Patients with celiac disease are known to be deficient in the amino acid L-carnitine, a nutrient essential for muscle energy production.
CASE 1: DHEA FOR TREATING DRY MOUTH
LJ is a 42-year-old woman seeking an herbal supplement for treating dry mouth. LJ has Sjögren’s syndrome and is trying to alleviate her symptoms by using a natural remedy in conjunction with OTC saliva replacement and lubricant eyedrop products. She found information on the use of herbal dehydroepiandrosterone (DHEA) for this condition and would like to know your thoughts about its use. LJ has no significant medical history and no known medication allergies; she takes an oral hormonal contraceptive tablet once daily. What recommendations can you provide?
DHEA is a synthetic OTC herbal supplement used to treat aging skin as well as to boost metabolism, memory, and immune function, among other purposes. This substance is produced naturally by the body and serves as a precursor for androgen and estrogen production.1 Sjögren’s syndrome, an autoimmune disease that primarily affects the salivary and lacrimal glands, is characterized by a reduction in circulating dehydroepiandrosterone sulfate (DHEA-S) levels.2 Supplementation of this hormone precursor thus has received attention for use in reducing the bothersome symptoms of Sjögren’s syndrome, although placebo-controlled studies have largely shown no benefit of supplemental DHEA at doses of 50 to 200 mg daily taken for up to 12 months.2,3 LJ should be told that the clinical evidence doesn’t support the use of DHEA for relief of Sjögren’s symptoms. Further, a theoretical interaction exists between LJ’s hormonal contraceptive and DHEA; combination hormonal contraceptives and conjugated estrogen supplements may reduce serum DHEA and DHEA-S levels and should not be used concomitantly.1 The best way for LJ to improve her dry mouth symptoms would be to continue using the saliva supplement and lubricant eyedrops based on her preferences.
CASE 2: VITAMIN D FOR PSORIASIS
JM is a 28-year-old man who would like some information about vitamin D supplementation to treat psoriasis. He has been suffering from mild to moderate psoriasis symptoms for as long as he can remember. He wants to avoid using any of the biologic agents because he is afraid of the side effects associated with these and other medications he’s already discussed with his physician. He has no allergies to medications and currently takes only ibuprofen, as needed for symptomatic pain relief, and cetirizine, as needed for seasonal allergies. How do you respond?
Although vitamin D is best recognized for its importance in supporting bone health, this nutrient has been implicated as playing a crucial role in the prevention and treatment of other chronic and autoimmune diseases. Psoriasis is a skin disorder characterized by the accumulation of cells on the skin surface, resulting in itchy, red, and sometimes painful plaques; therefore, topical application of vitamin D in the form of a prescription-only cream represents one of the local therapies that can be used for symptomatic relief.4 In clinical trials comparing the efficacy of topical corticosteroids with topical vitamin D analogues, using the combination of both topical agents was superior to the use of either class of agent alone.5 Although evidence supports oral OTC vitamin D supplements for alleviating psoriasis symptoms, JM should be referred to his primary care physician or rheumatologist to discuss use of the topical formulations or higher-dose prescription supplements if he desires or as indicated based on serum vitamin D level monitoring.6
CASE 3: FISH OIL FOR RHEUMATOID ARTHRITIS
DM, a 69-year-old woman suffering from rheumatoid arthritis, is seeking a natural alternative for treating symptoms of her condition. She complains that the joints in her fingers are swollen and sore, with pain that is worse in the morning and subsides over the course of the day. She has been using a nonsteroidal anti-inflammatory drug (NSAID) for symptomatic relief but would like to try something natural to augment the effects of the pain reliever. One of her friends recently recommended that she try fish oil, but she is unsure whether this is an appropriate use of the supplement, which she thought was used only for heart health. She has no known medication allergies but reports taking several other medications for dyslipidemia, hypertension, and asthma. What advice can you provide her at this time?
OTC fish oil supplements are widely recognized for their benefits in cardiovascular disease. A less obvious use of this supplement would be to alleviate symptoms of rheumatoid arthritis, which is an autoimmune condition. The omega-3 fatty acids in fish oil supplements are thought to suppress activity of inflammatory cyclooxygenase, interleukin, and tumor necrosis factor.7 Clinical trial results have demonstrated the use of fish oil supplements, either alone or in conjunction with NSAIDs, to be associated with reducing morning stiffness symptoms and analgesic requirements.7-9 If DM has decided to purchase such a supplement, she should be counseled on the potential for these agents to augment the effects of her antihypertensives and to monitor for symptoms of hypotension. It is also important to evaluate what specific agents she is taking to manage her cholesterol level to avoid the potential for therapeutic duplication.7
CASE 4: L-CARNITINE AND CELIAC DISEASE
DS is a 23-year-old woman who approaches the pharmacy counter seeking professional advice. She reports suffering from celiac disease and adhering to a glutenfree diet. A friend recently recommended that she try L-carnitine to relieve her bothersome gastrointestinal (GI) symptoms. She did some investigating on the Internet but isn’t sure what to make of the results; it seems like this supplement helps with fatigue associated with celiac disease but not the occasional GI symptoms she experiences. She would like the pharmacist to help her decide whether she should try this supplement. In addition to celiac disease, DS reports suffering from anemia and lactose intolerance, for which she takes iron sulfate 325 mg twice daily, along with an OTC lactase enzyme replacement as needed. She has no medication allergies. What recommendations can you give DS at this time?
Patients with celiac disease are known to be deficient in the amino acid L-carnitine, a nutrient essential for muscle energy production.10 Although clinical data exist to support the use of L-carnitine at a daily dose of 2 g for improvement of fatigue symptoms, supplementation with this agent has not been shown to improve quality of life or GI symptoms associated with celiac disease.11 If DS opts to purchase this type of supplement, she should be counseled on the potential for it to cause worsening GI symptoms, including nausea, vomiting, diarrhea, and cramping, as well as a “fishy odor” on the breath and in body fluids.12
Dr. Bridgeman is clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and internal medicine clinical pharmacist at Robert Wood Johnson University Hospital, New Brunswick, New Jersey. Dr. Mansukhani is clinical assistant professor at the Ernest Mario School of Pharmacy, Rutgers University, and transitions of care clinical pharmacist at Morristown Medical Center, Morristown, New Jersey.
1. DHEA. Natural Medicines Comprehensive Database [online]. Stockton, CA: Therapeutic Research Faculty, 2015. http://naturaldatabase.therapeuticresearch.com. Accessed January 20, 2015.
2. Forsblad-d’Elia H, Carlsten H, Labrie F, Konttinen YT, Ohlsson C. Low serum levels of sex steroids are associated with disease characteristics in primary Sjögren’s syndrome; supplementation with dehydroepiandrosterone restores the concentrations. J Clin Endocrinol Metab. 2009;94(6):2044-2051.
3. Hartkamp A, Geenen R, Godaert GL, et al. Effect of dehydroepiandrosterone administration on fatigue, well-being, and functioning in women with primary Sjögren syndrome: a randomised controlled trial. Ann Rheum Dis. 2008;67(1):91-97.
4. Mayo Clinic Staff. Diseases and conditions: Psoriasis. Mayo Clinic website. www.mayoclinic.org/diseases-conditions/psoriasis/basics/definition/con-20030838. Accessed January 19, 2015.
5. Bailey EE, Ference EH, Alikhan A, Hession MT, Armstrong AW. Combination treatments for psoriasis: a systematic review and meta-analysis. Arch Dermatol. 2012;148(4):511-522.
6. Kamangar F, Koo J, Heller M, Lee E, Bhutani T. Oral vitamin D, still a viable treatment option for psoriasis. J Dermatolog Treat. 2013;24(4):261-267.
7. Fish oil. Natural Medicines Comprehensive Database [online]. Stockton, CA: Therapeutic Research Faculty, 2015. http://naturaldatabase.therapeuticresearch.com. Accessed January 20, 2015.
8. Kjeldsen-Kragh J, Lund JA, Riise T, et al. Dietary omega-3-fatty acid supplementation and naproxen treatment in patients with rheumatoid arthritis. J Rheumatol. 1992;19(10):1531-1536.
9. Lau CS, Morley KD, Belch JJ. Effects of fish oil supplementation on non-steroidal anti-inflammatory drug requirement in patients with mild rheumatoid arthritis—a double-blind, placebo-controlled study. Br J Rheumatol. 1993;32(11):982-989.
10. Lerner A, Gruener N, Iancu TC. Serum carnitine concentrations in coeliac disease. Gut. 1993;34(7):933-935.
11. Ciacci C, Peluso G, Iannoni E, et al. L-carnitine in the treatment of fatigue in adult celiac disease patients: a pilot study. Dig Liver Dis. 2007;39(10):922-928.
12. L-carnitine. Natural Medicines Comprehensive Database [online]. Stockton, CA: Therapeutic Research Faculty, 2015. http://naturaldatabase.therapeuticresearch.com. Accessed January 20, 2015.