FROM: Nutrition Review ~ October 2011
By Hyla Cass, MD
A little known, but potentially life-saving fact is that common
medications deplete your body of a host of vital nutrients essential to
your health. In this practical guide I’ll show you how to avoid
drug-induced nutrient depletion and discuss options for replacing
nutrient-robbing medications with natural supplements.
America has been called a pill-popping society, and the statistics
bear this out. Nearly 50 percent of all American adults regularly take
at least one prescription drug, and 20 percent take three or more. 
Our increasing reliance on prescription medications has contributed to
the growing problem with nutrient depletion. The truth is that every
medication, including over-the-counter drugs, depletes your body of
specific, vital nutrients. This is especially concerning when you
consider that most Americans are already suffering from nutrient
depletion. Additionally, many of the conditions physicians see in their
everyday practice may actually be related to nutrient depletion. The
good news is that, armed with information and the right supplements, you
can avoid the side effects of nutrient depletion, and even better, you
may be able to control and prevent chronic diseases, such as diabetes,
cardiovascular disease and osteoporosis.
A Common Scenario
I have seen case after case of patients who have experienced nutrient
loss from taking prescribed medications. Too often, neither the
patients nor their doctors are aware that the medications are the real
cause of their symptoms.
For example, Kathy, a 57-year-old retired schoolteacher, was being
treated by her internist with three medications: the thiazide diuretic, Diuril, for high blood pressure; Fosamax for osteoporosis; and the beta-blocker, Tenormin, for heart palpitations.
Kathy was referred to me because she suffered from fatigue, anxiety,
depression and insomnia. I couldn’t find an obvious psychological
explanation for these symptoms, except perhaps for the stress of her
physical illnesses. The likeliest cause of her symptoms was the drugs
themselves. So, rather than adding an antidepressant, an anti-anxiety
pill or sleeping agent, I investigated the known nutrient depletions
associated with these medications.
Any one of her three medications could be depleting her potassium and
magnesium levels, resulting in arrhythmias, hypertension, fatigue and
depression. Additionally I discovered that the diuretic she was taking
could be depleting her zinc levels. Follow-up lab tests confirmed that
Kathy was deficient in three essential minerals: magnesium, potassium
Based on the lab results, Kathy’s internist agreed to oversee her
medications while I supervised her nutritional regimen. Daily doses of
magnesium, zinc and potassium, in addition to a high-potency
multivitamin, resolved Kathy’s “psychiatric” symptoms. Once her mineral
levels were restored, Kathy’s energy and mood were back to normal. Best
of all, not only was she spared the burden of taking additional
medications, she was able to lower the doses of the three she was
Drug-Induced Nutrient Depletion is Widespread
I see cases similar to Kathy’s more frequently than I’d like.
Physicians often tell their patients that symptoms arising from nutrient
depletion are simply “part of the illness” or just signs that they’re
“getting older.” To make matters worse, physicians frequently try to
address the symptoms arising from drug-induced nutrient depletion by
prescribing even more drugs, further compounding the problem.
To understand the role various medications play in causing nutrient
depletion, we must first look at the variety of nutrient-depleting
mechanisms in pharmacy.
Many drugs, such as the stimulants Ritalin (methylphenidate) and Adderall,
are prescribed for attention deficit disorder. These can reduce
appetite. This, in turn, decreases the intake of beneficial nutrients.
Some antidepressants also tend to have this appetite-reducing effect.
On the flip side, some drugs can deplete nutritional status by
increasing the desire for unhealthy foods, such as refined
carbohydrates. Many of the neuroleptics (anti-psychotic drugs) and some
antidepressants cause insulin resistance or metabolic syndrome, with
results in blood sugar swings. Patients then crave simple carbohydrates,
such as sugar, bread and pasta. Steroid drugs, including those given by
an inhaler, can create similar issues as well.
Certain medications reduce the absorption of specific nutrients in
the gastrointestinal tract by binding to them before they’re absorbed
into the bloodstream. The antibiotic, tetracycline, for example, can
block absorption by binding with minerals, such as calcium, magnesium,
iron and zinc in the GI tract. 
Weight loss drugs and cholesterol-lowering medicines similarly bind
to fats, preventing them from being absorbed. Drugs that treat acid
reflux or heartburn raise the pH environment of the upper GI tract,
which reduces absorption of needed vitamins and minerals. This is
especially problematic among the elderly, who often are already low in
Nutrients are essential to the metabolic activities of every cell in
the body. They're used up in the process and need to be replaced by new
nutrients in food or supplements. Some drugs deplete nutrients by
speeding up this metabolic rate. These drugs include antibiotics
(including penicillin and gentamicin) and steroids, such as prednisone,
and the gout medication, colchicine.
Other drugs block the nutrient's effects or production at the
cellular level. In addition to the intended effect on enzymes or
receptors, medications can influence enzymes or receptors that help
process essential nutrients. For example, widely prescribed statin drugs
block the activity of HMG-CoA, an enzyme that's required to manufacture
cholesterol in the body. This action also depletes the body of coenzyme
Q10 (CoQ10), which requires HMG-CoA for its production. This has a
serious negative impact on muscle and heart health.
Drugs also can increase the loss of nutrients through the urinary
system. Any drug that does this can drain the body's levels of
water-soluble nutrients, including B vitamins and minerals, such as
magnesium and potassium. The major offenders are medications to treat
hypertension, particularly the diuretics that reduce blood pressure by
increasing the volume of water flushed out of the body.
Common Nutrient Robbers
The bottom line here is, we need to be aware of drugs that are
nutrient robbers. The following provides some of the major drug
The ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent
Heart Attack Trial)  concluded that thiazide-type diuretics are
better than ACE inhibitors and calcium-channel blockers at preventing
heart attacks in high-risk people. Physicians often prescribe potassium
to offset the well-known potassium depletion associated with this
However, these diuretics are also known to deplete other minerals,
such as magnesium, sodium, potassium and zinc, which are seldom
specifically supplemented. One study found hypokalemia (low potassium)
in 8.5 percent of people treated with thiazide diuretics and
hyponatremia (low sodium) in 13.7 percent in the same patient
population. [2,3] This indicates the importance of testing levels, and
not simply restricting sodium. [2,3]
Thiazide diuretics also decrease magnesium in approximately 20
percent of patients  and can significantly decrease serum zinc. 
Loop diuretics deplete potassium, magnesium, calcium, zinc, pyridoxine,
thiamine and ascorbic acid.
One study showed that thiamine deficiency was found in 98 percent of
patients with congestive heart failure who took 80 mg of furosemide
daily, and in 57 percent of patients who took just 40 mg daily. This
shows a dose relationship. Furosemide also increases excretion of
ascorbic acid and pyridoxine. 
For these patients, consider the following daily supplements: calcium
(1,000 mg), magnesium (250 mg to 500 mg), potassium (100 mg), vitamins C
(1,000 mg), B1 (320 mg), B6 (10 mg to 25 mg) and zinc (25 mg).
Beta blockers are among the oldest classes of antihypertensive drugs.
They lower blood pressure by reducing the effects of catecholamines,
thereby reducing the force and speed of the heartbeat. Beta-adrenergic
blockers deplete CoQ10 by interfering with the production of this
essential enzyme for energy production.  This lack of CoQ10 is
particularly dangerous, considering that the target condition is
cardiovascular disease. Since the heart is particularly rich in
CoQ10-hungry mitochondria, the energy factory of the cell, the end
result can be heart failure. To offset this negative side effect you can
take CoQ10, 100 mg to 300 mg daily with fat-containing food for best
These drugs also reduce production of melatonin
(N-acetyl-5-methoxytryptamine). Produced from serotonin at night in the
pineal gland by stimulating adrenergic beta1- and alpha1-receptors, this
neuro-hormone regulates circadian rhythm and promotes sound sleep. By
blocking beta receptors, these drugs may inhibit the release of the
enzyme serotonin-N-acetyltransferase, which is necessary for the
synthesis of melatonin, resulting in sleep disturbance.  Take
melatonin (3 mg) at bedtime to counter this effect.
Statin drugs are the most widely prescribed medicines for lowering cholesterol. In fact, Lipitor
(atorvastatin) is the best-selling drug on the planet. However,
physicians need to address a serious risk. Statins deplete the body of
CoQ10 with the following potential side effects: heart failure, muscle
pain and weakness, irritability, mood swings, depression and impotence.
[9-11] The last few side effects may also be due to lack of cholesterol,
which is needed for brain cell and hormone production.
Therefore, people on statins should take 100 mg to 200 mg of CoQ10 daily to counter this potentially fatal depletion.
While no specific recommendations from the pharmaceutical industry
exist, one pharmaceutical statin manufacturer observed the depletion
effect in early research. This manufacturer holds a patent on a
combination statin and CoQ10. Sadly, the patents have never been
activated, nor have any warnings been provided by the U.S.
Health Canada, on the other hand, which is the federal department
responsible for helping Canadians maintain and improve their health,
requires that manufacturers of statin drugs include warnings on patient
safety information sheets about the potential for myopathies and
impaired cardiac function.
Antacids, histamine-2 receptor antagonists (H2 blockers) and
proton-pump inhibitors (PPIs) are commonly prescribed for treating
heartburn, gastro-esophageal reflux disease (GERD) and peptic ulcers.
Numerous studies indicate that these drugs cause several nutrient
For example, aluminum antacids (Maalox, Mylanta and Gaviscon) and calcium carbonate (Caltrate, Dicarbosil, Rolaids, Titralac and Tums) act by buffering or neutralizing the acid pH of the stomach.
Unfortunately, this reduction of stomach acid impairs the breakdown of
the ingested food into its component nutrients.
Both PPI and H2 blockers significantly increase the risk of vitamin
B12 deficiency in elderly patients. B12 requires adequate gastric acid
for absorption. This population is already prone to deficiency in
intrinsic factor, necessary for B12 absorption.  This lack of
stomach acid also decreases the absorption of folic acid, iron and zinc.
[13,14] H2 blockers (Tagamet, Pepcid, Axid and Zantac) decrease acid secretion by blocking histamine.
Proton pump inhibitors (PPIs, Prilosec, HK-20), the most potent of
acid-reducing medications, are increasingly popular. They reduce stomach
acid production by up to 99 percent by decreasing the action of proton
pumps, which are part of the stomach lining’s acid-making machinery.
This, however, can strongly interfere with nutrient absorption.
One study showed that high doses of PPIs, used for a year or more,
could make people 2.5 more times susceptible to hip fracture than
control subjects. Lower doses decreased the risk factor to 1.5 times
that of nonusers. The longer these drugs are used, the higher the
fracture risk. This heightened risk of osteoporosis is probably due to
the drastic drop in calcium and vitamin D absorption that occurs with
these drugs. Some experts believe the drugs themselves may hamper the
body’s ability to build new bone. 
For anyone taking acid-reducing medication, I recommend daily intake
of vitamin D3 (2,000 IU or more based on lab testing), B12 (200 mcg),
folic acid (800 mcg), calcium (1,000 mg), chromium (500 mcg), iron (15
mg), zinc (25 mg to 50 mg) and phosphorus (700 mg).
Metformin (Glucophage, Glucophage XR and Glucovance)
enhances the action of insulin in cases of insulin resistance, allowing
glucose to enter the cells. This reduces elevated blood sugar. A study
published in the Archives of Internal Medicine showed that
diabetics on metformin had B12 levels that were less than half those of
control subjects. The longer the drug had been used and the higher the
dose, the greater the drop in B12. 
In people with Type 2 diabetes who take metformin therapy, serum
folic acid levels decrease 7 percent and vitamin B12 levels decrease by
14 percent.  B12 and folic acid depletion also increases
homocysteine levels. In addition, metformin may deplete CoQ10, thereby
increasing heart disease risk. To reduce these effects, patients should
take vitamin B12 (800 mcg), folic acid (400 mcg) and CoQ10 (100 mg
For antidepressants to work optimally, an ongoing supply of the B
vitamins must be available as co-factors to help manufacture the needed
neurotransmitters, such as serotonin and dopamine. [18,19] So, while
these drugs may not directly deplete B vitamins, patients on these
medications should ensure they get enough of these vitamins. In
addition, be aware that lithium carbonate, used for treating bipolar
illness, depletes folic acid (take 800 mcg) and inositol (take 500 mg
Hormone Replacement Therapy
Many baby boomers are on hormone replacement therapy (HRT), which can
deplete vitamins B6 and B12, folic acid and magnesium. These nutrients
are critical for heart health, as well as for mood. Rather than an
antidepressant prescription, these women should be given the appropriate
supplements to restore balance. I have seen many women do well once
these nutrient depletions were addressed. This applies to younger women
on oral contraceptives as well.
For women on standard HRT (estrogen and progesterone, orally,
including as an oral contraceptive, or as a transdermal skin cream) I
may also recommend calcium (1,000 mg to 1,200 mg daily), folic acid (400
mcg to 800 mcg), magnesium (500 mg), vitamin B2 (25 mg), vitamin B6 (50
mg), vitamin B12 (500 mcg to 1,000 mcg), vitamin C (500 mg to 1000 mg)
and zinc (25 mg to 50 mg).
Antibiotics deplete biotin, inositol, vitamins B1, B2, B3, B5, B6,
B12 and vitamin K. Additionally, fluoroquinolones and all floxacins
(including ciprofloxacin or “Cipro”) deplete calcium and iron.
Tetracyclines (suffix, -cycline) deplete calcium and magnesium.
Trimethoprim-containing antibiotics (brand names Trimpex, Proloprim or Primsol)
deplete folic acid. Penicillins (suffix, -cillin) deplete potassium.
Aminoglycosides, such as gentamicin, cause imbalances of magnesium,
calcium and potassium.  In fact, one study showed that gentamicin
causes increased excretion of calcium by 5 percent and magnesium by 8.4
When you take antibiotics, consider a B vitamin complex along with
it. Or take a multivitamin that contains 25 mg of B1 (thiamine), 25 mg
of B2 (riboflavin), 50 mg of B3 (niacin), 50 mg of B6 (pyridoxine), 400
mcg to 800 mcg of folic acid, 10 mcg of B12, and 50 mg each of biotin
and B5 (pantothenic acid).
Inositol is part of the B vitamin complex, and is likely to be
included in a B vitamin or multivitamin formulation. Otherwise, take 500
mg of inositol. (The RDA is 100 mg per day.) In addition, either take a
multivitamin that includes magnesium (500 mg), calcium (1,000 mg) and
potassium (100 mg), or take them separately.
Antibiotics can disrupt the natural bacteria flora in the digestive system, killing “good” bacteria, including Lactobacillus acidophilus (L. acidophilus) and Bifidobacterium bifidum
(B. bifidum). These are probiotics or bacteria that normally live in
and on the human body, concentrated mostly in the digestive and
genital/urinary systems. Choose a supplement that contains at least 1
billion live organisms per daily dose.
You also may consider 50 mcg daily of vitamin K, which is normally
made by friendly intestinal bacteria. Vitamin K is required for proper
blood clotting. Deficiency is rare, but when it occurs, life-threatening
bleeding can occur from the smallest injury. Vitamin K also plays a
part in osteoporosis prevention.
Drug-induced nutrient depletion is far more common than has been acknowledged. In evaluating patients’ symptoms, doctors must assess whether symptoms are due to the illness, to the side effects of the drugs, or to drug-induced nutrient depletion. Considering the inadequate nutritional status of the majority of the population, we must remember that the illness itself may be due, in part, to nutrient deficiency. For insurance, it is easiest to provide baseline coverage: a daily high potency multivitamin mineral formula, CoQ10 (200 mg), omega-3 fatty acids (2 grams) and additional vitamin D and probiotics.
The bottom line: Physicians must (begin to) look more deeply and determine underlying causes to determine whether drugs are harming patients – and what we can do to reverse these effects. As a consumer, be aware of these drug-nutrient depletions, and do what you can to avoid taking medications whenever you can, using natural products instead.
For more information, see my book, Supplement Your Prescription: What Your Doctor Doesn’t Know About Nutrition, available at my website, www.cassmd.com
Centers for Disease Control and Statistics.
Health United States 2006.
The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group.
JAMA 2002; 288: 2998-3007.
Clayton JA, Rodgers S, Blakey J.
Thiazide diuretic prescription and
electrolyte abnormalities in primary care.
Br J Clin Pharmacol 2006 (Jan); 61: 87-95.
Correction of thiazide-induced hypomagnesemia by
potassium-magnesium citrate from review of prior trials.
Clin Nephrol 2000; 54: 271-275.
Khedun SM, Naicker T, Maharaj B.
Zinc, hydrochlorothiazide and sexual dysfunction.
Cent Afr J Med 1995; 41: 312-315.
Zenuk C, Healey J, Donnelly J, et al.
Thiamine deficiency in
congestive heart failure patients receiving long term furosemide
Can J Clin Pharmacol 2003; 10: 184-188.
Kishi T, Watanabe T, Folkers K.
Bioenergetics in clinical medicine
XV: Inhibition of coenzyme Q10-enzymes by clinically used adrenergic
blockers of beta-receptors.
Res Commun Chem Pathol Pharmacol 1977; 17: 157-164,
Stoschitzky K, Sakotnik A, Lercher P et al
Beta-blockers on Melatonin Release.
Eur J Clin Pharmacol. 1999 (Apr); 55 (2): 111-15.
Langsjoen PH, Langsjoen AM.
The clinical use of HMG CoA-reductase
inhibitors and the associated depletion of coenzyme Q10: A review of
animal and human publications.
Biofactors 2003; 18 (1-4): 101-111.
Biochemical functions of coenzyme Q10.
J Am Coll Nutr 2001; 20: 591-598.
Folkers K, Langsjoen P, Willis R, et al.
coenzyme Q levels in humans.
Proc Natl Acad Sci USA 1990; 87: 8931-8934.
Valuck RJ, Ruscin JM.
A case-control study on adverse effects: H2
blocker or proton pump inhibitor use and risk of vitamin B12 deficiency
in older adults.
J Clin Epidemiol 2004; 57: 422-428.
Russell RM, Golner BB, Krasinski SD.
Effect of antacid and H2
receptor antagonists on the intestinal absorption of folic acid.
J Lab Clin Med 1988; 112: 458-463.
Sturniolo GC, Montino MC, Rossetto L, et al.
Inhibition of gastric
acid secretion reduces zinc absorption in man.
J Am Coll Nutr 1991; 10: 372-375.
Yang, YX, Lewis JD, Epstein S, Metz DC.
Long-term proton pump inhibitor therapy and risk of hip fracture.
JAMA. 2006 (Dec 27); 296 (24): 2947-53.
Zhao-Wei Ting R, C Chun Szeto, M Ho-Ming Chan, et al.
“Risk factors of vitamin B12 deficiency in patients receiving metformin.”
Archives of Internal Medicine 2006 (Oct 9); 166 (18): 1975-9.
Wulffele MG, Kooy A, Lehert P, et al.
Effects of short-term
treatment with metformin on serum concentrations of homocysteine, folate
and vitamin B12 in type 2 diabetes mellitus: A randomized,
J Intern Med 2003; 254: 455-463.
“Folate, vitamin B12 and neuropsychiatric disorders."
Nutrition Review Dec 1996; 54 (12): 382-390.
Bottiglieri T, M Laundy, R Crellin, et al.
methylation, and monoamine metabolism in depression."
Journal of Neurology, Neurosurgery & Psychiatry 2001 (Mar); 70 (3): 419.
Landau D, Kher KK.
Gentamicin-induced Bartter-like syndrome.
Pediatr Nephrol 1997; 11: 737-740.
Elliott C, Newman N, Madan A.
Gentamicin effects on urinary
electrolyte excretion in healthy subjects.
Clin Pharmacol Ther 2000; 67: 16-21.
Return to the PHARMACY Section
Return to the NUTRIENT DEPLETION CHARTS