All about oral nutrition supplements

Elaine, a daily methadone patient, comes into the pharmacy. You see that she is very thin and has sunken eyes. Today she has a prescription for an oral nutrition drink.

Questions

1."My doctor said it's like a milkshake and just contains vitamins and minerals," Elaine tells you. The doctor is correct.

True/False?

2. All oral nutrition feeds are borderline substances.

True/False?

3. The only specified indications for prescribing oral nutrition feeds are malnutrition and dysphagia.

True/False?

4. Having looked at the NHRA's Advisory Committee on Borderline Substances (ACBS) indications you, as the pharmacist and someone who has known Elaine as a customer for a long time, are sure she does not fall into any one of these categories and so should not have been prescribed an oral nutrition feed.

True/False?

5.The prescription for the feed has not been marked with the 'ACBS' endorsement. You should send the prescription back to the doctor to have it amended.

True/False?

Discussion

1. False: Some oral nutrition drinks come in a milkshake-like formulation and some contain cow's milk as the primary source of protein but they are not milkshakes in terms of predominantly consisting of milk with some flavouring. Oral nutrition drinks are specially formulated to contain a balanced mixture of protein, energy and fibre as well as electrolytes, vitamins and minerals.

2. True: Some foods have characteristics of drugs and therefore may be regarded as drugs for the management of specified conditions. Advisory Committee on Borderline Substances (ACBS) advises that all nutrition feeds fall into this category and may be prescribed for specified indications as long as the prescription is endorsed with 'ACBS'.

3. False: The standard ACBS indications are: disease-related malnutrition, intractable malabsorption, pre-operative preparation of malnourished patients, dysphagia, proven inflammatory bowel disease, after total gastrectomy, short-bowel syndrome and bowel fistula.

4. False: Although Elaine may not fit into any of the ACBS indications, Nice CG32 - Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition - advises that oral nutrition support should be considered for the following groups of people: (a) people who are malnourished, as defined by any of the following: a body mass index (BMI) of less than 18.5kg/m2, unintentional weight loss greater than 10 per cent within the past three to six months, a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5 per cent within the last three to six months.

(b) people at risk of malnutrition, defined as those who have: eaten little or nothing for more than five days and/or are likely to eat little or nothing for five days or longer, a poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism.

Elaine's appearance may indicate her falling into either (a) or (b) above.

5. False: Prescriptions should only be endorsed with 'ACBS' if the prescribed nutrition feed has been prescribed in accordance with the advice of the ACBS and for the indications listed; if not, then the prescription does not require the endorsement. You can still dispense the product and will be reimbursed for it. Where products do not have the endorsement, the GP may have to justify the prescription to the relevant local prescribing monitoring authority.