Self Care of Magnesium Deficiency

by Herbert C. Mansmann, Jr. M.D.

A comprehensive review of the magnesium literature failed to disclose any articles describing self-care or self-management of normomagnesemia magnesium (Mg) deficiency (NMgD) requiring oral dosing with Mg supplication (MgS). A review of eleven books on Mg, mostly research conference proceedings, likewise showed a lack of interest in this essential modality of clinical medical care.

Yet physician guidelines are available that recommend , that at every opportunity the patient should be exposed to self-management education for a partnership in comprehensive asthma care, including self-medication.

1. Many books exist on this subject for asthmatics, as well for diabetics.

2 While patients with any degree of NMgD, can benefit by learning this routine, the authors believe it is essential in the most complicated situations, in order for the patient to feel in control of the disorder, their life and thus their outcome. Moreover, only the patient can live through the rapid changes on a daily bases.

Even seeing a physician weekly is an inadequate substitution for this experience and can only lead to a hopeless feeling and noncompliance, with worsening of the situation. Hypomagnesemia is surely to follow, requiring more intense acute medical therapy, and then followed by oral MgS. Self-care will again become essential to prevent acute illness and care. The purpose of this paper is to assure the reader that this modality can be very successful, and to recommend patient characteristics, and methods to implement self-care management of NMgD in selected patients with multiple medical problems and hence variable daily MgS needs.

OPTIMAL PATIENT CHARACTERISTICS

Self-care or self-management requires that the patient have the following characteristics (in bold type) in order to be successful with this approach to his/her medical therapy. The patient must be educable in order to become knowledgeable about the disease and the treatment methods. The patient must be sufficiently flexible to modify most lifestyle behaviors that aggravate magnesium deficiency (MgD). He/she must be motivated to learn what must be done and when to do it. The subject must be reasonably organized in able to do the necessary tasks and to keep accurate daily notes, and have an adaptable nature in order to meet the need to change doses in either direction on the same day, based on frequent changing symptoms. Must be objective so that the structure and the intensity of the treatment does not become overwhelming, and become an active team member oriented to properly utilize a necessary clinical care support systems. The elimination of the life style behavior is most helpful in the control of NMgD. This includes the control or omission of alcohol, caffeine, high intake of glucose, nicotine, phosphate containing sodas, theobromine, theophylline, and stress.

DOSING RECOMMENDATIONS AND REQUIREMENTS

A fast-acting supplement is five 500mg tablets of magnesium gluconate (MgG), each with 27mg of Mg2+, giving a total dose of 135 mg of elemental Mg2+ which is effective within an hour on an empty stomach, and a repeat dose every hour is well tolerated. The delayed acting supplements was a 250mg (elemental Mg) tablet of magnesium oxide (MgO), which has a peak effect at 5-6 hours and may require dosing every 6 hours (the most frequent dosing tested). An important goal is to establish the maximum tolerated dose that completely controls symptoms for 24 hours. The dose is need dependant and varies from 1 tablet every 12 hours to 4 tablets every 6 hours.

PERSONAL EXPERIENCE

A 71 year old male obese chronic dieter with asthma and non-insulin dependant diabetes mellitus, required daily high dose steroids, 40mg one day and & 20mg the next day of methylprednisolone (MP) in order to control polymyositis. After 4 months of this high steroids, the aldolase serum level fell from 9.8U/L to 4.8U/L (normal 2.0-7.0). At this time the dose of MP was slowly reduced to 40mg on alternate days. Since the aldolase has remained normal the steroid dose is now, a year later, being reduce by 1/2 mg/month and is at 7.5mg q2nd day. For several months the diabetes was under very poor control, in spite of glipizide XL 10mg daily, with swings between hyper and hypoglycemia. The HgA 1 c fell from 9.1% to 6.8% in 4 months with diet control and qid blood sugar monitoring. A 100 lb weight loss occurred. Many nights symptoms similar to NMgD (dysphagia, fasciculations and muscle cramps), hypoglycemia, and restless leg syndrome had to be differentiated, by a blood glucose level or a clinical response to MgG (135mg stat) in one hour. At 5 months edema of the feet and legs required Dyazide and furosemide. By this time the Mg requirement had gone from 1,500 mg of elemental Mg (sMg 2.2mEq/L and rbcMg of 2.1mEq/L) initially to 3,000mg of Mg/d. Since then the Mg requirement has varied between 3,000mg/d, which resulted in constipation, and 4,000mg/d, which occasionally caused diarrhea. A MgG dose of 135 mg at bedtime and at 3AM controlled the recurrent nighttime neuromuscular symptoms and assured restful sleep. This patient knew self-care for his asthma and his diabetes, and the addition of self-care of his NMgD was easily facilitated. It is worth noting that the patient’s nystagmus, first noted and has been continuous since age 24 years, disappeared when the Mg dose reached 2,000mg/d. The rbcMg was 4.5mEqL. Calcium, potassium and copper supplements were a fixed dose, but the zinc (Zn) deficiency resulted in corneal edema3 with severe blurred vision requiring frequent daily adjustment of the Zn supplement. The patient had the following causes of urinary Mg and Zn wasting that lead to the severe NMgD: chronic dieting with starvation diarrhea, frequent use of diet soda, high coffee and chocolate intake, frequent asthma medications, and daily verapamil (causes hypomagnesemia and hypozincemia). The addition of steroids increased hyperglycosuria and along with the diuretics resulted in an increased urinary Mg wasting. The dose of Mg needed frequent adjustments as discussed below.

PATIENT SUGGESTIONS AND RECOMMENDATIONS

LEARN TO COPE WITH DIARRHEA AND CONSTIPATION

1. Diarrhea is a common symptom in many gastrointestinal diseases, and the development of MgD is well documented. Less well known is the diarrhea that occurs with dieting, starvation induced. Here exists a paradox, that is also often unrecognized, which is this type of diarrhea is very responsive to an adequate dose of oral Mg. Diarrhea not induced by Mg is not a contraindication to Mg supplementation.

2. The development of constipation means that the maximum tolerated dose has not been reached.

IMPORTANT OVERDOSE SYMPTOMS TO RECOGNIZE

1. Diarrhea is the most common symptom of Mg overdose, but it is important to remember that diarrhea could be due to an acute viral infection or sorbitol found in many diet foods and candy. It could be due to a dietary indiscretion such as in the case of a known food allergy or intolerance.

2. Significant multiple muscle over-relaxation.

3. Urinary bladder relaxation with significant decrease in nocturia. In the absence of 1&2 above, this occurrence is likely to be very acceptable.

WHEN TO INCREASE THE DOSE

1. Constipated bowel movement, increase next MgO dose 25%.

2. With occurrence of one or more established end point systems; fasciculations, muscle cramps, dysphagia, and/or restless legs take a MgG dose of 135 Mg2+.

3. An increase of the MgO dose is taken when a new medication known to cause an increase in urinary Mg2+ excretion causes symptoms.

4. An increase in disease specific condition(s) that causes changes in Mg2+ metabolism; hyperglycemia documented by self-monitoring of blood sugar, an obvious increase in stress, etc.

5. In 2-4 above the maintenance dose should be increased to 25%.

WHEN AND HOW TO DECREASE THE DOSE

1. With watery diarrhea decrease only next dose 50%, since this is usually short lived, if present at the time of the next maintenance dose repeat the above lower dose. Then try to control symptoms with a 25% lower dose.

2. When a very soft bowel movement occurs, decrease the next dose 25%. May need to alternate doses regularly, such as 75% and 100% of maximum tolerated dose.

3. Comfortably soft bowel movements are a desirably objective and should be considered optional.

WHAT TO DO IF PATIENT FORGETS A DOSE OR DOSES

1. If it has been less than 1/2 the time between doses, take 1/2 the missed dose immediately. If acute symptoms occur in 2-6 hours take 135mg of MgG.

2. If over 1/2 the time has pasted, treat acute symptoms with MgG every hour if symptoms are not relieved. Don’t forget the next maintenance dose.

3. If after 12 hours, take 135 mg of MgG every hour until symptoms are tolerable, and at the same time restart the maintenance dose at the previous dose frequency.

CONCLUSION

NMgD can be controlled by self-care management techniques.

References

1. Guidelines for the diagnosis and management of asthma; National Heart, Lung, and Blood Institute of the National Institute of Health. 1997, NIH Publication No. 97-4051A.

2. Valentine V. Biermann J. Toohey B., Diabetes Type II & What To Do. Publ. Lowell House, Los Angeles, California, USA.

3. King JC, Keen CL. Zinc. In MODERN NUTRITIO IN HEALTH AND DISEASE, Ed by M.E. Shils, J.A. Olson and M. Shike, 8th Ed., Publ. Lea & Febiger, Philadelphia.

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