One of the hidden costs associated with medications is that many of them can lead to depletions of certain micronutrients (vitamins and minerals) in our bodies. I was entirely unaware of this until I studied nutrition -- no doctor had ever even mentioned this possibility for any of the medications I had been prescribed at one point or another. Here’s one chart that shows the extent of depletions across just a few commonly prescribed drugs including antibiotics, acid blockers, statins, oral contraceptives, and antihypertensives. Additionally, this is one of my favorite sites that allows you to type in the name of a medication and it returns a list of possible nutrient interactions with the scientific reference from PubMed. It’s by no means a comprehensive database, but it can help highlight nutrients of concern. One major caveat is that studies are often conflicted about which nutrients are depleted, if that depletion actually leads to clinically significant symptoms, and if supplementation is warranted. I think that’s why there’s rarely consensus among providers around replacing certain nutrients.
Anti-acid medications, especially the proton pump inhibitors (PPIs), are suspected of putting people at risk of several deficiencies due to their mechanism of action of blocking the production of acid that facilitates the absorption of iron (especially iron from non-animal sources), B12, magnesium, and zinc. This article from the Mayo Clinic reports a likely causative association of PPI use with low magnesium and low B12 levels.
I’m especially mindful of vegans and older adults who are on these medications long-term as these populations are already at risk of not getting enough B12. Furthermore, according to the FDA (the FDA! Not this overly-cautious dietitian), PPIs are NOT supposed to be taken for more than a 14-day course, yet people are often on these for years.
Statins, cholesterol-lowering drugs, are commonly prescribed (25% of the adult population is on one) and have been found to deplete an antioxidant called CoQ10. Our bodies can produce this antioxidant, though we do get it from diet as well. It is a critical piece of the electron transport chain and thus essential for energy production. One of the major side effects from statins is muscle pain / weakness with a likely culprit being the depletion of CoQ10. A recent review article mentions that “tissue deficiency can occur due to medications such as statins” and this meta-analysis of 12 randomized controlled trials reported that supplementation [of CoQ10] did indeed ameliorate muscle-related symptoms (pain, weakness, cramping). The majority of the studies focus on muscle pain, but deficiencies of CoQ10 can also lead to fatigue and exercise intolerance.
Like everything in health and nutrition, studies are often mixed and some have found that supplementation doesn’t help muscle pain and thus many providers advise against taking CoQ10. But knowing that statins DO deplete blood levels of nutrients (CoQ10 isn’t the only one), shouldn’t we be concerned about that fact alone? Who knows what other consequences are happening that studies haven’t yet measured?
If I were on a statin I would most definitely supplement with CoQ10, somewhere in the realm of 50-200 mg (some people may need higher levels if they’re symptomatic). As far as I know, studies have either suggested a benefit or at worst no effect from supplementation, so given this I’m not quite sure why more doctors don’t recommend taking a supplement given that the side effects from the supplement are rare and minor if they occur. The level of CoQ10 can also be measured in the blood, and although it’s not a perfect measurement (most of it is in the cell and not in the bloodstream), it is at least a piece of data that you can ask your doctor to check.
Another medication, metformin (for glucose control), has been found to be associated with B12 deficiency (here and here). And oral contraceptives can deplete a slew of nutrients.
I’ll stop here, but my motto in all of this is: why risk it? If there’s even a slim chance that certain drugs can cause specific nutrients to be depleted or not absorbed as well as they should be, why not focus on certain foods containing the nutrients in question or (as in the case of B12) take a reasonable supplemental dose?