Glucosamine-Fish Oil

Drug overview for GLUCOSAMINE-FISH OIL (glucosamine sulfate/omega-3 fatty acids/vitamin e):

Generic name: GLUCOSAMINE SULFATE/OMEGA-3 FATTY ACIDS/VITAMIN E
Drug class:
Therapeutic class: Alternative Therapy

Vitamin E is a fat-soluble vitamin and an antioxidant.

No enhanced Uses information available for this drug.

DRUG IMAGES

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The following indications for GLUCOSAMINE-FISH OIL (glucosamine sulfate/omega-3 fatty acids/vitamin e) have been approved by the FDA:

Indications:
None.

Professional Synonyms:
None.

The following dosing information is available for GLUCOSAMINE-FISH OIL (glucosamine sulfate/omega-3 fatty acids/vitamin e):

Dosing
Administration
Dosing Information
Generic

Vitamin E activity is generally expressed in USP or International Units which are equivalent; the International Unit of vitamin E is no longer officially recognized but continues to be used in the labeling of some preparations. It should be noted that vitamin E preparations are historically and incorrectly labeled as d- or dl-alpha-tocopherol and their respective esters. Vitamin E compounds include the all racemic (all rac)-alpha-tocopherol (dl-alpha-tocopherol (RRR-, RRS-, RSR-, RSS-, SSS-, SRS-, SSR-, and SRR-) or synthetic) form and its esters and the RRR-alpha-tocopherol (d-alpha-tocopherol or natural) form and its esters, and any of these compounds may be present in fortified foods and vitamin preparations.

One unit of vitamin E equals the biologic activity of 1 mg of all rac-alpha-tocopheryl acetate (dl-alpha-tocopheryl acetate), 1.12 mg of all rac-alpha-tocopheryl succinate (dl-alpha-tocopheryl acid succinate), 910 mcg of all rac-alpha-tocopherol (dl-alpha-tocopherol), 735 mcg of RRR-alpha-tocopheryl acetate (d-alpha-tocopheryl acetate), 830 mcg of RRR-alpha-tocopheryl succinate (d-alpha-tocopheryl acid succinate), and 670 mcg of RRR-alpha-tocopherol (d-alpha-tocopherol). However, because the USP potency unit for vitamin E was defined before studies showed a lack of human activity for the 2S-stereoisomers, the National Academy of Sciences (NAS) Food and Nutrition Board recommended in 2000 that the current equivalency defined in the USP standard be redefined based on the R-stereoisomeric forms of alpha-tocopherol, which are the forms that are active in humans. According to the NAS definition, each USP unit of vitamin E is equivalent to the biologic activity of 450 mcg of the synthetic all rac-alpha-forms of tocopherol and its esters or 670 mcg of the RRR-alpha-forms of tocopherol and its esters.

Vitamin E is usually administered orally. When oral administration is not feasible or when malabsorption is suspected, the drug may be given parenterally as a component of a multivitamin injection. Some clinicians use water-miscible oral vitamin E preparations in patients with malabsorption syndromes.

No dosing information available.

No generic dosing information available.

The following drug interaction information is available for GLUCOSAMINE-FISH OIL (glucosamine sulfate/omega-3 fatty acids/vitamin e):

Contraindicated
Severe
Moderate

There are 0 contraindications.

There are 0 severe interactions.

There are 3 moderate interactions. The clinician should assess the patient’s characteristics and take action as needed. Actions required for moderate interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration.

Drug Interaction	Drug Names
Orlistat/Fat Soluble Vitamins SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: The acetate ester forms of vitamin A and vitamin E must undergo hydrolysis for absorption from the gastrointestinal tract.(1) The enzyme responsible for this hydrolysis is inhibited by orlistat.(2) CLINICAL EFFECTS: Orlistat may reduce absorption of fat soluble vitamins, leading to a deficiency state. PREDISPOSING FACTORS: A pre-existing deficiency of fat soluble vitamins (A,D,E and K) or chronic malabsorption syndrome. PATIENT MANAGEMENT: The inhibition of fat soluble vitamin absorption by orlistat should be borne in mind during implementation of a vitamin supplementation strategy. Patients should be strongly encouraged to take a multivitamin supplement which contains fat soluble vitamins, particularly Vitamin D as it appears most susceptible to this interaction.(4,5) Multivitamin supplements should be taken at least two hours before or after the dose of orlistat, or at bedtime.(4) Patients with chronic malabsorption syndromes should not receive orlistat.(4) DISCUSSION: Adult patients taking orlistat without supplementation showed a greater reduction in vitamin A,D,E and beta-carotene levels compared to placebo during two or more consecutive visits in studies of 1-2 years duration; these patients had normal baseline values prior to orlistat therapy. Low vitamin values in orlistat patients were as follows: low Vitamin D 12%, low beta-carotene 6.1%, low Vitamin E 5.8%, low Vitamin A 2.2%.(4) A pharmacokinetic interaction study showed a 30% reduction in beta-carotene supplement absorption and a 60% decreased in vitamin E acetate absorption with concomitant orlistat.(4) In a study, orlistat produced the vitamin net concentration by approximately 43%.(1) In a study, no statistically significant decrease in vitamin A absorption was observed with concurrent orlistat.(2) In a study, mean vitamin D levels were significantly reduced compared with baseline after one month of orlistat therapy despite multivitamin supplementation.(5)	ORLISTAT, XENICAL
Coumarin Anticoagulants/Glucosamine and-or Chondroitin SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: The exact mechanism is unknown, but may be the result of additive or synergistic effects on coagulation. Glucosamine is a component of heparin(1) and chondroitin is a component of danaparoid.(2) Glucosamine has been shown not to inhibit CYP2C9,(3) thus inhibition of warfarin metabolism is thought to be unlikely. CLINICAL EFFECTS: Concurrent use of glucosamine-chondroitin may result in increased effects on coagulation, including elevated International Normalized Ratio (INR) and bleeding. PREDISPOSING FACTORS: The risk for bleeding episodes may be greater in patients with disease-associated factors (e.g. thrombocytopenia). Drug associated risk factors include concurrent use of multiple drugs which inhibit anticoagulant/antiplatelet metabolism and/or have an inherent risk for bleeding (e.g. NSAIDs). PATIENT MANAGEMENT: Use caution with adding or discontinuing glucosamine-chondroitin to warfarin therapy. Monitor patients receiving concurrent therapy closely for elevated INR and signs of bleeding. Patients who discontinue glucosamine-chondroitin may need their warfarin dosage adjusted to maintain therapeutic INRs. If concurrent therapy is warranted, monitor patients receiving concurrent therapy for signs of blood loss, including decreased hemoglobin, hematocrit, fecal occult blood, and/or decreased blood pressure and promptly evaluate patients with any symptoms. When applicable, perform agent-specific laboratory test (e.g. INR, aPTT) to monitor efficacy and safety of anticoagulation. Discontinue anticoagulation in patients with active pathologic bleeding. Instruct patients to report any signs and symptoms of bleeding, such as unusual bleeding from the gums or nose; unusual bruising; red or black, tarry stools; red, pink or dark brown urine; acute abdominal or joint pain and/or swelling. The time of highest risk for a coumarin-type drug interaction is when the precipitant drug is initiated or discontinued. Contact the prescriber before initiating, altering the dose or discontinuing either drug. DISCUSSION: There have been numerous reports of increased INR following the addition of glucosamine, glucosamine-chondroitin, or chondroitin alone to warfarin therapy, including 20 from the United States Food Drug Administration (US FDA), 22 from the World Health Organization (WHO), 3 from the Australian Therapeutic Goods Association (TGA), and 2 published reports. INR values typically increased between two and 20 days after the addition of glucosamine and/or chondroitin to warfarin therapy. In most cases, patients were asymptomatic; however, there were at least two reports of bleeding.(4-8) There has also been one report involving glucosamine and acenocoumarol.(9)	DICUMAROL, JANTOVEN, WARFARIN SODIUM
Colesevelam/Fat Soluble Vitamins SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Colesevelam may decrease the absorption of fat-soluble vitamins A, D, E, and K.(1) CLINICAL EFFECTS: Colesevelam may reduce absorption of fat soluble vitamins, leading to a deficiency state. PREDISPOSING FACTORS: A pre-existing deficiency of fat soluble vitamins (A,D,E and K) or chronic malabsorption syndrome. PATIENT MANAGEMENT: The inhibition of fat soluble vitamin absorption by colesevelam should be borne in mind during implementation of a vitamin supplementation strategy. Oral multivitamin supplements should be taken at least four hours before the dose of colesevelam.(1) DISCUSSION: Colesevelam may decrease the absorption of fat-soluble vitamins A, D, E, and K.(1)	COLESEVELAM HCL, WELCHOL

Moderate List
No disease contraindications

The following adverse reaction information is available for GLUCOSAMINE-FISH OIL (glucosamine sulfate/omega-3 fatty acids/vitamin e):

Overview
Severe
Less Severe

Adverse reaction overview.

No enhanced Common Adverse Effects information available for this drug.

There are 4 severe adverse reactions.

More Frequent	Less Frequent
None.	None.

Rare/Very Rare
Anaphylaxis Hemorrhage Increased alanine transaminase Increased aspartate transaminase

There are 14 less severe adverse reactions.

More Frequent	Less Frequent
Abdominal pain with cramps Diarrhea Gastric acid hypersecretory conditions Heartburn Nausea	Dysgeusia Dyspepsia Eructation Skin rash

Rare/Very Rare
Abnormal hepatic function tests Constipation Pruritus of skin Urticaria Vomiting

The following precautions are available for GLUCOSAMINE-FISH OIL (glucosamine sulfate/omega-3 fatty acids/vitamin e):

Pediatric
Pregnant
Lactation
Geriatric

No enhanced Pediatric Use information available for this drug.

Contraindicated

None

Severe Precaution

None

Management or Monitoring Precaution

None

Vitamin E has not been shown to be teratogenic. There is no evidence that vitamin E requirements in pregnant women differ from women who are not pregnant. (See Dosage: Dietary and Replacement Requirements, under Dosage and Administration.)

No enhanced Lactation information available for this drug.

No enhanced Geriatric Use information available for this drug.