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BLOG: Omega-3 part 3 — How to prescribe fish oil
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I know, I hurt your feelings when I told you that you weren’t doing the whole omega-3 fatty acid thing with fish oil correctly. Please accept my sincere apology. Admit it, though: After you read parts 1 and 2 of omega-3 you now know that a) dry eye docs must prescribe fish oil to pretty much all of their patients and b) we should be measuring pre- and post-Rx levels with the Omega Index. That still leaves us with the question of what kind of fish oil to suggest and how much should be taken.
How many times have you brought up fish oil with a patient only to hear something like: “I already eat salmon two or three times a week”? The proper response is to note that’s like trying to fill a swimming pool with a squirt gun. Ditto for those who take a single 1,000 mg pill from Costco or CVS. There are two very important take-home points from the study authored by Alice Epitropoulos and her team, and one of them is that you need to take a boatload of fish oil to have an effect. Study subjects took a total of 4,800 mg of fish oil, much more than you are probably suggesting right now.
What kind of fish oil matters, too. It is not enough to cleanse the oil of dangerous contaminants like mercury; the process that does so must be reversed (re-esterification) and the fish oil returned to the triglyceride forms EPA and DHA. In the study, the doses used were 1,680 mg of EPA and 560 mg of DHA per day for a total of 2,240 mg. Now it gets tricky.
Physicians Recommended Nutriceuticals (PRN) provided the fish oil for the study. Unlike Bausch + Lomb in the AREDS studies, PRN has patented both the total dose and the ratio of EPA/DHA. As you know, PRN will deliver this to your patients. There are other re-esterified formulas out there, notably ones made by Nordic Naturals (available at GNC) and PurePharma (popular with CrossFitters). Both suggest lower doses, and both have a different EPA/DHA ratio than the study formulation. Does that matter?
Here’s how to approach this. You and I both know that we are not going to get the majority of our patients to do pre- and post-Rx Omega Index tests. There’s just not enough chair time to convince them. The volume of EPA and DHA clearly matters; the minimum cumulative dose needs to be 2,240 mg/day. Does the ratio matter? PRN would certainly like us to think so. Who knows? There’s no comparative data. Like AREDS, all we know is that this particular formula worked. Let me make it really simple: The money/gram of EPA+DHA is actually equal or less with the PRN formula. It turns out the gold standard is also the value play.
It’s economics. QED.
Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations; is on the speakers board for Bausch + Lomb, Allergan and Shire; and has a financial interest in TearScience.