Understanding Self-Care

Self-Care Definition

• Self-care is how individuals, families, and communities promote and maintain health.
• It includes disease prevention and coping with illness, with or without healthcare provider support.

Drivers of Self-Care

• An aging population is increasing the need for self-care.
• There is a decreased availability of primary care physicians (PCPs).
• Healthcare costs are continuously rising.
• Changes in healthcare delivery models are occurring.
• There's an increased number of patients with chronic conditions.
• A high portion of people are underinsured or uninsured.
• There are changes in pharmacy design.
• Self-care offers easy access to medications and is convenient and cost-effective.

Scope of Self-Care

• The text does not specify the scope of self-care.

Risks of Internet Pharmacies

• Counterfeit, contaminated, and unsafe medications can be a risk.
• Lack of consultation and supervision can also be a risk.

Benefits of Internet Pharmacies

• Cost savings and convenience are benefits.

Verified Internet Pharmacy Practice Site (VIPPS)

• It is best to find a VIPPS-verified internet pharmacy.

Pharmaceutical Care Practices

• Pharmaceutical care involves a practitioner taking responsibility for a patient’s drug-related needs.
• The practitioner is held accountable for this commitment.
• It requires a dedicated patient care process, acceptance of accountability, and a recognizable identity among practitioners.
• Practitioners are responsible for identifying, resolving, and preventing drug therapy problems.

Pharmacist’s Patient Care Process - Collect

• Gather relevant health information using Quest SCHOLAR-MAC or OLDCART.

Pharmacist’s Patient Care Process - Assess

• Determine if the patient is an appropriate candidate for self-care.
• Correctly identify the patient’s primary problem.
• Identify exclusions for self-treatment.

Pharmacist’s Patient Care Process - Plan

• Suggest appropriate self-care strategies.
• Provide specific recommendations and instructions for selected treatments.

Pharmacist’s Patient Care Process - Implement

• Convey accurate information and basic counseling points.
• Ensure the patient understands the care plan.
• Solicit follow-up questions.

Pharmacist’s Patient Care Process - Follow-Up

• Many issues are self-limiting and may not need a follow-up.
• Follow-up with the patient when warranted.
• Address when the patient should seek additional care.
• Record and reassess the patient's condition.

Pediatric Patients

• Pediatric patients have a spectrum of ages and quick physiological changes from growth.
• Rapid growth alters pharmacokinetics.
• There are quick changes in metabolism and elimination due to liver and kidney function.
• Developing judgment requires special consideration for medication administration and the ability to follow instructions.
• Special dosage forms, like liquids, may be needed to help with swallowing.

Geriatric Patients

• Geriatric patients also have a spectrum of ages and physiological changes from a decline in function.
• Absorption increases pH and GI secretions and motility.
• Distribution decreases total body water and muscle mass while increasing total body fat.
• Metabolism and elimination are reduced due to decreased hepatic and renal function.
• Frailty and heightened medication sensitivity are considerations.
• Cognitive impairment may cause problems with memory and judgment, requiring special consideration for medication administration and the ability to follow instructions.
• Special dosage forms, like liquids, may be needed to help with swallowing.
• Polypharmacy (taking 5 or more medications) is common.

Importance of Reading Labels

• Labels should be read for specific information related to pediatric and geriatric use.

Improving Medication Use

• Educate the child, parents, and caregiver.
• Investigate concerns or fears.
• Ask about quality-of-life priorities.
• Follow up with the child, parent, or caregiver regarding efficacy and safety.
• Offer to follow-up with a pediatrician, PCP, or specialist to improve therapy.
• Encourage the child, parent, and caregiver to ask questions.

Issues - Misinterpretation of Labels

• Pediatrics: caregivers are influenced by pictures and terms like "infant" on products.
• Geriatric: difficulty understanding directions due to poor eyesight and poor health literacy.
• Misconceptions about disease process and appropriate treatments can be an issue.

Issues - Storage

• Pediatrics: need safety caps, "out of reach," and ensure medication doesn't look like candy.
• Geriatric: difficulty with safety caps, need easy access, and may need compliance packaging.
• Avoid storing medicine in the bathroom due to moisture and temperature.

Pediatric Considerations

• There's a distinct age group.
• The FDA recommends against self-medication with symptoms such as throbbing HA, dizziness/lightheadedness, lack of sweating, red/hot/dry skin, muscle weakness/cramps, N/V.
• For chronic anemia, effects on red blood cells can cause fatigue, SOB, pale skin, dizziness, HA, and cold hands and feet.

Hypertensive Urgency/Emergency

• Blood pressure >180/>90 indicates hypertensive urgency/emergency.
• It is an emergency if symptoms of target organ damage are present.

OTC Medication Approval - Commonly Asked Questions

• Is the condition self-diagnosable?
• Is the condition self-treatable?
• Does the product possess misuse/abuse potential?
• Is the product habit forming?
• Do methods of use (route of administration) preclude nonprescription availability?
• Do the benefits of availability outweigh the risks?
• Can adequate directions for use be written?
• Is there an adequate margin of safety?
• Has the efficacy literature been reviewed?
• Is there a potential for drug interaction?

Characteristics of OTC Medications

• Benefits outweigh risks.
• The potential for misuse and abuse is low.
• Consumers can use them for self-diagnosed conditions.
• They can be adequately labeled.
• Health practitioners are not needed for safe and effective use.

Required Components of OTC Drug Facts Label

• Must show how to use the drug safely and effectively.
• Must use terms understandable to patients, such as heartburn, acid indigestion, and pain relief.
• Marketing terms, such as pleasant tasting, are allowed.
• Packages must have some sort of tamper-evident quality.

Required Components of OTC Drug Facts Label (Don't Need to Memorize)

• Active ingredient, uses, warnings, directions, special populations dose, other information (storage), and inactive ingredients.

Product Line Extensions

• When original product has additional agents added.

Pharmacist's Role in Product Line Extensions

• Pharmacists should be certain of a product's ingredients and contraindications before recommending it.

Barriers to Drug Label Interpretation

• Understanding the information.
• Understanding the contraindications.

Pediatric Drug Label Interpretation

• Most medications will not be used for children under 2.

Acetaminophen Limits

• The maximum acetaminophen/day is 4000mg.

Anorexia Nervosa - Signs

• Restriction of energy intake relative to requirements, leading to significantly low body weight.
• Intense fear of gaining weight or persistent behavior that interferes with keeping a healthy weight.
• Disturbance in how one's body weight or shape is experienced.

Anorexia Nervosa - Subtypes

• Restricting Type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behaviors
• Binge-Eating/Purging Type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior.

Anorexia Nervosa - CV Symptoms

• Hypotension (low blood pressure)

Anorexia Nervosa - IV Nutrition Risks

• Can cause refeeding syndrome.
• Refeeding syndrome involves fluid and electrolyte shifts.
• It can occur in patients undergoing aggressive nutritional rehabilitation.
• Avoid by eating 1400-1600 kcal/day.

Anorexia Nervosa - Monitoring

• Monitor for hypophosphatemia and hypokalemia.
• Heart failure, edema, rhabdomyolysis, seizures, hemolysis, and respiratory distress.

Bulimia Nervosa - Signs

• Recurrent episodes of binge eating.
• Recurrent inappropriate compensatory behaviors to prevent weight gain.
• Both occur once a week for 3 months.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of anorexia nervosa.

Bulimia Nervosa - Symptoms

• Renal: Alkalosis
• Pulmonary: Aspiration pneumonia
• CNS: Seizures, caused by dehydration, hyperglycemia, and ketoacidosis.

Binge Eating Disorder - Signs

• Recurrent episodes of binge eating.
• Eating in a discrete period of time, amount of food that is more than most, a sense of lack of control.
• Binge-eating episodes associated with 3 or more of the following: eating much more rapidly than normal, until uncomfortably full, large amounts when not hungry, alone due to embarrassment, feeling disgusted, depressed, or guilty afterward.
• Marked distress regarding binge eating.
• Occurs once a week for 3 months.
• Not associated with inappropriate compensatory behaviors.

Binge Eating Disorder - Calorie Intake

• Often 5000 or more calories per episode.

Binge Eating Disorder - Symptoms

• Increased cholesterol, hypertension, diabetes, gall bladder disease, cancer.

Goals of Therapy - Anorexia Nervosa

• Nutritional rehabilitation: restoration of normal eating habits, body weight, and bodily functions.
• Monitor the amount of weight gain.

Goals of Therapy - Anorexia Nervosa - Psychosocial Treatment

• Psychoeducation, individual therapy, family therapy, group therapy.
• Goal: normalize body image.
• Behavioral and psychological therapy.
• Support groups, multidisciplinary, managed outpatient.

Goals of Therapy - Anorexia Nervosa - Pharmacotherapy

• No FDA approved medications.
• Off-Label: antipsychotics, antidepressants, anti-emetics, anti-anxiety.
• OTC: dietary calcium for bone health, elemental calcium 1200mg / day in divided doses, and Vitamin D 600-800 units/ day.

Goals of Therapy - Bulimia Nervosa - Non-pharmacological

• Psychotherapy: individual, group, family/marital.
• Support groups, self-help approaches/self-help manuals.

Goals of Therapy - Bulimia Nervosa - Pharmacotherapy

• Fluoxetine is the only FDA approved antidepressant.
• Off-label use of other antidepressants.
• Preferred regimen: psychotherapy and pharmacotherapy combined.

Goals of Therapy - Binge Eating Disorder - Non-Pharmacological

• Psychotherapy: cognitive-behavioral therapy is 1st line treatment.
• Ineffective for treating obesity in patients with binge eating disorder.
• Nutritional rehabilitation & counseling for weight loss.
• Behavioral strategies.
• Bariatric surgery, medications (short-term weight reduction).

BMI Classification - Anorexia

• Mild: >17, Moderate: 16-16.99, Severe: 15-15.99, Extreme:
• Waist circumference >40 in men and >35 in women

Obesity - Nonpharmacological

• Lifestyle intervention: diets help most with weight loss.
• Long-term changes need to be made rather than fad diets.
• Food additives & meal replacement therapy with liquid drinks, snack bar / frozen meal
• Physical activity: initiate slowly.
• Helps prevent additional weight gain and maintains weight loss; not helpful for initial weight loss.
• Walking 30 mins/day x 3 days week is good.
• Behavioral therapy & public health initiatives.

Obesity - Herbal Pharmacotherapy

• Not recommended for weight loss, often unsafe and marked with exaggerated claims about weight loss.
• Examples: bitter orange, cascara, caffeine, green tea, guar gum, ginseng, willow bark, dandelion.

Obesity - OTC Pharmacotherapy

• Orlistat (Alli): FDA approved for long-term use with diet and exercise for BMI >25 with risk factors or BMI >30.
• Rx strength: 120 mg TID (>12 y/o)
• OTC: 60 mg TID (>18 yo)
• MOA: Decrease absorption of dietary fats, and inhibits gastric and pancreatic lipases.
• Counseling: multivitamin supplementation needed due to decreased absorption of fat-soluble vitamins & take cyclosporin 3 hours before or after orlistat.

Eating Disorders - General Identification

• Anorexia: not eating
• Bulimia: purging food, FDA approved medication
• Binge eating: over eating

Weight Reduction Strategies

• Avoid herbals and try non-pharmacological approaches.

Drug Issues Post Bariatric Surgery

• Enteric-coated or extended-release products may not be absorbed.
• pH, absorption sites, drug solubility, and absorption (long-absorption phases = decreased bioavailability) are factors
• Decreased absorption of fat-soluble vitamins requires supplementation (AEDK, Calcium, iron, Vit B12).

Adverse Effects to Avoid Post Bariatric Surgery

• Avoid medications with ulceration risk (NSAIDs, Salicylates, and oral bisphosphonates).

Decreased Efficacy Post Bariatric Surgery

• This can occur because of a lack of absorption and passage of undissolved tablets.

Macro and Micronutrients - Protein

• Protein intake should be 15-35%.
• Required for body mass, structure, & enzymes.

Macro and Micronutrients - Lipids

• Lipid intake should be 25-40%.
• Important for energy, energy storage, cell membrane structure, cell signaling, gene regulation, and absorption of fat-soluble vitamins.

Macro and Micronutrients - Carbohydrates

• Carbohydrate intake should be 30-50%.
• It is used for energy production and storage.
• Functions as the brain's main source of energy.

Vitamin A (Retinoids)

• Functions include normal growth, reproduction, skeletal and tooth development, and functioning of most organs.
• Retinoids have a specialized function in the eye (conjunctiva, retina, & cornea) and visual pigments in retina.
• They are also involved in the differentiation of epithelial cells.
• Synthesis of glycoproteins for epithelial cell mucus secretion – mucosal barrier helps defined against upper respiratory infection .

Vitamin D (Calciferol)

• It is both a hormone and a vitamin.
• It is responsible for calcium & phosphate absorption from intestines and renal reabsorption of calcium.
• It is involved with parathyroid hormone, phosphate, and calcitonin to regulate serum calcium levels.
• It promotes bone formation and may reduce the risk of fractures in postmenopausal women with osteoporosis.
• It is involved in a lot of non-skeletal systems.

Vitamin E (Tocopherol)

• It is an antioxidant that preserves cell membranes from oxidative damage or destruction.
• Promotes normal RBC function.

Vitamin K (Phytonadione)

• It is involved in the synthesis of clotting factors II, VII, IX, & X along with anticoagulation proteins C& S.
• It activates osteocalcin, which helps with bone mineralization and prevention of osteoporosis

Thiamine B1

• Involved in myocardial and nerve cell function, nucleic acid synthesis, and carbohydrate metabolism.

Riboflavin B2

• Riboflavin (B2) is involved in energy production reactions.
• It is also used in Niacin synthesis.
• It functions as an antioxidant.

Niacin B3

• Niacin (B3) is a coenzyme in energy production.

Pyridoxine B6

• Is involved in the synthesis of neurotransmitters.
• It is used in the synthesis of niacin from tryptophan.
• Promotes hemoglobin synthesis and function.

Folic Acid B9

• Folic acid (B9) promotes cell division and brain and spinal cord development.
• Also assists with DNA production.
• Synthesis of methionine from homocysteine, and RBC formation

Cyanocobalamin B12

• Active in all cells, especially bone marrow, the CNS, and the GI tract.
• Protein and carbohydrate metabolism.
• DNA synthesis
• Necessary for folate and lipid metabolism.
• Promotes Myelin formation.

Ascorbic Acid Vitamin C

• Involved with the synthesis of hydroxyproline, which is a precursor for collagen, osteoid, and dentin.
• Norepinephrine synthesis.
• Carnitine synthesis.
• Acts as an antioxidant.
• Promotes the absorption of nonheme iron from food, and supports immune function.

Calcium

• Bones structure contains hydroxyapatite crystals
• Blood vessel constriction & relaxation
• Skeletal muscle and nerves contain voltage-dependent calcium channels in their cell membranes.

Iodine

• Used in the production of thyroid hormone.

Iron

• Oxygen and electron transport.

Magnesium

• Used for energy production (required by ATP synthesizing protein in mitochondria).
• Promotes the synthesis of DNA, carbohydrates, lipids, glutathione, bone, cell membranes, and cell-signaling.

Phosphorus

• Component of bone matrix.
• Functional component of phospholipids.
• Storage and release of energy (ATP).
• Used for Calcium and phosphorous homeostasis.

Zinc

• Zinc is used in various enzymatic processes.
• Promotes sense of taste & smell, and encourages immune Function
• Also assists with Growth and development.

Dietary Reference Intakes (DRIs)

• Reference values of daily nutrient intake recommended by the food and nutrition board of the institute of medicine of the national academies

Recommended Dietary Allowances (RDAs)

• Intake at which the risk of inadequacy is very small – 0.02-0.03

Estimated Average Requirements (EARs)

• Nutrient intake values that are estimated to meet the needs of half of the healthy individuals in a specific gender and age group

Adequate Intakes (AIs)

• Recommended intakes for nutrients for which inadequate scientific date exist to establish and EAR with confidence

Tolerable Upper Intake Level (ULs)

• At intakes above the UL , the risk od adverse effects may increase
• At intakes between the RDA and the UL, the risk of inadequacy and of excess are both close to 0

Vitamin A Deficiency/Toxicity

• Risk of deficiency from fat malabsorption, Celiac’s disease, Crohn’s, pancreatic disorders, cancers, tuberculosis, pneumonia, and prostate issues.
• Corticoid steroid use and orlistat can also cause vitamin A deficiency.
• Signs of deficiency include night blindness, dry eye, bitot spot, and phrynoderma.
• Excessive alcohol use, low body weight, and protein malnutrition can cause Vitamin A toxicity.
• Signs of toxicity include HA, double vision, N/V, vertigo, fatigue, drowsiness, liver abnormalities, birth defects, and peeling skin.

Vitamin D Deficiency/Toxicity

• Risk of deficiency from low intake, lack of exposure to sunlight, dark skin pigmentation, aging skin & impaired conversion, GI disease, gastric bypass, chronic renal failure, and antiepileptics.
• Signs of deficiency include calcium abnormalities.
• Risks of fracture, rickets, generalized muscle weakness.
• UL-4000IU- anorexia, hypercalcemia, soft tissue calcification, kidney stones, and renal failure.

Vitamin E Deficiency/Toxicity

• Premature infants and patients with fat malabsorption are at risk of deficiency.
• Signs of deficiency include hemolytic anemia, muscle weakness, ataxia, peripheral neuropathy, and intermittent claudication
• Premature infants are at increased risk from sepsis.
• Decreased platelet aggregation, and increase bleeding/bruising.
• .Chronic intake > 400 IU/day associated with increased all- call mortality & possibly increased prostate cancer.

Vitamin K Deficiency/Toxicity

• Bile production or secretion issues.
• Malabsorption syndromes, bowel resections, and liver disease.
• Broad Spectrum Antibiotics can also result in deficiency of vitamin K.
• Signs: Bleeding, bruising, and Hemorrhage in newborns.
• VERY RARE - Jaundice.
• Reversal agent for elevated INRs due to taking too much warfarin.

Vitamin B1 Thiamine Deficiency

• Risk: chronic alcohol use disorder, inadequate diet , thiamine requirements increase with carbohydrate load, malabsorptive syndromes, prolonged diarrhea, pregnancy , diuretics ( furosemide) increase urinary excretion of thiamine
• Signs: Beriberi- dry – polyneuritis with peripheral nerves and muscles (symmetrical peripheral motor & sensory neuropathy); Wet- heart abnormalities leading to heart failure
• Werrhicke’s encephalopathy- cerebellar & vestibular (ataxia- gait & trunk), encephalopathy ( confusion , inattention) , ocular ( ophthalmospasms), if not corrected in time it progresses to Korsakoff syndrome – irreversible amnestic confabulatory state.
• Impaired memory.
• Toxicity – Rare: Irritability, HA

Vitamin B2 Riboflavin Deficiency

• Caused by alcohol use & malabsorptive disorders
• Photophobia and burning eyes
• Corneal vascularization
• Stomatitis, seborrheic dermatitis, and glossitis
• Toxicity: Can cause yellow-orange fluorescence or discoloration of urine

Vitamin B3 Niacin Deficiency

• Signs: Pellagra- Dementia, Diarrhea, and Dermatitis
• Encephalopathy and Peripheral neuropathy.
• Toxicity Signs
• Liver damage
• Flushing
• GI upset

Vitamin B6 - Pyridoxine

• Deficiency signs: Microcytic anemia Neuropathy (symmetrical) painful burning Seizures
• Toxicity signs: Neuropathy

Vitamin B9 - Folic Acid

• Risk: MTHFR polymorphism and abililty to convert folica acid to active form.
• Genetic defects leading to elevated homocysteine levels, pregnancy, lactation infancy, infection , hemolytic anemia, blood loss, hyperthyroidism, alcohol use disorder, malabsorption from food, liver disease
• Medication induced causes of deficiency PPIs, H2R antagonist, Antacids, strong CYP2A4 inducers, antagonism/ anti-folate agents, sulfasalazine
• Signs: serum folate level 100 fL

Vitamin C – Ascorbic Acid

• Risk: informal formula without Vitamin C, malnourishment, smoking
• Signs: Scurvy (after 3-5 months without vitamin C), poor wound healing, keratosis of hair follicles, fatigue capillary hemorrhages and petechiae, swollen & hemorrhagic gums, bone changes
• Risk: hemolysis, mega doses in pregnancy, diabetes mellitus, recurrent renal calculi, renal dysfunction
• Signs: kidney stones, nausea & stomach cramping, Diarrhea

Calcium

• Deficiency Signs Deficiency Accelerated bone loss Tooth loss, muscle twitches / convulsions, on edge feeling
• Toxicity Signs Toxicity Kidney stones Hypercalcemia Calcification of soft tissue Constipation

Iodine

• Deficiency Signs of deficiency Goiter , hypothyroidism
• Toxicity Signs of toxicity Hyperthyroidism Parotitis ( inflammation of parotid glands)

Magnesium

• Deficiency Sign of deficiency Fingers on blackboard nervous feeling Muscle spasms, anxiety / depression , insomnia
• Toxicity Signs of toxicity

Phosphorus

• Deficiency Can be included by chronic aluminum hydroxide use as aluminum binds dietary phosphorus, weakness, anorexia, malaise, pain ,& bone loss
• Toxicity Common: diarrhea
• NONE; at higher doses can cause GI effects

Iron

• Deficiency Pallor Easy fatigability, dyspnea on exertion Iron deficiency (hypochromic microcytic) anemia Spilt or spoon shaped nails
• Toxicity Common side effects of normal iron use are nausea, constipation, & turning stool black, abdominal pain, vomiting, diarrhea, electrolytes abnormalities, CV collapse & shock

Zinc

• Deficiency Decreased sense of taste& smell, Impaired wound healing, dermatitis, birth defects, growth retardation, delayed sexual maturation, hypogonadism
• Toxicity Metallic taste, nausea/ vomiting

Enteral Nutrition

• Self-care includes Boost, ensure, Glucerna, specialty formulas, designed for oral consumption, used for meeting nutrition goals, available OTC, food for special dietary
• Medical supervision: Products used in tube feedings Products used > 3 weeks: o Jevity, osmolyte o Can be consumed PO, but doesn’t taste good, designed for specific disease states ( cancer , COPD), o Says needs medical supervision

Medications & Micronutrient interactions

• Vitamin B1 & diuretics
• Vitamin B6 & Medication depleting B6 (isoniazid , penicillamine, hydralazine)
• Vitamin B9 & PPIs, H2R antagonist, antiacids, CYP3A4 inducers , antagonism/ anti-folate agents, sulfasalazine

Increased/ Decreased Macronutrient Intake

• Protein requirement on CKD - decrease protein intake to reduce workload on the kidneys
• Severe trauma / burn & protein intake – Increase to help repair mass loss
• Cystic fibrosis change protein & lipid requirements will increase protein and lipids
• Diabetes on carbohydrates- will disrupt metabolism of carbohydrates

Calories - Recreationally Active

• General fitness is considered < 7 hours / week exercising
• Includes (30-40 mins/day X 3 / week)
• Calories are 1800-2400 kcal/day

Calories - Athletes

• Volume 7-20 + hours / week or High volume intense training > 20 hrs/ week
• Calories are 2000-7000 kcal/ day
• Elite athletes need from 6000 – 12000 kcal/day
• No specific caloric need for Pediatrics

Macronutrients

• Macronutrient intake is stored for use later
• Carbohydrate requirement increases as energy requirement increases
• 30-60 g of carbohydrates / hr of continued exercise

Fats

• 20-35 % Restricting to 2.2 g/kg didn't result in consistent weight gain

Exercise Recommendations

• Before pre hydration fluid should be 5-10 mL/kg consumed 2-4 hours prior to activity
• Carbohydrate loading: 200-300g consumed 3-4 hours exercise may enhance performance
• Do not experiment with food prior
• Exercise longer than an hour, recommended weights pre- & post for water weight loss
• Drink 16-24 fl oz for every 0.5 kg body weight loss
• Carbohydrates: 30-60 g of carbs per hour during exercise to maintain blood glucose levels
• After eat a balanced meal Protein: 1.2-2.0 g/kg w/ optimal around 1.62 g/kg/day Problems wirh muscle recovery if carb to protein ratio is not equal in calories
• After drinking low-fat milk more accurately reflected a postexercise meal & better for recover than a carbohydrate- only sports drink

Calories - Dietary Supplement Conversions

• Fats- 9
• Carbs- 4
• Protein- 4

B-hydroxy b-methylbutyrate (HMB)

• 1.5-3 g a day can increase muscle mass ( +0.5 -1 kg) & strength
• Essential amino- acids- Ingesting 6-12 g of EAA stimulates protein

Performance Supplement Recommendations

• B-alanine 4-6g/ day in divided dones help with activities that last lasting longer then 10 minutes

Symptoms of PMDD

Significant depression and hopelessness. Anxiety/ tension/ feeling on edge. Mood swings/ sudden sadness/ feeling rejected . Anger/ marked irritability . Symptoms Present the last week of the luteal phase of the menstrual cycle Interferes with work, school, social activities, and relationships Not an exacerbation of another psychological disorder Last 7 days of cycle and are 30 % worse than days 3-9

Bacterial Vaginosis

• Type of Infection: Polymicrobial.
• Discharge Characteristics: Thin (watery), white/discolored (green, gray, tan), foamy.
• Odor: Unpleasant “fishy” odor from trimethylamine.
• Patient Population: Predominately affects young, sexually active women.
• Important Notes. Always refer for treatment.

Bacterial Vaginosis Risk Factors

• IUD use.
• Douching.
• Tobacco use .
• Prior pregnancy and multiple partners.

Trichomoniasis

• Type of Infection: STI caused by trichomonas vaginalis.
• Discharge Characteristics: Copious, yellow-green, frothy discharge.
• Associated Symptoms: Dysuria, pruritus, and vaginal irritation.
• Important Notes: 50% asymptomatic initially; always refer for treatment.

Trichomoniasis Risk Factors

• Multiple sex partners.
• Presence of other STIs.

Vulvovaginal Candidiasis

• Type of Infection: Yeast infection.
• Discharge Characteristics: Odorless, thick & white “cottage cheese” discharge.
• Associated Symptoms: Itching, burning, erythema, vulvar edema.

Vulvovaginal Candidiasis Pathophysiology

• Lactobacillus bacteria convert glycogen to lactic acid (acidic pH = 4-4.5), protecting from bacteria.
• Increased Risks: Diabetes mellitus, Antibiotics, Immunosuppression.

VVC - Non Risk Factors

• Onset of sexual activity.
• Receptive oral sex
• Pregnancy and Contraceptive use.
• Menopause.

VVC Treatment

• Dietary changes (yogurt & lower sugar), probiotic supplement, avoid tight clothing.

VVC Frequent Treatment

• Frequent >3/year can check HIV & diabetes, evaluate for balanitis in partner

Atrophic Vaginitis

• Occurs due to decreased estrogen levels, leading to inflammation of the vaginal mucosa.
• Common Times of Life: Menopause, postpartum, breastfeeding.

Atrophic Vaginitis - Causes

• Stress and prior sexual assault.
• Diabetes and inflammatory bowel disease.
• Chronic heart failure.
• In women, 45% of postmenopausal experience symptomatic atrophic vaginitis.

Presentation of Vaginitis

• Decrease in vaginal lubrication.
• Symptoms= Vaginal irritation, dryness, burning, itching, dyspareunia (painful intercourse).
• Can have foul smelling discharge or spotting and minor tears.
• Refer cases of new episode of postmenopausal vaginal bleeding

Nonpharmacologic Treatment

• Avoid irritating products and use sexual intercourse to minimize symptoms.

Water/Oil Based Products

• Water soluble, petroleum-based, and natural oil-based or silicone based lubricant options
• Chronic symptoms may require daily use to treat dyspareunia, breast-feeding, birth.

Dysmenorrhea Exclusion

• Secondary dysmenorrhea
• History of gynecological problems
• Menorrhagia or vaginal bleeding outside of menses
• Allergy to NSAIDs/ ASA
• Use of warfarin, heparin or lithium
• Active GI disease o Use of IUD o Poor response to treatment o Sexually active o Bleeding disorder
• Severe pain or pain at other times during menstrual cycle

PMS / PMDD Exclusions

• Severe PMS/ PMDD
• Symptoms that disrupt relationships or affect usual activities or function productively.
• Uncertain pattern of symptoms
• Symptoms that coincide with use of OC’s or Hormone
• therapy

VVC Exclusions

• Pregnancy and the week after treatment.
• Recurrent infections greater then 3/year or occur in past 2 months
• Use of corticosteroids, cancer meds, SGLTs
• DM, HIV, Fever and pain in lower abdomen/ back

Toxic Shock Syndrome (TSS)

• Menstrual TSS: occurs within 2 days after onset to 2 days after menses.
• Higher tampons increase risk, affects young women, pads and IUD can minimize risk.
• Inflammatory response to staphylococcus aureus endotoxin.

Vaginal Antifungals

• All equally efficacious
• Clotrimazole- 3- 10 % absorption May be most important of INF
• Miconazole
• Tioconazole
• Limit dose induced vaginal irritation by selecting a longer course and lower strength Combo pack treats external & vaginal itching.

Cold and Cough treatment

• Colds occur at the beginning of September
• Colds are viral infections caused by rhinovirus
• Signs are mild such as fatigue and body aches
• Allergic rhinitis effects between 10 adn30%

Cold and Allergies

Affect kids Hay fever is allergies

• Allergic symptoms: Itching in nose, roof of the mouth, throat, eyes Sneezing Stuffy nose congestion rhinorrhea Tearing eyes Dark circles under the eyes (allergic shiners) Allergic salute (rub nose upwards)

Cough: Non-Phar

• Cough should drink more water, rest, humidification, non-medicated lozenges( camphor & menthol), topical anesthetics in their treatment.

Colds

• Non-pharmacological Adequate fluid intake & rest Upright positioning Nutritious diet Increased humidification Camphor/menthol rubs (vicks) not safe < 2 y/o Saline nasal sprays, drops, rines Nasal strips Lozenges

Cold Meds

pseudoephedrine & phenylephrine› systemic relief of nasal congestion, sinus pressure, ear fullness MOA: mixed alpha- and beta-adrenergic receptor agonist

Analgesics vs Antipyretics

Antipyretics should not be used for an extended period of time

Allergic Rhinitis Treatment

First line treatment are Intranasal Corticosteroids 1st line treatment › Flonase , Nasacort, rhinocort MOA: inhibits multiple cell types & mediators including histamine , cytokines, and leukotrienes Start 1 weeks before symptoms typically appear AE: mild; nasal irritation, epistaxis, disturbed sense of smell / taste

2 y/o ( triamcinolone) >4 y/o fluticasone

Anti-Histamine Treatment

First gen antihistaimes- Diphenhydramine, chlorpheniramine, meclizine, doxylamine Second generation antihistamines are Cetirizine, loratadine, fexofenadine Mast cell stabilizers are Cromolyn sodium- Cromolyn sodium Most common deffect is taste

Cold and Cough Referalls

4 y/o Chronic underlying disease with cough ( COPD, asthma, CHF, chronic bronchitis) Cough plus one or more: SOB, chest pain, hemoptysis, chills, night sweats, tight feeling in throat, swollen legs/ ankles, cyanosis, unintentional weight loss, rash, persistent HA Cough that produces thick yellow, tan, or green mucus High fever >103 / >102 children, or a low-grade fever that doesn’t resolve with usual care Foreign object aspiration Suspected drug-associated cough Cough > 7 days or worsen during self- treatment Development of new symptoms during self-treatment Medication can cause you to test positive.

Pain Headaches and Fevers

• Non selective Cox 1 and 2 inhibitors target inflammation and can reduce pain
• Reversible and irreversible inhibitor options are available
• Aspirin is an irreversible nsaids which is dosed once or twice

Naproxen

• naproxen reversable nsaids inhibits cox 1 and 2 but is dose 2-3 times/ day
• Nsaids cause increase in bleeding time and abdominal pain , fatigue with common side effects of GI symtpms with milk

Acetaminophen

• Acts as a Analgesic & antipyretic. Onset is 30mins and duration is 4 and 6-8 for ER. Children dose 10-15mg and adults can take 325-1000 max 4000 dose a day
• Can cause liver damage and toxicity, never take with liver diseases and alcoholic, can cause liver inflammation and skin redness and blisters
• Side effects can occur with topical

Topical Treatments for Pain

Topical analgesics are less effective they should be directed at areas of pain for 4 timesaday limited for 7 weeks. Adverse effects include localized reaction to skin but if there is a condition longer then 21 days go see pcp.

• Topical analgesics counterirritants MOA: topical anesthetics MOA: inhibits the conduction of nerve impulses
• topical anesthetics Apply q 6-8 hrs PRN, not to exceed 3-4 applications in 24 hrs, for up to 7 days Localized reactions ( rash, itching, skin irritation)

Heachache Symptoms and causes

• Can be caused from triggers
• Can be from lack of sleep/ stress
• Chocolate ,wine , hormones , medication and caffeine can be symptoms Causes of tension pain are aching tightening , or a muscle spasm
• Treatments are to just take caffeine or NSAIDS as needed

Migranes

• Migrane is caused by a sharp stabbing pain in the head and can last from 4 hours to 3 days
• Symptoms can be one side of the