Premasol - Sulfite-free (amino Acid)

Dosage of Alanine in clinical settings is almost always calculated as part of a total amino acid requirement. For adults receiving parenteral nutrition, the standard protein requirement ranges from 0.8 to 2.0 grams of amino acids per kilogram of body weight per day.

• Maintenance Nutrition: 0.8 to 1.0 g/kg/day.
• Moderate Stress/Trauma: 1.2 to 1.5 g/kg/day.
• Severe Burns or Sepsis: 1.5 to 2.5 g/kg/day.

In these mixtures, Alanine typically comprises approximately 6% to 20% of the total amino acid content, depending on the specific brand (e.g., Aminosyn vs. Travasol). For example, if a patient is prescribed 100g of amino acids, they may receive between 6g and 16g of L-alanine daily.

Pediatric requirements for amino acids are significantly higher than adult requirements due to the demands of growth and development.

• Neonates and Infants: 2.5 to 3.5 g/kg/day of total amino acids.
• Children (1-12 years): 1.5 to 2.5 g/kg/day.
• Adolescents: 1.0 to 2.0 g/kg/day.

Precise Alanine intake is adjusted by the healthcare provider based on the child's age, weight, and metabolic status. Excessive amino acid intake in neonates can lead to hyperammonemia (high blood ammonia), so careful titration is mandatory.

Renal Impairment

In patients with significant renal dysfunction, the ability to excrete urea (the byproduct of alanine metabolism) is compromised. Healthcare providers may reduce the total amino acid dose or use specialized 'renal' formulations that contain a higher proportion of essential amino acids and fewer non-essential amino acids like Alanine to prevent uremia (buildup of toxins in the blood).

Hepatic Impairment

Patients with severe liver disease or hepatic encephalopathy may require adjustments. While Alanine is metabolized in the liver, the primary concern is the liver's inability to process the resulting ammonia. Specialized 'hepatasol' formulations may be used, which alter the ratio of branched-chain amino acids to aromatic amino acids.

Elderly Patients

Dosing in the elderly should be cautious, usually starting at the lower end of the dosing range. This accounts for the higher frequency of decreased hepatic, renal, or cardiac function and concomitant disease or other drug therapy.

If you are receiving Alanine via intravenous infusion:

• It must be administered through a central or peripheral venous catheter by a healthcare professional.
• The infusion rate must be controlled using an infusion pump to prevent 'refeeding syndrome' or metabolic imbalances.
• Storage: TPN bags containing Alanine must often be refrigerated and protected from light, then brought to room temperature before administration.

If taking oral Alanine supplements:

• Follow the instructions on the product label or as directed by your doctor.
• It is generally recommended to take amino acid supplements with water on an empty stomach to maximize absorption, though taking them with a light meal may reduce gastrointestinal upset.

In a clinical setting (IV), missed doses are rare as the infusion is continuous. If an oral dose is missed, take it as soon as you remember. If it is almost time for the next dose, skip the missed dose. Do not double the dose to catch up.

An overdose of Alanine, particularly via IV, can lead to 'amino acid toxicity.' Symptoms may include:

• Nausea and vomiting
• Chills and fever
• Flushing of the skin
• Increased blood urea nitrogen (BUN)
• Metabolic acidosis

In case of suspected overdose, the infusion should be stopped immediately, and the patient's electrolyte and fluid status should be re-evaluated. Emergency measures focus on supporting renal function and correcting acid-base imbalances.

> Important: Follow your healthcare provider's dosing instructions exactly. Do not adjust your dose or stop the treatment without medical guidance.

Because Alanine is a naturally occurring amino acid, side effects are generally minimal when used at physiological doses. However, when administered as part of a concentrated intravenous solution, the following may occur:

• Injection Site Reactions: Redness, swelling, or 'phlebitis' (inflammation of the vein) at the site of the IV catheter.
• Flushing: A sudden feeling of warmth or redness in the face and neck, often occurring if the infusion rate is too rapid.
• Nausea: A mild feeling of stomach upset, which usually resolves as the body adjusts to the infusion.

• Increased Sweating (Diaphoresis): Some patients may experience clammy skin or excessive perspiration during administration.
• Headache: Mild to moderate tension-type headaches.
• Dizziness: A sensation of lightheadedness, particularly when moving from a sitting to a standing position.
• Fever and Chills: Sometimes referred to as a 'pyrogenic reaction,' which may be related to the solution or the administration set.

• Hyperammonemia: An abnormal increase in ammonia levels in the blood. This is rare in healthy adults but can occur in patients with underlying liver dysfunction or urea cycle defects. Symptoms include confusion, lethargy, and irritability.
• Metabolic Acidosis: An imbalance in the body's acid-base status, characterized by rapid breathing, confusion, and fatigue.
• Azotemia: An elevation of blood urea nitrogen (BUN) and serum creatinine, indicating that the kidneys are struggling to process the nitrogen load.

> Warning: Stop taking Alanine and call your doctor immediately if you experience any of the following serious symptoms. These may indicate a severe allergic reaction or a dangerous metabolic shift.

1. 1Anaphylaxis: Symptoms include hives, difficulty breathing, swelling of the face, lips, or throat, and a rapid drop in blood pressure.
2. 2Severe Confusion or Encephalopathy: Signs of brain dysfunction caused by high ammonia levels (hyperammonemia).
3. 3Pulmonary Edema: Shortness of breath, wheezing, or a cough producing frothy sputum, which may indicate fluid overload from the IV solution.
4. 4Jaundice: Yellowing of the eyes or skin, which may indicate TPN-associated liver disease (PNALD).
5. 5Seizures: Though extremely rare, severe metabolic disturbances can trigger neurological events.

Prolonged use of Alanine as part of parenteral nutrition can lead to several chronic conditions:

• Hepatic Steatosis: Also known as fatty liver, this can progress to more severe liver dysfunction if the nutritional balance is not adjusted.
• Gallbladder Sludge/Stones: Lack of enteral (oral) stimulation during long-term IV feeding can cause bile to thicken, leading to gallstones.
• Bone Demineralization: Long-term TPN can sometimes affect calcium and phosphorus balance, potentially leading to metabolic bone disease.

There are currently no FDA black box warnings specifically for Alanine as a standalone ingredient. However, many amino acid injections carry warnings regarding the risk of 'Aluminum Toxicity' in patients with impaired kidney function, especially in premature neonates. This is due to the trace amounts of aluminum that can be present in the glass vials or the manufacturing process of the IV solutions.

Report any unusual symptoms to your healthcare provider. Monitoring of blood chemistry is a standard part of Alanine therapy to ensure these side effects are caught early.

Alanine should only be used under the direct supervision of a healthcare professional experienced in clinical nutrition and metabolic management. Because Alanine contributes to the body's nitrogen load, it can exacerbate conditions where nitrogen processing is impaired. Patients must be monitored closely for signs of fluid and electrolyte imbalances, as well as changes in organ function.

No FDA black box warnings for Alanine. However, users should be aware of the general warnings associated with parenteral nutrition, including the risk of infection at the catheter site and the potential for severe metabolic complications if the infusion is not managed correctly.

Allergic Reactions / Anaphylaxis Risk

While rare, hypersensitivity to amino acid solutions can occur. If you have a known allergy to any components of the infusion (such as certain sulfites sometimes used as preservatives), notify your doctor immediately. Symptoms of an allergic reaction include skin rash, itching, and respiratory distress.

Hepatotoxicity and Liver Function

Long-term administration of amino acids like Alanine can lead to parenteral nutrition-associated liver disease (PNALD). Healthcare providers must monitor liver enzymes (ALT, AST) and bilirubin levels regularly. If liver function declines, the composition of the nutritional support may need to be altered.

Nephrotoxicity and Renal Function

In patients with pre-existing kidney disease, the nitrogen from Alanine can lead to an accumulation of urea in the blood (uremia). This can cause further damage to the kidneys and lead to systemic toxicity. Regular monitoring of BUN and creatinine is essential.

Fluid Overload

Amino acid solutions are often hypertonic and can cause fluid shifts. Patients with congestive heart failure or pulmonary edema must be monitored for signs of worsening fluid retention, such as swelling in the ankles (edema) or increased shortness of breath.

Patients receiving Alanine clinically will require frequent laboratory testing, including:

• Serum Electrolytes: Sodium, potassium, chloride, and bicarbonate levels.
• Blood Glucose: To monitor for hyperglycemia or hypoglycemia, as alanine affects glucose metabolism.
• Liver Function Tests (LFTs): To check for signs of liver stress.
• Renal Function Tests: BUN and creatinine levels.
• Ammonia Levels: Particularly in pediatric patients or those with liver disease.
• Fluid Balance: Daily weights and intake/output (I&O) monitoring.

Alanine itself does not typically cause sedation or cognitive impairment. However, the underlying conditions requiring Alanine therapy (such as severe illness or recovery from surgery) may affect your ability to drive or operate machinery. Always consult your doctor regarding your physical readiness for these activities.

Alcohol can interfere with the liver's ability to process amino acids and can exacerbate the risk of hypoglycemia or liver stress. It is generally advised to avoid alcohol consumption while receiving clinical nutritional support involving Alanine.

Alanine infusions should not be stopped abruptly, especially if they are providing a significant portion of the patient's caloric intake. Abrupt discontinuation can lead to 'rebound hypoglycemia' as the body's insulin levels may be elevated in response to the continuous glucose/amino acid load. The infusion rate is typically tapered down over several hours.

> Important: Discuss all your medical conditions, especially liver or kidney disease, with your healthcare provider before starting Alanine.

There are no drugs that are strictly contraindicated with Alanine in the same way that certain antidepressants interact with MAO inhibitors. However, Alanine should never be mixed in the same IV line with medications that are known to be physically or chemically incompatible with amino acid solutions, such as certain antibiotics or alkaline drugs, as this can cause the amino acids to precipitate (form solids), which can be fatal if injected.

Corticosteroids (e.g., Prednisone, Dexamethasone)

Corticosteroids promote protein breakdown (catabolism) and can interfere with the nitrogen-sparing effects of Alanine. This may lead to an increase in blood urea nitrogen (BUN) levels. Healthcare providers should monitor nitrogen balance and adjust the Alanine dose accordingly.

Tetracycline Antibiotics

Tetracyclines can have an anti-anabolic effect, which may reduce the efficiency with which the body utilizes Alanine for protein synthesis. This interaction can also lead to increased BUN levels.

Diabetes Medications (e.g., Insulin, Metformin)

Alanine can be converted into glucose in the liver. In patients with diabetes, supplemental Alanine may increase blood sugar levels, requiring an adjustment in insulin or oral hypoglycemic dosages. Conversely, Alanine has been shown in some studies to stimulate glucagon secretion, which also raises blood sugar.

Levodopa

Amino acids compete with Levodopa for transport across the blood-brain barrier. High protein or amino acid intake (including Alanine) can reduce the effectiveness of Levodopa in treating Parkinson's disease. Patients should maintain a consistent protein intake and discuss timing with their doctor.

High-Protein Diets

If taking Alanine supplements, a diet extremely high in other proteins may overwhelm the body's ability to process nitrogen, leading to fatigue or kidney strain.

Dairy and High-Fat Meals

For oral Alanine, high-fat meals may slow gastric emptying and delay the absorption of the amino acid, though this is rarely clinically significant.

Arginine and Other Amino Acids

Taking large amounts of other single amino acids alongside Alanine can create an 'amino acid imbalance,' where the absorption of one interferes with the others. It is best to take balanced amino acid complexes unless otherwise directed.

St. John's Wort

While there is no direct metabolic interaction, St. John's Wort can affect liver enzymes. Although Alanine doesn't use the CYP system, the overall metabolic state of the liver is important for Alanine processing.

• Serum ALT (Alanine Aminotransferase): Supplemental Alanine does not typically raise ALT levels directly, but the enzyme is required for its metabolism. High ALT levels in the blood usually indicate liver damage, not high alanine intake.
• Blood Urea Nitrogen (BUN): Increased Alanine intake will naturally lead to a slight increase in BUN as the nitrogen is processed.
• Urinary Ketones: In rare cases, Alanine metabolism can influence the presence of ketones in the urine, particularly in patients with metabolic disorders.

For each major interaction, the management strategy involves regular blood monitoring and dosage titration by a medical professional.

> Important: Tell your doctor about ALL medications, supplements, and herbal products you are taking, including over-the-counter vitamins.

Alanine must NEVER be used in the following circumstances:

1. 1Urea Cycle Disorders (UCDs): These are rare genetic conditions where the body lacks one of the enzymes needed to remove ammonia from the blood. Since Alanine metabolism generates nitrogen that must be processed by the urea cycle, giving Alanine to these patients can cause life-threatening hyperammonemia (brain-damaging levels of ammonia).
2. 2Severe Renal Failure (Without Dialysis): In patients whose kidneys cannot excrete urea, the administration of Alanine will lead to a rapid and dangerous buildup of nitrogenous waste (uremia).
3. 3Hypersensitivity: Any known history of severe allergic reactions to L-alanine or any component of the amino acid injection (such as sulfites).
4. 4Inborn Errors of Amino Acid Metabolism: Beyond UCDs, other rare metabolic disorders that specifically affect the transamination of alanine are absolute contraindications.

These conditions require a careful risk-benefit analysis by a healthcare provider:

• Hepatic Coma or Encephalopathy: While amino acids are needed for nutrition, the nitrogen load can worsen brain swelling in patients with end-stage liver failure.
• Congestive Heart Failure: The fluid volume required to deliver IV Alanine may exacerbate heart failure.
• Severe Acid-Base Imbalance: Because Alanine can have acidifying effects, it must be used cautiously in patients who are already in a state of metabolic acidosis.

Patients who are sensitive to other neutral amino acids (like Glycine or Serine) should be monitored closely, although true cross-sensitivity is rare because these are naturally occurring substances in the human body. The more common concern is sensitivity to preservatives or stabilizers used in the liquid formulations.

> Important: Your healthcare provider will evaluate your complete medical history, including genetic screenings if necessary, before prescribing Alanine-containing therapies.

Alanine is a naturally occurring amino acid and is a normal component of the maternal diet and fetal blood supply.

• FDA Pregnancy Category: Most amino acid injections are Category C. This means that while no well-controlled human studies exist, they should be used during pregnancy only if clearly needed.
• Clinical Considerations: Proper nutrition is vital for fetal development. If a pregnant woman cannot consume adequate protein orally (e.g., due to hyperemesis gravidarum), IV Alanine as part of TPN is considered necessary and generally safe under strict medical supervision. There is no known evidence of teratogenicity (birth defects) associated with L-alanine.

Alanine is a natural component of human breast milk. Supplemental Alanine taken by the mother is not expected to cause any adverse effects in the nursing infant. However, mothers receiving TPN should be monitored for overall nutritional balance to ensure the milk composition remains optimal for the infant's growth.

Alanine is essential for the growth of children.

• Approved Use: It is a standard component of pediatric and neonatal parenteral nutrition.
• Risks: The primary risk in neonates, especially those born prematurely, is hyperammonemia and aluminum toxicity. Because neonatal kidneys are immature, they cannot clear nitrogen or trace minerals as effectively as adults. Dosing must be calculated meticulously by a pediatric pharmacist or neonatologist.

In elderly patients, the use of Alanine requires caution due to the higher prevalence of:

• Reduced Renal Clearance: Aging kidneys may not process the urea resulting from alanine metabolism as efficiently.
• Cardiac Fragility: Older adults are more susceptible to fluid overload from IV infusions.
• Polypharmacy: Interactions with other medications (like diuretics or ACE inhibitors) that affect kidney function must be considered.

For patients with a Glomerular Filtration Rate (GFR) below 30 mL/min, the dose of Alanine should be significantly reduced. If the patient is on hemodialysis or peritoneal dialysis, higher doses may be tolerated because the dialysis process removes the excess urea and nitrogen. However, the timing of the infusion relative to dialysis is critical.

In patients with Child-Pugh Class B or C cirrhosis, Alanine should be used with extreme caution. The liver's reduced capacity for gluconeogenesis and urea synthesis means that Alanine may not be metabolized correctly, leading to an imbalance in the plasma amino acid profile and potentially triggering hepatic encephalopathy.

> Important: Special populations require individualized medical assessment and frequent laboratory monitoring to ensure safety.

L-alanine is a neutral, non-polar amino acid. Its primary molecular mechanism involves serving as a substrate for the enzyme Alanine Aminotransferase (ALT). This enzyme facilitates the reversible transfer of the amino group from alanine to alpha-ketoglutarate.

In the muscle, this allows for the disposal of nitrogen produced during protein catabolism. In the liver, the resulting pyruvate enters the gluconeogenic pathway, where it is converted into glucose-6-phosphate and eventually free glucose. This 'Glucose-Alanine Cycle' is a major pathway for endogenous glucose production, especially during periods of stress or starvation. Additionally, Alanine stimulates the alpha-cells of the pancreas to release glucagon, further supporting blood sugar levels.

The pharmacodynamic effect of Alanine is primarily nutritional and metabolic. There is a direct dose-response relationship between Alanine intake and nitrogen retention, up to a physiological ceiling. The onset of metabolic effect is rapid when given intravenously, with changes in plasma amino acid profiles occurring within minutes. The duration of effect lasts as long as the infusion continues, with metabolic byproducts being cleared within hours of cessation.

| Parameter | Value |

|---|---|

| Bioavailability | 100% (IV); ~70-90% (Oral) |

| Protein Binding | Negligible |

| Half-life | 30 to 60 minutes |

| Tmax (Oral) | 0.5 to 1.5 hours |

| Metabolism | Hepatic (Transamination via ALT) |

| Excretion | Renal (as Urea) |

• Molecular Formula: C3H7NO2
• Molecular Weight: 89.09 g/mol
• Solubility: Highly soluble in water (166.5 g/L at 25°C).
• Structure: A simple alpha-amino acid with a methyl group side chain, making it one of the smallest and most chemically stable amino acids.

Alanine is classified as a Non-Essential Amino Acid. Within the therapeutic hierarchy, it is part of the 'Amino Acid Injections' group used for parenteral nutrition. It is often grouped with other neutral amino acids like Leucine, Isoleucine, and Valine, although its metabolic pathway is distinct from these branched-chain amino acids.