Which supplements might be helpful for myeloma patients and should be discussed with their doctor to ensure they're safe and appropriate?

Which supplements might be helpful for myeloma patients and should be discussed with their doctor to ensure they're safe and appropriate? So when we think about supplements that patients should consider, there is very limited data in this space in terms of randomized trials that have given a supplement and seen a clear benefit. But because supplements are so widely used, those are very hard studies to do. So the data that we have is more of retrospectively analyzing patients who've taken supplements versus not and seeing if there are any outcomes. Vitamin D is one such supplement that has shown that people, patients who are on it or who have higher levels tend to have better survival or less aggressive disease or better outcomes. But it's not been tested by whether if we give the supplement, does it really change survival? And so it is challenging to fully know whether it will really make that difference. But I think vitamin D helps some patients in terms of bone health, of course, and then enhancing calcium absorption in terms of fatigue as well. So I think joint pains or achiness and overall just a sense of well-being. So I think keeping the levels about 30 and the range between 30 to 50 is ideally where we want to see the levels. But there isn't clear recommendation that we absolutely have to. Other supplements, calcium, I think if a patient has osteoporosis, osteopenia, that is something we want to be thinking about. And the main thing with calcium is we don't want to take very high doses at the same time because that can then deposit into the cardiovascular and increase risk of heart disease. So if we are taking calcium supplements, and I don't think every patient needs it because if the vitamin D levels are high enough, dietary calcium will get absorbed better. But if there is a reason why a patient feels they need it, I think taking doses of less than 500 milligrams at a time can help prevent the deposition into cardiovascular instead of taking high doses like 1000 milligrams at one time. So you can spread it out over the day 500, twice a day or thrice a day instead of taking 1000 once a day if that's the dose that's needed. Other supplements, again, if there is deficiency of iron, then maybe an iron supplement. If there's B12 or folate deficiency, then those would be things that we would consider. B12 deficiency is quite widespread and I do see it often. And part of it is because of where B12 comes from. It comes in the soil microbes. And when we eat, we eat very hygienically now so we don't get those microbes in our diet. And people who eat animal foods, the animals eat those microbes or they get injected in farming with B12. And so they may have some B12 in animal based foods. But plant based foods often may not have vitamin B12 because it is from the microbes and we're cleaning our produce before eating it. So it is something just to consider and potentially take a small dose like 500 micrograms once a week if you have had history of low levels or you're completely eating a plant based diet. There is another reason for B12 deficiency where there is a problem with absorption and that's usually an immune mediated autoimmune where it's called pernicious anemia where you don't absorb B12 as well due to antibodies that inhibit the absorption. But that's, I think, much rarer and usually it's more related to just dietary factors or the way we've processed our foods. Other supplements that patients with myeloma or small ring myeloma that I have seen often take are things like curcumin and omega-3. Again, the data around these supplements is very limited. We are actually conducting two studies, one called Nutrivention 3 at Memorial Sloan Kettering and Emory where we are looking at giving these supplements for a year to patients to understand the effects on the microbiome, the immune system and progression of disease and hopefully in a few years we'll be able to share that data. The other study is the Nutrivention 2 study being done with the Health Tree Foundation and in this study we're doing a really short intervention of a few weeks. Patients anywhere in the country can take part and you don't have to come into any site because you can do this study right from your home. In that study we're looking at a short intervention of these supplements to see whether that affects microbiome health and also helps understand the differences in the microbiome of patients with MGUS and small ring myeloma. So I urge you to take part if that is something, if you have MGUS or small ring myeloma. And then lastly, two other supplements would be magnesium. Magnesium is one that I again wouldn't recommend all patients take it, but magnesium is found in plant-rich foods or fiber-rich foods. So if you're not getting enough dietary fiber, you're probably not getting enough magnesium. Magnesium is used for muscle cramps, anxiety, insomnia or difficulty falling asleep and maybe sometimes constipation too. So these are some uses of magnesium and then in cardiovascular disease sometimes they, since the magnesium levels for sub-stabilizing heart function, the levels are also tried to keep them higher. The blood levels of magnesium are not a good marker of true magnesium stores because the blood is only a small percentage. Most of the magnesium is stored in the bones and so just checking blood magnesium levels is not going to clearly tell you whether you are deficient. And I think depending on people that are more likely to be deficient are those who are taking proton pump inhibitors like omeprazole or pantoprazole because it leads to some magnesium wasting. People who have diabetes that is uncontrolled especially because of excess urination and they can lose magnesium. Patients who get drugs like cisplatin or other chemotherapy sometimes can lead to magnesium loss. Chronic diarrhea is a place where you may have some more magnesium loss. So these are situations where you may want to think about whether you need to improve the diet to include magnesium. A lot of seeds, pumpkin seeds, chia seeds, oats, beans are all rich in magnesium and so I think if you're getting enough of those things then you're probably getting enough magnesium. And within magnesium there are two kinds organic and inorganic. The organic magnesium salts are like magnesium glycinate, have less effects on diarrhea and may be absorbed better. The magnesium citrate or magnesium oxide are the more commonly ones, inorganic ones and they can have side effects of diarrhea when taken at higher doses too. The dose of a supplement makes it whether it's helpful or could even be harmful or lead to toxicity. So when we talk about supplements that patients should take or not take it's very important that we're looking for the toxicity side to like vitamin D if the levels are too high. It could lead to hypercalcemia and other signs of toxicity whereas even vitamin B6, if levels are too high it can increase risk of peripheral neuropathy whereas even low vitamin B6 can cause peripheral neuropathy. So there's some vitamins we really don't want excess of. Vitamin B12 on the other hand if it's a bit higher than normal it's not a big deal because usually there's no toxicity seen from it. So that's quite important when we talk about which supplements not to take is also even the ones we are taking we don't want to take it in such excess that it leads to toxicity. I think it's important to note like I said before every patient doesn't need all these supplements and sometimes supplements can cause toxicity so it is important not to just think that oh I need all of these and I'm going to take them because also of the interactions.