Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China.
Ther Clin Risk Manag. 2013;9:37-43. doi: 10.2147/TCRM.S41022. Epub 2013 Feb 7.
A retrospective utilization study was performed to evaluate utilization patterns for enteral nutrition in a university teaching hospital.
Enteral nutrition was divided into three types according to the nitrogen source, ie, total protein type [Nutrison Fibre(®), Fresubin Energy Fibre(®), Fresubin(®), Supportan(®) (a special immunonutrition for cancer patients or patients with increased demands for omega-3 fatty acids), Fresubin Diabetes(®) (a diabetes-specific formula), Ensure(®)]; short peptide type (Peptison(®)); and amino acid type (Vivonex(®)). A pharmacoeconomic analysis was done based on defined daily dose methodology.
Among hospitalized patients taking enteral nutrition, 34.8% received enteral nutrition alone, 30% concomitantly received parenteral nutrition, and 35.2% received enteral nutrition after parenteral nutrition. Combined use of the different formulas was observed in almost all hospitalized patients receiving enteral nutrition. In total, 61.5% of patients received triple therapy with Nutrison Fibre, Fresubin Diabetes, and Supportan. Number of defined daily doses (total dose consumed/defined daily dose, also called DDDs) of formulas in descending order were as follows: Nutrison Fibre, Fresubin Energy Fibre, Fresubin Diabetes > Supportan > Peptison, Ensure > Vivonex, Fresubin. The ratio of the cumulative DDDs for the three types of enteral nutrition was 35:2.8:1 (total protein type to short peptide type to amino acid type). Off-label use of Fresubin Diabetes was also observed, with most of this formula being prescribed for patients with stress hyperglycemia. Only 2.1% of cancer patients received Supportan. There were 35 cases of near misses in dispensing look-alike or sound-alike enteral nutrition formulas, and one adverse drug reaction in an elderly malnourished patient who did not receive vitamin K1-enriched enteral nutrition during treatment with cefoperazone. After 4 months of the trial intervention, off-label use of Fresubin Diabetes was no longer endorsed by the Drug and Therapeutics Committee for nondiabetic patients, and the proportion of this formula prescribed for patients with stress hyperglycemia decreased by 20%, with a 10-fold increase in the amount of Supportan prescribed for cancer patients. Near misses in dispensing look-alike or sound-alike enteral nutrition were successfully abolished, and no severe coagulation disorders occurred after prophylactic administration of vitamin K1-enriched enteral nutrition in elderly malnourished patients receiving cefoperazone.
This utilization study indicates that continuous quality improvement is necessary and that a Drug and Therapeutics Committee can play an important role in promoting rational and safe use of enteral nutrition. Appropriateness of this therapy still needs to be improved, especially in addressing the issues of non-evidence-based combined use of multiple enteral nutrition formulas, the relatively high rate of concomitant use of enteral and parenteral nutrition, off-label use of diabetes-specific Fresubin Diabetes, insufficient use of Supportan in cancer patients, and unnecessary use of Supportan in intensive care patients not suffering from cancer.
本研究回顾性评估了某教学医院肠内营养的使用模式。
根据氮源，肠内营养分为三种类型，即整蛋白型[能全力（Nutrison Fibre®）、瑞素能量纤维（Fresubin Energy Fibre®）、瑞素（Fresubin®）、能全力特殊型（Supportan®，适用于癌症患者或需要更多ω-3 脂肪酸的患者）、瑞代（Fresubin Diabetes®，糖尿病专用配方）、安素（Ensure®）]、短肽型（百普素（Peptison®））和氨基酸型（维沃（Vivonex®））。采用限定日剂量（DDD）法进行药物经济学分析。
接受肠内营养的住院患者中，34.8%单独使用肠内营养，30%同时使用肠外营养，35.2%在使用肠外营养后开始使用肠内营养。几乎所有接受肠内营养的住院患者都联合使用了不同的配方。共有 61.5%的患者接受能全力、瑞代和能全力特殊型的三联治疗。按 DDD 排序，使用量最大的三种肠内营养配方分别为：能全力、瑞素能量纤维、瑞代>能全力特殊型>百普素、安素>维沃、瑞素。三种肠内营养的累积 DDD 比值为 35:2.8:1（整蛋白型与短肽型与氨基酸型之比）。也发现了瑞代的超适应证使用，主要用于应激性高血糖患者。只有 2.1%的癌症患者使用能全力特殊型。在配制外观相似或发音相似的肠内营养配方时，有 35 例接近差错，1 例老年营养不良患者在使用头孢哌酮时未给予富含维生素 K1 的肠内营养，出现药物不良反应。在试验干预后的 4 个月内，药物与治疗委员会不再支持将瑞代用于非糖尿病患者，应激性高血糖患者使用瑞代的比例下降了 20%，癌症患者使用能全力特殊型的比例增加了 10 倍。成功消除了配制外观相似或发音相似的肠内营养配方时的差错，在接受头孢哌酮治疗的老年营养不良患者中预防性给予富含维生素 K1 的肠内营养后，未出现严重凝血功能障碍。
本利用研究表明，需要持续进行质量改进，药物与治疗委员会在促进肠内营养的合理和安全使用方面可发挥重要作用。这种治疗的适宜性仍需改善，特别是要解决多种肠内营养配方联合使用缺乏循证依据、肠内营养与肠外营养同时使用比例较高、瑞代用于糖尿病的超适应证使用、癌症患者使用能全力特殊型不足、非癌症重症监护患者使用能全力特殊型不必要等问题。
