Amino Acid Formulation in Hepatic Failure/Hepatic Encephalopathy

Pronunciation: a-MEE-noe AS-id
Class: Amino acid combinations

Trade Names

HepatAmine
- Injection, solution 8%

Hepatasol 8%
- Injection, solution 8%

Pharmacology

Aids in the reversal of amino acid imbalances that are present in patients with liver disease who have hepatic encephalopathy.

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Indications and Usage

For the treatment of hepatic encephalopathy in patients with cirrhosis or hepatitis; to provide nutritional support for patients with cirrhosis or hepatitis who require parenteral nutrition and are intolerant of general-purpose amino acid injections, which are contraindicated in patients with hepatic coma.

Contraindications

Anuria; inborn errors of amino acid metabolism; hypersensitivity to 1 or more amino acids in the solution.

Dosage and Administration

Adults

IV 80 to 120 g of amino acids (nitrogen 12 to 18 g) per day. Increase gradually to the maximum required dose, as indicated by frequent determinations of glucose levels in blood and urine.

Children

IV 2 to 3 g/kg of amino acids for infants with adequate calories.

Concomitant therapy

May include dextrose/insulin, fat emulsion, electrolyte supplementation, and vitamins.

General Advice

  • The determination of nitrogen balance and accurate daily body weights, corrected for fluid balance, is probably the best means of assessing individual protein requirements.
  • Adults: Typically, 500 mL of amino acid 8% injection appropriately mixed with 500 mL of dextrose 50% supplemented with electrolytes and vitamins is administered over an 8- to 12-h period. This results in a total daily fluid intake of approximately 2 to 3 L. Patients with fluid restrictions may only tolerate 1 to 2 L.
  • Hypertonic admixtures may be administered by continuous infusion through a central venous catheter with the tip located in the superior vena cava.
  • Solutions administered to children by peripheral vein should not exceed twice normal serum osmolarity (718 mOsmol/L).
  • Administration time for a single bottle and set should never exceed 24 h.
  • Some additives may be incompatible. When introducing additives, mix thoroughly and do not store.
  • Peripheral infusions should be accompanied by adequate caloric supplementation.
  • IV fat emulsions should not be administered to polyvinyl chloride containers that use DEHP as a plasticizer.

Storage/Stability

Store at 77°F; however, brief exposure up to 104°F does not adversely affect the product. Avoid excessive heat. Protect from freezing. Protect from light until use. Any storage after mixing should be under refrigeration for as brief a time as possible, preferably less than 24 h.

Drug Interactions

None well documented.

Adverse Reactions

Cardiovascular

Venous thrombosis.

CNS

Asterixis.

Local

Extravasation; infection at the injection site; phlebitis extending from the injection site.

Metabolic-Nutritional

Dilutional hyponatremia; edema; hypervolemia; phosphorous deficiency; water weight gain.

Miscellaneous

Febrile response; flushing; increase in BUN.

Precautions

Monitor

Monitor glucose, serum electrolytes, ammonia, acid-base and fluid balance, serum proteins, kidney function tests, LFTs, serum osmolarity, hemogram, carbon dioxide content, and blood cultures.


Pregnancy

Category C .

Lactation

Undetermined.

Children

The use of amino acid injections in children as an adjunct in the offsetting of nitrogen loss or in the treatment of negative nitrogen balance is well established in the medical literature.

Elderly

Use with caution.

Renal Function

Elevated BUN may be augmented by renal impairment or GI bleeding. Do not use in patients with azotemia without regard to total nitrogen intake.

Hepatic Function

Amino acid injection may not affect the clinical course of patients with fulminant hepatitis who have a poor prognosis and who are generally unresponsive to treatment.

Special Risk Patients

Use with caution in patients with cardiac insufficiency to avoid circulatory overload.

Sulfite Sensitivity

HepatAmine contains a sulfite that may cause allergic-type reactions, including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people.

Administration

Administer strongly hypertonic nutrient solutions through an indwelling IV catheter with the tip located in the superior vena cava.

Aluminum toxicity

Parenteral products may contain aluminum that may be toxic. Aluminum may reach toxic levels with prolonged parenteral administration if kidney function is impaired. Premature neonates are particularly at risk.

Diabetes

Use special care when giving hypertonic glucose to diabetic or prediabetic patients. Insulin may be required to prevent severe hyperglycemia.

Electrolyte supplementation

May be required in the presence of extraordinary losses, such as protracted nasogastric suction, vomiting, diarrhea, or GI fistula drainage. Additional phosphate (along with calcium) may be required. Metabolic acidosis may be prevented or treated by administration of the acetate salts of a portion of the electrolytes. Keeping the chloride content to a minimum may prevent/treat hyperchloremic acidosis.

Fluid/Solute overload

May occur and result in dilution of serum electrolyte concentrations, overhydration, congested states, or pulmonary edema.

Metabolic complications

These have included metabolic acidosis, hypophosphatemia, alkalosis, hyperglycemia and glycosuria, osmotic diuresis and dehydration, rebound hypoglycemia, elevated liver enzymes, hypo- and hypervitaminosis, electrolyte imbalances, and elevated plasma amino acid levels and hyperammonemia in children. Monitor frequently, especially the first few days of therapy. Administration of glucose at a rate exceeding the patient's utilization may lead to hyperglycemia, coma, and death.

Myocardial infarction

In patients with MI, accompany amino acid infusion with dextrose.

Sepsis

The constant risk of sepsis is present during central venous nutrition.

Overdosage

Symptoms

None reported.

Patient Information

  • Advise patient that medication will be prepared and administered by a health care provider in a hospital setting.

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