PPIs and magnesium

Long term use of proton pump inhibitors (PPIs) has been reported to reduce levels of magnesium The TGA and US FDA have advised that prescribers should be alert to hypomagnesaemia in people taking PPIs20 round one third of Australians 18+ dont get the RDI of magnesium21 dietary shortfall becomes A more signicant at age 651

Antibiotics and disruption of GI microora

Antibiotics can affect benecial microora of gastro-intestinal tract linically-trialled probiotic strain Lactobacillus reuteri Protectis helps reduce incidence of bloating, C atulence and diarrhoea in people taking antibiotics24-26

Signs of magnesium deciency include: 11

Vertigo

Poor concentration

Lactobacillus reuteri Protectis has been shown to remain viable throughout the GI tract and to temporarily colonise the gut produces reuterin, an antimicrobial substance which is unique to this species of probiotic bacteria27

Could lling a script mean diminishing

Hyper-irritability and excitability

Blackmores BIOTIC Companion

Probiotic support when taking antibiotics Lactobacillus reuteri Protectis 200 million organisms per tablet Natural lemon/lime avoured chewable tablet No refrigeration required if stored below 25C Dosage adults and children over 2 years: Chew 2 tablets per day or as professionally prescribed. Tablets can be crushed if preferred*

Muscle cramps

Magnesium contributes to:22,23 uscle and nerve function M aintenance of healthy bones and teeth M ormal energy metabolism N lectrolyte balance E

Relationship to other prescribed medicines

If using L. reuteri Protectis with antibiotics to which L. reuteri is sensitive, separate doses by at least two hours.

In vitro resistance/sensitivity to L. reuteri 28,29

Blackmores PPI Companion

Nutritional support while taking PPIs Contains magnesium citrate, a highly bio-available form of magnesium, equivalent to 150 mg Dosage: 2 capsules once a day with meals or as professionally prescribed

Resistance demonstrated to certain antibiotics, including: Penicillins: Amoxycillin, amoxycillin with clavulanic acid, ampicillin, penicillin G Also: Vancomycin, streptomycin, doxycycline, tetracycline, trimethroprim, kanamycin and amikacin

Moderate resistance demonstrated to certain antibiotics, including: Cefaclor, gentamycin and chloramphenicol

Sensitivity demonstrated to certain antibiotics, including: Cephalexin, erythromycin, roxithromycin, clindamycin

No separation of dosing required

Consider recommending a dosing interval between antibiotic and BIOTIC Companion

Recommend separating doses by at least 2 hours

*Ifdiarrhoeapersistsinchildrenover2yearsformorethan12hours,medicaladviceshouldbesought.

E XCLUSIVE TO PHARMACY AND ENDORSED BY:

Relationship to other prescribed medicines

Proton pump inhibitors may cause hypomagnesaemia if taken long-term (usually >1 year). Magnesium supplementation is recommended. Magnesium may decrease the absorption and efcacy of tetracycline and quinolone antibiotics, bisphosphonates and chlorpromazine unless doses are separated by at least 2 hours.

References: 1. McLennan W, Podger A. National nutrition survey: Nutrient intakes and physical measures, Australia, 1995. Canberra: Commonwealth of Australia, 1998. 2. Higdon J. An evidenced based approach to vitamins and minerals. New York: Thieme. 2003. 3. Grasses G, et al. Magnesium Research. 2006;19:21026. 4. Cohen N, Golik A. Heart Fail Rev 2006;11(1):1924. 5. Baykal Y et al. J Hypertens. 2003;21(6):120711. 6. Gibson R, Heath AL. Nutr Dietetics 2011;68:97108. 7. Natural Standard Zinc monograph. Accessed May 2011 from www.naturalstandard.com 8. Yanagisawa H. Yakugaku Zasshi 2008;128(3):3339. 9. Hotz C, et al. Food Nut Bull, 2004;25(1 Supp 2): S91S204. 10. Tuerk M, Fazel N. Curr Opin Gastroenterol 2009;25:13643. 11. Braun L, Cohen M. Herbs & Natural Supplements. Australia: Elsevier. 2010. 12. Natural Medicines Comprehensive Database. Accessed June 2011 from www.naturaldatabase.therapeuticresearch.com 13. Marcoff L, Thompson PD. J Am Coll Cardiol 2007;49(23):22317. 14. Lee J, et al. J Am Coll Cardiol 2008;52:194956 15. Di Stasi SL, et al. Phys Ther 2010;90:153042. 16. Mabuchi H et al. Atherosclerosis 2007;195:182-9.17. Nowson CA, et al. Aust Fam Phys 2004;33(3):1338. 18. Peterlik M, et al. Int J Environ Res Public Health 2009;6:2585607. 19. Anagnostis P, et al. Curr Vasc Pharmacol, 2010, 8, 72030. 20. TGA. Medicines Safety Update Vol 2, No 3, June 2011. Accessed August 2011 from http://www.tga.gov.au/hp/msu-2011-03.htm 21. ABS national Nutritional Survey 1995 (unpublished data). `Adjusted nutrient intakes in comparison to RDI. 22. EFSA. Journal publication from The European Food Safety Authority (EFSA). Accessed Aug 2011 from www.efsa.europa.eu/en/scdocs/scdoc/1216.htm 23. Volpe SL. Magnesium, in Bowman BA, Russell RM (eds). Present knowledge in nutrition, 9th Ed, Vol 1. Washington, DC: International Life Sciences Institute, 2006. 24. Cimperman L et al. J Clin Gastroenterol 2011; J Clin Gastroenterol. 2011 May 5 [Epub ahead of print]. 25. Lionetti E, et al. Aliment Pharmacol Ther 2006;24:14618. 26. Francavilla R et al. Helicobacter 2008;13:12734. 27. Casas IA et al. Microbial Ecol Health Disease 2000;12:24785. 28. Consulchem Pty Ltd. Laboratory report (reference M4567). Unpublished data. December 2003. 29. Egervarn M. Antibiotic susceptibility proles of Lactobacillus reuteri strains ATCC 55730 and DSM 17938. Study performed by the Swedish national Food Administration. Uppsala, Sweden. December 2007. Unpublished data. OHW BLA0023 09/11

Helping offset the nutritional consequences of taking key prescription medicines

b l a c k m o re s c o m p a n i o n s . c o m . a u

Why should you think about nutrition with your next prescription?
Taking some prescription medicines long term can result in reduction of nutrients Many patients, especially those in older age groups, may already have low nutrient levels due to poor dietary intake1, reduced absorption2 and other factors3

Antihypertensives and zinc

Research has shown long term use of ACE inhibitors4, angiotensin-II receptor antagonists (ARBs)5 and thiazide diuretics4 may reduce zinc levels Age also affects zinc status6 43% of women over 65 years of age receive less than the RDI of zinc1

Statins, coenzyme Q10 and vitamin D3

Coenzyme Q10 (CoQ10) is a cofactor in energy production, especially important for the heart. It is naturally synthesised in the body, decreasing with age12 Serum CoQ10 levels may be disrupted whilst taking statins by up to 54%13

Consider zinc status in patients filling scripts for ACE inhibitors, ARBs or thiazide diuretics with the following presentations:
Poor appetite or low food consumption (especially meat)6 GI tract issues such as achlorhydria or diarrhoea, which may contribute to zinc deficiency11 Impaired sense of taste and smell7,8 Poor immunity8 (e.g. increased susceptibility to infections) Poor skin health (e.g. delayed wound healing)911

Adverse effects associated with statins

Myalgia is one of the most commonly reported adverse effects of statins its also one of the first signs of vitamin D deficiency14 Other symptoms include muscle cramping, soreness, fatigue, weakness15

Blackmores Companions are specially formulated to help offset the nutritional consequences of taking key prescription medicines

antihypertensives

statins

Clinical rationale for CoQ10 and vitamin D supplementation: CoQ10 at 100 mg/day increased plasma levels by an average of 127% without compromising lipid-lowering statin effects16 Vitamin D insufficiency is widespread in the Australian population,17,18 and has been associated with poor cardiovascular health19

Supplement sooner rather than later:

(ACE inhibitors, angiotensin-II receptor antagonists and thiazide diuretics)

Blackmores stat companion

Nutritional support while taking statins Easily absorbed form of CoQ10 (100 mg) and cholecalciferol (25 mg) equivalent to 1,000 IU vitamin D Dosage: 1 capsule a day with food, 2 hours away from medication, or as

Taking 2030mg supplemental zinc within 6 months of zinc deficiency onset results in improved therapy response rate (>70% greater than if initiated later than 6 months).8

ppis

antibiotics

Blackmores aNti-ht companion

professionally prescribed
If nutritional deficiency is suspected, pharmacists should refer customers to their GP for further investigation.

Nutritional support while taking ACE inhibitors, ARBS and thiazide diuretics Easily absorbed form of zinc (zinc gluconate, equivalent to 20 mg elemental zinc) Dosage: 1 capsule a day with food, 2 hours away from medication, or as professionally prescribed. Avoid taking with calcium, iron, coffee or phytates e.g. cereals, legumes and nuts
If nutritional deficiency is suspected, pharmacists should refer customers to their GP for further investigation.

Relationship to other prescribed medicines

CoQ10 may: Have hypotensive effects in patients with hypertension and may have additive effects on antihypertensive medications Interfere with some types of chemotherapeutic agents. Use with caution Decrease the anticoagulant effect of warfarin Decrease blood glucose levels in people on hypoglycaemic therapy Vitamin D3 may theoretically cause hypercalcaemia if taken with thiazide diuretics. Caution is advised in those with hyperparathyroidism, malignancies that increase serum calcium levels or other risk factors for hypercalcaemia.

Relationship to other prescribed medicines

Zinc may decrease absorption and blood levels of tetracycline and quinolone antibiotics unless doses are separated by at least 2 hours.