What you need to know about dietary supplements

What You Need to Know About Dietary Supplements

Lyndsey N. Hogg, PharmD, BCACPClinical Pharmacy Specialist, Ambulatory CareVia Christi Clinic, P.A.1 July 8th, 2014

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Introductions and Disclosures

About the Speaker Clinical Pharmacist at Via Christi Clinic Doctor of Pharmacy (PharmD) Board Certified Ambulatory Care Specialist (BCACP)

Disclosures Dr. Hogg has nothing to disclose concerning possible financial or personal relationships with

pharmaceutical manufacturers that may have a direct or indirect interest in the subject matter of this presentation

Via Christi Health and Dr. Hogg do not endorse any specific medications or indications which may be discussed during today’s presentation.

Always discuss with your health care provider(s) before starting, stopping, or changing any medications or dietary supplements.

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Today’s Goals

1) Provide you with knowledge to safely utilize dietary supplements

2) Guide you to reliable resources

3) Inform you on questions to ask about dietary supplements & medications

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Interesting Facts

More than 50% of Americans use dietary supplements on a regular basis

Regulated as foods, not drugs

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Key Points

Do not self-diagnose any health condition

Check with your health care providers before starting any supplements

Supplements should not replace prescribed medications or a healthy diet

Do your research- use reliable sources

What are Dietary Supplements?

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Dietary Supplements

Dietary supplements include: Vitamins Minerals Herbals & botanicals Amino acids Enzymes Many other products

Variety of forms: Tablets Capsules Powders Drinks Energy bars

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Who Regulates Supplements?

U.S. Food & Drug Administration (FDA)

Different set of regulations compared to “conventional” foods & drug products

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Supplements: How are they different from drugs? Research studies to prove safety are

not required FDA cannot take action against manufacturer until

after product is marketed

Proven efficacy is not required All claims must be followed by statement:

This statement has not been evaluated by the Food and Drug Administration.

This product is not intended to diagnose, treat, cure, or prevent any disease

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Which Products Do I Buy?

“Seals of Approval” U.S. Pharmacopeia NSF International Consumerlab.com

Seal of approval does NOT mean “safe & effective”. Rather provides assurance the product: Was properly manufactured Contains listed ingredients Does not contain harmful levels of contaminants

Determining What’s in a Supplement

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RDA vs. DV

RDA: Recommended Daily Allowance Food & Nutrition Board at the Institute of Medicine of

the National Academies Vary by age, gender and pregnancy status Recommended intake amount of nutrient per day

DV: Daily Value Food & Drug Administration Do NOT vary by age or gender (one DV for anyone >4 years old) Suggest how much nutrient per serving Often match or exceed RDA for most people

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Reading a Supplement Label

Serving Size varies among

products

% DVNot the RDA

Supplement Components

Fillers, binders,

flavors, etc.

Adapted from FDA’s “Dietary Supplement Labeling Guide”

Dietary Supplements

Don’t replace variety of foods important to a healthy diet Dietary Guidelines for Americans Choose MyPlate

Natural does NOT mean safe

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Brief Overview of Select Supplements

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Calcium

Use Osteoporosis (prevention & treatment)

Evidence Well-documented: adequate intake is important for

keeping bones strong & reducing bone loss

Regular weight-bearing & muscle-strengthening exercises are also important

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How Much Calcium Should I Take?Age RDA for Men1 RDA for Women1

19-50 1,000 1,000 mg

51-70 1,000 mg 1,200 mg

71+ 1,200 mg 1,200 mg

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300200

750

Estimating your daily calcium intake:

Table & Recommended Daily Allowances (RDA) obtained from National Osteoporosis Foundation: Clinician’s Guide to Prevention and Treatment of Osteoporosis (2014 Issue, Version 1)

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Forms of Calcium

Carbonate Most common (inexpensive & convenient) Take with food for best absorption Tends to cause more side effects (bloating,

constipation) Citrate

Take with or without food Other forms: gluconate, lactate, phosphate

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Tips on Taking Calcium

Optimizing your calcium intake No more than 500 mg per dose (your body can’t

absorb more than this at one meal) Take at separate time from multivitamin

Calcium can decrease absorption of: Certain antibiotics (Levaquin, tetracycline) Bisphosphonates (Fosamax, Boniva, etc) Levothyroxine (Synthroid) Phenytoin (Dilantin)

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Vitamin D

Use Bone health Helps with calcium absorption

Daily requirements National Osteoporosis Foundation

• <50 years: 400-800 IU/day• 50 years & older: 800-1000 IU/day

Institutes of Medicine Dietary Reference Intake• <70 years: 600 IU/day• 71 & older: 800 IU/day

Most people with osteoporosis need >1000 IU/day

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Folate (Folic Acid)

Critical for women of child-bearing potential prevention of certain birth defects (spina bifida

and anecephaly)

Recommended intake Childbearing potential: 400 mcg/day Pregnant: 600 mcg/day Most women will not obtain sufficient amounts

through their diet alone

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Black Cohosh Reported Uses:

Menopausal symptoms Evidence

Preliminary evidence encouraging but not sufficient (use < 6 months)

Side Effects Few reported (stomach upset, headaches) Long-term safety data unavailable

Who should not take it: Pregnant women Breast cancer Liver disorders

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Cranberry

Reported Uses: urinary track infections

Evidence Prevention- preliminary evidence not definitive Treatment- not effective

Side effects Stomach upset or diarrhea (when used in excess)

Who should not take it: Those taking warfarin (Coumadin) Possibly those on medications which affect the liver

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Vitamin C Reported Uses:

Common cold Evidence

Prevention: data does not support Duration/severity: no effect to mild

effect

Foods Containing Vit C† Amount of Vit C†

Citrus fruits Medium orange = 70 mg

Red & green peppers ½ cup red pepper = 96 mg

Other fruits & veggies (broccoli, strawberries, cantaloupe, tomatoes, etc)

½ cup broccoli = 39 mg½ cup strawberries = 40mgMedium tomato = 17 mg

Fortified foods & beverages

Recommended Amount†

Adult women 75 mg

Pregnant women

85 mg

Breastfeeding women

120 mg

Smokers add 35 mg

† National Institutes of Health Office of Dietary Supplements- “Vitamin C Quick Facts”

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Fish Oil & Omega-3 Fatty Acids

Side effects Bad breath, belching, heartburn, nausea, loose stools

Who should not take it: Fish or seafood allergy Liver disease Possibly those at high bleeding risk

Reported Uses† Evidence†

Heart disease Reduces all-cause mortalityHigh cholesterol May lower triglycerides

(dose-dependent)Cognitive function (memory) Inadequate evidenceAsthma No conclusions possible

† National Institutes of Health Office of Dietary Supplements- “Summary of AHRQ Report on Omega-3”

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Glucosamine/Chondroitin

Reported Uses Osteoarthritis

Evidence Does not slow joint destruction or relieve pain†

Pregnancy Use caution

Who should not take it: Allergy to shellfish (glucosamine)

† National Institutes of Health Office of Dietary Supplements- “Summary of GAIT Study”

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Coenzyme Q-10

Reported Uses: Heart disease Drug-induced muscle weakness (e.g. statins) Reproductive disorders Cancer

Evidence varies among uses Side effects

No serious effects reported Insomnia, rash, nausea, dizziness, headache

Use during pregnancy or breastfeeding- NO

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Interactions

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Interactions with Dietary Supplements Warfarin (Coumadin®) +

many herbal products Co Q-10 Ginkgo Biloba Ginseng Green Tea St. John’s Wort

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Examples of InteractionsRx Medications Dietary Supplement Possible EffectPropranolol (blood pressure) Vitamin C Increased blood pressure

(avoid >500mg/day vit C)

Coumadin- aka warfarin(blood thinner)

Cranberry Ginkgo biloba

Increased risk of severe bleeding (avoid combo)

Prilosec- aka omeprazole (reflux or heart burn)

Ginkgo biloba Decreased ability to reduce reflux (avoid combo)

Aspirin, ibuprofen(pain relievers)

Ginkgo biloba Increased risk of bleeding (avoid combo)

Levaquin- aka levofloxacin(antibiotic)

Calcium-containing products

Decreased antibiotic effect (avoid calcium during antibiotic course)

Coumadin, Prograf. Simvastatin, Zoloft, Paxil, Allegra, Digoxin, oral contraceptives & many others

St. John’s Wort Various effects

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Examples of Interactions with Food

Warfarin & vitamin K

Calcium-rich dairy products, antacids, & multivitamins + antibiotics

Grapefruit Cholesterol medicines Some heart medicines

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Helpful Resources

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Resources

Your local pharmacist

free mobile app “MyDS”

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Resources

Dietary Supplement Label Database (NIH) Searchable database for products, ingredients,

health-related claims, label statements

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Other Reliable Sources

NIH fact sheets Nutrient recommendations (NIH) PubMed Dietary Supplement Subset MedlinePlus (National Library of Medicine) Food & Drug Administration Federal Trade Commission

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Tips on Searching the Web for Information on Supplements Questions to think about:

Who operates the website? What is the purpose of the website?

• Educate the public vs sell a product What is the source of the information & is it

referenced?• Reputable peer-reviewed journals

Is the information current? How reliable is the internet or e-mail solicitations?

• UPPERCASE LETTERS & LOTS OF !!!!!!!!!!!!

Questions adapted from FDA.gov

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More Tips

Ask yourself: Does it sound too good to be true? Think twice about chasing the latest headline Contact manufacturer for more information Check your assumptions:

“Even if a product may not help me, it at least won’t hurt me.”

“When I see the term ‘natural’, it means that a product is healthful and safe.”

“A product is safe when there is no cautionary information on the product label.”

Questions adapted from FDA.gov

Video Quiz

Federal Trade Commission’s 7 Point ‘Gut Check’

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Questions to Ask

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Questions?

Who Should I Ask? Your doctor or other provider Your pharmacist

When should I ask? New medication started Medication stopped Medication dose change Significant change in diet

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General Questions to Ask

What is the name of my medicine? Why am I taking this medicine? How much do I take and how often? What side effects are possible?

What should I do if they occur? What should I do if I miss a dose or double

the dose? Is there anything I should avoid while taking

this medicine?

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Questions About Interactions

Is the interaction something my doctor can monitor for or should the medication/food be stopped?

If I take them at different times, will this prevent the interaction?

What side effects should I watch for? What should I do if they occur?

A few highlights from today

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Key Points

Dietary supplements do not replace necessary medications

Do your research- utilize reliable resources Natural ≠ safe Some dietary supplements can interact with

prescription medications Notify all providers of your current medications ALWAYS ask your pharmacist or provider before

starting (or stopping) dietary supplements

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Tips from a Pharmacist

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Know Your Medicines

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Electronic Medication Record

http://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Forms/UCM095018.pdf

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Utilizing Technology

MyMedSchedule.com

Mobile phone applications

Email and text reminders

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Tips from a Pharmacist

Keep a list of ALL your medications This includes vitamins & supplements!

Keep copies in your wallet & at your house Take to all provider appointments Track any changes Update after each provider appointment

Take medications exactly as prescribed

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Tips from a Pharmacist

Use ONE pharmacy

Check medications before leaving the pharmacy All necessary refills present? Any medications that were stopped?

When a medication is stopped: Cancel automatic refills Update medication list

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Summary

Know Your

PHARMACISTKnow Your

MEDICINE(and supplements)

Thank You!

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What You Need to Know About Dietary Supplements

Lyndsey N. Hogg, PharmD, BCACPClinical Pharmacy Specialist, Ambulatory CareVia Christi Clinic, P.A.53 July 8th, 2014