Formulae for Enteral Nutrition · Druml W, Roth E,, AKE recommendations for enteral and parenteral nutritional support, 2004 When whole protein formulae are not tolerated Severely

Life Long Life Long LearningLearning –– Module 8.4.Module 8.4.

FormulaeFormulae forfor EnteralEnteral NutritionNutrition

Luzia Valentini, Luzia Valentini, PhDPhDDepDep. of . of GastroenterologyGastroenterology,,

HepatologyHepatology & & EndocrinologyEndocrinologyCharitCharitéé –– UniversitUniversitäätsmedizin Berlin, Germanytsmedizin Berlin, Germany

Charité

Copyright © 2006 by ESPEN

General General characteristicscharacteristicsCharité

regulatesregulates

compositioncomposition labellinglabelling requirementsrequirements micronutrientmicronutrient contentcontent

standardvs. disease specific

nutritionally completevs. nutritionallyincomplete

content of nutrients,

origin & nature of protein

„important notices“ ...

1500 kcals mustcover the dailyrecommended intake(RDA)


General General characteristicscharacteristicsCharité

EnteralEnteral formulaeformulae do (do (usuallyusually) ) notnot containcontain::

LactoseLactose

CholesterolCholesterol

PurinPurin

GlutenGluten


OverviewOverview of of typestypes of EN of EN formulaeformulaeCharité

standardformulae

modified standardformulae

disease - specificformulae

+_

_ __

+

++

energy-denseminus fibre

plus proteinfibre-free

reduced water

high - proteinminus LCTplus MCT

MCT-rich

for instance renal formulae

Energy↑ electrolytes↓ Vit A ↓

Protein ↓/↑ etc...Copyright © 2006 by ESPEN

OsmoliteOsmoliteFibreFibre

NutricompNutricompStandardStandardFibreFibre

FresubinFresubinOriginalOriginalFibreFibre

IsosourceIsosourceFibreFibre

NutrisonNutrisonMulti Multi FibreFibre

Per 100 ml

AbbottAbbott B.BraunB.Braun Fresenius Fresenius KabiKabi

3.83.4

13.8Prot:Fat:CH ratio 17:32:51 15:30:55 15:30:55 15:30:55 16:35:49

E - density kcal/ml 1.0 1.0 1.0 1,0 1.0Osmolality mosm/l 237 260 250 232 210

2

NutriciaNutricia

Protein g 4.0 3.8

NovartisNovartisNutritionNutrition

3.83.4

13,6

4.0Fat g 3.5 3.3 3.9Carbohydrates g 12.4 13.8 12,3

1.4Fibres g 1.4 1.5 1.5

Druml W, Jadrna K. AKE recommendations for enteral & parenteral nutritional support, 2005/2006

TheThe almostalmost identicalidentical compositionscompositions of normal of normal energyenergy, , fibrefibre containingcontaining STANDARD FORMULAESTANDARD FORMULAE

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PeptidePeptide--basedbased formulaeformulae

Proteins Peptides

MaltodextrinsPolysaccharides / maltodextrins

Long-chain triglycerides Short-chain triglycerides

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WholeWhole proteinprotein formulaformula PeptidePeptide--basedbased formulaformula


INDICATIONS INDICATIONS PeptidePeptide--basedbased formulaeformulae

DrumlDruml W, Roth E,, AKE W, Roth E,, AKE recommendationsrecommendations forfor enteralenteral and parenteral and parenteral nutritionalnutritional supportsupport, 2004 , 2004

WhenWhen wholewhole proteinprotein formulaeformulae areare notnot toleratedtoleratedSeverelySeverely impairedimpaired resorptionresorption capacitycapacityAfter After prolongedprolonged starvationstarvationIn ICU In ICU patientspatients withwith jejunaljejunal tiptip placementplacement **In In severesevere acuteacute pancreatitispancreatitis withwith jejunaljejunal tiptip placementplacement ****Short Short bowelbowel syndromesyndromeCrohnCrohn‘‘ss diseasedisease withwith fistulafistula a.s.o*a.s.o*

* only if whole protein formulae are not tolerated** but standard formulae can be tried if tolerated (ESPEN Guidelines, Clin Nutr, 2006)

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Standard vs. Standard vs. peptidepeptide basedbased formulaeformulaein in acuteacute CrohnCrohn‘‘ss DiseaseDisease Charité

Favours whole protein Favours peptide-based

Enteral nutritional therapy for induction of remission in Crohn's disease (Cochrane Review). Zachos M, Tondeur M, Griffiths AM. In: The Cochrane Library, Issue 3, 2001


EN EN –– FormulaeFormulae in Diabetesin DiabetesCharité


TheThe „„classicclassic““ diabetesdiabetes formulaeformulaeCharité

areare characterisedcharacterised byby::

•• somesome partpart of of glucoseglucose isis exchangedexchanged forfor fructosefructose

•• higherhigher amountamount of of polysaccharidespolysaccharides

UsuallyUsually standardstandard formulaeformulae areare recommendedrecommended forforuncomplicateduncomplicated and and medicallymedically adequatelyadequately treatedtreated DMDM


High MUFA High MUFA diabetesdiabetes formulaeformulaeCharité

• up to 35 up to 35 energy%energy% of of monomono--unsaturatedunsaturated fattyfatty acidsacids (MUFA)(MUFA)

•• higherhigher total total fatfat

•• decreaseddecreased carbohydratescarbohydrates

BeneficialBeneficial in in complicatedcomplicated, , poorlypoorly controlablecontrolable DMDM

BloodBlood glucoseglucose controlcontrol in ICU in ICU patientspatients??StandardStandard-- oror ICUICU--specificspecific formulaeformulae →→ useuse of of exogenousexogenous insulininsulinto to achieveachieve strictstrict gylcaemicgylcaemic controlcontrol

Van den Berghe G, Introductory to ESPEN Guidelines 2006


High MUFA High MUFA diabeticdiabetic formulaeformulae vsvs standardstandard formulaeformulae

Change in blood glucose AUC (All trials RCT)

Trial size(study length)

Effect (95% Cl)Diabetes specificfavourable

Standard favourable

Goley et al1995

6 (6;6) (short-term, oral)

-1.38 (-2.67 to -0.1)

Printz et al1997


-1.22 (-2.18 to -0.26)

Hoffman et al2004

12 (12;12) (short-term, tube)

-0.89 (-1.73 to -0.05)

Hoffman et al2004


-1.46 (-2.46 to -0.47)

Meta analysis diabetes specific vs. standard

-1.19 (-1.89 to –0.7)

-3 -2 -1 0 +1 +2 +3Short-term:single meal or continuous feed with follow-up <24h Standardised mean difference (95% confidence interval)

CharitéElia M et al, Diabetes Care 2005, 28:2267


ENEN--formulaeformulae in in liverliver diseasediseaseCharité


LIVER High-Energy

Per 100 ml

Nutricomp HepaB.Braun

1.3

4

46%

5.8

50%

15.5

12:40:48

0,6

FresubinHepaFresenius - Kabi

Fresubin EnergyFibre Fresenius -Kabi

Energy density / ml (Kcal) 1.3

4

35%

4.9

35%

17,9

12:38:50

1 (5% soluble)

5.6

18%

5.8

14%Carbohydrates (CH) (g) 18.8

1.5

Prot:Fat:CH ratio 15:35:50

Protein g

BCAA (% Protein)

Fat g

MCT ( % Fat)

Fibre (g) 2.0 (40%- soluble)

Druml W, Jadrna K. AKE recommendations for enteral and parenteral nutritional support, 2005/2006

LIVER LIVER vsvs STANDARD FORMULAESTANDARD FORMULAECharité


ESPEN ESPEN GuidelinesGuidelines 2006: 2006: alcoholicalcoholic steatohepatitissteatohepatitis / / cirrhosiscirrhosis

Plauth M et al. Clinical Nutrition 2006

Recommendation Grade

Whole protein formulae ar generally recommended C

Consider high energy formulae in patients w/ ascites C

Use BCAA-enriched formulae in patients with hepatic Aencephalopathy arising during enteral nutrition

Oral BCAA supplementation can improve clinical outcome Bin advanced cirrhosis

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BCAA L-Alb MDXT

Admissions 15/58 27/56 28/59

Hospital stay 195 327 520(days, cumulative)

Mortality 5 11 9

ONS ONS withwith BCAA in BCAA in liverliver cirrhosiscirrhosis

Marchesini et al. Gastroenterology 2003: 124; 1792-1801

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IMMUNMODULATING FORMULAEIMMUNMODULATING FORMULAECharité


CHARACTERISTICSCHARACTERISTICSImmuneImmune--modulatingmodulating formulaeformulae

Contain immune-modulatory nutrients in supranormal amounts, e.g.:

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• ω-3 fatty acids

• arginine

• glutamine

• nucleotides

• antioxidant vitamins & minerals


GLUTAMINEGLUTAMINE

Natural glutamine content in commercial formulae (2000 ml) (26)

Whole protein formulae, normal protein 4-6 g

Whole protein formulae, high protein 6-8 g

Peptide-based formulae 2-3 g

Amino-acid based formula 0 g

Impact (Novartis Nutrition) 6.3 g

Immune-modulating formulae enriched with glutamine (2000 ml) (10)

Impact Glutamine (Novartis Nutrition) 20 g

Nutricomp Immun (B. Braun) 21 g

Fresenius Reconvan (Fresenius-Kabi) 20 g

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INDICATIONS INDICATIONS ImmuneImmune--modulatingmodulating formulaeformulae

ESPEN Guidelines, Clin. Nutr., 2006

Recommendation Grade

Perioperatively independent of nutritional status in A

Major neck surgery for cancerMajor upper abdominal cancer surgeryAfter severe trauma

In intensive care patients withmild sepsis (APACHE II < 15) BARDS (formulae containing ω-3 fatty acids) B

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CAVE! Severe sepsis → increased mortality CAVE!


0

20

40

60 Infection rate %

BMI 18-25 25-30 >30

Pre-OP Impact

Peri-OP Impact

Conventionell(Glucose / E´lytes i.v.)

PreoperativePreoperative immunonutritionimmunonutrition

Gianotti et al., Gastroenterology 2002; 122:1763

N=305 Pat. w/ GI-Tumors, 45 % w/ gastroesophageal resections

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PrPräädialyticdialytic FormulaeFormulae

In conservatively treated chronic renal failure for EN > 5 days (C).Essential amino acids and ketoanalogues, in association with verylow protein formulae, are proposed to preserve renal function (B).

DialyticDialytic FormulaeFormulaeFor tube feeding in patients on maintenance haemodialysis therapy (C).In acute renal failure in case of electrolyte derangements (B).

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IndicationsIndications forfor RENAL FORMULAERENAL FORMULAEESPEN Guidelines, Clin Nutr, 2006


CharacteristicsCharacteristicsHigher percentage of total energy from fat

CharitéENEN--FormulaeFormulae forfor lunglung diseasedisease

ESPEN Guidelines, Clin Nutr, 2006

IndicationsIndicationsStableStable COPDCOPD

No additional advantage of pulmonary ONS compared tostandard high protein or high energy ONS (B)

AcuteAcute respiratoryrespiratory deficiencydeficiency syndromesyndrome (ARDS)(ARDS)Use a pulmonary formulae enriched with ω-3 fatty acids and antioxidants (B).


Damien Hirst, MOMA, NY

ConclusionsConclusionsCharité

• Enteral formulae are available for a wide array of indications.

• Enteral formulae are designed food, still their energy components are „natural“and their artificiality is more or less a philosophical question.

• Although some formulae may contain nutrients in pharmacological amounts, enteral formulae are to be considered primarily as food, not as drugs.

• Standard formulae (including high energy & high protein formulae) are appropriate for the majority of patients.


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Formulae for Enteral Nutrition · Druml W, Roth E,, AKE recommendations for enteral and parenteral nutritional support, 2004 When whole protein formulae are not tolerated Severely