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
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