Download Calcium

Community pharmacy
Topic: 2
part(2)
Minerals supplements
Minerals
• The human body consists of number of
minerals and trace elements which are
required for various metabolism
function in the body.
• The important minerals involved are:
calcium, phosphorus, sodium, potassium,
iron and iodine.
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Calcium
• Calcium in association with vitamin D,
and phosphorus, is essential for the
hardening of the bone and teeth.
• Builds and protects bones and teeth.
• Helps with muscle contractions and
relaxation, blood clotting, and nerve
impulse transmission.
• Plays a role in hormone secretion and
enzyme activation.
• Helps maintain healthy blood pressure
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• There is no clear cut definition as signs
and symptoms due to the deficiency of
calcium. Children, expectant and nursing
mothers require higher amount of
calcium as it is needed for the growth
of tissues and bones
Table 1: Recommended Dietary Allowances (RDAs) for
Calcium
Age
Male
14–18
years
19–50
years
4
51–70
years
Female
Pregnant
Lactating
1,300 mg 1,300 mg
1,300 mg
1,300 mg
1,000 mg 1,000 mg
1,000 mg
1,000 mg
1,000 mg 1,200 mg
• Adults absorb roughly 30% of calcium
ingested, but this can vary depending on
the source
• Diets very high in calcium may increase
the risk of prostate cancer.
• Dietary supplements: The two main
forms of calcium in supplements are
carbonate and citrate.
-5
Calcium carbonate is more commonly available
both inexpensive and convenient
calcium carbonate is absorbed most efficiently when taken with food
Calcium citrate is also useful for people with achlorhydria,
inflammatory bowel disease, or absorption disorders
Calcium carbonate has more side effects (constipation, bloating….)
• Absorption is highest in doses ≤500 mg. So,
for example, one who takes 1,000 mg/day
of calcium from supplements might split
the dose and take 500 mg at two separate
times during the day.
• Absorption of calcium from gut depend
on:
- Amount consumed: the efficiency of absorption decreases as
calcium intake increases
- Age and life stage: net calcium absorption is as high as 60% in
infants and young children, decreases to 15%–20% in adulthood
(though it is increased during pregnancy)
- Vitamin D intake: this nutrient, obtained from food and
produced by skin when exposed to sunlight of sufficient
intensity, improves calcium absorption
- Other components in food: oxalic acid (milk, spinach)
• Amount of Ca eliminated from body
depend on:
- Sodium and protein intakes: high sodium intake
increases urinary calcium excretion
- Caffeine intake: increase calcium excretion and reduce
absorption.
- Alcohol intake: reducing its absorption
- Phosphorus intake: high levels of phosphate is
associated with reduced bone mass and increased
fracture risk
- Fruit and vegetable intakes: metabolic acids produced
by diets high in protein and cereal grains increase
calcium excretion
• Calcium supplements contain varying
amounts of elemental calcium. For
example, calcium carbonate is 40%
calcium by weight, whereas calcium
citrate is 21% calcium. Fortunately,
elemental calcium is listed in the
Supplement Facts panel, so consumers
do not need to calculate the amount of
calcium supplied by various forms of
calcium supplements.
• Calcium supplements contain varying
amounts of elemental calcium. For
example, calcium carbonate is 40%
calcium by weight, whereas calcium
citrate is 21% calcium, calcium gulconate
9% and calcium lactate 13%.
• Corrected calcium level:
• Corrected calcium = 0.8 * (4.0 - serum
albumin) + serum calcium
• Ex: ca: 12 mg/dl, albumin: 2 g/dl (N:3.45.4) ….. Corrected Ca level: 13.6 mg/dl
• Deficiency signs: Brittle bones,
unhealthy teeth, muscle spasms (tetany)
• Hypocalcemia results primarily from
medical problems or treatments,
including renal failure, surgical removal
of the stomach, and use of certain
medications (such as diuretics).
• Symptoms of hypocalcemia include
numbness and tingling in the fingers,
muscle cramps, convulsions, lethargy,
poor
appetite,
and
abnormal
heart
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rhythms
• Groups at Risk of Calcium Inadequacy:
• Postmenopausal women
• Amenorrheic women and the female
athlete triad
• Individuals with lactose intolerance or
cow's milk allergy
• Vegetarians
• Safety: High doses of calcium can cause
stomach upset, diarrhea, headache,
increased heart attack risk and gall and
kidney stones.
• Systemic antacids: calcium-containing
salts
• These can induce rebound acid secretion
and so should not be used for prolonged
periods. Prolonged high doses may cause
hypercalcaemia… provide: 200 to 400 mg
• Corticosteroid: Side-effects associated
with long-term high doses limit their
place in therapy. If long-term therapy is
required, monitor bone mineral density
and consider using calcium
supplementation and prophylactic
therapy for osteoporosis
• Hyperkalemia: Calcium gluconate or
calcium chloride (intravenous): aim is to
maintain cardiac function; prolonged use
may cause hypercalcaemia
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Phosphorus
• Phosphorus is associate of with calcium
and vitamin D in the hardening of bones
and teeth and helps to maintain the
constant composition of the body fluids.
Phosphorus are essential part for
energy transport inside cells.
• M: 700 mg, W: 700 mg
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Potassium
• It is found widely in all foods. The
normal intake of the potassium chloride
varies from 5-6 gm and this meets the
body's potassium requirements.
• It is the most commonly occurring intra
cellular cation and is involved in various
chemical activities inside cell. It also
plays important role in contraction of
the muscle, transmission of nerves
impulses and maintenance of electrolyte
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balance in the body.
• Balances fluids in the body. Helps maintain
steady heartbeat and send nerve impulses.
Needed for muscle contractions. A diet
rich in potassium seems to lower blood
pressure. Getting enough potassium from
your diet may benefit bones
• Hypokalemia: a K serum level <3.5 mmol/L).
• Aetiology: diuretics, diarrhoea, alkalosis, vomiting,
corticosteroids, renal tubular acidosis.
• Signs and symptoms: cardiac abnormalities, muscle
weakness, paralysis, weak pulse
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• Management of hypokalemia:
• Oral potassium solution is usually
preferred unless patient is unable to
swallow; gastrointestinal side-effects
may occur.
• Intravenous administration of
potassium: 20 mmol potassium in 1 mL
mixed with sodium chloride 0.9%.
Monitoring required includes ECG and
serum potassium levels.
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• Hyperkalaemia This condition is
characterised by a potassium serum
level 5 mmol/L.
• Aetiology: renal failure, acidosis,
potassiumsparing diuretics. Signs and
symptoms: cardiac arrhythmias, muscle
weakness.
• Management:Calcium gluconate or
calcium chloride (intravenous), Sodium
bicarbonate (intravenous), Glucose
solutions:
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Sodium
• Is found in most foods, artificially
enriched bread and as cooking and table
salt.
• The normal intake of sodium chloride/day
varies 5-20 gm( the daily requirements is between 2-5 gm),
excess amount is excreted in urine.
• Sodium is the most commonly extra
cellular cation and is associated with:
- the contraction of muscle
- transmission of nerve impulses in nerve
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fiber
- maintenance of electrolytes balance in
the body.
- In cold and influnza: Sodium chloride:
0.9%, safe product which can be used in
paediatric patients and during
pregnancy. Patient is advised to apply
product as required to provide relief
from congestion.
- Mouth washes: sodium chloride
• While experts recommend that people limit sodium
intake to 2,400 mg, most Americans consume 4,000–
6,000 mg a day.
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Iron
• Is soluble compound, found in green
leafy vegetable, liver, kidney, eggs yolk,
and whole meal bread. Normal adults
lose about 1 mg iron daily from the
body. The normal daily diet may contain
more but the amount absorbed is equal
to the amount lost. Higher intake is
necessary for women particularly during
pregnancy
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• Iron from an important component of
hemoglobin.
• Needed for chemical reactions in the
body and for making amino acids,
collagen, neurotransmitters, and
hormones.
• Women who do not menstruate probably
need the same amount of iron as men
• 31–50: M: 8 mg, W: 18 mg
• 51+: M: 8 mg, W: 8 mg
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• Because iron is harder to absorb from
plants, experts suggest vegetarians get
twice the recommended amount
(assuming the source is food).
• Causes of iron-deficiency anaemia
• Chronic blood loss: gastrointestinal
disease, drug induced, menstrual loss
• Increased requirements: pregnancy
• Malabsorption
• Dietary deficiency.
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• Clinical presentation of iron-deficiency
anaemia
• Pale skin and mucous membranes
• Glossitis
• Angular stomatitis
• Koilonychia
• Dysphagia
• Pica
• Atrophic gastritis.
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• Parenteral iron therapy includes:
• Iron dextran injection: deep
intramuscular injection.
• Iron sucrose injection: slow
intravenous injection or by intravenous
infusion.
• In pregnancy:
• Recommended supplementation, usually
given in combination with folic acid
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Iodine
• It is found in salt water fish and in
vegetables grown in soil containing iodine.
The minimum daily requirement of iodine
is 140 μg, for an adult man and 100 μg for
an adult woman
• Iodine is essential for the formation of
the thyroxin and triiodothyronine. Its
deficiency can lead to endemic goiter,
hypothyroidism and impaired hearing and
brain development.
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• Part of thyroid hormone, which helps
set body temperature and influences
nerve and muscle function, reproduction,
and growth. Prevents goiter and a
congenital thyroid disorder
• Sources: Iodized salt, processed foods,
seafood
• To prevent iodine deficiencies, some
countries add iodine to salt, bread, or
drinking water.
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• In mouth wash: povidone–iodine.
• Vaginal candidiasis: Alternative option:
povidone–iodine applied twice daily for
14 days. Disadvantages of povidone–
iodine: it stains and inconvenience of
dosage regimen.
• First aid items for cuts and grazes:
Antiseptic (iodine based, surgical spirit)
• Management of hyperthyroidism:
Radioactive iodine.
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• Hypothyroidism: The most common cause is a
secondary one due to radioactive iodine
therapy or surgery for hyperthyroidism.
Other causes include congenital disease,
hypopituitarism and hypothalamic disorders.
• Example of management during acute thyroid crisis:
Potassium iodide orally 15 mg three times daily
• Drugs associated with thyroid dysfunction
• Amiodarone: Used in the treatment of
arrhythmias, Contains iodine and may cause
thyroid disorders (hypothyroidism or
hyperthyroidism)
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Fluoride
• About 96% of fluoride is found in bones
and teeth. It is essential for the normal
mineralization of bones and formation
of dental enamel.
• The average adult man may ingest about
1 mg of fluoride from drinking water
and his daily diet may provide another
0.25 -0.35 mg of fluoride
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• Ingestion of large amount is associated
with dental and skeletal fluorosis
characterized by mottled enamel and
osteosclerosis respectively.
• On the hand, if the fluoride deficiency
occurs due to less than optimum intake
of fluoride, it may lead to development
of dental caries
• M: 4 mg, W: 3 mg
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• In bone disease: This increases bone
formation in cancellous bone rather
than cortical bone. It requires calcium
supplementation. However, concomitant
administration of fluoride with calcium
may adversely affect fluoride
absorption. To date there is limited
clinical experience with fluoride.
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MAGNESIUM
• Needed for many chemical reactions in
the body Works with calcium in muscle
contraction, blood clotting, and
regulation of blood pressure. Helps build
bones and teeth
• 31+: M: 420 mg, W: 320 mg
• Green vegetables such as spinach and
broccoli, cashews, sunflower seeds and
other seeds, whole-wheat bread, milk
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• The majority of magnesium in the body
is found in bones. If your blood levels
are low, the body may tap into these
reserves to correct the problem.
• Found in antacids ( causes diarrhea),
laxatives (Magnesium sulphate,
Magnesium hydroxide)
• Hypomagnesia : using thiazide durtics
• May be Used in Treatment for
idiopathic restless leg syndrome
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Trace elements
• Apart from the mentioned minerals,
there are other element which are
required by the body in very minute
amount and hence they are known as
trace elements.
Zinc:
• Is present in all the tissues and is
constitute of insulin and many enzymes
in the body. It is widely distributed in
the food stuffs both animal and
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vegetable.
• Helps to form many enzymes and proteins
and create new cells, Frees vitamin A
from storage in the liver. Needed for
immune system, taste, smell, and wound
healing.
• When taken with certain antioxidants,
zinc may delay the progression of agerelated macular degeneration
• Daily intake in adults range from 5-10 mg
• Low circulating zinc levels have been
associated with liver disease, pernicious
anemia and delayed wound healing.
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• Deficinecy signs: Skin, throat and eye
lesions, poor sense of smell and taste.
Poor wound healing and hair loss.
Diarrhea and pediatric growth issues.
• Because vegetarians absorb less zinc,
experts suggest that they get twice the
recommended requirement of zinc from
plant foods.
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• Safety: Over 100 mg a day side effects
include nausea, vomiting and stomach
cramping
• Do not take indigestion remedies or
medicines containing iron or zinc at the
same time of day as this medicine (e.g.
tetracyclines, quinolones).
• Barrier preparations in skin disorders:
Constituents include zinc oxide
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• Calamine: Contains zinc oxide and liquid
paraffin
• Dandruff management : Pyrithione zinc
• Prophelaxis in cold and influnza
• Hyperhidrosis managemnt: use of talc
and zinc oxide dusting powders to
adsorb excess sweat
• Management of haemorrhoids – topical
agents: Astringents (e.g. bismuth, zinc):
produce a protective coat
• Sun burns: zinc oxide,protection
39 against UVB and UVA
• SELENIUM
• Acts as an antioxidant, neutralizing
unstable molecules that can damage
cells. Helps regulate thyroid hormone
activity
• M: 55 mcg, W: 55 mcg
• Researchers are investigating whether
selenium may help reduce the risk of
developing cancer.
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• Dandruff: Selenium: not suitable for
children under 5 years of age. Avoid if
broken or inflamed skin since irritation
may occur. Apply twice weekly for 2
weeks, then once weekly for 2 weeks
and then as necessary.
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• References:
1. A Textbook of community pharmacy: new age
international publishers, rakesh saini, 2012.
2. Lecture Notes in Pharmacy Practice, Lilian M
Azzopardi, 2010.
3. Food and Vitamins and Supplements! Oh My!
Demystifying nutrition: the value of food,
vitamins and supplements, Harvard Medical
School, 2013
4. Listing of vitamins, Harvard medical school,
2009.
5. National institute of health, office of dietary
42 supplements, fact sheet ,USA