Cataract surgery had been performed several years prior, and she suffered from a multitude of ailments including hypertension, hypercholesterolaia, hypothyroidism and osteoarthritis. In addition to medications for these, she had also self-prescribed vitamin D for her bones, fish oil for her heart and glucosamine for her osteoarthritis.It was therefore not surprising to see that she was also taking vitamins for her AMD. My patient only had a few scattered drusen, yet she had been prescribed “macular vitamins” without any evidence supporting its use. Why?Approximately 60% of Australians take a supplent, and the Australian complentary medicine industry was valued at $4.7 billion in 2016. It clearly is a booming industry, with entire stores and websites dedicated to the product.Patients have become increasingly disenfranchised by the limitations of Western medicine, and vitamins and supplents are less regulated than prescription medications – the advertising of which is regulated by the Therapeutic Goods Administration. Many claims of efficacy of vitamins and supplents are driven more by marketing than good clinical evidence.{{quote-A:R-W:450-Q: Supplents can have a role in patient health, but that the indications are limited to the findings of good clinical evidence. }}Even if a supplent were useless in a given clinical setting, some would argue that they are at least harmless. This is not always true.Beta-carotene is associated with increased mortality in people who have ever smoked. High doses of vitamin A may be harmful in patients with ABCA4 gene mutations such as Stargardt’s disease. Aegeline, green tea catechins and black cohosh have all been associated with liver disease.Supplents can also interact with prescribed medications such as the blood-thinner warfarin or chotherapy agents. Patients may receive a false sense of security regarding the protective effect of a supplent and fail to consume a balanced diet or visit their GP for regular check-ups.So, what can we as clinicians do to support our patients? First, we must recognise that supplents can have a role in patient health, but that the indications are limited to the findings of good clinical evidence.The evidence for vitamin supplents in AMD originates from the Age-Related Eye Disease Study (AREDS) Research Group. They published findings from a large randomised controlled trial in 2001 that studied a specific combination of vitamins.These vitamins were found to have a role in intermediate AMD and advanced AMD in one eye, by reducing the development of “advanced AMD”, (choroidal neovascularisation or centre- involving geographic atrophy) by 25% at five years.There is no evidence that they are useful in patients with small drusen only, or in those with advanced AMD in both eyes. The vitamin formula was subsequently refined in a further study.It’s important to rber that often supplent manufacturers will add or subtract active ingredients, or alter its dosage. We should therefore check that the supplent a patient is taking corresponds with what was prescribed in the clinical trial supporting its use.Polypharmacy is hazardous, and attpts should always be made to rationalise unnecessary medications. That’s why we should also involve and inform a patient’s GP if a supplent is recommended to ensure there are no interactions with other medications.We must resist unproven claims of efficacy by companies manufacturing supplents. Part of our role is to educate patients on why they are taking a supplent, as too often they mistakenly think they are taking “macular vitamins” to improve their vision or treat their wet AMD.Finally, we should be an advocate for patients, recommending a balanced diet rich in fresh vegetables and fish, a personalised exercise regime and smoking cessation. As my mother always said: “rber to eat your greens.”AREDS2 vitamins are only useful in patients with intermediate AMD (extensive intermediate drusen or large drusen), or advanced AMD (CNV or centre involving geographic atrophy) in one eye.The recommended daily AREDS2 vitamin formula is: Vitamin C (500mg), vitamin E (400IU), copper (2mg), lutein (10mg), zeaxanthin (2mg) and zinc (25-80mg).
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Name: Adrian FungQualifications: MBBS(Hons), MMed (Clinical Epidiology), MMed (Ophthalmic Science), FRANZCOOrganisation: Westmead and Macquarie University HospitalsPosition: Associate ProfessorLocation: SydneyYears in the profession: Consultant for six years |
