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BNSSG Adult Joint Formulary

9.5 Nutrition

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Last edited: 29-08-2024

9.5.1 Nutrition (intravenous)

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

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

NHSE SCC 2344 Managing national compounding capacity for Home Parenteral Nutrition for adults, children and infants of all ages

9.5.2 Nutrition (oral)

Initiating Oral Nutritional Supplements (ONS) in Primary Care:

Please see the Remedy Malnutrition & Oral Nutritional Supplements page for information about Food First advice and when to consider prescribing ONS.

For patients with disease-related malnutrition, please refer to the Pathway for prescribing Oral Nutritional Supplements (ONS) in BNSSG for disease-related malnutrition (DRM) for further information prior to commencing ONS.

Please note, for management of malnutrition, a dietitian may recommend alternative oral nutritional supplement products not specifically listed on the formulary and this will be documented in the patient letter where applicable. A dietetic management plan recommendation overrides any MUST screening because a full nutritional assessment will have been completed. A dietitian review is more detailed than the use of a screening tool and uses clinical judgement of the individual's circumstances.

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.

Key

GF= Gluten free

LF= Lactose free

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)

Standard powdered shake. 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
Aymes^® Shake	GF	57g	384-389	19	Banana, Chocolate, Neutral, Strawberry, Vanilla,
Foodlink Complete^®	GF	57g	385	19	Banana, Chocolate, Natural, Strawberry, Vanilla
Aymes^® Actasolve Savoury (make with 200mL warm water)	GF	57g	250	9.2	Chicken, Vegetable, Potato and Leek

Standard Milkshake style. Ready to drink.

Supplement	'Free from' status	Size (mL)	Kcal per bottle	Protein (g)	Available flavours
Altraplen^® Energy	GF	200	300	12	Banana, Chocolate, Strawberry
Aymes^® Complete	GF, LF	200	300	12	Chocolate, strawberry, vanilla, banana,
Fortisip^®	GF, LF	200	300	12	Neutral, vanilla, chocolate, toffee, banana, orange, strawberry, tropical fruits

Low volume (Compact) powdered shake- 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
Foodlink Complete^® Compact	GF	57	318	15	Strawberry, Chocolate, Banana, Natural, Vanilla
Aymes^® Shake Compact	GF	57	321	15-15.4	Banana, Chocolate, Neutral, Strawberry, Vanilla, Ginger

Low Volume (Compact) Milkshake style. Ready to drink dose delivered in 1 bottle per day. Patient or carer needs to be able to split one 250mL bottle into two 125mL doses and store in fridge after opening.

Supplement	'Free from' status	Kcal per bottle	Protein (g)	Available flavours
Aymes ActaGain^® 600	GF	600	24	Strawberry, Vanilla, Banana
Altraplen^® Compact Daily	GF	600	24	Banana, Chocolate, Hazelnut, Strawberry, Vanilla

Low Volume (Compact) Milkshake Style. Ready to drink

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

Juice style. Use in caution in patients with Diabetes Mellitus.

Supplement	'Free from' status	Size (mL)	Kcal per bottle	Protein (g)	Available flavours
Aymes Actasolve Smoothie (powder based to make up with 150mL water)	GF, LF	66G	297	10.7	Strawberry and Cranberry, Mango, Peach, Pineapple
Aymes ^®ActaGain Juce	GF, LF	200	300	11	Apple, Orange, Mango and Passionfruit, Cranberry and Strawberry
Altrajuce^® (ready to drink)	GF, LF	200	300	7.8	Apple, Blackcurrant, Orange, Strawberry

Protein

Supplement	'Free from' status	Size (mL)	Kcal per bottle	Protein (g)	Available flavours
Aymes ^® ActaSolve Protein Compact (make up with 100mL of whole milk)	GF	57	312-315	20.2-20.5	Vanilla, strawberry, banana, chocolate, neutral
Altraplen^® Protein	GF	200	300	20	Strawberry, Vanilla

Fibre

Supplement	'Free from' status	Size (mL)	Kcal per bottle	Protein (g)	Available flavours
Foodlink^® Complete Fibre (4.5g) (make up with 100mL of whole milk)	GF	63	420	19.6	Vanilla, strawberry, banana, chocolate, neutral
Aymes^® Shake Fibre (5g)	GF	57	374	19	Vanilla, strawberry, banana, chocolate, neutral
Fortisip^® Compact Fibre (4.5g)	GF	125	300	11.8	Mocha, Strawberry, Vanilla

Pre-thickened ONS

Please note, International Dysphagia Diet Standardisation Initiative (IDDSI) levels are only a guide. The decision regarding the suitability of ONS for patients with dysphagia is a clinical decision and should be based on the prescribing clinician's judgement.

Supplement (g of fibre)	'Free from' status	Size (g)	Kcal per bottle	Protein (g)	Available flavours	IDDSI Level
Fresubin^® Thickened IDDSI Level 2 (1.6g)		200	300	20	Vanilla, Wild strawberry	2
Thickened IDDSI Level 3 (1.6g)		200	300	20	Vanilla, Wild strawberry	3
Nutilis^® Complete Drink Level 3 (4g)		125ml	306	12	Vanilla, Chocolate, Mango & Passion fruit, Lemon tea, Strawberry	3
Nutilis^® Complete Creme Level 3 (4g)		125g	306	16	Vanilla, strawberry, chocolate	3
Nutilis^® Fruit Level 4 (3.9g)		150g	206	10.5	Apple, strawberry	4
Aymes^® ActaSolve Delight (make with 75mL whole milk)		57	302	11.2	Butterscotch, Lemon, Mixed Berries	4
Nutricrem^® (ready to eat)		125	225	12.5	Chocolate, orange, strawberry, Vanilla, mint chocolate	4

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

Refer to BNSSG Pathway for prescribing Oral Nutritional Supplements (ONS) for disease-related malnutrition (DRM) available on the 'Blood and Nutrition Guidelines' page

NBT:

For management as inpatients or hospital supply, please refer to the Dietetic Formulary (available to view on the intranet).

UHBW:

For management as inpatients or hospital supply, please contact the dietetic department.

Useful Links

Food First Ideas

Sirona Leaflet Library

Pathway for prescribing Oral Nutritional Supplements (ONS) in BNSSG for disease-related malnutrition (DRM)

Online ‘MUST’ Calculator

‘MUST’ explanatory booklet

Malnutrition – NHS Choices

Malnutrition Task Force – Preventing Malnutrition in Later Life

9.5.3 Metabolic Supplements

Primary care are responsible for continuation of specialist dietary products for inherited metabolic disorders. Nutritional supplements not included on the formulary may be appropriate for less common metabolic conditions such as Tyrosinaemia, Homocysteinuria, Maple Syrup Urine Disorder requiring a low protein diet, specialist low protein foods and protein substitutes with specific amino acids omitted and should be supported by clinic letter. See link to British Inherited Metabolic Diseases Group formulary here

The Drug Tariff lists all products which are available for prescription on FP10.

Further information about prescribing for metabolic conditions is available on the PAEDIATRIC Joint Formulary page

9.5.4 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.

9.5.5 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)

According to NHS England Policy E12/P/a Sapropterin For Phenylketonuria: Use in Pregnancy
NICE TA729 Sapropterin for treating hyperphenylalaninaemia in phenylketonuria

9.5.6 Coeliac Disease

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

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