alanine + arginine + aspartic acid + 25 other active ingredients: clinical use

Prescribing considerations

• Confirm that oral or enteral nutrition is impossible, insufficient or contraindicated and assess whether the fixed nutrient composition meets the patient's requirements.
• Correct severe fluid, electrolyte and metabolic disturbances before treatment.
• Initiate cautiously in severe undernutrition because refeeding syndrome may cause intracellular shifts of phosphate, potassium and magnesium, thiamine deficiency and fluid retention.
• Use strict aseptic catheter and admixture technique; verify compatibility and final osmolarity after any addition.
• Use caution in renal or severe hepatic impairment, heart failure, pulmonary oedema, diabetes, severe coagulation disorders and unstable critical illness.

Contraindications and cautions

• Hypersensitivity to egg, soya or peanut proteins, any active substance, excipient or container component
• Congenital disorders of amino-acid metabolism
• Pathologically raised plasma sodium, potassium, magnesium, calcium or phosphorus
• Severe hyperglycaemia
• For the lipid-containing three-chamber mixture: severe hyperlipidaemia or severe lipid-metabolism disorder with hypertriglyceridaemia

Monitoring

• Fluid and electrolyte balance and serum osmolarity
• Blood glucose and acid–base balance
• Serum triglycerides and lipid clearance
• Liver and kidney function
• Full blood count, platelets and coagulation parameters
• Catheter site, infusion system, clinical signs of infection, extravasation, allergy and respiratory distress

Clinical pharmacology

This intravenous combination supplies amino-acid nitrogen, glucose-derived energy, electrolytes and, when the lipid chamber is activated, triglycerides and essential fatty acids. Intravenous administration makes the constituents fully bioavailable; they are subsequently distributed, metabolised and eliminated like the individual nutrients.

Formulation and product differences

• Three-chamber bag containing separate glucose, amino-acid/electrolyte and lipid compartments before activation.
• Two-chamber activation combines glucose with amino acids and electrolytes while excluding the lipid chamber.
• Three-chamber activation includes refined olive and soya oils; egg phospholipids are present as an excipient.
• The undiluted mixture requires central venous administration because of its high osmolarity; appropriately assessed dilution can permit peripheral infusion.
• Vitamins, trace elements or additional electrolytes are not automatically comprehensive and may be added only after clinical and compatibility assessment.
• The container components are free from natural rubber latex.