Self-Care Exam 2

BMI ≥ 30: qualifies for weight loss pharmacotherapy?

YES — regardless of comorbidities

BMI ≥ 27: qualifies for weight loss pharmacotherapy?

YES — ONLY if ≥ 1 obesity-related comorbidity (DM, HTN, hyperlipidemia, CVD, sleep apnea, NAFLD, osteoarthritis, insulin resistance, metabolic syndrome, or major depression)

Higher risk waist circumference: males

40 inches

Higher risk waist circumference: females

35 inches

When do you NOT need to measure waist circumference?

BMI ≥ 35 — provides no additional risk info

Central obesity increases risk of what diseases?

HTN, type 2 DM, hyperlipidemia, cardiovascular disease — independently of BMI

MOA of orlistat

Intestinal lipase inhibitor → blocks fat breakdown → fat stays in stool → fewer calories absorbed

Orlistat OTC dose

60 mg (Alli®) TID — during or up to 1 hour after a fat-containing meal

Orlistat: what if meal is skipped or fat-free?

Skip the dose

Orlistat GI side effects

Oily spotting, flatulence with discharge, fecal urgency, fecal incontinence — mostly in first 1–2 months

Orlistat: required supplementation

Daily multivitamin with fat-soluble vitamins (A, D, E, K) — take at least 2 hours before or after orlistat

Bitter Orange safety concerns

Contains synephrine (like ephedrine) → CNS stimulation (agitation, insomnia) + cardiovascular effects (HTN, tachyarrhythmia)

Green Tea Extract / EGCG safety concern

Hepatotoxicity at higher doses

Chromium for weight loss: evidence?

Insufficient evidence — extremely rare to be deficient in the US

Fat-soluble vitamins

A, D, E, K — "ADEK"

Water-soluble vitamins

C, B1, B2, B3, B5, B6, B7, B9, B12 — NOT stored well (except B12 in liver)

Vitamin C official name

Ascorbic acid

Vitamin B1 official name

Thiamine

Vitamin B2 official name

Riboflavin

Vitamin B3 official name

Niacin

Vitamin B6 official name

Pyridoxine

Vitamin B9 official name

Folate / Folic acid

Vitamin B12 official name

Cobalamin / Cyanocobalamin

Vitamin D2 official name

Ergocalciferol — from plant foods, supplements, fortified foods

Vitamin D3 official name

Cholecalciferol — from fatty animal foods, supplements, fortified foods; also made in skin with UVB exposure

Vitamin E official name

Alpha-tocopherol

RDA definition

Nutrient intake meeting needs of ~98% of healthy Americans; set by National Academy of Sciences; divided by sex and age

UL definition

Maximum daily intake unlikely to cause adverse effects in the general population

AI definition

Adequate Intake — used when insufficient evidence exists to set an RDA (ex: infants)

% Daily Value definition

(# nutrient per serving ÷ RDI) x 100 — shown on nutrition labels

Vitamin C UL

2000 mg/day — exceeding causes GI upset and increased kidney stone risk

Who needs folic acid supplementation?

ALL women of childbearing age who can become pregnant

Why is folic acid critical before/during early pregnancy?

Insufficient intake = leading risk factor for neural tube defects (brain/spinal cord) — neural tube closes before woman knows she's pregnant

Folic acid RDA: non-pregnant adult

400 mcg DFE/day

Folic acid RDA: pregnant women

600 mcg DFE/day

Folic acid UL

1000 mcg/day — exceeding can MASK vitamin B12 deficiency

Why did folic acid supplement labeling change to include DFEs?

Synthetic folic acid is MORE bioavailable than food folate — DFE accounts for this difference in bioavailability

Vitamin B12: 4 populations of concern

Vegans; adults >50 (low stomach acid); regular PPI users (low stomach acid); long-term metformin users

Why do adults >50 struggle to absorb food-bound B12?

Atrophic gastritis → decreased gastric acid → pepsin not activated → B12 not released from food protein

Does low stomach acid affect supplement or fortified food B12 absorption?

No — already in free form; still needs Intrinsic Factor but does NOT need acid to be released first

What is Intrinsic Factor and why does it matter?

Gastric protein required for intestinal B12 absorption — without it, B12 cannot be absorbed regardless of the source

Iron: main site of absorption

Duodenum

Iron: typical absorption percentage

~10–20%

Heme vs. non-heme iron absorption

Heme iron (meats) absorbs BETTER than non-heme iron (plants/grains)

Iron: things that INCREASE absorption

Vitamin C; empty stomach; heme iron sources

Iron: things that DECREASE absorption

Food (~50% reduction); tannins in coffee/tea; enteric-coated products; calcium supplements

Iron UL

45 mg elemental iron/day — exceeding causes stomach irritation, nausea, abdominal pain, diarrhea

Iron GI side effects to counsel patients about

Constipation and dark stools — both are NORMAL and expected

Iron: empty stomach vs. with food

Empty stomach = better absorption but harder to tolerate; food = less GI upset but ~50% less absorption

Why do enteric-coated iron products reduce absorption?

They dissolve past the duodenum — the main absorption site — so less iron is absorbed

Magnesium UL

400 mg/day from supplements

Magnesium: who should NOT take it?

Patients with renal disease — cannot excrete excess magnesium

Magnesium common uses

Constipation; leg cramps/muscle spasms; insomnia

Multivitamin: who might benefit?

Poor diet (disease, low income, alcohol abuse, older age); eliminated food groups; malabsorption problems

Episodic heartburn definition

Occurs infrequently or occasionally

Frequent heartburn definition

Occurs regularly (more than 2 days per week)

GERD definition

Symptoms AND/OR esophageal tissue damage from abnormal reflux of gastric acid — lasting 3 or more months; NOT self-treatable

GERD: typical symptoms

Frequent heartburn; regurgitation; sour/acid taste in throat; water brash (mouth filling with saliva)

GERD: atypical symptoms

Non-cardiac chest pain; dental erosion; chronic cough; chronic hoarseness/laryngitis; globus sensation (lump in throat)

Exclusions to self-treatment of heartburn: refer to physician if…

Heartburn >3 months; unresponsive to OTC therapy after 2 weeks; nighttime symptoms; difficulty swallowing; vomiting blood or black material; black tarry stools; unexplained weight loss; severe symptoms; chest pain suggesting MI

MOA of antacids

Partially neutralize gastric HCl already in the stomach — onset <5 min; do NOT reduce acid secretion

Antacid: calcium carbonate (Tums®) ADRs

Constipation (not common); belching/flatulence (CO2 produced); 10% absorbed; also a calcium supplement

Antacid: magnesium hydroxide ADRs

Dose-dependent osmotic DIARRHEA; avoid in renal disease

Antacid: aluminum hydroxide ADRs

Dose-dependent CONSTIPATION; avoid in renal disease

Why combine aluminum and magnesium antacids?

Balance each other's GI effects (Al = constipation, Mg = diarrhea); diarrhea tends to predominate

Antacid: sodium bicarbonate — key concerns

Most rapid acting; bloating/belching/flatulence; rare gastric rupture; high Na+ load; systemic alkalization with overuse — NOT for chronic use

Antacid duration: empty stomach

~20–30 minutes

Antacid duration: with food or up to 1 hour after eating

~2–3 hours

Relative antacid potency order (highest to lowest ANC)

Calcium carbonate > Sodium bicarbonate > Magnesium salts > Aluminum salts

MOA of alginic acid (Gaviscon®)

Forms a viscous raft that floats on stomach contents → barrier against reflux; lasts ~4 hours; only works upright; best taken after eating; chew completely + follow with water

MOA of H2 receptor antagonists (H2RAs)

Reversibly bind H2 receptors on parietal cells → DECREASE acid secretion (reduce production, unlike antacids)

H2RA: famotidine (Pepcid AC®) dose and duration

10–20 mg up to BID; duration ~8–10 hours

H2RA: cimetidine (Tagamet HB®) dose and duration

200 mg up to BID; duration ~6–8 hours

Cimetidine major drug interaction concern

Inhibits CYP450 enzymes (3A4, 2D6, 1A2, 2C9, 2C19) — warnings required for warfarin, theophylline, and phenytoin

H2RA appropriate self-care use

Patients ≥ 12 years; episodic mild-moderate heartburn; to treat OR prevent from known triggers; see physician if still symptomatic after 2 weeks

H2RA use in pregnancy

NOT for self-care — refer to PCP if antacids are insufficient

MOA of proton pump inhibitors (PPIs)

Irreversibly binds active H+/K+/ATPase proton pump → blocks FINAL step in acid secretion

PPI: Prilosec OTC® ingredient

Omeprazole magnesium 20.6 mg (= 20 mg omeprazole)

PPI: Prevacid-24hr® ingredient

Lansoprazole 15 mg

PPI: Nexium-24® ingredient

Esomeprazole magnesium 22.3 mg (= 20 mg esomeprazole)

Zegerid OTC: what makes it different?

Omeprazole 20 mg + 1,100 mg sodium bicarbonate — Na bicarb protects omeprazole from stomach acid and improves absorption; note the high sodium load

PPI appropriate self-care use

≥ 18 years only; FREQUENT heartburn occurring LESS than 3 months; 1 capsule daily x 14 days; do NOT repeat more often than every 4 months

PPIs: what they are NOT used for

NOT for immediate relief; NOT for prevention of heartburn from trigger foods; NOT in pregnancy for self-care

Non-drug therapy for heartburn

Avoid triggers; no large meals; don't lie down within 2–3 hours of eating; elevate head of bed 6–8 inches; weight loss if overweight; quit smoking; limit alcohol and caffeine

Common cold: most common viral cause

Rhinoviruses (30–50% of cases)

Common cold: most common transmission method

Self-inoculation — touching contaminated surfaces then depositing virus into eyes or nose

Common cold: typical duration

~1 week; ~25% last ≥ 2 weeks

Do 2nd generation antihistamines treat runny nose from a cold?

NO — they only work for ALLERGIC rhinitis; the cold is not histamine-driven

Do 1st generation antihistamines treat runny nose from a cold?

MIGHT — may reduce it ~30% in adults; less effective in children; unpredictable response

1st gen antihistamines: ADR to counsel about

Anticholinergic drying effect — thickens secretions, makes sinus drainage harder; drowsiness

1st gen antihistamines: precautions

Narrow angle glaucoma; urinary retention/BPH

1st gen antihistamines: age limit

NOT approved for children under 6 years

1st gen antihistamines from most to least sedating

Doxylamine > diphenhydramine > brompheniramine > chlorpheniramine

MOA of oral nasal decongestants

Sympathomimetic — alpha receptor stimulation constricts nasal blood vessels → reduces swelling → relieves congestion

Pseudoephedrine vs. phenylephrine: which is more effective?

Pseudoephedrine — superior oral decongestant; phenylephrine has low bioavailability (38%) and FDA proposed removing it from market Nov 2024

Pseudoephedrine max adult dose

60 mg per dose; max 240 mg/day (IR given q4–6h)

Pseudoephedrine SR dose

120 mg q12h (≥ 12 years only)

Pseudoephedrine ER dose

240 mg q24h (≥ 12 years only)

Oral decongestants: absolute contraindication

MAO inhibitor antidepressants (or within 14 days) — examples: phenelzine, tranylcypromine, isocarboxazid

Oral decongestants: use in pregnancy

Do NOT use — no self-care; refer to OBGYN (systemic vasoconstriction risk to fetus)