ASPEN, 2020, lipid emulsion, 안전성/안정성/투여속도/부작용/추천 용량/함량 (4)

ASPEN lipid recommendation

Recommended Adult Dosage for ILE Products

FO-ILE	OO,SO-ILE,	SO,MCT,OO,FO-ILE	SO-ILE
Omegaven (Fresenius Kabi)	Clinolipid (Baxter Healthcare Corporation)	SMOFLipid (Fresenius Kabi)	Itralipid (Baxter Healthcare Corporation), Nutrilipid (B. Braun Medical, Inc)

SO-ILE 추천 용량은 ASPEN recommendation에 따른 것이고 다른 ILE product는 manufacturer information에 따라 정리한 것이다.

※ 놀라운 사실은 SO-ILE 기준으로 중환자에게서 < 1 g/kg/day를 추천하고 있다는 것이다!

아래 표는 ASPEN에서 2019년 Appropriate Dosing for Parenteral Nutrition: ASPEN Recommendations에 수록된 표이다. 여기서도 lipid값을 SO-ILE 기준으로 추천한 값을 보여주고 있다.

ASPNE

Monitoring Considerations and Recommendations

* ILE의 AEs

fat overload syndrome, hypercoagulation, immune function interference, negative hepatic effects, pulmonary compromise, infection risk, hypertriglyceridemia, and pancreatitis.

- ILE의 AEs를 모니터링하기 위해서 serum TG level(baseline and weekly) 뿐만 아니라 LFTs during hospitalization

※ 이때 monitorin의 주기는 based on each patient’s clinical status

- ILE dose가 변경된다면 TG lab 반드시 check!

- long term PN therapy 환자(>1month)일 때, 1달에 한 번 check!

- Hypertriglyceridemia (TG > 400 mg/dL) 원인 :

과도한 ILE infusion rate (the ability of lipoprotein lipase to clear TGs from the blood)

Other common

= high dose of lipid-based medication (eg, propofol), hyperglycemia, overfeeding, and inflammation.

- serum TG > 200 mg/dL일 때 ILE 시작 주의!

하지만 TG lab 400 mg/dL까지 정기적인 모니터링을 통해서 허용!

- Severe hypertriglyceridemia along with severe disorders of lipid metabolism is a contraindication to ILE use

	SO-ILE	SO,MCT,OO,FO-ILE	OO,SO-ILE
Indications	EFA & energy 원천 EFAD 예방	EFA & energy 원천	EFA & energy 원천
Contraindications	- 정상 지질대사 ↓ (ex. pathologic hyperlipidemia, lipoid necrosis, or acute pancreatitis accompanied by hyperlipidemia) - Severe hyperlipidemia or severe disorders of fat metabolism characterized by hypertriglyceridemia	- 함유 성분에 hypersensitivity - Severe hyperlipidemia or severe disorders of fat metabolism (serum triglycerides > 1000 mg/dL)	- 함유 성분에 hypersensitivity - Severe hyperlipidemia or disorders of fat metabolism
Potential uses	- Short-term use (<2 weeks) - Normal LFTs - Treatment of EFAD	- Long-term use - Elevated LFTs - Elevated triglyceride - Inflammatory states	- Long-term use - Elevated LFTs - Elevated triglyceride
Administration	- Use a 1.2-μm filter - Use a nonvented infusion set or close vent on vented set - Use a non-DEHP set	- Use a 1.2-μm filter - Use a nonvented infusion set or close vent on vented set - Use a non-DEHP set	- Use a 1.2-μm filter - Use a nonvented infusion set or close vent on vented set - Use a non-DEHP set

* AEs risk factor

long term PN woth ILE

high dose (> 2.5 g/kg/d)

high rate of infusion (> 0.11 g/kg/hr for SO-ILE)

other AEs

1) SO-ILE infusion시 vitamin K 함유

warfarin을 복용하는 환자에게서 PT 감소될 가능성 (하지만 극히 미량이므로 그 위험도는 낮음)

스모프리피드20%주

인트라리피드20%주(정제대두유)

2) 과도한 infusion rate는 폐기능에 영향

This effect is thought to be due to hyperlipidemia and local eicosanoid imbalances resulting in decreased arterial oxygenation.

3) FA profile에 따른 면역 기능에 영향

SO-ILE = high ratio of ω-6 to ω-3 PUFA

ω-6	ω-3
precursors to proinflammatory eicosanoids and prostaglandins with negative effects on immune function	precursors to less inflammatory eicosanoids and the proresolving mediators
Excessive infusion rates of ILE reduce the function of the RES

4) 간독성

Free radical(lipid peroxidation 과정에서 생성)이 hepatocyte의 cell damage를 유발

The α-tocopherol content of ILEs is another important consideration in product selection as this component helps protect the long-chain FAs from peroxidation.

5) Intestinal failure–associated liver disease

많은 인자들이 존재하긴 하지만, PN therapy를 받는 환자에게서 잘 확립된 합병증.

인자 중 하나는 바로 phytosterol이다(naturally in plant oil)

- mechanism : the reduction in hepatic efflux transporters for bile

Cholestasis, or reduced bile flow	Steatosis, or excess hepatic accumulation of fat
elevations of serum bilirubin concentrations	clinically seen by an elevation in serum aminotransferases and is likely the result of overfeeding

* 해당 포스팅에 각 상품에 따른 phytosterol 함량이 소개되어 있다.

https://gimi-drug.tistory.com/63

ASPEN, 2020, lipid emulsion, 안정성, 추천용량 (3)

reference :

(1) 정혜련, et al. "단일 기관에서 지방유제 단독 제형 투여 처방의 적절성 평가." 한국정맥경장영양학회지 6.3 (2014): 108-113.

(2) Mirtallo, Jay M., et al. "ASPEN Lipid Injectable Emulsion Safety Recommendations, Part 1: Background and Adult Considerations." Nutrition in Clinical Practice (2020).

(3) Appropriate Dosing for Parenteral Nutrition: ASPEN Recommendations