What are the guidelines for chromium supplementation?

Guidelines for Chromium Supplementation

Chromium supplementation should not be routinely used to improve glycemia and dyslipidemia control in patients with type 2 diabetes, obesity, or non-diabetic patients. 1

Recommended Dosages for Different Clinical Scenarios

General Nutrition Support:

• Enteral nutrition: Should provide at least 35 μg/day chromium with 1500 kcal/day 1
• Parenteral nutrition: Should provide at least 10 μg/day 1

Specific Clinical Situations:

For Patients with Suspected Chromium Deficiency:

• Additional supplementation can be provided orally or IV as available 1
• IV chromium: 200-250 μg/day for a period of 2 weeks or longer 1
• Reassess insulin resistance after 2 weeks of supplementation 1

For Critically Ill Patients with Severe Insulin Resistance:

• IV chromium (as chromium chloride): 3-20 μg/h for 10 hours and up to 4 days 1
• Only applicable for patients requiring very high insulin doses (30-50 U/h to maintain blood glucose <10 mmol/L) 1

Monitoring Recommendations

• Regular monitoring of chromium status is not recommended 1
• Serum chromium determination is rarely required but can be performed when there is clinical suspicion of deficiency or toxicity 1

Clinical Manifestations of Chromium Deficiency

Chromium deficiency may present as:

• Glucose intolerance
• Insulin resistance
• Weight loss
• Elevated plasma free fatty acids
• Neuropathy 1

These manifestations have been primarily observed in adults with chronic intestinal failure after massive bowel resection receiving long-term parenteral nutrition without chromium supplementation 1, 2.

Efficacy of Chromium Supplementation

Despite earlier research suggesting benefits 2, 3, current high-quality evidence does not support routine chromium supplementation:

• A meta-analysis of 41 randomized controlled trials found only modest beneficial effects on glycemia and dyslipidemia in patients with type 2 diabetes 1
• No beneficial effect was observed in those without diabetes 1
• A systematic review of 9 RCTs found chromium supplementation ineffective for obesity treatment 1

Safety Considerations

Toxicity Risk:

• Parenteral chromium has higher potential toxicity than oral supplementation 1
• Chromium contaminants in PN solutions can increase the amount delivered by 10-100% 1
• High levels of chromium have been found in serum and urine of patients on PN, even short-term 1
• In autopsy tissues of patients on long-term PN, chromium levels were 10-100 fold higher than normal concentrations in heart, skeletal muscle, liver, and kidney 1

Special Populations:

• Chromium toxicity may be more concerning in pediatric patients 1
• Chromium accumulates in bones of patients with end-stage renal disease 1
• Increased serum chromium levels have been found in patients on maintenance hemodialysis 1

Practical Considerations

• Oral chromium is poorly absorbed 1
• Different formulations include chromium yeast, chloride, nicotinate, and picolinate (the latter being best absorbed) 1, 3
• Single element chromium additives for IV use may not be available in many countries 1
• In such cases, multi-trace element solutions may be necessary 1

Common Pitfalls to Avoid

1. Routine supplementation for diabetes or obesity management without evidence of deficiency
2. Failure to recognize potential chromium toxicity in long-term PN patients
3. Overlooking the significant contamination of PN solutions with chromium
4. Not considering special risks in pediatric patients and those with renal disease

When evaluating a patient for potential chromium supplementation, focus on clinical manifestations of deficiency rather than serum levels alone, and reserve therapeutic trials for specific clinical scenarios with close monitoring of response.