NMT150 Midterm PDF

NMT Midterm Friday, June 28th (9am, classroom 4) Weeks 1-6 BOT Week 1 : Strep Define the main herbal actions used to treat strep - Antimicrobial : Destroys or inhibits the growth of microorganisms (e.g. antibacterial, antifungal, antiviral, antiparasitic) - Lymphatic : Promotes t...

NMT Midterm Friday, June 28th (9am, classroom 4) Weeks 1-6 BOT Week 1 : Strep Define the main herbal actions used to treat strep - Antimicrobial : Destroys or inhibits the growth of microorganisms (e.g. antibacterial, antifungal, antiviral, antiparasitic) - Lymphatic : Promotes the proper functioning of the lymphatic system. - Immunostimulant – activates the immune system to help fight infection - Antipyretic (syn. Febrifuge) – reduces fever Identify commonly used herbs for strep (Remember both common names and latin binomial for the herbs discussed) - Classic formula for used for infections including strep : HEMP Hydrastis (Goldenseal), Echinacea (Purple coneflower), Myrrh, Phytolacca (Poke root) Research : HEMP formula study In vitro trials tested individual herbs for antibacterial properties. ONLY Hydrastis had antibacterial activity gram-negative Staphylococcus epidermis. Other herbs had no antibacterial activity. Why? - didn’t use strep, type of myrrh wrong, petri dish not suitable for immunostimulant (basically just not an accurate study) Explain the main indications and actions for the herbs (phytochemicals i listed in actions may be FYI ?) Evaluate the safety issues and contraindications of the herbs Provide a summary of the leading research on the herbs Goldenseal - Latin : Hydrastis canadensis (Ranunculaceae family) (Drug : Hydrastis rhizoma) - Plant part : root - Indications : “King of the mucous membranes” - inflammation and infections - Respiratory tract - Gastrointestinal tract - King’s American Dispensatory : indicated in catarrhal states of the mucous membranes and in purulent otitis media - Actions : Antimicrobial and digestive bitter (Isoquinoline alkaloids (berberine, hydrastine) Flavonolignans) - Contraindications : Pregnancy and lactation, Gastritis & stomach ulcers, obstructed gallbladder - Side Effects : May cause GI irritation leading to nausea, vomiting and diarrhea. - Research : In-vivo trial found that berberine inhibits Streptococcus pyogenes (no clinical trials) Echinacea - Latin : Purple ConeFlower : Echinacea purpurea - Narrow-leaved purple coneflower : Echinacea angustifolia - Pale purple coneflower : Echinacea pallida - (Asteraceae family) - Plant part : Root and herb - Indications: Strep throat, prevent & treat common cold/flu/URTI’s, vaginal candidiasis, UTI’s - King’s American Dispensatory : ​Echinacea angustifolia: use for "bad blood," tendency to sepsis and malignancy, as in gangrene - Actions : Immunostimulant (alkylamide, phenolics, polysaccharides, keto alkenes) - Contraindications : Caution in auto-immune diseases (theoretical) - Safe in pregnancy/lactation - Side Effects : / - Research : German Commission E - Echinacea purpurea herb (Approved) - Supportive therapy for colds and chronic infections of the respiratory tract and lower urinary tract. - Echinacea pallida root - (Approved) Supportive therapy for influenza-like infections. - In vivo trial : Echinacea purpurea whole herb extract inactivated strep pyogenes - Note: Echinacea angustifolia herb and root & Echinacea pallida herb are UNAPPROVED because of lack of clinical trials for the specific plant parts. Myrrh - Latin : Commiphora myrrha (or commiphora molmol) (Burseraceae family) (Drug: Myrrha) - Plant part : Resin - Indications: Tonsillitis and Gingivitis - King’s American : Chronic bronchitis, mild inflammations of oral and pharyngeal mucosa - Actions : Antimicrobial, Analgesic, Expectorant, Astringent (Oleoresin, Furano sesquiterpenoids) - Contraindications : not recommended in pregnancy - Side Effects : / - Research : German Commission E (Approved) - The Commission E approved myrrh for topical treatment of mild inflammations of the oral and pharyngeal mucosa. - In vivo trials : not tested against strep BUT exhibited antibacterial activity against strep mutans, staph aureus, pseudomonas aeruginosa, escherichia coli, Klebsiella pneumonia Poke Weed - Latin : Phytolacca americana (Phytolaccaceae family) (drug: Pyrolaceae Radix) - Plant part : Root - Indications: Lymphadenopathy and Cancer - King’s American : white erosions, tonsillitis, enlarged glands - Actions : Lymphatic, Emetic, Purgative (Triterpenoid glycosides, Lectins, Pokeweed antiviral protein (PAP), Alkaloid) - Contraindications : not recommended in pregnancy - Side Effects : Toxicity - may cause violent emesis, catharsis, convulsions, possibly death - Research : Not German Commission approved, no trials Usnea - Latin : Usnea barbata (Usneacea family) (drug: Usnea) - Plant part : Lichen - Indications: Infections (Respiratory, Skin) - Actions : Antimicrobial, Antiparasitic (Usnic acid) - Contraindications : not recommended in preg/lactation - Side Effects : Hepatotoxic : may cause drug-induced hepatitis via mitochondrial uncoupling - disrupts ETC  - Research : German Commission approved for mild inflammation of oral pharyngeal mucosa - In vivo trial : inhibits strep pyogenes Garlic - Latin : Allium sativum (Amaryllidaceae family) - Plant part : clove - Indications: Infections & Heart disease - King’ s American : coughs, catarrhal, pertussis/hoarseness - Actions : Antimicrobial, antiparasitic, stimulant, expectorant, rubefacient (organosulfur compounds - allicin) - Contraindications : Safe - Side Effects : / - Research : German Commission approved for elevated blood lipids, cough/colds, rhinitis - In vivo trial : allicin inhibits strep pyogenes Thyme - Latin : Thymus vulgaris (Lamiaceae family) - Plant part : whole (?) - Indications: Cold/flu, Spastic cough - King’s American : whooping cough, convulsive catarrhal coughs, stridor - Actions : Expectorant, antitussive, antispasmodic, antimicrobial, carminative, anti-inflammatory (Essential oils - monoterpenes thymol and carvacrol inhibit bacteria growth & polyphenol flavonoids) - Contraindications : generally safe, but unknown effect on preg/lact - Side Effects : toxicity - high amounts of pure essential oil may be toxic - Research : German Commission approved for bronchitis and whooping cough (catarrhs of URT) Thyme & Oregano Essential Oils (via steam distillation) - Rich in monoterpenes thymol and carvacrol which inhibit Streptococcus pyogenes - Actions : antiseptic - Research: Numerous studies show thymol and carvacrol exhibit potent activity against Streptococcus pyogenes. BOT week 2 : URTI/Common cold Define the main herbal actions used to treat colds Immunostimulant – activates the immune system to help fight off infection Diaphoretic - induces sweating Antitussive - soothes and relieves coughs Antispasmodic - relaxes smooth muscles Expectorant - liquify respiratory secretions to facilitate the expulsion of phlegm and mucous Mucolytic - Helps to break down mucous & loosen thick bronchial secretions (similar to expectorants) Demulcent - Soothes irritated mucous membranes Antimicrobial - Destroys or inhibits the growth of microorganisms (e.g. antibacterial, antifungal, antiviral, anti-parasitic) Antiadherance - prevents microorganisms from attaching and thus infecting the cells of the mucous membranes Antipyretic (syn. Febrifuge) - reduces a fever Lymphatic - Promotes the proper functioning of the lymphatic system. Understand what class of phytochemicals is responsible for the medicinal effects Identify commonly used herbs for colds Remember both common names and latin binomials for the herbs discussed Explain the main indications and actions for the herbs Evaluate the safety issues and contraindications of the herbs Provide a summary of the leading research on the herbs used to treat colds Echinacea - Latin : Echinacea purpurea/angustifolia/pallida - Plant part : Root and herb - Indications: prevent and treat common cold, flu, URTIs, vaginal candidiasis, UTIs - Actions : Immunostimulant, antimicrobial (alkylamides, phenolics, polysaccharides) - Contraindications : Caution in auto-immune disease, safe in preg and lact - Side Effects : / - Research : German Commission E - Echinacea purpurea herb (Approved) - Supportive therapy for colds and chronic infections of the respiratory tract and lower urinary tract. - Echinacea pallida root - (Approved) Supportive therapy for influenza-like infections. - Note: Echinacea angustifolia herb and root & Echinacea pallida herb are UNAPPROVED because of lack of clinical trials for the specific plant parts. - Clinical trial (2021): Echinacea purpurea (combo of root and herb) helped prevent respiratory tract infections and reduced associated antibiotic usage in children. Ginseng - Latin : Asian “Korean” Ginseng : Panax ginseng & Canadian ginseng : Panax quinquefolius (Araliaceae family) (Drug : Ginseng radix) - Plant part : Root - Indications: Stress, fatigue, cold/flu treat and prevent, low immunity - King’s American : loss of appetite, weak stomach, laryngitis, bronchitis - Actions : adaptogen, immunostimulant, immunomodulator, antiviral, aphrodisiac (Steroidal saponins, Polysaccharides) - Contraindications : Caution : High blood pressure, Korean ginseng safe in preg and lact - Side Effects : / - Research : German Commission E approved for fatigue and debility - Review (2021): Various clinical trials of ginseng have exhibited a reduction in repeated colds and the flu Andrographis - Latin : Andrographis paniculata  - Plant part : Herb - Indications: Colds, Colitis/infectious diarrhea, Liver disease, autoimmune disease - Actions : Immunomodulator, Antimicrobial, Bitter (“King of the Bitters”), Anti-inflammatory emmenagogue (Diterpene lactones = andrographolide, Polyphenols/flavonoids) - Contraindications : Gastritis & stomach ulcers, obstructed gallbladder, not recommended/unknown in preg and lact - Side Effects : May cause GI irritation -> nausea, vomiting, diarrhea - Research : Clinical trial (2009): Andrographis twice as effective as placebo in reducing symptoms and duration of URTI Siberian Ginseng - Latin : Eleutherococcus senticosus (Araliaceae family) (drug : eleuthero radix) - Plant part : root - Indications: Stress, Fatigue, treat/prevent cold and flu - Actions : Adaptogen, Immunistimulat, immunomodulator, antiviral (Steroidal saponins (modulates corticosteroids) - eleutheroside A) - Contraindications : Caution in high blood pressure, likely safe in preg and lact. - Side Effects : / - Research : German Commission E approved as a tonic in times of fatigue and debility and convalescence - In vivo: Eleutherococcus senticosus roots inhibited the productive replication of human rhinovirus (HRV), respiratory syncytial virus (RSV) and influenza A virus - Clinical trial (2004): Eleutherococcus and Andrographis combo more effective than an Echinacea formula (with zinc, vitamins & astragalus) - Clinical trial: Eleutherococcus and Andrographis reduced the recovery duration of patients by 21% and significantly relieves the severity of typical URTI Elderflower - Latin : European : Sambucus nigra, Canadian : Sambucus canadensis (Caprifoliaceae family) (Drug : sambuci flos, elderflower) - Plant part : flower and berries - Indications : Cold and flu - King’s American : crusts on epidermis, skin affections - Actions : Diaphoretic (sweating), Antiviral, Anti-Adherence (cant stick to cells), antirheumatic, diuretic, anti inflammatory (Anthocyanin, flavonoids, tannins, ascorbic acid, cyanogenic glycoside in unripe) - Contraindications : unknown in preg and lact  - Side Effects : flower and berries are safe, leaf bark and unripe fruit may cause severe vomiting and diarrhea - Research : German Commission E approved for colds - META-ANALYSIS: Elderberry supplementation significantly reduced the duration of upper respiratory symptoms compared to placebo. English Ivy Leaf - Latin : Hedera helix (Araliaceae family) (Drug : hederae helicis folium) - Plant part : leaf - Indications : cough, acute/chronic respiratory inflammation and phlegm - King’s American : pulmonary affections - Actions : Expectorant, antitussive, antispasmodic, antimicrobial (Saponins - hederacoside C) - Contraindications : Generally safe, short term during pregnancy - Side Effects : Toxicity - High amounts can cause irritation of GI tract -> nausea and vomiting - Research : German commission E approved for treatment of catarrhs and respiratory passages for chronic inflammatory bronchial conditions - Systematic review: All studies concluded that ivy leaf extract is an effective and safe option for the treatment of cough due to URTIs and bronchitis. Licorice - Latin : European licorice : Glycyrrhiza glabra & Chinese licorice : Glycyrrhiza uralensis (Family : Fabaceae) (Drug : Liquiritiae radix) - Plant part : Root - Indications : Respiratory tract infections, GI tract inflammation, Hepatitis/cirrhosis of liver, adrenal fatigue - King’s American : lessen irritation of mucous surfaces, coughs - Actions : antispasmodic, expectorant, antimicrobial, demulcent, adrenal tonic, antiulcer, hepatoprotective (Saponins - Glycyrrhizin, Flavonoids - licoflavone) - Contraindications : High blood pressure (Hypertension - can raise BP, caution with cardiovascular meds), caution in preg and lact (may be unsafe) - Side Effects : can cause potassium loss - Research : German commission E approved for URTIs and gastric ulcers - Review (2022). In vivo studies show antiviral effects but limited human research for licorice’s effectiveness in respiratory infections. Marshmallow - Latin : Althaea officinalis (Malvaceae family) (Drug : Althaeae radix & Althaeae folium)  - Plant part : root and flower - Indications : inflamed mucous membranes, respiratory tract infections, inflammation in GI tract, UTIs - King’s American : diseases of mucous tissues, as hoarseness, catarrh, pneumonia - Actions : Demulcent, Antitussive (Mucilage, Flavonoids) - Contraindications : unknown in preg and lact - Side Effects : may delay drug absorption - Research : German Commission E approved for irritation of oral and pharyngeal mucosa associated dry cough - Review: Marshmallow alone reduced cough but combinations (Zataria multiflora, Zingiber officinalis, or Helix hedera) increased the efficacy. Eucalyptus - Latin : Eucalyptus globulus (Myristicaceae family) - Plant part : essential oil - Indications : Respiratory tract infections, GI tract spasms - King’s American : catarrhal states of the broncho-pulmonary tract - Actions : Antitussive, Expectorant, Antimicrobial, Carminative (Essential oils - monoterpenoids - eucalyptol) - Contraindications : unknown in preg and lact - Side Effects : Pure eucalyptus essential oil can be irritating but considered safe - avoid pure essential oil - Research : German Commission E approved for catarrhs of the respiratory tract - In vitro (2013): Essential oils found in peppermint and eucalyptus are antitussive - Meta-Analysis (2022): Eucalyptus is safe but efficacy considered minimal. Week 2 cough/cold research summary : HERB RESEARCH DETAILS Thyme Clinical trials Reduce in combos. In vitro antispasmodic. Eucalyptus Clinical trials Reduce cough. In vitro some antimicrobial. Goldenseal In vitro Berberine has significant antiviral activity Garlic Clinical trials Shows some benefits. BOT Week 3 : Derm Describe the botanical treatment strategy for the topical treatment of skin inflammation and irritation. 1.Identify and treat the cause 2.Prevent/treat infection 3.Soothe irritation 4.Reduce pruritus 5.Prevent spreading and/or recurrence Identify herbal actions that would be most beneficial for dermatitis. Emollients Vulneraries Antimicrobials / Antiseptics Anti-inflammatories Antipruritics Lymphatics Astringents Connective tissue tonics List herbs that would be indicated in dermatitis. Recognize safety concerns regarding the use of the herbs discussed in today’s lecture. Calendula / Marigold - Latin : Calendula officinalis (Asteraceae family) - Plant part : Flowerheads and petals (Infusion and tincture for internal, ointments and poultices for external) - Indications : One of best remedies for local skin problems - rash, eczema, psoriasis, abrasions, etc. - Actions : Antimicrobial, lymphatic, antiseptic, anti-inflammatory, vulnerary, demulcent, emollient (Flavonoids, carotenoids, xanthophylls, mucilage) - Stimulates drainage of enlarged and inflamed lymph nodes - Stimulated granulation tissue - Contraindications : Generally safe, great in first aid kits for skin-healing needs - Side Effects : caution in asteraceae family allergy - Research : / (materia medica) Gotu Kola - Latin : Centella asiatica (Apiaceae family) - Plant part : Aerial parts (Infusion, tincture and standardized extracts for internal use, Topical: creams, ointments and poultices applied BID or PRN) - Indications : speeds up skin collagen formation and angiogenesis, increases antioxidant levels within wound in early stages of tissue repair, - Actions : Anti-inflammatory (Inhibition of iNOS and COX-2, NF-κB activity, and the release of TNF-α, IL-1β, IL-6, and IgE), CT builder, vulnerary, adaptogen, nervine tonic, anti-allergy (due to decreased mast cell infiltration and reduced expression of TNF-α, IL-4, IL-5, IL-6, IL-10, and IL-17) - ​Asiaticosides increase vascularization of connective tissue and the formation of structural glycosaminoglycans (chondroitin sulfate, hyaluronic acid) - (Saponins, Flavonoids, Alkaloids) - Contraindications : don't use in pregnancy and lactation, liver disease - Side Effects : Internal use - GI upset, contact dermatitis, sedation, headaches, interacts with anti-diabetics, antihyperlipidemics, CNS depressants and vasodilators - Research : Plantain - Latin : Plantago lanceolata & major (Plantaginaceae family) - Plant part : Leaves - Indications : wound healing - Actions : antimicrobial, lymphatic, anti-inflammatory, astringent, anti-hemorrhagic, emollient, vulnerary, CT tonic, antipruritic (Mucilage, tannins, flavonoids, resins, alkaloids, saponins, minerals Zn, K, Mg, P) - Allantoin promotes cell proliferation and induces transition of fibroblasts -> myofibroblasts to increase tensile strength of CT - Phenolic acids and flavonoids inhibit COX and LOX - Contraindications : generally safe - Side Effects : high doses internally -> laxative - Research : German Chamomile - Latin : Matricaria recutita (Asteraceae family) - Plant part : Flower heads (infusion and tincture for internal, ointments, baths, poultices external) - Indications : dermatological conditions - Actions : Anti-inflammatory (inhibition of COX and LOX), vulnerary, nervine sedative, emollient, antimicrobial (Volatile oils, flavonoids - inhibition of histamine release, sesquiterpene lactones, salicylic acid, mucilage) - Contraindications : generally safe, caution in asteraceae allergy - Side Effects : may cause contact dermatitis in cases of allergy or sensitivity - Research : Topical chamomile is comparable with 0.25% hydrocortisone for dermatological conditions (Brown and Dattner 1998) Burdock - Latin : Arctium lappa - Primary Actions: Alterative, hepatic, mild laxative, mild adaptogen. - Constituents: Lignans, carbohydrates, inulin. - Indications: Hepatic congestion, sluggish bowels, acne, eczema and other skin conditions, IBS, type II diabetes, nausea. - Cautions/Contraindications: Considered safe, even nutritious. - Part Used: Root Daily Therapeutic Dose Tincture: 9-18 mL (1:5 in 30%) Daily Therapeutic Dose Infusion or Decoction: 2-12 g root Pairs Well With: Zingiber officinalis for nausea of deficient stomach. Barberry - Latin : Berberis vulgaris - Plant part : Root - Indications : general infections, GI infections, hepatic/gallbladder conditions, constipation, type 2 diabetes, PCOS, any inflammatory skin condition - Actions : Hepatic, cholagogue, antimicrobial, bitter, antiinflammatory, alterative, endocrine modulator (insulin) (Isoquinoline alkaloids) - Contraindications : avoid during preg and lact - Side Effects : / - Research : regulation of blood sugar Coptis / Goldenthread - Latin : Coptis sinensis - Plant part : root - Indications : chronic or acute skin characterized by inflammation, acute GI infections, chronic sinusitis, hepatitis - Actions : antimicrobial, anti inflammatory, hepatic, bitter (Isoquinoline alkaloids) - Contraindications : avoid during preg and lact, non-toxic but very strongly bitter, not used for more than 3 weeks - Side Effects : / - Research : / Yellow Dock - Latin : Rumex crispus - Plant part : Root - Indications : Chronic skin conditions, constipation, convalescence - Actions : Alterative, laxative, hepatic, astringent, mild adaptogen, blood purifier and builder - Contraindications : Not to be eaten fresh, not in preg and lact - Side Effects : / - Research : / Red Clover - Latin : Trifolium pratense - Plant part : Flowers, aerial parts - Indications : skin conditions, PCOS, irregular menses, menopausal hot flashes - Actions : Alterative, lymphatic, mild female endocrine modulator - Contraindications : may interact with anticoagulants - Side Effects : / - Research : / Formulate a topical herbal remedy to alleviate skin inflammation and irritation. - Topical herbal pharmacy for skin rash - Ointments (salves) – semi-solid base of oil and beeswax, fats soften at skin temperature making material available to the skin. Creates a protective barrier for the skin. - Creams/lotions – suspensions of oil in water blended together. Often absorbed faster and more moistening for the skin. - Example: 2/3 cup rosewater, 1/3 cup aloe vera gel, ¾ calendula oil, 1/3 cocoa butter, 1 tsp lanolin, 2 tbsp. liquid lecithin, ½ ounce beeswax, 6 drops tea tree EO, 6 drops lavender EO, Vitamin A/E - Poultices – solid herb in some form (mashed/blended/cut), placed directly on skin, held in place with cloth - Example: blending or mashing fresh Plantago major and apply to affected area (may add a little water for consistency) - Pastes – mixture of powder in a liquid base, keep herbs on the surface for a longer period of time, but contents are not well absorbed - Example: 1 tsp Althea officinalis powder with Centella asiatica tincture. Mix until desired consistency - Also: compress, bath, steam BOT Week 4 : Joint Pain Identify herbal actions that would be most beneficial for joint pain - Alterative - Anti-inflammatory - Analgesic - Adaptogen Chai hu - Latin : Bupleurum chinensis - Plant part : root - Indications : Hepatic congestion, arthritis, chronic inflammation, acute infections with fever - Actions : Hepatic, alterative, anti inflammatory, hepatoprotective (Triterpene saponins, sterols, volatile oils, polysaccharides) - Contraindications : avoided in cold conditions or constitutions, unknown during preg and lact - Side Effects : / - Research : / Frankincense - Latin : Boswellia serrata - Plant part : Resin - Indications : Inflammatory joint conditions, IBD, topical antimicrobial - Actions : Antimicrobial, anti-inflammatory, astringent (resins, boswellic acid, volatile oils) - Contraindications : safe, not taken in large amounts - Side Effects : dissolved in 90% alcohol -> intoxication risk - Research : treatment of RA Cayenne - Latin : Capsicum frutescens - Plant part : Dried or powdered fruit - Indications : circulatory deficiencies, arthritic conditions, pain relief, depression - Actions : Stimulant, circulatory tonic, rubefacient, sialagogue, libido tonic (Capsaicinoids, steroidal saponins) - Contraindications : non toxic, unknown during preg and lact - Side Effects : large doses will cause sweating and possible syncope, avoid contact with mucous membranes  - Research : pain relief via local topical substance P depletion Turmeric - Latin : Curcuma longa - Plant part : root - Indications : general inflammatory conditions, OA and RA, possibly cancer lesions (topical), stomach ulcers and dyspepsia - Actions : Anti-inflammatory, mild antimicrobial, carminative, circulatory tonic (Phenolic antioxidants, curcumin, volatile oils) - Contraindications : generally safe (fine in preg, not in lact) (best absorbed with fats/oils) - Side Effects : mild inhibitor of phase 1 and inducer of phase 2 liver conjugation so use with mild caution in patients taking meds with narrow therapeutic window - Research : may protect against NSAID ulcers Ginkgo - Latin : Ginkgo biloba - Plant part : Leaf and fruit - Indications : Poor perfusion of tissues (especially cerebral), inflammation, clot formation, cognitive decline, erectile dysfunction, BPH - Actions : Circulatory tonic, vasodilator, anti-inflammatory, anticoagulant, nootropic, mild astringent - Contraindications : Preg B, Lact CC (Category B: No risk in animal studies (there are no adequate studies in humans, but animal studies did not demonstrate a risk to the fetus). Category C: Risk cannot be ruled out.) - Side Effects : may cause stomach discomfort or cramping - Research : / Licorice - Latin : Glycyrrhiza glabra - Plant part : root - Indications : ongoing stress, hypotension, asthma, eczema, chronic/acute bronchitis, emphysema, URTI, stomach ulcers - Actions : Adaptogen (adrenals), anti-inflammatory demulcent, antiviral, hypertensive (triterpene saponins (glycyrrhizin) chalcones) - Contraindications : hypertension, Preg A, Lact C - Side Effects : / - Research : / Devil’s Claw  - Latin : Harpagophytum procuumbens - Plant part : root - Indications : RA, inflammatory and arthritic conditions - Actions : anti-inflammatory, antirheumatic, mild anodyne, hepatic (glycosides - harpagoside, phenolic acids, quinone) - Contraindications : safe but research inconclusive, Preg B, Lact C - Side Effects : / - Research : anti-inflammatory for rheumatic pain St. John’s Wort - Latin : Hypericum perforatum - Plant part : Aerial parts - Indications : mood dysregulation, neuralgia, anxiety, viral infections - Actions : Uplifting nervine, antiviral, anti-inflammatory, vulnerary - Contraindications : potential drug interactions, possible serotonin syndrome when taken with SSRIs, Preg B, Lact CC - Side Effects : sensitization may occur at higher doses, photosensitivity possible - Research : induces CYP3A4 -> drug interactions Japanese Knotweed - Latin : Polygonum cuspidatum - Plant part : root - Indications : Any joint pain, inflammatory and auto-immune conditions (RA, psoriasis, lupus, hepatitis, stagnant menses, fibroids, endometriosis, difficulty urinating, Lyme) - Actions : anti-inflammatory, hepatic, anti-microbial, laxative, astringent, ant-oxidant (anthraquinone glycosides, tannins, resveratrol) - Contraindications : do not use in pregnancy - Side Effects : stimulating laxative, may cause nausea or stomach pain - Research : / BOT Week 5 : Radiculopathy Identify herbal actions that would be most beneficial for radiculopathy - Anti Inflammatory - Analgesic - Topical analgesic - Alterative - Carminatives - Chai hu - Bupleureum chinensis (week 4)  - Frankincense - Boswellia serrata (week 4) - Cayenne - Capsicum frutescens (week 4) - Turmeric - Curcuma longa (week 4) - Licorice - Glycyrrhiza glabra (week 2 and 4) - Devil’s Claw - Harpagophytum procumbens (week 4) - St. John’s Wort - Hypericum perforatum (week 4) - Japanese Knotweed - Polygonum cuspidatum (week 4) Corydalis / Yan hu suo - Latin : Corydalis yanhusuo (Papaver family) - Plant part : Root - Indications : Any pain, often used for menstrual pain relief - Actions : Analgesic, hepatic, warming carminative - Contraindications : do not use in pregnancy, scanty menses, post-partum, or patients with weak vitality - Side Effects : drowsiness in high doses - Research : opioid receptors BOT Week 6 : Identify herbal actions that would be most beneficial for mild-moderate depression - Warming adaptogen - Hepatic - Alterative Actions Herbs Adaptogen Rhodiola (Rhodiola rosea) North American ginseng (Panax Korean red ginseng (Panax quinquefolius) ginseng) Ashwagandha (Withania Sarsaparilla (Smilax officinalis) somnifera) Hepatic/ Bupleurum (Bupleurum St. John’s wort (Hypericum Alterative sinensis) perforatum) Stimulant Cayenne (Capsicum annua) Theobroma cacao (Chocolate bean) Coffea arabica (Coffee) Ephedra (Epherdra sinensis) Euphoric Kava kava (Piper Psilocybin spp. (Psilocybin) methysticum) - Chai hu - Bupleureum chinensis (week 4) - Cayenne - Capsicum frutescens (week 4) - St. John’s Wort - Hypericum perforatum (week 4) - Korean Red Ginseng - Panax Ginseng (week 2) - American Ginseng - Panax quinquefolius (week 2) Kava kava - Latin : Piper methysticum - Plant part : Root - Indications : Anxiety, insomnia, nervous tension, depression - Actions : Nervine, mild euphoric, analgesic, antispasmodic, antifungal (kavalactones, resins) - Contraindications : long term - elevated GGT (liver), Preg B, Lact CC - Side Effects : possible skin rash (high dose + long term) - Research : anxiolytic Rhodiola - Latin : Rhodiola rosea - Plant part : root - Indications : Fatigue from overwork, decreased libido, ongoing physical/mental stress, altitude sickness, ischemic heart disease - Actions : Adaptogen, vascular tonic (polyphenols (- rosavin, salidroside), quercetin, proanthocyanidins) - Contraindications : unknown for preg and lact - Side Effects : could be too stimulating for those with restlessness, insomnia, dizziness, or anxiety - Research : three-week cycles - potent adaptogen Sarsaparilla - Latin : Smilax officinalis - Plant part : root and rhizomes - Indications : Eczema, psoriasis, BPH, waning libido, RA, gout - Actions : Adaptogen, alterative, anti-inflammatory (Saponins based on the aglycone sarsasapogenin, sterols, volatile oils) - Contraindications : Considered safe. Safety rating during pregnancy and lactation not established. - Side Effects : / - Research : one of the original roots in root beer, good for fatigue following intense physical activity associated w joint pain Chocolate bean - Latin : Theobroma cacao - Plant part : bean - Indications : Asthma, COPD, low mood, stress, convalescence - Actions : Mild stimulant, adaptogen, nutritive - Contraindications : Lowers tone of lower esophageal sphincter, so avoided in GERD. Safety rating during pregnancy and lactation not established. - Side Effects : / - Research : roasted beans preferred, raw may contain fungal elements Withania - Latin : Withania somnifera - Plant part : root - Indications : Fatigue, nervous exhaustion, chronic inflammatory disease, anemia, lowered libido, convalescence, hypothyroid presentations - Actions : Adaptogen, hypotensive, immune modulator, anti-inflammatory, nootropic (Steroidal lactones (withanolides), alkaloids) - Contraindications : Considered safe. Preg B, Lact C. - Side Effects : / - Research : An excellent non-stimulating adaptogen useful in promoting performance and recovery without the symptoms of overstimulation. Sometimes thought of specifically as being useful as an adaptogen for the thyroid. Nutrition Case 1: Sore Throat Dietary Sugar - To much sugar can impact immune function - Pro-inflammatory proteins (TNF-alpha, CRP, IL-6) - Changes to microbiome - SImple carbohydrates can decrease phagocytic capacity of neutrophils (can last up to 5 hours) - What to eat? - Reduce refine sugars (sweets) - Eat fruits & veggies - No ice cream for sore throat instead lozenges Enough Dietary Protein - Deficiency impairs immune function and increases infections - Amino Acids are important to: - Activate T-lymphocyte, B-lymphocytes, NK cells & macrophages - Lymphocyte proliferation - Production of antibodies & cytokines - What to eat?  - Bone broth & soup - Congee made w/ bone broth - Rice & lentils Honey for Healing - Natural antimicrobial properties - Decrease inflammation - NO for infants under 1 yr. Old due to risk of Clostridium botulinum Probiotics - Supports healthy microbiome, esp. With antibiotic use - Safe & well tolerates - Streptococcus salivarius K12 support but more research needed Vitamin D - Enhance neutrophil killing of pathogenic streptococcal bacteria - Decrease excessive inflammatory responses & apoptosis - Chemotherapeutic potential again strep infections Vitamin D supplementation - Active form, Vitamin D3 - Fat-soluble vitamin Vitamin C - Can be used as supplementary therapy along w/ antiviral regimens to relieve patients of symptoms of common cold - Total efficacy, time for symptoms amelioration & time for healing was improved w/ vitamin C w/ antiviral therapy - Upper tolerable intake (UL) is 2g/d - Common adverse effects of high doses of oral vit C care gastrointestinal - Gastric irritation from decreased pH of stomach contents - Intestinal gas, bloating, cramping - Diarrhea - Dental erosion - Increasing vitamin C intake cause increase in urinary excretion of uric acid  - Decrease risk of gout Zinc - Shorten duration of cold symptoms - More effective in adults - Adverse events like bad taste & nausea Dietary Treatment Recommendation Looks like: - Individuality - Chosen diet - Allergies - Age - Availability - Past medical history & presenting illness Week 2: Case Sore Throat Pt. 2 Vitamin C & Zinc & Probiotics usage for common cold - Zinc - 30-50mg day for adults - Take w/ food - GI upset likely side effect - Don't take same time as antibiotics to avoid interference - Eg. meat, legumes  - Probiotics - Potential GI upset, likely dose-independent - Change in stool habits - Caution selection w/ dairy allergy - Help prevent side effects of antibiotics - Help resolve infection - Help prevent infections - Eg. fermented foods Recurrent Acute Otitis Media - Could be related to inflammatory state due to incorrect diet - Traditional Mediterranean diet (TMD) as treatment for RAOM - High Fat Diet - Assoc. w/ obesite & otitis media with effusion - Assoc. w/ OME Week 3: Atopic Dermatitis Popular Supplements: Zinc, Vitamin D, Fish Oil, Vitamin A Zinc - May help reduce eczema severity esp. If deficiency  - Ex. beef, shellfish, nuts & legumes Vitamin D - Deficiency risk of psoriasis & atopic dermatitis - Reduce inflammation & symptoms of eczema - Vitamin D3 (cholecalciferol) - Synthesis happens in epidermis of skin from UVB - Animal sources: fish, liver, meat, egg yolks - Vitamin D2 (ergocalciferol) - Plant sources: mushrooms, alfalfa sprouts Fish Oil - More studies are needed but shows promising findings on eczema Fatty Acids - Chains of hydrocarbons of diff. Lengths - Long-chain FAs: 14-24Cs - Medium-chain FAs: 8-12Cs - Short-Chain FAs:4,500 RAE (15k IU) per day of performed vitamin A in pregnant women assoc. w/ birth defects Contraindications & Cautions - High doses of vitamin A contraindicated in pregnancy & sexually active women w/o effective birth control - Patients w/ end stage renal disease should not be given vitamin A - People w/ liver disease, malnutrition & alcoholism higher risk of vitamin A toxicity Question: Susan, a 32-year-old pregnant female is concerned about skin dryness and eczema. You tell Susan that she needs to be cautious about taking this supplement…. - Vitamin A Week 4: Knee Pain (Inflammatory Joint Conditions) Malnutrition common w/ patient w/ RA* Food Allergy - Immune system mistakes protein in food as harmful → release immunoglobulin E, IgE - Next exposure, antibodies trigger release of histamine. Leading to hives, abdominal pain, or even anaphylaxis - Appears right after eating Food Sensitivity - More common than food allergies - Harder to track since symptoms does not show right away - IgG elevated in food sensitivity - Ex. red meat & dairy known to trigger inflammation - Nightshade veggies (potatoes, tomatories, peppers) trigger inflammation Special Diet: Mediterranean - Plant-based foods  - Replacing butter w/ healthy fats like olive oil - Using herbs & spiceds instead of salt to flavor foods - Fish & poultry 2x a week - exercise Special Diet: Vegan - Not enough evidence to recommend vegan diet for everyone w/ RA - Study found 4-weeks on low-fat vegan diet improvement RA joint pain, stiffness, swelling Fatty Acids - Omega-3 fatty acids seem to prevent or improve experimental arthritis - Shown to reduce joint pain, as well morning stiffness Folate - Common RA medication, methotrexate, destroys folate - Therefore doctors prescribe folate supplements on this medication - Sources - Green veggies - Fruits: strawberries & oranges - Folic acid to be added to refined grain products, already enriched w/ niacin, thiamin, riboflavin, iron Iron - Anemia common in patients w/ chronic inflammatory joint conditions - Source: Heme Iron - From hemoglobin & myoglobin - Found ONLY in animal products - 50-60% iron in animal products occurs in heme form - Source: Non-Heme Iron - Meats - Dark green leafy veggies - Blackstrap molasses - Enriched foods: flour, breads, pastas Question Clara M. is a 49-year-old married mother. Seven months ago, she began noticing stiffness in both hands in the morning that lasted longer and stiffness. At her visit with the Rheumatologist she was diagnosed with RA. The Rheumatologist recommended her to start oral methotrexate and see a physiotherapist. Which one of the following supplements do you recommend Clara take? - Vitamin B9 (folate) Week 5: Low back Pain Vitamin C - Increase calcium absorption in body which promotes strong & healthy bones - Helps process of healing fracture & broken bones, wounds, & burns - Sources - Fruits: kiwi, papaya, strawberry, citrus fruits - Veggies: red peppers, broccoli, asparagus - Percentage of Vitamin C absorbed decreases w/ increasing intake - Therefore IV administration required to achieve high levels in blood - Unabsorbed vitamin C metabolized by intestinal bacteria - Capacity to absorb oral vitamin C may increase acute illness People at Most Risk of Defiency  - Children < 1yr - Elderly, esp. In nursing homes - People w/ gastro-esophageal reflux disease - Upper Tolerable Intake Level (UL) for vitamin C is 2g/d - Adverse effects of high doses of oral Vitamin C - Gastric irritation - Gas - Diarrhea Caution - Increase risk of oxalate stone formation - Diseases of iron metabolism like hemachromatosis - Vitamin C supplementation above 2 grams per day is contraindicated during pregnancy Magnesium - Deficiency one of main causes of chronic back pain - Magnesium supports muscle & nerve function - Deficiency symptoms - Muscle tremor, cramps - Chest tightness & shortness of breath - Anxiety, depression, fatigue, insomnia - Loss of appetite, nausea, vomiting - Contraindications - End-stage renal disease - Myasthenia gravis - UTI - Kidney stone - Hyperparathyroidism Increased Risk of Deficiency - Renal disorders - Chronic alcohol abuse - Elderly Vitamin D - Bone & lower back pain symptoms of inadequate vitamin D levels - Helps maintain bone health by improving body’s absorption of calcium - Skin production depends on - Length of exposure to sun - Amount of skin exposed - Level of latitude - Degree of pigmentation - Age Susan, a 72-year-old female with chronic kidney disease is concerned about low back pain. She drinks 3 glasses of wine every day. She also feels muscle spasms, headaches, and constipation. Which one of the following supplements is the best option for Susan? - Magnesium Week 6: Depression (Mood Disorders) Diet & Mood Regulation - Blood sugar balance - Weight management - Stimulants - Food sensitivities Antioxidants - Intake is assoc, w/ improved depression & anxiety Spices - Saffron: effectiveness to antidepressant medication in reducing depressive symptoms - Tumeric: curcumin for 8 wks lower anxiety scores Omega-3 Fatty Acids - Beneficial effects on depression 5-HTP - Tryptophan - In turkey, chicken, milk, potatoes, turnip, collard greens B Vitamins  - Important role in anabolic & catabolic cellular processes essential for brain function - Supplementation may reduce anxiety & depression & benefit at-risk populations for stress Magnesium - Deficiency common among people w/ depression & Mg supplementation may reduce depressive symptoms Vitamin D - Could reduce risk fo depression by reducing inflammation, regulating mood & protecting against neurocognitive dysfunction - Serum vitamin D levels - Correlate w/ clinical depression Sarah is a 25-year-old CCNM student. She is concerned about fatigue and low mood. She does not have the motivation for daily tasks and feels hopeless. Sarah is following a healthy vegan diet for the last 7 years but is not receiving any supplements. She wants to know if there is a supplement that you recommend she take to help with her depression and fatigue. You decide to run a lab test and based on the result you consider this supplement:… - Vitamin D Homeo - Week 1: Sore Throat Remedies - Allium cepa - Affinity w/ mucous membranes & nerves - Sore throat: burning / lump - Larynx: tickling, pain from coughing - Headache worse from closing eyes - Nasal discharge burns nostrils and upper lip area, but tears are bland (euphrasia is opposite) - Shooting pains following a thin line - Worse : warm room, spring/fall, flowers, evening, cucumber - Better : in fresh air, onions - Mind : indifferent, lack of motivation, absent minded, worse in afternoon and with coffee - Belladonna - Stands for violence of attack & suddenness of onset - Heat (fever), redness, throbbing & burning. Great children’s remedy - Hot, red skin, flushed face, glaring/throbbing eyes - Red throat, tonsils enlarged, difficulty swallowing - Worse : afternoon, night, with motion, light touch, wind, light, noise, right side - Better : leaning head on something, bending, standing, in bed, morning, warmth - Symptoms - Throat pain - Painful swallowing - Red & swollen tonsils - Tiny red spots roof of mouth - Fever - Swollen tender lymph node - No thirst - Affinity - Brain, head.  - Cardio system - Fevers - Acute appear & disappear suddenly - Mind - lively, fits/tantrums, hide from hallucinations during fevers/nightmares, wild expression, dilated pupils, glassy eyes when sick - Gelsemium Sempervirens - Gradual onset of complaints - Muscular weakness - Muscle aches, soreness, pain, heaviness - Thirstless - Dizzy, drowsy (flu, mono) - Modalities - Better: open air, closing eyes, bending forward - Worse: heat, damp weather, before thunder, from bad news or excitement - Mental symptoms - Stage fright / exam funk - Timid in public - Act bravely or bold to fight inner fear Materia Medica - Symptoms strongly assoc. To trends & features frequently seen in a remedy - Can include characteristic symptoms and affinities of a remedy or be common - Usually accented with CAPITAL LETTERS - Or bold letters - Or italics - Or color - Week 2 : URTI Remedies - Spongia tosta - roasted sponge - Barking seal cough, like a saw, sibilant (SHHH or SSSS) - Spasmodic/short cough (hoarseness, asthmatic, wont stop) - Suffocation sensation (throat constricted, raw, or sore) - Dry airways - Glands/cervical nodes inflamed - Weak sensation in chest - heart pains/palpitations, valvular insufficiencies - Blood circulation problems - Worse : before midnight, dry cold wind, cold drinks, heat - Better : eating, drinking, warm things, resting - Mind : fear, wakes at night startled, sensitive, alternating moods, anxiety about heart disease/suffocation - Drosera rotundifolia - common sundew - #1 remedy for whooping cough - Respiratory illness (Laryngitis, bronchitis, tuberculosis) - Tormenting cough (short and ringing cough) - Paroxysms (attacks/fits) that follow one another quickly - Holding the chest to cough - Hot face, cold hands - Inability to cough due to pain - Worse : in the evening and after midnight-2am, lying down, after drinking, exertion, singing, smoking, measles, heat, talking, laughing - Better : walking, open air, pressure, sitting up - Mind : suspicious of others, easily angered, restless, fears being alone - Rumex crispus - yellow dock - Dry, tickling cough - Cough ends with sneeze - Cough in temperature changes - Skin itch in cool air (or sensitive to cold air) - Copious discharge from mucosa of nose, eyes, resp tract - Worse : cold air (inhale, laugh, talking), touch/pressure on throat, temp changes, motion, morning, before 11pm  - Better : drinking, sucking on candy - Mind : nervous in evening/night, restless, sad/depressed, aversion to mental work, fear of misfortune - Ipecacuanha - ipecac - Persistent nausea/vomiting - Spasmodic irritation in chest/stomach (vagus n.) - Shortness of breath - Gastric disturbances (nausea) - Bright red hemorrhage (rapidly clotting) - Fevers/infections (from epilepsy, whooping cough, indigestion, menstruation) - Vomiting with sensation as if all bones in body are being torn to pieces - Violent, spasmodic, suffocating cough (at 7pm) which brings on vomiting or nausea - Thirstless - Vomiting before or during menses, large clots, miscarriage, labor, pregnancy/placenta issues - Worse : warmth/damp warmth, overeating (rich foods), heat and cold, vomiting, motion, lying down - Better : open air, rest, pressure, closing eyes, cough better with cold drinks, rest - Mind : irritable, contempt for everything when irritated, impatient, anxiety during fever/coughing, many desires but can't express them (hard to please), intolerant to noise, tranquil after anger, anorexia and hypochondria with epigastric tension/constipation - Week 3 - Derm Remedies - Urtica Urens - Dwarf nettle - Itching, burning, stinging skin - burns/scalds - Insect bites/stings - Allergic rxn after shellfish - Disturbances in lactation (swelling, burning) - Rheumatism (RA) and Uric acid diathesis (gout, kidney stones) - Worse : cold bathing, cold/damp air, snow, touch - Better : / - Mind : / - Apis mellifica - mellifera - Swelling / edema - Stinging, burning pains, hives w puffy swelling - Insect bites, puncture wounds, splinters - Anaphylaxis - no/low thirst - Worse : night, heat touch, right side - Better : cold applications, cold water - Mind : rapidly developing complaints, passionate, busy (like a bee), restless, awkward/clumsy, irritable, jealous/grief, fear of birds, indifference/apathy, weepy - Rhus toxicodendron - Affinities - skin, mucous membranes, fibroid tissue (joints, tendons), aponeurosis - Stiffness and pain - RA - Itchy, red skin (chicken pox, herpes, psoriasis, urticaria, cellulitis) - Worse : at rest (stiff, restless), initial movement, cold damp - Better : heat, hot bath, stretching, continuous motion - Mind : busy, restless, dreams of travel, work, superstitious or ritualistic behavior - Sulfur - Itchy, red orifices - Dry skin, warts, blisters, dry nails - Slouches, hot in bed (uncovers feet) - Unkempt appearance  - Cat-nap sleepy - Eating at night - More thirsty than hungry (not hungry in morning) - Worse : pain from standing, heat, weather changes, baths, morning (diarrhea), night, left side - Better : dry weather, motion, lying on right side - Mind : opinionated, critical, independent, nervous, quick-tempered, argues ideas, speculates, high confidence / full of themselves, hard to get up in morning, fear of heights, anxiety/guilt - Graphites - Thick, Rough skin, scars, eruptions (at bends of skin), cracks/fissures, infections (fungal), keloids - Oozing sticky honey-like discharge - Eczema, psoriasis, herpes - Affinity for skin (folds), digestive organs, eyes - Tendency toward obesity, chilliness, constipation - Stomach disorders, pain worse with milk/eating - Constipation, chronic during/before menses - Anemia (pale mucosa, red face) - Menstrual issues, menopause - Photophobia, blepharitis - Alopecia at vertex or sides of head - Better : in dark, wrapped up - Worse : warmth, night, after menstruation - Mind : dull, slow, timid, reserved, changeable, easily startled, indecisive insecure, easily offended, fidgety, fear of something bad happening - Week 4 - Joint pain Remedies - Bryonia alba (white bryony) - Bryonia toxicity - glycosides have cytotoxic effect -> intense dryness of mucous membrane, respiratory and digestive mucosa - Affinity for serous membranes and tendons, ligaments, CT - Good for inflammation, dryness, exudation, joint pain and muscle stiffness - “Stitching” pain - averse to being examined or moved - Thirst for lots of water (extreme thirst) - Doesn't want to move - Large, hard stools - Better: rest, strong pressure, lying on painful side, sweating - Worse: any motion, heat (except local) - Mind: irritability, wants to be left alone, busy thoughts, - Rhus tox - joint/tendon/muscle ailments with stiffness and pain - Skin (last week) - Blood and mucous membranes, glands, nerves (sciatic) - Aversion to alcohol, meat, oysters, soup - Desire for milk, beer, cold drinks, oysters, sweetsm tonics - Red triangular tip of tongue - Better : continued motion, heat, warm drinks and food, milk rubbing, change of position, lying on hard surface - Worse : wet,cold air, washing, draft when wet/sweaty, beginning motion, rest, after midnight, before storms, winter, cold drinks/food, beer, bread, old cheese, cucumber, sour, tea, coffee - Mind : busy, restless, dreams of travel, work, superstitious or ritualistic behavior, lively (timid at first), irritable with prolonged pain - Ledum (marsh tea) - Lack of internal heat - Gouty joints - Shooting pains in foot, limbs, small joints (ball of great toe), ankles easily sprain - Ascending pain from feet upwards - Rheumatism alternating with hemoptysis - Better : cold application, cold air, soaking in cold water - Worse : heat, night in bed, motion, covering inflamed parts - Mind: /  - Week 5 - LBP with radiculopathy Remedies - Colocynthis (Bitter cucumber, Cucurbitaceae) - Cucurbitacin glycosides also present in bryonia alba - Affinity for smooth muscles of digestive tract, peripheral nervous system and cranial nerves - Cramping stomach pains with nausea or diarrhea (patient cries out) - Paroxysmal neuralgia localized in the area supplied by trigeminal or femoral nerves and sciatic nerve - Sciatica or femoral neuralgia (left sided shooting pain accompanied by numbness) - Violent drawing, twitching pains in left hip region or sharp pains in right hip region, suddenly appearing and disappearing when walking - drawing /pulling pain (thigh->knee) (all the limbs become “drawn up”) - Better : strong pressure, flexing thigh toward pelvis or bending over, heat, warmth of bed - Worse : annoying vexation/disrespect - Mind : extreme irritability, anger and agitation when in pain, paroxysmal pain following confrontation that triggers violent anger/annoyance, urinous odor of perspiration - Kalium carbonicum - potassium carbonate - Affinity for digestive/resp mucous membranes, circulatory, CNS, articular system - Shooting, stabbing, burning pain - Lumbar/joint pain with weakness (back of knees giving away) - Lumbago with sudden sharp pains extending up and down back to thighs - Hypersensitive to noise - Sensation of anxiety in solar plexus - soft pulse, coldness, general depression, and very characteristic stitches, which may be felt in any part of the body, or in connection with any affection - Viscous secretions - Cravings for sweets - Swelling around eyes - Better : heat, sitting, leaning forward, during movement - Worse : 2-4am, draft or cold weather - Mind : alternating moods, irritable, fear and imaginations, anxiety, never want to be alone, very sensitive (emotionally and physically) - Magnesium phosphate - The great antispasmodic remedy - Cramping with radiating/shooting neuralgic pains - Involuntary hand shaking/twitching, cramps in calves, sciatica, tender feet - Affinity for nervous system and muscles - Vertigo when moving, falls forward when eyes closed - Sensation of parts of the brain changing places, liquid (???) - Better : walking in open air, warmth/heat, bending over, local pressure - Worse : after mental labor, chilliness/cold - Mind : laments all the time about pain, inability to think clearly, sleepless bc of indigestion, tired /exhausted patients, Mental exertion, agitation, need to move - Week 6 : Depression & Anxiety Remedies - Aurum metallicum - gold - Affinity for cardiovascular system, psyche, bones/joints, lymph, liver/bile ducts - Extreme depression and loathing of life -> suicidal thoughts and self-destruction - thrist , desire for alcoholic drinks - Early stage : avoid superficial contact, aloof - Children : difficult to establish close friendship, prominence in class, serious, sensitive - *emotionally vulnerable, intellectually strong - Better: cold air (for vascular patients)  - Worse: at night, cold in winter for depression, noise, intellectual over-exertion - Mind : idealistic, good self-confidence, serious, introverted, leader, give and receive justice, refined, ambitious, destined for superior position in life, feelings of worthlessness, suicidal thoughts/speech (jumping from height), fear of death, anthropophobia, derangements, sensitive to noise - Ignatia amara - loganiaceae family - Strychnine toxicology : stimulates spinal cord and medulla with toxic effects resembling tetanus - agitation, anxiety, increases sensory perception and reflexes, balance disorders, painful stiff muscles in neck -> spasms, whole body convulsions, dyspnea and suffocation - Loganiaceae family triad : suddenness, intensity, violence (shocked, paralyzed, shattered) - Ignatia affinity for mind, nervous system, cerebro-spinal axis, right side - Involuntary sighing - Prone to exaggeration, spasmodic and erratic symptoms - Sensation of lump in throat, twitching around mouth - Aversion to fruit, tobacco smoke, meat, milk, warm food, wine, alcohol, bread, cooked food, sour - Desire for cold drinks and food, sour, bread and butter, charcoal, cheese, cranberries, pickles, raw food, tomatoes, vinegar - Better : change of position, lying on painful side, profuse urination, being alone, hard pressure, warmth, swallowing, physical exertion, while eating - Worse : consolation, emotion, open cold air, odors, touch, coffee, tobacco, winter, fast walking, morning on waking - Mind : keep control in shock/grief where others would feel torn to pieces, response to shock is to try to maintain control, silent grief*, anger, shame, sudden changes from high to low spirits, deeply offended but no inclination to violent anger/revenge - Arsenicum album (anxiety) - Intense burning, extreme weakness, extreme cold sensitivity - Thin, stylish/well-groomed  - Pale, flushes easily, fine skin/hair - Rapid fatigue upon exertion - Burning pains yet chilly - Thirsty for frequent small sips - Acute : diarrhea/vomiting from food poisoning, cold/flu, covid - Hot head and cold body, runny nose and eyes, cancer, asthma palpitations - Better : heat, changing position (restless), lying with head raised, motion/pacing, company - Worse : 12am-3am, cold, exhaustion worse at night - Mind : worry about health/incurable illness and death and health of family, insecure, need reassurance, restless and anxiety, plans for everything, meticulous, perfectionist, pessimist, all or nothing, opinionated, intolerant of others beliefs, cant rest until house is in order, depressed, suicidal, guilty fear of being alone, poverty, dark, burglary, ghosts Other remedies - Depression: - Natrum muruaticun - Phosphoricum acidum - Hypericum - Anxiety : - Argentum nitricum - Gelsemium - Aconitum Pharm - Week 1 - Intro - Pharmacology: study of “drugs” (any exogenous chemical) AND their effects on life → its goal is to understand the mechanisms by which drugs interact with biologic systems  - - EFFECT OF PH - Many drugs are weak acids or bases - Only non-ionized forms of drugs can easily pass through a lipid bilayer - For orally administered drugs there are 2 significant pH compartments in the digestive tract - 1. Stomach with low pH (normally around 1) - 2. Small intestines with neutral pH (normally around 7) - BIOAVAILABILITY - amount of the administered dose of a drug that reaches the systemic circulation in an active (unchanged) form → influenced by several factors - Intravenously administered drugs are 100% bioavailable - DISTRIBUTION - In terms of tissue targets, this is influenced by: - Size of the organ, Blood flow, Drug solubility, Protein binding - METABOLISM Aka biotransformation - The enzyme-catalyzed conversion of drugs to their metabolites - Most of this takes place in the liver, but the gut, kidneys, brain, lungs, and skin also contain drug-metabolizing enzymes - The primary goal is to inactive or detoxify foreign substances and to prepare them for excretion - Generally, the idea is to make a xenobiotic more water- soluble so that it can be readily excreted in by the kidneys - Not every drug needs to be metabolized in order to be eliminated - Not every drug is inactivated by metabolism - Prodrugs are common and are activated by metabolism  - Metabolites may retain some degree of pharmacological activity (active metabolites) - Not every xenobiotic is immediately detoxified - FIRST PASS EFFECT - Drugs absorbed via the gut reach the liver via the portal vein before entering the systemic circulation - The degree to which the drug is inactivated by liver enzymes prior to entering the systemic circulation substantially alters the drug’s bioavailability - PHASE 1 METABOLISM - Primary goal is to introduce or open up a binding site for hydrophilic compounds to be added later by phase II mechanisms - Oxidative reactions by far the most common - Microsomal cytochrome P450 (CYP450) system - PHASE 2 METABOLISM - Not all drugs require phase I metabolism prior to phase II but most do - These reactions essentially conjugate a water-soluble molecule to the spot opened up by phase 1 reactions - In many instances, this means conjugating something to an available hydroxyl group - Each phase 2 mechanism has its own enzyme that catalyzes the reactions - ENTEROHEPATIC CIRCULATION - Glucuronide conjugates are excreted in bile - Some commensal gut bacteria have glucuronidase enzymes which can cleave the glucuronide off the metabolite resulting in the parent drug being able to be reabsorbed  - - ELIMINATION - Most water-soluble drug metabolites are excreted by the kidneys - Various mechanisms exist throughout the sections of the nephron - Lipid-soluble drugs are excreted in the distal tubule if they’re small enough - Lipid-soluble drug metabolites and glucuronide-conjugates are excreted by the liver into bile and excreted in feces - PHARMACODYNAMICS - Essentially the study of a drug’s mechanism of action - Drug-receptor characterization and mechanics - Signal transduction mechanisms - IMPORTANT DEFINITIONS - Agonist – a substance that initiates a physiological response when combined with a receptor - Antagonist – a substance that interferes with or inhibits the physiological action of another substance - Competitive – used to describe when two substances use the same binding site on a receptor - Allosteric – used to describe when a substance binds to a receptor away from an active binding site but still alters the physiological effect - MEASURES OF SAFETY → TI = LD50 / ED50 - Therapeutic Index (TI)  - LD50 – dose at which causes death in 50% of individual (animal) - ED50 – dose at which causes a therapeutic response in 50% of individuals (human) - PRESCRIBING STANDARDS - Generic name – most suitable drug name to use as it is standard across all jurisdictions - Brand name – registered trademarked name of a drug used in marketing - Ex: atorvastatin vs Lipitor® - PRESCRIPTION REQUIREMENTS - Date - Name and address of patient - Name, strength, quantity and form of drug or ingredient(s) - Directions for use (include frequency or interval or maximum daily use) - Refill authorization (number and interval between refills) - Name and college ID of practitioner Signature of practitioner - PRESCRIBING STANDARDS - It is generally advised to write full words as much as possible and to avoid abbreviations - Never abbreviate the drug name - Use generic names unless brand name drug is dispensed - DRUG CHARTING - Date - Related subjective and objective symptoms - Assessment - Purpose and/or goal(s) of medication(s) - Name, dose, dosage form and quantity of medication prescribed - Monitoring plan - Informed consent & Signature - Week 2 - Acute Otitis Media - - ACUTE OTITIS MEDIA (AOM) - Typically a pediatric condition - Can be caused by both bacteria and viruses and co- infection is common, especially in those who experience chronic, recurrent otitis media - The most common bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis - Preventative factors include: - Vaccination (influenza and S. pneumoniae) as viral upper respiratory tract infections often precede AOM - Public health measures may reduce virus transmission leading to a reduction in AOM cases - Avoiding exposure to tobacco smoke - Breastfeeding - WATCHFUL WAITING - Spontaneous resolution is caused by top 3 bacterial pathogens: - S. pneumoniae – 20% - H. influenzae- 50% - M. catarrhalis – 75% - Withhold antibiotic prescriptions for 48 hours in children over 6 months of age provided they have: - Nonsevere illness (mild pain and fever < 39°C) - Uncomplicated AOM (no episode in the preceding month, no acute facial nerve palsy, mastoiditis, meningitis, or labyrinthitis)  - No craniofacial abnormalities, immunodeficiencies, cardiac or pulmonary disease, Down syndrome, or history of complicated AOM. - Parents are capable of recognizing worsening illness with ready access to medical care - EXCEPTIONS - Infants under 6 weeks of age should be immediately referred to the nearest emergency department - Patients aged 6 weeks to 6 months should begin antibiotic therapy immediately - Patients with 3 or more episodes in 6 months or 4 or more within a year should begin antibiotic therapy immediately - ANTIBIOTIC THERAPY - Antibiotic resistance is common among the three pathogens - S. pneumoniae resistance is a result of the alteration of penicillin-binding cell wall proteins leading to decreased drug affinity - This is overcome by doubling the dose of amoxicillin - H. influenzae and M. catarrhalis produce beta-lactamases which confer resistance - This is overcome by using a beta-lactamase inhibitor called clavulanate - When antibiotics are used, treatment failure should be considered if symptoms do not improve after 72 hours of treatment - Amoxicillin is considered first-line therapy in the treatment of AOM T - here is disagreement about the ideal dose and available evidence had not demonstrated superiority of one approach over others - In most areas of Canada, susceptibility of S. pneumoniae to amoxicillin is >90% - S. pneumoniae as the causative pathogen for AOM has been decreasing steadily with vaccination programs - Standard dose amoxicillin is a reasonable first-line option in children without risk factors for resistance - ALTERNATIVES TO AMOXICILLIN  - The combination of amoxicillin and clavulanate is typically used for treatment failure or recurrence - Diarrhea is commonly noted as an adverse effect of combination therapy - All other treatment options discussed later are less favourable but may be necessary depending on the patient - CEPHALOSPORINS - Cefuroxime axetil and Cefprozil - Second-generation cephalosporins have reasonable activity against H. influenzae and M. catarrhalis as they are more resistant to bacterial beta-lactamases - Less effective against S. pneumoniae - Considered second-line agents - MACROLIDES - Azithromycin and Clarithromycin should be reserved for patients with type 1 hypersensitivity reactions to beta- lactam antibiotics - Resistance to macrolides is common and treatment failure is common - LINCOSAMIDES - Clindamycin can be used for patients with type 1 hypersensitivity reactions to beta-lactam antibiotics - It does not cover H. influenzae or M. catarrhalis - SUPPORTIVE THERAPY - Antibiotics do not reduce pain within the first 24 hours of therapy and do little in the following days compared to placebo - Analgesics are recommended during watchful waiting and with antibiotic therapy - ANALGESICS - Acetaminophen → 10 – 15 mg/kg every 4 – 6 hours to a maximum of 75 mg/kg/day and not to exceed 4000 mg/day - Ibuprofen → 10 mg/kg every 6 – 8 hours to a maximum of 40 mg/kg/day and not to exceed 2400 mg/day - ANALGESICS - Aspirin should never be given to children or teenagers recovering from chickenpox or with flu-like symptoms  - Has been linked to Reye syndrome – a rare but serious condition that causes swelling of the liver and brain - PRACTICE QUESTION - The resistance mechanism produced by H. influenzae can be overcome by which of the following strategies? A. Doubling the dose of amoxicillin B. Giving amoxicillin and clavulanate together C. Using clindamycin as an alternative to amoxicillin D. Giving cefprozil and clavulanate together - Week 3 - Derm Pharm - INTRODUCTION - There are a large number of conditions that can cause a rash, pruritis, or both - Treatment for rashes secondary to infectious etiologies generally focus on the infection itself - Secondary infections are possible - For conditions like atopic dermatitis (eczema) pruritis is the most important symptom to control - CORTICOSTEROIDS - 2 main subclasses: glucocorticoids & mineralocorticoids - 1. Glucocorticoids - affect carbohydrate, fat, and protein metabolism - have anti-inflammatory, immunosuppressive, anti-proliferative, and vasoconstrictive properties - 2. Mineralocorticoids - primarily involved in electrolyte regulation by modifying renal excretion mechanisms - Both mineralocorticoid and glucocorticoid receptors are expressed in the skin - TOPICAL CORTICOSTEROIDS - The hydrocortisone backbone provides the basic structure from which all other topical corticosteroids (TCS) are derived - Fluorinating or esterifying certain carbons in the four-ring backbone can increase the potency of the TCS - MECHANISM OF ACTION - Once absorbed, TCSs interact with an intracellular glucocorticoid receptor  -The TCS-receptor complex then translocates to the nucleus where a large number of gene transcription changes take place - General upregulation of anti-inflammatory mediators and downregulation of inflammatory mediators - Vasoconstrictive effect which reduces delivery of inflammatory mediators and improves erythema - Anti-mitotic effect which inhibits cell proliferation and collagen synthesis - Immunosuppressant effect - More precise descriptions of their mechanism of action are usually discussed within the context of specific disorders, like atopic dermatitis, psoriasis, etc. - ADVERSE EFFECT - Many adverse effects are caused by overstimulation of glucocorticoid receptors - Stimulation of mineralocorticoid receptors in the skin may reduce the severity of some of these adverse effects - ADVERSE EFFECTS - When used topically... - Stinging or burning sensation - Dermal atrophy - Striae - Rosacea - Perioral dermatitis - Acne - Purpura - Increased hair growth - Skin pigment changes - Delayed wound healing - Many adverse effects are due to inappropriate use or using too high a potency for longer than is necessary - Systemic suppression of the HPA axis is generally only seen when TCSs are applied to large body surface areas, particularly more so in children - FINGERTIP UNITS  - Developed to help patients apply appropriate amounts of TCSs. - One FTU is approximately 0.5 g - The amount squeezed from a standard tube from the fingertip to the first crease of an adult finger - One FTU should cover an area equal to 2 adult handprints with fingers together - - TOPICAL DRUG VEHICLES - Topically administered drugs need to be compounded in a base to stabilize the drug and permit it to be stored in a manner that allows for as-needed delivery - There are many options each with their own pros and cons - Creams - Fairly standard and commonly used vehicle - Generally preferred from a patient perspective because they tend to absorb quickly and leave minimal residue - Tend to cause irritation due to additives - Are the least effective vehicle to allow the drug to penetrate the skin - Gel - An alcohol-based vehicle that can cause stinging and irritation if used on open lesions - Useful for hairy areas and oily skin - Lotion - Often an alcohol-based vehicle that can cause stinging and irritation if used on open lesions - Evaporates well leaving minimal residue and is useful for larger areas or hairy skin areas  - Ointment - Thick, greasy base like petroleum jelly - Least preferred by patients but offers the best vehicle to allow the drug to permeate the skin - Also has an emollient effect - Causes little to no irritation - Foam - An aerosolized oil-based formulation - Allows for application to hard-to-reach areas - Tends to leave a greasy residue - POTENCY - TCSs are classified by potency → divided into 7 classes: - Class 1 – highest potency aka superpotent or ultra-high class. - High potency drugs are needed to penetrate the palms and soles - Class 2 – high, Class 3 – medium-high, Class 4/5 - medium - Medium potency drugs can be used on the body and scalp - Class 6/7 – low potency - Low potency drugs should be used on the face and within skin folds as the skin is thinner and more absorption takes place - Potency can change depending on vehicle used → same drug at the same concentration is a higher potency when compounded in an ointment VS a cream - PRESCRIPTIONS - TCS prescriptions require some additional information - Drug name, concentration, base/vehicle - In addition to instructions, refills, etc. - Example: Halobetasol proprionate 0.05% ointment - Most are standard concentrations and many are available prepackaged in commonly used vehicles - SAMPLE QUESTION A high-potency topical corticosteroid would be an appropriate initial recommendation for the treatment of  which of the following body areas? A. Face B. Elbow C. Palm D. Scalp - Week 4 - NSAIDs - NON-OPIOID ANALGESICS - NonSteroidal Anti-Inflammatory Drugs (NSAIDs) - Non-specific COX inhibitor like acetylsalicylic Acid (ASA) and ibuprofen - COX-2 Specific Inhibitors like celecoxib - Non-specific COX inhibitors without anti-inflammatory effect like acetaminophen - INTRODUCTION - NSAIDs are most commonly prescribed medications for pain and inflammation → make up 5 – 10% of all meds prescribed each year - Up to 96% of patients over the age of 65 use NSAIDs in the family practice setting -  - - - - NON-OPIOID ANALGESICS - COX-2 prostaglandins are inflammatory and participate in inflammatory responses which can produce pain - The biggest issue with COX-1 inhibition is with GI function, particularly mucus secretion in the stomach - COX-1 inhibition leads to ulcers and increases the risk for major GI bleeds - ASA and Ibuprofen have significant COX-1 inhibitor activity and are known to have a substantial risk for dose dependent GI side effects - Celecoxib is substantially more specific to COX-2 and lacks the GI side effects  - Both classes still increase the risk of cardiovascular disease and mortality - - - ASA - ASA is notable in that it causes irreversible inhibition of COX by covalently bonding its acetyl group to the active binding site of COX → produces non-competitive inhibition - The remaining salicylate is a competitive inhibitor of COX - Short plasma half life as it is rapidly hydrolyzed to salicylic acid by plasma esterase - Eliminated in the urine after conjugation (primarily to glycine) - Rate of excretion is affected by urine pH  - Alkalinizing urine will increase ionization and increase elimination in overdose scenarios - ASA - Contraindicated in children with viral infections - GI irritation/ulcers/bleeding - Tinnitus – early sign of salicylate toxicity - High doses can cause hyperventilation, fever, dehydration, metabolic acidosis, impairment of hemostatis - Hypersensitivity reactions are uncommon but potentially fatal 5% cross reactivity to other NSAIDs - - ASA DOSING - Adults: 325 – 650 mg Q4H PO to a maximum of 4 g/day - Onset of action: 1 hour - Duration of action: 4 – 6 hours - IBUPROFEN - Adverse effects include: GI irritation, nausea, dyspepsia, bleeding - Hepatic toxicity - Renal toxicity including acute renal failure if dehydration occurs - IBUPROFEN DOSING - Adults: 200 – 400 mg Q6 – 8 hours PO to a max 1200 mg/d - Onset of action: 30 – 60 minutes - Duration of action: 4- 6 hours - ACETAMINOPHEN - Little effect on COX-1 or COX-2  - A third isoform, COX-3, recently discovered and acetaminophen has affinity for COX-3 - May explain analgesic and antipyretic effect - Little anti-inflammatory effect as it is rapidly inactivated by peroxides produced in inflamed tissue - ACETAMINOPHEN - Rapidly absorbed from the gut - Minimal plasma protein binding - Widely distributed to peripheral tissue and the CNS - Toxic intermediate formed with CYP1A2, 2E1, 3A isoenzymes - Normally conjugated with glutathione and renally excreted - Glutathione depletion can lead to hepatic necrosis - ACETAMINOPHEN DOSING - Adults: 325 – 650 mg Q4H PO or PR for acute pain 325 – 1000 mg Q4-6 hours PO for osteoarthritis - Maximum daily dose: 4 g/d - Onset of action: under 1 hour - Duration of action: 4 – 6 hours - CELECOXIB - Selective COX-2 Inhibitor - Potent anti-inflammatory activity without significant GI toxicity - Increased risk of cardiovascular disease and mortality - Does not inhibit platelet aggregation - CELECOXIB DOSING - 100 mg BID PO or 200 mg daily PO for osteoarthritis - GASTROPROTECTION - Risk of major GI bleeding: - Increased age - Concomitant use of systemic corticosteroids or warfarin - History of GI bleeding or peptic ulcer disease - 1 - 2% of people who use NSAIDs will develop GI complications, an annual rate 3 to 5 times higher than among those who do not use NSAIDs - GASTROPROTECTION - Strategies:  - Using COX-2 selective NSAIDs - Using prostaglandin analogues: misoprostol - Using proton pump inhibitors: omeprazole - SAMPLE QUESTION Which of the following NSAIDs acts through non- competitive inhibition of COX enzymes? A. Acetaminophen B. Acetylsalicylic acid C. Ibuprofen D. Celecoxib - Week 5 - NSAIDs/GABA derivatives & muscle relaxants for LBP - PHARMACOLOGIC OPTIONS - Acetaminophen and NSAIDs (discussed previously) - GABA derivatives - Muscle relaxants - Opioids (discussed in an upcoming lecture) - GABA DERIVATIVES - Pregabalin and Gabapentin - Typically reserved for soft tissue and hyperalgesic pain - Act centrally - Complicated mechanism of action → not fully explained - Originally designed as GABA analogues and are classified as anticonvulsants - Despite being structurally similar to GABA these drugs do not interact with GABA receptors - VOLTAGE-GATED CALCIUM CHANNEL - - MECHANISM OF ACTION - Bind α2δ1 receptors of voltage-gated calcium channels - This specific subtype is present in the brain, skeletal, cardiac, and smooth muscle - Most important area is the dorsal horn of the spinal column  - These receptors are upregulated as a response to pain - Modifies calcium entry and reduces neurotransmitter release - INDICATIONS - Typically reserved for neuropathic pain - Indicated or other disorders that will be discussed later - ADVERSE EFFECTS - Most common: sedation, ataxia, tremor, dizziness, dry mouth, weight gain - May also cause GI upset, peripheral edema, and vision changes - Cannot be abruptly discontinued – dose should be tapered over a minimum of 1 week to avoid withdrawal effects - DOSING Gabapentin: - Initial dose is 300 – 400 mg/day PO divided TID - Can increase at weekly intervals to a maximum of 3600 mg/day divided TID - Should not be taken with mineral supplements or antacids as this may decrease bioavailability - DOSING Pregabalin: - Initial dose is 50 – 150 mg daily PO divided BID - May increase weekly by 50 – 150 mg/day to a maximum of 600 mg/day divided BID - Does not have any significant interactions and is typically preferred as it is taken twice a day vs three times a day with gabapentin - MUSCLE RELAXANTS - A very broad term that includes drugs of a number of different drug classes - Loosely differentiated into antispasmodics and antispastics - All muscle relaxants are not recommended for those over the age of 65. - ANTISPASMODICS - Decrease muscle spasm associated with pain - Further classified as benzodiazepines or non- benzodiazepines - METHOCARBAMOL - A non-benzodiazepine antispasmodic  -Actually has no effect on the contraction of muscle fibers, motor end plates, or nerve fibers - Mechanism of action thought to be dependent on its CNS depressant activity by blocking spinal polysynaptic reflexes, decreasing nerve transmission, and prolonging the refractory period of muscle cells - ADVERSE EFFECTS - Can cause drowsiness, dry mouth, dizziness, fatigue, nausea, and constipation - Combination with other CNS depressants or opioids can increase the risk of CNS depression - DOSING - 1 g QID PO - ANTISPASTICS - Reduce muscle rigidity/spasticity that interferes with therapy or function (as in cerebral palsy, for example) - Mechanism of action is dependent on the actual drug as there are a number of drugs from various classes that fall into this category - BACLOFEN - A GABA receptor agonist specific for the beta subunit which is primarily expressed on pre- and post-synaptic neurons - Binding causes an influx of potassium into the neuron causing hyperpolarization and decreased calcium influx at presynaptic nerve terminals - Results in the reduced rate of action potentials and reduced activation of post-synaptic motor neurons that innervate muscle spindles - ADVERSE EFFECTS - Can cause sedation, muscle weakness, nausea, dizziness - In rare cases can cause hepatotoxicity - Potential additive CNS depression with other drugs like opioids and benzodiazepines - Dose should be adjusted gradually to minimize adverse effects and tapered to avoid withdrawal symptoms - DOSING - Initial dose: 5 mg TID PO  - Increase gradually to a maximum of 20 mg TID - LOW BACK PAIN - Use of muscle relaxants for low back pain is controversial - Mostly due to significant adverse effects - Most guidelines caution against their use - Despite that they are widely used, possibly given increased hesitancy to recommend opioids - SAMPLE QUESTION Which of the following drugs is classified as a non- benzodiazepine antispasmodic? A. Gabapentin B. Baclofen C. Pregabalin D. Methocarbamol - Week 6 - *doc is missing pharm weeks 4,5,6 and TCM weeks 1-6 and Health psych 1-6