1. Glutamine and Antioxidants in the critically ill: End of an Era? Daren K. Heyland MD Professor of Medicine Queen’s University, Kingston, ON Canada On behalf of the REDOXS Study Investigators

2. I LOVE TURKEY

3. Glutamine: Important Questions Is glutamine ‘conditionally essential’? Is glutamine safe? –Mechanism of harm? –Negative interactions between glutamine and antioxidants What are the recommendations for glutamine in 2015?

4. 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 Glutamine: A conditionally essential amino acid?

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

6. Potential Beneficial Effects of Glutamine Fuel for Enterocytes Lymphocytes NuclotideSynthesis Maintenance of Intestinal Mucosal Barrier Maintenance of LymphocyteFunction Preservation of TCA Function Decreased Free Radical availability (Anti-inflammatory action) GlutathioneSynthesis GLNpool Enhanced Heat Shock Protein Shock Protein Anti-catabolic effect Preservation of Muscle mass ReducedTranslocation Enteric Bacteria or Endotoxins Reduction of Infectious complications Inflammatory Cytokine Inflammatory CytokineAttenuation NF-kB NF-kB? Preserved Cellular Energetics- ATP content GLNPool Critical Illness Enhanced insulin sensitivity Glutamine Therapy

7. Plasma Levels of Glutamine in Subset of Patients P <0.001 Heyland N Engl J Med 2013;368:1489-97.

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

9. Future Trials Require Bedside Testing?

10. Double-blind, multicenter RCT 142 trauma patients (excluded renal failure) 0.5 gm/kg of Ala-Gln dipeptide x 5 days unrelated to PN vs. saline placebo (pharmaconutrition) Overall, no effect on infection (primary endpoint), LOS, or mortality No effect in subgroup of severe trauma (ISS>24) No effect in subgroup that had low levels of GLN at baseline (n=60) Of treated patients, 39% had low plasma levels at END of treatment – day 6 levels associated with worse outcomes

11. Glutamine: Is it safe?

12. 1200 ICU patients Evidence of Multi-organ failure R glutamine placebo Concealed Stratified by site R R antioxidants placebo Factorial 2x2 design Double blind treatment placebo antioxidants The REDOXS study Heyland N Engl J Med 2013;368:1489-97.

13. The Research Protocol 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 or <500ml/24 hrs –platelet < 50 Inclusion Criteria

14. Optimizing the Dose of Glutamine Dipeptides and Antioxidants In Critically Ill Patients: A Phase I dose finding study 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 ParenterallyEnterally Glutamine/day0.35 gms/kg30 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

15. Mortality Outcomes P=0.07 P=0.049 P=0.02 Note: all P values pertain to GLN vs No GLN; no significant differences between AOX vs. No AOX

16. Pre-specified Sub-group Analysis Glutamine vs. No Glutamine 28 day mortality, OR with 95% CI)

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

18. Post-hoc Secondary Analyses

19. Adjusted Analysis The 28-day mortality rates in the placebo, glutamine, antioxidant and combination groups were 25%, 32%, 29% and 33% respectively. After adjusting for all statistically significant baseline characteristics, the corresponding adjusted ORs remained virtually unchanged at: Glutamine 1.4 (1.0-2.1, P =0.054) Antioxidant 1.2(0.8-1.8, P =0.34) Both 1.4 (0.9-2.0, P =0.10) JPEN May 2014

20. Selected Subgroup Analyses OR (95% CI) compared to placeboP-values* SubgroupDeaths/n (%)GLN aloneAOX aloneGLN+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 Canada303/1044 (29%)1.41 (0.96-2.07)1.14 (0.77-1.67)1.29 (0.88-1.89) USA44/131 (34%)1.56 (0.51-4.81)1.43 (0.47-4.38)3.43 (1.17-10.07) Europe16/43 (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 0.37 <15 mcg/min162/595 (27%)1.58 (0.92-2.70)1.66 (0.97-2.84)1.50 (0.87-2.58) >=15 mcg/min201/623 (32%)1.32 (0.82-2.13)0.92 (0.57-1.51)1.39 (0.87-2.22) Renal dysfunction 0.035 No216/776 (28%)0.93 (0.59-1.46)0.90 (0.58-1.40)1.14 (0.74-1.77) Yes147/442 (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

21. 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.

22. Metaplus Study 14 ICUs 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

23. 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 secondary end points included mortality, Sequential Organ Failure Assessment (SOFA) scores, mechanical ventilation duration, ICU 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). Van Zanten JAMA 2014;312:514

24. 6 Month Survival Curves for REDOXS and METAPLUS Adjusted model, glutamine treated patients had higher rate of death (HR 1.57, 95% CI 1.03, 2.39, p=0.04)

25. GLN-enriched EN

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

28. Updated Meta-analysis of IV Glutamine (n=32 RCTs) Overall Mortality Note: Does not include EN GLN studies nor REDOXS study RR=0.87 (0.75,1.01) P=0.07)

29. Updated Meta-analysis of IV Glutamine (n=32 RCTs) Hospital Mortality RR=0.70 (0.53,0.92) P= 0.01

30. Updated Meta-analysis of IV Glutamine (n=32 RCTs) Hospital Mortality Influence of the number of study sites involved in the trial

31. Updated Meta-analysis of IV Glutamine (n=32 RCTs) Hospital Mortality Influence of the type of glutamine used in the trials

32. Updated Meta-analysis of IV Glutamine (n=32 RCTs) Infection RR=0.89 (0.77,1.03) P=0.12

33. Updated Meta-analysis of IV Glutamine (n=32 RCTs) ICU Length of Stay Note: Does not include EN GLN studies nor REDOXS study WMD=-1.91 (-4.10, -0.28) P=0.09

34. Updated Meta-analysis of IV Glutamine (n=32 RCTs) Hospital Length of Stay WMD=-2.56 (-4.71, -0.42) P=0.02

35. Temporal trend of short-term mortality in severely ill patients receiving parenteral glutamine supplementation Fadda Clinical Nutrition 32 (2013) 492–493 All the beneficial treatment effect seen in older studies (before 2003)

36. 2015 Canadian Nutrition CPGs: IV Glutamine Draft 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’

37. Updated Meta-analysis of EN Glutamine (n=11 RCTs) Mortality No overall treatment effect or in trauma subset but positive effect in burns (RR 0.19, 95% CI 0.06,0.67, p=0.01)

38. Updated Meta-analysis of EN Glutamine (n=11 RCTs) Infection Few studies reported infection No overall treatment effect or in trauma or burns subset

39. Updated Meta-analysis of EN Glutamine (n=11 RCTs) Hospital LOS Positive effect driven by 3 studies in burn patients

40. 2015 Canadian Nutrition CPGs: EN Glutamine Draft Conclusions: 1) Glutamine supplemented enteral nutrition may be associated with a reduction in mortality and shorter hospital LOS in burn patients, but inconclusive in other critically ill patients. 2) No overall effect in trauma patients 3) Concerns about safety of EN glutamine given METAPLUS study Draft Recommendation: We recommend enteral glutamine NOT be used in critically ill patients*. *downgraded from ‘should be considered in burn and trauma patients’

41. 2700 Burn Injury patients R EN glutamine placebo Concealed Stratified by site Double blind treatment A RandomizEd trial of ENtERal Glutamine to minimIZE thermal injury 6 month mortality

42. 2015 Canadian Nutrition CPGs: Combined IV+ EN Glutamine Draft 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

43. OFR CONSUMPTION OFR PRODUCTION Depletion of Antioxidant Enzymes OFR Scavengers Vitamins/Cofactors Infection Inflammation Ischemia OFR production > OFR consumption = Impaired - organ function - immune function - mucosal barrier function Complications and Death OXIDATIVE STRESS Rationale for Antioxidants

44. Meta-analysis of Supplemental Antioxidants: Combined Vitamins and Trace Elements Overall Mortality RR 0.86, 95% CI 0.75-0.99, p=0.03

45. Meta-analysis of Supplemental Antioxidants: Combined Vitamins and Trace Elements Infections RR 0.89, 95% CI 0.79-0.99, p=0.04

46. Meta-analysis of Supplemental Antioxidants: Combined Vitamins and Trace Elements Ventilator days WMD -1.76, 95% CI -3.87-0.36, p=0.10

47. Meta-analysis of Supplemental Antioxidants: Parenteral Selenium Overall Mortality RR 0.95, 95% CI 0.86-1.06, p=0.38 Awaiting publication of Germans SISPCT study

48. Meta-analysis of Supplemental Antioxidants: Parenteral Selenium

50. Draft Recommendation: We recommend that high dose selenium, not be used in critically ill patients* Use of combined antioxidants should be considered 2015 Canadian Nutrition CPGs: Supplemental Antioxidant Nutrients *downgraded from ‘should be considered’

51. 1400 high-risk patients undergoing cardiac surgery R IV Selenium placebo Concealed Stratified by site Double blind treatment SodiUm SeleniTe Adminstration IN Cardiac Surgery (SUSTAIN CSX ® -trial) Alive and free of POD Or Time to freedom from life- sustain treatments

52. Glutamine and Antioxidants End of an Era?

54. Questions?