What is the recommended daily dose of omega-3 (EPA and DHA)?

Omega-3 Dosing Recommendations

General Population: 500 mg EPA+DHA Daily

For general cardiovascular health in healthy adults, consume 500 mg of EPA+DHA daily through either two servings of fatty fish per week or supplements. 1, 2

• The American Heart Association recommends all adults eat fatty fish at least twice weekly, which provides approximately 400-500 mg/day of EPA+DHA combined 2
• For those who don't regularly consume fish, 500 mg EPA+DHA daily from supplements provides baseline cardiovascular protection 2
• Plant-based omega-3 sources (ALA from flaxseed, walnuts, canola oil) require 1.5-3 grams daily but are significantly less potent than marine-sourced EPA+DHA, as conversion to EPA is only 6% and to DHA is merely 3.8% 1, 3

Coronary Heart Disease: 1 Gram EPA+DHA Daily

For patients with documented coronary heart disease, take 1 gram (850-1,000 mg) of EPA+DHA daily. 4, 1, 2

• This dose reduces sudden cardiac death by 45% and total mortality by 15% based on the landmark GISSI-Prevenzione trial in 11,324 post-MI patients 4
• The protective effect appears within 3-4 months of starting supplementation 4
• The American College of Cardiology and American Heart Association both endorse this dosing based on Grade A evidence from large randomized trials 1, 2

Hypertriglyceridemia: 2-4 Grams EPA+DHA Daily

For patients with elevated triglycerides, prescribe 2-4 grams of EPA+DHA daily under physician supervision. 1, 2

• This dose lowers triglyceride levels by 20-40% 1
• Doses above 3 grams require physician monitoring, though no increased bleeding risk has been documented even up to 5 grams daily 1, 2
• The theoretical bleeding concern at higher doses has not materialized in clinical trials, even with concurrent antiplatelet or anticoagulant therapy 2

Major Depressive Disorder: 1-2 Grams EPA Daily

For major depressive disorder as adjunctive treatment, start with 1-2 grams of EPA daily (or EPA+DHA with EPA:DHA ratio >2:1), titrating up over 2-4 weeks if tolerated. 4

• The International Society for Nutritional Psychiatry Research emphasizes that EPA-predominant formulations (EPA:DHA ratio >2:1) are crucial for antidepressant effects 4
• Use as adjunctive treatment with standard antidepressants, not as monotherapy, as monotherapy trials have failed to show benefit 4
• For partial responders, increase the dose at 2 weeks, titrating to maximum dose by 4-6 weeks if tolerable 4

Pregnancy and Lactation: 200-250 mg DHA Daily

Pregnant and breastfeeding women should consume 250 mg/day of DHA+EPA from diet or supplements, with an additional 100-200 mg of DHA specifically to reduce preterm birth risk. 5

• Supplementation should ideally start before 20 weeks of pregnancy 5
• This dose improves neurological development, visual acuity, and reduces risk of preterm birth and preeclampsia 5
• Be cautious about mercury exposure from certain fish species, though cardiovascular benefits outweigh risks for most adults 1

Special Populations and Conditions

Cognitive Health in High-Risk Elderly

For individuals with APOE e4/e4 genotype at risk for cognitive decline, consider 1,500-2,000 mg EPA+DHA daily with higher EPA:DHA ratio (approximately 2:1). 1, 2

• Evidence strength is lower (observational studies and small trials) compared to cardiovascular indications 1

High Air Pollution Exposure

For individuals with established cardiovascular disease living in heavily polluted urban environments, increase to 1-3 grams EPA+DHA daily. 6

• Omega-3s prevent PM2.5-induced QTc prolongation and arrhythmia risk 6
• Pre-treatment for at least 4 weeks is essential before protective effects manifest 6

Critical Safety Thresholds and Monitoring

Upper Safety Limit: 5 Grams Daily

Long-term supplementation up to 5 grams EPA+DHA daily is safe without increased bleeding risk, even with concurrent anticoagulants. 1, 2

• No increased spontaneous bleeding occurs up to 5 grams daily 1
• EPA alone up to 1.8 grams daily has been specifically validated as safe 1

Atrial Fibrillation Risk at High Doses

High-dose omega-3 supplementation (≥4 grams daily) increases atrial fibrillation risk by 25%. 1, 2

• This dose-dependent relationship was demonstrated in multiple trials, with most increased risk occurring at doses >1 gram daily 1
• The REDUCE-IT trial with 4 grams daily of icosapent ethyl resulted in hospitalization for atrial fibrillation in 3.1% versus 2.1% in controls 1
• Balance cardiovascular benefits against arrhythmia risk when prescribing high doses 1

Monitoring Requirements

Patients taking >3 grams daily require physician supervision with monitoring for gastrointestinal symptoms and, in dialysis patients, bleeding time checks. 1

• Common side effects include fishy taste, belching, and nausea, which are dose-limiting but not dangerous 1
• For dialysis patients on 2-4 grams, perform bimonthly bleeding time checks initially, then monthly once stable 1

Common Pitfalls to Avoid

• Don't use omega-3s for diabetes management: No benefit exists for glycemic control or primary cardiovascular prevention in diabetes (Grade A evidence) 2
• Don't assume all omega-3 sources are equal: Marine-sourced EPA+DHA are far more potent than plant-derived ALA due to poor conversion rates 1, 3
• Don't delay supplementation in high-risk patients: Protective effects require 3-4 weeks of pre-treatment to manifest 4, 6
• Don't prescribe as monotherapy for depression: Use only as adjunctive treatment with standard antidepressants 4