Individualization of the infusion rate of a soybean oil-based intravenous lipid emulsion for inpatients, based on baseline triglyceride concentrations: A population pharmacokinetic approach

BACKGROUND

A rapid infusion rate for intravenous lipid emulsion (ILE) can cause adverse effects; therefore, safe and efficient infusion rates are desired. This study aimed to develop a triglyceride (TG) kinetic model after soybean oil-based ILE (SO-ILE) administration and individualize the infusion rate via a population pharmacokinetic approach.

METHODS

Eighty-three inpatients were enrolled in this prospective observational study. A TG kinetic model was applied to the observations based on population pharmacokinetics using a nonlinear mixed-effect model. The patients' characteristics and laboratory parameters were evaluated to identify predictors of TG kinetics, and the maximum acceptable infusion rate was defined as that for which the maximum TG concentration did not exceed 400 mg/dl in 90% of patients.

RESULTS

No adverse events associated with SO-ILE administration were observed. The developed TG kinetic model explained the observed TG concentrations and identified the baseline TG concentration and body weight as predictors of TG kinetics. The estimated maximum acceptable infusion rates greatly varied among individuals, ranging from <0.01 to 0.3 g/kg/h.

CONCLUSION

The present study suggested the necessity and demonstrated the feasibility of individualizing the infusion rates of SO-ILE, using a population pharmacokinetic approach.

New perspective toward nutritional support for malnourished cancer patients: Role of lipids

To improve the difficulties related to malnutrition, nutritional support has become an essential part of multidisciplinary comprehensive treatment for cancer. Lipids are essential nutrient source for the human body, and nowadays in clinical practices, it has a positive interventional effect on patients suffering from cancer. However, contribution of lipids in nutritional support of cancer patients is still poorly understood. Moreover, the sensory and physicochemical properties of lipids can severely restrict their applications in lipid-rich formula foods. In this review article, for the first time, we have presented a summary of the existing studies which were related to the associations between different lipids and improved malnutrition in cancer patients and discussed possible mechanisms. Subsequently, we discussed the challenges and effective solutions during processing of lipids into formula foods. Further, by considering existing problems in current lipid nutritional support, we proposed a novel method for the treatment of malnutrition, including developing individualized lipid nutrition for different patients depending on the individual's genotype and enterotype. Nonetheless, this review study provides a new direction for future research on nutritional support and the development of lipid-rich formula foods for cancer patients, and probably will help to improve the efficacy of lipids in the treatment of cancer malnutrition.

Composition and Functionality of Lipid Emulsions in Parenteral Nutrition: Examining Evidence in Clinical Applications

Lipid emulsions (LEs), an integral component in parenteral nutrition (PN) feeding, have shifted from the primary aim of delivering non-protein calories and essential fatty acids to defined therapeutic outcomes such as reducing inflammation, and improving metabolic and clinical outcomes. Use of LEs in PN for surgical and critically ill patients is particularly well established, and there is enough literature assigning therapeutic and adverse effects to specific LEs. This narrative review contrarily puts into perspective the fatty acid compositional (FAC) nature of LE formulations, and discusses clinical applications and outcomes according to the biological function and structural functionality of fatty acids and co-factors such as phytosterols, α-tocopherol, emulsifiers and vitamin K. In addition to soybean oil-based LEs, this review covers clinical studies using the alternate LEs that incorporates physical mixtures combining medium- and long-chain triglycerides or structured triglycerides or the unusual olive oil or fish oil. The Jaded score was applied to assess the quality of these studies, and we report outcomes categorized as per immuno-inflammatory, nutritional, clinical, and cellular level FAC changes. It appears that the FAC nature of LEs is the primary determinant of desired clinical outcomes, and we conclude that one type of LE alone cannot be uniformly applied to patient care.

Meta-analysis of the efficacy and safety of structured triglyceride lipid emulsions in parenteral nutrition therapy in China

BACKGROUND & AIMS

We performed a meta-analysis of data from recent studies to evaluate the safety and efficacy of parenteral nutrition (PN) with structured triglyceride (STG) lipid emulsions compared to medium-chain triglyceride (MCT)/long-chain triglyceride (LCT) lipid emulsions in Chinese patients.

METHODS

PubMed, Embase, Cochrane Library, China National Knowledge Internet, Wanfang, and VIP were searched for randomized controlled trials comparing STGs with MCTs/LCTs published in English or Chinese between January 1987 and October 2017. Two independent investigators screened and selected studies according to prespecified selection criteria. Data were pooled and analysed using RevMan^® version 5.3.

RESULTS

Thirty-two studies comprising 1944 patients were included in the meta-analysis. Compared with MCT/LCT emulsions, STGs resulted in a shorter hospital length of stay (LOS) (weighted mean difference [WMD], -1.65 days; 95% confidence interval [CI]: -2.63, -0.67; P = 0.001) and lower adverse event rates (relative risk, 0.64; 95% CI: 0.48, 0.85; P = 0.002). STGs were associated with a significantly better cumulative nitrogen balance (WMD, 4.04 g/24 h; 95% CI: 3.10, 4.97; P < 0.0001) as well as higher concentrations of pre-albumin (WMD 35.20 mg/L; 95% CI: 26.59, 43.81; P < 0.0001) and albumin (WMD, 1.64 g/L; 95% CI: 1.17, 2.10; P < 0.0001) compared with MCTs/LCTs. In contrast, significantly lower concentrations of plasma triglycerides (WMD, -0.21 mmol/L; 95% CI: -0.30, -0.12; P < 0.0001), total cholesterol (WMD, -0.45 mmol/L; 95% CI: -0.60, -0.29; P < 0.0001), alanine aminotransferase (WMD, -7.68 IU/L; 95% CI: -9.68, -5.68; P < 0.0001) and aspartate aminotransferase (WMD, -10.27 IU/L; 95% CI: -16.05, -4.49; P = 0.0005) were observed in patients receiving STGs compared with MCT/LCTs. STGs were also associated with reduced inflammation and improved immunological function, as reflected by significantly lower C-reactive protein concentrations (WMD, -2.67 mg/L; 95% CI: -4.55, -0.79; P = 0.005) and increased concentrations of IgG (WMD, 2.11 g/L; 95% CI: 0.23, 3.99; P = 0.03), IgA (WMD, 0.21 g/L; 95% CI: 0.14, 0.28; P < 0.0001), CD3+ (WMD, 5.81%; 95% CI: 0.92, 10.70; P = 0.02), and CD4+/CD8+ (WMD, 0.12; 95% CI: 0.00, 0.24; P = 0.04) compared with MCT/LCTs.

CONCLUSIONS

Administration of STGs was shown to improve hepatic function, nutrition status, and immunological function and reduce inflammation, LOS, and adverse events compared with MCT/LCTs in Chinese patients receiving PN.

Biological and Clinical Aspects of an Olive Oil-Based Lipid Emulsion-A Review

Intravenous lipid emulsions (ILEs) have been an integral component of parenteral nutrition for more than 50 years. Numerous formulations are available and are based on vegetable (soybean, olive, coconut) and animal (fish) oils. Therefore, each of these formulations has a unique fatty acid composition that offers both benefits and limitations. As clinical experience and our understanding of the effects of fatty acids on various physiological processes has grown, there is evidence to suggest that some ILEs may have benefits compared with others. Current evidence suggests that olive oil-based ILE may preserve immune, hepatobiliary, and endothelial cell function, and may reduce lipid peroxidation and plasma lipid levels. There is good evidence from a large randomized controlled study to support a benefit of olive oil-based ILE over soybean oil-based ILE on reducing infections in critically ill patients. At present there is limited evidence to demonstrate a benefit of olive oil-based ILE over other ILEs on glucose metabolism, and few data exist to demonstrate a benefit on clinical outcomes such as hospital or intensive care unit stay, duration of mechanical ventilation, or mortality. We review the current research and clinical evidence supporting the potential positive biological and clinical aspects of olive oil-based ILE and conclude that olive oil-based ILE is well tolerated and provides effective nutritional support to various PN-requiring patient populations. Olive oil-based ILE appears to support the innate immune system, is associated with fewer infections, induces less lipid peroxidation, and is not associated with increased hepatobiliary or lipid disturbances. These data would suggest that olive oil-based ILE is a valuable option in various PN-requiring patient populations.

Lipids in the intensive care unit: Recommendations from the ESPEN Expert Group

This article summarizes the presentations given at an ESPEN Workshop on "Lipids in the ICU" held in Tel Aviv, Israel in November 2014 and subsequent discussions and updates. Lipids are an important component of enteral and parenteral nutrition support and provide essential fatty acids, a concentrated source of calories and building blocks for cell membranes. Whilst linoleic acid-rich vegetable oil-based enteral and parenteral nutrition is still widely used, newer lipid components such as medium-chain triglycerides and olive oil are safe and well tolerated. Fish oil (FO)-enriched enteral and parenteral nutrition appears to be well tolerated and confers additional clinical benefits, particularly in surgical patients, due to its anti-inflammatory and immune-modulating effects. Whilst the evidence base is not conclusive, there appears to be a potential for FO-enriched nutrition, particularly administered peri-operatively, to reduce the rate of complications and intensive care unit (ICU) and hospital stay in surgical ICU patients. The evidence for FO-enriched nutrition in non-surgical ICU patients is less clear regarding its clinical benefits and additional, well-designed large-scale clinical trials need to be conducted in this area. The ESPEN Expert Group supports the use of olive oil and FO in nutrition support in surgical and non-surgical ICU patients but considers that further research is required to provide a more robust evidence base.

Safety and efficacy of an olive oil-based triple-chamber bag for parenteral nutrition: a prospective, randomized, multi-center clinical trial in China

Background

Small studies suggest differences in efficacy and safety exist between olive oil-based (OLIVE) and soybean oil-based (SOYBEAN) parenteral nutrition regimens in hospitalized adult patients. This large, prospective, randomized (1:1), open-label, multi-center, noninferiority study compared the delivery, efficacy, and safety of OLIVE (N = 226) with SOYBEAN (N = 232) in Chinese adults (≥18 years) admitted to a surgical service for whom parenteral nutrition was required.

Methods

Treatments were administered for a minimum of 5 days up to 14 days (to achieve approximately 25 kcal/kg/day, 0.9 g/kg/day amino acids, 0.8 g/kg/day lipid). Impact of treatment on anabolic/catabolic and serum inflammatory, chemistry, and hematological markers, safety, and ease of use were assessed. The primary efficacy variable was serum prealbumin level at Day 5.

Results

OLIVE (n = 219) was not inferior to SOYBEAN (n = 224) based on the prealbumin least square geometric mean [LSGM] ratio [95 % CI] 1.12 [1.06, 1.19]; P = 0.002), improved the anabolic/catabolic status of patients enrolled in the study, and was well tolerated compared with SOYBEAN. Improved anabolic status was supported by significantly higher levels of prealbumin at Day 5, albumin at Day 5 and IGF-1 at Day 14 in the OLIVE group, while catabolism was similar between groups. C-reactive protein, intercellular adhesion molecule-1, procalcitonin, and oxidation were similar in each group, but infections were significantly lower with OLIVE (3.6 % versus 10.4 %; P < 0.01).

Conclusions

OLIVE provided effective nutrition, was well tolerated, was associated with fewer infections, and conferred greater ease-of-use than SOYBEAN.

Trial registration

NTC 01579097.

Intravenous fish oil lipid emulsions in critically ill patients: an updated systematic review and meta-analysis

INTRODUCTION

Intravenous fish oil (FO) lipid emulsions (LEs) are rich in ω-3 polyunsaturated fatty acids, which exhibit anti-inflammatory and immunomodulatory effects. We previously demonstrated that FO-containing LEs may be able to decrease mortality and ventilation days in patients who are critically ill. Since 2014, several additional randomized controlled trials (RCTs) of FO-containing LEs have been published. Therefore, the purpose of this systematic review was to update our previous systematic review with the aim of elucidating the efficacy of FO-containing LEs on clinical outcomes of patients who are critically ill.

METHODS

We searched electronic databases from 1980 to 2014. We included four new RCTs conducted in critically ill adult patients in which researchers evaluated FO-containing LEs in parenterally or enterally fed patients.

RESULTS

A total of 10 RCTs (n = 733) met inclusion criteria. The mean methodological score was 8 (range, 3 to 12). No effect on overall mortality was found. When we aggregated the results of five RCTs in which infections were reported, we found that FO-containing LEs significantly reduced infections (risk ratio (RR) = 0.64; 95% confidence interval (CI), 0.44 to 0.92; P = 0.02; heterogeneity I (2) = 0%). Subgroup analysis demonstrated that predominantly enteral nutrition-based trials showed a tendency toward a reduction in mortality (RR = 0.69; 95% CI, 0.40 to 1.18; P =0.18; heterogeneity I (2) =35%). High-quality trials showed a significant reduction in hospital length of stay (LOS) (weighted mean difference = -7.42; 95% CI, -11.89 to -2.94; P = 0.001), whereas low-quality trials had no effect (P = 0.45). The results of the test for subgroup differences in hospital LOS was significant (P = 0.001).

CONCLUSION

FO-containing LEs may be associated with a reduction in infections and also could be associated with a reduction in duration of ventilation and hospital LOS. Further large-scale RCTs are warranted and should be aimed at consolidating potential positive treatment effects.

Anti-inflammatory and anti-fibrotic profile of fish oil emulsions used in parenteral nutrition-associated liver disease

Home parenteral nutrition (PN) is associated with many complications including severe hepatobiliary dysfunction. Commercial ω-6 fatty acid-soybean based-lipid emulsions in PN may mediate long term PN associate liver disease (PNALD) whereas ω-3-fish oil parenteral emulsions have shown to reverse PNALD in children. However, its clinical effectiveness in adults has been scarcely reported. In this work, we study the role of soybean and fish oil lipid commercial emulsions on inflammatory and profibrotic liver markers in adults with long term PNALD and in in vitro cellular models. Inflammatory and profibrotic markers were measured in serum of ten adults with long term PNALD and in culture supernatants of monocytes. Liver epithelial to mesenchymal transition (EMT) was induced by transforming growth factor beta 1 (TGFβ1) to evaluate in vitro liver fibrosis. Omegaven®, a 100% fish oil commercial emulsion, was infused during four months in two patients with severe long term PNALD reversing, at the first month, the inflammatory, profibrotic and clinical parameters of PNALD. The effect was maintained during the treatment course but impaired when conventional lipid emulsions were reintroduced. The other patients under chronic soybean oil-based PN showed elevated inflammatory and profibrotic parameters. In vitro human monocytes stimulated with lipopolysaccharide induced a strong inflammatory response that was suppressed by Omegaven®, but increased by soybean emulsions. In other experiments, TGFβ1 induced EMT that was suppressed by Omegaven® and enhanced by soybean oil lipid emulsions. Omegaven® improves clinical, anti-inflammatory and anti-fibrotic parameters in adults with long-term home PNALD.

Alternative lipid emulsions in the critically ill: a systematic review of the evidence

PURPOSE

Parenteral lipid emulsions (LEs) are commonly rich in long-chain triglycerides derived from soybean oil (SO). SO-containing emulsions may promote systemic inflammation and therefore may adversely affect clinical outcomes. We hypothesized that alternative oil-based LEs (SO-sparing strategies) may improve clinical outcomes in critically ill adult patients compared to products containing SO emulsion only. The purpose of this systematic review was to evaluate the effect of parenteral SO-sparing strategies on clinical outcomes in intensive care unit (ICU) patients.

METHODS

We searched computerized databases from 1980 to 2013. We included randomized controlled trials (RCTs) conducted in critically ill adult patients that evaluated SO-sparing strategies versus SO-based LEs in the context of parenteral nutrition.

RESULTS

A total of 12 RCTs met the inclusion criteria. When the results of these RCTs were statistically aggregated, SO-sparing strategies were associated with clinically important reductions in mortality (risk ratio, RR 0.83; 95 % confidence intervals, CI 0.62, 1.11; P = 0.20), in duration of ventilation (weighted mean difference, WMD -2.57; 95 % CI -5.51, 0.37; P = 0.09), and in ICU length of stay (LOS) (WMD -2.31; 95 % CI -5.28, 0.66; P = 0.13) but none of these differences were statistically significant. SO-sparing strategies had no effect on infectious complications (RR 1.13; 95 % CI 0.87, 1.46; P = 0.35).

CONCLUSION

Alternative oil-based LEs may be associated with clinically important reductions in mortality, duration of ventilation, and ICU LOS but lack of statistical precision precludes any clinical recommendations at this time. Further research is warranted to confirm these potential positive treatment effects.

Parenteral fish oil lipid emulsions in the critically ill: a systematic review and meta-analysis

INTRODUCTION

ω-3 Polyunsaturated fatty acids contained in fish oils (FO) possess major anti-inflammatory, antioxidant, and immunologic properties that could be beneficial during critical illness. We hypothesized that parenteral FO-containing emulsions may improve clinical outcomes in the critically ill.

METHODS

We searched computerized databases from 1980-2012. We included randomized controlled trials (RCTs) conducted in critically ill adult patients that evaluated FO-containing emulsions, either in the context of parenteral nutrition (PN) or enteral nutrition (EN).

RESULTS

A total of 6 RCTs (n = 390 patients) were included; the mean methodological score of all trials was 10 (range, 6-13). When the results of these studies were aggregated, FO-containing emulsions were associated with a trend toward a reduction in mortality (risk ratio [RR], 0.71; 95% confidence interval [CI], 0.49-1.04; P = .08; heterogeneity I (2) = 0%) and a reduction in the duration of mechanical ventilation (weighted mean difference in days [WMD], -1.41; 95% CI, -3.43 to 0.61; P = .17). However, this strategy had no effect on infections (RR, 0.76; 95% CI, 0.42-1.36; P = .35) and intensive care unit length of stay (WMD, -0.46; 95% CI, -4.87 to 3.95; P = .84, heterogeneity I (2) = 75%).

CONCLUSION

FO-containing lipid emulsions may be able to decrease mortality and ventilation days in the critically ill. However, because of the paucity of clinical data, there is inadequate evidence to recommend the routine use of parenteral FO. Large, rigorously designed RCTs are required to elucidate the efficacy of parenteral FO in the critically ill.

Superiority of a fish oil-enriched emulsion to medium-chain triacylglycerols/long-chain triacylglycerols in gastrointestinal surgery patients: a randomized clinical trial

OBJECTIVE

Compared with soybean oil, a fish oil-enriched emulsion can improve the clinical outcomes of patients requiring parenteral nutrition. However, the superiority of fish oil emulsion to medium-chain triacylglycerols/long-chain triacylglycerols for short-term administration has seldom been discussed.

METHODS

Sixty-four adult patients with gastrointestinal diseases were randomly assigned to receive isocaloric and isonitrogenous total parenteral nutrition with an ω-3 fatty acid-enriched emulsion (Lipoplus; study group, n = 32) or medium-chain triacylglycerols/long-chain triacylglycerols (Lipofundin; control group, n = 32) for 5 d after surgery. Safety and efficacy parameters were assessed on postoperative days 1, 3, and 6.

RESULTS

Clinical outcomes including infectious complications and systemic inflammatory response syndrome were comparable between the two groups. Total bilirubin decreased over time in the study group versus an increase in the control group (P = 0.017). Activated partial thromboplastin time in the study group was prolonged significantly compared with the control group from days 1 to 3 (P = 0.002), although the prolongation stopped at the study termination. There were no differences in changes of C-reactive protein, interleukin (IL)-1, IL-8, IL-10, vascular endothelial growth factor (VEGF), and the distribution of the T-cell subpopulation between the two groups. However, fish oil consumption led to an increase in leukotriene B5/ leukotriene B4 and significant decreases in IL-6, tumor necrosis factor-α, and nuclear factor-κB. Furthermore, the overall changes in tumor necrosis factor-α and nuclear factor-κB were positively associated (R(2) = 0.295, P < 0.001).

CONCLUSIONS

Gastrointestinal surgery patients benefited from a fish oil-enriched emulsion rather than medium-chain triacylglycerols/long-chain triacylglycerols in the amelioration of liver function and immune status. The positive association of tumor necrosis factor-α and nuclear factor-κB might be involved in the potential anti-inflammation mechanism of fish oil.