The pharmacists role in drug induced nutrient depletion n. jones

1. Drug Induced Nutrient
Depletion: The Pharmacist’s
Responsibility
By Nat Jones, R.Ph. FIACP

2. Learning Objectives
• Describe the role and effect on metabolic
pathways of selected medications
• Choose appropriate nutritional
supplementation to offset drug-induced
nutrient depletion
• Design a plan to develop a profitable
nutritional niche by preventing drug
induced nutrient depletion

3. Let food be thy medicine
and medicine be thy food.
– attributed to Hippocrates

4. Nutrients
• Are food substances that provides
energy or are necessary for growth
and repair
• Substances added to foods that
increases their vitamin, mineral
and/or protein content

5. Dietary Supplements
• Are intended to provide nutrients that
may otherwise not be consumed in
sufficient quantities
• Replace nutrients that may be
depleted by medication
• Taking micronutrient supplements
won’t make up for an unhealthy diet

6. Nutrient Depletion
• Some medications can affect the levels
of certain nutrients in the body, either
by interaction and/or by altering
absorption. There is considerable
interest in using nutritional
supplements to counteract these
possible drug-induced "nutrient
depletions."

7. To Make Matters Worse…
• Physicians often tell their patients that
symptoms arising from nutrient depletion
are simply “part of the illness” or just signs
that they’re “getting older.” To make
matters worse, physicians frequently try to
address the symptoms arising from drug-
induced nutrient depletion by prescribing
even more drugs, further compounding
the problem.

8. What Do We Know? (30,000 Ft. View)
• Pharmacists play a critical role in a
dysfunctional healthcare system
• Pharmacists, by training, have the
ability to objectively evaluate
healthcare options

9. What Do We Know? (30,000 Ft. View)
• Pharmacists are one of the most
accessible health professionals available
to the public and are considered the
most credible
• Pharmacists can implement drug
nutrient depletion programs and make
an impact on not only the health of their
patients but on their business as well

10. What Do We As Pharmacists Know?
(Clinically)
• Pharmacology
• Biochemistry
• Physiology
• Chemistry
• A whole lot more than the clerk at vitamin
store!
• The public prefers to obtain their
nutritional supplements and education
from a pharmacist

11. What Do We As Pharmacists
Know? (Business Side)
• Nutritional supplements are big business
• According to the Canadian Health Food
Association (CHFA), the Canadian natural health
industry is valued at more than $3-billion, and
employs more than 25,000 people
• According to data from Environics Analytics,
about 20 per cent of the Canadian population
took a multivitamin daily in 2012
thestar.com Jan. 11, 2013

12. Supplements… The Business Side
• A majority of Canadians utilize nutritional
supplements
• 70% of Canadians use natural health
products on a daily basis – either vitamins,
supplements or herbal remedies (includes
sports nutritional products but not sports
drinks and foods bars)
thestar.com Jan. 11, 2013

13. Supplements… Business Trends
• Vitamins and dietary supplements increased
by 4% in current value terms in 2015, which
was slightly slower than the growth seen in
2014. New product developments, new
ingredients, health and wellness, the ageing
population and self-care were the main
factors contributing to the growth of the
category.
Vitamins and Dietary Supplements in Canada
Dec 2015 | Pages: 42

14. Supplements… The Safety Side
• If the product in question has a Natural Product
Number (NPN) or Homeopathic Medicine
Number (DIN-HM) on its label, it has been
assessed for quality, safety and efficacy by Health
Canada
• Many product available in the US are not
available here because manufacturers must get a
product license from Health Canada to sell their
products in Canada

15. How Much Do We Need?
Recommended Daily Allowance (RDA)
vs.
Optimal Daily Intake (ODI)

16. Recommended Daily Allowance (RDA)
• Developed in the 1930’s to prevent
vitamin deficiency diseases
• Based on the minimal amount of
vitamins needed per day
• Does not take into consideration
contemporary nutritional challenges

17. Optimal Daily Intake (ODI)
• Takes into consideration individual
health issues and challenges
• Recognizes the need for quality
product and vitamin targeting
• Dosed at therapeutic, not minimal,
levels

18. Diet
Contemporary Nutritional Challenges
• 87% of Canadians agree that they are “trying
to eat healthfully but still want to do better”
• 61% say they’d “like to eat healthier but they
don’t want to give up eating their favourite
foods”
• 88% of the residents of Saskatchewan say they
would rather make a lifestyle change than a
quick-fix diet
IPSOS Poll, January 26, 2005, Canadians On Healthy Eating

19. Contemporary Nutritional Challenges
• 29% strongly agree that they “know it’s
important to make healthy food choices, but I
find it difficult to do so”
• Perceived cost is a deterrent to many
especially in low income families
• People find food claims and labeling confusing
• Number one perception of how to select food
products is to choose products with less fat
content, not less sugar
IPSOS Poll, January 26, 2005, Canadians On Healthy Eating

20. Obesity
• The prevalence of obesity in Canada was
24.1% (2009)
• Body mass index (BMI): kg/m²
– Obesity class I: BMI of 30.0 to 34.9 kg/m²
– Obesity class II: BMI of 35.0 to 39.9 kg/m²
– Obesity class III: BMI of 40.0 kg/m² or higher
Canadian Health Measures Survey (CHMS) 2007 - 2009

21. Overweight/Obese
• Body mass index, overweight or obese,
self-reported, adult (18+ years)
–54 % total
–61.8 % of males
–42.2 % of females
Statistics Canada Reported for 2014

22. Contemporary Nutritional Challenges
• Contemporary diet does little to support
optimal health
• The nutritional value of even healthy food gets
poorer every year
• Many drugs/chemicals deplete vitamin levels
in the body
• Most metabolic diseases prevalent today can
be impacted by nutritional and/or vitamin
supplementation

23. Integration
• So how do we integrate the clinically
trained pharmacist with all of the
patients requiring quality nutritional
products and information?
• EDUCATION

24. Education
• Education for:
–Yourself
–Your staff
–Prescribers
–Your customers
–Your world

25. Who are Our Patients and Customers?
• Anyone taking pharmaceutical agents (drug
induced nutrient depletion)
• Diabetics, the obese, bariatric surgery
patients and anyone attempting to lose
weight
• Athletes and those who participate in intense
exercise
• Cancer patients, hospice patients, wound care
patients and those with poor nutritional
status

26. Time Out!!!!!!
• As a pharmacist, why should I be
concerned about nutrient depletions?
– Nutrients are critical to normal body function
– Nutrient depletions can be multifactorial
– The onset of nutrient related symptoms and
problems is usually insidious
– The conventional therapy for symptoms
secondary to drug-induced nutrient depletion
is to prescribe another drug!!

27. Responsibilities
• Many ethical situations arise in the
pharmacist’s daily practice, and some of
these involve… products as well as nutrition
choices
• Pharmacists have duties with respect to
health, nutrition and fitness due to
normative ethical principles they must
adhere to according to the code of ethics that
guides their behavior The Pharmacist’s Role in Health,
Exercise, and Nutrition, Daniel Kusk
December 8, 2008

28. Responsibilities
• Addressing the nutritional needs of
the patients that we see is a
pharmacist’s responsibility
• Repleting nutrient loss brought about
by drug induced depletion or
blocking absorption of nutrients is
the pharmacist’s responsibility

29. What Do We Hear in the Media?
• We need to lower our cholesterol
• We need to eliminate our stomach acid
• Drugs presented are safe and effective
• Manufacturers research is unbiased and
always accurate

30. What Do We Not Hear in The Media?
• Cholesterol is essential for our good
health
• Stomach acid is essential for digestion
• Not everyone should be taking these
products, even if they are “safe”
• Drug manufacturers falsify results

31. The Overlooked Problem With the
Administration of Prescription Medications
• Prescription medications have a long
list of adverse effects which, when
taken over time and in consort with
other medications a patient may be
taking, will create greater problems
than what the medications are being
used to treat

32. How Do We Work?
Krebs
Cycle

33. How Do Medications Work?
• Medications work by inserting
themselves chemically into various
metabolic pathways
• In doing so, they can affect nutrient
absorption, synthesis, transport,
storage, metabolism, and excretion

34. Let’s Look at the Role of Cholesterol in
the Body
• Cholesterol is the precursor for the
production of all adrenal (stress) hormones
• Adrenal stress with suboptimal hormone
production creates increased cholesterol
levels
• Cholesterol is the precursor for the
production of the sex hormones, estrogen,
progesterone, and testosterone

36. Let’s Look at the Role of Cholesterol in
the Body
• Cholesterol is a precursor for Vitamin D
production
• Cholesterol is necessary for fat and
mineral absorption
• Cholesterol is necessary for the myelin
sheath that covers the nerves
• Cholesterol is necessary for cognitive
function

37. How Do Cholesterol Lowering Drugs
“Statins” Work?
• Competitive inhibitor of hydroxymethylglutaryl
Coenzyme A (HMG-CoA) reductase, which is
the rate-limiting hepatic enzyme responsible
for converting HMG-CoA to mevalonate, a
precursor of sterols including cholesterol
• By interfering with this enzyme, cholesterol
and other essential substances such as
coenzyme Q-10 are reduced
Lovastatin with CoQ10 patented by Merck in 1987

38. Questions…
Statin Deficiency?
Is cholesterol a bad thing?

39. The Role of Coenzyme Q-10
(mitochondrial catalyst)
• Coenzyme Q-10 is an
essential component of the
electron transport chain in
the mitochondria
• Multiple categories of drugs
deplete Coenzyme Q-10

41. NADH NADᶧ
I II III IV
Hᶧ
CoQ10
CoQ10 is an electron transporter
required for oxidative phosphorylation
Inner Membrane
O₂ H₂O
UCP2

42. The Role of Coenzyme Q-10
(mitochondrial catalyst)
• CoQ10 transports
electrons from
complexes I and II to
complex III in the
mitochondrial
respiratory chain and
is essential for the
stability of complex III

43. The Role of Coenzyme Q-10
(mitochondrial catalyst)
• Mitochondrial deficiencies
have been correlated to
obesity and Type II diabetes
• Coenzyme Q-10 has been
shown to be a safe and
effective treatment for a
broad range of
cardiovascular diseases

44. The Role of Coenzyme Q-10 (mitochondrial
catalyst)
• CoQ10 levels correlate with ROS production
• Optimal levels are not associated with
significant ROS production
• Deficient levels are accompanied by increased
ROS production and cell death
• The reduced form of CoQ10, ubiquinol, is one
of the most potent lipophilic antioxidants in
all cell membranes

45. Do Statins Lower Cholesterol Levels?
• Yes, but what else do we see?
– Muscle pain and weakness
– Body aches and pains
– Heart failure
– Brain fog and dementia
– Depression
• Could these side effects be due to a
lack of CoQ10?

46. Reality Check:
• Do you see patients on statins in your
practice?
• Do you think patients are being
counseled on Coenzyme Q-10
depletion at other pharmacies in your
marketplace?

47. Pharmacist Consultation:
• “I need to take my statin drug. Can these
problems be prevented?”
• Coenzyme Q-10 100mg daily for every
CQ-10 lowering drug taken
• Ubiquinol 100mg daily for every CQ-10
lowering drug taken
• Dose range: 100-400mg/day

48. Pharmacist Consultation:
• Are there any other alternatives for
cholesterol lowering other than statin
drugs?
– Diet and exercise
– Fish Oil (High quality fish oil product 2000-
2400mg daily)
– Niacin (1500-3000mg daily)
– Red Yeast Rice (600mg daily)
– Berberine (500mg twice daily)

49. Let’s Look at the Role of Stomach Acid
in Digestion
• Stomach acid enables dietary
enzymes (pepsin) to be activated
• Stomach acid breaks down dietary
protein
• Enhances the availability and
absorption of B-Vitamins

50. Let’s Look at the Role of Stomach Acid
in Digestion
• Helps reduce trivalent ferric iron to ferrous
iron
• Protects the body from food borne
infections
• Numerous minerals that appear to be
hydrochloric acid-dependent: magnesium,
chromium, copper, iron, manganese,
magnesium, molybdenum, selenium & zinc

51. How Do Acid Reducing Drugs Work?
• (H2 Receptor Antagonists, Proton Pump
Inhibitors)
– By blocking an enzyme in the gastric parietal cell,
the proton pump that secretes stomach acid
cannot secrete acid into the stomach. Without
acid production, the pH of the stomach will rise
abnormally.

52. What Problems Do We See With
Reduced Stomach Acid?
• Increased incidence of gastric cancer
and colon cancer
• Vitamin B-12 deficiency
• Vitamin and mineral deficiencies
• Greater incidence of allergic reactions
due to the presence of intact protein in
the lower G.I.

53. What Problems Do We See With
Reduced Stomach Acid?
• Bacterial overgrowth due to gastric pH
change (Increases in H. Pylori and C.
Difficile infections)
• Increases in yeast and candida
• Increase in bone loss due to impaired
Calcium and Vitamin D absorption

54. Nutrient Depletions Caused By
Decreased Stomach Acid
• Vitamin B-12 and the B-Vitamins
• Folic Acid
• Vitamin D
• Iron
• Zinc
• Copper
• Calcium
• Protein

55. Reality Check:
• Do you see patients in your practice
that are using H2 Receptor Antagonists
and PPIs?
• Do you think patients are being
counseled on nutrient depletions
secondary to decreased stomach acid
at other pharmacies in your
marketplace?

56. Pharmacist Consultation
• “Are there any other ways to address
gastric acid problems besides reducing
the gastric acid?”
– Lifestyle and diet modification
– Betaine HCI
– Digestive enzymes
– Glutamine
– Probiotics

57. Let’s Look at Gut Bacteria
(Microbiome)
• What does gut bacteria do?
• Manufactures Vitamin K and B-Vitamins
• Produces enzymes that aid in digestion
• Produces SCFAs that provide 5-10% of
our daily energy supply
• Responsible for 70% of our immune
process

58. What Do Antibiotics Do?
• They eliminate both pathogenic and good gut
bacteria resulting in an imbalance in the
normal gut flora
• The fecal microbiome was severely affected by
most antibiotics: for months (up to 12),
health-associated butyrate-producing species
became strongly underrepresented
MBio. 2015 Nov 10;6(6):e01693-15. doi: 10.1128/mBio.01693-15.
Same Exposure but Two Radically Different Responses to Antibiotics: Resilience
of the Salivary Microbiome versus Long-Term Microbial Shifts in Feces.
Zaura E1, et al.

59. Butyrate In The Intestines
• Plays a regulatory role on the
transepithelial fluid transport,
ameliorates mucosal inflammation and
oxidative status, reinforces the epithelial
defense barrier, and modulates visceral
sensitivity and intestinal motility
World J Gastroenterol. 2011 Mar 28; 17(12): 1519–1528.
Potential beneficial effects of butyrate in intestinal and extraintestinal diseases
Canani RB, et al.

60. Butyrate In The Intestines
• Has a role in the prevention and
inhibition of colorectal cancer
• Exerts potentially useful effects on
hemoglobinopathies, genetic metabolic
diseases, hypercholesterolemia, insulin
resistance, and ischemic stroke
World J Gastroenterol. 2011 Mar 28; 17(12): 1519–1528.
Potential beneficial effects of butyrate in intestinal and extraintestinal diseases
Canani RB, et al.

61. What Do Antibiotics Do?
• Because of their effect on gut flora,
antibiotics can create major nutrient
depletions in:
–Folic acid
–Inositol
–B-1, B-2, B-3, B-12
–Vitamin K

62. Ciprofloxacin May Deplete
• Biotin
• Inositol
• Thiamin
• Riboflavin
• Niacin
• Vitamin B6
• Vitamin B12
• Vitamin K
• Zinc

63. Pharmacist Consultation:
• “Are there ways to protect our good gut
bacteria from depletion by antibiotics?”
• Recommenmations
–Probiotics (repletion of the essential
bacteria flora)
–FOS
–Saccharomyces boulardi

64. Nutrient Depletions With Female
Hormone Products (HRT, BHRT)
• Folic acid
• Vitamin B-6
• Coenzyme Q-10
• Magnesium

65. OC Use
JULY JOGC JUILLET 2009
Contraceptive Use Among Canadian Women of
Reproductive Age: Results of a National Survey
Black, A, et al.

66. Nutrient Depletions With Female
Hormone Products (Oral Contraceptives)
• Folic acid
• B-6, B-1, B-2, B-3, B-12
• Vitamin C, Vitamin E, Magnesium,
Selenium, Zinc
• DHEA, Coenzyme Q-10, Tyrosine

67. Folic Acid Depletion with Oral
Contraceptives
• Anemia, weakness, low energy
• Birth defects
• Cervical dysplasia
• Elevated homocysteine
• Depression
• Increased incidence of breast and
colorectal cancer

68. Vitamin B-6 Depletion with Oral
Contraceptive Usage
• Reduced synthesis of serotonin and
melatonin; elevated homocysteine
• Symptoms: depression, anxiety, decreased
libido, impaired glucose tolerance
• Therapy: 40 mg B-6/day restores
biochemical values and relieves clinical
symptoms
* Bermond P. Arch Vitaminol Enzymatica 1982; 4(1-2):45-54

69. Oral Contraceptives: Effect of Folate
and Vitamin B-12 Metabolism
• Women using OC have significantly lower
serum and erythrocyte folic acid
• Serum B-12 also significantly lower
• “Clinicians are advised to ensure that
women who stop taking “the pill” have
adequate folate before becoming
pregnant”
* Shojania, AM Can Med Assoc 1982; Feb 126(3): 244-47

70. Oral Contraceptives: Folic Acid and
Cervical Tissue
• Changes were observed in cervical epithelium
in 101 women who had used OCs for over 6
months
• Significant difference in cervical megaloblastic
changes vs. controls
• 29 out of the study were treated with folate-
cervical changes disappeared in 26 of the
treated women
* Li. X, et.al Megablastic changes in the cervical epithelium associated with
oral contraceptives and changes after treatment with folic acid

71. Reality Check
• Do you see patients/ customers taking
HRT, BHRT or oral contraceptives?
• Do you think these women would
benefit from taking folic acid or L-
methylfolate, Vitamin B complex with B-
12 and B-6? How about Vitamin C,
Vitamin E, Magnesium, Selenium, Zinc?

72. Magnesium Deficiency
• Let’s dig a little deeper
–Magnesium deficiency is common in the
West (58-70%)
–Magnesium is a major co-factor in over
325 metabolic pathways
–Magnesium levels are difficult to
measure
–Magnesium is one of the easiest and
safest minerals to replete

73. Comparison of Side Effects: Thiazide
Diuretics and Mg Depletion
Magnesium Depletion
• Muscle cramps and spasms
• Migraines
• Anxiety, nervousness,
insomnia, Depression
• Low energy/fatigue
• Arrhythmia, heart palpations
• Constipation
• Blood sugar disturbances
• Kidney stones
Thiazide Diuretic Side Effects
• Muscle pain, weakness or
cramps
• Headache
• Mood changes
• Unusual tiredness or weakness
• Irregular heartbeat
• Constipation
• Glucose intolerance
• Low back pain
* Source: Facts & Comparisons

74. Magnesium
• In community-dwelling participants free of
cardiovascular disease, self-reported
magnesium intake was inversely associated
with arterial calcification, which may play a
contributing role in magnesium's protective
associations in stroke and fatal coronary
heart disease.
* JACC Cardiovasc Imaging. 2014 Jan;7(1):59-69. Magnesium intake is
inversely associated with coronary artery calcification: the Framingham
Heart Study. Hruby A1, O'Donnell CJ2, Jacques PF1, Meigs JB3, Hoffmann
U4, McKeown NM5

75. Magnesium
• Circulating and dietary magnesium are
inversely associated with CVD risk, which
supports the need for clinical trials to
evaluate the potential role of magnesium
in the prevention of CVD and IHD
* Am J Clin Nutr. 2013 Jul;98(1):160-73. doi: 10.3945/ajcn.112.053132. Epub
2013 May 29. Circulating and dietary magnesium and risk of
cardiovascular disease: a systematic review and meta-analysis of
prospective studies. Del Gobbo LC1, Imamura F, Wu JH, de Oliveira Otto
MC, Chiuve SE, Mozaffarian D.,

76. Magnesium and Type 2
Diabetes Risk
• 4637 Americans 18-30 free of Metabolic Syndrome
and Diabetes
• 15 year follow up 608 cases of Metabolic Syndrome
• Studies suggest magnesium intake may be inversely
related to risk of hypertension and type 2 diabetes
mellitus
• Higher intake of magnesium may decrease blood
triglycerides and increase high-density lipoprotein
(HDL) cholesterol levels.
* Circulation Epidemiology: Magnesium intake and incidence of Metabolic Syndrome
among young adults 2008; 113: 1875-1882 Published online

77. Magnesium and Risk of
Heart Disease
• 58,615 Japanese healthy men ages 40-79
• Study: 14.7 years
• Increased magnesium intake in diet
reduced CVD mortality risk by 50%
* Zhang W et al Associations of dietary magnesium intake with mortality
from cardiovascular disease: The JACC study Atherosclerosis, Vol 221,
Issue 2, April 2012 pg 587-595

78. Magnesium
• Estimated Average Requirement (EAR)
is the median daily intake value that is
estimated to meet the requirement of
half the healthy individuals in a life-
stage and gender group. At this level
of intake, the other half of the
individuals in the specified group
would not have their needs met.

79. Magnesium
• The prevalence of inadequate intake
of magnesium:
–More than 34% of Canadians over the
age of 19 consumed magnesium in
quantities below the EAR, with the
prevalence of inadequate intakes rising
to greater than 40% in half the adult age
and sex groups
2012

80. Magnesium
• Essential mineral in the body. Cofactor in
over 300 enzyme reactions.
• Low magnesium affects glucose tolerance
and energy production (ATP)
• Magnesium acts as a calcium channel
blocker helping to control blood pressure

81. Supplemental Sources of
Magnesium
• Magnesium amino acid chelate
• Magnesium glycinate
• Magnesium taurate
• Magnesium maleate
• Magnesium theonate
• Just not Magnesium oxide!

82. Depletions by Drug Category

83. Anti-Diabetic Drugs
• Sulfonylureas: Deplete Coenzyme Q-10
• Biguanides (Metformin): Deplete
Coenzyme Q-10 B-12, Folic Acid Insulin:
Depletes magnesium, by decreased
absorption and osmotic diuresis may
also contribute to low magnesium levels
in diabetic patients
Magnes Res. 2004 Jun;17(2):109-14.
Long term magnesium supplementation influences favourably the natural evolution
of neuropathy in Mg-depleted type 1 diabetic patients (T1dm). De Leeuw I, et al.

84. Malabsorption of Vitamin B-12 and Intrinsic
Factor Secretion During Biguanide Therapy
• 46 diabetic patients: 30% had malabsorption of
vitamin B-12
• Withdrawal normalized absorption in only half
of those with malabsorption
• Biguanides can induce malabsorption by 2
different mechanisms: one is temporary and
unrelated to intrinsic factor; other causes
permanent decrease in intrinsic factor
secretion.
* Adams JF, et al Diabetologia 1983 Jan; 24(1): 16-18

85. Anticonvulsants
• Barbiturates: Vitamin D, K Folic Acid,
Biotin, Calcium
• Phenytoin: Vitamin D, K, Folic Acid, B-
12, B-1, Biotin, Calcium
• Carbamazepine: Vitamin D, Folic Acid,
Biotin

86. Anticonvulsants
• Primidone: Vitamin D, K, Folic Acid,
Biotin, Calcium
• Valproic acid: Folic acid, Carnitine,
Copper, Selenium, Zinc
• Levetiracetam: B6, B12, D, K, folic acid,
calcium and magnesium

87. Anti-Anxiety Agents
• Benzodiazepines (Diazepam, Alprazolam)
can cause depletion of:
–Biotin, folic acid, and vitamins D and K,
calcium and melatonin
• Melatonin deficiency is associated with
insomnia, fogginess, lack of REM sleep,
increase cancer risk and increase free
radical damage

88. NSAID’s
• Diclofenac, etodolac, fenoprofen,
flurbiprofen ibuprofen, ketoprofen,
ketorolac, meclofenamate, mefenamic
acid, meloxicam, nabumetone, and
naproxen can deplete:
–Iron and folic acid
• Celebrex depletes potassium and sodium

89. Antihypertensives
• Clonidine depletes CoQ10
• Lisinopril and captopril deplete zinc
• Beta-blockers deplete CoQ10
• Thiazides decrease magnesium and zinc
• Loop diuretics deplete potassium,
magnesium, calcium, zinc, pyridoxine,
thiamine and ascorbic acid

90. Osteoporosis Medications
• Bisphosphonates (alendronate,
risedronate) and Selective estrogen
receptor modulators (SERMs)
(tamoxifen and raloxifen) can deplete:
–Boron, Calcium, Magnesium, vitamin D,
and vitamin K

91. Thyroid Replacement
• Levothyroxine, Liothyronine sodium,
Desiccated Thyroid
–Can deplete calcium if dosage is too high

92. Nutrient Depletions Caused
By Aspirin
• Vitamin C: drug most likely to
deplete in normal individuals
• Iron: due to blood loss in GI tract
• Folic Acid: displaces bound serum
folate
• Potassium: increased urinary loss

93. Nutrient Depletions Caused by
Chemotherapy
• Chemotherapy drugs universally deplete most
nutrients by the mechanism of action of the drug
and the physiologic effect on the patient.
• Damage to gastric and G.I. mucosa with resulting
malabsorption
– Inflamed G.I. tract
– Decreased appetite
– Nausea and vomiting
– Dysbiosis (depletion of good bacteria in the gut flora)

94. Nutrient Depletions Caused by
Chemotherapy
• Grade IV mucositis make the unable to
consume foods and liquids
• 42% of cancer patients die from
malnutrition
• Supporting the nutritional needs of the
patient does not mean you are supporting
the nutritional needs of the cancer!
Apothagram Aug. 2015, Nutritional Support for
Cancer Therapy Patients, Jones N

95. Nutritional Depletions
Encountered in Bariatric Surgery
and Other Weight Loss Programs

96. Bariatric Surgeries In Canada
• In 2012–2013, about 6,000 bariatric
surgeries were performed in Canadian
hospitals
• This represents an almost four-fold increase
over six years, due largely to increased
capacity for bariatric surgery in Ontario
• Current wait for procedure in Saskatchewan
is 2 to 3 years

97. Bariatric Surgeries In Canada
• From 2006–2007 the number of hospitals
performing bariatric procedures also
grew, from 34 to 46 nationwide
• An estimated 1,000 additional procedures
were performed in private clinics across
Canada in 2012

98. Bariatric Surgeries
• Currently, Canadian clinical practice
guidelines suggest bariatric surgery for
adults who have had previous unsuccessful
attempts at losing weight by lifestyle
modification and who have
– A BMI of 40 kg/m2 or higher (class III obesity); or
– A BMI of 35 kg/m2 or higher (class II obesity)
and obesity-related comorbidities

99. Bariatric Surgeries
• Are categorized by the surgical technique;
either a restrictive procedure or a
combination of restrictive and
malabsorption procedure
• Bariatric surgery is surgically induced
behavior modification which can result in
long term nutritional deficiencies

100. Pharmacists are Uniquely Qualified to
Be a Valuable Ally to Bariatric Patients
• Formulating medications into liquid or
transdermal forms
• Addressing endocrine changes
–Insulin, Estrogen, Thyroid
• Providing nutritional counseling, supplements,
and vitamins
–Quality, Solubility, Absorption

101. Nutritional Deficiencies Secondary
to Bariatric Surgery
• Calcium
–Type of salt used is critical
–Absorption can vary from 4-45%
–Use MCHC (Microcrystalline
hydroxyapatite) or calcium citrate

102. Nutritional Deficiencies Secondary
to Bariatric Surgery
• Iron
–Iron must be reduced from ferric (+++)
to ferrous (++) state for absorption
which requires stomach acid
–Use Vitamin C to increase gastric acidity
and increase iron absorption

103. Nutritional Deficiencies Secondary
to Bariatric Surgery
• Vitamin B-12
–B-12 absorption is dependent on the
presence of intrinsic factor from the
parietal cells in the stomach
–HCl is also necessary to cleave B-12
from protein in the stomach

104. Other Vitamin Absorption
Challenges with Bariatric Surgery
• Folate (L-Methylfolate)
• Fat soluble vitamins, A,D,E,K
• Magnesium
• Omega 3 Fatty Acids
• Vitamin B-6
• Multiple vitamin choices should be
capsules, chewables, or liquid

105. Nutritional Support for Diets Utilizing
Low Caloric Intake (<1000 calories/day)
• Chromium
• Vitamin B complex
• Vitamin B-12
• Vitamin C with Bioflavonoids
• Nutritional detoxification support protocols

106. • Given the obvious importance of nutritional
supplements, why aren’t nutritional
supplements more widely utilized in disease
state management?
• Lack of double blind placebo controlled studies
• The inadequacy of double blind placebo
controlled studies
• Issues of quality in formulation and salt choice
• Lack of standardization in the industry
• Failure to recognize the need for therapeutic
dosing and synergistic approach

107. Six Products to Improve the
Nutritional Foundation of Anyone

108. Multiple Vitamin with Minerals
• Should be easily absorbed form, capsules,
powders, or quick dissolve tablets
• Take at least twice a day
• Every nutrient should not be attached to
“HCl” salt
• Quality multiple vitamin product provides
solid nutritional foundation

109. Omega 3 Fish Oil or Flaxseed Oil
• Quality products list the EPA and DHA content
• Have a body-wide anti-inflammatory action
• Offset high level of saturated fats and trans fats
found in the Standard American Diet (SAD Diet)
• High quality fish oil should be molecularly distilled
to eliminate heavy metal toxicity
• Fish oil “burping” can be overcome by placing fish
oil in freezer
• Dose: 1200-2400 mg of a high quality product daily

110. Vitamin D3
• Vitamin D3 is actually a hormone
• Essential for the absorption and utilization
of calcium
• Most individuals are deficient, but 25-
hydroxy Vitamin D serum levels can be easily
measured, titrate dosage, re-check!
• Studies have demonstrated Vitamin D can be
cancer protective for multiple cancer forms
• Dose: 3000-5000 iu/daily

111. Magnesium
• Low magnesium leads to poor muscle
contractility, spasm, cramps, muscle pulls,
muscular fatigue, reduced stamina, poor
sleep
• Use appropriate salt form (Glycinate is
best!)
• Difficult to overdose (diarrhea)
• Dose: 500mg/day (elemental, titrate up!)

112. Vitamin B-Complex
• The B-vitamins are active co-factors in hundreds of
metabolic pathways
• B-vitamins are routinely depleted by drugs and chemicals
• B-vitamins are essential for neurological function and
energy
• Best taken as a complex with a minimum of 800-1000mcg
of folic acid
• Higher quality products utilize active metabolites of the B-
vitamins rather than HCl salts
• Water soluble and lost in the urine
• Dose: Take twice a day

113. CoQ-10
• Oil filled capsules are best
• Take with a fatty meal if possible
• Ubiquinol vs. Ubiquinone
– Either will do for most patients unless they have a
leaky gut or severely poor health, then ubiquinol
• Liposomal is absorbed best ($$$)
• Dose: 100mg daily if on a statin OR 100mg
daily if >50yr and additional 100mg if on a
statin, plus 100mg if on CV drugs

114. THE MOMENT OF TRUTH!!!!!
• When we get back to our pharmacies
–What are we going to do?
–When are we going to do it?
–Who is going to do it?

115. Can You Do This?
Yes!
Don’t feel guilty!
You’re doing a good thing!
You’re providing a much needed
service in a relative vacuum!

116. Two Plans for Profitability: Plan 1
• Survey current prescription records
and identify those products
generating greatest number of
prescriptions (80:20 rule)
• Determine the associated drug-
induced nutrient depletions
associated with those products

117. Two Plans for Profitability: Plan 1
• Sources of this information are:
* The University of Maryland Medical Center
Complementary and Alternative
* Medicine Guide
(http://umm.edu/health/medical/altmed)
* “Drug –Induced Nutrient Depletion Handbook”
(Pelton and Lavalle, 2001)
* “Herb, Nutrient and Drug Interactions” (Stargrove,
Treasure, McKee, 2007)
* Natural Medicines
https://naturalmedicines.therapeuticresearch.com/

118. • Incorporate recommended nutritional
supplementation into prescription processing
software
• Create patient messaging that explains why
pharmacist is recommending supplementation
• Attach supplement to the prescription at
prescription pick up point
• Create additional patient centered messaging
that discusses drug-induced nutrient
depletion and the benefits of nutritional
supplementation for other medications the
patient may be taking

119. Plan 1 continued
• Ask patients if they are experiencing side
effects that could be related to nutrient
deficiency (get specific)
• Ask them what supplements do they take
currently
• Make note in the patients profile that you
offered a supplement and if they accepted or
declined
• Ask those that accepted if they need more
when they call in their next refill

120. Two Plans for Profitability: Plan 2
• The key to integrating the pharmacist and his
staff with the customer base requiring
nutritional products and information is
EDUCATION!
– Education for the pharmacist
– Education for the staff
– Education for your patients and customers
– Education for your world!

121. Actively Educating Yourself
• International and American Association of
Clinical Nutritionists (IAACN) (Certified Clinical
Nutritionist, CCN)
• American College of Nutrition (Certified
Nutrition Specialist/CNS)
• Board of Pharmaceutical Specialties (Board
Certified Nutrition Support Pharmacy)
• American Academy of Anti-Aging Medicine
(A4M) (FAAFM)

122. Inactively Educating Yourself
• Google it!
• Life Extensions Subscription
• Integrative Medicine Alert
(www.ahcmedia.com)
• Proprietary Nutritional Supplement
Companies
• Vitamin Manufacturers

123. Develop A Library
• You don’t have to know everything. You
just need to know where to find it.
–“Disease Prevention and Treatment” (Life
Extensions)
–“Prescription for Nutritional Healing”
(Phyllis Balch)
–“Textbook of Natural Medicine”
(Pizzorno/Murray)
–Anything by Alan Gaby, M.D.!

124. Copyright 2011

126. Education for Your Staff
• Let one of your employees oversee your
nutritional programs
• Should be fun (challenges, games, etc.)
• Should incentivize (individually or as a
team effort)
• Should be at their level of understanding

127. Education for Your Patients and
Customers (In Store)
• Nutrient depletion handouts
• Vitamin of the month display
• Flyers, bag stuffers, product displays,
newsletters
• Keep your messaging consistent, but
change your featured product often

128. Feature Quality Products From
Supportive Vendors
• Gluten free, dye free, sugar free, dioxin
free, PCB free, heavy metal free,
preservative free
• Carry pharmaceutical grade
• Carry what the local professionals carry or
higher grade
• Utilize proprietary labeling
• Disease state vs. product educational
materials

129. Educate Your World
• Do presentations to the public and
collect e-mail addresses
• Constant contact
• Pharmacy website
• Blast fax to prescribers

130. Present to Local Support Groups
• Sports clubs and coaches
• Radiation oncology groups
• Breast cancer survivor groups
• Bariatric support groups
• Wound care centers

131. Make the most of what you already
have going for you!

132. Pharmacy Reception Area

133. Consultation Area