ESPEN Congress The Hague 2017
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1 ESPEN Congress The Hague 2017 Meeting nutritional needs of acute care patients Micronutrients in parenteral nutrition T. Nguyen (NZ)
2 Micronutrients in Parenteral Nutrition Truc Nguyen Counties Manukau Health New Zealand
3 Disclosure for Truc Nguyen In compliance with COI policy, ESPEN requires the following disclosures to the session audience: Shareholder Grant / Research Support Consultant Employee Paid Instructor Speaker bureau Other No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare No relevant conflicts of interest to declare Presentation includes discussion of the following off-label use of a drug or medical device: <N/A>
4 Learning Objectives Main risks of Micronutrient Deficiency/Excess Latest recommendations for Supplementing in PN Practicalities of Micronutrient Administration
5 What are Micronutrients? Vitamins or Trace elements: Essential for numerous stages of tissue function and involved in multiple areas of metabolism The human body can store majority of micronutrients but not all
6 Global Micronutrient Deficiencies Diet Lifestyle factors (Vegans) Elderly patients Religious Nutrient deprived areas Bailey.R et al. Ann Nutr Metab. 2015; 66 supple 2:22-33 Diaz. J et al. Eur J Clin Nutr Sep;57 supple 1:S70-72
7 Global Micronutrient Deficiencies Diet Vitamin A - Common in developing countries Iodine - Synthesis Thyroid hormone Folate - Macrocytic anaemia Zinc - Required for activity of over 100 enzymes Iron - most common micronutrient deficiency Bailey.R et al. Ann Nutr Metab. 2015; 66 supple 2:22-33 Diaz. J et al. Eur J Clin Nutr Sep;57 supple 1:S70-72
8 Risks of Micronutrient Deficiency Those with Malabsorption Short bowel, Crohns, UC, Chemotherapy patients Braga. M et al. Clin Nutr : Kalantar-Zaded. K. Adv Ren Replace Therp. 2003;10(3):170 Berger. M. Nutr Clin Pract Oct;21(5): Gernand. A et al. Nat Rev Endocrinol May;12(5):
9
10 Risks of Micronutrient Deficiency Those with malabsorption Short bowel, Crohns, UC, Chemotherapy patients Alcoholism Dialysis Burns Pregnancy Medications Braga. M et al. Clin Nutr : Kalantar-Zaded. K. Adv Ren Replace Therp. 2003;10(3):170 Berger. M. Nutr Clin Pract Oct;21(5): Gernand. A et al. Nat Rev Endocrinol May;12(5):
11 Medications Vitamin B1 Vitamin B6 Aspirin Furosemide Antacids/PPI Metformin Isoniazid Vitamin C Vitamin D Vitamin B 12 Iron Samaras. D et al. Nutrition. 2013;29: Thurnham. D. Nutr Res review. 2004;17:
12 Summary of Vitamin Recommendations
13 Summary of Vitamin Recommendations 2009 ESPEN Vitamin A Vitamin D Vitamin E 3400IU (1000µg RE) 200IU (5µg) 10mg Vitamin K 150µg Thiamine Riboflavin Niacin Pantothenic acid Pyridoxine Vitamin B mg mg 40-46mg Nil 4-4.5mg 5-6µg Folic acid 400µg Vitamin C Biotin mg 60-69µg
14 Summary of Vitamin Recommendations 2009 ESPEN 2012 ASPEN Position Paper Vitamin A 3400IU (1000µg RE) 3300IU (990µg RE) Vitamin D 200IU (5µg) 200IU (5µg) Vitamin E 10mg 10mg Vitamin K 150µg 150µg Thiamine 3-3.5mg 6mg Riboflavin mg 3.6mg Niacin 40-46mg 40mg Pantothenic acid Nil 15mg Pyridoxine 4-4.5mg 6mg Vitamin B12 5-6µg 5µg Folic acid 400µg 600µg Vitamin C mg 200mg Biotin 60-69µg 60µg
15 Summary of Vitamin Recommendations 2009 ESPEN 2012 ASPEN Position Paper 2016 AuSPEN Guidelines Vitamin A 3400IU (1000µg RE) 3300IU (990µg RE) 3500IU (1190µg RE) Vitamin D 200IU (5µg) 200IU (5µg) 200IU (5µg) Vitamin E 10mg 10mg 10mg Vitamin K 150µg 150µg Nil Thiamine 3-3.5mg 6mg 3mg Riboflavin mg 3.6mg 4-5mg Niacin 40-46mg 40mg 40-47mg Pantothenic acid Nil 15mg 16-17mg Pyridoxine 4-4.5mg 6mg 3mg Vitamin B12 5-6µg 5µg 5-6µg Folic acid 400µg 600µg 400µg Vitamin C mg 200mg mg Biotin 60-69µg 60µg 60µg
16 Summary of Trace Element Recommendations 2009 ESPEN 2012 ASPEN 2014 AuSPEN Zinc mg 3-4mg mg Copper mg mg mg Selenium 20-72µg µg µg Iron 1-1.2mg NS 1.1mg Manganese mg 0.055mg 0.055mg Chromium 10-15µg 1µg 10-15µg Molybdenum µg NS 19µg Iodine µg NS 126µg Fluoride 1mg NS NS Staun M.Clinical Nutrition. 2009;28: Osland E. Asia Pac J Clin Nutr. 2014;23(4): Vanek V. Nutr Clin Pract Aug;27(4): Osland E. Asia Pac J Clin Nutr. 2016;25(3): Takagi Y. Am J Clin Nutr. 2002;75: Shike. M et al. Gastroenterology. 2009;137(5) (suppl):s13-s17
17 Micronutrient Supplementation Numerous micronutrient products adhering to respective guidelines NOTE: These guidelines are Recommend Daily Intakes How about acute patients?? Top up with Pabrinex if clinically indicated or respective deficient micronutrient if known
18 Summary of Vitamin Recommendations 2009 ESPEN 2012 ASPEN Position Paper 2016 AuSPEN Guidelines Vitamin A 3400IU (1000µg RE) 3300IU (990µg RE) 3500IU (1190µg RE) Vitamin D 200IU (5µg) 200IU (5µg) 200IU (5µg) Vitamin E 10mg 10mg 10mg Vitamin K 150µg 150µg Nil Thiamine 3-3.5mg 6mg 3mg Riboflavin mg 3.6mg 4-5mg Niacin 40-46mg 40mg 40-47mg Pantothenic acid Nil 15mg 16-17mg Pyridoxine 4-4.5mg 6mg 3mg Vitamin B12 5-6µg 5µg 5-6µg Folic acid 400µg 600µg 400µg Vitamin C mg 200mg mg Biotin 60-69µg 60µg 60µg
19 Summary of Vitamin Recommendations 2009 ESPEN 2012 ASPEN Position Paper 2016 AuSPEN Guidelines Vitamin A 3400IU (1000µg RE) 3300IU (990µg RE) 3500IU (1190µg RE) Vitamin D 200IU (5µg) 200IU (5µg) 200IU (5µg) Vitamin E 10mg 10mg 10mg Vitamin A 10, ,000IU (IV) Vitamin K 150µg 150µg Nil Thiamine 3-3.5mg 6mg 3mg Riboflavin mg 3.6mg 4-5mg Niacin 40-46mg 40mg 40-47mg Pantothenic acid Nil 15mg 16-17mg Pyridoxine 4-4.5mg 6mg 3mg Vitamin B12 5-6µg 5µg 5-6µg Folic acid 400µg 600µg 400µg Vitamin C mg 200mg mg Biotin 60-69µg 60µg 60µg
20 Summary of Vitamin Recommendations 2009 ESPEN 2012 ASPEN Position Paper 2016 AuSPEN Guidelines Vitamin A 3400IU (1000µg RE) 3300IU (990µg RE) 3500IU (1190µg RE) Vitamin D 200IU (5µg) 200IU (5µg) 200IU (5µg) Vitamin E 10mg 10mg 10mg Vitamin K 150µg 150µg Nil Thiamine 3-3.5mg 6mg 3mg Riboflavin mg 3.6mg 4-5mg Vitamin D 300,000IU (IM) Niacin 40-46mg 40mg 40-47mg Pantothenic acid Nil 15mg 16-17mg Pyridoxine 4-4.5mg 6mg 3mg Vitamin B12 5-6µg 5µg 5-6µg Folic acid 400µg 600µg 400µg Vitamin C mg 200mg mg Biotin 60-69µg 60µg 60µg
21 Summary of Vitamin Recommendations 2009 ESPEN 2012 ASPEN Position Paper 2016 AuSPEN Guidelines Vitamin A 3400IU (1000µg RE) 3300IU (990µg RE) 3500IU (1190µg RE) Vitamin D 200IU (5µg) 200IU (5µg) 200IU (5µg) Vitamin E 10mg 10mg 10mg Vitamin K 150µg 150µg Nil Thiamine 3-3.5mg 6mg 3mg Vitamin K 10mg (IV) Riboflavin mg 3.6mg 4-5mg Niacin 40-46mg 40mg 40-47mg Pantothenic acid Nil 15mg 16-17mg Pyridoxine 4-4.5mg 6mg 3mg Vitamin B12 5-6µg 5µg 5-6µg Folic acid 400µg 600µg 400µg Vitamin C mg 200mg mg Biotin 60-69µg 60µg 60µg
22 Summary of Vitamin Recommendations 2009 ESPEN 2012 ASPEN Position Paper 2016 AuSPEN Guidelines Vitamin A 3400IU (1000µg RE) 3300IU (990µg RE) 3500IU (1190µg RE) Vitamin D 200IU (5µg) 200IU (5µg) 200IU (5µg) Vitamin E 10mg 10mg 10mg Vitamin K 150µg 150µg Nil Thiamine 3-3.5mg 6mg 3mg Riboflavin mg 3.6mg 4-5mg Niacin 40-46mg 40mg 40-47mg Pantothenic acid Nil 15mg 16-17mg Thiamine 500mg TDS + Ascorbic acid 1000mg Pyridoxine 4-4.5mg 6mg 3mg Vitamin B12 5-6µg 5µg 5-6µg Folic acid 400µg 600µg 400µg Vitamin C mg 200mg mg Biotin 60-69µg 60µg 60µg
23 Summary of Vitamin Recommendations 2009 ESPEN 2012 ASPEN Position Paper 2016 AuSPEN Guidelines Vitamin A 3400IU (1000µg RE) 3300IU (990µg RE) 3500IU (1190µg RE) Vitamin D 200IU (5µg) 200IU (5µg) 200IU (5µg) Vitamin E 10mg 10mg 10mg Vitamin K 150µg 150µg Nil Thiamine 3-3.5mg 6mg 3mg Riboflavin mg 3.6mg 4-5mg Pyridoxine 10-20mg (IV/IM) Niacin 40-46mg 40mg 40-47mg Pantothenic acid Nil 15mg 16-17mg Pyridoxine 4-4.5mg 6mg 3mg Vitamin B12 5-6µg 5µg 5-6µg Folic acid 400µg 600µg 400µg Vitamin C mg 200mg mg Biotin 60-69µg 60µg 60µg
24 Summary of Vitamin Recommendations 2009 ESPEN 2012 ASPEN Position Paper 2016 AuSPEN Guidelines Vitamin A 3400IU (1000µg RE) 3300IU (990µg RE) 3500IU (1190µg RE) Vitamin D 200IU (5µg) 200IU (5µg) 200IU (5µg) Vitamin E 10mg 10mg 10mg Vitamin K 150µg 150µg Nil Thiamine 3-3.5mg 6mg 3mg Riboflavin mg 3.6mg 4-5mg Vitamin B12 1mg (IM) Niacin 40-46mg 40mg 40-47mg Pantothenic acid Nil 15mg 16-17mg Pyridoxine 4-4.5mg 6mg 3mg Vitamin B12 5-6µg 5µg 5-6µg Folic acid 400µg 600µg 400µg Vitamin C mg 200mg mg Biotin 60-69µg 60µg 60µg
25 Summary of Vitamin Recommendations 2009 ESPEN 2012 ASPEN Position Paper 2016 AuSPEN Guidelines Vitamin A 3400IU (1000µg RE) 3300IU (990µg RE) 3500IU (1190µg RE) Vitamin D 200IU (5µg) 200IU (5µg) 200IU (5µg) Vitamin E 10mg 10mg 10mg Vitamin K 150µg 150µg Nil Thiamine 3-3.5mg 6mg 3mg Riboflavin mg 3.6mg 4-5mg Folic acid 5mg (IV) Niacin 40-46mg 40mg 40-47mg Pantothenic acid Nil 15mg 16-17mg Pyridoxine 4-4.5mg 6mg 3mg Vitamin B12 5-6µg 5µg 5-6µg Folic acid 400µg 600µg 400µg Vitamin C mg 200mg mg Biotin 60-69µg 60µg 60µg
26 Summary of Trace Element Recommendations 2009 ESPEN 2012 ASPEN 2014 AuSPEN Zinc mg 3-4mg mg Copper mg mg mg Selenium 20-72µg µg µg Iron 1-1.2mg NS 1.1mg Manganese mg 0.055mg 0.055mg Selenium 1000mcg (IV) Chromium 10-15µg 1µg 10-15µg Molybdenum µg NS 19µg Iodine µg NS 126µg Fluoride 1mg NS NS Staun M.Clinical Nutrition. 2009;28: Osland E. Asia Pac J Clin Nutr. 2014;23(4): Vanek V. Nutr Clin Pract Aug;27(4): Osland E. Asia Pac J Clin Nutr. 2016;25(3):636-50
27 Summary of Trace Element Recommendations 2009 ESPEN 2012 ASPEN 2014 AuSPEN Zinc mg 3-4mg mg Copper mg mg mg Selenium 20-72µg µg µg Iron 1-1.2mg NS 1.1mg Manganese mg 0.055mg 0.055mg Iron 1000mg (IV) Chromium 10-15µg 1µg 10-15µg Molybdenum µg NS 19µg Iodine µg NS 126µg Fluoride 1mg NS NS Staun M.Clinical Nutrition. 2009;28: Osland E. Asia Pac J Clin Nutr. 2014;23(4): Vanek V. Nutr Clin Pract Aug;27(4): Osland E. Asia Pac J Clin Nutr. 2016;25(3):636-50
28 Micronutrient Administration Protect IVN bags from light Degradation of micronutrients Mirkovic. D et al. Clin Nutr Suppl. 2011;6(1):93-94
29 Vitamin Stability Vitamin Light Oxygen ph Temperature Vitamin A Vitamin D Vitamin E Vitamin K Ascorbic acid Thiamine Riboflavin Nicotinamide Pyridoxine Folic acid Vitamin B12 Table adapted from Ferguson. T. e-spen April;9(2):e49-e53 Hoff. D. J Pediatr Pharmacol Ther Jul-Sep; 14(3):
30 Micronutrient Administration Protect IVN bags from light Degradation of micronutrients Micronutrients additions should be added to IVN bag in STRICT aseptic conditions Recommended to infuse micronutrients over a longer course Mirkovic. D et al. Clin Nutr Suppl. 2011;6(1):93-94
31 Take home messages Understanding/knowing your patients micronutrient deficiency risk factors will give you a clue in treatment Current recommendations are RDI, not a One Stop Shop Minimise degradation with light protective bags
32 Further Reading Berger. M et al. Vitamins and trace elements: practical aspects of supplementation. Nutrition Sep;22(9): Berger.M. Vitamin C requirements in Parenteral Nutrition. Gastroenterology 2009;137:s70-s78 Buch. A et al. Micronutrients in Parenteral Nutrition: Too Little or Too Much? The Past, Present, and Recommendations for the Future. Gastroenterology Nov;137(5):S1 S6 Stehle. P et al. Parenteral trace element provision: recent clinical research and practical conclusions. Eur J Clin Nutr Aug;70(8): Shenkin. A. Selenium in Intravenous Nutrition. Gastroenterology. 2009;137:s61-s69 Nielsen. F. Micronutritents in Parenteral Nutrition: Boron, Silicon, & Flouoride. Gastroenterology 2009;137:s55-s60 Shike. M et al. Copper metabolism and requirements in total parenteral nutrition. Gastroenterology 1981;81: Hardy. G. Manganese in Parenteral Nutrition: Who, When, and Why Should We Supplement? Gastroenterology 2009;137:s29-s35 Takagi Y et al. Evaluation of indexes of in vivo manganese status and the optimal intravenous dose for adult patients undergoing home parenteral nutrition. Am J Clin Nutr. 2002;75: Osland. E et al. Australasian society for parenteral and enteral nutrition (AuSPEN) adult vitamin guidelines for parenteral nutrition. Asia Pac J Clin Nutr. 2016;25(3): Osland. E et al. Australasian Society for Parenteral and Enteral Nutrition guidelines for supplementation of trace elements during parenteral nutrition. Asia Pac J Clin Nutr 2014; 23:
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