Omegaven

Fat Emulsions, Combinations
Fat Emulsions, Plain

Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.

Preparation of Total Nutrient Admixture (TNA)
30% Intralipid should only be administered as part of a 3-in-1 total nutrient admixture (TNA); it is NOT indicated for direct IV infusion. Diluting 30% formulations to a 20% concentration does not produce a solution equivalent to the commercially available 20% emulsions, and such a dilution should not be given by direct intravenous administration.
Pharmacy Bulk Packages are not for direct IV administration.
Prepare TNA using strict aseptic techniques.
Do not add intravenous lipid emulsion (ILE) to the parenteral nutrition (PN) container first; destabilization of the lipid may occur. The proper mixing sequence is dextrose, amino acids, and then lipid emulsion. Simultaneous transfer of dextrose, amino acids, and ILE to the PN container is also permitted.
Use gentle agitation during admixing; shake bags gently after each addition.
Do not add additives directly to ILE; additives to the TNA solution should be evaluated by a pharmacist for compatibility.
Storage: Use the Pharmacy Bulk Package within 4 hours after opening. Admixtures should be used promptly with storage under refrigeration not to exceed 24 hours and must be completely infused within 24 hours after removal from refrigeration.[61275] [61276] [61278] [63398]
 
Preparation of Bags for Direct Infusion
Inspect bag overwrap and primary bag; do not use if damaged. Inspect oxygen indicator and do not use if oxygen indicator is pink or dark pink (Nutrilipid) or black (SMOFlipid). Use only if container and seals are intact.
Remove infusion bag and discard oxygen indicator, oxygen absorber, and overwrap.
Discard bag if there is a separation of the lipid emulsion or any signs of discoloration and/or leakage.
Remove outlet port and attach administration set.[61275] [61276]
Additives may only be added to the medication port under strict aseptic techniques and only after evaluation by a pharmacist for compatibility.[61276]
Storage: After removing from the overwrap, ILE should be used immediately. If not used immediately, the product should not be stored longer than 24 hours under refrigeration. After removal from storage, the emulsion should be used within 24 hours.[61275]
 
Intravenous Infusion Administration
For intravenous infusion only through a peripheral or central line. When administered with dextrose and/or amino acids, solutions with an osmolarity of 900 mOsm/L or higher must be infused through a central line.[61275] [61276] [63398]
Use a 1.2 micron in-line filter for administration of intravenous lipid emulsion. This recommendation applies when administering PN as TNA as well as when giving dextrose and amino acids (2-in-1) and the IV lipid emulsion as a separate infusion. When administering the dextrose-amino acid component of the PN and the ILE as separate infusions, attach the filter below the Y-site where the infusions meet. If an occluded filter needs to be removed, replace it with a new filter. Do not allow an unfiltered admixture to continue to infuse.
Protect admixture from light during infusion.[61275] [61276] This includes containers and administration sets. The use of light-exposed parenteral nutrition products containing amino acids and/or lipids, particularly in admixtures with vitamins and/or trace elements, may lead to severe adverse effects, particularly in premature neonates. This is because exposure of these solutions to light causes the formation of peroxides and other degradation products.[64963]
Administration tubing and filter should be changed every 24 hours for TNA, dextrose/amino acid solutions (2-in-1), or lipid emulsions. When lipids are infused separately, ILE should hang for no more than 12 hours to minimize microbial growth potential. When administered as part of a 3-in-1 TNA, IV fat emulsions can hang for 24 hours.[61300] [61302] [63398]
To prevent air embolism, use a non-vented infusion set or close the vent on a vented set, avoid multiple connections, do not connect flexible bags in series, fully evacuate residual gas in the bag prior to administration, do not pressurize the flexible bag to increase flow rates, and if administration is controlled by a pumping device, turn off pump before the bag runs dry.[61275] [61276]
Do not use infusion sets and lines that contain di-2-ethyl hexyl phthalate (DEHP); administration sets that contain polyvinyl chloride (PVC) components have DEHP as a plasticizer.[61276] [61278] [63398]
Soybean oil-based lipid emulsions (i.e., Intralipid, Nutrilipid, SMOFlipid):
Adult patients: Initial infusion rate is 0.2 mL/kg/hour for first 15 to 30 minutes; gradually increase to the required rate after 30 minutes. Max: 0.5 mL/kg/hour (0.1 g/kg/hour). Infuse over 12 to 24 hours, depending on clinical situation.[52051] [61276]
Pediatric patients 11 to 17 years: Initial infusion rate is 0.2 to 0.4 mL/kg/hour for first 15 to 30 minutes; gradually increase to the required rate after 30 minutes. Max: 0.5 mL/kg/hour (0.1 g/kg/hour). Infuse over 12 to 24 hours, depending on clinical situation.[52051] [61276]
Pediatric patients 1 to 10 years: Initial infusion rate is 0.2 to 0.4 mL/kg/hour for first 15 to 30 minutes; gradually increase to the required rate after 30 minutes. Max: 0.75 mL/kg/hour (0.15 g/kg/hour). Infuse over 12 to 24 hours, depending on clinical situation.[52051] [61276]
Neonates and Infants:
Initial infusion rate is 0.1 to 0.2 mL/kg/hour for first 15 to 30 minutes; gradually increase to the required rate after 30 minutes. Max: 0.75 mL/kg/hour (0.15 g/kg/hour). Infuse over 24 hours to promote lipid tolerance.[52051] [61275] [61276] [61290]
The use of a dextrose/amino acids PN solution with ILE infused separately is recommended in neonates and infants due to the increased risk of calcium-phosphate precipitation in total nutrient admixtures.[43369]
Soybean oil/olive oil lipid emulsion (i.e., Clinolipid)
Adult patients: Initial infusion rate is 0.5 mL/minute for first 15 to 30 minutes; gradually increase to the required rate after 30 minutes. Max: 0.5 mL/kg/hour (0.1 g/kg/hour). Infuse over 12 to 24 hours, depending on clinical situation.
Fish oil triglycerides lipid emulsion (i.e., Omegaven)
Pediatric patients (all ages): Initial infusion rate is 0.2 mL/kg/hour for the first 15 to 30 minutes; gradually increase to the required rate after 30 minutes. Max: 1.5 mL/kg/hour (0.15 g/kg/hour). Infuse over 8 to 24 hours, depending on clinical situation.[63398]
 
Lipid Resuscitation Therapy (LRT) for Lipophilic Agent Overdose
LRT can be administered through a peripheral intravenous catheter.[61278]
Administer bolus over 1 to 3 minutes
After the bolus, attach the lipid emulsion bag to an intravenous pump for continuous infusion.
Continue infusion for at least 10 minutes after achievement of hemodynamic stability but no more than 60 minutes.[42615] [42616] [42699] [42701] [42705] [42707]

cyanosis / Early / 0-1.0
apnea / Delayed / Incidence not known
bradycardia / Rapid / Incidence not known
intestinal failure-associated liver disease / Delayed / Incidence not known
cholecystitis / Delayed / Incidence not known
aluminum toxicity / Delayed / Incidence not known

hypertriglyceridemia / Delayed / 0-38.0
elevated hepatic enzymes / Delayed / 0-6.0
hyperglycemia / Delayed / 2.0-5.0
hypertension / Early / 3.0-4.0
cholestasis / Delayed / 0-4.0
hyperbilirubinemia / Delayed / 3.0-3.0
thrombocytopenia / Delayed / 2.0-2.0
sinus tachycardia / Rapid / 0-2.0
chest pain (unspecified) / Early / 0-1.0
fluid retention / Delayed / 0-1.0
metabolic acidosis / Delayed / 0-1.0
dyspnea / Early / 0-1.0
phlebitis / Rapid / 0-1.0
hypertonia / Delayed / Incidence not known
neutropenia / Delayed / Incidence not known
erythema / Early / Incidence not known
fat overload syndrome / Delayed / Incidence not known
leukopenia / Delayed / Incidence not known
hepatomegaly / Delayed / Incidence not known
splenomegaly / Delayed / Incidence not known
anemia / Delayed / Incidence not known
steatosis / Delayed / Incidence not known
cholelithiasis / Delayed / Incidence not known
jaundice / Delayed / Incidence not known
hepatitis / Delayed / Incidence not known
bleeding / Early / Incidence not known

nausea / Early / 9.0-11.0
vomiting / Early / 5.0-7.0
infection / Delayed / 1.0-6.0
abdominal pain / Early / 2.0-4.0
fever / Early / 0-4.0
flatulence / Early / 2.0-4.0
dyspepsia / Early / 2.0-2.0
diarrhea / Early / 0-2.0
leukocytosis / Delayed / 0-1.0
dysgeusia / Early / 0-1.0
rash / Early / 0-1.0
back pain / Delayed / 0-1.0
flushing / Rapid / 0-1.0
pruritus / Rapid / 0-1.0
drowsiness / Early / 0-1.0
diaphoresis / Early / 0-1.0
dizziness / Early / 0-1.0
headache / Early / 0-1.0
agitation / Early / Incidence not known
injection site reaction / Rapid / Incidence not known

Clinolipid, Intralipid, Nutrilipid, Omegaven, Smoflipid

Rx

Fat emulsions primarily composed of varying ratios of medium-chain and long-chain triglycerides and/or fish oil triglycerides, egg phospholipids, and glycerol
Used for source of calories and essential fatty acids for parenteral nutrition or when deficiency occurs when oral or enteral nutrition is not possible, insufficient, or contraindicated; Omegaven indicated as lipid source in pediatric patients with parenteral nutrition-associated cholestasis
Used off-label for lipid resuscitation therapy (LRT) in cases of potentially fatal local anesthetic toxicity or lipophilic agent overdose or poisoning

8% to 10% of the caloric intake should be supplied by intravenous lipid emulsion for correction of fatty acid deficiency.

8% to 10% of the caloric intake should be supplied by intravenous lipid emulsion for correction of fatty acid deficiency.

8% to 10% of the caloric intake should be supplied by intravenous lipid emulsion for correction of fatty acid deficiency.

NOTE: Omegaven is not indicated for the prevention of PNAC. It has not been demonstrated that Omegaven prevents PNAC in patients on parenteral nutrition.

1 g/kg/day IV; initial doses may be lower and should be calculated according to individual requirements. Initiate Omegaven dosing as soon as direct or conjugated bilirubin concentrations are 2 mg/dL or greater in patients expected to require parenteral nutrition (PN) for at least 2 weeks. Administer until direct or conjugated bilirubin concentrations are less than 2 mg/dL or until the patient no longer requires PN.

1 g/kg/day IV; initial doses may be lower and should be calculated according to individual requirements. Initiate Omegaven dosing as soon as direct or conjugated bilirubin concentrations are 2 mg/dL or greater in patients expected to require parenteral nutrition (PN) for at least 2 weeks. Administer until direct or conjugated bilirubin concentrations are less than 2 mg/dL or until the patient no longer requires PN.

1 to 2 g/kg/day IV; may advance to a maximum of 2.5 g/kg/day. Fat emulsion should not comprise more than 60% of the patient's total caloric intake. Dosing is highly variable and should be calculated according to individual requirements. For the prevention of fatty acid deficiency, provide at least 2% to 4% of the total caloric intake as linoleic acid and 0.25% to 0.5% as alpha-linolenic acid, which for most adults can be supplied as 250 mL of 20% IV lipid emulsion once or twice weekly.

1 g/kg/day IV; may advance to a maximum dose of 2.5 g/kg/day. Fat emulsion should not comprise more than 60% of the patient's total caloric intake. Dosing is highly variable and should be calculated according to individual requirements. For the prevention of fatty acid deficiency, provide at least 2% to 4% of the total caloric intake as linoleic acid and 0.25% to 0.5% as alpha-linolenic acid, or approximately 0.5 to 1 g/kg/day.

1 to 2 g/kg/day IV; may advance to a maximum dose of 3 g/kg/day. Fat emulsion should not comprise more than 60% of the patient's total caloric intake. Dosing is highly variable and should be calculated according to individual requirements. For the prevention of fatty acid deficiency, provide at least 2% to 4% of the total caloric intake as linoleic acid and 0.25% to 0.5% as alpha-linolenic acid, or approximately 0.5 to 1 g/kg/day.

0.5 to 1 g/kg/day IV; advance by 0.5 g/kg/day, up to a maximum dose of 3 g/kg/day. Fat emulsion should not comprise more than 60% of the patient's total caloric intake. Dosing is highly variable and should be calculated according to individual requirements. For the prevention of fatty acid deficiency, provide at least 2% to 4% of the total caloric intake as linoleic acid and 0.25% to 0.5% as alpha-linolenic acid, or approximately 0.5 to 1 g/kg/day.

1 to 1.5 g/kg/day IV; may advance to a maximum of 2.5 g/kg/day. Fat emulsion should not comprise more than 60% of the patient's total caloric intake. Dosing is highly variable and should be calculated according to individual requirements. For the prevention of fatty acid deficiency, provide at least 2% to 4% of the total caloric intake as linoleic acid and 0.25% to 0.5% as alpha-linolenic acid, which for most adults can be supplied as 250 mL of 20% IV lipid emulsion once or twice weekly.

1.5 mL/kg (lean body weight) IV bolus administered over 1 to 3 minutes followed by 0.25 mL/kg/minute IV infusion for 30 to 60 minutes. If the patient remains unstable after the initial bolus, rebolus once or twice and double the infusion rate. If a significant response occurs quickly, adjust infusion to one-tenth of the initial rate (0.025 mL/kg/minute). If instability re-emerges, increase infusion back to 0.25 mL/kg/minute, or, in severe cases, repeat bolus. Suggested Max: 10 to 12 mL/kg. The safety of infusions beyond 1 hour has not been established.

1 to 1.5 mL/kg IV bolus, repeated every 3 to 5 minutes as needed (Max cumulative bolus: 3 mL/kg) followed by 0.25 mL/kg/minute IV infusion for no more than 60 minutes. American College of Medical Toxicology guidance recommends adjusting the infusion to one-tenth of the initial rate (0.025 mL/kg/minute) if a significant response occurs quickly. If instability re-emerges, increase infusion back to 0.25 mL/kg/minute, or, in severe cases, repeat bolus. Suggested Max: 10 mL/kg. 

Very limited data; 1 mL/kg IV bolus was reported in a 2-day-old neonate with bupivacaine-induced cardiotoxicity.

†Indicates off-label use

Specific guidelines for dosage adjustments in hepatic impairment are not available; the dose should be individualized based on clinical goals. Exercise caution when administering to patients with hepatic impairment as the liver is responsible for converting circulating free fatty acids to low density lipoproteins that enter the bloodstream. Additionally, hepatobiliary disorders are known to occur in patients receiving parenteral nutrition.

Specific guidelines for dosage adjustments in renal impairment are not available; the dose should be individualized based on clinical goals.

Acebutolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Acetaminophen; Aspirin, ASA; Caffeine: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Acetaminophen; Aspirin: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Acetaminophen; Aspirin; Diphenhydramine: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Angiotensin II receptor antagonists: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect. It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Angiotensin-converting enzyme inhibitors: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect. It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Anticoagulants: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Antithrombin III: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Apixaban: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Argatroban: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Aspirin, ASA: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Aspirin, ASA; Butalbital; Caffeine: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Aspirin, ASA; Caffeine: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Aspirin, ASA; Caffeine; Orphenadrine: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Aspirin, ASA; Carisoprodol: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Aspirin, ASA; Carisoprodol; Codeine: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Aspirin, ASA; Citric Acid; Sodium Bicarbonate: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Aspirin, ASA; Dipyridamole: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Aspirin, ASA; Omeprazole: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Aspirin, ASA; Oxycodone: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Atenolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Atenolol; Chlorthalidone: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Beta-adrenergic blockers: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Betaxolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Betrixaban: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Bisoprolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Bivalirudin: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Brimonidine; Timolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Butalbital; Aspirin; Caffeine; Codeine: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with aspirin. Theoretically, the risk of bleeding may be increased.
Calcium-channel blockers: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect. It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Carteolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Carvedilol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Central-acting adrenergic agents: (Moderate) Monitor blood pressure during concomitant fish oil and central-acting adrenergic agent use. Concomitant use may result in additive hypotension; high doses of fish oil may produce a blood pressure lowering effect.
Dabigatran: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Dalteparin: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Desirudin: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Dorzolamide; Timolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Doxazosin: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect. It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Edoxaban: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Enoxaparin: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Eplerenone: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect. It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Epoprostenol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect. It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Esmolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Fondaparinux: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Heparin: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Labetalol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Levobunolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Loop diuretics: (Moderate) Monitor blood pressure during concomitant fish oil and loop diuretic use. Concomitant use may result in additive hypotension; high doses of fish oil may produce a blood pressure lowering effect.
Mecamylamine: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect. It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Metoprolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Metoprolol; Hydrochlorothiazide, HCTZ: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Nadolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Nebivolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Nebivolol; Valsartan: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Pentosan: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Phenoxybenzamine: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect. It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Pindolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Platelet Inhibitors: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with other platelet inhibitors. Theoretically, the risk of bleeding may be increased.
Potassium-sparing diuretics: (Moderate) Monitor blood pressure during concomitant fish oil and potassium-sparing diuretic use. Concomitant use may result in additive hypotension; high doses of fish oil may produce a blood pressure lowering effect.
Prazosin: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect. It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Propranolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Propranolol; Hydrochlorothiazide, HCTZ: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Rivaroxaban: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
Thiazide diuretics: (Moderate) Monitor blood pressure during concomitant fish oil and thiazide diuretic use. Concomitant use may result in additive hypotension; high doses of fish oil may produce a blood pressure lowering effect.
Thrombolytic Agents: (Moderate) Fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents.
Timolol: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Vasodilators: (Moderate) High doses of fish oil supplements may produce a blood pressure lowering effect. It is possible that additive reductions in blood pressure may be seen when fish oils are used in a patient already taking antihypertensive agents.
Warfarin: (Moderate) Drug interactions with fish oil, omega-3 fatty acids (Dietary Supplements) or fish oil, omega-3 fatty acids (FDA-approved) are unclear at this time. However, because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 3-6 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant fish oil therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly. (Moderate) Monitor coagulation parameters closely during coadministration. Anticoagulant activity of warfarin may be counteracted by coadministration of intravenous lipid emulsions due to the natural vitamin K content of soybean and olive oils contained in the product.

Clinolipid/Intralipid/Nutrilipid/Soybean Oil Intravenous Inj Lipid Complex: 20%, 30%, 100mL, 4-16g
Omegaven/Smoflipid Intravenous Inj Emulsion: 0.1g, 1mL

2.5 g/kg/day IV for nutritional supplementation (soybean oil-based lipid emulsions); safety and efficacy of Omegaven has not been established; 12 mL/kg IV maximum cumulative dose recommended for lipid resuscitation therapy (off-label).

2.5 g/kg/day IV for nutritional supplementation (soybean oil-based lipid emulsions); safety and efficacy of Omegaven has not been established; 12 mL/kg IV maximum cumulative dose recommended for lipid resuscitation therapy (off-label).

2.5 g/kg/day IV (soybean oil-based lipid emulsions); 1 g/kg/day IV (Omegaven).

11 to 12 years: 2.5 g/kg/day IV (soybean oil-based lipid emulsions); 1 g/kg/day IV (Omegaven).
1 to 10 years: 3 g/kg/day IV (soybean oil-based lipid emulsions); 1 g/kg/day IV (Omegaven).

3 g/kg/day IV (soybean oil-based lipid emulsions); 1 g/kg/day IV (Omegaven).

3 g/kg/day IV (soybean oil-based lipid emulsions); 1 g/kg/day IV (Omegaven).

Intravenous lipid emulsions (ILEs) are utilized as a source of energy causing an increase in heat production, decrease in respiratory quotient, and increase in oxygen consumption. The most common mechanism of action for energy production derived from fatty acid metabolism is beta oxidation. Fatty acids are important for membrane structure and function, precursors for bioactive molecules (such as prostaglandins), and as regulators for gene expression. ILEs will prevent the biochemical lesions of essential fatty acid deficiency (EFAD) and correct the clinical manifestations of EFAD syndrome. ILEs are oil-in-water emulsions consisting of 1 or more triglyceride-containing oils, a phospholipid emulsifier, and glycerin. Phospholipid emulsifying agents, such as egg phosphatide, produce a barrier to prevent coalescence of oil droplets dispersed in the internal phase of the emulsion. The purpose of the emulsifying agent is to keep the particle size less than 0.5 micrometer. The phospholipid emulsifier provides stability to ILEs by functioning as both a mechanical and electrical barrier. Intravenous lipid emulsions are available as 10% concentration (lipid content of 0.1 g/mL), providing 1.1 kcal/mL, 20% concentration (lipid content of 0.2 g/mL), providing 2 kcal/mL, and 30% concentration (lipid content of 0.3 g/mL), providing 3 kcal/mL.
 
Lipid Resuscitation Therapy (LRT)
There are 3 proposed mechanisms for the efficacy of LRT, which include lipid sink sponge: ILEs sequester lipophilic drugs within serum, separating drug molecules from aqueous phase thus removing effects on end-organ tissues; mass action: ILEs provide abundance of free fatty acids as substrate to drive myocyte’s preferred energy pathway, mitochondrial beta-oxidation; and ion channel activation: ILEs activate voltage-gated calcium channels increasing intracellular calcium and cardiac contractility.

Lipid emulsions are administered intravenously. The infused fat particles are cleared from the bloodstream in a way thought to be similar to the clearing of naturally produced chylomicrons formed after enteral fat intake. After infusion, there is a transient increase in plasma triglycerides. The triglycerides are hydrolyzed to free fatty acids and glycerol by the enzyme lipoprotein lipase. The free fatty acids either enter the tissues (where they may be oxidized or resynthesized into triglycerides and stored) or circulate in the plasma, bound to albumin. In the liver, circulating free fatty acids are oxidized or converted to very low-density lipoproteins that re-enter the bloodstream. Lipids are normally cleared 5 to 6 hours after the lipid infusion is stopped. Three factors affect the plasma clearance of lipids: phospholipid content (both 20% and 30% intravenous lipid emulsions (ILEs) contain 1.2%), particle size, and infusion rate. Phosphatides are the hydrophobic components of membranes and provide electrically insulated layers. They are involved in the formation of membrane structures. Choline prevents deposition of fat in the liver. Glycerol is metabolized to carbon dioxide and glycogen or is used in the synthesis of body fats. The mean essential fatty acid content of SMOFlipid is 35 mg/mL (range: 28 to 50 mg/mL) of linoleic acid (omega-6) and 4.5 mg/mL (range: 3 to 7 mg/mL) of linolenic acid (omega-3). This represents a linoleic acid content of 14% to 25% and a linolenic content of 1.5% to 3.5%. This compares with 44% to 62% for linoleic acid and 4% to 11% for linolenic acid for soybean oil ILE products. The main fatty acid components of the fish oil in Omegaven are EPA (13% to 26%) and DHA (14% to 27%), which are omega-3 fatty acids. Omegaven also contains 1.5% and 1.1% of linoleic and alpha linolenic acid, respectively. The fish oil component has a total omega-3 fatty acid content of 40% to 54%. The osmolality of Omegaven is 342 mOsm/kg of water which represents an osmolarity of 273 mOsm/L. The osmolality of 20% ILEs is approximately 350 to 390 mOsm/kg of water, which represents an osmolarity of 260 to 280 mOsm/L. The osmolality of 30% ILEs is approximately 310 mOsm/kg of water, representing an osmolarity of 200 mOsm/L. The pH of ILEs ranges from 6 to 9.

There are no data available on the risks associated with intravenous lipid emulsion during pregnancy. Animal reproduction studies have not been performed with intravenous lipid emulsion, and it is not known if intravenous lipid emulsion can cause fetal harm when administered during pregnancy. Consider the risks and benefits of using intravenous lipid emulsion during pregnancy. Parenteral nutrition should be considered if the pregnant woman’s nutritional requirements cannot be met with oral or enteral intake.

There are no data available regarding the presence of intravenous lipid emulsion in human milk, the effects on the breast-fed infant, or the effects on milk production. Consider the developmental and health benefits of breast-feeding along with the mother’s clinical need for intravenous lipid emulsion, and any potential adverse effects on the breast-fed infant from intravenous lipid emulsion, or from the underlying maternal condition.