Natural Standard® Patient Monograph, Copyright © 2014 (www.naturalstandard.com). All Rights Reserved. Commercial distribution prohibited. This monograph is intended for informational purposes only, and should not be interpreted as specific medical advice. You should consult with a qualified healthcare provider before making decisions about therapies and/or health conditions. Background Vitamin E is a fat-soluble vitamin with antioxidant properties. Vitamin E exists in eight different forms: alpha-, beta-, gamma-, and delta-tocopherol; and alpha-, beta-, gamma-, and delta-tocotrienol. Alpha-tocopherol is the most active form in humans. Dosing for vitamin E is often given in alpha-tocopherol equivalents (ATEs). This accounts for the different activities that the different forms of vitamin E have in the body. One milligram of an ATE is equal to 1.5 international units (IU). Vitamin E supplements are available in natural or man-made forms. The natural forms are usually labeled with the letter “d” (for example, d-gamma-tocopherol), whereas synthetic forms are labeled “dl” (for example, dl-alpha-tocopherol). Foods that contain vitamin E include eggs, fortified cereals, fruit, green leafy vegetables (such as spinach), meat, nuts, nut oils, poultry, vegetable oils (corn, cottonseed, safflower, soybean, sunflower), argan oil, olive oil, wheat germ oil, and whole grains. Cooking and storage may destroy some of the vitamin E in foods. Vitamin E has been studied for the prevention or treatment of many health conditions. However, there is a lack of strong evidence to support its use for any disease at this time, aside from vitamin E deficiency. Concerns have been raised about the safety of vitamin E supplementation, particularly in high doses. An increased risk of bleeding may occur in people taking blood thinners, or those with vitamin K deficiency. Evidence suggests that regular use of high-dose vitamin E supplements may increase the risk of death from all causes by a small amount, although research is unclear. Caution is advised. Vitamin E has also been studied for scar prevention. However, there is a lack of evidence to support this use. Because of a risk of allergic skin symptoms, some researchers have advised against the use of this therapy. Related terms All rac-alpha-tocopherol, alpha-tocopherol acetate, alpha-tocopheryl acetate, alpha-tocotrienol, antisterility vitamin, beta-tocopherol, beta-tocotrienol, d-alfa-tocopherol acetate, d-alpha-tocopherol, d-alpha-tocopheryl, d-alpha-tocopheryl acetate, d-alpha-tocopheryl succinate, d-beta-tocopherol, d-delta-tocopherol, delta-tocopherol, delta-tocotrienol, d-gamma-tocopherol, d-tocopherol, d-tocopheryl acetate, dl-alpha-tocopherol, dl-alpha-tocopheryl acetate, dl-tocopherol, gamma-tocopherol, gamma-tocotrienol, mixed tocopherols, RRR-alpha-tocopherol, Spondyvit®, tocofersolan, tocopherol, tocopheryl succinate, tocotrienol, tocotrienol concentrate. Dosing The below doses are based on scientific research, publications, traditional use, or expert opinion. Many herbs and supplements have not been thoroughly tested, and safety and effectiveness may not be proven. Brands may be made differently, with variable ingredients, even within the same brand. The below doses may not apply to all products. You should read product labels, and discuss doses with a qualified healthcare provider before starting therapy. Adults (over 18 years old) Foods that contain vitamin E include eggs, fortified cereals, fruit, green leafy vegetables (such as spinach), meat, nuts, nut oils, poultry, vegetable oils (corn, cottonseed, safflower, soybean, sunflower), argan oil, olive oil, wheat germ oil, and whole grains. Cooking and storage may destroy some of the vitamin E in foods. Most people in the United States obtain vitamin E from the diet, although people with very low-fat diets or intestine disorders may need supplementation. The recommended daily intake for adults over 14 is 15 milligrams (or 22.5 IU); for pregnant women of any age, it is 15 milligrams (or 22.5 IU), and for breastfeeding women of any age, it is 19 milligrams (or 28.5 IU). For adults older than 18 years, pregnant women, and breastfeeding women, the maximum dose is 1,000 milligrams daily (or 1,500 IU). For age-related macular degeneration, 30 milligrams to 500-600 IU of vitamin E (alpha-tocopherol) has been taken by mouth daily for 4-8 years. For amyotrophic lateral sclerosis, 1,000 milligrams of vitamin E has been taken by mouth daily, as either one daily dose or in two divided doses, for up to 48 weeks. For clogged arteries, 45-3,200 IU has been taken by mouth daily for up to five years. For atopic eczema, 600 IU of all-rac-alpha-tocopherol has been taken by mouth daily for 60 days. For breast cancer, 4-20 milligrams has been taken by mouth daily. For cancer, 4-800 milligrams of vitamin E has been taken by mouth daily for up to 10 years. For heart disease, 33-3,200 IU has been taken by mouth daily or on alternate days for up to 10 years. Doses of all-rac-alpha-tocopherol ranging from 50-2,000 milligrams and doses of RRR-alpha-tocopherol ranging from 272-800 milligrams have been taken by mouth daily for up to 6.6 years. For heart disease in people undergoing kidney disease treatment, 800 IU has been taken by mouth daily for 519 days. For cataract prevention, 300-600 IU of vitamin E has been taken by mouth daily for up to six years, with conflicting results. Doses of 50-300 milligrams have been taken by mouth daily or on alternate days for 3.6-9.7 years. For chemotherapy side effects, 200-600 milligrams to 1,600-3,200 IU of vitamin E has been taken by mouth daily. A dose of 400 milligrams of vitamin E oil or dressing has been applied to the skin. A dose of 200 milligrams of alpha-tocopherol has been injected into the muscle. For colorectal cancer prevention, 30-600 milligrams of vitamin E has been taken by mouth daily or every other day for 1-12 years. For dementia/Alzheimer’s disease, 800-2,000 IU of Vitamin E has been taken by mouth 1-2 times daily for 2-3 years, with mixed results. For diabetes, 400-600 IU vitamin E has been taken by mouth once daily for 1.5-8 years. For leg pain due to clogged arteries, 300-1,600 milligrams of Vitamin E has been taken by mouth daily for up to 18 months. For liver disease (non-alcoholic fatty liver disease), 30-1,000 IU of vitamin E has been taken by mouth 1-2 times daily for two months to five years. For lung cancer, 50 milligrams or 400-600 milligrams of alpha-tocopherol has been taken by mouth 1-2 times daily or every other day for 2-8 years. For reducing risk of death, 16.5-5,500 IU of Vitamin E has been taken by mouth daily or every other day for up to 10 years, without benefit. A dose of 100 milligrams of vitamin E (d-alpha-tocopheryl acetate) or 200 IU vitamin E (dl-alpha-tocopherol) has been taken daily for 1-6 years. For Parkinson’s disease, 2,000-3,200 IU has been taken by mouth daily, without benefit. For prostate cancer prevention, 50 milligrams or 400 IU of vitamin E has been taken by mouth daily or every other day for a follow-up of 5-8 years. For stroke prevention, 50-800 milligrams of Vitamin E has been taken by mouth daily for greater than 10 years, without benefit. For tardive dyskinesia, 400-1,600 IU of Vitamin E has been taken by mouth daily for up to one year. Treatment of vitamin E deficiency should be under medical supervision. If the cause is due to poor nutrition, taking a dose by mouth that is 2-5 times greater than the RDA may be considered. If the cause is stomach or intestine problems, then injections of vitamin E may be needed. For scar prevention, vitamin E has been applied to the skin, without benefit. Children (under 18 years old) Common formulas used in children are alpha-tocopherol, alpha-tocopherol acetate, and tocofersolan. The recommended intakes are as follows: for healthy breastfeeding infants 0-6 months old, 4 milligrams daily (6 IU); for infants 7-12 months old, 5 milligrams daily (7.5 IU); for children 1-3 years old, 6 milligrams daily (9 IU); for those 4-8 years old, 7 milligrams daily (10.5 IU); for those 9-13 years old, 11 milligrams daily (16.5 IU); for those over 14 or pregnant women of any age, 15 milligrams daily (22.5 IU); and for breastfeeding women of any age, 19 milligrams daily (28.5 IU). For kidney disease, 400 IU (if weight was less than 30 kilograms) or 800 IU (if weight was more than 30 kilograms) has been taken by mouth for two years. For liver disease, 17-200 milligrams per kilogram of d-alpha-tocopherol has been taken by mouth daily. For supplementation in preterm and very low birth weight infants, 10-25 milligrams per kilogram have been injected into the muscle daily starting within 8-24 hours of birth and continued up to 30 days after. These doses have been accompanied by doses of 15-20 milligrams per kilogram injected into the vein, sometimes followed by 15-200 milligrams taken by mouth daily started after at least three days of life. Treatment of vitamin E deficiency should be under medical supervision. Vitamin E absorption may improve if given with meals and in small doses. Safety The U.S. Food and Drug Administration does not strictly regulate herbs and supplements. There is no guarantee of strength, purity or safety of products, and effects may vary. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy. Consult a healthcare provider immediately if you experience side effects. Allergies Avoid in people with known allergy or sensitivity to products that contain vitamin E. Skin reactions, including inflammation or itching, have been reported with vitamin E applied to the skin. Side Effects and Warnings Vitamin E is likely safe when used in healthy adults at doses commonly found in food, and in healthy people over 65 at doses up to 800 IU taken by mouth daily for up to four months. Vitamin E is possibly safe in people with diabetes or those using agents that lower blood sugar. Vitamin E may cause allergic skin reactions (inflammation or itching), blurred vision, changes in cholesterol levels, changes in insulin resistance, diarrhea, dizziness, fatigue, flu-like symptoms, headache, heart conditions, increased risk of death, increased risk of fainting or falls, increased risk of heart failure, increased risk of high blood pressure in pregnancy, increased risk of stroke, increased risk of tuberculosis, kidney dysfunction, nausea, severe response to infection (in preterm babies), sexual dysfunction, stomach pain, vision loss, and weakness. Use cautiously in smokers and in people with Alzheimer’s disease or mental decline, eye damage, kidney problems, heart conditions, and skin conditions. Use cautiously in preterm babies. Use cautiously when using long-term (more than 10 years). Vitamin E may increase the risk of bleeding. Avoid in people with bleeding disorders or taking drugs that may increase the risk of bleeding. Avoid using high doses by mouth or high doses injected into the vein. Avoid using high doses in pregnant women, due to the risk of heart problems in the baby. Avoid in people with known allergy or sensitivity to products that contain vitamin E. Pregnancy and Breastfeeding Many prenatal vitamins contain small amounts of vitamin E. Natural forms of vitamin E may be preferred to man-made forms. Use cautiously in preterm babies. Avoid using high doses in pregnant women, due to the risk of heart problems in the baby. Interactions Interactions with Drugs Vitamin E may increase the risk of bleeding when taken with drugs that increase the risk of bleeding. Some examples include aspirin, anticoagulants (“blood thinners”) such as warfarin (Coumadin®) or heparin, anti-platelet drugs such as clopidogrel (Plavix®), and non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin®, Advil®) or naproxen (Naprosyn®, Aleve®). Vitamin E may interfere with the way the body processes certain drugs using the liver’s “cytochrome P450” enzyme system. As a result, the levels of these drugs may be altered in the blood, and may cause altered effects or potentially serious adverse reactions. People using any medications should check the package insert, and speak with a qualified healthcare professional, including a pharmacist, about possible interactions. Vitamin E may also interact with agents that cause abortion, Alzheimer’s agents, amprenavir, anesthetics, anti-androgens, anti-arthritis agents, anti-asthma agents, anticancer agents, antidiabetic agents, anti-estrogens, anti-seizure agents, anti-tuberculosis agents, aromatase inhibitors, cholesterol-lowering agents, cholestyramine, colestipol, cyclosporine, gefinitib, gemfibrozil, heart agents, hormonal agents, hydrophilic agents, iron, isoniazid, letrozole, nervous system agents, orlistat, paclitaxel, propofol, remifentanil, sucralfate, and vancomycin. Interactions with Herbs and Dietary Supplements Vitamin E may increase the risk of bleeding when taken with herbs and supplements that are believed to increase the risk of bleeding. Multiple cases of bleeding have been reported with the use of Ginkgo biloba, and fewer cases with garlic and saw palmetto. Numerous other agents may theoretically increase the risk of bleeding, although this has not been proven in most cases. Vitamin E may interfere with the way the body processes certain herbs or supplements using the liver’s “cytochrome P450” enzyme system. As a result, the levels of other herbs or supplements may be altered in the blood. It may also alter the effects that other herbs or supplements possibly have on the P450 system. Vitamin E may also interact with aloe, Alzheimer’s herbs and supplements, anesthetics, anti-androgens, anti-arthritis herbs and supplements, anti-asthma herbs and supplements, anticancer herbs and supplements, antidiabetic agents, anti-estrogens, antioxidants, anti-seizure herbs and supplements, cholesterol-lowering herbs and supplements, cigarettes, copper, fish oil, heart herbs and supplements, herbs and supplements that cause abortion, hormonal herbs and supplements, hydrophilic herbs and supplements, iron, mineral oil, nervous system herbs and supplements, omega-6 fatty acids, stanyl esters, vitamin A, vitamin C, vitamin K, and zinc.