Block 2: Vitamins and Minerals Flashcards
How many people in the US are one multivitamins?
1/3
What health act instituted that dietary supplements are not drugs?
Dietary Supplement Health and Education Act (DSHEA) of 1994
Who do we need vitamens and trace minerals?
- Carry out bichemical reaction
- Synthesized inadequately or not at all in human body
Who need vitamins?
- Rare in western countries
- Malnourished
- Chronic ill, alcoholic, poverty, malabsorption
What are know drugs that cause vitamin deficiency?
Isoniazid: B6
Loop: K
Metformin: B12
PPI: Mg
What substances are absorbed in the duodenum?
- FA
- Calcium
- Mg
- P
- Zinc
- FOlate
- Thiamine
- ADEK
Substances absorbed in the jejunum?
- Molybdenum
- Chromium
What is EAR?
Estimated average requirements: meet the requirements of half of the healthy individuals in a specific gender and age group
What is RDA?
Recommended Dietary Allowances: Amount of a nutrient needed per day for maintenance of good health
What is AI?
Adequate Intakes: Recommended intakes for nutrients for which inadequate scientific data exist to establish an EAR
What is UIL?
Tolerable upper intake levels: Highest dose of nutrient intake that may by consumed daily without risk of adverse effects in the general population
How does ADEK get absorbed?
- Facilitated by bile
- Defs is do to fat intake limitations and malabsorption:
* Celiac
* CF
* Jaundice
* Cirrhosis
* Bariatric surgery
* Short-bowel syndrome
* Cholecystectomy
What are the drugs that cause malabsorption of ADEK?
- Cholestyramine
- Orlistat
What are the sources of vitamin A?
Liver, milk fat, egg yolk, yellow and dark green leafy vegetables, apricots, cantaloupe, peaches, carrots
What are the sources of Vitamin D?
Supplemented milk, egg yolk, liver, salmon, tuna, sardines, milk fat
What are the sources of vitmain K and E?
Liver, vegetable oil, spinach, kale, cabbage, cauliflower
Vit K: dark green leafy veggies
What are the forms of vitamin A?
- Retinoids: retinol
- Carotenoids: provitamin A
What are sx of vitamin A def?
Dermatologic: rough scaly skin, rough hair
Ocular: nyctalopia, xerophthalmia, bitots spot, night blindness
What is bitot’s spot?
Gray white, foamy, greasy, cheesy deposits on the conjunctiva near the cornia, fatty degenerated epithelial cells and leukocytes
What is the equivalents for retinol equivalents?
1 RE is equal to:
* 1 mcg retinol =3.33 IU retinol
* 2 mcg beta-carotene from supplements
What is the upper limit of vitamin A? Risks?
3 mg daily (prevention dose)
Teratogenic (large dose)
What are the forms of vitamin D?
Vitamin D3 (cholecalciferol)
Vitamin D2 (ergocalciferol)
What are the functions of Vitamin D?
- Increases calcium and phosphate absorption from the small intestine
- mobilizes calcium from bone
- permits normal bone mineralization
- improves renal reabsorption of calcium
- maintains serum calcium and phosphorous levels
What are the causes of vit d def?
- GI diseases
- Inadequate sunlight exposure
- Gastric bypass therapy
- Long term antiepileptic therapy
Presentations of Vit D def?
- Psychiatric disorders
- RIckets
Increased risk of CVD, osteoporosis, and rickets
WHat is the dosing of vit D def prevention?
800-1000 IU cholecalciferol QD
What are the functions of Vitmain E? Indications?
- Antioxidant
- Atherosclerosis
- Diabetes
- Cancer
- Parkinsons
- Alzheimers
Lack of benefit and increased risk of CHF
Dx states that cause vit e def?
Patients who don’t absorb fat normally (celiac disease, bariatric surgery)
Clinical presentation of vitamin E def?
- Peripheral neuropathy
- Intermittent claudication
- Muscle weakness
- Hemolytic anemia
What does the dosing of vit E look like?
1 mg of alpha-tocopherol vitamin E = 1.49 IU
Upper limit: 1000 mg daily
> 400 mg: ↑ all-cause mortality & prostate cancer
> 800 mg: ↓ platelet aggregation
caution with warfarin + aspirin or clopidogrel
- hold for surgery
UL of Vit E?
1000 mg QD
> 400 mg: ↑ all-cause mortality & prostate cancer
800 mg: ↓ platelet aggregation
caution with warfarin + aspirin or clopidogrel
Forms of vitmain K?
K1: phytonadione (vitamin K1) synthetic; naturally form phylloquinone food in many green leafy vegetables
Function of vitamin K?
Promotes the synthesis of and activates clotting factors II, VII< IX, X
Clinincal presentation of Vit K def?
Unusual bleeding, prolonged prothrombin time
What is the half-life of factor II?
Prothrombin: 50-80 hr
Vitmain K indications?
- VKA reversal
- Hemorrhage of newborn
Dosing of vitamin K?
Dosing: 2-5 mg po or IV for nonmajor bleeding events, 5-10 mg IV for major bleeding events
* Does not correct coagulopathy immediately
* Should always be used in combination with a repletion strategy (PCCs or plasma) in major bleeding events
What are the water soluble vitamins?
Vitamin C
Vitamin B1, B2, B6, and B12
Folic acid
Niacin
Sources of vitamin C?
Highest concentrations in uncooked fruits and vegetables
Fruit: oranges, lemons, strawberries,tangerines
Vegetables: Broccoli, cabbage, spinach, collard greens,kale, peppers
Sources of vitamin B12?
Exclusively found in meats, dairy, seafood, and eggs
None in vegetables, grains, or fruits
Sources of folate?
Liver, lean beef, wheat, whole-grain cereals, eggs, fish, dry beans, lentils, green leafy vegetables
Sources of niacin?
Lean meats, fish, liver, poultry, many grains, eggs, peanuts, milk, legumes
Sources of pantothenic acid?
Eggs, kidney, liver, salmon, yeast
Sources of B6?
Meats, cereals, lentils, legumes, nuts egg yolk, milk
Sources of riboflavin?
Meats, poultry, fish, dairy products, green leafy vegetables, enriched cereals and breads, eggs
Milk products
Function of vitmain C?
Hydroxyproline biosynthesis
Precursor of collagen
What are the clinical presentations of vitamin C def?
- Fatigue
- Capillary hemorrhages
- Swollen hemorrhagic gums
- Impaired wound healing
- Scurvy (gingivitis, anemia, skin hemorrhages)
Indications for use of vitamin C?
Common colds (only within first 2 days to limit duration of symptoms)
Dosing of vitamin C?
60-300 mg/day
Complete absorbed if < 100 mg
≤ 50% if > 1,000 mg
UL of Vitmain C?
Upper Limit: 2 g/day
Signs of Vitamin C tox?
Nephrolithiasis in CKD (↑ oxalate)
Causes of B12 def?
- The body stores enough vitamin B12 in the liver that a deficiency would take ~3 years.
- Patients > 50 are at an increased risk due to reduced gastric acidity
- Metformin and PPI use
- Pernicious anemia: lack of intrinsic factor -> decreased B12 absorption
Presentations of B12 def?
- Neurologic sx
- Megoblastic anemia (must correct B12 over folate)
Dosing of Vit B12?
Preventation: 1000mcg PO QD
Tx of def: 1000 mcg IM daily weekly -> monthly -> 8 weeks -> 12 weeks
MD: 1000 – 2000 mcg daily
UL of Vitamin B12?
Not established
Causes of folate def?
- increased need during pregnancy
- infection
- Alcoholism
- Malabsorption
- Drugs: methotrexate, trimethoprim, and anticonvulsants
Clincial presentation of folate?
- Megoblastic anemia
- NTD in children (spina bifida)
Dosing of folate?
- All women of childbearing age should take 400 mcg/day of folic acid either from fortified foods or dietary supplements
- Daily dose of 4 mg recommended for patients who have had previous pregnancy affected by neural tube defect
- Supplementation of at least 1 mg/day recommended for patients taking valproic acid and carbamazepine
FA treatment indications?
- Megaloblastic anemia
- Methotrexate tox
- Homocystinemia
Function of B1?
- Myocardial function
- Nerve cell function
- Carb metabolism
Causes of B1 def?
Alcoholism
What are the types of thiamine def?
Early stage: anorexia, irritability, decrease in short-term memory
Late stage: Beriberi
* Wet beriberi: affects the heart and circulatory system
* Dry beriberi – damages nerves
* Overlap: Pain and paresthesia
Chronic: CNS damage, Wernicke’s encephalophagy, Korsakoff psychosis
What are the sx of Wernicke?
- Opthalmoplegia (weakness of the eyes)
- nystagmus (involuntary eye movement)
- cerebellar ataxia
What are the sx of Korsakoff psychosis?
- Severly impaired retentive memory and cognitive function
- Apathy
- Confabulation
How does chronic alcohol consumption decrease thiamine?
- Reducing thiamin intake
- Impairing thiamine absorption
Indications of thiamine dosing?
- Actute alcohol withdrawl
- Beriberi
- Wernicke-Korsakoff syndrome
Deficiency of niacin?
Pellagra in alcoholics, poorly nourished elderly patients, corn based diet in patients
Presentations of pellagra?
- Dermatitis
- Diarrhea
- Delirium
- Death
Niacin toxicity?
Extended-release formulation may cause less flushing, but more gastric and hepatic side effects
What are the clinical presentations of B2 def?
- Mucocutaneous surfaces of the mouth and skin
- ANemia
- Corneal vascularization (bloodshot eyes)
What are the functions of vitamin B6?
- Neurotransmitter synthesis
- Conversion of tryptophan to niacin
Causes of B6 def?
- Alcoholism
- Severe diarrhea
- Malabsorptive syndromes
- Isoniazid (recommend B6 supplement)
Clincial presentations of B6 def?
- Peripheral neuropathy
- Scaliness around the nose, mouth, eyes
- Dulling of mentation in adults
Treatment dosing for B6 def indications?
Concomitant isoniazid therapy: 100 mg/day IV or IM for 3 weeks, followed by 30 mg/day po daily
Nausea & vomiting pregnancy associated: 12.5 -25 mg TID to QID
Indications for a banana bag?
Chronic alcohol ingestion causes mucosal erosion and villous-predominant epithelial loss
Vitamin deficiency: vitamin B1, B6, Folate
What is in a banana bag?
Inpatient- alcohol withdraw prophylaxis: Thiamine 100 mg, Folic acid 1mg and multivitamin 10 mL in 1L NS or D5W (banana bag)
Common minerals?
- Calcium
- Iron
- Mg
- P
Causes and presentations of calcium def?
Causes: Eldery, bariatric surgery, long-term anticovulsants
Sx: Bone fracture, bone pain, osteoporosis
Dosing and UL of Calcium?
1000 mg/d
2-3 g/day of elemental calcium
ADR of calcium?
Constipation
Sources of calcium?
8 oz non-fat milk 300 mg of calcium
Forms of iron in the body?
Functional or stored
Iron deficiency causes?
Blood loss
Dosing of iron?
UL 45 mg/day to prevention iron-deficiency – due to GI ADR
Better absorbed with acidic environment – empty stomach, vitamin C
ADR of iron supplements?
- Irritate the GI mucosa
- N
- Abdominal pain
- C
Medical emergency if tox
Dietary forms of iron?
Heme in meats (well absorbed)
Nonheme enriched grains and dark green vegetable (poorly absorbed)
Gold standard of iron?
Ferrous sulfate (325 mg/tablet) 20% elemental
Causes of Mg def?
- GI or renal losses
- Diarrhea
- Alcohol
- Diuretic therapy
- PPI
Dosing og Mg? ADR? Tox?
Prevention: UL 350 mg/day
ADR: diarrhea
Toxicity: Diminished deep tendon reflexes, muscle weakness, lethargy, sedation
Dietary sources of Mg?
- Fresh food
- Unprocessed food
What is the cause of P def?
Long term use aluminum hydroxide as antacid
Natural product of anxiety?
- Valerian
- Passionfrui
- St Johns wort
- Kava
Natural products for colds and flu?
- Echinacea
- Garlic
- Ginseng
- Zinc
- Vit C
- Elderberry
Natural products for dementia?
- Ginkgo
- Vitamin E
Natural products for depression?
- St. Johns worts
- SAMe
Natural products for dyslipidemia?
- Red yeast rice
- Garlic
- Niacin
- Fish oil
Natural products for weigh loss?
Bitter orange
Natural products for insomnia?
melatonin
Natural products for menopause?
Black cohoch
Evening primrose oil
Natural products for N/V, motion sickness?
Ginger
Natural products for osteoarthritis?
- Glucosamine
- Chondroitin
Natural products for prostate health?
Saw palmetto
Natural products that can cause cardiac tox?
Bitter orange
Natural products that can cause liver tox?
- Kava
- Black cohosh
Natural products that can cause increased risk of bleeding?
- Fish oil
- Vitamin E
- Garlic, garcinia, ginger, ginko, glucoasmine
MOA of St Johns wors?
Serotonic reuptake inhibitor
Counseling points of using St Johns?
- Risk of serotonin syndrome with antidepressants (SNRIs and SSRIs),
- CI with MAOIs (tranylcypromine)
- Strong CYP3A4 induction decreasing drug levels
- Photosensitivity
- Lower seizure threshold
