Transcript Vitamins Minerals Herbs-3

Valerie Dzubur EdD APRN FNP – BC
Samuel Merritt University
PHC I
 Vitamins
and Minerals
• Growth maintenance and repair
• Non-energy producing nutrients
 Vitamins - organic
 Fat – soluble A D E K
 Water soluble B complex & C
 Minerals - inorganic
 Major
 Trace
 Deficiency
• Inadequate dietary intake
• Increased metabolism
• Poor absorption
• Medications
 $7.5
billion spent annually
 However Vitamins and minerals are best
obtained from foods not pills
 Dietary
Reference Intakes (DRI)
• Replaced Recommended Daily Allowance
 Food
Labels
• % Daily Values
 Based on the DRI
 Vitamin
A - Fat Soluble
• Retinal & retinoic acid
• Carotenoids
• Stored in the Liver
• Required for bone growth, immune function, gene
expression, vision, integrity mucosal & epithelial surfaces
 Vitamin
A deficiency
• Visual disturbances
• Respiratory infections
• Dryness
• Keratinization of the skin
• Genitourinary disturbances
• Faulty bone formation
 Green
and yellow vegetables
 Cancer risk reduction unclear
 Vitamin A Toxicity
• Acute
 N/V, blurred vision, lack of muscle co- ordination
• Long term - large doses
 Fatigue, irritability, hepatic abnormalities,
 Anorexia, depression, nausea, vomiting, reduced bone density
 Vitamin
A
• Use with caution in pregnancy
• Accutane is a Vitamin A analog
• Drugs that decrease absorption – separate doses by two
hours
 Cholestyraine ( Questran)
 Colestipol (Colestid)
 Orlistat (Zenical)
 Mineral Oil
 Vitamin
D
• Synthesized in the skin
• Calciferol, ergocalciferol, cholecalciferol
• Ultraviolet triggers the synthesis
• Stored in Fat
• Needed for calcium and phosphorus homeostasis
 Vitamin
D Deficiency caused by
• Inadequate dietary intake of calcium
• Limited sun exposure
• Use of sunscreen
• Obesity
• Renal & Liver disease
• Inability of the skin to synthesize
 Fortified
Foods
 Fish liver oils, liver and Eggs
 Lab – Serum 25(OD) levels
• Level 30 – 60 ng/ml
 Rx
Ergocalciferol l50,000 IU once per week 6 –
8 weeks than 1,000 IU vit D 3 q day
 Vitamin
E
• Tocopherols and tocotrienols
• Stored in the Liver
• Deficiency
 Peripheral neuropathy, dry skin & hair, poor wound healing,
bruising, anemia, ataxia, muscle weakness, reproduction failure
 Vitamin
E
• An antioxidant & may prevent
 Select cancers
 Cardiovascular disease
 Age-related macular degeneration
 Visual acuity loss
 Muscle injury
 Further decline in Alzheimer
 Vitamin
E
• Toxicity
 Headache GI disturbances, diplopia, muscle weakness
• Found in nuts soy beans, green leafy vegetables,
wheat germ oil, whole wheat, whole grain cereals
 Vitamin
K
• Quinones or naphthoquinoine
• Fat soluble
• Coenzyme for the synthesis and activation of clotting
factors
• Creation of proteins in the plasma, kidney and bone
 Vitamin
K
• Deficiency caused by inadequate nutrition
• Relatively non-toxic
• Bile acid sequestrants, mineral oil, orlistat can interfere
with absorption
• Separate dose by 2 hours
 Thiamin
– Vitamin B 1
• Water soluble
• Energy metabolism nerve conduction and aerobic
metabolism
• Sources
 Enriched fortified cereal grains, organ meats, lean cuts of pork,
legumes, seeds and nuts
 Vitamin
B 1 deficiency – Berriberi
• Cardiac failure, muscle weakness, peripheral and central
neuropathy, gastrointestinal malfunction
 High
risk
• Alcoholics
• Adults with high carbohydrate intake
 White rice – Asian Countries
• Dialysis patients
• Parental nutrition
• Hypermetabolic states
 Vitamin
B 2 – Riboflavin
• Facilitates metabolism, energy production
• Sources
 Milk, eggs, cheese, organ meats, green leafy vegetables, whole
grains, enriched cereals & breads
 Little is stored - need daily intake
 Niacin
– Vitamin B 3
• Nicotinic acid & nicotinamide & tryptophan
• Lipid metabolism, tissue respiration, glycogenolysis
• Causes peripheral prostaglandin- mediated vasodilatation
and increased histamine-mediated gastric motility
 Affects
fibrinolytic system, glucose intolerance,
synthesis of VLDL –C and LDL – C
 Used to treat
• Hypercholesterolemia, mixed dyslipidemia,
hypertriglyceridemia
 Lowers LDL-C & Triglycerides
 Increases HDL – C
 Pre-medication
with ASA may help flushing
 Can exacerbate gout
 Increased LFT may result long term use
 Discontinue if LFT > 3 x normal
 Contraindicated in patients with liver disease
 Cholestyraine and Colestipol can decrease
absorption
 Niacin
• Increased insulin resistance
• Hypoglycemic medications may need to be increased
• Enhance effects of hypotensive effect of ganglionic-
blocking agents
 Niacin
• Sources
 Red meats
 Beans
 Fortified foods
 Milk and eggs contain Tryptophan
 Vitamin
B 5 – Pantothenic acid
• Acetylcholine synthesis
 Metabolism of fats carbohydrates and proteins
 Deficiency treated with Pantothenic acid
 Also good for pruritis and mild eczema
 Vitamin
B5
• Deficiency
 Somnolence, fatigue headache tingling (burning feet syndrome)
 Muscle weakness
 Increased susceptibility to infection
 Vitamin
B5
• Sources
 Widespread in many foods
 Eggs
 Liver fish poultry
 Whole grain breads cereals legumes
 Dexpanthenol is also available over the counter as Panthoderm
2%
 Vitamin
B 6 Pyridoxine
• Metabolism of Fats Proteins Carbohydrates
• Deficiency
 Alcoholism Malabsorption Drug interactions
 INH hydralazine penicillamine cycloserine
 S/S seborrheic dermatosis glossitis cheilosis, irritability
depression
 Vitamin
B 6 - Pyridoxine
• INH
 Prophylaxis with Vitamin B 6
• May be helpful for PMS
• Sources
 Brewer’s yeast wheat germ liver peanuts
 Legumes potatoes, bananas
 Vitamin
B 6 - Pyridoxine
• High does may be toxic
• S/S
 Tingling
 Decreased coordination
 Stumbling gait
 Folate
Vitamin B 9
• Also known as Folic acid and pteroylglutamic acid
• Production of new cells – pregnancy
• DNR RNA and Production of RBC
• Supplements provide more available Folate than foods
however degraded so a daily source is needed
 Folate
Deficiency
• Megaloblastic anemia
• Neural tube defects
• S/S
 Diarrhea, loss of appetite
 Weight loss weakness glossitis
 Headache heart palpitations irritability
 Folate
Deficiency
• Adults – anemia
• Child – grow slow
• Increase in homocysteine levels
• Folate Supplementation
 recently used to decrease homocysteine levels
 to reduce cardiac risk
 Folate
– Pregnancy
• A deficiency occurs in 1/3 pregnancies world wide
• High Risk
 Multiple gestations
 Teen pregnancy
 Closely spaced pregnancies
 Folate
replacement in anemia
• Diagnosis first
• Folate will mask the diagnosis of pernicious anemia
• But without Vitamin B 12 will not prevent neurologic
damage
 Folate
 Drug
Interactions
• Oral contraceptives
• Sulfasalazine
• Trimethoprim
• Methotrexate
• Phenytoin
 Decreased blood level of Phenytoin
 Decreased absorption of Folate
 Folate
• Non toxic water soluble
• Rapid excretion
• Folate Acid 1 mg Q D
• Sources
 Fortified cereal grains organ meats
 Green vegetables, eggs fresh fruits
 Vitamin
B 12 – Cyanocobalamin
• Normal blood cell formation
• Neurologic function
• Metabolism Fats Protein Carbohydrates
• Binds to gastric intrinsic factor
• Stored in the liver
 Vitamin
B 12
• Deficiency
 Pernicious Anemia
 Malabsorption
 Decreased secretion of intrinsic factor after gastric by-pass
surgery
 Vegan diet
 Pernicious
anemia
• Fatigue loss of appetite
• Peripheral neuropathy
• Poor blood clotting
• Easy bruising
 When
beginning replacement Vitamin B 12
• monitor electrolytes
• consider potassium replacement
• Can give it PO IM or Nasal
 Vitamin
B 12
• Sources
 Organ meats, liver eggs milk
 Chicken cheese
 Fortified cereals
 Biotin
• Readily available in most foods
• Deficiency
 Hair loss exfoliative dermatitis anorexia nausea
 Numbness of the extremities muscle pain
 At Risk
 Eat a lot of raw eggs prevents absorption
 Vitamin
C – Ascorbic Acid
• Water- Soluble daily replacement
• When does > 1000 mg absorption < 50 %
• Collagen synthesis integrity of connective tissue
 Vitamin
C
• Deficiency Scurvy
 Myalgia weakness irritability anemia
 Hemorrhage
 Hyperkeratotic follicles
 Corkscrew hairs
 Gingivitis
 Loose teeth
 Vitamin
C
• Deficiency risk
 Gastrointestinal diseases
 Acute and chronic inflammatory diseases
 Patients undergoing surgery
 Prolonged use of a high dose may increase metabolism causing
deficiency when intake reduced
 Vitamin
C in Pregnancy & Lactation
• S/S diarrhea cold or heat intolerance
• May need supplementation
• Large doses during pregnancy can cause scurvy in
neonates
 Vitamin
C
• In general non toxic
 Cholestyramine and Vitamin C dose should be separated
 Large doses may reduce anticoagulant action of Warfarin
 Use Vitamin C with FeSO4 > Iron absorption
 Smokers require more vitamin C
 False positive Occult Blood
 Buyer
Be Ware
• Have the potential to unexpected or unwanted effects
and toxicity
• Also ask people what herbs they use in the history
 Ginkgo
– memory
• Hypersensitivity GI disturbance bleeding
• Discontinue before surgery 36 hours
• Children - seizures
 Echinacea
– Prevention URI
• Anti viral activities
 GI disturbances fever unpleasant taste dizziness
 Allergic reactions
 High risk if allergic to ragweed daisies marigolds
 May interfere with immune-suppression Tx
 May exacerbate MS
 Use no more than 8 weeks
 Discontinue before surgery
 Garlic
-
• hypercholesterolemia hypertension and diabetes
• GI disturbances odor sweating allergic
• Increase risk for bleeding if taking Warfarin
• Discontinue 1 -2 weeks before surgery
• Hypoglycemia when taking hypoglycemic agents
 Asian
or Oriental Ginseng
• Stress enhance immune function
• Memory Physical endurance
• Insomnia mastalgia palpitations headache
• Decreased appetite hypotension and hypertension edema
hypoglycemia
• Increased risk of bleeding Pt on anti platelet drug
• Discontinue 7 days prior to surgery
 Soy
Phytoestrogens Isoflavones
• To manage post menopausal symptoms
• Prevent Osteoporosis and cardiovascular disease
• May be effective in lowering total cholesterol
• GI disturbances Nausea Bloating Constipation
• Allergic reactions
• Use with caution history of Breast Cancer
 Risk unknown
 Saw
Palmetto
• To Tx symptoms of BPH
 Does not effect PSA or size of prostate
• Headache GI disturbances
• May interfere with hormonal and contraceptive
pharmacotherapy
• Decreased ejaculatory volume
• Cholestatic hepatitis
 St.
John’s Wart – Hypericum perforatum
 To Tx Depression and anxiety
 Insomnia restlessness irritability GI upset
 Dizziness vivid dreams paresthesias
photosensitivity hypomania and mania
 An inducer of P-450 many drug interactions
 Discontinue prior to surgery
 Avoid
St. John’s Wart with
• Sumatriptan
• Other 5-hydroxytryptamine agonists
• Zoloft and other SSRIs
• Ultram and Serzone
• Quinolones Sulfonamides Tetracyclines
 Valerian
• For insomnia or anxiety
 Chronic use not recommended due to hepatotoxicity
 Many products also contain alcohol
 Use caution with driving or operating machinery
 Black
Cohosh
• Used to tx premenstrual symptoms
• Avoid in
 Pregnancy
 Estrogen receptive Breast Cancer
 Uterine Cancer
 Thromboembolic disorders
 Kava
• Used for anxiety stress and sleep disorders
 Use caution driving & operating machinery
 Stop 24 hours prior to surgery
 Hepatotoxicity has been reported
 Short term use only
 Long term use
 Pellagra-like syndrome known as kava dermopathy
 Dry flaky skin reddened eyes discoloration of skin and nails
 Milk
thistle
• to relieve gastrointestinal complaints help with liver
disease
• Antioxidant and hepato protective properties
• Laxative effect
• Allergic reactions
 Evening
Primrose Oil
• PMS & Menopause
• Mastalgia and rheumatoid arthritis
• S/S soft stools headache
• Avoid in pregnancy
• Avoid in Schizophrenic patients on phenothiazine , blood
levels
 Grape
Seed
• Management of venous insufficiency varicose veins
peripheral vascular disease wound healing
• Antioxidant properties
• High in essential fatty acids
 Bilberry
taken as a tea for many conditions
• GI, Visual, CV, Diabetes, Arthritis
• If taking hypoglycemic Rx monitor Glucose
• Avoid long term use risks unknown
• May effect platelet function avoid with antiplatelet or
anticoagulant medications
 Coenzyme
Q found in oily fish
• CHF Angina HTN
• Improving immune function
 May slow the decline in Parkinson’s Disease
 Melatonin
• Management of sleep disturbances
• Jet lag
• No driving 4 -5 hours after taking
• Contraceptive effect – avoid if attempting pregnancy
• Avoid with Liver disease
• May alter immune function
 Flaxseed
• Constipation
• Hypercholesterolemia Arthritis wt loss
• Maintain adequate hydration
 Intestinal blockage
 Separate from other medications 2 hours
 High fiber content < absorption
 Fish
Oils Omega 3 Fatty acids
• Hypertension
• Hyperlipidemia
• Hypertriglyceridemia
• Coronary Heart Disease
• > HDL < triglycerides
 Fish
Oils
• Decrease pulmonary function
 Use in caution with




Pt on antihypertensive meds
Prone to hypotension
ASA sensitive
Pt on anticoagulant or antiplatelet meds
 Glucosamine
Sulfate
• Used to tx osteoarthritis
 Often combined with chondroitin
 No evidence to support
 Long term use risks unknown
 Diabetics should monitor for hyperglycemia
 S-adenosyl-Lmethionin
• Depression osteoarthritis liver disorders
• Migraines fibromyalgia sleep modulation
• May exacerbate hyperhomocystinemia and increase risk
for thrombosis
• Avoid use with bi-polar disorders
 May precipitate mania
 Caffeine
• A stimulant and a diuretic
• Contained in many supplements
• Avoid doses in excess of 250 mgs/d
Medical Foods
 Regulated
by FDA
• As an orphan drug
• May not be covered by health insurance
• Requires a prescription
• Consider when people have not responded to
•
•
•
•
conventional therapy
Can be used as an augmentation therapy
For Depression
HIV
Alzheimer's, Parkinson’s, age related memory loss
Medical Foods
 Deplin
7.5 mg ($30.00 a month)
• L-methylfolate
• Regulations the synthesis of serotonin, nor-epinephrine
and dopamine
• Boosting levels of Folate in the brain
• Which in turn helps to activate neurotransmitters in the
brain that are associated with mood
Medical Foods
 Axona
• Improves cognitive function & memory
• As body digests Axona the liver produces extra ketones
•
•
•
•
which provide an alternative energy source for the brain
Ketones have a neuro protective property
Comes in the form of a sweet drink packet
$80.00 - $100 per month
218 calories in a packet
Medical Foods
 Cerefolin
• May help age associated memory impairment
• Patients with elevated homocysteine level
• www.pamlabs.com
• $50.00 for 30 tablets
Medical Foods
 Metanx
• Reduce pain in diabetic neuropathy
• Numbness
• Common Problem with a Gene MTHSR
 See research by NIH
• Results in decreased ability to process folic acid in foods
• This medical food provides folic acid in a more bio-
available form than is found in food