Exam 2 Flashcards
*How are dietary supplements defined?
Dietary Supplement Health and Education Act (DSHEA) -
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.
“dietary ingredients” in dietary supplements may include
vitamins,
minerals, herbs, and amino acids as well as substances such as
enzymes, organ tissues, metabolites, extracts or concentrates.
Dietary supplements can be found in many forms such as
pills, tablets, capsules,
liquids or powders.
They must be identified on the label as a
dietary
supplement.
*How are dietary supplements treated differently from drugs by the FDA?
- 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
Unsafe Botanicals are the Exception
- 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
*What guidance is provided by the FDA on the appropriate use of
dietary supplements?
- 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.
Some Supplements can provide data
to support “Health Claims”
example: calcium
– “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.”
Soy Health Claim
- “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.
DSHEA - Labeling Requirements
* Labeling must not:
– Claim to diagnose, prevent, mitigate, treat, or cure
a specific disease or class of diseases;
- Labeling may:
– Describe the role of a nutrient or dietary
ingredient intended to affect the structure or
function in humans
Examples of Labeling
- Silymarin
– Prohibited: Improves alcoholic cirrhosis
– Allowed: Supports normal liver function
- Echinacea
– Prohibited: Prevents colds and flu
– Allowed: Helps support immune function
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.
Protecting Intellectual Property
- Supplement manufacturers often will combine
ingredients into “proprietary blends”.
proprietary blends label
– 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
Dietary supplement labels
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
A growing number of dietary supplements
have been shown to have beneficial activity in
well controlled clinical trials
- There is no current control over the content of
even the “effective” products - Even “certified” products may vary over time
Agnus Castus (Vitex)
Common uses:
symptoms of premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), dysmenorrhea, mastalgia, and menopausal symptoms.
Agnus Castus (Vitex) Adverse effects:
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.
Curcumin/Tumeric
Common uses:
arthritis and inflammatory conditions.
Curcumin/Tumeric
Adverse Effects
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.
Glucosamine Common uses
osteoarthritis (OA) and joint health
Glucosamine Adverse Effects
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
Bitter Melon
Common uses:
increased cellular glucose uptake, decreased gluconeogenesis in the liver, and increased insulin secretion.
was able to significantly reduce fasting plasma glucose, postprandial glucose
Bitter Melon Adverse Effects
Well tolerated with primarily GI side effects, such as nausea, heartburn, and diarrhea.
Enchinacea Common Uses
prevent and treat colds and other respiratory infections
Enchinacea adverse effects
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
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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
Saw Palmetto
Common uses:
used to treat BPH. Benign prostatic hyperplasia (BPH) — also called prostate gland enlargement
Saw Palmetto Adverse Effects
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.
Cinnamon common uses :
lower blood glucose
cinnamon adverse effects
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.
Feverfew
Common uses:
prevent migraines and to treat dysmenorrhea, arthritis, and psoriasis
Feverfew Adverse Effects
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
Ginseng
Common uses:
boost physical and mental energy and to produce a sense of well-being
Ginseng Adverse Effects
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.
Garlic
Common uses:
hyperlipidemia, hypertension, type 2 diabetes mellitus,
Garlic Adverse Effects
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
Ginger
Common uses:
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.
Ginger adverse effects
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.
Ginko Biloba Common uses
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.
Ginko Biloba Adverse Effects
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
Black Cohosh
Common uses:
Black cohosh has been used to treat the symptoms of premenstrual syndrome, dysmenorrhea, menopause, and rheumatoid arthritis.
Black Cohosh Adverse Effects
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
Ashwaganda Common uses
calm the brain, reduce swelling, lower blood pressure, and alter the immune system
Ashwaganda Adverse effects
gastrointestinal upset, diarrhea, nausea and vomiting,
Elder Berry
Common uses:
Common uses:
used primarily for prevention or treatment of influenza and other upper respiratory illnesses.
Elder Berry Adverse Effects
Commercially available elderberry extracts are well tolerated, with few adverse effects reported. Insufficiently cooked or unripe berries can have GI tract issues.
*What agency sets the Daily Required Intake of nutrients and vitamins?
Food and Nutrition Board of the National Academies of Sciences Engineering, and Medicine.
Most interactions between supplements and
drugs are likely to be
pharmacodynamic
– Increasing or decreasing the effect of a drug
Few established pharmacokinetic interactions
- Increasing or decreasing the concentration of a
drug
*What topics, questions, or suggestions can be offered when
counseling someone asking about the use of dietary supplements?
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?
*What are the most commonly used herbal dietary supplements?
(from text: )What are they commonly used for, and what side effects
are common?
– Elder berry
-Echinacea
– Horehound
- Garlic
– Cranberry
-Fenugreek
– Tumeric
-Wheat grass
– Apple Cider Vinegar
Saw Palmetto
– Ginger
- Ashwaganada
Why might the ingestion of dietary supplements or high doses of
vitamins be unwise in patients being treated for cancer, HIV, or organ
Transplants?
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
Easy Suggestions for DS
- Cheap and documented benefits
–Daily vitamin if diet poor
–Calcium
–Vitamin D
–Green Tea (de-caffeinated, if desired)
–Fish Oil / Krill Oil
*What barriers exist for pharmacists to properly advise patients and
clients on the proper and safe use of dietary supplements?
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.
Significant decrease in drug concentration
– St John’s wort
– Garlic (maybe)
- Significant increase in drug concentration
– Berberine (Goldenseal)
- Significant risk with concurrent warfarin or other
anticoagulants (low molecular weight heparin)
and with:
– Danshen (increased warfarin conc)
– Platelet inhibitors (ginkgo, feverfew, etc.)
– Coumarin-containing (additive anticoagulation)
St John’s wort
- 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
St. John’s wort decreases the blood
concentrations of:
– Cancer chemotherapy (CPT-11)
– Heart failure therapy (digoxin)
– HAART HIV therapy (protease inhibitors)
– Immunosuppresants (cyclosporin)
– Anti-epileptics (phenytoin)
– Oral contraceptives
Increased Warfarin Risk
- Decreased platelet function
– Adherence and Aggregation
– Degranulation and cascade activation
- Several supplements have been associated with
this in a convincing manner:
– Ginkgo biloba
– Feverfew
– Garlic
Warfarin anticoagulation with herbs
containing coumarins will increase effect
(increased INR, risk of bleeding)
- Dong Quai
- Papaya
- Red Clover
Pharmacodynamic Interactions
(Modification of the Effect arising from a given Drug
Concentration)
diabetes potentiation
– Vanadium
– Ginkgo
– Bitter melon
– Cinnamon
- Hyperkalemic effect
– Spironolactone (K+ sparing) + licorice root
Enhanced effect – Synergy
Licorice root
- 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
Enhanced effect – Synergy
- Hawthorne seed extract for heart failure,
plus:
– ACE inhibitors, AR antagonists, digoxin? - Sildenafil and similar phosphodiesterase
inhibitors
– Ginkgo
– DHEA
– Possible hypotension and syncope
How credible are case reports?
- 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
- From these cases, should cranberry juice be
proscribed in patients who are taking warfarin?
– As beverage?
– As UTI prophylaxis?
Dietary Supplements to
Support Cancer Patients
- 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
- Ginseng (Panax ginseng)
– 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
Impairment of Chemotherapy by
Supplements that are Anti-Oxidants?
- 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
Examples of Antioxidants that may Attenuate
the Effect of Cancer Treatment
- Ascorbate (Vitamin C)
- Retinoids / -carotene
- Coenzyme Q10
- Tocopherol (Vitamin E)
- Green / Black Tea
- Grape Seed Extract
- Milk Thistle
- Pycnogenol (pine bark extract)
Most widely available dietary supplements are
safe when taken in
Suggested doses
There is a greater risk when dietary
supplements
combined with other
prescribed therapy
- Interactions with medications are
usually not known
High risk patients shout not
unilaterally start taking dietary supplements
- Heartburn
- 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”
Main symptom of GERD
heartburn
Heart burn usually occurs
within 1 hour after eating; often after large meal; worsened by lying down
GERD
- Chronic condition; frequent reverse flow of stomach acid and contents into the esophagus
- Heartburn 2 or more times per week
GERD complications
esophagitis, esophageal stricture, Barrett’s esophagus (pre-cancerous condition)
* Dyspepsia
symptoms of gerd generate from
gastroduodenal region
symptoms of gerd include
postprandial fullness, ___epigastric pain__________
* Associated symptoms: anorexia, belching, nausea, vomiting, upper abdominal bloating, heartburn, regurgitation
Heart burn aggravating factors
bending over, lying down
heart burn associated symptoms
- 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
mild heartburn
a little bothersome but dont affect normal activities
moderate heartburn
somewhat annoying or interfere with activities
severe heartburn
alarm symptoms
UES
upper esophageal sphincter
UES to
esophagus
Esophagus to
LES lower esophageal sphinicter
LES to
diaphragm
diaphragm to
stomach
help to keep acid &
stomach contents in stomach
LES and diaphragm
LES ______________ at rest
contracts
Heart burn risk factors
alcohol, acidic, caffeine, chocolate, exterme emotions, excersize, stress, obseity, asprin and nsaids, postasium.
Do not self treat: heart burn
- 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
Goals of therapy
- Provide complete symptom relief
- Reduce symptom recurrence
- Prevent/manage OTC medication side effects
Complementary and non-pharmacologic options
- 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)
Consider: OTC options
- Symptoms: frequency, duration, severity
- Medication cost
- Drug-drug interactions
- Adverse effects
- Patient ____preference___________
Medications: Heartburn
- Antacids
- Histamine-2 receptor antagonists
(H2RAs) - Proton pump inhibitors (PPIs)
- Bismuth subsalicylate
mild-mod, infrequent heart burn or dyspepsia & only need short-term relief
antacid or H2RA
antacid
rapid symptom relief
short term relief if take without food
interchangeable at recommended doses
antacid/alginic acid more effective in combo
h2RA
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
mild, mod infrequent or dyspepsia but need longer lasting relief
H2RA
hb 2 or more days per week
PPI or H@RA
ppi daily x 14 days
H2RA as needed
anatacids onset of relief and duration on empty stomach and food in stomach
within 5 minutes
empty: 20-30 min
food: up to 3 hours
H2RA’s onset and duration
30-45 minutes
4-8 hours
4-10 hours 9( famotidine)
Combo H2RA+ antacid onset and duration
within 5 minutes and lasts 8-10 hours
PPI single dose onset and duration
1-3 hours may need 1-4 days for full effect
12-24 hours
Follow-up Recommendations
- 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
antacid products
- 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®
Antacid MOA
neutralize gastric acid, increase __LES__ pressure
protective barrier)
Alginic acid + sodium bicarb in saliva = layer of sodium alginate on top of stomach contents
Indication:
treatment of mild, infrequent heartburn, sour stomach, and acid
indigestion
- Pharmacodynamics:
- Onset:
within 5 minutes
Liquid formulations faster
faster than tablets; quick-dissolving tablets next fastest
shortest duration
magnesium hydroxide
empty stomach
20-30 min
food in stomach
2-3 hours
pregnancy
calcium and magnesium antacids ok
lactation
aluminium, calcium, magnesium antacids ok
Antacids (continued)
* Dosing:
* Product-
recommended doses; do not exceed
repeat dose in
1-2 hours if needed
re-evaluate if
- Using more than twice a week
- Regularly for more than 2 weeks
main side effects
aluminum
constipation, hypophosphatemia (long-term use)
main side effects
calcium carbonate
belching, intestinal gas, constipation; hypercalcemia if
kidney dysfunction.
main side effects
magnesium
diarrhea. Manage by __product that has a combination with aluminum
main side effects sodium bicarb
belching, intestinal gas
memory trick
aluminum, A comes before Magnesium, M in the alphabet so Constipation comes before Diarrhea in the alphabet
calcium carbonate causes
constipation
3, C’s
antacids drug interactions
many
itraconazole, amphetamines
rosuvastatin
enteric coated meds
dasatinib
calcium carbonate, mag hydroxide, aluminum hydroxide rug interactions
levothryoxine
tetracyclines
fluroquinololnes
seperate by 4 hours for the first two
antibiotic 2 hours prior or 6 hours after antacid
aluminum or magnesium drug interaction
azithromycin
seperate by at least two hours
sodium bicarb drug interactions
Quinidine (decreased excretion)
Salicylates (increased excretion)
avoid concurrent use or monitor carefully
Antacids (last slide)
* Avoid:
- 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
avoid sodium bicard
Sodium restriction (274 mg sodium/gram sodium bicarbonate)
* Heart failure, kidney failure, cirrhosis, pregnancy
* Taking with calcium supplements
* Concomitant aspirin therapy
Histamine type 2 recepotor antagonists (H2RA)
- Cimetidine
Branded product: Tagamet HB® - Famotidine
Branded product: Pepcid AC®
Cimetidine, famotidine
* MOA
reduce acid secretion by inhibiting histamine at the H2 receptors on parietal cells, do not neutralize aicd (that is the antacid MOA)
- Indication:
- Mild to moderate, infrequent or episodic HB or prevention of HB
- Combo with antacid:
postprandial HB if not premedicated with H2RA
- Pharmacodynamics:
- Onset
30-45 min
- Duration:
- 4-8 hours (cimetidine)
- 4-10 hours (famotidine)
- Side effects:
Infrequent
Both: headache, diarrhea, constipation, drowsiness, dizziness reported
Cimetidine side effects
high doses may cause decreased libido, impotence or _____gyneocomastia, enlargement of the breasts____ due to weak antiandrogenic effect
- Avoid: (h2)
- older adults at high risk for delirium, sodium-sensitive health conditions
- Younger than __12__ years old
pregnancy (h2)
ok to use though meta-analysis suggested association of childhood asthma
Lactation:
famotidine preferred due to lower milk concentration but cimetidine ok per AAP
H2RA drug interactions
erlotinib, dasantinib, gefritnib, other TKIs, ripvirine, ledipasir, sofoburvir, itraconzabole, ketoconazole, atazanavir, iron sulfate, calcium carbonate
decreased absorption
avoid concurrent use
H2RA
* Dosing
- Onset of symptoms OR _30-60___ min prior to when HB is expected
- Note: Rx doses may need adjustment if kidney dysfunction
cimedtidine dose
200 mg once daily
famatodine dose
10-20 mg once or twice daily (max 40mg in 24 hours)
Proton pump inhibitors (PPIs)
- Esomeprazole magnesium 22.3 mg
* Delayed release tablet or capsule
*Branded product: Nexium® - Lansoprazole 15 mg
* Capsule containing enteric-coated granules
* Delayed-release orally disintegrating tablet
*Branded product: Prevacid® - Omeprazole
* Omeprazole magnesium 20.6 mg
* Delayed release tablet
*Branded product: Prilosec®
* Omeprazole 20 mg + sodium bicarbonate 1100 mg
* Immediate release
*Branded product: Zegerid®
PPIs
* MOA:
inhibit hydrogen potassium ATPase (proton pump) in stomach parietal cells
Indication: (PPIs)
heartburn symptoms 2 or more days per week
PPIs onset
1-3 hours start of relief (may need 1 to 4 days for full effect)
PPI’s duration
12-24 hours (single dose)
Side effects PPIs
uncommon
* Headache, abdominal pain, diarrhea, constipation, gas
* Increased risk ___traveler’s diarrhea_____ and _____C. Diff infection___ (PPI’s change ph in stomach, more basic)
- Avoid: PPIS
- crush/chew tablets or capsules
- severe diarrhea/gastroenteritis symptoms (seek care)
- Younger than _18___ years old
pregnancy PPI’s
low risk omeprazole, lansoprazole; possible childhood asthma risk (refer if frequent HB)
Lacatation PPIs
low milk amounts of omeprazole, esomeprazole (less than infant Rx)
Dosing: PPIS
30-60 min prior to
meal (esp breakfast); max 14
days; 1 course every 4 months
max*
PPI drug interactions
omprazole, esomeprozole- clopidogrel, clistazol, diazepam avoid concurrent use
PPIs- erlotinib, sasatinib, vir, itraconziole, irone sulfate, calcium carbonate, warfarin, theophyliine, tacrolimus, digoxin
avoid conccurent use.
Bismuth subsalicylate Branded product: Pepto-Bismol®
MAO
protects gastric mucosa
bismuth indication
heartburn, upset stomach, indigestion, nausea, diarrhea
bismuth onset
30-60 minutes
duration bismuth
30-60 minutes
side effects bismuth
black-colored tongue, stool, tinnitus^
drug interaction bismuth
- Warfarin (avoid)
- Tetracycline antibiotics (avoid)
- Methotrexate (avoid)
avoid- bismuth
children*, salicylate sensitivity/allergy, bleeding risks
dosing bismuth
262-525 mg every 30-60 minutes PRN
–chew tablets thoroughly (if chewable)
–nonchew: full glass water
–max 48 hours of therapy
pregnancy bismuth
use alternative drug if possible 1st , 2nd trimesters; avoid 3rd trimester
lactation bismuth
use alternative drug
Special populations
*Pregnancy
first
* First-line OTC:
* Max food/OTC calcium per day:
- Lifestyle/food changes first
- First-line OTC: calcium or magnesium antacids
- Max food/OTC calcium per day: 2500 mg
*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:
- 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
Older adults
- Avoid H2RAs if
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
intestinal gas causes
- 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)
Medical conditions associated with increased
intestinal gas
- 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
Medications that contribute to intestinal gas
- 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)
Presenting symptoms of intestinal gas
- Eructation: belching of swallowed air
- Bloating:
- Indigestion
- Abdominal pain/cramping
- Borborygmi: audible bowel sounds
- Flatulence: passage of air out through the rectum
Do not self-treat- gas
- 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
Goals of therapy
- 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
Complementary and non-pharmacologic options
- 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
OTC Options- prevention of gas
- alpha-galactosidase
- Lactase enzyme
OTC treatment of gas
- Simethicone
- Activated charcoal
Follow-up Recommendations
__try these agents for one week and if things arent better than to refer_________
Alpha-galactosidase
Branded product: Beano (food)
* MOA:
hydrolyzes oligosaccharides into component parts
Alpha-galactosidase- indication
prevention of intestinal gas
Alpha-galactosidase
onset
within 30 minutes
Alpha-galactosidase duration
at least 5 hours
Alpha-galactosidase side effects
possible allergic reaction (rash, swelling, hives, difficulty, breathing)
Alpha-galactosidase drug interactions
none known
Alpha-galactosidase avoid in
people with galactosemia, mold allergies
Alpha-galactosidase pregnancy
likely okay check with healthcare provider
Alpha-galactosidase lactation
likely ok, check with healthcare provider
dosing adults and adolescents Alpha-galactosidase
300-450 units per food serving
Alpha-galactosidase dose children
ask HCP
Lactase enzyme
Branded product: Lactaid
* MOA:
replacement enzyme that breaks down lactose into glucose +
galactose
lactase enzyme indication
dairy intolerance
onset lactase
immediate
duration lactase
while digesting dairy product
side effect lactase
non possible stomach pain
lactase drug interactions, avoid
?
Dosing for all ages* (first bite):
lactase
oringial, extr, ultra
Original strength: 3__caplets
Extra strength: __2 caplets
Ultra strength: 1 caplet (max 2)
*from website
lactase pregnancy
likely safe but check with HCP
lactase lactaton
no info available on excretion into milk; likely safe but check with HCP
Simethicone
Branded product: Gas-X
* MOA:
defoaming agent; reduces surface tension of gas bubbles in
GI tract mucus -> eliminated more easily
simethicone indication
intestinal gas
simethicone onset
within 30 minutes
simethicone duration
up to 4 hours
simethicone side effects, drug interactions, avoid
?
dosing after meals + bedtime
adults and adolescents: simethoicone
- 40-125 mg 4x daily PRN
- Children 2 to 12 years: simethicone
- 40-50 mg 4x daily PRN
children younger than 2 years: simethicone
20 mg 4x daily PRN
pregnancy and lactation
safe to use
Activated charcoal Branded product: CharcoCaps (supplement)
* MOA
?adsorb gas given charcoal large surface area
charcoal indication
promoted for relief of intestinal gas (not approved nor
shown to be effective)
- Onset:
- Duration:
charcoal
?
side effects charcoal
poor palatibility, capsule form found
drug interactions carchoal
may decrease drug absorption
avoid taking charcoal
within 1 hour after medications
dosing charcoal adults:
500-520 mg after meals PRN, may reapeat hourly
dosing adolescents children
?
pregnancy- charcoal
likely safe for occasional use, check with healthcare provider
lactation- charcoal
likely safe for occasional use; check with healthcare provider
- Hemorrhoid definition:
- inflamed, swollen blood vessels in
the rectum and anus that protrude
during bowel movements
Internal hemorrhoid
- Inside rectum
- Can’t see or feel; __rarely cause discomfort_______
External hemorrhoid
- Under skin around anus
- Usually have symptoms
presenting symptoms for internal
*Internal hemorrhoid
* Rare discomfort
* Stool passage may cause
painless bleeding (red on toilet
tissue but not dripping into toilet
bowl)
external hemorrhoid presenting symptoms
- Itching (pruritis)
- General discomfort/irritation
- Burning
- Inflammation
- Swelling
do not self treat hemorrhoids
- 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
goals of therapy hemorrhoids
- Resolve symptoms
- Keep stool soft; prevent straining with bowel movements
- Maintain remission of symptoms
- Prevent complications
Complementary and non-pharmacologic options- hemmorrhoids
- 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
OTC treatment options- hemmoroids
- Local anesthetics
- Vasoconstrictors
- Protectants
- Astringents
- Keratolytics
- Analgesics, anesthetics,
antipruritics - Corticosteroids
Follow-up Recommendations - __one week of self care- refer______
Local Anesthetics: benzocaine, benzyl alcohol, dibucaine,
dyclonine, lidocaine, pramoxine, tetracaine
MOA
block transmission of nerve impulses
local anestetics indication
temporary relief of external anal symptoms
local anestetics duration
depends on agent; mostly 4 hours
side effects local anestetics
allergic reactions, dermatitis
drug interactions local anestetics
no significant interactions
avoid -local anestetics
more severe anorectal disorders; open lesions
pregranacy and lactation- local anestetics
Pregnancy: likely okay; check with medical provider
Lactation: likely okay; check with medical provider
dosing- local anestetics
Applied __3-6___times/day; check
label
Vasoconstrictors: ephedrine, epinephrine, phenylephrine (topical)
* MOA:
stimulation of alpha-receptors to constrict arterioles and decrease swelling
Vasconstrictors indication
relief of discomfort, itching + reduce swelling;
- Ephedrine, phenylephrine: good for
internal, external
epinephrine is good for
external
vasoconstrictors onset
5-10 minutes
vasoconstrictors duration
about 6 hours
vasoconstrictors duration
about 6 hours
vasoconstrictors side effects
mild pain, stinging, if raw/bleeding skin
drug interactions vasoconstrictors
?
vasoconstrictors avoid
talk to provider before use if cardiac history, diabetes, BPH, thyroid
conditions
vasoconstrictor dosing
applied 4 times a day; check label
pregnancy and lactation- vasoconstrictor
likely okay, check with medical provider
Protectants: LOTS! Aluminum hydroxide gel, cocoa butter,
glycerin, lanolin, mineral oil, white petrolatum, zinc oxide and more
* MOA:
provide physical protective barrier
protectant indication
temporary relief of discomfort, irritation, burning
Glycerin used for
external
other protectants
use internal or external
protectant onset
?
protectant duration
4 hours or longer
side effects protectant
uncommmon, lanolin caution
drug interactions- protectant
?
avoid -protectants
applying other medications after protectants
dosing for protectants
petrolaum and all others
- Petrolatum: _as needed___
- Others: up to 6x/day or after
each bowel movement
protectants: preganacy and lactation
likely okay; check with medical provider
Astringents: calamine, zinc oxide, witch hazel
* MOA:
help coagulate surface proteins to protect lower tissue; decrease
cell volume, provide thin protective layer
Astringents Indication
temporary relief of itching, burning, irritation of anorectal d/o
Witch Hazel where applied
external
Calamine, zinc oxide where applied
internal or external
onset of astringents
?
Duration- astringent
up to 4 hours
side effects of witch hazel
slight stinging
drug interactions and avoidance for astringents
?
astringents dosing
apply up to 6 times/day
astringents: pregnancy and lactation
likely okay; check with medical provider
Keratolytics: alcloxa, resorcinol
* MOA:
cause sloughing of epidermal surface cells
keratolytics indication
treat pain & itching caused by minor skin irritations
onset keratolytics
?
duration keratolytics
up to 4 hours
side effects keratolytics
allergic reaction to resorcinol
drug interactions keratolytics
?
avoid using keratolytics when using
with harsh soaps
dosing keratolytics
apply 6 times daily
keratolytics pregnancy and lactation
likely okay; check with medical provider
Analgesics, anesthetics, antipruritics: menthol,
juniper tar, camphor
indication
temporary relief of burning, pain or itching; external
oneset of analgesics
?
duration of anelgesics
up to 4 hours
side effects of analgesics
allergic reactions
drug interactions of analegesics
?
avoid using analgesics on
on irritated or damaged skin
dosing of analgesics
up to 6 times daily
pregnancy and lactation analgesics
likely okay; check with medical provider
Corticosteroid: hydrocortisone 0.25-1%
* MOA:
lysosomal membrane stabilization + antimitotic activity
corticosteroid indication
temporary relief of minor external anal itching
onset of corticosterioid
?
duration of corticosterioid
up to 6-8 hours
side effects of corticosteroid
skin atrophy or thinning of skin
drug interaction: corticosteroid
?
Avoid doing this when using corticosterioids
- Avoid: prolonged use (max 7 days)
dosing of corticosteriods
apply up to 3 to 4 times a day
pregnancy and lactation corticosteroid
likely okay; check with medical provider
motion sickness
Brain senses “disconnect”
* Eyes see movement, inner ear
senses movement but body is still
* 33% people experience at some
time in life
highest risk of motion sickness
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
presenting symptoms of motion sickness
Cold sweats
* Dizziness
* Headache
* Inability to concentrate
* Increased salivation, nausea, vomiting
* Rapid breathing
do not self treat someone - motion sickness
- A person who feels “motion sickness” but isn’t traveling
goals of therapy motion sickness:
- Provide symptom relief
- Prevent episodes/recurrence
Complementary and non-pharmacologic options
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____
OTC Treatment Options- motion sickness
- First-generation antihistamines
- Cyclizine
- Dimenhydrinate
- Diphenhydramine
- Doxylamine
- Meclizine
- Scopolamine patches
if non drug and drug therapies do not work for motion sickness
medical referral
Antihistamines: cyclizine, meclizine, dimenhydrinate,
diphenhydramine, doxylamine
* MOA:
blockage of histamine-1 receptors
antihistamines indication
prevention of nausea, vomiting or dizziness associated with
motion sickness
antihistamines onset
30-60 minutes
duration of antihistamines
depends on agent, see table 19-4
side effects antihistamines
drowsiness, dry mouth, confusion, dizziness, constipation
Drug interactions antihistamines
CNS depressants
avoid antihistamines in those with
glaucoma, BPH, alcohol
dosing of antihistamines
see required reading table 19-4
preg and lact for antihistamines
check with MD
Scopolamine OTC patch
branded product: Transderm Scop®
* MOA:
blocks effect of acetylcholine on central nervous system = antimuscarinic
scope patch indication
prevention of nausea, vomiting caused by motion sickness
onset scope patch
at least 4 hours
duration scope patch
up to 3 days
side effects scope patch
disorientation, dry mouth, drowsiness, pupil dilation, dizziness,
sweating
drug interaction scope patch
meds affecting CNS including anticholinergic meds; oral drugs that absorbed in the stomach (____slowed stomach__ emptying)
aoid when wearing scope patch
wearing in MRI scanner; talk with provider if BPH, glaucoma; alcohol
preg and lac scope patch
check with MD
Scopolamine patch dosing & counseling tips
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
cyclizine dose
50 mg 30 min before travel then 50 mg every 4-6 hours
dimenhydrinate dose
50-100 mg every 4-6 hours
diphenhydramine dose
35-50 mg every 6-8 hours
meclizine dose
25-50 mg 1 hour before travel (50 mg)
Doxylamine dose
in pregnanact, 10-12.5 mg with. orwithout pyridoxine every 8 hours
Gastroenteritis definition (commonly confused with flu)
- Inflammation of the stomach and intestines due to viral infection or
bacterial/protozoal toxins which causes vomiting and diarrhea
causes of gastroenterities
- 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.
Gastroenteritis presenting symptoms
- Viral-Rotavirus
- Nausea
- Vomiting
- Fever
- Acute, watery diarrhea
- Viral-Norovirus
- Nausea
- Vomiting
- Fever
- Headache
- Myalgia
- Watery diarrhea
- Bacterial
Bacterial
ccamplo
salmonella
shigella
e.coli
symptoms
- 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
Do not self-treat- gastro
- 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
goals of therapy- gastro
- Prevent or correct fluid and electrolyte loss and acid-base
disturbance - Control symptoms
- Identify and treat cause
- Prevent acute morbidity and mortality
general treatment approach for gastro
- 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
inappropriate treatment for gastro
liquid diet, doesnt bulk up stool.
Complementary and non-pharmacologic options- gastro
- 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
Dietary management
* Children
- gastro
- 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
BRAT diet
NOT recommended = insufficient
calories, protein, fat
Adult recommendation - gastro
follow same guidance as for cchildren
OTC Treatment Options
* Loperamide
Loperamide
Branded product: Imodium A-D
* MOA:
stimulates peripheral micro-opioid receptors on intestinal circular muscles to slow motility so water & electrolytes can be absorbed
* = reduces peristalsis, increases intestinal transit time
loperamide indication
symptomatic relief of acture, non specific diarrhea
pharmacodynamics: loperamide onset
within 1 hour
loperamide duration
up to 3 days
loperamide sideeffects
occasional dizziness, constipation; euphoria if misused/abused
Loperaimide drug interactions
quinidine, ketoconazole (antifungal), ritonavir, protease inhibitors,
cyclosporine, erythromycin (antibiotic), clarithromycin, saquinavir, St. John’s wort (mood)
avoid loperamide if
high fever or blood/mucus in stool, NO LOPERAMIDE
Bad bacteria in the gut for too long: toxic megacolon
loperamide dosing max
48 hgours of use
adult dosing - loperamide
- 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
child dosing loperamide
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.
Bismuth subsalicylate
Branded product: Pepto-bismol
* MOA:
inhibition of prostaglandin synthesis, stimulation of sodium & potassium
reabsorption
indication of bismuth
what age
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)
onset bismuth
30min to 4 hours
Duration- bismuth
?
side effects of bismuth
mild tinnitus, black tongue or stool (>10% people)
drug interactions bismuth
warfarin, valproic acid, methotrexate, tetracycline &
fluoroquinoilone antibiotics
void bismuth if
gout, asthma-associated bronchospasm; if recovering from chickenpox of
influenza-like illness; within 6 weeks of chickenpox or influenza vaccine
bismuth dosing max
max 48 hours of use
adults dosing- bismuth
- 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)
child dosing- bismuth
not recommended
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
mild dehydration
less coffee
loperamide
75% doses handle like normal, as long as they swallow, take meds as uaual
Follow-up Recommendations- bismuth
- No improvement after 48
hours of drug therapy
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
C. Try a soft-bristled toothbrush & standard toothpaste with fluoride for a week
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
beeswax, petroleum
Presenting symptoms - caries
- 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_____
aries etiology
- 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)
refer for tooth
- 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
goals of therapy- caries
- Prevent or control dental plaque (soft stuff that you can brush off)
Calcium ( hard stuff calculus, breaks off teeth)
gingivitus Presenting symptoms
- Inflamed gingiva
- May progress to periodontal disease
Gingivitis etiology
- 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
Do not self-treat, refer- gingivitis
- Swollen gums
- Gums that bleed with brushing or flossing (running in mouth)
- Receding gums
- Gums that are darker__red__
Goals of therapy – gingivitis prevention
- Prevent calculus formation
- Remove and control supragingival plaque
Complementary and non-pharmacologic options: caries
and gingivitis prevention
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
- Activated charcoal
- Limited data to support claims about teeth whitening/absorbing pigments &
stains - Novelty
- Probiotics-caries- ginga
- 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
OTC Treatment Options- caries. andgina
- 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
Toothpaste Use
* Adults:
- 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
toothpoaste children
Age to start brushing?
- 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
Prevention of caries & gingivitis: Pharmacologic Methods
* Dentrifrices
MAO
- MOA: act directly on oral
bacteria or disrupt plaque
components to aid in
mechanical removal
3 functions of dentrifrices
- Help remove plaque, stain
- Reduce ____mouth odor_______
- Enhance personal appearance
* Products
* Powders
* Gels, pastes
* Categories of ingredients
* Abrasive
* Humectant
* Sweetener
* Surfactant
* Binder/thickener
* Flavor
* Anticaries activity agent (often)
Dentrifrice abrasive categories & ingredients
- Low abrasion: 10-25% silica abrasives
- Mild abrasion: baking soda
- High abrasion: 40-50%
- Dicalcium phosphate
- Calcium pyrophosphate
- Calcium carbonate
- Alumina trihydrate
Fluoride: anticaries agent
Sodium fluoride ->remineralize, strengthen weakened enamel,
reduce gingivitis, reduce sensitivity
Sodium monofluorophosphate
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
Other Dentrifrice Ingredients
- 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
Plaque control mouthrinses
* Ingredients
- 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
Mouthrinse Cautions
* Adverse effects
- 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)
Mouthrinse Use
- 1 to 2 tablespoonsful
- Swish 30 seconds
- 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
Plaque control with gum
* MOA
- Increased saliva flow
- Mechanical removal of debris
Use - Chew after eating as well as other times of day
- Sugarless gum only
Hailtosis
- Bad breath caused by volatile
sulfur compounds (VSCs) food particles in mouth and bacteria act on them
hailtosis causes
- 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
Do not self-treat- hal
- Medical conditions associated with halitosis
- Persistent halitosis despite good oral hygiene
halitosis prevention
- 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
Oral pain causes
* Etiologies
- Exposure of dentin (erosion, broken tooth, faulty tooth repair)
- Injury to mouth or lips or with RAS or herpes simplex labialis
- 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
Presenting symptoms oral pain
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
do not self treat oral pain when
- 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
Goals of therapy- oral pain
- Repair damaged tooth surface via appropriate toothpaste
- Correct inappropriate tooth brushing technique (too aggressive)
Complementary and non-pharmacologic options- oral pain
- Stop triggers (acidic foods, aggressive toothbrushing)
- Avoid toothbrushing within 30-60 min of acidic foods/drinks
- Correctly brushing teeth with fluoride toothpaste
OTC Treatment Options- oral pain
- Standard toothpaste with
fluoride, 1st line - Potassium nitrate 5% in
fluoride-containing toothpaste, 2nd line
follow up recommendations
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
Potassium nitrate 5% + fluoride (in toothpaste)
* MOA:
depolarizes nerves in tubules & pulp to block perception of stimuli;
seals exposed dentin
indication potassium
tooth hypersensitivity if never diagnosed refer
t potassium
2 weeks, may need 4-6 weeks
duration potassium
duration o use and beyond
side effects of potassium
?
interactions with potassium
- 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
avoid: potassium
high abrasion toothpastes, whitening toothpaste cause more irritation
dosing for potassium
brush with one inch strip BID
pregnancy and lactation potassium
no concern
Arginine 8% + calcium carbonate
* MOA:
depolarizes nerves in tubules & pulp to block perception of
stimuli
indication for arginine
tooth sensitivity
onset for argine
2 weeks
duration for argine
2 weeks
side effects and drug interactions for argine
?
avoid using argine and
fluoride tooth paste at the same time
dosing for argine
brush wtih one inch strip BID
Recurrent Aphthous Stomatitis
- Canker sore or aphthous ulcer
cancker sore etiology
- 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
Do not self treat canker
- If underlying cause
- Lesions present 14 days or more
- Frequent recurrence
- Sx of systemic illness
- Self-care ineffective
Goals of therapy - RAS
- Relieve pain & irritation
- Heal lesions
- Be able to eat/drink & do usual oral care
- Prevent secondary bacterial infection
- Prevent recurrence
Complementary and non-pharmacologic options-RAS
- 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)
OTC Treatment Options-RAS
- Pharmacologic therapy
- Topical
1. Oral debriding & wound
cleansing agents
2. topical oral anesthetics
3. topical oral protectants
4. oral rinses - Systemic : analgesics
follow up recommendations-RAS
- 7 days of treatment or 14
days since lesion/s first
appeared - Side effects of topicals: see
medical provider
RAS Pharmacologic Therapies
- 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
- Avoid:RAS
toothpastes containing
sodium lauryl sulfate
- Dosage/administrationRAS
- 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!
Topical Anesthetics for RAS
- *Benzocaine 5% to 20%
- *Butacaine sulfate 0.05% to 0.1%
- *Dyclonine 0.05% to 0.1%
Topical oral protectants & rinses for RAS
* Barrier protectants
* MOA
- protect
- decrease friction
- provide temporary relief
- Coat ulcers with topical oral
protectants
- 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)
Minor Oral Mucosal Injury/Irritation
- Etiology
- Dental procedures
- Accidental injury: biting tongue/cheek, abrasion from sharp foods
not self treat oral mucosal injury
same list as tooth hypersensitivity
goals of therapy minor oral mucosal
- Control discomfort
- Aid healing
- Prevent secondary bacterial infection
- Nonpharmacologic therapy-Mnor oral
- 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)
Pharmacotherapy of Minor Oral Mucosal
Injury/Irritation
* Same as RAS:
1. Topical analgesics and anesthetics
2. Oral protectants
3. Oral debriding/wound cleansing
* Astringents: tissue contraction, stop secretions
When to refer patient?- injury
Sx persist after 7 days treatment or 10 days of initial injury
Symptomsx ___worsen___ during treatment
Sx of infection develop (fever, redness, swelling)
herpes simplex
Causes & presenting symptoms
Causes
* HSV-1
* HSV-2
* CMV
* Epstein-barr virus
Infected for life
Herpes symptoms
- 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
not self-treat
- Lesions present more than 14 days
- Increased outbreak frequency
- Symptoms of infection (fever, swollen glands, rash)
- No prior cold sore
Goals of therapy - HSL
- Relieve pain & irritation
- Prevent secondary infection
- Prevent spread of lesions
Complementary and non-pharmacologic options- cold sore
- 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
OTC Treatment Options- cold sore
- Topical skin protectants (see
RAS) - External
analgesics/anesthetics (see
RAS) - Docosanol 10%
- Benzalkonium chloride (?)
Follow-up Recommendations- cold sore
14 days
Docosanol 10% cream (abreva)
* MOA:
inhibits fusion of virus to cell membrane; prevents viral
replication
docosanol indication
reduce duration & severity of HSL symptoms
cosanol pharmacodynamics
decreases time to heal by ~1 day compared to placebo
? side effects unknown, drug interactions: none
avoid if have cold sore
placing aspirin tablet on lesions; hydrocortisone; astringents,
zinc sulfate
dosing of doscosonal
apply 5x/day starting in prodrome until lesion healed; max 10 days
Benzalkonium chloride*
Branded product: Viroxyn® liquid
* benzalkonium chloride 0.3%
benzocaine 7.5%
* $40 (?
Benzalkonium chloride* MOA
- 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
Xerostomia etiologies (dry mouth) Causes
- 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
dry mouth presenting symptoms
- 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
Do not self-treat- dry mouth
- 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
Goals of therapy - xerostomia
- 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
OTC Treatment Options- dry mouth
- Artificial saliva products
- Sprays
- Gels
- Gums
- Toothpastes
Follow-up Recommendations - Re-evaluate after __5-7 days__ of
therapy
Artificial saliva
* MOA:
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
Cheilitis
- causes
- 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
symptoms of chelitis
- Dry
- Scaly
- Cracking (lip, corner of mouth)
- Irritated, painful
vention and treamtne tof chelitis
- 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
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
dimethicone, beeswax, petroleum jelly
Tooth discoloration & staining
* Etiology
- Intrinsic:
within tooth structure
* Causes: aging, health conditions, damage, tetracycline antibiotics
Tooth discoloration & staining
* Etiology
extrinsic
- Extrinsic: surface of tooth
- Causes: tobacco, foods (coffee & tea)
- Do NOT self-treat: ___intrinsic causes_______
- Goals of therapy: lighten color/whiten teeth
Tooth discoloration & staining self-care
* Nonprescription options
- 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
- 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
Adverse effects:
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
viamtin
compound
mineral
element
Dietary Supplements
*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
Fat Soluble Vitamins
*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
vit A function
cell division and vision
vit E function
antioxidant
D function
calcium balance bones
vit k function
clotting factors bones
vit a deficiencie
night vision loss
vit. e deficiencies
peripheral neuropathy
vitamin d deficiencies
rickets
vit k deficiencies
bone fractures, impaired coagulation
toxicities of vit a
double vision
toxicities of vit e
risk of congestive heart failure
toxicities of vit D
renal failure
soft tissue calcification
causes of deficiencies of fat soluble vitamins
all malabsorption
vit k cause of def
liver diease, disruption of gut microflora
vitamin d cause of def
chronic renal disease
inadequate sun exposure
Water Soluble Vitamins
*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
Function of Vit B5 Pantothenic Acid + Vitamin B3 Niacin
Fatty acid & steroid production
function of vit b6 pyridoxine and vitamin b3
formation of proteins
Vit B6 Pyridoxine function
formation of neurotransmitters
Vit B2 Riboflavin function
vision, integrity of cell membranes, reduction/oxidation reactions
vit c absorbic acid function
reduces ferric to ferrous
vit c and vit b1 thiamine function
co factor for metabolism
vit b1 thiamine function
myocardial function
vit b1 and vit b12 cyanoco balamin function
neurologic nerve function
vit b9 folate function
cell division and brain and spinal cord development
vit b9 folate and vit b12 cyanoco balamin function
dna production
vit b5 pantothenic acid deficiency
paresthesia
vit b2 riboflavin deficiencies
ocular symptoms
vit b2 riboflavin toxicities
discoloration of urine
vit b5 pantothenic acid deficienciey
paresthesia
vit b3 niacin toxicities
hepatoxicity
vitamin b3 niacin deficiencies
red/beefy tongue
dementia
diarrhea
vitamin b3 niacin and vit b6 pyridoxine deficiencies
perioheral neuropathy
vitamin b6 pyridoxine toxicity
prolactin inhibition
vitamin b1 thiamine deficiencies
encephalopathy
peripheral neuropathy
cardiac dysfunction
vit c toxicity
gi symptoms
vit c deficiencies
impaired wound healing
scurvy
vit b12 and vit b9 deficiencies
neurologic symptoms
anemia
cuases of deficiency for vit b2 b5 b3 and b6, vitc, vit b9, vit b12, vit b1
malabsorption
alcoholism
auses of deficiency for vit b3 and vit b6
isonisxid therapy
vit ccauses of deficiency
smoking inadequate diet of fresh foods
vit b1 thiamine cause of def
chronic furosemide use
vit b 12 cause
reduced gut acidity
vegetarian diet
prolonged use of metformin
vit b9 folate def cause
genetic polymorphism
medication use (methotrexate, anticonvulsants, sulfasalazine)
Minerals
*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
iron
oxygen. andelectron transport
phosphorous
used in dna. rna, phospholipids
buffer system
calcium
bone formation/structure
calcium and magnesium
muscle function
magnesium
postassium transport
iron deficiency
anemia
iron toxicities
cardiovascular dysfunction
megnesium deficiencies
delirium
magneisum toxicity
dimished deep tendon reflexes
and muscle weakness
calcium and magnesium deficiency
convulsions
calcium toxicity
renal sotnes and deposition of calcium in soft tissies
iron cause
increased blood demand
magnesium cause
diarrhea
calcium cause
hypoparathyrodiusm
vitamin d deficiency
renal failure
increased demand due to rapid growth
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?
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
*What immediate follow‐up questions do you have for the father to
make a good recommendation?
-describe the eating habits
-why is your child a picky eater
*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.
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
*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?
Water soluble vitamins: b-vitamin-niacin, thiamine, b12, folic acid, B6
Fat soluble vitamins, A,D
Minerals: iron, magnesium, calcium
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?
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
*What immediate follow‐up questions would you ask so you can make a
good recommendation?
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
Infant growth & organ maturation
- Growth charts
- Length/height & weight & head circumference
- Organ maturity
- GI
somtach capacity at birth and by 1 month old
- 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
when does kidney filtration begin
week 9
GFR reaches adult values in
third year of life
Functional GI Maturity
* Nutritive sucking
- 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
- Gastric functionality
- Gastric motility delayed in first few days of life
Weight
* Average birth weight:
3500 grams (7 pounds 11 ounces)
- Low-birth-weight
less than 2500 grams (5 pounds 8 ounces)
Very low-birth-weight:
less than 1500 grams (3 pounds 4 ounces)
Extremely low-birth-weight:
less than 1000 grams (2 pounds 2 ounces)
“Micropreemies”
less than 750 grams (1 pound 10 ounces)
- Water weight loss immediately after birth
6-10%
Term infants double birth weight by
4-6 months old, triple by 12 mos
- Normal values for length/height, weight, head circumference:
expressed in
“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”
Basic Requirements of Healthy Diet
- Water
- Carbohydrates
- Proteins and amino acids
- Fat and essential fatty acids
- Micronutrients
Basic Requirements: Water
- Estimate maintenance water needs for term infants
Holliday-Segar Method:
first 10 kg: 100ml/kg
second 10kg: 50ml/kg
additional kg: 20ml/kg
- Greater needs for premature infants
(120-170 mL/kg/day)
- Human milk or formula
adequate daily water for first 6 months of life
Try it Calculate the maintenance fluid needs for a 22.8 kg child
1556
Basic Requirements: Carbohydrates
- __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
Basic Requirements: Proteins & amino acids
- 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
Basic Requirements: Fat & Essential Fatty Acids
- 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
Fat & Essential Fatty Acids continued
- 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
Basic Requirements: Micronutrients
- 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
Infant Food Sources
- Human milk
- Animal milk: cow and goat
- Commercial infant formulas
- Human milk
- 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
Why is breast/chest feeding best?
- 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
Parent benefits
- 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
Contraindications to breast/chest feeding
- HIV infection (in United States)
- Infant galactosemia
- Parental untreated TB
- Parental human T cell lymphotropic virus type I or II infection
- Presence of a herpes simplex lesion on the breast
- Parental use of contraindicated medications
- Animal Milk
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
- Goat: powdered, evaporated
- Fat digested more easily than
cow milk - Must be fortified with folate,
iron & vitamin D
- Commercial infant formulas
- Types
- Premature, newborn, infant/toddler, or specific health condition
- Manufactured as
- Milk-based, soy protein, or casein hydrolysate-based
- Concentrated liquid, powder, or ready-to-feed
- Standard, fortifier, therapeutic, and modular
- Compositions
- Varying compositions to best feed individual infant’s needs (table 26-6 is 10 pages of infant formulas—do not need to read)
Standard Formula Considerations
- 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
Modular macronutrient components
- 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
Human milk fortifiers
- 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)
Therapeutic formulas
- 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
Number of daily feedings
- 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
Diarrhea or vomiting in infants
- 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)
Diarrhea or vomiting: when to call medical provider
- 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
Preparing equipment for feeding
- Wash hands before handling feeding materials (bottle, nipples,
rings, etc.) or preparing formula - 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
Preparing formula for feeding
- 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
Feeding with expressed human milk
- 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
Formula beyond use dating
Liquid formula
1. Liquid concentrate
- Refrigerate up to 48 hours
- Ready-to-use formula
REfrigerate 48
Powdered formula
- Unused, reconstituted liquid
* Refrigerate up to _48__ hours - Unused powder
* Store at room temperature up
to 1 month
Functional foods
Definition:
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
Functional food (FF) categories–background
5 categories based on:
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
Functional Food Categories 1 & 2
- 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 - 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”
Functional Food Categories 3, 4, 5
- 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 - 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 - 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
Health Claim: Authorized
5 points:
- publication of FDA regulation and extensive literature review + scientific agreement that
food/nutrient and dz relationship is well-established - reduction of disease risk and required to use words “may” or “might
- 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 - 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) - 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.
Health Claim: Authoritative
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
Health Claim: Qualified
Weakest of all of them
Emerging evidence
Claim wording indicates _____there is weak _______evidence associated with it
Examples
* Walnuts: heart disease
* Green tea: cancer
Fiber
Description:
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
Daily Fiber Intake-United States
Recommendations
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:
Increasing daily fiber
How to increase fiber intake
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:
How to manage:
Increase daily water consumption
Careful with carbonated beverage intake, ____gum chewing__________
CAUTION for people with: poor GI motility/dysfunction, including __narcotic induced____ dysmotility
Fiber Benefits
- Improved bowel function
Laxation from insoluble fiber (see prior slide) - Lipid effects
Decreased CHD risk - Blood glucose effects
Soluble fiber’s MOA (see prior slide) - 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
Medical Foods & Meal Replacement Foods
Medical food definition
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)
Other Enteral Formula Uses + Examples
Supplementation of food intakes
Marketing to consumers as “meal replacements”
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
Types of Enteral Formulas
Polymeric
Who uses?
normal digestive capability
What do the formulas contain? ____mixture of macronutrients______________ (whole proteins, carbs, fatty acids/oils)
Examples: Boost, Ensure
Oligomeric
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
Polymeric or oligomeric
Optimize nutrition if health conditions such as kidney insufficiency, diabetes, liver dysfunction
Requires medical supervision
Enteral Formula Use
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.