Trace Elements

Name: Trace Elements

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Injection, solution:

Addamel N: Chromium 1 mcg, copper 0.13 mg, fluoride 0.095 mg, iodide 0.013 mg, iron 0.11 mg, manganese 0.027 mg, molybdenum 1.9 mcg, selenium, 3.2 mcg, and zinc 0.65 mg per 1 mL (20 mL [DSC])

Multitrace-4: Chromium 4 mcg, copper 0.4 mg, manganese 0.1 mg, and zinc 1 mg per 1 mL (10 mL) [contains aluminum, benzyl alcohol]

Multitrace-4 Concentrate: Chromium 10 mcg, copper 1 mg, manganese 0.5 mg, and zinc 5 mg per 1 mL (1 mL) [contains aluminum]; chromium 10 mcg, copper 1 mg, manganese 0.5 mg, and zinc 5 mg per 1 mL (10 mL) [contains benzyl alcohol]

Multitrace-4 Neonatal: Chromium 0.85 mcg, copper 0.1 mg, manganese 0.025 mg, and zinc 1.5 mg per 1 mL (2 mL) [contains aluminum]

Multitrace-5: Chromium 4 mcg, copper 0.4 mg, manganese 0.1 mg, selenium 20 mcg, and zinc 1 mg per 1 mL (10 mL) [contains aluminum, benzyl alcohol]

Multitrace-5 Concentrate: Chromium 10 mcg, copper 1 mg, manganese 0.5 mg, selenium 60 mcg, and zinc 5 mg per 1 mL (1 mL) [contains aluminum]; chromium 10 mcg, copper 1 mg, manganese 0.5 mg, selenium 60 mcg, and zinc 5 mg per 1 mL (10 mL) [contains benzyl alcohol]

Peditrace: Copper 20 mcg, iodide 1 mcg, fluoride 57 mcg, manganese 1 mcg, selenium 2 mcg, and zinc 250 mcg per 1 mL (10 mL [DSC])

Trace Elements 4 Pediatric: Chromium 1 mcg, copper 0.1 mg, manganese 0.03 mg, and zinc 0.5 mg per 1 mL (10 mL) [contains aluminum, benzyl alcohol]

Injection, solution [preservative free]:

Multitrace-4 Pediatric: Chromium 1 mcg, copper 0.1 mg, manganese 0.025 mg, and zinc 1 mg per 1 mL (3 mL) [contains aluminum]

Pharmacologic Category

  • Trace Element, Parenteral

Dosing Adult

Trace metal supplement for TPN: IV:

Manufacturer labeling:

Chromium: 10 to 15 mcg/day (20 mcg/day with intestinal fluid loss)

Copper: 500 to 1,500 mcg/day

Manganese: 150 to 800 mcg/day

Selenium: 20 to 40 mcg/day

Zinc: 2.5 to 4 mg/day. Consider an additional 2 mg/day for acute catabolic states; with fluid loss from the small bowel, an additional 12.2 mg/L of small bowel fluid lost, or an additional 17.1 mg/kg of stool or ileostomy output is recommended.

ASPEN Guidelines (Mirtallo 2004):

Chromium: 10 to 15 mcg/day

Copper: 300 to 500 mcg/day

Manganese: 60 to 100 mcg/day

Selenium: 20 to 60 mcg/day

Zinc: 2.5 to 5 mg/day

Dosing Pediatric

Trace metal supplement for TPN: Infants, Children, and Adolescents: IV:

Trace Metal Supplement for TPN: Manufacturer Labeling

Infants

Children and Adolescents

Chromium

0.14 to 0.2 mcg/kg/day

0.14 to 0.2 mcg/kg/day

Copper

20 mcg/kg/day

20 mcg/kg/day

Manganese

2 to 10 mcg/kg/day

2 to 10 mcg/kg/day

Selenium

3 mcg/kg/day

3 mcg/kg/day

Zinc

Preterm, ≤3 kg: 300 mcg/kg/day

Full term: 100 mcg/kg/day

100 mcg/kg/day

Table has been converted to the following text.

Trace metal supplement for TPN: Manufacturer labeling

Chromium: Infants, Children, and Adolescents: 0.14 to 0.2 mcg/kg/day

Copper: Infants, Children, and Adolescents: 20 mcg/kg/day

Manganese: Infants, Children, and Adolescents: 2 to 10 mcg/kg/day

Selenium: Infants, Children, and Adolescents: 3 mcg/kg/day

Zinc:

Infants, preterm, ≤3 kg: 300 mcg/kg/day

Infants, full term: 100 mcg/kg/day

Children and Adolescents: 100 mcg/kg/day

Trace Elements: ASPEN Guidelines (Mirtallo 2004)

Trace Element1

Infants 3 to 10 kg

Infants, Children, and Adolescents 10 to 40 kg

Adolescents >40 kg

1Recommended intakes of trace elements cannot be achieved through the use of a commercially available combination trace element product. Only through the use of individualized trace element products can recommended intakes be achieved.

2Reduce dose in patients with renal impairment.

3Reduce dose by 50% in patients with impaired biliary excretion or cholestatic liver disease.

4Omit in patients with impaired biliary excretion or cholestatic liver disease.

5Indicated for use in long-term parenteral nutrition patients (ie, >1 month of therapy).

Chromium2

0.2 mcg/kg/day

0.14 to 0.2 mcg/kg/day

5 to 15 mcg/day

Copper3

20 mcg/kg/day

5 to 20 mcg/kg/day

200 to 500 mcg/day

Manganese4

1 mcg/kg/day

1 mcg/kg/day

40 to 100 mcg/day

Selenium2,5

2 mcg/kg/day

1 to 2 mcg/kg/day

40 to 60 mcg/day

Zinc

50 to 250 mcg/kg/day

50 to 125 mcg/kg/day

2 to 5 mg/day

Table has been converted to the following text:

Trace Elements: ASPEN Guidelines1 (Mirtallo 2004):

Chromium:

Reduce dose in patients with renal impairment.

Infants 3 to 10 kg: 0.2 mcg/kg/day

Infants, Children, and Adolescents 10 to 40 kg: 0.14 to 0.2 mcg/kg/day

Adolescents >40 kg: 5 to 15 mcg/day

Copper:

Reduce dose by 50% in patients with impaired biliary excretion or cholestatic liver disease.

Infants 3 to 10 kg: 20 mcg/kg/day

Infants, Children, and Adolescents 10 to 40 kg: 5 to 20 mcg/kg/day

Adolescents >40 kg: 200 to 500 mcg/day

Manganese:

Omit in patients with impaired biliary excretion or cholestatic liver disease.

Infants 3 to 10 kg: 1 mcg/kg/day

Infants, Children, and Adolescents 10 to 40 kg: 1 mcg/kg/day

Adolescents >40 kg: 40 to 100 mcg/day

Selenium:

Reduce dose in patients with renal impairment; indicated for use in long-term parenteral nutrition patients.

Infants 3 to 10 kg: 2 mcg/kg/day

Infants, Children, and Adolescents 10 to 40 kg: 1 to 2 mcg/kg/day

Adolescents >40 kg: 40 to 60 mcg/day

Zinc:

Infants 3 to 10 kg: 50 to 250 mcg/kg/day

Infants, Children, and Adolescents 10 to 40 kg: 50 to 125 mcg/kg/day

Adolescents >40 kg: 2 to 5 mg/day

Dosing Renal Impairment

There are no dosage adjustments provided in the manufacturer's labeling; use chromium with caution and decrease dose in pediatric patients. Decrease dose or omit selenium in pediatric patients with renal impairment.

Warnings/Precautions

Disease-related concerns:

• GI malfunction: Consider reduction in dosage or deletion of selenium in patients with GI malfunction.

• 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. Consider reduction in dosage or deletion of selenium in patients with renal impairment.

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer’s labeling.

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.

• 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.

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