Oral Nutritional Supplements Prescribing in Adults (oral use six stage approach) (221)

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Introduction

NHS Scotland produced Guidelines for the appropriate use of oral nutritional supplements in adults (oral use)1 in April 2018. NHSGGC have now adopted this guideline which recommends a six stage approach to ONS prescribing. This document summarises that approach and includes supporting information local to NHSGGC (this has a blue shaded background) for all health and care staff involved in ONS use across all settings.

Notes:

1.  Settings / specialist patient groups: For guidance on ONS use for people in care homes / institutions, palliative and end of life care and for those with a substance misuse issue please refer to the full NHS Scotland guideline.

2.  In patient settings: It is acknowledged that across in-patient settings ONS are not ‘prescribed’. The terms ‘prescribing / prescribe / prescribed ONS’ within this document are synonymous with ‘recommending / initiating ONS’ across in-patient settings. Please note that people who are initiated on ONS during an in-patient admission may not require ONS on prescription once home. They may have required ONS whilst acutely unwell or during recovery from surgery, but once the ongoing requirement for ONS is often negated. It is therefore recommended that ONS are not prescribed following hospital discharge without first assessing need in line with these six stage guidelines. Where ONS are required post hospital discharge, the first line preferred primary care formulary product should be used (unless otherwise advised by a dietitian) and people should be provided with at least 1 week’s supply on discharge with ongoing care and a clear nutritional monitoring plan in place.

Stage 1: Identifying nutritional risk

The Malnutrition Universal Screening Tool2 (MUST) is a validated, easy to use 5-step screening tool for assessing adults who have established, or are at risk of malnutrition. It is used throughout the NHS in a variety of different settings, including across primary and secondary care.

A MUST score of 0 = low risk, 1 = medium risk and ≥ 2 = high risk.

An online MUST score calculator can be accessed at here (this link works with mobile devices). A full version of the MUST screening tool can be found here.

MUST screening is embedded within NHSGGC care pathways e.g. the NHSGGC Community MUST patient pathway3 , adult in-patient settings and the NHSGGC Nutrition Resource Manual,4 section 3.3 Nutritional Screening.

Stage 2: Assessing other factors affecting nutritional status

Assess and, where possible, address underlying causes of malnutrition and consider the person’s ability to achieve an adequate dietary intake:

  • Physical symptoms (i.e. vomiting, pain, constipation, diarrhoea, severe dry mouth, dehydration, low mood)
  • Impact of any treatment / medication and / or requirement for medication to be reviewed to manage above symptoms
  • Prognosis
  • Ability to chew and swallowing issues
  • Environmental and social issues e.g. cooking skills and facilities
  • Psychological issues
  • Substance or alcohol misuse
  • Dentition
  • Impact of either religious or personal beliefs

Consider referral to appropriate local services e.g. dentist, social services, Speech and Language Therapy, local cookery classes

 

People with complex nutritional needs, e.g. renal disease, liver disease, poorly controlled diabetes and gastrointestinal disorders may require specialist advice and should be referred to dietetic services. 

 

Stage 3: Setting a treatment aim

Agree and document a treatment aim for addressing malnutrition with a timescale e.g.

  • Target weight / target weight gain / target BMI over a period of time
  • Preventing further weight loss / reduce rate of weight loss over a period of time
  • Weight maintenance (where weight gain is unrealistic or undesirable)
  • Improved activities of daily living, improving strength or mobility
  • Wound healing
  • Increasing intake and improving nutritional value of foods and drinks

Additional benefits of improving nutritional status include improvements to physical and mental health e.g.

  • Reduced risk of falls
  • Reduced infections
  • Prevention of pressure ulcers / improved wound healing and recovery
  • Improved mood
  • Improved cognition

Stage 4: Setting dietary goals - to increase the nutritional value of everyday foods

Use this dietary approach where MUST ≥ 1, re-screening (weekly in hospital and monthly in community settings) and re-assessing on a regular basis. Where possible people should be encouraged to self-manage e.g. checking weight, keeping a food diary and repeating their MUST score using BAPEN's Malnutrition Self Screening Tool15

Dietary goals may include:

  • Varied diet with regular meals and snacks. If required, advise on quick / easy / cheap meals at home and meal delivery companies
  • Additional snacks will be needed to meet requirements, especially for those with a small appetite
  • Regular fluids: 1500 – 2000ml per day which equates to 6-8 drinks per day
  • Encourage nourishing drinks and over the counter (OTC) ONS products*
  • Nourishing, high calorie food fortification advice
  • Further advice can be found at: BDA Food Facts: Malnutrition5
  • NHSGGC dietary advice leaflets are also available here6 

* Home-made nourishing drinks and retail / over the counter (OTC) ONS products, e.g. Aymes® Retail, Complan® Milkshake or soups, Meritene® Energis (formerly Build Up®) milkshakes or soups, Nurishment® should be encouraged. Products are available from retail outlets and local pharmacies. Community pharmacy staff can provide further information on OTC products.

Stage 5: Prescribing ONS

It is recommended that people should be referred to a dietitian before they are prescribed ONS.

  • Across in-patient settings the NHSGGC Policy for Oral Nutritional Supplements (ONS) administration via the inpatient medicine prescription form (kardex)7 authorises dietitians to request any items listed on NHSGGC ONS formulary to be administered to inpatients within Acute, Paediatrics and Mental health areas by writing the specific item on the kardex.
  • The NHSGGC Prescribing Protocol for the management of specified Oral Nutritional Supplement (ONS) products by Registered Dietitians8 authorises dietitians to initiate and amend primary care ONS prescriptions directly e.g. within GP practices or with participating community pharmacies.

Where dietary advice alone is unlikely to or has not achieved an improvement in line with treatment goals (e.g. in those who are unwell and in whom the disease has severely limited appetite) people may require ONS in addition to dietary advice to achieve their treatment aim. ONS should be used as a supplement to the dietary approach outlined in Stage 4 above.

Patients must meet at least one ACBS* criteria to be eligible for an NHS prescription for ONS. ACBS criteria vary for different products, therefore it is sensible to consult the English Drug Tariff 9 which has a definitive list of ACBS criteria and specifies criteria for each ONS product: English Drug Tariff.

There are standard ACBS indications which apply to some ONS products. These are: Short bowel syndrome, intractable malabsorption, pre-operative preparation of patients who are undernourished, proven inflammatory bowel disease, following total gastrectomy, dysphagia, bowel fistulae or disease-related malnutrition* but it is important to note that many commonly used ONS do not have standard ACBS indications. *Where disease-related malnutrition is suspected it is essential to use a validated screening tool such as MUST to confirm this - only consider prescribing ONS for patients with a MUST score of ≥ 2.

If ONS are prescribed please note and advise people on the following to manage expectations from the outset:

1. Dosage, timing, reason for prescribing (aligned to ACBS indication) and length of treatment should be specified. Clinical benefits of ONS are often seen with 300 – 900kcal/day (e.g. 1-3 ONS servings per day). In the community benefits are typically seen with 2-3 months supplementation, however supplementation periods may be shorter or longer (up to 1 year) according to clinical need10.

2. Consider the most clinical and cost-effective product and ensure that the product and flavour are tailored to the person’s needs, likes and dislikes. A one week trial or starter pack should always be prescribed or provided initially to avoid wastage in case products are not well tolerated. Avoid repeat prescribing of ONS starter packs.

For patients living in NHSGGC, the NHSGGC Adult ONS formulary is available here11 Ensure Shake mixing instructions14 can be provided to patients when prescribing the preferred list, first line product Ensure® Shake.

3. ONS should not be prescribed on a repeat basis unless they are being monitored by a healthcare professional.

4. Take into account an individual’s medical history and special dietary requirements (including dysphagia, food allergies) when recommending an ONS product. Some products may not be appropriate for those with, for example, chronic kidney disease, diabetes or who are pregnant. ONS should not be prescribed for people at high risk of re-feeding syndrome unless on the advice of a dietitian (NHSGGC Clinical Guideline - Adults at risk of re-feeding syndrome in Primary Care 12) (NHSGGC Nutrition Resource Manual SECTION 5: CLINICAL NUTRITION (PART 1) 5.3 Re-feeding syndrome13). People with diabetes should not routinely be prescribed juice based ONS. These products have a higher glycaemic index, and blood glucose levels would require monitoring, with possible changes required to medication / dose.

5. To maximise the effectiveness of ONS and avoid spoiling appetite ONS should be taken between or after meals and not before or as a meal replacement. ONS not finished in one sitting can be stored in the fridge and consumed within 24 hours to avoid wastage.

6. ONS can be added to foods e.g. soups, puddings, breakfast cereals

The NHSGGC patient leaflet: Guide to taking a nutritional supplement provides supportive information to patients regarding timing, preparation and safe storage of ONS.

Stage 6: Reviewing, monitoring and discontinuing ONS

Review regularly (at a minimum 4-6 weekly) to monitor agreed goals and assess continued need for ONS.

The following parameters should be monitored:

  • Weight / BMI / wound healing depending on the goal set – if unable to weigh people, record other measures to assess if weight has changed, e.g. mid-upper arm circumference (instructions for measuring MUAC2), clothes / rings / watch looser or tighter, visual assessment.
  • Changes in food and drink intake.
  • Compliance with ONS and stock levels at home / care home.
  • When conducting general medication reviews, ONS should be included as above.
  • Discontinue ONS:
    • When aim of treatment is met.
    • If the person no longer wishes to take them.
    • If aim of treatment is not met after 3-6 months and there has been no clear benefit of ONS therapy.
    • If people fail to engage in review and monitoring.
  • Where people require long term ONS prescribing (i.e. ≥ 6 months) they should be reviewed by a dietitian at least annually.
  • If the patient no longer meets ACBS criteria, ONS must be discontinued as they should no longer be prescribed by the NHS. If the patient wishes to continue with ONS they can be advised that OTC ONS are available. They can also be advised on the food first approaches and homemade nourishing drinks as in Stage 4.
  • If clinically indicated, review after discontinuation of ONS (e.g. after 1 month) to ensure that there is no recurrence of the precipitating problem and targets are still being met.

Advisory Committee for Borderline Substances (ACBS)

The Advisory Committee for Borderline Substances (ACBS) is responsible for advising on the prescribing of toiletries and foodstuffs. These products are only allowed to be prescribed on the NHS as medicinal products, under certain circumstances or for certain conditions. Oral nutritional supplements are borderline substances that are only considered to be medicinal products eligible for prescribing on the NHS where the person meets at least one of the criteria stated by the Department of Health. People must meet at least one of these ACBS indications to be eligible for an NHS prescription of ONS.

References

1 NHS Scotland (2018) Guidelines for the appropriate use of oral nutritional supplements in adults (oral use). Available: https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/08/Gudelines-for-appropriate-prescribing-of-Oral-Nutritional-Supplements-in-adults.pdf [Accessed 22nd May 2019]

2 BAPEN (2019) Introducing MUST. Available: https://www.bapen.org.uk/screening-and-must/must/introducing-must [Accessed 10th May 2019]

3 NHSGGC (2019) Community MUST patient pathway Available: http://www.staffnet.ggc.scot.nhs.uk/Partnerships/Greater%20Glasgow%20and%20Clyde%20Services/FFN/Pages/ReferralPathwaysandForms.aspx [Accessed 22nd May 2019] 

4 NHSGGC Nutrition Resource Manual Available: http://www.staffnet.ggc.scot.nhs.uk/Acute/Division%20Wide%20Services/Food%20Fluid%20And%20Nutrition/Pages/FFN_nutrman_LMCD_310812.aspx [Accessed 22nd May 2019] 

5 British Dietetic Association (2019) Food Facts – Malnutrition. Available: https://www.bda.uk.com/foodfacts/malnutrition [Accessed 22nd May 2019]

6 NHSGGC (2019) Food First patient advice leaflet. Available: http://www.staffnet.ggc.scot.nhs.uk/Partnerships/Greater%20Glasgow%20and%20Clyde%20Services/FFN/Pages/ResourcesforMUST.aspx [Accessed 22nd May 2019]

7 NHSGGC Policy for Oral Nutritional Supplements (ONS) administration via the inpatient medicine prescription form (kardex)

8 NHSGGC (2018) Prescribing Protocol for the management of specified Oral Nutritional Supplement (ONS) products by Registered Dietitians

9 NHS Business Services Authority (2019) Drug Tariff. Available: https://www.nhsbsa.nhs.uk/pharmacies-gp-practices-and-appliance-contractors/drug-tariff [Accessed 4th September 2019] 

10 Multi-professional consensus panel (2017) Managing Adult Malnutrition in the Community Including a pathway for the appropriate use of oral nutritional supplements (ONS). Available: http://malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf [Accessed 16th February 2018] - PAGE NOT FOUND 2/11/21. Try resources here - https://www.malnutritionpathway.co.uk/health-resources

11 NHSGGC (2020) Oral and Enteral Nutrition Formulary (Adults and Older Children). Available: https://ggcmedicines.org.uk/media/0phcmlkt/nhsggc-oral-and-enteral-nutrition-formulary-updated-november-2020-with-new-iddsi-v3-201113-incl-links.pdf [Accessed 8th December 2020] 

12 NHSGGC (2018) Clinical Guideline – Adults at risk of re-feeding syndrome in Primary Care. Available: http://www.staffnet.ggc.scot.nhs.uk/Info%20Centre/PoliciesProcedures/GGCClinicalGuidelines/GGC%20Clinical%20Guidelines%20Electronic%20Resource%20Direct/Adults%20At%20Risk%20Of%20Re-Feeding%20Syndrome%20in%20Primary%20Care.pdf [Accessed 4th September 2019]

13 NHSGGC (2017) Nutrition Resource Manual SECTION 5: CLINICAL NUTRITION (PART 1) 5.3 Re-feeding syndrome. Available: http://www.staffnet.ggc.scot.nhs.uk/Acute/Division%20Wide%20Services/Food%20Fluid%20And%20Nutrition/Documents/Nutrition% 20Manual/NRM%20-%20Section%205.3%20Refeeding%20Syndrome.pdf [Accessed 4th September 2019] 

14 BAPEN (2019) Malnutrition Self Screening Website. Available: https://www.malnutritionselfscreening.org/ [Accessed 10th May 2019]

Last reviewed: 15 January 2020

Next review: 15 August 2022

Author(s): Lynsey Robinson

Version: 1

Author Email(s): [email protected]

Approved By: Therapeutics Subcommitte of ADTC

Document Id: 221