Nutritional Pharmacology - Lecture 1 Flashcards
(155 cards)
1
Q
What is a medicine
A
Any substance or combination of substances which may be used in, or administered to, human beings, either with a view to restoring, correcting or modifying physiological functions by exerting a pharmacological, immunological or metabolic action, or to making a medical diagnosis
2
Q
Restrictions definitions for:
* Prescription only (POM)
* Controlled medicines
* Pharmacy only (PO)
* General sales list (GSL)
A
- Prescription only (POM) — supplied only under direction of qualified healthcare professional e.g., doctor’s prescription, levothyroxine.
- Controlled medicines — special group of medicines that require extra controls e.g., codeine, morphine, Valium.
- Pharmacy only (PO) — sold by a registered pharmacy – you can visit the pharmacist do get them e.g. antifungal medication, hay fever medication
- General sales list (GSL) — can be sold via a number of outlets including supermarkets. E.g. Ibuprofen, aspirin
3
Q
Why do clients choose self medication
A
- To treat a minor ailment e.g., a cough mixture, general aches and pains, mild headaches
- To support a chronic illness when not fully controlled by prescribed medicines e.g., ibuprofen for osteoarthritis.
4
Q
Type of OTC drugs:
A
- Analgesics (codeine, paracetamol, aspirin, ibuprofen) => low dose aspirin to prevent the progression of CVD.
- Laxatives (bisacodyl, senna) => routinely used to prevent constipation
- Proton pump inhibitors (omeprazole) => prevent HCl production, prescribed for gastric reflux
- Cough mixtures (diphenhydramine).
- Anti-histamines (chlorphenamine, cetirizine) => during pollen season or through the year
- Decongestants (pseudoephedrine)
5
Q
Name 3 types of OTC drugs clients may use:
A
- Analgesics (codeine, paracetamol, aspirin, ibuprofen) => low dose aspirin to prevent the progression of CVD.
- Laxatives (bisacodyl, senna) => routinely used to prevent constipation
- Proton pump inhibitors (omeprazole) => prevent HCl production, prescribed for gastric reflux
- Cough mixtures (diphenhydramine).
- Anti-histamines (chlorphenamine, cetirizine) => during pollen season or through the year
- Decongestants (pseudoephedrine)
6
Q
What is the active ingredient of a drug?
A
- Active ingredient: This is the part of the drug that is intended to deliver its mode of action and is responsible for side effects e.g., ibuprofen to reduce inflammation
7
Q
What is the inactive ingredient of a drug?
A
- Inactive ingredients: These alter the physical properties of the drug e.g., fillers, colouring agents, preservatives, lactose, gluten, aspartame (can create intolerance type reaction), other E numbers, aluminium (found in antiacid medication and that is a neurotoxic).
8
Q
What is the issue with inactive ingredients?
A
Studies increasingly show that inactive ingredients can trigger allergic reactions and food intolerances.
9
Q
What is a generic name and brand name of pain medication?
A
Generic: paracetamol (Europe), acetaminophen (US).
Brand: Panadol (UK), Tylenol (US).
10
Q
Define the following drug terminologies:
- Drug class
- Indication
- Contraindication
- Side effects
- Interactions
A
- Drug class: Penicillin is an antibiotic (are a class of drugs and penicillin is an example of this) .
- Indication: What the drug is intended for, e.g., hypertension (high blood pressure).
- Contraindication: When the drug must not be used e.g., in pregnancy (can cross the placenta barrier), renal failure (kidney issues as drugs are excreted via the kidneys puts pressure on the tubules / or when kidney can’t excrete drugs properly can create drug build up in he body).
- Side effects: Ibuprofen can produce gastric ulcers.
- Interactions: A drug’s activity is affected by another substance causing an increase, decrease or a new effect (e.g. grapefruit juice and liver metabolism of some drugs).
11
Q
What is the difference between a drug and a nutrient?
A
- Drugs suppress and manage symptoms: They do not target the actual underlying cause!
- Nutrients encourage the body to restore homeostasis and heal.
12
Q
What is herb is aspirin derived from? What is the issue with using plant extract in drugs?
A
aspirin is derived from willow bark
- Willow bark contains salicin, which does not convert to salicylic acid (a gastric irritant) until it reaches the bloodstream and body tissues. It naturally reduces fever, inflammation and pain without GI side effects.
- Through research, aspirin was synthetically developed from salicylic acid. Aspirin can cause gastrointestinal bleeding, peptic ulceration and hypersensitivity!
- Willow bark contains numerous active components which influence each other and in totality contribute to its overall healing potential.
13
Q
Define pharmacokinetics? Why is it important?
A
Movement of drugs within the body - the timed movement of any drug going into, through and out of the body.
14
Q
Define pharmacodynamics? Why is it important?
A
How drugs interact with the body to exert their effect - make sure we do not prescribe supplements that have the same function or interact.
15
Q
What are the 5 most important drug concepts?
A
- Pharmacokinetics
- Pharmacodynamics
- Side-effects
- drug-nutrient interaction
5 Nutrient depletion
16
Q
Which factors can impact pharmacokinetics?
A
Age, genetics, alcohol consumption, weight loss can affect the timing (send the client back to the GP!)
17
Q
What key organ can impact pharmacokinetics if impaired?
A
The liver
18
Q
What 4 key processes are involved in pharmacokinetics?
A
Absorption, distribution, metabolism and elimination (ADME)
19
Q
Define all the ADME in pharmacokinetics
A
A - absorption. To exert its action (or toxicity) internally, a drug must first enter the body and be absorbed into the bloodstream.
D - distribution. In the bloodstream, the drug can now be distributed to its target site (normally a receptor) to exert its action.
M - metabolism. Once the drug and receptor have interacted, the drug returns to the bloodstream and progresses to the liver to be metabolised and then eliminated from the body. Reducing or changing the dugs – deactivation, activation
E - elimination. Once metabolised, excretion normally takes place via urine or bile. The route for excretion need to be open (bile, urine and stool) to avoid drug reabsorptions and side effects
20
Q
What is the first pass metabolism? What does this effect means?
A
The process by which drugs taken orally are absorbed from the GIT and taken via the portal vein into the liver to be metabolised
The effects of this mean that drug concentrations can be reduced by the time they enter systemic circulation
21
Q
What 2 factors determine whether a drug reaches its target site of action in the body?
A
- Bioavailability — this simply refers to the ‘proportion’ of drug that can reach the bloodstream and is, therefore, available for distribution to its intended site of action.
- Route of administration — how a drug is administered e.g., oral tablets, sublingual B12, suppository, injectables, topical creams, patches, all directly influence the medicine’s bioavailability.
22
Q
Name 3 routes of administration
A
- Oral: Tablets, capsules, liquids (elderly and young children): Absorption is mainly via the small intestine.
- Sublingual / buccal - Bypasses liver metabolism.
- Topical:
Local effect: Creams, patches, ear and eye drops.
Systemic effect: Inhalation (rapid effects). - Parenteral: Injections: Intravenous, sub-cutaneous, intra-muscular (epi-pen).
23
Q
what factor can affect drug absorption? (related to the body x3)
A
- Gastro-intestinal motility: Diarrhoea increases motility and reduces absorption.
- Malabsorption states reduce absorption e.g., Coeliac disease, SIBO, Chron’s disease – reduce small intestine capacity to absorb the drugs.
- Presence of other substances: E.g., absorption of iron is reduced when given with milk. Calcium and Levothyroxine.
24
Q
what factor can affect drug absorption? (related to the medicine x3)
A
- Absorption is greatest for lipid soluble and small molecule drugs (can easily pass through our lipoids cell membrane)
- Acidic drugs absorb quicker in an acidic environment e.g., stomach. Penicillin will work better if taken with food !
- A liquid medicine will absorb quicker than a solid tablet. Easier for the guts to break down
25
What factors affect the distribution of a drug in the body? x4
o Binding to plasma proteins which affects the active concentration of the drug. When two drugs are given together a larger amount of unbound drugs (not bound to a plasma protein because there is not enough plasma proteins) that are metabolised very fast and therefor the drugs is not being used fully by the body. That is why certain drugs are not prescribed alongside other drugs.
o Binding to other tissues e.g., tetracycline (antibiotic – given for acne on LT and short term for gut bacterial infection) binds to calcium in bones and teeth. When the teeth are calcifying (in children) if they had tetracycline during childhood or adolescence they can have permanent stain on the teeth and probably bone issues
o Accumulation in lipids e.g., general anaesthetics. Especially with clients on a weight loss program, we want them to lose weight slowly (as they probably have a high toxic load within the fat cells and they need to detoxify efficiently as they process those fat cells
o Natural barriers to distribution e.g., blood brain barrier (endothelial barrier covered in astrocytes), placental barrier.
26
What is drug metabolism?
the process by which drugs are chemically changed from a lipid soluble to a more water-soluble form suitable for excretion by the kidney
27
What are the 2 phases of drug metabolism ?
* Phase I: Drug / toxin is altered chemically to make it suitable for Phase II reactions or for excretion. Involves the cytochrome P450 enzyme family. These enzymes de-activate drugs in order to effectively pass it to phase II
* Phase II: Molecules from Phase I (or in some cases unchanged drugs) are conjugated to a more water-soluble product and aid excretion.
28
What are the main routes of excretion? x2
What organ is key?
Urine, faeces. We want clients to drink water and a daily bowel movement to make sure drugs is excreted properly
Renal dysfunction can, therefore, affect the rate at which a drug / metabolite is cleared from the body.
29
What are the minor routes of excretion? x4
Minor excretion routes: Exhaled air, sweat, saliva, tears.
30
What is entero-hepatic circulation? Name 3 types of drugs like that?
Some drugs (very lipid soluble) may be re-absorbed and re-enter the portal vein. This is known as ‘entero-hepatic circulation’ and prolongs excretion times. Ibuprofen, OCP, Oral Replacement Therapy. Gut flora plays a key role in these medication to allow them to be re-absorbed – be mindful of antibiotics courses and the impact on gut flora and the impact on drugs.
31
What factors affect pharmacodynamics?
Factors affecting a drug’s mode of action include advancing age (can have more adverse reaction to a drug), genetic mutations, malnutrition, medical conditions e.g., Parkinson’s disease, Alzheimer’s disease
32
What 3 information provide pharmacodynamics and pharmacokinetics?
Mode of action and administration route.
Dosage (incl. knowledge of toxic doses).
Side effects and drug interactions.
33
Name 5 most common side effects?
* Nausea and vomiting – opioids like codeine/morphine at its slows down digestion. Inflammation of the liver like anti-fungal (athletes foot)
* Headache.
* Dizziness.
* Constipation.
* Diarrhoea.
* Indigestion.
* Skin rashes.
* Dry mouth. Diuretics are prescribed to people on HBP medication as side effect is swelling of the ankle. Because of the release of the urine this could make the client feel dehydrated (dry mouth)
* Insomnia. Medication for flu and common cold can contain caffeine
34
Name 3 side effects of LT medication and a drug example
* Nutrient deficiencies e.g., metformin and B12 deficiency. PPI can also lead to a B12 deficiency. Look for sign and symptoms of B12 deficiency.
* Metabolic effects e.g., omeprazole PPI and hypomagnesaemia -> low levels of magnesium as it inhibits absorption
* Dependence e.g., diazepam, opiate analgesics (codeine).
* Osteoporosis e.g., corticosteroids => lead to faster bone turnover and reduce the amount of calcium absorbed
* Gout e.g., thiazide diuretics => happen faster when urine is more diluted so the uric acid crystals build up more quickly
* Cardiovascular disease e.g., diclofenac (NSAID).
* Peptic ulceration e.g., NSAID long-term (especially OTC) – blood on the stool red flag to GP as there may be an ulceration of the guts…
35
Name 5 side effects PPI are associated with?
* Bone fractures. Impact on bones as impact absorption
* Hypomagnesaemia (low blood magnesium).
* Vitamin B12 deficiency.
* Bacterial enteric infections e.g., serious Clostridium difficile. HCl is an antimicrobial and will prevent bacterial overgrowth in the small intestine
* Rebound acid hypersecretion (when PPI is stopped). When client come off the PPI the PP will over secrete HCl and then the PP will regulate itself. Client need a heads up about this to work through the withdrawal of the PPI.
* Kidney disease.
* Dementia.
36
Give 3 example of PPIs
- Lansoprazole (Lanzol Relief, Solox)
- Omeprazole
- Pantoprazole (Panzop Relief)
37
What to do as a NT if you suspect a client is having side effects?
1. Check the presenting sign / symptom against the drug in your selected resource e.g., the BNF.
2. Advise the client to consult his / her GP or medical specialist.
3. Ensure that the food or supplement that you recommend does not interact with the client’s drug which could then cause side effects.
38
Why do nutritional therapists need to know about pharmacology?
To understand the mode of action of the drug to understand the effect the drug is having on the body. Makes it easier for us to understand the side-effects and understand more clearly the type of foods and supplements that mey intercat with the client medication
39
What do drugs contain?
Active ingredients
Inactive ingredients
Both can cause side effects or intolerances
Aspirin salicylic active is the active component but there are fillers and binders to which client might react to like aspartame.
40
Compare the use of willow bark and aspirin
Willow bark and aspirin are used as a pain relief / anti inflammatory
Willow bark acts with a synergy of ingredients that work together in the body whereas aspirin as a synthetic form of the salicylic acid is abrasive to the guts. This is why aspirin has the side effect of gut ulceration but willow bark not. That is because willow bark salicylic acid is only metabolised down the digestive system
41
Explain how the cytochrome P450 system affects drugs (HINT: Phase 1 drug metabolism).
Enzyme systems when drugs are metabolised, they can reduce that drug (dactivated) that is made into a metabolite more readily metabolised for phase II conjugation
42
Define a drug interaction
An interaction occurs when the effects of one drug are altered by the co-administration of another substance. Other substances can include:
* Drugs.
* Herbal medicines.
* Food and drinks.
* Nutritional supplements.
* Environmental chemical agents
43
How these 4 nutrients interact with drugs?
St John's wort, Goldenseal, Grapefruit and alcohol
1. St John’s wort should not be taken with antidepressant because they have additive effects (both enhanced serotonin) !
2. Goldenseal is an antibacterial and can inhibit phase 1 enzyme system CYP450 and if a client is taking a drug being broken down by this enzyme it could cause a level of toxicity or the drug could not work because not activated by the enzyme.
3. Grapefruit and pomegranate juice alter how some drugs are metabolised.
4. Alcohol depresses the CNS (act as a sedative), if a client take a sleeping pill with alcohol it has an additive effect - Alcohol affect the CYP450 enzyme operates and make the system work more faster and drug leaves the system faster than what they are meant to do.
44
What are Narrow Therapeutic Index (NTI) drugs - give one example
What should a NT do about it during consultation?
* Drugs that may become dangerously toxic or ineffective with only relatively small changes in their blood concentrations.
* Examples: Digoxin (heart failure), phenytoin (epilepsy), theophylline (asthmatic), warfarin (anticoagulant), lithium (bi-polar disorder).
* During a consultation it is essential that these medicines are clearly highlighted on case notes.
* With each follow up ask clients about their drugs if there has been any changes
45
Which population groups are at higher risk of serious side effects from polypharmacy?
* Patients experiencing renal and liver dysfunction (metabolism and excretion of drugs!).
* Elderly patients who take more medicines and whose renal and liver function is declining.
* Patients taking drugs for chronic long-term illnesses
e.g., same patient has epilepsy, diabetes and cardiovascular disease (think of the number of drugs administered!) – those clients are more likely to experience side-effects
* Critically-ill patients. There will be known side to side interaction but the priority is to keep the patient alive.
46
Explain the drug nutrient interaction between garlic and blood thinners?
* Interactions have been reported with cholesterol and blood pressure drugs, such as atorvastatin, propranolol, hydrochlorothiazide or captopril.
* Garlic could theoretically interact with anticoagulant or antiplatelet drugs, but current evidence has shown that at 4g / day it has little effect on warfarin-stabilised patients.
* Garlic interspersed throughout the diet is okay, but regular, high dietary intake and / or supplements could allow for interactions.
47
Explain the drug nutrient interaction between Ginkgo – anti-coagulant ?
* Should be avoided with any antiplatelet and anti-coagulant medication, as it has a small potential to increase bleeding risk. It should be stopped one week before surgery.
* Due to possible CYP induction (enzymes will work faster to break down drugs), it is best to monitor with the following drugs: Benzodiazepines (sedatives), anti-epileptic medication, anti- psychotic drugs, diabetic drugs, HIV medications, omeprazole (for gastrointestinal reflux), nifedipine and talinolol (blood pressure drugs).
48
Explain the drug nutrient interaction of grapefruit and pomegranate?
* Selectively inhibits CYP3A4 in the intestinal wall for up to 24 hours, but NOT in the liver. Caution is advised with the many drugs that are metabolised via this pathway ― e.g., digoxin, statins. CYP3A4 is involved in the metabolism of over 50% of all drugs.
49
Explain the drug nutrient interaction of green vegetables?
* Large amounts of green vegetables such as broccoli, spinach, cabbage, Brussels sprouts, seem to reduce the effect of anticoagulants such as warfarin.
* They contain indoles which increase the metabolism of warfarin, and also contain vitamin K, which reduces the anti-clotting effects of warfarin. Vitamin K is a coagulant, whilst warfarin is an anti-coagulant. It would be counterproductive to put a lot of vitamin K in the diet whilst the client is on anticoagulant medication
50
Explain the drug nutrient interaction of soy?
* Soy decreases absorption of levothyroxine: Separate ingestion by three hours.
* Soy may also interfere with oestrogen-blocking drugs such as Tamoxifen (oestrogen blocking drug used for breast cancer by woman), due to its isoflavone (phytoestrogen) content (both positive and negative effects observed).
* Soy may reduce the effectiveness of warfarin (for stroke, thrombosis).
51
Explain the drug nutrient interaction of dairy calcium?
* Calcium can bind to antibiotics like the quinolones and tetracycline, and also bisphosphonates (woman with osteoporosis) reducing their absorption; reduces levothyroxine absorption (take four hours apart).
52
Explain the effect of high protein diets on medication?
* High protein diets may reduce the effects of theophylline (drug given to asthmatics - appears to increase renal clearance) and L-Dopa (drug for Parkinson’s disease - decreases intestinal absorption and interferes with transport from the bloodstream to the brain).
53
Explain the effect of high fibres diets on medication?
* High-fibre diets can reduce serum levels of tricyclic antidepressants e.g., amitriptyline (decreases intestinal absorption ― take medication away from high-fibre meals). Take the medication away from a high fibre meal
54
Explain the effect of low salt diets on medication?
* Salt restriction can increase serum lithium to toxic levels (sodium is involved in active transport of lithium, low levels can cause lithium to accumulate in cells).
55
Name 3 nutrients depleted by PPI?
What is the mechanism?
Beta-carotene, calcium chromium, iron, magnesium, folate, vit. B12, vit. C, zinc
Reduced gastric acid levels inhibit absorption.
Signs and symptoms – reduced immune functions, cognitive decline, mental fatigue, sore tongue (B12)
56
Name 3 nutrients depleted by Steroids (Prednisolone)?
What is the mechanism?
Calcium, vit. D, chromium, folic acid, magnesium, potassium, strontium, zinc
Increase urinary excretion, losses from bone tissue.
Look at caffeine, alcohol consumption which would make the bone issue worse
57
Name 3 nutrients depleted by Statins?
What is the mechanism?
CoQ10
Block synthesis of mevalonic acid, which is a precursor of cholesterol and coenzyme Q10.
Cell more at risk of free radical damage as CoQ10 is an antioxidant.
58
Name 3 nutrients depleted by antibiotics?
What is the mechanism?
Biotin, pantothenic acid (B5), pyridoxine (B6) riboflavin (B2), thiamine (B1), vit. B12, vit. K.
Destruction of normal intestinal microflora (for 1+ year) may lead to decreased production of various B vitamins and vitamin K.
Deficiency signs of B vitamins and Vitamin K
59
Name 3 nutrients depleted by Metformin?
What is the mechanism?
Vitamin B12, folate.
Malabsorption of B12 and B9.
1 in 3 diabetic taking metformin for over a year is deficient in B12. Lower folate => higher homocysteine levels which is negative on heart health
60
Name 3 nutrients depleted by Diuretics?
What is the mechanism?
Calcium, magnesium potassium, folate, vits. B1, B6, C.
Increased urinary loss.
Loss in Ca and Mg main lead to nerve or muscle function issues.
61
Name 3 nutrients depleted by Antacids?
What is the mechanism?
Calcium, iron, chromium, folate.
Increased gastric pH may reduce solubility and absorption. Aluminium- containing antacids can bind to calcium preventing absorption.
62
Name 3 nutrients depleted by Thyroxine?
What is the mechanism?
Calcium
Increased bone turnover may lead to increased urinary calcium losses.
63
Name 3 nutrients depleted by OCP?
What is the mechanism?
Folate
Magnesium
Vitamin B6
Vitamin B2
Vitamin B1
Vitamin A
Vitamin B12
Vitamin C
Zinc
Reduced absorption, increased excretion, increased protein binding and induction of liver enzymes.
Shift from plasma to tissues.
Reduced absorption or interference with conversion to active form.
Reduction in activity of the thiamine- dependent enzyme.
Reduced liver storage of vit. A.
Reduced B12 protein binding.
Increased requirement.
64
How can alcohol inhibit drug's metabolism?
* Long-term alcohol ingestion may activate drug-metabolising enzymes, thus decreasing the drug's availability and diminishing its effects.
* Enzymes activated by chronic alcohol consumption transform some drugs into toxic chemicals that can damage the liver or other organs.
Alcohol can inhibit a drug's metabolism by competing with the drug for the same set of metabolising enzymes:
65
Why alcohol and antibiotics should not be taken together?
* Alcohol and antibiotics should not be taken with antibiotics – With LT alcohol ingestion it acts on the liver by triggering the enzyme required to metabolise and break down drugs (as it is the same as the one required to break down alcohol) => drugs are being broken down more rapidly than they are supposed to so they are less efficient.
* Transform some drugs into toxic chemical 1-3g paracetamol + alcohol can lead to liver failure…
66
Other effects of alcohol on medications?
- Alcohol can magnify the inhibitory effects of sedative and narcotic drugs at their sites of action in the brain (codeine, morphine, fentanyl)
- cimetidine (reduces stomach acid) appears to inhibit the enzyme needed to break down alcohol (alcohol dehydrogenase).
- Alcohol can also force certain drugs (slow-release ‘depot’ injections) out of their depot (storage in muscle) resulting in overdose; this can happen with some antipsychotic drugs.
67
Describe ACE inhibitors/Angiotensin II antagonists medications and the mode of action?
Name 3 brands
Prescribed for: Heart failure, hypertension
Angiotensin II naturally construct blood vessels which then bring BP up
ACE inhibitors drug inhibits the action of Angiotensin II by inhibiting the conversion of angiotensin I to angiotensin II.
Angiotensin II antagonist drugs block the receptor sites on which the Angiotensin II hormone acts in the kidneys and cardiac tissues.
* ACE inhibitor examples: Ramipril, lisinopril, captopril.
* Angiotensin II antagonist examples: Losartan, candesartan.
68
Contraindications of ACE inhibitors/Angiotensin II antagonists medications
Pregnancy / breastfeeding, previous allergic reaction to ACE inhibitor.
69
Common side effects of ACE inhibitors/Angiotensin II antagonists medications
Hyperkalaemia, postural hypotension, constipation, diarrhoea, nausea, vomiting.
70
Specific side effects of ACE inhibitors?
ACE inhibitors cause a persistent dry cough (due to rise in bradykinin – contracts smooth tissues and lead to this irritating cough) and angioedema (skin rash – allergic reaction).
71
What nutrient to avoid with ACE inhibitors
Avoid potassium-rich diets if not taking a drug which lowers potassium alongside (e.g., a thiazide or loop diuretic).
72
What are statins prescribed for?
Hypercholesterolaemia (incl. familial), hypertriglyceridemia, prevention of cardiovascular events in those with atherosclerotic disease or diabetes:
73
What is the mode of action of statins?
Competitively inhibits HMG CoA reductase — an enzyme involved in cholesterol (and COQ10 – needed for mitochondrial functions) synthesis.
74
Statins contraindications?
Pregnancy, breastfeeding, liver disease (liver disease can be a consequences of liver disease – look at signs of potential liver disease).
75
Statins caution and side effects?
* Caution: High alcohol intake, liver disease history.
* Side effects: GIT disturbance, headaches, fatigue, insomnia, myositis (inflammation of muscles), statin-induced myopathy.
* Statin use can lead to rhabdomyolysis — the breakdown of muscle cells. This can result in kidney disease and even failure.
76
Food interaction with statins? x1
Grapefruit juice / pomegranate juice: Significantly increases GI absorption of CYP3A4 substrates and increases peak levels of statins. This combination should be completely avoided.
77
Nutrient depletion statins?
CoQ10 (watch for muscle pain / fatigue) – each client taking statins could benefit for a CoQ10 supplement
78
Additive effect of food and statins?
* Red yeast rice (fermented rice in yeast): A combination of mevinic acids and derivatives – natural approach mimic statins effects e.g., monacolin K (identical to the active in Lovastatin), and other constituents that exhibit cholesterol lowering activity. Combining with statins may increase overall side effects – additive effect it would be counter indicated.
79
What are diuretics prescribed for?
Prescribed for: Oedema due to heart failure, hypertension – can be preventative to excrete potassium as it ca cause adverse effect on hypertensive medications:
80
Example of diuretics drug names x3
: Furosemide (loop diuretic – block the reabsorption of sodium, chloride and water within the kidney tubule to increase urine excretion), bendroflumethiazide (thiazide diuretic). Spironolactone (potassium-sparing diuretic).
81
Mode of action of diuretics?
Inhibit reabsorption of filtrate from various sections of the nephron (i.e., increased urine output), decreasing blood volume and pressure
82
Contraindication for diuretics?
Metabolic imbalances (hypokalaemia (low level of potassium), hyponatraemia (low levels of sodium), hypercalcaemia (high levels of calcium)), Addison’s disease. When we take diuretics we lose urine and those electrolytes are key for nervous system function.
83
Cautions and side effects of diuretics medications?
Caution: Exacerbates diabetes, gout and SLE. Elderly are susceptible to side effects! It is unwise for a client in a prediabetic stage to take diuretics => because of the low potassium risks and potassium is required for carbs metabolism for the conversion of glucose to glycogen !
Side effects: Hypokalaemia (can be dangerous – mental confusion, feeling deezy or shaky), hypotension, GIT disturbance, impotence. Milk-alkali syndrome (too much calcium in the system) may occur when thiazides are combined with large quantities of calcium carbonate!
84
What is a natural diuretics
Taraxacum officinalis — (dandelion)
Acts as a diuretic but also supplies potassium (the leaf), unlike most pharmaceutical diuretics
85
What is Digoxin prescribed for?
Atrial fibrillation (irregular heart beat), heart failure:
86
Digoxin mode of action?
Increases force of myocardial contraction and reduces conductivity within the atrio-ventricular node.
87
Digoxin contraindications?
Heart block, ventricular tachycardia.
88
Digoxin cautions and side effects?
Caution: Hypokalaemia and low blood magnesium can increase the risk of toxicity from digoxin! Diuretics leads to hypokalaemia => and if take Digoxin could increase the toxicity risk!
Side effects (usually in overdose): Nausea, vomiting, diarrhoea, loss of appetite, abdominal pain, visual disturbance, arrhythmias. The elderly are especially susceptible to side effects. Age related kidney issues, renal function decline as we get older.
89
Digoxin drug nutrient interaction?
Interactions: Hawthorn can increase myocardial contraction. Concomitant use may require digoxin’s dose to be reduced.
90
What are antacids prescribed for?
Prescribed for: Gastro-oesophageal reflux disease (GORD), indigestion
91
Examples of antacids?
Calcium carbonate, magnesium, aluminium.
92
Antacids mode of action?
Neutralisation of stomach acid: acid + base = water + salt.
93
Antacids caution and side effects ?
Cautions: Low gastric HCl. Overuse can result in a rebound effect if the drug is discontinued (the acid comes back more strongly).
Side effects: Impaired nutrient absorption; magnesium versions can be laxative, aluminium versions can be constipating.
94
Antacids drug nutrient interaction?
Vit. D may ↑ aluminium absorption if taken at the same time.
95
Alternative to antacids?
Alternatives: Diet and lifestyle changes:
Chew food well, fluids away from meals; demulcent / anti-inflammatory herbs ― aloe vera juice, slippery elm, liquorice, marshmallow root; avoid caffeine, lose weight
if needed, stop smoking; manage stress e.g., breathing exercises to support a shift into a parasympathetic state – box breathing before a meal.
96
What are PPI prescribed for?
Prescribed for: Gastro-oesophageal reflux disease (GORD), prevention of NSAID-associated ulcers, triple therapy with antibiotics for gastric / duodenal ulceration:
In NZ PPIs are the 3rd most commonly used medication after paracetamol and statins! Are often prescribed and are also pharmacy only medication.
97
Example of PPIs x3?
Omeprazole, lansoprazole, esomeprazole.
98
PPI mode of action?
Blocks gastric cells proton (hydrogen) pump. They have a lock and key effect with the receptors on the proton pump and block the release of gastric acid.
99
PPI caution and side effects ?
Cautions: Liver disease, pregnancy, breast-feeding, gastric cancer (masks symptoms – blood in the stools, nausea and weight loss symptoms).
Side effects: Headache, GI disturbances, rebound gastric hypersecretion and heartburn after discontinuation of drug.
100
Key long term effects of PPIs? x4
* Increased risk of GI infections (e.g., Clostridium difficile) and SIBO. Alkaline gastric pH allows bacterial survival.
* Increased fracture risk: Reduced calcium absorption leads to decreased bone
mineral density, possible inhibition of osteoclast activity.
* Vitamin B12 deficiency: Gastric acid is needed for release of vit. B12 from proteins to help intestinal absorption.
* Low blood magnesium due to decreased intestinal absorption. Also reduced iron absorption (= possible iron deficiency anaemia).
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Describe how the 5R approach can support clients to withdraw PPIs?
Remove:
* Remove trigger foods (acidic — tomatoes, alcohol, caffeine, spicy food, fatty foods, dairy, chocolate). Identify and manage any food intolerances e.g., gluten. Stop smoking.
* Avoid overeating, avoid fluid intake with meals — also to reduce stomach distension. Eat last meal at least 4 hours before bed.
* Prone position ― elevate head of bed by 4‒6 inches.
* Reduce intra-abdominal pressure — weight loss / avoid tight-fitting clothes.
Replace (introduce):
* Increase nutritious foods to replace deficiencies e.g., magnesium rich. Clients may also need supplementation B12, magnesium, Vitamin A (introduce a general multivitamin and mineral).
* Digestive enzymes / betaine HCl / digestive bitters.
Repopulate:
* Introduce probiotics — some clients may suffer from SIBO after long-term acid suppression.
* Use anti microbials before we repopulate the guts like Garlic or Berberine to dissolve the biofilm ad body can get rid of the bacterial overgrowth.
Repair:
* To protect and repair the gut lining ― use slippery elm, marshmallow, chamomile, glutamine.
Rebalance:
* Reduce and manage stress — acupuncture, aerobic exercise (not following meals). Stress is a key trigger. Forest bathing, Box Breathing, app, etc.
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What herb can help with PPI withdrawal?
Slippery elm contains mucilage, which can reduce the absorption of oral drugs and decrease their effectiveness. Therefore, you should take slippery elm at least one hour after taking an oral drug
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What is warfarin (anti-coagulant) prescribed for?
DVT (blood clot developed in the deep veins of the legs and arms), pulmonary embolism (when a blood clot come off and make it to the lungs), transient ischaemic attacks (lack of blood flow to the tissues – mini stroke – lack of blood flow to the veins
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Anti coagulant mode of action?
Antagonises the effects of vitamin K — a co-factor for the production of four clotting factors
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anti coagulant contraindications?
Haemophilia, cerebral thrombosis (blood clot within the brain), peptic ulcers, hypertension, pregnancy.
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anti coagulant caution and side effects?
Cautions: Surgery, Liver / Kidney impairment, breastfeeding.
Side effects: Haemorrhage is the worrying side effect!
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Anti coagulant drug nutrient interaction?
Major changes in diet (salads / green vegetables) and alcohol consumption (drug will be broken down at a faster rate than desired) can affect anticoagulant control.
Pomegranate juice increases the INR (international normalised ratio) by inhibiting the CYP450 enzyme that metabolises warfarin.
High doses of vitamin E (blood thinning potential) inhibit platelet aggregation and should be avoided with warfarin as has an additive effect.
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Levothyroxine mode of action
Lifelong replacement. Overtime the thyroid gland will stop producing its own hormone.
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Levothyroxine contraindication?
Thyrotoxicosis. Hyperthyroidism.
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Levothyroxine caution and side effects ?
Cautions: Elderly (increases bone turnover and leads to more porous bones – put a solid bone support plan in place), cardiovascular disorders.
Side effects: Headache, insomnia, tremor, anxiety, flushing. If dosage is too high metabolism works too quickly.
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Levothyroxine dosing?
The dose should be taken 30–60 minutes pre-breakfast or caffeine containing liquids to avoid reduced absorption
112
Levothyroxine drug nutrient interaction?
Oral iron and calcium supplements (and cow’s dairy) reduce the absorption of levothyroxine. It is important that doses are separated by at least four hours.
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Sedating antihistamine brands
Chlorphenamine (Histafen®)
Dexchlorpheniramine (Polaramine®)
Doxylamine (Dozile®)
Promethazine (Phenergan®, Allersoothe®).
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Non sedating anti-histamine brands
Bilastine (Labixten®)
Cetirizine (Zista®, Histaclear®, Zyrtec®, Razene®, Zetop®)
Desloratadine (Aerius®)
Fexofenadine (Fexaclear®, Telfast®, Fexofast®)
Levocetirizine (Levoclear®, Levrix®)
Loratadine (Loraclear®, Claratyne®, Lora-tabs®, Lorafix®).
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2 side effects of sedating anti histamine
Headache, psychomotor impairment, antimuscarinic effects (such as urinary retention, dry mouth, blurred vision, gastro-intestinal disturbances)
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Natural approach to treat allergies like hay fever?
- Nutritional (immune modulation & anti-inflammatory)
- Raw honey (local honey as pollen from the same place, very effective and concept where using like with like (with a fever use something warm instead of something cold – with a food intoxication use arsenical – diluted arsenicum, idea is by giving a “toxic” substance will make the body create the appropriate response to it). ,
- Apple cider vinegar
- Quercetin (red pigment in fruit and vegetable, very beneficial for the body, anti histamine, anti oxidants)
- Probiotics
- Herbs (e.g. Echinacea, nettle (help to reduce the effect of an allergic response)
- Homeopathy, acupuncture.
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1 phytonutrient with anti-histamine properties? Food sources of the nutrient?
QUERCETIN – FLAVANOIDS – supplement form 200-400mg 3x day
Or if counter indicated chose foods like apples with skins on, grapes, berries and capers
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What ate anti depressant / SSRIs prescribed for?
SSRIs = Selective Serotonin Re- uptake Inhibitors
Prescribed for: Depressive illness, post-traumatic stress, obsessive compulsive disorder, anxiety:
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Brand examples of SSRIs?
Sertraline, citalopram, fluoxetine – check with drug resource what type of drug the client is taking
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SSRI mode of action?
Selectively inhibit the re-uptake of serotonin (5-hydroxytryptamine, 5-HT) in the pre-synapse, increasing the available serotonin in the brain.
121
SSRI contraindication?
Poorly-controlled epilepsy.
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SSRI side effects?
GIT disturbance, constipation, diarrhoea, insomnia, anxiety, agitation, sexual dysfunction, reduced appetite.
123
What is the serotonin syndrome?
The serotonin syndrome is associated with an excess of serotonin due to therapeutic drug use, overdose or interactions between drugs
124
When can the serotonin syndrome happen?
It can occur when two or more drugs affecting serotonin are given at the same time or after one serotonergic drug is stopped and another started.
Special care is needed when switching from an SSRI to an MAOI (mono amine oxidase inhibitor) or vice versa.
125
What are the symptoms of Serotonin syndrome?
confusion, disorientation, exaggerated reflexes, abnormal movements, fever, sweating, hypo / hypertension.
126
Drug nutrient interactions with SSRI? How does it work for both nutrient?
5-HTP and St. John’s wort must not be combined with SSRIs as the additive effect significantly increases the risk of serotonin syndrome.
Advice the client to stop taking 5-HTP with the SSRI as there is the potential additive effect! Send them back to GP if want to stop taking their SSRI.
5-HTP is one of the building block of AA L-Tryptophan on the pathway to Serotonin building.
St John’s wort works similarly to and SSRI – blocks the re-uptake of serotonin in the brain
127
What are NSAIDs prescribed for?
Pain relief, inflammation, temperature reduction
128
Examples of brands of NSAIDs
Ibuprofen, diclofenac, naproxen
129
NSAIDs mode of action
Inhibits the activity of cyclooxygenases (COX-1 and COX-2), thereby inhibiting prostaglandin synthesis. Block COX enzymes and block prostaglandins (responsible for inflammation, pain), but when we systematically block prostaglandins (which also offer some protection within the body), we see adverse effects
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NSAIDs contraindication
Peptic ulceration, history of gastrointestinal bleeding or hypersensitivity to aspirin, IBD. NSAIDs irritate the guts.
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NSAIDs cautions
Asthma, cardiac impairment, impaired renal function – drugs leave the body via the urine
132
Drug drug interaction of NSAIDs?
Coadministration with warfarin increases bleeding risk.
133
Drug nutrient interaction of NSAIDs?
Concomitant use of NSAIDs with high doses of nutrients and herbs with antiplatelet activity e.g., vitamin E, garlic and turmeric, may increase the risk of bleeding.
134
NSAIDs side effects?
Inhibit prostaglandins that play a vital role in gastric mucosal defence, increasing the risk of gastric bleeding and ulceration. The mucosal layer is protective against the acidic environment -> LT use of NSAIDs lead to gastric bleeding and ulcerations.
Block renal prostaglandins that normally dilate vessels in the kidneys. This can lead to reduced blood flow and oxygen supply causing acute kidney damage.
135
what is the side effects of COX-2 inhibitor selective NSAIDs?
NSAIDS that selectively inhibit COX-2 allow COX-1-induced production of prostaglandins that have important gastro-protective effects. However, they are associated with an increased risk of cardio-vascular events in those with heart disease.
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Alternative options to NSAIDs
Willow bark (Salix alba) reduces inflammation and fever and has analgesic properties.
Willow bark does not have antiplatelet activity and can be safely used alongside NSAIDs where pain is more severe.
Turmeric (curcumin), ginger and boswellia are also COX inhibitors.
Ensure an anti-inflammatory / alkalising diet incorporating a range of fruit and vegetables rich in flavonoids and chlorophyll.
Quercetin inhibits LOX and COX pathways and down-regulates NF-kB. Food sources include red onions, asparagus, apples, berries
137
What are CORTICOSTEROIDS – anti-inflammatories prescribed for?
Asthma, eczema, IBD, hypersensitivity reactions, autoimmune conditions
138
examples of corticosteroids?
Prednisolone, hydrocortisone. Corticosteroids are synthetics analogues of steroid hormones produced in the body.
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Corticosteroids mode of action
Modulates protein synthesis by binding to DNA. It stimulates the production of a glycoprotein called lipocortin, which inhibits the activity of phospholipase A2 and hence inflammatory mediators.
140
Corticosteroids contraindication
Active infection, live virus vaccination (with Measles, Mumps, Rubella vaccination clients need to get off the medication 2 weeks before taking the vaccines as the corticosteroids in immune suppressing).
141
Corticosteroids side effects?
Long-term systemic use increases risk of Cushing’s syndrome (moon face, purple stretched marks on the skin), diabetes mellitus (increased thirst, urination, fatigue, dizziness – cortisone push up blood glucose and can lead to insulin resistance), osteoporosis (corticosteroids reduce the absorption of calcium and lead to rapid bone turnover) and infections (suppress the immune system).
142
Why should clients not withdraw of corticosteroids suddenly?
Abrupt withdrawal after a prolonged period can lead to acute adrenal insufficiency (vital that client should not suddenly withdraw from medication as cortisol is key to maintain blood pressure – signs of adrenal insufficiency dizziness, extreme fatigue, mental confusion), hypotension or death
143
Alternative approach to corticosteroids?
Anti-inflammatory diet; nutrients and herbs that inhibit inflammatory mediators e.g., EFAs, quercetin, turmeric, ginger. Anti-inflammatory diet.
144
1 drug nutrient interaction with corticosteroids?
* Liquorice root has been shown to modify or even increase the body’s levels of cortisol. Liquorice, if given in large quantities with corticosteroids, may cause additive hypokalaemia (increases potassium loss from the urine) – important even if the client is just drinking liquorice tea (often use in weight loss diet as satiate the appetite as quite sweet and works well in appetite control). Pharmacodynamic interactions are possible with liquorice and fludrocortisone due to mineralocorticoid effects, and with liquorice and medicines that deplete potassium levels such as diuretics.
145
Name 1 bulk laxative brand (fibre supplement)
i. Bonvit®
ii. Konsyl-D®
iii. Metamucil®
146
Name 1 stimulant laxative
i. bisacodyl (Dulcolax tablet)
ii. sennoside B (Senokot tablet).
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What is the difference between bulk laxatives and stimulant laxatives?
stimulant laxative - laxatives stimulate the nerves in the bowel, causing muscle contractions and in this way gets the bowel moving.
Bulk laxatives: fibre supplement
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2 side effects of laxatives
Constipation - because the bowel loses muscle and nerve response and can no longer move poos out. This results in dependency on the laxative, so that higher doses are needed to poo.
Diarrhoea
Dehydration
149
natural approach to constipation?
Unprocessed wheat bran
Oat bran
Water
High fibre diet
Stress => to relax the colon
SIBO => can lead to diarrhoea or constipation (depends on the kind of bacteria that growth within the small intestine – if it is the methane producers it inhibits peristalsis and slow down the bowels)
Hypothyroidism?
150
What do you ask clients to get a full picture of the drugs they are taking?
1. Ensure that a full list of drugs is identified (prescribed and OTC drugs).
2. Understand why they are using the drug even if it is obvious e.g., levothyroxine for underactive thyroid.
3. The duration of treatment — how long has the client taken / used the medication?
4. Establish how often they take / use the medication e.g., once daily, twice daily, with breakfast, which food type.
5. Ensure the dosage is recorded e.g., levothyroxine 100 mcg.
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1. During a consultation, you identify that a prescribed drug is contributing to severe side effects. How would you manage this scenario?
Go to reputable drug resource guide and see based on evidence that the drug is capable of triggering the side effect
Educate
Explain
Send them to GP to discuss changing or reducing drug – write a letter to illustrate timeline and symptoms the client is experiencing
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2. Think of TWO prescribed drugs that must never be abruptly stopped.
SSRIs
Levothyroxine
Corticosteroids
Anti-convulsant for epilepsy
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3. Explain how you might withdraw a client off a PPI, after taking it for GORD. What are the side effects of long-term PPI use?
PPI is a medication that inhibits the release of gastric acid – if stop suddenly they will have rebound where PP over produce gastric acid
Explain that rebound issue to client
Remove any trigger food – caffeine, dairy, gluten
Repopulate the gut by friendly bacteria
Repair the guts – slippery elm, L-Glutamine, Marshmallow
Rebalance the gut – digestive enzymes, Betaine, HCl, digestive herbs like watercress, rocket to stimulate digestive enzymes
Box breathing around mealtime – manage stress levels if needed
LT use of PPIs reduce the absorption of macronutrients like B12 and Magnesium. Might affect metabolic action of the body.
Client might have SIBO as HCl role is also to kill microbe
Bone health micronutrient will be less bioavailable so we should think of a bone support program.
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Identify TWO drugs that could cause gastrointestinal irritation
PPIs
Antiacids
NSAIDs
Corticosteroids
Opioids
Antihypertensive medication
155
Consider how you might manage a client who would like to reduce / cease their use of OTC paracetamol to treat a tension headache.
Why the client has a tension headache? (dehydration, screen, additive , aspartame, coffee, period headache)
Study show that many people with tension headache and migraine have magnesium deficiency? Poor dietary choices or medication they are taking? Epsom salt bath, supplement, unwind
