562800
research-article2014
NCPXXX10.1177/0884533614562800Nutrition in Clinical PracticeMirtallo
Clinical Dilemma
Perspectives on Parenteral Micronutrient Shortages Jay M. Mirtallo, MS, RPH, FASHP, FASPEN, BCNSP1
Nutrition in Clinical Practice Volume XX Number X Month 201X 1–6 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614562800 ncp.sagepub.com hosted at online.sagepub.com
Abstract Micronutrients are essential components of parenteral nutrition (PN). Problems related to deficiency and toxicity occur during routine practice, which could be related to the content of commercial sources, inadequate prescribed doses, and the high frequency of at-risk patients receiving PN. Shortages of commercial products result in increased risk of deficiency. Even though there are recommendations to conserve supplies for those at highest risk, practices that provide no micronutrients or doses less than desired are not safe. This article reviews the evidence describing patients at risk for micronutrient deficiency, the rationale for micronutrient product reformulation, and characteristics of deficiency observed during shortages of micronutrient products. (Nutr Clin Pract.XXXX;xx:xx-xx)
Keywords parenteral nutrition solutions; nutritional support; micronutrients; parenteral nutrition; trace elements; vitamins; public policy;
Micronutrients are essential components of parenteral nutrition (PN). Both anabolic and catabolic processes within the body are intimately related to micronutrient status. Historically, the optimal supplementation of micronutrients has been a challenge. Symptoms of deficiency and toxicity are difficult to discern from symptoms of the underlying disease. Clinician knowledge of micronutrients beyond standard doses is lacking. For example, it is unfortunate that vitamins (vital to life) could be omitted from PN because organizations “didn’t observe” any consequences when there was a short supply and continued to constrain supply on their own accord after the shortage was resolved. This mind-set needed to be addressed by making a statement in American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Safe PN Practices that multivitamins must be included in PN daily.1 The more recent drug shortages involving trace elements have also created an issue of omitting these PN components simply because there was no commercial supply. This occurred at a time when A.S.P.E.N. had put micronutrients in the spotlight. First, there was the A.S.P.E.N. Research Workshop on micronutrients, which asked, “Micronutrients in Parenteral Nutrition: Too Little or Too Much?”2 This was followed by the A.S.P.E.N. position paper, which made recommendations for changes in commercially available parenteral multivitamin and trace element products.3 Concurrent with both of these publications, shortages of micronutrients have hindered our collective ability to advance the practice of these essential nutrients for PN therapy. It has been necessary to constrain the existing commercial supply (ie, saving product for those having the most need such as those with deficiencies or who are at high risk of developing a deficiency if micronutrients are omitted or provided in a lower than recommended standard dose). The dilemma for clinicians with respect to micronutrients currently involves the following:
1. Consistent evidence that micronutrients are an issue in disease management, including malnutrition and diet. This includes the variability in patient requirements. 2. The role of micronutrients beyond their normal use as a nutrient continues to be investigated. 3. Evidence that current micronutrient commercial sources need to be reformulated 4. The duration of micronutrient shortages impedes clinicians’ ability to provide optimal micronutrient dosages, exposing patients to deficiencies. This also places pressure on clinicians to know and adequately monitor for micronutrient status, a practice that has historically been inconsistent and confounded by limitations of serum monitoring. Recent literature has provided insights into optimal micronutrient dosages, monitoring, and assessments based on physical findings. In addition to the A.S.P.E.N. position statement on multivitamin and multitrace element products, Fessler4 provides an excellent review of trace element dosing and monitoring in adult patients, while Rigassio Radler and Lister5 provide physical findings of the oral cavity to monitor for nutrient deficiencies. Also, Daniells and Hardy6 offer a perspective on hair loss as it relates to micronutrient deficiencies.
From 1The Ohio State University, Columbus, Ohio. Financial disclosure: None declared. Corresponding Author: Jay M. Mirtallo, MS, RPH, FASHP, FASPEN, BCNSP, The Ohio State University, 500 W 12th Avenue, Columbus, OH 43210-1291, USA. Email: [email protected]
Downloaded from ncp.sagepub.com at FRESNO PACIFIC UNIV on January 4, 2015
2
Nutrition in Clinical Practice XX(X)
Table 1. Percentage of Pediatric Patients With Intestinal Failure Experiencing Micronutrient Deficiencies During and After Transition to Full Enteral Nutrition (FEN).8 Micronutrient Deficiency % of Patients (Range)
During FEN Transition
After FEN Transition
research-article2014
NCPXXX10.1177/0884533614562800Nutrition in Clinical PracticeMirtallo
Clinical Dilemma
Perspectives on Parenteral Micronutrient Shortages Jay M. Mirtallo, MS, RPH, FASHP, FASPEN, BCNSP1
Nutrition in Clinical Practice Volume XX Number X Month 201X 1–6 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614562800 ncp.sagepub.com hosted at online.sagepub.com
Abstract Micronutrients are essential components of parenteral nutrition (PN). Problems related to deficiency and toxicity occur during routine practice, which could be related to the content of commercial sources, inadequate prescribed doses, and the high frequency of at-risk patients receiving PN. Shortages of commercial products result in increased risk of deficiency. Even though there are recommendations to conserve supplies for those at highest risk, practices that provide no micronutrients or doses less than desired are not safe. This article reviews the evidence describing patients at risk for micronutrient deficiency, the rationale for micronutrient product reformulation, and characteristics of deficiency observed during shortages of micronutrient products. (Nutr Clin Pract.XXXX;xx:xx-xx)
Keywords parenteral nutrition solutions; nutritional support; micronutrients; parenteral nutrition; trace elements; vitamins; public policy;
Micronutrients are essential components of parenteral nutrition (PN). Both anabolic and catabolic processes within the body are intimately related to micronutrient status. Historically, the optimal supplementation of micronutrients has been a challenge. Symptoms of deficiency and toxicity are difficult to discern from symptoms of the underlying disease. Clinician knowledge of micronutrients beyond standard doses is lacking. For example, it is unfortunate that vitamins (vital to life) could be omitted from PN because organizations “didn’t observe” any consequences when there was a short supply and continued to constrain supply on their own accord after the shortage was resolved. This mind-set needed to be addressed by making a statement in American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Safe PN Practices that multivitamins must be included in PN daily.1 The more recent drug shortages involving trace elements have also created an issue of omitting these PN components simply because there was no commercial supply. This occurred at a time when A.S.P.E.N. had put micronutrients in the spotlight. First, there was the A.S.P.E.N. Research Workshop on micronutrients, which asked, “Micronutrients in Parenteral Nutrition: Too Little or Too Much?”2 This was followed by the A.S.P.E.N. position paper, which made recommendations for changes in commercially available parenteral multivitamin and trace element products.3 Concurrent with both of these publications, shortages of micronutrients have hindered our collective ability to advance the practice of these essential nutrients for PN therapy. It has been necessary to constrain the existing commercial supply (ie, saving product for those having the most need such as those with deficiencies or who are at high risk of developing a deficiency if micronutrients are omitted or provided in a lower than recommended standard dose). The dilemma for clinicians with respect to micronutrients currently involves the following:
1. Consistent evidence that micronutrients are an issue in disease management, including malnutrition and diet. This includes the variability in patient requirements. 2. The role of micronutrients beyond their normal use as a nutrient continues to be investigated. 3. Evidence that current micronutrient commercial sources need to be reformulated 4. The duration of micronutrient shortages impedes clinicians’ ability to provide optimal micronutrient dosages, exposing patients to deficiencies. This also places pressure on clinicians to know and adequately monitor for micronutrient status, a practice that has historically been inconsistent and confounded by limitations of serum monitoring. Recent literature has provided insights into optimal micronutrient dosages, monitoring, and assessments based on physical findings. In addition to the A.S.P.E.N. position statement on multivitamin and multitrace element products, Fessler4 provides an excellent review of trace element dosing and monitoring in adult patients, while Rigassio Radler and Lister5 provide physical findings of the oral cavity to monitor for nutrient deficiencies. Also, Daniells and Hardy6 offer a perspective on hair loss as it relates to micronutrient deficiencies.
From 1The Ohio State University, Columbus, Ohio. Financial disclosure: None declared. Corresponding Author: Jay M. Mirtallo, MS, RPH, FASHP, FASPEN, BCNSP, The Ohio State University, 500 W 12th Avenue, Columbus, OH 43210-1291, USA. Email: [email protected]
Downloaded from ncp.sagepub.com at FRESNO PACIFIC UNIV on January 4, 2015
2
Nutrition in Clinical Practice XX(X)
Table 1. Percentage of Pediatric Patients With Intestinal Failure Experiencing Micronutrient Deficiencies During and After Transition to Full Enteral Nutrition (FEN).8 Micronutrient Deficiency % of Patients (Range)
During FEN Transition
After FEN Transition
