Strategy of nutrition management
Patients should have their gastrointestinal
function assessment before deciding about
their nutrition therapy - Takeshi Iwamoto

Those whose GI function is not working should
be managed by parenteral nutrition

KARACHI: The patients who require the nutrition therapy, their gastrointestinal function must be assessed first. If the GI function is working, patients are given enteral nutrition. However, if the GI function is not working, the patients should be managed by parenteral nutrition. In case of short term, peripheral parenteral nutrition is selected and for longer than one week or more, total parenteral nutrition using central venous route for infusion should be selected. This was stated by Mr. Takeshi Iwamoto, Director Marketing Support International Division from Otsuka Pharmaceutical Factory in Japan while giving a presentation on the basic strategy of nutrition management held at Kidney Center Karachi, recently. Meeting was attended by staff of Kidney Centre, Ms. Mozamila Saeed, Ms. Shabnam Razi Executive members of Pakistan Nutrition and Dietetic Society, Senior Executives from Otsuka Pakistan and Mr. Daisuke Hashimoto from Otsuka Japan.

Otsuka Pharmaceuticals, Takeshi Iwamoto stated is developing the intravenous infusion products, clinical nutrition products and our focus is on the total nutrition management. We have basic intravenous infusion products, parenteral nutrition and enteral nutrition, and we have the products for hepatic disease. Enteral nutrition is more physiological way and we must select the enteral nutrition if the GI function is working. When we think about nutrition management, we must think to maintain the protein. If we select the worst method, we lose body protein and when we lose protein it decrease the muscle mass, decrease the visceral protein, it leads to immunocompetence disorder, delay wound healing and results in organ damage. Glucose or dextrose can spare the body protein but it is not perfect. Taking the glucose could prevent the loss of protein, but there was a limit. We must consider to spare the loss of protein or amino acid by administering nutrition products.

Another product PROTEN GOLD, he stated contain the high quality soy protein 10g/sachet, which is used to fulfill daily protein requirement. Talking about nutrition products of liver disease with mechanism of BCAA rich products, he said that Leucine, isoleucine and valine are called BCAA. The significance of BCAA are that these are used as energy source of muscle, used in gluconeogenesis via Alanine, Promoting protein synthesis, inhibiting protein degradation, detoxification of blood ammonia and Playing central role in both promoting synthesis and inhibiting degradation of protein. Branched-chain amino acids (BCAA), amino acids which are metabolized in muscle, have been known to play an important role in a variety of pathological conditions, particularly in surgical stress and metabolism and nutrition during the hepatic coma. The BCAA prevents the hepatic encephalopathy by competing against the aromatic amino acids (phenylalanine and tyrosine), pre-false neurotransmitter in the blood-brain barrier of the brain . BCAA are also known that can improve hepatic encephalopathy.

Aminoleban Oral is a specially formulated nutritional formula for patients with chronic liver impairment. It is a nutritional supplement that contains high concentration of Branched-chain amino acids. It is a specially formulated nutritional formula for patients with chronic liver impairment. It is a nutritional supplement that contains high concentration of Branched-chain amino acids. It is indicated for the improvement of nutritional state in chronic liver impairment including those with hepatic encephalopathy. Aminoleban Oral is contraindicated in patients with a history of allergy to milk.

Mr. Takeshi Iwamoto from Otsuka Japan delivered a lecture on basic strategy of nutrition
management at Kidney Center Karachi, recently. Group Photograph taken at the occasion
shows Mr. Takeshi Iwamoto, Mr. Daisuke Hashimoto from Japan photographed with, Mr.
Tariq Shahid, Mr. Khalid Munir, Mr. Arshad Khan,
Ms. Mozamila Saeed, Ms. Faiza Khan,
Ms. Shabnam Razi, Urooj Aslam, Uzma Mustafa and others.

Hepatic encephalopathy Mr. Takeshi Iwamoto pointed out varies from mild to deep coma. Initial symptoms including restlessness, loss of attention, affection liability, sensitivity to stimulation and night awakening and daytime sleepiness. These symptoms may not be noticed even by family members without careful watching. However, it is important to notice at this point and start treatment in early stage. When the disease gets severe, the patient falls into deep coma and treatment is difficult. Usefulness of Aminoleban IV was examined in 368 patients with hepatic encephalopathy. The usefulness rate was 70.4% in a total of 368 patients. The Japanese Medical Guidelines for Liver cirrhosis also suggests that BCAA infusion solution is recommend, because it is effective for hepatic encephalopathy or coma. AMINOLEBAN Injection is effective in hepatic encephalopathy but after awakening a patient with Aminoleban IV, do not withdraw it promptly after oral intake becomes possible. Continue the administration for about one week while increasing dietetic proteins gradually to a meal for hepatic failure and, then, switch from Aminoleban IV to Aminoleban Oral combined with meals for hepatic failure.

Enteral nutrition, Takeshi Iwamoto further stated is the first choice, but sometimes enteral nutrition cannot reach in sufficient amount of calories and protein. It depends on the situation of patients. Enteral nutrition often cause vomiting or diarrhea. In critically ill patients, supplemental PN should be waited three days for nutritional risk patients, and seven days for other patients. For critically ill patients, supplement of protein or amino acids is required to maintain body protein. PAN-AMIN G can provide 27g of amino acid by 1000mL infusion with low calorie. It is very useful for supplement of amino acids. It is recommended to use for the patients who can eat food, but cannot eat enough due to several reason, like diarrhea, nausea .For thinking protein delivery, quality is important. Because the protein is the chain of decided amino acids. If the essential amino acid is deficient, the protein cannot be synthesized, insufficient quality of essential amino acid can’t make body protein. Quality is very important. Essential amino acid need to be administered. PAN-AMIN G contain the all kind of essential amino acids, he added.

Continuing Takeshi Iwamoto said that in a study, we investigated the effectiveness of peripheral venous administration of amino acids after esophagectomy. The results demonstrated that peripheral venous administration of amino acids in addition to enteral following high surgical stress is an extremely effective method of nutritional control, increase in Alb and PreAlb, and maintain body weight. Our next products, BFLUID injection, will become the first choice for supply amino acids and best products for supplemental parenteral nutrition. Administering BFLUID is the first choice to supply amino acid in short-term PN. Introduce early enteral nutrition and supplemental PN together, suggest that BFLUID is the most suitable product. Traditional beliefs still persist among surgeons to delay initiating nutrition support, despite recommendations to the contrary. Combinations of enteral and parenteral nutrition should be considered in patients in whom there is an indication for nutritional support, he added.

Ms. Faiza Khan on behalf of Pakistan Nutrition and Dietetic Society in her remarks urged Otsuka Management to organize scientific sessions and seminars for dietitians, physicians, para medics, and Nurses so that they are aware of importance of the nutritional management of Patients suffering from different diseases. Mr. Tariq Shahid, Director Marketing & Sales Otsuka Pakistan thanked the participants and assured to organize such programs to highlight the importance of nutritional therapy management. A Hand Book (Quick Review of Clinical Nutrition) printed by Otsuka Pakistan was distributed among the participants. Dr. Uzma Mustafa, Product Manager Otsuka Pakistan moderated the session.

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