.9 = Healthy weight 0 0 0 0 25-29 = Overweight 0 0 0 0 >30 = Obese 0 0 0 0 > 10% weight loss 2 2 2 2 5 10% weight loss 1 1 1 1 < 5% weight loss 0 0 0 0 STEP 3: Acute Disease Effect Score* Patient has an acute illness AND there has been or is likely to be NO nutritional intake for > 5 days *Often not applicable in the community Unable to weigh due to: YES 2 2 2 2 NO 0 0 0 0 Total Score Signature/ Initials Date: If weight cannot be measured, the following subjective indicators can be used: Nutrition Risk Category Low Risk Medium Risk High Risk Date Physical Appearance Not thin. No unplanned weight loss, weight is stable or is gaining weight. No change to appetite. Thin as a result of disease/ medical condition and/ or has history of unplanned weight loss over the previous 3 to 6 months. Appetite Is reduced. Thin/ very thin and/ or substantial unplanned weight loss over the previous 3 to 6 months. Appetite is reduced. Nutrition Risk Category Signature/ Initials 6

Appendix B: Appropriate Prescribing of ONS Initiating and reviewing Oral Nutritional Supplements (ONS) for Adults in Primary Care Nutrition Screening - The Malnutrition Universal Screening Tool (MUST) is recommended to help identify patients at risk of malnutrition. The BAPEN calculator can be used to quickly calculate MUST score. - Follow steps 1 to 4 if patient is at medium or high risk of malnutrition. Medium risk = MUST score 1 (BMI 18.5 20 OR 5 to 10% unintentional weight loss over 3 to 6 months) High risk = MUST score 2+ (BMI <18.5 OR >10% unintentional weight loss over 3 to 6 months OR BMI 18.5-20 AND 5 to 10% weight loss over 3 to 6 months). Assessment Treatment Aims Dietary Advice - Identify any underlying causes of malnutrition and ensure these are appropriately managed. - Contributing factors may include effects of disease, loss of appetite caused by symptoms such as nausea, vomiting, diarrhoea and constipation mental health issues such as depression and dementia, poor dental health, dysphagia, or social issues such as inability to shop for or cook food. - Agree aims of treatment with the patient, e.g. target weight. - Aims can be agreed with relatives or carers where necessary. - Dietary advice should be trialled for at least one month. - Dietary advice sheets are available on the APC website. - Over the counter (OTC) supplements may be considered. OTC products available include: Aymes, Complan, Meritene and Nurishment. Consider ONS Consider ONS if: Nutritional status has not improved after following dietary advice for one month. - AND the patient meets ACBS prescribing criteria: Short bowel syndrome, intractable malabsorption, pre-operative preparation of patients who are undernourished, proven inflammatory bowel disorder, total gastrectomy, dysphagia, bowel fistula and disease-related malnutrition - Recommended dosage is 1 to 2 supplements daily in addition to dietary changes. - Review regularly to ensure ONS are effective (refer to Dietitian if nutritional status Review worsens) and that they are discontinued when treatment aims are met. - If ONS are no longer required, gradually decrease quantity prescribed and discontinue if nutritional status is maintained. Refer to the guideline Appropriate Use of Prescribed ONS in the Community for further information relating to: - Diabetes - Dysphagia - Home Enteral Feeding - Palliative Care 7

Appendix C: ONS Formulary Oral Nutritional Supplement (ONS) Formulary It is recommended that supplements not listed in this formulary are only prescribed under dietetic supervision. Does the patient require thickened fluids? YES Refer to the Dietitian. NO Does the patient dislike or are they unable to tolerate milky drinks? YES Choose ONS from table 3 below. NO Can the patient or their carer prepare drinks? YES: choose ONS from table 1 below. NO: choose ONS from table 2 below. Table 1: Powdered Supplements Powdered supplements should be reconstituted with full fat (whole) milk. The patient s or carer s ability to prepare the drinks should be considered before prescribing. These products cannot be administered via a feeding tube. Product Presentation Calories Per Unit Price per Sachet ( ) Aymes Shake 7 x 57g sachets 388 0.60 Foodlink Complete 7 x 57g sachets 386 0.61 Foodlink Complete with fibre (vanilla flavour) 7 x 63g sachets 399 0.67 Complan Shake 4 x 57g sachets 387 0.70 Ensure Shake 7 x 57g sachets 389 0.70 Calories listed above are when reconstituted with 200mls full fat milk. Less can be used, but this will lower the calorie content. Table 2: Milkshake Style Ready to Drink Supplements Product Presentation Calories Per Unit Price per Bottle ( ) Aymes Complete 4 x 200ml 300 1.11 Ensure Plus Milkshake 220ml 330 1.12 Ensure Plus Yoghurt style 200ml 300 1.12 Fortisip Bottle 200ml 300 1.12 Nutricomp Drink Plus 4 x 200ml 300 1.12 Consider 125ml products if your patient is fluid restricted or cannot manage larger volumes: Ensure Compact 4 x 125ml 300 1.35 Altraplen compact 4 x 125ml 300 1.45 Fortisip Compact 4 x 125ml 300 1.45 Table 3: Juice Style Ready to Drink Supplements Product Presentation Calories Per Unit Price per Unit ( ) Ensure Plus Juce Style 220ml 330 1.97 Fresubin Jucy 4 x 200ml 300 1.99 Fortijuce 200ml 300 2.02 Prices correct as of 1/9/17 8

Appendix D: Example Dietitian letter to request ONS on prescription Thank you for referring the above patient for dietary advice OR The above patient was referred to our services by REFERRER. I assessed/ reviewed him/her DATE AND LOCATION. Reason for referral: REASON Assessment: Box below is optional/ rows can be added/ deleted as required. Weight kg Height m Body Mass Index kg/m 2 % body weight lost over past 3 to 6 months % Malnutrition Universal Screening Tool (MUST) Category Weight change since DATE Aims of Dietary Treatment Detail aims of treatment here, for example, target weight. Delete if not appropriate. If discharging patient back to GP on ONS, include clear monitoring aims for the GP here. Dietary Advice Provided Detail dietary advice given, including diet sheets provided. Oral Nutritional Supplement Prescription Oral nutritional supplements are required for the indication of ACBS INDICATION. OR I recommend the following changes to this patient s oral nutritional supplement prescription. OR Oral nutritional supplements are no longer required. Please remove the following item(s) from this patient s prescription. Action Required START/ STOP/ CONTINUE START/ STOP/ CONTINUE Oral Nutritional Supplement Name/ Presentation Size/ Flavours/ Daily Quantity Name/ Presentation Size/ Flavours/ Daily Quantity Please prescribe the oral nutritional supplement(s) as ACUTE/REPEAT. Monthly Prescription (28 days) /month /month Review This patient will be reviewed by TEAM AND TIME PERIOD. We will keep you informed of the patient s progress and whether any changes to the oral nutritional supplement prescription are required. OR This patient will not be reviewed by our services and so will require a review by your team in one month. Treatment aims are given above. If you have any queries regarding this request, please contact us on the above number. 9