Parenteral Copper Supplementation: Make Sure You Are on the Proper Dose
Davina Ngo, PharmD, BCNSP
(Published in the Oley Foundation’s newsletter)
Trace metals (also called trace minerals or elements) play an important role in your health. “Trace” metals or elements are “required in minute quantities by an organism to maintain proper physical functioning” (American Heritage Medical Dictionary). When you are receiving home parenteral nutrition (HPN), trace metals must be prescribed and added to your HPN. The five trace metals most commonly prescribed in the United States are zinc, copper, selenium, chromium, and manganese.
I’d like to focus on copper. Copper plays a role in a variety of metabolic processes in the body. Too little copper can result in anemia, low white blood cell count, and reduced bone calcification. Deficiency is rare, but it has been reported in prolonged severe malnutrition, premature infants, children recovering from severe malnutrition, and patients on long-term HPN with no copper supplementation.
Too much copper, on the other hand, may cause cirrhosis and neurologic disorders as seen in Wilson’s disease (a rare inherited disorder where copper accumulates in the liver because it cannot be adequately excreted in bile). There are several reports of hepatic copper levels in PN patients equivalent to those in seen in Wilson’s disease. (1) The relationship of this copper to hepatic damage is less clear.
In 1979, dietary copper intake was thought to be 3 to 5 mg/day, and with approximately 15% absorption, the American Medical Association (AMA) advised a parenteral dose of 0.5–1.5 mg/day for adults. The AMA’s recommendation led to a multiple-trace element (MTE) concentrate providing approximately 1 mg of copper a day.
Subsequent research showed that adult requirements were in fact 0.3–0.5 mg/day. (2) In 1984 the AMA changed their recommendation to 0.3–0.5 mg/day for adults. Unfortunately this lower recommendation never resulted in an adjustment to a lower copper in the MTE solution.
In 2009, the American Society of Parenteral and Enteral Nutrition (ASPEN) gathered a team of national and international nutrition experts to develop an updated consensus of the parenteral requirements of the fourteen nutrients deemed most controversial. The recommendations from that workshop regarding copper dosing have been adopted as part of ASPEN’s current guidelines (3, 4):
- Copper should be routinely prescribed in PN patients.
- For long-term PN patients, the usual dose of copper in PN should be 0.3 mg/day for adults and 20 mcg/kg/day for pediatric patients.
- Patients with persistent diarrhea or GI fluid losses should receive between 0.4 mg/day and 0.5 mg/day.
- Patients with liver disease should receive a lower dose of 0.15 mg/day.
- Copper requirements should periodically be reassessed and corrections made as needed.
- For patients on no copper supplementation, serum copper and ceruloplasmin levels are useful indicators of copper depletion. In patients receiving copper, these parameters are less helpful. Other factors, such as high intestinal output and inflammation, can affect copper requirements and such clinical circumstances should be taken into account.
Recent national drug shortages have included MTE concentrate as well as copper. Due to the lack of MTE availability, these trace metals are being added individually to consumers’ PN. Frequently, prescribers are persisting in their use of 1 mg/day, which is excessive. Consumers should make sure they are getting the appropriate dose.
In adults, a daily copper requirement is 0.3 mg/day, increased to 0.4-0.5 with GI output of more than 1-2 liters per day, and decreased to 0.15 mg/day in patients with liver disease. The recommended dose for pediatric patients is 20 mcg/kg/day. Check your solution label.
- L. Howard, C. Ashley, D. Lyon, A. Shenkin, Autopsy Tissue Trace Elements in 8 Long-Term Parenteral Nutrition Patients Who Received the Current U.S. Food and Drug Administration Formulation, Journal of Parenteral and Enteral Nutrition 2007;31(5): 388–96.
- M. Shike, M. Roulet, R. Kurian et al., Copper Metabolism and Requirements in Total Parenteral Nutrition, Gastroenterology 1981;81:290–7.
- M Shike, Copper in Parenteral Nutrition, Gastroenterology 2009; 137(suppl 1):S13–17.
- A.S.P.E.N. Position Paper: Recommendations for Changes in Commercially Available Parenteral Multivitamin and Multi-Trace Element Products, V. Vanek, P. Borum, A. Buchman et al., Nutrition in Clinical Practice, 2012;27:440–91.
Davina Ngo is a pharmacist with Nutrishare, Inc. This article was reviewed by Oley Medical Director Lyn Howard, MB, FRCP.