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Herb and Supplement Guidelines During Transplantation and High-Dose Chemotherapy

Herbs and nutritional supplements can reduce the effectiveness of your treatment and even cause serious infection in patients receiving high-dose chemotherapy or bone marrow transplants. This guide, developed by Seattle Cancer Care Alliance dietitians, will help you avoid problems.

At your initial evaluation, SCCA dietitians and physicians will ask about any supplements or herbals you use and recommend that you stop taking them. This guide explains why.

Why Supplements Are a Concern During Treatment

There are four areas of concern with nutritional supplements, herbals, and other preparations during bone marrow or stem cell transplantation or high-dose chemotherapy.

  1. Interactions between these supplements and prescribed medications. Supplements may reduce the effectiveness of drugs routinely used during the course of transplantation or chemotherapy.
  2. Potential contamination of supplements derived from plants. Inadequate purification and sterilization may cause bacterial, fungal, or parasitic infections. Even boiling water may not destroy some infectious organisms that can contaminate these products.
  3. Serious toxic side effects. A few specific preparations have been repeatedly associated with damage to the liver, blood, kidneys, heart, and other body organs.
  4. Questionable dosages and ingredients. The U.S. Food and Drug Administration does not regulate the production, distribution, and labeling of herbal preparations and nutrient supplements. As a result, the label may list an inaccurate dosage and may not list all ingredients a product contains.

Read more for details about specific issues.

Herbal and Botanical Preparations

Herbal and botanical preparations include a variety of products derived directly from plants. They may be sold as tablets, capsules, liquid extracts, teas, powders, and topical preparations. There are no manufacturing regulations for the cleanliness or purity of these products. Therefore, there is a danger the products may be contaminated with fungus, bacteria, parasites, or other chemicals, which can be life-threatening to a person with an impaired immune system, including persons receiving chemotherapy or transplantation. Even boiling water may not kill some organisms which can contaminate these products.

Your SCCA health care team recommends that all herbal and botanical products be avoided during chemotherapy and as long as your immune system is impaired. The decision to use any preparation should be discussed with your doctor, who will consider the effects of the product on your kidneys, liver, and other organs, as well as your risk of infection and any interactions it may have with other medications.

Some herbals may decrease blood clotting. People with low platelet counts should not take garlic and gingko bilboa.

The following list includes herbal and botanical medications with known dangerous side effects and should not be taken under any circumstance. Other herbs and botanicals could be found to be dangerous in the future. Always talk with your doctor before taking herbal and botanical preparations.

  • Alfalfa
  • Borage
  • Chaparral
  • Chinese herbs
  • Coltsfoot
  • Comfrey
  • DHEA
  • Dieter’s Tea (including senna, aloa, rhubarb root, buckthorn, cascara, castor oil)
  • Ephedra or MaHuange
  • Groundsel or Life Root
  • Heliotrope or Valerian
  • Kava Kava
  • Laetrile (Apricot Pits)
  • Licorice Root
  • Lobelia
  • L-tryptophan
  • Maté Tea
  • Pau d’ arco
  • Pennyroyal
  • Sassafras
  • St. John’s Wort
  • Yohimbe and Yohimbine

Do not use any product that is given as an injection into the central line or as an injection under the skin.

Adult Daily Supplement Intake Recommendations

Your healthcare team will prescribe a multiple vitamin and mineral supplement that provides nutrients at about the same levels of the Dietary Reference Intakes. DRIs are issued by the National Academy of Sciences and list recommended levels of nutrients and safe upper limits. Sometimes patients wish to take higher doses of specific vitamins, minerals, or antioxidants. Higher doses are not suggested--they may be toxic or interact with other medications. The following list may provide guidance for you.

  • Vitamin A: 2700 – 3000 IU/800 – 1000 RE or mcg
    No more than 10,000 IU or 3,000 mcg
  • Vitamin C (Ascorbic Acid): 120 mg
    No more than 500 mg
  • Vitamin D (Calciferol): 200 – 600 IU or 5-15 mcg
    No more than 2000 IU or 50 mcg
  • Vitamin E (-Tocopherol): 8 – 10 mg or IU
    No more than 100 mg or IU while on anticoagulant therapy. No more than 800 mg or IU in other cases
  • ß-Carotene: No Dietary Intake Recommendation
    No more than 25,000 IU or 15 mg
  • Folic Acid (Folate): 400 mcg
    No more than 1000 mcg or 1 mg
  • Vitamin B1 Thiamin: 1.1 – 1.2 mg
    While high intakes of B-vitamins may not be toxic, it is important to maintain a balance among the B-vitamins. Talk with your dietitian about your particular needs.
  • Vitamin B2 Riboflavin: 1.1 – 1.3 mg
    While high intakes of B-vitamins may not be toxic, it is important to maintain a balance among the B-vitamins. Talk with your dietitian about your particular needs.
  • Niacin (mg of Niacin equivalents): 14 – 16 mg
    No more than 25,000 IU or 15 mg
  • Vitamin B6 Pyridoxine: 1.3 – 1.7 mg
    No more than 100 mg
  • Vitamin B12 (Cobalamin): 2.4 mg
    While high intakes of B-vitamins may not be toxic, it is important to maintain a balance among the B-vitamins. Talk with your dietitian about your particular needs.
  • Biotin: 30 mcg
    While high intakes of B-vitamins may not be toxic, it is important to maintain a balance among the B-vitamins. Talk with your dietitian about your particular needs.
  • Pantothenic Acid: 5 mg
    While high intakes of B-vitamins may not be toxic, it is important to maintain a balance among the B-vitamins. Talk with your dietitian about your particular needs.
  • Iron: 12 – 15 mg
    Iron supplementation is not recommended post transplant.
  • Selenium: 40 – 70 mcg
    No more than 200 mcg
  • Calcium: 1000 – 1200 mg
    No more than 2500 mg

Recommended Vitamin Brands for Adults

Vitamins brands that contain Iron and/or extra C are not recommended.

  • One-a-Day 50 Plus
  • Nature Made Mature Balance

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Pediatric Daily Supplement Intake Recommendations

The following are micronutrient dietary reference intakes and safe upper limits.

Vitamin A

  • Birth – 1 year: 375 mcg/1250 IU
  • 1 –10 years: 400 – 700 mcg/1333 – 2333 IU
  • Birth – 10 years: No more than 3000 mcg or 10,000 IU
  • 11 years+: 800 – 1000 mcg/2700 – 3300 IU 
  • 11 years+: No more than 6000 mcg or 20,000 IU

Vitamin C (L-ascorbic acid)

  • Birth – 6 mo.: 30 mg 
  • 7 – 12 mo.: 35 mg 
  • 1 – 3 years: 40 mg
  • 4 – 6 years: 45 mg
  • 7 – 10 years: 45 mg
  • Birth – 10 years: No more than 250 mg
  • 11 years+: 50 – 60 mg; No more than 500 mg

Vitamin D (Calciferol)

  • Birth – 18 years: 200 IU or 5 mcg
  • Birth – 12 mo.: No more than 1000 IU or 25 mcg
  • 1 - 18 years: No more than 2000 IU or 50 mcg

Vitamin E (Tocopherol – most active form)

  • Birth – 6 mo.: 3 mg (pre-mature: 17 mg)
  • 7 – 12 mo.: 4 mg or 4 IU
  • 1 – 3 years: 6 mg
  • 4 – 10 years: 7 mg
  • 11 years+ Female: 8 – 10 mg
  • 11 years.+ Male 10 mg
  • No more than 50 mg or 50 IU

Beta – Carotene

  • No Dietary Reference Intake
  • Birth – 10 years: No more than 15,000 IU or 9 mg
  • 10 +: No more than 25,000 IU or 15 mg

Iron

  • Birth – 6 mo.: 6 mg
  • 6 mo. – 10 years: 10 mg
  • 11 years+: Female 15 mg
  • 11 years+: Male 12 mg

Iron supplementation is not recommended post transplant.

Folic Acid (folate)

  • Birth – 6 mo.: 65 mcg; No more than 65 mcg
  • 7 – 12 mo.: 80 mcg; No more than 80 mcg
  • 1 – 3 years: 150 mcg; No more than 300 mcg
  • 4 – 8 years: 200 mcg; No more than 400 mcg
  • 9 – 13 years: 300 mcg; No more than 600 mcg
  • 14 – 18 years: 400 mcg; No more than 800 mcg

Vitamin B1: Thiamin

  • Birth – 6 mo.: 0.2 mg
  • 7 – 12 mo.: 0.3 mg
  • 1 – 3 years: 0.5 mg
  • 4 – 8 years: 0.6 mg
  • 9 – 13 years: 0.9 mg
  • 14 - 18 years+ Female: 1.0 mg
  • 14 - 18 years+ Male: 1.2 mg

While high intakes of B-Vitamins may not be toxic, it is important to maintain a balance among the B-vitamins. Talk with your child’s dietitian to discuss individual needs.

Vitamin B2: Riboflavin

  • Birth – 6 mo.: 0.3 mg
  • 7 – 12 mo.: 0.4 mg
  • 1 – 3 years: 0.5 mg
  • 4 – 8 years: 0.6 mg
  • 9 – 13 years: 0.9 mg
  • 14 - 18 years+ Female: 1.0 mg
  • 14 - 18 years+ Male: 1.3 mg

While high intakes of B-Vitamins may not be toxic, it is important to maintain a balance among the B-vitamins. Talk with your child’s dietitian to discuss individual needs.

Vitamin B: Niacin (mg of Niacin equivalents)

  • Birth – 6 mo.: 2 mg; No more than 2 mg
  • 7 – 12 mo.: 4 mg; No more than 4 mg
  • 1 – 3 years: 6 mg; No more than 10 mg
  • 4 – 8 years: 8 mg; No more than 15 mg
  • 9 – 13 years: 12 mg; No more than 20 mg
  • 14 - 18 years+ Female: 14 mg; No more than 30 mg
  • 14 - 18 years+ Male: 16 mg; No more than 30 mg

Vitamin B6: Pryroxidine

  • Birth – 6 mo.: 0.1 mg; No more than 0.1 mg
  • 7 – 12 mo.: 0.3 mg; No more than 0.3 mg
  • 1 – 3 years: 0.5 mg; No more than 30 mg
  • 4 – 8 years: 0.6 mg; No more than 40 mg
  • 9 – 13 years: 1.0 mg; No more than 60 mg
  • 14 - 18 years+ Female: 1.2 mg; No more than 80 mg
  • 14 - 18 years+ Male: 1.3 mg; No more than 80 mg

Vitamin B12: (Cobalamin)

  • Birth – 6 mo.: 0.4 mcg
  • 7 – 12 mo.: 0.5 mcg
  • 1 – 3 years: 0.9 mcg
  • 4 – 8 years: 1.2 mcg
  • 9 – 13 years: 1.8 mcg
  • 14 - 18 years+: 2.4 mcg

While high intakes of B-Vitamins may not be toxic, it is important to maintain a balance among the B-vitamins. Talk with your child’s dietitian to discuss individual needs.

Biotin

  • Birth – 6 mo.: 5 mcg
  • 7 – 12 mo.: 6 mcg
  • 1 – 3 years: 8 mcg
  • 4 – 8 years: 12 mcg
  • 9 – 13 years: 20 mcg
  • 14 - 18 years+: 25 mcg

While high intakes of B-Vitamins may not be toxic, it is important to maintain a balance among the B-vitamins. Talk with your child’s dietitian to discuss individual needs.

Pantothenic Acid

  • Birth – 6 mo.: 1.7 mcg
  • 7 – 12 mo.: 1.8 mcg
  • 1 – 3 years: 2 mcg
  • 4 – 8 years: 3 mcg
  • 9 – 13 years: 4 mcg
  • 14 - 18 years+: 5 mcg

While high intakes of B-Vitamins may not be toxic, it is important to maintain a balance among the B-vitamins. Talk with your child’s dietitian to discuss individual needs.

Selenium

  • Birth – 6 mo.: 10 mcg; No more than 100 mcg
  • 7 – 12 mo.: 15 mcg 
  • 1 – 10 years: 20 – 30 mcg
  • 11 years+:  40 – 50 mcg
  • 6 mo.+: No more than 200 mcg

Calcium

  • Birth – 6 mo.: 210 mg; No more than 210 mg
  • 7 – 12 mo.: 270 mg; No more than 270 mg
  • 1 – 3 years: 500 mg
  • 4 – 8 years: 800 mg
  • 9 – 18 years: 1300 mg
  • 1 – 18 years: No more than 2500 mg

Recommended Vitamin Brands for Children and Teens

Vitamins that contain Iron and/or extra C are not recommended.

  • Centrum Jr 
  • Flintstones
  • Sesame Street
  • Bugs Bunny
  • Fruity Chews Tablets 
  • One-A-Day Essential Tablets

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Antioxidants and B-Vitamins

A high intake of some antioxidants (vitamin C, vitamin E, and ß-carotene) may protect against the development of certain types of cancer. However, taking antioxidant supplements during radiation and chemotherapy may reduce the effectiveness of these treatments in destroying diseased cells. Therefore, you should stop antioxidant supplementation before chemotherapy and radiation.

Antioxidants may be inappropriate post transplant due to interactions with medications, immunosuppressive therapy or other vitamins and minerals in your body. Your dietitian can provide you with more information. If you are considering taking antioxidants post transplant, discuss this with your physician.

The B vitamins (thiamin, niacin, riboflavin, pyridoxine (B6), folate, cobalamin (B12), biotin, and pantothenic acid,) are water-soluble nutrients that assist in energy production. High levels of supplementation may not be toxic. However, it is important to maintain a balance among these B-vitamins. High doses of one may have a negative effect.

Recommendations for Specific Treatments

As your immune system begins to recover and strengthen, you may be able to include herbal supplements and vitamins in your diet, depending on the type of transplant you have had. Some people wish to start using the supplements they were taking before transplant.

It is critical to check with your health care team before taking any vitamin or herbal supplement, as some may put your still immature immune system at risk.

Allogeneic Transplantation

Patients undergoing allogeneic transplantation (from an unrelated or family donor) are at risk for infections until all immunosuppressive medications have been stopped and you are free of active chronic GVHD (graft versus host disease). Immunosuppressive medications include cyclosporine (Neoral), tacrolimus (FK-506), prednisone, thalidomide, Imuran, Rapamycin, mycophenolate mofetil (MMF, CellCept), and interferon. Discuss use of herbals or botanicals with your attending and infectious disease physicians. If vitamin and mineral supplementation above the Dietary Reference Intake is desired, consult with both your doctor and dietitian.

Autologous Transplantation

Even beyond the neutropenic period, patients undergoing autologous transplantation may be at risk for infection. Herbals and botanicals should be avoided until you have no active gastrointestinal (“GI”) problems and have been off prednisone therapy for one month. Use of herbals or botanicals after that time should be discussed with your physician, and under the direction of a licensed naturopathic physician. Vitamin and mineral supplementation above the DRI should be discussed with your physician and dietitian.

Chemotherapy

Patients undergoing chemotherapy for stem cell mobilization or tumor debulking should follow the recommendations for autologous transplantation.