3003 Exam 2

• FDA definition: product intended to supplement diet & contains > 1 of the following: Vitamins (top selling supplement), Minerals
• micronutrients: Essential dietary component, Body only requires small amounts, Catalysts (co-factors) and substrates in essential metabolic reactions, Part of tissue structures, enzyme systems, cellular function & neurotransmissions
• Approximately 1 out of 3 people (33%) use vitamins or minerals
• OTC “Dietary Supplement” Individual Micronutrients: Touted for specific groups in the population, have a tendency to be “mega-doses”
• OTC "Dietry Supplements" are logical paired combinations of vitamins and minerals
• Multivitamins/Minerals (MVM): marketed for general population or specific population groups
• micronutrients needed for poor intake:

  • <1600 calories per day: cachexia, N/V, anorexia, diets (multiple micronutrients)
  • Vegans and vegetarians (Vit B12, calcium, iron, zinc)
  • anyone eliminating an entire food group from their diet (depends on diet)
• micronutirents needed for malabsorption:

  • Diseases: inflammatory bowel disease (multiple micronutrients), cystic fibrosis (Vit A, D, E, K), liver cirrhosis (Vit D)
  • Stomach or intestinal surgery: bariatric surgery [gastric bypass (Vit B12, D, folate, zinc, iron, copper, calcium); gastric banding (same vit and minerals but less severe) and “short gut” (multiple micronutrients)
  • Food allergies and intolerances: Celiac disease (Thiamin, Riboflavin, Niacin, Folate, Iron), gluten sensitivity (same vit and iron but less severe), lactose intolerance (calcium, vit D, magnesium)
• micronutrients needed to counteract drugs:

  • Laxatives (iron)
  • Lomitapide, orlistat, bile acid sequestrants, mineral oil (Vit A, D, E, K)
  • Antiepileptics: phenytoin, carbamazepine, phenobarbital, primidone, valproic acid (vit D)
• micronutrients needed when greater demand

  • Heavy menstruation (iron)
  • Pregnant & lactating (folic acid, iron, vit D)
  • Postmenopausal (calcium, vit D)
• water soluble vitamins:

  • Only stored in body to limited degree, need frequent consumption
  • Excess – often excreted in urine
  • Often need processing: Phosphorylation, Coupling with purine or pyridine nucleotide
  • Typical use – as a cofactor for enzymes
• lipophilic vitamins:

  • Infrequent consumption sufficient, stored to massive degree (toxicity issues)
  • Metabolic processing, e.g., double bonds added and/or changed, isomerization
  • Often work by intracellular receptors and modulation of gene expression, (lipid soluble – can cross cell membrane)
• Vitamin A1 = Retinol
• Vitamin B1 = Thiamine
• Vitamin D2 = Ergocalciferol 
• Vitamin B3 = Niacin, nicotinic acid, pyridine-3-carboxylic acid, vitamin PP
• •Alcoholics = Thiamine
• Alcoholics = Thiamine
• Pregnancy = Folic acid (B9)
• Megaloblastic anemia = Folic acid (B9) and/or vitamin B12
• Microcytic anemia = Iron
• Osteoporosis = Calcium and Vitamin D
• Macular degeneration = zinc, copper, lutein, zeaxanthin, vitamin E, and vitamin C
• RPh role in supplements

  1. Ask patients about supplement use and take opportunity to discuss benefits & risks
  2. Assess patient for evidence of an individual’s risk of nutrient deficiency or toxicity; refer if needed
  3. One in three adults in the U.S. take both prescription drugs and dietary supplements (Identify medications and disease states that can interact with micronutrients)
  4. Recommend/counsel a patient on an appropriate micronutrient given their specific clinical situation
• Pharmacist Assessment:

  • Does the patient have what they think they have?
  • Is it safe to self-treat this condition?
  • Are there any patient-specific factors that contradict self-treatment?
  • Medication interactions, disease interactions, allergies, age, pregnancy, lactation, etc.
  • Will this product provide benefit to the patient?
• EAR = Estimated Average Requirement:  average daily nutrient intake level estimated to meet requirements of half of the healthy individuals in a particular life stage & gender group
• RDA = Recommended Daily Allowance: mean daily intake sufficient to meet requirements of nearly all individuals. Set at 2 SD above EAR
• AI = Adequate Intake: similar to an RDA but is more of an approximation used when there is not sufficient information to develop an RDA
• UL = Tolerable Upper Limit Level: highest level of daily intake of a nutrient that is unlikely to result in adverse effects for most people.  As intake increases above the UL, the risk of adverse effects may increase.
• Daily value = RDA or AI
• supplements for adults and children > 4 years of age
• Lomitapide: Impact: severe, must supplement with A, D, E, K
• Bile acid sequestrants: Colesevelam has less effect than cholestyramine and colestipol

  • Impact: modest to major (may need to supplement)
• Orlistat: the weight loss supplement that blocks fat absorption, Xenical (Rx), Alli (OTC)

  • Impact: modest (may need to supplement)
• Mineral Oil: Impact: Minor (if using chronically for legitimate reasons, may need to supplement)
• Drugs that block all fat soluble vitamin absorption: lomitapide, bile acid sequestrants, orlistat, mineral oil

  • Take a multivitamin >2 hrs before or after the last 3 drug classes, take anytime with lomitapide
• 10 IU of Beta-Carotene = 3.3 IU of Retinol Requirements (Vitamin A)
• vitamin A causes eye Issues: Soft Corneas,  Dry Eye,  Foamy Plaques, Night Blindness
• in excess, vitamin A causes:

  • Teratogenicity
  • Hepatotoxicity
  • Skin Issues: Red, Itchy, Dry, Peeling Palms and Soles. Carotonemia (orangeish skin)
  • Alopecia
  • Muscle and Bone Pain
• Retinol (preformed vitamin A) from animal-derived sources