Current Status of Multi-Trace Element Products for Parenteral Nutrition in the United States

Advances in Trace Element Supplementation for Parenteral Nutrition

Parenteral nutrition (PN) provides support for patients lacking sufficient intestinal absorption of nutrients. Historically, the need for trace element (TE) supplementation was poorly appreciated, and multi-TE products were not initially subjected to rigorous oversight by the United States Food and Drug Administration (FDA). Subsequently, the American Society for Parenteral and Enteral Nutrition (ASPEN) issued dosage recommendations for PN, which are updated periodically. The FDA has implemented review and approval processes to ensure access to safer and more effective TE products. The development of a multi-TE product meeting ASPEN recommendations and FDA requirements is the result of a partnership between the FDA, industry, and clinicians with expertise in PN. This article examines the rationale for the development of TRALEMENT^® (Trace Elements Injection 4*) and the FDA’s rigorous requirements leading to its review and approval. This combination product contains copper, manganese, selenium, and zinc and is indicated for use in adults and pediatric patients weighing ≥10 kg. Comprehensive management of PN therapy requires consideration of many factors when prescribing, reviewing, preparing, and administering PN, as well as monitoring the nutritional status of patients receiving PN. Understanding patients’ TE requirements and incorporating them into PN is an important part of contemporary PN therapy.

The metabolic effects of multi-trace elements on parenteral nutrition for critically ill pediatric patients: a randomized controlled trial and metabolomic research

BACKGROUND

We investigated the efficacy and metabolic dose-effect of multi-trace element injection I [MTEI-(I)] for severe pediatric patients via a parallel, randomized control study.

METHODS

The inclusion criteria were as follows: (I) patients who required parenteral nutrition (PN) due to various diseases, and were expected to receive PN for >5 days; (II) patients aged <18 years; (III) patients with no serious cardiac, hepatic, renal, or pulmonary dysfunction; and (IV) patients with an established central venous pathway. Enrolled patients were randomly assigned into two groups using sequentially numbered, sealed, opaque envelopes: Group A (low-dose group) received MTEI-(I) at 1 mL/kg/d, and Group B (high-dose group) received MTEI-(I) at 2 mL/kg/d, up to a maximum dose of 15 mL/d. The concentrations of manganese (Mn), copper (Cu), zinc (Zn), and selenium (Se) were detected. The following indexes were measured after 5 days of treatment (T5): β-oxidation of very-long-chain fatty acids, arginine and proline metabolism, pentose phosphate metabolism, ketone body metabolism, citric acid cycle, purine metabolism, caffeine metabolism, and pyruvate metabolism. The participants, care givers, and data analysis staff were blinded to the group assignment.

RESULTS

Overall, at T5, Mn and Cu levels were decreased, while Zn and Se levels were increased. The increase of Zn levels (A: 0.170±0.479 vs. B: 0.193±0.900) and decrease of Cu levels (A: -0.240±0.382 vs. B: -0.373±0.465) of patients in Group B (n=22) were significantly higher than those in Group A (n=18). At T5, the β-oxidation of very-long-chain fatty acids, arginine and proline metabolism, pentose phosphate metabolism, ketone body metabolism, citric acid cycle, purine metabolism, caffeine metabolism, and pyruvate metabolism were variably decreased (P<0.05) in Group B compared to Group A.

CONCLUSIONS

Our results suggested that the high-dose administration of MTEI-(I) is safe for severe pediatric patients, and may alleviate inflammation and antioxidation, relieve hyperactivity caused by stress, and improve tissues-based hypoxia and renal function.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100052198.