Monthly Archives: February 2014

Cardiovascular Medication and Associated Drug-Induced Nutrient Depletion

Medications are essential in the treatment of cardiovascular disease.

However, it is well published in the literature that medication can deplete us of certain nutrients and it is specific for the drug in question. Nutrient depletion is also well known as a cause of chronic disease. Bruce Ames PhD, Professor Emeritus, Biochemical and Molecular Biology, University of California Berkeley, has published extensively regarding nutrient depletion accelerating chronic disease and obesity.

While visiting with an esteemed colleague of mine over Christmas who is a cardiologist, we had a chat about this and he asked me to come up with a list of the common nutrient depletions associated with certain cardiovascular drugs. This is in the hopes of improving the overall health of his patients as well as others. This certainly is not an attempt to minimize drug therapy but educate physicians as well as patients which nutrients one may consider supplementing while taking these drugs. I shall list the drugs as well as the nutrients depleted as well as some of the consequences associated with this particular nutrient depletion. I want to thank ahead of time Dr. James Lavelle who is a pioneer in this area.
  •  Angiotensin-converting enzyme inhibitors: Lisinopril, enalapril, Prinivil among others potentially deplete Zinc and generally the recommended replacement dose while taking these is 25 mg daily, I like the chelated form which is better absorbed. Potential health consequences of depletion (partial list): Decreased immunity, wound healing, depression, insulin resistance, increased oxidative stress which in turn leads to worsening of hypertension.
  • Angiotensin receptor blockers: (Multiple in this class) recently also had literature suggesting Zinc depletion.
  •  Beta blockers: Atenolol, Metoprolol, Toprol, Coreg, Corgard, Sotalol, among others potentially deplete Co-enzyme Q10 and Melatonin. Potential health consequences of depletion of Coenzyme Q10 (partial list): Hypertension, congestive heart failure, muscular fatigue and weakness, irregular heartbeat, insulin resistance. Recommended dose of a well absorbed Coenzyme Q10 is 100 mg daily. Be careful to obtain a form of coenzyme Q10 that is well absorbed as there are several on the market without documented absorption rates or blood levels. Potential health consequences of depletion of Melatonin (partial list): Sleep disturbances that may lead to insulin resistance and other problems, increased cancer risk, increased oxidative stress in the brain. Dosage repletion of Melatonin is generally 3-6 mg at night.
  •  Digoxin: Potential depletion of Magnesium, Calcium, Phosphorus and Vitamin B1 (thiamine). Magnesium is the one that is most commonly described. Potential health consequences of depletion of Magnesium: Muscle cramps, weakness, fatigue, insomnia, restless legs syndrome, anxiety, insulin resistance, depression, hypertension, headaches, cardiovascular problems. There are several forms of Magnesium, I personally prefer the chelated or Glycinated form as it is very well absorbed. In the nutritional world, magnesium oxide is generally not felt to be the preferred form. Magnesium glycinate dose is 200 mg twice daily. Other forms include magnesium citrate, taurate, and malate.
  • Potential health consequences of depletion of Calcium: Increased risk of osteoporosis, heart and blood pressure problems, back or leg problems. Usual dose to replete is 500 mg daily of a citrate/carbonate/ascorbate complex.
  • Potential health consequences of depletion of Phosphorus: Decreased calcium absorption, increased risk of osteoporosis. Repletion is usually in a good multiple vitamin.
  • Potential health consequences of depletion of Vitamin B1 (thiamine): Depression/mood imbalances, irritability, memory loss, confusion, muscular weakness, irregular heartbeat, numbness and tingling. Repletion is usually in a high potency multiple vitamin.
  • Statins: Zocor, Lipitor, Crestor, Pravachol etc. Potential depletion of Coenzyme Q10 is the most common, however several vitamins and minerals have been associated with these. Testosterone is potentially lowered as well because cholesterol is the parent molecule of all of our hormones. Consider Coenzyme Q10 100 mg daily, in addition to the 100 mg taken for your beta blocker. I also recommend a good multiple vitamin along with this and to maintain a Vitamin D level in the 50-80 range.
  • Diuretics: There are different classes of diuretics and I will outline below.
  • Lasix (furosemide), Bumex (bumetanide): Potential depletion of Calcium, Magnesium, Vitamin B1, Potassium, Sodium, Vitamin B6, Vitamin C, Zinc.
  • Magnesium, Zinc B1 and B6 are the ones that most often come to mind. Potassium is generally supplemented and tested for routinely. One very important concept regarding Magnesium depletion is that it causes ongoing potassium depletion because of renal leak induced by the magnesium depletion.
  • Potential health consequences of depletion of Vitamin B1, nerve inflammation, PMS, anemia, elevated homocysteine, seborrheic dermatitis, depression and sleep disturbances among others. Repletion is usually in a good multiple vitamin.
  • Thiazide diuretics (hydrochlorothiazide, metolazone, Lozol): Essentially the same potential of nutrients depleted, but in addition, Coenzyme Q10.

So, the above are the most commonly prescribed cardiovascular medications. However, many cardiovascular patients are on additional drugs including metformin, proton pump inhibitors or H2 blockers. I will outline these as well.

  • Metformin: Potential depletion of Co-enzyme Q10, Folic acid, Vitamin B12. Potential health consequences of depletion of Vitamin B12: Fatigue, peripheral neuropathy, macrocytic anemia, depression, memory loss, increased cardiovascular risk, decreased methylation. Repletion is usually in a good multiple vitamin. In addition, many times, additional vitamin B-12, especially the methylated form, Methyl B12 is beneficial, usually in a dose of 1000 µg daily.
  • Potential health consequences of depletion of Folic acid: Anemia, heart disease, elevated homocysteine, fatigue, insomnia, decreased methylation, increased cancer risk. Repletion is usually in a good multiple vitamin. Again, an excellent form of this that bypasses our bodies need to place the methyl group on the folic acid is methyl tetrahydrofolic acid or Methyl-Folate. This inability to place the methyl group on the folic acid as well as vitamin B12 is actually a fairly common problem. Many of the nutraceutical companies have a combination of the active (methyl) form of both B12 and folic acid. Please see below.
  •  Proton pump inhibitors: (Nexium, Prilosec, Dexilant, Prevacid etc) and H2 Blockers: Potential depletion of Calcium, Magnesium, Zinc, Folic acid, B12, Vitamin D, Iron.
  • Potential health consequences of depletion of Iron: Anemia, fatigue, hair loss, brittle nails and decreased thyroid hormones. I prefer a chelated form of iron which tends to be less constipating than many iron supplements. Beware, however, do not supplement iron unless it is low. Iron overload can be associated with increased risk of coronary disease. Please check with your healthcare provider and have your iron checked before supplementing with any iron supplements. However, adequate iron is needed for optimal thyroid function. Usually, the dose of a chelated iron is 1-3 daily.
  • Antidepressants, specifically SSRIs: Potential depletion of Melatonin and Tryptophan. Potential health consequences of depletion of Tryptophan: Neurochemical imbalance (tryptophan helps make serotonin which is the calming brain chemical), anxiety, depression, other psychiatric disorders, insomnia, sleep disturbances and food cravings. Tryptophan can be supplemented, usually around 500 mg daily.

And so, this is probably fairly overwhelming to both a cardiologist that is not trained in nutrition as well as their patients. I will try to summarize below a short list that may help.

  • In general, a high potency multivitamin, multi mineral, multi vitamin supplement will suffice. And when I say a high potency vitamin as above, I usually am referring to a nutraceutical grade vitamin. A typical One-A-Day vitamin does not fulfill these criteria. B vitamins in a higher potency multi generally are in the range of 25-50 mg of the basic B’s. Calcium and magnesium are usually in the 500 mg range, usually in a 1:1 ratio. An example of a high potency multivitamin multi mineral vitamin is Basic Preventative Five by Douglas labs, and the dosage is usually 3 tablets twice daily.
  • A very good high potency multivitamin (but not multi mineral) which has a Phytonutrient complex added to it is the PhytoMulti by Metagenics. This is a 2 a day vitamin which is outstanding. However, one must take an additional mineral complex would be needed if indicated by the above guidelines.
  • Vitamin D3 supplemented to a level between 50 and 80, this usually requires at least 4000-5000 units daily, please be advised however that the Institute of Medicine recommendations is 1200 units daily although I rarely see a therapeutic level at that dose. Potential depletion by Statins, PPIs, H2 Blockers. Various available one of my favorites is Multigenics D3 Liquid,1000 units per drop, 2000 drops per bottle!
  • Co-enzyme Q10: 100 mg daily for each drug that depletes this: Potential depletion by beta blockers, statins, metformin, thiazide diuretics. I use Citrus Sol-Q by Douglas, or Ubiquinol by Ortho Molecular.
  • Methyl B12, Methyl Folate: Ortho Molecular makes a very good supplement simply called Methyl B12 that includes 5000 mcg of Methyl B12 and 1000 mcg Methyl Folate in one tablet per day. Potential depletion by Metformin, PPIs, Diuretics.
  •  Melatonin 3-6 mg nightly. Potential depletion by SSRIs, Beta blockers. Various available OTC. Also available on website.
  •  Amino-Iron by Douglas Laboratories is a very good chelated iron supplement.

John B Abell M.D. ABIM, FAARFM, ABAARM