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Specialty Areas: Nepro versus Glucerna
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09/08/10 03:57 PM | Edit ReplyReply   |    Nepro versus Glucerna
GRD
958 Posts

Registered Dietitian

I'm confused on this one. Diabetics = Glucerna, ESRD = Nepro, but if a patient is diabetic and has ESRD, we normally use Nepro in our facility. Why would the Nepro win out over the Glucerna? Is it because of free H2O? Glucerna has fewer carbs then Nepro, so wouldn't that be better for BG control and therefore more important, assuming the patient is not on a tight fluid restriction?

09/09/10 07:44 AM | Edit ReplyReply   |    RE: Nepro versus Glucerna
hokiegirl
453 Posts

Registered Dietitian

Hi Glass Geranium---fluid is one part of it, but the mineral content is another. Glucerna is higher in K and Phos than Nepro---and while it may not seem like a big difference, consider that most ESRD patients are limited to 800-1000 mg of phos a day. It's easy to get there. I have patients take a binder with supplements.

Also, thinking about glucose, it's easier to medicate a high glucose than a high potassium. You can always give more insulin or do other things to adjust the carbs. A high potassium can kill them on the spot if it goes unchecked.

09/09/10 12:55 PM | Edit ReplyReply   |    re
GRD
958 Posts

Registered Dietitian

Ah, I see - that makes sense. Thanks for the help!

09/09/10 01:23 PM | Edit ReplyReply   |    RE: re
hokiegirl
453 Posts

Registered Dietitian


    Inserito da GlassgeraniumRD:
    Ah, I see - that makes sense. Thanks for the help!

:-)

09/11/10 07:43 AM | Edit ReplyReply   |    RE: re
SZT
615 Posts

Registered Dietitian

Exactly what I was going to say. The only thing I'll mention is that not all renal pts require a renal formula(and not all diabetics require a DM product for that matter either). Lots of our docs/NP/PA (and even some RDs for that matter) just instantly request Nepro. Drives me crazy. If their labs/needs aren't altered then quite often a standard formula will do the trick.

09/14/10 03:05 PM | Edit ReplyReply   |    RE: Nepro versus Glucerna
DNS1920
212 Posts

Registered Dietitian


    Posted by GlassgeraniumRD:
    I'm confused on this one. Diabetics = Glucerna, ESRD = Nepro, but if a patient is diabetic and has ESRD, we normally use Nepro in our facility. Why would the Nepro win out over the Glucerna? Is it because of free H2O? Glucerna has fewer carbs then Nepro, so wouldn't that be better for BG control and therefore more important, assuming the patient is not on a tight fluid restriction?

No research to support the use of specialty formulas. If we are practicing evidence based nutrition there is no evidence that the specialty products are beneficial for any client. I would use renal product only if you have to have an electrolyte restriction that you can not control with dialysis otherwise I would not bother. As for diabetic products there is still no evidence and no need to use them. I would always look for independent research from the company that relates to the products. I suggest the Enteral Formula article in Practical Gastroenterology and the one that talks about diabetic products found at www.healthsystem.virginia.edu/internet/digestive_health/nutrition/resources. Just because a doctor or other dietitians are suggesting the use of a specialty formula it does not make it correct. If the client is a Medicare patient and you have not tried other formulas and had the trial fail many times Medicare will not pay for the formula as an outpatient and the patient will have to pay for it. That is not fair to them. Always do what is the best for your patient. Start with a fiber containing or a nonfiber containing if fiber is not desired long term and allow the patient to show some type of symptom to the formula. I can't say I've seen many patients that needed a specialty formula in 10 years of practice. Just my thoughts.

09/16/10 07:18 AM | Edit ReplyReply   |    RE: Nepro versus Glucerna
SZT
615 Posts

Registered Dietitian

I just completed ASPEN's webinar for the CNSC exam. The enteral expert did recommend some specialized formulas in certain situations (yes, I am familiar with the research). Pulmonary formulas are out (good recent article on that). The DM formulas are a debate. I agree. Fiber standard formula my first go to. But on our formulary we don't really have one that fits ASPEN CHO profile. BUT I believe that you can usually moderate the TOTAL CHO provision by using a higher PRO containing formula- such as Jevity 1.5 (usually here in acute care, we are providing to meet pro rather than total kcal needs). Often our Renal pts do require a Nepro type product d/t labs...

09/16/10 09:02 AM | Edit ReplyReply   |    RE: Nepro versus Glucerna
hokiegirl
453 Posts

Registered Dietitian

I only ask LTC RDs to pick Nepro over standard formulas when the electrolytes are consistently high, or the fluid is a big issue. It's not an issue with everyone. And it's not a given that Renal = Nepro. But if your resident is having consistent hyperphosphatemia or hyperkalemia, Nepro or similar can be very useful. Although, I usually prefer my patients be put on protein modulars unless their po intake has really tanked or they need to gain weight.

There are also sometimes other ways to deal with electrolyte problems, if for some reason a standard formula needs to be used. Like extra binders, or changing the dialysis treatment to pull extra potassium (or pull less). This is why I like monthly contact with LTC RDs about our shared patients, because we can usually come up with a pretty good plan as a team!

09/18/10 04:21 PM | Edit ReplyReply   |    RE: Nepro versus Glucerna
DNS1920
212 Posts

Registered Dietitian


    Posted by SZT:
    I just completed ASPEN's webinar for the CNSC exam. The enteral expert did recommend some specialized formulas in certain situations (yes, I am familiar with the research). Pulmonary formulas are out (good recent article on that). The DM formulas are a debate. I agree. Fiber standard formula my first go to. But on our formulary we don't really have one that fits ASPEN CHO profile. BUT I believe that you can usually moderate the TOTAL CHO provision by using a higher PRO containing formula- such as Jevity 1.5 (usually here in acute care, we are providing to meet pro rather than total kcal needs). Often our Renal pts do require a Nepro type product d/t labs...

Read the enteral summary posted on the ASPEN website from ASPEN and Critical Care Medicine from JPEN May-June 2009 Section E2 "Patients with ARDS and severe acute lung injury should be placed on an enteral formulation characterized by an anti-inflammatory lipid profile (ie omega 3 fish oils, borage oil) and antioxidants." Even though they did make a recommendation for this specific type of formula it also stated there was still controversy that further study is needed. Immune modulating formulas are recommended for a specific population for a specific period of time. A renal formula may be considered if significant electrolyte abnormalities exist or develop otherwise the client should be on standard formula. Pulmonary and hepatic formulas are not needed. Formulas for elevated glucose require further research and are not recommended at this time. I've not seen anything specifically printed this year that changes the recommendations that they made last year in March and May so for now these should be the guidelines used unless others have peer reviewed literature from this year.

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