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BNSSG Adult Joint Formulary

9.5 Nutrition

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Last edited: 17-07-2025

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. stage 4 or 5 kidney disease, malabsorption, diabetes mellitus and dysphagia) should be referred to a Dietitian before ONS are prescribed.

Diabetes and Nutrition Services – Sirona care & health NHS services website, has more information about their service. If you have any queries about starting ONS, contact the Dietitians within the Diabetes and Nutrition Service (Sirona Care and Health) on 0300 124 5908 or sirona.dieteticsadvice@nhs.net for advice and guidance.

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 at the time of review. Please ensure a lower acquisition cost ONS is prescribed. Manufacturers may change their products’ formulation or the suppliers of their excipients. Current status of the product ingredients e.g. free-from status should therefore be obtained from the manufacturer.

Note that 1kcal/mL sip feeds are not recommended (e.g. 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

Savoury powdered soup. Requires the patient or carer to make up using 200ml warm water

Supplement	'Free from' status	Size (g)	Kcal per sachet	Protein (g)	Available flavours
Aymes^® Actasolve Savoury (make with 200mL warm water)	GF	57g	250	9.2	Chicken, Vegetable, Potato and Leek

Standard Milkshake style. Ready to drink bottle/carton

Supplement

'Free from' status

Size (mL)

Kcal per bottle

Protein (g)

Available flavours

Altraplen^® Energy

200

300

Banana, Chocolate, Strawberry

Actagain 1.5 Complete (previously called Aymes^® Complete)

GF, LF

200

300

Chocolate, strawberry, vanilla, banana,

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	315-320	15-15.4	Banana, Chocolate, Neutral, Strawberry, Vanilla, Ginger

Low Volume (Compact) Milkshake style. Ready to drink single bottle/carton which is equivalent to 2 standard compact (125ml) ONS. This is a more cost-effective and ecofriendly presentation. Can be used flexibly throughout the day.

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 bottle/carton. (If prescribing twice daily then consider using equivalent above which is a more cost effective and ecofriendly presentation).

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

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

Supplement	'Free from' status	Size (mL)	Kcal per bottle	Protein (g)	Available flavours
Aymes ^®ActaGain Juce (branded as Aymes ^®ActaGain 1.5 Juce)	GF, LF	200	300	10	Juicy Apple, Zesty Orange, Berry Medley, Exotic Fruit, Juicy Peach
Fortijuice	GF, LF	200	300	7.8	Tropical, Strawberry, Apple, Orange

Plant-based options

Alternative Smoothie/Milkshake Style ONS for patients who prefer plant-based options. Options include – powder shake to be made up with 150mL water* OR readymade bottle/cartons**.

Plant-based smoothies (powdered shake to be made up with 150ml water)

Supplement	'Free from' status	Size	Kcal per bottle	Protein (g)	Available flavours
Aymes Actasolve Smoothie*	GF, LF	66G sachet	298	11	Strawberry and Cranberry, Mango, Peach, Pineapple
Foodlink Smoothie*	GF, LF	66G sachet	287	10	Orange and Mango, Red Berry, Peach, Tropical

Plant-based: Ready to drink bottle/carton

Supplement	'Free from' status	Size (mL)	Kcal per bottle	Protein (g)	Available flavours
Fortisip Plant Based 1.5 kcal**	GF, LF	200	300	12	Mango, Passion Fruit, Mocha
Aymes Actagain 1.5 plant powered**	GF, LF	200	300	13.4	Madagascan Vanilla, Cafe Latte, Salted Caramel

Additional Protein Milkshake-style. Options include – powder shake to be made up with 100mL whole milk* OR readymade bottle/cartons.

Supplement	'Free from' status	Size	Kcal per bottle	Protein (g)	Available flavours
Aymes ^® ActaSolve Protein Compact	GF	57g	312-315	20.2-20.5	Vanilla, strawberry, banana, chocolate, neutral
Fresubin Pro compact	GF, LF	125ml	300	18	Vanilla, Apricot-peach, Cappuccino

Additional Fibre Milkshake-style. Options include – powder shake to be made up with 100mL whole milk OR readymade bottle/cartons.

Supplement	'Free from' status	Size	Kcal per bottle	Fibre (g)	Protein (g)	Available flavours
Foodlink^® Complete Fibre (4.5g)	GF	63g	397	4.5	19	Vanilla, strawberry, banana, chocolate, neutral
Aymes^® Shake Fibre (5g)	GF	57g	375	5	19	Vanilla, strawberry, banana, chocolate, neutral
Fortisip^® Compact Fibre (4.5g)	GF	125	300	4.5	11.9	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.

IDDSI Level 2

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

IDDSI Level 3

Supplement (g of fibre)	'Free from' status	Size (g)	Kcal per bottle	Protein (g)	Available flavours	IDDSI Level
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

IDDSI Level 4

Supplement (g of fibre)	'Free from' status	Size (g)	Kcal per bottle	Protein (g)	Available flavours	IDDSI Level
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:

PKU society guidance on quantities of prescribed low protein foods

Sapropterin dihydrochloride (TLS Red)

NICE TA729 Sapropterin for treating hyperphenylalaninaemia in phenylketonuria

In addition to low protein foods, diet-treated patients with PKU are required to take a protein substitute which provides amino acids or peptides in a form with minimal or zero phenylalanine. Patients who respond can receive sapropterin either with or without dietary treatment, subject to their genotype and phenotype, i.e. some sapropterin treated patients still require ACBS products

9.5.6 Coeliac Disease

Coeliac disease

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) gluten free foods should not be routinely prescribed to patients aged 18 and over. Prescriptions are still available for those patients aged under 18 from a limited choice of products.

Please ensure all patients with coeliac disease have been offered a dietitian referral. For further information, or if a patient is struggling with strict adherence to a gluten free diet, please refer to the dietitians and see resources on Coeliac Disease (Remedy BNSSG ICB) or Coeliac UK

Consider if calcium supplementation is needed for those with coeliac disease. Calcium requirements are significantly higher in coeliac disease than the rest of the general population (1000-1500mg/day compared to 700mg/day), with much higher incidences of osteoporosis. For most patients, especially those with secondary lactose intolerance, post-menopausal women, breastfeeding, other secondary risk factors of coeliac disease who need to aim for the higher end, it is difficult to achieve through diet alone so they may require additional calcium supplements

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

BNSSG Gluten free prescribing guidelines

Further information about coeliac disease is on the remedy page.

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