Magnesium
DRUG INTERACTIONS
Do not take supplements @ same time as:
QUINOLONE ABx** /// **TETRACYCLINES
BISPHOSPHONATES
Take supplement 2 HOURS AFTER taking the above medications
Dietary Sources of
IRON
- *Heme iron**
- *Meat + Seafood + Poultry**
- *Non-Heme**
- *Nuts + Beans + Veggies + Fortified Grain**
Magnesium
FACTS
Important for BONE Structure
Involved in several BioChemical Processes / Reactions
- *muscle / nerve fxn**
- *blood glucose control**
- *HEART rhythem**
Adults contain 25g of Mg
50-60% in bone
Rest in soft tissue
Vitamin D Facts
Fat Soluble Vitamin
that MAINTAINS CALCIUM levels in the body
Main role:
Promotes absorption of dietary calcium from small intestine
helps regulate calcium + phosphorus metabolism in BONE
Neuromuscular activity / cell growth / immune function
Excess Calcium
ADR / CI / P
>2,500 mg for ALL ages
GI:
Upset stomach / Bloating / Belching / Flatulence / Diarrhea
Constipation
EXCESSIVE Supplementation
–> KIDNEY STONES
CV: INCREASED risk for MI in postmenopausal women / older adults
Indications for
MAGNESIUM Supplementation
Mg DEFICIENCY
- *GERD / Dyspepsia**
- *contained in** ANTACIDS
Constipation
contained in LAXATIVES
Dietary Supplement Health & Educaion Act of 1994
Regulate Vitamins & Minerals
+ Herbs / Amino Acids / Enzymes
Should Clearly state that product is a dietary supplement
Should be taken by MOUTH
Intended to SUPPLEMENT Diet
Magnesium in
CONSTIPATION TREATMENT
Want to take account for DIARRHEA
Citrate / Sulfate / Hydroxide Salts
SULFATE salt
is the MOST POTENT** in causing **DIARRHEA
Dietary Sources of
MAGNESIUM
Legumes / Whole Grains
Brocolli / squash / green veggies / seeds / nuts
DAIRY / meats / chocolate / cofee
30%-40% of dietary Mg absorbed by body
SLOW-FE
142mg Ferrous Sulfate = IRON 45mg
ER
1T QD WF
Recommended is 8 males / 18mg females /
27mg Pregnancy / 9 mg Lactation
Calcium Citrate
Citrical
May be taken on an EMPTY STOMACH
21% elemental calcium
Daily Reference Intakes
Recommended Dietary Allowance = RDA
avg daily intate that meets needs of MOST healthy people
Adequate Intake = AI
level established when data lacking on nutrient requirements
Tolerable upper Intake level = UL
MAX daily intake, unlikely to cause adverse health effects
Estimated Average Requirement = EAR
RDA of
MAGNESIUM
Increased need w/ age
19-30 yo///31-50 yo
Male = 400 /// 420 mg
Female = 310 /// 320 mg
Pregnancy = 350 /// 360 mg
Lactation = 310 /// 320 mg
same as regular female
MAX DOSE = 350mg for ALL >19 yo
Calcium Supplementation
INDICATIOn
Maintain normal calcium stores to
PREVENT Osteoporosis
&
Glucocorticoid-induced Osteoporosis
Treat hypoCalcemia
RDA of Calcium
&
MAX
19-50 years
1,000 mg for ALL
1,200 mg for females >51 yo
2,500 mg MAX for all
Diet Considerations
IRON
Seperate by 1-2 hours
Acidic Food/Beverage
INCREASES ABSORPTION
- *Dairy & Tea**
- DECREASE absorption*
Vitamin D
Counseling Points
DO NOT EXCEED > 4,000 IU
> 9 y/o limit
SUNLIGHT Exposure is KEY!
VERY LOW FAT DIET can lead to deficiency
Risk Factors for
IRON DEFICIENCY
Group @ Risk:
Pregnant women
Infants + Young children
Heavy Menstrual Bleeding
Frequent Blood Donors
Cancer / GI Surgery + Disorders
Heart failure
Iron
Max Dose / ADR / CI-P
< 45 mg / day
GI Upset:
ab pain / constipation / diarrhea / NV
Contraindications / Precautions
Existing GI Disease = PUD / Ulcers - AVOID IRON USE
Frequent Blood Transfusions
Elderly = risk of OD
Pediatric = accidental OD
leading cause of fatal poisoning age <6
What Vitamins / Minerals have interactions with
LOOP DIURETICS
furosimide / torsemide / bumetanide
- *CALCIUM & MAGNESIUM**
- Decrease in these minerals*
ALSO CAUSE:
THIAMINE DEFICIENCY
B1
Drugs that
DECREASE
Iron Absorption
H2RA / PPI
- *ANTACIDS** with:
- *Al / Mg / Ca**
Tetracycling + Doxycycline
Cholestyramine
Carbonyl Iron
- *100% Elemental Iron**
- NOT AN IRON SALT,* highly purified iron
- *Dissolves in Gastric Secretion** –> converted to HCL salt
- *–> SLOW RATE** –> continued release of iron for 1-2 days
LESS TOXIC
in comparison to iron salts, need a much higher dose for toxicitiy
RDA of IRON
19-50 y/o
Male = 8
Female = 18
Pregnancy = 27
Lactation = 9
ALL MAX = 45mg
Ergocalciferol
Vitamin D2
Derived from PLANTS
400 / 2k / 8k / 50k
Drug levels
AFFECTED by IRON
DECREASES ALL OF THESE
Levodopa + Methyldopa
Levothyroxine = chelates w/ iron - wait 3-4 hours
Penicillamine / Fluoroquinolones
Tatracycline + Doxycycline
wait 2 hours before iron admin
Mycophenolate
Magnesium
Formulation CONSIDERATIONS
GLUCONATE / CHLORIDE > Oxide
due to less diarrhea
Sustained Release > immediate release
due to slower absorption*** –> ***minimizes RENAL EXCRETION
Elemental Mg + BioAvailability
also must be considered
Chloride has high % elemental Mg, but it is only _20% absorbed_
Indications for SUPPLEMENTATION of
VITAMIN D
Vit D Deficiency
Community Dwelling Adults
>65 y/o & at risk for falls
in combination with exercise + PT to prevent fractures
USPSTF recommendation
Calcium Deficiency
RISK FACTORS
Loop Diuretics + Corticosteroids
- *POST-menopausal** women
- *Amenorrheic** women
- *Female Athletes**
Lactose Intolerance
Vegetarians
vegans eat no animal products
Alcoholism Affects Which Vitamins?
C / A MAGNESIUM
B = 123 - 69
Thiamine = 1
Riboflavin = 2
Niacin = 3
Pyridoxine = 6
Folate = 9
What Vitamin/Mineral interacts with
Thiazide Diuretics = HCTZ / Chlorthalidone
CALCIUM
will cause an INCREASE in Calcium
- but it will have a decrease in:*
- MAGNESIUM*
- sodium / potassium / phosphate*
Calcium Dosing
for Corticosteroid-Induced Osteoporosis
1200-1500mg Elemental calcium
+
800 - 1200 units of Vitamin D
Cholecalciferol
Vitamin D3
Derived from ANIMALS
400 / 1000 / 2000 / 3000 / 50k IU
MAGNESIUM in
DYSPEPIA TREATMENT
Varies on ONSET OF ACTION:
Trisilicate** > **Carbonate** > **Hydroxide
TCH
want to treat it quicker
Iron
FACTS
Needed for Hg production for
Oxygen Transport + Metabolism
Involved in NT Production
15% stored for use in situations of inadequate dietary inake
Calcium Dosing
for IOM - Osteoporosis / Fracture Prevention
ALL Adults 19-50:
1000mg QD in 2 divided doses
1200mg in 2divdoses for women >51 or men >70
Corticosteroids
Drug Related Vitamin Deficiency
DECREASED
Vitamins A + D + C
Iron Supplementation
INDICATION
Iron Deficiency ANEMIA
ANEMIA of Chronic Disease
Vitamin D
DOSING
For Vitamin D *DEFICIENCY:*
1000-2000 IU
QD for maintanance
for Corticosteroid-Induced Osteoporosis:
800-1200 IU units of Vitamin D
+
1200-1500 mg Elemental CALCIUM
Iron Dosing
Deficiency Treatment:
150-300mg elemental iron daily
in 2-3 divided doses
to maximize tolerability
Onset after treatment:
TAKES TIME: HgB levels should should increase by
1g/dl q 2-3 weeks
after HGB levels are normal, may take up to
~4months to replensih iron stores
Thiazide Diuretics
Drug - Mineral
INTERACTIONS
HCTZ / Chlorthalidone
INCREASE in CALCIUM
decrease in:
Na / K / Mg + P
Dietary Supplement CLAIMS
Health Claims
will reduce risk of disease / condition
Structure/Function Claims
may affect organs/systems of body = can NOT mention disease state
Nutrient Claims
fortified / high / rich in / excellent source of / high potency / good source
“This statement has not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.”
IRON
Counseling Points
- *Seperate from DAIRY + ANTACIDS**
- *2 hours**!
Keep away from children
- *Acid food/beverages –> INCREASE**
- *Milk / Tea** –> DECREASE
GI SE associated w/ DOSE, not formulation/salt
EC / Controlled release –> decrease nausea
but have LOWER absorption rate
Liquid –> blacken teeth
Oral –> darken stool
What Mineral/Vitamin affects
LEVOTHYROXINE?
IRON
will decrease the efficacy / CHELATE of levothyroxine
SEPERATE by 4 HOURS
Which Magnesium Salt is PREFERRED?
CHLORIDE & GLUCONATE
CL= Enteric coating/poorly absorbed, but higher % elemental Mg
Gluconate = better absorbed but TAKE ON EMPTY STOMACH
better than OXIDE due to less diarrhea
Sulfate = most potent though
Minerals
In-Organic elements neded to maintain life
Sources:
Soil & Water
absorbed by plants / eaten by animals
Calcium Carbonate
Requires STOMACH ACID for absorption
should be taken WITH FOOD
Highest % of Elemental Calcium
cheaper
Vitamins
Organic Nutrients that are supplied by the DIET
generally NOT made endogenously EXCEPT:
Vitamin D / Niacin
from skin / from tryptophan
Loop Diuretics
Drug Related Vitamin Deficiency
Thiamine DEFICIENCY
B1
Risk Factors for
MAGNESIUM deficiency
GI Disease
crohns disease –> chronic diarrhea
T2 Diabetes
due to INCREASED output secondary to high glucose conc. in kidney
- *Alcohol dependence**
- *GI - NVD** + renal dysfunction
- *Older age**
- decreased intake / absorption +* increased renal loss
Risk Factors for
Vitamin D Deficiency
Breastfed Infants
Individuals with DARK SKIN
Elderly
OBESITY
FAT-Malabsorption DISORDERS
H/O of Gastric Bypass Surgery
Proton Pump Inhibitors
Drug Related Vitamin Deficiency
Vitamin B12 MALABSORPTION
reduced ACID –> impaired RELEASE of B12 from Food
same as H2RA’s
CITRACAL
- *CALCIUM** CITRATE
- sometimes with Vitamin D + other minerals*
Help reduce the risk of Osteoporosis
- *1T QD/BID**
- can DISREGARD MEALS*
1000mg QD
>2500mg QD –> may lead to KIDNEY STONES
MAGNESIUM
Max Dose / ADR / CIP
<350 mg / dose for all >19 yo
ADR:
Diarrhea / Nausea / Ab Cramps
Excess magnesium –> eliminated by KIDNEYS
can accumulate and have risk in person with RENAL DYSFUNCTION
Contraindication / Precaution:
Excessive intake –> HYPERmagnesemia
RESPIRATORY / MUSCLEparalysis
complete HEART BLOCK
Magnesium Patient Counseling
TAKE WHOLE
some enteric coating to delay release
may be taken with food
- *do NOT exceed 2 TABLETS DAILY**
- unless advised*
Calcium Facts
MOST ABUNDANT MINERAL
5th most common element in body
Main roles:
Formation & metablism of BONE
Intracellular messenger
Magnesium DOSING
Deficiency Treatment
200-400mg /day
of oral elemential magnesium, divided
BID to TID
to LIMIT side effects
VItamin D
Max Dose / ADR
<4,000 IU for ALL > 9y/o
Well tolerated
OVER SUPPLEMENTATION can lead to:
anorexia / urination / weight loss
+ INCREASED CALCIUM levels
–> vascular / renal / cardiac calcification
Women’s Health Initiative:
increase risk of kidney stones with calcium + vitamin D
women should AIM to get CALCIUM + VITAMIN D from DIET
(100mcg)
Histamine 2 Antagonist
Drug Related Vitamin Deficiency
Vitamin B12 MALABSORPTION
reduced ACID –> impaired release of B12 from food
same as PPI’s
Loop Diuretics
Drug - Mineral
INTERACTIONS
Furosemide / Torsemide / Bumetanide
DECREASE in
Na / K / C / Mg
Iron Formulations
Best = CARBONYL IRON (not a salt )
SIMILAR absorption between salts
Ferrous Sulfate/Gluconate/Citrate
is more soluble than Ferric (Fe3+)
ferric has the LEAST risk of Poisoning
addition of Cu/Co/Mb/ other minerals
has NO ADVANTAGE, just INCREASED COST
Ferrous Sulfate = Preferred supplement:
due to tolerability / efficacy / cost
CITRATE is the most common though
Excess of WHAT Vitamin supplement causes
KIDNEY STONES
nephrolithiasis
CALCIUM
Magnesium
FORMULATIONS
Absorption VARIES between SALT forms
CHLORIDE
enteric coating delays absorption
GLUCONATE
take on an empty stomach
L-Lactate / Aspartate
take with food / can be granules
What is CALCIUM’s
THRESHOLD ABSORPTION
500 MG
is the maximum calcium that we can absorb @ 1 time
dose should be:
1200mg** in **2 DIVIDED DOSES
Vitamin D
Dietary Sources
few foods contain enough VITAMIN D
most American Diet is FORTIFIED
- *Flesh of Fatty Fish**
- *Fish Liver Oil**
Beef LIVER / Cheese / Egg yoks : TRACE levels
What Magnesium salt needs to be taken on a
EMPTY STOMACH?
Mg GLUCONATE
better absorbed than chloride
chloride = Enteric coating –> delays absorption
RDA for VITAMIN D
19-50 y/o
600 IU = 15 mcg
FOR ALL
Max >4,000 IU (100mcg) for ALL
SLOW-MAG
- *Magesium Chloride** + Calcium Carbonate
- *Enteric Coated**
- *2 Tabs = 1 Serving**
- *143mg Mg** + 238mg Calcium
Recommended doses:
400mg Males / 310mg Females+lactation
350mg Pregnancy