Vitamins and Minerals Notes PDF

Vitamins and Minerals Notes Learning Objectives: ❖​Identify patients who may be at risk of certain deficiencies ❖​Determine whether a vitamin or mineral should be recommended to a patient based on effectiveness and safety info ❖​Provide key counseling points to patients regarding n...

Vitamins and Minerals Notes Learning Objectives: ❖​Identify patients who may be at risk of certain deficiencies ❖​Determine whether a vitamin or mineral should be recommended to a patient based on effectiveness and safety info ❖​Provide key counseling points to patients regarding niacin, folic acid, vitamin D, calcium and iron Water Soluble Vitamins: ★​Thiamine (vitamin B1) ○​ OTC: oral ○​ RX: injection ○​ Infantile beriberi: ​Among infants who are breastfed by women w/ thiamine deficiency leading to heart failure and loss of reflexes ○​ Adult beriberi: ​Among pts who have had weight loss surgery or complications w/ total parenteral nutrition ​ Dry: symmetrical peripheral neuropathy ​ Wet: cardiac involvement ○​ Wernicke-Korsakoff Syndrome: ​Among patients w/ chronic alcohol abuse ​ Wernicke’s encephalopathy: acute syndrome requiring immediate treatment to prevent death and neurologic disease ​ Korsakoff syndrome: chronic neurologic condition of impaired short-term memory and distorted memories ★​Riboflavin (Vitamin B2) Deficiency ○​ OTC: oral  ○​ Ariboflavinosis: ​Anorexia nervosa ​Malabsorptive syndromes like celiac disease, short bowel syndrome, etc ​Long-term use of phenobarbital and other barbiturates ○​ Mild signs and symptoms (*challenging to diagnose*) ​Sore throat ​Excessive blood vessels and edema in mucous membranes ​Dry, cracked, peeling lips ​Sores in mouth ​Inflammation of tongue ​Anemia ​Scaly and itchy scalp ○​ Rare, but may be under diagnosed ★​Niacin (Vitamin B3) Deficiency ○​ OTC and RX: oral ○​ Pellagra: pelle agra aka “rough skin” ​Chronic alcohol abuse ​Weight loss surgery ​Anorexia nervosa ​Malabsorptive syndromes ​Use of isoniasid, 5-fluorouracil, phenobarbital, & azathioprine ○​ 4 D’s: ​Dermatitis in sun-exposed areas ​Diarrhea ​Dementia ​Death may occur ○​ Rate in US due to enriched flour ○​ Supplements:  ​Dietary supplement should not be used as an alternative to prescription niacin for the treatment of hyperlipidemia ​Inositol hexanicotinate: ​ Inositol that has been esterified with niacin on all six of inositol’s alcohol groups ​ Usually sold as “no-flush” niacin ​ Sold OTC and often labeled as niacin, misleading consumers into thinking they are getting the active form of the med ★​Pantothenic acid (Vitamin B5) Deficiency ○​ OTC: oral ○​ Pantothenic acid deficiency: ​Severely malnourished people such as during war or famine ○​ Symptoms: ​Numbness ​Painful burning ​Tingling in feet know as “burning feet syndrome” ​GI distress ○​ Rare due to many dietary sources & from colonic bacteria ★​Pyridoxine (Vitamin B6) Deficiency ○​ OTC: oral ○​ RX: injection ○​ Vitamin B6 Deficiency ​Asthma ​Heart disease ​Chronic alcohol abuse ​Pregnancy  ​Sickle-cell anemia ​Drugs that interfere w/ pyridoxine metabolism: isoniazid, hydralazine, carbidopa/levodopa ○​ Symptoms: ​Marginal deficiency (more common): ​ Sores in mouth ​ Swollen tongue ​ Cracks in corners of mouth ​ Irritability ​ Confusion ​ Depresion ​ Peripheral neuropathy (rare) ​Severe deficiency: ​ Scaly and itchy scalp ​ Microcytic anemia ​ Seizures ★​Biotin (Vitamin B7) Deficiency ○​ OTC: oral ○​ Biotin deficiency: ​Long-term parenteral nutrition prior to supplementation ​Consuming large amounts of raw egg whites (avidin) ○​ Symptoms: ​Dermatitis around eyes, nose and mouth ​Conjunctivitis ​Alopecia ​Changes in mental status ​Lethargy ​Hallucinations ​“Pins and needles”  ○​ Products frequently reported for nail and hair health, but there is insufficient evidence for this indication ★​Folic Acid (Vitamin B9) Deficiency ○​ OTC: oral ○​ RX: oral & injection ○​ Folic acid deficiency: ​Malabsorptive syndromes ​Weight loss surgery ​Severe malnutrition ​Chronic alcohol use ​Infants fed exclusively goat milk ○​ Prevention of neural tube defects ​Dec. occurrence and recurrence of neural tube defects ​Folic acid supplement is recommended for all women of childbearing potential ​Higher dose in women at higher risk for having a child w/ neural tube defect ○​ Prevention of side effects in pts taking methotrexate ​Methotrexate interferes w/ the cellular utilization of folic acid ​Folic acid supplement is recommended for all patients taking low-dose methotrexate to reduce nausea, vomiting and abdominal pain ★​Cobalamin (Vitamin B12) Deficiency ○​ OTC: sublingual & oral ○​ Prescription: injection & nasal spray ○​ Vitamin B12 deficiency ​Vegan or vegetarian diet ​Weight loss surgery ​Malabsorption from small intestine  ​Nitrous oxide exposure as N2O chemically inactivates vitamin B12-derived methylcobalamin molecule at the active site of methionine synthase ​Use of H2 receptor antagonists or PPIs ○​ Pernicious anemia ​Deficiency due to autoantibodies that inhibit vitamin B12 absorption ○​ Symptoms ​Symptomatic anemia ​Neurologic ​Neuropsychiatric changes ★​Ascorbic Acid (Vitamin C) Deficiency ○​ OTC: oral ○​ RX: injection ○​ Scurvy: ​Major cause of mortality during Europe great potato famine, US civil war, Exploration of North Pole, & California Gold Rush ​Severely malnourished ppl ​Living in poverty w/ diets lacking fruits and veggies ​Children w/ autism who eat highly selective diets ​Pts w/ iron overload (ex. sickle-cell anemia) because ferric deposits can accelerate the catabolism of ascorbic acid ○​ Symptoms ​Small red/purple spots on skin ​Bruising ​Gingivitis ​Joint pain ​Impaired wound healing Questions Regarding Safety and Effectiveness Ratings: ★​Water-soluble vitamins are generally considered _____ when taken orally by non-pregnant adults at appropriate doses. A.​Possible safe B.​Likely unsafe C.​ Likely safe D.​Unsafe ★​Thiamine (B1) is considered effective to treat: A.​Infantile beriberi B.​Wernicke-Korsakoff syndrome C.​ Adult beriberi D.​All of the above ★​Riboflavin (B2) is considered effective to treat: A.​Scurvy B.​Thiamine C.​ Folate deficiency D.​Ariboflavinosis ★​Niacin (B3) is ____ to treat dyslipidemia and pellagra A.​Effective B.​Likely effective C.​ Possibly effective D.​Insufficient evidence ★​Pantothenic acid (B5) is effective to treat: A.​Pantothenic acid deficiency B.​Pellagra C.​ Both A and B D.​Insufficient evidence to support effectiveness ★​Which of the following statements are true concerning pyridoxine (B6)? A.​It’s effective to treat vitamin B6 deficiency B.​It’s possibly effective to treat age-related macular degeneration  C.​ It’s possibly effective to treat pregnancy-induced nausea and vomiting D.​All of the above statements are true ★​Biotin (B7) is effective to treat biotin deficiency, but insufficient evidence to support its use for… A.​Hair loss B.​Brittle nails C.​ Acne D.​None of the above ★​Which of the following statements is true regarding folic acid (B9)? A.​It’s effective to treat folate deficiency B.​It’s likely effective to treat end-stage renal disease (reduce homocysteine) C.​ It’s likely effective to treat nausea and vomiting from methotrexate D.​It’s likely effective to treat neural tube defects E.​ Only A and B are true F.​ Statements A-D are true ★​What is cobalamin (B12) effective to treat? A.​Vitamin B12 deficiency B.​Scurvy C.​ Brittle nails D.​Dyslipidemia ★​Which of the following statements are true regarding ascorbic acid (vitamin C)? A.​It’s effective to treat scurvy B.​It’s possibly effective to treat iron absorption and reduce common cold by 1-1.5 days at high doses C.​ It’s likely effective to treat iron absorption D.​It’s possibly effective to reduce common cold by 1-1.5 days at high doses  E.​ Both A and B F.​ Statements A, C and D are true Mnemonics to remember water-soluble vitamins (no vitamin B4 or B8!!!) ​ The Rivercourt Nathan Plays At Protects Basketball For Children Always ○​ Thiamine= B1 ○​ Riboflavin=B2 ○​ Niacin=B3 ○​ Pantothenic Acid=B5 ○​ Pyridoxine=B6 ○​ Biotin=B7 ○​ Folic acid=B9 ○​ Cobalamin=B12 ○​ Ascorbic acid=C Providing Recommendations: Patient Care Process: ★​Questions to ask ○​ Is a supplement needed? ○​ Is a supplement safe for the indication? ○​ Is the supplement effective for the indication ○​ What is the timeline for follow-up & what should be monitored? Fat Soluble Vitamins ★​Vitamin A: ○​ Dietary sources: ​ Liver ​ Kidney ​ Fish liver oils ​ Fruits and veggies  ○​ Deficiency: ​ Rare in US and first world countries ​ 3rd most common nutritional deficiency in the world ​ 500,000 children become blind each year ○​ Toxicity: ​ Highly toxic in large amounts (either acutely or chronically) ○​ Drug interactions: ​ Retinoids like the following can cause additive toxic effects: ​ Acitretin ​ Isotretinoin ​ Tretinoin (vitamin A derivative) ​ Warfarin + vitamin A toxicity inc risk of bleeding ​ Possibly due to vitamin K antagonist ○​ Other concerns: ​ Two large trials found beta-carotene may inc risk of lung cancer among former or current smokers ★​Vitamin D Deficiency: ○​ Sources: ​ UV sunlight ​ Brief exposure to arms and face is equivalent to ingesting 200 IU ​ Varies based on skin type, latitude, season and time of day ○​ Deficiency: ​ Causes: ​ Low sun exposure: infants, disabled ppl, older adults ​ Dec. ability of skin to convert vitamin D effectively: >70 y/o  ​ Chronic renal insufficiency as kidneys are not able to produce 1,25-dihydroxyvitamin D ​ Chronic use of high dose glucocorticoids inhibit intestinal v-D dependent calcium absorption ​ Consequences: ​ Reduced intestinal absorption of calcium and phosphorus ​ Osteoporosis, inc risk of falls, & possible fractures ★​Vitamin D Toxicity ○​ Toxicity: ​ Intake at which it will become toxic is unclear ​ Cases have been reported among adults taking > 60,000 IU daily ​ Excess sun exposure does not result in toxicity ○​ Photoconversion of previtamin D3 and vitamin D3 to inactive metabolites ​ Symptoms from acute intoxication are due to hypercalcemia: ○​ Confusion ○​ Polyuria ○​ Polydipsia ○​ Anorexia ○​ Vomiting ○​ Muscle weakness ★​Vitamin E ○​ Dietary sources: ​ Wheat germ, sunflower oil, almonds & hazelnuts, green leafy vegetables, tomato products, pumpkin, sweet potato ○​ Deficiency:  ​ Typically only observed in cases of severe malnutrition (or genetic defects) ○​ Toxicity ​ Difficult to achieve ​ (>3000 mg/day study did NOT show significant toxicity) ​ In infants, >1000 mg/day can lead to hepatotoxicity ○​ Drug interactions: ​ Anticoagulants/antiplatelets ​ May inc the risk of bleeding by inhibiting platelet aggregation and antagonizing the effect of vitamin K-dependent clotting factors ○​ Dose dependent ○​ Clinically significant at doses of ≥800 units/day ​ Chemotherapy ​ Antioxidants could reduce the activity or the antitumor agent ​ Other researchers theorize it might make chemotherapy more effective by reducing oxidative stress that might interfere w/ apoptosis of cancer cells ★​Vitamin E Clinical Controversy ○​ V-E is included in AREDs formula to help lower risk of developing macular degeneration ○​ Mixed evidence regarding whether high dose V-E may inc risk of prostate cancer ​ SELECT study: 400 IU daily inc risk of prostate cancer among health men compared to placebo ​ ATBC study: 50 mg daily had a 35% reduction in risk of prostate cancer  ​ PHS II study: 400 IU EOD found no effect on incidence of prostate cancer ★​Vitamin K Deficiency ○​ Uncommon: generally results from intestinal obstruction, celiac or Crohn’s disease ​ Exception: V-K deficiency in newborns bc of immature liver does not effectively utilize V-K as well as low V-K stores. Therefore, parenteral dose of V-K routinely recommended at birth ○​ Symptoms: ​ Excessive bleeding ​ Stomach pains ​ Bone defects ★​Vitamin K toxicity ○​ No real toxicity ★​Vitamin K Drug Interactions ○​ Warfarin: antagonizes the effect of warfarin, reducing the anticoagulant effect ★​Vitamin K Uses ○​ Hemorrhagic disease of newborns ○​ Vitamin-K dependent clotting factors deficiency ○​ Reversal of warfarin anticoagulation Questions Regarding Safety and Effectiveness Ratings: ★​Fat-soluble vitamins are considered _______ when taken orally by non-pregnant adults at appropriate doses. A.​Likely safe B.​Safe C.​ Possibly safe D.​Insufficient evidence ★​Vitamin A is effective for vitamin A deficiency. What other indications is it possibly effective for? A.​Reduce risk of breast cancer (evidence for high dietary intake) B.​Reduce risk of cataracts C.​ Both A and B D.​None ★​Vitamin D is ______ to treat hypoparathyroidism, osteomalacia, and vitamin D deficiency. A.​Effective B.​Likely effective C.​ Possibly effective D.​Insufficient evidence ★​Vitamin D is _____ to treat corticosteroid-induced osteoporosis and osteoporosis A.​Effective B.​Likely effective C.​ Possibly effective D.​Insufficient evidence ★​Which vitamin has insufficient evidence to support the indication of fall risk because of clinical controversy due to inclusion of calcium, study design and study populations? A.​Vitamin A B.​Vitamin D C.​ Vitamin E D.​Vitamin K ★​Vitamin E is effective for vitamin E deficiency. What is vitamin E possibly effective for? A.​Fall risk B.​Osteoporosis C.​ Slow progression of Alzheimer’s disease D.​None  ★​Vitamin K is effective to treat: A.​Hemorrhagic disease in newborns B.​Reversal of warfarin anticoagulation C.​ Stomach pains D.​Both A and B Minerals ★​Calcium ○​ OTC: ​ Acetate- oral ​ Carbonate- oral ​ Citrate- oral ​ Gluconate- oral ○​ RX: ​ Acetate- oral ​ Gluconate- injection ○​ Amount of elemental Ca: ​ Calcium carbonate: 40% ​ Calcium citrate: 21% ​ *Recommended for patients taking H2RA or PPI* ○​ Recommend MAX of 500 mg elemental Ca at once ○​ Estimate Ca in diet: ​ 8 oz/ 1 cup milk= 300 mg ​ 6 oz yogurt= 300 mg ​ 1 oz cheese= 200 mg ​ Add 250 mg for non dairy sources ○​ Drug Interactions: ​ Calcium excretion inc by: ​ Thiazide diuretics ​ Aluminum & magnesium containing antacids ○​ Excessive Supplementation:  ​ Very high doses can lead to: ​ Hypercalcemia ​ Renal insufficiency ​ Vascular & soft tissue calcification ​ Hypercalciuria ​ Kidney stones ★​Iron ○​ OTC: ​ Oral fumarate ​ Oral gluconate ​ Oral sulfate ○​ Drug interactions: ​ Fe and zinc can interfere w/ each other’s absorption ​ PPI can dec iron absorption ○​ Excessive supplementation: ​ Acute overdose ​ Leads to poisoning & potentially death, esp in children ​ Long-term use of high doses can cause Fe overload & multiple organ damage (lethal) ★​Cation Drug Interactions ○​ Supplements can dec the absorption of medications- separate doses by at least 2-4 hours ​ Bisphosphonates ​ Fluoroquinolones ​ Levothyroxine ​ Tetracyclines ★​Potassium and Sodium ○​ Potassium: ​ OTC: ​ Gluconate- oral ​ RX:  ​ Acetate- injection ​ Chloride- injection & oral ​ Citrate- oral ​ Gluconate- oral ​ Phosphate- injection & oral ○​ Sodium: ​ OTC: ​ Bicarbonate- oral ​ Chloride-oral ​ Citrate-oral ​ RX: ​ Acetate-injection ​ Bicarbonate- injection & oral ​ Chloride- injection ○​ Drug interactions ​ The high intracellular concentration of K+ is maintained via the activity of the Na+/K+-ATPase pump. Because this enzyme is stimulated by insulin, alterations in the plasma concentration of insulin can affect cellular influx of K+ and thus plasma concentration of K+. ○​ Hypokalemia can be caused by: ​ Diuretics ​ Excessive laxatives ○​ Hyperkalemia can be caused by: ​ ACE inhibitors ​ ARBs ​ Potassium-sparing diuretics * Most of these drugs have similar effects on Na as well Questions Regarding Safety and Effectiveness Ratings: ★​Which of the following minerals are classified as likely safe when taken orally by non-pregnant adults at appropriate doses? A.​Calcium B.​Iron C.​ Potassium D.​Sodium E.​ All of the above ★​Which of the following is calcium classified as effective for treating? A.​Antacid B.​Renal failure (phosphate binder) C.​ Osteoporosis D.​All of the above E.​ Only A and B ★​Which of the following is calcium classified as likely effective for treating? A.​Weight loss B.​Osteoporosis C.​ Fall prevention D.​Antacid ★​Which of the following is calcium classified as possibly effective for treating? A.​Weight loss B.​Osteoporosis C.​ Fall prevention D.​Antacid ★​Which of the following is calcium classified as not having sufficient evidence for treating? A.​Weight loss B.​Osteoporosis  C.​ Fall prevention (w/ vitamin D) D.​Antacid ★​Which of the following is iron classified as effective for treating? A.​Restless leg B.​Anemia of chronic disease C.​ Iron deficiency anemia D.​Both A and C E.​ Both B and C ★​Which of the following is iron classified as possibly effective for treating? A.​Heart failure B.​Fatigue C.​ Restless leg syndrome D.​Both A and B E.​ Both A and C ★​Which of the following is iron classified as insufficient evidence for treating? A.​Iron deficiency B.​Heart failure C.​ Fatigue D.​None ★​Which of the following is potassium effective for treating? A.​Hyperkalemia B.​Hypokalemia C.​ Hypertension D.​Hypotension ★​Which of the following is potassium possibly effective for treating? A.​Hyperkalemia B.​Hypokalemia C.​ Hypertension ★​Sodium is effective for treating: A.​Hyponatremia B.​Hypernatremia C.​ Cystic fibrosis (nebulized solution) D.​Sinusitis (intranasally) ★​Sodium is likely effective for treating: A.​Hyponatremia B.​Hypernatremia C.​ Cystic fibrosis (nebulized solution) D.​Sinusitis (intranasally) ★​Sodium is possibly effective for treating: A.​Hyponatremia B.​Hypernatremia C.​ Cystic fibrosis (nebulized solution) D.​Sinusitis (intranasally)