PHARMACEUTICAL COMPOSITION FOR USE IN THE TREATMENT OR PREVENTION OF VITAMIN AND MINERAL DEFICIENCIES IN PATIENTS WHICH HAVE BEEN SUBJECTED TO GASTRIC BYPASS-SURGERY

Abstract

The present invention relates in a first aspect to a pharmaceutical composition and in a second aspect to a therapeutic combination for use in the treatment or prevention of vitamin and mineral deficiencies in patients which have been subjected to gastric bypass-surgery. A third aspect of the present invention relates to a pharmaceutical composition as such.

Claims

1.-16. (canceled)

17. A method for the treatment or prevention of vitamin and mineral deficiencies in patients subjected to gastric bypass surgery, the method comprising administration of a composition comprising: (a) 250 to 500 μg of vitamin B12; (b) 0.5 to 1.5 mg of vitamin B6; and (c) 50 to 150 mg iron.

18. The method according to claim 17, wherein the composition comprises: (d) less than 0.1 mg calcium and (e) less than less than 0.1 μg vitamin K.

19. The method according to claim 17, wherein the first unit dose further comprises: (vi) 15 to 30 mg zinc; (vii) 400 to 800 μg folic acid; (viii) less than 1 mg magnesium.

20. The method according to claim 19, wherein the first unit dose comprises less than 0.1 mg magnesium.

21. The method according to claim 17, wherein the gastric bypass-surgery is Roux-en-Y Gastric Bypass (RYGB).

22. The method according to claim 17, wherein the administration is oral.

23. The method according to claim 17, wherein the composition is administered at least once daily.

24. The method according to claim 17, wherein the composition is in the form of a tablet, capsule or powder.

25. A method of treatment or prevention of vitamin and mineral deficiencies in patients subjected to gastric bypass-surgery, the method comprising: (a) administering a first unit dose comprising: (i) 250 to 500 μg of vitamin B12; (ii) 0.5 to 1.5 mg of vitamin B6; (iii) 50 to 150 mg of iron; (iv) less than 0.1 mg calcium; and (v) less than 0.1 μg vitamin K; and (b) administering a second unit dose comprising: (i) 450 to 3000 mg calcium; (ii) 5 to 15 μg vitamin D; and (iii) 50 to 250 μg vitamin K.

26. The method according to claim 25, wherein the gastric bypass-surgery is Roux-en-Y Gastric Bypass (RYGB).

27. The method according to claim 25, wherein the second unit dose is administered to the patient at least one hour after or before administering the first unit dose.

28. The method according to claim 25, wherein the first unit dose further comprises: (vi) 15 to 30 mg zinc; (vii) 400 to 800 μg folic acid; (viii) less than 1 mg magnesium.

29. The method according to claim 28, wherein the first unit dose comprises less than 0.1 mg magnesium.

30. The method according to claim 25, wherein the administration of the first unit dose and/or the second unit dose is an oral administration.

31. The method according to claim 25, wherein the first unit dose and/or the second unit dose is in the form of a tablet, capsule or powder.

32. A method for the treatment or prevention of vitamin and mineral deficiencies in patients subjected to gastric bypass surgery, the method comprising daily administration of: (a) 250 to 500 μg of vitamin B12; (b) 0.5 to 1.5 mg of vitamin B6; and (c) 50 to 150 mg iron.

33. A pharmaceutical composition comprising: (a) 250 to 500 μg of vitamin B12; (b) 0.5 to 1.5 mg of vitamin B6; (c) 50 to 150 mg iron; (d) less than 0.1 mg calcium; and (e) less than less than 0.1 μg vitamin K.

34. The composition according to claim 33, further comprising 15 to 30 mg zinc.

35. The composition according to claim 33, further comprising 400 to 800 μg folic acid.

36. The composition according to claim 33, comprising less than 1 mg magnesium.

37. The composition according to claim 33, further comprising a pharmaceutically acceptable excipient.

Description

DETAILED DESCRIPTION OF THE INVENTION

[0049] Besides the great benefits of bariatric surgery, there are also disadvantages for the patients such as hampered food intake, dumping, defecation problems and nutrient deficiencies resulting from malabsorption. Common deficiencies, found in patients which have been subjected to a gastric bypass procedure include iron and vitamin B12. Anemia is therefore very common in this group of patients. The deficiencies that occur after surgery are mostly the result of an inadequate intake and malabsorption of essential micronutrients.

[0050] The reduced absorption of micronutrients from the intestine occurs primarily in the interventions with a malabsorptive component and is largely the result of skipping the stomach, the duodenum and the proximal portion of the jejunum. Because the food after a RYGB no longer comes into contact with gastric acid before it reaches the intestines, certain nutrients are not converted to a form that can be absorbed. In addition, the duodenum and proximal jejunum are the most important absorption locations for many micronutrients.

[0051] In an attempt to balance the iron and vitamin B12 deficiencies in patients which have been subjected to a gastric bypass, these patients are prescribed standard multivitamin supplements, which supplements generally comprise 100% of the recommended daily allowance (RDA) for iron, vitamin B12 and other vitamins. However, in the clinical study carried out by the present inventors it has now for the first time been shown that the administration of such standard multivitamin preparations did not result in solving the iron and vitamin B12 deficiencies commonly observed in these types of patients. Furthermore, clinical studies also showed that the amount of vitamin B6 provided by means of these standard multivitamin supplements is too high for this patient group and leads of hypervitaminosis. The pharmaceutical composition according to the present invention aims to solve these problems.

[0052] A first aspect of the present invention relates to a pharmaceutical composition for use in the treatment or prevention of vitamin and mineral deficiencies in patients which have been subjected to gastric bypass-surgery comprising: [0053] vitamin B12 or a source thereof; [0054] vitamin B6 or a source thereof; [0055] iron or a source thereof; [0056] a pharmaceutically acceptable carrier; and
wherein the patients in need thereof are administered per day 250 to 500 μg vitamin B12, 0.5 to 1.5 mg vitamin B6 and 50 to 150 mg iron.

[0057] The inventors of the present invention remarkably found that in order to avoid iron and vitamin B12 deficiencies in these types of patients, extremely high doses of said nutrients need to be administered. The administration of standard multivitamin preparations, which generally comprise 100% of the RDA of said nutrients resulted in an average decline of vitamin B12 and ferretin in said patients. The administration of the pharmaceutical composition according to the present invention, comprising about 10.000 to 15.000% of the RDA for vitamin B12 and 350 to 500% of the RDA for iron resulted in a marked increase of vitamin B12 and a steady ferretin level within said patients.

[0058] This is surprising for reasons that it was generally assumed in the scientific literature that the addition of higher amounts of vitamin B12 and iron would not be helpful due to the fact that after a gastric bypass operation (in particular after a RYGB) the release of intrinsic factor is significantly reduced, which significantly compromises vitamin B12 and iron absorption. Furthermore, also due to the reduced secretion of hydrochloric acid, pepsin and pancreatic enzymes it was assumed that increasing the amounts of vitamin B12 and iron would not have a beneficial effect. Thus, contrary to what was expected in the art, the present inventors found that extremely high doses of said nutrients avoids iron and B12 deficiencies in patients which have been subjected to a gastric bypass procedure, in particular a RYGB.

[0059] Although, it is theoretically possible to achieve with common multivitamin compositions the recommended vitamin B12 intake, the intake of several multivitamin tablets a day will lead to hypervitaminosis of other vitamins present in said common multivitamin compositions, such as hypervitaminosis of vitamin A, K or B6.

[0060] In this regard it is further noted that the administration of standard multivitamin preparations comprising 100% of the RDA for vitamin B6 already resulted in hypervitaminosis of said vitamin in patients which have been subjected to a gastric bypass procedure.

[0061] Depending on the gender and age of the patient, the amount of iron provided to said patients may vary. Men and post-menopausal women are preferably provided 50 to 80 mg of iron per day, whereas pre-menopausal women are preferably provided with 100 mg or more per day.

[0062] In a preferred embodiment of the present invention the pharmaceutical composition comprises a unit dose, which dose comprises the complete daily dosage of vitamins and minerals needed for patients which have been subjected to a gastric bypass procedure. Such a unit dose is preferably formulated as a tablet or capsule and comprises: [0063] 250 to 500 μg of vitamin B12; [0064] 0.5 to 1.5 mg of vitamin B6; [0065] 50 to 150 mg iron; [0066] less than 0.1 mg calcium; [0067] less than 0.1 μg vitamin K;
and a pharmaceutically acceptable excipient.

[0068] In order to avoid interactions between vitamin B12, iron and calcium the content of the latter is preferably kept low. Furthermore, it has also been found that it is important to keep the amount of vitamin K in said unit dose relatively low. Vitamin K is a known coagulant and may have a negative effect on anti-coagulants provided to said patients after they have been operated. Hence, from a safety perspective the amount of vitamin K in the composition according to the present invention is preferably less than 0.1 μg.

[0069] In a preferred embodiment of the present invention a unit dose of said composition comprises further: [0070] 15 to 30 mg zinc; [0071] 400 to 800 μg folic acid; [0072] less than 1 mg, preferably less than 0.1 mg magnesium.

[0073] Although patients having been subjected to a gastric bypass operation often lack from a vitamin B12 and iron deficiency, they are also at risk for developing other deficiencies. In order to prevent this, the pharmaceutical composition according to the present invention and in particular a unit dose thereof also comprises the above mentioned vitamins and minerals. With respect to the use of zinc it is noted that additional zinc is necessary to avoid loss of hair after the surgery has been carried out.

[0074] The pharmaceutical composition according to the present invention is preferably formulated as a fixed dose combination. More preferably, the fixed dose combination is a solid dosage form, such as a capsule, tablet or powder which are relatively easy to administer.

[0075] Besides the above mentioned minerals and vitamins, the pharmaceutical composition according to the present invention also comprises a pharmaceutically acceptable excipient. Such an excipient may be chosen from ingredients which are commonly used in the pharmaceutical technology for preparing granulate, solid or liquid oral dosage formulations.

[0076] Examples of categories of excipients include, but are not limited to, binders, disintegrants, lubricants, glidants, fillers and diluents. One of ordinary skill in the art may select one or more of the aforementioned excipients with respect to the particular desired properties of the granulate and/or solid oral dosage form by routine experimentation and without any undue burden. The amount of each excipient used may vary within ranges conventional in the art. The following references which are all hereby incorporated by reference disclose techniques and excipients used to formulate oral dosage forms. See “The Handbook of Pharmaceutical Excipients”, 4th edition, Rowe et al., Eds., American Pharmaceuticals Association (2003); and “Remington: The Science and Practice of Pharmacy”, 20th edition, Gennaro, Ed., Lippincott Williams & Wilkins (2000).

[0077] A second aspect of the present invention relates to a therapeutic combination for use in the treatment or prevention of vitamin and mineral deficiencies in patients which have been subjected to gastric bypass-surgery, wherein the composition comprises:

(a) a first unit dose comprising: [0078] 250 to 500 μg of vitamin B12; [0079] 0.5 to 1.5 mg of vitamin B6 [0080] 50 to 150 mg of iron; [0081] less than 0.1 mg calcium; [0082] less than 0.1 μg vitamin K and
(b) a second unit dose comprising [0083] 450 to 3000 mg calcium; [0084] 5 to 15 μg vitamin D; and optional [0085] 50 to 250 μg vitamin K.

[0086] The first unit dose of the therapeutic combination according to the present invention comprises the unit dose as already described above. In addition to said first unit dose the therapeutic combination according to the present invention also comprises a second unit dose, which dose comprises at least calcium, vitamin D and optionally vitamin K. However, in order to avoid interactions between iron on the one hand and the other nutrients on the other hand, a combination of two unit doses is provided.

[0087] Furthermore, with respect to vitamin K, it is noted that a small amount is needed for the body to be able to take up calcium. However, too much vitamin K may impair the function of anti-coagulants provided after the gastric bypass procedure. Hence, said second unit dose may also comprise vitamin K after the patient has recovered from the gastric-bypass procedure and the administration of anti-coagulants has been stopped.

[0088] The provision of extra vitamin D, calcium and optionally vitamin K is of importance to patients which have been subjected to a gastric bypass procedure because after the operation the pressure on weight-bearing bones is reduced by the rapid weight loss. This reduction causes lower stimulation of the osteoclasts, which in turn causes osteoblasts to produce less bone. This first phase lasts about three months. A second phase of bone resorption takes place six months postoperatively. This phase is due to a lack of intake of vitamin D and an insufficient absorption of calcium. The response of the body to the shortage of calcium is to absorb calcium from the skeleton reducing its strength. After one year, the bone loss in all the bones, especially in weight-bearing bones like the pelvis and lower back, has become significantly large at 7.8% to 10.5%. In the long term this is very detrimental to the patient as they develop a significantly greater risk of fractures. Hence, additional vitamin D and calcium is needed for this group of patients.

[0089] The combination according to the present invention is preferably administered at least once per day. In special cases, the combination may be administered more times a day, although it is assumed that this is only beneficial for a limited amount of time, e.g. one to three months.

[0090] In order to also avoid interactions of the different vitamins and minerals in the body it is preferred to administer the second unit dose to a patient in need thereof at least one hour, preferably at least two hours and more preferably at least three hours after or before administering the first unit dose to said patient.

[0091] Preferably, the first unit dose comprises further: [0092] 15 to 30 mg zinc; [0093] 400 to 800 μg folic acid; [0094] less than 1 mg, preferably less than 0.1 mg magnesium.

[0095] The first unit dose and/or the second unit dose is preferably formulated as a fixed dose combination, preferably an oral fixed dose combination, most preferably a tablet, capsule or powder.

[0096] Besides the vitamins and minerals the unit doses of the therapeutic combination according to the present invention also comprises a pharmaceutically acceptable excipient. Suitable excipient for use in the first and second unit doses include, but are not limited to, binders, disintegrants, lubricants, glidants, fillers and diluents. One of ordinary skill in the art may select one or more of the aforementioned excipients with respect to the particular desired properties of the granulate and/or solid oral dosage form by routine experimentation and without any undue burden.

[0097] The amount of each excipient used may vary within ranges conventional in the art. The following references which are all hereby incorporated by reference disclose techniques and excipients used to formulate oral dosage forms. See “The Handbook of Pharmaceutical Excipients”, 4th edition, Rowe et al., Eds., American Pharmaceuticals Association (2003); and “Remington: The Science and Practice of Pharmacy”, 20th edition, Gennaro, Ed., Lippincott Williams & Wilkins (2000).

[0098] A third aspect of the present invention relates to a method for the treatment or prevention of vitamin and mineral deficiencies in patients which have been subjected to a gastric bypass surgery, wherein the method comprises the daily administration of [0099] 250 to 500 μg of vitamin B12; [0100] 0.5 to 1.5 mg of vitamin B6; and [0101] 50 to 150 mg iron.

[0102] According to a preferred embodiment of the method of the present invention said patients are administered a pharmaceutical composition as described above or a therapeutic combination as described above.

[0103] A last aspect of the present invention relates to a pharmaceutical composition as such comprising: [0104] 250 to 500 μg of vitamin B12 [0105] 0.5 to 1.5 mg of vitamin B6; [0106] 50 to 150 mg iron; [0107] less than 0.1 mg calcium [0108] less than 0.1 μg vitamin K; [0109] 15 to 30 mg zinc; [0110] 400 to 800 μg folic acid; [0111] less than 1 mg, preferably less than 0.1 mg magnesium; and
a pharmaceutically acceptable excipient.

[0112] Besides the vitamins and minerals, the pharmaceutical composition also comprises a pharmaceutically acceptable excipient. Suitable excipient for use in the first and second unit doses include, but are not limited to, binders, disintegrants, lubricants, glidants, fillers and diluents. One of ordinary skill in the art may select one or more of the aforementioned excipients with respect to the particular desired properties of the granulate and/or solid oral dosage form by routine experimentation and without any undue burden.

[0113] The amount of each excipient used may vary within ranges conventional in the art. The following references which are all hereby incorporated by reference disclose techniques and excipients used to formulate oral dosage forms. See “The Handbook of Pharmaceutical Excipients”, 4th edition, Rowe et al., Eds., American Pharmaceuticals Association (2003); and “Remington: The Science and Practice of Pharmacy”, 20th edition, Gennaro, Ed., Lippincott Williams & Wilkins (2000).

[0114] The pharmaceutical composition according the present invention is preferably formulated as a unit dose, preferably as an oral dosage form such as a tablet or capsule.

[0115] The present invention will be illustrated further by means of the following non-limiting example.

EXAMPLE

Double Blind, Randomized Study Comparing a Pharmaceutical Composition (WLS Forte) According to the Present Invention With a Standard Multivitamin Supplement (sMVS)

[0116] A double-blind, randomized, 12-month study was conducted comparing WLS forte with a standard multivitamin supplement (sMVS) containing approximately 100% of recommended daily allowance (RDA) for iron, vitamin B12 and folic acid. WLS Forte contains vitamin B12 at a level 14000% RDA, iron at 500% RDA, and folic acid at 300% RDA per capsule.

Patients

[0117] Between June 2011 and March 2012 a total of 150 patients who were scheduled for a primary laparoscopic RYGB (LRYGB) were randomized for postoperative multivitamin supplementation for a duration of twelve months. All patients met the criteria for bariatric surgery according to NIH Consensus Development Conference Panel for bariatric surgery. Patients were randomized to receive either standard multivitamin supplements (sMVS, FitForMe, Rotterdam, The Netherlands) or RYGB specific multivitamin supplements (WLS Forte, FitForMe, Rotterdam, The Netherlands). A computer-generated variable block schedule was used for randomization. Patients, surgeons and researchers were blinded for the supplements. Both supplements were similar for color, size, and packaging, and both were dosed as one capsule daily. The composition of both supplements is shown in Table 1. The sMVS served as control and contained the compounds of interest in a dose equivalent to the recommended daily allowance (RDA), whereas WLS Forte contained much higher doses, in particular, of iron (5 times RDA) and vitamin B12 (140 times RDA).

Surgical Procedure

[0118] All procedures were performed by one of 3 bariatric surgeons all beyond their learning curve (>750 procedures each). They performed an antecolic antegastric LRYGB, with a proximal gastric pouch of 30 ml, a biliopancreatic limb (BPL) of 50 cm and a Roux limb of 150 cm. All patients received low-molecular heparin (Nadroparin 5700IU daily) for 6 weeks and proton-pump inhibitor (Omeprazol 40 mg daily) for 6 months, as a part of our standard postoperative protocol.

Follow-Up and Outcome

[0119] All patients followed a strict postoperative schedule consisting of 17 visits in the first year, and on each visit patients were encouraged to keep taking their supplements. Standard laboratory blood test were performed at baseline, 6 and 12 months. This included a complete blood count (CBC, (normal range (NR) hemoglobin: females: 7.4-9.9 mmol/L, males: 8.4-10.8 mmol/L), mean cell volume (MCV, [NR: 80-100 fL]), creatinine [NR: 45-90 μmol/L], sodium [NR: 135-145 mmol/l], potassium [NR: 3.5-4.7 mmol/l], calcium [NR: 2.10-2.55 mmol/l], phosphate [NR: 0.87-1.45 mmol/l], magnesium [NR: 0.71-0.93 mmol/l], zinc [NR 9.2-18.4 μmol/L], albumin [35-50 g/l], fasting glucose (FG, [NR: 4.0-5.6 mmol/l]), Hb1Ac [NR: 20-42 mmol/mol], total cholesterol [NR <6.50 mmol/l], HDL-cholesterol [NR >1.10 mmol/l], LDL-cholesterol [NR: 3.50-4.50 mmol/l], and triglycerides [NR: 0.8-2.0 mmol/l]), iron [NR: 9.0-31.0 μmol/l], total-iron-binding-capacity (TIBC, [NR: 45.0-81.0 μmol/L]), ferritin [NR 20-200 μg/L], folic acid [NR: 9.0-36.0 nmol/l], vitamin B12 [NR: 150-640 pmol/l], 25-hydroxyvitamin D (25-OHD, [NR: >50 nmol/L]), parathyroid hormone (PTH, [NR: 1.3-6.8 pmol/l]), vitamin B1 [NR: 95-175 nmol/L], vitamin B6 [NR: 25-100 nmol/L].

[0120] Primary outcome variables were the percentage of iron and vitamin B12 deficiencies developed during the 12 month after LRYGB. Iron Deficiency (ID), was defined as a serum ferritin <20 μg/L and vitamin B12 deficiency if the level was <150 pmol/L). Vitamin D deficiency was diagnosed if 25-OHD<50 nmol/L, hypocalcemia if serum calcium <2.1 mmol/L), and zinc deficiency of the serum level was <9.2 μmol/L. Calcium data are shown as calcium levels corrected for albumin 130 (Cacorr), according to the following equation: Ca.sub.corr=Total Calcium−(0.025×albumin)+1.

Statistical Analysis

[0121] Sample size calculation was performed by the epidemiologist of the Research Department of Rijnstate Hospital in Arnhem (NL) using Openepi.com. Sample size calculation was based on the number of patients developing ID. To detect a 25% reduction of ID 12 months after surgery, with a confidence interval 95% and a power of 90%, a minimum of 56 patients per group were needed. Taking into account a 10% drop-out and 15% deficiency of iron at 6 months which will be supplemented at that time, it was decided to include 75 patients per 160 treatment group.

All data were analyzed using IBM® SPSS® Statistics 20 for Windows. Data were expressed in mean (±standard deviation), unless otherwise specified. Difference between groups were calculated using student-t test for continuous data and chi-square test for ordinal/nominal data. A P-value<0.05 was considered statistically significant.

Results

[0122] Two patients were excluded after randomization: one patient in the WLS Forte group because he underwent a sleeve gastrectomy instead of a LRYGB because of multiple adhesions during surgery, and one patient in the sMVS group because he cancelled the scheduled operation procedure. In total 148 patient (74 in each group) underwent a LRYGB and were included for analysis. Both groups were similar with respect to age, sex, weight, body mass index (BMI) and preoperative deficiencies. However, dyslipidaemia was twice as frequent in the WLS Forte group as compared to the sMVS group (P=0.04).

Weight Loss

[0123] The degree of weight loss over 12 months was similar in both groups. Weight dropped to 90.6±17.4 kg compared 93.8±16.9 kg in sMVS versus WLS Forte (p=0.24), respectively. Percentage Excess Weight Loss (%EWL), defined as weight loss divided by excess weight based on ideal body weight at BMI 25 kg/m2, were after 12 months 72.5±20.9 180 kg/m2 versus 72.1±23.2 kg/m2 for MVS and WLS Forte (p=0.92), respectively.

Iron

[0124] The total number of patients developing ferritin deficiency during follow-up were 8 (10.7%) patients in sMVS and 1 (1.3%) patients in WLS Forte (p=0.03). In total 55 (37.2%) patients, 28 (37.8%) in sMVS and 27 (36.5%) in WLS Forte group, received additional iron medication at any time during the 12 month follow-up. Results after exclusion of these patients are shown in Table 4. Mean serum ferritin decreased by 18.4±61.8 ug/L in the sMVS group, but remained stable in the WLS Forte group (p=0.08).

Vitamin B12

[0125] Mean vitamin B12 serum levels decreased by −38.9±141.3 pmol/L in the sMVS group and increased by 44.1±138.8 pmol/L in the WLS Forte group (<0.001) after 12 months, and as a result mean vitamin B12 blood serum levels at 6 months and 12 months were significant higher with WLS Forte compared to sMVS (p<0.05). After 12 months, vitamin B12 deficiency had developed in 5 (7.9%) patients receiving sMVS versus 1 (1.6%) in WLS Forte group (p=0.207).

TABLE-US-00001 TABLE 1 Dosages of supplement ingredients Standard MVS WLS Forte Ingredients Dosage RDA (%) Dosage RDA (%) Biotin (μg) 25.00 50.0 600.0 1200.0 Calcium (mg) 91.43 110.4 0.0 0.0 Chloride (mg) 0.14 0.0 0.54 0.1 Chrome (μg) 40.00 100.0 160.00 400.0 Copper (μg) 999.60 100.0 3000.20 300.0 Folic acid (μg) 200.00 100.0 600.00 300.0 Iodine (μg) 153.70 102.5 225.04 150.0 Iron (mg) 14.00 100.0 70.00 500.0 Manganese (mg) 2.00 100.1 3.00 150.0 Magnesium (mg) 30.00 8.0 0.0 0.0 Molybdenum (μg) 50.00 100.0 112.40 224.8 Selenium (μg) 55.00 100.0 105.00 190.9 Vitamin A (μg) 599.70 75.0 600.00 75.0 Vitamin B1 (mg) 1.10 99.7 2.75 249.7 Vitamin B2 (mg) 1.40 100.0 3.50 250.0 Vitamin B3 (mg) 16.0 100.0 32.00 200.0 Vitamin B5 (mg) 6.00 100.0 18.00 300.1 Vitamin B6 (mg) 1.40 100.2 0.98 70.0 Vitamin B12 (μg) 12.50 100.0 350.00 14000.0 Vitamin C (mg) 80.00 100.0 120.00 150.0 Vitamin D (μg) 4.00 80.0 12.50 250.0 Vitamin E (mg) 10.00 83.4 24.00 200.0 Vitamin K1 (μg) 25.00 33.3 <0.01 0.0 Zinc (mg) 10.00 100.0 22.50 225.0 RDA: European Recommended Dietary Allowance

TABLE-US-00002 TABLE 2 Laboratory blood tests of hemoglobin metabolism excluding patients with additional iron and/or vitamin B12 medication Serum levels Standard MVS WLS Forte p-value Hemoglobin (mmol/L) Baseline 8.5 ± 0.6 8.6 ± 0.7 0.38 6 months 8.6 ± 0.7 8.4 ± 0.7 0.25 12 months 8.5 ± 0.8 8.5 ± 0.6 1.00 Δ 0-12 months 0.029 ± 0.7  −0.063 ± 0.5    0.64 Ferritin (μg/L) Baseline 103.0 ± 86.1  102.1 ± 71.0  0.95 6 months 84.5 ± 73.2 97.8 ± 66.7 0.29 12 months 80.8 ± 71.0 108.3 ± 83.1  0.05 Δ 0-12 months −18.4 ± 61.8    4.9 ± 81.3 0.08 Vitamin B12 (pmol/L) Baseline 305.5 ± 107.1 302.8 ± 100.9 0.88 6 months 249.9 ± 85.6  351.3 ± 135.6 <0.001 12 months 267.2 ± 100.1 349.8 ± 122.1 <0.001 Δ 0-12 months  −38.9 ± 141.3    44.1 ± 138.8 0.002 Numbers are mean (±SD), MVS: Multivitamin Supplement