Intravenous Lipids: Clinical & Practical Updates. Nora AlBanyan, R.Ph., SSC-PhP, SSCPN, BCNSP

Transcription

1 Intravenous Lipids: Clinical & Practical Updates Nora AlBanyan, R.Ph., SSCPhP, SSCPN, BCNSP

2 Disclosure Information I have no financial relationship to disclose. AND I will not discuss off label use and/or investigational use in my presentation.

3 Learning Objectives At the completion of this activity, you will be able to: Identify the importance of lipids in clinical nutrition Explain the differences between lipid emulsions Discuss clinical implication and guidelines

4 Attention! IVFE ILE

5 Do you think there is any difference between Fat and Lipids? Yes No

6 Lipids vs Fats Lipids Lipids are a broad group of biomolecules whereas fats are a type of lipids Fats

7 The History William Courten 17th century Intravenous olive oil 1g/kg given to a dog Fatal outcome Severe respiratory distress (Pulmonary embolism) Edward Hodder 1873 (Canada) Milk infusion in 3 patients with cholera 2/3 survived effect magical Could not be reproduced by others unmodified fats could not be given IV

8 The History 1957 Cottonseed oil 1960 Soybean 1980 Soybean + MCT 1990 Olive Oil Present Fish Oil

9 Generations 1960 Soybean 1980 Soybean + MCT 1990 Olive Oil 2006 Fish Oil FDA Approval 1972 Intralipid 2013 Clinolipid 2016 SMOFlipid 2018 Omegaven

10 What Is Lipid Source of energy Provide structural and metabolically functional component of biological membranes The lipid used in PN contain fatty acids in the form of triglycerides A triglycerides consists of 3 fatty acid molecules bonded to a glycerol molecule

11 Lipid Function as. A. Energy Production and Storage B. Essential Fatty Acids C. Cell Wall Structure D. Digestion and Absorption E. Inflammation Promotion (eicosanoids) and Resolution F. Hormone Production G. Antidote

12 Why Use Parenteral Lipids Meet high caloric intake Reduce risks from hyperglycemia Reduce the osmolarity of the formulas Enhances the bioavailability of fat soluble vitamins Provide essential fatty acids Other Uses Local anesthetic toxicity and drug overdoses Treatment for recurrent miscarriage (off label indication)

13 Learning Objectives At the completion of this activity, you will be able to: Identify the importance of lipids in clinical nutrition Explain the differences between lipid emulsions Discuss clinical implication and guidelines

14 Similar, but Different

15 What s Common to ALL ILE Products Water for injection 1.2% egg yolk phospholipi ds 2.25%2.5% glycerin Sodium hydroxide

16 What s Common to ALL ILE Products Water for injection Black Box Warning 1.2% egg yolk phospholipi ds 2.25%2.5% glycerin Sodium hydroxide Death in premature neonates

17 Contraindications for ILE Hypersensitivity to Lipid ingredients or excipients Severe hyperlipidemia Severe blood coagulation disorder Acute shock and unstable conditions Severe liver or renal insufficiency in patients with no access to hemofiltration or dialysis

18 What s Different Phytosterol content Vitamin E content Inflammator y characterist ics Typically not noted on the product label!

19 Phytosterols Plant sterols Typically only small amounts absorbed by GI tract Undergo hepatic metabolism IV phytosterols reduce bile acid flow

20 Comparison of Lipid Emulsions OIL Intralipid Lipofundin Omegaven Clinoleic SMOF lipid Lipidem/Lipo plus Soybean % MCT % Olive % Fish % Glycerol g/100 ml Egg Phospholipid g/100ml Phytosterols (mg/l) 439± ± ± NA Vitamin E mg/100 ml

21 Vitamin E (alpha tocopherol) Antioxidant Prevents hepatic injury (animal models) Prolonged use of soybean oil ILE may reduce αtocopherol concentrations in plasma lipoproteins Soybean oil contains γtocopherol Less bioactive than αtocopherol

22 Comparison of Lipid Emulsions OIL Intralipid Lipofundin Omegaven Clinoleic SMOF lipid Lipidem/Lipo plus Soybean % MCT % Olive % Fish % Glycerol g/100 ml Egg Phospholipid g/100ml Phytosterols (mg/l) 439± ± ± NA Vitamin E mg/100 ml

23 Inflammatory Profile & Immune Promotion Immune and Inflammatory Response Kelley DS. Nutrition. 2001;17(78): WolowczukI, et al. ClinDevImmunol. 2008;2008: BattistellaFD, et al. J Trauma. 1997;43(1):5258. Calder PC, et al. ClinNutr. 1994;13(2):6974.

24 Optimal Outcome Evidence RCT? Statistical significance? Clinical outcomes? Guidelines? Clinical scenario? Availability? Cost? Physician or NST expertise? Clinical Practice Patient Biochemical individuality & monitoring response and evolution

25 IVLE Practical Aspects EFA deficiency Inflammatory profile + immune promotion Long term PN (home care) Liver impact and cholestasis Blood coagulation and platelet aggregation Premixed VS Compounded PN Central VS Peripheral PN Comorbidities Cost of lipid emulsion Availability

26 IVLE Soybeans Medium Chain Triglycerides (MCT) Olive Oil Fish Oil 1st 2nd 3rd 4th HIGH phytosterol content LOW phytosterol content LOWER phytosterol content Trace phytosterol content LOW αtocopherol content LOW αtocopherol content HIGH αtocopherol content Abundant αtocopherol content Inflammatory potential Immune Neutral Easy Metabolized CONTAIN NO ESSENTIAL FATTY ACIDS Immune Neutral Improved glucose tolerance LESS proinflammatory

27 Learning Objectives At the completion of this activity, you will be able to: Identify the importance of lipids in clinical nutrition Explain the differences between lipid emulsions Discuss clinical implication and guidelines

28 Practical Considerations Adult Avoid EFA deficiency (34 % kcal from soy) Avoid IVLE instability Limit heparin quantity Respect calcium and phosphorus limits Caloric calculation 20 % IVLE = 10 kcal / gram Individualize dose g/kg and choose wisely

29 Practical Considerations Pediatric Presence of Phytosterols (plant sterols) Lack of αtocopherol (Vitamin E) Fat overload syndrome Parenteral nutrition associated liver disease (PNALD) Individualize dose g/kg and choose wisely

30 The Evidence Treatment of Intestinal failureassociated liver disease Fish oil SMOF lipid 50/50 blend FO + SO Reduced dose SO

31 Fish Oil: Hong Kong RCT

32 Fish Oil D billi & ALT Fish Oil 1.5 g/kg/day Reversal IFALD at 4 months SO 1.5 g/kg/day D billi & ALT Rates of increase of D bili & ALT in SO group > FO group 13.5 vs.0.6 μmol/l/wk and 9.1 vs. 1.1 IU/l/wk (p = 0.03) SO: Soybeans Neonatology 2014;105:290296

33 SMOF Lipid Birmingham Children s Case series infants/ children with PNALD while on SO & switched to SMOF lipid (n=8) 1 patient died, 1 listed for transplant Remaining 6: sudden, often dramatic and sustained fall in bilirubin 13 months after switching to SMOF lipid

34 50/50 FO + SO Canada Retrospective cohort 12 patients with PNALD 1 g/kg/d SO + 1 g/kg/d FO Complete resolution of PNALD occurred in 9 patients (75%) J Pediatr Gastroenterol Nutr Feb;48(2):20915

35 Soy Lipid Restriction Prospective Control: 3 g/kg/d, Intervention: 1 g/kg twice weekly, n = 31 each group Results: 42% resolution (fat reduction) 10% resolution control group J Pediatr Mar;160(3):4217.

36 Guidelines for Use American Society for Parenteral and Enteral Nutrition Canadian Critical Care Nutrition Guideline European Society for Parenteral and Enteral Nutrition

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39 Guidelines for Use

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41 Which IVLE Is Optimum for My Patient? 100% LCT 50 % LCT 50 % MCT 80 % Olive 20 % Soy 30 % Soy, 30 % MCT, 25 % Olive, 15 % Fish Short term PN Long term PN Peripheral PN Surgical patient Critical patient Hyper inflammatory Acidosis state ++ ++

42 Conclusion To select the best ILE take into account each patient characteristics and the specific clinical scenario Same patient can use different ILE during their treatment or hospital stay There is no good and bad ILE, better or worst, it depends on how and when you use it and alternative lipid emulsions are an excellent choice for many patients

43 Additional Literature/References Waitzberg DL,Torrinhas RS. The complexity of prescribing intravenous lipid emulsions. World Rev Nutr Diet.2015;112:15062 Waitzberg DL, et al. New Parenteral Lipid Emulsions for Clinical Use. JPEN J Parenter Enteral Nutr. 2006;30(4): Wanten GJA, Calder PC. Immune modulation by parenteral lipid emulsions. Am J ClinNutr. 2007;85(5): Vanek VW,SeidnerDL,Allen P, et al. A.S.P.E.N. position paper: Clinical role for alternative intravenous fat emulsions. NutrClinPract.2012Apr;27(2):15092 PironiL, Guidett im, Verrastro O, et al. Functional lipidomicsin patients on home parenteral nutrition: Effect of lipid emulsions. World J Gastroenterol.2017 Jul 7;23(25): Abbasoglu O, Hardy G, Manzanares W, PontesArrudaA. Fish OilContaining Lipid Emulsions in Adult Parenteral Nutrition: A Review of the Evidence. JPEN J Parenter Enteral Nutr Aug 1: Raman M, Almutairdi A, MulesaL, et al. Parenteral Nutrition and Lipids. Nutrients Apr 14;9(4) Mateude Antonio J, FloritSureda M. Effects unrelated to antiinflammation of lipid emulsions containing fish oil in parenteral nutrition for adult patients. NutrHosp Feb 1;34(1):193203

44 Thank you