Is zinc supplementation warranted in a patient with Bechets disease, taking 150 mg Imuran (azathioprine) daily and 6 mg prednisone daily, with a low zinc level of 56 mcg/dl?

Zinc Supplementation in Behçet's Disease with Low Zinc Level

Yes, zinc supplementation is warranted in this Behçet's disease patient with a documented low zinc level of 56 mcg/dL (normal range typically 60-120 mcg/dL), particularly given the specific evidence supporting zinc therapy in Behçet's disease and the general principle of correcting demonstrated micronutrient deficiencies.

Rationale for Supplementation

Evidence-Based Support for Zinc in Behçet's Disease

• A randomized, double-blind, crossover trial specifically in Behçet's disease demonstrated that zinc sulfate 100 mg three times daily significantly reduced disease activity (Clinical Manifestations Index) with no side effects, and found an inverse correlation between disease activity and serum zinc levels 1

• Patients with Behçet's disease have been shown to have statistically significantly lower serum zinc levels compared to healthy controls 1

• The study showed clinical improvement began within the first month of zinc therapy and disease activity increased again when zinc was discontinued, suggesting a direct therapeutic effect 1

Guideline Support for Correcting Micronutrient Deficiencies

• The ESPEN guidelines on inflammatory bowel disease (applicable to other chronic inflammatory conditions) strongly recommend that patients should be checked for micronutrient deficiencies regularly and specific deficits should be appropriately corrected 2

• When demonstrated or suspected vitamin/micronutrient deficiencies exist, they should be treated as they can compound disease manifestations (Level of Evidence 4,88% consensus) 2

• The Clinical Nutrition guidelines recommend considering zinc assessment in patients exhibiting clinical signs of zinc deficiency, including increased susceptibility to infections and anorexia 3

Recommended Treatment Approach

Dosing Protocol

• Based on the Behçet's disease trial, initiate zinc sulfate 100 mg three times daily (300 mg total daily dose) 1

• Organic zinc compounds (zinc gluconate, zinc histidinate, or zinc orotate) show better tolerability than inorganic zinc sulfate if gastrointestinal side effects occur 4, 5

• Zinc supplements are best tolerated in divided doses 3

• Take zinc 30 minutes before meals to maximize absorption, though this timing may be adjusted if gastric irritation occurs 3

Monitoring Strategy

• Recheck serum zinc levels after 3 months of supplementation 4

• Monitor clinical disease activity using objective measures (oral ulcers, skin lesions, ocular symptoms, arthralgia) 1

• When giving additional zinc supplements, maintain a ratio of 8-15 mg zinc to 1 mg copper to prevent copper deficiency 4

Important Considerations with Current Medications

Azathioprine and Prednisone Interactions

• The patient's current immunosuppressive regimen (azathioprine 150 mg daily and prednisone 6 mg daily) represents standard therapy for Behçet's disease and is compatible with zinc supplementation 6, 7

• Combination therapy approaches are generally more effective than single-agent regimens in Behçet's disease 6

• The addition of zinc addresses a documented deficiency while potentially providing additional anti-inflammatory benefits specific to Behçet's disease 1

Safety Profile

• The Behçet's disease trial reported no side effects with zinc sulfate 300 mg daily over 6 months 1

• Excessive zinc intake (>1-2 g) can cause toxicity symptoms including nausea, vomiting, and abdominal pain, but the recommended dose is well below this threshold 5

• Monitor for potential copper depletion with long-term high-dose zinc therapy 4

Clinical Pitfalls to Avoid

• Do not ignore documented micronutrient deficiencies even when patients are on standard immunosuppressive therapy - deficiencies can persist and contribute to ongoing disease activity 2

• Do not use routine zinc supplementation without documented deficiency in other conditions (such as hepatic encephalopathy where it is not recommended), but Behçet's disease with documented low zinc is a specific indication 2

• Ensure compliance by educating the patient that zinc deficiency may directly contribute to disease activity and that supplementation has specific evidence in Behçet's disease 1

• Consider switching to organic zinc formulations if gastrointestinal intolerance occurs with zinc sulfate 4