A Neglected Field of Peptic Ulcer Disease Therapy: Its Relation with Vitamin Supplements

Introduction: Market supply and consumer demand for vitamins have been growing worldwide over the last decade. Peptic ulcer disease (PUD) accounts for a large proportion of morbidity of gastrointestinal disorders. Interactions of over the counter (OTC) or prescribed vitamins with pharmacotherapeutic agents for PUD are often ignored by gastroenterologists and may have important therapeutic implications as the PUD patient population is vulnerable to harmful drug-vitamin interactions This is a systematic review to assess the negative clinical outcomes with concomitant use of vitamins and common pharmaceutical agents for PUD. Methods: Study Selection Criteria: Studies relevant to the negative outcomes after taking vitamins with Histamine H2-receptor antagonists (H2RA) and proton pump inhibitors (PPI) were selected. Data collection & extraction: Articles were searched in PubMed, Medline, and two other databases. Data analysis: Outcomes related to vitamin use with above PUD meds were retrieved and all relevant data was extracted to an Excel® spreadsheet with data abstraction checklists. Results: Data was extracted from 27 studies on the outcomes of concomitant use of vitamins with H2RA and PPI. 10 single vitamins, including vitamin A (retinol), thiamine, niacin, vitamin B6, folic acid, vitamin B12, vitamin c, vitamin D, vitamin E and vitamin K, were involved in more than 50 interactions with medications for peptic ulcer disease, which include H2RA (n=29, 46%): cimetidine (n=11), ranitidine (n=6), famotidine (n=8), nizatidine (n=4); PPI (n=34, 54%), including omeprazole, lansoprazole, esomeprazole, rabeprazole and pantoprazole. The majority (61.1%) of outcomes was attributed to pharmacokinetic-related mechanisms. 26.7% and 12.2 % were attributable to pharmacodynamics and combined mechanisms, respectively. Vitamin E appeared to bind with the nuclear receptor, pregnane X receptor, which results in increased expression of CYP3A4, therefore, increase metabolism of omeprazole. Conclusion: The significance of drug interactions of vitamins with commonly used anti-ulcer medications appears to be ill-appreciated by practicing gastroenterologists. To improve the treatment outcomes in PUD patients, gastroenterologist must be familiar with the consequences of combining vitamins with current pharmaceutical agents for PUD. However, clinical adverse outcomes such as slow or no ulcer healing, increased risk of ulcer-related bleeding or other complications, are rarely reported and merit further studies.