Community pharmacy Topic 2 part2 Minerals supplements Minerals

Community pharmacy Topic: 2 part(2) Minerals supplements

Minerals • The human body consists of number of minerals and trace elements which are required for various metabolism function in the body. • The important minerals involved are: calcium, phosphorus, sodium, potassium, iron and iodine. 2

Calcium • Calcium in association with vitamin D, and phosphorus, is essential for the hardening of the bone and teeth. • Builds and protects bones and teeth. • Helps with muscle contractions and relaxation, blood clotting, and nerve impulse transmission. • Plays a role in hormone secretion and enzyme activation. • Helps maintain healthy blood pressure 3

• There is no clear cut definition as signs and symptoms due to the deficiency of calcium. Children, expectant and nursing mothers require higher amount of calcium as it is needed for the growth of tissues and bones Table 1: Recommended Dietary Allowances (RDAs) for Calcium Age Male 14– 18 years 19– 50 years 4 51– 70 years Female Pregnant Lactating 1, 300 mg 1, 000 mg 1, 000 mg 1, 200 mg

• Adults absorb roughly 30% of calcium ingested, but this can vary depending on the source • Diets very high in calcium may increase the risk of prostate cancer. • Dietary supplements: The two main forms of calcium in supplements are carbonate and citrate. 5 - Calcium carbonate is more commonly available both inexpensive and convenient calcium carbonate is absorbed most efficiently when taken with food Calcium citrate is also useful for people with achlorhydria, inflammatory bowel disease, or absorption disorders Calcium carbonate has more side effects (constipation, bloating…. )

• Absorption is highest in doses ≤ 500 mg. So, for example, one who takes 1, 000 mg/day of calcium from supplements might split the dose and take 500 mg at two separate times during the day. • Absorption of calcium from gut depend on: - Amount consumed: the efficiency of absorption decreases as calcium intake increases - Age and life stage: net calcium absorption is as high as 60% in infants and young children, decreases to 15%– 20% in adulthood (though it is increased during pregnancy) - Vitamin D intake: this nutrient, obtained from food and produced by skin when exposed to sunlight of sufficient intensity, improves calcium absorption - Other components in food: oxalic acid (milk, spinach)

• Amount of Ca eliminated from body depend on: - Sodium and protein intakes: high sodium intake increases urinary calcium excretion - Caffeine intake: increase calcium excretion and reduce absorption. - Alcohol intake: reducing its absorption - Phosphorus intake: high levels of phosphate is associated with reduced bone mass and increased fracture risk - Fruit and vegetable intakes: metabolic acids produced by diets high in protein and cereal grains increase calcium excretion

• Calcium supplements contain varying amounts of elemental calcium. For example, calcium carbonate is 40% calcium by weight, whereas calcium citrate is 21% calcium. Fortunately, elemental calcium is listed in the Supplement Facts panel, so consumers do not need to calculate the amount of calcium supplied by various forms of calcium supplements.

• Calcium supplements contain varying amounts of elemental calcium. For example, calcium carbonate is 40% calcium by weight, whereas calcium citrate is 21% calcium, calcium gulconate 9% and calcium lactate 13%. • Corrected calcium level: • Corrected calcium = 0. 8 * (4. 0 - serum albumin) + serum calcium • Ex: ca: 12 mg/dl, albumin: 2 g/dl (N: 3. 45. 4) …. . Corrected Ca level: 13. 6 mg/dl

• Deficiency signs: Brittle bones, unhealthy teeth, muscle spasms (tetany) • Hypocalcemia results primarily from medical problems or treatments, including renal failure, surgical removal of the stomach, and use of certain medications (such as diuretics). • Symptoms of hypocalcemia include numbness and tingling in the fingers, muscle cramps, convulsions, lethargy, poor appetite, and abnormal heart 10 rhythms

• Groups at Risk of Calcium Inadequacy: • Postmenopausal women • Amenorrheic women and the female athlete triad • Individuals with lactose intolerance or cow's milk allergy • Vegetarians • Safety: High doses of calcium can cause stomach upset, diarrhea, headache, increased heart attack risk and gall and kidney stones.

• Systemic antacids: calcium-containing salts • These can induce rebound acid secretion and so should not be used for prolonged periods. Prolonged high doses may cause hypercalcaemia… provide: 200 to 400 mg • Corticosteroid: Side-effects associated with long-term high doses limit their place in therapy. If long-term therapy is required, monitor bone mineral density and consider using calcium supplementation and prophylactic therapy for osteoporosis

• Hyperkalemia: Calcium gluconate or calcium chloride (intravenous): aim is to maintain cardiac function; prolonged use may cause hypercalcaemia 13

Phosphorus • Phosphorus is associate of with calcium and vitamin D in the hardening of bones and teeth and helps to maintain the constant composition of the body fluids. Phosphorus are essential part for energy transport inside cells. • M: 700 mg, W: 700 mg 14

Potassium • It is found widely in all foods. The normal intake of the potassium chloride varies from 5 -6 gm and this meets the body's potassium requirements. • It is the most commonly occurring intra cellular cation and is involved in various chemical activities inside cell. It also plays important role in contraction of the muscle, transmission of nerves impulses and maintenance of electrolyte 15 balance in the body.

• Balances fluids in the body. Helps maintain steady heartbeat and send nerve impulses. Needed for muscle contractions. A diet rich in potassium seems to lower blood pressure. Getting enough potassium from your diet may benefit bones • Hypokalemia: a K serum level <3. 5 mmol/L). • Aetiology: diuretics, diarrhoea, alkalosis, vomiting, corticosteroids, renal tubular acidosis. • Signs and symptoms: cardiac abnormalities, muscle weakness, paralysis, weak pulse 16

• Management of hypokalemia: • Oral potassium solution is usually preferred unless patient is unable to swallow; gastrointestinal side-effects may occur. • Intravenous administration of potassium: 20 mmol potassium in 1 m. L mixed with sodium chloride 0. 9%. Monitoring required includes ECG and serum potassium levels. 17

• Hyperkalaemia This condition is characterised by a potassium serum level 5 mmol/L. • Aetiology: renal failure, acidosis, potassiumsparing diuretics. Signs and symptoms: cardiac arrhythmias, muscle weakness. • Management: Calcium gluconate or calcium chloride (intravenous), Sodium bicarbonate (intravenous), Glucose solutions: 18

Sodium • Is found in most foods, artificially enriched bread and as cooking and table salt. • The normal intake of sodium chloride/day varies 5 -20 gm( the daily requirements is between 2 -5 gm), excess amount is excreted in urine. • Sodium is the most commonly extra cellular cation and is associated with: - the contraction of muscle - transmission of nerve impulses in nerve 19 fiber

- maintenance of electrolytes balance in the body. - In cold and influnza: Sodium chloride: 0. 9%, safe product which can be used in paediatric patients and during pregnancy. Patient is advised to apply product as required to provide relief from congestion. - Mouth washes: sodium chloride • While experts recommend that people limit sodium intake to 2, 400 mg, most Americans consume 4, 000– 6, 000 mg a day. 20

Iron • Is soluble compound, found in green leafy vegetable, liver, kidney, eggs yolk, and whole meal bread. Normal adults lose about 1 mg iron daily from the body. The normal daily diet may contain more but the amount absorbed is equal to the amount lost. Higher intake is necessary for women particularly during pregnancy 21

• Iron from an important component of hemoglobin. • Needed for chemical reactions in the body and for making amino acids, collagen, neurotransmitters, and hormones. • Women who do not menstruate probably need the same amount of iron as men • 31– 50: M: 8 mg, W: 18 mg • 51+: M: 8 mg, W: 8 mg 22

• Because iron is harder to absorb from plants, experts suggest vegetarians get twice the recommended amount (assuming the source is food). • Causes of iron-deficiency anaemia • Chronic blood loss: gastrointestinal disease, drug induced, menstrual loss • Increased requirements: pregnancy • Malabsorption • Dietary deficiency. 23

• Clinical presentation of iron-deficiency anaemia • Pale skin and mucous membranes • Glossitis • Angular stomatitis • Koilonychia • Dysphagia • Pica • Atrophic gastritis. 24

• Parenteral iron therapy includes: • Iron dextran injection: deep intramuscular injection. • Iron sucrose injection: slow intravenous injection or by intravenous infusion. • In pregnancy: • Recommended supplementation, usually given in combination with folic acid 25

Iodine • It is found in salt water fish and in vegetables grown in soil containing iodine. The minimum daily requirement of iodine is 140 μg, for an adult man and 100 μg for an adult woman • Iodine is essential for the formation of the thyroxin and triiodothyronine. Its deficiency can lead to endemic goiter, hypothyroidism and impaired hearing and brain development. 26

• Part of thyroid hormone, which helps set body temperature and influences nerve and muscle function, reproduction, and growth. Prevents goiter and a congenital thyroid disorder • Sources: Iodized salt, processed foods, seafood • To prevent iodine deficiencies, some countries add iodine to salt, bread, or drinking water. 27

• In mouth wash: povidone–iodine. • Vaginal candidiasis: Alternative option: povidone–iodine applied twice daily for 14 days. Disadvantages of povidone– iodine: it stains and inconvenience of dosage regimen. • First aid items for cuts and grazes: Antiseptic (iodine based, surgical spirit) • Management of hyperthyroidism: Radioactive iodine. 28

• Hypothyroidism: The most common cause is a secondary one due to radioactive iodine therapy or surgery for hyperthyroidism. Other causes include congenital disease, hypopituitarism and hypothalamic disorders. • Example of management during acute thyroid crisis: Potassium iodide orally 15 mg three times daily • Drugs associated with thyroid dysfunction • Amiodarone: Used in the treatment of arrhythmias, Contains iodine and may cause thyroid disorders (hypothyroidism or hyperthyroidism) 29

Fluoride • About 96% of fluoride is found in bones and teeth. It is essential for the normal mineralization of bones and formation of dental enamel. • The average adult man may ingest about 1 mg of fluoride from drinking water and his daily diet may provide another 0. 25 0. 35 mg of fluoride 30

• Ingestion of large amount is associated with dental and skeletal fluorosis characterized by mottled enamel and osteosclerosis respectively. • On the hand, if the fluoride deficiency occurs due to less than optimum intake of fluoride, it may lead to development of dental caries • M: 4 mg, W: 3 mg 31

• In bone disease: This increases bone formation in cancellous bone rather than cortical bone. It requires calcium supplementation. However, concomitant administration of fluoride with calcium may adversely affect fluoride absorption. To date there is limited clinical experience with fluoride. 32

MAGNESIUM • Needed for many chemical reactions in the body Works with calcium in muscle contraction, blood clotting, and regulation of blood pressure. Helps build bones and teeth • 31+: M: 420 mg, W: 320 mg • Green vegetables such as spinach and broccoli, cashews, sunflower seeds and other seeds, whole-wheat bread, milk 33

• The majority of magnesium in the body is found in bones. If your blood levels are low, the body may tap into these reserves to correct the problem. • Found in antacids ( causes diarrhea), laxatives (Magnesium sulphate, Magnesium hydroxide) • Hypomagnesia : using thiazide durtics • May be Used in Treatment for idiopathic restless leg syndrome 34

Trace elements • Apart from the mentioned minerals, there are other element which are required by the body in very minute amount and hence they are known as trace elements. Zinc: • Is present in all the tissues and is constitute of insulin and many enzymes in the body. It is widely distributed in the food stuffs both animal and 35 vegetable.

• Helps to form many enzymes and proteins and create new cells, Frees vitamin A from storage in the liver. Needed for immune system, taste, smell, and wound healing. • When taken with certain antioxidants, zinc may delay the progression of agerelated macular degeneration • Daily intake in adults range from 5 -10 mg • Low circulating zinc levels have been associated with liver disease, pernicious anemia and delayed wound healing. 36

• Deficinecy signs: Skin, throat and eye lesions, poor sense of smell and taste. Poor wound healing and hair loss. Diarrhea and pediatric growth issues. • Because vegetarians absorb less zinc, experts suggest that they get twice the recommended requirement of zinc from plant foods. 37

• Safety: Over 100 mg a day side effects include nausea, vomiting and stomach cramping • Do not take indigestion remedies or medicines containing iron or zinc at the same time of day as this medicine (e. g. tetracyclines, quinolones). • Barrier preparations in skin disorders: Constituents include zinc oxide 38

• Calamine: Contains zinc oxide and liquid paraffin • Dandruff management : Pyrithione zinc • Prophelaxis in cold and influnza • Hyperhidrosis managemnt: use of talc and zinc oxide dusting powders to adsorb excess sweat • Management of haemorrhoids – topical agents: Astringents (e. g. bismuth, zinc): produce a protective coat • Sun burns: zinc oxide, protection 39 against UVB and UVA

• SELENIUM • Acts as an antioxidant, neutralizing unstable molecules that can damage cells. Helps regulate thyroid hormone activity • M: 55 mcg, W: 55 mcg • Researchers are investigating whether selenium may help reduce the risk of developing cancer. 40

• Dandruff: Selenium: not suitable for children under 5 years of age. Avoid if broken or inflamed skin since irritation may occur. Apply twice weekly for 2 weeks, then once weekly for 2 weeks and then as necessary. 41

• References: 1. A Textbook of community pharmacy: new age international publishers, rakesh saini, 2012. 2. Lecture Notes in Pharmacy Practice, Lilian M Azzopardi, 2010. 3. Food and Vitamins and Supplements! Oh My! Demystifying nutrition: the value of food, vitamins and supplements, Harvard Medical School, 2013 4. Listing of vitamins, Harvard medical school, 2009. 5. National institute of health, office of dietary 42 supplements, fact sheet , USA