RE-ENERGIZE Training Edmonton A RandomizEd Trial of ENtERal Glutamine to MinimIZE Thermal Injury: A multicenter Pragmatic RCT (definitive study) Study Sponsor Dr. Daren Heyland Clinical Evaluation Research Unit Project Leader: Maureen Dansereau September 20th 2011

www.criticalcarenutrition.com

A RandomizEd trial of ENtERal Glutamine to minimIZE thermal injury Double blind treatment EN glutamine 2700 patients with TBSA ≥ 20% if 18-59 yrs age ≥ 15% if 18-59 yrs age with inhalation injury ≥ 10% if ≥ 60 yrs age R 6 month mortality Concealed Stratified by site Maltodextran placebo

Total Sites: 59 sites worldwide! Sweden: 1 Germany: 1 Canada: 8 France: 1 Serbia: 1 Spain: 3 United States: 38 Greece: 2 Italy: 1 Israel: 1 Australia: 2 Total Sites: 59 sites worldwide!

Why are we doing this trial?

RE-ENERGIZE Training Edmonton Potential Beneficial Effects of Glutamine Enhanced Heat Shock Protein Enhanced insulin sensitivity Decreased Free Radical availability (Anti-inflammatory action) Inflammatory Cytokine Attenuation NF-kB ? Glutamine Therapy Glutathione Synthesis Reduced Translocation Enteric Bacteria or Endotoxins Reduction of Infectious complications Maintenance of Intestinal Mucosal Barrier Lymphocyte Function Fuel for Enterocytes Lymphocytes Nuclotide Synthesis GLN pool Critical Illness GLN Pool Preservation of TCA Function Anti-catabolic effect Preservation of Muscle mass Preserved Cellular Energetics- ATP content September 20th 2011

Glutamine: Important Questions Is glutamine ‘conditionally essential’? Is glutamine safe? Mechanism of harm? Negative interactions between glutamine and antioxidants What is the evidence for benefit in Burn patients?

Glutamine: A conditionally essential amino acid? Glutamine levels drop: - following extreme physical exercice - after major surgery - during critical illness Low glutamine levels are associated with: immune dysfunction higer mortality in critically ill patients Novak F, Heyland DK, A Avenell et al., Crit Care Med 2002 Oudemans-van Straaten HM, Bosman RJ, Treskes Met al., Intensive Car Med 2001

The “Oudemans-van Straaten-Study” “high” “low” => Low plasma glutamine at ACU admission is related to mortality.

Plasma Levels of Glutamine in Subset of Patients Baseline median plasma glutamine and selenium levels were within normal limits in all patients (Supplementary Figure 2 and Table S5). Glutamine supplementation led to a statistically significant increase in plasma glutamine at both day 4 and day 7 of ACU stay (P < 0.001) whereas antioxidant supplementation led to a significant increase in plasma selenium at day 4 and 7 of ACU stay (P < 0.001). Heyland N Engl J Med 2013;368:1489-97.

Glutamine and glutathione at ACU admission in relation to outcome Rodas Clinical Science (2012) 122, 591–597

P<0.001 P=NS

Future Trials Require Bedside Testing?

Plasma Glutamine Levels in Burn-injured Patients 24 Health Patients (control) Parry-Billings Lancet 1990

GLN Levels in RE-ENERGIZE Burn Pts N=18, unpublished observations

RCTs of IV Glutamine in ACU Patients (n=29) RE-ENERGIZE Training Edmonton RCTs of IV Glutamine in ACU Patients (n=29) A trend towards a reduction in mortality RR, 0.87, 95 % CI 0.75,1.01, p = 0.07, 27 trials, A significant reduction in hospital mortality RR 0.70, 95% CI 0.53, 0.92, p= 0.01, 15 trials, A trend towards a reduction in infectious complications RR, 0.89, 95 % CI 0.77,1.03, p = 0.12, 13 trials, A significant reduction in hospital length of stay weighted mean difference in days -2.56, 95% CI -4.71, -0.42, p=0.02, 11 trials www.criticalcarenutiriont.com\CPGs September 20th 2011

RCTs of EN Glutamine in ACU Patients (n=10) RE-ENERGIZE Training Edmonton RCTs of EN Glutamine in ACU Patients (n=10) No significant difference on mortality RR, 0.94, 95 % CI 0.65,1.36, p = 0.74 No impact on in infectious complications RR, 0.93, 95 % CI 0.79,1.10, p = 0.39, 4 trials A significant reduction in hospital length of stay weighted mean difference in days -4.73, 95% CI -8.56,-0.90, p=0.02, 7 trials. www.criticalcarenutiriont.com\CPGs September 20th 2011

On behalf of the REDOXS Study Investigators A RANDOMIZED TRIAL OF HIGH-DOSE GLUTAMINE AND ANTIOXIDANTS IN CRITICALLY ILL PATIENTS WITH MULTIORGAN FAILURE   The REDOXS study On behalf of the REDOXS Study Investigators N Engl J Med 2013;368:1489-97.

R R R The REDOXS study antioxidants glutamine 1200 ACU patients Factorial 2x2 design Double blind treatment glutamine R 1200 ACU patients R Concealed Stratified by site Evidence of placebo Multi-organ failure antioxidants placebo R placebo

The Research Protocol Inclusion Criteria Adults (>18) With 2 or more organ failures related to their acute illness : Requiring mechanically ventilation (P/F<300) Clinical evidence of hypoperfusion defined by need for vasopressor agents for more than 2 hour Renal dysfunction : Cr>171 (>1.93 mg/dL) or <500ml/24 hrs platelet < 50

High dose associated with Optimizing the Dose of Glutamine Dipeptides and Antioxidants In Critically Ill Patients: A Phase I dose finding study Parenterally Enterally Glutamine/day 0.35 gms/kg 30 gms Antioxidants per day 500 mcg Selenium Vit C 1500 mg Vit E 500 mg B carotene 10 mg Zinc 20 mg Se 300 ug High dose appears safe High dose associated with no worsening of SOFA Scores greater resolution of oxidative stress greater preservation of glutathione Improved mitochondrial function Heyland JPEN Mar 2007

Mortality Outcomes Note: all P values pertain to GLN vs No GLN; no significant differences between AOX vs. No AOX

Other Clinical Outcomes No differences between groups SOFA Need for dialysis Duration of mechanical ventilation PODS infections ACU and Hospital LOS

Selected Subgroup Analyses   OR (95% CI) compared to placebo P-values* Subgroup Deaths/n (%) GLN alone AOX alone GLN+AOX Overall 363/1218 (30%) 1.40 (0.98-2.00) 1.20 (0.84-1.72) 1.42 (1.00-2.03) Study Setting Region 0.37 Canada 303/1044 (29%) 1.41 (0.96-2.07) 1.14 (0.77-1.67) 1.29 (0.88-1.89) USA 44/131 (34%) 1.56 (0.51-4.81) 1.43 (0.47-4.38) 3.43 (1.17-10.07) Europe 16/43 (37%) 0.86 (0.12-5.9) 2.40 (0.39-14.88) 0.89 (0.14-5.48) Baseline Patient Characteristics Admission category 0.52 Surgical 59/255 (23%) 2.16 (0.91-5.15) 1.94 (0.78-4.82) 1.58 (0.67-3.76) Medical 304/963 (32%) 1.28 (0.87-1.89) 1.08 (0.73-1.60) 1.43 (0.97-2.12) Cancer patients 0.74 No 297/1048 (28%) 1.48 (1.01-2.18) 1.15 (0.77-1.71) 1.42 (0.97-2.10) Yes 66/170 (39%) 1.05 (0.41-2.73) 1.43 (0.60-3.40) 1.38 (0.58-3.27) Etiology of Shock 0.71 Cardiogenic 74/240 (31%) 1.24 (0.56-2.79) 1.62 (0.75-3.51) 2.19 (1.03-4.67) Septic 256/826 (31%) 1.43 (0.93-2.19) 1.06 (0.69-1.63) 1.21 (0.79-1.86) Other/Unkown/None 33/152 (22%) 1.45 (0.46-4.57) 1.45 (0.43-4.86) 1.83 (0.60-5.78) Vasopressors <15 mcg/min 162/595 (27%) 1.58 (0.92-2.70) 1.66 (0.97-2.84) 1.50 (0.87-2.58) >=15 mcg/min 201/623 (32%) 1.32 (0.82-2.13) 0.92 (0.57-1.51) 1.39 (0.87-2.22) Renal dysfunction 0.035 216/776 (28%) 0.93 (0.59-1.46) 0.90 (0.58-1.40) 1.14 (0.74-1.77) 147/442 (33%) 2.75 (1.50-5.03) 2.16 (1.15-4.07) 2.15 (1.17-3.94) OR-odds ratio; CI-confidence interval; GLN-Glutamine; AOX-antioxidants

Conclusions Glutamine and antioxidants at doses studied in this study do not improve clinical outcomes in critically ill patients with multi-organ failure Glutamine may be harmful For both glutamine and antioxidants, the greatest signal of harm was in patients with multi-organ failure that included renal dysfunction upon study enrollment.

Metaplus Study 14 ACUs in the Netherlands, Germany, France, and Belgium. 301 adult patients who were expected to be ventilated and to require EN for more than 72 hours Randomized to intervention feed High-protein EN enriched with 21 grams of glutamine, extra antioxidants including an additional 275 mcg of selenium and an additional 7.5 grams of fish oils, n = 152) or control (standard high-protein EN, n = 149). Intention-to-treat analysis for total population as well as predefined medical, surgical, and trauma subpopulations. Van Zanten JAMA 2014;312:514

Metaplus Study No differences in infection (primary end point) 53% in the enriched group vs 52% in the control group (P = .96). No differences in any secondary end points including mortality, Sequential Organ Failure Assessment (SOFA) scores, mechanical ventilation duration, ACU and hospital lengths of stay, and subtypes of infections according to CDC definitions. hazard ratio of 1.57 (95%CI, 1.03-2.39; P = .04) for 6-month mortality adjusted for age and Acute Physiology and Chronic Health Evaluation II score A higher 6-month mortality rate in the medical subgroup: 54% (95%CI, 40%-67%) in the enriched group vs 35% (95%CI, 22%-49%) in the control group (P = .04). No signal of harm in renal failure Van Zanten JAMA 2014;312:514

2015 Canadian Nutrition CPGs: IV Glutamine Recommendation: When parenteral nutrition is prescribed to critically ill patients, we recommend parenteral supplementation with glutamine NOT be used*. There are insufficient data to generate recommendations for intravenous glutamine in critically ill patients receiving enteral nutrition, but given the safety concerns we also recommend intravenous glutamine NOT be used in enterally fed critically ill patients. *downgraded from ‘should be considered’

2015 Canadian Nutrition CPGs: Combined IV+ EN Glutamine Recommendation: Based on one level 1 study (REDOXS) and 1 level 2 study, we strongly recommend that high dose combined parenteral and enteral glutamine supplementation NOT be used in critically ill patients

Key Question If we conclude that glutamine has potential for harm, what impact does this have on our clinical recommendations for burn patients?

RE-ENERGIZE Training Edmonton RCTs of Glutamine in Burn Injury Patients Total of 6 studies involving 225 patients Effect on Mortality (n=4) Margot, please update The analysis of the 6 trials in 225 burn patients shows a significant effect on mortality (RR, 0.22, 95% CI 0.07, 0.62, p = 0.005, 4 trials), no effect on infections (RR, 0.78, 95 % CI 0.46, 1.31, p = 0.34, 3 trials) but a significant reduction in hospital length of stay (WMD: 6.06, 95% CI -9.91, -2.20, p= 0.002, 5 trials).15 RR, 0.22, 95% CI 0.07, 0.62, p = 0.005 www.criticalcarenutrition.com September 20th 2011

RCTs of Glutamine in Burn Injury RE-ENERGIZE Training Edmonton RCTs of Glutamine in Burn Injury Effect on Infection (n=3) RR, 0.78, 95 % CI 0.46, 1.31, p = 0.34 September 20th 2011

RCTs of Glutamine in Burn Injury RE-ENERGIZE Training Edmonton RCTs of Glutamine in Burn Injury Effect on Hospital Length of Stay (n=5) WMD: 6.06, 95% CI -9.91, -2.20, p= 0.002 September 20th 2011

RE-ENERGIZE Training Edmonton International observational study of nutritional support in mechanically ventilated patients following major burn injury (90 patients from 15 Countries) Energy and Protein deficits in relation to mortality (Relationship persisted despite adjustment for severity of illness) Protein Deficit (g) Energy Deficit (Kcal) Energy deficit Protein deficit Survived Died 48% of patients receiving glutamine Glutamine administration was associated with survival when adjusted for APACHE II ( p = 0.007). Czapran Burns 2014 September 20th 2011

RE-ENERGIZE and REDOXs Differences Between RE-ENERGIZE and REDOXs

Compelling Need to Answer the Study Question Primary research question: In patients with severe, life-threatening burn injury, what is the effect of enteral glutamine on 6 month mortality? Secondary Research question: In patients with severe, life-threatening burn injury, what is the effect of enteral glutamine on -time to discharge alive from hospital, -hospital-acquired blood infections, -hospital mortality, -duration of stay in ACU and hospital, -health-related quality of life -and health care resources?

A RandomizEd trial of ENtERal Glutamine to minimIZE thermal injury Double blind treatment EN glutamine 2700 patients with TBSA ≥ 20% if 18-59 yrs age ≥ 15% if 18-59 yrs age with inhalation injury ≥ 10% if ≥ 60 yrs age R 6 month mortality Concealed Stratified by site Maltodextran placebo

< 72 h (ACU admission to time of consent) Study Overview 6 month < 74 hours Mortality assessment < 72 h (ACU admission to time of consent) 2 h ACU Admission Consent Obtained First Dose of IP Randomization 3 mos. Dosing until 7 days after last graft up to 3 mos. Maintain regular contact 6 month Data collection from ACU admission to 10 days after last graft up to 3 mos. SF-36 Quality of Life Assessment Activities of Daily Living Instrumental Activities of Daily Living Employment Status Assessment

Definitive Study: Inclusion Criteria Deep 2nd and/or 3rd degree burns requiring skin grafting*. For patients age 18 – 59 years we require a burn of ≥ 20% TBSA (Total Body Surface Area) or a minimum of 15 % TBSA when concomitant inhalation injury is present. For patients aged 60 years or older we require a burn of ≥10% TBSA. Smoke inhalation injury is defined as: restricted to injury below the glottis caused by products of combustion. Diagnosis of inhalation injury requires both of the following:        1) history of exposure to products of combustion        2) bronchoscopy revealing one of the following below the glottis                       evidence of carbonaceous material                       signs of edema or ulceration *Note: there is no minimum area that requires grafting. As long as the total burn size meets the inclusion criteria and a graft is required, the patient is eligible.

Definitive Study: Exclusion Criteria >72 hrs from admission to ACU (Acute Care Unit) to time of consent Patients younger than 18 years of age (age of maturity for an eligible patient to obtain consent is 18 years in Canada and in the US) In patients without known renal disease, renal dysfunction defined as a serum creatinine >171 μmol/L or >1.93 mg/dL or urine output of less than 500 ml/last 24 hours (or 80 ml/last 4 hours if a 24 hour period of observation is not available). In patients with acute on chronic renal failure (pre-dialysis), an absolute increase of >80 μmol/L or >0.9 mg/dL from baseline or pre-admission creatinine or a urine output of <500 ml/last 24 hours (or 80 ml/last 4 hours) will be required. Patients with chronic renal failure on dialysis will be excluded. Changed to REDOXS criteria to address reviewer’s concerns

Definitive Study: Exclusion Criteria 4. Liver cirrhosis -Child’s class C liver disease 5. Pregnancy (urine/blood tests for pregnancy will be done on all women of childbearing age by each site as part of standard ACU practice) 6. Contra-indication for EN: intestinal occlusion or perforation, intra-abdominal injury 7. Patients with injuries from high voltage electrical contact 8. Patients who are moribund (not expected to survive the next 72 hours) 9. Patients with extreme body sizes: BMI < 18 or > 50 kg/m2 10. Enrolment in another industry sponsored ACU intervention study (co-enrollment in academic studies will be considered on a case by case basis) 11. Received glutamine supplement for > 24 hrs prior to randomization 12. Known allergy to maltodextrin, corn starch, corn, corn products or glutamine

Study Intervention OR MALTRIN® Maltodextrin Enteral glutamine (0.5 gm/kg/day) or maltodextrin will be given through the feeding tube, q4h until 7 days post last successful graft

Study Intervention The study intervention is to be mixed in 50 mL of water per 5g packet and given as a bolus every 4 hours via the enteral route.   Administer the study intervention immediately after mixing with water to avoid thickening of the mixture. If the mixture becomes too thick to administer as a bolus, add water. Have not observed increase in tube blockages When the patient is tolerating oral feeds, the boluses may be switched to TID or QID via the oral route according to the patient’s preference, as long as the patient receives the daily prescribed number of packets.  

Study Intervention Avoid mixing the IP in water when given orally. Patients who participated in the pilot study reported it did not taste good when mixed with water. There should be little to no difference in taste of the glutamine and maltodextrin. Do NOT mix the study intervention with: soda or highly acidic juices, such as: grapefruit juice orange juice lemonade.   Why? The study intervention becomes unstable in an acidic medium.

Duration of Study Intervention ACU admission 7 days post last successful graft (max 3 months or ACU d/c, whichever first) Study Intervention Randomization

Co-interventions: Standardization of Nutrition Prescribed calorie ranges Prescribed protein ranges Vitamin/mineral prescription Optimization of the Delivery of Enteral Nutrition Glycemic control Arginine enriched formulas (> 6 gms arginine/L) i.e. Pivot, Perative Glutamine supplements or formulas containing higher than standard amounts of glutamine i.e. Juven

Enteral Feeding Protocol STOP enteral nutrition if the patient develops : -bowel obstruction -bowel perforation -paralytic ileus Start Enteral Nutrition as soon as possible after burn injury, preferably within 24 hrs of burn injury, if possible WATER FLUSHES: Flush tube with at least 10 mls of sterile water: -q4hrs during feedings -after aspiration for GRVs -before and after meds BLOCKED TUBE: Pancrealipase, 8000 units, with crushed Na Bicarb 500mg in 5ml warm water via feeding tube as needed. Elevate HOB to 45 degrees, if possible If gastric feeding, check GRVs q 4 hrs. 1) Refeed gastric residual 2) Continue with Enteral Nutrition Is the GRV > 250 mls? NO YES Is this the 1st GRV > 250 ml*? YES NO 1) Refeed GRV to 250ml max and discard the rest 2) Start Maxeran 10mg IV q 6 hrs 3) Continue with Enteral Nutrition This is a rechecked residual >250 mls: 1) Discard the residual 2) Continue with Motility agents 3) Switch to SMALL BOWEL FEEDING 4) Restart Enteral Nutrition 5) Monitor enteral nutrition tolerance, but do not monitor GRVs if small bowel feeding * Gastric residual volume (GRV) of 250 mls is the minimum threshold volume. Volumes higher than 250 mls are acceptable if allowed at the individual site.

Outcomes Primary Outcome: 6 month mortality Secondary Outcome: Time to discharge alive Teritiary Outcomes: Health-related quality of life (SF-36 @ 6 months) Incidence of acquired bacteremias due to Gram negative organisms Hospital Mortality Duration of mechanical ventilation ACU stay and hospital stay 50

Results of Pilot Study 203 patients enrolled in 8 sites Approx 1 patient/site/month >90% of prescribed doses of study medication were delivered. Only 2% of patients have been lost to follow-up at 6 months. Good compliance with study procedures and filling out the case report form Plan to roll the data from the pilot trial into this current proposal so we have not analyzed the trial by group.

Results of Pilot Study: Patient Characteristics RE-ENERGIZE Training Edmonton Results of Pilot Study: Patient Characteristics Characteristics n Male/Female % 79/21 168 Age , yrs (mean, SD) 47.7 ± 18.3 179 % TBSA (mean, SD) 32.3 ± 15.3 Age + % TBSA (mean, SD) 80.0 ± 19.6 age + %TBSA <60 16.8% age + %TBSA 60-89 52.0% age + % TBSA >90 31.3% % Mechanically Ventilated 64/149 (43%) 149 ACU LOS days (mean, SD) 32.6 ± 26.8 159 Hospital LOS days (mean, SD) 34.9 ± 29.5 153 ACU mortality 8/142 (6%) 150 6 month mortality 15% 106 September 20th 2011

Current Status and Timelines Definitive Trial Funded by CIHR Site start-up in progress Pilot sites resume by Dec 1, 2015 Rest of Canadian sites initiate by end of 2015 New sites on board by end of second quarter 2016 Continue to develop network of interested burn units 4 years of enrolling patients

Questions and Discussion Points? Patients? Study Products Feeding protocol 6 month follow up Adequate research infrastructure Competing studies Financials and Timelines

Conclusions RE-ENERGIZE trial Thank you for your interest and support Will ask a clinically important question Has the potential to save lives and reduce morbidity whether positive or negative Largest burn trial ever! Thank you for your interest and support

RE-ENERGIZE Training Edmonton Questions? September 20th 2011