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Issues related to the rational use of nutritional preparations in patients with inflammatory bowel disease are clearly explained in one article

 Last Update: 2023-02-01
 Source: Internet
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Contains 4 classic prescription analysis ~

written | Xie Dong and Tang Shihui
inflammatory bowel disease (IBD), mainly including ulcerative colitis (UC) and Crohn disease (CD), is a non-specific, chronic, recurrent, inflammatory disease
that mainly affects the gastrointestinal tract 。 Studies believe that IBD is more common in Western Europe and North America, and is closely related to Western lifestyles such as high-fat, high-protein and high-sugar diets, but in the past 20 years, due to obvious changes in Chinese people's eating habits, rhythm of life and environment, the incidence of IBD in China has grown rapidly
.

1.
What are the causes of nutritional disorders in IBD patients?

Nutritional disorders in IBD patients are common clinically, and clinical studies have found that more than 70% of IBD patients, more than 80% of CD patients, more than 90% of hospitalized CD patients, and more than 95% of CD patients requiring surgery are malnourished or at risk
of nutrition.

Nutritional disorders in IBD patients include malnutrition and nutritional risks, and the causes are complex, mainly including: (1) eating can induce or aggravate abdominal pain, diarrhea and other symptoms,
resulting in patients afraid of eating, often self-restricting diet, Ultimately leads to reduced nutrient intake;
(2) Intestinal mucosal lesions, intestinal fistula and other reasons greatly reduce the effective absorption area of the intestinal mucosa;
(3) Intestinal inflammation causes intestinal peristalsis to move too fast;
(4) abnormal intestinal microecology caused by various reasons;
(5) Intestinal and extraintestinal inflammation or concurrent infection lead to high catabolic state, and energy consumption is relatively increased;
(6) A large amount of nutrients are lost due to intestinal or extraintestinal inflammation;
(7) Some drugs will affect appetite and the digestion and absorption of nutrients, interfering with nutrient metabolism;
(8) Factors such as reduced outdoor activities affect the absorption of vitamin D and lead to muscle atrophy
.

2.
What are the dangers of nutritional disorders in IBD patients?

The malnutrition and nutritional risks of IBD are serious, mainly including:
(1) aggravating the condition;
(2) affect the efficacy;
(3) change the course of the disease;
(4) affect prognosis;
(5) affect the growth and development of pediatric patients;
(6) Affect the conception, pregnancy and fetal development of women of childbearing age;
(7) increase hospitalization and surgery rates;
(8) Increase the risk of postoperative complications and affect postoperative recovery;
(9) Increase the cost of diagnosis and treatment; (10) Reduce the quality of life
.

3.
How to conduct nutritional risk screening and nutritional status assessment for IBD patients?

Systematic analysis
of nutritional status in patients with IBD should be routinely performed.

There are many tools for nutritional risk screening, and the most common nutritional risk screening tool used by IBD patients is NRS-2002
.
A score of ≥3 indicates a nutritional risk and requires further nutritional assessment and nutrition therapy
based on the results of the assessment.
For patients with a score of <3, dynamic nutritional screening<b22> is recommended.

The assessment of nutritional status consists of two parts
: subjective and objective.

The patient's subjective overall assessment form PG-SGA is recommended as a subjective assessment tool
.
The main evaluation content of PG-SGA is composed of two parts: patient self-assessment and medical staff assessment, and the nutritional status is divided into severe malnutrition (≥9 points), moderate malnutrition (4~8 points) and normal nutrition (0~3 points).

The objective part includes two types of measurement indicators
: static and dynamic.
Static indicators refer to anthropometric indicators, including height, body weight, BMI, body composition, triceps skin fold thickness, upper arm muscle circumference, and other indicators used to assess chronic malnutrition; Dynamic measurements include nitrogen balance and visceral proteins with short half-lives, such as prealbumin
.

4.
How to choose enteral nutrition VS parenteral nutrition?

Nutritional support approaches include enteral nutrition (EN) as well as parenteral nutrition (PN), so how to choose?
Both have their pros and cons, but the general rule should be followed "as long as the intestine is functional, use the intestine; If part of the intestine is functional, use this part of the intestine; If part of the intestine has part of the function, also use this part of the intestine function" principle, EN
is preferred.

The role of enteral nutrition therapy in UC is mainly to correct malnutrition and reduce nutritional risks
.
The role of enteral nutrition therapy in CD is not only to correct malnutrition and reduce nutritional risk, but more importantly, to induce and maintain CD remission
.

Fifth, how much enteral nutrition is enough?

The total energy required by IBD patients is calculated as follows: the energy supply during remission is 25~30 kcal·kg-1·^d-1; The active phase needs to be 8%~10% higher than the remission period; An additional 10%~20%
should be given during the growth and development period.
The protein supply of IBD patients in remission should reach 1.
0g/kg-1·d-1, and the protein supply in the active phase should reach 1.
2~1.
5g/^kg-1·^d-1^.
Patients with IBD often have vitamin and trace element deficiencies and should be supplemented as
appropriate.

6.
How to choose appropriate enteral nutrition?

Enteral nutrition preparations are usually divided into three categories
: whole protein type, short peptide type and amino acid type.
IBD patients have intestinal microbiome imbalance, intestinal mucosal barrier structure and function abnormalities, and immune dysfunction, while whole-protein enteral nutrition preparations have certain immunogenicity and require further digestion before they can be absorbed
.

Therefore, IBD patients with severe intestinal lesions or severe dyspepsia should choose amino acid enteral nutrition preparations
.
IBD patients with intestinal lesions that are not severe can choose more cost-effective rectin or short peptide enteral nutrition preparations for nutritional therapy
.

7.
Precautions for the implementation of enteral nutrition

Pathways to enteral nutrition include oral and tube feeding
.
When implementing enteral nutrition therapy, priority should be given to enteral nutrition therapy by oral enteral nutrition
preparations.

In order to improve the tolerance and compliance of patients with oral enteral nutrition preparations, the following methods can be used: select the appropriate enteral nutrition preparations, mix 200~300 mL each time according to the instructions, put them in a thermos cup, and take 30~50 mL
orally every 3~5 minutes.
The above improved treatment methods may not only improve the efficacy, but also be easy to implement, and avoid the side effects
that may occur during nutritional therapy.

8.
Analysis of classic prescriptions

■ Prescription 1
Ansu - enteral nutrition powder (TP)
indications: can be used as a total nutritional support or partial nutritional supplement, Suitable for adults and children
over 4 years old.
Can be given orally or tube-feeding
.

Medication analysis: Ansul is a whole protein enteral nutrition preparation, containing protein, fat, carbohydrates, vitamins, minerals 5 major nutrients, no dietary fiber, no lactose, suitable for patients who need a low-residue formula, such as inflammatory bowel disease patients
.
Add 200ml of cold water to the cup, slowly stir and add Ansulin powder (55.
8g), stir until dissolved, and prepare into a dosage of 250ml, three
times a day.

Precautions: Ansulin is contraindicated in situations where oral or enteral intake is not possible, including intestinal obstruction, severe short bowel disease, or fistula
with high excretion.
It should not be used for patients
with galactosemia and cow's milk or soy protein allergy.

■Prescription 2
can be vegan - whole protein enteral nutrition (powder).

Indications: 1.
Anorexia and its related diseases; Such as loss of appetite caused by trauma or burns and late stage of tumor treatment 2.
mechanical gastrointestinal dysfunction; swallowing disorders, upper gastrointestinal obstruction, such as esophageal stricture 3.
critical diseases; 4.
preoperative feeding of malnourished patients; can be used for diabetic patients
.

Medication analysis: Nengquanglu is the only EN formula that has entered the "National Essential Drugs List
".
Can be vegan as a powder, more suitable for oral administration, family enteral nutrition is preferred; No slag, adjustable energy density, cost-effective
.
Each jar of 320g, providing 1500Kcal energy, dissolved 200ml of water per 9 scoops, providing 200Kcal energy, oral 3-5 times a day, 9 scoops/200ml
.

Precautions: Gastrointestinal discomfort such as nausea, vomiting, diarrhea and abdominal pain may occur when ingested too quickly or in severe excess, and should be used
in small amounts and multiple times.

■ Prescription 3
Baipro - short peptide enteral nutrition
Indications: For patients
who have loss of gastrointestinal function and are unable or unwilling to eat a sufficient amount of regular food to meet the nutritional needs of the body who should undergo enteral nutrition therapy.

Medication analysis: Baiprosu is a short peptide enteral nutrient
.
Short peptides are more effective in maintaining the intestinal barrier and reducing microflora displacement
.
Fast absorption, high utilization rate, rapid increase in protein levels
.
Low-fat formula with fast gastric emptying reduces the risk of
reflux aspiration.
Fill the container with 50ml of warm boiled water, add 1 bag of Baipro, and mix
thoroughly.
After the powder is completely dissolved, warm boiled water to 500ml, stir gently and mix well
.
For general patients, giving 2000kcal (4 sachets) per day can meet the body's needs
for nutrients.

Precautions: Patients with severe glucose metabolism should be used with caution; Patients with severe hepatic and renal insufficiency should be used
with caution.

■ Prescription 4
Vivo – Enteral Nutrition Powder (AA).

Indications: Enteral nutrition support
for patients with severe metabolic disorders and gastrointestinal dysfunction.
Such as the following patients: short bowel syndrome patients, pancreatitis patients, albumin low patients (less than 2.
5/100ml), chronic kidney disease patients, radiation enteritis cancer patients, postoperative patients
.

Medication analysis: Vivo is amino acid enteral nutrition, IBD patients with severe intestinal lesions or severe digestive malabsorption are best to choose amino acid enteral nutrition
.

Note: Before and after medication and during medication, body fluid balance
should be checked or monitored during medication.
Vivo combined with vitamin K-containing preparations with oral anticoagulants (eg, coumarins) can interfere with vitamin K metabolism
.

Expert profile
: Professor Cao Xiaocang

Chief physician and professor of the Department of Gastroenterology of Tianjin Medical University General Hospital, master tutor of Tianjin Medical University, Ph.
D.
of Peking Union Medical College∙Tsinghua University Health Science Center, postdoctoral fellow of Texas State University School of Medicine, and postdoctoral visiting scholar
of University of Lille School of Medicine, France.

Member of the Digestive Endoscopy Committee of the Inflammatory Bowel Disease Group of the Gastroenterology Branch of the Chinese Medical Association, Vice Chairman of the Youth Committee of the Behavioral Medicine Branch of the Chinese Medical Association, Member of the Clinical Epidemiology Collaborative Group of the Gastroenterology Branch of the Chinese Medical Association, Member of the Inflammatory Bowel Disease Group of the Gastroenterology Branch of the Chinese Medical Equipment Association, Member of the Intractable Diseases Professional Committee of the Inflammatory Enterology Professional Committee of the Proctology Branch of the Chinese Medical Doctor Association, Member of the Inflammatory Bowel Disease Expert Committee of the Digestive Endoscopy Professional Committee of the Chinese Society of Integrative Medicine, Member of the Inflammatory Bowel Disease Expert Committee of Beijing Medical Award Foundation, Member of the Standing Committee of the Inflammatory Bowel Disease Alliance of Wu Jieping Medical Foundation, Member of the Standing Committee of the Intestinal Microecology Professional Committee, Member of the Standing Committee of the Stem Cell Engineering Technology Branch of the Chinese Society of Biomedical Engineering, and Vice Chairman of the Inflammatory Bowel Group of the Gastroenterology Branch of Tianjin Medical Association

Research interests: biological therapy and cell therapy for autoimmune diseases of inflammatory bowel disease and digestive tract immune diseases, especially clinical application research of mesenchymal stem cell transplantation
.
His research achievements have been awarded by international conferences such as the American Annual Conference of Gastroenterology and the Annual Conference of Gastroenterology of the European Union, and dozens of papers
have been published in SCI journals and Chinese journals.

Xie Dong
is a clinical pharmacist at the General Hospital of Tianjin Medical University, a clinical pharmacist with a professional in gastroenterology at the National Clinical Pharmacist Training Base, and an MTM pharmacist certified by the American Pharmacists
Association (APhA).

Tang Shihui The web version of the clinical pharmacist

and doctor station of Tianjin Children's Hospital is online

Scan the QR code to directly view more clinical knowledge of gastroenterology and hepatology

👇👇👇 References:[1] HUANG Zhaopeng, CHAO Kang, LIN Minzhi, GAO Xiang.
Application status of enteral nutrition in the treatment of inflammatory bowel disease[J].
Chinese Journal of Digestion,2022,42(4):281-284.
DOI:10.
3760/cma.
j.
cn311367-20210616-00338 [2] DUAN Xia,LI Na,CHEN Xueshan.
Characteristics and application selection of enteral nutrition preparations[J].
Chinese Community Physician,2015,31(15):5,7.
DOI:10.
3969/j.
issn.
1007-614x.
2015.
15.
1.
[3] Enteral Parenteral Nutrition Branch of Chinese Medical Association, Inflammatory Bowel Disease Professional Committee of Chinese Medical Education Association.
Chinese Journal of Gastroenterology and Imaging (Electronic Edition),2021,11(1):8-15.
DOI:10.
3877/cma.
j.
issn.
2095-2015.
2021.
01.
002

Review of this article: Professor Cao Xiaocang Responsible editor: Wen Jiaxin
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