2. Pharmaconutrition A New Emerging Paradigm Daren K. Heyland, MD, FRCPC, MSc Professor of Medicine, Queen’s University, Kingston, Ontario

3. The First Ever Recorded Clinical Trial [Nebuchadnezzar, king of Babylon, carried away children of Israel, into his court ] 5 And the king appointed them a daily provision of the king's meat, and of the wine which he drank: 8 Daniel would not defile himself with the portion of the king's meat, nor with the wine 10 Prince of the eunuchs said unto Daniel, I fear the king, who hath appointed your meat and your drink: for why should he see your faces worse liking than the children which are of your sort? then shall ye make me endanger my head to the king. Book of Daniel 1:1-15

4. 11 Then said Daniel to Melzar, whom the prince of the eunuchs had set over Daniel, 12 Prove thy servants, I beseech thee, ten days; and let them give us pulse to eat, and water to drink. 13 Then let our countenances be looked upon before thee, and the countenance of the children that eat of the portion of the king's meat: and as thou seest, deal with thy servants. 14 So he consented to them in this matter, 15 And at the end of ten days their countenances appeared fairer and fatter in flesh than all the children which did eat the portion of the king's meat. The First Ever Recorded Clinical Trial Book of Daniel 1:1-15

5. 16 [from all the children of Israel in the King’s Court] Thus Melzar took away the portion of their meat, and the wine that they should drink; and gave them pulse. Translating Research Findings into Practice ! Book of Daniel 1:1-16

6. www.criticalcarenutrition.com  Updated October 2008  Summarizes 198 trials studying 21283 patients  34 topics 17 recommendations

7. Validation of the CPG’s: Results of a Prospective Observational Study Summary –Patients and Sites that were more consistent with CPG recommendations tended to receive more EN Adoption of Canadian CPGs will likely lead to improved nutrition support practices in ICUs Heyland CCM 2004;32:2260

8. www.criticalcarenutrition.com Our efforts to translate best evidence into practice!

9. www.criticalcarenutrition.com

10. Immunonutrition Specific nutrients found to have effects on immune system, metabolism, and GI structure and function  Arginine  Glutamine  Omega-3 fatty acids  Nucleic acids  others Glutamine Arginine

11. Largest Randomized Trial of Immunonutrition  Good Methods  Multicenter RCT  double-blinded  ITT analysis  Heterogeneous group of patients (597)  Elective and urgent surgery (50%)  Trauma (8%)  Medical including septic (42%)  high protein entered formula  enriched with  arginine (10 g/L),  Glutamine  Antioxidants  omega 3 FAs (Stresson®) No other differences in Outcome No subgroup differences Kieft Int Care Med 2005;31:524

12. Updated Analysis: Effect on Mortality www.criticalcarenutrition.com

13. Updated Analysis: Effect on Infectious Complications www.criticalcarenutrition.com

14. Why is it not working? Old Immunonutrition New Pharmaconutrients NutritionNutrients Combined nutrientsSingle nutrients Heterogeneous populations Homogenous Patients Weak methodsRigorous Small single centerLarge multicenter Heyland Int Care Med 2005;31:501

15. Nutrition vs Nutrients Impacts mortality! arginine glutamine antioxidants omega-3 fatty acids Impacts morbidity EN vs PN Early EN small bowel feeding

16. Pharmaconutrients Impact Outcomes! www.criticalcarenutrition.com 1 10 1000.1.01 Glutamine Antioxidants Fish/Borage Oils Plus AOX Effect on Mortality Arginine

17. Nutrition vs Nutrients Vitamin A Supplementation for extremely Low Birth weight Infants reduces chronic lung disease NEJM 1999;340:1962 B carotene supplementation in AIDS associated with improved survival Eur J Clin Nutr; 2006;60:1266 N-3 fatty acids associated with survival advantage post-MI Circulation 2002; 105: 1897 L-Arginine associated with higher post infarction mortality JAMA 2006; 295: 58 Examples of Placebo-controlled trials where nutrients are tested in addition to standard care

18. Cocktail Approach? Specific nutrients found to have effects on immune system, metabolism, and GI structure and function  Arginine  Glutamine  Omega-3 fatty acids  Nucleic acids  others Rationale for combining substances into products?

19. Elective Surgery Critically Ill GeneralSepticTraumaBurnsAcute Lung Injury ArginineBenefitNo benefitHarmNo benefit GlutamineBenefitPN Beneficial (? receiving EN) …EN Possibly Beneficial … Omega 3 FFA ……………Beneficial Antioxidants…Possible Benefit ………… Population Nutrients Pharmaconutrition: Which Nutrient for Which Population? Canadian Clinical Practice Guidelines JPEN 2003;27:355 www.criticalcarenutrition.com

21. = Homogenous Patient Populations?

22. Effect of Parenteral Nutrition on Mortality Risk ratio (log scale) Malnourished Non-malnourished Quality score <7 Quality score >= 7 Published before 1988 Published after 1989 Lipids No Lipids Critically Ill Surgical Overall Effect 0.11 10 TPN Benefical TPN Harmful Mortality p=0.12 p=0.07 p=0.025 Heyland JAMA 1998

23. Heyland JAMA 2001;286:944 Effect of Immunonutrition: A meta-analysis

24. Mito Function In Search of the Magic Nutraceutical

25. Largest Randomized Trial of Antioxidants  Multicenter RCT in Germany  double-blinded  non-ITT analysis  249 patients with severe sepsis  standard nutrition plus 1000 ug bolus followed by 1000 ug/day or placebo x14 days Greater treatment effect observed in those patients with: supra normal levels vs normal levels of selenium Higher APACHE III More than 3 organ failures Crit Care Med 2007;135:1 p=0.11

26. Influence of early antioxidant supplements on clinical evolution and organ function in critically ill cardiac surgery, major trauma and subarachnoid hemorrhage patients. CRP levels daily in the Control groups Significant reduction with AOX in Cardiac and Trauma but not SAH Berger Crit Care 2008  RCT  200 patients  IV supplements for 5 days after admission (Se 270 mcg, Zn 30 mg, Vit C 1.1 g, Vit B1 100 mg) with a double loading dose on days 1 and 2 (AOX group), or placebo.  No affect on clinical outcomes

27. Effect of Antioxidants on Mortality: Relationship to Control Group Mortality

28. Baseline Risk of Patients Impacts on Magnitude of Treatment Effect  A meta-analysis found calcuim supplementation to be effective in preventing preeclampsia  Large RCT found no risk reduction in health nulliparous women  Exploration of heterogeneity across studies  Stratify for high and low baseline risk JAMA 1999;282:664

29. Baseline Risk of Patients Impacts on Magnitude of Treatment Effect

30. Why is it not working? Old (Immunonutrition) New (Pharmaconutrients) NutritionNutrients Combined nutrientsSingle nutrients Heterogeneous populations Homogenous Patients Weak methodsRigorous Small single centerLarge multicenter

31. A Review of the True Methodological Quality of Nutrition Support Trials Conducted in the Critically Ill: Time for Improvement! Appraised the methodological quality of 111 nutrition RCTs and compared to sepsis trials in ICU setting Compared to sepsis trials, nutrition trials were: –less likely to use blinding (31% vs 80%) –less likely to present ITT analysis (58% vs 93%). –less likely to conceal randomization (17% vs 30%) –more likely to have excessive amounts of lost to follow up (18% vs 0) Doig Anesth Analg 2005;100:527-33

35. REducing Deaths from OXidative Stress: The REDOXS study A multicenter randomized trial of glutamine and antioxidant supplementation in critical illness

36. Effect of Glutamine in the Critically ill Patient: Mortality www.criticalcarenutrition.com

37. Effect of Combined Antioxidant Strategies in the Critically Ill www.criticalcarenutrition.com Mortality

38. The Research Protocol In enterally fed, critically ill patients with a clinical evidence of acute multi organ dysfunction –What is the effect of glutamine supplementation compared to placebo –What is the effect of antioxidant supplementation compared to placebo …on 28 day mortality? The Question(s)

39. 1200 ICU patients Evidence of organ failure R glutamine placebo Concealed Stratified by  site R R antioxidants placebo Factorial 2x2 design placebo antioxidants  Shock REducing Deaths from OXidative Stress: The REDOXS study

40. GroupEnteral Supplement Parenteral Supplement ( Glutamine AOX) (Glutamine AOX) AGlutamine + AOX+Glutamine + Selenium BPlacebo + AOX+Placebo + Selenium CGlutamine + Placebo+Glutamine + Placebo DPlacebo + Placebo+Placebo + Placebo Combined Entered and Parental Nutrients

41. Glutamine Dipeptides Free L-glutamine has limited solubility and stability Synthetic dipeptides (ala-gln, gly-gln) overcome these difficulties 8.5 gms of dipeptide=6 gms of glutamine Vit C 1500 mg Vit E 500 mg B-carotene 10 mg Zinc 20mg Selenium 300ug Glutamine 30 gms

42. Optimal Dose? High vs Low dose: –observations of meta-analysis Providing experimental nutrients in addition to standard enteral diets

43. Optimizing the Dose of Glutamine Dipeptides and Antioxidants in Critically ill Patients: A phase 1 dose finding study of glutamine and antioxidant supplementation in critical illness Heyland JPEN 2007;31:109

44. The Research Protocol In critically ill patients with a clinical evidence of hypoperfusion... What is the maximal tolerable dose (MTD) of glutamine dipeptides and antioxidants as judged by its effect on multiorgan dysfunction? The Question

45. The Research Protocol Single Center Open-label Dose-ranging study Prospective controls The Design Critically Ill patients in shock Patients

46. The Research Protocol Intervention Group NDose of Dipeptides (glutamine) Parenterally* (gm/kg/day) Enterally^ (gm/day) AOX 130000 27.5 (.35)00 37 21 (15)½ can 47.5 (.35)42 (30)full can 57.5 (.35)42 (30) full can + 500ug IV Selenium

47. The Research Protocol Outcomes Primary: ∆SOFA Secondary (groups 2-5); Plasma levels of Se, Zn, and vitamins TBARS Glutathione Mitochondrial function (ratio)

48. Control N = 30 Group 2 N =7 Group 3 N= 7 Group 4 N= 7 Group 5 N=7 All N=58 Age (Mean)64.265.565.265.671.865.6 Female (%)11 (37%)2(29%)1(14%)2(29%)3(43%)19(33%) APACHE II score (Mean)23.225.122.121.920.622.8 Etiology of shock Cardiogenic (%) Septic (%) Hypovolemic (%) 6 (86%) 1(14%) 3 (43%) 4 (57%) 3 (43%) 4 (57%) 1(14%) 5(71%) 1(14%) 13(46%) 14(50%) 1(4%) ICU days (Median)6.414.37.913.19.78.0 28 day mortality (%)9(30%)3(43%)2(29%)3(43%)1(14%)18(31%) Baseline Characteristics

49. 4 vs 5: p=0.17 Effect on SOFA

50. Inferences High dose appears safe High dose associated with –no worsening of SOFA Scores –greater resolution of oxidative stress –greater preservation of glutathione –Improved mitochondrial function Heyland JPEN Mar 2007 ParenterallyEnterally Glutamine/day0.35 gms/kg30 gms Antioxidants per day 500 mcg Selenium Vit C 1500 mg Vit E 500 mg B carotene 10 mg Zinc 20 mg Se 300 ug

51. REDOXS: A new paradigm! Nutrients dissociated from nutrition Focus on single nutrient administration Rigorous, large scale, multicenter trial of nutrition related intervention powered to look at mortality High risk, sick homogenous population Preceded by: –standardization of nutrition support thru the development and implementation of CPGs –a dosing optimizing study Funded by CIHR

52. Conclusions Nutrition Therapy : Modulating the Stress Response Adjunctive Supportive Care Proactive Primary Therapy

53. Implications of the New Paradigm? Research – explosion of research opportunities –Methodological challenges Education – included in critical care curriculum? Models of Care Delivery – Expect Physicians to order pharmaconutrients just like they order antibiotics? who will they consult for difficult cases? Revitalized Nutrition Support Teams?

54. Blind Administration of Pharmacologically Active Nutrients? Hotchkiss NEJM 2003;348:138

55. Pharmaconutrition: The Future oWhich nutrient? oWhat patient? oAt what time point? oFor how long?