Download Community pharmacy Topic: 2 part(1) Vitamins supplements

Community pharmacy
Topic: 2
part(1)
Vitamins supplements
1
Vitamins
• They are complex organic compounds
required by the body in very small
amounts. They are concerned with vital
metabolic function in the body, and
hence essential for maintenance of
health.
• Since vitamins can not be manufactured
in body, they have to be supplied
through
the
diet.
2
• Vitamins are classified into two major
groups:
1. Fat soluble vitamins: A, D,E,K
2. Water soluble vitamins: B complex and
C (ascorbic acid)…
3
Ref: 4Food and Vitamins and Supplements! Oh My! Demystifying nutrition: the value of
food, vitamins and supplements, Harvard Medical School, 2013
IU
mg
5
mcg
• Dietary supplement containing multiple vitamins
for children and adults
Recommended doses classification
1. Recommended Dietary Allowance (RDA):
• average daily level of intake sufficient to
meet the nutrient requirements of nearly
all (97%–98%) healthy individuals.
2. Adequate Intake (AI):
• established when evidence is insufficient
to develop an RDA and is set at a level
assumed to ensure nutritional adequacy.
7
3. Estimated Average Requirement
(EAR):
• average daily level of intake estimated
to meet the requirements of 50% of
healthy individuals. It is usually used to
assess the adequacy of nutrient
intakes in population groups but not
individuals.
4. Tolerable Upper Intake Level (UL):
• maximum daily intake unlikely to cause
adverse health effects.
8
• International unit (IU)
• Standard measure of the biological
activity (biological effect) of
manufactured medicinal drugs and
vitamins.
• For every substance to which this unit is
assigned, there is an internationally
accepted biological effect expected with a
dose of 1 IU.
•
-
Ex:
1 IU =
0.3 microgram (0.0003 milligram) of vitamin-A
50 micrograms (0.050 milligram) of vitamin-C
25 nanograms (0.000025 milligram) of vitamin-D.
Vitamin A
• VITAMIN A: Retinol, retinal, and retinoic
acid — two forms of vitamin A in the body
are:
- preformed vitamin A (retinol and its
esterified form, retinyl ester)
- Alpha,Beta carotene can easily be
converted to vitamin A as needed.
10
In pregnancy
Teratogenic in excessive amounts
Avoid multivitamins containing vitamin A
like fish liver oils
• Benefits:
1. Vision:
- Essential component of rhodopsin
( protein that
absorbs light in the retinal receptors)
- It supports the normal differentiation and
functioning of the conjunctival membranes
and cornea
- Foods rich in the carotenoids may protect
against cataracts
2. Skin: Keeps tissues and skin healthy.
3. Bone: Plays an important role in bone
11growth.
4. Cancer: Diets rich in the carotenoids
alpha carotene and lycopene seem to
lower lung cancer risk.
5. Antioxidants : Carotenoids.
6. Body system:
• supports cell growth and differentiation,
• playing a critical role in the normal
formation
• Maintenance of the heart, lungs, kidneys
• involved in immune function, reproduction
12
Recommended amount (daily RDA or
daily AI)
• Because the body converts all dietary
sources of vitamin A into retinol, 1 mcg
of physiologically available retinol is
equivalent to the following amounts
from dietary sources:
- 12 mcg of beta-carotene
- 24 mcg of alpha-carotene.
• Vitamin A is listed on food and
supplement labels in international units
13 (IUs).
• Converting from RAE to IU depend on vit
A type
• From dietary supplements, the body
converts 2 mcg of beta-carotene to 1 mcg
of retinol.
• 1 IU retinol = 0.3 mcg RAE
• Ex: the RDA of 900 mcg RAE for adolescent and adult men is
equivalent to 3,000 IU if the food or supplement source is
preformed vitamin A (retinol)
• Multivitamin supplements typically contain
2,500–10,000 IU vitamin A, often in the
form of both retinol and beta-carotene
14
Table 1: Recommended Dietary Allowances (RDAs)
for Vitamin A
Age
Male
Female
14–18 years
900 mcg RAE
700 mcg RAE
19–50 years
900 mcg RAE
700 mcg RAE
51+ years
900 mcg RAE
700 mcg RAE
•Deficiency signs :Loss of night vision (night
blindness)….xerophthalmia
•Risk groups:
Premature Infants
Infants and Young Children in Developing
Countries
Pregnant and Lactating Women in
Developing Countries
People with Cystic Fibrosis
16
• Health Risks from Excessive Vitamin A
• Chronic intake of excessive amount:
increased intracranial pressure, dizziness,
nausea, headaches, skin irritation, pain in
joints bones, liver damage, and even coma
• Congenital birth defects: Total intakes of
preformed vitamin A that exceed the UL
and some synthetic retinoids used as
topical therapies (such as isotretinoin)
• Risk of lung cancer and cardiovascular
disease in smokers
17
THIAMIN (vitamin B1)
• Benefits: Helps to convert food into
energy. Needed for healthy skin, hair,
muscles, and brain and helps the nervous
system, heart, digestive system and
nerve tissues damaged by alcoholism.
Table 1: Recommended Dietary Allowances (RDAs) for
Thiamin
Age
Male
Female Pregnancy
Lactation
14–18 years
1.2 mg
1.0 mg
1.4 mg
1.4 mg
19-50 years
1.2 mg
1.1 mg
1.4 mg
1.4 mg
51+ years
1.2 mg
1.1 mg
18
• Heating foods containing thiamin can
reduce their thiamin content. For example, bread
has 20%–30% less thiamin than its raw ingredients, and
pasteurization reduces thiamin content in milk by up to 20%
• Thiamin is available in many dietary
supplements. Multivitamin supplements
with thiamin typically provide about 1.5 mg
thiamin (100% of the DV) and sometimes
more
• The most commonly used forms of thiamin
in supplements are thiamin mononitrate
and thiamin hydrochloride
19
• Deficiency signs:
- Early stage: can cause weight loss and
anorexia, confusion, short-term memory
loss, muscle weakness; and cardiovascular
symptoms.
- Beriberi: rare condition which is
characterized mainly by peripheral
neuropathy, some have impaired sensory,
motor, and reflex functions. In rare cases,
beriberi causes congestive heart failure
that leads to edema in the lower limbs and,
occasionally,
death
20
• Wernicke-Korsakoff syndrome : 8–10
times more in alcoholic
• Groups at Risk of Thiamin Inadequacy:
•
•
•
•
•
People with alcohol dependence
Older adults
People with HIV/AIDS
People with diabetes
People who have undergone bariatric
surgery
21
RIBOFLAVIN(vitamin B2)
• Helps to convert food into energy.
Needed for healthy skin, hair, blood,
brain, proper metabolism of fat,
protein and carbohydrates, the eyes and
sensitive oral areas.
• M: 1.3 mg, W: 1.1 mg
• Deficiency signs: Itching of the lips,
eyes, throat, nose and mouth. Can also
show up as cracking in the lip corners.
22
• Safety: This vitamin is water soluble
and excess amounts are excreted in the
urine. No known toxicity
• During lactation there is increased
requirements for some vitamins and
minerals (folate, vitamin B2, B6, B12, C)
• Avoid use of megadose regimens.
23
NIACIN (vitamin B3, nicotinic acid)
• Helps convert food into energy.
Essential for healthy skin, blood cells,
brain, and nervous system
• M: 16 mg, W: 14 mg
• Niacin occurs naturally in food and can
also be made by your body from the
amino acid tryptophan, with the help of
B6.
24
PANTO-THENIC-ACID (vitamin B5)
• Helps to convert food into energy. Helps
to make lipids (fats), neurotransmitters,
steroid hormones, and hemoglobin
• M: 5 mg, W: 5 mg
• Deficiency: causes burning in feet and
other neurologic symptoms.
• Wide variety of nutritious foods,
including chicken, whole grains, broccoli,
mushrooms, avocados, tomato products
25
VITAMINB6(pyridoxine, pyridoxamine)
• Help in lowering homocysteine levels and
may reduce the risk of heart disease.
• Helps to convert tryptophan to niacin and
serotonin (a neurotransmitter that plays key roles in sleep,
appetite, and moods).
• Helps to make red blood cells, enzyme
reactions and protein metabolism
• 31–50: M: 1.3 mg, W: 1.3 mg
• 51+: M: 1.7 mg, W: 1.5 mg
26
• Prevents issues with nerves, skin problems,
increases proper absorption of
carbohydrates and protein
• Deficiency signs:
• Isolated vitamin B6 deficiency is uncommon;
inadequate vitamin B6 status is usually
associated with low concentrations of other
B-complex vitamins, such as B12 and folic
acid….Inflammation of the skin
• Vitamin B6 deficiency is associated with
microcytic anemia
27
• Dietary supplements:
• Vitamin B6 is available in multivitamins,
in supplements containing other B
complex vitamins, and as a stand-alone
supplement . The most common form in
supplements is pyridoxine (in the form
of pyridoxine hydrochloride
28
Groups at Risk of Vitamin B6
Inadequacy
• Individuals with Impaired Renal
Function
• Individuals with Autoimmune
Disorders(RA inflammation)
• People with Alcohol Dependence
• Safety: chronic use may cause issues
with the nervous system (administration of 1–6 g oral
pyridoxine per day for 12–40 months can cause severe and progressive sensory
29 neuropathy characterized by ataxia (loss of control of bodily movements)
Vitamin B12(cobalamin)
• Vitamin B12 is required for proper red
blood cell formation, neurological
function, and DNA synthesis.
• M: 2.4 mcg, W: 2.4 mcg
• Meat, fish, milk, cheese, eggs, fortified
cereals and liver, fortified soymilk
30
• Dietary supplements:
• In dietary supplements, vitamin B12 is usually
present as cyanocobalamin, body readily
converts to the active forms methylcobalamin
and 5-deoxyadenosylcobalamin
• Prescription medications:
- The form of cyanocobalamin and occasionally
hydroxocobalamin
- can be administered parenterally, usually by
intramuscular injection
- vitamin B12 deficiency caused by pernicious
anemia
31
Table 1: Recommended Dietary Allowances (RDAs) for
Vitamin B12
Age
Male
Female
4–8 years 1.2 mcg
1.2 mcg
9–13 years 1.8 mcg
1.8 mcg
14+ years
2.4 mcg
2.4 mcg
Pregnancy
Lactation
2.6 mcg
2.8 mcg
• Vitamin B12 deficiency: malabsorption,
pernicious anaemia – lack of gastric
intrinsic factor.
• Deficiency Signs: Anemia, fatigue,
memory issues, numbness and tingling.
32
Groups at Risk of Vitamin B12
Deficiency
• Older adults
• Individuals with pernicious anemia
• Individuals with gastrointestinal
disorders
• Individuals who have had
gastrointestinal surgery
• Vegetarians
• Pregnant and lactating women who
follow strict vegetarian diets and their
33 infants
• Dementia and cognitive function:
• A deficiency in vitamin B12 causes an
accumulation of homocysteine in the blood
and might decrease levels of substances
needed to metabolize neurotransmitters
• A positive associations between elevated
homocysteine levels and the incidence of
both Alzheimer's disease and dementia.
• Low vitamin B12 status has also been
positively associated with cognitive
decline.
34
• Energy and endurance
Due to its role in energy metabolism,
vitamin B12 is frequently promoted as an
energy enhancer and an athletic
performance and endurance. As The
anemia caused by vitamin B12 deficiency
associated with symptoms of fatigue and
weakness.
• However, vitamin B12 supplementation
appears to have no beneficial effect on
performance in the absence of a
nutritional deficit
35
• Metformin
Metformin, a hypoglycemic agent used
to treat diabetes, might reduce the
absorption of vitamin B12, possibly
through alterations in intestinal
mobility, increased bacterial
overgrowth, or alterations in the
calcium-dependent uptake by ileal cells
of the vitamin B12-intrinsic factor
complex
36
• Some people, particularly older adults,
are deficient in vitamin B12 because they
have trouble absorbing this vitamin
from food.
• Safety: This vitamin is water soluble
and not known to be toxic.
• Damaged By: Alcohol, estrogen, sunlight
and water.
37
BIOTIN (Vitamin H)
• Helps to convert food into energy and
synthesize glucose. Helps to make and
break down some fatty acids. Needed for
healthy bones and hair
• Strong's the hair and nails, keeping blood
sugar levels stable and helping metabolism
react to changes in the body.
• M: 30 mcg, W: 30 mcg
38
• body needs very little biotin. Some is
made by bacteria in the GI tract.
However, it’s not clear how much of this
the body absorbs.
• It’s a Key role in metabolizing fats,
carbohydrates, and proteins
• Deficiency: Not common; symptoms
include baldness, a rash around the mouth
and nose, dry and flaky skin, Fatigue, loss
of hair, muscle weakness and pain, poor
appetite, & depression and nausea.
39
• Biotin can used in high doses. For
example, in the treatment of seborrheic
dermatitis in infants, no adverse
effects are reported.
40
Vitamin C (ascorbic acid)
• Foods rich in vitamin C may lower the
risk for some cancers, including those
of the mouth, esophagus, stomach, and
breast.
• Long-term use of supplemental vitamin C
may protect against cataracts.
• Helps to make collagen (a connective tissue that
knits together wounds and supports blood vessel walls)
• Vitamin C supplementation (citrus fruit)
improves absorption of iron.
41
• Helps to make the neurotransmitters
serotonin and norepinephrine Acts as an
antioxidant, neutralizing unstable
molecules that can damage cells.
• Wound healing, protection from viral and
bacterial infections, immune system
support, prevention of scurvy, cell
lifespan and lowering cholesterol.
• Total body content of vitamin C ranges
from 300 mg (at near scurvy) to about 2 g
42
Table 1: Recommended Dietary Allowances (RDAs) for
Vitamin C
Age
Male
Female
Pregnancy Lactation
9–13 years
45 mg
45 mg
14–18 years
75 mg
65 mg
80 mg
115 mg
19+ years
90 mg
75 mg
85 mg
120 mg
Smokers
Individuals who smoke require 35 mg/day
more vitamin C than nonsmokers.
Safety: Over 2000 mg daily can cause
nausea and diarrhea. There is a chance that
1000 to 5000 mg daily can have damaging
effects on DNA
43
• For cold and influenza: Vitamin C is an
antioxidant that neutralises the
oxidising compounds released by
neutrophils during a viral infection.
Doses of 1–4 g/ day decrease duration
and severity of cold symptoms by 10–
30%.
• At high doses it interferes with
diabetes urine tests and increases risk
of production of urinary oxalate leading
to
renal
stones.
44
• Deficiency: Acute vitamin C deficiency
leads to scurvy. Poor wound healing,
fatigue and gum bleeding
• Damage by: Heat, smoking, boiling
foods, and light.
• Risk groups: Smokers and passive,
Infants fed evaporated or boiled milk,
Individuals with limited food variety or
with malabsorption and certain chronic
diseases
45
VITAMIN D(calciferol)
• Vitamin D promotes calcium absorption
in the gut and maintains adequate serum
calcium and phosphate concentrations to
enable normal mineralization of bone
and to prevent hypocalcemic tetany
Serum [25(OH)D] Concentrations and Health*
nmol/L** Health status
<30
Associated with vitamin D deficiency, leading to
rickets in infants and children and osteomalacia in
adults
30–50
≥50
Generally considered adequate for bone and overall
health in healthy individuals
>125
Emerging evidence links potential adverse effects to
such high levels, particularly >150 nmol/L (>60
ng/mL)
46
47
• Safety: Vitamin D is stored in the
body’s fat cells and can accumulate. Too
much vitamin D can cause toxicity, but
the overdose amounts are different for
everyone. For example, children should
not take more than 400 iu daily.
• cod liver oil, 1 tablespoon (1,360 IU)
• salmon, cooked, 3 ounces (447 IU)
• vitamin D-fortified orange juice, 1 cup
(137 IU)
48
•
•
•
•
•
Calcitriol (hydroxylated derivative of
vitamin D)
Stimulates active transport of calcium
Acts on bone mineralisation
Side-effect: occurrence of
hypercalcaemia
• Monitor plasma calcium concentration
and creatinine levels.
49
Recommended Dietary Allowances (RDAs) for Vitamin D
Age
Male
14–18
years 600 IU
(15 mcg)
19–50
years 600 IU
(15 mcg)
51–70
years 600 IU
(15 mcg)
>70
years 800 IU
(20 mcg)
Female
Pregnancy
600 IU
(15 mcg)
600 IU
(15 mcg)
600 IU
(15 mcg)
800 IU
(20 mcg)
600 IU
(15 mcg)
600 IU
(15 mcg)
Lactation
600 IU
(15 mcg)
600 IU
(15 mcg)
In supplements and fortified foods, vitamin D is available in two
forms, D2 (ergocalciferol) and D3(cholecalciferol)
50
Groups at Risk of Vitamin D
Inadequacy
•
•
•
•
•
Breastfed infants
Older adults
People with limited sun exposure
People with dark skin
People with inflammatory bowel disease
and other conditions causing fat
malabsorption
• People who are obese or who have
undergone gastric bypass surgery
51
VITAMIN E (alpha-tocopherol)
• Acts as an antioxidant, neutralizing
unstable molecules that can damage
cells. Protects vitamin A and certain
lipids from damage. Diets rich in vitamin
E may help prevent Alzheimer’s disease.
Supplements may protect against
prostate cancer
• M: 15 mg, W: 15 mg (15 mg equals about
22IU from natural sources of vitamin E
52 and 33 IU from synthetic vitamin E)
• Deficiency: Fertility issues and muscle
weakness.
• Safety: Amounts in excess of 400 iu
daily can increase the risk of death
from long term illness and heart failure.
Known drug interaction with Coumadin
to increase the risk of bleeding issues
53
VITAMIN K(phylloquinone)
• Activates proteins and calcium essential
to blood clotting, May help prevent hip
fractures
• M: 120 mcg, W: 90 mcg
• Intestinal bacteria make a form of
vitamin K that accounts for half of
requirements
• Assists with blood clotting after injury,
wound healing, protects bones from
osteoporosis and may protect against
54 cancer.
• Deficiency: Bleeding gums, easy bruising,
anemia, nose bleeds and increase
menstrual bleeding in females.
• It is only considered clinically relevant
when prothrombin time increases
significantly.
• Significant vitamin K deficiency in adults
limited to a malabsorption disorders or
those taking drugs that interfere with
vitamin K metabolism
55
• Groups at Risk of Vitamin K Inadequacy
• Newborns not treated with vitamin K at
birth
• People with malabsorption disorders
• Osteoporosis:
• Vitamin K is a cofactor …. gammacarboxylation of many proteins
(osteocalcin ) ….. undercarboxylated
osteocalcin are associated with lower
bone mineral density
FOLIC ACID
• The total body content of folate is
estimated to be 10 to 30 mg; about half
of this amount is stored in the liver
• Vital for new cell creation
• Helps prevent brain and spine birth
defects when taken early in pregnancy;
should be taken regularly by all women
of child-bearing age since women may
not know they are pregnant in the first
weeks of pregnancy.
57
• Can lower levels of homocysteine and may
reduce heart disease risk
• May reduce risk for colon cancer.
Table 1: Recommended
Folate
Age
Male
9–13 years 300 mcg
DFE
14–18 years 400 mcg
DFE
19+ years
400 mcg
DFE
Dietary Allowances (RDAs) for
Female
Pregnant
Lactating
400 mcg
DFE
600 mcg
DFE
500 mcg
DFE
400 mcg
DFE
600 mcg
DFE
500 mcg
DFE
300 mcg
DFE
1 mcg DFE = 1 mcg food folate,
dietary folate equivalents (DFEs)
• Many people don’t get enough of this
nutrient. Occasionally, folic acid masks a
B12deficiency, which can lead to severe
neurological complications. That’s not a
reason to avoid folic acid; just be sure
to get enough B12.
• association with poor diet, alcoholism,
and, sometimes, malabsorptive disorders
59
• When taken within the first three
months of pregnancy can assist with
cleft lip, cleft palate and spinal bifida
prevention, helps to build healthy red
blood cells.
• Women who are planning to become
pregnant or who are in the first 3
months of pregnancy need to take 400
mcg daily. All others should take 200
mcg daily.
60
• Deficiency signs: Anemia, red tongue
and fatigue from anemia.
• Folate deficiency can also produce
soreness and shallow ulcerations in the
tongue and oral mucosa; changes in skin,
hair, or fingernail pigmentation.
• Risk groups: People with alcohol
dependence, Women of childbearing age
, Pregnant women, People with
61 malabsorptive disorders
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
supplements, fact sheet ,USA