Regulation of P-Glycoprotein in the Brain.

Maintenance of the tightly regulated homeostatic environment of the brain is facilitated by the blood-brain barrier (BBB). P-glycoprotein (P-gp), an ATP-binding cassette transporter, is expressed on the luminal surface of the endothelial cells in the BBB, and actively exports a wide variety of substrates to limit exposure of the vulnerable brain environment to waste buildup and neurotoxic compounds. Downregulation of P-gp expression and activity at the BBB have been reported with ageing and in neurodegenerative diseases. Upregulation of P-gp at the BBB contributes to poor therapeutic outcomes due to altered pharmacokinetics of CNS-acting drugs. The regulation of P-gp is highly complex, but unravelling the mechanisms involved may help the development of novel and nuanced strategies to modulate P-gp expression for therapeutic benefit. This review summarises the current understanding of P-gp regulation in the brain, encompassing the transcriptional, post-transcriptional and post-translational mechanisms that have been identified to affect P-gp expression and transport activity.

The Ubiquitin E3 Ligase Nedd4 Regulates the Expression and Amyloid-ß Peptide Export Activity of P-Glycoprotein.

The ATP-binding cassette transporter, P-glycoprotein (P-gp), has been demonstrated to facilitate the clearance of amyloid-beta (Aß) peptides, exporting the neurotoxic entity out of neurons and out of the brain via the blood-brain barrier. However, its expression and function diminish with age and in Alzheimer's disease. P-gp is known to undergo ubiquitination, a post-translational modification that results in internalisation and/or degradation of the protein. NEDD4-1 is a ubiquitin E3 ligase that has previously been shown to ubiquitinate P-gp and reduce its cell surface expression. However, whether this effect translates into altered P-gp activity remains to be determined. siRNA was used to knockdown the expression of Nedd4 in CHO-APP cells. Western blot analysis confirmed that absence of Nedd4 was associated with increased P-gp protein expression. This was accompanied by increased transport activity, as shown by export of the P-gp substrate calcein-AM, as well as enhanced secretion of Aß peptides, as shown by ELISA. These results implicate Nedd4 in the regulation of P-gp, and highlight a potential approach for restoring or augmenting P-gp expression and function to facilitate Aß clearance from the brain.

Regulation of ATP binding cassette transporter A1 (ABCA1) expression: cholesterol-dependent and - independent signaling pathways with relevance to inflammatory lung disease.

The role of the ATP binding cassette transporter A1 (ABCA1) in maintaining cellular lipid homeostasis in cardiovascular disease is well established. More recently, the important beneficial role played by ABCA1 in modulating pathogenic disease mechanisms, such as inflammation, in a broad range of chronic conditions has been realised. These studies position ABCA1 as a potential therapeutic target in a diverse range of diseases where inflammation is an underlying cause. Chronic respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD) are driven by inflammation, and as such, there is now a growing recognition that we need a greater understanding of the signaling pathways responsible for regulation of ABCA1 expression in this clinical context. While the signaling pathways responsible for cholesterol-mediated ABCA1 expression have been clearly delineated through decades of studies in the atherosclerosis field, and thus far appear to be translatable to the respiratory field, less is known about the cholesterol-independent signaling pathways that can modulate ABCA1 expression in inflammatory lung disease. This review will identify the various signaling pathways and ligands that are associated with the regulation of ABCA1 expression and may be exploited in future as therapeutic targets in the setting of chronic inflammatory lung diseases.

New Evidence for P-gp-Mediated Export of Amyloid-ß PEPTIDES in Molecular, Blood-Brain Barrier and Neuronal Models.

Defective clearance mechanisms lead to the accumulation of amyloid-beta (Aß) peptides in the Alzheimer's brain. Though predominantly generated in neurons, little is known about how these hydrophobic, aggregation-prone, and tightly membrane-associated peptides exit into the extracellular space where they deposit and propagate neurotoxicity. The ability for P-glycoprotein (P-gp), an ATP-binding cassette (ABC) transporter, to export Aß across the blood-brain barrier (BBB) has previously been reported. However, controversies surrounding the P-gp-Aß interaction persist. Here, molecular data affirm that both Aß40 and Aß42 peptide isoforms directly interact with and are substrates of P-gp. This was reinforced ex vivo by the inhibition of Aß42 transport in brain capillaries from P-gp-knockout mice. Moreover, we explored whether P-gp could exert the same role in neurons. Comparison between non-neuronal CHO-APP and human neuroblastoma SK-N-SH cells revealed that P-gp is expressed and active in both cell types. Inhibiting P-gp activity using verapamil and nicardipine impaired Aß40 and Aß42 secretion from both cell types, as determined by ELISA. Collectively, these findings implicate P-gp in Aß export from neurons, as well as across the BBB endothelium, and suggest that restoring or enhancing P-gp function could be a viable therapeutic approach for removing excess Aß out of the brain in Alzheimer's disease.

Oxysterols: Old Tale, New Twists.

Oxysterols have long been known for their important role in cholesterol homeostasis, where they are involved in both transcriptional and posttranscriptional mechanisms for controlling cholesterol levels. However, they are increasingly associated with a wide variety of other, sometimes surprising cell functions. They are activators of the Hedgehog pathway (important in embryogenesis), and they act as ligands for a growing list of receptors, including some that are of importance to the immune system. Oxysterols have also been implicated in several diseases such as neurodegenerative diseases and atherosclerosis. Here, we explore the latest research into the roles oxy-sterols play in different areas, and we evaluate the current evidence for these roles. In addition, we outline critical concepts to consider when investigating the roles of oxysterols in various situations, which includes ensuring that the concentration and form of the oxysterol are relevant in that context--a caveat with which many studies have struggled.

The Adaptor Protein Alix is Involved in the Interaction Between the Ubiquitin Ligase NEDD4-1 and its Targets, ABCG1 and ABCG4.

Several ATP-Binding Cassette (ABC) transporters, including ABCG1 and the related ABCG4, are essential regulators of cellular lipid homeostasis. ABCG1 is expressed ubiquitously and is functional in the context of atherosclerosis. However, ABCG4 is expressed almost exclusively in brain and has been linked to Alzheimer's disease (AD). These transporters are highly regulated post-translationally by E3 ubiquitin ligases, with the ligase NEDD4-1 (Neural precursor cell-expressed developmentally downregulated gene 4) implicated in their protein stability. In this study, we investigated interacting partners of ABCG1 using peptide-mass spectrometry and identified the potential adaptor protein, Alix (apoptosis-linked gene 2-interacting protein X). In this paper, we hypothesized and investigated whether Alix could facilitate the interaction between NEDD4-1 and the ABC transporters. We showed that Alix and NEDD4-1 proteins were co-expressed in several commonly used cell lines. Knockdown of Alix in cells overexpressing ABCG1 or ABCG4 increased transporter protein expression while co-immunoprecipitation experiments showed interaction between NEDD4-1, Alix, and ABC transporters. In summary, we provide evidence that Alix serves as a co-factor for the interaction between the E3-ubiquitin ligase NEDD4-1 and the ABC transporter targets, ABCG1 and ABCG4.

The E3 ubiquitin ligase, HECTD1, is involved in ABCA1-mediated cholesterol export from macrophages.

The ABC lipid transporters, ABCA1 and ABCG1, are essential for maintaining lipid homeostasis in cells such as macrophages by exporting excess cholesterol to extracellular acceptors. These transporters are highly regulated at the post-translational level, including protein ubiquitination. Our aim was to investigate the role of the E3 ubiquitin ligase HECTD1, recently identified as associated with ABCG1, on ABCG1 and ABCA1 protein levels and cholesterol export function. Here, we show that HECTD1 protein is widely expressed in a range of human and murine primary cells and cell lines, including macrophages, neuronal cells and insulin secreting ß-cells. siRNA knockdown of HECTD1 unexpectedly decreased overexpressed ABCG1 protein levels and cell growth, but increased native ABCA1 protein in CHO-K1 cells. Knockdown of HECTD1 in unloaded THP-1 macrophages did not affect ABCG1 but significantly increased ABCA1 protein levels, in wild-type as well as THP-1 cells that do not express ABCG1. Cholesterol export from macrophages to apoA-I over time was increased after knockdown of HECTD1, however these effects were not sustained in cholesterol-loaded cells. In conclusion, we have identified a new candidate, the E3 ubiquitin ligase HECTD1, that may be involved in the regulation of ABCA1-mediated cholesterol export from unloaded macrophages to apoA-I. The exact mechanism by which this ligase affects this pathway remains to be elucidated.

Examining the role of ABC lipid transporters in pulmonary lipid homeostasis and inflammation.

Respiratory diseases including asthma and chronic obstructive pulmonary disease (COPD) are characterised by excessive and persistent inflammation. Current treatments are often inadequate for symptom and disease control, and hence new therapies are warranted. Recent emerging research has implicated dyslipidaemia in pulmonary inflammation. Three ATP-binding cassette (ABC) transporters are found in the mammalian lung - ABCA1, ABCG1 and ABCA3 - that are involved in movement of cholesterol and phospholipids from lung cells. The aim of this review is to corroborate the current evidence for the role of ABC lipid transporters in pulmonary lipid homeostasis and inflammation. Here, we summarise results from murine knockout studies, human diseases associated with ABC transporter mutations, and in vitro studies. Disruption to ABC transporter activity results in lipid accumulation and elevated levels of inflammatory cytokines in lung tissue. Furthermore, these ABC-knockout mice exhibit signs of respiratory distress. ABC lipid transporters appear to have a crucial and protective role in the lung. However, our knowledge of the underlying molecular mechanisms for these benefits requires further attention. Understanding the relationship between cholesterol and inflammation in the lung, and the role that ABC transporters play in this may illuminate new pathways to target for the treatment of inflammatory lung diseases.

The E3 ubiquitin ligases, HUWE1 and NEDD4-1, are involved in the post-translational regulation of the ABCG1 and ABCG4 lipid transporters.

The ATP-binding cassette transporter ABCG1 has an essential role in cellular cholesterol homeostasis, and dysregulation has been associated with a number of high burden diseases. Previous studies reported that ABCG1 is ubiquitinated and degraded via the ubiquitin proteasome system. However, so far the molecular mechanism, including the identity of any of the rate-limiting ubiquitination enzymes, or E3 ligases, is unknown. Using liquid chromatography mass spectrometry, we identified two HECT domain E3 ligases associated with ABCG1, named HUWE1 (HECT, UBA, and WWE domain containing 1, E3 ubiquitin protein ligase) and NEDD4-1 (Neural precursor cell-expressed developmentally down regulated gene 4), of which the latter is the founding member of the NEDD4 family of ubiquitin ligases. Silencing both HUWE1 and NEDD4-1 in cells overexpressing human ABCG1 significantly increased levels of the ABCG1 monomeric and dimeric protein forms, however ABCA1 protein expression was unaffected. In addition, ligase silencing increased ABCG1-mediated cholesterol export to HDL in cells overexpressing the transporter as well as in THP-1 macrophages. Reciprocally, overexpression of both ligases resulted in a significant reduction in protein levels of both the ABCG1 monomeric and dimeric forms. Like ABCG1, ABCG4 protein levels and cholesterol export activity were significantly increased after silencing both HUWE1 and NEDD4-1 in cells overexpressing this closely related ABC half-transporter. In summary, we have identified for the first time two E3 ligases that are fundamental enzymes in the post-translational regulation of ABCG1 and ABCG4 protein levels and cellular cholesterol export activity.

Cholesterol sensing by the ABCG1 lipid transporter: Requirement of a CRAC motif in the final transmembrane domain.

The ATP-binding cassette (ABC) transporter, ABCG1, is a lipid exporter involved in removal of cholesterol from cells that has been investigated for its role in foam cells formation and atherosclerosis. The mechanism by which ABC lipid transporters bind and recognise their substrates is currently unknown. In this study, we identify a critical region in the final transmembrane domain of ABCG1, which is essential for its export function and stabilisation by cholesterol, a post-translational regulatory mechanism that we have recently identified as dependent on protein ubiquitination. This transmembrane region contains several Cholesterol Recognition/interaction Amino acid Consensus (CRAC) motifs, and its inverse CARC motifs. Mutational analyses identify one CRAC motif in particular with Y667 at its core, that is especially important for transport activity to HDL as well as stability of the protein in the presence of cholesterol. In addition, we present a model of how cholesterol docks to this CRAC motif in an energetically favourable manner. This study identifies for the first time how ABCG1 can interact with cholesterol via a functional CRAC domain, which provides the first insight into the substrate-transporter interaction of an ABC lipid exporter.

Cellular cholesterol regulates ubiquitination and degradation of the cholesterol export proteins ABCA1 and ABCG1.

The objective of this study was to examine the influence of cholesterol in post-translational control of ABCA1 and ABCG1 protein expression. Using CHO cell lines stably expressing human ABCA1 or ABCG1, we observed that the abundance of these proteins is increased by cell cholesterol loading. The response to increased cholesterol is rapid, is independent of transcription, and appears to be specific for these membrane proteins. The effect is mediated through cholesterol-dependent inhibition of transporter protein degradation. Cell cholesterol loading similarly regulates degradation of endogenously expressed ABCA1 and ABCG1 in human THP-1 macrophages. Turnover of ABCA1 and ABCG1 is strongly inhibited by proteasomal inhibitors and is unresponsive to inhibitors of lysosomal proteolysis. Furthermore, cell cholesterol loading inhibits ubiquitination of ABCA1 and ABCG1. Our findings provide evidence for a rapid, cholesterol-dependent, post-translational control of ABCA1 and ABCG1 protein levels, mediated through a specific and sterol-sensitive mechanism for suppression of transporter protein ubiquitination, which in turn decreases proteasomal degradation. This provides a mechanism for acute fine-tuning of cholesterol transporter activity in response to fluctuations in cell cholesterol levels, in addition to the longer term cholesterol-dependent transcriptional regulation of these genes.

ABCG1 is involved in vitamin E efflux.

Vitamin E membrane transport has been shown to involve the cholesterol transporters SR-BI, ABCA1 and NPC1L1. Our aim was to investigate the possible participation of another cholesterol transporter in cellular vitamin E efflux: ABCG1. In Abcgl-deficient mice, vitamin E concentration was reduced in plasma lipoproteins whereas most tissues displayed a higher vitamin E content compared to wild-type mice. α- and γ-tocopherol efflux was increased in CHO cells overexpressing human ABCG1 compared to control cells. Conversely, α- and γ- tocopherol efflux was decreased in ABCG1-knockdown human cells (Hep3B hepatocytes and THP-1 macro- phages). Interestingly, α- and γ-tocopherol significantly downregulated ABCG1 and ABCA1 expression levels in Hep3B and THP-1, an effect confirmed in vivo in rats given vitamin E for 5 days. This was likely due to reduced LXR activation by oxysterols, as Hep3B cells and rat liver treated with vitamin E displayed a significantly reduced content in oxysterols compared to their respective controls. Overall, the present study reveals for the first time that ABCG1 is involved in cellular vitamin E efflux.

The pharmacogenomics of statins.

The statin class of cholesterol-lowering drugs have been used for decades to successfully lower plasma cholesterol concentrations and cardiovascular risk. Adverse effects of statins are generally considered mild, but increase with age of patients and polypharmacy. One aspect of statin therapy that is still difficult for prescribers to predict is the individual's response to statin therapy. Recent advances in the field of pharmacogenomics have indicated variants of candidate genes that affect statin efficacy and safety. In this review, a number of candidates that affect statin pharmacokinetics and pharmacodynamics are discussed. Some of these candidates, in particular those involved in import and efflux of statins, have now been linked to increased risk of side effects. Furthermore, pharmacogenomic studies continue to reveal new players that are involved in the fine-tuning of the complex regulation of cholesterol homeostasis and response to statins.

The role of signalling in cellular cholesterol homeostasis.

Cholesterol is a vital lipid and performs diverse functions on a whole body and cellular level. However, excess cellular cholesterol is toxic, and thus, elegant mechanisms have evolved to tightly regulate this important lipid. The regulation of cholesterol homeostasis is an area of intense research, and the role that signalling plays is gradually becoming more widely recognised. Cholesterol homeostasis is achieved through intricate mechanisms involving synthesis, uptake, and efflux. Although there is a large body of work elucidating these cholesterol-related pathways, less is known about the role of signalling in these processes. Here, we discuss the variety of ways that signalling impacts on these modes and levels of cholesterol homeostasis, including transcriptional regulation. Most work thus far has investigated the role of kinases in cholesterol efflux (especially on ATP-binding cassette transporter A1, ABCA1), and therefore constitutes a major focus of this review. We also indicate further avenues to explore in the area of signalling in cellular cholesterol homeostasis.

Pharmacy education in traditional and complementary medicines - A systematic review.

BACKGROUND: Traditional and complementary medicines (T&CMs) are not typically covered in medical curricula despite 80% of the world's population using some form of herbal product as part of their healthcare. Concurrent use of T&CMs with conventional therapies is common, and both are primarily accessed in pharmacies. There is an expectation that pharmacists should be knowledgeable about T&CMs. Therefore, this review aimed to investigate what is currently known about pharmacists' T&CMs education and training to inform developments in pharmacy education. METHODS: Eligible studies published between 01/01/2016 and 28/02/2023 were identified across six databases (PubMed, Scopus, Web of Science, EMBASE, ScienceDirect and MEDLINE). Data were extracted from included studies and categorized into key themes and sub-themes and reported descriptively. FINDINGS: Fifty-eight studies were identified, conducted across 30 countries, that included information about pharmacists' T&CMs education and training. Within the four main themes extracted, six subthemes were identified including: T&CMs education and training received; inadequate education and training opportunities; knowledge, and confidence towards T&CMs in the pharmacy setting; professional practice behaviour associated with T&CM; university education for pharmacy students; and continuing professional development for practicing pharmacists, including T&CM-drug interactions, interpreting T&CM research, T&CM-specific communication skills, T&CM use in pregnancy and breastfeeding, and efficacy and safety of T&CM in specific conditions. CONCLUSION: Overall pharmacists are receiving limited T&CM education in undergraduate and continuing professional training and report a lack of resources to inform the advice they provide to consumers. The findings of this review can inform developments in T&CMs curriculum and accreditation standards that support the training needs of pharmacists who play a role in fostering the safe and appropriate use of these products.

Protein kinase A modulates the activity of a major human isoform of ABCG1.

ABCG1 is an ABC half-transporter that exports cholesterol from cells to HDL. This study set out to investigate differences in posttranslational processing of two human ABCG1 protein isoforms, termed ABCG1(+12) and ABCG1(-12), that differ by the presence or absence of a 12 amino acid peptide. ABCG1(+12) is expressed in human cells and tissues, but not in mice. We identified two protein kinase A (PKA) consensus sites in ABCG1(+12), absent from ABCG1(-12). Inhibition of PKA with either of two structurally unrelated inhibitors resulted in a dose-dependent increase in cholesterol export from cells expressing ABCG1(+12), whereas ABCG1(-12)-expressing cells were unaffected. This was associated with stabilization of the ABCG1(+12) protein, and ABCG1(+12)-S389 was necessary to mediate these effects. Mutation of this serine to aspartic acid, simulating a constitutively phosphorylated state, resulted in accelerated degradation of ABCG1(+12) and reduced cholesterol export. Engineering an equivalent PKA site into ABCG1(-12) rendered this isoform responsive to PKA inhibition, confirming the relevance of this sequence. Together, these results demonstrate an additional level of complexity to the posttranslational control of this human ABCG1 isoform that is absent from ABCG1(-12) and the murine ABCG1 homolog.

Attitudes, behaviours, and self-reported confidence of Australian pharmacy students and interns towards nutritional counselling.

INTRODUCTION: Pharmacists play a prominent role in the counselling and education of patients complementary to provision of medicines. The increase in non-communicable diseases associated with poor quality diets has placed a greater demand on pharmacists to play a role in the provision of nutritional education to patients. This study aimed to investigate pharmacy students' and interns' attitudes, behaviours, and self-reported confidence towards nutritional counselling and to examine factors associated with their intention to counsel patients in nutrition. METHODS: An online survey was designed using the theory of planned behaviour and was distributed to final-year pharmacy students and interns enrolled at the University of Sydney. Data analysis was conducted to test for correlations between behavioural intentions, attitudes, confidence, subjective norms, and perceived behavioural control. RESULTS: Sixty-six surveys were completed, representing an average response rate of 19.6%. Half of all participants reportedly were providing nutritional advice to patients at least once per week or more often when working in a pharmacy. Participants' intention to counsel patients about nutrition was influenced by preceptors' encouragement. The participants' average level of confidence in having the knowledge and skills to provide nutritional counselling, reported over 13 medical conditions, showed that they were on average "somewhat confident" in providing nutritional counselling, with the level of confidence differing depending upon the specific topic areas. CONCLUSIONS: Participants acknowledged the role of pharmacists in the provision of nutritional counselling, but a more comprehensive nutrition curriculum integrated within existing pharmacy curricula is warranted to increase pharmacy students' and interns' confidence.

A review of primary healthcare practitioners' views about nutrition: implications for medical education.

Objectives: This study aimed to review literature that reports on the perspectives and opinions of Australian and New Zealand primary healthcare practitioners on their role in nutrition counselling of their patients. Methods: A systematic search of relevant articles reporting on attitudes towards nutrition counselling by Australian and New Zealand doctors/physicians, nurses including midwives, pharmacists and dentists was conducted. The search included literature from the past ten years until March 2021 and identified 21 relevant papers, with most of the studies including medical practitioners and nurses. Results: Three main themes were identified from qualitative and quantitative data, which included education and training, practitioner experiences and challenges. Consistent with previous literature, health care practitioners acknowledged their important role in the provision of dietary advice to patients. Challenges that influenced the provision of this advice included insufficient education and training, time constraints and limited knowledge and confidence. Time constraints during normal consultations led to a low priority of nutrition counselling. An absence of assessment opportunities to demonstrate nutrition competence and limited coverage of specific nutrition-related advice during training were also reported. Conclusions: Primary healthcare practitioners acknowledge the importance of playing a role in the provision of nutrition advice but require education and access to evidence-based information that can be utilised effectively within the time constraints of standard consultations. Medical education curricula can be improved to provide more emphasis on nutrition education, including relevant assessment opportunities.

Apolipoprotein E isoform-dependent effects on the processing of Alzheimer's amyloid-ß.

Since the identification of the apolipoprotein E (apoE) *ε4 allele as a major genetic risk factor for late-onset Alzheimer's disease, significant efforts have been aimed at elucidating how apoE4 expression confers greater brain amyloid-ß (Aß) burden, earlier disease onset and worse clinical outcomes compared to apoE2 and apoE3. ApoE primarily functions as a lipid carrier to regulate cholesterol metabolism in circulation as well as in the brain. However, it has also been suggested to interact with hydrophobic Aß peptides to influence their processing in an isoform-dependent manner. Here, we review evidence from in vitro and in vivo studies extricating the effects of the three apoE isoforms, on different stages of the Aß processing pathway including synthesis, aggregation, deposition, clearance and degradation. ApoE4 consistently correlates with impaired Aß clearance, however data regarding Aß synthesis and aggregation are conflicting and likely reflect inconsistencies in experimental approaches across studies. We further discuss the physical and chemical properties of apoE that may explain the inherent differences in activity between the isoforms. The lipidation status and lipid transport function of apoE are intrinsically linked with its ability to interact with Aß. Traditionally, apoE-oriented therapeutic strategies for Alzheimer's disease have been proposed to non-specifically enhance or inhibit apoE activity. However, given the wide-ranging physiological functions of apoE in the brain and periphery, a more viable approach may be to specifically target and neutralise the pathological apoE4 isoform.

Do medicines commonly used by older adults impact their nutrient status?

Background: Chronic health conditions and polypharmacy are common among the older population and associated with increased risks of adverse events, medicine-interactions, geriatric syndromes, falls and mortality. Poor nutrition is also common in older people. Causal associations between medication use and older people's nutrient status is seldom discussed. Objectives: The objectives of this review were to summarise the literature reporting associations between medicines commonly prescribed to older adults and nutrient deficiencies, and to discuss the clinical implications and management. Methods: Medicine information resources (n = 5) were searched for information about nutrient deficiencies associated with common medicines used by older people and listed within the top 50 medicines prescribed by volume on the Australian Pharmaceutical Benefits Scheme. This was followed by a search for clinical studies published on PubMed from inception to April 2020. Data was extracted, tabulated and summarised with clinical information relevant to pharmacists and clinicians involved in the care of older people taking medicines. Results: A total of 23 clinical studies were identified reporting medicine-induced nutrient deficiencies in older adults. Vitamin B12, sodium, magnesium were identified as the 3 main nutrients susceptible to deficiency by medicines used to treat cardiovascular disease, neurological conditions, gastrointestinal conditions, and diabetes. The coenzyme CoQ10 was depleted by statins.Conclusion: Certain medicines commonly prescribed to older adults are associated with nutrient deficiencies that may be clinically significant. Given the high prevalence of comorbidities and polypharmacy it is possible that some of these individual drug-induced nutrient deficiencies are compounded, warranting both clinical and research attention.