Chapter 53, Problem 5O

Summary Introduction

To identify:

The mechanisms of actions, dosages, recommended daily allowances, indications, drug interactions, cautions, contraindications, and routes of administration of all the vitamins and minerals.

Concept introduction:

The human body needs vital building blocks to develop and sustain it. The proteins, carbohydrates, minerals, and fats are the providers of these building blocks. The essential nutrients for life are referred to as vitamins and minerals. Proper intake of nutrient-rich meals (balanced) and fluids satisfy the daily needs of vitamins and minerals. This will ultimately help to offer enzymes, hormones, and chemicals, maintain intestinal structures and inhibit the bacterial outgrowth. Inadequate amounts of vitamins and minerals in the human body lead to diseases such as goiter, anemia, impaired vision, and tooth and bone decay.

Explanation of Solution

The mechanisms of actions, dosages, recommended daily allowances, indications, drug interactions, cautions, contraindications, and routes of administration of all the vitamins and minerals are described below:

Vitamin A

Mechanism of action: Vitamin A plays an important role for normal vision and night vision, as it is a part of rhodopsin. The human system metabolizes the beta-carotene into retinal. This retinal is again reduced into retinal, which is again oxidized into retinoic acid. The role of the retinoic acid includes cell development, morphogenesis (the development of the body’s physical shapes and parts), development and growth of teeth and bones, maintenance of epithelial and mucosal surfaces integrity, reproduction, and steroid and cholesterol synthesis.

Indications: Night blindness, hyperkeratosis of sclera and stratum corneum of the skin, xeropthalmia, generalized weakness, and infant growth retardation increase the changes to get an infection (mucous membranes).

Cautions: Intake of vitamin A in excess amount leads to toxicity, which happens in children (most usually) such as drowsiness, coma, irritability, vomiting, diarrhea, and vertigo. In infants, cranial pressure leads to papilledema, bulging fontanelles, exophthalmos, headache, and visual difficulties. In this case, immediately report to the physician.

Contraindications: It includes drug product allergy and hypervitaminosis.

Adverse effects: It includes nausea, headache, anorexia, lethargy, abdominal pain, dry skin, hypercalcemia, increased pigmentation, hypomenorrhea, night sweats, and growth retardation.

Route of administration: It includes oral and intravenous.

Dosages: PO-100,000 units per day for three days and 50,000 units per day for fourteen days.

Interactions: Absorption of vitamin A is inhibited when it is taken with cholestyramine and laxatives. Similarly, the simultaneous use of vitamin A supplement with isotretinoin leads to toxicity.

Recommended daily allowances: Above 14 years – 700 to 900 micrograms/day and for nursing women 1,200 to 1,300/day.

Vitamin E

Mechanism of action: Vitamin E acts as a biological antioxidant. The nutritional function and drug effects of vitamin E are not completely revealed. It is believed to defend cellular membranes (fatty acids), and obstruct ascorbic acid and vitamin A deterioration.

Indications: It inhibits the oxidation of several substances that inhibit toxic chemical formation inside the body (eg, cancer).

Cautions: Before taking vitamin E supplements, the patient should report the physician about current medications, pre-existing disease, counter products, and allergies.

Contraindications: Contraindication occurs only in the case of known drug allergy. It includes an allergy to a particular product of vitamin E.

Adverse effects: It includes nausea, fatigue, flatulence, weakness, blurred vision, and headache.

Route of administration: It includes oral supplementation and intramuscular injection.

Dosages: PO – 60 to 75 units per day.

Interactions: Bleeding and bruising occur when vitamin E is taken along with warfarin.

Recommended daily allowances: 15 milligrams/day.

Vitamin K

Mechanism of action: Vitamin K plays an important role in coagulating the blood. It enables the biosynthesis (hepatic) of coagulating factors II, VII, IX, and X. Hypoprothrombinemia (coagulation disorder) occurs if vitamin K is inadequate. It is treated by administering vitamin K supplements.

Indications: Vitamin K is indicated for treating the deficiency state and for dietary supplementations.  In rare case administration of broad-spectrum, antibiotics prevent the normal flora to secrete vitamin K that leads to a deficiency state. Vitamin K deficiency also occurs by administering warfarin (oral anticoagulant).

Cautions: Hemolysis can occur in infants. Before taking vitamin E supplements, the patient should report the physician about current medications, pre-existing disease, counter products, and allergies.

Contraindications: It includes the known drug allergy.

Adverse effects: It includes nausea, headache, hemoglobinuria, urticarial, hyperbilirubinemia, brain damage, and rashes.

Route of administration: Oral and intravenous.

Dosages: PO- 1.25 to 10 mg (single dose) and IV/IM: 1-10 mg (single dose)

Interactions: Diet and nutrition affect warfarin treatment.

Recommended daily allowances: Infant – 5mg/day, adult male - 80 mg/day, and for an adult female – 65 mg/day.        

Vitamin D

Mechanism of action: Vitamin D plays an important role in regulating absorption and utilization of phosphorous and calcium, and also for calcification of bones. By means of removing bone calcium and calcium absorption (small intestine), vitamin D regulates the serum calcium level in association with calcitonin and parathyroid hormone. Cholecalciferol and ergocalciferol are the inactive forms of vitamin D. The parathyroid hormone biotransforms the vitamin D2 and vitamin D3 (in the liver) into calcifediol. The kidney is the place where the calcifediol is further transformed into calcitriol (active form). Calcitriol stimulates the phosphorous and calcium deposition, (into bones and teeth) and intestinal absorption (phosphorus and calcium).

Indications: Vitamin D is used to treat long-term deficiency, which leads to tetany, osteomalacia, and infantile rickets.

Cautions: Ingesting vitamin D in excessive amount leads to toxic effects. Children are commonly affected by high doses of vitamin D.

Contraindications: It includes known drug allergy, hyperphosphatemia, hypercalcemia, and renal dysfunction.

Adverse effects: It includes nausea, headache, hypertension, fatigue, albuminuria, muscle pain, metallic taste, constipation, dysrhythmias, cramps, dry mouth, and anorexia.

Route of administration: It includes oral and intravenous.

Dosages: PO- 1.25 to 10 mg (single dose) and IV/IM: 1-10 mg (single dose)

Interactions: Administration of vitamin D with cholestyramine and lubricant laxatives leads to a decreased vitamin D absorption.

Recommended daily allowances: Calcifediol PO- 50 micrograms/day, calcitriol IV/PO- 0.25 to 2 microgram per day, and ergocalciferol PO-50,000 to 2000,000 units per day.

Vitamin B₁

Mechanism of action: Vitamin B₁ (thiamine) acts as a precursor for thiamine pyrophosphate. If thiamine is bound with the adenosine triphosphate, the resultant is thiamine pyrophosphate coenzyme, which is needed for the citric acid cycle.

Indications: Vitamin B₁ is used to treat metabolic disorders. This includes maple syrup urine disease, subacute necrotizing encephalopathy, lactic acidosis, and hyper-beta-alaninemia. A few deficiency states of vitamin B₁ are beriberi, peripheral neuritis, and Wernicke’s encephalopathy. Vitamin B₁ is used to prevent malabsorption that is stimulated by GI disease, cirrhosis, and alcoholism.

Cautions: People who are allergic to some other drugs and foods should immediately report to the prescriber.

Contraindications: It includes the known drug allergy.

Adverse effects: It includes nausea, pulmonary edema, urticarial, restlessness, pruritus, sweating, cyanosis, weakness, and cardiovascular collapse.

Route of administration: Oral and intravenous.

Dosages: 100 mg per day.

Interactions: Vitamin B₁ is incompatible with sulfite and alkaline containing solutions.

Recommended daily allowances: The daily need for an adult is 1.2-1.5 mg.

Vitamin B₂

Mechanism of action: Vitamin B₂ (riboflavin) is transformed into flavin adenine dinucleotide and flavin mononucleotide. These two coenzymes are essential for tissue respiration. Riboflavin is also involved in the catabolism of carbohydrate and it is needed by the vitamin B for activation.

Indications: Patient with liver disease, long-term disease,  alcoholism may experience riboflavin deficiency. Microcytic anemia, congenital methemoglobinemia, acne, microcytic anemia, Grierson-Gopalan syndrome, muscle cramps, and migraine headache are treated with thiamine.

Cautions: People allergic to riboflavin should avoid taking this supplement.

Contraindications: It includes the known drug allergy.

Adverse effects: Riboflavin is an effective (safe) vitamin till now no adverse effects have been reported.

Route of administration: Oral route is recommended.

Dosages: 5 to 30 mg per day.

Interactions: Administration of vitamin B₂ with a combination of drugs (tetracycline) leads to the inhibition of riboflavin absorption.

Recommended daily allowances: For adult men- 1.3 mg and for adult women- 1.1 mg.

Vitamin B₃

Mechanism of action: Nicotinamide adenosine dinucleotide phosphate and nicotinamide adenosine dinucleotide are essential for glycogenolysis pathway.

Indications: Niacin is indicated for the treatment and prevention of pellagra.

Cautions: A patient facing dark-colored urine, muscle pain, muscle cramps, and stiffness should immediately report tp the prescriber for further actions.

Contraindications: It includes severe hypotension, peptic ulcer, and arterial hemorrhage.

Adverse effects: Hyperuricemia, headache, anxiety, dysrhythmias, hepatitis, abnormal function of the liver, dry skin, keratosis, decreased glucose tolerance, and flushing.

Route of administration: Oral and intramuscular.

Dosages: PO-500 mg per day.

Interactions: Interact with bile-acid sequestrates that decrease the drug’s effectiveness.

Recommended daily allowances: 35 mg (for all adults).

Vitamin B₆

Mechanism of action: Pyridoxamine, pyridoxal, and pyridoxine are transformed in erythrocytes into active forms (pyridoxamine phosphate, and pyridoxal phosphate), which are essential for metabolic function.

Indications: Pyridoxine is indicated for treatment and prevention of morning sickness, seizures, and deficiency that can result from medication.

Cautions: Alcohol drinking should be avoided.

Contraindications: It includes the drug (known) allergy.

Adverse effects: Pain at the site of injection, flushing, lethargy, and paresthesias.

Route of administration: Oral and IV.

Dosages: IV/PO- 2.5 to 10 mg per day.

Interactions: Interact with levodopa and affect its effectiveness.

Recommended daily allowances: Depends on age (0.1 mg for 6-month infant and for adult 1.7 mg).

Vitamin B₁₂

Mechanism of action: Cyanocobalamin maintains sulfhydryl groups in the reduced state, which is needed for carbohydrate and fat metabolisms.

Indications: Cyanocobalamin is indicated for treatment and prevention of pernicious anemia, and megaloblastic anemia.

Cautions: Includes pregnant and breastfeeding women, and patient with an allergy should inform the medical practitioner before taking this supplements.

Contraindications: It includes the drug (known) allergy.

Adverse effects: Diarrhea, hypokalemia, vascular thrombosis, and pain at the site of injection.

Route of administration: Deep subcutaneous and intramuscular injection is recommended.

Dosages: Subcut/IM-1000 mcg per month and intranasal gel- 500 mcg per weak.

Interactions: Interact with an aminoglycoside and anticonvulsant.

Recommended daily allowances: 2.4 mg for an adult.

Vitamin C

Mechanism of action: Vitamin C is oxidized into dehydroascorbic acid (acts in oxidation-reduction reaction), which is essential for bone maintenance, capillaries maintenance, and important for erythropoiesis.

Indications: Used to treat lactation, pregnancy, fever, infection, and hyperthyroidism.

Cautions: Low dose is risk-free. High dose causes bowel looseness.

Contraindications: It includes the drug (known) allergy.

Adverse effects: Megados cause abdominal cramps, vomiting, and headache.

Route of administration: Oral and IV.

Dosages: IM/PO/IV/Subcut – 100-250 mg (2 times daily).

Interactions: Interact with many drugs. Erythromycin and penicillin must be avoided while taking this supplement.

Recommended daily allowances: 75 mg for an adult.

Minerals (calcium)

Mechanism of action: Acts as a cofactor in the pathways of blood coagulation. Calcium transforms fibrinogen into fibrin and prothrombin into thrombin, which leads to blood clotting.

Indications: Used for growing children and breastfeeding, and pregnant women.

Cautions: Low dose is risk-free. High dose causes bowel looseness

Contraindications: It includes a drug (known) allergy and heart’s ventricular fibrillation.

Adverse effects: Hypercalcemia and venous irritation.

Route of administration: Oral

Dosages: PO-1000 to 1500 mg per day.

Interactions: Interact with quinolones and tetracyclines.

Recommended daily allowances: 800 mg for an adult.

Minerals (phosphorus)

Mechanism of action: Acts as a precursor for the generation of essential chemicals and acts as a vital building block. It acts as a structural unit for adenosine phosphate complexes and nucleic acid synthesis.

Indications: Used to treat deficiency state.

Cautions: People suffering from renal impairment.

Contraindications: It includes hypocalcemia and hyperphosphatemia.

Adverse effects: Diarrhea, GI disturbances, vomiting, weakness, confusion, and breathing difficulties.

Route of administration: Available in the oral and parenteral formulations.

Dosages: 250-500 mg-PO.

Interactions: Interact with antacids that reduce phosphorus absorption.

Recommended daily allowances: For adult 800 to 1200 mg.

Minerals (magnesium)

Mechanism of action: Acts as a cofactor for various enzyme systems. It generates the anticonvulsant effect by preventing neuromuscular transmission.

Indications: Used to treat magnesium deficiency, management of pregnancy complications (eclampsia and preeclampsia), used as a tocolytic drug, to treat acute nephropathy (pediatric), and cardiac dysrhythmias management.

Cautions: People who are allergic to some other drugs and foods should immediately report to the prescriber.

Contraindications: It includes a drug (known) allergy, adrenal gland failure, and heart block.

Adverse effects: Hypermagnesemia (bowel movement difficulties and tendon reflex loss).

Route of administration: Available in oral and injectable forms.

Dosages: PO-400mg (two times daily).

Interactions: Interact with CNS depressant drugs and neuromuscular blocking drugs.

Recommended daily allowances: 310 to 420 mg for an adult.

Minerals (zinc)

Mechanism of action: Zinc reinstates enterocyte brush-border enzyme activity and mucosal barrier integrity. It stimulates antibodies stimulation.

Indications: Used to treat zinc deficiency wound healing diarrhea, male fertility, and pneumonia.

Cautions: People who are allergic to some other drugs and foods should immediately report to the prescriber.

Contraindications: It includes a drug (known) allergy, nausea, stomach damage, itching, skin burning, metallic taste, and diarrhea.

Adverse effects: Taking a high dose of zinc causes stomach pain, fever, fatigue, and cough.

Route of administration: Available in oral and injectable forms.

Dosages: PO-400mg (two times daily).

Interactions: Administration of zinc with a combination of drugs leads to inhibition of zinc absorption.

Recommended daily allowances: For an adult- 40 mg.

Minerals (copper)

Mechanism of action: Copper is integrated into varies metalloenzymes and proteins that play an important role in metabolic functions.

Indications: Used to treat copper deficiency and anemia.

Cautions: People suffering from allergy, epilepsy, kidney diseases, asthma, migraine, and headache should immediately report to the prescriber.

Contraindications: Kidney failure, anemia, diarrhea, low blood pressure, and stomach pain.

Adverse effects: Anemia, diarrhea, nausea, heart problems, and fever.

Route of administration: Intravenous.

Dosages: 0.4mg/ml (parentral nutrition).

Interactions: Administration of copper with a penicillamine affects effectiveness and absorption of penicillamine.

Recommended daily allowances: For an adult- 900 mcg.

Minerals (sodium)

Mechanism of action: Zinc reinstates enterocyte brush-border enzyme activity and mucosal barrier integrity. It stimulates antibodies stimulation.

Indications: Used to treat sodium deficiency excessive sweating, dehydration, and muscle contractions.

Cautions: People who are allergic to some other drugs and foods should immediately report to the prescriber.

Contraindications: Contraindications occur in patient with heart failure (congestive) renal impairmemnt, liver cirrhosis, and oedema.

Adverse effects: Taking a high dose of sodium causes stomach pain, chest pain, tiredness, swelling of the hand and feet, muscle weakness, and muscle twitching.

Route of administration: Available in injectable forms.

Interactions: Administration of copper with potassium supplements, steroids, and diuretics cause drug interaction.

Recommended daily allowances: For an adult- 1 to 1.6 mg/day.

Conclusion

The mechanisms of actions, dosages, recommended daily allowances, indications, drug interactions, cautions, contraindications, and routes of administration of all the vitamins and minerals are explained.