My Guidelines to Initiating Glaucoma Supplement Therapy
I currently recommend over a dozen supplements to my patients with glaucoma. Do I expect any of my patients with glaucoma to take all of them? No. Taking so many different supplements daily could be overwhelming. Most of my patients have medical conditions other than glaucoma requiring them to take prescription medications multiple times each day. Additionally, many of the supplements I recommend can cost over $40 for a monthly supply. It would simply be unreasonable to expect all of my patients to both afford and coordinate the dosing schedule of so many additional supplements each day.
So, how do I make my recommendations? I do so individually, based upon laboratory test results, what each patient can afford, and what other conditions (such as diabetes) may be present. As I know that not everyone will have the opportunity to consult with me for a personalized recommendation, I’ve outlined the basic approach I take to recommending glaucoma supplement therapy.
Please note that these are guidelines I use when making personalized recommendations to my patients in whom I have a knowledge of both their glaucoma and general health conditions. These guidelines should not be considered medical advice. When adding any supplement to your daily routine it is important to make your physician aware of this change as many supplements can interact with prescription medications.
First Consider What Should be Avoided
“Natural” supplements may be extracted from fruits, leaves, and other plant-based sources. That doesn’t mean they are without risk. Many supplements that are generally recognized as safe (GRAS) by the FDA when taken in commonly available over-the-counter doses can still interact with prescription medications or other health conditions in undesirable ways.
Be Aware of Interactions with Blood Thinners
Anyone taking prescription blood thinners must be very careful with what they ingest. This is true for food, drink, and supplements. A number of supplements have anti-platelet/anticoagulant activity. Undesirable and potentially dangerous bleeding could occur if these supplements are added to a daily routine of prescription anticoagulant therapy. The following supplements should be used with care or not at all if you are already on a prescription blood thinner such as aspirin, apixaban (Eliquis), clopidogrel (Plavix), dabigatran (Pradaxa), rivaroxaban (Xarelto)and warfarin (Coumadin):
- Black Currant
- Dan Shen (Salvia miltiorrhiza)
- Forskolin (Coleus)
- Ginkgo biloba
- May be OK if the only blood thinner being taken is aspirin.
- Omega-3 Fatty Acids (combined DHA and EPA)
- May be OK if only DHA is taken
- Tumeric (Curcumin)
- Vitamin E
- Wolfberry (Goji Berry)
Supplements may Negatively Impact Hormone Sensitive Cancers or Conditions
Many supplements (such as the flavonoids) have a structure that is similar to estrogen. As such, they may alter estrogen metabolism. Women with breast, uterine, and ovarian cancer, as well as endometriosis and uterine fibroids should avoid use of the following supplements:
Start with what’s Easy, Inexpensive, and has Evidence Supporting other Health Benefits
If you’re going to start a supplement program for glaucoma, wouldn’t it be great if the supplements not only treated your glaucoma, but your general health as well? The following have well-established health benefits, can be taken only once daily, and are inexpensive:
Consider Glaucoma Type
Normal Tension Glaucoma in those Not Taking a Blood Thinner
Normal Tension Glaucoma (aka Low Tension Glaucoma) results in loss of vision even when the intraocular pressure (IOP) is in the “normal” range. It is a particularly challenging type of glaucoma to treat. This is because all available prescription and surgical treatments work by lowering the IOP. If the IOP is already low what else is there to do?
It appears that Ginkgo biloba may be able to protect those with Normal Tension Glaucoma from progressive visual field loss. However, Ginkgo biloba may also increase the risk of bleeding so should be avoided in those who are using prescription blood thinning medications.
Consider How Each Supplement Will Interact with Other Health Conditions and Medications
There are no supplements that affect only glaucoma. The mechanisms by which they protect the optic nerve are also used in the body for other biochemical processes. Thus supplements will often benefit multiple conditions. This also means that supplements can interfere or be additive to other supplements and prescription medications. Too much of a good thing is seldom good. However, when more than one condition is not well-controlled there is the opportunity to select supplements that can potentially benefit both conditions. Following are a few conditions that if not well-controlled could be used to guide glaucoma supplement use:
There are multiple compelling reasons to consider adding oral supplementation with Melatonin. For those with trouble getting to sleep, as little as 0.5mg of Melatonin can be of benefit. Melatonin may also lower IOP as well as protect the optic nerve and retinal ganglion cells from oxidative damage. It is also one of the less expensive supplements available with few potential side effects.
Low Serum Vitamin D Levels
If you are over 40 years old it’s not a bad idea to get your Vitamin D blood levels checked. If low, your internist would likely recommend initiating supplementation with Vitamin D. Patients with glaucoma should definitely have this blood test done as Vitamin D deficiency is associated with a higher risk of glaucoma. At least for those with a deficiency, Vitamin D supplementation may provide some protection from glaucomatous damage.
Diabetes that is Not Well-Controlled
The following supplements appear to have blood sugar lowering properties in addition to their potential glaucoma treatment benefits. For those with uncontrolled blood sugar one or more of these supplements may be worth considering:
- Alpha-Lipoic Acid
- Mirtogenol® (Bilberry plus Pycnogenol®)
- Tumeric (Curcumin)
Systemic Hypertension (High Blood Pressure) that is Not Well-Controlled
The following supplements appear to have blood pressure lowering properties in addition to their potential glaucoma treatment benefits. For those with uncontrolled blood pressure one or more of these supplements may be worth considering:
Purchase only from Trusted Brands
“But the brand name supplements are so expensive!” you say? Well, which is more expensive: paying a premium for a product that contains the amount of active ingredient you wish to take or paying a discount for a bottle of filler with essentially no active ingredient? The latter is what you may be doing if you purchase generic or store brand (aka “Private Label”) supplements. The New York Attorney General conducted an investigation of privately labeled supplements sold by GNC, Target, Walgreens, and Walmart. They found that 80% of the supplements they tested contained none of the active ingredient!
What supplement brands do I recommend to my patients? The following brands have (to date at least) demonstrated a commitment to quality:
- Jarrow Formulas
- Life Extension
- Nordic Naturals
- Paradise Herbs
Add One Supplement at a Time
Not everyone responds to all supplements. Additionally, supplements are not without side effects. If more than one supplement is added at a time and side effects are encountered it will be more challenging to determine which supplement caused the unwanted side effect. By adding one supplement at a time it is possible to pair side effects and results to individual supplements. This will save time, frustration, and money.
Give Each Supplement a Chance to Work
Unlike glaucoma eye drops, many supplements can take weeks or even months to result in a measurable glaucoma treatment benefit. It is important, therefore, when adding a supplement to give it adequate time to produce a result before deciding that it is or is not worth continuing.
If Possible, Monitor Your Own Intraocular Pressure (IOP)
Although expensive, IOP measuring devices can be purchased for use at home. Why make such an investment? Because IOP naturally fluctuates. By self-measuring, an individual can become aware of his or her IOP trends in a manner that is simply not possible with one in-office measurement performed every few months.
Recognize that Not All Supplements Work to Reduce IOP
Supplements such as Forskolin (Coleus), Melatonin, Mirtogenol, Palmitoylethanolamide (PEA), Rutin, and Saffran may have IOP lowering benefits. Other supplements, however, appear to work through anti-oxidative, anti-inflammatory, and neuroprotective mechanisms. Such IOP-independent benefits are much harder to measure requiring in-office tests such as threshold visual fields and nerve fiber layer scans.
Include Your Physician in Your Supplement Treatment
It’s important to let your physicians know about your use of supplements. Why? Because they are there to help you and because they need to know what you are putting in your body in order to adequately monitor and treat your medical conditions.
Granted, Western-trained medical doctors have in the past been known to pooh-pooh the use of herbs, supplements, and all forms of Eastern-based medicine. That attitude is changing as modern research is demonstrating the potential medical benefit of many easily available supplements.
Adding supplements to one’s glaucoma treatment program can easily become overwhelming and expensive. A step-wise approach taking into account other medical conditions can decrease both complexity and cost. Using such a method, it is possible to develop a personalized supplement program that has the potential to benefit not only one’s glaucoma but one’s general health as well.
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David Richardson, MD
Medical Director, San Marino Eye
David Richardson, M.D. is recognized as one of the top cataract and glaucoma surgeons in the US and is among an elite group of glaucoma surgeons in the country performing the highly specialized canaloplasty procedure. Morever, Dr. Richardson is one of only a few surgeons in the greater Los Angeles area that performs Micropulse(r) P3 "Cyclophotocoagulation" (MP3) glaucoma laser surgery. Dr. Richardson graduated Magna Cum Laude from the University of Southern California and earned his Medical Degree from Harvard Medical School. He completed his ophthalmology residency at the LAC+USC Medical Center/ Doheny Eye Institute. Dr. David Richardson is also an Adjunct Assistant Professor of Clinical Ophthalmology at the Keck School of Medicine of USC. Twice weekly, he treats veterans at the VA Greater Los Angeles Veterans Healthcare System.