Glutamine Supplementation in Traumatic Brain Injury

Direct Recommendation

The European Society for Clinical Nutrition and Metabolism (ESPEN) provides a Grade A recommendation for glutamine supplementation in trauma patients receiving enteral nutrition, at doses of 0.2-0.57 g/kg/day 1, 2, 3

ESPEN guidelines recommend glutamine supplementation in trauma patients, including those with traumatic brain injury, with a Grade A recommendation 1, 2, 3
A study of 72 trauma patients demonstrated significantly lower rates of bacteremia, pneumonia, and sepsis with glutamine supplementation added to standard enteral formulas 1, 2, 3

For parenteral nutrition, 0.2-0.57 g/kg/day of glutamine (equivalent to 10-30 g glutamine/24 hours or 0.3-0.6 g/kg/day of alanyl-glutamine dipeptide) is recommended 4, 5
Standard dosage is 0.5 g/kg/day of L-alanyl L-glutamine dipeptide when exclusive parenteral nutrition is required 4, 5

Concerns about glutamate neurotoxicity in head trauma patients have not been substantiated, with cerebral glutamate levels not affected by glutamine supplementation 4, 5
Glutamine supplementation has been safely tolerated in doses of 10-30 g/24 hours with restoration of plasma levels and no harmful effects reported in critically ill patients 4, 5

High-dose parenteral glutamine should not be used in critically ill patients with acute kidney injury or chronic kidney disease, as it is associated with increased mortality 6
A large multicenter RCT showed high-dose glutamine in critically ill patients with organ dysfunction increased mortality risk 6

Confirm diagnosis of traumatic brain injury requiring nutritional support, and screen for contraindications: acute kidney injury, chronic kidney disease, or multi-organ failure 1, 2, 3, 6

Enteral route is preferred, with glutamine added to standard enteral formula if gut function permits 1, 2, 3
Parenteral route may be used with glutamine-containing dipeptides (alanyl-glutamine or glycyl-glutamine) if exclusive parenteral nutrition is required 4, 5, 6

Enteral dosing follows trauma patient guidelines with glutamine-supplemented standard formulas 1, 2, 3
Parenteral dosing is 0.2-0.57 g/kg/day of glutamine, typically 0.5 g/kg/day of alanyl-glutamine dipeptide 4, 5, 6

Assess renal function regularly and discontinue glutamine supplementation if organ dysfunction develops 6

The evidence for glutamine in heterogeneous critically ill patients is insufficient and potentially harmful, but trauma patients (including TBI) represent a specific subgroup with demonstrated benefit 1, 2, 3
Glutamine supplementation should be part of standard nutrition formulas, not complex immune-modulating formulas that may have negative effects in severely ill patients 1, 2, 3
Continuous renal replacement therapy increases glutamine loss by 4-7 g/day, potentially increasing supplementation needs in this context 4, 5