Self Care Final - Test 3

What are some benefits of smoking cessation?

* lowers the risk of lung and other types of cancer
* reduces the risk of heart disease and stroke w/in 1 to 2 years by 50%
* after 5 to 10 years, a previous smoker's risk for heart disease is equal to someone who never smoked
* reduces respiratory symptoms
* slows the rate of decline in lung function
* reduces the risk of infertility

What are the two sides of the problem of tobacco dependence?

Physiological and behavioral

What describes physiological tobacco dependence?

the addiction to nicotine

What describes behavioral tobacco dependence?

The habit of using tobacco

What is true of treatments for tobacco dependence?

They should address the physiological and behavioral aspects of dependence

What should we start with in the treatment of tobacco dependence?

A good medical history; helps tailor therapy, avoid risky therapies, find out about the support they may or may not have, and gives insight into their motivation to quit

What kind of questions should we ask a patient who is not ready to quit smoking?

Do you ever plan to quit?

How would it benefit you to quit now, instead of later?

What would have to change for you to decide to quit sooner?

What are the 5 A's of counseling?

@@Ask- ask if they smoke cigs@@

@@Advise - offer personalized advice to quit@@

@@Assess - Ask if the patient is willing to quit@@

@@Assist - Behavioral counseling + FDA Rx@@

@@Arrange - Arranging a follow-up visit@@

What are some behavioral counseling points we can provide patients dealing with tobacco dependence?

set a quit date

tell others and ask for support

plan for challenges/cravings

remove all tobacco products

clean house, car, clothing

emphasize abstinence

use a calendar and contact

brainstorm better uses of money

quit lines

What are the 7 FDA approved medications for tobacco cessation?

nicotine gum,

nicotine patch,

nicotine lozenge,

nicotine nasal spray,

nicotine inhaler,

bupropion SR (Zyban),

varenicline (Chantix)

What are some typical challenges that come with tobacco cessation?

Craving and withdrawal symptoms, facing triggers, and fear of weight gain

What is the MOA of bupropion SR?

Blocks neuronal reuptake of dopamine and norepinephrine

What is the MOA of varenicline?

Partial nicotinic receptor agonist

When should bupropion SR and varenicline be started and how long should treatment last when treating tobacco dependence?

Start 1 week before the quit date and continue for 3 months in total

What are some exclusions for self treatment of tobacco cessation?

severe heart disease (MI, arrhythmia, severe angina)

high blood pressure not controlled with medication,

pregnancy or breastfeeding,

under 18 years old,

active peptic ulcer disease

What is not FDA approved for smoking cessation?

E-cigarettes

What is true of e-cigarettes?

There is no long-term safety data; other methods should be reinforced to help quit smoking

What FDA-approved medications for smoking cessation are classified as NRTs? (nicotine replacement therapies)

nicotine gum, lozenge, patch, nasal spray, oral inhaler

What are some first-line pharmacotherapies for smoking cessation not classified as NRTs?

Bupropion SR and varenicline

Why do we want to give NRTs or other medications for smoking cessation?

They reduce physical withdrawal from nicotine,

eliminate the rewarding effects of nicotine,

allow the patient to focus on behavioral/psychological aspects of tobacco cessation

How long can nicotine withdrawal symptoms last?

From 12 weeks to up to 6 months

What is the proper chewing technique for nicotine?

Chew slowly → stop chewing at the first sign of peppery taste or tingling sensation → park between cheek and gum, → chew again when the peppery taste or tingle fades

How should nicotine gum/lozenges be dosed?

\
* If first cig. of day is more than 30 mins after waking up: 2 mg gum/lozenge
* If first cig. of day is within 30 mins after waking up: 4 mg gum/lozenge

What is the recommended duration of treatment with nicotine gum/lozenges?

12 weeks

What is the appropriate starting dose of the **nicotine patch** for someone who smokes **10 cigarettes a day or less?**

14 mg \* 6 weeks → 7 mg \* 2 weeks

What is the appropriate **starting dose** of the **nicotine patch** for someone who smokes **more than 10 cigarettes a day?**

21 mg \* 6 weeks → 14 mg \* 2 weeks → 7 mg \* 2 weeks

Which NRTs are available only by prescription?

Nicotine nasal spray and oral inhaler

What is the max amount of nicotine gum per day?

24 pieces

What is the max amount of nicotine lozenges per day?

20 pieces

What is the recommended duration of treatment with nicotine transdermal patches?

8 - 10 weeks

* 6 → 2 → 2 weeks or
* 6 → 2 weeks

What is important to remember about nicotine transdermal patches?

The patch application site should be rotated daily

How should nicotine nasal spray be dosed?

1 - 2 doses per hour

* spray into each nostril

What is the max amount of nicotine nasal spray per day?

40 doses

How should nicotine oral inhalers be dosed?

6 - 16 cartridges per day

What is the recommended duration of treatment with nicotine nasal spray?

12 weeks

What is the recommended duration of treatment with a nicotine oral inhaler?

3 - 6 months

What is the max dose of bupropion SR?

300 mg/day

Which smoking cessation medication is **contraindicated** in patients with a history of **seizures**?

bupropion

What kind of adverse effects can you expect with the use of nicotine gum/lozenges?

mouth irritation, hiccups, GI complaints

What kind of adverse effects can you expect with the use of nicotine transdermal patches?

local skin reactions and sleep disturbances

What kind of adverse effects can you expect with the use of nicotine nasal spray?

nasal/throat irritation, ocular irritation, sneezing, cough

What kind of adverse effects can you expect with the use of nicotine oral inhalers?

Mouth/throat irritation, cough, hiccups, GI complaints

What are some precautions to keep in mind when recommending NRTs?

Recent heart attack (2 weeks),

heart arrhythmias,

angina,

pregnancy/breastfeeding,

being under 18 years old

What are some precautions to keep in mind when recommending bupropion SR (Zyban)?

medications that lower the seizure threshold,

hepatic impairment,

pregnancy/breastfeeding,

being under 18 years old

What are some contraindications for Bupropion SR (Zyban)?

Seizure disorders,

concomitant bupropion (Wellbutrin) therapy,

bulimia/anorexia nervosa,

abrupt discontinuation of alcohol/benzos,

use of MAOIs (w/in 2 weeks)

What are some precautions to keep in mind when recommending varenicline?

Renal impairment,'

pregnancy/breastfeeding,

being under 18 years old,

can cause severe neuropsychiatric symptoms

How many medications are FDA-approved for smoking cessation?

7

* bupropion, varenicline, & 5 NRT

How many NON-PRESCRIPTION medications are FDA-approved for smoking cessation?

Three Gum, lozenges, patch

What are some causes of reflux disease?

Esophageal dysmotility,

the @@ineffective barrier between the esophagus and stomach,@@

stomach abnormalities

What are some typical symptoms of reflux disease?

heartburn and regurgitation

How can reflux disease be identified?

If a patient takes acid medication and it relieves their typical reflux symptoms, the symptoms were probably due to acid reflux

How can reflux disease be diagnosed?

Endoscopy; can see erosive esophagitis or Barrett's esophagus

What are some non-pharmacologic treatments for heartburn and dyspepsia?

Weight loss,

head of bed elevation,

avoiding meals 2-3 hours before bedtime,

avoiding trigger foods

What are the different types of pharmacologic treatments for heartburn and dyspepsia?

Antacids/bismuth-containing products,

histamine type 2 receptor antagonists,

proton pump inhibitors

What is the MOA of antacids?

neutralize stomach acid to form water

What kind of effect would a magnesium-containing antacid have?

laxative effects

* Renally-eliminated

What kind of effect would an aluminum-containing antacid have?

causes constipation

* avoid in renal failure

What are some precautions with the use of magnesium-containing antacids?

diarrhea and renal impairment

What are some precautions with the use of aluminum-containing antacids?

Constipation, and overuse can lead to hypophosphatemia, and should be avoided in renal failure

What are some precautions with the use of calcium-containing antacids?

Belching,

flatulence,

constipation,

kidney stones,

should be avoided in renally impaired patients

What are some precautions with the use of sodium bicarbonate?

belching,

flatulence,

fluid overload,

systemic alkalosis,

milk-alkali syndrome

How can most drug interactions with antacids be avoided?

Separating doses by 2 to 4 hours

Antacids + antifungals, iron, atazanavir

Antacids + rosuvastatin

Antacids + enteric coated meds

Separate by 2+ hrs

Antacids + Levothyroxine

Separate by 4 hrs

Antacids + Amphetamines

AVOID CONCURRENT USE

Who should Bismuth subsalicylate not be used in?

Children - Reye’s syndrone

Those with salicylate/aspirin allergies,

anyone at risk for bleeding

What is the MOA of H2RAs?

Blocks the action of histamine on the parietal cells at histamine 2 receptors in the stomach, causing a decrease in acid secretion

How should H2RAs be used?

30 to 60 minutes before eating or at symptom onset; should not be used more than 2 times a day

What are some serious adverse effects of the use of H2RAs?

thrombocytopenia

Weak antiandrogenic effect (High dose)

Decreased libido, @@incompetence@@, gynecomastia in men

What is the MOA of PPIs?

Inhibit hydrogen potassium ATPase (proton pump) that are actively secreting acid

How should PPIs be used?

30 to 60 minutes before a meal (best before breakfast) and self care should be limited to 14 days every 4 months

What is important to remember about PPI tablets and capsules?

They should not be chewed or crushed

What are some serious adverse/choronic use effects of the use of PPIs?

Acute interstitial nephritis,

subacute cutaneous lupus erythematosus,

traveler's diarrhea,

spontaneous bacterial peritonitis

@@c. diff@@

@@Hypomagnesemia@@

What are some exclusions for self-treatment of heartburn and dyspepsia?

Antacids: Children under 2 years

H2RAs: under 12 years

PPIs: under 18 years,

heartburn that continues after 2 weeks of treatment,

unexplained weight loss

When would an H2RA be indicated over a PPI?

For infrequent, mild to moderate heartburn or dyspepsia

When would a PPI be indicated over and H2RA?

For treatment of frequent heartburn (more than 2 days a week)

PPIs + warfarin, theophylline, tacrolimus, mycophenolate

* PPI inhibit CYP2C19
* AVOID CONCURRENT USE

PPIs + Digoxin

* PPI may increase digoxin absorption
* CHECK W/ PROSCRIBER

PPIs + Methorexate

* Risk of toxicity
* AVOID CONCURRENT USE W/ HIGH DOSE METHO

Omeprazole, esomeprazole + clopidogrel

* CYP enzyme interactions
* AVOID CONCURRENT USE

Omeprazole, esomeprazole + Diazepam

* Inhibit metabolism → increase concentration of target drug
* AVOID CONCURRENT USE

PPI’s Generic - Brand

* Omeprazole - Prilosec
* Pantoprazole - Protonix
* Esomeprazole - Nexium
* Lansoprazole - Prevacid
* Famotidine - Pepcid
* Ranitidine - Zantac

What are the most frequent clinical manifestations of intestinal gas?

eructation, bloating, and flatulence

What is intestinal gas primarily composed of?

Nitrogen, oxygen, carbon dioxide, hydrogen, and methane

What are some causes of intestinal gas?

Eating quickly/gulping beverages,

consuming carbonated beverages,

high fiber diet,

dairy products

sulfate containing foods

lactose intolerance

IBS

Celiac disease

What are some examples of food that increase intestinal gas production?

* Dietary sugars,
* fatty foods,
* foods rich in complex carbohydrates,
* indigestible oligosaccharides

What are some sulfate containing foods?

* Cruciferous vegetables,
* bread and beers with sulfate additives,
* proteins like eggs, peanuts, and pistachios

What are some examples of types of oligosaccharidecontaining foods?

Vegetables, beans, and grains

What are some types of drugs that can cause intestinal gas?

Drugs that affect intestinal flora, metabolism of glucose, GI motility, and that contain or release gas

What are the goals of treatment for intestinal gas?

Reduce frequency, intensity, and duration of intestinal gas symptoms

What treatment guide should be followed for intestinal gas?

\
Assess patient history and severity of symptoms

Assess the patient’s diet, medication use, and relevant medical conditions

Assess if symptoms are associated with the ingestion of foods containing lactose or oligosaccharides

Determine if the patient meets the exclusion criteria

Recommend lifestyle modification/pharmacological agents/medical referral as appropriate

What are some nonpharmacologic therapies for the treatment of intestinal gas?

\
* Change in eating habits, diet, medication use, and lifestyle;
* avoid gas producing food, rushing through a meal, be sure to chew food thoroughly,
* avoid gulping and sipping liquids,
* dont overload the stomach at any one meal,
* limit gas producing medications,
* smoking cessation

What are some pharmacologic agents and supplements used in the treatment of intestinal gas?

Simethicone, digestive enzymes, and probiotic products

What is the MOA of simethicone?

Reduces surface tension of gas bubbles in the GI tract, causing them to be broken up easier

What is a contraindication with simethicone?

Suspected intestinal perforation or obstruction

What is the MOA of alpha-galactosidase?

Breaks down oligosaccharides → easier to break down

What is a contraindication with alpha-galactosidase?

CI in patients w/ galactosemia

What is a precaution to be aware of with alpha-galactosidase?

It is derived from mold; caution in patients allergic to mold

What is important to remember about alpha-galactosidase?

There is no safety-dosing information for children

What is the MOA of lactase enzyme replacement?

Breaks down lactose into the monosaccharides glucose and galactose