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ω-3 fatty acids, γ-linolenic acid, and antioxidants: immunomodulators or inert dietary supplements?
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PMID:  23176247     Owner:  NLM     Status:  Publisher    
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EXPANDED ABSTRACT: CITATION: Rice TW, Wheeler AP, Thompson BT, deBoisblanc BP, Steingrub J, Rock, P. Enteral Omega-3 Fatty Acid, γ-Linolenic Acid, and Antioxidant Supplementation in Acute Lung Injury. JAMA. 2011; 306(14):1574-1581. PubMed PMID: 21976613. BACKGROUND: The omega-3 (n-3) fatty acids docosahexaenoic acid and eicosapentaenoic acid, along with γ-linolenic acid and antioxidants, may modulate systemic inflammatory response and improve oxygenation and outcomes in patients with acute lung injury. METHODS: Objective: To determine if dietary supplementation of these substances to patients with acute lung injury would increase ventilator-free days to study day 28.Design: The OMEGA study, a randomized, double-blind, placebo-controlled, multicenter trial conducted from January 2, 2008, through February 21, 2009. All participants had complete follow-up.Setting: This trial occurred at 44 hospitals in the National Heart, Lung, and Blood Institute ARDS Clinical Trials Network.Subjects: Participants were 272 adults within 48 hours of developing acute lung injury requiring mechanical ventilation whose physicians intended to start enteral nutrition.Intervention: Twice-daily enteral supplementation of n-3 fatty acids, γ -linolenic acid, and antioxidants compared with an isocaloric control. Enteral nutrition, directed by a protocol, was delivered separately from the study supplement.Outcomes: Ventilator-free days to study day 28. RESULTS: The study was stopped early for futility after 143 and 129 patients were enrolled in the n-3 and control groups. Despite an 8-fold increase in plasma eicosapentaenoic acid levels, patients receiving the n-3 supplement had fewer ventilator-free days (14.0 vs 17.2; P=.02) (difference, -3.2 [95% CI, -5.8 to -0.7]) and intensive care unit-free days (14.0 vs 16.7; P=.04). Patients in the n-3 group also had fewer nonpulmonary organ failure-free days (12.3 vs 15.5; P=.02). Sixty-day hospital mortality was 26.6% in the n 3 group vs 16.3% in the control group (P=.054), and adjusted 60-day mortality was 25.1% and 17.6% in the n-3 and control groups, respectively (P=.11). Use of the n-3 supplement resulted in more days with diarrhea (29% vs 21%; P=.001). CONCLUSIONS: Twice-daily enteral supplementation of n-3 fatty acids, γ-linolenic acid, and antioxidants did not improve the primary end point of ventilator-free days or other clinical outcomes in patients with acute lung injury and may be harmful.
Authors:
Christopher K Schott; David T Huang
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2012-11-23
Journal Detail:
Title:  Critical care (London, England)     Volume:  16     ISSN:  1466-609X     ISO Abbreviation:  Crit Care     Publication Date:  2012 Nov 
Date Detail:
Created Date:  2012-11-26     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  9801902     Medline TA:  Crit Care     Country:  -    
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Languages:  ENG     Pagination:  325     Citation Subset:  -    
Affiliation:
Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA. huangdt@ccm.upmc.edu.
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Journal ID (nlm-ta): Crit Care
Journal ID (iso-abbrev): Crit Care
ISSN: 1364-8535
ISSN: 1466-609X
Publisher: BioMed Central
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Copyright ©2012 BioMed Central Ltd
Print publication date: Year: 2012
Electronic publication date: Day: 23 Month: 11 Year: 2012
Volume: 16 Issue: 6
First Page: 325 Last Page: 325
PubMed Id: 23176247
ID: 3672597
Publisher Id: cc11863
DOI: 10.1186/cc11863

ω-3 fatty acids, γ-linolenic acid, and antioxidants: immunomodulators or inert dietary supplements?
Christopher K Schott1 Email: schottck@upmc.edu
David T Huang12 Email: huangdt@ccm.upmc.edu
1Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
2The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA, USA

Commentary

Interest in the use of immunomodulation through nutrition for patients with Acute Lung Injury (ALI) came to attention after a 1999 article by Gadek et al demonstrated an increase in 28-day ventilator free days (VFD), reduction of intensive care unit (ICU) length of stay and new organ failure when enteral diets were supplemented with omega-3 fatty acid, γ-linolenic acid (GLA), and antioxidants[1]. Subsequent studies have had similar findings. A 2006 study by Pontes-Arruda et al. demonstrated a similar increase in VFDs, increase in ICU free days as well as a reported 19% absolute reduction in mortality with the use of the same enteral supplements [2]. Another study in 2006, by Singer and colleagues, found an increase in oxygenation through this supplementation, but no change in ICU length of stay, VFDs or mortality [3]. These three studies became the basis of a meta-analysis on the subject as well as the justification to provide a Grade A level recommendation by the Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) to endorse the use of these enteral supplements in patients with ALI [4-6].

OMEGA sought to evaluate the primary endpoint of VFDs at 28 days through bolus supplementation of omega-3 fatty acids, GLA and antioxidants compared to no immunomodulation supplementation. OMEGA was a trial performed concurrently in a 2×2 factorial distribution with EDEN, a trial to assess differences in full versus trophic enteral nutrition in patients with ALI. Patients in the OMEGA trial were randomized to receive twice daily supplementation or an iso-caloric control compound in addition to their baseline enteral nutrition. Using an intent-to-treat analysis, their results demonstrate a statistically significant decrease in VFDs compared with the control arm as well as a trend toward increased mortality. Their results also did not demonstrate any clinically or statistically significant improvement in pulmonary function or physiology on ventilator support. This prompted the study's data and safety monitoring board (DSMB) to stop the trial early for futility.

Although the study was ended early, it did provide significant findings in terms of enteral immunomodulation in the treatment of ALI. One of this study's greatest strengths is its size. OMEGA was able to recruit and randomize 272 patients, compared to the 165 patients or fewer in each of the prior three studies, making it the largest to evaluate an effect of enteral immunomodulaiton on ALI. Another significant strength of this study was the ability to demonstrate the biologic effects of omega-3 fatty acids, GLA and antioxidants. They demonstrate (Figure 2 and efigure 2a, 2b) that serum levels of eicosapentaenoic acid did rise, but there was no change in the serum levels of measured inflammatory mediators, interleukins (IL) 6 and 8. The destination of these substances could be accounted for by a rise in urinary concentrations. Additionally, a 2x2 factorial analysis was performed to demonstrate no interaction between these arms of the study and those involved in the EDEN component (p = 0.47).

This was a well done study without many weaknesses. There was no benefit from enteral supplementation with omega-3 fatty acids, GLA and antioxidants, but there was statistical significance for decreased VFDs opposing the results from previously conducted studies. Another potential weakness is that this trial utilized bolus dosing opposed to continuous supplementation that was utilized in prior studies on the affects of omega-3 fatty acids, GLA and antioxidants on ALI. Finally, the enriched supplement appears to have a different composition (when converted to equivalent units of measurement) than the omega-3 fatty acids, GLA and antioxidants utilized in prior studies. These points are not direct weakness inherent in this trial's design, but rather limits external validation to previous studies.

The results of this study raise enough attention to question the foundations of the A.S.P.E.N. grade A recommendations to utilize enteral nutrition with omega-3 fatty acids, GLA and antioxidants in ALI. The strengths of this study are enough to reconsider practice guidelines to endorse their use in the treatment of ALI. While the idea of using enteral nutrition to modulate the immune seemed promising, other studies have subsequently showed little benefit, ranging from cardiovascular events, glycemic control or rates of infectious complications in critically ill patients as well as the primary care setting [7]8. The authors of the OMEGA study suggest that the changes seen in this trial, compared to the prior studies on the use of omega-3 fatty acids, GLA and antioxidants in ALI may have been the result of changes in non-experimental covariates, such as increased attention to fluid management and lung-protective ventilation, as a result of the ARDSnet trials. Although omega-3 fatty acids, GLA and antioxidants substances appear to have good bioavailability, their physiologic effects seem to be more as inert substrates than modifiers of inflammation as measured by this trial.


Recommendation

Although this study was ended early for futility to decrease VFDs through enteral supplementation with omega-3 fatty acids, GLA and antioxidants, it also raises concern for the potential for increased mortality. Moreover, it is rare that a single study greatly change practice patterns. The strongest conclusion made from this article is that these substrates do not decrease ventilator free days. Consequently, this article has enough merits to warrant a revision in the current guidelines which provide a grade A level recommendation to endorse the use of enteral omega-3 fatty acids, GLA and antioxidants in the treatment of ALI.


Competing interests

The authors declare that they have no competing interests.


References
Gadek JE,DeMichele SJ,Karlstad MD,et al. Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral Nutrition in ARDS Study GroupCrit Care MedYear: 199916814091420 PMID 10470743. 10.1097/00003246-199908000-0000110470743
Pontes-Arruda A,Aragao AM,Albuquerque JD,Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shockCrit Care MedYear: 200616923252333 PMID 16850002. 10.1097/01.CCM.0000234033.65657.B616850002
Singer P,Theilla M,Fisher H,Gibstein L,Grozovski E,Cohen J,Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injuryCrit Care MedYear: 200616410331038 PMID 16484911. 10.1097/01.CCM.0000206111.23629.0A16484911
Pontes-Arruda A,Demichele S,Seth A,Singer P,The use of an inflammation-modulating diet in patients with acute lung injury or acute respiratory distress syndrome: a meta-analysis of outcome dataJPEN J Parenter Enteral NutrYear: 2008166596605 PMID 18974237. 10.1177/014860710832420318974237
McClave SA,Martindale RG,Vanek VW,et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)JPEN J Parenter Enteral NutrYear: 2009163277316 PMID 19398613. 10.1177/014860710933523419398613
Bosch J,Gerstein HC,Dagenais GR,et al. n-3 fatty acids and cardiovascular outcomes in patients with dysglycemiaN Engl J MedYear: 2012164309318 PMID 22686415. 22686415
Umpierrez GE,Spiegelman R,Zhao V,et al. A double-blind, randomized clinical trial comparing soybean oil-based versus olive oil-based lipid emulsions in adult medical-surgical intensive care unit patients requiring parenteral nutritionCrit Care MedYear: 201216617921798 PMID 22488002. 10.1097/CCM.0b013e3182474bf922488002

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