Gluten Free Products

Gluten-free Prescribing Guidance

Research undertaken by Coeliac UK suggests that access to gluten-free (GF) food on prescription is viewed as the most important factor for people with coeliac disease (CD)and Dermatitis Herpetiformis (DH) in terms of adherence to a GF diet. It is recognised that GF foods are more expensive: practitioners are encouraged to prescribe adequate quantities to ensure patients are not financially disadvantaged. The guidance provides advice on the amounts of GF food required by individuals with gluten-sensitive enteropathies.

It is important to make patients aware that naturally occurring GF food e.g. potatoes, rice, fresh vegetables and fruits (which can be purchased by the patient) are essential and should form the basis of their regular diet, in line with the nutritional recommendations for a healthy well balanced diet.

Products included

Bread, rolls, baguettes, bread mix, flour mix, pasta, crispbread, breakfast cereals

Products to be prescribed on the advice of a dietician, to meet individual patient needs:

Crackers, savoury biscuits, pizza bases

Products not included

Biscuits, sweet

Cakes, cake mix

Items not in the ‘products included list’

Non-essential items such as sweet biscuits and cakes are considered to be low priority for prescribing on the NHS and are not included in the formulary.
GF products, including brands that are not approved for NHS prescription, are widely available in supermarkets/pharmacies: it is accepted that (commercial) GF foods are more expensive in comparison to equivalent gluten-containing products.

Prescribing Advice

1. Before newly prescribing a patient gluten-free items, diagnosis should be confirmed through a positive serological test followed by endoscopy/biopsy by a gastroenterologist for CD and skin biopsy by a dermatologist for DH. All patients should be read-coded in medical notes for CD or DH. It is important that the diagnosis is made by a suitably qualified medical practitioner and not by self-testing kits.

1. GF foods vary from brand to brand. What may be suitable and taste good to one patient will not necessarily suit another. On initial diagnosis, it is best for the patient to be issued with a small quantity as an acute prescription so that they can try a range of products. Inform patients that they can also contact manufacturers directly, who will give them information on their range of products and are usually happy to send out samples. Signpost the patient toCoeliac UK. Once patient’s preferences have been established relevant items can be issued as a repeat prescription.

1. Having agreed a list of GF foods on prescription, regular reviews are important. The patient still needs the flexibility to change items as dietary needs vary throughout life. As the patient improves so will their appetite and quantities may need to be adjusted accordingly.

1. Only GF items on a GP clinical system should be prescribed as this ensures all items are Advisory Committee on Borderline Substances (ACBS) approved; handwritten prescriptions should not be issued. ACBS supports the prescribing of GF foods for patients with established gluten enteropathy. ACBS annotation notifies NHSBSA Prescription Servicesthat the item is being prescribed for an appropriate condition. GPs are not expected to prescribe outside the ACBS recommendations.

1. Quantities of food are difficult to estimate; it is necessary to assess how much gluten containing foodse.g. bread, pasta, flour, cakes, biscuits and pastries were consumed on a monthly basis before the patient started experiencing symptoms. Does the patient have the skills or facilities to cook or bake? It is also important to consider that quantities differ i.e. one loaf of standard sized bread is not equal to a GF loaf. Use the monthly amount of units prescribing guide.

1. Supply should usually be limited to 4 weeks at a time for all patients. All requests for large quantities of foods should be checked because they may be difficult to store and become out of date.

1. People with CD and DH in England do not receive prescriptions free of charge, unless they are exempt for another reason. Patients willusually need to paya separate prescription charge for each item of GF food. Patients who have to pay for more than three prescription items in three months, or 12items in 12 months, could save money by buying a pre-payment certificate, which covers the cost of all items onprescriptions (including medications).
   Information regarding current pre-payment certificate costs and forms can be obtained from a pharmacy or fromthe NHSBSA website.

Resources

British Society of Gastroenterology

Primary Care Society forGastroenterology

Coeliac UK

The Association of UK Dieticians (BDA)

British Society of Paediatric Gastroenterology, Hepatology and Nutrition

Written by: NHS Doncaster CCG Medicines Management Team, Martin Deakin, Senior Acute Team Dietician, Dietetic and Nutrition Service, DRI

Date of Preparation: May 2016Approved by: Medicines Management GroupDate of approval: June2016Review date: June 2018