Parenteral nutrition; maintenance requirements: IV: As an additive to parenteral nutrition solution; see individual agents (chromium, copper, manganese, and zinc) (ASPEN [Vanek 2012])
Parenteral nutrition; maintenance requirements: Infants, Children, and Adolescents: IV: As an additive to parenteral nutrition solution; see individual agents (chromium, copper, manganese, and zinc) (ASPEN [Vanek 2012])
There are no dosage adjustments provided in the manufacturer's labeling; some compenents may require dosing adjustment; see individual agents
There are no dosage adjustments provided in the manufacturer's labeling; some components may require dosing adjustment; see individual agents
(For additional information see "Trace metals: Drug information")
Parenteral nutrition, maintenance requirements: Note: Does not contain chromium. Use in patients who require supplementation with all 4 of the individual trace elements (zinc, copper, manganese, and selenium).
IV: 1 mL per day added to parenteral nutrition (1 mL provides the following: zinc 3 mg, copper 0.3 mg, manganese 55 mcg, selenium 60 mcg).
There are no dosage adjustments provided in the manufacturer's labeling.
There are no dosage adjustments provided in the manufacturer's labeling.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Intravenous [preservative free]:
Tralement: Copper 300 mcg, manganese 55 mcg, selenium 60 mcg, and zinc 3,000 mcg per 1 mL (1 mL)
Multrys (Pediatric product): Copper 60 mcg, manganese 3 mcg, selenium 6 mcg, and zinc 1,000 mcg per 1 mL (1 mL)
Yes
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Intravenous:
Micro+ 4 Regular: Chromium 4 mcg, copper 400 mcg, manganese 100 mcg, and zinc 1,000 mcg per 1 mL (5 mL)
Micro+ 6 Concentrate: Chromium 10 mcg, copper 300 mcg, iodide 75 mcg, manganese 55 mcg, selenium 60 mcg, and zinc 5,000 mcg per 1 mL (10 mL)
Generic: Chromium 4 mcg, copper 400 mcg, manganese 100 mcg, and zinc 1,000 mcg per 1 mL ([DSC])
Parenteral: Must be diluted prior to use and infused as component of parenteral nutrition or parenteral solutions
For IV use only. Must be diluted prior to use and infused as component of parenteral nutrition or parenteral solutions. Do not administer undiluted solutions by direct injection into a peripheral vein.
Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F).
Store admixed solution at 2°C to 8°C (36°F to 46°F).
Prevention and treatment of trace metal deficiencies (FDA approved in all ages)
Hypersensitivity to zinc, copper, or any component of the formulation; administration of undiluted solutions by direct injection into a peripheral vein.
Concerns related to adverse effects:
• Hypersensitivity reactions: Hypersensitivity reactions (eg, angioedema, dyspnea, pruritus, rash, urticaria) have been reported in patients exposed to copper or zinc containing products (eg, zinc-containing insulin or copper-containing intrauterine devices). Discontinue treatment and institute appropriate treatment if hypersensitivity occurs.
Disease-related concerns:
• Hepatic impairment: Copper and manganese may accumulate in severe hepatic impairment and/or biliary obstruction; consider reduction in dosage or deletion of copper and manganese in patients with severe hepatic impairment or biliary obstruction.
• Renal impairment: Use with caution in patients with renal impairment; metals may accumulate in renal failure.
Other warnings/precautions:
• Aluminum toxicity: Contains aluminum; toxic aluminum concentrations may be seen with high doses, prolonged use, or in patients with renal impairment. Premature neonates are at higher risk due to immature renal function and aluminum intake from other parenteral sources. Parenteral aluminum exposure of >4 to 5 mcg/kg/day is associated with CNS and bone toxicity; tissue loading may occur at lower doses.
• Manganese toxicity: Basal ganglia accumulation (detected on MRI) and clinical symptoms (eg, neuropsychiatric, seizures, parkinsonian-like tremor, dysarthria, mask-face, halting gate, dystonic movements) of manganese toxicity have been reported in adult and pediatric patients, including patients receiving manganese at or below recommended doses and with normal blood manganese levels. Risk may be increased in patients receiving higher than recommended doses and with cholestatic liver disease. Symptoms and MRI findings generally improve over weeks to months following discontinuation of manganese but may not completely resolve. Monitor manganese blood levels and for neurologic toxicity in patients receiving manganese long-term as a component of parenteral nutrition therapy. If manganese toxicity is suspected, temporarily discontinue and further evaluate.
• Overdose potential: Multiple trace metal solutions present a risk of overdosage when the need for one trace element is appreciably higher than for others in the formulation; utilization of individual trace metal solutions may be needed (especially chromium since product does not contain chromium).
ASPEN 2020 :
Copper: 0.3 to 0.5 mg/day.
Manganese: 55 mcg/day.
Selenium: 60 to 100 mcg/day.
Zinc: 3 to 5 mg/day.
Refer to individual elements for requirements in pregnancy.
Copper: Cofactor for serum ceruloplasmin, an oxidase necessary for proper formation of the iron carrier protein, transferrin; also helps maintain normal rates of red and white blood cell formation and prevents development of leukopenia, neutropenia, anemia, depressed ceruloplasmin levels, impaired transferrin formation and secondary iron deficiency.
Manganese: Activator for enzymes such as polysaccharide polymerase, liver arginase, cholinesterase and pyruvate carboxylase and prevents development of nausea and vomiting, weight loss, dermatitis, and changes in growth and hair color.
Selenium: Protects cell components from oxidative damage due to peroxides produced in cellular metabolism and prevents development of muscle pain and tenderness.
Zinc: Facilitates wound healing, helps maintain normal growth rates, normal skin hydration and senses of taste and smell and prevents development of parakeratosis, hypogeusia, anorexia, dysosmia, geophagia, hypogonadism, growth retardation and hepatosplenomegaly.
Excretion:
Copper: Urine, bile.
Manganese: Bile.
Selenium: Urine, feces.
Zinc: Urine, feces.
Solution (Multitrace-4 Neonatal Intravenous)
100-25-1500 mcg/mL (per mL): $6.95
Solution (Multitrace-4 Pediatric Intravenous)
1-100-25-1000 mcg/mL (per mL): $4.86
Solution (Trace Elements 4/Pediatric Intravenous)
1-100-30-500 mcg/mL (per mL): $0.88
Solution (Tralement Intravenous)
300-55-60-3000 mcg/mL (per mL): $25.80
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