ESPEN Congress The Hague 2017

ESPEN Congress The Hague 2017 Meeting nutritional needs of acute care patients Micronutrients in parenteral nutrition T. Nguyen (NZ)

Micronutrients in Parenteral Nutrition Truc Nguyen Counties Manukau Health New Zealand

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>

Learning Objectives Main risks of Micronutrient Deficiency/Excess Latest recommendations for Supplementing in PN Practicalities of Micronutrient Administration

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

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. 2003 Sep;57 supple 1:S70-72

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. 2003 Sep;57 supple 1:S70-72

Risks of Micronutrient Deficiency Those with Malabsorption Short bowel, Crohns, UC, Chemotherapy patients Braga. M et al. Clin Nutr. 2009 28:378-386 Kalantar-Zaded. K. Adv Ren Replace Therp. 2003;10(3):170 Berger. M. Nutr Clin Pract. 2006 Oct;21(5):438-449 Gernand. A et al. Nat Rev Endocrinol. 2016 May;12(5):274-289

Risks of Micronutrient Deficiency Those with malabsorption Short bowel, Crohns, UC, Chemotherapy patients Alcoholism Dialysis Burns Pregnancy Medications Braga. M et al. Clin Nutr. 2009 28:378-386 Kalantar-Zaded. K. Adv Ren Replace Therp. 2003;10(3):170 Berger. M. Nutr Clin Pract. 2006 Oct;21(5):438-449 Gernand. A et al. Nat Rev Endocrinol. 2016 May;12(5):274-289

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;29:605-610 Thurnham. D. Nutr Res review. 2004;17:211-240

Summary of Vitamin Recommendations

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 B12 3-3.5mg 3.6-4.9mg 40-46mg Nil 4-4.5mg 5-6µg Folic acid 400µg Vitamin C Biotin 100-125mg 60-69µg

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 3.6-4.9mg 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 100-125mg 200mg Biotin 60-69µg 60µg

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 3.6-4.9mg 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 100-125mg 200mg 110-150mg Biotin 60-69µg 60µg 60µg

Summary of Trace Element Recommendations 2009 ESPEN 2012 ASPEN 2014 AuSPEN Zinc 2.5-6.5mg 3-4mg 3.2-6.5mg Copper 0.3-1.5mg 0.3-0.5mg 0.32-0.51mg Selenium 20-72µg 60-100µg 60-100µg Iron 1-1.2mg NS 1.1mg Manganese 0.165-0.3mg 0.055mg 0.055mg Chromium 10-15µg 1µg 10-15µg Molybdenum 19.5-25.5µg NS 19µg Iodine 1.3-130µg NS 126µg Fluoride 1mg NS NS Staun M.Clinical Nutrition. 2009;28:467-479 Osland E. Asia Pac J Clin Nutr. 2014;23(4):545-54 Vanek V. Nutr Clin Pract. 2012 Aug;27(4):440-91 Osland E. Asia Pac J Clin Nutr. 2016;25(3):636-50 Takagi Y. Am J Clin Nutr. 2002;75:112-118 Shike. M et al. Gastroenterology. 2009;137(5) (suppl):s13-s17

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

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 3.6-4.9mg 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 100-125mg 200mg 110-150mg Biotin 60-69µg 60µg 60µg

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 10,000-100,000IU (IV) Vitamin K 150µg 150µg Nil Thiamine 3-3.5mg 6mg 3mg Riboflavin 3.6-4.9mg 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 100-125mg 200mg 110-150mg Biotin 60-69µg 60µg 60µg

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 3.6-4.9mg 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 100-125mg 200mg 110-150mg Biotin 60-69µg 60µg 60µg

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 3.6-4.9mg 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 100-125mg 200mg 110-150mg Biotin 60-69µg 60µg 60µg

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 3.6-4.9mg 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 100-125mg 200mg 110-150mg Biotin 60-69µg 60µg 60µg

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 3.6-4.9mg 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 100-125mg 200mg 110-150mg Biotin 60-69µg 60µg 60µg

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 3.6-4.9mg 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 100-125mg 200mg 110-150mg Biotin 60-69µg 60µg 60µg

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 3.6-4.9mg 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 100-125mg 200mg 110-150mg Biotin 60-69µg 60µg 60µg

Summary of Trace Element Recommendations 2009 ESPEN 2012 ASPEN 2014 AuSPEN Zinc 2.5-6.5mg 3-4mg 3.2-6.5mg Copper 0.3-1.5mg 0.3-0.5mg 0.32-0.51mg Selenium 20-72µg 60-100µg 60-100µg Iron 1-1.2mg NS 1.1mg Manganese 0.165-0.3mg 0.055mg 0.055mg Selenium 1000mcg (IV) Chromium 10-15µg 1µg 10-15µg Molybdenum 19.5-25.5µg NS 19µg Iodine 1.3-130µg NS 126µg Fluoride 1mg NS NS Staun M.Clinical Nutrition. 2009;28:467-479 Osland E. Asia Pac J Clin Nutr. 2014;23(4):545-54 Vanek V. Nutr Clin Pract. 2012 Aug;27(4):440-91 Osland E. Asia Pac J Clin Nutr. 2016;25(3):636-50

Summary of Trace Element Recommendations 2009 ESPEN 2012 ASPEN 2014 AuSPEN Zinc 2.5-6.5mg 3-4mg 3.2-6.5mg Copper 0.3-1.5mg 0.3-0.5mg 0.32-0.51mg Selenium 20-72µg 60-100µg 60-100µg Iron 1-1.2mg NS 1.1mg Manganese 0.165-0.3mg 0.055mg 0.055mg Iron 1000mg (IV) Chromium 10-15µg 1µg 10-15µg Molybdenum 19.5-25.5µg NS 19µg Iodine 1.3-130µg NS 126µg Fluoride 1mg NS NS Staun M.Clinical Nutrition. 2009;28:467-479 Osland E. Asia Pac J Clin Nutr. 2014;23(4):545-54 Vanek V. Nutr Clin Pract. 2012 Aug;27(4):440-91 Osland E. Asia Pac J Clin Nutr. 2016;25(3):636-50

Micronutrient Administration Protect IVN bags from light Degradation of micronutrients Mirkovic. D et al. Clin Nutr Suppl. 2011;6(1):93-94

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. 2014 April;9(2):e49-e53 Hoff. D. J Pediatr Pharmacol Ther. 2009 Jul-Sep; 14(3): 132 143

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

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

Further Reading Berger. M et al. Vitamins and trace elements: practical aspects of supplementation. Nutrition. 2006 Sep;22(9):952-5. 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. 2009 Nov;137(5):S1 S6 Stehle. P et al. Parenteral trace element provision: recent clinical research and practical conclusions. Eur J Clin Nutr. 2016 Aug;70(8):886-93 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;81:290-297 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;75:112-118. 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):636-50 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: 545 554.