Strategies for parenteral nutrition weaning in adult patients with short bowel syndrome

Use of teduglutide in adults with short bowel syndrome-associated intestinal failure

Short bowel syndrome (SBS) is a rare gastrointestinal disorder associated with intestinal failure (SBS-IF) and poor health-related outcomes. Patients with SBS-IF are unable to absorb sufficient nutrients or fluids to maintain significantly metabolic homeostasis via oral or enteral intake alone and require long-term intravenous supplementation (IVS), consisting of partial or total parenteral nutrition, fluids, electrolytes, or a combination of these. The goal of medical and surgical treatment for patients with SBS-IF is to maximize intestinal remnant absorptive capacity so that the need for IVS support may eventually be reduced or eliminated. Daily subcutaneous administration of the glucagon-like peptide 2 analog, teduglutide, has been shown to be clinically effective in reducing IVS dependence and potentially improving the health-related quality of life of patients with SBS-IF. The management of patients with SBS-IF is complex and requires close monitoring. This narrative review discusses the use of teduglutide for patients with SBS-IF in clinical practice. The screening of patient eligibility for teduglutide treatment, initiation, monitoring of efficacy and safety of treatment, adapting or weaning off IVS, and the healthcare setting needed for SBS-IF management are described, taking into consideration data from clinical trials, observational studies, and clinical experience.

Sustained elimination of parenteral support in adult patients with under 60 cm of small intestine: A case series

Patients with short bowel syndrome (SBS) are often managed by expert multidisciplinary teams. One of the main goals in the management of SBS is the weaning of parenteral support (PS). Weaning of PS removes the risks associated with long-term central line placement and eliminates the need for intestinal transplant. Whereas several papers detail the ongoing care and management of patients with SBS who are dependent on PS, there are few reports discussing the successful weaning of PS in this patient population. We present five case studies examining weaning of PS in adult patients with <60-cm small bowel and partial or full colon who were enrolled in a multidisciplinary adult intestinal rehabilitation program. The case studies demonstrate weaning can occur >2 years after initial assessment and enrollment in an expert program. The ability of the program to focus on individualized care and frequent patient communication is key to PS weaning in patients with SBS.

Concise review on short bowel syndrome: Etiology, pathophysiology, and management

Adults have approximately 20 feet of small intestine, which is the primary site for absorbing essential nutrients and water. Resection of the intestine for any medical reason may result in short bowel syndrome (SBS), leading to loss of major absorptive surface area and resulting in various malabsorption and motility disorders. The mainstay of treatment is personalized close dietary management. Here we present SBS with its pathophysiology and different nutritional management options available. The central perspective of this paper is to provide a concise review of SBS and the treatment options available, along with how proper nutrition can solve major dietary issues in SBS and help patients recover faster.

Short Bowel Syndrome in Adults

Short bowel syndrome (SBS) is a rare disorder characterized by severe intestinal dysfunction leading to malabsorption of macronutrients and micronutrients that often results in permanent need of parenteral nutrition support. Patients can develop SBS because of massive intestinal resection or loss of intestinal function and consequently experience significant morbidity and increased healthcare utilization. The remaining anatomy and length of bowel after intestinal resection have important prognostic and therapeutic implications. Because patients with SBS constitute a heterogenous group, management is complex and multifaceted, involving nutrition support, fluid and electrolyte management, and pharmacologic therapies in particular to control diarrhea. Surgical interventions including intestinal transplantation may be considered in selected individuals. Successful care of these patients is best accomplished by a multidisciplinary team that is experienced in the management of this syndrome.

Real-world etiologies and treatments of pediatric short bowel syndrome in Japan

BACKGROUND

Short bowel syndrome (SBS) is a rare disease that can result in intestinal failure (IF). Short bowel syndrome intestinal failure leads to stunted growth and development and high mortality rates. The primary goal of treatment is to enhance intestinal adaptation and nutrient absorption. Parenteral nutrition (PN) is used to support this process until enteral autonomy can be restored. Some patients experience prolonged partial or complete dependency on PN and face an increased risk of life-threatening catheter-related bloodstream infections and intestinal failure-associated liver disease. This study aimed to provide real-world insights into the patient characteristics and treatment dynamics of PN-dependent children with SBS-IF in Japan.

METHODS

This retrospective observational study used anonymized information from a large hospital-based medical insurance database to identify pediatric patients who received PN for ≥6 months between April 2008 and January 2020. The primary endpoint was weaning from PN. Secondary endpoints included duration and complications of PN.

RESULTS

Forty-eight children (mean age, 2.9 years) were eligible for inclusion. The most common causes of SBS-IF were mechanical bowel obstruction, functional bowel disorders, and Hirschsprung's disease. Twenty-two patients (45.8%) were weaned from PN during the study. The mean time to first weaning was 464.2 days and five patients (22.7%) restarted PN. The mean total duration of PN was 692.6 days in weaned patients and 1,170.9 days in unweaned patients. The most frequent complications were sepsis, catheter infections (both 79.2%), and liver dysfunction (64.6%).

CONCLUSIONS

Pediatric patients with SBS-IF faced difficulties when weaning off PN and rates of life-threatening complications were high.

Short bowel syndrome: treatment options

Introduction Short bowel syndrome (SBS) refers to the malabsorptive state that occurs following extensive intestinal resection and is associated with several complications.

Methods The research for this review was conducted in the Pubmed database. Relevant scientific articles dated between 1991 and 2015 and written in Portuguese, Spanish or English were selected.

Results Several therapies, including nutritional support, pharmacological options and surgical procedures have been used in these patients.

Conclusions Over the last decades new surgical and pharmacological approaches emerged, increasing survival and quality of life (QoL) in patients with SBS. All SBS patients ought to have an individualized and multidisciplinary care that promotes intestinal rehabilitation.

Secondary Kwashiorkor Disease in a Patient with Gastric Bypass Surgery and Short Gut Syndrome

BACKGROUND Kwashiorkor disease is a subtype of severe acute protein malnutrition characterized by peripheral edema associated with hypoalbuminemia and ascites. It can result from both protein deficiency and protein loss. In resource-poor countries, the disease often is caused by inadequate dietary intake, but in resource-rich countries, it can be seen as a rare complication of severe malabsorption. CASE REPORT We present the case of a 60-year-old woman who presented with 1 week of progressive anasarca in the setting of decreased dietary intake and poor tolerance of total parenteral nutrition (TPN). She had a history of Roux-en-Y gastric bypass surgery which was complicated by a strangulated internal hernia that required an exploratory laparotomy and small bowel resection. She subsequently developed short gut syndrome with TPN dependence. Work-up revealed hypoalbuminemia with several micronutrient deficiencies consistent with secondary kwashiorkor disease. With a multidisciplinary approach that included Gastroenterology, Pharmacy, and Nutrition, she was treated with albumin, furosemide, nutritional supplementation, and ultimately rechallenged with TPN. At discharge, her swelling had improved, her weight had decreased, and her albumin improved to the normal range. CONCLUSIONS This case is a unique presentation of secondary kwashiorkor disease. In our patient, the combination of gastric bypass surgery and short gut syndrome with poor TPN tolerance likely led to severe protein malabsorption. This underscores the importance of recognizing the signs and symptoms of kwashiorkor disease and understanding the associated complications so that treatment can be instituted promptly. Furthermore, the case demonstrates how an interdisciplinary approach to management can increase the chance of a successful outcome.

Nutritional Rehabilitation in Patients with Malnutrition Due to Crohn's Disease

BACKGROUND

Crohn's disease (CD) is a chronic inflammatory bowel disease frequently associated with malabsorption and secondary protein-energy malnutrition (PEM).

METHODS

Biochemical and clinical data of 63 (34 females, 29 males) patients with PEM due to CD sent to our outpatient unit for nutritional evaluation were retrospectively analyzed. Patients were divided into two groups, according to disease activity. Thirty-eight patients (group A) had the active disease, and 25 patients (group B) suffered from malabsorption resulting from past intestinal resections due to CD. After a physical and hemato-biochemical evaluation at the first visit, all patients received disease-specific personalized dietetic indications. When indicated, oral nutritional supplements, oral/parenteral vitamins, micronutrients, and electrolytes, up to parenteral nutrition, were prescribed.

RESULTS

After 1, 3, and 6 months of nutritional therapy, body weight, body mass index (BMI), and serum butyryl-cholinesterase significantly improved in both groups. In 8 out of 13 (61.5%) patients with a cutaneous stoma, intestinal continuity was restored.

CONCLUSIONS

This study confirms the effectiveness of nutritional rehabilitation and provides information on the time required for nutritional treatment in patients with CD, both during the acute phase and after malabsorption due to intestinal resection.

Weaning from Parenteral Nutrition

The ultimate goal of treatment of short bowel syndrome/intestinal failure patients is to achieve enteral autonomy by eliminating parenteral nutrition (PN)/intravenous fluids (IV). After optimization of diet, oral hydration and anti-diarrheal medications, attempt should be made to eliminate PN/IV. Weaning from PN/IV should be individualized for each patient. Although teduglutide is the preferred agent for PN/IV volume reduction or successful weaning, optimal patient selection and long-term safety need further evaluation. Following PN/IV elimination, patients need long-term monitoring for nutritional deficiencies. This article will address clinical considerations before, during, and after PN/IV weaning to facilitate safe and successful PN/IV weaning process.

Short bowel syndrome in children and adults: from rehabilitation to transplantation

Short bowel syndrome (SBS) is a dramatic clinical condition in both children and adults; the residual bowel length is not sufficient to avoid intestinal failure, with subsequent malnutrition and growth retardation, and intravenous support is required to provide the nutrients normally coming from the intestine. Apart from the primary disease, the medical status can be worsened by complications of intestinal failure: if there are irreversible, the prognosis is poor unless a successful intestinal rehabilitation is achieved. Areas covered: The rescue of the remnant small bowel requires a multidisciplinary expertise to achieve digestive autonomy. The use of intestinal trophic factors has shown encouraging results in improving the intestinal adaptation process. Whenever the residual bowel length is inadequate, in a well-selected population weaning parenteral nutrition (PN) off could be attempted by surgery through lengthening procedures. A further subset of patients, with total and irreversible intestinal failure and severe complications on PN, may have an indication to intestinal transplantation. This procedure is still affected by poor long-term results. Expert commentary: Novel approaches developed through a multidisciplinary team work, such as manipulation of microbiota or tissue bioengineering, should be added to current therapies to treat successfully SBS.

When Is Parenteral Nutrition Appropriate?

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.

Teduglutide: a guide to its use in short bowel syndrome

Teduglutide (Gattex(®)) is a recombinant analogue of human glucagon-like peptide-2 and is indicated for the treatment of adults with short bowel syndrome (SBS) dependent on parenteral support (PS). In a pivotal, 24-week clinical trial in SBS patients, subcutaneous teduglutide 0.05 mg/kg once daily increased absorption from the remnant intestine as evidenced by significant reductions in PS volume requirements versus placebo. Improvements attained in absorption in the first 6 months of therapy were maintained during the extension trial (total teduglutide treatment periods of up to 30 months), with evidence indicating that benefits accrue over time. Among patients who received teduglutide treatment for up to 30 months, 11 of 30 were able to achieve at least one additional day off PS and another ten achieved complete independence from PS. Subcutaneous teduglutide was generally well tolerated in clinical trials, including over the long term, with most adverse events that led to study discontinuation being gastrointestinal in origin.

ESPEN Guidelines on Parenteral Nutrition: gastroenterology

Undernutrition as well as specific nutrient deficiencies has been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome. In the latter, water and electrolytes disturbances may be a major problem. The present guidelines provide evidence-based recommendations for the indications, application and type of parenteral formula to be used in acute and chronic phases of illness. Parenteral nutrition is not recommended as a primary treatment in CD and UC. The use of parenteral nutrition is however reliable when oral/enteral feeding is not possible. There is a lack of data supporting specific nutrients in these conditions. Parenteral nutrition is mandatory in case of intestinal failure, at least in the acute period. In patients with short bowel, specific attention should be paid to water and electrolyte supplementation. Currently, the use of growth hormone, glutamine and GLP-2 cannot be recommended in patients with short bowel.

Improving clinical outcome in patients with intestinal failure using individualised nutritional advice

BACKGROUND

Patients with intestinal failure are required to adhere to a complex regimen. Written information may increase knowledge leading to improvements in clinical outcomes. The present study aimed to evaluate the effectiveness of nutrition advice incorporating the use of a booklet.

METHODS

Each patient completed a questionnaire evaluating their knowledge of the regime and quality of life and kept a diet and gastrointestinal output diary. The diary was assessed and they were given the booklet with a verbal explanation tailored to individual requirements. The booklet explained the causes of intestinal failure, diet and fluid recommendations in relation to intestinal anatomy, information on medications and long-term monitoring. Patients were reassessed at their next appointment using the same tools. The primary endpoint was an improvement in knowledge. Secondary endpoints were an improvement in oral nutritional intake, nutritional status, quality of life and the content of home parenteral nutrition.

RESULTS

Forty-eight patients completed the study. Knowledge improved significantly after dietetic intervention in association with the provision of the booklet (P < 0.001). Oral energy (P = 0.04) and fat (P = 0.003) intake increased with an improvement in body mass index (P = 0.02). Patients on home parenteral nutrition showed a reduction in parenteral energy (P = 0.02), nitrogen (P = 0.003), volume (P = 0.02) and frequency (P = 0.003).

CONCLUSIONS

A booklet for patients with intestinal failure in conjunction with personalised dietary counselling improves knowledge and clinical outcomes.

Short bowel syndrome

Treatment of short bowel syndrome (SBS) is often a difficult endeavor due to the high variability among patients with SBS in regard to remaining anatomical structure and functional capacity. Research efforts to substantiate the use of existing therapies in the treatment of SBS are ongoing, with newer developments yet to be fully explored. Current therapy for SBS begins with the implementation of a modified diet based on the presence or absence of the colon. Patients with difficulty ingesting enough nutrients and fluids for weight maintenance and fluid balance may benefit from nocturnal enteral nutrition and hydration. Those with inadequate absorptive capacity despite maximization of oral and enteral intake will need parenteral nutrition (PN) or hydration. Medications, including antisecretory agents, antidiarrheals, pancreatic enzymes, bile acid sequestrants, and antibiotics, often are useful in abating symptoms commonly associated with SBS. Growth factors, including recombinant human growth hormone and glucagon-like peptide 2, may be trialed to stimulate intestinal adaptation and enhance absorption in PN-dependent SBS patients. The gradual refinement of surgical procedures for SBS, including small bowel transplantation, has led to improved outcomes, and early referral of SBS patients to centers of excellence will optimize care.

Home parenteral and enteral nutrition

Home parenteral and enteral nutrition (HPEN) has evolved to become a very successful, lifesaving treatment in the management of patients with intestinal and oral failure, respectively. Nevertheless, the provision of HPEN remains intrusive, expensive, and continues to be associated with significant morbidity. The management of HPEN by a nutrition support team that optimally includes an experienced clinician, nurse specialist, dietitian, and pharmacist reduces HPEN-related morbidity and may reduce costs associated with its use. Because clinical expertise in the management of patients receiving HPEN is not widely available, the referral of these patients to experienced centers for periodic assessment should be encouraged.

Treatment of adult short bowel syndrome with recombinant human growth hormone: a review of clinical studies

Extensive resection of the intestinal tract frequently results in inadequate digestion and/or absorption of nutrients, a condition known as short bowel syndrome (SBS). Several therapies, including parenteral nutrition (PN), bowel rehabilitation, and surgical procedures to reconstruct the bowel, have been used for patients with SBS. However, these treatments only partially correct the underlying problem of reduced bowel function in some patients. This review investigates the results of studies of recombinant human growth hormone (r-hGH) in patients with SBS. In one randomized, controlled and five open-label studies, treatment with r-hGH significantly increased absorption of energy, protein and/or carbohydrates. Four studies also demonstrated significantly increased body weight, lean body mass, total body potassium and/or total body water in response to r-hGH. However, in two other randomized controlled trials, r-hGH had no significant effect on energy or fluid absorption. In one randomized, controlled study and six open-label trials, treatment with r-hGH also allowed a majority of patients, including those with no colon and significant bowel resection, to eliminate or substantially reduce PN. Optimal clinical benefits appear to be achieved when r-hGH is administered in combination with a specialized oral diet and perhaps with glutamine. Although the use of r-hGH to treat SBS patients remains controversial, results from these studies suggest that short-term r-hGH treatment in combination with optimized medical and dietetic treatments can enhance bowel absorption and function and, with the continuation of optimized medical and dietetic treatments, may reduce PN requirements for a wide range of patients with SBS.

Indications and recommendations for the use of recombinant human growth hormone in adult short bowel syndrome patients dependent on parenteral nutrition

Given the lack of published guidelines regarding the use of trophic factors to treat patients with short bowel syndrome (SBS), a group of experts in the field convened to discuss best-practice strategies. Trophic factors, such as recombinant human growth hormone (r-hGH) and glucagon-like peptide-2 (GLP-2), may enhance intestinal adaptation and decrease parenteral nutrition (PN) requirements; therefore, their utility in treating SBS patients was evaluated. Available clinical data on use of r-hGH therapy in SBS patients were discussed, as were the utility of r-hGH in the PN weaning process, the optimal timing of r-hGH therapy, and how to select appropriate patients for r-hGH therapy. In addition, contraindications and precautions as well as adverse effects of r-hGH treatment were discussed. The meeting culminated with the development of a treatment algorithm to summarize best-practice recommendations for the management of SBS in adult patients. This algorithm involves attempting to wean patients off PN without the use of trophic factors. If this is unsuccessful, it is recommended that patients be treated with an r-hGH regimen or participate in investigational studies using other trophic factors.