Recommendations for Lipid Administration in Patients on Home Parenteral Therapy
Home parenteral therapy is an important part of treatment for patients with chronic intestinal failure who cannot achieve adequate nutrition through enteral feeding. An integral component of this therapy is lipid emulsion, which provides a source of energy and essential fatty acids. However, long-term administration of lipid emulsion may be associated with liver damage. According to available studies, the risk can be reduced by adjusting the dosage of lipid emulsion and preferring emulsions without soybean oil.
Introduction
The population requiring home parenteral therapy exhibits high variability in daily fluid and energy intake requirements, depending on the etiology of intestinal failure. Despite this variability, professional societies agree that intravenous lipid emulsion is an essential component of home parenteral therapy.
According to current guidelines for chronic intestinal failure therapy, patients should receive at least 1 g/kg/week of intravenous lipid emulsion with essential fatty acids to prevent their deficiency. Soybean oil-based lipid emulsions, which have long been a standard part of parenteral therapy, are an excellent source of essential fatty acids. However, their administration can contribute to the development of intestinal failure-associated liver disease (IFALD). Liver damage typically manifests as cholestasis, cholelithiasis, steatosis, and fibrosis. Rarely, it can progress to cirrhosis and liver failure, especially in newborns and children.
Recommendations for Home Parenteral Therapy
One reason for liver damage when administering soybean oil-based lipid emulsion may be the high ratio of ω-6 to ω-3 polyunsaturated fatty acids. The metabolism of ω-6 fatty acids produces pro-inflammatory substances and has a relatively high phytosterol content. Clinical evidence in this case is limited, and the correlation between phytosterols and cholestasis remains not fully understood.
Several measures have been adopted to prevent and minimize the risk of liver damage, including administering parenteral nutrition in cycles, avoiding hepatotoxic substances, and preventing or early managing sepsis. Another measure is the reduction of intravenous lipid emulsion dosage, particularly if it is soybean oil-based.
According to consensus recommendations prepared by an expert panel at an international lipid summit on parenteral nutrition in the USA in November 2018, to prevent liver damage in patients requiring long-term home parenteral therapy (> 6 months), the dose of soybean oil-based lipid emulsion should not exceed 1 g/kg body weight/day. Currently, there is sufficient clinical evidence suggesting that the risk of liver complications in adults on home parenteral therapy can be reduced by using fish oil-based emulsion. These emulsions should be preferred for patients at risk of developing liver damage. Other alternative sources of lipid emulsion include medium-chain triglycerides and olive oil-based emulsions.
In patients with developed liver damage, it is recommended as part of the treatment strategy to reduce the risk of overfeeding, limit soybean oil-based lipid emulsions to a dose of < 1 g/kg/day, and lower the ω-6 to ω-3 fatty acid ratio. Fish oil-based lipid emulsions appear beneficial, potentially due to fish oil’s higher content of the antioxidant α-tocopherol compared to other lipid emulsions.
Conclusion
Intravenous lipid emulsions are an important part of home parenteral therapy as an excellent source of non-protein energy and essential fatty acids. However, when administering soybean oil-based lipid emulsion long-term, the dose should not exceed 1 g/kg/day due to the potential risk of liver damage. Although this assertion needs verification through randomized controlled clinical studies, the available evidence suggests that the risk of liver damage in patients on long-term parenteral therapy can be reduced by administering lipid emulsions based on other oils (e.g., fish oil) with a lower ω-6 to ω-3 polyunsaturated fatty acid ratio.
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Source: Mundi M. S., Klek S., Martindale R. G. Use of lipids in adult patients requiring parenteral nutrition in the home setting. JPEN J Parenter Enteral Nutr 2020 Feb; 44 (Suppl. 1): S39–S44, doi: 10.1002/jpen.1755.
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