Exam 2

Question 1

*How are dietary supplements defined?

Dietary Supplement Health and Education Act (DSHEA) -

Answer 1

Includes herbal medicines in the definition of a dietary supplement,
assures consumers access to all supplements on the market as long as
they are not determined to be unsafe, and allows for structure and
function claims to appear on the label.

Question 2

“dietary ingredients” in dietary supplements may include

Answer 2

vitamins,
minerals, herbs, and amino acids as well as substances such as
enzymes, organ tissues, metabolites, extracts or concentrates.

Question 3

Dietary supplements can be found in many forms such as

Answer 3

pills, tablets, capsules,
liquids or powders.

Question 4

They must be identified on the label as a

Answer 4

dietary
supplement.

Question 5

*How are dietary supplements treated differently from drugs by the FDA?

Answer 5

• No safety data required for products available before
  DSHEA enacted
• Previously no mandatory reporting of adverse events
• No requirement for product potency or consistency
  unless labeled as such (USP)
• No requirements that inferred benefits are true or
  Tested

Variability in DS product content is
potentially high
* Product content is not stipulated by FDA
* Most studies are small
– High likelihood of negative publication bias
* Most studies are short
– Long term benefit and/or toxicities less well
characterized

Question 6

Unsafe Botanicals are the Exception

Answer 6

• Drug-Herb Interactions appear to have far greater potential
  for unintended harm than adverse effects arising directly from
  common supplements
• Exceptions (Recognized herbs with specific adverse effects):
  – Aconite Guar Gum (obstruction)
  – Licorice Root Pennyroyal
  – Pyrrolizidine alkaloids Mistletoe/Skullcap
  – Allergic Reactions Aristolochic Acid
  – Broom Chapparal
  – Comfrey Ephedra
  – Germander Heavy Metal Adulteration

Question 7

*What guidance is provided by the FDA on the appropriate use of
dietary supplements?

Answer 7

• If the FDA (law) dose not allow supplements
  to carry drug claims, then the FDA cannot say
  whether they are effective or not
• Product content cannot be stipulated
• Similarly, the FDA cannot state that one brand
  or mixture of dietary supplement is more
  effective than another.
  – It would again infer that the “better” one had
  drug-like effects, which cannot be claimed.

Question 8

Some Supplements can provide data
to support “Health Claims”

example: calcium

Answer 8

– “Regular exercise and a healthy diet with enough
calcium helps teen and young adult white and
Asian women maintain good bone health and may
reduce their high risk of osteoporosis later in life.”

Question 9

Soy Health Claim

Answer 9

• “Diets low in saturated fat and cholesterol that include 25 grams of soy protein a day may reduce the risk of heart disease. One serving of (name of food) provides __ grams of soy protein.”

To qualify for the claim foods must contain per serving:
* 6.25 grams of soy protein
* low fat (less than 3 grams)
* low saturated fat (less than 1 gram)
* Low cholesterol (less than 20 milligrams)
* sodium value of less than 480 milligrams for individual foods, less than 720 milligrams if considered a main dish, and less than 960 milligrams if considered a meal.

Question 10

DSHEA - Labeling Requirements
* Labeling must not:

Answer 10

– Claim to diagnose, prevent, mitigate, treat, or cure
a specific disease or class of diseases;

Question 11

• Labeling may:

Answer 11

– Describe the role of a nutrient or dietary
ingredient intended to affect the structure or
function in humans

Question 12

Examples of Labeling

Answer 12

• Silymarin

– Prohibited: Improves alcoholic cirrhosis

– Allowed: Supports normal liver function

• Echinacea

– Prohibited: Prevents colds and flu

– Allowed: Helps support immune function

Question 13

If the FDA (law) dose not allow supplements
to carry drug claims, then the FDA cannot say

Answer 13

whether they are effective or not
* Product content cannot be stipulated
* Similarly, the FDA cannot state that one brand
or mixture of dietary supplement is more
effective than another.
– It would again infer that the “better” one had
drug-like effects, which cannot be claimed.

Question 14

Protecting Intellectual Property

Answer 14

• Supplement manufacturers often will combine
  ingredients into “proprietary blends”.

Question 15

proprietary blends label

Answer 15

– The label must include the components and the
total weight of the mixture
– The label DOES NOT need to include the exact
amount of each ingredient
* As with foods, the most prevalent component is listed
first, etc..
* No need to demonstrate benefit of mixture

Question 16

Dietary supplement labels

Answer 16

suggested use and dose as a claim and is not required

also does not necessarily have to match SFB information

all other ingreedients including excipients, lubricants, and capsule material must be listed below SFB

Question 17

A growing number of dietary supplements
have been shown to have beneficial activity in
well controlled clinical trials

Answer 17

• There is no current control over the content of
  even the “effective” products
• Even “certified” products may vary over time

Question 18

Agnus Castus (Vitex)

Common uses:

Answer 18

symptoms of premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), dysmenorrhea, mastalgia, and menopausal symptoms.

Question 19

Agnus Castus (Vitex) Adverse effects:

Answer 19

GI complaints occur occasionally with use of chasteberry. Other symptoms include dry mouth, headache, rashes, itching, acne, menstrual disorders, and agitation. Chasteberry should be avoided during pregnancy because of insufficient data to support safe use and the possibility of lactation suppression. Theoretically, chasteberry may interact with medications that impact dopamine, as well as hormone replacement therapies and oral contraceptives.

Question 20

Curcumin/Tumeric

Common uses:

Answer 20

arthritis and inflammatory conditions.

Question 21

Curcumin/Tumeric
Adverse Effects

Answer 21

The most common side effects are GI discomfort and nausea. Human studies show good tolerance with doses as high as 12,000 mg daily.

Curcumin inhibits platelet aggregation, so patients on antithrombotic agents should use curcumin cautiously.

Question 22

Glucosamine Common uses

Answer 22

osteoarthritis (OA) and joint health

Question 23

Glucosamine Adverse Effects

Answer 23

Adverse effects for both components include mild GI upset, nausea, diarrhea,
and constipation, which can often be alleviated by taking divided doses with
meals. Drowsiness, headache, and skin reactions have been reported infrequently with glucosamine

Question 24

Bitter Melon

Common uses:

Answer 24

increased cellular glucose uptake, decreased gluconeogenesis in the liver, and increased insulin secretion.

was able to significantly reduce fasting plasma glucose, postprandial glucose

Question 25

Bitter Melon Adverse Effects

Answer 25

Well tolerated with primarily GI side effects, such as nausea, heartburn, and diarrhea.

Question 26

Enchinacea Common Uses

Answer 26

prevent and treat colds and other respiratory infections

Question 27

Enchinacea adverse effects

Answer 27

allergic reactions may occur with use of echinacea. Patients with a history of asthma or atopy should avoid echinacea; a severse allergy to the Asteraceae/Compositae family, which includes ragweed and chrysanthemums, is also a contraindication. Adverse effects include mild GI discomfort and headache. More serious reactions are possible: after taking an echinacea root product for 5 days while ill with a flu-like syndrome, one patient developed acute cholestatic hepatitis, which resolved quickly after product 140 discontinuation. Echinacea should not be used by patients with severe systemic illnesses such as HIV infection or AIDS, multiple sclerosis, tuberculosis, and autoimmune disorders, and by patients taking

Question 28

Saw Palmetto Common uses:

Answer 28

used to treat BPH. Benign prostatic hyperplasia (BPH) — also called prostate gland enlargement

Question 29

Saw Palmetto Adverse Effects

Answer 29

In comparative studies, saw palmetto was better tolerated than finasteride and tamsulosin. Mild GI complaints, along with fatigue and headache, were the most common symptoms. Significant bleeding has been seen. Individuals taking antithrombotic agents should be avoided. Should not be used in pregnancy and lactation.

Question 30

Cinnamon common uses :

Answer 30

lower blood glucose

Question 31

cinnamon adverse effects

Answer 31

Patients should not confuse cinnamon supplements with cinnamon oil; hypersensitivity reactions to the oil can occur, as well as pediatric poisoning. Severe adverse effects of dry cinnamon powder, other than allergic reactions, no adverse events. One case of medication probable induced hepatitis.

Question 32

Feverfew Common uses:

Answer 32

prevent migraines and to treat dysmenorrhea, arthritis, and psoriasis

Question 33

Feverfew Adverse Effects

Answer 33

GI adverse effects may result from ingestion of feverfew. Oral ulcers can occur from chewing fresh leaves. Post-feverfew syndrome has been reported after abrupt withdrawal from chronic use, resulting in anxiety, headaches, insomnia, and muscle stiffness. Patients who are allergic to plants in the Asteraceae/ Compositae family should avoid use of feverfew, as should women who are pregnant or breastfeeding. Possible antiplatelt effects, so patients taking antithrombotic agents should use with caution

Question 34

Ginseng Common uses:

Answer 34

boost physical and mental energy and to produce a sense of well-being

Question 35

Ginseng Adverse Effects

Answer 35

Ginseng may cause nervousness, excitation, inability to concentrate, estrogenic effects, Stevens–Johnson syndrome, allergy, and hypoglycemic effects; may interact with several drugs including warfarin, digoxin, and alcohol.

Question 36

Garlic Common uses:

Answer 36

hyperlipidemia, hypertension, type 2 diabetes mellitus,

Question 37

Garlic Adverse Effects

Answer 37

though well tolerated, garlic may cause GI adverse effects including nausea, reflux, vomiting, and heartburn, especially with higher dosages or in the first week of therapy. Garlic breath and body odor also may occur. Allergic reactions have been reported rarely. Garlic should be stopped 10–14 days prior to surgical procedures to avoid excessive bleeding. Patients taking antithrombotic agents should use garlic supplements with caution because of the potential risk of bleeding, which may vary with the type of product; however, dietary amounts of garlic do not affect platelet function

Question 38

Ginger Common uses:

Answer 38

The primary use of ginger has been to relieve nausea and vomiting associated with pregnancy, motion sickness, chemotherapy, and surgery. Ginger also has been used for indigestion, colic, and arthritis.

Question 39

Ginger adverse effects

Answer 39

Adverse Effects: Mild heartburn and belching have been reported with ginger. Ginger may increase the risk of hypoglycemia. Ginger may alter platelet function, although findings are mixed; ginger should be used with caution by individuals taking antithrombotic agents.

Question 40

Ginko Biloba Common uses

Answer 40

Ginkgo has been used for Alzheimer’s disease (AD), vascular dementia, attention-deficit/hyperactivity disorder (ADHD), tardive dyskinesia, intermittent claudication, tinnitus, acute mountain sickness, and age-related macular degeneration.

Question 41

Ginko Biloba Adverse Effects

Answer 41

Studies have shown ginkgo to be generally well tolerated. Mild GI adverse effects, headache, dizziness, and allergic skin reactions have been reported Ginkgo should be avoided during pregnancy and lactation because of the lack of safety information. Several potential drug interactions with ginkgo are listed Increased bleeding risk has been associated with use of ginkgo, although the evidence has been associated with the use of ginkgo

Question 42

Black Cohosh Common uses:

Answer 42

Black cohosh has been used to treat the symptoms of premenstrual syndrome, dysmenorrhea, menopause, and rheumatoid arthritis.

Question 43

Black Cohosh Adverse Effects

Answer 43

adverse effects are mild and include GI complaints, headache, rash, and weight gain. Hepatitis, seizures, and cardiovascular disease have been reported in patients taking combination products that contain black cohosh, although a casual relationship has not been established. Potential hepatoxicity

Question 44

Ashwaganda Common uses

Answer 44

calm the brain, reduce swelling, lower blood pressure, and alter the immune system

Question 45

Ashwaganda Adverse effects

Answer 45

gastrointestinal upset, diarrhea, nausea and vomiting,

Question 46

Elder Berry Common uses:

Answer 46

Common uses: used primarily for prevention or treatment of influenza and other upper respiratory illnesses.

Question 47

Elder Berry Adverse Effects

Answer 47

Commercially available elderberry extracts are well tolerated, with few adverse effects reported. Insufficiently cooked or unripe berries can have GI tract issues.

Question 48

*What agency sets the Daily Required Intake of nutrients and vitamins?

Answer 48

Food and Nutrition Board of the National Academies of Sciences Engineering, and Medicine.

Question 49

Most interactions between supplements and drugs are likely to be

Answer 49

pharmacodynamic – Increasing or decreasing the effect of a drug

Question 50

Few established pharmacokinetic interactions

Answer 50

- Increasing or decreasing the concentration of a drug

Question 51

*What topics, questions, or suggestions can be offered when counseling someone asking about the use of dietary supplements?

Answer 51

Are you taking any vitamins? * Are you taking any minerals, such as calcium? * Are you taking any herbal products to improve your health? * Are you taking any fish oil or therapeutic plant-based oils? * Any body-building supplements like protein or amino acid supplements? Do you take this / these products regularly, occasionally, or when you think about it? * Do you notice an improvement in your ___ when you take the supplement? * Are you noticing any side effects around times when you are taking the supplement? Assuming you have a good medical and other Rx/OTC history... * Are there issues with your Rx/OTCs that are bothering you, or lack of sufficient benefit? * What do you hope that this supplement will do for you? * How will you know that it is working? * How long do you plan to try it for benefit?

Question 52

*What are the most commonly used herbal dietary supplements? (from text: )What are they commonly used for, and what side effects are common?

Answer 52

– Elder berry -Echinacea – Horehound - Garlic – Cranberry -Fenugreek – Tumeric -Wheat grass – Apple Cider Vinegar Saw Palmetto – Ginger - Ashwaganada

Question 53

Why might the ingestion of dietary supplements or high doses of vitamins be unwise in patients being treated for cancer, HIV, or organ Transplants?

Answer 53

Try to avoid ... * Immune enhancers in patients with organ transplants or auto-immune disorders: –Echinacea –Astralgus –Ginseng –Various mushrooms Try to avoid ... * High doses of strong antioxidants in patients undergoing chemotherapy or radiation for cancer: –Vitamin C –Vitamin E –Co-Q10 –Selenium Try to avoid ... * Most herbals with warfarin: –Red clover –Dong quai –Ginkgo biloba –Feverfew –Garlic –Curcumin –Ginseng –Ginger Try to avoid ... * Supplements touted as hypoglycemics in patients with diabetes –Bitter Melon –Chromium salts –Vanadium –Gymnema –Cinnamon –Fenugreek

Question 54

Easy Suggestions for DS

Answer 54

* Cheap and documented benefits –Daily vitamin if diet poor –Calcium –Vitamin D –Green Tea (de-caffeinated, if desired) –Fish Oil / Krill Oil

Question 55

*What barriers exist for pharmacists to properly advise patients and clients on the proper and safe use of dietary supplements?

Answer 55

Patients are not likely going to offer what DS they are taking –They may not think of them as such –Embarrassed –Forget or time pressured * They may not get them from your store –Internet –Direct marketing (Herbalife, Nutrilite, etc) –Sold at Gyms, etc.

Question 56

Significant decrease in drug concentration

Answer 56

– St John’s wort – Garlic (maybe)

Question 57

* Significant increase in drug concentration

Answer 57

– Berberine (Goldenseal)

Question 58

* Significant risk with concurrent warfarin or other anticoagulants (low molecular weight heparin) and with:

Answer 58

– Danshen (increased warfarin conc) – Platelet inhibitors (ginkgo, feverfew, etc.) – Coumarin-containing (additive anticoagulation)

Question 59

St John’s wort

Answer 59

* Increases the removal rate of many drugs (>50% of those used) through induction of increased activity of: – Metabolizing enzymes * CYP3A4, 2E1, 2C19 * Glucuronidation – Transporting proteins (pGP and BCRP) * Increased removal from blood * Increased removal from brain and tumors * Return from intestinal epithelium to gut lumen

Question 60

St. John’s wort decreases the blood concentrations of:

Answer 60

– Cancer chemotherapy (CPT-11) – Heart failure therapy (digoxin) – HAART HIV therapy (protease inhibitors) – Immunosuppresants (cyclosporin) – Anti-epileptics (phenytoin) – Oral contraceptives

Question 61

Increased Warfarin Risk

Answer 61

* Decreased platelet function – Adherence and Aggregation – Degranulation and cascade activation

Question 62

* Several supplements have been associated with this in a convincing manner:

Answer 62

– Ginkgo biloba – Feverfew – Garlic

Question 63

Warfarin anticoagulation with herbs containing coumarins will increase effect (increased INR, risk of bleeding)

Answer 63

* Dong Quai * Papaya * Red Clover

Question 64

Pharmacodynamic Interactions (Modification of the Effect arising from a given Drug Concentration) diabetes potentiation

Answer 64

– Vanadium – Ginkgo – Bitter melon – Cinnamon

Question 65

* Hyperkalemic effect

Answer 65

– Spironolactone (K+ sparing) + licorice root Enhanced effect – Synergy

Question 66

Licorice root

Answer 66

* Licorice root has aldosterone-like effects – Sodium, water retention – Potassium loss * Antagonism of diuretics and antihypertensives * Theoretical interaction with lithium * Pro-toxic effect with digoxin if K+ is low

Question 67

Enhanced effect – Synergy

Answer 67

* Hawthorne seed extract for heart failure, plus: – ACE inhibitors, AR antagonists, digoxin? * Sildenafil and similar phosphodiesterase inhibitors – Ginkgo – DHEA – Possible hypotension and syncope

Question 68

How credible are case reports?

Answer 68

* Cranberry –warfarin interaction – Suvarna R, et al. BMJ 2003; 327: 1454 – 70 yo male with recent treatment for a chest infection (Tx with cefalexin) – Rx: digoxin, phenytoin, warfarin – Poor appetite –was drinking only cranberry juice x 2-6 weeks – Hospitalized with an INR > 50 (usual range 2-3) * Died of GI and Pericardial hemorrhage 7 other cases mentioned to have been reported to the British authorities – 4 cases not dramatic – 2 cases, patients had previously unstable INR – 1 case, the INR DECREASED – Compliance / Adherance to regimen is unclear

Question 69

* From these cases, should cranberry juice be proscribed in patients who are taking warfarin?

Answer 69

– As beverage? – As UTI prophylaxis?

Question 70

Dietary Supplements to Support Cancer Patients

Answer 70

* Cancer patients may take supplements to: – Prevent or slow growth of disease – Increase their immune response – Decrease the toxic effects of the treatment – “Turn a new leaf” of a healthier lifestyle. * Changes in diet and exercise are typically not a concern. We are concerned about – Institution of antioxidants (may affect apoptosis) – Institution of immunostimulant

Question 71

* Ginseng (Panax ginseng)

Answer 71

– Increases neutrophil, WBC count recovery in mice treated with cytotoxics – Effect is similar to that sought from G-CSF – Concurrent use of P. ginseng may increase toxicity of chemo- or radiotherapy by putting stem cells in growth fraction – Ginseng should be stopped >3d before Tx

Question 72

Impairment of Chemotherapy by Supplements that are Anti-Oxidants?

Answer 72

* Chemotherapy and radiotherapy in part act by damaging cells, leading to self-destruction (apoptosis) – Many activation steps of apoptosis are initiated by oxidative stress – Antioxidants may decrease these steps leading to apoptosis, decreasing the benefit of cytotoxic treatment – Some pre-clinical studies show a BENEFIT of antioxidants (high dose Vit C, E, K3) * These effects appear to be concentration-dependent * Free radicals formed from XRT may be too short-lived to react with anti-oxidants, but the apoptotic signaling after cell damage may be attenuated with antioxidants

Question 73

Examples of Antioxidants that may Attenuate the Effect of Cancer Treatment

Answer 73

* Ascorbate (Vitamin C) * Retinoids / -carotene * Coenzyme Q10 * Tocopherol (Vitamin E) * Green / Black Tea * Grape Seed Extract * Milk Thistle * Pycnogenol (pine bark extract)

Question 74

Most widely available dietary supplements are safe when taken in

Answer 74

Suggested doses

Question 75

There is a greater risk when dietary supplements

Answer 75

combined with other prescribed therapy

Question 76

* Interactions with medications are

Answer 76

usually not known

Question 77

High risk patients shout not

Answer 77

unilaterally start taking dietary supplements

Question 78

* Heartburn

Answer 78

* Burning in the stomach or lower chest; may extend up toward neck, & occasionally to the back * Other terms people may use synonomously: * Indigestion, acid regurgitation, acid indigestion, “sour stomach”, “bitter belching”

Question 79

Main symptom of GERD

Answer 79

heartburn

Question 80

Heart burn usually occurs

Answer 80

within 1 hour after eating; often after large meal; worsened by lying down

Question 81

GERD

Answer 81

* Chronic condition; frequent reverse flow of stomach acid and contents into the esophagus * Heartburn 2 or more times per week

Question 82

GERD complications

Answer 82

esophagitis, esophageal stricture, Barrett’s esophagus (pre-cancerous condition) * Dyspepsia

Question 83

symptoms of gerd generate from

Answer 83

gastroduodenal region

Question 84

symptoms of gerd include

Answer 84

postprandial fullness, ___epigastric pain__________ * Associated symptoms: anorexia, belching, nausea, vomiting, upper abdominal bloating, heartburn, regurgitation

Question 85

Heart burn aggravating factors

Answer 85

bending over, lying down

Question 86

heart burn associated symptoms

Answer 86

* Regurgitation (bitter acid fluid in back of throat) * Water brash (sudden appearance of clear, salty fluid from salivary glands) * Burping * Hiccups * Nausea * Vomiting * Symptom classifications

Question 87

mild heartburn

Answer 87

a little bothersome but dont affect normal activities

Question 88

moderate heartburn

Answer 88

somewhat annoying or interfere with activities

Question 89

severe heartburn

Answer 89

alarm symptoms

Question 90

UES

Answer 90

upper esophageal sphincter

Question 91

UES to

Answer 91

esophagus

Question 92

Esophagus to

Answer 92

LES lower esophageal sphinicter

Question 93

LES to

Answer 93

diaphragm

Question 94

diaphragm to

Answer 94

stomach

Question 95

help to keep acid & stomach contents in stomach

Answer 95

LES and diaphragm

Question 96

LES ______________ at rest

Answer 96

contracts

Question 97

Heart burn risk factors

Answer 97

alcohol, acidic, caffeine, chocolate, exterme emotions, excersize, stress, obseity, asprin and nsaids, postasium.

Question 98

Do not self treat: heart burn

Answer 98

* Alarm symptoms * Dysphagia*, odynophagia, vomiting, GI bleeding, unexplained weight loss * Atypical symptoms * Noncardiac chest pain, asthma, voice changes, feeling of “lump in the throat”, chronic cough, trouble sleeping/staying asleep, dental erosion

Question 99

Goals of therapy

Answer 99

1. Provide complete symptom relief 2. Reduce symptom recurrence 3. Prevent/manage OTC medication side effects

Question 100

Complementary and non-pharmacologic options

Answer 100

* Acupunture for reflux, GERD sx, dyspepsia * Melatonin (limited data) * Weight loss (even 10% body weight helpful) * No food within 2-3 hours of bedtime * Sleep on left side—why? Shape of stomach, where pouch is, gravity and the angle of connection of the stomach to the esophagus is important. The left side helps to keep acid and stomach contents in the stomach rather than laying on the right side. * Elevate head of bed with 6-8 inch blocks underneath legs or foam GERD pillow* * Stop tobacco use * ______Meditarrian_________diet * Symptom diary to help ID trigger foods (avoid triggers) * Assess Rx & OTC meds! * Modify lifestyle (see risk factors table)

Question 101

Consider: OTC options

Answer 101

* Symptoms: frequency, duration, severity * Medication cost * Drug-drug interactions * Adverse effects * Patient ____preference___________

Question 102

Medications: Heartburn

Answer 102

1. Antacids 2. Histamine-2 receptor antagonists (H2RAs) 3. Proton pump inhibitors (PPIs) 4. Bismuth subsalicylate

Question 103

mild-mod, infrequent heart burn or dyspepsia & only need short-term relief

Answer 103

antacid or H2RA

Question 104

antacid

Answer 104

rapid symptom relief short term relief if take without food interchangeable at recommended doses antacid/alginic acid more effective in combo

Question 105

h2RA

Answer 105

slower relief can use with antacid can use to prevent HB if take 30-60 min prior to known cause of symptoms lower dose for mild symptoms, higher dose for moderate

Question 106

mild, mod infrequent or dyspepsia but need longer lasting relief

Answer 106

H2RA

Question 107

hb 2 or more days per week

Answer 107

PPI or H@RA ppi daily x 14 days H2RA as needed

Question 108

anatacids onset of relief and duration on empty stomach and food in stomach

Answer 108

within 5 minutes empty: 20-30 min food: up to 3 hours

Question 109

H2RA's onset and duration

Answer 109

30-45 minutes 4-8 hours 4-10 hours 9( famotidine)

Question 110

Combo H2RA+ antacid onset and duration

Answer 110

within 5 minutes and lasts 8-10 hours

Question 111

PPI single dose onset and duration

Answer 111

1-3 hours may need 1-4 days for full effect 12-24 hours

Question 112

Follow-up Recommendations

Answer 112

1. If initial therapy with (1) antacid or (2) alginic acid/antacid combo or (3) OTC H2RA or (4) H2RA/antacid combo not helpful after expected time to effect: * Try different agent OR medical referral 2. If initial therapy above IS helpful: * Continue with lifestyle/diet changes and PRN meds * Re-evaluate if any change in symptoms/frequency 3. If heartburn 2 or more days per week & take PPI once daily x 14 days OR H2RA as needed: * Not better after 2 weeks: refer * Better: continue with lifestyle/diet changes, stop PPI; may repeat PPI every _4__ months if needed or continue H2RA PRN

Question 113

antacid products

Answer 113

* Aluminum (hydroxide, phosphate) Branded products: Alternagel®, Amphogel® * Calcium carbonate Branded product: TUMS® * Magnesium (hydroxide, carbonate, trisilicate) Branded product: Mylanta® * Sodium bicarbonate Branded product: Alka-Seltzer®

Question 114

Antacid MOA

Answer 114

neutralize gastric acid, increase __LES__ pressure

Question 115

protective barrier)

Answer 115

Alginic acid + sodium bicarb in saliva = layer of sodium alginate on top of stomach contents

Question 116

Indication:

Answer 116

treatment of mild, infrequent heartburn, sour stomach, and acid indigestion

Question 117

* Pharmacodynamics: * Onset:

Answer 117

within 5 minutes

Question 118

Liquid formulations faster

Answer 118

faster than tablets; quick-dissolving tablets next fastest

Question 119

shortest duration

Answer 119

magnesium hydroxide

Question 120

empty stomach

Answer 120

20-30 min

Question 121

food in stomach

Answer 121

2-3 hours

Question 122

pregnancy

Answer 122

calcium and magnesium antacids ok

Question 123

lactation

Answer 123

aluminium, calcium, magnesium antacids ok

Question 124

Antacids (continued) * Dosing: * Product-

Answer 124

recommended doses; do not exceed

Question 125

repeat dose in

Answer 125

1-2 hours if needed

Question 126

re-evaluate if

Answer 126

* Using more than twice a week * Regularly for more than 2 weeks

Question 127

main side effects aluminum

Answer 127

constipation, hypophosphatemia (long-term use)

Question 128

main side effects calcium carbonate

Answer 128

belching, intestinal gas, constipation; hypercalcemia if kidney dysfunction.

Question 129

main side effects magnesium

Answer 129

diarrhea. Manage by __product that has a combination with aluminum

Question 130

main side effects sodium bicarb

Answer 130

belching, intestinal gas

Question 131

memory trick

Answer 131

aluminum, A comes before Magnesium, M in the alphabet so Constipation comes before Diarrhea in the alphabet

Question 132

calcium carbonate causes

Answer 132

constipation 3, C's

Question 133

antacids drug interactions

Answer 133

many itraconazole, amphetamines rosuvastatin enteric coated meds dasatinib

Question 134

calcium carbonate, mag hydroxide, aluminum hydroxide rug interactions

Answer 134

levothryoxine tetracyclines fluroquinololnes seperate by 4 hours for the first two antibiotic 2 hours prior or 6 hours after antacid

Question 135

aluminum or magnesium drug interaction

Answer 135

azithromycin seperate by at least two hours

Question 136

sodium bicarb drug interactions

Answer 136

Quinidine (decreased excretion) Salicylates (increased excretion) avoid concurrent use or monitor carefully

Question 137

Antacids (last slide) * Avoid:

Answer 137

* Dyspepsia* * Aluminum or calcium if kidney dysfunction * Calcium: Total daily MAX calcium intake (food + meds): * 2500 mg (age 19-50) * 2000 mg (age 51 and older) * Magnesium if CrCl less than 30 mL/min

Question 138

avoid sodium bicard

Answer 138

Sodium restriction (274 mg sodium/gram sodium bicarbonate) * Heart failure, kidney failure, cirrhosis, pregnancy * Taking with calcium supplements * Concomitant aspirin therapy

Question 139

Histamine type 2 recepotor antagonists (H2RA)

Answer 139

* Cimetidine Branded product: Tagamet HB® * Famotidine Branded product: Pepcid AC®

Question 140

Cimetidine, famotidine * MOA

Answer 140

reduce acid secretion by inhibiting histamine at the H2 receptors on parietal cells, do not neutralize aicd (that is the antacid MOA)

Question 141

* Indication:

Answer 141

* Mild to moderate, infrequent or episodic HB or prevention of HB

Question 142

* Combo with antacid:

Answer 142

postprandial HB if not premedicated with H2RA

Question 143

* Pharmacodynamics: * Onset

Answer 143

30-45 min

Question 144

* Duration:

Answer 144

* 4-8 hours (cimetidine) * 4-10 hours (famotidine)

Question 145

* Side effects:

Answer 145

Infrequent Both: headache, diarrhea, constipation, drowsiness, dizziness reported

Question 146

Cimetidine side effects

Answer 146

high doses may cause decreased libido, impotence or _____gyneocomastia, enlargement of the breasts____ due to weak antiandrogenic effect

Question 147

* Avoid: (h2)

Answer 147

* older adults at high risk for delirium, sodium-sensitive health conditions * Younger than __12__ years old

Question 148

pregnancy (h2)

Answer 148

ok to use though meta-analysis suggested association of childhood asthma

Question 149

Lactation:

Answer 149

famotidine preferred due to lower milk concentration but cimetidine ok per AAP

Question 150

H2RA drug interactions

Answer 150

erlotinib, dasantinib, gefritnib, other TKIs, ripvirine, ledipasir, sofoburvir, itraconzabole, ketoconazole, atazanavir, iron sulfate, calcium carbonate decreased absorption avoid concurrent use

Question 151

H2RA * Dosing

Answer 151

* Onset of symptoms OR _30-60___ min prior to when HB is expected * Note: Rx doses may need adjustment if kidney dysfunction

Question 152

cimedtidine dose

Answer 152

200 mg once daily

Question 153

famatodine dose

Answer 153

10-20 mg once or twice daily (max 40mg in 24 hours)

Question 154

Proton pump inhibitors (PPIs)

Answer 154

1. Esomeprazole magnesium 22.3 mg * Delayed release tablet or capsule *Branded product: Nexium® 2. Lansoprazole 15 mg * Capsule containing enteric-coated granules * Delayed-release orally disintegrating tablet *Branded product: Prevacid® 3. Omeprazole * Omeprazole magnesium 20.6 mg * Delayed release tablet *Branded product: Prilosec® * Omeprazole 20 mg + sodium bicarbonate 1100 mg * Immediate release *Branded product: Zegerid®

Question 155

PPIs * MOA:

Answer 155

inhibit hydrogen potassium ATPase (proton pump) in stomach parietal cells

Question 156

Indication: (PPIs)

Answer 156

heartburn symptoms 2 or more days per week

Question 157

PPIs onset

Answer 157

1-3 hours start of relief (may need 1 to 4 days for full effect)

Question 158

PPI's duration

Answer 158

12-24 hours (single dose)

Question 159

Side effects PPIs

Answer 159

uncommon * Headache, abdominal pain, diarrhea, constipation, gas * Increased risk ___traveler’s diarrhea_____ and _____C. Diff infection___ (PPI’s change ph in stomach, more basic)

Question 160

* Avoid: PPIS

Answer 160

* crush/chew tablets or capsules * severe diarrhea/gastroenteritis symptoms (seek care) * Younger than _18___ years old

Question 161

pregnancy PPI's

Answer 161

low risk omeprazole, lansoprazole; possible childhood asthma risk (refer if frequent HB)

Question 162

Lacatation PPIs

Answer 162

low milk amounts of omeprazole, esomeprazole (less than infant Rx)

Question 163

Dosing: PPIS

Answer 163

30-60 min prior to meal (esp breakfast); max 14 days; 1 course every 4 months max*

Question 164

PPI drug interactions

Answer 164

omprazole, esomeprozole- clopidogrel, clistazol, diazepam avoid concurrent use PPIs- erlotinib, sasatinib, vir, itraconziole, irone sulfate, calcium carbonate, warfarin, theophyliine, tacrolimus, digoxin avoid conccurent use.

Question 165

Bismuth subsalicylate Branded product: Pepto-Bismol® MAO

Answer 165

protects gastric mucosa

Question 166

bismuth indication

Answer 166

heartburn, upset stomach, indigestion, nausea, diarrhea

Question 167

bismuth onset

Answer 167

30-60 minutes

Question 168

duration bismuth

Answer 168

30-60 minutes

Question 169

side effects bismuth

Answer 169

black-colored tongue, stool, tinnitus^

Question 170

drug interaction bismuth

Answer 170

* Warfarin (avoid) * Tetracycline antibiotics (avoid) * Methotrexate (avoid)

Question 171

avoid- bismuth

Answer 171

children*, salicylate sensitivity/allergy, bleeding risks

Question 172

dosing bismuth

Answer 172

262-525 mg every 30-60 minutes PRN --chew tablets thoroughly (if chewable) --nonchew: full glass water --max 48 hours of therapy

Question 173

pregnancy bismuth

Answer 173

use alternative drug if possible 1st , 2nd trimesters; avoid 3rd trimester

Question 174

lactation bismuth

Answer 174

use alternative drug

Question 175

Special populations *Pregnancy first * First-line OTC: * Max food/OTC calcium per day:

Answer 175

* Lifestyle/food changes first * First-line OTC: calcium or magnesium antacids * Max food/OTC calcium per day: 2500 mg

Question 176

*Children older than 2 years with mild, transient, infrequent HB or sour Stomach * Refer if * MAX total daily calcium for children (including food/beverages): * Ages 2-3: * Ages 4-8: * Ages 9-18:

Answer 176

* Children’s formulas of calcium carbonate antacid + lifestyle/food changes * Refer if frequent HB or antacid ineffective * MAX total daily calcium for children (including food/beverages): * Ages 2-3: 700 mg * Ages 4-8: ___1,000__ mg * Ages 9-18: 1300 mg

Question 177

*Older adults* * Avoid H2RAs if

Answer 177

Triage carefully as HB can be symptom of more serious pathology, especially in older adults * Consider drug-drug interactions * Consider other health conditions & kidney function * Avoid H2RAs if high risk for delirium * Short course PPI likely ok but long-term risk for C. difficile infection, fractures; long-term use only if ok with ___recommendation from a medical provider

Question 178

intestinal gas causes

Answer 178

* Swallowing (food/air/saliva) * Especially if gulp/eat too fast * Smoking * Gum chewing * Sucking on hard candy * Carbonated beverages * Anxiety & hyperventilating * Sugar alcohols in food (e.g. sorbitol, mannitol) * Fiber in diet * Some medical conditions (see next slide) * Genetics * Altered gut bacteria * Food intolerances*(e.g. lactose, fructose, sucrose; stone fruits; wheat)

Question 179

Medical conditions associated with increased intestinal gas

Answer 179

* Irritable bowel syndrome: 5-15% of U.S. population * Lactose intolerance/malabsorption: 29% of U.S. population * Celiac disease * 1-3% of U.S. population * 10% of first-degree relatives of people with celiac disease * Pancreatic insufficiency: <1% of U.S. population 7 Note: healthy people have about 200 mL of intestinal gas at all times

Question 180

Medications that contribute to intestinal gas

Answer 180

* Meds that affect gut biome (e.g. lactulose, antibiotics) * Agents that affect metabolism of glucose & dietary substances * E.g. acarbose/miglitol, metformin, orlistat (= GI lipase inhibitor) * Drugs that affect GI motility * E.g. narcotics, anticholinergics, calcium channel blockers, psyllium, cholestyramine * Meds that contain or release gas (e.g. Alka-seltzer)

Question 181

Presenting symptoms of intestinal gas

Answer 181

* Eructation: belching of swallowed air * Bloating: * Indigestion * Abdominal pain/cramping * Borborygmi: audible bowel sounds * Flatulence: passage of air out through the rectum

Question 182

Do not self-treat- gas

Answer 182

* Symptoms persist for more than a few days or occur several times a month * Symptoms so severe they are debilitating * Sudden change in the location of abdominal pain or significant increase in frequency or severity of symptoms * New onset of symptoms in people older than 40 years * Significant discomfort or sudden bowel function change (diarrhea or constipation) * Gas occurs in conjunction with other symptoms such as severe or persistent diarrhea or constipation, GI bleeding, fatigue, unintentional weight loss, or frequent symptoms at night

Question 183

Goals of therapy

Answer 183

* Reduce symptoms (frequency/intensity/duration) * Minimize gas impact on_____a persons lifestyle__________ * NOT eliminate gas since it’s a normal part of GI tract function

Question 184

Complementary and non-pharmacologic options

Answer 184

* Probiotics (single and combination) * 14-day trial * Fermented food products with live active cultures (kombucha tea, kefir) * Herbal carminatives (fennel seed, Japanese mint, peppermint, spearmint) * Insufficient evidence * Avoid if GERD since carminatives lower LES tone/pressure * Avoid fennel seed in pregnancy, lactation

Question 185

OTC Options- prevention of gas

Answer 185

* alpha-galactosidase * Lactase enzyme

Question 186

OTC treatment of gas

Answer 186

* Simethicone * Activated charcoal

Question 187

Follow-up Recommendations

Answer 187

__try these agents for one week and if things arent better than to refer_________

Question 188

Alpha-galactosidase Branded product: Beano (food) * MOA:

Answer 188

hydrolyzes oligosaccharides into component parts

Question 189

Alpha-galactosidase- indication

Answer 189

prevention of intestinal gas

Question 190

Alpha-galactosidase onset

Answer 190

within 30 minutes

Question 191

Alpha-galactosidase duration

Answer 191

at least 5 hours

Question 192

Alpha-galactosidase side effects

Answer 192

possible allergic reaction (rash, swelling, hives, difficulty, breathing)

Question 193

Alpha-galactosidase drug interactions

Answer 193

none known

Question 194

Alpha-galactosidase avoid in

Answer 194

people with galactosemia, mold allergies

Question 195

Alpha-galactosidase pregnancy

Answer 195

likely okay check with healthcare provider

Question 196

Alpha-galactosidase lactation

Answer 196

likely ok, check with healthcare provider

Question 197

dosing adults and adolescents Alpha-galactosidase

Answer 197

300-450 units per food serving

Question 198

Alpha-galactosidase dose children

Answer 198

ask HCP

Question 199

Lactase enzyme Branded product: Lactaid * MOA:

Answer 199

replacement enzyme that breaks down lactose into glucose + galactose

Question 200

lactase enzyme indication

Answer 200

dairy intolerance

Question 201

onset lactase

Answer 201

immediate

Question 202

duration lactase

Answer 202

while digesting dairy product

Question 203

side effect lactase

Answer 203

non possible stomach pain

Question 204

lactase drug interactions, avoid

Answer 204

?

Question 205

Dosing for all ages* (first bite): lactase oringial, extr, ultra

Answer 205

Original strength: _3__caplets Extra strength: __2_ caplets Ultra strength: 1 caplet (max 2) *from website

Question 206

lactase pregnancy

Answer 206

likely safe but check with HCP

Question 207

lactase lactaton

Answer 207

no info available on excretion into milk; likely safe but check with HCP

Question 208

Simethicone Branded product: Gas-X * MOA:

Answer 208

defoaming agent; reduces surface tension of gas bubbles in GI tract mucus -> eliminated more easily

Question 209

simethicone indication

Answer 209

intestinal gas

Question 210

simethicone onset

Answer 210

within 30 minutes

Question 211

simethicone duration

Answer 211

up to 4 hours

Question 212

simethicone side effects, drug interactions, avoid

Answer 212

?

Question 213

dosing after meals + bedtime adults and adolescents: simethoicone

Answer 213

* 40-125 mg 4x daily PRN

Question 214

* Children 2 to 12 years: simethicone

Answer 214

* 40-50 mg 4x daily PRN

Question 215

children younger than 2 years: simethicone

Answer 215

20 mg 4x daily PRN

Question 216

pregnancy and lactation

Answer 216

safe to use

Question 217

Activated charcoal Branded product: CharcoCaps (supplement) * MOA

Answer 217

?adsorb gas given charcoal large surface area

Question 218

charcoal indication

Answer 218

promoted for relief of intestinal gas (not approved nor shown to be effective)

Question 219

* Onset: * Duration: charcoal

Answer 219

?

Question 220

side effects charcoal

Answer 220

poor palatibility, capsule form found

Question 221

drug interactions carchoal

Answer 221

may decrease drug absorption

Question 222

avoid taking charcoal

Answer 222

within 1 hour after medications

Question 223

dosing charcoal adults:

Answer 223

500-520 mg after meals PRN, may reapeat hourly

Question 224

dosing adolescents children

Answer 224

?

Question 225

pregnancy- charcoal

Answer 225

likely safe for occasional use, check with healthcare provider

Question 226

lactation- charcoal

Answer 226

likely safe for occasional use; check with healthcare provider

Question 227

* Hemorrhoid definition:

Answer 227

* inflamed, swollen blood vessels in the rectum and anus that protrude during bowel movements

Question 228

Internal hemorrhoid

Answer 228

* Inside rectum * Can’t see or feel; __rarely cause discomfort_______

Question 229

External hemorrhoid

Answer 229

* Under skin around anus * Usually have symptoms

Question 230

presenting symptoms for internal

Answer 230

*Internal hemorrhoid * Rare discomfort * Stool passage may cause painless bleeding (red on toilet tissue but not dripping into toilet bowl)

Question 231

external hemorrhoid presenting symptoms

Answer 231

* Itching (pruritis) * General discomfort/irritation * Burning * Inflammation * Swelling

Question 232

do not self treat hemorrhoids

Answer 232

* Younger than ____12____ * Ulcerative colitis or Crohn’s Disease * Family history colon cancer * Anorectal disorder previously dx by medical provider (e.g. fistula, abscess) * Acute onset severe pain; bleeding (more than just a little on toilet tissue); seepage; black tarry stools; severe symptoms (see prior slide) * Minor symptoms not responding to _7__ days of self-care

Question 233

goals of therapy hemorrhoids

Answer 233

* Resolve symptoms * Keep stool soft; prevent straining with bowel movements * Maintain remission of symptoms * Prevent complications

Question 234

Complementary and non-pharmacologic options- hemmorrhoids

Answer 234

* Dietary modification * Avoid alcohol, caffeine, citrus foods, fatty foods * Adequate fiber (more info in nutrition lecture) * Avoid lifting heavy objects * Proper bowel habits * Defecation * Toilet sitting time * Avoid excessive cleaning * AVOID commercial wipes/pads * Sitz baths Severe hemorrhoids may require surgery

Question 235

OTC treatment options- hemmoroids

Answer 235

* Local anesthetics * Vasoconstrictors * Protectants * Astringents * Keratolytics * Analgesics, anesthetics, antipruritics * Corticosteroids Follow-up Recommendations * __one week of self care- refer______

Question 236

Local Anesthetics: benzocaine, benzyl alcohol, dibucaine, dyclonine, lidocaine, pramoxine, tetracaine MOA

Answer 236

block transmission of nerve impulses

Question 237

local anestetics indication

Answer 237

temporary relief of external anal symptoms

Question 238

local anestetics duration

Answer 238

depends on agent; mostly 4 hours

Question 239

side effects local anestetics

Answer 239

allergic reactions, dermatitis

Question 240

drug interactions local anestetics

Answer 240

no significant interactions

Question 241

avoid -local anestetics

Answer 241

more severe anorectal disorders; open lesions

Question 242

pregranacy and lactation- local anestetics

Answer 242

Pregnancy: likely okay; check with medical provider Lactation: likely okay; check with medical provider

Question 243

dosing- local anestetics

Answer 243

Applied __3-6___times/day; check label

Question 244

Vasoconstrictors: ephedrine, epinephrine, phenylephrine (topical) * MOA:

Answer 244

stimulation of alpha-receptors to constrict arterioles and decrease swelling

Question 245

Vasconstrictors indication

Answer 245

relief of discomfort, itching + reduce swelling;

Question 246

* Ephedrine, phenylephrine: good for

Answer 246

internal, external

Question 247

epinephrine is good for

Answer 247

external

Question 248

vasoconstrictors onset

Answer 248

5-10 minutes

Question 249

vasoconstrictors duration

Answer 249

about 6 hours

Question 250

vasoconstrictors duration

Answer 250

about 6 hours

Question 251

vasoconstrictors side effects

Answer 251

mild pain, stinging, if raw/bleeding skin

Question 252

drug interactions vasoconstrictors

Answer 252

?

Question 253

vasoconstrictors avoid

Answer 253

talk to provider before use if cardiac history, diabetes, BPH, thyroid conditions

Question 254

vasoconstrictor dosing

Answer 254

applied 4 times a day; check label

Question 255

pregnancy and lactation- vasoconstrictor

Answer 255

likely okay, check with medical provider

Question 256

Protectants: LOTS! Aluminum hydroxide gel, cocoa butter, glycerin, lanolin, mineral oil, white petrolatum, zinc oxide and more * MOA:

Answer 256

provide physical protective barrier

Question 257

protectant indication

Answer 257

temporary relief of discomfort, irritation, burning

Question 258

Glycerin used for

Answer 258

external

Question 259

other protectants

Answer 259

use internal or external

Question 260

protectant onset

Answer 260

?

Question 261

protectant duration

Answer 261

4 hours or longer

Question 262

side effects protectant

Answer 262

uncommmon, lanolin caution

Question 263

drug interactions- protectant

Answer 263

?

Question 264

avoid -protectants

Answer 264

applying other medications after protectants

Question 265

dosing for protectants petrolaum and all others

Answer 265

* Petrolatum: _as needed___ * Others: up to 6x/day or after each bowel movement

Question 266

protectants: preganacy and lactation

Answer 266

likely okay; check with medical provider

Question 267

Astringents: calamine, zinc oxide, witch hazel * MOA:

Answer 267

help coagulate surface proteins to protect lower tissue; decrease cell volume, provide thin protective layer

Question 268

Astringents Indication

Answer 268

temporary relief of itching, burning, irritation of anorectal d/o

Question 269

Witch Hazel where applied

Answer 269

external

Question 270

Calamine, zinc oxide where applied

Answer 270

internal or external

Question 271

onset of astringents

Answer 271

?

Question 272

Duration- astringent

Answer 272

up to 4 hours

Question 273

side effects of witch hazel

Answer 273

slight stinging

Question 274

drug interactions and avoidance for astringents

Answer 274

?

Question 275

astringents dosing

Answer 275

apply up to 6 times/day

Question 276

astringents: pregnancy and lactation

Answer 276

likely okay; check with medical provider

Question 277

Keratolytics: alcloxa, resorcinol * MOA:

Answer 277

cause sloughing of epidermal surface cells

Question 278

keratolytics indication

Answer 278

treat pain & itching caused by minor skin irritations

Question 279

onset keratolytics

Answer 279

?

Question 280

duration keratolytics

Answer 280

up to 4 hours

Question 281

side effects keratolytics

Answer 281

allergic reaction to resorcinol

Question 282

drug interactions keratolytics

Answer 282

?

Question 283

avoid using keratolytics when using

Answer 283

with harsh soaps

Question 284

dosing keratolytics

Answer 284

apply 6 times daily

Question 285

keratolytics pregnancy and lactation

Answer 285

likely okay; check with medical provider

Question 286

Analgesics, anesthetics, antipruritics: menthol, juniper tar, camphor indication

Answer 286

temporary relief of burning, pain or itching; external

Question 287

oneset of analgesics

Answer 287

?

Question 288

duration of anelgesics

Answer 288

up to 4 hours

Question 289

side effects of analgesics

Answer 289

allergic reactions

Question 290

drug interactions of analegesics

Answer 290

?

Question 291

avoid using analgesics on

Answer 291

on irritated or damaged skin

Question 292

dosing of analgesics

Answer 292

up to 6 times daily

Question 293

pregnancy and lactation analgesics

Answer 293

likely okay; check with medical provider

Question 294

Corticosteroid: hydrocortisone 0.25-1% * MOA:

Answer 294

lysosomal membrane stabilization + antimitotic activity

Question 295

corticosteroid indication

Answer 295

temporary relief of minor external anal itching

Question 296

onset of corticosterioid

Answer 296

?

Question 297

duration of corticosterioid

Answer 297

up to 6-8 hours

Question 298

side effects of corticosteroid

Answer 298

skin atrophy or thinning of skin

Question 299

drug interaction: corticosteroid

Answer 299

?

Question 300

Avoid doing this when using corticosterioids

Answer 300

* Avoid: prolonged use (max 7 days)

Question 301

dosing of corticosteriods

Answer 301

apply up to 3 to 4 times a day

Question 302

pregnancy and lactation corticosteroid

Answer 302

likely okay; check with medical provider

Question 303

motion sickness

Answer 303

Brain senses “disconnect” * Eyes see movement, inner ear senses movement but body is still * 33% people experience at some time in life

Question 304

highest risk of motion sickness

Answer 304

Highest risk: * Women * Children ages __2-12____years * Factors increasing risk * Family history * Hormonal birth control * Inner ear conditions * Menstrual periods * Migraines * Parkinson’s disease * Pregnancy

Question 305

presenting symptoms of motion sickness

Answer 305

Cold sweats * Dizziness * Headache * Inability to concentrate * Increased salivation, nausea, vomiting * Rapid breathing

Question 306

do not self treat someone - motion sickness

Answer 306

* A person who feels “motion sickness” but isn’t traveling

Question 307

goals of therapy motion sickness:

Answer 307

* Provide symptom relief * Prevent episodes/recurrence

Question 308

Complementary and non-pharmacologic options

Answer 308

Travel by ... sit... * Boat: in middle on upper deck * Bus: window seat * Car: front passenger seat or be the driver * Plane: wing section * Train: forward-facing seat Prevent ± Treat * Look at the horizon * Avoid phone/tablet/book * Lay back & close eyes * Drink water * Eat low-fat, bland, starchy food prior to travel * Fresh air/air vents toward you * Acupressure wristband * Ginger: tea, ginger ale, raw, candy, powder in capsules * Avoid___alcohol____

Question 309

OTC Treatment Options- motion sickness

Answer 309

* First-generation antihistamines * Cyclizine * Dimenhydrinate * Diphenhydramine * Doxylamine * Meclizine * Scopolamine patches

Question 310

if non drug and drug therapies do not work for motion sickness

Answer 310

medical referral

Question 311

Antihistamines: cyclizine, meclizine, dimenhydrinate, diphenhydramine, doxylamine * MOA:

Answer 311

blockage of histamine-1 receptors

Question 312

antihistamines indication

Answer 312

prevention of nausea, vomiting or dizziness associated with motion sickness

Question 313

antihistamines onset

Answer 313

30-60 minutes

Question 314

duration of antihistamines

Answer 314

depends on agent, see table 19-4

Question 315

side effects antihistamines

Answer 315

drowsiness, dry mouth, confusion, dizziness, constipation

Question 316

Drug interactions antihistamines

Answer 316

CNS depressants

Question 317

avoid antihistamines in those with

Answer 317

glaucoma, BPH, alcohol

Question 318

dosing of antihistamines

Answer 318

see required reading table 19-4

Question 319

preg and lact for antihistamines

Answer 319

check with MD

Question 320

Scopolamine OTC patch branded product: Transderm Scop® * MOA:

Answer 320

blocks effect of acetylcholine on central nervous system = antimuscarinic

Question 321

scope patch indication

Answer 321

prevention of nausea, vomiting caused by motion sickness

Question 322

onset scope patch

Answer 322

at least 4 hours

Question 323

duration scope patch

Answer 323

up to 3 days

Question 324

side effects scope patch

Answer 324

disorientation, dry mouth, drowsiness, pupil dilation, dizziness, sweating

Question 325

drug interaction scope patch

Answer 325

meds affecting CNS including anticholinergic meds; oral drugs that absorbed in the stomach (____slowed stomach__ emptying)

Question 326

aoid when wearing scope patch

Answer 326

wearing in MRI scanner; talk with provider if BPH, glaucoma; alcohol

Question 327

preg and lac scope patch

Answer 327

check with MD

Question 328

Scopolamine patch dosing & counseling tips

Answer 328

Apply patch on completely dry skin behind ear at least 4 hours before effects needed * Wash hands after applying patch * Works up to 3 days * Do not__cut the patch_________ * Generally not affected by bathing or swimming * If need to replace patch, use different area of skin behind same or other ear

Question 329

cyclizine dose

Answer 329

50 mg 30 min before travel then 50 mg every 4-6 hours

Question 330

dimenhydrinate dose

Answer 330

50-100 mg every 4-6 hours

Question 331

diphenhydramine dose

Answer 331

35-50 mg every 6-8 hours

Question 332

meclizine dose

Answer 332

25-50 mg 1 hour before travel (50 mg)

Question 333

Doxylamine dose

Answer 333

in pregnanact, 10-12.5 mg with. orwithout pyridoxine every 8 hours

Question 334

Gastroenteritis definition (commonly confused with flu)

Answer 334

* Inflammation of the stomach and intestines due to viral infection or bacterial/protozoal toxins which causes vomiting and diarrhea

Question 335

causes of gastroenterities

Answer 335

* Viral -> major cause of gastroenteritis * Norovirus: year-round, peak during winter; transmitted by contaminated water/food, P2P, environmental surfaces * Rotavirus: seasonal Nov-Feb; transmitted fecal-oral route * Other viruses * Bacterial -> 10%; main = Campylobacter spp, Salmonella spp, Shigella spp, Escherichia coli + others; transmitted by food, food/water associated w/travel * Protozoal—least common; no nonrx therapy; self-management inappropriate, never self treat.

Question 336

Gastroenteritis presenting symptoms

Answer 336

* Viral-Rotavirus * Nausea * Vomiting * Fever * Acute, watery diarrhea * Viral-Norovirus * Nausea * Vomiting * Fever * Headache * Myalgia * Watery diarrhea * Bacterial

Question 337

Bacterial ccamplo salmonella shigella e.coli symptoms

Answer 337

* Bacterial *Campylobacter jejuni * Nausea, vomiting, HA, malaise, fever, watery diarrhea *Salmonella * Diarrhea, fever, chills, malaise, myalgia, epigastric pain, anorexia *Shigella * Nausea, vomiting, diarrhea (± blood or mucus), fever *E. Coli * Watery diarrhea, fever, abdominal cramps, bloating, malaise, occasional vomiting All have diarrhea, rota, noro campto, e.coli, watery diarrhea. all have fever

Question 338

Do not self-treat- gastro

Answer 338

* Age < 6 months or weight < 17.5 pounds (8 kg) * Persistent fever (see temp & age differences in Figure 16-1 exclusions box) * Visible blood, pus or mucus in stool * Persistent vomiting * Signs of severe dehydration * Behavioral changes * Not urinated in 8 hours * No tears when baby cries * Severe abdominal pain/distress: tenderness, distention * Risk for important complications * Diabetes, severe CVD, kidney Disease * Immunocompromised (e.g., cancer chemotherapy, organ transplat, AIDS, frail people aged 65 or older) * Pregnancy (always refer even if mild, for health of placenta at any stage) * Chronic or persistent diarrhea * Suboptimal response to ORS (oral rehydration soultion) already administered * No improvement or worsening after 48 hours of self-care

Question 339

goals of therapy- gastro

Answer 339

1. Prevent or correct fluid and electrolyte loss and acid-base disturbance 2. Control symptoms 3. Identify and treat cause 4. Prevent acute morbidity and mortality

Question 340

general treatment approach for gastro

Answer 340

* Fluid & electrolyte replacement via ORS (oral rehydration solution) * Antidiarrheal drugs in selected individuals, not everyone should be using * Self-limiting condition (usually) * Improvement 24-48 hours; normal bowel function 24-72 hours

Question 341

inappropriate treatment for gastro

Answer 341

liquid diet, doesnt bulk up stool.

Question 342

Complementary and non-pharmacologic options- gastro

Answer 342

* Fluid & electrolyte management : rehydration + maintenance (children) * Self-care algorithms *Required Reading figure 16-1 (children age 6 months to 5 years) *Required Reading figure 16-2 (age 5 years through adult) * Commercial products (solutions or dry powders requiring addition of water)—See Table 16-6 * Ceralyte, Enfalyte, Pedialyte, Rehydralyte Do not use household products for this situation only. Very little in these products that is going to help * Household products (nonequivalent to commercial products: Table 16-6) * Apple juice, chicken broth, colas, Gatorade*(low in sodium, supplement), ginger ale, tea * Acceptable mild, self-limiting diarrheas * Avoid dehydration symptoms or moderate to severe diarrhea; children younger than 5 (even mild illness) * Adults: * ORS recommended, but little evidence if otherwise healthy, mild diarrhea & can maintain adequate oral fluid intake, one tablespoon full every 15 minutes, getting GI system ready to accept more fluid. *supplement with crackers or pretzels for more sodium

Question 343

Dietary management * Children - gastro

Answer 343

* Children * important; withhold food no longer than 24 hours if withhold food at all * Normal, age-appropriate diet once child is rehydrated (3-4 hours) * Avoid fatty foods, simple sugars such as carbonated soda, juice, gelatin desserts -> can cause osmotic diarrhea * Avoid spicy foods can cause Gi upset * Avoid caffeine promotes fluid secretion * Children can tolerate breast/milk and cow milk

Question 344

BRAT diet

Answer 344

NOT recommended = insufficient calories, protein, fat

Question 345

Adult recommendation - gastro

Answer 345

follow same guidance as for cchildren

Question 346

OTC Treatment Options * Loperamide Loperamide Branded product: Imodium A-D * MOA:

Answer 346

stimulates peripheral micro-opioid receptors on intestinal circular muscles to slow motility so water & electrolytes can be absorbed * = reduces peristalsis, increases intestinal transit time

Question 347

loperamide indication

Answer 347

symptomatic relief of acture, non specific diarrhea

Question 348

pharmacodynamics: loperamide onset

Answer 348

within 1 hour

Question 349

loperamide duration

Answer 349

up to 3 days

Question 350

loperamide sideeffects

Answer 350

occasional dizziness, constipation; euphoria if misused/abused

Question 351

Loperaimide drug interactions

Answer 351

quinidine, ketoconazole (antifungal), ritonavir, protease inhibitors, cyclosporine, erythromycin (antibiotic), clarithromycin, saquinavir, St. John’s wort (mood)

Question 352

avoid loperamide if

Answer 352

high fever or blood/mucus in stool, NO LOPERAMIDE Bad bacteria in the gut for too long: toxic megacolon

Question 353

loperamide dosing max

Answer 353

48 hgours of use

Question 354

adult dosing - loperamide

Answer 354

* Adults ( 2 mg caplets, 1 mg/7.5 mL liquid) * Caplets: 4 mg initially, then 2 mg after each loose stool; max 8 mg/24 hours ((max 4 tabs in 24) * Liquid: 4 mg (= 30 mL) initially, then 2 mg (15 mL) after each loose stool; max 8 mg (60 mL) /24 hours

Question 355

child dosing loperamide

Answer 355

Children * younger than 6: seek medical advice * 6-8 years (48-59 pounds = 22-27 kg) * Caplets: 2 mg initially, then 1 mg after each loose stool; max 4 mg/24 hours * Liquid: 2 mg (15 mL) initially, then 1 mg (7.5 mL) after each loose stool; max 4 mg/24 hours * 9-11 years (60-95 pounds = 27-43 kg) * Caplets: 2 mg initially, then 1 mg after each loose stool; max 6 mg/24 hours * Liquid: 2 mg (15 mL) initially, then 1 mg (7.5 mL) after each loose stool; max 6 mg/24 hours 8 year old, 85 pounds, inbetween dose.

Question 356

Bismuth subsalicylate Branded product: Pepto-bismol * MOA:

Answer 356

inhibition of prostaglandin synthesis, stimulation of sodium & potassium reabsorption

Question 357

indication of bismuth what age

Answer 357

management of acute diarrhea in people aged 12 & older (grey zone, 12-18, problem with aspirin (salicylate), viral illnesss, and give them a salicylate, do not want REYES syndrome) (do not recommend bismuth because anyone can use loperamide)

Question 358

onset bismuth

Answer 358

30min to 4 hours

Question 359

Duration- bismuth

Answer 359

?

Question 360

side effects of bismuth

Answer 360

mild tinnitus, black tongue or stool (>10% people)

Question 361

drug interactions bismuth

Answer 361

warfarin, valproic acid, methotrexate, tetracycline & fluoroquinoilone antibiotics

Question 362

void bismuth if

Answer 362

gout, asthma-associated bronchospasm; if recovering from chickenpox of influenza-like illness; within 6 weeks of chickenpox or influenza vaccine

Question 363

bismuth dosing max

Answer 363

max 48 hours of use

Question 364

adults dosing- bismuth

Answer 364

* Adults (262 mg tablets & caplets; liquid 262 mg/15 mL and 525 mg/15 mL) * Tablets/caplets: 525 mg every 30-60 minutes up to 4200 mg/day (8 doses in 24 hours) * liquid 262 mg/15 mL * 525 mg (30 mL) every 60 minutes up to 240 mL/day (8 doses in 24 hours) * liquid 525 mg/15 mL * 1050 mg (30 mL) every 60 minutes up to 120 mL/day (4 doses in 24 hours)

Question 365

child dosing- bismuth

Answer 365

not recommended

Question 366

A 25-year-old person asks for your recommendation. She has diarrhea that started last evening & has had 3 loose stools since then. She tried 2 TUMS tablets this morning (calcium carbonate), but it didn’t help. Associated symptoms are slight nausea and some fatigue, though she was able to eat her usual breakfast and drink coffee this morning. She is a waitress and wants something OTC so she can go to work later today. Medications/OTCs: daily multivitamin, oral contraceptive. She is allergic to penicillin. Medical conditions: none. what do you recommend

Answer 366

mild dehydration less coffee loperamide 75% doses handle like normal, as long as they swallow, take meds as uaual

Question 367

Follow-up Recommendations- bismuth

Answer 367

* No improvement after 48 hours of drug therapy

Question 368

A 44-year-old adult asks you what they should use for tooth pain. They were diagnosed with tooth hypersensitivity on one occasion several years ago but haven’t had any problems since then. They brush their teeth twice daily and are careful not to eat sweets more than a couple times a week. They describe the pain as sharp and stabbing, and it occurs whenever they drink coffee. 6 A. Use a toothpaste containing baking soda & avoid coffee B. Make an appointment with a dentist and take acetaminophen or ibuprofen OTC until then C. Try a soft-bristled toothbrush & standard toothpaste with fluoride for a week D. Use a desensitization toothpaste with soft-bristled toothbrush twice daily for 2 weeks

Answer 368

C. Try a soft-bristled toothbrush & standard toothpaste with fluoride for a week

Question 369

Which of the following ingredients would be important to look for on the label of a product for someone with cheilitis? Select all that apply: 1. Aloe 2. Beeswax 3. Dimethicone 4. Lanolin 5. Paraffin 6. Petroleum jelly

Answer 369

beeswax, petroleum

Question 370

Presenting symptoms - caries

Answer 370

* No initial symptoms * Progressive lesion on tooth * Visualize * Sensitive to stimuli (heat, cold, sweetness, chewing) * Continuous pain ± difficulty chewing if lesion invades dental pulp (lots of discomfort) * Can progress to abscess and ____tooth loss_____

Question 371

aries etiology

Answer 371

* Carbohydrates in diet * Oral bacteria * Host resistance alterations * Orthodontic appliances * Zerostonium- dry mouth * Medications * Radiation therapy * Tobacco product use * Alcohol use * Immune system dysregulation (chemo, Sjogrens, HIV/AIDs)

Question 372

refer for tooth

Answer 372

* Symptoms of toothache * pain with or without chewing difficulty * Localized swelling * Hot or cold sensitivity * Fever or headache * Visualized lesion * Entire tooth discoloration * Bleeding, swelling or reddened gums * Persistent mouth odor despite regular use of flouride toothpaste

Question 373

goals of therapy- caries

Answer 373

* Prevent or control dental plaque (soft stuff that you can brush off) Calcium ( hard stuff calculus, breaks off teeth)

Question 374

gingivitus Presenting symptoms

Answer 374

* Inflamed gingiva * May progress to periodontal disease

Question 375

Gingivitis etiology

Answer 375

* Accumulation of supragingivival bacterial plaque (soft stuff) * Medications * Calcium channel blockers (deltidiz, velapronin) Older calcium not amlodipine * Cyclosporine * Phenytoin * Reduced saliva flow * __Anticolenergics___________ * Antidepressants * Tobacco (smoked and smokeless) * Pregnancy * Hormones * Connective tissue changes

Question 376

Do not self-treat, refer- gingivitis

Answer 376

* Swollen gums * Gums that bleed with brushing or flossing (running in mouth) * Receding gums * Gums that are darker__red__

Question 377

Goals of therapy – gingivitis prevention

Answer 377

* Prevent calculus formation * Remove and control supragingival plaque

Question 378

Complementary and non-pharmacologic options: caries and gingivitis prevention

Answer 378

Dietary * Avoid highly cariogenic foods * 15% or more sugar * sticks to teeth * can remain in mouth after being chewed * Drink adequate water Plaque removal * Chewing sugarless gum x 20 min after a meal * Brushing & flossing (adults & children older than 5 years) * Manual * Electric-consider battery power * Toothbrushes * Dental floss: at least __once__ daily * Types * Dental floss * Dental tape * Tapered picks * Waxed vs unwaxed * Irrigating devices-removes minimal amount of plaque; supplement to brushing & flossing

Question 379

* Activated charcoal

Answer 379

* Limited data to support claims about teeth whitening/absorbing pigments & stains * Novelty

Question 380

* Probiotics-caries- ginga

Answer 380

* Possible benefit for ___reducing frequency an severity of gingivitis_____ * Vitamin D * Adequate vit D during pregnancy can reduce caries in children * Xylitol * Children: 2017 meta-analysis: no stat sig. benefit

Question 381

OTC Treatment Options- caries. andgina

Answer 381

* Chemical plaque management * Fluoride * Dentrifrices (toothpastes) * Fluoride-containing * Tartar control * Antiplaque/antigingivitis * Whitening * Botanical-based * Mouthrinses Follow-up Recommendations * Professional dental cleanings every __6_ months

Question 382

Toothpaste Use * Adults:

Answer 382

* Adults: size of pea * Frequency: BID * Type of brush/how often to change * Soft * Change every 3-4 months * Kind of toothpaste * Fluoride-containing * Hold at 45 degree angle * Where to brush * Inner, outer, chewing surfaces * Flossing: at least daily

Question 383

toothpoaste children Age to start brushing?

Answer 383

* Children * Age to start brushing?_when teeth erupt____ * Kind of toothpaste: fluoride * Spit but no rinse (keep fluoride in mouth) * Amount: * Younger than 3 years: size of rice grain * Older than 3 years: size of _pea__ * Supervise * Parental education * Supervise, esp spitting & amount * Too much fluoride: flecks/stripes or brown spots on teeth, enamel pits

Question 384

Prevention of caries & gingivitis: Pharmacologic Methods * Dentrifrices MAO

Answer 384

* MOA: act directly on oral bacteria or disrupt plaque components to aid in mechanical removal

Question 385

3 functions of dentrifrices

Answer 385

1. Help remove plaque, stain 2. Reduce ____mouth odor_______ 3. Enhance personal appearance * Products * Powders * Gels, pastes * Categories of ingredients * Abrasive * Humectant * Sweetener * Surfactant * Binder/thickener * Flavor * Anticaries activity agent (often)

Question 386

Dentrifrice abrasive categories & ingredients

Answer 386

* Low abrasion: 10-25% silica abrasives * Mild abrasion: baking soda * High abrasion: 40-50% * Dicalcium phosphate * Calcium pyrophosphate * Calcium carbonate * Alumina trihydrate

Question 387

Fluoride: anticaries agent

Answer 387

Sodium fluoride ->remineralize, strengthen weakened enamel, reduce gingivitis, reduce sensitivity

Question 388

Sodium monofluorophosphate

Answer 388

Stannous fluoride -> above + adds protective layer over teeth to prevent plaque ->slight tooth staining if use continuously x 2-3 months; removed at professional cleanings not permanent

Question 389

Other Dentrifrice Ingredients

Answer 389

* Whitening dentrifrices * NOT tooth-bleaching products * Ingredients: baking soda; titanium dioxide; or aluminum oxide + citrate salt + papain; peroxides * Chemotherapeutic agents may be combined in a whitening dentrifrice * Fluoride * Potassium nitrate * Stanous flouride * Metal salts * Essential oils * Hydrogen peroxide * Sodium bicarbonate * Triclosan (cross out) won’t see anymore not allowed in toothpaste

Question 390

Plaque control mouthrinses * Ingredients

Answer 390

* Aromatic oils * Antimicrobials (quaternary ammonium compounds: cetylpyridinium chloride) kill them * Phenol * MOA * Aromatic oils: antibacterial, local anesthesia * Anticrobials: bactericidal activity * Phenol: local anesthetic, antiseptic, bactericidal activity

Question 391

Mouthrinse Cautions * Adverse effects

Answer 391

* Occasional burning, irritation of oral mucosa; may cause sloughing of oral epithelium * Cautions * Mouth ulcers or irritation: only use under dental advice * Keep out of reach of children most have alcohol content (5-10 ounces to kill child) * Supervise use in children * Alcohol content issues * Poisoning (alcohol dependence) * Oral cancer (if already have cancer do not use)

Question 392

Mouthrinse Use

Answer 392

1. 1 to 2 tablespoonsful 2. Swish 30 seconds 3. Spit * Most effective before brushing except if contains fluoride (want to keep on teeth) * 1 to 2 times per day * Avoid eating/drinking x 30 min afterward * Supervise children younger than 12 yrs

Question 393

Plaque control with gum * MOA

Answer 393

* Increased saliva flow * Mechanical removal of debris Use * Chew after eating as well as other times of day * Sugarless gum only

Question 394

Hailtosis

Answer 394

* Bad breath caused by volatile sulfur compounds (VSCs) food particles in mouth and bacteria act on them

Question 395

hailtosis causes

Answer 395

* Systemic * Medications: TCAs, (tricycling anticholenergic effects) first-gen antihistamines, oxybutynin, meclizine, Parkinson’s meds * Kidney/liver failure * Cancer * Ketosis * Oral * Poor hygiene * Xerostomia * Foods/beverages * garlic or onions * tobacco

Question 396

Do not self-treat- hal

Answer 396

* Medical conditions associated with halitosis * Persistent halitosis despite good oral hygiene

Question 397

halitosis prevention

Answer 397

* Remove cause if possible * Mechanical * See caries prevention * Tongue brushing * Chemical * Zinc salts, chlorine dioxide * MOA * Zinc salts: reduce receptor binding for VSCs * Chlorine dioxide: breaks disulfide bonds, oxidizes VSC precursors

Question 398

Oral pain causes * Etiologies

Answer 398

1. Exposure of dentin (erosion, broken tooth, faulty tooth repair) 2. Injury to mouth or lips or with RAS or herpes simplex labialis 3. nerve pain of face, facial herpes zoster, cluster headaches * Dentin/tooth hypersensitivity * 2 aspects for development * Exposed dentin * Dentin tubules open to valves open to fluid flow to outside of tooth_and tooth pulp on inside so both sides have to be open * Symptoms: short & stabbing/sharp * Thermal, chemical (acid) or physical (pressure) stimulus to exposed dentin or reach open tubule: tubule fluid flow______increased->nerve stimulation-> pain

Question 399

Presenting symptoms oral pain

Answer 399

Pain from hot, cold, sweet or sour liquids * Pain from hot or cold air on teeth * See Table 32-1 to differentiate from toothache, toothache should not be self treated, hypersensitivity may be self treated

Question 400

do not self treat oral pain when

Answer 400

* Toothache * Mouth soreness associated with dentures * Fever or swelling * Loose teeth * Bleeding gums * Broken teeth * Severe tooth pain started or worsened by hot, cold, or chewing (8,9,10) * Trauma to the mouth

Question 401

Goals of therapy- oral pain

Answer 401

1. Repair damaged tooth surface via appropriate toothpaste 2. Correct inappropriate tooth brushing technique (too aggressive)

Question 402

Complementary and non-pharmacologic options- oral pain

Answer 402

* Stop triggers (acidic foods, aggressive toothbrushing) * Avoid toothbrushing within 30-60 min of acidic foods/drinks * Correctly brushing teeth with fluoride toothpaste

Question 403

OTC Treatment Options- oral pain

Answer 403

* Standard toothpaste with fluoride, 1st line * Potassium nitrate 5% in fluoride-containing toothpaste, 2nd line

Question 404

follow up recommendations

Answer 404

Follow-up Recommendations * Standard toothpaste with fluoride & soft bristled brush * Resolved? * Yes: continue regimen * No: see 14 days as below * 14 days of desensitization toothpaste * Resolved? * Yes: switch to regular strength fluoride toothpaste * No: dental referral

Question 405

Potassium nitrate 5% + fluoride (in toothpaste) * MOA:

Answer 405

depolarizes nerves in tubules & pulp to block perception of stimuli; seals exposed dentin

Question 406

indication potassium

Answer 406

tooth hypersensitivity if never diagnosed refer

Question 407

t potassium

Answer 407

2 weeks, may need 4-6 weeks

Question 408

duration potassium

Answer 408

duration o use and beyond

Question 409

side effects of potassium

Answer 409

?

Question 410

interactions with potassium

Answer 410

* ACEi, ARB, potassium-sparing diuretics: increased risk hyperkalemia * Sodium or stannous fluoride: calcium in foods/supplements, staining or compounds to form on the teeth, good tooth brushing technique

Question 411

avoid: potassium

Answer 411

high abrasion toothpastes, whitening toothpaste cause more irritation

Question 412

dosing for potassium

Answer 412

brush with one inch strip BID

Question 413

pregnancy and lactation potassium

Answer 413

no concern

Question 414

Arginine 8% + calcium carbonate * MOA:

Answer 414

depolarizes nerves in tubules & pulp to block perception of stimuli

Question 415

indication for arginine

Answer 415

tooth sensitivity

Question 416

onset for argine

Answer 416

2 weeks

Question 417

duration for argine

Answer 417

2 weeks

Question 418

side effects and drug interactions for argine

Answer 418

?

Question 419

avoid using argine and

Answer 419

fluoride tooth paste at the same time

Question 420

dosing for argine

Answer 420

brush wtih one inch strip BID

Question 421

Recurrent Aphthous Stomatitis

Answer 421

* Canker sore or aphthous ulcer

Question 422

cancker sore etiology

Answer 422

* Unknown for most patients * Triggers: stress, local trauma, food allergy/gluten sensitivity, hormonal changes, genetic predisposition * Systemic diseases (e.g. SLE,(lupus) allergies, IBD, nutritional deficiencies, HIV) * Signs & symptoms * Epithelial, circular ulcer on nonketatinized, movable mouth surfaces * Last 5 to 14 days, 0.5 to 2 c

Question 423

Do not self treat canker

Answer 423

* If underlying cause * Lesions present 14 days or more * Frequent recurrence * Sx of systemic illness * Self-care ineffective

Question 424

Goals of therapy - RAS

Answer 424

1. Relieve pain & irritation 2. Heal lesions 3. Be able to eat/drink & do usual oral care 4. Prevent secondary bacterial infection 5. Prevent recurrence

Question 425

Complementary and non-pharmacologic options-RAS

Answer 425

* Correct any diagnosed nutritional deficiencies * Avoid food allergy triggers * Avoid spicy/acidic foods if active lesions * Avoid textured foods that can irritate lesions * Apply ice to lesions x 10 minutes; max 20 minutes in an hour * DIY salt water rinses (table salt in tap water, swish then spit)

Question 426

OTC Treatment Options-RAS

Answer 426

* Pharmacologic therapy * Topical 1. Oral debriding & wound cleansing agents 2. topical oral anesthetics 3. topical oral protectants 4. oral rinses * Systemic : analgesics

Question 427

follow up recommendations-RAS

Answer 427

* 7 days of treatment or 14 days since lesion/s first appeared * Side effects of topicals: see medical provider

Question 428

RAS Pharmacologic Therapies

Answer 428

* Oral debriding and wound cleansing agents * Carbamide peroxide 10% to 15% in anhydrous glycerin * Hydrogen peroxide 3% (DIY) * Sodium perborate monohydrate * Sodium bicarbonate (DIY) * MOA: release of molecular oxygen * Use: up to 4x daily x 7 days * Side effects * Mouth tissue irritation * Short-term tooth hypersensitivity * Black hairy tongue

Question 429

* Avoid:RAS

Answer 429

toothpastes containing sodium lauryl sulfate

Question 430

* Dosage/administrationRAS

Answer 430

* Drops of carbamide peroxide or hydrogen peroxide applied x 1 min * Rinse: carbamide peroxide drops on tongue, mix with saliva, swish x 1 min * (DIY) 50:50 mix of hydrogen peroxide 3% & water: swish x 1 min * Sodium perborate monohydrate powder: dissolve in 1 oz water & use right away * DIY: baking soda + water paste right on lesion * Expectorate!

Question 431

Topical Anesthetics for RAS

Answer 431

* *Benzocaine 5% to 20% * *Butacaine sulfate 0.05% to 0.1% * *Dyclonine 0.05% to 0.1%

Question 432

Topical oral protectants & rinses for RAS * Barrier protectants * MOA

Answer 432

1. protect 2. decrease friction 3. provide temporary relief

Question 433

* Coat ulcers with topical oral protectants

Answer 433

* Orabase®, Zilactin® * denture adhesive * Dissolvable patch: hold on lesion x 10- 20 seconds to adhere; dissolves over 8-12 hours * Rinses * Listerine® * Saline rinse (1 to 3 tsp salt in 4 to 8 oz warm tap water)

Question 434

Minor Oral Mucosal Injury/Irritation

Answer 434

* Etiology * Dental procedures * Accidental injury: biting tongue/cheek, abrasion from sharp foods

Question 435

not self treat oral mucosal injury

Answer 435

same list as tooth hypersensitivity

Question 436

goals of therapy minor oral mucosal

Answer 436

1. Control discomfort 2. Aid healing 3. Prevent secondary bacterial infection

Question 437

* Nonpharmacologic therapy-Mnor oral

Answer 437

* Sodium bicarbonate * Baking soda ½ to 1 tsp in 4 oz water; swish x 1 minute then expectorate * Saline rinse * MOA: debride, clean wound, stimulate health * Salt 1 to 3 tsp in 4 to 8 oz warm water * Ice x 10 minutes (max 20 min in an hour)

Question 438

Pharmacotherapy of Minor Oral Mucosal

Answer 438

Injury/Irritation * Same as RAS: 1. Topical analgesics and anesthetics 2. Oral protectants 3. Oral debriding/wound cleansing * Astringents: tissue contraction, stop secretions

Question 439

When to refer patient?- injury

Answer 439

Sx persist after 7 days treatment or 10 days of initial injury Symptomsx ___worsen___ during treatment Sx of infection develop (fever, redness, swelling)

Question 440

herpes simplex

Answer 440

Causes & presenting symptoms Causes * HSV-1 * HSV-2 * CMV * Epstein-barr virus Infected for life

Question 441

Herpes symptoms

Answer 441

* Prodrome: * Burning, itching, tingling, numbness in future lesion location * Visual: * small, red papules of fluid-filled vesicles 1 mm to 3 mm diameter; can coalesce (form together) * Inflamed border * Crust on top of mature lesion * Spontaneous healing over 10 days

Question 442

not self-treat

Answer 442

* Lesions present more than 14 days * Increased outbreak frequency * Symptoms of infection (fever, swollen glands, rash) * No prior cold sore

Question 443

Goals of therapy - HSL

Answer 443

* Relieve pain & irritation * Prevent secondary infection * Prevent spread of lesions

Question 444

Complementary and non-pharmacologic options- cold sore

Answer 444

* Keep lesions clean * Handwashing * Avoid sharing utensils, drinking vessels * Moisturize involved skin (petroleum jelly applied with clean fingertip) * Avoid triggers that slow healing (stress, local trauma, wind/sun, fatigue) * Facial/lip sunscreen if sun is trigger * Tea tree oil, lysine, lemon balm

Question 445

OTC Treatment Options- cold sore

Answer 445

* Topical skin protectants (see RAS) * External analgesics/anesthetics (see RAS) * Docosanol 10% * Benzalkonium chloride (?)

Question 446

Follow-up Recommendations- cold sore

Answer 446

14 days

Question 447

Docosanol 10% cream (abreva) * MOA:

Answer 447

inhibits fusion of virus to cell membrane; prevents viral replication

Question 448

docosanol indication

Answer 448

reduce duration & severity of HSL symptoms

Question 449

cosanol pharmacodynamics

Answer 449

decreases time to heal by ~1 day compared to placebo ? side effects unknown, drug interactions: none

Question 450

avoid if have cold sore

Answer 450

placing aspirin tablet on lesions; hydrocortisone; astringents, zinc sulfate

Question 451

dosing of doscosonal

Answer 451

apply 5x/day starting in prodrome until lesion healed; max 10 days

Question 452

Benzalkonium chloride*

Answer 452

Branded product: Viroxyn® liquid * benzalkonium chloride 0.3% benzocaine 7.5% * $40 (?

Question 453

Benzalkonium chloride* MOA

Answer 453

* MOA: disrupts viral envelope * Indication: treatment of HSL or fever blisters * Pharmacodynamics: average time to healing 3-5 days * Side effects: stinging when medication is applied * Drug interactions: none * Avoid : children younger than 2 years; brushing teeth or drinking soda/juice x 1 hour after application *Dosing: single dose; may repeat if lesion returns; max 10 days *Administration: * clean affected area with warm water/washcloth * Prepare applicator * Touch applicator to lesion to numb it (= action of benzocaine) * Massage lesion with applicator

Question 454

Xerostomia etiologies (dry mouth) Causes

Answer 454

* Health conditions: Sjogrens, DM, depression, Crohn’s disease * Radiation therapy * Medications: first-gen antihistamines, decongestants, diuretics, TCAs, antipsychotics, sedatives * Excessive alcohol consumption * Tobacco use * Excessive alcohol use * Mouth-breathing

Question 455

dry mouth presenting symptoms

Answer 455

* Dry mouth (less than 1.5 L saliva in 24 hours) * Difficulty talking, swallowing * Mouth sores (stomatitis) * Halitosis * Altered taste, loss of appetite * Tooth hypersensitivity * Over time: caries

Question 456

Do not self-treat- dry mouth

Answer 456

* Tooth erosion, decay * Candidiasis, gingivitis * Decreased denture-wearing time * Mouth soreness due to dentures * Fever or swelling * Loose teeth * Broken teeth * Severe tooth pain worsened by hot, cold or chewing * Mouth trauma * Sjogren syndrome

Question 457

Goals of therapy - xerostomia

Answer 457

* Relieve discomfort & any symptoms such as difficulty talking * Reduce risk of dental decay * Prevent & treat associated infections Complementary and non-pharmacologic options * Avoid tobacco, caffeine, hot spicy foods, alcohol (including mouth rinses) * Adjust or change causative meds if possible * Limit sugary food intake * Limit acidic food intake * Chew gum with sugar alcohol (e.g. xylitol) * Increase______water consumption_______ * Cool mist humidifier in home * VERY SOFT bristled toothbrushes

Question 458

OTC Treatment Options- dry mouth

Answer 458

* Artificial saliva products * Sprays * Gels * Gums * Toothpastes Follow-up Recommendations * Re-evaluate after __5-7 days__ of therapy

Question 459

Artificial saliva * MOA:

Answer 459

mimics natural saliva; replacement (not cure) * Indication: dry mouth * Pharmacodynamics: * Onset: minutes * Duration: few hours * Side effects: hypersensitivity if preservatives * Drug interactions: _no drug interactions___ * Avoid: sodium-based products if low-salt diet Dosing: * ½-inch of gel on tongue; spread throughout mouth * Minimum frequency: after meals, at bedtime

Question 460

Cheilitis - causes

Answer 460

* Severe dry skin on or around lips * Etiology 1. Dry or cold weather 2. Excessive sun exposure 3. Frequent licking of lips 4. Food sensitivity 5. Personal care products: lip balm, lipstick, toothpaste, mouthwash, sunscreen 6. Medications: retionoids 7. Health conditions: eczema, Crohn’s disease, nutritional deficiencies, sarcoidosis

Question 461

symptoms of chelitis

Answer 461

* Dry * Scaly * Cracking (lip, corner of mouth) * Irritated, painful

Question 462

vention and treamtne tof chelitis

Answer 462

* 5 steps: 1. Avoid licking/peeling/biting/exfoliating lips or surrounding skin 2. Protect lips with quality lip balm (+ sunscreen if outside) prior to lipstick/gloss * Ingredients a. Best = beeswax or petroleum jelly b. Dimethicone: seals off cracks in lips * Apply __6-8__ coats during day 3. Hydrate: drink water, humidify air 4. Avoid irritants 5. Breathe through nose rather than mouth * Refer if severely cracked or swollen OR doesn’t improve with above steps

Question 463

Which of the following ingredients would be important to look for on the label of a product for someone with cheilitis? Select all that apply: 1. Aloe 2. Beeswax 3. Dimethicone 4. Lanolin 5. Paraffin 6. Petroleum jelly

Answer 463

dimethicone, beeswax, petroleum jelly

Question 464

Tooth discoloration & staining * Etiology * Intrinsic:

Answer 464

within tooth structure * Causes: aging, health conditions, damage, tetracycline antibiotics

Question 465

Tooth discoloration & staining * Etiology extrinsic

Answer 465

* Extrinsic: surface of tooth * Causes: tobacco, foods (coffee & tea) * Do NOT self-treat: ___intrinsic causes_______ * Goals of therapy: lighten color/whiten teeth

Question 466

Tooth discoloration & staining self-care * Nonprescription options

Answer 466

* Nonprescription options 1. Bleaching ingredients/products * Ingredients: hydrogen peroxide (up to 10%), carbamide peroxide * Product types: strips/dissolving strips, emulsion, brush-on gels, applicator pens, trays withgel * See requiredreading article in Canvas about time/duration of use Used from 30 minutes to 2 hours daily for periods of 5 to 14 days 2. Nonbleaching ingredients/products = whitening toothpastes * Ingredients:___sodium bicarb________, hydrated silica * May be combined with peroxides * Lightens stains & _____prevent formation of new stains * See requiredreading article in Canvas about * Side effects & their symptoms (including duration) * How to manage side effects

Question 467

Adverse effects:

Answer 467

Tooth sensitivity and gingival irritation are the most frequently reported adverse effects with bleaching. Both problems are usually transient, lasting no more than a few days after the initiation of treatment. Patients with bothersome problems can decrease the frequency with which they use teeth whiteners, use a product with a lower concentration or not brush their teeth before bleaching FDA does not regulate these because it is cosmetic

Question 468

viamtin

Answer 468

compound

Question 469

mineral

Answer 469

element

Question 470

Dietary Supplements

Answer 470

*Manufacturers of food and dietary supplements must follow standards for manufacturing, packaging, and labeling *Do NOT require proof of safety or efficacy before being marketed *FDA takes action if an unsafe product reaches the market *Differs from drugs that must be FDA‐approved before distribution

Question 471

Fat Soluble Vitamins

Answer 471

*Soluble in lipids – absorption facilitated by bile *Stored in body tissues *Deficiencies tend to occur when fat absorption is compromised *Examples of conditions that cause fat malabsorption include Celiac disease, pancreatic disorders, cancers, cystic fibrosis, Crohn’s disease, hepatic cirrhosis, bariatric surgical procedures *Bile acid sequestrant medications and prolonged mineral oil use can impact fat absorption VIT. A, E K, D

Question 472

vit A function

Answer 472

cell division and vision

Question 473

vit E function

Answer 473

antioxidant

Question 474

D function

Answer 474

calcium balance bones

Question 475

vit k function

Answer 475

clotting factors bones

Question 476

vit a deficiencie

Answer 476

night vision loss

Question 477

vit. e deficiencies

Answer 477

peripheral neuropathy

Question 478

vitamin d deficiencies

Answer 478

rickets

Question 479

vit k deficiencies

Answer 479

bone fractures, impaired coagulation

Question 480

toxicities of vit a

Answer 480

double vision

Question 481

toxicities of vit e

Answer 481

risk of congestive heart failure

Question 482

toxicities of vit D

Answer 482

renal failure soft tissue calcification

Question 483

causes of deficiencies of fat soluble vitamins

Answer 483

all malabsorption

Question 484

vit k cause of def

Answer 484

liver diease, disruption of gut microflora

Question 485

vitamin d cause of def

Answer 485

chronic renal disease inadequate sun exposure

Question 486

Water Soluble Vitamins

Answer 486

*Not stored in the body *B‐complex vitamins come from similar sources – if deficient in one likely deficient in all *Common cause for deficiencies include malabsorptive conditions like Celiac disease or Chron’s disease and alcoholism *Drug interactions are unique for each vitamin vit b5, b3, b6, b2, vit c, vit b1, vit b12, vit b9

Question 487

Function of Vit B5 Pantothenic Acid + Vitamin B3 Niacin

Answer 487

Fatty acid & steroid production

Question 488

function of vit b6 pyridoxine and vitamin b3

Answer 488

formation of proteins

Question 489

Vit B6 Pyridoxine function

Answer 489

formation of neurotransmitters

Question 490

Vit B2 Riboflavin function

Answer 490

vision, integrity of cell membranes, reduction/oxidation reactions

Question 491

vit c absorbic acid function

Answer 491

reduces ferric to ferrous

Question 492

vit c and vit b1 thiamine function

Answer 492

co factor for metabolism

Question 493

vit b1 thiamine function

Answer 493

myocardial function

Question 494

vit b1 and vit b12 cyanoco balamin function

Answer 494

neurologic nerve function

Question 495

vit b9 folate function

Answer 495

cell division and brain and spinal cord development

Question 496

vit b9 folate and vit b12 cyanoco balamin function

Answer 496

dna production

Question 497

vit b5 pantothenic acid deficiency

Answer 497

paresthesia

Question 498

vit b2 riboflavin deficiencies

Answer 498

ocular symptoms

Question 499

vit b2 riboflavin toxicities

Answer 499

discoloration of urine

Question 500

vit b5 pantothenic acid deficienciey

Answer 500

paresthesia

Question 501

vit b3 niacin toxicities

Answer 501

hepatoxicity

Question 502

vitamin b3 niacin deficiencies

Answer 502

red/beefy tongue dementia diarrhea

Question 503

vitamin b3 niacin and vit b6 pyridoxine deficiencies

Answer 503

perioheral neuropathy

Question 504

vitamin b6 pyridoxine toxicity

Answer 504

prolactin inhibition

Question 505

vitamin b1 thiamine deficiencies

Answer 505

encephalopathy peripheral neuropathy cardiac dysfunction

Question 506

vit c toxicity

Answer 506

gi symptoms

Question 507

vit c deficiencies

Answer 507

impaired wound healing scurvy

Question 508

vit b12 and vit b9 deficiencies

Answer 508

neurologic symptoms anemia

Question 509

cuases of deficiency for vit b2 b5 b3 and b6, vitc, vit b9, vit b12, vit b1

Answer 509

malabsorption alcoholism

Question 510

auses of deficiency for vit b3 and vit b6

Answer 510

isonisxid therapy

Question 511

vit ccauses of deficiency

Answer 511

smoking inadequate diet of fresh foods

Question 512

vit b1 thiamine cause of def

Answer 512

chronic furosemide use

Question 513

vit b 12 cause

Answer 513

reduced gut acidity vegetarian diet prolonged use of metformin

Question 514

vit b9 folate def cause

Answer 514

genetic polymorphism medication use (methotrexate, anticonvulsants, sulfasalazine)

Question 515

Minerals

Answer 515

*Present throughout the body in every tissue! *Incorporated in enzymes or hormones or vitamins *Function as free ions *Mainly used for regulation *Cell membrane permeability, action potentials, acid‐base balance, etc... *Usually charged so many drug interactions as they may influence absorption of the medication (especially levothyroxine, tetracyclines, fluoroquinolones) *Deficiency is mainly caused by inadequate diet

Question 516

iron

Answer 516

oxygen. andelectron transport

Question 517

phosphorous

Answer 517

used in dna. rna, phospholipids buffer system

Question 518

calcium

Answer 518

bone formation/structure

Question 519

calcium and magnesium

Answer 519

muscle function

Question 520

magnesium

Answer 520

postassium transport

Question 521

iron deficiency

Answer 521

anemia

Question 522

iron toxicities

Answer 522

cardiovascular dysfunction

Question 523

megnesium deficiencies

Answer 523

delirium

Question 524

magneisum toxicity

Answer 524

dimished deep tendon reflexes and muscle weakness

Question 525

calcium and magnesium deficiency

Answer 525

convulsions

Question 526

calcium toxicity

Answer 526

renal sotnes and deposition of calcium in soft tissies

Question 527

iron cause

Answer 527

increased blood demand

Question 528

magnesium cause

Answer 528

diarrhea

Question 529

calcium cause

Answer 529

hypoparathyrodiusm vitamin d deficiency renal failure increased demand due to rapid growth

Question 530

Patient Case 1 *A father comes into the pharmacy with his 9 year old son, LH. He is concerned because his son is an extremely picky eater and he’d like to give his son a multivitamin. *What nutritional concerns do you have for a 9 year old male?

Answer 530

Children are growing and have high nutritional demands: we need to make sure this child has nutrients needed for vision development, bone growth, red blood cell formation. Most children n the US can get enough nutrients from food and rarely need a supplement

Question 531

*What immediate follow‐up questions do you have for the father to make a good recommendation?

Answer 531

-describe the eating habits -why is your child a picky eater

Question 532

*The father tells you that LH used to enjoy food. He loved peanut butter and jelly sandwiches and chicken nuggets. But now LH complains of stomach aches after eating. Most days of the week LH has diarrhea and will even vomit some evenings. It seems sandwiches make his symptoms worse. LH was never a picky eater but over the past year as become one! He picks his food apart. For example, LH started picking the breading off the chicken nuggets.

Answer 532

Malabsoption due to frequent fiarrhea and vomiting *What recommendation do you make to LH’s father? This sounds serious and the health concern causing the malabsoprtive state needs to be addressed. Refer LH to be seen by his PCP

Question 533

*LH and his father come back into the pharmacy a few weeks later. LH was diagnosed with Celiac disease. *What nutritional concerns do you have for LH with his new diagnosis?

Answer 533

Water soluble vitamins: b-vitamin-niacin, thiamine, b12, folic acid, B6 Fat soluble vitamins, A,D Minerals: iron, magnesium, calcium

Question 534

Patient Case 2: PZ and Calcium PZ, a 73 year old female presents to the pharmacy to pick up her new prescription of alendronate (medication used to treat osteoporosis) and purchase a calcium supplement. She has heard a lot on the news about the dangers of calcium and wants to discuss her calcium supplements with you. *What nutritional concerns do you have for a 73 year old female?

Answer 534

Calcium intake as post-menopausal woman Older adults are at risk for numerous nutrition concerns due to : Impaired absorption Decreased appetite and sense of taste/smell Dementia Increased medication use Aging skin and decreased sun exposure

Question 535

*What immediate follow‐up questions would you ask so you can make a good recommendation?

Answer 535

Why is she nervous about calcium supplements Decreased appetite and sense of taste/smell Dementia Increased medication use Aging skin and decreased sun exposure 850mg from diet and we want 1200mg

Question 536

Infant growth & organ maturation

Answer 536

* Growth charts * Length/height & weight & head circumference * Organ maturity * GI

Question 537

somtach capacity at birth and by 1 month old

Answer 537

* Stomach capacity 20-90 mL (__7/10-3__ounces) at birth; 90-150 mL (3-5 ounces) by 1 month old * Human milk empties more rapidly from the stomach = more frequent feedings * Short small intestine length affects nutrient absorption

Question 538

when does kidney filtration begin

Answer 538

week 9

Question 539

GFR reaches adult values in

Answer 539

third year of life

Question 540

Functional GI Maturity * Nutritive sucking

Answer 540

* Depends on coordination of sucking, swallowing, and breathing * Swallowing develops by end of first trimester, sucking develops ~22-23 weeks gestation * Effective sucking = rhythmic alternation between suction and swallowing * Nutritive sucking develops 33-34 weeks gestation; mature pattern at 37 weeks gestation * Premature infants: inefficient pattern for ≥ 1 month or more of life

Question 541

* Gastric functionality

Answer 541

* Gastric motility delayed in first few days of life

Question 542

Weight * Average birth weight:

Answer 542

3500 grams (7 pounds 11 ounces)

Question 543

* Low-birth-weight

Answer 543

less than 2500 grams (5 pounds 8 ounces)

Question 544

Very low-birth-weight:

Answer 544

less than 1500 grams (3 pounds 4 ounces)

Question 545

Extremely low-birth-weight:

Answer 545

less than 1000 grams (2 pounds 2 ounces)

Question 546

“Micropreemies”

Answer 546

less than 750 grams (1 pound 10 ounces)

Question 547

* Water weight loss immediately after birth

Answer 547

6-10%

Question 548

Term infants double birth weight by

Answer 548

4-6 months old, triple by 12 mos

Question 549

* Normal values for length/height, weight, head circumference: expressed in

Answer 549

“percentile for age” * Example: an infant at 50th percentile is “average”; infant at 12.5th percentile is “below average”; infant at 75th percentile is “above average”

Question 550

Basic Requirements of Healthy Diet

Answer 550

1. Water 2. Carbohydrates 3. Proteins and amino acids 4. Fat and essential fatty acids 5. Micronutrients

Question 551

Basic Requirements: Water

Answer 551

* Estimate maintenance water needs for term infants

Question 552

Holliday-Segar Method:

Answer 552

first 10 kg: 100ml/kg second 10kg: 50ml/kg additional kg: 20ml/kg

Question 553

* Greater needs for premature infants

Answer 553

(120-170 mL/kg/day)

Question 554

* Human milk or formula

Answer 554

adequate daily water for first 6 months of life

Question 555

Try it Calculate the maintenance fluid needs for a 22.8 kg child

Answer 555

1556

Question 556

Basic Requirements: Carbohydrates

Answer 556

* __40-50__% of daily calorie needs (kcal/day) * Primary source = lactose (human milk or milk-based formulas) * Balance with fat intake for proper neurologic development * Fiber * AI (adequate intake): not established 0-12 months * 6-12 months: whole cereals, green veggies, legumes to provide dietary fiber

Question 557

Basic Requirements: Proteins & amino acids

Answer 557

* Total body protein increases from 11 to 15% of body weight in 1st year * Preterm infants: early higher protein needs not met by human milk * Fortification with commercial powders/liquids needed * Human milk protein content changes with growing infant needs * Essential amino acids can’t be synthesized from other amino acids * Cysteine, histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, tyrosine, valine * __Tuarine___: especially important * High amounts in human milk, all formulas supplemented * Not source of energy * Cell membrane protector, conjugates bile acids * Deficiency: affects vision, hearing, fat absorption

Question 558

Basic Requirements: Fat & Essential Fatty Acids

Answer 558

* 9 kcal/gram (vs 4 kcal/g for protein or carbohydrate) * 50% of non-protein energy in human milk/formula * Fat NEEDED for proper growth & development * Do not restrict fat if younger than _2 years___(rapid growth/development) unless advised by medical professional * Age 12 months to 2 years & at increased risk for CVD (family hx obesity, dyslipidemia or CVD): reduced-fat milk products as advised by medical professional

Question 559

Fat & Essential Fatty Acids continued

Answer 559

* 2 essential polyunsaturated fatty acids (PUFAs) * Linoleic acid (an omega-6 fatty acid) arachidonic acid (ARA) * Linolenic acid (an omega-3 fatty acid) docosohexaenoic acid (DHA) * Essential fatty acid deficiency (rare in U.S.) * Increased metabolic rate, failure to thrive, hair loss, dry flaky skin, thrombocytopenia, impaired wound healing * Linoleic acid = most of PUFAs in formulas * Supplementation of DHA without ARA ___can result in growth suppresion__________ * Supplementation of DHA and ARA during pregnancy/lactation = controversial; discuss with medical provider

Question 560

Basic Requirements: Micronutrients

Answer 560

* Daily recommended intakes (DRIs) for vitamins & minerals * Tables 23-3 and 23-4 (not required reading) * Formulas supplemented to meet daily needs * Human milk needs fortification to meet needs of premature infants

Question 561

Infant Food Sources

Answer 561

1. Human milk 2. Animal milk: cow and goat 3. Commercial infant formulas

Question 562

1. Human milk

Answer 562

* WHO & American Academy of Pediatrics recommendexclusive breastfeeding for first _6_____of life + recommend through 12 months if appropriate for parent/child * Parents less likely to breast/chest feed: Black, poor, unmarried, poorly educated

Question 563

Why is breast/chest feeding best?

Answer 563

* Optimal nutrition source for infant * Improved parent-child bonding * Decreased risk of infant infections (GI tract, respiratory, otitis media) * Decreased risk SIDS, type 1 & type 2 diabetes, leukemia, overweight, obesity, hyperlipidemia, asthma, atopic dermatitis, eczema, celiac disease, childhood inflammatory bowel disease *Possible enhanced performance on cognitive development

Question 564

Parent benefits

Answer 564

* Improved bonding * Decreased postpartum bleeding * Decreased menstrual blood loss * Increased spacing between children * Earlier return to pre-pregnancy wt * Decreased risk breast, ovarian CA * Decreased risk of RA * Decreased risk of postmenopausal hip fracture, osteoporosis * No $$ for formula purchases

Question 565

Contraindications to breast/chest feeding

Answer 565

1. HIV infection (in United States) 2. Infant galactosemia 3. Parental untreated TB 4. Parental human T cell lymphotropic virus type I or II infection 5. Presence of a herpes simplex lesion on the breast 6. Parental use of contraindicated medications

Question 566

2. Animal Milk

Answer 566

v* Cow: whole, reduced fat (skim 0.1%, low-fat 1%, reduced-fat 2%) 1. NOT for infants < __less than_1 year of age___: low iron, too much protein 2. Reduced fat NOT for < 2 years (unless family hx CVD & medical provider recommends) 3. AVOID evaporated milk 4. Source of commercially prepared, milk-based infant Formula

Question 567

* Goat: powdered, evaporated

Answer 567

1. Fat digested more easily than cow milk 2. Must be fortified with folate, iron & vitamin D

Question 568

3. Commercial infant formulas

Answer 568

* Types * Premature, newborn, infant/toddler, or specific health condition

Question 569

* Manufactured as

Answer 569

* Milk-based, soy protein, or casein hydrolysate-based * Concentrated liquid, powder, or ready-to-feed * Standard, fortifier, therapeutic, and modular

Question 570

* Compositions

Answer 570

* Varying compositions to best feed individual infant’s needs (table 26-6 is 10 pages of infant formulas—do not need to read)

Question 571

Standard Formula Considerations

Answer 571

* Liquid formulations manufactured to be sterile * Still require sterile preparation before feeding! * Powdered formulations notrequired or guaranteed to be sterile * Premature & immunocompromised infants should only receive__ready to feed to diluted with sterile water______ * Standard caloric density is 20 kcal/oz (67 kcal/100 mL) * Formulas may be fortified or made to be more concentrated by varying amount of water added * BUT, only concentrate with medical advice, since reduction in free water can cause dehydration

Question 572

Modular macronutrient components

Answer 572

* Can add to either human milk or infant formula; alternative to concentrated formula * Protein, carbohydrates, fat, combinations * More expensive & time-consuming than concentrating the formula * Use modular when only a single nutrient is needed for adding to a formula or concentrating further not appropriate *Use macronutrient components with medical advice

Question 573

Human milk fortifiers

Answer 573

* Parents who give birth to premature infants produce breast/chest milk that is higher in protein, sodium, potassium, chloride, and iron than parents who deliver at full term (37-40 weeks gestation). * Even preterm milk can’t supply all nutritional needs of premature infant supplementation needed * All supplementation products are liquid (and sterile) * Mixed into ___60-100ml____ of human milk (varies by product)

Question 574

Therapeutic formulas

Answer 574

* For infants with health conditions requiring dietary adjustment *Used with medical supervision * Selected indications for therapeutic infant formulas: a. Allergy or sensitivity to cow milk or soy protein b. Biliary atresia c. Celiac disease d. Cystic fibrosis e. Various causes of diarrhea f. Gastroesophageal reflux g. Hepatitis h. Lactose intolerance i. Prematurity j. Refractory seizure disorder k. Renal insufficiency

Question 575

Number of daily feedings

Answer 575

* Depends on baby, size, age, and food source * Smaller babies feed in small amounts + more often * Birth to 2 weeks: 6-10 feedings/day (2-3 ounces/feed) * 2 weeks-1 month: 6-8 feedings/day (3-5 ounces/feed) * 1 to 3 months: 5-6 feedings/day (4-6 ounces/feed) * 3 to 4 months: 4 to 5 feedings/day (6-7 ounces/feed) * 4-12 months: 3-5 feedings/day (7-8 ounces/feed) * Avoid over or under-feeding * If concerned, seek guidance from medical providers

Question 576

Diarrhea or vomiting in infants

Answer 576

* Infants may pass a stool after each feeding; many more than usual= contact provider * Loss of fluid by diarrhea or vomiting can produce severe dehydration within __24 hours____ (including fluid & electrolyte imbalances, shock, death) * Mild diarrhea usually resolved without intervention but watch closely for dehydration signs and symptoms; may need to supplement feeding with oral replacement solution (ORS: Pedialyte, Enfalyte)

Question 577

Diarrhea or vomiting: when to call medical provider

Answer 577

* Potential formula-related cause if incorrect dilution of concentrated product or incorrect addition of modular product * OR, call provider if: * Severe (many more stools per day than usual) * __72__ hours * Signs/symptoms on prior slide * Bloody stool * Projectile vomiting or green, bilious vomiting

Question 578

Preparing equipment for feeding

Answer 578

1. Wash hands before handling feeding materials (bottle, nipples, rings, etc.) or preparing formula 2. Sterilize feeding equipment a. Using tongs, place all equipment in a deep pan & cover with COLD water b. Bring to a rolling boil & continue boiling for _5__ minutes c. Remove equipment from pan using tongs & place on clean towel d. OR sterilize in a dishwasher with a heated drying cycle

Question 579

Preparing formula for feeding

Answer 579

* Sterilize tap OR bottled water: * Bring to a rolling boil for 1-2 minutes then allow to cool to room temperature for __30_ minutes * Formulas * Wash top of can with hot water and detergent, rinse in hot water, dry * Shake liquid formulas (not needed for powders) * Mix appropriate amounts of sterilized water and formula (concentrated liquids or powdered) * Do NOT dilute ready-to-use cans of formula * Assemble equipment and feed baby * Shake each bottle before feeding * Warm in hot water bath or hold under hot, running water (NEVER microwave) *Test temperature before feeding baby! * After feeding, discard any formula left in bottle + rinse bottle/nipple in cool water

Question 580

Feeding with expressed human milk

Answer 580

* Store up to _96__ hours in glass or plastic airtight container in fridge * Ok to freeze human milk up to 6 months * Thaw rapidly by holding container under lukewarm water or placing in lukewarm water bath * Use thawed human milk within _24__ hours of thawing; never refreeze

Question 581

Formula beyond use dating Liquid formula 1. Liquid concentrate

Answer 581

* Refrigerate up to 48 hours

Question 582

2. Ready-to-use formula

Answer 582

REfrigerate 48

Question 583

Powdered formula

Answer 583

1. Unused, reconstituted liquid * Refrigerate up to _48__ hours 2. Unused powder * Store at room temperature up to 1 month

Question 584

Functional foods Definition:

Answer 584

No legal definition Functional food = part food + part drug Can be regulated either as food or drug, depending on subcategory (next slide) “provides health benefits in addition to basic nutrition” Examples: Tomatoes: lycopene Soybeans: isoflavones OJ fortified with calcium Margarine with added stanol ester

Question 585

Functional food (FF) categories--background 5 categories based on:

Answer 585

Legal___definitons________ Regulatory guidelines Medical supervision: need for supervision varies by ___category______ Labeling claims: Require prior FDA approval ______level of evidence for labeling claim________ varies by category

Question 586

Functional Food Categories 1 & 2

Answer 586

1. Health claims (recognized by FDA) a. What’s allowed? i. Allowed: reduction of disease risk ii. Not allowed: anything related to definition of __a drug____* A drug: agent used in diagnosis, cure, mitigation or treatment of disease b. 3 subtypes—each associated with LoE and labeling requirements; future slides explain these in more detail i. Authorized ii. Authoritative iii. Qualified 2. Structure/function claim: effect that food has on body __structure or function____ a. Probiotic yogurt: “improves digestion”- no diagnosis of health conditon, treatment, mitagating, curing, improves some function of body. Vague, nothing about disease b. “promotes urinary tract health” c. “supports the immune system”

Question 587

Functional Food Categories 3, 4, 5

Answer 587

3. Special dietary use a. supply particular dietary needs or supplement/fortify usual diet b. Does NOT meet general dietary needs c. Examples: a specific health condition, pregnancy, underweight, overweight, infancy, need to sodium-restrict 4. Medical foods a. Prescribed/recommended by MD & used under medical supervision (but can be sold without MD written order) b. Not natural foods—specially formulated to meet nutritional requirements of a condition 5. Specified conventional foods a. Catch-all for what doesn’t fit in categories 1-4 b. Usually no clinical trials, ___weak________ evidence c. Examples i. Apples flavenols decreased risk of some cancers ii. Fatty fish Omega-3 fatty acids decreased TG & risk of heart disease iii. Tree nuts monounsaturated fatty acids, vit E decreased risk of CHD

Question 588

Health Claim: Authorized 5 points:

Answer 588

1. publication of FDA regulation and extensive literature review + scientific agreement that food/nutrient and dz relationship is well-established 2. reduction of disease risk and required to use words “may” or “might 3. Label must state that condition depends on many factors so that people don’t think the food is the only important aspect for dz mgt 4. No claim allowed if more than 13 g fat, 4 g sat fat, 60 mg chol or 480 mg Na per reference ( do not memorize amounts) amount consumed (1 serving) 5. Not allowed for children younger than 2 Examples (see slide with table and pictures of diced tomatoes & Cheerios) Know these are the things FDA regulate, cant have a lot of fat, saturated fat, cholesterol in it.

Question 589

Health Claim: Authoritative

Answer 589

Mfg makes claim based on authoritative statement from scientific body of US government which has responsibility to protect public health OR the US gov’t body does research related to human nutrition * Authoritative scientific body of US government: NIH, CDC, National Academy of Sciences * FDA itself doesn’t do extensive review (like does for authorized) Examples * Whole grain foods & risk of heart disease/certain cancers * Fluoridated water & reduced risk of dental caries/cavities

Question 590

Health Claim: Qualified

Answer 590

Weakest of all of them Emerging evidence Claim wording indicates _____there is weak _______evidence associated with it Examples * Walnuts: heart disease * Green tea: cancer

Question 591

Fiber Description:

Answer 591

indigestible components of the diet Types * Dietary fiber: “roughage”, “bulk”; intact carbohydrate + lignins from plants * Examples: cellulose, xanthan gum, pectin, agar * Functional fiber: carbohydrate extracted from plant or animal sources then added to supplement foods/drinks * Examples: beta-glucans, cellulose * Soluble fiber * Slows digestion & prolongs time to absorb glucose from foods * Bind fatty acids lowers LDL cholesterol * Examples: inulin, beta-glucans, psyllium * Insoluble fiber: * Hydrates & helps move __the stool___ through intestines * Examples: cellulose, lignin

Question 592

Daily Fiber Intake-United States Recommendations

Answer 592

14 grams total fiber per 1000 calories consumed Actual intake Mean: 15-18 grams per day for adults How many grams of fiber to you consume a day? Chart of high-fiber foods:

Question 593

Increasing daily fiber How to increase fiber intake

Answer 593

SLOWLY! Add 1-2 servings of high fiber foods every_____1-2 weeks___ until goal fiber Chart of high-fiber foods: https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthyeating/in-depth/high-fiber-foods/art-20050948 * Foods: Whole-wheat grain, oatmeal, brown rice, whole wheat pasta, canned/rehydrated beans * Cooking: bake with whole-grain flours * Desserts & snacks: fruit, bean dip/hummus, nuts/seeds * Food labels: whole grain should be 1st ingredient Main fiber side effects:

Question 594

How to manage:

Answer 594

Increase daily water consumption Careful with carbonated beverage intake, ____gum chewing__________ CAUTION for people with: poor GI motility/dysfunction, including __narcotic induced____ dysmotility

Question 595

Fiber Benefits

Answer 595

1. Improved bowel function Laxation from insoluble fiber (see prior slide) 2. Lipid effects Decreased CHD risk 3. Blood glucose effects Soluble fiber’s MOA (see prior slide) 4. Weight loss/maintenance Lower BMI if high fiber diet Why? Delayed ___stomach emptying_______ & prolonged _small intestine transient time____________ which are associated with satiety and gut function

Question 596

Medical Foods & Meal Replacement Foods Medical food definition

Answer 596

Requires recommendation from and ongoing supervision by MD/authorized prescriber Enteral formula Definition: semisynthetic liquid formulas for oral consumption or provision through feeding tube Complete nutritional replacements Who uses? Patients with impaired digestion: specific formulas, monitoring by HCP Examples: * Pulmocare (>50% calories from fat) * Peptamen (protein as peptides or free amino acids)

Question 597

Other Enteral Formula Uses + Examples Supplementation of food intakes Marketing to consumers as “meal replacements”

Answer 597

Examples (from table 24-10 in textbook) Routine formula * Boost: 240 calories/mL, 10 grams protein, no fiber, hypertonic * Ensure: 250 calories/mL, 9 grams protein, no fiber, hypertonic * Jevity 1 Cal: 250 calories/mL, 10.4 grams protein, 3.4 grams fiber from soy, isotonic Routine formula with extra protein * Boost High Protein: 240 calories/mL, 15 grams protein, no fiber * Ensure High Protein: 160 calories/mL, 16 grams protein, no fiber Routine concentrated (high-calorie) formula * Boost Plus: 360 calories/mL, 14 grams protein, 3 grams fiber * Ensure Plus: 350 calories/mL, 13 grams protein, no fiber

Question 598

Types of Enteral Formulas Polymeric Who uses?

Answer 598

normal digestive capability What do the formulas contain? ____mixture of macronutrients______________ (whole proteins, carbs, fatty acids/oils) Examples: Boost, Ensure

Question 599

Oligomeric

Answer 599

Require minimal digestion; “predigested” formulas What’s in them? Free amino acids, hydrolyzed protein, less complex carbs Can you drink them?____dont taste good, ng tube or g tube______________ Usually require medical supervision; examples: Vital HN, Peptamen VHP Modular Single macronutrient Examples: protein powder, medium-chain triglyceride (MCT) oil, flavorless glucose polymers Specialty

Question 600

Polymeric or oligomeric

Answer 600

Optimize nutrition if health conditions such as kidney insufficiency, diabetes, liver dysfunction Requires medical supervision

Question 601

Enteral Formula Use

Answer 601

Enteral Formula Use Administration Vary flavors Consume after trying to eat meal What if don’t use entire container at one feeding? Keep in fridge but discard after __24__ hours Monitoring Medical supervision for tube feeds Refer if nausea, diarrhea or abdominal distention Food-Medication Interactions Consult references given many interaction possibilities In general, be wary of: phenytoin, carbamazepine, warfarin How to manage? Withhold tube feed for __1-2_______ hours before and after giving medication Check formula for ____how much vitamin k is in it because it can counteract effects of warfarin.