5/3/2017

Danna Park, MD: May not be replicated without author's permission. 1

Supplements for Health: Hype

or Helpful?

OLLI Spring 2017

Danna Park, MD, FAAP, FACP

Director, Mountain Integrative Medicine,

PLLC

How Many People Use Vitamins/Herbs/ Supplements?

• At least 50% of adults

• Higher rates of use if

chronic condition

• At least a $23 billion

industry

“Shelf Vertigo”

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Danna Park, MD: May not be replicated without author's permission. 2

What Does DSHEA Do?

Insures that what is on the label is in the bottle

Requires specific records and testing requirements

Requires specific labeling requirements

FDA can prosecute if requirements for

manufacture or claims for product not

met

Savvy Supplement Users:

Pick a company that has a base of

operations in France, Germany or

Canada

Have to adhere to pharmaceutical grade

standards for manufacturing!

Look for markers of quality control and independent testing

Talk with healthcare provider or pharmacist

Weigh risk vs. benefit

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Danna Park, MD: May not be replicated without author's permission. 3

Look at Labeling

Must include:

Common (usual name) of botanical

ingredient(s)

Part(s) of the plant used

Nutrition info in the form of a "Supplement

Facts" panel

A complete list of ingredients

Must state:

That it is a supplement

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Danna Park, MD: May not be replicated without author's permission. 4

EVIDENCE FOR USE

RISK

high

low

lowhigh

What kind of

evidence?

Maybe avoid,

maybe consider

Proceed

High caution, but

consider

Avoid

Identify the Myths;

Decrease the Risks

“Natural is safe”

“Natural is better”

“More is better”

“If it’s been used for thousands of years, it must be safe”

“Mixing medicines and supplements is safe”

Bottom line:

Don’t take supplements like my mother does!

5/3/2017

Danna Park, MD: May not be replicated without author's permission. 5

Five Most Important Questions

for You to Ask Yourself

Is this information reliable?

Is this safe for me to take at this time

during this treatment while I’m on

these medications?

Are there side effects and/or

medication interactions?

Will this affect my treatments?

Have I let all my healthcare team

know?

http://www.mskcc.org/mskcc/html/69236.cfm

5/3/2017

Danna Park, MD: May not be replicated without author's permission. 6

www.naturaldatabase.com

The Brain

St. John’s Wort

Omega-3 fats

5HTP

GABA

Ginkgo

Ginseng

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Danna Park, MD: May not be replicated without author's permission. 7

St. John’s Wort

Used for:

Mild-moderate depression

Anxiety

Insomnia

Likely as effective as low-dose tricyclic antidepressants or SSRI’s;

better tolerated

Modulate serotonin, dopamine, norepinepherine

Works on GABA receptors- has antianxiety effects

St John’s Wort

In 16 years of practice, I have not used this.

Many possible severe drug interactions

Potent inducer of some cyto P450 enzymes

Increased clearance of some medications,

including cyclosporine, indinavir, and amitriptyline

Prolongs clearance of other medications

Photosensitivity risk

Banned in France in 2000.

Omega-3 Fats: A No-Brainer

People have lower levels of

omega-3 fats

Improved executive

function

Higher dietary intake

associated with better

memory, faster and better

cognitive status overall.

(Andruchow ND, Konishi K et al, Neuropsych 2017)

5/3/2017

Danna Park, MD: May not be replicated without author's permission. 8

Omega-3 Fats

Dietary intake: Walnuts, soybeans, eggs, fish, green

leafy vegetables, limit fish to two 6oz portions/week

Dose Cautions

Children ages 4-6

Children > 6 years old

500 mg/day

1 gram/day

Blood thinning effects

Adults 1g/day

Limit men to 1g/day

EPA dose higher than

DHA dose.

Use product screened for heavy metals/toxins/PCBs

Triglyceride form may be best absorbed/utilized- less burp

Krill oil most expensive

Ethyl ester form cheapest (most likely to cause burp)

5- Hydroxy-Tryptophan (5HTP)

Used for depression and insomnia

Converted to serotonin in the body

Banned by FDA in 1989

Eosinophilia-myalgia syndrome

Cannot be used with

antidepressant medications

Multiple potential side effects

I do not recommend this

5/3/2017

Danna Park, MD: May not be replicated without author's permission. 9

Gamma-Aminobutyric Acid (GABA)

Neurotransmitter amino acid

Has anticonvulsant, sedative, and

anxiolytic effects

Oral GABA does not cross the blood

brain barrier

There are 475 GABA products on the

market

Supplement to Definitely Avoid

Picamilon

Nicotinyl GABA

Banned by FDA in 2015

Technically a prescription drug

Can lower blood pressure

A current variant available over

the counter…for now.

Contains niacin, GABA, B6

Other Brain Supplements to Definitely

Avoid

Huperzine A

Technically a drug

Crosses into brain, increases acetylcholine

Multiple drug interactions and serious cholinergic side effects

Vinpocetine

Technically a drug

From periwinkle plant- potentially toxic

Increases cerebral metabolism and catecholamine turnover in brain

Decreases platelet aggregation- bleeding risk!

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Danna Park, MD: May not be replicated without author's permission. 10

Other Supplements to Avoid

Ginkgo biloba

2008 NIH Ginkgo for Evaluation of Memory

No benefit in preventing dementia or

progression to Alzheimer’s

No differences in incidence of heart attack,

angina, high blood pressure or stroke compared

to placebo

Multiple reports of spontaneous bleeding,

increases stroke risk and has other serious

potential medication interactions.

Note that these were

NOT listed on the front

of the bottle!

Ginseng (Panax)

Unclear if benefits in cognition, memory

or attention

Multiple potential drug interactions

can potentiate effectiveness of Coumadin,

cause Lasix resistance,

Can interfere with serum digoxin lab

testing and give false results

Bleeding risk

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Danna Park, MD: May not be replicated without author's permission. 11

Ornish D et al. GEMINAL study.

PNAS 2008;105(4):8369-74.

Jeans

Genes

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Danna Park, MD: May not be replicated without author's permission. 12

Antioxidants

Alpha lipoic acid

Coenzyme Q10

Green tea/ EGCG

Vitamin C

Alpha Lipoic Acid (ALA)

Has been used to help treat diabetic neuropathy

May be helpful in improving chemotherapy induced

neuropathy

IV use in Europe has been most effective

Usual dose is around 200mg three times a day

Can lower blood sugar

Cannot be used if on thyroid medication (Synthroid)

Decreases conversion to active T3 form of thyroid hormone.

Coenzyme Q10

What is it?

Cofactor in the electron transport chain required to

make ATP

AKA ubiquinone or ubiquinol

Multiple cardiac benefits:

Lowers blood pressure

Supports a normal heart rhythm

Improves heart “squeeze”

Good to add if on a statin medication

Statins (lipitor, etc.) deplete coQ10

(Reilly J, 2013; Littarru GP et al, 2010)

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Danna Park, MD: May not be replicated without author's permission. 13

CoQ10- Cautions

Dose depends on reason for use

30mg daily to 240mg/day in divided

doses if being used for cardiac or

blood pressure reasons.

Need to work with your provider

May need to decrease blood pressure

lowering medications

Biggest issue- looks like vitamin K

so makes Coumadin less effective

Green Tea

Contains numerous compounds with antioxidant activity

Epigallocatechin-3-gallate (EGCG) is the one most studied for anticancer benefits

Green Tea

Avoid green tea extracts

Linked to liver toxicity and

liver failure

Avoid products that contain

green tea extracts

Green tea as a beverage

2-3 cups/day may be

optimum-exact dosage is

unknown.

(Mazzani G et al, 2009; Rohde J et al, 2011; Lambert J et al,

2007)

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What We Didn’t Know We

Didn’t Know Do NOT use green tea as a

beverage, EGCG or vitamin C

if taking:

bortezumib (Velcade)

erlotinib (Tarceva)

sunitinab (Sutent)

genfitinib (Iressa)

irinotecan (Camposar)

Avoid for now if on paclitaxel

(Taxol)

Vitamin C

Antioxidant, immune function,

essential for building connective

tissue (wound healing)

Water soluble vitamin

250mg per day is adequate for

saturating body tissues

Body capacity increases with acute

illness

250mg-3g usually well-tolerated

Too much?- GI distress/ diarrhea

Decrease dose or stop supplement

Extra credit:

what is this?

Vitamin C: Cautions

Cannot use if:

iron overload or hemochromatosis

kidney disease or kidney stones

if Glucose-6-Phosphate Deficiency

(G6PD)

May decrease effectiveness of newer

biologic cancer medications (mibs,

nabs, mabs)

Can affect a variety of medications

(antibiotics, cardiac meds, Coumadin,

psychiatric meds)

(Hoffer LJ et al, Ann Onc, 2008)

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Bones and Joints

Calcium

Magnesium

Vitamin D

Strontium

Glucosamine

Chrondroitin

Calcium Supplements: Good or Bad?

High serum calcium levels associated with

higher risk of artery calcification and

cardiac risk

Calcium supplements raise serum calcium

levels faster and higher than dietary

intake.

Dietary intake best

(Chung M et al, Ann Int Med, 2012; IOM Report Brief, 2010)

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Danna Park, MD: May not be replicated without author's permission. 16

Calcium

Goal dose usually 1,000 mg to

1200 mg daily

Get from diet

Subtract 250mg per serving of

calcium rich foods

If need to make up difference,

take in divided doses throughout

the day

250- 500mg at a time for best

absorption

(Mao PJ et al, 2013; Lin HC et al 2013; Williams CD et al, 2012)

Supplement Advice: Calcium

Take on an empty stomach separate from

medications

Affects absorption of certain drugs (thyroid

medication, bisphosphonates, some antibiotics)

For osteopenia/osteoporosis, evidence may

support these also:

vitamin D 600 to 1,000 IU/ day

Magnesium glycinate 200-600 mg (Ca:Mg ratio of 2:1)

Boron 1 to 3mg /day

Vitamin K2 (menaquinone)- 90 micrograms daily

Check for drug interactions before using!

Forms of CalciumProbably best:

•calcium citrate

•calcium malate

Cheapest: TUMS

(calcium carbonate)

Avoid dolomite, oyster

shell or bone meal sources

May contain lead or

heavy metals.

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1 tablet equals 250mg.

Vitamin D

High quality words:

Vitamin D3 (cholecalciferol)

Low quality words:

Vitamin D2 (ergocalciferol)

OK to use if vegan/vegetarian

Must use vitamin D2 if very high weekly dosing

Do not supplement if granulomatous disease,

sarcoidosis or lymphoma

Vitamin D toxicity: low appetite, nausea, vomiting,

weakness, kidney problems, frequent urination

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Supplement Advice:

Vitamin D

Don’t know exact dosing

600-1,000 IU/day probably safe

Not enough evidence yet to support use of

very high doses to reach certain D level for

disease prevention

Too much associated with:

Higher LDL levels ( with 50,000 IU/week)

New onset atrial fibrillation (with blood D

level>100ng/dL)

Strontium

May artificially alter DEXA (bone) scan

Makes it look like there is improvement in bone density when

actually there is not

Needs to be taken separately from calcium- can impair

calcium absorption

Studies that showed benefit used strontium ralenate which is

not available in US

Strontium citrate may not have same effects

Increased risks of blood clots were noted in European trials

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Glucosamine

Found in cartilage, tendons and ligaments

May be joint protective

Either made synthetically or from shrimp, lobster and crab

shell

Caution if allergic to shellfish but usually allergen is protein in

shellfish meat.

Inhibits inflammation via creation of COX-2

1500 mg/day of glucosamine sulfate most common dose

Decreased pain, increased walk time in OA

Glucosamine: Cautions

Can potentiate Coumadin- increase bleeding

risk.

Do not exceed 1500mg/day- pancreas toxicity!

Should not be used with chemotherapy agents

such as etoposide (Toposar) or doxorubicin

(Doxil)

theoretically could induce resistance of cancer cells

to these agents.

Chondroitin

Functions in cartilage elasticity

May inhibit cartilage degradation

Blocks inflammatory chemicals and cells in joints

Increases lubricating and cushioning compounds in joints

Decreases inflammatory cells in joints

Made from shark cartilage or cow trachea

800 to 1200 mg/day of chondroitin most common dose

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Chondroitin Cautions

Can potentiate Coumadin- increase bleeding

risk.

Major source of chondroitin is cow trachea

? Risk of prion disease (“mad cow”)

May worsen asthma symptoms

asthmatics may have heightened immune reactivity to

chondroitin

Do not use if have prostate cancer

may increase risk of prostate cancer progression