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Emergency Department Visits Related to Dietary Supplements To the Editor: Geller et al. (Oct. 15 issue)1 report on emergency department visits for adverse events related to dietary supplements, yet Table S2 in the Supplementary Appendix (available with the full text of their article at NEJM.org) included products that are not regulated under the Dietary Supplement Health and Education Act of 1994 (DSHEA). Instead, these products are homeopathic or over-the-counter drugs, including homeopathic eyedrops, homeopathic sulfur eardrops, and calcium polycarbophil (Table 1). Given the authors’ recognition that over-thecounter and homeopathic drugs are not dietary supplements and are regulated differently, it would have been appropriate to eliminate those products, as well as products such as proges-

terone, human growth hormone, and human chorionic gonadotropin, which are being marketed illegally as dietary supplements although they are actually unapproved drugs. At the very least, the authors should have included a stronger discussion of the limitations of the study. Regardless of what one thinks about the regulatory framework for the dietary supplement industry, meaningful discussions about improving public policy for one industry should not be based on statistics that cover a patchwork of several industries. Douglas MacKay, N.D. Council for Responsible Nutrition Washington, DC dmackay@​­crnusa​.­org

Table 1. Homeopathic or Over-the-Counter Drugs and Other Products Incorrectly Categorized as Dietary Supplements.* Product Category Immunity or infection

Homeopathic Drugs Cough and cold remedies (Zarbee’s, Hyland’s)

Laxative

Pain or arthritis relief



Arnica Pokeweed

Sexual enhancement

Over-the-Counter Drugs

Other Products That Are Not Supplements





Calcium polycarbophil Castor oil Malt soup Methylcellulose Mineral oil —





Clove oil Pain-relief gel (Sombra)

Erectile dysfunction medi­ cation



Skin or hair health

Thuja occidentalis Acne treatments (Nature’s Cure)



Tea tree oil Topical herbal products Various hair products (Nioxin, Nutrisol-Rf)

Sleep, sedation, or anxiolysis

Ignatia amara





Other specified products

Aconite Belladonna Calcarea carbonica Eupatorium or mistletoe Rhus toxicodendron Gripe water Pulsatilla intestinal formula Lomatium dissectum Homeopathic eyedrops Homeopathic sulfur eardrops Teething-relief remedies (Hyland’s, Humphreys’)



Cinnamon oil Peppermint oil Other oils (Olbas Oil)

* These products were listed in Table S2 of the Supplementary Appendix of the article by Geller et al.1

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Correspondence

gency department visits reported in our article involved products that are regulated as dietary supplements. The 3.4% of cases involving other products did not affect key findings such as 1. Geller AI, Shehab N, Weidle NJ, et al. Emergency department emergency department visits for cardiovascular visits for adverse events related to dietary supplements. N Engl J events associated with weight-loss products or Med 2015;​373:​1531-40. energy products or swallowing problems associDOI: 10.1056/NEJMc1514454 ated with micronutrients. Finally, the inclusion of these products did not alter suggested opportuniThe authors reply: MacKay notes the compli- ties for prevention. In summary, the product incated regulatory patchwork for oversight of com- clusion criteria that we used provide a perspective plementary health products. Our inclusion of a that is relevant to consumers and public health. handful of products that do not fall under the Andrew I. Geller, M.D. regulatory definition of dietary supplements was Centers for Disease Control and Prevention intentional and detailed in the Methods section Atlanta, GA ageller@​­cdc​.­gov of our article. It is important for public policy discussions Robert P. Mozersky, D.O. to include data in categories that are familiar to Food and Drug Administration consumers as well as to those who manufacture College Park, MD these products. Consumers are unlikely to be Daniel S. Budnitz, M.D., M.P.H. able to discern between complementary health Centers for Disease Control and Prevention products that are regulated under the DSHEA Atlanta, GA and those that are regulated in other ways,1 and Since publication of their article, the authors report no furconsumers do not have access to the results of ther potential conflict of interest. confirmatory testing for illegal or contaminated 1. Dodge T. Consumers’ perceptions of the Dietary Supplement ingredients. Health and Education Act: implications and recommendations. In addition, 96.6% (95% confidence interval, Drug Test Anal 2015 November 2 (Epub ahead of print). 95.9 to 97.4) of the total annual estimated emer- DOI: 10.1056/NEJMc1514454

Dr. MacKay reports being a full-time employee of the Council for Responsible Nutrition, a trade association representing the dietary supplement industry. No other potential conflict of interest relevant to this letter was reported.

Drug-Induced Megaloblastic Anemia To the Editor: In their review article, Hesdorffer and Longo (Oct. 22 issue)1 analyze the causes of drug-related megaloblastic anemia, describing the biochemical processes and the most common drugs involved. To our knowledge, sunitinib, a multitargeted tyrosine kinase inhibitor that has been approved for the treatment of metastatic renal-cell carcinoma and gastrointestinal stromal tumor, can also induce macrocytosis and subsequent anemia. Rini et al.2 found a correlation between macrocytosis and sunitinib-based treatment. Similar results were obtained by Price et al.3 in a review of 43 patients who had been treated with sunitinib; macrocytosis developed in 49% of those patients, and anemia developed in 86% during the treatment. Schallier et al.4 described some cases of tyrosine kinase inhibitor–induced mac-

rocytosis in patients who had been treated with sunitinib and imatinib and suggested the hypothesis that inhibition of c-kit could be involved in this drug-related toxic effect. In these retrospective studies, no correlation between hypothyroidism or nutritional deficiency and macrocytosis was reported. In contrast, Gillessen et al.5 reported a correlation between vitamin B12 deficiency and sunitinib-induced macrocytosis and suggested that sunitinib interferes with cobalamin absorption. In our opinion, the precise mechanism of action requires further investigation and remains unclear. Sebastiano Buti, M.D. Angelica Sikokis, M.D. University Hospital of Parma Parma, Italy angelicasikokis@​­live​.­it

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Emergency Department Visits Related to Dietary Supplements.

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