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Herbal and dietary supplement use is prevalent. Medication reconciliation should include a careful review of herbal and dietary supplements, including medical and nonmedical harms and benefits. The use of shared decision-making is recommended to integrate these findings into a patient-centered treatment plan.
A man in his 80s was seen in the geriatrics clinic to establish care and for evaluation of cognitive decline. He had a medical history of benign prostatic hyperplasia and a longstanding interest in dietary supplements. He was previously treated by an antiaging physician, from whom he was transferring care. The patient’s medications included more than 50 supplements that had been recommended to him by this physician. He also reported purchasing additional dietary products to improve his health. Collectively, these supplements were marketed to treat memory impairment, sexual performance, urinary symptoms, digestive health, or aging. They comprised multiple vitamins, minerals, amino acids, caffeine stimulants, hormones, and proprietary formulas. His invoice for the supplements provided by his antiaging physician totaled almost $9000 per quarterly shipment. His other dietary products cost him an additional several hundred dollars per month.
On initial evaluation, he appeared younger than his stated age. He scored 18 out of 30 points on the Montreal Cognitive Assessment. He was found to have mild kidney insufficiency and anemia. The geriatrician and 2 nurse practitioner (NP) students made a home visit to assess his supplement inventory and personal safety. The patient revealed a pantry filled with hundreds of pill bottles, injectable hormone solutions, and unused syringes. Supplements distributed by his antiaging physician were found in unlabeled, sealed, clear plastic bags. The patient demonstrated limited insight into the financial strain that he was accruing through his supplement use. His family, however, revealed he was spending more than his limited income.
To address the excessive supplement use, the NP students performed a literature review of the patient’s supplements. Given his primary complaint of memory loss, the supplements were evaluated for their role in neurologic function, evidence of benefit or harm, and cost. Some of his supplements, such as deanol bitartrate, had potential adverse neurologic effects, with reports of sedation and peripheral cholinergic effects.1 Human growth hormone, dessicated thyroid, and an ergot mesylate met the Beers criteria2 for medications to potentially avoid in older adults. The review also revealed supplements with inconclusive evidence for efficacy, such as selenium.3 There were insufficient data on the patient’s remaining supplements to support their continuation. Pharmacists collaborated with the team on a plan to taper and discontinue the supplements that lacked evidence supporting their use and that could potentially cause harm. A pared-down list of 6 evidence-based medications and vitamins was developed for the patient based on his medical conditions. These included finasteride and tamsulosin for benign prostatic hyperplasia, and cholecalciferol and cyanocobalamin supplements for deficiencies. The geriatrician prescribed levothyroxine sodium and testosterone tapers with plans for repeated laboratory tests to evaluate his level of deficiency, as he had been using exogenous hormones for many years.
This case study presents an example of the excessive and inappropriate use of dietary supplements, which can present challenges akin to those recognized in polypharmacy. Reconciling pharmaceuticals as well as dietary supplements must take into account drug interactions, adverse effects, pill burden, cost, and possible withdrawal effects on discontinuation. The patient’s excessive volume of supplements demonstrated additional issues, such as lack of evidence supporting their use, crippling financial burden, the use of supplements to treat symptoms in place of evidence-based treatments, and medical waste in the form of unconsumed supplements and unused syringes.
It is important for clinicians to recognize that supplements are regulated by the Dietary Supplement Health and Education Act of 19944 and are brought to market without extensive testing for safety and efficacy. Another issue of concern is the inconsistency in product content and, in some cases, adulteration, or contamination with unlabeled ingredients.5 Approximately $32.5 billion were spent by American consumers on dietary supplements in 2012.6 Most of these costs likely represent out-of-pocket expenditures. But despite these issues and the prevalence of dietary supplement consumption, clinicians are often unaware of the use of these agents in their patients and lack appropriate training, making it difficult to incorporate their use into treatment plans.
Little evidence exists regarding methods for reconciling dietary supplements. Ashar and Rowland-Seymour7 suggest a 6-step approach to engage in shared-decision making with patients. These steps include inquiring about supplement use, evaluating their evidence-based benefits, discussing the state of industry regulation and safety, comparing these factors to allopathic treatments, and assessing response and adverse effects. Interprofessional collaboration lends valuable, diverse expertise to complex medical and pharmacologic cases. Finally, a patient-centered approach to reconciliation of dietary supplements facilitates a dialogue that is neither dismissive nor negative but encourages general health, alleviation of symptoms, safety, and informed consumers. The prevalence and financial impact of supplement consumption is high. Therefore, the clinician’s acknowledgment of supplement use should not end with history taking but be integrated into individualized treatment plans.
Corresponding Author: Helen Kao, MD, Geriatrics Clinical Programs, University of California, San Francisco, 3333 California St, Ste 380, San Francisco, CA 94118 (email@example.com).
Published Online: May 26, 2014. doi:10.1001/jamainternmed.2014.1879.
Conflict of Interest Disclosures: None reported.
Additional Contributions: Timothy Cutler, PharmD, GCP, Candy Tsourounis, PharmD, and Cathi Dennehy, PharmD, University of California, San Francisco, consulted on the patient case, made recommendations on which herbal and prescription medications to taper or stop, performed a comprehensive literature review on polysupplement use and overuse, and participated in revisions of the manuscript. They were not compensated for their contributions.
Strewler A, Conroy R, Kao H. Approach to Overuse of Herbal and Dietary Supplements: A Teachable Moment. JAMA Intern Med. 2014;174(7):1033–1034. doi:10.1001/jamainternmed.2014.1879
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