Continued Risk of Dietary Supplements Adulterated with Approved and Unapproved Drugs: Assessment of the FDA Tainted Supplements Database 2007 through 2021

Natural products for the treatment of age-related macular degeneration

BACKGROUND

Age-related macular degeneration (AMD) is a chronic retinal disease that significantly influences the vision of the elderly.

PURPOSE

There is no effective treatment and prevention method. The pathogenic process behind AMD is complex, including oxidative stress, inflammation, and neovascularization. It has been demonstrated that several natural products can be used to manage AMD, but systematic summaries are lacking.

STUDY DESIGN AND METHODS

PubMed, Web of Science, and ClinicalTrials.gov were searched using the keywords "Biological Products" AND "Macular Degeneration" for studies published within the last decade until May 2023 to summarize the latest findings on the prevention and treatment of age-related macular degeneration through the herbal medicines and functional foods.

RESULTS

The eligible studies were screened, and the relevant information about the therapeutic action and mechanism of natural products used to treat AMD was extracted. Our findings demonstrate that natural substances, including retinol, phenols, and other natural products, prevent the development of new blood vessels and protect the retina from oxidative stress in cells and animal models. However, they have barely been examined in clinical studies.

CONCLUSION

Natural products could be highly prospective candidate drugs used to treat AMD, and further preclinical and clinical research is required to validate it to control the disease.

Visual authenticating hazardous adulterant phenolphthalein in slimming foods: Target-mimicking hapten epitope improved immunoassay

Screening for the hazardous adulterant phenolphthalein (PTH) in slimming foods is necessary. Herein, the linkage of the PTH target epitope with various spacer arms was proposed for hapten design, aiming to produce highly sensitive and specific antibodies targeting PTH. To understand the influence of spacer arms on epitope, comprehensive evaluations were conducted using computer-aided chemistry and animal immunization. The resulting antibody exhibited maximal half-inhibitory concentration (IC50) of 0.25 ng/mL. Then, a lateral flow immunoassay (LFIA) was established with detection capability for screening (CCβ) of less than 140, 240, and 25 ng/g for PTH in tea, instant coffee, and oral liquid, respectively. Furthermore, blind sample results agreed well with LFIA and liquid chromatography-tandem mass spectrometry (LC-MS/MS). Therefore, this work not only provides a robust tool for detecting PTH adulteration but also suggests that the careful pairing of spacer arms with hapten epitope is a key factor in advancing rational hapten design.

General hapten skeleton motivated duplex-immunoassay for emergent bisoxatin adulterants in slimming foods

Adulterating hazardous bisoxatin (BSO) and bisoxatin acetate (BSOA) in slimming foods poses a threat to public health. A rapid synchronous detection method is urgently needed. Herein, the precise design of four novel haptens based on the general skeleton of BSO and BSOA was driven by computer-chemical visualization strategy, which was used to raise monoclonal antibody (mAb) toward both target compounds. The generated mAb 1F1 recognized BSO and BSOA with maximal half-inhibitory concentration (IC50) of 0.26 and 16.85 ng/mL, respectively. The molecular mechanism governing the duplex-recognition of mAb was elucidated by homology modeling and molecular docking. Finally, an immunochromatography (ICA) was developed for identifying BSO and BSOA, demonstrating a detection capability for screening (CCβ) estimated to be 10-500 ng/g in candy tablets, jellies, and oral liquids. This study provides a robust approach for determining adulteration in food and offers insights into hapten design to improve antibody recognition spectrum.

Epitope-Shared Hapten Enhancing Antibody Polyreactivity for Simultaneous Immunochromatography of Oxyphenisatin Adulterants

Given the significant threat posed by oxyphenisatin adulterants (OPHs) in weight-loss foods, simultaneous analysis of the OPHs is necessary. Herein, four novel haptens based on the general epitope shared among the OPHs were raised by computer-aided chemical modeling prediction, with the expectation of eliciting antibody responses targeting three of the OPHs. One obtained monoclonal antibody (mAb) showed maximal half-inhibitory concentration (IC50) of 0.40-12.11 ng/mL for OPHs. The key interaction forces responsible for the corecognition of the OPHs were revealed by the intrinsic molecular mechanism. The developed immunochromatography (ICA) indicated a detection capability for screening (CCβ) for OPHs estimated to be 5-600 ng/g in jelly, candy tablets, and oral liquid. Furthermore, the analysis of 15 real samples by our method showed a good correlation with liquid chromatography-tandem mass spectrometry (LC-MS/MS). Our research not only presented a rapid approach for identifying OPHs adulteration but also proposed an effective hapten prediction strategy to enhance antibody polyreactivity.

Effects of CYP2D6 *10 and *41 Variants in Healthy Chinese Men on the Pharmacokinetics of Dapoxetine

Dapoxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat premature ejaculation (PE), and is mainly metabolized by CYP2D6, CYP3A4, and flavin-containing monooxygenase 1. The purpose of the study was to evaluate the effect of CYP2D6 polymorphism on the pharmacokinetics of dapoxetine in healthy Chinese men. Thirty-nine subjects who received a single oral dose of 30 mg dapoxetine hydrochloride were classified based on their CYP2D6 genotype: *1/*1 (n = 9), *1/*41 (n = 1), *1/*10 (n = 12), *10/*41 (n = 3), or *10/*10 (n = 14). The difference in pharmacokinetic parameters between different genotype groups was analyzed and then scored according to the activity score system. Compared with the wild-type subjects of CYP2D6 *1/*1, the peak plasma concentration (Cmax) and the area under the plasma drug concentration-time curve (AUCinf) of dapoxetine in the *10/*10 and *10/*41 groups were notably increased (P ≤ .05). Significant differences in Cmax, AUC, volume of distribution/bioavailability (V/F) and clearance/bioavailability (CL/F) were observed among dapoxetine activity score groups (P ≤ .05). The AUCinf was increased significantly (154% and 89.73%, P ≤ .05) and the Cmax was increased significantly (73.45% and 42.67%, P ≤ .05) in CYP2D6 *10/*41 subjects, compared with CYP2D6 *1/*1 and *1/*10 subjects. The results obtained indicated that CYP2D6 *10 and *41 polymorphisms have significant effects on the pharmacokinetic properties of dapoxetine.

Microscopy, HPTLC, and LC-DAD-Q-ToF validation of nut-based weight-loss dietary supplements, Aleurites moluccanus (candlenut) and Bertholletia excelsa (Brazil nut)

Aleurites moluccanus (candlenut) and Bertholletia excelsa (Brazil nut) are marketed as dietary supplements for weight loss. These dietary supplements have been found to sometimes be adulterated with toxic nuts/seeds from Cascabela thevetia, commonly known as yellow oleander or lucky nut. This study emphasizes the key identification parameters to differentiate the genuine and adulterated nuts. Samples were obtained from authenticated sources of the nuts and from commercial sources of dietary supplements. This study examined 38 samples, including voucher and commercial samples. All eight commercial candlenut dietary supplement samples were adulterated. Additionally, two samples sold as Brazil nuts were also found to be adulterated. Other nuts were screened for the presence of Cardiac Glycosides, but none were found to be positive. The presence of yellow oleander was confirmed in all commercial dietary supplement samples marketed as candlenut as well as in commercial samples of Brazil nut. This study provides simple key identification characters using micro-morphology and histochemical localization of cardiac glycosides in the commercial nuts, HPTLC fingerprints, and LC-DAD-Q-ToF analytical parameters to detect and identify adulteration in commercial products.

Eye Drop Quality Issues: Can the FDA See This One Through?

The Food and Drug Administration (FDA) has long suffered from a lack of resources limiting their inspection capacity. They have fallen behind on proactive surveillance inspections of foreign manufacturing sites, relying instead on for-cause inspections after a problem has been discovered. Over-the-counter (OTC) products are especially vulnerable because the FDA considers them lower priority. This issue recently made big news after improperly manufactured OTC eye drops harmed users across the country, in some cases causing blindness. To prevent future harm to Americans, it is imperative that the FDA receives enough resources to keep up with their routine inspections.

DNA barcoding for the identification and authentication of medicinal deer (Cervus sp.) products in China

Deer products from sika deer (Cervus nippon) and red deer (C. elaphus) are considered genuine and used for Traditional Chinese Medicine (TCM) materials in China. Deer has a very high economic and ornamental value, resulting in the formation of a characteristic deer industry in the prescription preparation of traditional Chinese medicine, health food, cosmetics, and other areas of development and utilization. Due to the high demand for deer products, the products are expensive and have limited production, but the legal use of deer is limited to only two species of sika deer and red deer; other wild deer are prohibited from hunting, so there are numerous cases of mixing and adulteration of counterfeit products and so on. There have been many reports that other animal (pig, cow, sheep, etc.) tissues or organs are often used for adulteration and confusion, resulting in poor efficacy of deer traditional medicine and trade fraud in deer products. To authenticate the deer products in a rapid and effective manner, the analysis used 22 deer products (antler, meat, bone, fetus, penis, tail, skin, and wool) that were in the form of blind samples. Total DNA extraction using a modified protocol successfully yielded DNA from the blind samples that was useful for PCR. Three candidate DNA barcoding loci, cox1, Cyt b, and rrn12, were evaluated for their discrimination strength through BLAST and phylogenetic clustering analyses. For the BLAST analysis, the 22 blind samples obtained 100% match identity across the three gene loci tested. It was revealed that 12 blind samples were correctly labeled for their species of origin, while three blind samples that were thought to originate from red deer were identified as C. nippon, and seven blind samples that were thought to originate from sika deer were identified as C. elaphus, Dama dama, and Rangifer tarandus. DNA barcoding analysis showed that all three gene loci were able to distinguish the two Cervus species and to identify the presence of adulterant species. The DNA barcoding technique was able to provide a useful and sensitive approach in identifying the species of origin in deer products.

Industry Review of Best Practices for Risk Management of Drug-Induced Liver Injury from Development to Real-World Use

The relative treatment benefit of a drug for patients during development, marketing authorization review, or after approval includes an assessment of the risk of drug-induced liver injury (DILI). In this article, the Pharmacovigilance and Risk Mitigation Working Group of the IQ-DILI Initiative launched in June 2016 within the International Consortium for Innovation and Quality in Pharmaceutical Development presents and reviews three key topics for essential risk management activities to identify, characterize, monitor, mitigate, and communicate DILI risk associated with small molecules during drug development. The three topics are: (1) Current best practices for characterizing the DILI phenotype and the severity and incidence of DILI in the treatment population, including DILI identification, prediction and recovery. (2) Characterization of the relative treatment benefit for patients who will be exposed to a drug and the attendant risk of DILI in conjunction with existing global risk mitigation strategies. (3) Implementation of risk mitigation strategies during drug development highlighting patient factors, healthcare settings and site of product administration, and prescriber and healthcare provider factors. Industry guidance is provided for assessing whether the product labeling is sufficient to minimize the risk of DILI or whether a United States Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy (REMS) or European Medicines Agency (EMA) Risk Management Plan (RMP) with additional Risk Minimization Measures (aRMM) is needed.

Prevalence of adulteration in dietary supplements and recommendations for safe supplement practices in sport

The prevalence of dietary supplement use among athletes continues to rise with 60-80% of athletes often reporting current or previous use of dietary supplements. While select dietary ingredients have been shown to improve acute performance and enhance training adaptations over time, it is important to still consider the risk vs. reward for athletes before opting to consume a dietary supplement. Previous work has indicated that certain dietary supplements may pose risks for inadvertent doping, may be susceptible to mislabelling, could be banned by certain governing bodies of sport, or pose health risks for certain populations. The purpose of the current narrative review is to summarize the prevalence of adulteration in dietary sport supplement products, outline the risks of inadvertent doping for athletes, and highlight best practices regarding safe supplementation strategies. Analytical studies have found anywhere from 14 to 50% of samples analyzed from dietary supplement products have tested positive for anabolic agents or other prohibited substances. It is important for the consumer to adhere to safe supplementation strategies, which include following serving size recommendations, cross-referencing ingredient profiles with the list of prohibited substances, choosing quality products that have been verified by a third-party certification program, and being cognizant of consuming multiple dietary supplement products with overlapping ingredient profiles. Once these practices have been considered, it is reasonable for an athlete to utilize dietary supplements as a strategy to optimize performance and health, with a low risk of failing a drug test (adverse analytical finding) and experiencing adverse events.

Notifications and Health Consequences of Unauthorized Pharmaceuticals in Food Supplements

Health concerns associated with the consumption of food supplements rise in parallel with the rise in the popularity and market availability of these products. In pursuit of data related to the unauthorized presence of pharmaceuticals in food supplements, the Rapid Alert System for Food and Feed (RASFF) database was searched for the 2011-2022 period. The most "popular" pharmaceuticals for the adulteration of food supplements were phosphodiesterase-5 inhibitors (235 records); anorexics and laxatives (76), including sibutramine and its active metabolite N-didesmethyl sibutramine, phenolphthalein and 2,4-dinitrophenol; stimulants, among which 1,3-dimethylamine (97), and synephrine (53) were the most numerous; nootropic drugs (24); anabolics and prohormones (16); and cannabinoid cannabidiol (14) (pending authorization as a novel food ingredient). Over 65% of notifications of interest were classified as serious risks, and over 80% of these were alert or border rejection notifications, mainly generated as a result of official control on the market. The alarming number of RASFF notifications should be considered a public health issue, demanding clear and targeted recommendation for action for the legislature and authorities. A harmonized nutrivigilance system should be considered as a tool to detect and scrutinize the adverse health effects of food supplements, along with measures to improve their safety, quality, and testing.

LC-HRMS analysis of 13 classes of pharmaceutical substances in food supplements

Food supplements should not contain substances considered unsafe or pose a health risk to consumers. In recent years illegal adulterants have been found in various functional foods without notification of their presence or amount in the labelling. In this study, a validated method was developed and applied as a screening method to detect 124 forbidden substances belonging to 13 classes of compounds in food supplements. Liquid chromatography coupled with high-resolution mass spectrometry (LC-HRMS) and a simple and rapid extraction protocol was applied to 110 food supplements collected from the internet market or during official controls in Italy. The percentage of non-compliant samples was 4.5%, relatively high compared with the official control results for these substances usually obtained on other food matrices. The results suggested the need to strengthen controls in this field to detect food supplement adulteration, which represents a potential health risk for the consumer.

Dietary Supplements for Weight Loss

The Federal Drug Administration has approved, following rigorous testing, 6 pharmacologic agents and one drug in device form for the management of overweight and obesity. Myriad products that purport to act on physiological mechanisms leading to weight loss also pervade the market with minimal regulatory oversight. Systematic reviews and meta-analyses of these products and their ingredients fail to establish any as meaningfully effective at the clinical level. Moreover, safety concerns prevail with adulteration, hypersensitivity reactions, and recognized adverse reactions. Lifestyle, pharmacologic, and bariatric surgical treatments are increasingly available, effective, and safe management tools for practitioners who should council patients, many of whom are susceptible to misinformation, on the lack effective and safe dietary supplements for weight loss.

The POWER saga from 2007 to 2022: An example of a sexual enhancement dietary supplement tainted by different adulterants and still on the market

Ten POWER dietary supplements, chronologically called tabs, pills then caps, and advertised as 100% natural aphrodisiacs, were analyzed by ¹H NMR from 2007 to 2022. They were all tainted by PDE-5 inhibitors. Eight different adulterants were identified (sildenafil (1), sildenafil analogues (6), and vardenafil analogue (1)). Their amounts ranged from 15 to 145 mg/capsule. Four supplements contained at least 100 mg/capsule of PDE-5 inhibitor or analogue, the maximal recommended dose of sildenafil. The nature of the adulterant has changed over time, probably to evade its detection by regulatory agencies routine screening tests. Despite several warnings and/or seizures from several European food and/or health authorities, the dietary supplement POWER is still on sale on the Internet, thus demonstrating the impossibility of controlling this market. Faced with this situation, the consumer should be better informed by establishing at the European level a public database of tainted dietary supplements on the model of that of the US Food and Drug Administration. It should indicate the product name, its photo, the adulterant name, and be easily accessible to everyone.

Liquid chromatography-quadrupole orbitrap and liquid chromatography-tandem mass spectrometry system for rapid identification and quantitation of thirty nonsteroidal anti-inflammatory drugs and acetaminophen in illegal products

RATIONALE

As the public interest in healthcare increases, illegal dietary supplements, foods, and drugs containing unauthorized pharmaceutical ingredients, including nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, have been identified. Excessive and unintentional consumption is toxic to the gastrointestinal tract, kidneys, and liver; therefore, these pharmaceuticals must be monitored using analytical methods.

METHODS

A rapid and reliable analysis system involving liquid chromatography-quadrupole orbitrap mass spectrometry (LC-Q-Orbitrap/MS) and liquid chromatography-tandem mass spectrometry (LC/MS/MS) was established and validated to identify and quantify 30 NSAIDs and acetaminophen. In addition, we obtained the MS² spectrum for each component with the proposed structure of the fragment ions.

RESULTS

The analytical method was applied to 505 samples of illicitly distributed dietary supplements, foods, and pharmaceuticals. Non-steroidal analgesics were detected in 126 samples. Carbamazepine (42.9%) and diclofenac (30.2%) were the most detected components in the samples; other pharmaceutical adulterants were also detected in some cases. Additionally, we present the identification of an unknown component, dexamethasone (799 μg/g), using LC-Q-Orbitrap/MS in a sample containing the unknown component with meloxicam (15.4 mg/g).

CONCLUSIONS

The developed analysis system, consisting of qualitative analysis using LC-Q-Orbitrap/MS and quantitative analysis using LC/MS/MS, can rapidly and accurately identify and quantify NSAIDs and acetaminophen while also identifying non-analytical components.

Dietary supplements could prevent cardiometabolic syndrome: Are they safe and reliable enough for disease prevention and health promotion?

Dietary supplements (DS) and their purchase is often based on a consumer's personal choice and advertisements. The associated DS regulations, particularly in manufacturing and marketing, are far more flexible and permissive than that of the well-regulated prescription pharmaceuticals. However, the adverse health effects associated with the inadvertent use of mega-doses of DS are not well understood. The demand for DS, nutraceuticals, and herbal remedies has experienced an upswing during the past two to three decades, and global product sales have thrived. More so, the prevention of cardiometabolic syndrome (CMS) and related disorders like diabetes mellitus, obesity, hypertension, and serum lipid abnormalities, as well as of other noncommunicable diseases (NCDs), is of highest health care priority globally, since these disorders impose very high economic burdens on health care systems and society. In this review, we argue why DS could prevent cardiometabolic syndrome, by providing the potential benefits and risks associated with them, especially self-medication considering their intake by the public at large. Good manufacturing practices and quality control are absolutely necessary for the manufacture of DS products, and proper labeling is needed regarding the optimal dose schedules of various DS and bioactive ingredients. Specific examples are used to underscore the indications and dosage recommendations made for the marketing and promotion of fish oil, coenzyme Q10, and Mg-containing products for the prevention of cardiometabolic syndrome.

Challenges in Reporting Adverse Events from Dietary Supplements

In 2008, the Institute of Medicine (IOM) Committee on Dietary Supplement Use by Military Personnel recommended the development of service wide military policies (e.g., education or regulations) to guide commanders in management practices for safe use of dietary supplements (DS). This review summarizes the activities the military has undertaken to advance the safe use of DS by Service Members and develop best practices on reporting adverse events across the Department of Defense (DoD). In March 2022, the Department of Defense issued a DoD Instruction (DoDI) regarding the use of DS by members of the U S. military. This DoDI provides guidelines to establish an official list of prohibited substances. The DoDI also identifies Operation Supplement Safety (OPSS) at CHAMP as DoD's "go to" program for DS use and information about DS and ingredients. Noted are a number of gaps in the reporting of adverse events from DS that need to be addressed by multiple constituencies.

Dietary Supplements Questioned in the Polish Notification Procedure upon the Basis of Data from the National Register of Functional Foods and the European System of the RASFF

Dietary supplements (DS) in the countries of the European Union falls within the scope of the food law. DS may, however, contain substances that are simultaneously applied in medicinal products as defined in the pharmaceutical law. The presence of such ingredients may cause problems with the product qualification. The phenomenon of applying such borderline ingredients in dietary supplements may require additional regulations, and ensuring them may be problematic. We conducted an analysis aiming to identify dishonest market practices resorted to by the producers and distributors of non-conforming dietary supplements. We examined mostly questioned DS and compared them with data from the RASFF system and registers of medicinal substances and pharmaceutical entities. The results show that some operators tend to re-notify the same products in response to the initiation of official control procedures. Products in the form of capsules or powders were the most common re-notifications within the 50–100 days. Based on the data obtained, it can be concluded that some entities are obliged to document the safety of the product or its compliance with the regulations, use the imperfection of the notification procedure, and re-notify the questioned product in order to keep it on the market despite potential non-compliance.

First-Time Submassive Pulmonary Embolism Likely Caused by Testosterone-Enhancing Supplement

Pulmonary embolism (PE) is a potentially fatal occurrence with a broad spectrum of risk factors. A 75-year-old male presented to the emergency room with five days of shortness of breath, back pain, and hemoptysis. A CT angiogram demonstrated bilateral pulmonary emboli with a larger thrombus on the right, as well as signs of right heart strain. The patient was started on IV heparin and ultimately underwent a successful embolectomy. Evaluation to determine the underlying etiology of this patient's first-time PE was performed to further stratify his risk of recurrence and the length of anticoagulation required. The provoking factor for his PE was initially unclear as he lacked any risk factors such as recent surgeries, periods of immobility, or previous diagnosis of malignancy. The patient was noted to be on an erectile dysfunction supplement called “Eroxin,” and he had been taking it for the past six months. Eroxin contains an ingredient called fenugreek, which is believed to enhance testosterone levels by inhibiting aromatase and 5-alpha-reductase activity. Fenugreek has previously been associated with the formation of PEs, and likely contributed to the PE in this patient. This is likely due to testosterone-induced polycythemia and increased platelet aggregation. This case highlights the concern around supplements as their ingredients are poorly regulated and occasionally found to be tainted with unlisted ingredients. This also highlights the importance of gathering a complete supplement history from patients as their use can lead to serious illness. Lastly, it encourages considering testosterone use as a potential thrombogenic risk factor.

Healthcare Professionals' Knowledge and Behaviors Regarding Drug-Dietary Supplement and Drug-Herbal Product Interactions

Given the widespread use of dietary supplements (DS) and herbal products (HP), healthcare professionals (HCPs) will increasingly encounter patients who use these preparations with conventional drugs and who need their services to reduce the consequences of adverse therapeutic outcomes. The aim of our survey was to assess the knowledge and behaviors of HCPs regarding the risk of potential drug−dietary supplement (DDSIs) and drug−herbal product (DHPIs) interactions. This cross-sectional survey collected data via on paper-based questionnaire among general practitioners (GPs) (n = 105), specialty doctors (n = 87) and nurses (n = 154). The HCPs were mostly familiar with the interaction of doxycycline with magnesium (83%) and were least familiar with interaction of warfarin with glucosamine (14%). The results on DDSIs and DHPIs knowledge showed that GPs scored significantly higher than nurses (p < 0.001 and p = 0.003, respectively), while specialty doctors scored significantly higher than nurses only on DDSIs knowledge (p < 0.001). Only 28% of respondents reported that they often or always ask patients on drug therapy about the use of DS or HP, and 25% of respondents record such data in the medical documentation of patients. Our results showed that HCPs have sufficient knowledge about most major DDSIs and DHPIs, but insufficient knowledge about most moderate interactions. However, their overall knowledge and behavior regarding the risk of these interactions indicate the need for further continuing education and training.