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                       Berkshire Adult Nutritional Supplement and Tube Feed Formulary 
                                                                                                      
                   
              Traffic Light Coding: 
              Green:  Can be initiated by any prescriber when ACBS guidelines for prescription of borderline substances are met (see page 13).  
              Amber: Should only be prescribed on the recommendation of a Dietitian or other specialist – refer to their advice for quantity and duration of 
              prescription. 
              
               
                If further guidance on nutritional supplementation is required, the patient should be referred to a Dietitian for assessment.  
                The products included in this formulary should be safe and suitable for most patients to use. Please refer to the BNF, manufacturer’s information 
                  or Dietitian for advice if a patient is following a restricted diet for medical/religious purposes, or has complex nutritional needs. 
                If a Dietitian is recommending a product not included on the Formulary, they should state the clinical reasons for choosing the product over 
                  Formulary products and inform the prescriber that the product is non-formulary. 
                Please note that all prescriptions of Oral Nutritional Supplements should be reviewed every 3-6 months (or more frequently if there is a clinical 
                  need) as per NICE CG32 guidance. To assist in the management of this, please put ONS on ‘acute’ prescription and consider using ‘starter packs’ 
                  to provide a one week supply in a variety of flavours, to help identify preference. Tube Feeds should remain on Repeat prescriptions. 
                For patients who can make up a shake, Powder ONS are recommended first line as they are more cost-effective than bottled versions. Please 
                  see indication column for guidance on the use of each product. 
                   
                           Authors: Prescribing Support Dietitians - East Berkshire CCG,  Berkshire West CCG                 Issue date:                               
                           Authorised by: Effective Prescribing & Performance Group and Frimley Area Prescribing Committee   Review date:                            Version 1 
                            
         Abbreviations: ACBS (Advisory Committee on Borderline Substances), BD (twice daily), BNF (British National Formulary), CKD (Chronic Kidney Disease), FFM (Full Fat Milk), g 
         (grams), HP (High Protein), kcals (Kilocalories), MCT (Multiple Chain Triglycerides), ONS (Oral Nutritional Supplements), OTC (Over The Counter), RTH (Ready to Hang), SALT 
         (Speech and Language Therapist), TF (Tube Feed). Prices based on August 2018 MIMS data. Please note prices may change, but will only be updated annually. 
                   
                                           Oral Nutritional Supplements (ONS)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   2 
                                                            
                                                                                  
                                             Please check patient meets ACBS prescribing criteria. Screen using the MUST nutritional assessment tool, refer to dietetic action plans and give first line 
                                                           Food Fortification advice prior to initiating ONS. A MUST score of 2 or above meets the prescribing criteria for ONS. 
                                             Resources available on CCG website and DXS: ‘A Food First approach – making the most of what you eat’ and ‘Nourishing drinks’. 
                                                     Borderline  Substance and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Formulation                                                                                                                                                                                Calories/                                                          Protein/                                                          Cost/                                                  Traffic light 
                                                                             available flavours                                                                                                                                                                                                         Indication                                                                                                                                                and Volumes                                                                                       Monthly BD                                                                                      serving                                                          serving                                                   serving                                                                  coding 
                                                                 (as per BNF Appendix 2)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        volume                                                                                 (kcals)                                                                   (g) 
                                                  FIRST LINE: Powder Oral Nutritional Supplements (ONS):  Some of the milk-containing products in this document are not suitable for those with cow’s 
                                                  milk/lactose intolerance or galactosaemia, or as a sole source of nutrition. Use with caution in CKD Stage 3 and only under Dietitian recommendation for CKD 4 and 5. 
                                                  Standard Volume Milkshake-Style ONS (recommended dose: two sachets daily) 
                                                  Ensure Shake (Abbott)                                                                                                                                                Powder: For use when patient/carer is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                       able to make up a shake and when                                                                                                                                                                                                                 57g sachet                                                                                      56 sachets                                                                                                                                                                                                                                                                                                         
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              389 
                                                  Banana, Chocolate,                                                                                                                                                   protein and energy needs are                                                                                                                                                                                                                        (mixed with                                                                                                                                                                      (when made                                                                           17                                                £0.60                                                   Community 
                                                  Strawberry, Vanilla                                                                                                                                                                                                                                                                                                                                                                                                    200mls FFM)                                                                                 (8 boxes of 7                                                                           with 200mls                                                                                                                                                                                                 Green 
                                                                                                                                                                                                                       increased.                                                                                                                                                                                                                                                                                                                                               sachets)                                                                                     FFM) 
                                                  Please note this is different                                                                                                                                                                                                                                                                                                                                                                                        7 x 57g Pack                                                                                                                   
                                                  to ‘Enshake’.                                                                                                                                                        Contains lactose and milk proteins.  
                                                   
                                                  Reduced Volume, Milkshake-Style ONS (recommended dose: two sachets daily) 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                  Aymes Shake Compact                                                                                                                                                  Powder: For use when patient/carer is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        57g sachet                                                                                                                                                                                                                                                                                                                                                                                                         
                                                  (Aymes)                                                                                                                                                              able to make up a shake and needs a                                                                                                                                                                                                                                                                                                              56 sachets                                                                                                                                                                                                                                                                                                         
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
                                                                                                                                                                                                                       smaller volume/fluid restriction.                                                                                                                                                                                                                   (mixed with                                                                                                                                                                                        316                                                           12.6                                                   £0.60                                                   Community 
                                                  Banana, Chocolate, Neutral,                                                                                                                                                                                                                                                                                                                                                                                           100mls FFM)                                                                                  (8 boxes of 7                                                                                                                                                                                                                                                                                       Green 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                sachets) 
                                                  Strawberry, Vanilla                                                                                                                                                  Contains lactose and milk proteins.                                                                                                                                                                                                             7 x 57g Pack 
                                                  Reduced volume, Smoothie-Style ONS (recommended dose: two sachets daily) 
                                                  Aymes Shake Smoothie                                                                                                                                                 Powder: For use when patient/carer is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
                                                  (Aymes)                                                                                                                                                              able to make up a shake and cannot                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        66g sachet                                                                                      56 sachets                                                                                                                                                                                                                                                                                                         
                                                                                                                                                                                                                       tolerate the above milkshake-style                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
                                                  Mango, Peach, Pineapple,                                                                                                                                                                                                                                                                                                                                                                                                 (mixed with                                                                                                                                                                                        297                                                           10.7                                                   £1.00                                                   Community 
                                                  Strawberry and Cranberry                                                                                                                                             ONS.                                                                                                                                                                                                                                          150mls water)                                                                                   (8 boxes of 7                                                                                                                                                                                                                                                                                       Green 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                sachets) 
                                                                                                                                                                                                                       Contains soya and may contain traces of milk                                                                                                                                                                                                    7 x 66g Pack                                                                                                                   
                                                                                                                                                                                                                       proteins. Is lactose-free.                                                                                                                                                                                                                                                                                                                                                     
                                                                                                                                                                                                                        
                                         Abbreviations: ACBS (Advisory Committee on Borderline Substances), BD (twice daily), BNF (British National Formulary), CKD (Chronic Kidney Disease), FFM (Full Fat Milk), g 
                                         (grams), HP (High Protein), kcals (Kilocalories), MCT (Multiple Chain Triglycerides), ONS (Oral Nutritional Supplements), OTC (Over The Counter), RTH (Ready to Hang), SALT 
                                         (Speech and Language Therapist), TF (Tube Feed). Prices based on August 2018 MIMS data. Please note prices may change, but will only be updated annually. 
                                                                                  
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                                               SECOND LINE: Ready to Drink Oral Nutritional Supplements (ONS): 
                                               Standard Volume, Milkshake-Style ONS (recommended dose: two bottles daily) 
                                               Ensure Plus Milkshake                                                                                                                                    To be used when patient/carer is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
                                               (Abbott)                                                                                                                                                 unable to make up a powder shake.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Acute and 
                                               Banana, Chocolate, Coffee,                                                                                                                               Clinically lactose free, but not milk-free.                                                                                                                                                                                 200ml bottle                                                                                     11200mls                                                                                     300                                                       12.5                                                £1.11                                              Community 
                                               Fruits of the Forest, Neutral,                                                                                                                                                                                                                                                                                                                                                                                                                                                    (56x200ml)                                                                                                                                                                                                                                                                      Green 
                                               Peach, Raspberry, Strawberry,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
                                               Vanilla                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
                                               Reduced Volume, Milkshake-Style ONS (recommended dose: two bottles daily) 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
                                               Ensure Compact (Abbott)                                                                                                                                  When a patient/carer is unable to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
                                                                                                                                                                                                        make up a powder shake and needs a                                                                                                                                                                                          125ml bottle                                                                                        7000mls                                                                                                                                                                                                                                                        Acute and 
                                               Banana, Cafe Latte,                                                                                                                                      smaller volume/fluid restriction.                                                                                                                                                                                                                                                                                                                                                                                         300                                                            13                                             £1.33                                              Community 
                                                                                                                                                                                                                                                                                                                                                                                                                                        4 x 125mls =                                                                                 (14 x 500ml 
                                               Strawberry, Vanilla                                                                                                                                                                                                                                                                                                                                                                                                                                                                               packs)                                                                                                                                                                                                                                                          Green 
                                                                                                                                                                                                        Contains lactose and milk proteins.                                                                                                                                                                                                500ml pack 
                                               Standard Volume, Juice-Style ONS (recommended dose: two bottles daily) 
                                               Ensure Plus Juce (Abbott)                                                                                                                                Use only if patient is unable to make                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
                                               Apple, Fruit Punch, Lemon                                                                                                                                up a shake and cannot tolerate the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Acute and 
                                                                                                                                                                                                        above milkshake-style ONS.                                                                                                                                                                                                  220ml bottle                                                                                     12320mls                                                                                     330                                                       10.6                                                £1.97                                              Community 
                                               and Lime, Orange, Peach,                                                                                                                                                                                                                                                                                                                                                                                                                                                          (56x220ml)                                                                                                                                                                                                                                                                      Green 
                                               Strawberry                                                                                                                                               Clinically lactose free, but not milk-free. 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
                                                  Please note:  The above juice/fruit products are not to be used as a sole source of nutrition. Use with caution in patients with diabetes due to higher sugar 
                                                                                                                                                               content. These products may be recommended by a renal Dietitian due to lower potassium/phosphate content. 
                                               Liquid Modular ONS: Please note the above supplements may also be given as ‘shots’ or split doses if volume is an issue. 
                                               Altrashot (Nualtra)                                                                                                                                      To be used when a patient requires a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Based on 120ml daily:                                                                                                                                                                                                                                                                                    
                                                                                                                                                                                                        low volume ONS.                                                                                                                                                                                                             120ml bottle                                                                                                                                                                                                                                                                                                               
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        3360mls                                                                                   420                                                               6                                           £2.00                                              Community 
                                               Vanilla and Strawberry                                                                                                                                   Recommended dose:                                                                                                                                                                                                                                                                                                          (7 x 4 packs or                                                                                           
                                                                                                                                                                                                                                                                                                                                                                                                                                   4 x 120ml pack                                                                                                                                                                      (based on                                                                                                                                                                               Amber 
                                                                                                                                                                                                        3 x 40ml  or 4 x 30ml shots daily.                                                                                                                                                                                                                                                                               28 x 120ml bottles)                                                                              4 x 30ml 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               shots) 
                                                                                                                                                                                                        Clinically lactose free, but not milk-free. 
                                       Abbreviations: ACBS (Advisory Committee on Borderline Substances), BD (twice daily), BNF (British National Formulary), CKD (Chronic Kidney Disease), FFM (Full Fat Milk), g 
                                       (grams), HP (High Protein), kcals (Kilocalories), MCT (Multiple Chain Triglycerides), ONS (Oral Nutritional Supplements), OTC (Over The Counter), RTH (Ready to Hang), SALT 
                                       (Speech and Language Therapist), TF (Tube Feed). Prices based on August 2018 MIMS data. Please note prices may change, but will only be updated annually. 
                                                                             
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                                                  Higher Fibre ONS:  please follow dietitian’s or manufacturer’s recommendations for dosage. 
                                                  Foodlink Complete with                                                                                                                                               Powder: For use when patient/carer is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
                                                  Fibre (Nualtra)                                                                                                                                                      able to make up a shake and need a                                                                                                                                                                                                               63g sachet                                                                                                                                                                                                                                                                                                                                                                                                         
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
                                                                                                                                                                                                                       high-calorie and high-fibre ONS.                                                                                                                                                                                                                    (mixed with                                                                                                 Follow                                                                                 420                                                           19.6                                                   £0.71                                                   Community 
                                                  Banana, Chocolate, Natural,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Dietitian’s 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        200mls FFM)                                                                                                                                                                                                                                                                                                                                                                                    Amber 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              (made with 
                                                  Strawberry, Vanilla                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        recommendations.                                                                                                                                                                           
                                                                                                                                                                                                                       Contains lactose and milk proteins. 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                       7 x 63g pack                                                                                                                                                                        200mls FFM) 
                                                  Fibre = 4.5g per sachet 
                                                   
                                                  Ensure Plus Fibre (Abbott)                                                                                                                                           When a patient/carer is unable to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
                                                                                                                                                                                                                       make up a powder shake and needs a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
                                                  Banana, Chocolate,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Follow                                                                                                                                                                                                                                                                  Acute and 
                                                  Raspberry, Strawberry, Vanilla                                                                                                                                       high-calorie and high-fibre bottled ONS.                                                                                                                                                                                                   200ml bottle                                                                                                 Dietitian’s                                                                                    310                                                                13                                                £2.07                                                   Community 
                                                                                                                                                                                                                       Fibre = 5.0g per bottle                                                                                                                                                                                                                                                                                                               recommendations.                                                                                                                                                                                                                                                                                          Amber 
                                                  Fibre = 5.0g per bottle                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
                                                                                                                                                                                                                       Clinically lactose free, but not milk-free. 
                                                  High-Protein ONS: when protein needs are increased e.g. for wound healing, burns or muscle wastage. Follow Dietitian’s dosage recommendations. 
                                                  Ensure Shake (Abbott)                                                                                                                                                Powder: For use when patient/carer is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        57g sachet                                                                                                                    
                                                                                                                                                                                                                       able to make up a shake and when                                                                                                                                                                                                                    (mixed with                                                                                                                                                                                        389                                                                                                                                                                                                          
                                                  Banana, Chocolate,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Follow                                                               (when made                                                                                                                                                                                     Community 
                                                  Strawberry, Vanilla                                                                                                                                                  protein needs are increased.                                                                                                                                                                                                                      200mls FFM)                                                                                           Dietitian’s                                                                                                                                                       17                                                £0.60 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             recommendations.                                                                                with 200mls                                                                                                                                                                                                 Green 
                                                  Please note this is different to                                                                                                                                     Contains lactose and milk proteins.                                                                                                                                                                                                             7 x 57g pack                                                                                                                                                                                          FFM) 
                                                  ‘Enshake’. 
                                                  Altraplen Protein (Nualtra)                                                                                                                                          To be used when patient/carer is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
                                                                                                                                                                                                                       unable to make up a shake and when                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
                                                  Strawberry, Vanilla                                                                                                                                                  protein needs are increased. Ready to                                                                                                                                                                                                      200ml bottle                                                                                                         Follow                                                                                                                                                                                                                                                              Community 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Dietitian’s                                                                                    300                                                                20                                                £1.59 
                                                                                                                                                                                                                       drink ONS.                                                                                                                                                                                                                                4 x 200ml pack                                                                              recommendations.                                                                                                                                                                                                                                                                                          Amber 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
                                                                                                                                                                                                                       Clinically lactose free, but not milk-free. 
                                                                                                                                                                                                                        
                                                  Savoury-style ONS:  (recommended dose: two sachets daily) 
                                                  Aymes Savoury (Aymes)                                                                                                                                                Powder: For use when patient does not                                                                                                                                                                                                          57g  Sachet                                                                                                                                                                                                                                                                                                                                                                                                          
                                                                                                                                                                                                                       tolerate sweet supplements.                                                                                                                                                                                                                         (mixed with                                                                                                 Follow                                                                                                                                                                                                                                                              Community 
                                                  Chicken, Vegetable                                                                                                                                                                                                                                                                                                                                                                                                         200mls hot                                                                                        Dietitian’s                                                                                    251                                                              9.2                                                 £0.70                                                               Amber 
                                                                                                                                                                                                                       Contains lactose and milk proteins.                                                                                                                                                                                                                             water)                                                                recommendations.                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                       7 x 57g pack 
                                         Abbreviations: ACBS (Advisory Committee on Borderline Substances), BD (twice daily), BNF (British National Formulary), CKD (Chronic Kidney Disease), FFM (Full Fat Milk), g 
                                         (grams), HP (High Protein), kcals (Kilocalories), MCT (Multiple Chain Triglycerides), ONS (Oral Nutritional Supplements), OTC (Over The Counter), RTH (Ready to Hang), SALT 
                                         (Speech and Language Therapist), TF (Tube Feed). Prices based on August 2018 MIMS data. Please note prices may change, but will only be updated annually.