Guideline sources The following summarized guidelines for the management of vitamins, minerals, and dietary supplements are prepared by our editorial team based on guidelines from the World Health Organization (WHO 2022), the U.S. Preventive Services Task Force (USPSTF 2022; 2018; 2017; 2015; 2014), the American Association for the Study of Liver Diseases (AASLD 2022), the American College of Obstetricians and Gynecologists (ACOG 2021), the American College of Gastroenterology (ACG 2021), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2021; 2016), the Canadian Neurological Sciences Federation (CNSF 2019), the European Association for the Study of the Liver (EASL 2019), the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC 2017), the European Association for the Study of Obesity (EASO 2017), the American Society for Metabolic and Bariatric Surgery (ASMBS 2017), the American Association of Family Physicians (AAFP 2017), the Eastern Association for the Surgery of Trauma (EAST 2016), the American Heart Association (AHA/ACC 2014), the American College of Endocrinology (ACE/OS/AACE 2013), the Obesity Society (OS/AACE 2013), the American Society for Parenteral and Enteral Nutrition (ASPEN 2013), the Canadian Headache Society (CHS 2012), the Australian and New Zealand Bone and Mineral Society (ANZBMS/OA/ESA 2012), the Endocrine Society (ES 2011), the Osteoporosis Canada Foundation (OC 2010), and the European Federation of Neurological Societies (EFNS 2009). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Guidelines 1. Nonpharmacologic interventions Vitamin B2: https://web.pathway.md/diseases/recN7vuHW8QVxkwMM 1/8 6/29/23, 3:44 AM Vitamins, minerals, and dietary supplements Pathway As per CHS 2012 guidelines, offer riboflavin (400 mg/day) in eligible patients for migraine prophylaxis. B As per EFNS 2009 guidelines, offer riboflavin (400 mg) as a third-line choice for migraine prophylaxis. B Vitamin B9: do not use folic acid, with or without vitamins B6 and B12, for secondary prevention of NSTEMI. D Vitamin C: As per SEIMC 2017 guidelines, do not use vitamin C for the prevention of recurrent UTIs. D As per AHA 2014 guidelines, do not use vitamin C for secondary prevention of NSTEMI. D Vitamin D and calcium, daily requirements: As per OS/ACE/AACE 2013 guidelines, advise older adults, individuals with increased skin pigmentation, or those exposed to insufficient sunlight to increase their vitamin D intake from vitamin D-fortified foods and/or supplements to at least 800-1,000 IU/day. A As per OA/ESA/ANZBMS 2012 guidelines, advise maintaining vitamin D intake (from dietary sources and supplementation) of at least 600 IU/day in 70 years old adults and 800 IU/day in > 70 years old adults. Consider advising higher doses in individuals at high risk or with substantial sun avoidance. E As per OC 2010 guidelines: Advise maintaining routine supplementation of vitamin D3 (400-1,000 IU/day) in healthy adults at low risk of vitamin D deficiency. B Advise maintaining higher-dose supplementation of vitamin D3 daily (800-1,000 IU/say) in > 50 years old adults at moderate risk of vitamin D deficiency. Recognize that supplementation of > 1,000 IU/day may be required to achieve optimal vitamin D status. Recognize that daily doses of up to 2,000 IU are safe and do not necessitate monitoring. B Vitamin D and calcium, prevention of falls: As per USPSTF 2018 guidelines, do not use vitamin D supplements for the prevention of falls in community-dwelling 65 years old adults. D As per EAST 2016 guidelines, consider offering vitamin D and calcium supplementation for the prevention of fall-related injuries in frail elderly individuals. C Vitamin D and calcium (prevention of fractures): insufficient evidence to assess the balance of benefits and harms of vitamin D and calcium supplementation, alone or combined, for the primary prevention of fractures in males and premenopausal females. I Show 3 more Vitamin E: As per USPSTF 2022 guidelines, do not use vitamin E or -carotene supplements for the prevention of CVD or cancer. D As per CNSF 2019 guidelines, do not use vitamin E as a neuroprotective therapy in patients with Parkinson's disease. D As per AHA 2014 guidelines, do not use vitamin E or -carotene for secondary prevention of NSTEMI. D https://web.pathway.md/diseases/recN7vuHW8QVxkwMM 2/8 6/29/23, 3:44 AM Vitamins, minerals, and dietary supplements Pathway As per AACE 2013 guidelines, do not use vitamin E supplements to decrease cardiovascular events or cancer. D Multivitamins: As per USPSTF 2022 guidelines, insufficient evidence to assess the balance of benefits and harms of multivitamins for the prevention of CVD or cancer. I As per AACE 2013 guidelines, consider offering daily multivitamins to complement food intake in older adults unable to achieve adequate micronutrient intake otherwise. C Dietary supplements (cardiovascular/cancer prevention): insufficient evidence to assess the balance of benefits and harms of single- or paired nutrient supplements (except -carotene and vitamin E) to prevent CVD or cancer. I Dietary supplements, migraine attack prevention: As per CHS 2012 guidelines, offer coenzyme Q10 (100 mg TID) for migraine prophylaxis in eligible patients. B Show 3 more As per EFNS 2009 guidelines, offer coenzyme Q10 (300 mg) as a third-line choice for migraine prophylaxis. B Dietary supplements (neuroprotection for PD): do not use coenzyme Q10 as a neuroprotective therapy in patients with Parkinson's disease. D Dietary supplements (caries prevention): Offer oral fluoride supplementation in children starting at age 6 months if the water supply is deficient in fluoride. B Apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. B 2. Specific circumstances Neonatal and pediatric patients, vitamin D: As per ASPEN 2013 guidelines, consider offering vitamin D supplementation in healthy breastfed infants and in infants with malnutrition and/or rickets. C As per ES 2011 guidelines, ensure vitamin D intake of at least 400 IU/day in 0-1 year old infants and children, and at least 600 IU/day in 1 year old children, to maximize bone health. Insufficient evidence of whether 400 and 600 IU/day in 0-1 and 1-18 years old children, respectively, are enough to provide all the potential nonskeletal health benefits associated with vitamin D to maximize bone health and muscle function. Recognize that at least 1,000 IU/day of vitamin D may be required to raise the serum level of 25- hydroxyvitamin D consistently > 30 ng/mL. B Show 2 more Neonatal and pediatric patients (preterm infants): initiate enteral iron, B zinc, vitamin D, and vitamin A supplementation in human milk-fed preterm or low-birth-weight infants not receiving these micronutrients from other sources. B Elderly patients, vitamin D: https://web.pathway.md/diseases/recN7vuHW8QVxkwMM 3/8 6/29/23, 3:44 AM Vitamins, minerals, and dietary supplements Pathway As per USPSTF 2018 guidelines, do not use vitamin D supplements for the prevention of falls in community-dwelling 65 years old adults. D As per EAST 2016 guidelines, consider offering vitamin D and calcium supplementation for the prevention of fall-related injuries in frail elderly individuals. C Elderly patients (multivitamins): consider offering daily multivitamins to complement food intake in older adults unable to achieve adequate micronutrient intake otherwise. C Pregnant patients (prenatal vitamins): prescribe daily prenatal vitamins in all females during pregnancy. A Pregnant patients (vitamin A): do not supplement vitamin A excessively as intake of > 10,000 IU/day is teratogenic. D Pregnant patients (vitamin B6): consider prescribing preemptive doxylamine/pyridoxine at the onset of pregnancy in females at high risk of NVOP. B Pregnant patients, vitamin B9 and B12: As per SOGC 2021 guidelines, offer a diet of folate-rich foods and a daily oral multivitamin supplement containing 0.4 mg folic acid and vitamin B12 for at least 2-3 months before conception, throughout the pregnancy, and for 4-6 weeks postpartum or as long as breastfeeding continues in females at low risk for neural tube defects or other folic acid- sensitive congenital anomalies if the male partner also has a low risk. B Show 2 more As per USPSTF 2017 guidelines, offer folic acid supplements (400-800 g/day) in all females planning or capable of pregnancy. A Pregnant patients (vitamin D): ensure intake of at least 600 IU/day of vitamin D during pregnancy recognizing that at least 1,500-2,000 IU/day of vitamin D may be needed to maintain a blood level of 25-hydroxyvitamin D > 30 ng/mL. B Pregnant patients, iron: As per ACOG 2021 guidelines, offer low-dose iron supplementation in the first trimester to decrease the prevalence of maternal anemia at delivery. A As per USPSTF 2015 guidelines, insufficient evidence to assess the balance of benefits and harms of routine iron supplementation during pregnancy for the prevention of adverse maternal health and birth outcomes. I Pregnant patients (iodine): ensure ingestion of a minimum of 250 g/day of iodine during pregnancy. B Patients after bariatric surgery, general principles: As per EASO 2017 guidelines, initiate long-term mineral and multivitamin supplementation in all bariatric patient according to the procedure. Individualize supplementation according to periodic laboratory surveillance. B As per EASO 2017 guidelines, initiate two adult multivitamins plus mineral supplements - each containing iron, folic acid, and thiamine - in a chewable form initially for 3-6 months, in all patients after Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy, with minimal daily supplementation of: B https://web.pathway.md/diseases/recN7vuHW8QVxkwMM 4/8 6/29/23, 3:44 AM Vitamins, minerals, and dietary supplements Pathway 1,200-1,500 mg of elemental calcium - in diet and as a citrated supplement in divided doses B 3,000 IU of vitamin D - titrated to therapeutic 25-hydroxyvitamin D levels > 30 ng/mL B vitamin B12 as needed to maintain B12 levels in the normal range - sublingual, SC, or IM preparations, or PO, if determined to be adequately absorbed B 45-60 mg of total iron via multivitamins and additional supplements. Show 2 more Patients after bariatric surgery (vitamin B1): initiate prompt oral or parenteral thiamine supplementation in all bariatric patients experiencing persistent vomiting severe enough to interfere with regular nutrition, even in the absence or before confirmatory laboratory data. B Patients after bariatric surgery (vitamin B9): initiate folate supplementation (400-800 g/day PO; 800-1,000 g/day in females of childbearing age) in all patients post-bariatric surgery. B Patients after bariatric surgery, vitamin B12: As per AAFP 2017 guidelines, initiate oral vitamin B12 supplementation (1 mg/day) and continue indefinitely in patients post-bariatric surgery. B As per ASMBS 2017 guidelines, initiate vitamin B12 supplementation in all patients post- bariatric surgery at doses depending on the route of administration: Situation Guidance 350-500 g/day PO (disintegrating tablet, sublingual, or liquid) As directed by the manufacturer Nasal spray 1,000 g/month. B Parenteral (IM or SC) As per OS/AACE 2013 guidelines, initiate oral crystalline vitamin B12 (1 mg/day) in patients after bariatric surgery. A Show 2 more Patients after bariatric surgery (pregnancy): initiate micronutrient supplementation in all pregnant patients following bariatric surgery, in the form of prenatal multivitamin preparations, B12 injections, and oral calcium supplements. B Patients with herbal and dietary supplement-induced liver injury: As per AASLD 2022 guidelines: Recognize that herbal and dietary supplements can cause severe hepatotoxicity with variable clinical, laboratory, and histological phenotypes. E Recognize that: genetic polymorphisms in the HLA region and the conditions under which a product is consumed may influence the likelihood of a patient developing herbal or dietary supplement-induced hepatotoxicity HLA-B35:01 has been associated with hepatotoxicity attributed to green tea extract in White populations and Polygonatum multiflorum hepatotoxicity in Asian populations. E https://web.pathway.md/diseases/recN7vuHW8QVxkwMM 5/8 6/29/23, 3:44 AM Vitamins, minerals, and dietary supplements Pathway As per ACG 2021 guidelines, encourage patients to report the use of herbal and dietary supplements to their healthcare providers, acknowledging that supplements are not subjected to the same rigorous testing for safety and efficacy as prescription medications. B Show 5 more As per EASL 2019 guidelines, consider suspecting herbal and dietary supplements as potential causative agents associated with liver injury. 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