Chapter 107

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

Chapter 107Chapter 107

Dietary SupplementsDietary Supplements

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. 2

Dietary SupplementsDietary Supplements FDA definition:FDA definition: “ “vitamins, minerals, herbs or other botanicals, vitamins, minerals, herbs or other botanicals,

amino acids, and substances such as amino acids, and substances such as enzymes, organ tissues, glandulars, and enzymes, organ tissues, glandulars, and metabolites” intended to supplement the diet metabolites” intended to supplement the diet


Regulation of Dietary SupplementsRegulation of Dietary Supplements

The Dietary Supplement Health and The Dietary Supplement Health and Education Act (DSHEA) of 1994Education Act (DSHEA) of 1994

Package labelingPackage labeling Adverse effectsAdverse effects Impurities, adulterants, and variabilityImpurities, adulterants, and variability National Center for Complementary and National Center for Complementary and

Alternative MedicineAlternative Medicine Promotional materialsPromotional materials


Regulation of Dietary SupplementsRegulation of Dietary Supplements

Dietary Supplement and Nonprescription Dietary Supplement and Nonprescription Drug Consumer Protection Act of 2006Drug Consumer Protection Act of 2006

FDA Current Good Manufacturing Practices FDA Current Good Manufacturing Practices (CGMPs) ruling, 2007(CGMPs) ruling, 2007

Quality certification programsQuality certification programs Standardization of dietary supplementsStandardization of dietary supplements


Common Herbal RemediesCommon Herbal Remedies Black cohoshBlack cohosh Coenzyme Q-10Coenzyme Q-10 Cranberry juiceCranberry juice EchinaceaEchinacea FeverfewFeverfew FlaxseedFlaxseed GarlicGarlic Ginger rootGinger root Ginkgo bilobaGinkgo biloba


Common Herbal RemediesCommon Herbal Remedies Glucosamine Green tea Probiotics Saw palmetto Soy St. John’s wort Valerian


Harmful Supplements to AvoidHarmful Supplements to Avoid Comfrey Kava Ma huang (ephedra)


Black CohoshBlack Cohosh Cimicifuga racemosaCimicifuga racemosa Used to treat symptoms of menopauseUsed to treat symptoms of menopause MOA unknownMOA unknown EffectivenessEffectiveness

Some studies have shown it to be as effective as Some studies have shown it to be as effective as estrogenestrogen

Has not been evaluated for long-term useHas not been evaluated for long-term use


Black CohoshBlack Cohosh Drug interactionsDrug interactions

May potentiate antihypertensives and the May potentiate antihypertensives and the hypoglycemic effect of oral agents and insulinhypoglycemic effect of oral agents and insulin

Adverse effectsAdverse effects Safe for routine useSafe for routine use GI are most common side effectsGI are most common side effects Also rash, headache, dizziness, weight gain, and Also rash, headache, dizziness, weight gain, and

crampscramps


Coenzyme Q-10Coenzyme Q-10 Potent antioxidant in the body; participates in Potent antioxidant in the body; participates in

production of ATP at the mitochondrial levelproduction of ATP at the mitochondrial level Therapeutic usesTherapeutic uses

Mitochondrial encephalomyopathies, CHF, and Mitochondrial encephalomyopathies, CHF, and myopathies due to HMG-CoA reductase inhibitors myopathies due to HMG-CoA reductase inhibitors (statins)(statins)


Coenzyme Q-10Coenzyme Q-10 Adverse effectsAdverse effects

Well tolerated, may have GI symptomsWell tolerated, may have GI symptoms Drug interactionsDrug interactions

CoQ-10 is structurally similar to vitamin KCoQ-10 is structurally similar to vitamin K22 and and may antagonize the effects of warfarinmay antagonize the effects of warfarin


Cranberry JuiceCranberry Juice Therapeutic useTherapeutic use

Prevents UTIPrevents UTI The proanthocyanidins it contains interfere with The proanthocyanidins it contains interfere with

bacterial adhesion to the urinary tractbacterial adhesion to the urinary tract EffectivenessEffectiveness

Daily intake helps prevent UTIs in women in their Daily intake helps prevent UTIs in women in their teens or 20s and elderly women – not older adults teens or 20s and elderly women – not older adults or young girlsor young girls

Contradictory evidence that cranberry juice Contradictory evidence that cranberry juice may increase INR of warfarin patientsmay increase INR of warfarin patients


EchinaceaEchinacea Echinacea angustifolia, E. purpurea, Echinacea angustifolia, E. purpurea,

E. pallidaE. pallida Used orally and topicallyUsed orally and topically

Produces antiviral, anti-inflammatory, and Produces antiviral, anti-inflammatory, and immunostimulant effectsimmunostimulant effects

Widely taken, but effectiveness is highly Widely taken, but effectiveness is highly questionablequestionable

InteractionsInteractions May interfere with immunosuppressant drugsMay interfere with immunosuppressant drugs


FeverfewFeverfew Used primarily for prophylaxis of migraineUsed primarily for prophylaxis of migraine MOA not well understoodMOA not well understood Has shown to be effectiveHas shown to be effective Adverse effectsAdverse effects

Well tolerated, no serious effectsWell tolerated, no serious effects Mild GI reactionsMild GI reactions

Long-term safety studies are lackingLong-term safety studies are lacking


FlaxseedFlaxseed Used to treat dyslipidemia and constipationUsed to treat dyslipidemia and constipation Soluble plant fiberSoluble plant fiber Seems to decrease total cholesterol and LDL, Seems to decrease total cholesterol and LDL,

similar to other fiber productssimilar to other fiber products Adverse effects are GI-related (bloating, Adverse effects are GI-related (bloating,

cramping, etc.)cramping, etc.) Should be taken 1 hour before or 2 hours Should be taken 1 hour before or 2 hours

after other medicationsafter other medications


GarlicGarlic Used primarily for cardiovascular system Used primarily for cardiovascular system

effectseffects To reduce levels of TG and LDL and raise HDLTo reduce levels of TG and LDL and raise HDL

Also used to reduce blood pressure, Also used to reduce blood pressure, suppress platelet aggregation, increase suppress platelet aggregation, increase arterial elasticity, and decrease formation of arterial elasticity, and decrease formation of atherosclerotic plaque; antimicrobial and atherosclerotic plaque; antimicrobial and anticancer effectsanticancer effects


GarlicGarlic Can have favorable effects on blood pressure Can have favorable effects on blood pressure

and plasma lipidsand plasma lipids Must be raw, not cooked (allicin and allinase)Must be raw, not cooked (allicin and allinase) 1-2 cloves twice daily for effect1-2 cloves twice daily for effect Only 5 of 18 common garlic products contain Only 5 of 18 common garlic products contain

allicin in effective amountsallicin in effective amounts Generally well tolerated except for unpleasant Generally well tolerated except for unpleasant

taste and bad breathtaste and bad breath Has significant antiplatelet effectsHas significant antiplatelet effects


Ginger RootGinger Root Primary usesPrimary uses

To treat vertigoTo treat vertigo To suppress nausea and vomiting caused by To suppress nausea and vomiting caused by

motion sickness or morning sickness; to suppress motion sickness or morning sickness; to suppress post-op nausea and vomitingpost-op nausea and vomiting

For cancer chemotherapyFor cancer chemotherapy Can suppress platelet aggregationCan suppress platelet aggregation


Additional Supplements Additional Supplements Ginkgo Ginkgo

Generally well tolerated Generally well tolerated GlucosamineGlucosamine

Use with caution in patients with shellfish allergyUse with caution in patients with shellfish allergy Increased risk for bleedingIncreased risk for bleeding

Green teaGreen tea Overconsumption leads to caffeine overdoseOverconsumption leads to caffeine overdose


Additional SupplementsAdditional Supplements ProbioticsProbiotics

Generally well tolerated – some GI effectsGenerally well tolerated – some GI effects Saw palmettoSaw palmetto

Conflicting results in treatment of BPHConflicting results in treatment of BPH May have antiplatelet effectsMay have antiplatelet effects

SoySoy Should not be used with antiestrogenic Should not be used with antiestrogenic

medications (tamoxifen)medications (tamoxifen)


St. John’s WortSt. John’s Wort Widely used to treat depressionWidely used to treat depression Limited clinical studies show St. John’s wort Limited clinical studies show St. John’s wort

is useful for mild to moderate depression – is useful for mild to moderate depression – not severe depressionnot severe depression

No prescription needed in United StatesNo prescription needed in United States Interacts adversely with many drugsInteracts adversely with many drugs

Induction of cytochrome P450 enzymesInduction of cytochrome P450 enzymes Induction of P-glycoprotein Induction of P-glycoprotein Intensification of serotonin effectsIntensification of serotonin effects


Additional SupplementsAdditional Supplements ValerianValerian

Generally well toleratedGenerally well tolerated Does not seem to potentiate CNS depressant Does not seem to potentiate CNS depressant

effects of alcohol, but this may occureffects of alcohol, but this may occur Used as a tranquilizer in World War IIUsed as a tranquilizer in World War II


Harmful SupplementsHarmful Supplements ComfreyComfrey

Contains pyrrolizidine alkaloids that are associated Contains pyrrolizidine alkaloids that are associated with veno-occlusive diseasewith veno-occlusive disease

KavaKava Can result in severe hepatic damageCan result in severe hepatic damage

Ma huang (ephedra)Ma huang (ephedra) Can elevate BP and stimulate the heart and CNSCan elevate BP and stimulate the heart and CNS

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