Glutamine Therapy A lifesaving therapy Daren K Heyland

Glutamine Therapy: A life-saving therapy? Daren K. Heyland Professor of Medicine Queen’s University, Kingston, ON Canada

Conclusions Nutrition Therapy : Modulating the Inflammatory Response and Improving Patient Outcomes Adjunctive Supportive Care Proactive Primary Therapy

What’s new about this paradigm? Old Nutrition Support New Nutrition Therapy Emphasis on metabolic and nutritional effects Emphasis on clinical outcomes Minimize substrate loss Achieve pharmacological effect Heterogeneous patients Homogeneous Patients Focus on nutrition Focus on nutrients Small single center Large multicenter Weak methods Strong methods

Case Scenario • • Mr KT 76 per’d diverticulum Septic shock, ARDS, MODS Day 1 - high NG drainage, distended abdomen • Day 3 - trickle feeds • Feeds on and off again for whole first week • No PN, no small bowel feeds, no specialized nutrients

Case Scenario Caloric Debt Adequacy of EN Prolonged ICU stay, discharged weak and debilitated. Dies on day 43 in hospital from massive PE

To what extent did nutrition therapy (or lack thereof) play a role in this patient’s demise?

Pathophysiology of Critical Illness (1) endothelial dysfunction Insult activation of coagulation • infection • trauma • I/R • hypoxemic/ hypotensive elaboration of cytokines, NO, and other mediators generation of OFR (ROS + RNOS) mitochondrial dysfunction = Microcirculatory Dysfunction oxidative stress cellular = energetic failure Key nutrient deficiencies (e. g. glutamine, selenium) organ = failure Death

Loss of Gut Epithelial Integrity Bacteria INTESTINAL EPITHELIUM SIRS DISTAL ORGAN INJURY (Lung, Kidneys) via thoracic duct

Mitochondrial Function Cell mitochondria Respiratory chain ROS n. DNA mt. DNA nucleus Mitochondria are the power house of the cell, generate energy through oxidative phosphorylation (OXPHOS) RNS

In Search of the Magic Nutriceutical Mucosal Barrier Integrity Oxidative Stress Mito Function Cellular Immune Function Inflammation

Glutamine supplementation?

Glutamine: A conditionally essential amino acid • • The most abundant amino acid in the body Usually considered non essential amino acid Has many essential metabolic functions Not usually present in parenteral nutrition products due to manufacturing reasons Glutamine

Glutamine: A conditionally essential amino acid Glutamine levels drop: - following extreme physical exercice - after major surgery - during critical illness Low glutamine levels are associated with: - immune dysfunction - higer mortality in critically ill patients Novak F, Heyland DK, A Avenell et al. , Crit Care Med 2002 Oudemans-van Straaten HM, Bosman RJ, Treskes Met al. , Intensive Car Med 2001

The “Oudemans-van Straaten-Study” “high” “low” => Low plasma glutamine at ICU admission is related to mortality.

Potential Beneficial Effects of Glutamine Enhanced insulin sensitivity Enhanced Heat Shock Protein Decreased Free Radical availability (Anti-inflammatory action) Inflammatory Cytokine Attenuation Glutamine Therapy Glutathione Synthesis Critical Illness Preservation of TCA Function Preserved Cellular Energetics. ATP content GLN Pool pool Fuel for Enterocytes NF-�B ? Maintenance of Reduced Translocation Intestinal Enteric Bacteria Mucosal Barrier or Endotoxins Nuclotide Synthesis Maintenance of Fuel for Anti-catabolic Lymphocytes effect Function Preservation of Muscle mass Reduction of Infectious complications

Glutamine-regulated genes in the Pancreatic B cell line

Induction of Heat Shock Protein Leads to Protein Stabilization Induction Hsp 72 Protein Stress: e. g. HEAT HSP-bound protein stabilized for survival and repair No Induction Aggregation, denaturation, degradation Paul Wischmeyer

IV Glutamine Enhances Serum HSP-70 in Critically Ill Patients with Sepsis/SIRS ALA-GLN treatment leads to significant enhancement of serum HSP-70 with 7 days of treatment * ALA-GLN mediated enhancement of HSP-70 correlates with decreased ICU length of stay and time on ventilator Ziegler Intensive Care Medicine, 31: 1079 -1086, 2005

Mechanism of Glutamine • 3 RCTs of enteral glutamine • Burns patients – – – Increased plasma glutamine Improved permeability Decreased endotoxin levels Reduced GNB infections Reduced hospital LOS Reduced mortality Garrell CCM 2003; 31: 2444, Zhou JPEN 2003 27; 241; Peng Burns 2004; 30: 135

Effect of Glutamine: A Systematic Review of the Literature Infectious Complications Updated Jan 2009, see www. criticalcarenutrition. com

Effect of Glutamine: A Systematic Review of the Literature Mortality Updated Jan 2009, see www. criticalcarenutrition. com

Antioxidant-supplemented specialized diets?

Rationale for Antioxidants Infection Inflammation Ischemia OFR CONSUMPTION OFR PRODUCTION Depletion of Antioxidant Enzymes OFR Scavengers Vitamins/Cofactors OFR production > OFR consumption = OXIDATIVE STRESS Impaired - organ function - immune function - mucosal barrier function Complications and Death

Rationale for Antioxidants • Endogenous antioxidant defense mechanisms • Enzymes (superoxide dismutase, catalase, glutathione perioxidase, glutathione reductase including their cofactors Zn and Selenium) • Sulfhydryl group donors (glutathione) • Vitamins E, C, and B-carotene Low endogenous levels ØLipid peroxidation and inflammation ØOrgan failure ØMortality

Oxidative Stress Connected to Organ Failure Motoyama Crit Care Med 2003; 31: 1048

Rationale for Antioxidants • 21 patients with septic shock • Exposed plasma from patients to naïve human umbilical vein endothelial cells and quantified degree of oxidative stress by a fluorescent probe (2, 7, dichorodihydrofluorescien diacetate) Huet CCM 2007; 35: 821

Rationale for Antioxidants Huet CCM 2007; 35: 821

Underlying Pathophysiology of Critical Illness (2) • preserved ATP Genetic down regulation • Recovery of mt DNA • Regeneration of mito proteins Tissue hypoxia cytokine effect Prolonged inflammation NO Endocrine effects Survivors ↓ mitochondrial activity • ↓mt DNA • ↓ ATP, ADP, NADPH • ↓ Resp chain activity • Ultra structural changes Metabolic Shutdown Death

Mitochondrial Dysfunction is a Time. Dependent Phenonmenon Hypoxia Accelerates Nitric Oxide Inhibition of Complex 1 Activity 21% O 2 Nitration of Complex 1 in Macrophages activated with LPS and IFN Frost Am J Physio Regul Interg Comp Physio 2005; 288: 394

Mitochondrial Damage Cell mitochondria Respiratory chain ROS n. DNA mt. DNA RNS nucleus LPS exposure leads to GSH depletion and oxidation of mt. DNA within 6 -24 hours Potentially Irreversible by 48 hours Levy Shock 2004; 21: 110 Suliman CV research 2004; 279

Heyland JPEN 2007; 31: 109

Effect of Antioxidants on Mitochondrial Function Heyland JPEN 2007; 31: 109

Smallest Randomized Trial of Selenium in Sepsis § Single center RCT § double-blinded § ITT analysis § 40 patients with severe sepsis § Mean APACHE II 18 § Primary endpoint: need for RRT § standard nutrition plus 474 ug x 3 days, 316 ug x 3 days; 31. 6 ug thereafter vs 31. 6 ug/day in control Mishra Clinical Nutrition 2007; 26: 41 -50

Smallest Randomized Trial of Selenium in Sepsis Effect on SOFA scores • Increased selenium levels • Increased GSH-Px activity • No difference in • RRT (5 vs 7 patients) • mortality (44% vs 50%) • Other clinical outcomes *p=<0. 006 * * • Mishra Clinical Nutrition 2007; 26: 41 -50

Randomized, Prospective Trial of Antioxidant Supplementation in Critically Ill Surgical Patients controls § Surgical ICU patients, mostly trauma § 770 randomized; 595 analysed § alpha-tocopherol 1, 000 IU (20 m. L) q 8 h per naso- or orogastric tube and 1, 000 mg ascorbic acid IV q 8 h or placebo § treated Tendency to less pulmonary morbidity and shorter duration of vent days Nathens Ann Surg 2002; 236: 814

Largest Randomized Trial of Antioxidants p=0. 11 § 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 x 14 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

Effect of Combined Antioxidant Strategies in the Critically Ill Effect on Mortality Updated Jan 2009, see www. criticalcarenutrition. com

Biological Plausibility! Mitochondrial dysfunction Antioxidants Inflammation/oxidative stress Antioxidants Organ dysfunction Antioxidants

Pharmaconutrients Impact Outcomes! Effect on Mortality Glutamine Antioxidants Fish/Borage Oils Plus AOX Arginine. 01 0. 1 1 10 100 www. criticalcarenutrition. com

What’s new about this paradigm? Old Nutrition Support New Nutrition Therapy Emphasis on metabolic and nutritional effects Emphasis on clinical outcomes Minimize substrate loss Achieve pharmacological effect Heterogeneous patients Homogeneous Patients Focus on nutrition Focus on nutrients Small single center Large multicenter Weak methods Strong methods

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

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

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

Combined Entered and Parental Nutrients Group Enteral Supplement (Glutamine AOX) Parenteral Supplement (Glutamine AOX) A Glutamine + AOX + Glutamine + Selenium B Placebo + AOX + Placebo + Selenium C Glutamine + Placebo + Glutamine + Placebo D Placebo + Placebo

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 Glutamine 30 gms Vit C 1500 mg Vit E 500 mg B-carotene 10 mg Zinc 20 mg Selenium 300 ug

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

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 JPEN 2007

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

The Research Protocol Intervention Group N Dose of Dipeptides (glutamine) Parenterally* (gm/kg/day) Enterally^ (gm/day) AOX 1 30 0 2 7 . 5 (. 35) 0 0 3 7 . 5 (. 35) 21 (15) ½ can 4 7 . 5 (. 35) 42 (30) full can 5 7 . 5 (. 35) 42 (30) full can + 500 ug IV Selenium

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

Baseline Characteristics 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. 2 65. 5 65. 2 65. 6 71. 8 65. 6 Female (%) 11 (37%) 2(29%) 1(14%) 2(29%) 3(43%) 19(33%) APACHE II score (Mean) 23. 2 25. 1 22. 1 21. 9 20. 6 22. 8 6 (86%) 1(14%) 3 (43%) 4 (57%) 1(14%) 5(71%) 1(14%) 13(46%) 14(50%) 1(4%) Etiology of shock Cardiogenic (%) Septic (%) Hypovolemic (%) ICU days (Median) 6. 4 14. 3 7. 9 13. 1 9. 7 8. 0 28 day mortality (%) 9(30%) 3(43%) 2(29%) 3(43%) 1(14%) 18(31%)

Effect on SOFA 4 vs 5: p=0. 17

Effect on TBARS

Effect on Glutathione

Effect of Antioxidants on Mitochondrial Function Heyland JPEN 2007; 31: 109

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

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 • sick homogenous population • Preceded by: – standardization of nutrition support thru the development and implementation of CPGs – a dosing optimizing study • Funded by CIHR

REDOXS Study A new way of thinking!

Conclusions Nutrition Therapy : Modulating the Inflammatory Response and Improving Patient Outcomes Adjunctive Supportive Care Proactive Primary Therapy

To what extent did nutrition therapy (or lack thereof) play a role in this patient’s demise?

Case Scenario Caloric Debt Adequacy of EN Prolonged ICU stay, discharged weak and debilitated. Dies on day 43 in hospital from massive PE

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