The safety and efficacy of patients’ medication therapies can be critically evaluated by looking at how the drugs they are taking may be affecting their nutrient levels. Many drug-induced nutrient depletions are not well-known by pharmacists, so they are not diagnosed or treated properly. This article provides an overview of common medications that can cause nutrient deficiencies. There is reasonable evidence to support the nutrient deficiency associated with particular medications. There are common deficiencies that need to be evaluated for clinical significance and patient-care recommendations.
While the occurrences of drug-induced nutrient depletion are complex, they generally result in inconsistent prevalence among patients taking the same medications. Patients who take more medications may be more likely to have reduced levels of certain nutrients due to nutrient depletions from many pharmacologic treatments. Some nutrient depletions may be intentional, for example, when cancer treatments deplete folate, while others may cause new problems or have unintended consequences. There is often a lack of understanding of the mechanisms that lead to this depletion, as well as the subsequent outcomes. Although common foods contain these nutrients, they are not present at high enough levels or have absorption issues. Therefore patients may require supplementation to avoid deficiencies.
Although pharmacists are supposed to assess patients’ medications for things such as proper dosage, safety, and potential drug interactions, they don’t often evaluate how those medications might cause nutrient depletion. There is also a lack of information available to help pharmacists make these assessments. Pharmacists play an important role in drug utilization reviews, especially in community pharmacies. DUR is the review of a medication’s appropriateness before it is dispensed to a patient. DUR should be used to screen for potential problems that could arise from drug-drug interactions, therapeutic duplication, drug-disease interactions, drug-allergy contraindications, clinical abuse and misuse, inappropriate dose and duration, and drug-food interactions. Patients and clinicians may not be aware of potential nutrient depletions that could be caused by medication, providing an opportunity for pharmacists to contribute to interdisciplinary care.
NUTRIENT DEPLETIONS
Calcium
If you use corticosteroids for a long time, it can reduce how much calcium your body absorbs and make your kidneys get rid of more calcium. This may impair bone formation and increase fracture risk. In patients with chronic conditions who take corticosteroids long-term, supplementation is generally required. The need for supplementation should be confirmed before offering it, and vitamin D should be considered as well to improve calcium absorption. Benzodiazepines can decrease calcium absorption and increase vitamin D metabolism.
There is evidence from radiographs, histology, and biochemistry that many anticonvulsant drugs are associated with low levels of calcium. The decreased bone mineral density and hypocalcemia are most often associated with medications that induce the cytochrome P450 enzyme. Valproate has also been associated with hypocalcemia. There is no one mechanism that explains hypocalcemia and how it affects bone health. Patients taking antiepileptic drugs for a long period of time should be monitored for bone disease.
Folic Acid (B9)
Folic acid, or folate, is also commonly referred to as B9. It is a water-soluble vitamin. Folate deficiency can be present as megaloblastic-macrocytic anemia. Several medications can cause folate deficiency. Many pharmacists are familiar with folate deficiency, which can be caused by the medication methotrexate. Methotrexate works by inhibiting dihyrofolic acid reductase. However, there is no clear consensus on the best way to manage this deficiency. Low-dose methotrexate is considered safe for long-term use, with few side effects. Many healthcare providers may suggest taking over-the-counter folic acid supplements to reduce the risk of side effects associated with this antifolate therapy. In practice, taking additional methotrexate often leads to improvements in clinical symptoms. The toxic effects of methotrexate only occur when there is a folic acid deficiency. Pharmacists should ensure that patients taking methotrexate have their folic acid levels checked often. Sulfamethoxazole has also been found to undermine levels of folate. While this deficiency may not have a clinical significance often, it could be relevant owing to the limited amount of time antibiotics are taken.
Many women who take estrogen every day can develop a folate deficiency. It reduces the absorption of folic acid and increases its excretion. Folic acid is important for women’s health, but if they are already getting enough of it, it probably won’t make much of a difference. Since the CDC recommends folic acid supplementation for all women of childbearing potential, pharmacists should make sure women who are taking oral contraceptives are also taking folic acid supplements. Estrogen can also lead to deficiencies in several other nutrients, including vitamins B2 (riboflavin), B6 (pyridoxine), B12 (cobalamin), vitamin C, vitamin E, magnesium, selenium, and zinc. These deficiencies can lead to side effects experienced with oral contraceptives. Pancreatic enzymes can reduce the absorption of folic acid, which is another common medication that can cause deficiency. Pharmacists should monitor for depletion. The opposite is true for folic acid—it can reduce the levels of anticonvulsants in the body, which in turn increases the risk of seizures. While some anticonvulsants can reduce a patient’s folic acid levels, this is not a class-wide effect. Some patients may require supplementation. Pharmacists need to look up each anticonvulsant drug’s interactions with folic acid so they can manage them accordingly.
Magnesium
Another extremely common dietary deficiency involves magnesium. The USDA reported that three-fourths of Americans consume less than the RDA of magnesium. A large number of drugs that are commonly prescribed can lead to a magnesium deficiency. This means taking birth control pills and either Premarin or Estratab. There are various antibiotics that can cause a depletion of magnesium, such as tetracyclines and doxycline. Magnesium-depleting drugs such as diuretics and digoxin can lead to magnesium deficiency, which can then cause congestive heart failure. Corticosteroids also deplete magnesium.
While calcium has received a lot of attention, magnesium has been relatively ignored. Ironic that too much calcium can lead to magnesium deficiency Magnesium is important for more than just the bones and teeth—it plays an essential role in a lot of different bodily functions. The authors say that magnesium is important for many different processes in the body. For example, without magnesium, muscles would not be able to move, and nerves would not be able to send signals. Magnesium is also needed for the phosphorylation reactions that produce ATP. Manganese is an important mineral that helps the body create DNA and RNA and also helps with blood sugar control and detoxification. The authors believe that magnesium is very important for cardiovascular disease prevention. Magnesium deficiency is often associated with atherosclerosis, heart attack, hypertension, and stroke. A cardiac spasm that is caused by low magnesium levels can be very dangerous and potentially life-threatening.
The elderly sometimes experience leg cramps that disrupt their sleep. This is a less severe version of the muscular cramps that can be caused by magnesium deficiency. Some other signs that a person may not be getting enough magnesium include trouble sleeping, feeling agitated or restless, irritability, feeling nervous or anxious, depression, fatigue, and weak or brittle bones. Magnesium deficiency seems to be a factor in migraines and PMS. Interestingly, so is asthma. Some diabetics show a magnesium deficiency. Magnesium is also important for the kidneys. It helps prevent the formation of kidney stones.
This could also eliminate the need for blood-pressure-lowering drugs when magnesium is combined with other alternative health measures. Similarly, diabetics could reduce or eliminate their need for insulin and other anti-diabetic drugs if they followed a treatment that includes magnesium, which is known to help stabilize blood sugar. Magnesium relaxes bronchial muscles, so it is also useful for treating asthma, bronchitis, and emphysema. Asthmatics should take magnesium supplements, especially because corticosteroids reduce magnesium levels. If you suffer from insomnia, migraines, PMS, fibromyalgia, or are prone to kidney stones, you should consider taking magnesium supplements.
Potassium
Corticosteroids can also cause potassium levels to drop, in addition to calcium levels. 11 Some patients may require potassium-chloride supplementation, but deficiency should be verified before supplementation is started due to risks associated with hyperkalemia. Many diuretics (loop diuretics, thiazide diuretics) can cause potassium depletion, and pharmacists should be aware of this. If you are taking a loop diuretic, your potassium levels should be checked often, and you may need to take potassium supplements.
Vitamin B6 (Pyridoxine)
Vitamin B6 is necessary for many enzymatic reactions. Deficiency is rare in healthy individuals. If you experience any of the following symptoms, you may be deficient in vitamin B12: weakness, dizziness, irritability, inflammation, bilateral limb numbness, and confusion. ental contraceptives, hormone replacement therapy) interfere with the metabolism of vitamin B6; however, low-dose oral contraceptives seem to be able to fix this problem.
Zinc
A zinc deficiency is a problem that many people have in the United States and other parts of the world. The absorption of nutrients decreases with age, and many elderly people have inadequate diets, leading to nutrient deficiencies. Diets that are mostly or entirely plant-based and that contain a lot of grains that are high in phytates often result in zinc deficiency. The zinc that is found in food is often lost during processing. Zinc deficiency can lead to a number of problems, including alcoholism, diabetes, liver and kidney disease, macular degeneration, inflammatory bowel disease, and melanoma.
Different drugs can lead to a depletion of zinc in the body, similar to how magnesium can be depleted. There are various drugs that can help with the symptoms of lupus, which include corticosteroids, oral contraceptives, oral estrogens, ACE inhibitors, diuretics, triamterene, Bumex, the cholesterol-lowering drug cholestyramine resin, and the anti-ulcer drug Cimetidine.
Zinc is an important nutrient needed for the activity of over 300 enzymes in the human body. A deficiency in zinc can lead to problems with cell function and growth. One of them is alcohol dehydrogenase, which detoxifies alcohol. Zinc is essential for the function of alkaline phosphatase, which is important for bone metabolism. There are other enzymes in addition to the ones mentioned above, such as the cytochrome C system, zinc/copper superoxide dismutase (a very important antioxidant enzyme), carbonic anhydrase (which helps get rid of carbon dioxide), and carboxypeptidase (necessary for protein digestion). One of the most important enzymes regulating gene expression, DNA methyltransferase, contains zinc.
Zinc also helps to create and/or improve the function of several hormones. Zinc is a key part of insulin and may also help control insulin receptors. Zinc also helps thyroid hormones to work more effectively by helping to convert thyroxine (T4) into the more active triiodothyronine (T3). Zinc is also important for the production of the thymus hormone, thymulin.
Zinc is needed for the synthesis of DNA and RNA, protein synthesis, and cell division. In addition, zinc helps protect DNA from damage.
Zinc also helps to enhance immunity. Zinc has been shown to be effective in reducing the duration and severity of cold symptoms. Zinc performs a number of tasks in regard to the immune system, such as regulating the activity of different cells and producing interleukin 2. Zinc regulates the levels of vitamin A by controlling its release from the liver; vitamin A also has a significant impact on the immune system.
If you are deficient in zinc, you may notice slow wound healing, poor sense of smell and taste, problems with skin, hair, and nails, low immune response and frequent infections, night blindness, excessive sensitivity to light, depression, and even lethargy, anemia, menstrual and fertility problems, male sterility, various pregnancy complications, and joint pain. Benign prostate enlargement may reflect zinc deficiency. Zinc deficiency can cause stretch marks during pregnancy. Zinc deficiency can be determined by looking for white spots on fingernails.
Zinc is found in seafood (including oysters), eggs, and meat. These are the best dietary sources of zinc. Plant food does not provide a lot of zinc and what zinc it does provide is not well absorbed by the human body. Even though zinc monomethionate is an excellent zinc supplement, it is still affordable for people. This supplement is known to be well absorbed, even with the presence of fiber. For a very small amount of money each day, you can prevent a lot of different problems.
Conclusion
Patients taking medication may experience a depletion of nutrients, which should be monitored and managed accordingly. Although a lack of nutrients can have serious consequences for patients, supplements should not be given unless a deficiency has been confirmed (for example, through testing); there is good reason to think there is a deficiency or the risks of giving supplements when there is no proven deficiency are low.
