A recent article in Today’s Dietician offers advice on drug shortages with TPN.

The following is a link (from a Kipp Ellsworth retweet) and an excerpt: http://t.co/CBKti0mNep

Lipids. Two US manufacturers produce three lipid concentrations  (10%, 20%, and 30%) of IV fat emulsions. The 30% concentration can be used only  in total nutrient admixtures. ICU patients receiving propofol can forgo IV fat  emulsions, since propofol is in a lipid-based emulsion that provides 1.1  kcal/mL, just like the 10% IV fat emulsion.

Since essential fatty acid deficiency doesn’t develop until  after two weeks of lipid-free PN, IV fat emulsions can be safely withheld for  the first two weeks if lipids are in short supply.1 After two weeks of  lipid-free PN, the minimum dose of IV fat emulsions, which is 100 g/week, can  be provided to prevent essential fatty acid deficiency.

IV fat emulsions should be discontinued in patients  tolerating EN and who don’t have malabsorption concerns.

IV Multiple Vitamins               When there’s a shortage of IV multiple vitamins, dietitians  should evaluate all patients for their ability to absorb enteral multiple  vitamin supplements in capsule, tablet, liquid, or chewable forms. For patients  who can’t absorb enteral vitamin supplements, the IV multiple vitamin dose  should be decreased from 10 mL to 5 mL/day to conserve supplies. If IV multiple  vitamins remain in short supply despite conservation efforts, the standard dose  of 10 mL should be given three times per week.2

If supplies have been exhausted, PN must be supplemented  intravenously with individual parenteral vitamins according to the following  ASPEN recommendations: thiamin: 6 mg; folate: 0.6 mg; ascorbic acid: 200 mg;  pyridoxine: 6 mg; and vitamin K: 0.5 to 1 mg/day or 5 to 10 mg/week.2 In  addition, cyanocobalamin (vitamin B12) must be given intramuscularly at least  once per month.2

Trace Elements               Combination trace elements and individual trace element  products offer alternatives to PN products in short supply.

Combination Multiple Trace Element Products               Dietitians have a choice of two different multiple trace  element combination products: MTE4 and MTE5. MTE4 products contain zinc,  copper, chromium, and manganese and come in a standard 3 mL dose or a 1 mL  concentrated dose. MTE5 products contain the same four trace elements with the  addition of selenium in either the standard 3 mL dose or the 1 mL concentrated  dose.

If there’s a shortage of the concentrated products, RDs can  use the standard 3 mL dose of MTE4 and MTE5. When MTE4 products aren’t  available, RDs can substitute the MTE5 products. If MTE5 products aren’t  available, RDs should substitute MTE4 products and add 60 mcg of selenium  individually to achieve the equivalent composition of MTE5.

…If no MTE products are available, individual trace elements  should be added to PN solutions.

Individual Trace Elements               Individual trace elements are used when combination trace  element products are unavailable…

There’s no need to supplement manganese when there are  shortages of multiple trace element products. Whole blood manganese levels  frequently are elevated in long-term PN patients, and manganese contamination  often occurs in other PN products. No alternative IV forms of chromium are  available but, like manganese, there may be some chromium despite the fact it  isn’t intentionally added because of its contamination potential in other PN  products. RDs can evaluate a patient’s ability to absorb chromium as part of  multivitamin and mineral supplementation through the enteral route and monitor  for signs of deficiencies.

Other than the selenium content of MTE5 products, selenium  is available as a single IV trace element product. When MTE5 products and individual  IV selenium products aren’t available, RDs can consider using oral selenium  supplementation.

Copper is available as a single PN trace element in two  forms: IV copper chloride or IV cupric sulfate. If all supplies of IV copper  have been exhausted, a patient should be evaluated for oral copper supplements.

Zinc is available in either IV zinc sulfate or IV zinc  chloride. It’s important to note that if zinc is given enterally in high doses,  RDs should monitor for a copper deficiency, as zinc and copper both compete for  absorption with the same carrier protein when EN is used….

— Mandy L. Corrigan,  MPH, RD, LD, CNSC, is a nutrition support dietitian with Coram Specialty  Infusion Pharmacy.

 Professional  Resources • American Society of Health-System Pharmacists Drug  Shortages Resource Center: www.ashp.org/menu/DrugShortages

• American Society for Parenteral and Enteral Nutrition Drug  Shortages Update: www.nutritioncare.org/Professional_Resources/Drug_Shortages_Update

• FDA Current Drug Shortages Index: www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm

• FDA Fact Sheet: Drug Products in Shortage in the United  States: www.fda.gov/RegulatoryInformation/Legislation/FederalFoodDrugandCosmeticActFDCAct/ SignificantAmendmentstotheFDCAct/FDASIA/ucm313121.htm

• FDA Frequently Asked Questions About Drug Shortages: www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050796.htm

• Fresenius Kabi Adult Multitrace Element Availability  (product information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM355392.pdf

• Fresenius Kabi Pediatric Multitrace Element Availability  (product information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM354265.pdf

• Fresenius Kabi Phosphate Injection Availability (product  information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM354277.pdf

• National Medication Errors Reporting Program (patients and  clinicians): www.ismp.org/orderforms/reporterrortoISMP.asp

 

For More Information               The following references can serve as viable resources for  dietitians to learn more about parenteral nutrition drug shortages and their  impact on patient safety and patient care:

• Buchman AL, Howard LJ, Guenter P, Nishikawa RA, Compher  CW, Tappenden KA. Micronutrients in parenteral nutrition: too little or too  much? The past, present, and recommendations for the future. Gastroenterology.  2009;137(5 Suppl):S1-S6.

• Corrigan ML, Kirby DF. Impact of a national shortage of  sterile ethanol on a home parenteral nutrition practice: a case series. JPEN  J Parenter Enteral Nutr. 2012;36(4):476-480.

• Holcombe B. Parenteral nutrition product shortages: impact  on safety. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):44S-47S.

Related Blog Posts:

• Drug Shortages and Selenium Deficiency | gutsandgrowth
• Critical drug shortages in U.S. | gutsandgrowth

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical management interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.