Pharmacology 2 - Exam 1

immunosuppressants

• these inhibit the immune response

• uses → prevention of organ transplant rejection and autoimmune conditions (ex. lupus, RA, crohn’s)

calcineurin inhibitors

• use → prevent organ transplant rejection and manage autoimmune conditions

• most effective immunosuppressants → cyclosporine, tacrolimus, pimecrolimus

• MOA → suppresses T-cell activity which decreases the immune system’s ability to attack transplanted organs or the body’s own tissues in autoimmune conditions

• these drugs require lifelong adherence

  • missing doses can lead to acute rejection

cyclosporine

• brand name: Sandimmune

• this is a calcineurin inhibitor (immunosuppressant)

• use → primarily to prevent organ rejection

• adverse effects → nephrotoxicity, HTN, infection, hepatotoxicity, hirsutism

• drug and food interactions → grapefruit juice, CYP3A4 inhibitors and inducers (ex. phenytoin, carbamazepine, St. John’s Wort), repaglinide (can lead to hypoglycemia)

• contraindications → LIVE vaccines

tacrolimus

• brand name: Prograf

• this is a calcineurin inhibitor (immunosuppressant)

• use → primarily to prevent organ rejection…an alternative to cyclosporine

• adverse effects → nephrotoxicity, HTN, infection

• drug and food interactions → grapefruit juice, CYP3A4 inhibitors and inducers (ex. phenytoin, carbamazepine, St. John’s Wort), repaglinide (can lead to hypoglycemia)

• contraindications → LIVE vaccines

mTOR inhibitors

• class of immunosuppressants

• MOA → protein kinase that helps regulate cell growth, proliferation, and survival

• structurally similar to tacrolimus but has a different mechanism that does not involve the inhibition of calcineurin

sirolimus

• brand name: rapamune

• this is a mTOR (immunosuppressant)

• use → ONLY for the prevention of renal transplant rejection, used in conjunction with cyclosporine and glucocorticoids

• adverse effects → nephrotoxicity, increased cholesterol and triglyceride levels, infection, hepatotoxicity, severe lung complications, rash, acne, anemia, thrombocytopenia, joint pain, diarrhea, hypokalemia

• drug and food interactions → grapefruit juice, CYP3A4 inhibitors and inducers (ex. phenytoin, carbamazepine, St. John’s Wort), high-fat foods

everolimus

• brand name: zortress, afinitor

• this is a mTOR (immunosuppressant)

• use → prevention of renal or liver transplant rejection

• drug and food interactions → grapefruit juice, CYP3A4 inhibitors and inducers (ex. phenytoin, carbamazepine, St. John’s Wort), high-fat foods

glucocorticoids

• commonly known as steroids

• ex. prednisone

• use

  • widely suppress the immune response

    • allograft rejection, treatment of asthma, RA, SLE, MS

  • large doses used to prevent organ rejection

• adverse effects → infection, thinning of skin, bone dissolution with fracture, impaired growth in children, suppression of the hypothalamic-pituitary-adrenal axis

cytotoxic drugs

• MOA → suppress the immune system by killing B and T lymphocytes

• nonspecific → aka toxic to all proliferating cells

• ex. chemotherapy drugs

• use → last resort in organ transplant patients experiencing rejection

• adverse effects → bone marrow suppression (leading to neutropenia and thrombocytopenia), GI disturbances, reduced fertility, alopecia

antibodies

an adjunct treatment used with organ transplant patients or other patients requiring immunosuppressant medications

histamine

• found in specialized cells that are present in almost all tissues, especially high in skin, lungs, and GI tract

• plays an important role in allergic reactions and regulation of gastric acid secretion

• two types of receptors: H1 and H2

• triggers

  • allergic reactions

  • physical triggers (ex. itching the skin releases histamine and makes it more itchy)

  • drugs/chemicals

  • anaphylaxis

H1 activation

stimulation of these receptors causes

• vasodilation

• increased capillary permeability → leaky vessels (causing redness, swelling, hives)

• bronchoconstriction → tightening of the airway

• CNS effects → makes you more awake

• itching and pain

• mucous secretion → runny nose and watery eyes

H2 activation

stimulation of these receptors causes

• secretion of gastric acid

• promotion of acid release

H1 antagonist

• MOA → block the actions of histamine at H1 receptors, do not block H2 receptors

• 1st generation → highly sedating, cross BBB

• 2nd generation → less sedating, do not cross BBB

• pharmacologic effects

  • peripheral effects → decreased redness, rash, itching, pain

  • CNS effects → 1st generation = drowsiness

• overdose → causes CNS stimulation, makes individuals hyper and can lead to seizures, give lorazepam (Ativan) to reduce seizure risk

• therapeutic uses

  • mild allergy, severe allergy, motion sickness, insomnia, common cold

• adverse effects

  • sedation, dizziness, confusion, N/V, anticholinergic effects

  • severe respiratory depression → Promethazine

  • severe local tissue injury due to extravasation → IV Promethazine (give IM or diluted via IV when given parenterally)

• drug interactions

  • other sedative meds and alcohol

• contraindications

  • pregnancy and lactation, use with caution in kiddos (weight-based dosing), infants

  • glaucoma, urinary retention (BPH), constipation

1st generation H1 antagonist drugs

1. Diphenhydramine (Benadryl)

2. Chlorpheniramine (Chlor-Trimeton)

3. Hydroxyzine (Vistaril, Atarax) → itching, off-label anxiety

4. Promethazine (Phenergan) → N/V related to motion sickness, contraindicated in kids

5. Meclizine (Antivert) → vertigo/motion sickness

6. Dimenhydrinate (Dramamine) → motion sickness

7. Doxylamine (Unisom) → OTC sleep aid, off-label pregnancy induced morning sickness

8. Cyproheptadine

9. Brompheniramine

10. Carbinoxamine

2nd generation H1 antagonist

• these produce much less sedation than first generation agents

• cross the BBB poorly

• have a low affinity for H1 receptors of the CNS

• largely devoid of anticholinergic actions

• these are largely available OTC

2nd generation H1 antagonist drugs

1. Cetirizine (Zyrtec)

2. Fenofexadine (Allegra)

3. Loratadine (Claritin)

Fenofexadine

• brand name → Allegra

• 2nd generation H1 antagonist (offers the best combination of efficacy and safety)

• uses → oral therapy of seasonal allergic rhinitis and for chronic idiopathic urticaria

• use with caution in patients with renal impairment

• do not take with fruit juice

Cetirizine

• brand name → Zyrtec

• 2nd generation H1 antagonist (more sedating than other 2nd generation antihistamines but still less sedating than 1st generation)

• uses → allergic rhinitis and chronic idiopathic urticaria

• food delays absorption

Loratadine

• brand name → Claritin

• 2nd generation H1 antagonist

• use → seasonal allergic rhinitis

• food delays absorption

• use with caution in patients with signification hepatic and/or renal impairment

COX-1

• “good cox“

• protects the stomach lining by producing prostaglandins

• supports platelet aggregation → blood clotting

• maintains kidney function by promoting blood flow

COX-2

• “bad cox” → often activated by injury

• triggers inflammation → produces prostaglandins that cause swelling, pain, and redness

• produces fever → acts on the brain to elevate body temperature

• increases sensitivity to pain → amplifies pain signals

COX inhibitors

• uses → suppress inflammation, relieves pain, reduces fever

• adverse effects → gastric ulceration, bleeding, renal impairment

• MOA → inhibits COX, the enzyme that converts arachidonic acid into prostanoids

• inhibition of COX-1 can lead to…

  • gastric ulceration

  • bleeding

  • renal impairment

  • protection against MI and stroke

• inhibition of COX-2 can lead to…

  • suppression of inflammation

  • alleviation of pain and reduction of fever

  • protection against colorectal fever

COX-1 inhibition

negative effects → stomach ulcers, increased bleeding, kidney issues

positive effects → reduce platelet aggregation, preventing MI and stroke

COX-2 inhibition

positive effects → reduces inflammation, pain, and fever; may protect against certain cancers (ex. colorectal cancer)

1st generation NSAIDs

• inhibit both COX-1 and COX-2

• ex. Aspirin, Ibuprofen (Motrin, Advil), Naproxen (Aleve), Indomethacin, Diclofenac

• uses → inflammatory disease (RA, OA), alleviate mild to moderate pain, suppress fever

• contraindications → patients with active ulcers, bleeding disorders, or renal dysfunction

• patient education

  • short-term use if recommended due to GI and renal complications

  • use the lowest effective does for the shortest duration to minimize risks

aspirin

• 1st generation NSAID → inhibits COX-1 and COX-2

• uses

  • analgesic

  • antipyretic

  • anti-inflammatory

  • suppression of platelet aggregation → prevention of MI and stroke

  • protection in thrombotic disorders → AFib, history of blood clots

  • cancer prevention → colorectal cancers

  • prevention of alzheimer’s disease

• adverse effects

  • GI ulcers/bleeding, GI upset, increased bleeding risk, renal impairment, Salicylism (with OD), Reye’s syndrome (neuro disorder in kids), pregnancy (causes anemia, postpartum hemorrhage, may prolong labor), hypersensitivity reaction

• drug interactions

  • anticoagulants (warfarin and heparin), glucocorticoids (increases GI ulcer risk), alcohol, ibuprofen (increased bleeding risk), ACE inhibitors and ARBS (decreased renal function)

aspirin poisoning

• also called Salicylism

• symptoms → tinnitus (ringing in the ears), sweating, headache, dizziness

• initially respiratory alkalosis occurs → leads to metabolic acidosis

• immediate threats to life include: respiratory depression, hyperthermia, dehydration, acidosis

• there is no antidote → treatment is largely supportive

ibuprofen

• brand name → Advil, Motrin

• 1st generation NSAID → inhibits both COX-1 and COX-2

• uses → anti-inflammatory, analgesic, antipyretic

• generally well tolerated

• low incidence of adverse effects but GI bleeding is the main adverse effect

2nd generation NSAIDs

• just as effective as traditional NSAIDs, like ibuprofen, in suppressing inflammation and pain

• lower risk for GI side effects

• adverse effects → impaired renal function, HTN, edema

• increased risk of MI and stroke! (because these don’t inhibit COX-1)

celecoxib

• brand name → Celebrex

• 2nd generation NSAID/COX-2 inhibitor

• associated with fewer GI issues (ex. ulcers and bleeding)

• last choice drug for long-term management of pain due to increased risk of MI and stroke → don’t give if at high risk (ex. AFib patients)

acetaminophen

• brand name → Tylenol

• uses → analgesic, antipyretic

• no anti-inflammatory properties!

• MOA → inhibits prostaglandin synthesis in CNS

• adverse effects → liver damage

• overdose → won’t kill you but will cause severe kidney and liver damage

• antidote → Acetylcystine (Mucocyst)

• drug interactions

  • alcohol → hepatotoxicity (limit intake to no more than 2000 mg/day)

  • warfarin

  • vaccines

glucocorticoids

• has anti-inflammatory and immunosuppressant effects

• uses

  • RA, SLE, IBS, miscellaneous inflammatory disorders, allergic conditions, asthma, dermatologic disorders, neoplasms, suppression of allograft rejection, prevention of respiratory distress syndrome in preterm infants

• adverse effects

  • adrenal insufficiency with prolonged administration (growth suppression in kids)

  • osteoporosis with prolonged therapy

  • increased infection risk

  • hyperglycemia and glycosuria

  • myopathy (weakness and cramps)

  • hypernatremia and water retention

  • hypokalemia

  • cataracts and glaucoma

  • peptic ulcer disease

iatrogenic cushing’s syndrome

• adverse effect of glucocorticoid therapy (steroid therapy)

• symptoms

  • hyperglycemia and glycosuria

  • fluid and electrolyte disturbances (hypernatremia and fluid retention)

  • osteoporosis

  • muscle weakness

  • purple striae (stretch marks)

  • increased infection risk

  • potbelly, moon face, and buffalo hump

  • thin extremities

anti-arthritic drugs

• NSAIDS → primarily symptom relief

  • these help with pain and swelling

• DMARDS → slow disease progression

  • symptom relief takes several weeks to months to set in

  • these should be initiated within 3 months of RA diagnosis

• glucocorticoids → not used for long term treatment

  • should be used for flares

DMARDs I

• major conventional DMARDs

• chemically made

• ex. Methotrexate and Leflunomide

Methotrexate

• DMARD I → folate antagonist

• MOA → blocks rapidly dividing cells

• most rapid acting DMARD → 3-6 weeks before symptom relief occurs

• administered once a week

• adverse effects

  • hepatic fibrosis, bone marrow suppression (anemia, infections, bleeding), GI ulceration, pneumonitis

• taking folic acid supplements prevents the risks of adverse effects

Leflunomide

• DMARD I → powerful immunosuppressant for adults with active RA

• can decrease signs and symptoms and slow disease progress

• reserved for second line use (when Methotrexate fails)

• contraindicated for pregnant patients

• if patients wish to become pregnant, the MUST follow a three-step protocol

  • stop the drug

  • take Cholestyramine

  • testing Leflunomide drug levels (ensure less than 20 mcg/L)

DMARDs II

• major biologic DMARDs

• MOA → mute TNF inflammatory signal

• these suppress immune function → increases risk of infection

• ex. Entanercept, Rituximab

Entanercept

• DMARD II → inactivates TNF

• use → treats moderate to severe RA

• adverse effects

  • serious infections, severe allergic reactions, heart failure, hematologic disorders, liver injury, MS

Rituximab

• DMARD II → reduces the number of B lymphocytes

• use → reduces symptoms of RA and slows disease progression

• adverse effects

  • infusion reactions, monocutaneous reactions, hepatitis B reactivation, progressive multifocal leukoencephalopathy (PML)

• nursing considerations

  • pre-medicate with tylenol, benadryl, and sometimes a steroid

gout drug therapy

1. control symptoms → short term

   1. used for infrequent flare-ups (fewer than 2 times/year)

   2. goal of therapy → releiving inflammation and pain

   3. medications used → NSAIDS, colchicine, glucocorticoids

2. prevent future attacks by lowering uric acid buildup → long-term

   1. used in patients with two or more gout flares per year

   2. goal of therapy → lowering uric acid levels

   3. medications used

      1. xanthine oxidase inhibitors → block production of uric acid

      2. uricosuric drugs → increase uric acid excretion to remove buildup

      3. recombinant uric acid oxidase → convert uric acid to allantoin (easily excreted from kidneys)

3. protect joints → long-term

NSAIDs for gout

commonly used NSAIDs for acute flares

• Indomethacin (Indocin)

• Naproxen (Naprosyn)

• Diclofenac (Voltaren)

colchicine

• anti-inflammatory agent specific for gout flares

• uses

  • treats acute gouty attack

  • reduces incidence of attacks

  • aborts and impending attack

• adverse effects

  • N/V, myopathy (muscle pain or weakness, increased risk when combined with statins), myelosuppression

• drug interaction

  • statins → can cause rhabdomyalysis/muscle breakdown

  • P-glycoprotein inhibitors

  • inhibitors of CYP3A4 → toxic levels of colchicine

chronic gout drug management

• goals of therapy

  • lower uric acid levels

  • reduce frequency of attacks

  • prevent long-term joint damage

• Allopurinol → xanthine oxidase inhibitor

  • MOA → inhibits uric acid formation

• Febuxostat → xanthine oxidase inhibitor

  • MOA → inhibits uric acid formation

• Probenecid → uricosuric agent

  • MOA → increases uric acid excretion

• Pegloticase → recombinant uric acid oxidase

  • MOA → converts uric acid to allantoin which is more easily excreted by the kidneys

Allopurinol

• xanthine oxidase inhibitor → inhibits uric acid formation

• uses

  • chronic tophaceous gout

  • hyperuricemia due to chemotherapy

  • certain blood dyscrasias → polycythemia vera, myelpid metaplasia, leukemia

• drug of choice for chronic gout

• adverse effects → generally well tolerated

  • hypersensitivity syndrome (fever, rash, can be fatal), initial therapy may elicit acute gout flares, GI reactions, neurologic effects, cataracts if used longer than 3 years

Febuxostat

• xanthine oxidase inhibitor → inhibits uric acid formation

• uses

  • chronic tophaceous gout (second-line drug after Allopurinol)

• adverse effects

  • liver function abnormalities, nausea, arthralgia (joint pain), rash

Probenecid

• uricosuric agent → increases uric acid excretion

• uses

  • chronic tophaceous gout

• adverse effects

  • mild GI effects, risk of kidney damage (drink water and avoid nephrotoxic meds!)

• drug interactions

  • aspirin and other salicylates → reduce the effectiveness of probenecid

Pegloticase

• recombinant uric acid oxidase → converts uric acid to allantoin which is more easily excreted by the kidneys

• uses

  • IV infusion for severe refractory gout (a form of gout that isn’t responding to other treatment)

• adverse effects

  • gout flare-up, anaphylactic reactions, infusion reactions

• key points

  • costly, used as a last resort

calcium regulation

• parathyroid hormone (PTH) and vitamin D → raises blood calcium levels

• calcitonin → lowers blood calcium levels

hypercalcemia

• > 10.5

• usually asymptomatic but can be FATAL

• if symptoms are present → kidney stones, nausea, confusion

• causes

  • cancer, hyperparathyroidism, vitamin D intoxication, sarcoidosis, thiazide diuretics

• treatment

  • acute management → IV saline and loop diuretic

  • drugs

    • edetate disodium

    • glucocorticoids

    • calcitonin/biphosphonates

    • gallium nitrate

hypocalcemia

• < 8.5

• primary concern → increased neuromuscular excitability (neurons are more ready for action potentials)

• clinical presentation

  • tetany, convulsions, spasm of the pharynx (can be FATAL)

• causes

  • deficiency of PTH, deficiency of vitamin D, deficiency of calcium, chronic renal failure, long-term use of certain medications

• treatment

  • acute management if symptomatic → IV calcium gluconate

  • maintenance therapy once calcium levels have been restored → calcium citrate and vitamin D

calcium salts

• oral (chewable recommended)

  • uses → mild hypocalcemia, dietary supplements, PMS, reduce risk of colorectal adenoma

  • limit to 600mg at one time

  • adverse effects → hypercalcemia

  • avoid green leafy vegetables as they reduce the absorption of calcium

• parenteral

  • only given when hypocalcemia is life-threatening

  • adverse effects → highly irritating, can cause IV extravasation

  • do NOT give IM

  • drug interactions → Digoxin (increased risk of arrhythmias)

vitamin D

• uses

  • rickets and osteomalacia

  • hypoparathyroidism

  • vitamin D deficiencies

• formulations (manyyyy)

  • Cholecalciferol

• nursing consideration → vitamin D toxicity (hypercalcemia is main concern)

Raloxifene

• SERM → selective estrogen receptor modulator

• structurally similar to estrogen and binds to estrogen receptors

• therapeutic uses → helps prevent bone loss

  • osteoporosis

  • reduces breast cancer risk

• adverse effects

  • DVT, PE, stroke, fetal harm

Calcitonin

• used for conditions where calcium levels are HIGH or bone turnover is abnormal

• MOA

  • inhibits the activity of osteoclasts

  • decreases bone resorption

  • inhibits tubular resorption of calcium

  • increases calcium excretion

• uses

  • osteoporosis, Paget’s disease, hypercalcemia

biphosphonates

• -dronate

• MOA → stop/slow bone breakdown

• uses

  • post-menopausal osteoporosis, osteoporosis in men, glucocorticoid-induced osteoporosis, Paget’s disease of bone, hypercalcemia of malignancy

• may also help prevent and treat bone metastases in patients with cancer

• adverse effects

  • esophagitis, esophageal ulcers, gastritis, ocular inflammation, osteonecrosis of the jaw (ONJ), atypical femur fractures, Afib

• drug examples

  • Alednronate, Risedronate, Ibandronate, Tiludronate

Alendronate

• most widely used oral bisphonphonate

• uses

  • post-menopausal osteoporosis, osteoporosis in men, glucocorticoid-induced osteoporosis, Paget’s disease of bone

• adverse effects

  • esophageal ulceration, atypical femoral fracture, esophageal cancer, musculoskeletal pain, ocular problems, ONJ, hyperparathyroidism, Afib

• nursing considerations

  • take on an empty stomach with a full glass of water, stay upright for 30 minutes after taking this medication

Teriparatide

• form of PTH

• stimulates bone formation (only bone building drug)

• generally well tolerated

• adverse effects

  • nausea, headache, back pain, leg cramps

Denosumab

• first-in-class RANKL inhibitor

• uses

  • osteoporosis in postmenopausal women and men at high risk for fractures

  • bone loss in women and me receiving certain anticancer therapy

  • prevention of skeletal-related events in patients with bone metastases from solid tumors

• adverse effects

  • hypocalcemia, serious infections, dermatologic reactions, osteonecrosis of the jaw (ONJ)

Cinacalcet

• calcimimetic drug → mimic calcium and reduces calcium levels in the body

• uses

  • primary hyperparathyroidism and secondary hyperparathyroidism (related to CKD)

• adverse effects

  • N/V/D, hypocalcemia

fat soluble vitamins

vitamins A, D, E, and K

vitamin A

• EYES

• also known as Retinol

• deficiency → night blindness, xerophthalamia, keratomalacia

• toxicity → risk of birth defects, and liver injury

• alert → stay below 3000mcg/day, especially if pregnant

vitamin D

• BONE

• deficiency → rickets in children, osteomalacia in adults

• toxicity → hypercalcemia, leading to kidney stones

• alert → balance sun exposure with supplementation risks

vitamin E

• antioxidant properties

• sources → fresh greens, seeds, oils

• toxicity → increased risk of bleeding and hemorrhagic stroke

vitamin K

• CLOTTING FACTOR

• role → essential for synthesizing clotting factors, “no clotting without K”

• deficiency → increased risk of bleeding and hemorrhage

• alert → this is the direct antidote for Warfarin

vitamin C

• use → required for the production of collagen and other compounds that bind cells together, part of the synthesis of adrenal steroids

• sources → citrus fruits/juices, tomatoes, potatoes, strawberries, melons, spinach, broccoli

• deficiency → leads to scurvy

niacin

• deficiency

  • pellagra → dermatitis characterized by scaling and cracking of the skin in areas exposed to the sun

  • GI disturbances

  • CNS symptoms → irritability, insomnia, memory loss, anxiety, dementia

• toxicity → vasodilation with flushing, dizziness, and nausea

• uses → small doses to treat deficiency, large doses can lower cholesterol

vitamin B12

• also called Riboflavin

• actions → involved in numerous enzymatic reactions

• toxicity → none for humans

• uses → riboflavin deficiency, migraines

vitamin B1

• also called Thiamin

• actions

  • coenzyme for carbohydrate metabolism

  • increased requirements during pregnancy and breastfeeding

• dificiency

  • wet beriberi

    • fluid accumulation in the legs

    • heart abnormalities → palpitations, high-output heart failure

    • circulatory collapse and death

  • dry beriberi

    • neurologic and motor deficits with no edema or cardiovascular symptoms

  • Wernicke-Korsakoff syndrome (caused by alcoholism)

    • serious CNS disorder → neurologic and psychologic

    • nystagmus, diplopia, ataxia, inability to remember recent past

vitamin B6

• also called Pyroxidine

• deficiency cause → can be induced by the TB drug Isoniazid

• deficiency signs → peripheral neuritis, confusion → rare unless and alcoholic

• toxicity → >100mg/day can cause ataxia and numbness

folic acid

• also known as B9

• role → prevents neural tube defects, ancencephaly, and spina bifida

• alert → all women of child-bearing age need 400-800mcg/day

• risk → doses >800mcg/day can lead to increased cancer risk

vitamin B12

• action → essential in the synthesis of DNA

• deficiency → leads to megaloblastic anemia

biotin

essential co-factor for several reactions involved in the metabolism of carbohydrates and fats

Orlistat

• this is a lipase inhibitor

• brand name → Alli

• MOA → acts in the GI tract to reduce absorption of fat

• adverse effects

  • GI effects → oily stools, gas with discharge, frequent BMs

  • possible liver damage

  • acute pancreatitis

  • kidney stones

• drug and nutrient interactions

  • levothyroxine → may impair absorption, take 4 hours before or after

  • fat soluble vitamins (A, D, E, and K) → reduces the absorption of these vitamins, take a multivitamin 2 hours before or after

  • warfarin → reduced absorption of vitamin K may increase anticoagulant effects

glucagon-like-peptide 1 agonists

• also known as GLP-1

• drug examples → Liraglutide and Semiglutide

• the “I just ate“ hormone that tells your body that is is full by slowing down digestion

• adverse effects

  • GI → nausea/vomiting (due to food sitting in the stomach for too long)

  • hypoglycemia → DM patients at high risk

harmful dietary supplements

• comfrey

• kava

• ma huang (ephedra)

black cohosh

• used to provide menopause relief

• may increase the risk of liver damage

coenzyme Q-10

used to help with migraine prevention, CHF, and myopathies related to statins

cranberry juice

• uses → prevents UTI

• effectiveness → daily intake helps prevent UTI in women in their teens and 20s and elderly women but NOT in middle age adults and young girls

• contraindicated with Warfarin due to increased bleeding risk

feverfew

• used for the prophylaxis of a migraine

• can have mild GI reactions

• can increase bleeding risk when taken with antiplatelets or anticoagulants

garlic

• use → cardio health

• risk → bleeding risk → avoid with warfarin and aspirin

ginger

• use → nausea

• risk → bleeding risk → avoid with warfarin and aspirin

ginkgo biloba

• use → pain-free walking with PAD

• generally well tolerated

st. john’s wort

• use → depression (mild-to-moderate)

• risk → reduces effects of warfarin, risk of serotonin syndrome with SSRIs