Patient assessment: Supplements

Note: I have no idea about what we have to learn in this workshop, there is a lot of information that was given, especially about what each vitamin and mineral does and what happens if you have not enough or too much of it. I'll try to focus on the critically important ones. Two special cases: In pregnancy There are two which are recommended by the Ministry of Health Folic acid- prevent neural tube defects Iodine- required for normal brain development Folic acid tablets 0.8mg daily 1 week before trying to get pregnant and till 12 weeks after conception 5mg daily if associated with a high risk of defects: Family history Taking antiepileptics (reduces absorption and availability of folate) Folic acid 0.8mg tablets (alone) are available in pharmacies. Don't rip off your customers by recommending a combination product (see below) Please try and not rip the customers off. It's a pet peeve of mine. Iodine tablets 0.15mg (150 micrograms) daily during pregnancy and breastfeeding These are available in pharmacies Do not recommend seaweed containing products, only the ones with pure iodine. Because, there is too much variation in natural products. What about the others? Only recommended if not maintaining a healthy diet (i.e. if there is a deficiency) Plenty of fruit and veges and whole grains Minimise refined grains, saturated and trans fats, sugar and salt If they can't maintain a healthy diet, then you can recommend a multivitamin product Increasing B vitamin intake does not increase energy. Only B12 deficiencies need to be corrected (see below) Iron is also important. Although there is no recommendation to take it by the MoH, iron requirements increase during pregnancy Refer women who are looking tired or pale and if they say they don't each much red meat or iron containing products. Especially in third trimester, where IV iron may be required. Lastly, for both recommended supplements, they are able to see their doctor to get a prescription to get it subsidised Note: not all these recommendations were mentioned in the workshop, but ethically, we are bound to follow best practice guides, so it's a good idea to know these. (Why do I know about this? It's because of the presentation we had to do on supplements during pregnancy. So don't freak out if you didn't know about these recommendations) Vegans and strict vegetarians A spectrum of 'vegetarianism' exists Demi-vegetarianism is where they only avoid red meats. White meats (such as chicken or fish) tend to be okay Not at risk of vitamin B12 deficiency At risk of iron deficiency Some vegetarians aren't happy to eat any flesh, but they are happy to eat eggs or milk At risk of vitamin B12 and iron deficiency Vegans aren't happy to eat any animal products at all At risk of vitamin B12 and iron deficiency
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 At risk of vitamin B12 and iron deficiency Anything stricter than that (e.g. cereals only) will result in risk of other deficiencies. Vitamin B12 Passed down the food chain through animal products Only produced by bacteria (therefore, plants won't produce it) Important deficiency, leads to pernicious anaemia (and spinal cord degeneration) Comes as sublingual drops, one drop under the tongue daily Iron Heme iron found in meats is the most bioavailable form of iron Vegetarians and vegans won't get the heme iron, so they might be at risk of iron deficiency Comes in a wide range of products Tablets (either alone or with vitamin C to enhance absorption) Oral liquids (good for paediatric use) Oral melts BUT if you see iron on a prescription, CHECK THE IRON SALT FORM. Iron comes in a range of salts and they are NOT equivalent. But you do need to tell them about a few things: Take on an empty stomach (1 hour before or 2 hours after food) Avoid antacids (same timeframe as above) Can turn stool black Can cause constipation or diarrhoea Deficiencies, toxicities, diseases and interactions (just the major/important ones) Water soluble vitamins B1 (thiamine) deficiency can cause beriberi Extreme lethargy CNS effects/paralysis/changes in gait Would probably refer anyway Rare now, due to vitamin fortification in food. Plus it's found in wheatgerm (so wholegrain is best), peas, beans and yeasts BUT can occur in heavy drinkers as it impairs thiamine absorption and storage B2 (riboflavin) Also seen in alcoholism Deficiency causes ariboflavinosis Signs: Normocytic normochromic anaemia Variety of skin conditions From milk and green veges High doses will turn urine bright yellow (can be seen with Berroca consumption) B3 (niacin) Deficiency results in Pellagra The 4 Ds (symptoms) Dementia Dermatitis Diarrhoea Death Found in meat, wholegrains, beans Can cause flushing at high doses (vasodilator effect) Used in high doses to reduce blood lipids Notable interaction: can reduce the glucose sensitivity in type 2 diabetes. Concomitant use may be okay as benefits may outweigh risks. However, a dose modification of the diabetic medication will be required B6 (pyroxidine) Notable Interaction: with amiodarone Increases photosensitivity Notable Interation: phenytoin
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 Notable Interation: phenytoin NOT to be taken together (impairs metabolism) Overdose warning: High doses are associated with arrhythmia and nerve damage (peripheral neuropathy) B9 (folate) Important for pregnancy (see above) Also important for thymidine production (especially for red blood cell production) Therefore, a deficiency can cause megalocytic anaemia High doses (outside pregnancy) are not recommended, as it can hide vit B12 deficiency B12 was discussed above (see the section on vegans) Note: there are more B vitamins, but I've only picked out the ones which are associated with interactions, overdoses or if the deficiency was common enough to be associated with disease. B vitamins tend to be widespread and fortified in foods anyway. With the exception of B12 in vegans, supplementation shouldn't be required. Also, the group B vitamins tend to be cofactors for metabolic processes Vitamin C (ascorbic acid) A deficiency in vitamin C will lead to scurvy, as vitamin C is important for collagen production Wound healing is severely limited and old wounds will open back up Gum disease and dry mucosae can also be seen Vitamin C is found in fresh fruits (especially citrus) and vegetables Maximum dose of 1g is suggested, as higher doses are associated with acidosis and GI upset Fat soluble vitamins Notable Interaction: orlistat and fat soluble vitamins Orlistat is a drug designed to deliberately inhibit fat absorption as a weight loss aid Inhibiting fat absorption also prevents the absorption of fat soluble vitamins Vitamin A Found in liver (overconsumption of liver is toxic due to Vit A), carrots etc. Deficiencies are rare Important overdose: teratogenic in large amounts. Pregnant women should avoid supplements and foods containing high amounts of vitamin A (such as liver) Note: the stuff found in carrots is inactive, and it won't be activated if vitamin A levels are high enough, so it's harmless in overdose Vitamin D Produced when the skin is hit by UV light, or from dietary sources such as milk and veges Deficiencies most common in the elderly. Severe in children The elderly tend not to spend long in the sun, but they will only experience mild symptoms as the bone has already been calcified Children need it, as it is important for proper absorption and calcification of bone, so a deficiency will lead to rickets, with bowing of the legs being possible due to soft bones Refer cases Vitamin E Extremely unlikely to be deficient, commonly found in fats and oils Vitamin K Notable Interaction: with warfarin Warfarin antagonises the action of vitamin K to produce anticoagulant action (i.e. concomitant use will lead to anti-anti-coagulation. In fact, vitamin K is an antidote to warfarin Deficiencies are also unlikely Minerals
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Minerals Iron An important mineral for red blood cell production (as well as enzymes like the CYP superfamily) A deficiency can cause anaemia Need to prevent overdoses, males generally do not require supplementation to avoid overdosing Remember: the body can't secrete iron, so it's easy to accumulate Multivitamin products for men won't contain iron for this reason While multivitamin products for women will contain iron, as they need the extra iron to replace the iron lost via menstruation Interactions: Tetracyclines and qinolones Bisphosphonates Levodopa (can reduce absorption, be cautious for any changes in efficacy) Calcium An important mineral for bone growth and maintenance Can lead to osteoporosis Found mainly in dairy products Interactions: Tetracyclines and qinolones (e.g. doxycycline)- not to be taken together due to chelation, reducing the absorption of both Bisphosphonates- same as above Phenytoin Zinc A favourite of pharmacies NZ-wide due to it's easy screening method: The 'taste test' they have indicates if a person is zinc deficient Used in a variety of enzymes of the body Found in oysters, legumes and meat Associated with stunted growth and decreased smell and taste Interactions: Being a divalent cation (i.e. has a 2+ charge) it also chelates the same things as calcium Chromium Abundant in food, unlikely to be an issue Used in enzymes as a cofactor for glucose metabolism So a deficiency will lead to type 2 diabetes Magnesium May be recommended for myoclonic jerks (twitches while nodding off to sleep) Thought to be important for nerve and muscle function Interactions: as with divalent cations. Interactions (not covered above) ACE inhibitors and potassium ACE inhibitors will cause hyperkalemia as a side effect (i.e. high potassium) Therefore, taking a potassium containing supplement is not recommended For the same reason, do not take potassium with potassium sparing diuretics (such as amiloride) With warfarin A wide range of supplements will affect warfarin Probably a good idea to look up a warfarin interaction because it can interact with so much stuff Glucosamine (used as a supplement in osteoarthritis treatment) will increase INR and its use is not recommended with warfarin Cranberry supplements will just destabilise the INR (i.e. can go up or down), so again, using them together isn't a good idea
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together isn't a good idea Cranberry is cautioned with any blood thinning drugs Garlic (high dose supplements) increases the likelihood of bleeding, because garlic might reduce thromboxane A2, the substance which reduces platelet aggregation. But information on this interaction is limited For this reason, garlic can be used for high blood pressure, but need to be careful when using it with other blood thinning drugs Thiazides One effect they have is hypercalcemia, which is due to calcium reabsorption So calcium supplements shouldn't be taken at the same time Meanwhile, loop diuretics will increase calcium loss... Peppermint oil + omeprazole Random interaction Omeprazole increases pH (reduces acidity) of the stomach, which causes the enteric coat of the peppermint oil capsules to fail This causes peppermint oil release into the stomach, so less peppermint oil reaches the intestine (reduces the effect of the peppermint oil, as it needs to reach the intestines) Plus the release of peppermint oil into the stomach stimulates acid secretion, which reduces the effectiveness of the omeprazole St. John's wort Inducer of CYP3A4 Therefore interacts with a wide, wide range of drugs Reduces the efficacy of the COC Reduces levels of warfarin Etc.

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