Recommendations Summary

ONC: Parenteral Glutamine and Hematopoietic Cell Transplantation (HCT) in Adult Oncology Patients 2013

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

• Recommendation(s)

  ONC: Parenteral Glutamine and Hematopoietic Cell Transplantation (HCT) in Adult Oncology Patients

  When parenteral nutrition (PN) is required for patients undergoing hematopoietic cell transplantation (HCT), the registered dietitian nutritionist (RDN) may or may not recommend parenteral glutamine (GLN) in doses ranging from 0.2g to 0.5g per kg per day. Research indicates parenteral GLN should be initiated early in the treatment course. Parenteral GLN is associated with improved nitrogen balance and decreased morbidity. However, decreased hospital length of stay (LOS) was found only when data from allogeneic and autologous transplants were combined.

  Rating: Fair
  Conditional

  • Risks/Harms of Implementing This Recommendation

    • Use caution when considering provision of parenteral glutamine to oncology patients who have hepatic failure or insufficiency
    • Recommend monitoring liver function tests
    • Risks associated with parenteral glutamine administration are similar to those of parenteral nutrition (i.e., increased risk of infection).

  • Conditions of Application

    • Recommendation is applicable to adult oncology patients undergoing HCT, who require PN
    • Availability and access to supplemental IV glutamine
    • Consider advance directives when planning nutrition intervention.

  • Potential Costs Associated with Application

    Additional costs may be incurred with use of parenteral glutamine.

  • Recommendation Narrative

    Guideline B4

    Parenteral GLN in pharmacologic doses may be beneficial in patients undergoing HCT (August et al, 2009).

    • Rationale: Studies evaluating the impact of enterally administered GLN show no reduction in morbidity or mortality. Studies evaluating parenterally administered GLN show an improvement in nitrogen balance and decreased morbidity.
    • When data from allogeneic and autologous transplants were combined, there was a shorter hospital LOS, compared to no effect from GLN-supplemented PN, when given post transplant to patients undergoing autologous transplantation
    • In one small study of prophylactic PN vs. PN initiated after a decrease in oral intake,  patients had a shorter disease-free survival, with no impact on morbidity or overall survival when they received supplemental GLN. These patients had a reduction in the incidence of severe mucositis after receiving supplemental GLN parenterally. These positive results were not duplicated with orally supplemented GLN.
    • A Cochrane Review concluded that while PN-supplemented GLN may not be associated with reduced hospital LOS,  patients may have fewer bloodstream infections
    • More research is needed to determine appropriate dose and timing. However, use of parenteral GLN continues to be complicated, since parenteral GLN is only available as a prescription prepared by a compounding pharmacy in the US.

  • Recommendation Strength Rationale

    The Academy of Nutrition and Dietetics (AND) and the Oncology Expert Work Group concurs with the American Society of Parenteral and Enteral Nutrition (ASPEN) Clinical Guidelines: Nutrition Support Therapy During Adult Anticancer Treatment and in Hematopoietic Cell Transplantation and approved the following equivalency scale: External Guideline EAL Equivalency Rating.

    Evidence to support the recommendation is Grade C (EAL Rating Equivalent: Fair).

  • Minority Opinions

    None.

• Supporting Evidence

  The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

  • References
  • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

    August DA, Huhmann MB; American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr. 2009 Sep-Oct; 33 (5): 472-500. doi: 10.1177/0148607109341804. No abstract available. PMID: 19713551.

    Vanek VW, Matarese LE, Robinson M, Sacks GS, Young LS, Kochevar M; Novel Nutrient Task Force, Parenteral Glutamine Workgroup; American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. position paper: parenteral nutrition glutamine supplementation. Nutr Clin Pract. 2011 Aug; 26 (4): 479-494. doi: 10.1177/0884533611410975. Epub 2011 Jun 22. No abstract available. PMID:21697551.