Drugs for treatment of migraine are listed in Table 2 on page 9. Drugs for prevention of migraine are listed in Table 3 on page 10. Treatment of migraine in the emergency room, which may involve use of intravenous drugs, is not included here.

An advertisement in a recent issue of Ophthalmology introduces PreserVision Eye Vitamin AREDS 2 Formula from Bausch & Lomb. No specific indication is mentioned, but the ad states that “…[the new product] builds on the original PreserVision Eye Vitamin AREDS Formula, the only formula proven to slow the progression of moderate-to-advanced AMD.”

Resveratrol is a phytochemical found in the skin of red grapes and in many other plants, including berries, plums and peanuts. As a constituent of red wine, it has been associated with cardioprotective effects. Dietary supplements containing resveratrol are now being widely promoted as antioxidants that can prevent agerelated diseases.

Red yeast rice is a food product that has been used in Chinese cooking and medicine for centuries. It is available in the US in a capsule formulation and is often used by patients who want a "natural" product to lower cholesterol.

The FDA recently advised health care professionals and consumers not to use a number of dietary supplements found to contain the phosphodiesterase-5 inhibitor sildenafil (Viagra) or an analog of the drug (www.fda.gov). Although the effects of sildenafil may be noticeable (in men), the presence of other, possibly more toxic adulterants in dietary supplements may be more difficult or impossible to detect.

Other drugs previously found in dietary supplements have included lovastatin (Mevacor, and others), estrogen, alprazolam (Xanax, and others), indomethacin (Indocin, and others) and warfarin (Coumadin, and others). Aristolochic acid in Chinese herbal weight loss products caused acute renal failure in about 100 women in Belgium; at least 70 of them required dialysis or transplantation, and at least 18 developed urothelial cancer (Med Lett Drugs Ther 2002; 44:84).

Dietary supplements do not require FDA approval before marketing. The agency does have the power to remove mislabeled or adulterated products from store shelves, but the burden of discovery and proof is entirely on the government.

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The results of a randomized, placebo-controlled trial of calcium and vitamin D supplements in more than 36,000 postmenopausal women, conducted as part of the Women’s Health Initiative (RD Jackson et al. N Engl J Med 2006; 354:669), have been misinterpreted by some patients to mean that they should stop taking such supplements.

At the time of recruitment, the participants in this study had an average daily calcium intake of 1100-1200 mg. They were randomized to take either 1000 mg of calcium carbonate plus 400 IU of vitamin D₃ or a placebo for an average of 7 years. Both groups were permitted to take calcium and vitamin D supplements on their own as well. In the intention-to-treat population, the study supplements increased hip bone density but did not decrease the incidence of hip fractures. The subgroup of women who adhered to the protocol and actually took the study supplements showed a significant reduction in hip fractures compared to the control group.

Men and women over age 50 should have a total calcium intake of about 1200 mg per day (Treat Guidel Med Lett 2005; 3:69). If they need a supplement to achieve that, calcium citrate is more expensive, but it offers some advantages over calcium carbonate: it can be taken without food, causes less GI disturbance and may be less likely to cause kidney stones.

With any calcium salt, vitamin D is necessary for optimal absorption. The recommended minimum daily requirement of vitamin D (vitamin D₃ is preferred) is 400 IU for people 50-70 years old and 600 IU for those over 70. But those infrequently exposed to the sun may need 800- 1000 IU of vitamin D daily, and many experts recommend 800 IU or more for all postmenopausal women.

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Omega-3 (n-3) polyunsaturated fatty acids (PUFAs), mainly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are essential human nutrients. The main dietary source of PUFAs is fatty fish such as salmon, but small amounts may be converted from α-linolenic acid in nuts, seeds, and plant oils such as canola or flaxseed oil. An increased intake of these fatty acids has been shown to modify membrane function, inhibit thrombus formation, decrease inflammation, lower plasma triglycerides, and alter the electrical activity of the myocardium.

Coenzyme Q10, a fat-soluble antioxidant also known as ubidecarenone, ubiquinone and CoQ10, is marketed as a dietary supplement in the US, both as a single ingredient and in various combination products.

Chromium is marketed as a dietary supplement, usually containing 20-500 mcg of a chromium salt. It has been promoted for weight loss, muscle building, and for prevention and treatment of diabetes, among other claims. As a dietary supplement, chromium can be sold without proof of efficacy or safety.

Dehydroepiandrosterone (DHEA), an endogenous adrenal steroid, is marketed as a dietary supplement in the US. It is widely promoted to reverse the effects of aging (loss of muscle, memory and libido) and has been used by athletes as a substitute for anabolic steroids. DHEA is banned by the International Olympic Committee, National Collegiate Athletic Association, National Football League and other sports organizations, but it was specifically exempted from becoming a controlled substance in the Anabolic Steroid Control Act of 2004.

Patients may be asking about Airborne, a dietary supplement that is being heavily promoted for prevention and treatment of colds. It contains 7 herbal extracts, 3 vitamins, 2 amino acids, selenium, zinc and many other ingredients. Airborne Jr is available for children. There are some concerns. First, there is no conclusive evidence that this product or any of its ingredients prevents colds or shortens their duration. Second, the adult tablet contains 1 g of vitamin C, and the directions for use advise taking 1 tablet at the first sign of a cold and repeating the dose every 3 hours as necessary. Vitamin C in doses higher than 1 g increases oxalate and urate excretion and may cause kidney stones (EN Taylor et al, J Am Soc Nephrol 2004; 15:3225). Third, the safety of this herbal extraction combination has not been established. And with herbs and dietary supplements in general, we only have the manufacturers' word on the label for what's in them.

Millions of people now take herbal products and other "dietary supplements." The Physicians' Desk Reference has published a PDR for Herbal Medicines listing their ingredients and indications, and the Drug Topics Red Book lists their prices.

Echinacea, a plant also called purple coneflower, is widely used as a dietary supplement for prevention and treatment of colds.

PC Spes, a dietary supplement sold for "prostate health", is being used increasingly to treat prostate cancer.

Saw palmetto, an "herbal supplement,"is now being heavily promoted to the general public for treatment of urinary symptoms related to prostatic enlargement. It has not been approved for any use by the FDA.