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REMEDY : BNSSG referral pathways & Joint Formulary

BNSSG Adult Joint Formulary

9.5 Nutrition

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9.5.1 Nutrition (intravenous)


First line drugs Second line drugs Specialist drugs Secondary care drugs

Link to BNF Intravenous nutrition 

Plasma-Lyte® 148 (TLS Red)

  • Intravenous Fluid replacement
 

Millimoles per litre

  Na+ K+ Acet- Cl- Mg2+
Plasma-Lyte® 148 140 5 27 98 1.5

 

All intravenous nutrition (TLS Red)

NBT: Please contact the Dietetic Department regarding parenteral nutrition

UHB: Please contact the Nutrition Team regarding parenteral nutrition. Nutrition nurses : ext 23088 and bleep 2659

Hyperlink to Prescribing and Provision of Parenteral nutrition at UHBristol

 

9.5.2 Nutrition (oral)

Link to BNF Enteral nutrition

NBT:

  • Please refer to the Dietetic Formulary (available to view on the intranet)

UHB:

  • Please contact the dietetic department

 

Patients discharged from Secondary care on Oral Nutritional Supplements (ONS):

  • Do not routinely add ONS to repeat prescription without review
  • Check the indication for the prescription and the duration required
  • Check current nutritional status (e.g. appetite, weight, height if available, weight loss, factors affecting dietary intake)
  • Consider issuing 1 months prescription as ‘acute’
  • Agree a review appointment (at review check weight, BMI and ‘MUST’ score) before issuing a further prescription

 

Initiating Oral Nutritional Supplements (ONS) in Primary Care: 

Oral Nutritional Supplement Prescribing for Malnourished Adults

Food First advice (click here) should be trialled for 2 - 4 weeks. If goals are not achieved, consider prescribing ONS twice daily, supported by a planned review process.

The other criteria that should be fulfilled before an ONS is prescribed, as discussed in the NICE guideline CG32, are essentially that:

  • Patient’s MUST score is appropriate
  • Patient’s condition is ACBS approved

ONS are only available on FP10 prescriptions for specific indications as agreed by the Advisory Committee on Borderline Substances (ACBS).

 

Standard ACBS Indications: Disease-related malnutrition, intractable malabsorption, pre-operative preparation of patients who are undernourished, dysphagia, proven inflammatory bowel disease, following total gastrectomy, short bowel syndrome, bowel fistula.

 

 Please ensure clear review/stopping criteria are established at the time of prescribing.

 

First Choice ONS in Community Settings:


Sip feeds appear in the tables below according to category and maximum calories content for cost. Please ensure a lower acquisition cost ONS is prescribed.

Note that 1kcal/mL sip feeds are not recommended (Ensure®, Fortimel® and Fresubin® Original)

 

Powdered shake (1.5-1.6kcal/mL) - Requires the patient or carer to make up using 200mL whole milk.

Supplement 'Free from' status Size (g) Kcal per sachet Protein (g) Available flavours Cost per sachet
Aymes® Shake sachets GF

57g

384-389

19 Banana, Chocolate, Neutral, Strawberry, Vanilla,  £0.49
Ensure® Shake sachets GF

57g

389

17 Chocolate, Strawberry, Vanilla,   £0.49
Foodlink Complete® GF

57g

385

19 Banana, Chocolate, Natural, Strawberry, Vanilla £0.49
Foodlink Complete® Fibre GF

63g

399

19 Banana, Chocolate, Natural, Strawberry,  Vanilla £0.71

 

 

If powder products are unsuitable prescribe Standard Milkshake style (1.5kcal/mL) - ready to drink. 

Supplement

 

'Free from' status Size (mL) Kcal per bottle Protein (g) Available flavours Cost per bottle
Aymes® Complete GF, LF 200 300 12 Chocolate, strawberry, vanilla, banana, chicken £1.11
Ensure® Plus GF, LF 220 330 13.8 Banana, chocolate, coffee, fruits of the forest, neutral, orange, peach, raspberry, strawberry, vanilla, savoury £1.11
Fortisip® GF, LF 200 300 12 Neutral, vanilla, chocolate, toffee, banana, orange, strawberry, tropical fruits £1.12

 

 

If lower volume products are required prescribe High Energy Compact Powdered shakes- requires the patient or carer to make up using 100ml whole milk

 

Supplement 'Free from' status Size (g) Kcal per bottle Protein (g) Available flavours Cost per sachet
Aymes® Shake Compact GF 57 321 12.2-12.6 Banana, Chocolate, Neutral, Strawberry, Vanilla £0.60

 

 

If powdered products are unsuitable and higher energy lower volume products are required, prescribe High Energy Milkshake Style (2.4kcal/mL)- ready to drink 

Supplement 'Free from' status Size (mL) Kcal per bottle Protein (g) Available flavours Cost per bottle
Altraplen® Compact GF, LF 125 300 12 Strawberry, Vanilla £1.33
Ensure® Compact GF 125 300 12.8 Banana, Coffee, Mocha, Strawberry, Vanilla £1.33
Fortisip®  Compact  GF 125 300 12 Apricot, Banana, Chocolate, Forest Fruits, Mocha, Strawberry, Vanilla £1.33

Juice style (1.5kcal/mL) - Use in caution in patients with Diabetes Mellitus.

 

Supplement 'Free from' status Size (mL) Kcal per bottle Protein (g) Available flavours Cost per bottle
Aymes® Shake Smoothie (powder-based to make up with 150ml water) GF, LF 66g 297 10.7 Cranberry, Mango, Peach, Pineapple, Strawberry £1.00
Altrajuce® (ready to drink) GF, LF 200 300 7.8 Apple, Blackcurrant, Orange, Strawberry £1.70
Ensure® Plus Juce (ready to drink) GF, LF 220 330 10.6 Apple, Fruit punch, Lemon and lime, Peach, Strawberry £1.97
Fresubin® Jucy (ready to drink) GF, LF 200 300 8 Apple, Blackcurrant, Cherry, Orange, Pineapple £1.99

Key

GF= Gluten free

LF= Lactose free

 

Please note, modules such as: Altrashot®Calogen®, Calogen® extra, Pro-cal® shot and Fresubin® 5kcal shot and other specialist products such as Ensure Advance, Fortisip Compact protein, Fortisip Compact fibre, Procal powder, Prosource Jelly and Vital 1.5kCal should only be prescribed on the advice of a dietitian.

 

Please note patients with complex medical conditions (e.g. advanced renal disease, malabsorption, diabetes mellitus and dysphagia) should be referred to a Dietitian before ONS are prescribed.

 

Useful Links

Food First Ideas

Food First Leaflets

Online ‘MUST’ Calculator

‘MUST’ explanatory booklet

Malnutrition – NHS Choices

Malnutrition – Overcoming the Problem (British Dietetic Association)

Malnutrition Task Force – Preventing Malnutrition in Later Life

 

 

Drink Thickeners for Adults with Dysphagia

Nutilis Clear 

Please note, the thickening of standard oral nutritional supplements is not recommended and patients with dysphagia requiring oral nutritional supplements should only have texture level specific supplements or pre-thickened supplements prescribed on the advice of a dietitian or SALT team. 

9.5.3 Phenylketonuria

Patients with phenylketonuria (PKU) are managed with a low protein diet, including special low protein versions of common foods such as flour, bread and pasta which are not freely available other than on prescription.

ACBS indications for prescribing low protein foods include inherited metabolic disorders, renal or liver failure requiring a low protein diet. Thus prescribing low protein foods for individuals with PKU is in line with ACBS criteria. Once initiated by the specialist centre, it is the responsibility of the GP to continue prescribing these low protein foods.

Please see guidance on prescribing in PKU below:

Prescquipp PKU prescribing bulletin 

PKU society guidance on quantities of prescribed low protein foods

 

Sapropterin dihydrochloride (TLS Red)

 

9.5.4 Special diets

Coeliac disease

Intolerance to gluten in coeliac disease is managed by completely eliminating gluten from the diet.

Following consultations by North Somerset and South Gloucestershire CCGs (Summer 2017) and Bristol CCG (early 2018) the newly formed Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (BNSSG CCG) no longer prescribes gluten free foods to patients aged 18 and over. Prescriptions are still available for those patients aged under 18 from a limited choice of products. 

If you have further questions or feel you need further support in managing your condition, please contact the surgery to make an appointment.

Bristol, North Somerset and South Gloucestershire (BNSSG) CCG have developed guidance for prescribing within the area:

BNSSG Gluten free prescribing guidelines (Dec 2018 update)

Contact Us

Got a question or comment about the Joint Formulary? 

Please use the email address below to contact us and we will endeavour to respond within 2 working days.

BNSSG.formulary@nhs.net