Why are doctors still prescribing bed rest in pregnancy?

Maternity care providers have traditionally prescribed "bed rest," or
activity restriction, for a host of pregnancy complications (including
preterm contractions, short cervix, multiple gestation, and
preeclampsia) despite evidence that it does not improve maternal or
neonatal outcomes. On the other hand, prolonged activity restriction in
pregnancy increases risk for muscle atrophy, bone loss, thromboembolic
events, and gestational diabetes. Although it did not include this
practice in its Choosing Wisely "Five Things Physicians and Patients Should Question" list, the Society of Maternal and Fetal Medicine (SMFM) recently published a strongly worded position paper recommending against activity restriction in pregnancy for any reason.


This isn't the first time reviewers have examined the evidence for activity restriction and found it lacking; a 2013 summary
of several Cochrane reviews of therapeutic bed rest in pregnancy also
found such poor data to support the practice that the authors concluded
its use should be considered unethical outside of the context of a
randomized controlled trial.


The message isn't getting through to physicians or patients, though. A 2009 survey
of SMFM members found that 71 percent would recommend bed rest to
patients with arrested preterm labor, and 87 percent would advise bed
rest for patients with preterm premature rupture of membranes at 26
weeks gestation, even though most of them did not believe it would make
make any difference in the outcome (the most common answers were
"minimal benefit" and "minimal risk"). Unfortunately, the risk may be
more than minimal. Not only does activity restriction expose pregnant
women to harm, a secondary analysis of a randomized trial of preterm birth prevention found that nulliparous women with short cervices whose activity was restricted were actually more likely to deliver before 37 weeks' gestation than those who were not.


Similarly, a search of the terms "bed rest" on popular pregnancy websites Babyzone and Pregnancy.org yielded
the following statements that fly in the face of evidence: "Changing
the force of gravity usually helps minimize preterm labor." "It [bed
rest] helps keep blood pressure stable and low." "In most cases, bed
rest is used to help the body have the best chance to normalize." A
handout on WebMD provided a more balanced assessment:

Bed rest has been a way of treating pregnancy complications for
more than a hundred years. But there's a problem. While bed rest is a
common treatment, there's no proof that it helps. It doesn't seem to
protect your health or your baby's. In fact, bed rest has risks itself.
Doctors still prescribe it, but more because of tradition than good
evidence that it works.


The handout went on to advise patients to question their physicians
closely or get a second opinion if bed rest is recommended. That's
sensible advice. Doctors who are reluctant to abandon this useless and
potentially harmful maternity practice should consult the SMFM paper or the American Family Physician By Topic collections on Prenatal Care and Labor, Delivery, and Postpartum Issues, where no articles recommend activity restriction for pregnancy complications.

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Birth control pills over-the-counter: debate evidence, not politics

I've waited to address this sensitive topic until after the midterm
elections, when political slogans such as the phony "war on women" and
trumped-up threats to religious liberty were discarded like so many
campaign posters. It was curious to see the American College of
Obstetricians & Gynecologists (ACOG) and Planned Parenthood
attacking Republican Senate candidates for supporting over-the-counter birth control pills without a prescription -
a position that, if the pills were free or the candidates were
Democrats, they would probably have cheered. (When the American Academy
of Family Physicians quietly supported oral contraceptives over the counter earlier this year, it was careful to specify that such purchases be covered by health insurance.)


As outlined in a 2012 ACOG opinion paper,
the rationale for granting over-the-counter status to birth control
pills goes something like this: unintended pregnancies are common;
visiting a doctor for a prescription is inconvenient and unnecessary;
oral contraceptives are safer than many medications already available
without a prescription; women can screen themselves for
contraindications; and women wouldn't stop seeing doctors for other
preventive services. There are, however, very few studies that actually
support these arguments; much of the literature simply surveys what other countries do
regarding contraceptive access and assumes that outcomes are better (or
at least not worse). And surprisingly, there's no research whatsoever
that shows making oral contraceptives over-the-counter reduces
unintended pregnancies.


This hypothesis would be relatively straightfoward to test in a
randomized clinical trial. Enroll, say, five hundred non-pregnant,
sexually active, pre-menopausal women without contraindications to oral
contraceptives who don't want to become pregnant in the next 12 months.
Randomly assign half of them to receive birth control pills without a
prescription at a convenient pharmacy, and assign the other half to
obtain contraceptives the usual way, by requesting a prescription from
their family doctor or gynecologist. After a year, compare the numbers
of unintended pregnancies and adverse events (deep venous thromboses,
strokes, sexually transmitted infections) in each group. Other outcomes
could include contraceptive adherence, appropriate use, and use of
recommended preventive health care such as immunizations and screenings.


Why hasn't this study been performed already? Some physicians have told
me that this question doesn't need to be studied because it's obvious
that over-the-counter access to contraceptives would lead to fewer
pregnancies. Others have insinuated that even asking the question is
"anti-woman" and insensitive to the long history of gender bias in
health and men using fertility to control and oppress women.


I say bull. This isn't only a political question, it's also a scientific
one. Otherwise, why stop at putting oral contraceptives over the
counter? Why not, for example, make it easier for millions of women and
men with poorly controlled ("unintended") high blood pressure to treat
themselves by making anti-hypertensive drugs over-the-counter? In fact,
self-monitoring and self-titration of blood pressure medications is a
strategy that is being seriously considered in high-risk populations. A
recent randomized trial published in JAMA compared
this strategy to usual care in five hundred primary care patients with
hypertension and a history of stroke, coronary heart disease, diabetes,
or chronic kidney disease. After 12 months, the mean blood systolic
blood pressure of the intervention group was 9 points lower than that of
the control group, with no difference in adverse events.


The outcome of the hypertension study wasn't obvious. It might easily
have gone the other way. And for that reason, it was a question that
deserved to be rigorously studied. Similarly, over-the-counter birth
control need not be an evidence-free debate. Regardless of where you
stand on this issue personally or politically, it's time to stop with
the slogans and inform the discussion with science.

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All about Vitamin D

Find a Vitamin or Supplement

VITAMIN D

VITAMIN D Overview Information

Vitamin D is a vitamin. It can be found in small amounts in a few foods, including fatty fish such as herring, mackerel, sardines and tuna. To make vitamin D more available, it is added to dairy products, juices, and cereals that are then said to be “fortified with vitamin D.” But most vitamin D – 80% to 90% of what the body gets – is obtained through exposure to sunlight. Vitamin D can also be made in the laboratory as medicine.

Vitamin D is used for preventing and treating rickets, a disease that is caused by not having enough vitamin D (vitamin D deficiency). Vitamin D is also used for treating weak bones (osteoporosis), bone pain (osteomalacia), bone loss in people with a condition called hyperparathyroidism, and an inherited disease (osteogenesis imperfecta) in which the bones are especially brittle and easily broken. It is also used for preventing falls and fractures in people at risk for osteoporosis, and preventing low calcium and bone loss (renal osteodystrophy) in people with kidney failure.

Vitamin D is used for conditions of the heart and blood vessels, including high blood pressure and high cholesterol. It is also used for diabetes, obesity, muscle weakness, multiple sclerosis, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), asthma, bronchitis, premenstrual syndrome (PMS), and tooth and gum disease.

Some people use vitamin D for skin conditions including vitiligo, scleroderma, psoriasis, actinic keratosis, and lupus vulgaris.

It is also used for boosting the immune system, preventing autoimmune diseases, and preventing cancer.

Because vitamin D is involved in regulating the levels of minerals such as phosphorous and calcium, it is used for conditions caused by low levels of phosphorous (familial hypophosphatemia and Fanconi syndrome) and low levels of calcium (hypoparathyroidism and pseudohypoparathyroidism).

Vitamin D in forms known as calcitriol or calcipotriene is applied directly to the skin for a particular type of psoriasis.

If you travel to Canada, you may have noticed that Canada recognizes the importance of vitamin D in the prevention of osteoporosis. It allows this health claim for foods that contain calcium: "A healthy diet with adequate calcium and vitamin D, and regular physical activity, help to achieve strong bones and may reduce the risk of osteoporosis.” But the US version of this osteoporosis health claim does not yet include vitamin D.

How does it work?

Vitamin D is required for the regulation of the minerals calcium and phosphorus found in the body. It also plays an important role in maintaining proper bone structure.

Sun exposure is an easy, reliable way for most people to get vitamin D. Exposure of the hands, face, arms, and legs to sunlight two to three times a week for about one-fourth of the time it would take to develop a mild sunburn will cause the skin to produce enough vitamin D. The necessary exposure time varies with age, skin type, season, time of day, etc.

It’s amazing how quickly adequate levels of vitamin D can be restored by sunlight. Just 6 days of casual sunlight exposure without sunscreen can make up for 49 days of no sunlight exposure. Body fat acts like a kind of storage battery for vitamin D. During periods of sunlight, vitamin D is stored in fatty fat and then released when sunlight is gone.

Nevertheless, vitamin D deficiency is more common than you might expect. People who don’t get enough sun, especially people living in Canada and the northern half of the US, are especially at risk. Vitamin D deficiency also occurs even in sunny climates, possibly because people are staying indoors more, covering up when outside, or using sunscreens consistently these days to reduce skin cancer risk.

Older people are also at risk for vitamin D deficiency. They are less likely to spend time in the sun, have fewer “receptors” in their skin that convert sunlight to vitamin D, may not get vitamin D in their diet, may have trouble absorbing vitamin D even if they do get it in their diet, and may have more trouble converting dietary vitamin D to a useful form due to aging kidneys. In fact, the risk for vitamin D deficiency in people over 65 years of age is very high. Surprisingly, as many as 40% of older people even in sunny climates such as South Florida don’t have enough vitamin D in their systems.

Vitamin D supplements may be necessary for older people, people living in northern latitudes, and for dark-skinned people who need extra time in the sun, but don’t get it.

VITAMIN D Uses & Effectiveness

Effective for:

• Treating conditions that cause weak and painful bones (osteomalacia).
• Low levels of phosphate in the blood (familial hypophosphatemia).
• Low levels of phosphate in the blood due to a disease called Fanconi syndrome.
• Psoriasis (with a specialized prescription-only form of vitamin D).
• Low blood calcium levels because of a low parathyroid thyroid hormone levels.
• Helping prevent low calcium and bone loss (renal osteodystrophy) in people with kidney failure.
• Rickets.
• Vitamin D deficiency.

Likely Effective for:

• Treating osteoporosis (weak bones). Taking a specific form of vitamin D called cholecalciferol (vitamin D3) along with calcium seems to help prevent bone loss and bone breaks.
• Preventing falls in older people. Researchers noticed that people who don’t have enough vitamin D tend to fall more often than other people. They found that taking a vitamin D supplement reduces the risk of falling by up to 22%. Higher doses of vitamin D are more effective than lower doses. One study found that taking 800 IU of vitamin D reduced the risk of falling, but lower doses didn’t.
  
  Also, vitamin D, in combination with calcium, but not calcium alone, may prevent falls by decreasing body sway and blood pressure. This combination prevents more falls in women than men.
• Reducing bone loss in people taking drugs called corticosteroids.

Possibly Effective for:

• Reducing the risk of multiple sclerosis (MS). Studies show taking vitamin D seems to reduce women’s risk of getting MS by up to 40%. Taking at least 400 IU per day, the amount typically found in a multivitamin supplement, seems to work the best.
• Preventing cancer. Some research shows that people who take a high-dose vitamin D supplement plus calcium might have a lower chance of developing cancer of any type.
• Weight loss. Women taking calcium plus vitamin D are more likely to lose weight and maintain their weight. But this benefit is mainly in women who didn’t get enough calcium before they started taking supplements.
• Respiratory infections. Clinical research in school aged children shows that taking a vitamin D supplement during winter might reduce the chance of getting seasonal flu. Other research suggests that taking a vitamin D supplement might reduce the chance of an asthma attack triggered by a cold or other respiratory infection. Some additional research suggests that children with low levels of vitamin D have a higher chance of getting a respiratory infection such as the common cold or flu.
• Reducing the risk of rheumatoid arthritis in older women.
• Reducing bone loss in women with a condition called hyperparathyroidism.
• Preventing tooth loss in the elderly.

Possibly Ineffective for:

• Breast cancer. Many studies have looked at whether vitamin D can help prevent breast cancer, but their results have not always agreed. The best evidence to date comes from a large study called the Women’s Health Initiative, which found that taking 400 IU of vitamin D and 1000 mg of calcium per day does not seem to lower the chance of getting breast cancer. The possibility remains that high doses of vitamin D might lower breast cancer risk in younger women. But the doses needed would be so high that they might not be safe.
• High blood pressure.
• Improving muscle strength in older adults.
• Preventing bone loss in people with kidney transplants.

Insufficient Evidence for:

• Asthma. Some research suggests that people with asthma are more likely to have low vitamin D levels in the body. In children with asthma, taking a vitamin D supplement might reduce the chance of an asthma attack during a cold or other respiratory infection. But it is too soon to know if taking a vitamin D supplement can prevent or treat asthma symptoms.
• Heart disease. Research suggests that people with low levels of vitamin D in their blood are much more likely to develop heart disease, including heart failure, than people with higher vitamin D levels. However, taking vitamin D does not seem to extend the life of people with heart failure.
• Chronic obstructive pulmonary disease (COPD). Some research shows that people with COPD have lower than normal vitamin D levels. But there is not enough information to know if taking a vitamin D supplement can decrease symptoms of COPD.
• High cholesterol. People with lower vitamin D levels seem to be much more likely to have high cholesterol than people with higher vitamin D levels. Limited research shows that taking calcium plus vitamin D daily, in combination with a low-calorie diet, significantly raises “good (HDL) cholesterol” and lowers “bad (LDL) cholesterol” in overweight women. But taking calcium plus vitamin D alone, does not reduce LDL cholesterol levels.
• Gum disease. Higher blood levels of vitamin D seem to be linked with a reduced risk of gum disease in people 50 years of age or older. But, this doesn’t seem to be true for adults younger than 50.
• Diabetes. People with lower vitamin D levels are significantly more likely to have type 2 diabetes compared to people with higher vitamin D levels. But, there is no reliable evidence that taking vitamin D supplements can treat or prevent type 2 diabetes.
• Premenstrual syndrome (PMS). There is some evidence that getting more vitamin D from the diet might help to prevent PMS or reduce symptoms. Taking vitamin D supplements might help reduce symptoms but doesn't seem to help prevent PMS.
• A blood cell disease called myelodysplastic syndrome.
• A muscle disease called proximal myopathy.
• Colorectal cancer.
• Warts.
• Bronchitis.
• Asthma.
• Breathing disorders.
• Metabolic syndrome.
• Muscle pain caused by medications called "statins."
• Vaginal atrophy.
• Other conditions.

More evidence is needed to rate vitamin D for these uses.

VITAMIN D Side Effects & Safety

Vitamin D is LIKELY SAFE when taken by mouth in recommended amounts. Most people do not commonly experience side effects with vitamin D, unless too much is taken. Some side effects of taking too much vitamin D include weakness, fatigue, sleepiness, headache, loss of appetite, dry mouth, metallic taste, nausea, vomiting, and others.

Taking vitamin D for long periods of time in doses higher than 4000 units per day is POSSIBLY UNSAFE and may cause excessively high levels of calcium in the blood. However, much higher doses are often needed for the short-term treatment of vitamin D deficiency. This type of treatment should be done under the supervision of a healthcare provider.

Special Precautions & Warnings:   

Pregnancy and breast-feeding: Vitamin D is LIKELY SAFE during pregnancy and breast-feeding when used in daily amounts below 4000 units. Do not use higher doses. Using higher doses might cause serious harm to the infant.

Kidney disease: Vitamin D may increase calcium levels and increase the risk of “hardening of the arteries” in people with serious kidney disease. This must be balanced with the need to prevent renal osteodystrophy, a bone disease that occurs when the kidneys fail to maintain the proper levels of calcium and phosphorus in the blood. Calcium levels should be monitored carefully in people with kidney disease.

High levels of calcium in the blood: Taking vitamin D could make this condition worse.

“Hardening of the arteries” (atherosclerosis): Taking vitamin D could make this condition worse.

Sarcoidosis: Vitamin D may increase calcium levels in people with sarcoidosis. This could lead to kidney stones and other problems. Use vitamin D cautiously.

Histoplasmosis: Vitamin D may increase calcium levels in people with histoplasmosis. This could lead to kidney stones and other problems. Use vitamin D cautiously.

Over-active parathyroid gland (hyperparathyroidism): Vitamin D may increase calcium levels in people with hyperparathyroidism. Use vitamin D cautiously.

Lymphoma: Vitamin D may increase calcium levels in people with lymphoma. This could lead to kidney stones and other problems. Use vitamin D cautiously.

VITAMIN D Interactions 

Moderate Interaction be cautious with this combination

• Aluminum interacts with VITAMIN D

Aluminum is found in most antacids. Vitamin D can increase how much aluminum the body absorbs. This interaction might be a problem for people with kidney disease. Take vitamin D two hours before, or four hours after antacids.

• Calcipotriene (Dovonex) interacts with VITAMIN D

Calcipotriene is a drug that is similar to vitamin D. Taking vitamin D along with calcipotriene (Dovonex) might increase the effects and side effects of calcipotriene (Dovonex). Avoid taking vitamin D supplements if you are taking calcipotriene (Dovonex).

• Digoxin (Lanoxin) interacts with VITAMIN D

Vitamin D helps your body absorb calcium. Calcium can affect the heart. Digoxin (Lanoxin) is used to help your heart beat stronger. Taking vitamin D along with digoxin (Lanoxin) might increase the effects of digoxin (Lanoxin) and lead to an irregular heartbeat. If you are taking digoxin (Lanoxin), talk to your doctor before taking vitamin D supplements.

• Diltiazem (Cardizem, Dilacor, Tiazac) interacts with VITAMIN D

Vitamin D helps your body absorb calcium. Calcium can affect your heart. Diltiazem (Cardizem, Dilacor, Tiazac) can also affect your heart. Taking large amounts of vitamin D along with diltiazem (Cardizem, Dilacor, Tiazac) might decrease the effectiveness of diltiazem.

• Verapamil (Calan, Covera, Isoptin, Verelan) interacts with VITAMIN D

Vitamin D helps your body absorb calcium. Calcium can affect the heart. Verapamil (Calan, Covera, Isoptin, Verelan) can also affect the heart. Do not take large amounts of vitamin D if you are taking verapamil (Calan, Covera, Isoptin, Verelan).

• Water pills (Thiazide diuretics) interacts with VITAMIN D

Vitamin D helps your body absorb calcium. Some "water pills" increase the amount of calcium in the body. Taking large amounts of vitamin D along with some "water pills" might cause to be too much calcium in the body. This could cause serious side effects including kidney problems.

Some of these "water pills" include chlorothiazide (Diuril), hydrochlorothiazide (HydroDIURIL, Esidrix), indapamide (Lozol), metolazone (Zaroxolyn), and chlorthalidone (Hygroton).

Minor Interaction be watchful with this combination

• Cimetidine (Tagamet) interacts with VITAMIN D

The body changes vitamin D into a form that it can use. Cimetidine might decrease how well the body changes vitamin D. This might decrease how well vitamin D works. But this interaction probably isn't important for most people.

• Heparin interacts with VITAMIN D

Heparin slows blood clotting and can increase the risk of breaking a bone when used for a long period of time. People taking these medications should eat a diet rich in calcium and vitamin D.

• Low molecular weight heparins (LMWHS) interacts with VITAMIN D

Some medications called low molecular weight heparins can increase the risk of breaking a bone when used for a long periods of time. People taking these medications should eat a diet rich in calcium and vitamin D.

These drugs include enoxaparin (Lovenox), dalteparin (Fragmin), and tinzaparin (Innohep).

VITAMIN D Dosing                  

The following doses have been studied in scientific research:

BY MOUTH:

• For preventing osteoporosis and fractures: 400-1000 IU per day has been used for older adults. Some experts recommended higher doses of 1000-2000 IU daily.
• For preventing falls: 800-1000 IU/day has been used in combination with calcium 1000-1200 mg/day.
• For preventing multiple sclerosis (MS): long-term consumption of at least 400 IU per day, mainly in the form of a multivitamin supplement, has been used.
• For preventing all cancer types: calcium 1400-1500 mg/day plus vitamin D3 (cholecalciferol) 1100 IU/day in postmenopausal women has been used.
• For muscle pain caused by medications called "statins": vitamin D2 (ergocalciferol) or vitamin D3 (cholecalciferol) 50,000 units once a week or 400 IU daily.
• For preventing the flu: vitamin D (cholecalciferol) 1200 IU daily.

Most vitamin supplements contain only 400 IU (10 mcg) vitamin D.

The Institute of Medicine publishes recommended daily allowance (RDA), which is an estimate of the amount of vitamin D that meets the needs of most people in the population. The current RDA was set in 2010. The RDA varies based on age as follows: 1-70 years of age, 600 IU daily; 71 years and older, 800 IU daily; pregnant and lactating women, 600 IU daily. For infants ages 0-12 months, an adequate intake (AI) level of 400 IU is recommended.

Some organizations are recommending higher amounts. In 2008, the American Academy of Pediatrics increased the recommended minimum daily intake of vitamin D to 400 IU daily for all infants and children, including adolescents. Parents should not use vitamin D liquids dosed as 400 IU/drop. Giving one dropperful or mL by mistake can deliver 10,000 IU/day. The US Food and Drug Administration (FDA) will force companies to provide no more than 400 IU per dropperful in the future.

The National Osteoporosis Foundation recommends vitamin D 400 IU to 800 IU daily for adults under age 50, and 800 IU to 1000 IU daily for older adults.

The North American Menopause Society recommends 700 IU to 800 IU daily for women at risk of deficiency due to low sun (e.g., homebound, northern latitude) exposure.

Guidelines from the Osteoporosis Society of Canada recommend vitamin D 400 IU per day for people up to age 50, and 800 IU per day for people over 50. Osteoporosis Canada now recommends 400-1000 IU daily for adults under the age of 50 years and 800-2000 IU daily for adults over the age of 50 years.

The Canadian Cancer Society recommends 1000 IU/day during the fall and winter for adults in Canada. For those with a higher risk of having low vitamin D levels, this dose should be taken year round. This includes people who have dark skin, usually wear clothing that covers most of their skin, and people who are older or who don't go outside often.

Many experts now recommend using vitamin D supplements containing cholecalciferol in order to meet these intake levels. This seems to be more potent than another form of vitamin D called ergocalciferol.

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All about Vitamin C (Ascorbic Acid)

VITAMIN C (ASCORBIC ACID)

Vitamin C (VITAMIN C (ASCORBIC ACID)) Overview Information

Vitamin C is a vitamin. Some animals can make their own vitamin C, but people must get this vitamin from food and other sources. Good sources of vitamin C are fresh fruits and vegetables, especially citrus fruits. Vitamin C can also be made in a laboratory.

Most experts recommend getting vitamin C from a diet high in fruits and vegetables rather than taking supplements. Fresh-squeezed orange juice or fresh-frozen concentrate is a better pick than ready-to-drink orange juice. The fresh juice contains more active vitamin C. Drink fresh-frozen orange juice within one week after reconstituting it for the most benefit. It you prefer ready-to-drink orange juice, buy it 3 to 4 weeks before the expiration date, and drink it within one week of opening.

Historically, vitamin C was used for preventing and treating scurvy. Scurvy is now relatively rare, but it was once common among sailors, pirates, and others who spent long periods of time onboard ships. When the voyages lasted longer than the supply of fruits and vegetables, the sailors began to suffer from vitamin C deficiency, which led to scurvy.

These days, vitamin C is used most often for preventing and treating the common cold. Some people use it for other infections including gum disease, acne and other skin infections, bronchitis, human immunodeficiency virus (HIV) disease, stomach ulcers caused by bacteria called Helicobacter pylori, tuberculosis, dysentery (an infection of the lower intestine), and skin infections that produce boils (furunculosis). It is also used for infections of the bladder and prostate.

Some people use vitamin C for depression, thinking problems, dementia, Alzheimer's disease, physical and mental stress, fatigue, and attention deficit-hyperactivity disorder (ADHD).

Other uses include increasing the absorption of iron from foods and correcting a protein imbalance in certain newborns (tyrosinemia).

There is some thought that vitamin C might help the heart and blood vessels. It is used for hardening of the arteries, preventing clots in veins and arteries, heart attack, stroke, high blood pressure, and high cholesterol.

Vitamin C is also used for glaucoma, preventing cataracts, preventing gallbladder disease, dental cavities (caries), constipation, Lyme disease, boosting the immune system, heat stroke, hay fever, asthma, bronchitis, cystic fibrosis, infertility, diabetes, chronic fatigue syndrome (CFS), autism, collagen disorders, arthritis and bursitis, back pain and disc swelling, cancer, and osteoporosis.

Additional uses include improving physical endurance and slowing aging, as well as counteracting the side effects of cortisone and related drugs, and aiding drug withdrawal in addiction.

Sometimes, people put vitamin C on their skin to protect it against the sun, pollutants, and other environmental hazards. Vitamin C is also applied to the skin to help with damage from radiation therapy.

How does it work?

Vitamin C is required for the proper development and function of many parts of the body. It also plays an important role in maintaining proper immune function.

Vitamin C (VITAMIN C (ASCORBIC ACID)) Uses & Effectiveness

Effective for:

• Treatment and prevention of vitamin C deficiency, including a condition called “scurvy.”

Likely Effective for:

• Improving the way the body absorbs iron.
• Treating a disease called tyrosinemia in newborns when given as an injection.

Possibly Effective for:

• Wrinkled skin. Skin creams containing vitamin C or vitamin C in combination with acetyl tyrosine, zinc sulfate, sodium hyaluronate, and bioflavonoids (Cellex-C High Potency Serum) seem to improve wrinkles in facial skin aged by sun exposure.
• Reducing the risk of certain cancers of the mouth and breast. This only works when fresh fruits and vegetables high in vitamin C are eaten, not with vitamin C supplements.
• Treating the common cold. There is a lot of controversy about the effectiveness of vitamin C for treating the common cold. However, the majority of evidence shows that taking high doses of vitamin C might shorten the course of the cold by 1 to 1.5 days in some patients. But it is not effective for preventing the common cold.
• Lowering high blood pressure. Taking vitamin C along with conventional high blood pressure medications appears to decrease systolic blood pressure (the top number in a blood pressure reading) by a small amount, but does not seem to decrease diastolic pressure (the bottom number). Taking vitamin C supplements alone, though, doesn’t seem to affect blood pressure.
• Preventing sunburn. Taking vitamin C along with vitamin E seems to prevent sunburn. But taking vitamin C alone doesn’t prevent sunburn.
• Reducing the risk of gallbladder disease. There is some evidence that taking vitamin C might help to prevent gallbladder disease in women. But vitamin C doesn’t seem to have this effect in men.
• Slowing the worsening of osteoarthritis. Obtaining vitamin C from dietary sources seems to prevent cartilage loss and worsening of symptoms in people with osteoarthritis.
• Treating an eye disease called AMD (age-related macular degeneration) when used with other medicines. Taking vitamin C in combination with zinc, vitamin E, and beta-carotene daily seems to help prevent vision loss or slow worsening of AMD in patients with advanced AMD. There isn't enough evidence to know if this combination helps people with less advanced macular disease or prevents AMD. Using vitamin C with other antioxidants, but without zinc, doesn't seem to have any effect on AMD.
• Decreasing protein in the urine of people with type 2 diabetes (albuminuria). This might help to lower the risk of developing serious kidney disease.
• Redness (erythema) after cosmetic skin procedures. There is some evidence that a particular vitamin C skin cream can decrease the amount of redness and the time it lasts following laser resurfacing for scar and wrinkle removal.
• Decreasing lung infections caused by heavy exercise. Using vitamin C in amounts of 600 mg to 1 gram per day before heavy physical exercise, such as a marathon, might prevent upper respiratory infections that sometimes follow heavy exercise.
• Treating ulcers in the stomach caused by bacteria called H. pylori. Taking vitamin C seems to decrease some of the side effects caused by treatment. After H. pylori bacteria are killed, vitamin C appears to decrease the occurrence of precancerous changes in stomach tissue.
• Helping medicines used for chest pain, such as nitroglycerin, to work longer.
• Reducing the risk in women of a circulatory system disorder called peripheral arterial disease.
• Preventing “hardening of the arteries” (atherosclerosis).
• Preventing kidney problems related to contrast media used during a diagnostic test called angiography.
• Reducing human immunodeficiency virus (HIV) transmission by mothers to their newborns when taken with vitamins B and E.
• Reducing complications after a broken wrist called complex regional pain syndrome, or reflex sympathetic dystrophy.
• Reducing lead in the blood by eating foods high in vitamin C.
• Reducing complications of a high-risk pregnancy (pre-eclampsia).
• Improving physical performance and strength in the elderly.

Possibly Ineffective for:

• Preventing the common cold.
• Reducing the risk of stroke.
• Reducing the risk for Alzheimer's disease and other brain diseases that may cause intellectual loss.
• Preventing eye disease associated with a medicine called interferon.
• Treating bronchitis.
• Reducing skin problems in people being treated for cancer with radiation.
• Preventing pancreatic cancer.
• Preventing prostate cancer.
• Preventing type 2 diabetes.

Insufficient Evidence for:

• Hay fever (Allergic rhinitis). There is conflicting evidence about the effects of vitamin C on symptoms of hay fever. Taking vitamin C doesn’t seem to prevent hay fever.
• Cataracts. There is conflicting information about the use of vitamin C to prevent cataracts. Vitamin C plus vitamin E and beta-carotene doesn't seem to have any significant effect on age-related loss of vision due to cataracts in well-nourished people who take the supplement long-term (for an average of 6.3 years). On the other hand, other research suggests that taking multivitamins that contain vitamin C for 10 years seems to prevent cataracts. Use of supplements for shorter periods doesn't appear to work.
• Bladder cancer. Taking vitamin C does not seem to affect survival.
• Lowering cholesterol. Taking vitamin C daily doesn’t seem to lower cholesterol in people whose cholesterol is not too high to start with. The effect of vitamin C on cholesterol levels in patients with high cholesterol is not known.
• Cancer (Esophageal cancer, and colorectal cancer). Taking vitamin C in combination with beta-carotene plus vitamin E doesn't seem to prevent these types of cancer.
• Stomach cancer. Not all research agrees on whether or not taking vitamin C supplements or getting extra vitamin C in the diet can prevent stomach cancer. Taking vitamin C supplements in combination with beta-carotene or beta-carotene plus vitamin E does not seem to reduce the risk of stomach cancer. But some evidence suggests that taking vitamin C alone might keep precancerous sores in the stomach from progressing to cancer in people at high risk for stomach cancer.
• Mental stress. Limited evidence suggests that vitamin C might reduce blood pressure and symptoms during times of mental distress.
• Ovarian cancer. Dietary vitamin C does not seem to affect the risk of getting ovarian cancer.
• Kidney disease.
• Liver disease.
• Cystic fibrosis.
• Infertility.
• Diabetes.
• Heart disease.
• Attention deficit-hyperactivity disorder (ADHD).
• Lyme disease.
• Chronic fatigue syndrome (CFS).
• Treating and preventing sun-damaged skin when vitamin C is put on the skin.
• Wounds.
• Pressure sores.
• Tuberculosis.
• Dental cavities.
• Constipation.
• Acne.
• Other conditions.

More evidence is needed to rate vitamin C for these uses.

Vitamin C (VITAMIN C (ASCORBIC ACID)) Side Effects & Safety

Vitamin C is LIKELY SAFE for most people when taken by mouth in recommended doses or when applied to the skin. In some people, vitamin C might cause nausea, vomiting, heartburn, stomach cramps, headache, and other side effects. The chance of getting these side effects increases the more vitamin C you take. Amounts higher than 2000 mg per day are POSSIBLY UNSAFE and may cause a lot of side effects, including kidney stones and severe diarrhea. In people who have had a kidney stone, amounts greater than 1000 mg per day greatly increase the risk of kidney stone recurrence.

Special Precautions & Warnings:

Pregnancy and breast-feeding: Vitamin C is LIKELY SAFE for pregnant or breast-feeding women when taken in the recommended amount of 120 mg per day. Taking too much vitamin C during pregnancy can cause problems for the newborn baby.

Angioplasty, a heart procedure: Avoid taking supplements containing vitamin C or other antioxidant vitamins (beta-carotene, vitamin E) immediately before and following angioplasty without the supervision of a health care professional. These vitamins seem to interfere with proper healing.

Cancer: Cancerous cells collect high concentrations of vitamin C. Until more is known, only use high doses of vitamin C under the direction of your oncologist.

Diabetes: Vitamin C might raise blood sugar. In older women with diabetes, vitamin C in amounts greater than 300 mg per day increases the risk of death from heart disease. Do not take vitamin C in doses greater than those found in basic multivitamins.

Blood-iron disorders, including conditions called “thalassemia” and “hemochromatosis”: Vitamin C can increase iron absorption, which might make these conditions worse. Avoid large amounts of vitamin C.

Kidney stones, or a history of kidney stones: Large amounts of vitamin C can increase the chance of getting kidney stones. Do not take vitamin C in amounts greater than those found in basic multivitamins.

A metabolic deficiency called “glucose-6-phosphate dehydrogenase deficiency” (G6PDD): Large amounts of vitamin C can cause red blood cells to break in people with this condition. Avoid excessive amounts of vitamin C.

Sickle cell disease: Vitamin C might make this condition worse. Avoid using large amounts of vitamin C.

Vitamin C (VITAMIN C (ASCORBIC ACID)) Interactions 

Moderate Interaction be cautious with this combination

• Aluminum interacts with VITAMIN C (ASCORBIC ACID)

Aluminum is found in most antacids. Vitamin C can increase how much aluminum the body absorbs. But it isn't clear if this interaction is a big concern. Take vitamin C two hours before or four hours after antacids.

• Estrogens interacts with VITAMIN C (ASCORBIC ACID)

The body breaks down estrogens to get rid of them. Vitamin C might decrease how quickly the body gets rid of estrogens. Taking vitamin C along with estrogens might increase the effects and side effects of estrogens.

• Fluphenazine (Prolixin) interacts with VITAMIN C (ASCORBIC ACID)

Large amounts of vitamin C might decrease how much fluphenazine (Prolixin) is in the body. Taking vitamin C along with fluphenazine (Prolixin) might decrease the effectiveness of fluphenazine (Prolixin).

• Medications for cancer (Chemotherapy) interacts with VITAMIN C (ASCORBIC ACID)

Vitamin C is an antioxidant. There is some concern that antioxidants might decrease the effectiveness of some medications used for cancers. But it is too soon to know if this interaction occurs.

• Medications used for HIV/AIDS (Protease Inhibitors) interacts with VITAMIN C (ASCORBIC ACID)

Taking large doses of vitamin C might reduce how much of some medications used for HIV/AIDS stays in the body. This could decrease the effectiveness of some medications used for HIV/AIDS.
Some of these medications used for HIV/AIDS include amprenavir (Agenerase), nelfinavir (Viracept), ritonavir (Norvir), and saquinavir (Fortovase, Invirase).

• Medications used for lowering cholesterol (Statins) interacts with VITAMIN C (ASCORBIC ACID)

Taking vitamin C, beta-carotene, selenium, and vitamin E together might decrease the effectiveness of some medications used for lowering cholesterol. It is not known if vitamin C alone decreases the effectiveness of some medications used for lowering cholesterol. Some medications used for lowering cholesterol include atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), and pravastatin (Pravachol).

• Niacin interacts with VITAMIN C (ASCORBIC ACID)

Taking vitamin C along with vitamin E, beta-carotene, and selenium might decrease some of the helpful effects of niacin. Niacin can increase the good cholesterol. Taking vitamin C along with these other vitamins might decrease the effectiveness of niacin for increasing good cholesterol.

• Warfarin (Coumadin) interacts with VITAMIN C (ASCORBIC ACID)

Warfarin (Coumadin) is used to slow blood clotting. Large amounts of vitamin C might decrease the effectiveness of warfarin (Coumadin). Decreasing the effectiveness of warfarin (Coumadin) might increase the risk of clotting. Be sure to have your blood checked regularly. The dose of your warfarin (Coumadin) might need to be changed.

Minor Interaction be watchful with this combination

• Acetaminophen (Tylenol, others) interacts with VITAMIN C (ASCORBIC ACID)

The body breaks down acetaminophen (Tylenol, others) to get rid of it. Large amounts of vitamin C can decrease how quickly the body breaks down acetaminophen. It is not clear exactly when or if this interaction is a big concern.

• Aspirin interacts with VITAMIN C (ASCORBIC ACID)

The body breaks down aspirin to get rid of it. Large amounts of vitamin C might decrease the breakdown of aspirin. Decreasing the breakdown of aspirin might increase the effects and side effects of aspirin. Do not take large amounts of vitamin C if you take large amounts of aspirin.

• Choline Magnesium Trisalicylate (Trilisate) interacts with VITAMIN C (ASCORBIC ACID)

Vitamin C might decrease how quickly the body gets rid of choline magnesium trisalicylate (Trilisate). But it is not clear if this interaction is a big concern.

• Nicardipine (Cardene) interacts with VITAMIN C (ASCORBIC ACID)

Vitamin C is taken up by cells. Taking nicardipine (Cardene) along with vitamin C might decrease how much vitamin C is taken in by cells. The significance of this interaction is not clear.

• Nifedipine interacts with VITAMIN C (ASCORBIC ACID)

Vitamin C is taken up by cells. Taking nifedipine (Adalat, Procardia) along with vitamin C might decrease how much vitamin C is taken in by cells. The significance of this interaction is not clear.

• Salsalate (Disalcid) interacts with VITAMIN C (ASCORBIC ACID)

Vitamin C might decrease how quickly the body gets rid of salsalate (Disalcid). Taking vitamin C along with salsalate (Disalcid) might cause too much salsalate (Disalcid) in the body, and increase the effects and side effects of salsalate.

Vitamin C (VITAMIN C (ASCORBIC ACID)) Dosing

The following doses have been studied in scientific research:

BY MOUTH:

• For scurvy: 100-250 mg once or twice daily for several days.
• For treating the common cold: 1-3 grams daily.
• For preventing kidney damage related to contrast media used during diagnostic tests: vitamin C 3 grams is given before coronary angiography and then 2 grams is given after the procedure in the evening and again the following morning.
• For slowing progression of hardening of the arteries: slow-release vitamin C 250 mg in combination with 91 mg (136 IU) of vitamin E twice daily for up to 6 years.
• For tyrosinemia in premature infants on high protein diets: 100 mg of vitamin C.
• For reducing protein in the urine of patients with type 2 diabetes: vitamin C 1250 mg with vitamin E 680 IU daily for 4 weeks.
• For preventing complex regional pain syndrome in patients with wrist fractures, vitamin C 500 mg daily for 50 days.

The daily recommended dietary allowances (RDAs) are: Infants 0 to 12 months, human milk content (older recommendations specified 30-35 mg); Children 1 to 3 years, 15 mg; Children 4 to 8 years, 25 mg; Children 9 to 13 years, 45 mg; Adolescents 14 to 18 years, 75 mg for boys and 65 mg for girls; Adults age 19 and greater, 90 mg for men and 75 mg for women; Pregnancy and Lactation: age 18 or younger, 115 mg; ages 19 to 50 years 120 mg. People who use tobacco should take an additional 35 mg per day.
Do not take more than the following amounts of vitamin C: 400 mg per day for children ages 1 to 3 years, 650 mg per day for children 4 to 8 years, 1200 mg per day for children 9 to 13 years, and 1800 mg per day for adolescents and pregnant and breast-feeding women 14 to 18 years, and 2000 mg per day for adults and pregnant and lactating women.

APPLIED TO THE SKIN:

• Most topical preparations used for aged or wrinkled skin are applied daily. Studies have used creams containing 5% to 10% vitamin C. In one study a specific vitamin C formulation (Cellex-C High Potency Serum) used 3 drops applied daily to areas of facial skin. Don’t apply vitamin C preparations to the eye or eyelids. Also avoid contact with hair or clothes. It can cause discoloration.

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