80. Dietary Supplements, Natural + Complementary Medicine Flashcards by Yerin M

____ establishes standards for dietary supplements

The United States Pharmacopeia (USP)

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T/F: supplements have to be approved by the FDA before being on the market

False - safety is the manufacturer’s responsibility, would have to be proved “unsafe” by FDA in order to be taken off the market

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What enzymes does St. John’s Wort affect?

SJW induces CYP3A4, 2C19, 2C9, and 1A2, and P-gp (decreases level of other drugs)

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What are some interactions to be careful of when using St. John’s Wort?

CYP450 and P-gp inducer = decreases level of other drugs
serotonergic (do NOT use with MAOi, SSRIs, or SNRIs)
Photosensitivity and sun protection needed (caution with diuretics, retinoids, quinolones, sulfamethoxazole, tetracyclines, and transplant drugs)
may lower seizure threshold (caution with bupropion, quinolones, tramadol, PCN, and carbapenems or hx of seizures)

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Which supplements increase risk of bleeding?

5Gs: garlic, ginger, ginko, ginseng, and glucosamine
Fish oils (at higher doses )
Vit E
Dong quai
Willow bark (a salicylate) - do not use with other anticoags

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What supplements increase risk of liver toxicity?

Black cohosh (used for menopausal symptoms)
Kava (used for stress/anxiety)
Others: Chaparral, comfrey, green tea “extracts”

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Which supplements increase risk of cardiac toxicity?

Ephedra - removed d/t cardiac toxicity
Bitter orange (citrus aurantium or synephrine) replaced ephedra in many products (stimulants with dose-dependent cardiac toxicity, increase BP and HR, reports of MI, stroke, and arrhythmias)

Yohimbe (used for libido and ED) - increases BP, HR, and risk of seizures

Others:
DMAA (dimethylamylamine, amphetamine derivative for body-building ,increases BP and HR)
Licorice (contains glycyrrhizin, artificially flavored licorice do NOT have this compound, glycyrrhizin in large amounts can lower K and increase BP)

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What affects does caffeine have on the heart?

May increase BP and HR

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Commonly used supplements for Anxiety

Valerian
Passionflower
Kava
St. John’s wort

Others: chamomile, 5-hydroxytryptophan (5-HTP)

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Commonly used supplements for ADHD

Omega-3 fatty acids

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Commonly used supplements for cold sores

L-lysine

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Commonly used supplements for colds and flu

Echinacea
Zinc
Vit C

Others: eucalyptus oil (nasal congestion/allergies), probiotics

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Commonly used supplements for dementia/memory

Ginkgo
Vitamin E

Others: Vit D, acetyl-L-carnitine, vinpocetine (memory, neuroprotection, weight loss)

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Commonly used supplements for depression

St. John’s wort
SAMe (S-adenosyl-L-methionine) (for depression, osteoarthritis)
Valerian
5-HTP

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Commonly used supplements for DM

Alpha lipoic acid (diabetic neuropathy, memory, neuroprotection)
Chromium
Cassia cinnamon

Others: Mg, American ginseng, Panax ginseng

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Commonly used supplements for HLD

Red yeast rice (contains a natural form of lovastatin)
Omega-3 fatty acids
Others: Garlic (controversial benefit; small decrease TC and LDL), Plant sterol, fibers (barley, psyllium, oat bran), artichoke extract

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Commonly used supplements for dyspepsia

Calcium
Magnesium

Others: peppermint, chamomile

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Commonly used supplements for energy/weight loss

Bitter orange (synephrine)
Caffeine
Guarana, green tea powder (contains caffeine)

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Commonly used supplements for erectile dysfunction

Ginseng
L-arginine
Yohimbe

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Commonly used supplements for HF, heart health

Coenzyme Q10 (ubiquinone, used adj with HF meds
Hawthorn
Omega-3 fatty acids

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Commonly used supplements for HTN

Omega-3 fatty acids
L-arginine
Coenzyme Q10
Garlic (controversial benefit; small decrease in SBP)
Other: fiber (psyllium, oats, and wheat bran), potassium

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Commonly used supplements for GI health

Fibers (for diarrhea, constipation; examples: psyllium (in Metamucil, barley, oat bran))
Chamomile
Probiotics
Others: peppermint, horehound (GI health, constipation), wheatgrass (GI health, detox)

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Commonly used supplements for inflammation

Omega-3 fatty acids
Flax seeds/oil (converted to DHA and EPA
Tumeric

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Commonly used supplements for insomnia/sleep

Melatonin (nightly, help prevent/treat jet lag (0.5-2mg taken pre-flight and higher doses such as 5mg post-flight)
Valerian
Chamomile
Others: lemon balm, passionflower, Coenzyme Q10 (if d/t HF), 5-HTP and L-trptophan

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Commonly used supplements for Liver disease

Milk thistle

Commonly used supplements for menopause

Black cohosh Dong quai Evening primrose oil Soy, red clover

Commonly used supplements for migraine prophylaxis

Feverfew Butterbur Magnesium Riboflavin (vit B2) Others: Coenzyme Q10, guarana (for caffeine) or other caffeine sources

Commonly used supplements for Motion sickness

Ginger Peppermint

Commonly used supplements for Osteoarthritis

Glucosamine (best evidence with sulfate salts) Chondroitin SAMe (used for depression, osteoarthritis) Tumeric (decrease inflammation/pain)

Commonly used supplements for Osteoporosis

Calcium Vit D Soy Other: ipriflavone

Commonly used supplements for prostate health

Saw palmetto (used often, may be ineffective) Lycopene Others: Pygeum, pumpkin seed (contains beta-sitosterol)

Commonly used supplements for UTI

Cranberry Others: yogurt, probiotics

Commonly used supplements for skin conditions

Tea tree oil (for acne, dandruff, fungal infections) Others: alo vera, topica vit D, biotin

Commonly used supplements for weight loss

Garcinia cambogia

Safety issues with 5-HTP

Serotonergic - increased risk with other serotonergic meds

Safety issues with bitter orange (synephrine component)

Stimulant; dose-related increased BP, HR, arrhythmia risk

Safety issues with Black cohosh

May be hepatotoxic Do NOT use with meds for HF: ACEi/ARBs, BB, amiodarone

Safety issues with caffeine (includes guarana, green tea powder)

Increased BP and HR others: dizziness, agitation, irritability

Safety issues with chamomile

Allergic reactions (uncommon), cross-sensitivity with other members of Asteraceae family (e.g. ragweed, asters, chrysanthemums, artichoke)

Safety issues with chondroitin

Increased risk of bleeding at higher dose, increases INR with warfarin

Safety issues with dong quai

Increased bleeding risk

Safety issues with Echinacea

Controversial safety with autoimmune disorders Use cautiously with other members of Asteraceae family (e.g. ragweed, asters, chamomile, chrysanthemums, artichoke)

Safety issues with feverfew

Mouth ulceration (inflammation of oral cavity/tongue) Increased bleeding risk

Safety issues with fibers (barley, psyllium, oat bran)

GI effects (e.g.. bloating, cramping, flatulence)

Safety issues with garlic, ginger, ginko, ginseng, glucosamine

Increased risk of bleeding

Safety issues with Hawtorn

Positive inotrope Avoid concurrent use with digoxin (Additive effect), decreases BP

Safety issues with Kava

Avoid d/t hepatotoxicity

Safety issues with L-arginine

May decrease BP and increase dizziness Caution for additive effect with BP lowering drugs Avoid concurrent use with nitrates (L-arginine converts into nitric oxide)

Safety issues with Melatonin

When used chronically for sleep, endogenous melatonin can be decreased = dependency

Safety issues with omega-3 fatty acids

Increase bleeding risk with high doses May increase LDL

Safety issues with passionflower

QT prolongation

Safety issues with potassium

K levels should be measured in lab and dosed accordingly (not with OTC supps)

Safety issues with probiotics

Separate use from oral abx Safety concern with use of live bacteria in immunocompromised states

Safety issues with red yeast rice (contains natural form of lovastatin)

CYP450 inhibitors will increase red yeast rice levels Red yeast rice decreases coenzyme Q10 which may increase myopathy risk Do NOT use with statins

Safety issues with SAMe

Serotonergic - increased risk with other serotonergic drugs Increased bleeding risk Do NOT use in bipolar disorder d/t increased risk manic behavior

Safety issues with Soy, red clover

Soy may increase breast cancer risk in postmenopausal women who are not producing estradiol

Safety issues with St. John's Wort

Many drug interactions - Induces CYP450 and P-gp Serotonergic Photosensitivity

Safety issues with Valerian

Sedation CNS depressant

Safety issues with vitamin C (ascorbic acid)

Nephrolithiasis with high doses False-negative stool occult blood 48-72 hrs after ascorbic acid ingestion

Safety issues with vitamin E (alpha-tocopherol)

Do NOT exceed 400 IU daily Bleeding risk CVD risk

Safety issues with Yohimbe

Increased BP and HR Seizure risk

Safety issues with Zinc

Nasal products can cause loss of smell

Vitamin A name

Retinol

Vitamin B1 name

Thiamine

Vitamin B2 name

Riboflavin

Vitamin B3 name

Niacin

Vitamin B6 name

Pyridoxine

Vitamin B9 name

Folic acid

Vitamin B12 name

Cobalamin

Vitamin C name

Ascorbic acid

Vitamin D2 name

Ergocalciferol

Vitamin D3 name

Cholecalciferol

Vitamin E name

Alpha-tocopherol

____ vitamin deficiency is common in alcoholism and can cause ____ encephalopathy

Thiamine (vit B1) Wernicke's

S/sx of Wernicke's

Mental confusion, ataxia, tremor, vision changes

As the symptoms of Wernicke's fade, ___ syndrome tends to develop which is permanent neurologic damage

Korsakoff syndrome

What type of med can contribute to calcium deficiency?

Anticonvulsants

The American Academy of Pediatrics (AAP) recommends vitamin D for infants and children in certain situations. What are they?

1. exclusively breastfed babies or drinking less than 1 L of baby formula - need 400 IU of vit D 2. older children who do not drink at least 4 cups of vit D fortified milk

All women of childbearing age should obtain ____ of folic acid

400mcg/day

During pregnancy, folate requirements increase to ____ per day

600 mcg/day

When should patients start taking folic acid?

at least 1 month before pregnancy continue for first 2-3 months of pregnancy (probably will be throughout pregnancy)

Prescription prenatal vitamins usually contain ___ of folate

1000 mcg (1mg) of folate

___ and __ contain the potassium-sparing progestin drospirenone, with ethinyl estridiol and levomefolate

Beyaz Safyral

Vit E in foods is considered healthy, but excess intake of supplements can be a health risk, particularly ____ risk patients should NOT exceed ___ daily

CV risk 400 IU daily

American Academy of Pediatrics (AAP) recommendations for Iron: 0-4 months

Not required

American Academy of Pediatrics (AAP) recommendations for Iron: 4-6 months

Formula - not needed (usually in formula) Breastfed babies need 1mg/kg/day from 4-6 months until consuming iron-rich foods

American Academy of Pediatrics (AAP) recommendations for Iron: 6-12 months

Need 11 mg/day of iron Food sources preferred, supplement prn

American Academy of Pediatrics (AAP) recommendations for Iron: 1-3 years

Need 7 mg/day of iron Food sources preferred, supplement prn

Preterm (<37 weeks) breastfed infants should receive ___ of elemental iron supplementation from age ___ to ___

2mg/kg/day age 1-12 months

Adolescent girls are at risk of ___ once menstruation begins.

anemia

What formulation are Fer-In-Sol supplements?

Iron supplement drops

What formulation are Feosol supplements?

Tablets and caplets

When would you use Poly-Vi-Sol supplements?

Vitamin drops with iron - use if both vit D AND iron are needed

Antiepileptics (includes carbamaepine, lamotrigine, oxcarbazepine, phenobarbital/primidone, phenytoin, topiramate, valproic acid/divalproex, zonisamide) can cause ___ nutrient depletion

Calcium (supplementation usually required, with vit D if needed)

Amphotericin B can cause ___ nutrient depletion

Mg, K

Isoniazid can cause ___ nutrient depletion

Vit B6

Loop diuretics can cause ___ nutrient depletion

Metformin can cause ___ nutrient depletion

Vit B12

Methotrexate can cause ___ nutrient depletion

Folate

Orlistat can cause ___ nutrient depletion

Beta-carotene, fat-soluble vitamins

PPIs can cause ___ nutrient depletion

Mg, Vit B12 (>2 yrs of treatment)

Acetazolamide can cause ___ nutrient depletion

Calcium, K

Sulfamethoxazole can cause ___ nutrient depletion

Folate

___ supplement is recommended in patients with alcohol use disorder

Vitamin B1, folate

___ supplement is recommended in patients with goiter

Iodine (iodized salt)

___ supplement is recommended in patients with microcytic anemia

Ferrous sulfate

___ supplement is recommended in patients with macrocytic anemia

Vit B12 and/or folate

___ supplement is recommended in patients with pregnancy

Folate, calcium, vit D, pyridoxine (nausea)

___ supplement is recommended in patients with osteopenia/osteoporosis

Calcium, vit D

___ supplement is recommended in patients with CKD

Vit D

Patient brings in a Rx for orlistat. Which vitamins should the patient take while on this medication?

Vitamin A, D, E, and K (fat soluble vitamins)

T/F: all agents used to increase bone density should be taken with supplemental calcium and vit D

True - they require adequate calcium and vitamin D intake

___ supplement is recommended in patients with scurvy

Vit C

___ supplement is recommended in patients with Crohn's Disease (possibly ulcerative colitis)

Patient-specific, depends on levels; can require iron, zinc, folate, calcium, vit D, B vitamins