alanine + arginine + aspartic acid + 17 other active ingredients: clinical use

Prescribing considerations

• Assess individual energy, nutrient, fluid and electrolyte requirements; this formulation does not provide a complete electrolyte or micronutrient prescription.
• Correct fluid, electrolyte and acid–base disturbances before starting.
• Consider refeeding risk in severely malnourished or depleted patients.
• Use caution with impaired lipid metabolism, diabetes, sepsis, pancreatitis, hypothyroidism, renal or hepatic impairment and cardiac dysfunction.
• Account for concurrent glucose, lipid, fluid and nutrient sources.

Contraindications and cautions

• Hypersensitivity to an active substance, egg, fish, peanut or soya protein, or an excipient
• Children younger than 2 years
• Inborn errors of amino-acid metabolism
• Severe hypertriglyceridaemia, severe coagulopathy, acidosis or hyperglycaemia unresponsive to insulin
• Severe hepatic insufficiency, intrahepatic cholestasis, or severe renal insufficiency without renal replacement therapy
• Acute thromboembolic events, lipid embolism, unstable circulation, inadequate cellular oxygen supply, acute pulmonary oedema or decompensated cardiac failure

Monitoring

• Fluid balance, weight, serum electrolytes and acid–base status
• Blood glucose and serum triglycerides
• Renal and hepatic function
• Full blood count, coagulation status and clinical signs of infection
• Phosphate, potassium and magnesium closely where refeeding is a concern
• Catheter site and observations for infusion or hypersensitivity reactions

Clinical pharmacology

This intravenous combination supplies amino acids for protein synthesis, glucose for readily available energy, and medium- and long-chain triglycerides for energy and essential fatty acids. Medium-chain triglycerides are cleared and oxidised more rapidly than long-chain triglycerides.

Formulation and product differences

• Three-chamber emulsion containing separate glucose, amino-acid and lipid compartments that are mixed before use
• Almost electrolyte-free and essentially sodium-free; electrolytes must be prescribed according to clinical need
• Contains medium-chain triglycerides, refined soya-bean oil and fish-derived omega-3 triglycerides
• Contains egg phospholipids as an excipient
• Vitamins and trace elements are not inherently supplied and require separate assessment
• Suitable only for central venous infusion