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Focusing on Patient Management in
Home Parenteral Nutrition

It is estimated that approximately 39.000 people are receiving parenteral nutrition in their home. Patient support occurs through the coordination of several different healthcare professionals, and this process starts before the patient is discharged from the hospital. The hospital nutrition support team works with the home infusion company to determine effective ways to reach the patient's nutritional support goals.

A key element in the planning process involves evaluation of the patient's insurance criteria. Thereby, reassessment and alteration in therapy may be made without inconveniencing the patient and their family to identify an optimal alternative. Another very important element is the patient's home parenteral nutrition prescription. The home infusion company will review the formula and make recommendations to adjust the prescription to meet the patient's needs in the home. This may include suggesting a 3-in-1 solution (lipids, amino acids, and dextrose) to avoid multiple infusion pumps; an ambulatory pump to provide mobility, cyclic administration (12- 14 hours) for convenience; and assessing which items must be added just prior to use due to limited stability (i.e. multivitamins). The home infusion company trains the patient on the storage, preparation, administration, and disposal of their parenteral nutrition and supplies.

It is important that home infusion providers focus on patient satisfaction Optimal outcomes occur with good clinical care, careful monitoring, and experience. (LLS)

Reference: Management of the Home Parenteral Nutrition Patient. Nutrition in Clinical Practice. August 2003. Vol. 18 No.4.
 

Parenteral Iron Therapy

Iron deficiency anemia may be a problem in patients who cannot absorb or tolerate oral iron supplementation. The largest categories of these patients are those receiving hemodialysis (losses of iron) and long-term parenteral nutrition (inability to absorb iron). Patients who have undergone bariatric surgery for the treatment of obesity may require parenteral iron supplementation. Patients with low iron stores will have a decreased response to erythropoietin therapy.

There are 3 parenteral iron preparations currently available: iron dextran, sodium ferric gluconate, and iron sucrose. Iron dextran is FDA approved for the treatment iron deficiency in patients for whom oral administration is unsatisfactory or impossible. The indication for both sodium ferric gluconate and iron sucrose is limited to the treatment of iron deficiency in patients undergoing chronic hemodialysis who are receiving supplemental erythro-poietin therapy. There is clinical experience with the use of sodium ferric gluconate and iron sucrose beyond the approved indications.

The product labeling of iron dextran carries a "black box" warning because of the risk of anaphylactic reaction. A test dose of 25 mg is needed to determine susceptibility to a severe reaction, followed by a one hour observation period. Appropriate agents for the treatment of anaphylactic reaction must be available.

The safety profiles of sodium ferric gluconate and iron sucrose have shown a lower risk of serious adverse reactions. These products have been available in Europe for 40 years. Safety comparisons have been based on historical and retrospective data, no prospective trials have been done These safety profiles may change with expanded use of the newer agents. Data does not support cross-sensitivity between the iron preparations.

Hypotension (non-allergy mediated) is the most common adverse event with all the iron preparations. This is associated with rapid administration and results in flushing, lightheadedness, severe pain in the back and other symptoms usually resolving in 1-2 hours. Other reactions may be delayed in onset to 24-48 hours. Delayed reactions may include myalgia, arthralgia, backache, fever, headache, nausea, vomiting and dizziness. These reactions are more likely dose related.

Advantages of iron dextran include greater clinical experience and ability be added to nonlipid parenteral nutrition formulas which simplifies administration in home parenteral nutrition patients. There are no compatibility studies with parenteral nutrition for sodium ferric gluconate or iron sucrose, however overall safety profiles of these supplements may lead to increased use. (SP)

Reference: Updale on Parenleral lron Therapy. Nutrition in Clinical Practice 18:318-326, August 2003.
 

New Intravenous Immune Globulin

On August 28, 2003. Gamunex® (Immune globulin, Bayer) gained FDA approval for primary immunodeficiency (PI) and idiopathic thrombocytopenic purpura (ITP), Gamunex® is a ready to use solution form of immune globulin produced with a new purification process, This purification process has the benefit of extending the half-life and shelf life of GamuneX® as compared to Gamimune®-N (Bayer), It also has and increased stability without the use of sugar.

The recommended dosage for PI is 300-600 mg/kg at 3 or 4 week intervals to prevent infection, Total dosing for ITP is 2 g/kg total.
This may be given in 2 divided doses of 1 g/kg on two consecutive days, or 5 divided doses of 0.4 gm/kg on five consecutive days. If platelets increase adequately after the first dose of the two-day regimen, the second dose may be withheld.

Gamunex® is infused initially at 0.01 ml/kg/min for 30 min, and may then gradually be increased to O.08ml/kg/min. No filtration is needed.

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The articles herein are provided for general information and are not intended to provide specific advice or recommendations for any reader.