Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Chapter 107 Dietary Supplements

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.2 Dietary Supplements  FDA definition: “vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, glandulars, and metabolites” intended to supplement the diet “vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, glandulars, and metabolites” intended to supplement the diet

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.3

4 Regulation of Dietary Supplements  The Dietary Supplement Health and Education Act (DSHEA) of 1994  Package labeling  Adverse effects  Impurities, adulterants, and variability  National Center for Complementary and Alternative Medicine  Promotional materials

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.5 Regulation of Dietary Supplements  Dietary Supplement and Nonprescription Drug Consumer Protection Act of 2006  FDA Current Good Manufacturing Practices (CGMPs) ruling, 2007  Quality certification programs  Standardization of dietary supplements

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.6 Common Herbal Remedies  Black cohosh  Coenzyme Q-10  Cranberry juice  Echinacea  Feverfew  Flaxseed  Garlic  Ginger root  Ginkgo biloba

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.7 Common Herbal Remedies   Glucosamine   Green tea   Probiotics   Saw palmetto   Soy   St. John’s wort   Valerian

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.8 Harmful Supplements to Avoid   Comfrey   Kava   Ma huang (ephedra)

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.9 Black Cohosh  Cimicifuga racemosa  Used to treat symptoms of menopause  MOA unknown  Effectiveness  Some studies have shown it to be as effective as estrogen  Has not been evaluated for long-term use

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.10 Black Cohosh  Drug interactions  May potentiate antihypertensives and the hypoglycemic effect of oral agents and insulin  Adverse effects  Safe for routine use  GI are most common side effects  Also rash, headache, dizziness, weight gain, and cramps

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.11 Coenzyme Q-10  Potent antioxidant in the body; participates in production of ATP at the mitochondrial level  Therapeutic uses  Mitochondrial encephalomyopathies, CHF, and myopathies due to HMG-CoA reductase inhibitors (statins)

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.12 Coenzyme Q-10  Adverse effects  Well tolerated, may have GI symptoms  Drug interactions  CoQ-10 is structurally similar to vitamin K 2 and may antagonize the effects of warfarin

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.13 Cranberry Juice  Therapeutic use  Prevents UTI  The proanthocyanidins it contains interfere with bacterial adhesion to the urinary tract  Effectiveness  Daily intake helps prevent UTIs in women in their teens or 20s and elderly women – not older adults or young girls  Contradictory evidence that cranberry juice may increase INR of warfarin patients

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.14 Echinacea  Echinacea angustifolia, E. purpurea, E. pallida  Used orally and topically  Produces antiviral, anti-inflammatory, and immunostimulant effects  Widely taken, but effectiveness is highly questionable  Interactions  May interfere with immunosuppressant drugs

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.15 Feverfew  Used primarily for prophylaxis of migraine  MOA not well understood  Has shown to be effective  Adverse effects  Well tolerated, no serious effects  Mild GI reactions  Long-term safety studies are lacking

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.16 Flaxseed  Used to treat dyslipidemia and constipation  Soluble plant fiber  Seems to decrease total cholesterol and LDL, similar to other fiber products  Adverse effects are GI-related (bloating, cramping, etc.)  Should be taken 1 hour before or 2 hours after other medications

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.17 Garlic  Used primarily for cardiovascular system effects  To reduce levels of TG and LDL and raise HDL  Also used to reduce blood pressure, suppress platelet aggregation, increase arterial elasticity, and decrease formation of atherosclerotic plaque; antimicrobial and anticancer effects

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.18 Garlic  Can have favorable effects on blood pressure and plasma lipids  Must be raw, not cooked (allicin and allinase)  1-2 cloves twice daily for effect  Only 5 of 18 common garlic products contain allicin in effective amounts  Generally well tolerated except for unpleasant taste and bad breath  Has significant antiplatelet effects

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.19 Ginger Root  Primary uses  To treat vertigo  To suppress nausea and vomiting caused by motion sickness or morning sickness; to suppress post-op nausea and vomiting  For cancer chemotherapy  Can suppress platelet aggregation

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.20 Additional Supplements  Ginkgo  Generally well tolerated  Glucosamine  Use with caution in patients with shellfish allergy  Increased risk for bleeding  Green tea  Overconsumption leads to caffeine overdose

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.21 Additional Supplements  Probiotics  Generally well tolerated – some GI effects  Saw palmetto  Conflicting results in treatment of BPH  May have antiplatelet effects  Soy  Should not be used with antiestrogenic medications (tamoxifen)

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.22 St. John’s Wort  Widely used to treat depression  Limited clinical studies show St. John’s wort is useful for mild to moderate depression – not severe depression  No prescription needed in United States  Interacts adversely with many drugs  Induction of cytochrome P450 enzymes  Induction of P-glycoprotein  Intensification of serotonin effects

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.23 Additional Supplements  Valerian  Generally well tolerated  Does not seem to potentiate CNS depressant effects of alcohol, but this may occur  Used as a tranquilizer in World War II

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.24 Harmful Supplements  Comfrey  Contains pyrrolizidine alkaloids that are associated with veno-occlusive disease  Kava  Can result in severe hepatic damage  Ma huang (ephedra)  Can elevate BP and stimulate the heart and CNS