alanine + arginine + aspartic acid + 16 other active ingredients: clinical use

Prescribing considerations

• Assess whether oral or enteral nutrition is impossible, insufficient or contraindicated.
• Correct fluid, electrolyte and acid-base disturbances before infusion.
• Provide individually required electrolytes, trace elements and vitamins separately, including adequate potassium replacement.
• Use caution with diabetes, sepsis, pancreatitis, hypothyroidism with hypertriglyceridaemia, impaired lipid metabolism, and cardiac, renal or hepatic dysfunction.
• Use strict aseptic technique and a dedicated central venous route.

Contraindications and cautions

• Hypersensitivity to an active substance, egg, peanut, soya protein or an excipient.
• Age under 2 years.
• Inborn amino-acid metabolism disorders, severe hypertriglyceridaemia, uncontrolled hyperglycaemia or acidosis.
• Severe hepatic failure, intrahepatic cholestasis, or severe renal failure without renal replacement therapy.
• Severe coagulopathy, active thromboembolism, lipid embolism or major bleeding tendency.
• Shock or collapse, acute myocardial infarction or stroke, inadequate tissue oxygenation, acute pulmonary oedema, decompensated heart failure, or uncorrected fluid or electrolyte disturbance.

Monitoring

• Serum electrolytes, fluid balance and acid-base status.
• Blood glucose and serum triglycerides.
• Blood count, coagulation, and hepatic and renal function.
• Clinical signs of hypersensitivity, infection, fluid overload, refeeding disturbance and fat overload syndrome.
• Allow for lipid interference with some laboratory tests when timing blood sampling.

Clinical pharmacology

Intravenous amino acids enter protein synthesis or normal amino-acid metabolism. Glucose is used for energy and cellular substrates; triglycerides are hydrolysed to glycerol and fatty acids for energy and lipid synthesis. Long-chain triglycerides supply essential fatty acids, while medium-chain triglycerides are cleared and oxidised comparatively rapidly.

Formulation and product differences

• Electrolyte-free, three-chamber formulation with separate glucose, amino-acid and lipid compartments before activation.
• The lipid component combines refined soya-bean oil with medium-chain triglycerides and uses egg phospholipids as an excipient.
• The mixed product is a milky-white emulsion intended only for central venous infusion.
• Available as several multichamber bag sizes; preparation strengths are managed separately.