Pycnogenol French Maritime Pine Bark Extract 100 mg [Discontinued] by Life Extension

POSSIBLY EFFECTIVE

• Asthma. Oral maritime pine bark extract, taken as an adjunct to conventional asthma medications, may improve symptoms and reduce rescue inhaler use in patients with asthma. Details: Three small clinical studies in children and adults with asthma of varying severity show that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 1 mg/lb body weight or 100 mg daily in addition to conventional asthma medications increases peak expiratory flow, decreases asthma symptoms, and decreases the need for rescue medications when compared with conventional therapy alone (13120,50863,50926). Maritime pine bark extract has not been studied as monotherapy for asthma and should not be used in place of conventional medicine for this purpose.
• Chronic venous insufficiency (CVI). Oral maritime pine bark extract may improve leg pain and heaviness and reduce edema in patients with CVI. Details: Several clinical studies in patients with CVI show that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) reduces edema, the rate of ankle swelling, and symptoms of leg pain and heaviness when used for 3-12 weeks. The most commonly used dose is 100-120 mg three times daily (2451,2462,2493,7693,50892). However, lower doses of 50 mg three times daily (16906,50892,50900,50915) or 45-100 mg once daily also seem to be effective (2435,97401). When compared with the use of below-knee compression stockings worn throughout the day, maritime pine bark reduces induration and the rate of ankle swelling when compared to baseline in patients with CVI. While both treatments reduce venous edema and pain when compared with baseline, a more pronounced reduction is seen in patients taking the maritime pine bark extract (97401). Other clinical research in adults who have had CVI for more than 3 years shows that taking the same extract, 50 mg three times daily for 8 weeks, in addition to wearing compression stockings, improves microcirculation and subjective symptom scores when compared with compression stockings alone (103616). However, compliance with the use of compression stockings in this study was poor.
• Osteoarthritis. Small clinical studies suggest that oral maritime pine bark extract may modestly improve symptoms and reduce the need for analgesics in patients with knee osteoarthritis. Details: Two small clinical studies in patients with knee osteoarthritis shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 100-150 mg daily for 3 months reduces overall osteoarthritis symptoms, pain, and the use of anti-inflammatory medication when compared with placebo (50903,50905). Topical maritime pine bark has also been evaluated. Observational research in patients with knee osteoarthritis found that applying standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 220 mg, as two patches daily, for three weeks is associated with reduced pain and reduced need for rescue analgesics when compared with control (100356).

POSSIBLY INEFFECTIVE

• Hyperlipidemia. Oral maritime pine bark extract may not improve lipid levels in patients with hyperlipidemia. Details: Although individual clinical trials have shown mixed results (7693,91965,97408), a meta-analysis of 4 small clinical trials in patients with hyperlipidemia shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 100-150 mg daily for 4-24 weeks does not reduce total cholesterol, low-density lipoprotein (LDL) cholesterol, or triglyceride levels when compared with a control (100357).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Age-related cognitive decline. It is unclear if oral maritime pine bark extract is beneficial in elderly patients with age-related cognitive decline. Details: One observational registry study in healthy elderly patients ages 55-70 years has found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 100 mg daily for 12 months is associated with improved cognitive function, mental performance, and attention when compared with matched controls (97405). However, the validity of these findings is limited by the unblinded, non-randomized nature of the study. Also, a small clinical study in healthy elderly patients 60-85 years of age shows that taking the same extract, 150 mg daily for 3 months, improves spatial working memory, but not numeric working memory, episodic memory, attention, or psychomotor performance, when compared with placebo (50906).
• Aging skin. Although there has been interest in using oral and topical maritime pine for aging skin, there is insufficient reliable information about the clinical effects of maritime pine for this purpose.
• Allergic rhinitis (hay fever). It is unclear if oral maritime pine bark extract is beneficial in people with allergic rhinitis. Details: A small clinical study in patients with birch allergies shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 50 mg twice daily, starting at least 5 weeks before allergy season, decreases nasal symptoms associated with birch allergies when compared with placebo (17300).
• Androgenic alopecia. It is unclear if oral maritime pine bark is beneficial for androgenic alopecia. Details: A small clinical study in postmenopausal patients conducted in China shows that taking maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily for 6 months improves hair density when compared to baseline (112713). However, the interpretation of these findings is limited by the lack of a statistical comparison to the placebo group.
• Antidepressant-induced sexual dysfunction. It is unclear if oral maritime pine bark is beneficial for improving sexual function in adults taking escitalopram. Details: A small, open-label clinical study shows that taking standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 50 mg daily for 4 months with escitalopram 10-20 mg daily seems to improve sexual dysfunction when compared with escitalopram alone (100361).
• Atherosclerosis. Oral maritime pine bark extract has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A non-randomized clinical trial in adults with atherosclerosis shows that taking a specific maritime pine bark product (Pycnogenol, Horphag Research) 150 mg and gotu kola 225 mg, in two divided doses daily for 3 months, reduces plaque height and length and increases plaque echogenicity and stability when compared to control (97030). However, these benefits may be at least partially due to gotu kola. Another non-randomized clinical study in adults with atherosclerotic plaques and no other cardiovascular risk factors shows that taking Pycnogenol 100 mg and gotu kola extract 100 mg daily for up to 4 years reduces plaque progression and increases plaque echogenicity to a greater extent than Pycnogenol alone or no treatment at all. Taking Pycnogenol with gotu kola is also associated with a reduced rate of clinical vascular events, including angina, myocardial infarction, minor transient ischemic attacks (TIAs), and minor strokes, when compared with taking Pycnogenol alone or receiving no treatment at all (97029).
• Athletic performance. It is unclear if oral maritime pine bark extract is beneficial for improving exercise capacity in recreationally trained adults; the available evidence is conflicting. Details: One small clinical study shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 200 mg orally daily for 30 days improves exercise capacity during a treadmill test in recreational athletes aged 20-35 years (2554). Additionally, an observational registry study found that taking this same maritime pine bark extract 100 mg orally daily for 8 weeks along with training improves performance in the Army Physical Fitness Test, including reducing two-mile treadmill time by about 45-60 seconds and increasing the number of push-ups and sit-ups by about 5-7 when compared to control training alone. Taking this maritime pine bark extract during training also appears to improve total triathlon time by about 6 minutes when compared with training alone (91966). However, the validity of this finding is limited by the unblinded, non-randomized nature of the study. Additionally, a small study in college-age males who exercise regularly shows that taking the same maritime pine bark extract 800 mg daily, starting 14 days prior to a cycle ergometer test and continuing for 2 days after, does not improve maximum oxygen consumption or power generated in the test when compared with placebo (103617). Maritime pine extract has also been studied in combination with other ingredients. A small clinical study in non-professional athletes shows that taking a combination product (PycnoRacer, Kobayashi Pharmaceutical Company) containing maritime pine extract 15 mg, L-leucine 0.6 grams, L-arginine 0.3 grams, L-isoleucine 0.3 grams, and L-valine 0.3 grams four times daily for 3 weeks during training improves running distance by about 19%, compared with 9% in athletes drinking water plus Gatorade. Maritime pine park also improved maximal oxygen consumption and reduced subjective scores of muscle pain and cramps when compared with water and Gatorade (103613). It is unclear if these benefits are due to maritime pine, other ingredients, or the combination.
• Attention deficit-hyperactivity disorder (ADHD). It is unclear if oral maritime pine bark extract is beneficial in children or adults with ADHD. Details: A small clinical study in adults with ADHD shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) does not seem to improve ADHD symptoms when compared with placebo (9984). However, a small clinical study in children with ADHD shows that taking this standardized maritime pine bark extract 1 mg/kg daily for one month appears to improve attention and hyperactivity scores when compared with placebo (50891).
• Behcet syndrome. It is unclear if oral maritime pine bark extract is beneficial in patients with Behcet syndrome. Details: A small clinical study in patients with Behcet syndrome shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily for 3 weeks reduces skin ulcer size and improves self-reported symptoms of burning and pain when compared to baseline (100358). The validity of these findings is limited by the lack of a comparator group.
• Benign prostatic hyperplasia (BPH). It is unclear if oral maritime pine bark extract is beneficial in patients with BPH. Details: A small observational registry study in patients with BPH found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily for 8 weeks is associated with modest improvement of symptoms such as bladder emptying, urgency, flow, straining, and nocturia (100359). This study was limited by small size, reporting inaccuracies, and its unblinded, non-randomized design.
• Cognitive function. Small clinical studies suggest that oral maritime pine bark extract might improve cognitive function in healthy adults. Details: A small observational registry study in healthy adults aged 30-55 years found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily for 12 weeks is associated with slightly improved memory and cognition when compared with matched controls (97410). However, the validity of these findings is limited by the unblinded, non-randomized nature of the study. A small clinical study in healthy college students also shows that taking the same extract 100 mg daily for 2 months seems to reduce failed tests by 4.5% and improve average test scores by about 8% when compared with control (50928).
• Cognitive impairment. It is unclear if oral maritime pine bark extract improves cognitive function in patients with mild cognitive impairment. Details: An observational registry study in adults with mild cognitive impairment found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily for 8 weeks improves global cognitive function when compared to no supplementation. All patients in this study also received standard management of mild cognitive impairment, which included lifestyle modifications such as improved sleep, physical exercise, reduced sugar and salt intake, lowering cardiovascular risk factors, and avoiding use of stimulants or depressants (97406). However, the validity of these findings is limited by the unblinded, non-randomized nature of the study.
• Common cold. It is unclear if oral maritime pine bark extract is beneficial in the treatment of the common cold. Details: An observational registry study in otherwise healthy adults with a cold found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 50 mg twice daily, along with best management for colds, is associated with about one less day of a perceived cold when compared to "best management" alone. This standardized maritime pine bark extract is also linked to reduced use of over-the-counter products to manage symptoms in cases of colds lasting longer than 4 days (91962). However, the validity of these findings is limited by the unblinded, non-randomized nature of the study.
• Dental plaque. It is unclear if chewing gum containing maritime pine bark extract can reduce dental plaque. Details: A small clinical study shows that chewing a minimum of six pieces of gum containing a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 5 mg daily for 14 days reduces gingival bleeding by 55% and prevents an increase in gingival plaque when compared with a control sugar-free gum (50857).
• Diabetes. Small clinical studies suggest that oral maritime pine bark extract may modestly improve glycemic control in patients with type 2 diabetes. Details: Three small clinical studies in patients with type 2 diabetes show that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 50-200 mg daily for 3-12 weeks modestly decreases blood glucose and glycated hemoglobin (HbA1C) levels when compared with placebo (15521,15522,50908). Another small clinical trial in patients with type 2 diabetes and microalbuminuria shows that taking a different standardized maritime pine bark extract (Oligopin, DRT Group) 100 mg daily for 8 weeks reduces HbA1c by around 1%, but does not reduce fasting blood glucose, when compared with placebo (105781).
• Diabetic foot ulcers. It is unclear if oral or topical maritime pine bark extract is beneficial for diabetic foot ulcers. Details: A small clinical study in patients with diabetic foot ulcers shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily orally as well as applying the extract topically 100 mg daily heals ulcers in 89% of subjects compared with 61% of control subjects. Using oral or topical maritime pine bark extract alone seems to result in complete ulcer healing in about 85% of subjects (50896).
• Diabetic microangiopathy. It is unclear if oral maritime pine bark extract is beneficial in patients with diabetic microangiopathy. Details: A small, unblinded clinical study in patients with diabetic microangiopathy, symptoms of neuropathy, and edema in the absence of severe cardiovascular disease shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 50 mg three times daily for 4 weeks improves microcirculation (measured by laser Doppler flowmetry) and symptoms when compared with no treatment (15523).
• Diabetic retinopathy. It is unclear if oral maritime pine bark extract is beneficial in patients with diabetic retinopathy. Details: A small, unblinded clinical study in patients with retinopathy due to various causes, including diabetes, atherosclerosis, or central venous thrombosis, shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 50 mg three times daily for 2 months may slow or prevent further deterioration of retinal function when compared with no treatment (2536).
• Dry mouth. It is unclear if oral maritime pine bark extract is beneficial in patients with dry mouth. Details: Two small observational studies in otherwise healthy adults or patients with diabetes suggest that adding a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) for 2 weeks along with standard saliva supplements is associated with improvement in patient-reported mouth dryness, salivary flow, and the number of small mucosal breaks when compared with saliva supplements alone. One study dosed maritime pine bark extract 150 mg orally daily and the other used a spray formulation dosed 10 mg six times daily (103612,112714). However, the validity of these findings is limited by the unblinded, non-randomized nature of the studies.
• Dysmenorrhea. It is unclear if oral maritime pine bark extract is beneficial in patients with dysmenorrhea. Details: Two small clinical studies in patients with dysmenorrhea show that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 30-60 daily for up to 3 menstrual cycles reduces pain when compared to baseline (15424,50904). The validity of this finding is limited by the lack of a comparator group.
• Erectile dysfunction (ED). Small clinical studies suggest that oral maritime pine bark extract, taken alone or in combination with L-arginine, may modestly improve sexual function in patients with ED. Details: Several small clinical studies in adults with ED show that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) at a dose of 120 mg daily for 3 months, either alone (12012) or in combination with L-arginine (10416,32149,50924), might improve sexual function when compared with placebo or baseline measurements. It seems to take up to 3 months of treatment for significant improvement. Similarly, a meta-analysis of 2 small clinical studies in males with mild to moderate ED shows that taking maritime pine 80 mg with L- arginine daily for 1-6 months improves International Index of Erectile Dysfunction scores by 9 points when compared with control (112715). It is unclear if this effect is from maritime pine, L-arginine, or the combination.
• Exercise-induced muscle soreness. Oral maritime pine bark extract has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical study in non-professional athletes shows that taking a combination product (PycnoRacer, Kobayashi Pharmaceutical Company) containing maritime pine extract 15 mg, L-leucine 0.6 grams, L-arginine 0.3 grams, L-isoleucine 0.3 grams, and L-valine 0.3 grams four times daily for 3 weeks during training improves subjective scores for muscle pain and cramps when compared with water plus Gatorade (103613). It is unclear if these benefits are due to maritime pine, other ingredients, or the combination.
• Glaucoma. Oral maritime pine has only been evaluated in combination with other ingredients; its effects when used alone is unclear. Details: One small, unblinded clinical trial in Japanese patients with open-angle glaucoma shows that taking a specific product (Sante Glagenox, Saten Pharmaceutical Co. Ltd.) containing maritime pine extract 40 mg and bilberry fruit extract 90 mg daily for 4 weeks reduces intraocular pressure by 8.7% when compared to baseline (104192). The validity of this finding is limited by the lack of a comparator group.
• Heart failure. Oral maritime pine bark extract has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small observational study in patients with mild to moderate heart failure has found that taking a specific combination product (PycnoQ10, Natural Health Science Inc.) containing a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) and coenzyme Q10 for 12 weeks is associated with improved exercise capacity and heart function (44178). It is unclear if these findings are due to maritime pine, coenzyme Q10, or the combination.
• Hemorrhoids. It is unclear if oral or topical maritime pine bark extract is beneficial in patients with hemorrhoids. Details: A small clinical study in patients with acute hemorrhoidal episodes shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150-300 mg daily orally, alone or in combination with a cream containing 0.5% standardized maritime pine bark extract (Pycnogenol, Horphag Research) for 7 days, improves both quality of life and hemorrhoidal symptoms when compared with placebo tablets/cream (50912). Additionally, an observational registry study in postpartum adults with internal or external hemorrhoids found that taking this same extract of maritime pine bark 150 mg daily for 6 months, in conjunction with standard hemorrhoid care, is associated with improved symptoms, including thrombosis, pain, swelling, and bleeding, when compared to standard care alone (97416). However, the validity of these findings is limited by the unblinded, non-randomized nature of the study.
• Hypertension. It is unclear if oral maritime pine bark reduces blood pressure; the available research is conflicting. Details: A very small clinical study in patients with mild hypertension (systolic 140-159 mm Hg; diastolic 90-99 mm Hg) shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 200 mg daily for 8 weeks may modestly reduce systolic, but not diastolic, blood pressure when compared with placebo (10214). Another very small study in hypertensive patients treated with ramipril, taking this same standardized maritime pine bark extract 50 mg three times daily for 6 months, appears to further reduce diastolic, but not systolic, blood pressure (50913). Conflicting results have been reported with other maritime pine products. A small clinical study in adults with untreated, mild hypertension shows that taking a different standardized extract of maritime pine (Oligopin, DRT Group), 75 mg twice daily for 5 weeks, does not lower systolic or diastolic blood pressure when compared with placebo (97407). Also, a small clinical study in obese patients with prehypertension or hypertension shows that taking a different maritime pine bark extract (Toyo-FVG, Toyo Bio-Pharma) 200 mg daily for 12 weeks does not lower systolic or diastolic blood pressure when compared with placebo (50919). Results of meta-analyses are also contradictory. An analysis of 7 clinical trials using maritime pine bark extract 90-200 mg daily for 2-24 weeks shows no significant effect overall on systolic or diastolic blood pressure, mean arterial pressure, or pulse pressure (103609). However, an analysis of 12 trials using doses of 60-200 mg daily for 4-24 weeks shows a mean reduction of about 3 mmHg in systolic blood pressure, and about 2 mmHg in diastolic blood pressure. There was high heterogeneity between the studies, and the effect on diastolic blood pressure was only seen with a treatment duration of at least 12 weeks (103610).
• Idiopathic interstitial pneumonia. Oral maritime pine bark extract has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small observational registry study in males less than 65 years old with idiopathic interstitial pneumonia has found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 50 mg three times daily in combination with gotu kola (Centellicum; Horphag Research) 225 mg three times daily for 8 months is associated with a modest improvement in Karnofsky Performance Scale scores and a reduction in fatigue when compared with pirfenidone (108862). However, the validity of these findings is limited by the unblinded, non-randomized nature of the study.
• Irritable bowel syndrome (IBS). It is unclear if oral maritime pine bark extract is beneficial in patients with IBS. Details: An observational registry study in adults with idiopathic IBS found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily for 4 weeks, in conjunction with standard treatment, is associated with reduced abdominal pain, cramps, and the use of medical care and rescue medications when compared to standard treatment alone. In both groups, standard treatment included specific nutritional recommendations and Buscopan Compositum, hyoscine-N-butylbromide, or acetaminophen for pain relief (97402). However, the validity of these findings is limited by the unblinded, non-randomized nature of the study.
• Jet lag. It is unclear if oral maritime pine bark extract can prevent or treat jet leg. Details: An observational registry study found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily for up to 10 days, starting 3 days before a plane flight, is associated with reduced signs and symptoms of jet lag when compared to control (97437). Additionally, a small clinical study shows that taking this extract 50 mg three times daily for 7 days, starting 2 days before a plane flight, reduces jet lag symptoms and the average duration of symptoms by a little over 1 day when compared with placebo (97412).
• Leg cramps. It is unclear if oral maritime pine bark extract is beneficial for leg cramps. Details: A small clinical study in patients experiencing at least 4 episodes of leg cramps per week associated with athletic activity, venous insufficiency, or an unknown cause shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 200 mg daily for 4 weeks may decrease the incidence of leg cramps when compared to baseline (15524). The validity of this finding is limited by the lack of a comparator group.
• Male infertility. Although there has been interest in using oral maritime pine for male infertility, there is insufficient reliable information about the clinical effects of maritime pine for this purpose.
• Melasma. It is unclear if oral maritime pine bark extract is beneficial for melasma. Details: A small clinical study in females with melasma shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 75 mg twice daily for 60 days, along with topical application of sunscreen during the day and a triple cream containing hydroquinone, tretinoin, and fluocinolone at night, improves scores related to melasma severity and aesthetics, but not quality of life, when compared with placebo plus sunscreen and triple cream (105782).
• Meniere disease. It is unclear if oral maritime pine bark extract is beneficial in patients with Meniere disease. Details: Observational registry research in patients with Meniere disease found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily along with standard treatment is associated with a greater reduction in the severity of tinnitus and the number of work-days lost when compared with standard treatment alone. After 6 months of treatment, about 87% of patients taking maritime pine bark were asymptomatic, compared to about 35% of patients receiving standard treatment alone (97413). However, the validity of these findings is limited by the unblinded, non-randomized nature of the study.
• Menopausal symptoms. Small clinical studies suggest that oral maritime pine bark extract might improve some menopausal symptoms. Details: Several small clinical studies in patients with menopausal symptoms shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 60-200 mg daily for 2-6 months modestly reduces perimenopausal symptoms, including tiredness, headache, depression and anxiety, sleep disturbances, vaginal dryness, hot flashes, and loss of memory, when compared with placebo or control (14899,50927,50945).
• Metabolic syndrome. It is unclear if oral maritime pine bark extract is beneficial in patients with metabolic syndrome. Details: A small clinical study in patients with metabolic syndrome shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 50 mg three times daily for 6 months lowers triglyceride levels by 46 mg/dL, increases high-density lipoprotein (HDL) cholesterol levels by about 10 mg/dL, reduces fasting plasma glucose by 18 mg/dL, and lowers systolic and diastolic blood pressure by 7 mmHg and 5 mmHg, respectively, when compared to baseline. The validity of these findings is limited by the lack of statistical comparison to a control group. Taking the maritime pine bark extract was also associated with a reduction in the percentage of patients presenting with five risk factors of metabolic syndrome (91960).
• Oral mucositis. It is unclear if topical maritime pine bark extract is beneficial in children with chemotherapy-related oral mucositis. Details: A small clinical study in children 6-15 years of age with chemotherapy-related oral mucositis shows that application of a solution containing a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 1 mg/kg in three divided doses daily for one week promotes complete healing in 58% of patients and improved healing in 38% of patients. This improvement was significantly greater than treatment with glycerine solution and similar to treatment with vitamin E solution (91964).
• Osteopenia. It is unclear if maritime pine bark extract is beneficial in patients with osteopenia. Details: A small clinical study in postmenopausal adults with osteopenia shows that taking a standardized extract of maritime pine bark (Oligopin, DRT Group) 150 mg daily for 12 weeks improves markers of bone turnover when compared with placebo (105783). It is unknown if maritime pine bark extract improves bone mineral density or reduces the risk of fractures in patients with osteopenia.
• Parkinson disease. It is unclear if oral maritime pine bark extract is beneficial in patients with Parkinson disease. Details: Two small observational studies in adults with mild to moderate Parkinson disease suggest that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily for 4 or 8 weeks in conjunction with carbidopa/levodopa therapy is associated with a reduction in scores for tremor, bradykinesia, and rigidity when compared with carbidopa/levodopa therapy alone. Maritime pine is also associated with an increase in the Karnofsky Performance Status Scale score from approximately 75 (cares for self, unable to carry on normal activity or do active work) to approximately 85 (normal activity with effort, some signs or symptoms of disease), compared with little to no change from a score of around 75 in the control group (103614,112716).
• Pregnancy-related pain. It is unclear if oral maritime pine bark extract is beneficial for reducing pain during the third trimester of pregnancy. Details: A small clinical study in patients in the third trimester of pregnancy shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 30 mg daily modestly reduces lower back pain, hip joint pain, pelvic pain, and pain due to varicose veins or calf cramps when compared with a control group (15423).
• Psoriasis. It is unclear if oral maritime pine bark extract is beneficial in patients with psoriasis. Details: An observational registry study in adults with moderate to severe plaque psoriasis found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily for 12 weeks along with standard treatment is associated with improved quality of life, increased water and moisture content of the skin, reduced plaque severity and total affected body area, and reduced use of corticosteroids when compared with standard treatment alone (97417). However, the validity of these findings is limited by the unblinded, non-randomized nature of the study.
• Raynaud syndrome. It is unclear if oral maritime pine bark extract is beneficial in patients with Raynaud syndrome. Details: A small clinical study in females with mild, primary Raynaud syndrome shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 50 mg twice daily for 4 weeks decreases coldness, burning pain, paresthesias, skin color changes, and low temperature areas of the hands when compared with lifestyle changes alone. The lowest finger temperature increased by 30% in those taking this product, compared with 13% in those implementing lifestyle changes alone (103615).
• Restless legs syndrome (RLS). It is unclear if oral maritime pine is beneficial for RLS. Details: A small observational study in adults with RLS suggests that taking maritime pine bark extract (Pycnogenol, Horphag Research) 150 mg daily along with standard management (i.e., regular sleep, exercise, vitamin C, B vitamins, proper footwear, and instruction on diet and posture) improves self-reported symptoms associated with RLS when compared to baseline. Maritime pine bark may also be associated with less analgesic use compared with standard management alone (112717). However, the interpretation of these findings, other than analgesic use, is limited by lack of a statistical comparison to the other study group.
• Sarcopenia. It is unclear if oral maritime pine bark extract is beneficial in patients with sarcopenia. Details: Observational registry research in adults over 70 years of age with signs of muscle loss has found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily along with strength training for 2 months improves hand grip strength, walking distance, total weight lifted, number of steps climbed, and general fitness scores when compared with strength training alone (97404). However, the validity of these findings is limited by the unblinded, non-randomized nature of the study.
• Sexual dysfunction. Oral maritime pine bark extract has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical study in females with sexual dysfunction shows that taking a specific combination tablet (Lady Prelox, Horphag Research) containing a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 20 mg, L-arginine 200 mg, L-citrulline 200 mg, and a standardized rose hip extract (Rosvita) orally 50 mg daily for 8 weeks, in combination with a management program consisting of lifestyle, diet, exercise, and stress control changes, improves overall sexual function when compared with the management program alone (91963). Taking the same product in a dose of 2 tablets twice daily for 8 weeks, in addition to the lifestyle management program, improves vaginal dryness in pre- and post-menopausal patients when compared with lifestyle management alone (103611). The effect of maritime pine alone on sexual dysfunction is unclear.
• Sjogren syndrome. It is unclear if oral maritime pine bark extract is beneficial in patients with Sjogren syndrome. Details: A very small observational study in patients with Sjogren syndrome found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily in addition to standard therapy is associated with a reduction in dry eye, dry mouth, and the need for corticosteroids when compared with standard therapy alone (100360).
• Systemic lupus erythematosus (SLE). It is unclear if oral maritime pine bark extract is beneficial in patients with SLE. Details: A very small clinical study in adults with SLE shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 120 mg daily for 30 days, followed by 60 mg daily for 30 days, modestly reduces symptoms of SLE in some patients when compared with control (50851).
• Traumatic brain injury (TBI). It is unclear if oral maritime pine bark extract is beneficial in patients with TBI. Details: A clinical study in patients admitted to the intensive care unit with TBI shows that administering a standardized maritime pine bark extract (Oligopin, DRT Group) 50 mg three times daily with enteral nutrition for 10 days improves scores on the sequential organ failure assessment (SOFA) and APACHE II [Acute Physiology and Chronic Health Evaluation II], as well as nutritional status, when compared with placebo. At day 28, survival rate was 86% in the treatment group, compared to 71% in the placebo group; however, this difference was not statistically significant (108861).
• Urinary tract infections (UTIs). It is unclear if oral maritime pine bark extract is beneficial in patients with recurrent UTIs or interstitial cystitis. Details: An observational registry study in adults aged 30-40 years with a recent history of recurrent UTIs has found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily for 2 months is associated with a normal urinalysis in 92% of patients, compared with 68% of those who received no supplementation (108860). Another observational registry study in patients with recurrent UTIs or interstitial cystitis has found that taking this same dose for 2 months is associated with a normal urinalysis in 100% of patients, compared with 35% of patients who took oral cranberry extract 400 mg daily and 36% of those who received no treatment (108859). However, the validity of these findings is limited by the unblinded, non-randomized nature of these studies.
• Varicose veins. It is unclear if oral maritime pine bark extract is beneficial in patients with varicose veins. Details: Observational registry research in postpartum adults has found that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 50 mg daily for 6 months, in addition to using below-knee compression stockings, is associated with reduced edema, leg cramps, total number of varicose veins, and number of visible spider vein clusters when compared with compression stockings alone (97403). However, the validity of these findings is limited by the unblinded, non-randomized nature of the study.
• Venous thromboembolism (VTE). While some conflicting evidence exists, low-quality clinical research suggests that oral maritime pine bark extract might prevent superficial thrombosis during flights and reduce the incidence of post-thrombotic syndrome (PTS) in patients with a history of deep vein thrombosis (DVT). Details: Observational registry research has found that a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 150 mg daily for 10 days is not associated with reduced occurrence of DVT, a type of VTE, when compared with compression stockings or control (97437). However, an older clinical study in patients at moderate or high risk for thrombotic events shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 200 mg 2-3 hours before a flight seems to reduce superficial thrombosis, but not DVT risk, when compared with placebo (50874). Some observational research also has also found that taking standardized maritime pine bark extract (Pycnogenol, Horphag Research) is associated with reduced post-thrombotic syndrome (PTS) and recurrent DVT (100355). Also, some clinical research shows that taking standardized extract of maritime pine bark (Pycnogenol, Horphag Research) daily for one year, while wearing or not wearing compression stockings, reduces the incidence of PTS in patients with a single prior episode of DVT (50925). Maritime bark has also been studied in combination with other natural products. There is some evidence that taking a specific combination product (Flite Tabs, Aidan Products) before a flight and then again 6 hours later might decrease the risk of DVT during long-haul plane flights in high-risk patients. The product combines a blend of 150 mg of standardized extract of maritime pine bark (Pycnogenol, Horphag Research) plus nattokinase (12075).
• Wrinkled skin. It is unclear if oral maritime pine bark extract can reduce wrinkles or improve skin health in people with significant sun exposure. Details: A small crossover study in Chinese adults working outdoors shows that taking a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 50 mg twice daily for 12 weeks improves skin hydration and reduces transepidermal water loss and skin darkening when compared with placebo (105784). More evidence is needed to rate maritime pine for these uses.

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EFFECTIVE

• Vitamin C deficiency. Oral or intramuscular vitamin C is effective for preventing or treating vitamin C deficiency. Details: Administering vitamin C orally or intramuscularly prevents and treats vitamin C deficiency, including scurvy. Vitamin C administration can reverse complications of scurvy within 2 days to 3 weeks (4844). In newborns with transient tyrosinemia due to vitamin C deficiency, oral or intramuscular vitamin C can correct this condition (15).

POSSIBLY EFFECTIVE

• Anemia of chronic disease. Oral vitamin C seems to improve markers of anemia in patients on hemodialysis. Details: Meta-analyses of clinical research in hemodialysis patients with anemia shows that treatment with vitamin C 200-300 mg three times weekly for 3-6 months increases hemoglobin levels by approximately 0.9 grams/dL, increases transferrin saturation by about 8%, and decreases the required recombinant human erythropoietin dose by 17 U/kg weekly when compared with standard care (83447,83475).
• Atrial fibrillation. Oral and intravenous vitamin C seems to help prevent atrial fibrillation after cardiac surgeries. Details: Meta-analyses of clinical research show that taking vitamin C prior to and after cardiac surgery reduces the risk of postoperative atrial fibrillation by 27% to 53%. Most studies administered vitamin C at doses of 1-2 grams orally daily for 1-3 days prior to cardiac surgery, followed by 1-2 grams in two divided doses daily for 4-5 days after cardiac surgery. Some studies provided vitamin C intravenously at similar doses, but oral vitamin C seems to be more effective (91233,96703,96705). Despite these findings, a meta-analysis of clinical research conducted only in the U.S. does not support the benefit of vitamin C for reducing postoperative atrial fibrillation (96703). These differences may be related to lifestyle factors such as nutrition, as well as differences in hospital treatments. Vitamin C has also been studied in combination with eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) with evidence of benefit (90701).
• Bowel preparation. Powdered vitamin C is approved for use as part of a polyethylene glycol-based bowel preparation for colonoscopy. Details: Clinical research shows that treatment with 2 liters of oral solution containing polyethylene glycol (PEG) plus vitamin C achieves a similar quality of bowel cleansing as treatment with 4 liters of PEG when administered on the evening prior to colonoscopy or when administered in a split-dose regimen. Patients given 2 liters of PEG plus vitamin C solution also have better adherence and experience fewer adverse events, such as nausea, vomiting, or abdominal bloating, compared to patients treated with 4 liters of PEG solution without vitamin C (90413,90415,90420,90424,90428). This treatment also appears to be effective and tolerable in elderly patients aged 60-79 years, including those with poor bowel habits and a high number of comorbidities (108085). Other clinical research in older adults undergoing bowel preparation for colonoscopy also shows that taking 1 liter of PEG plus vitamin C (CleanViewAL, Taejoon Pharm) results in similar quality of bowel cleansing overall and per segment with similar tolerability and adverse effects as sodium picosulfate 170 mL plus magnesium citrate or oral sulfate solution alone (111297,112476). The most common PEG plus vitamin C preparation used in clinical research is MoviPrep (Norgine BV), which contains macrogol 3350 100 grams, sodium sulfate 7.5 grams, sodium chloride 2.7 grams, potassium chloride 1 gram, vitamin C 4.7 grams, and sodium ascorbate 5.9 grams per liter of solution (90413,90415,90424). In the U.S., MoviPrep is approved by the Food and Drug Administration (FDA) for bowel preparation prior to a colonoscopy.
• Cataracts. Dietary and supplemental intake of vitamin C may reduce the risk of developing cataracts. Details: Population research suggests that people with the highest total intake of vitamin C have about a 19% reduced risk of developing cataracts when compared with those with the lowest total intake, with the most benefit observed for nuclear cataracts (96711). Additionally, another observational study shows that higher supplemental intake of vitamin C over 10 years is associated with a 60% reduction in the incidence of nuclear and cortical cataracts (4208). Other population research suggests that individuals with the highest blood levels of vitamin C have a 33% lower odds of developing age-related cataract, but any benefit is limited to Asian populations (90944). An umbrella review of meta-analyses also shows that dietary intake of vitamin C is associated with a 27% lower odds of cataract development (112095). However, a prospective clinical study shows that a combination of vitamin C, vitamin E, and beta-carotene does not prevent age-related loss of vision from cataracts in well-nourished people with an average supplementation duration of 6.3 years (7304).
• Common cold. Oral high-dose vitamin C might modestly shorten and reduce cold symptoms; however, taking vitamin C prophylactically does not seem to prevent the development of a cold. Details: There is substantial controversy about the effectiveness of vitamin C for treating the common cold (1969,1989,7100,9835,9836). The majority of evidence shows that taking high doses of vitamin C orally might decrease the duration of cold symptoms by 1-1.5 days in some patients (1966,1967,1968,1987,6458,7102,9832,83487). However, other studies have found no effect with doses up to 3 grams daily (9833). A meta-analysis of clinical research in healthy children and adults shows that taking vitamin C 1-4 grams daily for one week to 5 months reduces cold severity by 13%, limits absences from daily activities, and improves the duration of severe symptoms, but does not reduce the duration of mild symptoms, when compared with placebo (113665). Vitamin C has also been investigated for preventing the common cold. A meta-analysis of clinical research suggests that vitamin C supplementation decreases the incidence of cold in individuals exposed to physical stress, but not in the general population (83487). Other research suggests vitamin C may be more effective for treating cold symptoms in children than in adults. Also, there may be a dose-dependent response; doses of at least 2 grams daily seem to work better than 1 gram doses (9834). Taking vitamin C supplements prophylactically does not decrease the risk of catching a cold (1966,1967,1968,1987,3042,6458,7101,9832). Dietary intake of vitamin C also does not seem to affect the risk of getting a cold (10780).
• Complex regional pain syndrome. Most research shows that taking oral vitamin C after a distal radius (i.e. wrist) fracture or surgery seems to reduce the risk of developing complex regional pain. However, it is unclear if oral vitamin C is beneficial in reducing the risk of complex regional pain in other orthopedic surgeries. Details: Although some research has found no benefit in patients with distal radius (i.e. wrist) fractures (90411,96702), most clinical research shows that taking vitamin C 500 mg daily, and possibly doses of up to 1500 mg daily, for 45-50 days beginning immediately after fracture can reduce the risk of developing complex regional pain syndrome (2045,16302,96700,96706). Reasons for discrepancies are unclear but might relate to differences in diagnostic criteria for complex regional pain syndrome (96702). Research in patients undergoing various orthopedic surgeries has also shown benefit with the use of vitamin C for the prevention of complex regional pain syndrome; however, some findings are conflicting. (90422,108076,115613). One meta-analysis of clinical research in patients undergoing ankle, foot, or wrist surgery shows that taking vitamin C 500-1000 mg for 42-50 days following surgery reduces the rate of complex regional pain syndrome, and may improve pain following ankle or foot surgery, when compared with placebo (108076). The validity of these findings is limited by the high heterogeneity of included trials. An additional meta-analysis of clinical research in patients undergoing a broader variety of orthopedic surgery types (i.e., ankle, foot, knee, shoulder, wrist) shows that taking vitamin C 500 to 1500 mg does not reduce the incidence of complex regional pain syndrome (115613). The reasons for these discrepant findings are unclear but may relate to the inclusion of a wide range of orthopedic surgeries.
• Exercise-induced respiratory infections. High-dose oral vitamin C seems to reduce the risk of respiratory infections associated with strenuous exercise. Details: Some preliminary clinical research suggests that prophylactic use of vitamin C in doses of 600 mg to 1 gram daily for 3-8 weeks before heavy physical exercise, such as a marathon, might prevent upper respiratory infections that sometimes follow heavy exercise (9831,83370). More recently, high doses of vitamin C have been studied. A large clinical study in army recruits undergoing basic military training shows that taking vitamin C 6 grams daily for one month reduces the odds of getting a cold by 20% when compared with placebo (102975).
• Hypercholesterolemia. Oral vitamin C seems to reduce lipid levels in patients with hypercholesterolemia. Details: A meta-analysis of clinical research in patients with hypercholesterolemia shows that taking vitamin C 500 mg daily for at least 4 weeks reduces low-density lipoprotein (LDL) cholesterol by about 8 mg/dL and reduces triglycerides by about 20 mg/dL when compared with control (83445).
• Hypertension. Oral vitamin C seems to modestly reduce blood pressure in patients with hypertension, but some evidence is conflicting. Details: Vitamin C seems to modestly reduce systolic blood pressure (SBP), without meaningful effects on diastolic blood pressure (DBP) (2044,9822,13162,83483,102974). A meta-analysis of 13 clinical trials in patients with hypertension, with or without other comorbidities, shows that taking a median dose of vitamin C 500 mg daily for 8 weeks reduces SBP but not DBP by about 5 mmHg. Some of the studies used vitamin C in combination with other supplements, such as vitamin E and magnesium. When studies assessing vitamin C alone were analyzed, the magnitude of reduction in SBP decreased (83483). A newer meta-analysis of small clinical studies in patients with essential hypertension shows that taking vitamin C 200 mg or more daily reduces SBP by about 4 mmHg and DBP by about 2 mmHg (102974). However, this newer analysis omitted numerous relevant studies and included studies with normotensive patients and those without an adequate control, limiting the validity of its findings. In contrast, a network meta-analysis of small, low-quality clinical studies comparing five different vitamins in adults with essential hypertension shows that vitamin C does not reduce SBP, DBP, mean 24-hour SBP, mean 24-hour DBP, or heart rate when compared with placebo and when indirectly compared with vitamin B2, vitamin D, vitamin E, and folic acid. However, the included studies were of low quality and high heterogeneity, particularly in dosing, limiting the validity of the results (113668).
• Laser skin resurfacing. Topical vitamin C seems to reduce erythema occurring after cosmetic laser skin resurfacing procedures intended to reduce scars and wrinkles. Details: There is some evidence that an aqueous formulation of topical vitamin C can decrease the degree and duration of erythema following cutaneous carbon dioxide laser resurfacing for scar and wrinkle removal (1959).
• Lead toxicity. Dietary vitamin C seems to lower concentrations of lead in the blood. Details: Observational research has found that consuming more vitamin C from dietary sources is associated with lower blood concentrations of lead. People who consumed at least 340 mg of vitamin C daily as part of the diet had lower blood lead levels than those who consumed less than 100 mg vitamin C daily (3097,3098,3099).
• Nitrate tolerance. Oral vitamin C might prevent nitrate tolerance in some patients. Details: Small clinical studies show that taking vitamin C orally seems to prevent the development of nitrate tolerance in patients taking sublingual nitroglycerin. There is some evidence that short-term vitamin C supplementation can prevent tolerance to the vasodilatory effects of nitrates (1441,1961).
• Postoperative pain. Oral or intravenous vitamin C might prevent acute postoperative pain following certain surgeries. It is unclear if vitamin C reduces chronic postoperative pain. Details: A meta-analysis of 7 small clinical studies in adults undergoing elective surgery shows that receiving perioperative vitamin C, either as 1 gram orally, 2-3 grams intravenously, or 50 mg/kg intravenously, modestly reduces acute pain and opioid requirements for up to 24 hours when compared with control (105457). Most surgeries were laparoscopic and included cholecystectomy, colectomy, hysterectomy; two non-laparoscopic surgeries included uvulopalatopharyngoplasty with tonsillectomy and major abdominal surgery (90418,99840,105457). A meta-analysis of clinical trials in adults undergoing noncardiac surgery (i.e., orthopedic, abdominal, gynecologic, kidney transplantation) shows that administering perioperative vitamin C, either orally or intravenously, reduces postoperative intravenous morphine requirements at 2, 24, and 48 hours after surgery and improves pain scores at 2, 6, and 24 hours after surgery when compared with placebo. The dose of vitamin C did not appear to impact outcomes. However, when only laparoscopic surgeries are included, perioperative vitamin C does not improve pain or morphine use when compared with placebo (108087). Use of vitamin C perioperatively has also been evaluated in other surgery types with generally similar outcomes. A moderate-sized clinical study in adults undergoing total hip arthroplasty shows that intravenous vitamin C 3 grams perioperatively reduces 24-hour post-operative morphine use and subjective pain scores when compared with placebo; however, these improvements do not appear to be clinically significant (115500). The validity of these results is limited by a short follow-up period. Additionally, a small observational study in adults undergoing surgery for wisdom tooth extraction shows that taking vitamin C 500 mg three times daily for 7 days in addition to standard treatment reduces pain 24, 48, and 72 hours after surgery when compared with control (113664). However, a moderate-sized clinical study in adults undergoing transurethral resection of a bladder tumor under general anesthesia shows that administering intravenous vitamin C 1 gram after induction of anesthesia reduces the incidence and severity of catheter-related bladder discomfort immediately after surgery and at 1 and 2 hours postoperatively, but not 6 hours, when compared with placebo. Further, vitamin C does not reduce postoperative pain scores or analgesic requirements when compared with placebo (111645). Vitamin C has also been evaluated for reducing chronic pain after surgery. Clinical research in patients undergoing surgery for foot or ankle trauma shows that taking vitamin C 500 mg orally twice daily postoperatively for 6 weeks reduces pain scores when compared with placebo at 2 weeks and 6 weeks. The mean total amount of diclofenac used for pain relief over the 6-week period is also reduced, from 5.7 grams with placebo to 3.4 grams with vitamin C (102131).
• Wrinkled skin. Topical vitamin C might reduce the appearance of existing wrinkles. Details: Topical preparations containing vitamin C seem to improve the appearance of wrinkled skin. Some evidence shows that vitamin C 3% applied for 12 weeks might reduce facial wrinkles (14008). A small clinical study shows that applying a dissolving microneedle patch containing vitamin C 5.6% every 4 days for 12 weeks to crow's feet on one side of the face reduces wrinkles when compared to control treatment applied on the other side of the face (98780). Other clinical research in females aged 30-60 years shows that applying an oil-soluble cream containing the vitamin C derivative tetra-isopalmitoyl ascorbic acid 1%, 2%, or 3% to the periorbital area twice daily for 8 weeks reduces visual wrinkle grading when compared with placebo. A dose analysis shows greater improvements in wrinkle parameters, average wrinkle depth, and mean depth with the lower concentration, while greater improvements in maximum roughness and maximum depth are observed with the higher concentration (108072). This study only included individuals defined as having Fitzpatrick skin type III or IV; it effects on other skin types is unclear. Preparations containing vitamin C in combination with other ingredients have also been investigated. A small low-quality trial in females with moderately photodamaged and hyperpigmented facial skin shows that applying a moisturizer with vitamin C 30%, vitamin E, and coenzyme Q10 once daily in the morning, along with applying retinol 0.5% once daily or once every other day for 12 weeks, seems to improve skin tone, photodamage, and wrinkles when compared to baseline (99085). In another small trial, a topical preparation containing vitamin C 10% as L-ascorbic acid along with acetyl tyrosine, zinc sulfate, sodium hyaluronate, and bioflavonoids (Cellex-C High Potency Serum) applied to photo-aged facial skin for 3 months improves fine and coarse wrinkling, yellowing and sallowness, roughness, and skin tone when compared with placebo (6155). It is unclear if the beneficial effects of these products are due to vitamin C, other ingredients, or the combination.

POSSIBLY INEFFECTIVE

• Acute bronchitis. Oral vitamin C doesn't seem to improve symptoms of acute bronchitis. Details: A clinical study in adults with acute bronchitis shows that taking vitamin C orally 500 mg on day 1, then 250 mg on days 2 through 5 (similar to an azithromycin regimen) doesn't seem to have any effect on quality of life or bronchitis duration when compared with azithromycin (9827).
• Asthma. Oral vitamin C doesn't seem to prevent asthma or improve lung function. Details: Although some observational research has found that some patients with asthma might have lower serum vitamin C levels (5873), other observational research found that increased dietary vitamin C intake is not associated with a reduced risk of asthma or improved lung function (15006,34567). In addition, clinical research shows that supplemental intake of vitamin C does not reduce asthma symptoms, improve lung function, or reduce the use of inhaled steroids in asthma patients (90409).
• Atherosclerosis. Oral vitamin C does not seem to reduce the progression of atherosclerosis. Details: A clinical study shows that taking a specific combination product containing slow-release vitamin C 250 mg and vitamin E 136 IU (CellaVie, Ferrosan A/S) twice daily modestly slows the 3-year progression of atherosclerosis of the carotid artery in males, but not females. This result persisted at a 6-year follow-up of this study (1918,10473). However, when this form of vitamin C is used alone, it does not slow the 3-year progression of atherosclerosis of the carotid artery (1918).
• Bladder cancer. Oral vitamin C does not reduce the risk of bladder cancer or mortality from bladder cancer. Details: Epidemiological research has found that supplemental vitamin C intake is not associated with mortality rate in patients with bladder cancer (9839). A secondary analysis of a large clinical trial, the Physicians' Health Study II, in healthy men aged at least 50 years also shows that taking vitamin C 500 mg daily alone or with vitamin E 400 IU daily for up to 10 years does not reduce the risk of developing bladder cancer or bladder cancer-related deaths when compared with placebo (90097).
• Cardiovascular disease (CVD). Oral vitamin C does not seem to be beneficial for either primary or secondary CVD prevention. Details: Vitamin C does not seem to be beneficial for primary prevention of CVD. Some population research has found that higher supplemental vitamin C or dietary vitamin C has been associated with a reduced risk of developing CVD (10358,14108,109779), while other observational research has found no benefit (34566,10358,14108). However, meta-analyses of clinical research in healthy patients show that vitamin C supplementation does not prevent CVD or coronary heart disease when compared with control (97308,104025). In 2004, the American Heart Association stated that current evidence does not justify use of antioxidants such as vitamin C for reducing the risk of CVD (12142). Evidence is also negative for secondary prevention in people with coronary heart disease. Population studies have found that higher serum vitamin C was associated with no effect or decreased CVD mortality from CVD (3910,5878). A meta-analysis of two large clinical trials shows that vitamin C supplementation does not reduce CVD events or CVD mortality when compared with control (97308).
• Colorectal cancer. Oral vitamin C does not seem to prevent colorectal cancer. Details: Population research has found that dietary vitamin C intake is not associated with a reduced risk of developing colon cancer. When total vitamin C intake from food and supplements is considered, there is a modest association (34600). However, most clinical trials show that supplemental vitamin C, alone or along with other antioxidants, does not reduce the risk of colorectal cancer development, colorectal cancer or adenoma recurrence, or colorectal cancer-related mortality (34580,34581,34594,90097,90089,92903).
• Fetal and premature infant mortality. Oral vitamin C does not seem to prevent neonatal death. Details: Meta-analyses of clinical research show that taking vitamin C alone or with other supplements does not reduce the risk of neonatal death (83472,96707).
• Fractures. Oral vitamin C does not seem to improve fracture healing. Details: Clinical research shows that taking vitamin C 500 mg daily for 50 days following an acute distal radial fracture does not improve physical function, symptoms, or healing rates when compared with placebo (90411).
• Helicobacter pylori. Oral vitamin C does not seem to improve eradication of H. pylori. Details: Most clinical research shows that treatment with vitamin C, alone or in combination with vitamin E, does not improve the eradication rate of H. pylori when taken with a standard eradication regimen when compared with the eradication regimen alone (83476,90094).
• Hereditary motor and sensory neuropathy. Oral vitamin C does not seem to improve neuropathy in these patients. Details: In a meta-analysis of five studies in patients with Charcot-Marie-Tooth disease type 1A, taking vitamin C 1-4 grams orally daily for 1 year did not improve neuropathy when compared with placebo (99084). Continuing vitamin C 4 grams daily for 2 years also does not improve neuropathy in these patients (90419).
• Interferon-related retinopathy. Oral vitamin C does not seem to improve retinopathy associated with interferon therapy. Details: A small clinical study in patients with chronic hepatitis C receiving interferon therapy shows that taking vitamin C 600 daily orally does not seem to reduce the risk of retinopathy from interferon therapy when compared with control (10355).
• Leukemia. Oral vitamin C does not seem to reduce the risk of leukemia or mortality from leukemia. Details: A large clinical trial in men aged at least 50 years shows that taking vitamin C 500 mg daily, alone or along with vitamin E 400 IU daily, for up to 10 years does not reduce the risk of developing leukemia or leukemia-related deaths when compared with placebo (90097).
• Low birth weight. Oral vitamin C does not seem to reduce the risk of infants being born with a low birth weight. Details: Meta-analyses of clinical research show that maternal use of oral vitamin C alone or with other supplements does not reduce the risk of giving birth to infants with low birth weight when compared with control (83450,83472).
• Lung cancer. Oral vitamin C does not seem to reduce the risk of lung cancer. Details: Two meta-analyses of clinical research suggest that taking vitamin C, alone or in combination with vitamin E, does not reduce the incidence of lung cancer or lung cancer-related mortality (34528,34632). Also, a clinical study in females shows that taking supplemental vitamin C 500 mg daily, with or without vitamin E and beta carotene, is associated with an INCREASED risk of lung cancer when compared with placebo (34580). However, another large epidemiological cancer screening trial with a mean follow-up of over 12 years suggests that moderate dietary intake of vitamin C around 500 mg daily is protective against lung cancer, but higher doses of vitamin C might increase the risk of lung cancer (112096).
• Melanoma. Oral vitamin C does not seem to reduce the risk of melanoma. Details: Clinical research shows that taking vitamin C 500 mg daily, alone or along with vitamin E 400 IU daily, for up to 10 years does not reduce the risk of developing melanoma or melanoma-related deaths when compared with placebo in men aged at least 50 years (90097).
• Miscarriage. Oral vitamin C does not seem to reduce the risk of miscarriage. Details: A meta-analysis of clinical research shows that taking vitamin C alone or with other supplements does not reduce the risk of miscarriage when compared with control (94820).
• Overall mortality. Oral vitamin C does not reduce overall mortality. Details: Although population research suggests that higher dietary intake and higher plasma vitamin C levels are associated with a reduced risk of mortality from all causes (3910,109779), vitamin C supplementation does not seem to affect overall mortality. Meta-analyses of clinical research show that taking vitamin C supplements does not reduce overall mortality when compared with control (34622,111641). Clinical studies of vitamin C used in combination with vitamin E, beta carotene, and/or selenium and zinc, also show no benefit for overall mortality (9817,14109).
• Pancreatic cancer. Oral vitamin C does not seem to prevent pancreatic cancer. However, it is unclear if intravenous vitamin C is beneficial for treatment of pancreatic cancer. Details: Observational research has found that increased dietary vitamin C intake is associated with up to a 30% reduced risk of pancreatic cancer (99083,99086). However, clinical research shows that supplemental vitamin C 500 mg daily does not reduce the risk of pancreatic cancer in females (34580). Also, taking vitamin C in combination with beta-carotene plus vitamin E does not reduce the risk of pancreatic cancer (12185,34581). While research suggests oral vitamin C may not prevent pancreatic cancer, intravenous vitamin C is being explored in the treatment of pancreatic cancer. A small, open-label clinical study in adults with stage IV pancreatic ductal adenocarcinoma shows that administration of intravenous vitamin C 75 grams three times weekly throughout each cycle of chemotherapy increases median overall survival and progression free survival by approximately 8 months and 2 months, respectively, when compared with chemotherapy alone (115499). The validity of these results is limited by potential overestimation of treatment effects, influenced by small sample size, differences in chemotherapy doses, and early study termination.
• Pre-eclampsia. Oral vitamin C does not seem to prevent pre-eclampsia. Details: Despite some early positive research in high-risk pregnancies, the majority of meta-analyses and clinical studies show that taking vitamin C alone or with vitamin E or other supplements does not reduce the risk of pre-eclampsia when compared with control. There is even some concern that vitamin C supplementation may increase the risk of gestational hypertension (3236,83450,83472,83474,96707).
• Preterm labor. Oral vitamin C does not seem to prevent preterm labor. Details: Meta-analyses of clinical research show that taking vitamin C alone or with other supplements does not reduce the risk of preterm labor when compared with control (83450,83472,96707).
• Prostate cancer. Oral vitamin C does not seem to prevent prostate cancer. However, it is unclear if intravenous vitamin C is beneficial for the treatment of prostate cancer. Details: A large-scale clinical study (The SU.VI.MAX study) shows that a combination of vitamin C 120 mg, vitamin E (alpha-tocopherol) 30 mg, beta-carotene 6 mg, selenium 100 mcg, and zinc 20 mg, taken daily for an average of 8 years, does not reduce the risk of prostate cancer overall. However, it might reduce the risk of prostate cancer in those who have normal PSA levels. It does not seem to be beneficial for reducing the risk of prostate cancer in patients with PSA levels above 3 mcg/L (14135). Another large scale study (Physician's Health Study II) shows that taking vitamin C 500 mg daily for an average of 8 years does not significantly reduce the risk of prostate cancer when compared with placebo (16708). Similarly, results from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial seem to show that supplemental or dietary intake of vitamin C does not reduce the risk of prostate cancer when compared to individuals not taking vitamin C (14124). While research suggests oral vitamin C may not prevent prostate cancer, intravenous vitamin C is being explored in the treatment of prostate cancer. A small clinical study in adults with metastatic castration-resistant prostate cancer shows that administration of intravenous vitamin C 1 gram/kg twice weekly in combination with docetaxel for up to 24 weeks does not reduce prostate-specific antigen (PSA) by 50% or more when compared with docetaxel alone (115611). This study may have been underpowered to show a difference between groups.
• Radiation dermatitis. Topical vitamin C does not seem to prevent radiation dermatitis in cancer patients. Details: A small clinical study shows that applying a 10% vitamin C solution does not appear to protect from radiation dermatitis when applied to the scalps of patients treated with radiation for intracranial tumors (789).
• Small for gestational age (SGA). Oral vitamin C does not seem to reduce SGA. Details: Meta-analyses of clinical research show that taking vitamin C alone or with other supplements does not reduce the risk of small for gestational age birth when compared with control (83450,83472).
• Stillbirth. Oral vitamin C does not seem to prevent stillbirth. Details: Meta-analyses of clinical research show that maternal use of vitamin C alone or with other supplements does not reduce the risk of stillbirth when compared with control (83472,96707).

LIKELY INEFFECTIVE

• Coronavirus disease 2019 (COVID-19). Oral vitamin C, even at high doses, does not seem to speed recovery from COVID-19 in non-hospitalized patients. Most studies show that oral or intravenous vitamin C given to patients hospitalized with COVID-19 does not improve organ function or survival, but the evidence is conflicting. It is unclear whether vitamin C is beneficial for long COVID. Details: A clinical study in adult outpatients with confirmed COVID-19 shows that taking oral vitamin C (ascorbic acid) 8000 mg in 2-3 divided doses daily, alone or with zinc gluconate 50 mg daily, for 10 days does not reduce symptom severity when compared with standard care (104450). The study was terminated prior to complete enrollment due to futility and apparent lack of effect from vitamin C and/or zinc supplementation. Limitations of this study include a lack of placebo control and blinding. Additionally, this study has been criticized for methodologic concerns (106624). Another small clinical trial in adult outpatients with confirmed COVID-19 shows that taking vitamin C 1000 mg daily for 14 days does not improve symptoms or quality of life when compared with placebo (109462). Vitamin C has also been evaluated in patients hospitalized with COVID-19. A very large analysis of two multinational clinical studies in critical and non-critical adults hospitalized with COVID-19 shows that administering intravenous vitamin C 50 mg/kg every 6 hours for 96 hours does not improve organ support-free days or survival and has a high probability of futility and worsened outcomes when compared with placebo (113666). Individual prospective and retrospective studies in critically ill patients hospitalized with COVID-19 in various countries have found that administering vitamin C, either enterally as 500-1000 mg daily or intravenously as 8-24 grams daily or 50 mg/kg daily, does not significantly reduce in-hospital or short-term mortality, hospital length of stay, or end-organ failure when compared with control groups receiving standard care alone. Additionally, all but one study found no change in the need for mechanical ventilation (105458,105465,106937,106938,108075,108079,108081). However, a meta-analysis and some small individual studies have found that vitamin C is modestly beneficial for patients hospitalized with COVID-19. A meta-analysis of 10 clinical trials and 9 observational studies in patients hospitalized with COVID-19 shows that receiving oral or intravenous vitamin C daily reduces the odds of in-hospital mortality by 41% when compared with control. When only clinical trials were considered, the odds of in-hospital mortality were decreased by 56%; however, this reduction was only identified in studies using vitamin C 10 grams daily or less. Conversely, supplementation with vitamin C increased the length of intensive care unit (ICU) stay by nearly 2 days and did not impact length of hospital stay or reduce the need for mechanical ventilation, liver injury, or cardiac injury (109955). Similarly, a meta-analysis of 8 clinical studies in primarily hospitalized patients with moderate to severe COVID-19 shows that vitamin C administered orally or intravenously decreases the risk of all-cause mortality by 16% when compared with control (114488). Additionally, a small study found a small improvement in survival when compared with standard care; however, the overall survival rate in this study was low (108075). Another clinical study in patients hospitalized in Turkey with COVID-19 shows that adding high-dose intravenous sodium ascorbate 50 mg/kg to a treatment regimen of hydroxychloroquine, azithromycin, and zinc may improve recovery time, with 57% and 39% of patients achieving total recovery at day 15 in the vitamin C and control groups, respectively (108071). However, the validity of this trial is limited due to unclear reporting. Vitamin C has also been evaluated in combination with other ingredients in patients with long COVID. Preliminary clinical research in adults with long COVID and persistent fatigue shows that taking a specific combination product containing vitamin C 500 mg and L-arginine 1.66 grams (Bioarginina C, Farmacetici Damor) for 28 days increases 6-minute walk test distance by 10% and reduces self-reported fatigue when compared with placebo (110390). However, it is unclear whether these effects are due to vitamin C, L-arginine, or the combination.
• Sepsis. Intravenous vitamin C, alone or in combination with thiamine and/or hydrocortisone, does not prevent organ failure, reduce intensive care or hospital length of stay, or reduce mortality in sepsis or septic shock. Details: Observational research suggests that patients with septic shock are more likely to have low plasma levels of vitamin C (100317). However, three randomized clinical trials in patients with sepsis or septic shock show no benefit with intravenous vitamin C, with or without thiamine, for improving organ function and preventing organ failure when compared with control treatment (102130,104027,114489). A small clinical study in patients with septic shock shows that intravenous vitamin C 50 or 150 mg/kg daily for 4 days does not improve organ dysfunction or failure rates, duration of hospital or intensive care unit (ICU) length of stay, duration of mechanical ventilation, or mortality rate when compared with placebo (114489). Another clinical study in patients with septic shock shows that administering an intravenous bolus of vitamin C 1000 mg followed by a continuous infusion of 250 mg/hour for 96 hours, starting within 24 hours of vasopressor initiation, does not improve 28-day or ICU mortality when compared with placebo. A subgroup analysis shows that the addition of corticosteroids does not affect outcomes in either group (108078). This study may have been inadequately powered to detect a difference between groups. Also, a larger clinical trial in adults with sepsis receiving vasopressor therapy in the ICU shows that intravenous administration of vitamin C 50 mg/kg every 6 hours for up to 4 days increases the risk of death or persistent organ dysfunction at day 28 by 14% to 21% when compared with placebo. There were no differences in mortality at 6 months (109459,111643). Vitamin C has also been frequently studied in patients with sepsis and septic shock in a specific combination regimen (HAT therapy) which includes intravenous vitamin C 1.5-2 grams with hydrocortisone 50 mg every 6 hours and thiamine 200 mg every 12 hours. While some retrospective research has found HAT therapy to be beneficial in sepsis (100315,102980), high quality, prospective clinical research has not confirmed these findings (105447,106620,109956). Several meta-analyses of randomized controlled trials and small clinical studies in patients with sepsis or septic shock show that intravenous vitamin C, either alone, as a component of HAT therapy, or in combination with thiamine, does not reduce short- or long-term mortality, ICU or hospital length of stay, kidney injury, or duration of mechanical ventilation, but modestly improves duration of vasopressor use and procalcitonin clearance, when compared with placebo or standard care. These analyses also show mixed results with respect to improvement in sequential organ failure assessment (SOFA) scores within 72 hours (105447,106620,106935,108073,109460,111298,111300,111301,111642,112479). Most studies included in the analyses administered HAT therapy for 2-10 days and compared it with normal saline control or with hydrocortisone alone (102129,102998,104027,104028,104032,105446). Although some subgroup analyses suggests that intravenous vitamin C alone in patients with sepsis may improve short-term mortality (106620,111298), other meta-analyses have not shown this benefit in subgroup analyses (111300). In addition, meta-analyses have identified significant publication bias (111298,111300). Long-term follow up from a study in patients with sepsis-induced respiratory and/or cardiovascular dysfunction shows that receiving HAT therapy does not improve cognitive, psychological, or functional status after 6 months and, for some domains, HAT therapy was worse when compared with placebo (111299). Studies evaluating intravenous vitamin C, either alone, as a component of HAT therapy, or in combination with thiamine, in mixed critically ill populations have also shown mixed findings. Four meta-analyses of randomized controlled trials and observational studies show that intravenous vitamin C does not have a significant effect on the length of hospital stay, mortality at 1 month, ICU mortality, use of invasive ventilation, use of renal replacement therapy, organ function, or incidence of kidney injury when compared with placebo or standard care. The meta-analyses reach conflicting conclusions on whether intravenous vitamin C reduces the risk of in-hospital mortality, 30-day mortality, and the duration of ICU stay. When only data from low risk-of-bias clinical trials are considered, the effects of intravenous vitamin C on mortality at any point are no longer significant (106933,106934,109957,113663). However, a subgroup analysis in one of these analyses suggests that intravenous vitamin C as monotherapy, or in doses of at least 10 grams daily, may improve overall mortality (106934). Vitamin C also does not appear to benefit complications from sepsis, such as vasoplegic shock. A small clinical study in adults in the ICU with vasoplegic shock mostly secondary to sepsis and requiring moderate vasopressor support shows that administering intravenous vitamin C as sodium ascorbate 1.5 grams every 6 hours for 5 days or until cessation of vasoactive therapy does not reduce the duration of vasopressors, vasopressor dose, hospital or ICU length of stay, or mortality outcomes when compared with placebo (112475).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Atrophic acne scars. It is unclear if applying topical vitamin C after microblading improves atrophic acne scars. Details: A clinical study in adults with mild to severe atrophic acne scarring shows that applying a serum containing vitamin C 17% to the face after a once-monthly home microblade treatment for 4 months improves the appearance of acne scars at month 5 when compared with baseline (108086). Although this study enrolled a control group that used topical insulin in place of vitamin C, no between-group statistical comparisons were conducted, limiting the validity of this study.
• Age-related macular degeneration (AMD). It is unclear if dietary vitamin C or oral vitamin C taken in combination with other ingredients prevents AMD. Details: An umbrella review of meta-analyses shows that increased dietary intake of vitamin C is associated with 21% higher odds of developing AMD (112095). A population study suggests that vitamin C intake is associated with increased odds of developing age-related maculopathy (9823). However, other population studies have found no association between dietary or supplemental vitamin C intake and the risk of developing AMD (14007,14257). When taken in combination with other ingredients, most clinical and population research shows that taking vitamin C 500 mg along with other antioxidants such as vitamin E 400 IU, beta-carotene 15 mg, and/or elemental zinc 80 mg reduces the risk of visual acuity loss by 23% to 27%, progression to advanced AMD at 5 years by 25% to 32%, and AMD overall (7303,7304,11326,14257,90069). The antioxidant plus zinc combination seems to reduce the risk of progression to advanced AMD in these patients more than taking the antioxidants without zinc (7303,90069). More evidence is needed to determine what role, if any, vitamin C intake has on the risk of developing AMD.
• Aging skin. Topical vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Clinical research in females aged 30-65 years shows that applying a specific liquid (Antioxidant and Collagen Booster Serum, Max Biocare Pty Ltd.) containing vitamin C 20%, red raspberry leaf cell culture extract 0.0005%, and vitamin E 1% to the face nightly for 8 weeks, in addition to regular facial skin products, improves skin color, elasticity, radiance, smoothness, and appearance of wrinkles when compared with regular facial skin products alone (102355).
• Albuminuria. Oral vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical study shows that taking vitamin C 1250 mg plus vitamin E 680 IU daily for 4 weeks can reduce the excretion of albumin by about 19% when compared with placebo in patients with type 2 diabetes (10434).
• Allergic rhinitis (hay fever). It is unclear if oral vitamin C is beneficial in patients with hay fever. Details: Epidemiological research has found that higher vitamin C plasma levels are not associated with a decreased risk of allergic rhinitis (15200). However, clinical research shows that some forms of vitamin C might help. In one small clinical study, intranasal vitamin C administered three times daily for 2 weeks reduces nasal secretions, nasal blockage, and edema in up to 74% of patients with perennial allergic rhinitis (15201). Another small clinical study in patients with seasonal allergic rhinitis shows that taking a single oral dose of vitamin C 2 grams reduces bronchial responsiveness to histamine at one hour after ingestion (15202). However, in another small study in patients with seasonal allergic rhinitis taking vitamin C orally in doses up to 4 grams daily for 3 days does not appear to suppress cutaneous or nasal response to histamine when compared to placebo (15203).
• Alzheimer disease. It is unclear if dietary vitamin C helps to prevent this condition. Details: Most epidemiological research has found that dietary intake of vitamin C is associated with a 17% reduced risk of developing Alzheimer disease (4636,9824,10131,13165,90082).
• Amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease). It is unclear if oral vitamin C helps to prevent ALS. Details: Observational research has found that increased dietary or supplemental intake of vitamin C is not associated with risk of developing ALS (90412).
• Anthracycline cardiotoxicity. Although there is interest in using oral vitamin C for anthracycline-induced cardiac toxicity, there is insufficient reliable information about the clinical effects of vitamin C for this condition.
• Aspirin-associated gastric damage. It is unclear if oral vitamin C helps to prevent gastric damage caused by aspirin. Details: Some clinical research shows that vitamin C 480 mg might prevent gastric damage associated with taking aspirin 400 mg by decreasing blood loss and preventing decreased gastric blood flow (10357). However, a small clinical study in healthy patients shows that taking vitamin C 500 mg as ascorbic acid with aspirin 600 mg actually increases gastrointestinal permeability to a greater extent than either ingredient taken alone (98781).
• Athletic performance. It is unclear if oral vitamin C improves athletic performance. Details: Although some small preliminary clinical studies suggest that vitamin C might improve certain biomarkers during exercise (82922), a meta-analysis of small clinical trials in older and younger adults shows that taking vitamin C 500-1000 mg daily, with or without vitamin E, does not improve endurance, lean mass, or muscle strength when compared with placebo (102973). A more recent, small clinical study in recreationally trained males shows that taking vitamin C 1000 mg and vitamin E (as alpha-tocopherol) 235 mg daily for 10 weeks while participating in a resistance training program does not improve measures of muscle strength when compared with placebo (109959).
• Atopic disease. It is unclear if dietary vitamin C helps to prevent atopic disease. Details: Population research has found that higher intake of vitamin C is not associated with a reduced risk of eczema, wheeze, IgE-mediated food allergy, or allergic sensitization (90098).
• Attention deficit-hyperactivity disorder (ADHD). Small clinical studies suggest that high-dose oral vitamin C may not improve symptoms in patients with ADHD. Details: Some research suggests that taking megadose vitamins, including vitamin C, does not improve ADHD symptoms (9957,9958,9959). However, other preliminary clinical research shows that taking 25 mg of vitamin C in combination with flaxseed oil providing alpha-linolenic acid 200 mg twice daily might improve measures of attention, impulsivity, restlessness, and self-control in children with ADHD when compared with baseline (14443). It is not clear if these effects are due to vitamin C, flaxseed oil, or the combination.
• Autism spectrum disorder. It is unclear if oral vitamin C is beneficial in patients with autism spectrum disorder. Details: One small clinical study shows that taking vitamin C 8 grams per 70 kg daily for 10 weeks modestly reduces autism symptom severity in school children when compared with placebo (83604).
• Bleeding. It is unclear if intravenous vitamin C can reduce bleeding after total abdominal hysterectomy. Details: A small clinical study in patients undergoing total abdominal hysterectomy shows that administration of intravenous vitamin C 1 gram the night before surgery and 1 gram during surgery reduces postoperative hemorrhage volume by around 40 mL when compared with placebo (109465).
• Brain tumor. It is unclear if oral vitamin C helps to prevent brain tumors. Details: Population research has found that vitamin C intake is associated with a 14% reduced risk of glioma. This risk reduction was more prevalent in America compared to other geographic locations (98782).
• Breast cancer. It is unclear if oral vitamin C helps to prevent breast cancer, its recurrence, or breast cancer-related mortality. Details: Some epidemiological research has found that dietary vitamin C is associated with a reduced risk of breast cancer (1444,10823,10824). However, other epidemiological research has found no association with dietary or supplemental vitamin C (10825,10826,108080). One cohort study found no association between breast cancer risk and total, dietary, or supplemental vitamin C, regardless of dose, treatment duration, or formulation (single ingredient or combination product). Additionally, hormone and menopausal status did not appear to impact risk. Vitamin C intake might be associated with a reduced risk in individuals with a family history of breast cancer in first-degree relatives (108080). In patients with breast cancer, supplemental or dietary intake of vitamin C might be associated with a reduced risk of mortality. A meta-analysis of results from population research shows that vitamin C supplementation following breast cancer diagnosis is associated with a 15% lower risk of breast cancer-related mortality when compared with no supplementation (90416). A large, observational study in patients with breast cancer undergoing radiation therapy has found that vitamin C supplementation does not reduce the risk of breast cancer recurrence over a period of 5 years when compared with no supplementation. Although the vitamin C group had notably less aggressive tumor types, recurrence-free survival was similar in both vitamin C and control groups (108082). The validity of these findings is limited due to unknown doses of vitamin C and the inclusion of various breast cancer subtypes.
• Burns. Small studies suggest that intravenous vitamin C may modestly improve symptoms in patients with severe burns. Details: A small clinical study in patients with severe burns shows that administering vitamin C intravenously (IV) 66 mg/kg hourly over 24 hours, as part of fluid resuscitation using lactated ringer solution, reduces wound edema and the volume of fluid needed when compared with fluid resuscitation alone (83145). A retrospective review of adults hospitalized with severe burns has found that those who receive a continuous IV infusion of at least 10 grams of vitamin C within 2 days of admission have an in-hospital mortality rate of 46%, compared with 58% for those who do not receive vitamin C (102128).
• Cancer. It is unclear if oral or intravenous vitamin C helps to prevent cancer or cancer-related mortality. Details: Some population research has found that DIETARY intake of vitamin C is linked with a lower risk of cancer and cancer-related mortality (3910,5878,10819,109779). However, clinical research shows that taking vitamin C SUPPLEMENTS does not reduce the risk for cancer (10819,14109,34580,90097). In people with cancer, although some clinical research has shown that taking high-dose vitamin C supplements can improve survival rates (9809,96704), other clinical research has not shown this benefit (4842,4843). In 2003, the US Food and Drug Administration (FDA) determined that it would allow a qualified health claim stating that some scientific evidence suggests that antioxidant vitamins, such as vitamin C, may reduce the risk of certain forms of cancer. However, the FDA has determined that there is little scientific evidence supporting this claim (102334). Preliminary clinical research has also evaluated vitamin C supplements in patients with cancer. High-dose oral vitamin C, 10 grams daily, in patients with advanced cancer does not seem to improve survival or decrease disease progression (4842,4843,106617). However, preliminary clinical research suggests high doses of vitamin C, given intravenously, might have a beneficial effect on some outcomes, including survival rate in some patients with cancer (9809,96704,106617). However, there is no benefit to other patients studied in the case reports and this has not been tested in well-designed clinical trials (9809,96704).
• Cardiac arrest. It is unclear if intravenous vitamin C is beneficial for patients after cardiac arrest. Details: A small clinical study conducted in Slovenia in adult survivors of out-of-hospital cardiac arrest shows that administering intravenous vitamin C 1.5 grams every 12 hours for 8 consecutive doses, with the first dose administered within 6 hours of resuscitation, in addition to standard care protects against arrhythmias and reduces the length of intensive care unit (ICU) stay when compared with placebo and standard care. However, intravenous vitamin C does not appear to protect against neurological or myocardial injury, reduce the need for mechanical ventilation, reduce the duration of hospital stay, or increase survival when compared with placebo (113667).
• Carpal tunnel syndrome. Vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A clinical study in adults with mild to moderate carpal tunnel syndrome shows that taking a combination product containing vitamins C, E, B1, B2, B6, and B12, alpha-lipoic acid, acetyl-L-carnitine, phosphatidylserine, and turmeric twice daily for 60 days reduces symptom severity and pain but does not improve measures of hand and wrist function when compared with control (111702). The validity of these effects is limited by a lack of blinding. The study may also be inadequately powered to detect a difference between groups. Additionally, it is unclear if the effects are due to vitamin C, other ingredients, or the combination.
• Cervical cancer. It is unclear if oral vitamin C helps to prevent cervical cancer. Details: Observational research has found that higher vitamin C intake is associated with a 33% to 42% reduced odds of cervical neoplasm. Increasing vitamin C intake by 50 mg daily is associated with an 8% reduced odds of cervical neoplasm (34609,98771).
• Child growth. Some clinical research in pregnant smokers suggests that taking vitamin C during pregnancy may improve pulmonary function in the offspring from birth to 6 years of age. Details: A meta-analysis of 4 data sets from one large clinical study in pregnant adults who smoke at least one cigarette daily shows that taking supplemental vitamin C 500 mg daily during pregnancy reduces lower airway resistance and improves lung capacity of the offspring at 0, 3, 12, and 60 months of age, but does not improve airway obstruction, when compared with control (113670). Additionally, one of the clinical studies included the meta-analysis shows that taking vitamin C during pregnancy lowers the occurrence of wheezing in offspring at 4-6 years of age (114496,114497).
• Chronic fatigue syndrome (CFS). Although there is interest in using oral vitamin C for CFS, there is insufficient reliable information about the clinical effects of vitamin C for this condition.
• Colistin-induced nephrotoxicity. It is unclear if intravenous vitamin C helps to prevent nephrotoxicity from colistin. Details: A small clinical study shows that intravenous administration of vitamin C 2 grams every 12 hours along with colistin for around 9-10 days does not prevent nephrotoxicity when compared with colistin therapy alone (99839). However, this study was limited by a lack of statistical power to detect differences between the study groups.
• Contrast induced nephropathy. It is unclear if oral vitamin C helps to prevent contrast-induced nephropathy (CIN). Details: Some clinical research shows that taking vitamin C before and after coronary angiography reduces the risk of developing CIN by 33% to 55% when compared with placebo in patients with renal dysfunction (12234,90421). However, other clinical evidence published since 2012 suggests that vitamin C given orally and/or intravenously before and after angiography does not reduce the risk of CIN compared with control in high-risk patients with chronic renal insufficiency or diabetes (91232,91236,90410,90425). Reasons for the discrepancies are not entirely clear. However, it is possible that the lack of significant benefit from vitamin C in the latter studies results from the fact that incidences of CIN have become less common than in the past due to avoidance of dehydration, use of smaller catheters, and use of contrast agents with reduced nephrotoxicity (90429).
• Coronary artery bypass graft (CABG) surgery. It is unclear if intravenous vitamin C helps to improve patient outcomes after CABG surgery. Details: A small clinical study shows that giving vitamin C 5 grams intravenously (IV) before anesthesia induction and 5 grams in the cardioplegia solution used during surgery shortens the length of stay in the intensive care unit (ICU) by about 8 hours (102127). However, some limited research suggests that IV vitamin C does not resolve cardiac surgery complications. A small clinical study in patients with vasoplegia after receiving CABG and other cardiac surgeries shows that receiving IV vitamin C 1.5 grams every 6 hours after being admitted to the ICU does not improve vasoplegia when compared with control (102981).
• Delirium. Oral vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Observational research in adults with septic shock has found that receiving intravenous thiamine 400 mg daily with vitamin C 6 grams daily, both in divided doses, is not associated with reduced delirium when compared with control (103001).
• Dental plaque. It is unclear if vitamin C in a chewing gum helps to reduce dental plaque formation. Details: A small clinical study in patients with calculus shows that chewing 10 pieces of gum, each containing 60 mg of vitamin C, daily for 3 months reduces the formation of dental calculus, visible plaque, and the number of bleeding sites when compared not chewing gum (83303). The validity of this finding is limited by a lack of placebo group.
• Depression. It is unclear if oral vitamin C is beneficial for the treatment or prevention of depression. Details: A small clinical study in children and adolescents shows that taking vitamin C 500 mg orally twice daily in combination with fluoxetine 10-20 mg daily for 6 months reduces most symptoms of major depressive disorder when compared with taking fluoxetine alone (90404). However, a small clinical study in adults shows that taking vitamin C up to 1000 mg daily for 2 months does not improve the response rate or decrease symptoms of depression in adults also taking citalopram when compared with citalopram alone (96708). Reasons for these conflicting results may relate to the age of the patients, study duration, or differences in antidepressant medication being taken. One clinical guideline also provisionally recommends against the use of oral vitamin C to treat patients with depression based on low-quality evidence (110318). Some research has also evaluated vitamin C intake for the prevention of depression. A secondary analysis of pre- and peri-menopausal adults enrolled in the Study of Women's Health Across the Nation (SWAN) program suggests that vitamin C intake is inversely associated with depressive symptoms. This association persisted regardless of age, race, physical activity, body mass index, antidepressant use or menopausal status (108083). The validity of these findings is limited due to the secondary nature of this study; additionally, follow-up time is unclear.
• Diabetes. It is unclear if oral vitamin C prevents diabetes. Some low-quality research suggests that vitamin C might improve glycemic control in patients with diabetes. Details: Population research has not found a link between dietary vitamin C and the risk of developing type 2 diabetes (14004). However, low certainty clinical research has found some benefit of taking vitamin C supplements for glycemic control. Two meta-analyses of several small, heterogeneous clinical studies in patients with type 2 diabetes show that taking vitamin C 200-3000 mg daily for 2-48 weeks reduces fasting blood glucose by approximately 11 mg/dL (112478) and glycated hemoglobin (HbA1c) by an average of 0.5% when compared with placebo, standard treatment, or no treatment (105461,112478). Subgroup analyses suggest that durations of supplementation longer than 12 weeks show greater glycemic benefit, and although one meta-analysis suggests there is no dose-response relationship (105461), another meta-analysis suggests that doses of vitamin C 1000 mg and higher are most beneficial for improving glycemic indices (112478). Some research has evaluated the effects of vitamin C supplementation on the lipid profile in patients with diabetes, with mixed findings. One meta-analysis of 17 small clinical studies shows that taking vitamin C 200-3000 mg daily for 2 to 48 weeks improves levels of triglycerides and total cholesterol, but not low-density lipoprotein (LDL) or high-density lipoprotein (HDL) cholesterol. Subgroup analysis suggests that study durations of at least 12 weeks show greater benefit (106621). However, two other meta-analyses in patients with diabetes, one of 16 small heterogenous clinical studies and one of 11 small clinical studies, show no clinically important improvement in lipid levels after vitamin C supplementation (105461,105464).
• Dry mouth. Oral vitamin C has only been evaluated in combination with vitamin E; its effect when used alone is unclear. Details: A small clinical trial in patients receiving radiotherapy for head and neck cancer shows that taking vitamin E 100 IU and vitamin C 500 mg twice daily for an average of 3 months improves dry mouth when compared to baseline (99080). The validity of these results is limited by the lack of comparison with a control group.
• Endometrial cancer. Increased dietary vitamin C has been linked to reduced risk of endometrial cancer. Details: Population research has found that intake of vitamin C from dietary sources is associated with a slightly decreased risk of endometrial cancer when compared with control. However, this benefit is not observed when results from a prospective cohort study are assessed (34578).
• Endometriosis. Oral vitamin C has only been evaluated in combination with vitamin E; its effect when used alone is unclear. Details: A small clinical study in patients with endometriosis and pelvic pain shows that taking vitamin C 1000 mg and vitamin E 800 IU daily for 8 weeks improves dysmenorrhea, dyspareunia, and chronic pelvic pain scores when compared with placebo. Vitamin C and vitamin E supplementation also reduces some biochemical markers of oxidative stress when compared with placebo (106622). Additionally, a meta-analysis of 4 other, mostly small clinical studies in patients with endometriosis shows that taking vitamin C 1000 mg and vitamin E 800-1200 IU daily for 6-8 weeks reduces chronic pelvic pain and improves dysmenorrhea and dyspareunia when compared with placebo (114491).
• Endoscopy-associated adverse effects. It is unclear if a topical vitamin C spray reduces mucosal irritation in patients undergoing Lugol chromoendoscopy. Details: A small clinical trial in patients receiving a Lugol chromoendoscopy shows that spraying a vitamin C 2% solution after the application of the Lugol iodine 2% solution reduces the severity of mucosal irritation, heartburn, and pain when compared with using a normal saline spray after the Lugol iodine 2% solution (104030).
• Esophageal cancer. Oral vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Population research has found that higher dietary intake of vitamin C is associated with reduced odds of esophageal adenocarcinoma. A 50 gram increase in dietary vitamin C intake is associated with a 13% reduced odds of esophageal cancer (34551,98770). However, a meta-analysis of clinical research shows that taking a vitamin C supplement in combination with beta-carotene and vitamin E does not reduce the risk of esophageal cancer (34581).
• Exercise-induced asthma. Small clinical studies suggest that oral vitamin C may modestly improve symptoms in patients with exercise-induced asthma. Details: A meta-analysis of the available clinical research shows that vitamin C supplementation might reduce exercise-induced breathlessness when compared with placebo or control. However, the available research is of poor quality, and no clear conclusions can be drawn regarding its benefits for exercise-induced asthma (90409).
• Exercise-induced muscle damage. It is unclear if oral vitamin C is beneficial in exercise-induced muscle damage. Details: A small clinical study in healthy females shows that taking vitamin C 1000 mg before moderate intensity cycling does not prevent muscle damage when compared with placebo (99837). Another small clinical study in endurance-trained runners shows that taking vitamin C 1000 mg and vitamin E (as alpha-tocopherol) 235 mg 2 hours prior to an exercise protocol does not reduce delayed onset muscle soreness or improve other markers of exercise-induced muscle damage when compared with placebo (109961).
• Gallbladder disease. It is unclear if oral vitamin C reduces the risk of gallbladder disease. Details: Cross-sectional epidemiological evidence has found that vitamin C supplementation and increased vitamin C serum levels are associated with a decreased risk of developing gallbladder disease in females, but not males (5877).
• Gastric cancer. It is unclear if dietary or supplemental vitamin C reduces the risk of gastric cancer. Details: Most population research has not found an association between DIETARY intake of vitamin C and gastric cancer risk (9194,10822,10819,90083). Also, clinical research shows that taking vitamin C supplements in combination with other antioxidants does not reduce the risk of gastric cancer or precancerous gastric lesions (14447,34581,90085). However, some research suggests that it might be associated with a reduced risk for specific forms of gastric cancer (9838,90083). One clinical study shows that taking vitamin C orally 500 mg daily for 6 months after eradication of Helicobacter pylori infection decreases the incidence of precancerous changes in stomach tissue when compared with no treatment (10359). Also, other clinical research shows that taking vitamin C orally 1 gram daily helps promote the regression of precancerous gastric lesions in people at high risk for gastric cancer (2579). In 2009, the US Food and Drug Administration (FDA) determined that it would allow a qualified health claim stating that vitamin C supplements may reduce the risk of gastric cancer. However, the FDA has concluded that it is highly uncertain that vitamin C supplements actually reduce the risk of gastric cancer (102332).
• Gastritis. There is limited evidence on the oral use of vitamin C in omeprazole-induced corpus gastritis. Details: A small clinical study shows that taking vitamin C orally 1200 mg daily along with omeprazole decreases corpus gastritis associated with omeprazole therapy in patients with H. pylori infection (10360).
• Gout. It is unclear if oral vitamin C helps to prevent or manage gout. Details: Population research in men has found that taking vitamin C 500-1500 mg daily from the diet and/or supplements is associated with up to a 34% reduced risk of gout when compared with less than 250 mg daily (16755). Also, men who ingest over 500 mg of vitamin C daily from the diet and supplements have serum uric acid levels that are slightly lower than men who consume less than 90 mg daily (16820). However, taking supplemental vitamin C 500 mg daily for 8 weeks does not seem to lower serum uric acid levels in patients who already have gout (90423).
• Hearing loss. There is limited evidence on the intravenous use of vitamin C in idiopathic sudden sensorineural hearing loss. It is unclear if dietary vitamin C intake can affect the risk of hearing loss. Details: A small clinical study in patients with idiopathic sudden sensorineural hearing loss shows that receiving intravenous high-dose vitamin C 200 mg/kg daily in combination with steroid therapy for 10 days, followed by oral vitamin C 2000 mg daily for 30 days, increases recovery rate two-fold and modestly improves hearing threshold levels when compared with receiving steroid therapy only (90417). In addition, population research in females has found that high dietary intake of vitamin C is associated with a 22% increased risk of developing self-reported hearing loss over a 22-year period when compared with low intake (109807).
• Heart transplant complications. Oral vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical trial shows that a combination of vitamin C 500 mg and vitamin E 400 IU, taken twice daily for 1 year starting within the first 2 years after cardiac transplant, reduced the progression of vasculopathy as measured by intravascular ultrasonography (IVUS) when compared with placebo. This suggests that the combination may help slow the progression of CAV (82826).
• Hepatitis C. It is unclear if oral vitamin C is beneficial in patients with hepatitis C. Details: A small clinical study in patients with confirmed hepatitis C shows that taking vitamin C 1000 mg daily with conventional therapy (sofosbuvir plus daclatasvir) for 4 weeks improves serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, and albumin when compared with conventional therapy alone (109463).
• HIV/AIDS. Oral vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small, low-quality study in men with HIV shows that taking vitamin C 250 mg daily in combination with vitamin A, beta-carotene, vitamin E, selenium, and coenzyme Q10 does not improve viral load, although it seems to improve markers of oxidative stress when compared to baseline. However, a 1000 mg dose of vitamin C, as well as higher doses of the other antioxidants, do not seem to provide any additional effect (9830).
• HIV transmission. Oral vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A clinical study in HIV-positive mothers shows that taking vitamin B, vitamin C, and vitamin E daily during pregnancy and while breast-feeding for 20 weeks seems to reduce child mortality and HIV transmission through breast milk when compared with taking vitamin A (9801).
• Hyperphosphatemia. Intravenous vitamin C might be beneficial for reducing phosphate levels in patients with end-stage renal disease. Details: A small clinical study in hemodialysis patients with elevated phosphorus levels suggests that administering vitamin C 500 mg intravenously three times weekly for 8 weeks reduces phosphorus levels about seven-fold when compared with placebo (90414).
• Idiopathic interstitial pneumonia. Oral vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical study in patients with idiopathic pulmonary fibrosis, a form of idiopathic interstitial pneumonia, shows that taking a combination of vitamin C 250 mg every other day, vitamin D 50,000 IU daily, and vitamin E 200 IU daily for 12 weeks improves some, but not all, measures of lung function and reduces markers of inflammation and oxidative stress when compared to baseline (109464). The validity of these findings is limited by a lack of placebo control group.
• Infertility. It is unclear if oral vitamin C is beneficial in anovulatory females. Details: A very small clinical study suggests that taking vitamin C 400-1000 mg daily might improve fertility, resulting in ovulation and pregnancy in some anovulatory females, when compared to baseline (14018). The validity of these findings is limited by the small study size and lack of a comparator group. However, a very large observational study suggests that there is no association between dietary vitamin C intake and in-vitro fertilization (IVF) outcomes including good oocyte quality, embryo transfer success rates, clinical pregnancy rates, and successful term pregnancy rates in subfertile couples who are candidates for IVF (112097).
• Male infertility. It is unclear if oral or intravenous vitamin C is beneficial in males with infertility. Details: A meta-analysis of three small, low-quality clinical trials in males with infertility shows that taking vitamin C up to 1000 mg daily for up to 12 weeks can improve sperm count, motility, and vitality, but does not seem to increase semen volume or sperm concentration, when compared with control (109461). It is unclear if vitamin C can increase pregnancy rates, as these studies did not assess this outcome. A retrospective study in males with or without varicocele-related infertility has found that taking a specific combination product containing vitamin C 90 mg, zinc 10 mg, L-carnitine fumarate 1725 mg, acetyl-L-carnitine 500 mg, coenzyme Q10 20 mg, folic acid 0.2 mg, selenium 0.05 mg, and vitamin B12 0.015 mg (Proxeed Plus, Sigma-Tau) orally twice daily for 6 months improves sperm count, sperm concentration, and sperm motility when compared with baseline. Improvement in semen parameters were greatest in subjects with more severe varicoceles. The validity of this study is limited by the lack of a comparator group (111296).
• Mastalgia. Oral vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical trial in patients with mastalgia shows that taking a combination of vitamin C 100 mg, vitamin B12, and gamma-linolenic acid daily for 12 weeks does not improve the proportion of patients with minimal or no pain when compared with placebo (111059).
• Melasma. It is unclear if topical vitamin C is beneficial in patients with melasma. Details: A small clinical study in patients with bilateral symmetrically distributed facial melasma shows that applying 0.5 mL of vitamin C (Cosmotech, Alpha Medical Cosmotech) following dermapen microneedling every 2 weeks for 6 weeks is similarly effective to tranexamic acid for improving melasma severity and pigmented, but not vascular, findings on dermoscopic examination (106939). Additionally, a small clinical study in adults with melasma shows that applying 1 to 2 mL of 20% vitamin C solution following dermapen microneedling every 2 weeks for 8 weeks does not improve the degree of pigmentation when compared with topical metformin but does improve the degree of pigmentation when compared to baseline (115610).
• Nonalcoholic fatty liver disease (NAFLD). It is unclear if oral vitamin C is beneficial in patients with NAFLD. Details: A clinical study in patients with NAFLD shows that taking vitamin C 250 mg, 1000 mg, or 2000 mg daily for 12 weeks improves some biochemical markers of liver health and glucose metabolism when compared with baseline. However, the improvement from baseline was similar between groups (106942).
• Nonalcoholic steatohepatitis (NASH). Oral vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research suggests vitamin C in combination with vitamin E might improve hepatic fibrosis in patients with NASH. However, it does not seem to decrease liver inflammation (14005).
• Non-Hodgkin lymphoma. It is unclear if oral vitamin C reduces the risk of developing diffuse large B-cell lymphoma. Details: In one population study, higher dietary or supplemental intake of vitamin C was associated with a reduced risk of diffuse large B-cell lymphoma, a type of non-Hodgkin lymphoma, when compared with lower intake in postmenopausal adults (90945).
• Oral cancer. It is unclear if oral vitamin C reduces the risk of developing oral cancer. Details: Population research has found that higher dietary intake of vitamin C is associated with a reduced risk of oral cancer (10821). However, clinical research has not shown benefit with oral vitamin C supplements. A small clinical trial in Japanese adults with oral leukoplakia shows that taking vitamin C 500 mg and beta-carotene 10 mg daily for 12 months does not reduce the development of oral cancer over 5 years when compared with vitamin C 50 mg daily (91384).
• Oral leukoplakia. Oral vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical trial in Japanese adults with oral leukoplakia shows that taking vitamin C 500 mg and beta-carotene 10 mg daily for 12 months does not improve leukoplakia symptoms or reduce the development of oral cancer over 5 years when compared with vitamin C 50 mg daily (91384).
• Osteoarthritis. It is unclear if dietary vitamin C reduces the risk of developing osteoarthritis. Details: Observational research has found that increased vitamin C from dietary sources is associated with a reduced risk of cartilage loss and disease progression in people with osteoarthritis (5881).
• Osteoporosis. It is unclear if dietary vitamin C improves bone density or reduces fracture risk in patients at risk for osteoporosis. Details: Some cross-sectional observational research in postmenopausal patients without a history of smoking or estrogen use has found that higher serum vitamin C levels are associated with lower bone mineral density (9828). However, other observational research in a larger population of adults at risk for osteoporosis has found that higher dietary vitamin C intake is not associated with fracture risk (104415).
• Ovarian cancer. Dietary vitamin C might not affect the risk of ovarian cancer. Details: Epidemiological research has found that dietary vitamin C intake is not linked with ovarian cancer risk (9193,102977).
• Pancreatitis. It is unclear if intravenous vitamin C is beneficial in patients with acute pancreatitis. Details: A small meta-analysis of clinical studies in patients with acute pancreatitis shows that intravenous vitamin C does not improve the odds of developing organ failure when compared with placebo or no intervention. Intravenous vitamin C seems to reduce hospital stay, but not in-hospital mortality (106941).
• Parkinson disease. Dietary vitamin C might not affect the risk of developing this condition. Details: Observational research has found that moderate or high dietary intake of vitamin C is not associated with a reduced risk of Parkinson disease (83316).
• Periodontitis. Oral vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. It is also unclear if dietary vitamin C reduces the risk of periodontitis. Details: A small clinical study in patients with moderate or advanced periodontitis shows that taking a supplement containing vitamin C 100 mg, alpha-lipoic acid, coenzyme Q10, cranberry extract, grapeseed extract, selenium, vitamin E, and zinc twice daily for 8 weeks in addition to standard nonsurgical therapy does not improve periodontal indices including bleeding on probing, gingival recession, plaque index, or inflammation, among others, when compared with placebo (111708). It is unclear if these effects are due to vitamin C, other ingredients, or the combination. There is also interest in whether dietary vitamin C intake impacts the risk of periodontitis. Observational research in US adults has found that individuals with dietary intake of vitamin C in the third quartile, but not the second or fourth quartiles, have lower odds of periodontitis when compared with vitamin C intake in the lowest quartile. Furthermore, the investigators identified a non-linear relationship between vitamin C intake and periodontitis risk, suggesting that individuals with intakes either much lower or much higher than 158 mg daily are at increased risk of developing periodontitis (109958).
• Peripheral arterial disease (PAD). It is unclear if dietary vitamin C helps to reduce the risk of developing PAD. Details: In females, epidemiological evidence has found that dietary intake of vitamin C of 142 mg daily or greater is associated with a 36% reduced risk of PAD when compared with lower intake levels of less than 80 mg daily (10130).
• Physical performance. It is unclear if oral vitamin C helps to improve physical performance and muscle strength in older people. Details: Population research has found that higher intake of dietary vitamin C is associated with improved physical performance and muscle strength in elderly people (14006). In contrast, a small clinical study in elderly men undergoing strength training shows that taking vitamin C 1000 mg and vitamin E 258IU daily for 12 weeks does not increase strength, and might even attenuate increases in muscle mass, when compared with strength training alone (96701).
• Pneumonia. It is unclear if oral or intravenous vitamin C helps to prevent or treat pneumonia. Details: A meta-analysis of 6 clinical studies in adults with community-acquired pneumonia shows that oral or intravenous vitamin C does not reduce overall mortality, hospital or intensive care unit length of stay, or the risk of mechanical ventilation when compared with control (114490). The interpretation of these results is limited by significant heterogeneity of the included studies. An earlier meta-analysis of two small, low-quality clinical studies in children shows that vitamin C does not seem to reduce the risk of pneumonia when compared with a control (104033).
• Postoperative recovery. It is unclear if oral or intravenous vitamin C improves postoperative recovery. Details: Meta-analyses of clinical research show that oral or intravenous vitamin C can shorten the duration of hospitalization after cardiac surgery when compared with control (91233,96703). However, other research shows no decrease in intensive care unit (ICU) or hospital stay with vitamin C supplementation (96705), while another clinical study in patients undergoing cardiac surgery with extracorporeal circulation shows that intravenous vitamin C administered during surgery and 48 hours after surgery reduces ICU stay and re-admission rates, wound infection, and hospital mortality, but not length of hospital stay, when compared with control (114492). A meta-analysis of 37 clinical trials in adults undergoing low- to high-risk noncardiac surgery (i.e., orthopedic, abdominal, gynecologic, or kidney transplantation), shows that receiving perioperative vitamin C, either orally or intravenously, does not improve duration of hospitalization or overall mortality when compared with control (108087).
• Postoperative pulmonary complications. It is unclear if intravenous vitamin C improves postoperative pulmonary complications. Details: A large, single-blind clinical study in patients with recent cardiac surgery with extracorporeal circulation shows that parenteral administration of vitamin C 50 mg/kg intraoperatively and 50 mg/kg every 6 hours for the next 48 hours, followed by oral vitamin C 2000 mg daily until 1-week post-discharge, reduces the incidence of postoperative pulmonary complications (PPC) by 22% and improves PPC severity scores when compared with control. Specifically, vitamin C reduces the incidence of pneumothorax, pleural effusion, pneumonia, and re-intubation and may ameliorate lung damage as suggested by higher Horowitz index when compared with control (114492). A small clinical trial in patients undergoing low-risk cardiac surgery shows that receiving intravenous vitamin C 1 gram 10 minutes after anesthesia might slightly reduce the rate of postoperative pulmonary complications when compared with receiving a saline injection (104034).
• Postoperative swelling. It is unclear if vitamin C reduces postoperative swelling after dental surgery. Details: A small observational study in adults undergoing surgery for wisdom tooth extraction shows that taking vitamin C 500 mg three times daily for 7 days in addition to standard treatment reduces swelling 7 days after surgery when compared with control. However, vitamin C does not seem to reduce swelling 3 days after surgery when compared with control, suggesting that longer durations are needed for anti-inflammatory effects (113664).
• Premature rupture of membranes (PROM). Oral vitamin C seems to reduce the risk of PROM in some patients; however, the addition of oral vitamin E seems to negate any benefit. Details: A meta-analysis of clinical research shows that taking vitamin C alone decreases the risk of both term and preterm PROM by 45% and 34%, respectively, when compared with placebo or control (96707). Another meta-analysis of clinical research shows that taking vitamin C during pregnancy decreases the risk of PROM by 43% and preterm PROM by 33%, but does not decrease the risk of term PROM, when compared with a control. While vitamin C was studied in doses of 100, 500, and 1000 mg daily, the decreased risk of PROM was only observed in studies of 100 mg daily (114493). A moderate-sized clinical study in patients with a history of PROM shows that taking vitamin C 100 mg daily, starting at 14 weeks' gestation, increases the gestational age at recurrent PROM by around 1 week and increases the gestational age at birth by around 1.3 weeks when compared with placebo (109960). Additionally, a meta-analysis of observational studies suggests that vitamin C levels in the blood tend to be lower in patients with PROM, particularly preterm PROM (114493). Taking vitamin C in combination with vitamin E, however, does not seem to reduce the risk of term or preterm PROM; some research suggests that it might even increase the risk of non-preterm PROM (83472,96707). However, other research shows that taking vitamin C 1000 mg plus vitamin E 400 IU daily, beginning at 24 to 34 weeks gestation and continuing until delivery, may help increase the latency period until delivery by 5 days and increase gestational age at delivery by almost 1 week when compared with placebo in patients with preterm PROM (90078).
• Pressure ulcers. It is unclear if oral vitamin C, when used alone or in combination with other ingredients, can improve the healing of pressure ulcers. Details: A small clinical study in institutionalized patients with pressure ulcers shows that taking vitamin C 500 mg twice daily for 12 weeks does not improve wound closure or increase healing rates when compared with vitamin C 10 mg twice daily (83617). Oral vitamin C has also been evaluated in combination with other ingredients for the treatment of grade II-IV pressure ulcers. Two small clinical studies in hospitalized patients with pressure ulcers shows that administering an oral nutritional supplement enriched with vitamin C, L-arginine, and zinc improves ulcer healing when compared with a standard diet (31953,87173). Also, clinical research in patients living in long-term care facilities shows that taking an oral nutritional supplement enriched in protein, vitamin C, L-arginine, and zinc daily for 9 weeks reduces ulcer area and decreases oozing when compared to baseline (32045). The validity of this finding is limited by the lack of a comparator group.
• Radiation proctopathy. Oral vitamin C has only been evaluated in combination with vitamin E; its effect when used alone is unclear. Details: A small clinical study in patients with chronic radiation proctitis shows that vitamin C 500 mg plus vitamin E 400 IU three times daily might improve symptoms when compared with baseline (9825). The validity of these findings is limited by the lack of a comparator group.
• Renal cell carcinoma. It is unclear if increased dietary intake of vitamin C helps to reduce the risk of renal cell carcinoma. Details: Population research has found that increased dietary intake of vitamin C is associated with a 12% reduced risk of renal cell carcinoma (98779).
• Respiratory tract infections. It is unclear if oral vitamin C is beneficial for preventing respiratory tract infections or reducing the duration of these infections. Details: A meta-analysis of clinical research in children and adults shows that, when compared with placebo, oral vitamin C supplementation reduces the average number of symptomatic days per individual, but does not reduce the average symptom days per respiratory episode. Also, vitamin C intake does not reduce the incidence or severity of respiratory disease or improve recovery in hospitalized patients with respiratory tract infections (108077). The validity of this trial is limited by the high heterogeneity of included studies, which evaluated various vitamin C regimens, ranging from 100 mg to 8 grams daily, as preventive therapy or as an adjuvant to active treatment. A clinical study in children aged 3-10 years shows that taking vitamin C 50 mg in combination with a specific product (Lab4) containing Lactobacillus acidophilus, Bifidobacterium bifidum, and Bifidobacterium animalis subsp. lactis daily for 6 months reduces the incidence of cough and sore throat by 16% and 20%, respectively, when compared with placebo. However, it did not improve total symptoms, nasal congestion, nasal discharge, or sneezing. Also, aside from a 33% reduction in the average number of days with a sore throat, daily supplementation does not reduce the duration of individual symptoms or total symptoms (106943). It is unclear if these effects are due to vitamin C, the probiotics, or the combination.
• Restless legs syndrome (RLS). It is unclear if oral vitamin C helps to reduce symptoms of stress. Details: A small clinical study in hemodialysis patients with RLS shows that taking vitamin C 200 mg daily, alone or in combination with vitamin E 400 mg, for 8 weeks reduces the severity of RLS when compared with placebo (90093). More research is needed to determine if vitamin C is beneficial in treating RLS that is not associated with hemodialysis.
• Sunburn. Topical and oral vitamin C has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Taking vitamin C orally in combination with vitamin E seems to prevent ultraviolet (UV) radiation-induced erythema (sunburn) (4715,4716). Vitamin C in combination with high dose oral RRR-alpha-tocopherol (natural vitamin E) seems to protect against skin inflammation after exposure to UV radiation (4715). Also, applying topical vitamin C in combination with topical vitamin E and melatonin seems to provide modest photoprotective effects when used prior to UV exposure. However, it has no effect when used during or after UV exposure (4713,4714).
• Stress. It is unclear if oral vitamin C helps to reduce symptoms of stress. Details: A small clinical study in healthy adults shows that taking vitamin C 3000 mg daily for 14 days modestly reduces blood pressure and subjective stress response to psychological stress when compared with placebo (10353).
• Stroke. Observational research has found that although taking vitamin C supplements does not seem to be beneficial, eating more vitamin C-rich food is linked with reduced risk of stroke. Details: Lower plasma levels of vitamin C have been associated with increased stroke risk (90408). Additionally, population research has found that higher dietary intake of vitamin C is associated with a 8% to 19% reduction in stroke risk when compared to lower intake (90408,109779). This reduction appears to be dose-dependent, with each 100 mg/day increase in dietary vitamin C intake associated with about a 17% reduction (90408). However, taking vitamin C supplements has not been found to be associated with reduced stroke risk (1449,90408).
• Tetanus. It is unclear if intravenous vitamin C helps to reduce symptoms of tetanus. Details: A low quality clinical trial in children and young adults with tetanus shows that intravenous vitamin C 1 gram daily along with conventional treatment reduces fatality when compared to control (21539).
• Tooth extraction. It is unclear if oral vitamin C is beneficial for reducing pain or improving healing after tooth extraction. Details: A small clinical study in healthy patients aged 14-41 years who are undergoing bilateral premolar extraction shows that taking vitamin C 200 mg three times daily, beginning immediately after extraction and continued for 10 days, improves pain on days 1-3, and may reduce mesio-distal wound size between days 1 and 7, when compared with placebo, but not when compared with vitamin C 500 mg three times daily. A dose of 500 mg three times daily did not improve pain scores or extraction wound healing when compared with placebo (108084). The validity of this trial is limited by the short duration of treatment; additionally, this study did not report baseline vitamin C levels.
• Urinary tract infections (UTIs). Although there is interest in using oral vitamin C for UTIs, there is insufficient reliable information about the clinical effects of vitamin C for this condition.
• Vascular dementia. It is unclear if oral vitamin C reduces the risk of vascular dementia. Details: Population research has found that supplemental intake of vitamin C and vitamin E is associated with a reduced risk of vascular dementia in Japanese-American men (4636). However, when cases in which dementia was diagnosed prior to the study are excluded from data analysis, intake of vitamin C and vitamin E is not associated with a reduced risk of vascular dementia in these patients (9824).
• Wound healing. It is unclear if oral vitamin C improves the healing of chronic foot ulcers. It is also unclear if intravenous vitamin C improves healing of surgical wounds after total abdominal hysterectomy. Details: A very small clinical study in adults with chronic foot ulcers shows that taking slow-release vitamin C 500 mg daily for 8 weeks seems to result in a median of 100% ulcer healing, compared with a median of 14% ulcer healing in patients taking glucosamine 1000 mg daily (105456). This finding is limited due to the small and heterogeneous patient population, which included patients with diabetes, vascular disease, and/or vitamin C deficiency. Another small clinical study in patients undergoing total abdominal hysterectomy shows that administration of intravenous vitamin C 1 gram the night before surgery and 1 gram during surgery does not reduce the rate of surgical site infection or wound dehiscence when compared with placebo (109465). However, this study may not have been adequately powered to detect differences between groups. More evidence is needed to rate vitamin C for these uses.

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POSSIBLY SAFE ...when used orally and appropriately. A standardized extract of maritime pine bark (Pycnogenol, Horphag Research) has been safely used in doses of 50-450 mg daily for up to one year (2435,2451,2462,2554,2556,7693,10214,10416,12012,14899) (15424,15521,15522,15523,15524,100359,105782). The same extract has also been used with apparent safety in a dose of 800 mg daily for 16 days (103617). A different standardized extract of maritime pine bark (Oligopin, DRT Group) has been used with apparent safety in doses of up to 150 mg daily for up to 12 weeks (105781,105783). ...when applied topically as a cream or powder. A standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 0.5% cream has been used for up to 7 days (50912). Powder from a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) 100 mg has been applied to the skin daily for up to 6 weeks (50887,50896).

CHILDREN: POSSIBLY SAFE
when used orally and appropriately, short-term. A standardized extract of maritime pine bark (Pycnogenol, Horphag Research), administered in a dose of 1 mg/lb body weight daily, has been safely used in a clinical study of children aged 6-18 years for up to 3 months (13120).

PREGNANCY: POSSIBLY SAFE
when used orally during the third trimester of pregnancy. In one small clinical study, a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) has been used at a dose of 30 mg daily with apparent safety during the third trimester of pregnancy (15423). However, more evidence is needed; use cautiously or avoid using.

LACTATION:
There is insufficient reliable information available regarding the safety of maritime pine when used during lactation; avoid using.

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LIKELY SAFE ...when used orally, topically, intramuscularly, or intravenously and appropriately. Vitamin C is safe when taken orally in doses below the tolerable upper intake level (UL). Tell patients not to exceed the UL of 2000 mg daily (1959,4713,4714,4844). ...when used intravenously or intramuscularly and appropriately. Injectable vitamin C is an FDA-approved prescription product (15) and has been used with apparent safety in clinical trials up to 150 mg/kg daily for up to 4 days (114489) and up to 200 mg/kg daily for up to 2 days (114492).

POSSIBLY UNSAFE ...when used orally in excessive doses. Doses greater than the tolerable upper intake level (UL) of 2000 mg daily can significantly increase the risk of adverse effects such as osmotic diarrhea and gastrointestinal upset (4844).

CHILDREN: LIKELY SAFE
when used orally and appropriately (4844,10352,14443).

CHILDREN: POSSIBLY UNSAFE
when used orally in excessive amounts. Tell patients not to use doses above the tolerable upper intake level (UL) of 400 mg daily for children ages 1 to 3 years, 650 mg daily for children 4 to 8 years, 1200 mg daily for children 9 to 13 years, and 1800 mg daily for adolescents 14 to 18 years. Higher doses can cause osmotic diarrhea and gastrointestinal upset (4844).

PREGNANCY AND LACTATION: LIKELY SAFE
when used orally and appropriately (4844).

PREGNANCY AND LACTATION: POSSIBLY UNSAFE
when used orally in excessive doses. Tell patients over age 19 not to use doses exceeding the UL of 2000 mg daily when pregnant or breast-feeding and for those 14-18 years of age not to use doses exceeding 1800 mg daily when pregnant or breast-feeding. Higher doses can cause osmotic diarrhea and gastrointestinal upset. Large doses of vitamin C during pregnancy can also cause newborn scurvy (4844); avoid using.

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ANTICOAGULANT/ANTIPLATELET DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, maritime pine bark extract might increase the risk of bleeding when used with antiplatelet or anticoagulant drugs.  Details Clinical research suggests that maritime pine bark extract inhibits platelet aggregation (3283,50844,50942). However, the clinical significance of this effect is unclear.

ANTIDIABETES DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = B Theoretically, maritime pine bark extract might increase the risk of hypoglycemia when used with antidiabetes drugs.  Details One clinical study shows that maritime pine bark extract decreases blood sugar in patients with diabetes being treated with antidiabetes agents (15522). Monitor blood glucose levels closely. Dose adjustments might be necessary.

IMMUNOSUPPRESSANTS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, maritime pine bark extract might decrease the effectiveness of immunosuppressant therapy.  Details In vitro and animal research suggests that maritime pine bark extract has immunostimulant activity (2435,2636). This effect has not been reported in humans.

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ACETAMINOPHEN (Tylenol, others) Interaction Rating = Minor Be watchful with this combination. Severity = Insignificant •  Occurrence = Probable •  Level of Evidence = B High-dose vitamin C might slightly prolong the clearance of acetaminophen.  Details A small pharmacokinetic study in healthy volunteers shows that taking high-dose vitamin C (3 grams) 1.5 hours after taking acetaminophen 1 gram slightly increases the apparent half-life of acetaminophen from around 2.3 hours to 3.1 hours. Ascorbic acid competitively inhibits sulfate conjugation of acetaminophen. However, to compensate, elimination of acetaminophen glucuronide and unconjugated acetaminophen increases (6451). This effect is not likely to be clinically significant.

ALKYLATING AGENTS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, antioxidant effects of vitamin C might reduce the effectiveness of alkylating agents.  Details The use of antioxidants like vitamin C during chemotherapy is controversial. There is concern that antioxidants could reduce the activity of chemotherapy drugs that generate free radicals, such as cyclophosphamide, chlorambucil, carmustine, busulfan, and thiotepa (391). In contrast, some researchers theorize that antioxidants might make chemotherapy more effective by reducing oxidative stress that could interfere with apoptosis (cell death) of cancer cells (14012,14013). More evidence is needed to determine what effect, if any, antioxidants such as vitamin C have on chemotherapy.

ALUMINUM Interaction Rating = Moderate Be cautious with this combination. Severity = Mild •  Occurrence = Probable •  Level of Evidence = B Vitamin C can increase the amount of aluminum absorbed from aluminum compounds.  Details Research in animals and humans shows that vitamin C increases aluminum absorption, theoretically by chelating aluminum and keeping it in solution where it is available for absorption (10549,10550,10551,21556). In people with normal renal function, urinary excretion of aluminum will likely increase, making aluminum retention and toxicity unlikely (10549). Patients with renal failure who take aluminum-containing compounds such as phosphate binders should avoid vitamin C supplements in doses above the recommended dietary allowances.

ANTITUMOR ANTIBIOTICS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, the antioxidant effects of vitamin C might reduce the effectiveness of antitumor antibiotics.  Details The use of antioxidants like vitamin C during chemotherapy is controversial. There is concern that antioxidants could reduce the activity of chemotherapy drugs which generate free radicals, such as doxorubicin (391). In contrast, some researchers theorize that antioxidants might make chemotherapy more effective by reducing oxidative stress that could interfere with apoptosis (cell death) of cancer cells (14012,14013). More evidence is needed to determine what effects, if any, antioxidants such as vitamin C have on chemotherapy.

ASPIRIN Interaction Rating = Minor Be watchful with this combination. Severity = Insignificant •  Occurrence = Possible •  Level of Evidence = B Acidification of the urine by vitamin C might increase aspirin levels.  Details It has been suggested that acidification of the urine by vitamin C could increase reabsorption of salicylates by the renal tubules, and increase plasma salicylate levels (3046). However, short-term use of up to 6 grams daily of vitamin C does not seem to affect urinary pH or salicylate excretion (10588,10589), suggesting this interaction is not clinically significant.

CHOLINE MAGNESIUM TRISALICYLATE (Trilisate) Interaction Rating = Minor Be watchful with this combination. Severity = Insignificant •  Occurrence = Possible •  Level of Evidence = B Acidification of the urine by vitamin C might increase choline magnesium trisalicylate levels.  Details It has been suggested that acidification of the urine by vitamin C could increase reabsorption of salicylates by the renal tubules, and increase plasma salicylate levels (3046,4531). However, short-term use of up to 6 grams daily of vitamin C does not seem to affect urinary pH or salicylate excretion (10588,10589), suggesting this interaction probably is not clinically significant.

ESTROGENS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = B Vitamin C might increase blood levels of estrogens.  Details Increases in plasma estrogen levels of up to 55% occur under some circumstances when vitamin C is taken concurrently with oral contraceptives or hormone replacement therapy, including topical products (129,130,11161). It is suggested that vitamin C prevents oxidation of estrogen in the tissues, regenerates oxidized estrogen, and reduces sulfate conjugation of estrogen in the gut wall (129,11161). When tissue levels of vitamin C are high, these processes are already maximized and supplemental vitamin C does not have any effect on estrogen levels. Increases in plasma estrogen levels may occur when patients who are deficient in vitamin C take supplements (11161). Monitor these patients for estrogen-related side effects.

FLUPHENAZINE (Prolixin) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, vitamin C might decrease levels of fluphenazine.  Details In one patient there was a clinically significant decrease in fluphenazine levels when vitamin C (500 mg twice daily) was started (11017). The mechanism is not known, and there is no further data to confirm this interaction.

INDINAVIR (Crixivan) Interaction Rating = Moderate Be cautious with this combination. Severity = Mild •  Occurrence = Probable •  Level of Evidence = B Vitamin C can modestly reduce indinavir levels.  Details One pharmacokinetic study shows that taking vitamin C 1 gram orally once daily along with indinavir 800 mg orally three times daily reduces the area under the concentration-time curve of indinavir by 14%. The mechanism of this interaction is unknown, but it is unlikely to be clinically significant in most patients. The effect of higher doses of vitamin C on indinavir levels is unknown (11300,93578).

LEVOTHYROXINE (Synthroid, others) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = B Vitamin C can increase levothyroxine absorption.  Details Two clinical studies in adults with poorly controlled hypothyroidism show that swallowing levothyroxine with a glass of water containing vitamin C 500-1000 mg in solution reduces thyroid stimulating hormone (TSH) levels and increases thyroxine (T4) levels when compared with taking levothyroxine alone. This suggests that vitamin C increases the oral absorption of levothyroxine, possibly due to a reduction in pH (102978).

NIACIN Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = A Vitamin C might decrease the beneficial effects of niacin on high-density lipoprotein (HDL) cholesterol levels.  Details A combination of niacin and simvastatin (Zocor) effectively raises HDL cholesterol levels in patients with coronary disease and low HDL levels. Clinical research shows that taking a combination of antioxidants (vitamin C, vitamin E, beta-carotene, and selenium) along with niacin and simvastatin (Zocor) attenuates this rise in HDL, specifically the HDL-2 and apolipoprotein A1 fractions, by more than 50% in patients with coronary disease (7388,11537). It is not known whether this adverse effect is due to a single antioxidant such as vitamin C, or to the combination. It also is not known whether it will occur in other patient populations.

SALSALATE (Disalcid) Interaction Rating = Minor Be watchful with this combination. Severity = Insignificant •  Occurrence = Possible •  Level of Evidence = B Acidification of the urine by vitamin C might increase salsalate levels.  Details It has been suggested that acidification of the urine by vitamin C could increase reabsorption of salicylates by the renal tubules, and increase plasma salicylate levels (3046). However, short-term use of up to 6 grams/day vitamin C does not seem to affect urinary pH or salicylate excretion (10588,10589), suggesting this interaction probably is not clinically significant.

WARFARIN (Coumadin) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D High-dose vitamin C might reduce the levels and effectiveness of warfarin.  Details Vitamin C in high doses may cause diarrhea and possibly reduce warfarin absorption (11566). There are reports of two people who took up to 16 grams daily of vitamin C and had a reduction in prothrombin time (9804,9806). Lower doses of 5-10 grams daily can also reduce warfarin absorption. In many cases, this does not seem to be clinically significant (9805,9806,11566,11567). However, a case of warfarin resistance has been reported for a patient who took vitamin C 500 mg twice daily. Cessation of vitamin C supplementation resulted in a rapid increase in international normalized ratio (INR) (90942). Tell patients taking warfarin to avoid taking vitamin C in excessively high doses (greater than 10 grams daily). Lower doses may be safe, but the anticoagulation activity of warfarin should be monitored. Patients who are stabilized on warfarin while taking vitamin C should avoid adjusting vitamin C dosage to prevent the possibility of warfarin resistance.

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General ...Orally and topically, maritime pine bark extract seems to be well tolerated.
Most Common Adverse Effects:
Orally: Gastrointestinal complaints, dizziness, and vertigo.

Cardiovascular ...A single case of chest pain has been reported for a patient treated with a standardized extract of maritime pine bark (Pycnogenol, Horphag Research). However, the patient had a history of myocardial infarction (50905). Another patient taking the same maritime pine bark extract experienced acute decompensation of heart failure. The patient previously has stable coronary artery disease (50929). It is not clear if either of these adverse effects were directly related to maritime pine bark extract.

Gastrointestinal ...Orally, a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) may cause gastrointestinal problems (15521,15522,17300,50891,50942). Also, mouth ulcer and bad breath have been reported in a single trial (15521).

Neurologic/CNS ...Orally, a standardized extract of maritime pine bark (Pycnogenol, Horphag Research) may cause dizziness and severe vertigo (15521,15522,17300,50904,50933). Also, headache has been reported in a single trial (15521).

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General ...Orally, intravenously, and topically, vitamin C is well-tolerated.
Most Common Adverse Effects:
Orally: Abdominal cramps, esophagitis, heartburn, headache, osmotic diarrhea, nausea, vomiting. Kidney stones have been reported in those prone to kidney stones. Adverse effects are more likely to occur at doses above the tolerable upper intake level of 2 grams daily.
Topically: Irritation and tingling.
Serious Adverse Effects (Rare):
Orally: There have been rare case reports of carotid inner wall thickening after large doses of vitamin C.
Intravenously: There have been case reports of hyperoxalosis and oxalate nephropathy following high-dose infusions of vitamin C.

Cardiovascular ...Evidence from population research has found that high doses of supplemental vitamin C might not be safe for some people. In postmenopausal adults with diabetes, supplemental vitamin C intake in doses greater than 300 mg per day is associated with increased risk of cardiovascular mortality. However, dietary intake of vitamin C is not associated with this risk. Also, vitamin C intake is not associated with an increased risk of cardiovascular mortality in patients without diabetes (12498).
Oral supplementation with vitamin C has also been associated with an increased rate of carotid inner wall thickening in men. There is preliminary evidence that supplemental intake of vitamin C 500 mg daily for 18 months can cause a 2.5-fold increased rate of carotid inner wall thickening in non-smoking men and a 5-fold increased rate in men who smoked. The men in this study were 40-60 years old (1355). This effect was not associated with vitamin C from dietary sources (1355).
There is also some concern that vitamin C may increase the risk of hypertension in some patients. A meta-analysis of clinical research suggests that, in pregnant patients at risk of pre-eclampsia, oral intake of vitamin C along with vitamin E increases the risk of gestational hypertension (83450). Other clinical research shows that oral intake of vitamin C along with grape seed polyphenols can increase both systolic and diastolic blood pressure in hypertensive patients (13162). Three cases of transient hypotension and tachycardia during intravenous administration of vitamin C have also been reported (114490).

Dental ...Orally, vitamin C, particularly chewable tablets, has been associated with dental erosion (83484).

Dermatologic ...Topically, vitamin C might cause tingling or irritation at the site of application (6166). A liquid containing vitamin C 20%, red raspberry leaf cell culture extract 0.0005%, and vitamin E 1% (Antioxidant and Collagen Booster Serum, Max Biocare Pty Ltd.) has been reported to cause mild tingling and skin tightness (102355). It is unclear if these effects are due to vitamin C, the other ingredients, or the combination.

Gastrointestinal ...Orally, the adverse effects of vitamin C are dose-related and include nausea, vomiting, esophagitis, heartburn, abdominal cramps, gastrointestinal obstruction, and diarrhea. Doses greater than the tolerable upper intake level (UL) of 2000 mg per day can increase the risk of adverse effects such as osmotic diarrhea and severe gastrointestinal upset (3042,4844,96707,104450,114493,114490). Mineral forms of vitamin C, such as calcium ascorbate (Ester-C), seem to cause fewer gastrointestinal adverse effects than regular vitamin C (83358). In a case report, high dose intravenous vitamin C was associated with increased thirst (96709).

Genitourinary ...Orally, vitamin C may cause precipitation of urate, oxalate, or cysteine stones or drugs in the urinary tract (10356). Hyperoxaluria, hyperuricosuria, hematuria, and crystalluria have occurred in people taking 1 gram or more per day (3042,90943). Supplemental vitamin C over 250 mg daily has been associated with higher risk for kidney stones in males. There was no clear association found in females, but the analysis might not have been adequately powered to evaluate this outcome (104029). In people with a history of oxalate kidney stones, supplemental vitamin C 1 gram per day appears to increase kidney stone risk by 40% (12653). A case of hematuria, high urine oxalate excretion, and the presence of a ureteral stone has been reported for a 9-year-old male who had taken about 3 grams of vitamin C daily since 3 years of age. The condition resolved with cessation of vitamin C intake (90936).

Hematologic ...Prolonged use of large amounts of vitamin C can result in increased metabolism of vitamin C; subsequent reduction in vitamin C intake may precipitate the development of scurvy (15). In one case, a patient with septic shock and a large intraperitoneal hematoma developed moderate hemolysis and increased methemoglobin 12 hours after a high-dose vitamin C infusion. The patient received a blood transfusion and the hemolysis resolved spontaneously over 48 hours (112479).

Neurologic/CNS ...Orally, the adverse effects of vitamin C are dose-related and include fatigue, headache, insomnia, and sleepiness (3042,4844,83475,83476).

Renal ...Hyperoxalosis and oxalate nephropathy have been reported following high-dose infusions of vitamin C. Hyperoxalosis and acute kidney failure contributed to the death of a 76-year-old patient with metastatic adenocarcinoma of the lung who received 10 courses of intravenous infusions containing vitamins, including vitamin C and other supplements over a period of 1 month. Dosages of vitamin C were not specified but were presumed to be high-dose (106618). In another case, a 34-year-old patient with a history of kidney transplant and cerebral palsy was found unresponsive during outpatient treatment for a respiratory tract infection. The patient was intubated for acute hypoxemic respiratory failure, initiated on vasopressors, hydrocortisone, and antibacterial therapy, and received 16 doses of vitamin C 1.5 grams. Serum creatinine level peaked at greater than 3 times baseline and the patient required hemodialysis for oliguria and uncontrolled acidosis. Kidney biopsy revealed oxalate nephropathy with concomitant drug-induced interstitial nephritis (106625). In another case, a 41-year-old patient with a history of kidney transplant presented with fever, nausea, and decreased urine output 4 days after receiving intravenous vitamin C 7 grams for urothelial carcinoma. Serum creatinine levels increased from 1.7 mg/dL to 7.3 mg/dL over those 4 days, and hemodialysis was initiated 3 days after admission due to anuria. Renal biopsy confirmed the diagnosis of acute oxalate nephropathy (109962).

Other ...Intravenously, hypernatremia and falsely elevated ketone levels is reported in a patient with septic shock and chronic kidney disease after a high-dose vitamin C infusion. The hypernatremia resolved over 24 hours after cessation of the infusion (112479).

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