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Lipid Formulations for Patients Requiring Parenteral Nutrition: A Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines – An Update

Last updated: August 2, 2019
Project Number: RC1164-000
Product Line: Rapid Response
Research Type: Drug
Report Type: Summary with Critical Appraisal
Result type: Report

Question

  1. What is the clinical effectiveness of lipid formulations in adult and pediatric patients requiring total parenteral nutrition?
  2. What is the cost-effectiveness of lipid formulations in adult and pediatric patients requiring total parenteral nutrition?
  3. What are the evidence-based guidelines associated with the use of lipid formulations in adult and pediatric patients requiring total parenteral nutrition?

Key Message

This review included seven systematic reviews, eight randomized controlled trials, two economic studies, and two guidelines. Evidence of low to very low quality was insufficient to determine the comparative clinical effectiveness of different types of lipid formulations for parenteral nutrition in preterm, term, or late preterm infants (with or without surgical conditions or parenteral nutrition-associated liver disease/cholestasis). In hospitalized adult patients, patients with fish oil enriched parenteral nutrition had significantly reduced infection rate and length of hospital stay, and in improved liver function and inflammatory status in comparison to patients with non-fish oil enriched parenteral nutrition, despite no difference in mortality. In adult patients requiring long-term parenteral nutrition, there were no significant differences between different lipid emulsions including those containing fish oil with respect to liver function, inflammatory status and other biochemical outcomes. Economic evaluations from the Chinese hospital perspective suggested that fish oil enriched parenteral nutrition was more cost-effective than non-fish oil enriched parenteral nutrition, and structured triglyceride-based parenteral nutrition was associated with cost benefit compared to medium chain triglyceride/long chain triglyceride parenteral nutrition in critically ill intensive care unit patients. The European Society for Parenteral and Enteral Nutrition guideline on clinical nutrition in liver disease recommends that fish oil enriched parenteral nutrition can be used in infants and children with parenteral nutrition-associated cholestasis, and lipid emulsions with a reduced ratio of n-6 over n-3 fatty acids can be used in adult patients with suspected parenteral nutrition-associated liver disease/cholestasis. Another European Society for Parenteral and Enteral Nutrition guideline on clinical nutrition in the intensive care unit recommends that fish oil enriched parenteral nutrition (fish oil dose 0.1 to 0.2 g/kg/day) can be given to intensive care unit patients requiring parenteral nutrition. The recommendations in both guidelines were made based on low quality evidence, but with strong consensus.Larger well-designed trials are needed to determine the optimal lipid composition, and whether the addition of fish oil lipid emulsions has any advantage over other formulations for clinical and biochemical outcomes in infants requiring parenteral nutrition. Findings may not be generalizable to the Canadian context, and given their limitations they should be interpreted with caution.