Dietary supplement health and education act (DSHEA): dietary supplement manufacture needs to make sure their products are safe and effective before they are sold and should follow cGMP (current good manufacturing practices).
Patients and providers can report adverse effects through FDA’s MedWatch program.
Manufacturers cannot make the claim that the product treats or cures a condition.
The United States Pharmacopeia (USP) establishes standards for dietary supplements.
Drug interactions:
John’s Worts induces 3A4 and P-gp and other CYP enzymes (one of the potent inducers) and lowers the seizure threshold.
Bleeding risk (Gs): garlic, ginkgo, ginger, ginseng, and glucosamine; others: fish oil, willow bark, Saw palmetto, V-E.
Liver toxicity: black cohosh (used for menopause), kava (stress/anxiety).
Cardiac risk: ephedra and bitter orange due to their stimulant effects (vasoconstriction).
Common dietary treatments
Anxiety: kava, valerian.
ADHD: fish oil.
Cold sore: L- lysine.
Cold and flu: echinacea, vitamin C, Zinc
Dementia/memory: ginkgo, vitamin E.
Depression: 5HT, SJW (lots of DDI), SAMe.
DM: alpha-lipoic acid, cinnamon, chromium.
Dyslipidemia: red yeast rice, niacin, fish oil, garlic
Weight loss: bitter orange, caffeine.
Heart failure: Co-Q10, hawthorn.
HTN: Co-Q10, fish oil, garlic, L-arginine.
Insomnia: melatonin, chamomile.
Liver disease: milk thistle.
Menopause: evening primrose, black cohosh, soy.
Motion sickness: ginger, peppermint, b6.
Osteoarthritis: glucosamine, chondroitin, SAMe.
Osteoporosis: Ca + V-D, soy.
Prostate health: Saw palmetto, pygeum.
Skin: tea tree oil (acne, dandruff, antifungal), aloe vera (burns, psoriasis).
UTI: cranberry, probiotics.
Drugs cause nutrient loss
Antiepileptics: Ca (some AEDs’ MOA are Ca channel blockers)
Isoniazid: V-b
Loops: K, so significant that requires K supplement.
Methotrexate/sulfamethoxazole: folate.
Orlistat and lipid binders like Welcol: fat-soluble vitamins.
Metformin: B12
PPI: Mg, B12.
Conditions with recommended supplements
Alcoholism: folate, B1
Microcytic anemia: Iron
Macrocytic anemia: B12, folate
Pregnancy: folic acid, Ca, V-d, pyridoxine
Bone disorders: Ca +V-d
Scurvy: V-C
Cold and Cough
OTC cough products are generally avoided in children < 4 yo, can recommend homeopathic for under 4 yo.
Avoid antihistamine in children, use nasal bulbs, saline drops instead.
Expectorant
Drugs: guaifenesin (Mucinex)
Mechanism of Action: Possibly increases the amount of liquid in respiratory tract thereby promoting loosening of mucus
Cold product
APAP infant and children’s drops now contain the same concentration to help reduce dosing errors (previously infant drops were more concentrated). APAP infant: 80mg/0.8ml(10-15mg/kg) Vs. APAP Children: 160mg/5ml. Infant formulas were more concentrated probably due to that fever in infants is more severe and dangerous compared to children, therefore it is more critical to treat the cold and control fever (< 104o)
General dosing by weight (don’t dose by age): Tylenol 10–15mg/kg PO Q4–6H, Ibuprofen 5–10 mg/kg PO Q4–6H
Gas: Simethicone (Mylicon®) infant drops before meals and every night as needed
Constipation: Glycerin-based products or suppository, e.g. Pedi-Lax, MiraLax.
Nausea: Emetrol - a mixture of fructose, glucose, and phosphoric acid, exerts its antiemetic action by delaying gastric emptying time and reducing smooth muscle contraction.
Dramamine (an antihistamine) can also help nausea due to its anticholinergic effect (inhibits smooth muscle movement).
Ca+ V-D
Ergocalciferol (AKA vitamin D₂ and calciferol): is a type of vitamin D found in food and used as a dietary supplement.
V-D aids in body Ca absorption.
Vitamin B
B1: thiamine; deficiency is common in alcoholism; deficiency can cause Wernicke’s -encephalopathy and Korsakoff syndrome.
B6: pyridoxine, the level can be reduced by isoniazid. Ingredient of a combo morning sickness drug Diclegis.
B7: biotin, hair/skin/nails growth. FYI: can cause falsely low TSH, PSA, troponin & cause falsely high free T3 or T4, folate, testosterone levels
B9: folic acid; Common use in pregnancy to minimize the risk of neural tube defects, alcoholism can cause folic acid deficiency; Deficiency can lead to macrocytic anemia; Meds ↓ folic acid levels: MTX/ sulfasalazine, phenytoin/fosphenytoin, phenobarbital, primidone, sulfamethoxazole/ trimethoprim.
B12: cyanocobalamin, deficiency commonly with the use of metformin, deficiency causes macrocytic anemia, the level can decrease due to metformin, PPIs.
B2: riboflavin, B5: pantothenic acid
Herbals
Feverfew: Migraine prophylaxis
Evening primrose oil: Eczema, but it can decrease seizure threshold
Saw palmetto: Treat symptoms of an enlarged prostate (benign prostatic hypertrophy, BPH); May slow blood clotting. Taking saw palmetto with medications that also slow clotting increases the chances of bleeding.
Licorice
Indications: Addison's disease (a type of diabetes caused by a hormone deficiency (diabetes insipidus)), high potassium levels, chronic fatigue syndrome (CFS) - a condition in which there is too much muscle tone (hypertonia).
many DDI due to enzyme inhibiting effect thus raise the level of CYP substrates: real licorice contains glycyrrhizin (cause irregular heartbeat when combined with digoxin); avoid consuming with most blood pressure drugs (reduce effectiveness), blood thinners (intensify thinning effect), and birth control pills (lower K+ levels).
Poisoning
To prevent med poisoning of children: don’t call med "candy", take meds out of sight of children.
Call poison center: advise saving the number into the phone.
Don’t advise trying to manage with activated charcoal or induced vomiting.
Ipecac can do more harm than good: Not reliable, risky with caustic substances, etc.; Dispose of any ipecac still around.
Quiz
Which of the following conditions might St. John’ s wort be used to treat?
BPH
Depression
Diabetes
Hypertriglyceridemia
Menopause symptoms
Which of the following vitamins is used to treat Wernicke-Korsakoff syndrome?
Thiamine
Folic acid
Pyridoxine
Riboflavin
Which of the following contain dextromethorphan?
Mucinex
Delsym
Astepro
ZzzQuil
Which of the following should be used only 3 days to treat nasal congestion?
Phenylephrine
Doxylamine
Claritin
Naphazoline
Benadryl
A patient is complaining bilateral knee pain caused by arthritis. He requests an herbal product. Which of the following herbal medications may you recommend for the patient's arthritis?
Echinancea
St. John’s wort
Osteo Bi-Flex
Saw palmetto
A 33 yo female patient is requesting something to help with her seasonal allergies. She complains about itchy, watery eyes and runny nose. She prefers a product that will not make her drowsy. Which of the following would be most appropriate recommendation?
A.Brompheniramine
B.Chlorpheniramine
C.Doxylamine
D.Fexofenadine
E.Pseudoephedrine
Which condition can terbinafine be used to treat?
A.Athlete’ s foot
B. Eczema
C.Diarrhea
D.Lactose intolerance
E.Seasonal allergies
Which of the following vitamins is/are fat soluble? (Select ALL that apply.)
A.Vitamin A
B.Vitamin B12
C.Vitamin C
D.Vitamin D
E. Vitamin K
Which of the following medications used to treat constipation should be used with caution in a patient with impaired renal function?
Milk of Magnesia
Psyllium
Bisacodyl
PEG3350
Which of the following is a stool softener that can be used to treat constipation?
A.Docusate sodium
B.Polycarbophil
C.Psyllium
D.PEG3350
E.Docusate sodium– S
Which of the following are used in morning sickness in pregnancy?
Benadryl
Diclegis
Vitamin B6
Pyridoxine
Doxylamine
Which of the following may be administered with ferrous sulfate to increase its absorption?
Ascorbic acid
Calcium carbonate
Milk
Omeprazole
Absorption of which of the following medications may be impaired if given concurrently with oral ferrous sulfate? (Select ALL that apply.)
Penicillin
Ciprofloxacin
Doxycycline
Trimethoprim
HL is a 26 yofemale who just confirmed that she is pregnant. Which of the following should be recommended for JJ to prevent neural tube defects?
Cyanocobalamin
DHA
Ferumoxytol
Folic acid
Which of the following statements istrue regarding cyanocobalamin?
A.Injection solution is red to pink in color.
B.It is used for the treatment of folate deficiency.
C.It must be initiated with the nasal form.
D.Levels may be depleted by sulfonylureas.
B. St. John’ s wort may be used to treat depression, as it can increase the level of serotonin in the CNS. BPH may be treated with saw palmetto. Diabetes may be managed with the herbal supplement ginseng. Hypertriglyceridemia may be treated with omega-3 fatty acids, and menopausal symptoms may be treated with soybean extract - isoflavone.
A. Wernicke-Korsakoff syndrome occurs in severe thiamine (vitamin B1) deficiency.
B. Delsym contains dextromethorphan which is used as cough-suppressant. Mucinex is a brand name for guaifenacin. Astepro is a nasal antihistamine that contains azelastine. ZzzQuil (diphenhydramine) is an antihistamine used to treat insomnia.
D. Nasal decongestants— oxymetazoline and naphazoline, should only be used for 3 days to prevent rebound nasal congestion.
C. Osteo Bi-Flex (glucosamine and chondroitin) may be useful in treating arthritis pain by building cartilage. Echinacea may be used as an immune stimulant, saw palmetto may be used for benign prostatic hypertrophy.
D. Fexofenadine is a second-generation antihistamine and is less sedating that the first-generation antihistamines (brompheniramine, chlorpheniramine, and Doxylamine). Pseudoephedrine is a decongestant and would not help with allergy symptoms of itchy, watery eyes or runny nose.
A. Terbinafine is a topical antifungal used to treat athlete’ s foot.
ADE. Vitamins A D E K are fat soluble vitamins; Fat-soluble vitamins may accumulate and cause toxicities if ingested in large quantities. Water soluble vitamins are excreted by the kidneys when the body has achieved adequate levels.
C. Magnesium hydroxide (Milk of Magnesia) should be used with caution in patients with renal impairment due to the potential accumulation of magnesium.
A. Docusate sodium (Colace) is a stool softener to treat constipation. Polycarbophil and psyllium are bulk-forming laxatives that should be taken with a full glass of water. PEG3350 is an osmotic laxative, and S - senna is a stimulant laxative.
BCDE. Pyridoxine (B6) and doxylamine are commonly used in pregnancy for morning sickness, the prescription drug is Diclegis.
A. Oral iron products need an acidic environment for absorption. Ascorbic acid (vitamin C) or a glass of orange juice can be administered with oral iron products to increase absorption.
BD. Oral iron products can bind to both quinolone and tetracycline antibiotics, leading to a decreased serum concentration. If iron needs to be given with either a quinolone or a tetracycline antibiotic, they should be spaced out.
D. Folic acid can be used to prevent neural tube defects. Cyanocobalamin (vitamin B12) is used to increase B12 levels and prevent pernicious anemia.
A. The injection solution is red to pink and is stable at room temperature. Cyanocobalamin is used to treat B12 deficiency, not folate deficiency. B12 therapy is often initiated with the IM formulation and then transitioned to oral therapy; the nasal form is rarely used. Levels of B12 may be depleted with metformin, not sulfonylureas.
