How your daily prescription pills could be draining your body of vital VITAMINS . . . and what you can do about it

Around half of us now take prescription pills daily, with a quarter on three different types, and millions of pensioners taking five a day on average. What many people may not realise is that their medication — while combatting chronic and even life-threatening conditions — could also be depriving them of vital minerals and vitamins, leading to symptoms such as fatigue, hair loss, depression, loss of sex drive and muscle pains.

They can even cause crumbly bones, as Julie Sharp discovered (see box below) — she has severe asthma, and at 32, she’s also just been diagnosed with osteoporosis. This is a condition usually associated with old age, but the high-dose oral steroids she needs for her asthma affected the absorption of vital bone minerals including calcium and vitamin d.

‘There’s no doubt I needed steroids,’ she says now, ‘but why did no one warn me I should also take calcium and vitamin d supplements to protect my bones?’

Vitamin and mineral deficiencies as sideeffects of medication don’t get as much attention from doctors, pharmacists or patients as they should, admits Heidi Wright, practice and policy lead for England at the royal Pharmaceutical Society. ‘This is particularly true where patients are on two or three drugs that inhibit the same pathway [have a similar mode of action], which a lot of elderly people are.

‘GPs and pharmacists should be aware of this when prescribing — it is part of undergraduate training for pharmacists.’

This problem is ‘so widespread we need specialist pharmacists specialising in nutritional and drug issues in GP practices, running clinics’, adds Anja St. Clair Jones, a consultant pharmacist in surgery and gastroenterology at Brighton and Sussex university NHS Trust and a spokeswoman for the royal Pharmaceutical Society.

‘Lots of older people are on multiple drugs, have absorption problems and don’t eat very much so may be deficient in vitamins and minerals. We just don’t know how many might be affected.’

Here we look at the commonly prescribed drugs that can potentially ‘drain’ your body of vitamins and minerals . . .

HEARTBURN TABLETS

YOU COULD BE MISSING OUT ON: Iron, calcium, magnesium, vitamins C and B12 Proton pump inhibitors (PPI) such as omeprazole are taken by millions of Britons; omeprazole is the third most prescribed drug in the UK. It works by reducing stomach acid production and is often prescribed for heartburn and also to prevent stomach ulcers, bleeding and anaemia in patients who are taking non-steroidal antiinflammatory drugs for arthritis (see box top right).

Iron, calcium and magnesium, vitamins C and B12 ‘all need an acidic environment to be absorbed in the stomach and PPIs reduce acid production, so you can get absorption problems,’ explains Anja St. Clair Jones.

While there are warnings about these risks in some patient information leaflets, the problems ‘need to be flagged up more’, she says.

‘It’s particularly severe in people who are elderly — because they have absorption problems anyway and tend not to eat very much — and in those who don’t eat a wide enough range of foods.’

Lack of calcium can lead, in the long term, to osteoporosis and lack of magnesium can lead to muscle cramps and loss of appetite.

‘Iron requires a very acidic environment to help absorption, so if you’re suppressing stomach acid secretion that can lead to iron deficiency and that is something patients should be aware of,’ says Toby richards, professor of surgery at university College London, who also runs The Iron Clinic.

‘Low iron levels are a huge problem in the UK affecting around 3.5 million people and medication side-effects are a factor in this, along with heavy periods and lack of iron in the diet.’

Symptoms of iron deficiency anaemia include tiredness and fatigue, breathlessness, restless legs and hair loss. Patients who complain of fatigue tend to be tested for iron deficiency and anaemia, says Anja St. Clair Jones ‘but they are not tested so much for calcium and magnesium deficiency as symptoms aren’t so obvious, so problems can go undiagnosed’.

Ms St. Clair Jones says that PPIs are over-prescribed and that more patients with dyspepsia (indigestion) could be managed with lifestyle changes such as cutting out spicy food and losing weight, rather than taking a pill every day.

She adds that if you are taking a PPI you should ‘be aware of the nutritional risks and have regular blood tests to check for anaemia and other deficiencies’.

STATINS

YOU COULD BE MISSING OUT ON: Co-enzyme Q10 ONE in seven Britons now takes a daily statin to lower cholesterol, a risk factor for a heart attack. Last year, atorvastatin was the most frequently prescribed drug in England, according to NHS digital.

A known side-effect of the drug is that it blocks the release of an enzyme called co-enzyme Q10, which is needed for energy production, particularly in muscles, including the heart. Low levels of CoQ10 can cause leg cramps and, less commonly, muscle weakness, memory problems and shortness of breath.

Sultan dajani, a community pharmacist in Eastleigh, Hampshire, says that leg cramps are the problem he sees most often among patients on statins (although cramps are not common). ‘Leg cramps are a known side-effect of taking statins, we warn patients about it when they get their first prescription and tell them to go and see their GP,’ he says.

‘In the vast majority of cases, switching to another type of statin resolves the problem, so people shouldn’t just give up taking them because they do save lives.’

dr Louise newson, a Stratfordupon-Avon GP, says patients who experienced muscle cramps and took CoQ10 supplements to counter them are ‘very positive’ about the effects.

‘There isn’t much evidence that they work but that doesn’t mean they aren’t safe, just that the trials haven’t been done.’

CONTRACEPTIVES

YOU COULD BE MISSING OUT ON: Folic acid, vitamins B2, B6, B12, C, and E, magnesium, selenium and zinc Women taking the Pill can lack key nutrients, according to a 2014 review published in the European review for Medical and Pharmacological Services by the university

of rome — specifically folic acid, vitamins B2, B6, B12, C and e and the minerals magnesium, selenium and zinc.

The authors concluded that ‘the possibility of preventing vitamin and mineral deficiency through the intake of dietary supplements should be considered as a first line approach by clinicians’, suggesting that the ideal supplement would contain a vitamin B complex, zinc, magnesium and selenium.

emma Derbyshire, a spokeswoman for the Health Supplements information Service, suggests ‘considering taking a multi-vitamin supplement to fill the gaps while taking the Pill, though more research is needed to discover what the underlying mechanisms might be’.

HEART DRUGS

YOU COULD BE MISSING OUT ON: Potassium AroUnD 900,000 people in the UK are thought to have heart failure, where the heart can no longer pump blood around the body effectively. one of the most common symptoms is fluid build-up in the lungs causing breathing problems and swelling in the legs, which is why many patients are prescribed diuretics, or water pills.

These help the kidneys excrete more fluids and salts, such as sodium and potassium. Diuretics are also prescribed to bring down high blood pressure.

However, a side-effect can be that too much potassium is removed from the body — or too much is retained.

Potassium is needed for muscle health, including the heart muscle, so inappropriate amounts of potassium can cause abnormal heart rhythms and, in extreme cases, cardiac arrest.

Angela Graves, a consultant nurse adviser in heart failure and clinical lead with the heart charity Pumping Marvellous foundation, says some patients can be on more than one type of water pill as they work in different ways.

‘This is why it’s so important that patients prescribed diuretics have regular blood tests to check their potassium levels. Keeping potassium levels in the healthy range is one of the biggest challenges in treating heart failure.

‘Patients with low potassium can feel lethargic and nauseous. But if their potassium levels go too high they can also feel generally unwell, dizzy and light-headed and their heart may be beating too fast or slow.’

Treatment can include taking prescribed potassium supplements (it’s important you never take them unless prescribed) or being switched to a different type of diuretic.

Pharmacist Sultan Dajani says that he advises all patients on diuretics to drink more water.

‘This may seem counter-intuitive when you are taking drugs to help you wee more,’ he explains, ‘but the body needs enough water to prevent dehydration and keep the kidneys pumping and this also helps minimise diuretic sideeffects such as headaches.

‘How much you should drink will depend on what you are taking diuretics for, so always check with your doctor or pharmacist.

‘People on diuretics with low potassium levels are often prescribed a slow-release drug called Slow-K potassium to replace lost potassium.’

DIABETES PILLS

YOU COULD BE MISSING OUT ON: Vitamin B12 MeTforMin, one of the top 10 drugs prescribed in england, lowers blood sugar by improving the way the body handles insulin, a hormone that controls blood sugar.

However, some studies, including a 2014 review of six high-quality trials by Sichuan University in Chengdu, China, published in the journal PLoS one, have found it depletes levels of vitamin B12 needed for energy, a healthy brain and nervous system and red blood cell formation.

The authors found that patients treated with metformin had vitamin B12 levels significantly lower than those taking a placebo or other diabetes drugs, and concluded that patients treated with metformin may benefit from taking B12 supplements, but said that more trials were needed to confirm this.

Lack of B12 can cause muscle cramps, confusion, fatigue, pins and needles and depression. The signs of deficiency are insidious and slow to develop, so ‘people often think they are just getting old’, according to David Smith, a professor emeritus of pharmacology at oxford University and an expert on anaemia.

However Libby Dowling, senior clinical adviser at Diabetes UK, adds: ‘B12 levels are unlikely to be checked routinely, and blood tests would only be done if an individual became anaemic.’

STEROIDS

YOU COULD BE MISSING OUT ON: Calcium and vitamin D CorTiCoSTeroiDS (steroids) are anti-inflammatory drugs, and an artificial form of hormones normally produced in the body by the adrenal glands (which sit on top of the kidney).

These are prescribed for a large number of conditions including asthma, inflammatory bowel diseases such as Crohn’s and ulcerative colitis, chronic obstructive pulmonary disease (such as emphysema) and allergic rhinitis — though for the latter, in most cases only, they are given as a short-term treatment.

Steroids have a major effect on the absorption of calcium and vitamin D — they affect the movement of calcium around the body and its absorption in the gut, for example.

Julia Thomson, nurse manager with the national osteoporosis Society charity, says that often oral steroids are the only drugs that can control certain severe medical conditions, but that bone thinning can be a consequence.

‘Doctors who are prescribing corticosteroids continuously for more than three months, or even for shorter periods at high doses, need to be thinking about bone health and in some cases, patients will need to be prescribed calcium and vitamin D as a preventative as it’s very important this deficiency is rectified. ‘Sadly, patients like Julie Sharp

(see box below) are not alone in discovering they have osteoporosis after treatment with oral steroids.’

The kind of doses patients should take are 700mg a day of calcium and 10mcg of vitamin D daily in autumn and winter. Mr Dajani says he advises patients to take sugar-coated steroid pills as these don’t irritate the stomach lining as much and are less likely to affect mineral absorption.

‘Also, don’t crush the tablets as this will break up their coating and make stomach irritation more likely and this increases the risk of developing a deficiency,’ he adds.

Sonia Munde, head of services at the charity Asthma UK, says an estimated 32,000 people in the UK take high-strength, long-term steroid tablets, which may affect levels of calcium or vitamin D.

Low doses of steroids in preventer inhalers do not cause the same side-effects, as most of the steroid in these stays in the lungs and doesn’t get absorbed into the rest of the body, she stresses.

ANTIBIOTICS

YOU COULD BE MISSING OUT ON: Sodium, potassium, vitamin C and zinc AnTiBioTiCS work by killing bacteria, but they also destroy so-called ‘good’ bacteria and upset the balance of gut flora. This can cause diarrhoea which in turn can lead to loss of mineral salts such as sodium and potassium, and soluble vitamins such as vitamin C and zinc.

Around one in three people who takes antibiotics suffers from diarrhoea, which normally ceases when they stop taking the pills.

Pharmacist Sultan Dajani says while a lot of people on antibiotics will end up being depleted of mineral salts, in most healthy people these will be replenished by the body within a few days.

However, the elderly, pregnant women, or the very young, are vulnerable — symptoms of mineral salt depletion include exhaustion, tiredness, vomiting and muscle cramps — so may need rehydration solutions.

These contain a mixture of glucose and salts such as potassium chloride and sodium chloride.