9.4.2 Formulary choice oral nutritional supplements

Please refer to guidance on Adult Malnutrition

Alongside oral nutritional supplements (ONS) prescribers should consider providing patients with food advice first to optimise their dietary intake. This involves increasing the calorie and protein content of food and drink consumed, without increasing the volume. Patients should be encouraged to choose full fat foods and milky drinks and eat small, frequent, high calorie meals and snacks enriched with butter, cream, milk powder or cheese.

There are two leaflets available to help patients and carers. There is a guide to making the most of your food and advice for patients and carers who are prescribed nutrition drinks (nutritional supplements).

ONS should only be considered in patients who have one of the specific indications outlined by the Advisory Committee on Borderline Substances (ACBS):

  • Disease-related malnutrition
  • Intractable malabsorption
  • Pre-operative preparation of malnourished patients
  • Dysphagia
  • Proven inflammatory bowel disease
  • Following total gastrectomy
  • Short-bowel syndrome
  • Bowel fistula

Patients not fitting one of the indications above should have their sip feeds reviewed.

ONS must not be prescribed at NHS expense for nursing home patients who do not meet ACBS criteria as rules state that food items are not prescribable.

All children requiring nutritional support should be referred to a Paediatric Dietitian or Paediatrician for assessment. No adult ONS should be prescribed for a child weighing less than 30kg without expert advice.

For acute hospital, all ONS must be written and authorised on the prescription chart according to the individual trust policy. On discharge patients should be given 7 days supply and if it is intended that supplements are continued a dietitian will contact the patient's GP by letter to inform them of the patient's MUST score, nutritional goals, ONS prescribed and plans for review.

Patient specific advice can be sought from:

Northern Devon Healthcare NHS Trust Dietetic Department:

Nutritional supplements (standard)

Powder supplements to be reconstituted with fresh full fat milk

Powder milk shakes are not suitable for patients with severe or end stage kidney failure (CKD Stage 4-5), or for patients with Stage 3B CKD who are hyperkalemic. They may not be suitable for patients with poor manual dexterity.

Foodlink® Complete
  • Powder banana, strawberry, chocolate, neutral, vanilla (£0.60 = 57g sachet)
  • One sachet reconstituted with 200ml full fat milk provides approximately 386kcal and protein 18.3g
Ensure® Shake
  • Powder strawberry, vanilla, chocolate, banana (£0.60 = 57g sachet)
  • One sachet reconstituted with 200ml full fat milk provides approximately 389kcal and protein 17g

Ready to drink milkshake style sip feed

Although more expensive, these may be more suitable for patients with poor manual dexterity, who are unable to prepare powder milk shakes.

Currently ready to drink standard nutritional products that contain 2kcal per ml are more expensive per pack than the 1.5kcal per ml versions; however their higher nutritional content may allow some patients to be treated with one pack per day and may also be helpful where compliance with multiple daily dosing is an issue.

Ensure® Plus
  • Liquid chocolate, strawberry, vanilla, fruits of the forest, banana, raspberry, orange, coffee, peach, neutral (£1.11 = 200ml bottle)
  • 300kcal, protein 12.5g, carbohydrate 40.4g, fat 9.84g per 200ml
  • 1.5kcal per ml
Fortisip® Bottle
  • Liquid neutral, vanilla, caramel/toffee, chocolate, banana, orange, strawberry or tropical fruits (£1.12 = 200ml bottle)
  • 300kcal, protein 12g, carbohydrate 36.8g, fat 11.6g per 200ml
  • 1.5kcal per ml
Fresubin® 2kcal
  • Liquid neutral, vanilla, apricot-peach, toffee, cappuccino, fruits of the forest (£2.10 = 200ml bottle)
  • 400kcal, protein 20g, carbohydrate 45g, fat 15.6g per 200ml
  • 2kcal per ml
Fresubin® Energy
  • Liquid vanilla, strawberry, chocolate, cappuccino, tropical fruit, blackcurrant, neutral, banana lemon (£1.40 = 200ml bottle)
  • 300kcal, protein 11.2g, carbohydrate 37.6g, fat 11.6g per 200ml
  • 1.5kcal per ml

High energy low volume sip feed

These may be more suitable for patients that have a small appetite and struggle to drink a full cup of fluid. They may also be helpful for patients with fluid restriction.

Ensure® Compact
  • Liquid vanilla, strawberry, café latte, banana (£1.33 = 125ml bottle)
  • 300kcal, protein 12.75g, carbohydrate 36g, fat 11.6g, per 125ml
Fortisip® Compact
  • Liquid neutral, strawberry, vanilla, banana, mocha, apricot, forest fruit, chocolate (£1.45 = 125ml bottle)
  • 300kcal, protein 11.75g, carbohydrate 31.5g, fat 13g, per 125ml

Nutritional supplements (with fibre)

Fibre-containing ONS are useful for those with constipation (not suitable for those requiring a fibre-free diet)

Powder supplements to be reconstituted with fresh full fat milk

Powder milk shakes are not suitable for patients with severe or end stage kidney failure (CKD Stage 4-5), or for patients with Stage 3B CKD who are hyperkalemic. They may not be suitable for patients with poor manual dexterity.

Foodlink® Complete with Fibre
  • Powder (with added fibre) banana, strawberry, chocolate, vanilla, natural (£0.71 = 63g sachet)
  • One sachet reconstituted with 200ml full fat milk provides approximately 386kcal, protein 18.3g and fibre 4.5g

Ready to drink milkshake style sip feed

Although more expensive, ready to drink may be more suitable for patients with poor manual dexterity, who are unable to prepare powder milk shakes.

The higher nutritional content in 2kcal ready to drink products may allow some patients to be treated with one pack per day and may also be helpful where compliance with multiple daily dosing is an issue.

Fresubin® 2kcal fibre
  • Liquid chocolate, lemon, cappuccino, apricot-peach, neutral vanilla (£2.10 = 200ml bottle)
  • 400kcal, protein 20g, carbohydrate 45g, fat 15.6g, fibre 3g (3.2g for chocolate flavour) per 200ml
  • 2kcal per ml
Fresubin® Energy Fibre
  • Liquid strawberry, chocolate, caramel, cherry, vanilla, banana (£2.17 = 200ml bottle)
  • 300kcal, protein 11.2g, fat 11.6g, carbohydrate 37.6g, fibre 3g per 200ml
  • 1.5kcal per ml

High energy low volume sip feed

These products may be more suitable for patients that have a small appetite and struggle to drink a full cup of fluid. They may also be helpful for patients with fluid restriction.

Fortisip® Compact Fibre
  • Liquid vanilla, strawberry, mocha (£2.09 = 125ml bottle)
  • 300kcal, protein 11.75g, carbohydrate 31.5g, fat 13g, dietary fibre 5.62g per 125ml

Nutritional supplements (patient preferences)

Dislike of sweet flavours

Standard energy soups may be suitable for patients who dislike sweet flavours, for disease related malnutrition, and for hypoproteinaemia

AYMES® Savoury
  • Powder chicken (£0.70 = 57g sachet)
  • 251kcal, protein 9.2g, carbohydrate 34.3g, fat 8.5g, fibre 0.23g per 57g
Ensure® Plus Savoury
  • Liquid chicken (£1.11 = 200ml bottle)
  • 300kcal, protein 12.5g, carbohydrate 40.4g, fat 9.84g per 200ml
Vitasavoury®
  • Powder chicken, leek and potato, golden vegetable, mushroom (£2.01 = 50g sachet)
  • 309.5kcal, protein 6g, carbohydrate 11.25g, fat 26g, fibre 3.2g per 50g

Dislike of milky drinks

These products are fat free and may be appropriate for patients who dislike milky drinks or for those with fat malabsorption. They have high carbohydrate content and may not be suitable for diabetic patients.

Ensure® Plus Juce

Liquid orange, apple, lemon and lime, strawberry, peach, fruit punch (£1.97 = 220ml bottle)330kcal, protein 10.56g, carbohydrate 71.94g per 220ml

Fresubin® Jucy
  • Liquid orange, apple, pineapple, cherry, blackcurrant (£2.01 = 200ml)
  • 300kcal, protein 8g, carbohydrate 67g per 200ml

Taste Fatigue

These yogurt style drinks may be useful for patients with taste fatigue from first line sip feeds.

Ensure® Plus Yogurt
  • Liquid orchard peach, strawberry (£1.11 = 200ml bottle)
  • 330kcal, protein 13.75g, carbohydrate 44.44g, fat 10.82g per 200ml
Fresubin® YoDrink
  • Liquid raspberry, apricot/peach, lemon (£1.40 = 200ml bottle)
  • 300kcal, protein 15g, carbohydrate 39g, fat 9.4g per 200ml

Swallowing difficulties

Feed Thickeners

Indicated for patients with dysphagia, as identified by Speech and Language, who have advised on the stage of thickened fluids required.

Thick and Easy
  • Powder (225g tin = £5.21)
Thick and Easy Clear
  • Powder (126g tin = £6.50)

Notes

  1. If a patient is prescribed thickener whilst in hospital, it is important to continue the same product into primary care for clinical continuity and to reduce errors in mixing.
  2. Clear (gum based) products have very specific mixing instructions which must be adhered to, to ensure the product is the correct thickness for patient safety. Please refer to mixing instructions on the tins or seek appropriate advice.
  3. Sachets are significantly more expensive than tins. Sachets do not display mixing instructions and can be cumbersome to use. Routine use of sachets is not recommended.

Number of tins of Thick & Easy (225g) or tins of Thick & Easy Clear (126g) required per month (28 days):

Consistency Thick & Easy
Thick & Easy Clear
Stage I
3 tins 2 tins
Stage II 4 tins 3 tins
Stage III 6 tins 4 tins

The above is based on recommended usage of Thick & Easy or Thick & Easy Clear for 500ml fluids per day.
The communication from the Speech and Language Therapist should state the consistency to be used. If a different amount is required a clinical reason should be stated.

Semi-solid Desserts

Indicated for patients with dysphagia

Nutricrem®
  • Semi-solid vanilla, chocolate, banana, forest fruits (£1.59 = 125g pot)
  • 200kcal, protein 11.87g, carbohydrate 24.12g, fat 6.25g per 125g
Fresubin® 2kcal crème
  • Semi-solid vanilla, wild strawberry, cappuccino, chocolate, praline (£2.04 = 125g)
  • 250kcal, protein 12.5g, carbohydrate 28.12g, fat 9.75g per 125g
Fresubin® YoCrème
  • Semi-solid apricot-peach, biscuit, lemon, raspberry (£2.04 = 125g pot)
  • 187.5kcal, protein 9.37g, carbohydrate 24.37g, fat 5.87g per 125g

Pre-thickened drinks

Indicated for patients with dysphagia who require additional nutritional support.

Slõ® Drinks Milkshake Stage 1
  • Milkshakes containing thickener in chocolate and strawberry (£5.88 = 7 sachets)
  • One sachet reconstituted with 200ml full fat milk provides approximately 333kcal and protein 24g
Slõ® Drinks Milkshake Stage 2
  • Milkshakes containing thickener in chocolate and strawberry (£5.88 = 7 sachets)
  • One sachet reconstituted with 200ml full fat milk provides approximately 333kcal and protein 24g
Fresubin® Thickened stage 1
  • Liquid lactose free, syrup consistency, vanilla, wild strawberry (£2.35 = 200ml)
  • 300kcal, protein 20g, carbohydrate 24.4g, fat 13.4g per 200ml
Fresubin® Thickened stage 2
  • Liquid lactose free, custard consistency, vanilla, wild strawberry (£2.35 = 200ml)
  • 300kcal, protein 20g, carbohydrate 24g, fat 13.4g per 200ml

Specialist products

The specialist nutritional products are not listed in priority order. Patient compliance should be paramount in the product choice. Seek guidance from a registered dietitian before prescribing the following products.

High energy powder supplements to be reconstituted with fresh whole fat milk

For disease related malnutrition and for hypoproteinaemia. Not nutritionally complete

Calshake®
  • Powder, vanilla, chocolate, banana (£2.53 = per sachet)
  • One sachet reconstituted with 240ml full fat milk provides approximately 600kcal and 12g protein
Enshake®
  • Powder 450kcals per strawberry, vanilla, chocolate, banana (£2.45 = 1 sachet)
  • One sachet reconstituted with 240ml full fat milk provides approximately 600kcal and 16g protein

High Protein milkshake style sip feeds

Altraplen® Protein
  • Liquid strawberry, vanilla (£1.59 = 200ml bottle)
  • 300kcal, protein 20g, carbohydrate 30g, fat 11.2g, per 200ml
Fortsip® Compact Protein
  • Liquid vanilla, strawberry, banana, peach and mango, mocha (£2.00 = 125ml bottle)
  • 300kcal, protein 18g, carbohydrate 30.5g, fat 11.75g per 125ml

Fat, protein and carbohydrate supplement

For hypoproteinaemia

Pro-cal®

Powder 667kcal/100g (£15.53 = 510g tub)Protein 13.6g, carbohydrate 28.2g, fat 55.5g per 100g

Single nutrient supplements

Carbohydrate based calorie powder supplement

Use as an energy enhancer in disease related malnutrition. Lactose free, fat free

Care when used in diabetics. Not to be used as a sole source of nutrition

Maxijul® Super Soluble
  • Powder 3.8kcal/g (£2.73 = 200g)
  • Carbohydrate 95g/100g
Polycal®
  • Powder 3.8kcal/g (£4.53 = 400g)
  • Carbohydrate 90g/100g

Carbohydrate based calorie liquid supplement

Polycal® Liquid
  • 494kcal per 200ml orange, neutral (£1.81 = 200ml)

Notes

  1. Use as an energy enhancer in disease related malnutrition
  2. Lactose free, fat free

Fat and carbohydrate calorie supplement

Duocal® Super Soluble
  • Powder 5kcal/g (£18.96 = 400g)
  • Carbohydrate 72.7g, fat 22.3g per 100g

Notes

  1. For high energy, low fluid, low electrolyte requirements e.g. renal disease, catabolic states
  2. Suitable for use in infants, children and adults

Protein powder supplement

For hypoproteinaemia. Contains residual lactose

Protifar®
  • Powder 3.8kcal and 0.9g protein/g (£9.20 = 225g)

Fat and protein liquid supplement

Disease related malnutrition, conditions requiring fortification with fat and for hypoproteinaemia. Recommended dose: 120ml per day in divided doses. Do not exceed this dose.

Altrashot®
  • Liquid in vanilla, strawberry (£2.00 = 120ml bottle)
  • 420kcal, protein 6g, carbohydrate 20g, fat 35g per 120ml
Pro-cal® Shot
  • Liquid in neutral, banana, strawberry (£2.45 = 120ml bottle)
  • 400kcal, protein 8g, carbohydrate 16g, fat 34g per 120ml

Fat based calorie liquid supplement

For conditions requiring fortification with a high fat supplement. Not to be used as a sole source of nutrition. Do not exceed recommended doses.

Fresubin® 5kcal Shot
  • Liquid in neutral, lemon (£2.96 = 120ml)
  • Recommended dose: 30ml three or four times daily
  • 600kcal, carbohydrate 4.8g, fat 64.56g, fibre 0.48g per 120ml bottle
Calogen®
  • Liquid in unflavoured, strawberry, banana (£4.61 = 200ml)
  • Recommended dose: 30ml three times daily
  • 900kcal, fat 100g per 200ml bottle

Disease specific supplements

Special additives for conditions of intolerance

VSL#3®
  • Sachets (£34.36 = 30 sachets)

Indications

  • Maintenance of remission of ileoanal pouchitis induced by antibacterials in adults

Notes

  1. To be initiated by a consultant gastroenterologist
  2. It is recommended to take VSL#3 for at least one month to see the best benefit. In general it takes up to seven days for the bacteria colonies to become established in the gut. By day 20 the maximum concentration of bacteria will have colonised the gut.

Anti-inflammatory (Crohn's disease)

Modulen® IBD
  • Powder 100kcals, 3.6g protein/ 100ml reconstituted powder (£15.59 = 400g)
  • Protein 18g, carbohydrate 54g, fat 23g per 100g

Notes

  1. For Crohn's disease – active phase and in remission if malnourished

Peptide based supplement

Vital 1.5kcal
  • Liquid in mixed berry, café latte, vanilla. (£3.17 = 200ml)
  • 300kcals, protein 13.5g, carbohydrate 36.8g, fat 11g per 200ml

Notes

  1. For malabsorption

 

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