Vitamins and Minerals Introduction PDF

Vitamins and Minerals: an introduction (0.75 lecture hours) Vanessa Lesneski, PharmD, BCPS, CPh  List List all the names of the different vitamins Identify Identify uses and interactions associated with each vitamin Determine requirement of vitamin supplementation given...

Vitamins and Minerals: an introduction (0.75 lecture hours) Vanessa Lesneski, PharmD, BCPS, CPh  List List all the names of the different vitamins Identify Identify uses and interactions associated with each vitamin Determine requirement of vitamin supplementation given Determine patient data Explain the symptoms of an excess or deficiency for each Explain Objectives vitamin Describe key counseling points as well as contraindications and Describe warnings List List the percentage of elemental substance found in products Identify Identify common brand names Reading Required Suggested Chapter 23 in the Handbook of Natural Medicines database has Nonprescription Drugs information about vitamins and minerals The Impact – Vitamins are key components to many metabolic reactions in our bodies – Nutrients that cannot be synthesized in the body or at least not enough and must be obtained through the diet – Both deficiencies and excesses can cause a variety of health problems – Vitamins can be involved in drug-drug, drug-food, and drug-lab test interactions The Industry – The Vitamin and supplement industry is a $36+ billion industry – Use is increasing – >1/3 of the US uses a multivitamin (MVI) daily – Obtaining vitamins and minerals from diet is recommended – Risk of not seeking medical help because treating with OTC supplements – Risk of worsening diet – Incorrect thinking that a vitamin will cover up for bad diet  Poverty, eating disorders, dementia, or restrictive diets Inadequate dietary intake Poor dentition, swallowing difficulty, or xerostomia Loss of taste, smell, or sight perception Consumption of energy-dense but nutrient-poor foods Poor diet Lack of knowledge about balanced nutrition Cystic fibrosis, short bowel syndrome, Roux-en-Y gastric Decreased absorption or synthesis bypass, gastric hypochlorhydria, or chronic diarrhea Some risk factors for Inability to buy or prepare meals Anorexia Reduced physical activity, social isolation, pain, disease, or depression nutritional deficiencies Such as from alcoholism or certain genetic Abnormal metabolism polymorphisms Severe injury/infection, trauma, pregnancy, or Increased metabolic requirements prolonged physical exercise Affecting judgment, coordination, memory, appetite, Medications nutrient absorption, gastric pH, or gastrointestinal tract function Estimated Average Requirement (EAR) Intake value estimated to meet the requirements 50% of Dietary healthy individuals in a specific age and gender group Reference Recommended Dietary Allowance (RDA) Average dietary intake level of a nutrient that prevents a Intakes (DRI) deficiency in 98% of population Adequate Intake (AI) Reference value of daily Values used when sufficient evidence is not available to nutrient intake estimate an average intake requirement or RDA Tolerable Upper Intake Level (UL) Highest level of a nutrient that is likely to pose no risk of adverse health effects in 98% of population Vitamins – Non-energy producing organic substances Water-Soluble – Essential in small amounts for Vitamin B maintenance of normal metabolic Vitamin C function Fat-Soluble – All vitamins except D, K, and Vitamin A biotin (B7) must come from dietary sources Vitamin D Vitamin E Vitamin K Fat Soluble Vitamins This Photo by Unknown Author is licensed under CC BY Fat Soluble A D E K  Vitamin A Retinoids and Carotenoids – Retinoids found in animal sources: retinol – Animal sources: Dairy, fish, meat – Carotenoids found in plants: alpha-carotene, beta-carotene, beta-cryptoxanthin – Plant sources: Carrots, sweet potato, kale, spinach, pumpkin – Active vitamin A is retinal and retinoic acid – Plant-based carotenoids not converted to active vitamin A include: lycopene, lutein, and zeaxanthin – Important in growth and reproduction, teeth and bone development, mucous, and organs, notably the eyes  – Recommended intake: 3,000 IU (max: 10,000 IU/day) – Dose in deficient adult: 100,000 IU for 3 days, then 50,000 IU for 14 days – Deficiency: Dermatitis, poor growth, night blindness, infections, blindness, dry eye – Excess: Liver toxicity, cheilosis, nausea/vomiting, Vitamin A bone fractures, congenital birth defects – Uses: Night blindness, dry eye, wound healing – 90% stored in the liver – Do NOT exceed daily limit when pregnant – Do NOT use intravenously (IM only) Retinol Activity Equivalents (RAE) Table 23-8 1 RAE is equal to: 1 retinol equivalent 1 mcg of retinol Vitamin A 12 mcg of beta-carotene 24 mcg of alpha-carotene 24 mcg of beta-cryptoxanthin 3.33 IU vitamin A activity from retinol 10 IU vitamin A activity from beta-carotene  Vitamin D (calciferol) – AKA – Cholecalciferol (D3) is naturally occurring form of vitamin D – From endogenous or dietary cholesterol upon exposure to sunlight (UV radiation) – Ergocalciferol (D2) is used as a food additive – Vitamin D is activated by hydroxylation to 25-hydroxycholecalciferol (calcidiol) in the liver then to 1,25-dihydroxycholecalciferol (calcitriol) – Either renal or hepatic dysfunction may result in vitamin D deficiency  Vitamin D (calciferol) – Vitamin D has many roles in the body that are still being discovered – Functions as a hormone and a vitamin – Functions in bone growth and remodeling – Acts in concert with the parathyroid hormone, phosphate, and calcitonin in maintaining homeostasis of serum calcium levels – Plays a role in immune and gut health Vitamin D (calciferol) – Uses: Osteoporosis, hypoparathyroidism, hypophosphatemia, PMS, decreased fall risk – Deficiency – Results from inadequate intake, GI disease, renal failure, inadequate exposure to sunlight, genetic disorders, medications, obesity or bypass surgery – Rickets, osteoporosis, osteomalacia, muscle weakness, hypocalcemia, increased risk of cardiovascular disease – Hypervitaminosis D: Hypercalcemia (arrhythmias), anorexia, constipation, dehydration, irritability, vomiting, kidney damage Rickets Vitamin D Intake – Recommended intake: – Age 19-70: 600 IU daily (max: 4,000 IU, some say 10,000 IU) – Age >70: 800 IU daily – Even 40,000 IU each day likely will not cause toxicity – Sun exposure: 30 minutes of full body exposure = 10,000 IU – Other: Low vitamin D levels becoming increasingly common in elderly and children – Natural sources: Sunlight, fish liver oil, fatty fish, eggs – Vitamin D to maintain adequate serum levels (36-50 ng/mL); many people need 5000 iu/d to obtain and maintain optimum levels Vitamin D Supplementation – Vitamin D supplements must undergo hydroxylation by the liver and kidneys to become calcitriol – Those with liver and kidney dysfunction may not be able to complete this process and need calcitriol (prescription only) – 400 IU recommended for exclusively breastfed infants or those consuming 100ng/mL = Potential for Toxicity  Vitamin E – Also known as: Tocopherols – Naturally occurring in plants – Role: Antioxidant – Works in concert with selenium and vit. C – May also play role in heme biosynthesis, steroid metabolism, and collagen formation – Deficiency: Hemolytic anemia, peripheral neuropathy, muscle weakness – Excess: Hemorrhagic toxicity, congestive heart failure, prostate cancer – Controversial side effect profile – appears to have CVD risk – Uses: Alzheimer’s disease, cardiovascular disease, hot flashes, burns, anti-aging creams Vitamin E – Recommended intake: 15 IU (max: 1,000 IU) – Deficiency: 60-75 IU daily – Do not recommend more than 400 IU daily – Natural sources: Leafy vegetables, eggs, milk, avocado, nuts, vegetable oils, grains – Drug-drug interaction: Antagonizes vitamin K – watch clotting time in patients on warfarin – SELECT trial examined 400 IU vitamin E +/- 200mcg selenium – Increased risk of prostate cancer and bleeding – HOPE-TOO study also demonstrated increased CHF risk Vitamin K – Also known as: Phylloquinone or phytonadione (K1), menaquinone (K2 or MK), menadione (K3) – Role: Blood clotting – Deficiency: Bleeding (ecchymosis, petechiae, hematomas) – Excess: No known problems Ecchymosis Petechiae Vitamin K – Recommended intake: 90-120mcg – Microbiologic flora in the gut synthesize most of the body’s need – Uses: – Given to newborns to prevent vitamin k deficiency bleeding – 1 dose of 1mg (injection) – Natural sources: Leafy, green vegetables, avocado, kiwi, parsley – Changes in dietary intake can impact clotting in patients taking warfarin Water Soluble Vitamins This Photo by Unknown Author is licensed under CC BY-NC-ND  Vitamin B1 – Also known as thiamine – Role: Substrate for many enzymes; greatest effect on heart and nervous system – Uses: – Best evidence: Thiamine deficiency, some metabolic syndromes (maple syrup urine disease) – Some evidence: Acute alcohol withdrawal, TPN – Limited evidence: Heart failure, atherosclerosis, cancer, Alzheimer’s – Recommended intake: 0.9-1.1mg – Beriberi dose: 30mg/day for 1 month – Wernicke-Korsakoff: 500mg TID x 3 days then 250mg TID x 3 days IV administration – Heart failure dose: 200mg daily (IV or PO) Thiamine – All organisms use thiamine – Only synthesized in bacteria, fungi, and plants – Essential for animals – For example: Thiamin diphosphate (ThDP) also known as thiamin pyrophosphate(TPP) coenzyme in carbohydrate and amino acid metabolism  Vitamin B1 – Rationale for use in heart failure: – Furosemide can cause low thiamine levels – Furosemide commonly is used in CHF – Studies have shown that supplementation with thiamine, decreases symptoms and improves left ventricular ejection fraction – Deficiency: Beriberi, Wernicke-Korsakoff syndrome, fatigue, lactic acidosis, wasting – Excess: Irritability, headache, tremor – Natural sources: Yeast, pork, grains, oatmeal, brown rice, asparagus, kale Vitamin B1 – Deficiency – Symptoms – Beriberi – Peripheral neuritis – Loss of muscle strength – Muscle wasting (dry beriberi) – Edema (wet beriberi) – Tachycardia – Enlarged heart Vitamin B1 – Deficiency – Symptoms – Wernicke-Korsakoff syndrome – Paralysis of eye muscles and nystagmus – Encephalopathy – Confusion – Tremor – Neurologic damage Vitamin B1 Deficiency Causes – Use of diuretics – High intake of thiaminase-rich foods – Raw fish – Foods with anti-thiamine factors – Tea – Coffee – Chronic diseases – HIV – GI diseases – Excessive alcohol intake – Poor dietary habits – Alcohol impairs thiamine absorption and transport across intestines – Decreased activation of thiamine pyrophosphate cheilosis Vitamin B2 – Also known a riboflavin – Role: Metabolism of proteins, carbohydrates, fats, and ketone bodies – Deficiency: Dermatitis, stomatitis, cheilosis, glossitis, photophobia, normocytic anemia – Excess: No adverse effects noted with high doses – Additional uses: Jaundice treatment in infants, migraine prevention, and anemia Vitamin B2 – Recommended intake: 0.9-1.3mg – Deficiency dose: 5-30mg/day, then 1-4mg daily – Other: – Exposure to light destroys activity – High doses of riboflavin cause bright yellow urine – Used as a food coloring – Natural sources: Milk, meats, leafy green vegetables, legumes, eggs, mushrooms, almonds Vitamin B3 – Also known as niacin or niacinamide – Role: Involved in DNA repair, steroid synthesis – Uses: – Cholesterol: Lowering triglycerides, raising HDL, lowering LDL, lowering total cholesterol – Prevent detection of THC (tetrahydrocannabinol) in urine drug tests – No proven efficacy (increased risk of ADRs) – Deficiency known as pellagra – Symptoms – 4 D’s: dermatitis diarrhea dementia death – Deficiency causes: Alcoholism, poor nutrition, excessive corn in the diet Vitamin B3 Deficiency “Necklace of Lesions” https://images.app.goo.gl/T2rZqHgpwncdMLG78 https://images.app.goo.gl/tqRmLdC9qKaMoXzg7 Vitamin B3 – Dose: – 150-500mg daily for pellagra (deficiency) – 1-2 grams daily to treat cholesterol – Maximum is 6 grams daily or 2 grams for Niaspan (controlled release) – Side effects: – Flushing – GI distress – Increased glucose – Hepatotoxicity – Increased BP, HR – Skin lesions – Contraindications: Liver disease, active peptic ulcer disease, gastritis – Warnings: Gout, diabetes Vitamin B3 – Natural sources: Liver, fish, milk, beans, avocado, dates, tomatoes, nuts, mushrooms – Counseling points: – Take at bedtime after a snack – Applesauce (pectin)-reduces flushing – Take aspirin 30 minutes before dose – What strength of ASA? – Are NSAIDs okay? – Is APAP okay? Flush-free Niacin – Really is Inositol hexanicotinate (INH) – Evidence currently suggests that this is not effective in lowering cholesterol – Use caution when recommending products for your patients Vitamin B5 – Also known as Pantothenic acid – Precursor for Coenzyme-A (CoA) – CoA is involved in the metabolism and synthesis of carbs, fats, and proteins – Deficiency results in fatigue, muscle weakness (legs), abdominal cramps, numbness – Toxicity-typically at dose > 10 grams/day – Diarrhea – Heartburn (rare) Recommended intake is 5 mg per day Vitamin B5 Hair and skin care products, morning stiffness, pain associated Other uses: with RA, peripheral neuropathy, burning feet syndrome Meats, whole grains, broccoli, Natural sources: avocado, eggs, legumes May be listed under other Pantothenol or calcium pantothenate names  Vitamin B6 – Also known as pyridoxine – 6 compounds have vitamin B6 activity pyridoxine, pyridoxal, pyridoxamine, and their 5′-phosphates – Role: Amino acid metabolism, gene expression, gluconeogenesis, lipid metabolism, neurotransmitter synthesis – Uses: – Best evidence: Hereditary sideroblastic anemia, preventing adverse effects in patients taking cycloserine, pyridoxine deficiency, pyridoxine-dependent seizures in newborns – Also used as an adjunct to hydralazine, carbidopa, and isoniazid therapy – Some evidence: Nausea and vomiting associated with pregnancy, cardiovascular disease, immune system function, carpal tunnel syndrome, PMS, migraine Interconversion of the vitamin B6 vitamers Citation: Micronutrients: Vitamins & Minerals, Rodwell VW, Bender DA, Botham KM, Kennelly PJ, Weil P. Harper's Illustrated Biochemistry, 31e; 2018. Available at: https://accesspharmacy.mhmedical.com/content.aspx?booki d=2386&sectionid=187836268 Accessed: June 29, 2020 Copyright © 2020 McGraw-Hill Education. All rights reserved Vitamin B6 – Recommended intake: 1.0-1.7mg (max: 100mg, aim for 50 mg) – Counseling points: – Excess: Sensory neuropathy, nausea, vomiting, somnolence, hip fracture – Deficiency: Dermatitis (especially on face), glossitis, convulsions, anemia, peripheral neuropathy – May increase the metabolism of some anticonvulsants – Natural sources: Meats, vegetables, whole grains, nuts Vitamin B7 – Also known as: Biotin – Role: Metabolism of fatty acids and carbohydrates – Deficiency: Dermatitis, depression, somnolence, hair loss, graying of skin – Excess: None noted – May cause laboratory test interactions (some taking up to 650 times the recommended intake) – Troponin – Thyroid – Drug-drug interactions: Some anticonvulsants may decrease biotin levels Vitamin B7 – Uses: Strengthening hair and nails, cradle cap, diabetes, MS – No FDA-approved use – Recommended intake: 20-30mcg – Other: – Deficiency is rare because intestinal bacteria normally produce daily requirement – Can be caused by eating raw egg whites – Natural sources: Cooked eggs, yeast, nuts, legumes Vitamin B9 – Also known as folate, folic acid – Folic acid is a synthetic version – Role: DNA synthesis and repair, RBC production, brain and spinal cord development – Deficiency: Megaloblastic anemia, irritability, diarrhea, neural tube defects, sores in mouth – Excess: Masks B12 deficiency – Uses: Birth defect prevention, heart disease, cancer, obesity, depression, schizophrenia, diabetes, bone health  Recommended intake: 300-400mcg (max: 1000mcg) **Pregnancy: 400-800mcg/day** Take one month before pregnancy and continue for at Deficiency: 1mg/day least the first 2-3 months Vitamin B9 Natural sources: Leafy vegetables, fortified cereals and breads, beans, liver Deficiency can be caused by: Oral contraceptives, dihydrofolate reductase Alcoholism, poor diet inhibitors (methotrexate, trimethoprim), anticonvulsants (phenytoin), sulfasalazine Vitamin B12 – Also known as cyanocobalamin (most common form), refers to the cobalamins – Contain cobalt – Role: Normal brain & nervous system functioning, RBC development, DNA synthesis and fatty acid synthesis, energy production – Intrinsic factor is secreted by parietal cells in stomach and regulates amount of B12 absorbed in terminal ileum – Deficiency: pernicious anemia, macrocytic anemia, mental confusion, peripheral neuropathy, jaundice, glossitis Vitamin B12 – Deficiency causes: – Inability to absorb B12 – Atrophic gastritis – inadequate production of intrinsic factor – Reduced intestinal motility, achlorhydria – Gastric acid lowering agents (PPIs, H2 blockers) - increase bacterial overgrowth in small intestine; bacteria use available B12 – Metformin – Vegetarian diet – Excess: Headache, vomiting, pruritis, hip fracture – Uses: deficiency, cyanide poisoning, age related macular degeneration, postherpetic neuralgia, fatigue/energy loss Vitamin B12 – Recommended intake: 1.8-2.4mcg – Deficiency dose: 1000mcg IM/SC once weekly, then 1000mcg monthly – 500-2000mcg orally once daily – Other: – Only water-soluble vitamin stored in the body (liver) – Natural sources: Meat, shellfish, milk, eggs, cheese – Side effects: Thrombosis, diarrhea, itching, hypokalemia, gout – Dosage forms: Oral, sublingual, injection, intranasal – Avoid sustained release forms-have not been studied well B Vitamin Common name B1 Thiamine B2 Riboflavin B3 Niacin B5 Pantothenic acid B6 Pyridoxine B7 Biotin B9 Folate B12 Cyanocobalamin  Vitamin C – Also known as ascorbic acid – Role: Antioxidant; synthesis of collagen, carnitine, neurotransmitters – Uses: – Best evidence: Deficiency treatment, acidify urine – Some evidence: Iron absorption enhancement, UTI prevention during pregnancy – Limited evidence: Asthma, ischemic heart disease, pneumonia prevention, common cold prevention and treatment, many others Vitamin C – Dose: – Recommended intake: 45-90mg (max: 2000mg) – Some recommend a Vitamin C “megadose” of 2300mg – Deficiency treatment: 100-300mg daily for at least 2 weeks – Deficiency is known as scurvy – Deficiency symptoms: Impaired wound healing, liver spots, lethargy, bleeding, Ecchymosis petechial hemorrhages, easy bruising, loose teeth due to gum inflammation, muscle weakness, joint pain – After 3-5 months with no vitamin C – Excess: GI disturbance (DIARRHEA), kidney stones, nausea, vomiting, dizziness Vitamin C – Counseling Points: – Take with a full glass of water – Side effects: Nausea, vomiting, heartburn, abdominal cramps, headache, fatigue – Chewable tablets associated with dental decay – Large doses associated with diarrhea and GI upset – Natural sources: Red pepper, parsley, guava, kiwi, broccoli, papaya, strawberry Vitamin C – Drug-laboratory interaction: – Do not take 48-72 hours before an amine-dependent stool blood test – May interfere with urinary glucose test – Pregnancy: – Vitamin C supplements during pregnancy have been associated with vitamin C tolerance/resistance in infants at birth (excessive amounts) – Avoid exceeding daily intake – Pregnancy category C – Warnings: – Increase risk of iron toxicity Minerals This Photo by Unknown Author is licensed under CC BY-SA-NC  Calcium – Commonly used taken by 43% of population and 70 % of older females – Most abundant mineral in body – Role in the body: Muscle function, nerve transmission, hormone secretion, bone health Source: http://www.medindia.net/patients/patientinfo/osteopenia.htm – Pharmacologic uses: Bone health, antacid – Deficiency: Rare due to bones acting as storage; overtime may result in osteopenia  Calcium recommendations Age Female Male – RDA is based on elemental calcium 19-50 1,000mg 1,000mg – Administration: – 500-600mg twice daily 51-70 1,200mg 1,000mg – Better absorbed at