“For every dollar we spend on prescription drugs, we spend a dollar to fix a complication. Understanding how nutritional supplements affect these drugs could make them safer and more effective.”
— Mehmet Oz, M.D., Professor of Surgery at Columbia University and author of bestsellers YOU: The Owner’s Manual and YOU: On a Diet
In my last blog, I introduced the concept that common medications deplete vital nutrients essential to your health, and explained how this happens. In part 2 here, you’ll find a practical guide to avoiding specific drug-induced nutrient depletion. Later blogs will tell you how to replace your medications with natural supplements whenever possible. You can also find this information in my book Supplement Your Prescription.
I will cover many of the major drug categories, with names of the most common drugs, their nutrient depletions, and how to avoid them. I’ve included numbered references if you’d like to check sources.
Anti-hypertensives. The ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) (2) concluded that thiazide-type diuretics are better than ACE inhibitors and calcium-channel blockers at preventing heart attacks in high-risk people. Physicians often prescribe potassium to offset the well-known potassium depletion associated with this prescription.
However, these diuretics are also known to deplete other minerals, such as magnesium, sodium, potassium and zinc, which are seldom specifically supplemented. One study found hypokalemia (low potassium) in 8.5 percent of people treated with thiazide diuretics and hyponatremia (low sodium) in 13.7 percent in the same patient population.2,3) This indicates the importance of testing levels, and not simply restricting sodium. (2,3) Thiazide diuretics also decrease magnesium in approximately 20 percent of patients (4) and can significantly decrease serum zinc. (5) Loop diuretics deplete potassium, magnesium, calcium, zinc, pyridoxine, thiamine and ascorbic acid. One study showed that thiamine deficiency was found in 98 percent of patients with congestive heart failure who took 80 mg of furosemide daily, and in 57 percent of patients who took just 40 mg daily. This shows a dose relationship. Furosemide also increases excretion of ascorbic acid and pyridoxine.6
For these patients, consider the following daily supplements: calcium (1,000 mg), magnesium (250 mg to 500 mg), potassium (100 mg), vitamins C (1,000 mg), B1 (320 mg), B6 (10 mg to 25 mg) and zinc (25 mg).
Beta blockers. Beta blockers are among the oldest classes of antihypertensive drugs. They lower blood pressure by reducing the effects of catecholamines, the stimulating chemical messengers such as adrenalin, thereby reducing the force and speed of the heartbeat. Beta-adrenergic (ie adrenalin producing) blockers deplete CoQ10 by interfering with the production of this essential enzyme for energy production. (7) This lack of CoQ10 is particularly dangerous, considering that the target condition is cardiovascular disease. Since the heart is particularly rich in COQ10-hungry mitochondria, the energy factories inside every cell, the end result can be heart failure. To offset the negative side effects, you can take CoQ10, 100 mg to 300 mg daily with fat-containing food for best absorption.
These drugs also reduce production of melatonin (N-acetyl-5-methoxytryptamine). Produced from serotonin at night in the pineal gland by stimulating adrenergic beta1- and alpha1-receptors, this neuro-hormone regulates circadian rhythm and promotes sound sleep. By blocking beta receptors, these drugs may inhibit the release of the enzyme serotonin-N-acetyltransferase, which is necessary for the synthesis of melatonin, resulting in sleep disturbance.8 Take melatonin (3 mg) at bedtime to counter this effect.
Cholesterol-lowering drugs. Statin drugs are the most widely prescribed medicines for lowering cholesterol. In fact, Lipitor (atorvastatin) is one of the best-selling drug on the planet. However, physicians need to address a serious risk. Statins deplete the body of a vital enzyme, coenzyme Q10 or CoQ10, with the following potential side effects (a selected few of many more): heart failure, muscle pain and weakness, irritability, mood swings, depression, memory loss, and impotence. (9-11) The last few side effects may also be due to lack of cholesterol, which is needed for brain cell and hormone production.
Therefore, people on statins should take 100 mg to 200 mg of CoQ10 daily to counter this potentially fatal depletion. (Also, I might add, be sure your cholesterol doesn’t go too low, either, causing brain and sexual problems). While no specific recommendations from the pharmaceutical industry exist, one pharmaceutical statin manufacturer observed the depletion effect in early research. This manufacturer holds a patent on a combination statin and CoQ10. Sadly, the patents have never been activated, nor have any warnings been provided by the U.S. pharmaceutical industry. Health Canada, on the other hand, which is the federal department responsible for helping Canadians maintain and improve their health, requires that manufacturers of statin drugs include warnings about related CoQ-10 deficiencies.
Acid blockers. Antacids, histamine-2 receptor antagonists (H2 blockers) and proton-pump inhibitors (PPIs) are commonly prescribed for treating heartburn, gastro-esophageal reflux disease (GERD) and peptic ulcers. Numerous studies indicate that these drugs cause several nutrient deficiencies. Remember when heartburn was just heartburn, and you simply avoided the foods that gave it to you? Now we have GERD, multiple medications for it, and commercials that invite you to pop a little pill for fast relief (after you pig out on questionable fast-food).
There are several categories of drug for this symptom. For example, aluminum antacids (Maalox, Mylanta and Gaviscon) and calcium carbonate (Caltrate, Dicarbosil, Rolaids, Titralac and Tums) act by buffering or neutralizing the acid pH of the stomach. Unfortunately, this reduction of stomach acid interferes with the breakdown of the ingested food into its component nutrients.
Both PPI and H2 blockers significantly increase the risk of vitamin B12 deficiency in elderly
patients. B12 requires adequate gastric acid for absorption. This population is already prone to deficiency in intrinsic factor, necessary for B12 absorption. (12) This lack of stomach acid also decreases the absorption of folic acid, iron and zinc. (13,14) H2 blockers (Tagamet, Pepcid, Axid and Zantac) decrease acid secretion by blocking histamine.
Proton pump inhibitors (PPIs, Prilosec, HK-20), the most potent of acid-reducing medications, are increasingly popular. They reduce stomach acid production by up to 99 percent by decreasing the action of proton pumps, which are part of the stomach lining’s acid-making machinery. This, however, can strongly interfere with nutrient absorption.
One study showed that high doses of PPIs, used for a year or more, could make people 2.5 more times susceptible to hip fracture than control subjects. Lower doses decreased the risk factor to 1.5 times that of nonusers. The longer the period of use, the higher the fracture risk. This heightened risk of osteoporosis is probably due to the drastic drop in calcium and vitamin D absorption that occurs with these drugs. Some experts believe the drug themselves may hamper the body’s ability to build new bone.15For anyone taking acid-reducing medication, I recommend daily intake of vitamin D3 (2,000 IU or more based on lab testing. Many of my patients are taking 5000-10,000 IU daily, based on their lab tests), B12 (200 mcg), folic acid (800 mcg), calcium (1,000 mg), chromium (500 mcg), iron (15 mg), zinc (25 mg to 50 mg) and phosphorus (700 mg).
Oral hypoglycemics. Metformin (Glucophage, Glucophage XR and Glucovance) enhances the action of insulin in cases of insulin resistance, allowing glucose to enter the cells. This reduces elevated blood sugar. A study published in the Archives of Internal Medicine showed that diabetics on metformin had B12 levels that were less than half those of control subjects. The longer the drug had been used and the higher the dose, the greater the drop in B12.16In people with type 2 diabetes who take metformin therapy, serum folic acid levels decrease 7 percent and vitamin B12 levels decrease by 14 percent. (17) B12 and folic acid depletion also increases homocysteine levels. In addition, metformin may deplete CoQ10, thereby increasing heart disease risk. To reduce these effects, patients should take vitamin B12 (800 mcg), folic acid (400 mcg) and CoQ10 (100 mg daily)
Psychotropic (psychiatric) medications. For antidepressants to work optimally, an ongoing supply of the B vitamins must be available as cofactors to help manufacture the needed neurotransmitters, such as serotonin and dopamine. (18, 19) So, while these drugs may not directly deplete B vitamins, patients on these medications should ensure they get enough of these vitamins. In addition, be aware that lithium carbonate, used for treating bipolar illness, depletes folic acid (take 800 mcg) and inositol (take 500 mg bid). Stimulant drugs for ADD and ADHD can deplete the amino acid carnitine, especially worrisome in vegetarians, since it’s found in meat.
Hormone replacement therapy. Both young women on oral contraceptives and female baby boomers on hormone replacement therapy (HRT), can be depleted of vitamins B6 and B12, folic acid and magnesium. These nutrients are critical for heart health, as well as for mood. Rather than an antidepressant prescription, these women should be given the appropriate supplements to restore balance. I have seen many women do well once these nutrient depletions were addressed.
For women on standard HRT (estrogen and progesterone, orally, including as an oral contraceptive, or as a transdermal skin cream) I may also recommend calcium (1,000 mg to 1,200 mg daily), folic acid (400 mcg to 800 mcg), magnesium (500 mg), vitamin B2 (25 mg), vitamin B6 (50 mg), vitamin B12 (500 mcg to 1,000 mcg), vitamin C (500 mg to 1000 mg) and zinc (25 mg to 50 mg).
Antibiotics. These drugs deplete biotin, inositol, vitamins B1, B2, B3, B5, B6, B12 and vitamin K. Additionally, fluoroquinolones and all floxacins (including ciprofloxacin or “Cipro”) deplete calcium and iron. Tetracyclines (suffix -cycline) deplete calcium and magnesium. Trimethoprim-containing antibiotics (brand names Trimpex, Proloprim or Primsol) deplete folic acid. Penicillins (suffix -cillin) deplete potassium. Aminoglycosides, such as gentamicin, cause imbalances of magnesium, calcium and potassium.20In fact, one study showed that gentamicin causes increased excretion of calcium by 5 percent and magnesium by 8.4 percent.21When you take antibiotics, consider a B vitamin complex along with it. Or take a multivitamin that contains 25 mg of B1 (thiamine), 25 mg of B2 (riboflavin), 50 mg of B3 (niacin), 50 mg of B6 (pyridoxine), 400 mcg to 800 mcg of folic acid, 10 mcg of B12, and 50 mg each of biotin and B5 (pantothenic acid).
Inositol is part of the B vitamin complex, and is likely to be included in a B vitamin or multivitamin formulation. Otherwise, take 500 mg of inositol. (The RDA is 100 mg per day.) In addition, either take a multivitamin that includes magnesium (500 mg), calcium (1,000 mg) and potassium (100 mg), or take them separately.
Antibiotics can disrupt the natural bacteria flora in the digestive system, killing “good” bacteria, including Lactobacillus acidophilus (L. acidophilus) and Bifidobacterium bifidum (B. bifidum). These are probiotics or bacteria that normally live in and on the human body, concentrated mostly in the digestive and genital/urinary systems. Choose a supplement that contains at least 1 billion live organisms per daily dose.
You also may consider 50 mcg daily of vitamin K, which is normally made by friendly intestinal bacteria. Vitamin K is required for proper blood clotting. Deficiency is rare, but when it occurs, life-threatening bleeding can occur from the smallest injury. Vitamin K also plays a part in osteoporosis prevention.
In conclusion, drug-induced nutrient depletion is far more common than we thought. In evaluating patients’ symptoms, we doctors must assess whether symptoms are due to the illness, to side effects of the drugs — or to drug-induced nutrient depletion. Considering the inadequate nutritional status of most people, consider that the illness itself may even be due, at least in part, to nutrient deficiency. To cover all bases, it is easiest to provide this basic daily coverage to anyone on medication (and adjusting as needed to the specific one):
- High potency multivitamin mineral formula
2. CoQ10 (200 mg)
3. Omega-3 fatty acids (2 grams)
4. Additional dose of vitamin D (2000 IU, and preferably one with added 200 mcg vit K)
5. Probiotics (1 billion units).
Physicians must look more deeply to determine whether drugs are harming patients, and what they can do to reverse these effects. As a consumer, be aware of these drug-nutrient depletions, and take the appropriate measures. Do what you can to avoid taking medications, and whenever possible, use natural products instead. Future blogs will covers specific natural substitutes for common medications.
The complete article can be found at Total Health Magazine online, p. 40 ff.
For more information, see my book, Supplement Your Prescription: What Your Doctor Doesn’t Know About Nutrition available at my website, www.cassmd.com.
- Centers for Disease Control and Statistics. Health United States 2006. Accessed via www.cdc.gov/nchs/data/hus/hus06.pdf#093. (cited in part 1 of this blog)
- The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. JAMA 2002;288:2998-3007.
- Clayton JA, Rodgers S, Blakey J. Thiazide diuretic prescription and electrolyte abnormalities in primary care. Br J Clin Pharmacol 2006 Jan;61:87-95.
- Pak CY. Correction of thiazide-induced hypomagnesemia by potassium-magnesium citrate from review of prior trials. Clin Nephrol 2000;54:271-275.
- Khedun SM, Naicker T, Maharaj B. Zinc, hydrochlorothiazide and sexual dysfunction. Cent Afr J Med 1995;41:312-315.
- Zenuk C, Healey J, Donnelly J, et al. Thiamine deficiency in congestive heart failure patients receiving long term furosemide therapy. Can J Clin Pharmacol 2003;10:184-188.
- Kishi T, Watanabe T, Folkers K. Bioenergetics in clinical medicine XV: Inhibition of coenzyme Q10-enzymes by clinically used adrenergic blockers of beta-receptors. Res Commun Chem Pathol Pharmacol 1977;17:157-164,
- Stoschitzky K, Sakotnik A, Lercher P et al Influence of Beta-blockers on Melatonin Release. Eur J Clin Pharmacol. Apr1999;55(2):111-15.
- Langsjoen PH, Langsjoen AM. The clinical use of HMG CoA-reductase inhibitors and the associated depletion of coenzyme Q10: A review of animal and human publications. Biofactors 2003;18(1-4):101-111.
- 10 Crane FL. Biochemical functions of coenzyme Q10. J Am Coll Nutr 2001;20:591-598.
- Folkers K, Langsjoen P, Willis R, et al. Lovastatin decreases coenzyme Q levels in humans. Proc Natl Acad Sci U S A 1990;87:8931-8934.
- Valuck RJ, Ruscin JM. A case-control study on adverse effects: H2 blocker or proton pump inhibitor use and risk of vitamin B12 deficiency in older adults. J Clin Epidemiol 2004;57:422-428.
- Russell RM, Golner BB, Krasinski SD. Effect of antacid and H2 receptor antagonists on the intestinal absorption of folic acid. J Lab Clin Med 1988;112:458-463.
- Sturniolo GC, Montino MC, Rossetto L, et al. Inhibition of gastric acid secretion reduces
zinc absorption in man. J Am Coll Nutr 1991;10:372-375.
- Yang, YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA 296 (24): 2947-53
- Zhao-Wei Ting R, C Chun Szeto, M Ho-Ming Chan, et al. “Risk factors of vitamin B12 deficiency in patients receiving metformin.” Archives of Internal Medicine Oct 9, 2006: 1975-1979.
- Wulffele MG, Kooy A, Lehert P, et al. Effects of short-term treatment with metformin on serum concentrations of homocysteine, folate and vitamin B12 in type 2 diabetes mellitus: A randomized, placebo-controlled trial. J Intern Med 2003;254:455-463.
- Bottiglieri T. “Folate, vitamin B12 and neuropsychiatric disorders.” Nutrition Review Dec 1996; 54(12): 382-390.,
- Bottiglieri T, M Laundy, R Crellin, et al. “Homocysteine, folate, methylation, and monoamine metabolism in depression.” Journal of Neurology, Neurosurgery & Psychiatry Mar 2001; 70(3): 419.
- Landau D, Kher KK. Gentamicin-induced Bartter-like syndrome. Pediatr Nephrol 1997;11:737-740.
- Elliott C, Newman N, Madan A. Gentamicin effects on urinary electrolyte excretion in healthy subjects. Clin Pharmacol Ther 2000;67:16-21.
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Author and physician practicing integrative medicine