Pharmanex Medical Division

1. Pharmanex Medical Division Drug-Nutrient Depletion Dr. James LaValle

2. The PMD Opportunity The PMD Opportunity • Majority of American adults are using supplements • Physicians are the most trusted source of information • Patients see a pharmacist 7 or 8 times more often than a doctor • HCPs are a trusted source for information • 95% of Americans trust their physicians • 56% of Americans use them as a source of information • 84% of the time people are taking their pharmacists advice

3. The PMD Opportunity • Many HCPs stock-and-dispense supplements • There are over 100,000 alternative practitioners in the U.S. • 60-70% stock-and-dispense product

4. The PMD Opportunity • HCPs who stock-and-dispense supplements have potential to move a lot of volume • Many are generating significant monthly revenues. Pharmanex Medical Representatives can be the sole providers of scientific information to HCPs and pharmacists in the dietary supplement category

5. The PMD Mission 1. Provide scientific materials for HCPs to benefit their practice 2. Provide a unique opportunity that each HCP can be involved in • Advocate • Rebating • Retailing (Alopathic MDs, Alternative Practicioners, Chiropractors) 3. Provide unparalleled products and service to patients who become Pharmanex consumers • Effective, safe products recommended by their physician

6. The Future of PMD • Focused efforts on the education of pharmacists, doctors, and other HCPs in the following areas: • Drug-Induced Nutrient Depletions • Drug-Herb Interactions • Herb-Herb Interactions • Increased awareness of monetary compensation through this knowledge

7. Drug Induced Nutrient Depletions Drug Induced Nutrient Depletions • Drugs can inhibit nutrient absorption,synthesis, transport, storage, metabolism, or excretion • Multi-factorial problem • Tremendous opportunity for HCPs outcomes of patients and increase sales of nutritional supplements

8. Female Hormone Medications Oral contraceptives: deplete folic acid, B6, B1, B2, B3, B12, C, Mg, Se, Zn, tyrosine Estrogen replacement therapy (ERT & HRT): deplete B6, Mg

9. Effect of Oral Contraceptive Agents on Vitamin Nutrition Status • Women using low-dose OCs for 6 to 12 months •  excretion on kynurenic and xanthurenic acid •  EGOT activity with B6 challenge •  in erythrocyte folate levels •  in erythrocyte riboflavin conc. and fall in erythrocyte glutathione reductase activity F. Ahmed, et al., Am J Clin Nutr 28 (6) (Jun 1975): 606-15.

10. Folic Acid Depletion with Oral Contraceptive Use • Anemia: weakness, low energy • Birth defects • Cervical dysplasia • Elevated homocysteine • Depression •  breast and colorectal cancer

11. Vitamin B-6 Depletion with Oral Contraceptive Use • Reduced synthesis of serotonin and melatonin; elevated homocysteine • Symptoms: depression, anxiety, decreased libido, impaired glucose tolerance • Therapy: 40 mg B6/day restores biochemical values and relieves clinical symptoms P. Bermond, Acta Vitaminol Enzymol 1982; 4(1-2): 45-54

12. Blood Pressure Regulators Hydralazine: B6, CoQ10 Loop: Ca, Mg, K, Zn, B1, B6, C Thiazides: Mg, K, Zn, CoQ10 Potassium-sparing: Ca, Zn, FA Beta-blockers: CoQ10, melatonin Clonidine/Methyldopa: CoQ10 ACE: Zn Chlorthalidone: Zn

13. Magnesium • Muscle relaxant-Ca channel blocker •  platelet aggregation (like aspirin) • Thins the blood (like Coumadin) • Blocks Ca uptake (like Procardia) • Relaxes blood vessels (ACE inhibitors) • Improves cardiac contractibility which •  oxygenation of the heart

14. Lanoxin • Calcium, magnesium, phosphorus via increased urinary excretion • Magnesium deficiencies increase likelihood of cardiac dysrhythmias and atrial fibrillation

15. Cholesterol Lowering Drugs HMG-CoA Reductase Inhibitors “Statins” : deplete CoQ10 The “fibrates” : depletes B12, E, Cu, Zn Gemfibrozil: depletes CoQ10, E Bile Acid sequest: depletes A, D, E, K, Ca B12, Mg, P, Zn, Fe, Folic Acid, fat, beta-carotene

16. Anti-diabetic Drugs • Sulfonylureas • depletes CoQ10 • Biguanides • depletes CoQ10, B12, FA

17. Psychotherapeutic Drugs Phenothiazines: depletes B2 & CoQ10, melatonin Tricyclic antidepressants: deplete B2 & CoQ10 Phelezine (MAOI): depletes vitamin B6 Haloperidol: depletes CoQ10, vitamin E, melatonin Lithium: depletes inositol

18. Anti-inflammatory Drugs Corticosteroids: Vit A, C, D, B6, B12, FA, Ca, Cr, Mg, K, Se, Zn Colchicine: Vit B12, Ca, Na, K, P, B-carotene Sulfasalazine: Folic acid Indomethacin: Folic acid, iron NSAIDS: Folic acid Aspirin/salicylates: Vit C, FA, B5, Ca, Fe, Na, K

19. Anti-Anxiety AgentsDiazepam (Valium) and Alprazolam (Xanax) Both drugs deplete melatonin: • Insomnia • Greater cancer risk • Increased free radical aging damage

20. Antibiotics • Beneficial bacteria manufacture B vitamins and vitamin K in the GI tract • Beneficial bacteria produce proteases, lipases, and lactase that aid in digestion of nutrients • Bifidobacteria produce SCFAs that provide from 5-10% of our daily energy supply • Dysbiosis further disrupts digestion and absorption of nutrients

21. Antiviral AgentsZidovudine and Related HIV/AIDS Drugs Carnitine: abnormal lipids, liver function, glucose Copper: anemia, cardio & connective tissue problems Zinc:  immunity, wound healing, taste & smell Vitamin B12: anemia,  CVD risk, depression

22. Chemotherapy Drugs • Most nutrients are depleted • Cytotoxic drugs can cause: • damage to gastric & GI mucosa/malabsorption • inflamed GI tract/painful, decreased appetite • nausea and vomiting • dysbiosis

23. Timed Release KC1 Drugs • Vitamin B12 depletion • Slow release of KC1 salts alters intestinal pH, which decreases B12 absorption • Anemia, elevated homocysteine, depression, neurological problems

24. Bronchodilators • Theophylline: depletes vitamin B6-inhibits synthesis of the enzyme pyridoxal kinase which is necessary to convert B6 to pyridoxal-5-phosphate • Beta2 adrenergic agonists: deplete potassium

25. Coumadin • Vitamin K depletion • Interferes with the enzyme responsible for the synthesis of vitamin K

26. Aspirin Vitamin C: drug most likely to deplete in normal individuals Iron: due to blood loss in GI tract Potassium: increased urinary loss Folic acid folate: displaces bound serum

27. Laxatives • Mineral Oil •  absorption of vitamins A, D, E, K, and beta-carotene, calcium & phosphorus • Bisacodyl • depletes potassium • Intense peristalsis and rapid bowel emptying can cause hypokalemia • Sodium phosphate enema • depletes Ca & Mg

28. Antacids • Mg/Al antacids • deplete calcium, phosphorus and folic acid (protein) • Sodium bicarbonate • deplete potassium and folic acid (protein)

29. Summary • Pharmanex Medical Representatives have the opportunity to increase sales and increase their income by utilizing Drug-Nutrient Depletions in conjunction with their Health Care Professionals. • Many Representatives are currently achieving increased success through the Medical Divison.

30. Pharmanex Medical Division E-HEALTH CARE PREVENTIVE MEDICAL MODEL FOR THE HEALTHCARE PROFESSIONAL Michael Jason, MD, FACP, FACC, FCCP Clinical Asst Professor Medicine&Cardiology Cornell University Medical College/NYU

31. APPROACH HCP • Medical Model • DX, RX • Preventive Model • Clinical solutions • Natural diagnosis • History (survey) • Non invasive screening

32. PATIENT QUESTIONAIRE

33. Non Invasive Screening LIPID HYPERLIPIDEMIA GLUCOSE DIABETES % BODY FAT OBESITY BONE DENSITY OSTEOPOROSIS PFT ASTHMA/COPD SURVEY SED PSYCHOMETRICS DEMENTIA/ADD SURVEY DEPRESSION FAM/PERS HX CANCER

34. Why Introduce Herbal & Nutritional Supplements to Patients in a Clinical Practice? Educating patients (and healthcare professionals) about nutrition, exercise and targeted, safe and effective, rational nutritional and herbal supplementation enables a patient to become increasingly more informed about preventable determinants of chronic illness and disease and, therefore, more empowered and in charge of the powerful aspects of their own health care. (eg. chronically ill, oncology patients)

35. There is a new emphasis on nutrition and lifestyle intervention that is now taking center stage in the overall wellness programs recommended by many health care professionals. Why are so many HCP’s interested inNutrition and Lifestyle Intervention?

36. Why are Natural Medicines ImportantIn a Modern Clinical Setting? Times are changing in the rapidly emerging world of health care and managed care. There is a resurgence of interest in natural approaches to health.

37. The modern clinical “Renaissance” is making Natural Medicines the most rapidly growing and popular segment of OTC products in Pharmacies, Health Food Stores, and ultimately recommended by Physicians , Alternative Practitioners and other Health Care Professionals, as part of a more preventive and comprehensive, preventive program integrated with routine clinical care. NATURAL MEDICINE RENAISSANCE

38. Healthcare Professionals (Physicians, Pharmacists and Alternative Practitioners) are being approached more and more often by their patients and other health care professionals about the 1) proper usage, 2) side effects, 3) contraindications, 4) drug-herb and herb-herb interactions and 5) correct dosage of natural medicines, and how these products should be incorporated into the clinical management of patients with multiple pre-existing illnesses and coadministered drugs. INCREASED CONSUMER DEMAND

39. Why is Complimentary Medical Care so Important in Today’s Modern Medicine Complimentary Care = Integrative Medicine Key Clinical Concept There is a need for complimentary medicine practices to be incorporated into today’s modern medicine, and it needs to be done judiciously, with clinical results presented in a scientific manner, focused on evidence based medicine with clinical proof that certain complimentary interventions work before suggesting them to our patients.

40. Why are modern HCP’s so eager to learn more about Natural Remedies? From a professional standpoint, there is an educational and experiential deficit that is seeking more information, looking for help and answers and easier access to information because of a great need and desire to be educated.