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pharmaceutics
Review
EvidenceofDrug–NutrientInteractionswith
ChronicUseofCommonlyPrescribed
Medications: AnUpdate
EmilyS.Mohn1,HuaJ.Kern2,EdwardSaltzman1,SusanH.Mitmesser2andDianeL.McKay1,*
1 Jean MayerUSDAHumanNutritionResearchCenteronAging,
andFriedmanSchoolofNutritionScienceandPolicy,TuftsUniversity,Boston,MA02111,USA;
emily.mohn@tufts.edu (E.S.M.); edward.saltzman@tufts.edu (E.S.)
2 Nutrition & Scientific Affairs, Nature’s Bounty Co., Ronkonkoma, NY 11779, USA;
carinakern@nbty.com (H.J.K.); susanmitmesser@nbty.com (S.H.M.)
* Correspondence: diane.mckay@tufts.edu; Tel.: +1-781-608-7183
Received: 13 February 2018; Accepted: 16 March 2018; Published: 20 March 2018
Abstract: The long-term use of prescription and over-the-counter drugs can induce subclinical and
clinically relevant micronutrient deficiencies, which may develop gradually over months or even years.
Giventhelargenumberofmedicationscurrentlyavailable,thenumberofresearchstudiesexamining
potential drug–nutrient interactions is quite limited. A comprehensive, updated review of the potential
drug–nutrient interactions with chronic use of the most often prescribed medications for commonly
diagnosed conditions among the general U.S. adult population is presented. For the majority of the
interactionsdescribedinthispaper,morehigh-qualityinterventiontrialsareneededtobetterunderstand
their clinical importanceandpotentialconsequences. Anumberofthesestudieshaveidentifiedpotential
risk factors that may make certain populations more susceptible, but guidelines on how to best manage
and/orpreventdrug-inducednutrientinadequaciesarelacking. Althoughwidespreadsupplementation
is not currently recommended, it is important to ensure at-risk patients reach their recommended
intakes for vitamins and minerals. In conjunction with an overall healthy diet, appropriate dietary
supplementationmaybeapracticalandefficaciouswaytomaintainorimprovemicronutrientstatusin
patients at risk of deficiencies, such as those taking medications known to compromise nutritional status.
Thesummaryevidencepresentedinthisreviewwillhelpinformfutureresearcheffortsand,ultimately,
guiderecommendationsforpatientcare.
Keywords:drug–nutrientinteraction;micronutrientdeficiencies;nutrientinadequacies;multivitamin;
dietary supplement
1. Introduction
Thelong-termuseofprescriptionandoverthecounter(OTC)drugscaninducesubclinicaland
clinically relevant micronutrient deficiencies which may develop gradually over months or even years.
Unfortunately, nutrient deficiencies seldom present as classically described and, with the exception
of the most commonmicronutrientissues, manyhealthcareprovidersarenotknowledgeableabout
micronutrient deficiency or excess. This may lead to erroneous attribution of deficiency states to
adiseasestate or the aging process itself [1] and may delay diagnosis. Drug-induced micronutrient
depletion may be the origin of otherwise unexplained symptoms, some of which might influence
medication compliance [2].
Drug–nutrientinteractions are defined as physical, chemical, physiologic, or pathophysiologic
relationships between a drug and a nutrient, and typically involve multiple factors [3,4]. Drugs can
influencefoodintake,nutrientdigestion,absorption,distribution,metabolismtoactiveforms,function,
Pharmaceutics 2018, 10, 36; doi:10.3390/pharmaceutics10010036 www.mdpi.com/journal/pharmaceutics
Pharmaceutics 2018, 10, 36 2of45
catabolism and excretion [5,6]. Additionally, the presence of compound-specific transport proteins,
receptors, and enzymes in different tissues alters the pattern and location of where drugs and
nutrients interact, creating scores of possible tissue-specific interactions [4,5], and makes prediction of
clinical effects difficult. Ethanol and tobacco also influence micronutrients in ways similar to drugs,
but discussion of this is beyond the scope of this review.
AccordingtotheNationalAmbulatoryCareServiceSurveyreleasedbytheNationalCenterfor
HealthStatistics, the chronic conditions most often present in patients >45 years that require chronic
drug use include hypertension, hyperlipidemia, arthritis, diabetes, depression, asthma, ischemic
heart disease, and chronic obstructive pulmonary disease (COPD) [7]. Data from the National Health
Interview Survey showed the prevalence of hypertension among adults was 29.0% in 2011–2014
and increased with age [8]. Furthermore 12% of individuals aged 45–64 years, and 29.4% aged
≥65 years were diagnosed with heart disease (all types), 27.4% of all adults aged ≥20 years had
hypercholesteremia, and 11.9% had diabetes. Although only 3.4% of adults were reported to have
serious psychological distress, including depression, these adults were more likely to have COPD,
heart disease, and diabetes [9]. This suggests there is a higher prevalence of depression in individuals
withchronicdisease. A substantial number of adults reported having conditions that may warrant
the use of nonsteroidal anti-inflammatory drugs (NSAIDS) or corticosteroids, including osteoarthritis,
which is the most common cause of disability in older adults, as well as low back pain (28.1% of
adults), severe headache or migraine (15.3%), and neck pain (14.6%). The overall prevalence of asthma
amongadultsis7.6%,butthisrateincreasedwithobesity(11.1%),particularly among women(14.6%).
In addition, a considerable number of women (26.7%) aged <45 years reported the regular use of
oral contraceptives.
Given the large number of medications currently available, the number of research studies
examiningpotentialdrug–nutrientinteractionsisquitelimited. APubmedsearchrevealedthenumber
of published research studies describing the potential effects of drug–drug interactions exceeds those
describing drug–nutrient interactions by 100 fold. Often the resources on drug–nutrient interactions
that are readily available to health care providers simply repeat the same lists of outdated or obscure
examples, and seldom provide any perspective on the degree or quality of the supporting evidence.
Acomprehensive,updatedreviewofthepotentialdrug–nutrientinteractionswithuseofthemostoften
prescribed medications for commonly diagnosed conditions among the general U.S. adult population
is warranted. Thus, the goal of this review is to update the available evidence as it relates to these
conditions, and enhance awareness of the potential nutrition-related problems with chronic use of
commonlyprescribedmedications(Table1).
Pharmaceutics 2018, 10, 36 3of45
Table1. Summaryofpotentialdrug–nutrientinteractions and knownriskfactors.
DrugCategory Name Nutrient Effect on Nutrient HumanStudies1 RiskFactors References
Status or Function
Advancedage
5observational H.pylori infection
5intervention Genetics (slow metabolizers
Decrease 1observation Lowdietaryintake(vegetarians) [10–17]
VitaminB12 Decrease 4intervention H.pylori infection [18–22]
VitaminC Decrease 2casereports Pre-existing iron deficiency [23]
Acid-Suppressing Drugs Proton PumpInhibitors Iron Decrease 1observational Vegetarians [24–28]
CalciumMagnesium Decrease 2intervention Advancedage [29–31]
Zinc Decrease >10observational Women –
β-Carotene Decrease 4intervention Advancedage –
30 case reports Durationofdruguse
2intervention Women
1intervention Undetermined
Undetermined
1observational Absenceofcoldvirus
Non-Steroidal Aspirin VitaminC Decrease 4intervention Advancedage [32–35]
Anti-InflammatoryDrugs Iron Decrease 6observational H.pylori infection [36–39]
8intervention
Dose/durationofdruguse
Formofloopdiuretic
Advancedage
Women
Advancedage
Heartfailure
LowMgintake
Alcohol use
>20observational Long-termuse
9intervention Coronaryheartfailure
>10observational Advancedage
1intervention Lowdietarythiaminintake
Decrease (loop) 4observational Hepatic cirrhosis [40–48]
Calcium Increase (thiazide) 2intervention Diabetes mellitus loop
Magnesium Decrease (loop and 3observational Heartfailure [42,49–54]
Thiamin thiazide) 6intervention Gastro-intestinal disorders thiazide
Diuretics (loop, thiazide) Zinc Decrease (loop) 3observational Renaldisease [55–57]
Diuretics Potassium Decrease (thiazide) >100intervention Lowdietaryzincintake [58–62]
Anti-Hypertensives (potassium-sparing) Folate Decrease (thiazide) 2casereports Dose [63–69]
Angiotensin-Converting Zinc Decrease 1observational Formofthiazideused [70–74]
EnzymeInhibitors Potassium Decrease 3observational Lowfolatestatus [75,76]
CalciumChannelBlockers Iron 2 Increase 6intervention Impairedliver function [77–85]
Folate N/A 2casereports Liver cirrhosis (alcoholics) [86–91]
Potassium Decrease 3observational Useofcaptopril –
Increase 1intervention Heartfailure [92–99]
1intervention Renaldisease [100–103]
6casereports Age(elderly)
3observational Renaldisease
2casereports Diabetes mellitus
2observational Congestive heart failure
Potassiumsupplementuse
Undetermined
Presence of dental plaque
Poororalhygiene
Gender(men)
Dose
Lowfolateintakes
Concurrentuseofbeta-blockers
Pharmaceutics 2018, 10, 36 4of45
Table1. Cont.
DrugCategory Name Nutrient Effect on Nutrient HumanStudies1 RiskFactors References
Status or Function
7observational Dose
CoenzymeQ10 >10intervention Advancedage
VitaminD Decrease >10observational Statin-associated myopathy [104–114]
Hypercholesterolemics Statins Vitamin Increase/Decrease 4intervention Heartdisease [115–128]
E/β-Carotene Increase/Decrease 1observational VitaminDdeficiency –
6intervention Statin-associated myopathy
Undetermined
Dose/durationofdruguse
>10observational Advancedage
Hypoglycemics Biguanides (Metformin) VitaminB12 Decrease >10intervention Vegetarians [129–140]
Thiazolidinediones Calcium/VitaminD Decrease 3observational Advancedage [141–145]
>10intervention Women
Lowcalcium/vitaminDintake
>80observational
Calcium/VitaminD Decrease >10intervention Lowcalcium/vitaminDintake [146–154]
Corticosteroids Glucocorticoids (oral) Sodium/Potassium Increase (sodium) ~5case Atriskforbonefracture/loss –
Chromium Decrease (potassium) reports/observational Undetermined –
Decrease 1intervention Undetermined
1intervention
>10observational Presence of COPDSmoking
Bronchodilators Corticosteroids (inhaled) Calcium/VitaminD Decrease >10intervention Atriskforbonefracture/loss [155–159]
Lowcalcium/vitaminDintake
Lowfolateintake
Selective Serotonin Folate 3 Increase 3 5observational Genetics (MTHFRvariants) [160–167]
Antidepressants ReuptakeInhibitors Calcium/VitaminD Decrease 2intervention Alcoholism [168–171]
>10observational Atriskforbonefracture/loss
Lowcalcium/vitaminDintake
Undetermined
>10observational Vegetarians
5intervention Lowfolateintake
VitaminB6 Decrease 4casereports Genetics (folate) –
VitaminB12/Folate Decrease >30observational Durationofdruguse [172–183]
Oral Contraceptives Estrogen and/or Calcium Increase/decrease 5intervention Durationofdruguse [184–193]
Progesterone Magnesium Decrease 7observational Physical activity level [194–200]
VitaminC/VitaminE Decrease 6intervention Lowcalciumintake –
>20observational Ageatfirstuse
>10observational Race
2intervention TypeofcombinedOCused
Undetermined
1 Total number of studies that have investigated the potential drug–nutrient interaction (includes both significant and null results); 2 Nutrient effect on drug side effect; 3 Effect of nutrient
ondrugefficacy.
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