alanine + arginine + aspartic acid + 20 other active ingredients: clinical use

Prescribing considerations

• Assess individual amino-acid, energy, electrolyte and fluid requirements and account for other intravenous glucose or electrolyte sources.
• Correct fluid, electrolyte and acid–base disturbances before infusion.
• Correct pre-existing thiamine deficiency before giving the glucose-containing solution.
• Consider additional lipid, essential fatty acids, vitamins and trace elements.
• Use strict aseptic technique and confirm compatibility before adding any component.
• Use caution in cardiac, renal, hepatic, adrenal or pulmonary impairment and in increased serum osmolarity.

Contraindications and cautions

• Hypersensitivity to an active ingredient or excipient
• Inborn errors of amino-acid metabolism
• Uncontrolled hyperglycaemia
• Acidosis
• Intracranial or intraspinal haemorrhage
• Severe hepatic insufficiency
• Severe renal insufficiency without renal replacement therapy
• Newborn infants, infants and children younger than 2 years
• Life-threatening circulatory instability, fluid overload or pulmonary oedema
• Acute myocardial infarction, stroke or an unstable metabolic state

Monitoring

• Blood glucose
• Serum electrolytes, especially potassium, phosphate and magnesium during refeeding
• Fluid balance, weight and urine output
• Acid–base balance and serum osmolarity where relevant
• Renal and hepatic function
• Temperature and central-line site
• Blood count and coagulation during prolonged administration

Clinical pharmacology

Intravenous administration makes amino acids, glucose and electrolytes immediately available. Amino acids support protein and nitrogen-containing molecule synthesis; glucose is metabolised for energy and may contribute to lipid synthesis; excess glucose may be excreted once the renal threshold is exceeded.

Formulation and product differences

• Two-chamber bag separating the amino-acid/electrolyte solution from the glucose/calcium solution until activation.
• Hyperosmolar formulation intended only for central venous infusion.
• Does not itself provide lipid, essential fatty acids, vitamins or trace elements.
• Only clear solution from an intact bag should be used; compatible additions require aseptic preparation and filtration.