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Nonprescription (OTC) Medications NAPLEX PG 405. Major categories of products to review Most important antacids, antidiarrheals cough and cold remedies.

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Presentation on theme: "Nonprescription (OTC) Medications NAPLEX PG 405. Major categories of products to review Most important antacids, antidiarrheals cough and cold remedies."— Presentation transcript:

1 Nonprescription (OTC) Medications NAPLEX PG 405

2 Major categories of products to review Most important antacids, antidiarrheals cough and cold remedies diabetes products dietary supplements internal analgesics laxatives motion sickness vitamins Most important antacids, antidiarrheals cough and cold remedies diabetes products dietary supplements internal analgesics laxatives motion sickness vitamins Less Important diet aids eye solutions external antiseptics hemmorhoidal preps mouthwashes nutritional supplements sunscreens PG 405

3 Strategies for reviewing Be realistic – impossible to know all OTC products and their ingredients Concentrate on the types of ingredients in each category cough suppressants – whats available? Be realistic – impossible to know all OTC products and their ingredients Concentrate on the types of ingredients in each category cough suppressants – whats available?

4 Strategies for reviewing Learn only the major (best-selling) OTC products and their ingredients and dosing Walk your shelves Recognize the major problems (interactions, key warnings/precautions) with each ingredient Be alert for Rx-to-OTC switches Learn only the major (best-selling) OTC products and their ingredients and dosing Walk your shelves Recognize the major problems (interactions, key warnings/precautions) with each ingredient Be alert for Rx-to-OTC switches

5 Antacids A pH range of between 3 and 4 should be maintained during antacid therapy approximately 98% of all stomach acid is neutralized but the gastric enzymes are still active for digestion Antacids evaluated with USP Acid Neutralizing Capacity Test based on the mEq of HCl consumed by the antacid while still maintaining a pH of 3.5 A pH range of between 3 and 4 should be maintained during antacid therapy approximately 98% of all stomach acid is neutralized but the gastric enzymes are still active for digestion Antacids evaluated with USP Acid Neutralizing Capacity Test based on the mEq of HCl consumed by the antacid while still maintaining a pH of 3.5 PG 406

6 Major Ingredients of Antacids Ingredient AdvantagesDisadvantages Aluminum hydroxide (Amphojel) may cause constipation decreased absorption of phosphates Magnesium hydroxide (MOM) may cause diarrhea accumulation of magnesium ion in blood – avoid if renal failure Aluminum and magnesium combo (Maalox, Mylanta) Fewer side effects than plain Al or Mg may still cause metabolic alkalosis and magnesium accumulation in renal failure PG 406

7 Major Ingredients of Antacids Ingredient AdvantagesDisadvantages Calcium carbonate (Tums, Alka-mints) source of calcium for osteoporosis prevention may cause hypercalcemia and kidney stones Sodium bicarbonate (alka-seltzer, Soda Mint, ie) High pH may cause acid rebound High sodium levels – CHF/HTN PG 406 Plus=simethacone

8 From the Pharmacists Letter You'll soon see a new formulation of Renagel called Renvela. The original Renagel is the hydrochloride salt of sevelamer... Renvela is a carbonate salt. Both work equally well to bind phosphates in the gut...and will cost about the same. The carbonate salt is an acid buffer...the hydrochloride is not. Therefore Renvela might help reduce the risk of acidosis. Keep in mind that Renagel will still be available for now. Watch for potential mix-ups with Renagel and Renvela...the names are very similar and the dosing is the same.

9 General Comments on Antacids Gavison and Algicon are intended for the treatment GERD (lower neutralizing capacity) Separate administration of Rx meds and antacids by 2 hrs. iron, levodopa, quinolones, tetracyclines ketoconazole – needs lower pH for absorption Can cause decrease activity of anticoagulants, digoxin, phenothiazines, tetracylines as well Gavison and Algicon are intended for the treatment GERD (lower neutralizing capacity) Separate administration of Rx meds and antacids by 2 hrs. iron, levodopa, quinolones, tetracyclines ketoconazole – needs lower pH for absorption Can cause decrease activity of anticoagulants, digoxin, phenothiazines, tetracylines as well PG 407

10 Which of the following agents is NOT an effective treatment for peptic ulcer disease? a. nizatidine b. calcium carbonate c. cetirizine d. omeprazole e. pantoprazole Which of the following agents is NOT an effective treatment for peptic ulcer disease? a. nizatidine b. calcium carbonate c. cetirizine d. omeprazole e. pantoprazole

11 Which of the following agents is NOT an effective treatment for peptic ulcer disease? a. nizatidine (Axid) b. calcium carbonate (Tums) c. cetirizine (Zyrtec) d. omeprazole (Prilosec) e. pantoprazole (Protonix) Which of the following agents is NOT an effective treatment for peptic ulcer disease? a. nizatidine (Axid) b. calcium carbonate (Tums) c. cetirizine (Zyrtec) d. omeprazole (Prilosec) e. pantoprazole (Protonix)

12 OTC H 2 -Antagonists & PPI Cimetidine (Tagamet), famotidine (Pepcid), ranitidine (Zantac), nizatidine (Axid) all have OTC status dosing – half of RX dose interactions with cimetidine are significant Pepcid Complete – famotidine + calcium carbonate + magnesium hydroxide provides rapid relief (CaCO3 and MgOH) plus sustained acid suppression Omeprazole (Prilosec OTC) 20 mg daily before a meal for 14 days Cimetidine (Tagamet), famotidine (Pepcid), ranitidine (Zantac), nizatidine (Axid) all have OTC status dosing – half of RX dose interactions with cimetidine are significant Pepcid Complete – famotidine + calcium carbonate + magnesium hydroxide provides rapid relief (CaCO3 and MgOH) plus sustained acid suppression Omeprazole (Prilosec OTC) 20 mg daily before a meal for 14 days PG 407

13 Laxatives

14 Drugs known to cause constipation Antacids (calcium and aluminum) Anticholinergics Anticonvulsants Antidepressants (TCAs) Beta-blockers Calcium Channel Blockers (verapamil) Diuretics Iron Opiates (stimulant laxative is a must) Clonidine Methyldopa Antacids (calcium and aluminum) Anticholinergics Anticonvulsants Antidepressants (TCAs) Beta-blockers Calcium Channel Blockers (verapamil) Diuretics Iron Opiates (stimulant laxative is a must) Clonidine Methyldopa PG 409

15 Laxatives Classified into 5 categories bulk-forming emollient lubricants saline stimulants Categories have advantages/disadvantages. Recognize abuse potential w/all laxatives Classified into 5 categories bulk-forming emollient lubricants saline stimulants Categories have advantages/disadvantages. Recognize abuse potential w/all laxatives PG 407

16 Bulk Forming Good initial choice; mild action products swell and provide bulk for stool formation onset is hrs., must take full glass of H 2 O psyllium - Metamucil, Citracel, Fibercon cellusoses calcium polycarbophil Mitrolan and Equilactin can be used for constipation or diarrhea used in the treatment of IBS Good initial choice; mild action products swell and provide bulk for stool formation onset is hrs., must take full glass of H 2 O psyllium - Metamucil, Citracel, Fibercon cellusoses calcium polycarbophil Mitrolan and Equilactin can be used for constipation or diarrhea used in the treatment of IBS PG 410

17 Emollients (stool softeners) Used in patients w/severe HTN and cardiovascular disease, post-hemorrhoidal surgery act as a surfactant to soften stool Limits straining docusate (Colace) most common available in combination with a stimulant docusate + senna (Peri-colace) docusate + danthron (Doxidan) Used in patients w/severe HTN and cardiovascular disease, post-hemorrhoidal surgery act as a surfactant to soften stool Limits straining docusate (Colace) most common available in combination with a stimulant docusate + senna (Peri-colace) docusate + danthron (Doxidan) PG 408

18 Lubricants Sometimes used in elderly patients also can act to soften stools mineral oil most commonly used disadvantage: impairs absorption of fat-soluble vitamins (A,D,E,K) aspiration risk in debilitated elderly – pneumonia avoid in pregnant women or patients on warfarin Sometimes used in elderly patients also can act to soften stools mineral oil most commonly used disadvantage: impairs absorption of fat-soluble vitamins (A,D,E,K) aspiration risk in debilitated elderly – pneumonia avoid in pregnant women or patients on warfarin PG 408

19 Saline Laxatives Used for acute bowel evacuation acts by osmotic pressure to increase water in intestines/colon Examples: magnesium sulfate/citrate (Epsom salts) – avoid in renal impairment Phosphate salts (Fleets Phospho-soda) – have high sodium levels Lactulose (Chronulose) – also used in hepatic failure Sorbitol rapid onset of action – dont go far from home Used for acute bowel evacuation acts by osmotic pressure to increase water in intestines/colon Examples: magnesium sulfate/citrate (Epsom salts) – avoid in renal impairment Phosphate salts (Fleets Phospho-soda) – have high sodium levels Lactulose (Chronulose) – also used in hepatic failure Sorbitol rapid onset of action – dont go far from home PG 409

20 Stimulants Used alone or combination with other categories stimulates GI motility glycerin suppositories – dual action of stimulant and lubricant Senna (Senokot, Ex-Lax) bisacodyl (Dulcolax) acts on colon, action in 6-10 hours when given PO, min rectally enteric coated to prevent stomach irritation (avoid with milk and antacids) castor oil – too strong, not recommended Used alone or combination with other categories stimulates GI motility glycerin suppositories – dual action of stimulant and lubricant Senna (Senokot, Ex-Lax) bisacodyl (Dulcolax) acts on colon, action in 6-10 hours when given PO, min rectally enteric coated to prevent stomach irritation (avoid with milk and antacids) castor oil – too strong, not recommended PG 409

21 Cold and Allergy Products Classes of Agents to Know Antihistamines Decongestants Antitussives Expectorants Analgesics / Antipyretics Very many brand names, very few ingredients See top selling list on page 412 NyQuil, Robitussin, Dimetap, Claritin, Sudafed, Classes of Agents to Know Antihistamines Decongestants Antitussives Expectorants Analgesics / Antipyretics Very many brand names, very few ingredients See top selling list on page 412 NyQuil, Robitussin, Dimetap, Claritin, Sudafed, PG 410

22 Antihistamines Block H-1 receptors, decrease smooth muscle response to histamine Active Ingredients brompheniramine – Dimetapp, Dimetane chlorpheniramine – Chlor-Trimeton clemastine – Tavist (D w / pseudoephedrine) diphenhydramine – Benadryl Loratadine – Claritin & Alavert Cetirizine - Zyrtec Counseling Points may cause drowsiness, CNS stimulation in children anticholingeric effects (dry mouth, tachycardia, urinary retention) can be problematic in elderly patients, BPH narrow angle glaucoma Block H-1 receptors, decrease smooth muscle response to histamine Active Ingredients brompheniramine – Dimetapp, Dimetane chlorpheniramine – Chlor-Trimeton clemastine – Tavist (D w / pseudoephedrine) diphenhydramine – Benadryl Loratadine – Claritin & Alavert Cetirizine - Zyrtec Counseling Points may cause drowsiness, CNS stimulation in children anticholingeric effects (dry mouth, tachycardia, urinary retention) can be problematic in elderly patients, BPH narrow angle glaucoma PG 410

23 Decongestants Stimulate alpha-adrenergic receptors, causing vasoconstriction of blood vessels Active Ingredients phenylephrine – Neo-Synephrine drops/spray oxymetazoline or Xylometazoline – Afrin spray caution patients on overuse and secondary rebound congestion – do not use for more than 3-5 consecutive days pseudoephedrine – Sudefed, given po, 30-60mg q6h ; available in numerous combinations Use with caution in patients with HTN Cromolyn nasal spray – mast cell stabilizer for nasal allergies and allergic rhinitis – few side effects Stimulate alpha-adrenergic receptors, causing vasoconstriction of blood vessels Active Ingredients phenylephrine – Neo-Synephrine drops/spray oxymetazoline or Xylometazoline – Afrin spray caution patients on overuse and secondary rebound congestion – do not use for more than 3-5 consecutive days pseudoephedrine – Sudefed, given po, 30-60mg q6h ; available in numerous combinations Use with caution in patients with HTN Cromolyn nasal spray – mast cell stabilizer for nasal allergies and allergic rhinitis – few side effects PG 411

24 Antitussives / Expectorants Antitussives - suppress cough reflex in the medullary cough center dextromethorphan most common codeine limited by control drug laws may cause some drowsiness Delsym has dextromethorphan alone - longer acting formulation Expectorants thin mucous secretions in bronchioles guaifenesin is only one available counsel patients to consume large amounts of water Robitussin +/- DM, Benylin, Mucinex Antitussives - suppress cough reflex in the medullary cough center dextromethorphan most common codeine limited by control drug laws may cause some drowsiness Delsym has dextromethorphan alone - longer acting formulation Expectorants thin mucous secretions in bronchioles guaifenesin is only one available counsel patients to consume large amounts of water Robitussin +/- DM, Benylin, Mucinex PG 411 Trade Names: Robitussin DM, Naldecon, Dimetapp, PediaCare, Vicks, Triaminic, Benylin

25 Analgesics Background on pain highly subjective, individualized symptom numerous potential causes organic pain – pathologic disturbance psychogenic pain – emotional disturbance somatic pain – from musculoskeletal system or skin visceral pain – from organs, especially the stomach Internal analgesics most effective for: Headache, neuralgia, myalgia, arthralgia, RA Available agents APAP, ASA, ibuprofen, naproxen, ketoprofen Background on pain highly subjective, individualized symptom numerous potential causes organic pain – pathologic disturbance psychogenic pain – emotional disturbance somatic pain – from musculoskeletal system or skin visceral pain – from organs, especially the stomach Internal analgesics most effective for: Headache, neuralgia, myalgia, arthralgia, RA Available agents APAP, ASA, ibuprofen, naproxen, ketoprofen PG 413

26 Analgesics (cont.) Aspirin (ASA) Available as 81mg, 325mg, EC, mg for CVD, mg TID for pain, high dose for inflammation, RA avoid use in young children (Reye Syndrome) Acquired encephalopathy in young children (infantcy-19 years) Acetaminophen (APAP) 325mg, 500mg (extra strength), 650mg (max 4grms/day) no anti-inflammatory liver damage w/high dose, long-term, avoid alcohol, warfarin interaction Non-steroidal Anti-inflammatory Agents (NSAIDs) ibuprofen 200mg, naproxen 220mg, ketoprofen 12.5mg avoid if GI disorders, frail elderly, kidney disease Aspirin (ASA) Available as 81mg, 325mg, EC, mg for CVD, mg TID for pain, high dose for inflammation, RA avoid use in young children (Reye Syndrome) Acquired encephalopathy in young children (infantcy-19 years) Acetaminophen (APAP) 325mg, 500mg (extra strength), 650mg (max 4grms/day) no anti-inflammatory liver damage w/high dose, long-term, avoid alcohol, warfarin interaction Non-steroidal Anti-inflammatory Agents (NSAIDs) ibuprofen 200mg, naproxen 220mg, ketoprofen 12.5mg avoid if GI disorders, frail elderly, kidney disease PG 415

27 External Analgesics Used to treat local pain, itching from insect bites, burns, muscle soreness Anesthetics benzocaine 5% - 20% and lidocaine 2% Anti-inflammatory hydrocortisone 0.5 – 1%, diphenhydramine 1-2% Counterirritants methyl salicylate (Ben gay), menthol, camphor, eucalyptus capsaicin (inhibits substance P) – postherpetic neuralgia; use continously, wash hands thoroughly, do not cover Used to treat local pain, itching from insect bites, burns, muscle soreness Anesthetics benzocaine 5% - 20% and lidocaine 2% Anti-inflammatory hydrocortisone 0.5 – 1%, diphenhydramine 1-2% Counterirritants methyl salicylate (Ben gay), menthol, camphor, eucalyptus capsaicin (inhibits substance P) – postherpetic neuralgia; use continously, wash hands thoroughly, do not cover PG 415

28 OTCs Continued Sleep Aid Products diphenydramine – note: Tylenol PM Doxylamine (Unisom and in Nyquil) be aware of many other products with antihistamines do not use for long term; caution side effects Not intended for kids <12 Not to be taken with alcohol Sunscreen Agents Sun Protection Factor = exposure time with skin protection exposure time without SPF of 15 should protect all day although reapplication is recommended if swimming, sweating, ect. Para-aminobenziod acid (PABA) 5% usual level Most common Sleep Aid Products diphenydramine – note: Tylenol PM Doxylamine (Unisom and in Nyquil) be aware of many other products with antihistamines do not use for long term; caution side effects Not intended for kids <12 Not to be taken with alcohol Sunscreen Agents Sun Protection Factor = exposure time with skin protection exposure time without SPF of 15 should protect all day although reapplication is recommended if swimming, sweating, ect. Para-aminobenziod acid (PABA) 5% usual level Most common PG 416

29 A patient who is experiencing a runny nose, sneezing, headache and watery eyes should be counseled to take which of the following OTC agents? I. diphenhydramine II. acetaminophen III. pseudoephedrine a. I only b. III only c. I and II only d. II and III only e. I, II, and III A patient who is experiencing a runny nose, sneezing, headache and watery eyes should be counseled to take which of the following OTC agents? I. diphenhydramine II. acetaminophen III. pseudoephedrine a. I only b. III only c. I and II only d. II and III only e. I, II, and III

30 A patient who is experiencing a runny nose, sneezing, headache and watery eyes should be counseled to take which of the following OTC agents? I. diphenhydramine II. acetaminophen III. pseudoephedrine a. I only b. III only c. I and II only d. II and III only e. I, II, and III A patient who is experiencing a runny nose, sneezing, headache and watery eyes should be counseled to take which of the following OTC agents? I. diphenhydramine II. acetaminophen III. pseudoephedrine a. I only b. III only c. I and II only d. II and III only e. I, II, and III

31 Antidiarrheals Causes of diarrhea microbes, drugs, IBS, colitis, foods Consultation w/ MD Duration >2 days, children <3y/o, fever or blood in stool Agents Adsorbants (water and toxins) – Kaopectate, pepto-bismol, (bismuth) Bulking agents – calcium polycarbophil (Fibercon, Fiberall) Antiperistaltic agents – loperamide (Immodium 2mg) 2mg tabs, 1mg/5ml (Regimen – 4mg immediately, then 2mg until loose bowel movement) Reestablish normal flora – lactobacillus acidophilus (Lactinex) reseed the bowel, supress pathogenic organisms---KEEP REFRIGERATED Rehydrating solutions – Pedialyte, Infalyte Causes of diarrhea microbes, drugs, IBS, colitis, foods Consultation w/ MD Duration >2 days, children <3y/o, fever or blood in stool Agents Adsorbants (water and toxins) – Kaopectate, pepto-bismol, (bismuth) Bulking agents – calcium polycarbophil (Fibercon, Fiberall) Antiperistaltic agents – loperamide (Immodium 2mg) 2mg tabs, 1mg/5ml (Regimen – 4mg immediately, then 2mg until loose bowel movement) Reestablish normal flora – lactobacillus acidophilus (Lactinex) reseed the bowel, supress pathogenic organisms---KEEP REFRIGERATED Rehydrating solutions – Pedialyte, Infalyte PG 417

32 OTC Agents (cont.) Calcium Supplements Important for women to supplement, esp. post-menopausal or those taking drugs for osteoporosis Rec. doses: 50: mg/d Calcium carbonate (Oscal, Caltrate) taken with food, requires acidic environment for absorption in stomach Calcium citrate (Citracal) taken w/ or w/o, better absorbed in elderly patients who have reduced stomach acid secretion DONT FORGET VIT D Head Lice Products (parasites) Permethrin (Nix) – caution if allergy to chrysanthemums Pyrethrins (A-200, Rid, Pronto) – avoid if allergic to ragweed Wash hair without conditioner Leave on hair 10 minutes May repeat in 1 week Must comb out nits Calcium Supplements Important for women to supplement, esp. post-menopausal or those taking drugs for osteoporosis Rec. doses: 50: mg/d Calcium carbonate (Oscal, Caltrate) taken with food, requires acidic environment for absorption in stomach Calcium citrate (Citracal) taken w/ or w/o, better absorbed in elderly patients who have reduced stomach acid secretion DONT FORGET VIT D Head Lice Products (parasites) Permethrin (Nix) – caution if allergy to chrysanthemums Pyrethrins (A-200, Rid, Pronto) – avoid if allergic to ragweed Wash hair without conditioner Leave on hair 10 minutes May repeat in 1 week Must comb out nits PG 423

33 Premenstrual Syndrome Products Analgesics – Reduce synthesis of prostaglandins Antihistamines – Pyrilamine - acts on smooth muscles and reduce production of prolactin Diuretic – Reduce bloating Ammonium Chloride, caffeine, pamabrom Combination Products Aqua Ban, Midol, Midol PMS, Pamprin, Sunril Analgesics – Reduce synthesis of prostaglandins Antihistamines – Pyrilamine - acts on smooth muscles and reduce production of prolactin Diuretic – Reduce bloating Ammonium Chloride, caffeine, pamabrom Combination Products Aqua Ban, Midol, Midol PMS, Pamprin, Sunril PG 425

34 Dietary Supplements NAPLEX PG 427

35 Dietary Supplements - Definitions Complimentary and Alternative Medicine Medicine practices not considered conventional Includes herbal therapy, chiropractic, acupuncture, homeopathy, biofeedback Dietary Supplements Any product intended for ingestion as a supplement to the diet Includes herbal supplements, vitamins, minerals Herbal Supplements medicinal and pharmacological effects Plant derived dietary supplements reported to have medicinal and pharmacological effects Complimentary and Alternative Medicine Medicine practices not considered conventional Includes herbal therapy, chiropractic, acupuncture, homeopathy, biofeedback Dietary Supplements Any product intended for ingestion as a supplement to the diet Includes herbal supplements, vitamins, minerals Herbal Supplements medicinal and pharmacological effects Plant derived dietary supplements reported to have medicinal and pharmacological effects PG 426

36 Regulatory Process Industry began to take off in late-1980s herbal product use expanded, health concerns arose FDA began scrutinizing companies in early 90s consumers and the industry demanded the right to take and sell these dietary supplements wrote letters to Congress to campaign against regulations FDA gave in and passed DSHEA of 1994 Dietary Health and Education Act Industry began to take off in late-1980s herbal product use expanded, health concerns arose FDA began scrutinizing companies in early 90s consumers and the industry demanded the right to take and sell these dietary supplements wrote letters to Congress to campaign against regulations FDA gave in and passed DSHEA of 1994 Dietary Health and Education Act

37 Dietary Supplement Health and Education Act of 1994 Categorized herbals, vitamins, protein bars, shakes as dietary supplements manufacturers are not required to demonstrate safety, purity or efficacy of supplements labeling must include FDA statement: Statement not evaluated by FDA, not intended to diagnose, treat, cure or prevent disease products cannot have specific claims on labels use phrases like helps boost, support, enhance… FDA can pull products if suspected unsafe Ephedra and Ma Huang Categorized herbals, vitamins, protein bars, shakes as dietary supplements manufacturers are not required to demonstrate safety, purity or efficacy of supplements labeling must include FDA statement: Statement not evaluated by FDA, not intended to diagnose, treat, cure or prevent disease products cannot have specific claims on labels use phrases like helps boost, support, enhance… FDA can pull products if suspected unsafe Ephedra and Ma Huang PG 426

38 DSHEA of Limitations Safety is reactive, not proactive; limited safety information available Available studies are small and poorly designed; a wide variety of products are not available in the US There are no standards for manufacturing practices; labeled amounts and ingredients may be inaccurate The FDA is considering imposing a requirement for good manufacturing practices (GMPs) for all dietary supplements. Safety is reactive, not proactive; limited safety information available Available studies are small and poorly designed; a wide variety of products are not available in the US There are no standards for manufacturing practices; labeled amounts and ingredients may be inaccurate The FDA is considering imposing a requirement for good manufacturing practices (GMPs) for all dietary supplements. PG 426

39 The Top 20 Dietary Supplements Glucosamine/Chondroitin Echinacea Ginkgo biloba Ginseng Saw palmetto Fish oil St Johns Wort Garlic Melatonin Coenzyme Q10 Glucosamine/Chondroitin Echinacea Ginkgo biloba Ginseng Saw palmetto Fish oil St Johns Wort Garlic Melatonin Coenzyme Q10 Cranberry Feverfew Ginger Milk thistle Soy isoflavones Black cohosh Valerian Hawthorn SAM-e MSM PG 426

40 GlucosamineGlucosamine Not an herbal; glycoprotein derived from marine exoskeletons or synthetically active compounds: glucosamine itself;(HCL or SO 4 ) Proposed Uses treatment of osteoarthritis; used in combination w/ chondroitin mechanism of action Glucosamine stimulates metabolism of chondrocytes in articular cartilage; preventing cartilage breakdown and potential regrowth Chondroitin believed to serve as substrate for production of joint matrix substances (minimally absorbed) dosing 500mg TID, (w/ mg of chondroitin) Not an herbal; glycoprotein derived from marine exoskeletons or synthetically active compounds: glucosamine itself;(HCL or SO 4 ) Proposed Uses treatment of osteoarthritis; used in combination w/ chondroitin mechanism of action Glucosamine stimulates metabolism of chondrocytes in articular cartilage; preventing cartilage breakdown and potential regrowth Chondroitin believed to serve as substrate for production of joint matrix substances (minimally absorbed) dosing 500mg TID, (w/ mg of chondroitin) PG 426

41 Glucosamine/Chondroitin - Safety Few common or serious ADRs reported GI, n/v, HA, drowsiness, similar to placebo Interactions antidiabetic drugs - decreased effect anticoagulants w/chondroitin Caution in DM, HTN, Hyperlipidemia Caution in shellfish allergy Few common or serious ADRs reported GI, n/v, HA, drowsiness, similar to placebo Interactions antidiabetic drugs - decreased effect anticoagulants w/chondroitin Caution in DM, HTN, Hyperlipidemia Caution in shellfish allergy PG 428

42 Glucosamine/Chondroitin - Efficacy Osteoarthritis Widely studied w/most trials demonstrating benefits shown to reduce pain and joint stiffness studied against low-moderate dose NSAIDs pain benefits modest but significant Reginster et al. - effect on disease progression 106 pts. w/knee OA treated for 3 years with 1500mg/day vs. 106 pts. on placebo endpoints: radiographic changes, joint-narrowing results: -0.06mm tx. vs. –0.31mm placebo, also symptom improvements Osteoarthritis Widely studied w/most trials demonstrating benefits shown to reduce pain and joint stiffness studied against low-moderate dose NSAIDs pain benefits modest but significant Reginster et al. - effect on disease progression 106 pts. w/knee OA treated for 3 years with 1500mg/day vs. 106 pts. on placebo endpoints: radiographic changes, joint-narrowing results: -0.06mm tx. vs. –0.31mm placebo, also symptom improvements Reginster JY et al. Lancet 2001; 357: PG 428

43 Glucosamine/Chondroitin - Efficacy Some important counseling points requires 4-6 weeks of tx. for benefits to be seen not for PRN use, must continually use the sulfate salt is recommended, also some controversy on combo w/chondroitin May confer benefits unlike other OA treatments cost is an issue, should insurance pay for it? Some important counseling points requires 4-6 weeks of tx. for benefits to be seen not for PRN use, must continually use the sulfate salt is recommended, also some controversy on combo w/chondroitin May confer benefits unlike other OA treatments cost is an issue, should insurance pay for it? PG 426

44 EchinaceaEchinacea Extracts of E. purpurea and E. angustifolia active compounds: several active constituents Proposed Uses treating and preventing the common cold and URIs immunostimulant for treatment of infections mechanism of action some direct antiviral activity, stimulates lymphocyte activity, increases phagocytosis, also antifungal activity dosing 300mg TID for 7-14 days, must start at first sign of sxs. 6-9ml of E. purpurea juice daily Extracts of E. purpurea and E. angustifolia active compounds: several active constituents Proposed Uses treating and preventing the common cold and URIs immunostimulant for treatment of infections mechanism of action some direct antiviral activity, stimulates lymphocyte activity, increases phagocytosis, also antifungal activity dosing 300mg TID for 7-14 days, must start at first sign of sxs. 6-9ml of E. purpurea juice daily PG 429

45 Echinacea- Safety Adverse Effects allergic reactions, rash fever, n/v a number of case reports of allergic reactions Drug Interactions Immunosuppressants may interfere w/therapy May inhibit CYP450 enzymes (CYP3A4) avoid in pts. w/ autoimmune disorders Adverse Effects allergic reactions, rash fever, n/v a number of case reports of allergic reactions Drug Interactions Immunosuppressants may interfere w/therapy May inhibit CYP450 enzymes (CYP3A4) avoid in pts. w/ autoimmune disorders PG 427

46 Echinacea – Efficacy Prevention of colds/flu – benefits unclear Grimm et al. Prevention w/ E.purpurea juice 109 pts. w/>3 colds in prev. year 4ml juice or placebo BID x 8 weeks infx. rate: 65% vs. 74% (tx. vs. placebo) no statistical benefit vs. placebo Turner et al. Prevention of experimental colds No statistical difference in infection or illness rates vs. placebo, but trend toward benefit w/Echinacea Prevention of colds/flu – benefits unclear Grimm et al. Prevention w/ E.purpurea juice 109 pts. w/>3 colds in prev. year 4ml juice or placebo BID x 8 weeks infx. rate: 65% vs. 74% (tx. vs. placebo) no statistical benefit vs. placebo Turner et al. Prevention of experimental colds No statistical difference in infection or illness rates vs. placebo, but trend toward benefit w/Echinacea Grimm et al. Am J Med 1999;106: Turner et al. Antimicrob Agents Chemother 2000;44: PG 427

47 Echinacea – Efficacy Treatment of cold and flu Overall data suggests modest reductions in duration and severity of symptoms studies varied in preparations used All initiated therapy at first sign of symptoms improvements seen on subjective symptoms severity and duration questionnaires reduction in duration of approx. 1-2 days Treatment of cold and flu Overall data suggests modest reductions in duration and severity of symptoms studies varied in preparations used All initiated therapy at first sign of symptoms improvements seen on subjective symptoms severity and duration questionnaires reduction in duration of approx. 1-2 days Barrett et al. J Fam Pract 1999;48: PG 427

48 Gingko Biloba Extract derived from leaves of tree active compounds: flavonoids, terpenoids Proposed Uses conditions assoc. w/cerebral vascular insufficiency Alzheimers dementia, memory loss, vertigo, tinnitus Others: intermittent claudication, motion sickness mechanism of action antioxidant activity, decrease blood viscosity (inhibits platelet activation factor (PAF)), improve circulatory flow dosing mg of leaf extract day/divided doses Extract derived from leaves of tree active compounds: flavonoids, terpenoids Proposed Uses conditions assoc. w/cerebral vascular insufficiency Alzheimers dementia, memory loss, vertigo, tinnitus Others: intermittent claudication, motion sickness mechanism of action antioxidant activity, decrease blood viscosity (inhibits platelet activation factor (PAF)), improve circulatory flow dosing mg of leaf extract day/divided doses PG 429

49 Gingko Biloba - Safety Adverse Effects Few common or serious ADRs documented mild GI upset, constip. Dizziness, HA high doses: diarrhea, restlessness, bleeding? Drug Interactions** Anticoagulants, antiplatelet agents inhibits platelet activation factor (PAF) May inhibit CYP450 enzymes inhibits 1A2, 2D6; induce or inhibit 3A4 Caution in diabetes patients, epileptics Adverse Effects Few common or serious ADRs documented mild GI upset, constip. Dizziness, HA high doses: diarrhea, restlessness, bleeding? Drug Interactions** Anticoagulants, antiplatelet agents inhibits platelet activation factor (PAF) May inhibit CYP450 enzymes inhibits 1A2, 2D6; induce or inhibit 3A4 Caution in diabetes patients, epileptics PG 427

50 Gingko Biloba – Efficacy Dementia: Alzheimers or vascular meta-analysis in 1998: 50 studies identified, only 4 met criteria ( 212 pts. total, 3-6 mos. in duration) fairly consistent improvements in cognitive function shown (ADAS-Cog.) may delay progression Memory Improvement some improvements in short-term memory and cognition in adults w/o dementia Vertigo, Claudication few positive studies Dementia: Alzheimers or vascular meta-analysis in 1998: 50 studies identified, only 4 met criteria ( 212 pts. total, 3-6 mos. in duration) fairly consistent improvements in cognitive function shown (ADAS-Cog.) may delay progression Memory Improvement some improvements in short-term memory and cognition in adults w/o dementia Vertigo, Claudication few positive studies Oken et al. Arch Neurol. 1998;55: PG 427

51 GinsengGinseng Extract from plant root; three types (American, Asian** (Panax), Siberian) active compounds: ginsenosides Proposed Uses (panax ginseng) adaptogen (increases resistance to stress), improve immune function, general tonic to improve energy mechanism of action wide range of possible effects, stimulate immune cells, affect adrenal gland secretion, increase cortisol levels, many others dosing 200mg – 600mg/day in capsule form, also in tea form Extract from plant root; three types (American, Asian** (Panax), Siberian) active compounds: ginsenosides Proposed Uses (panax ginseng) adaptogen (increases resistance to stress), improve immune function, general tonic to improve energy mechanism of action wide range of possible effects, stimulate immune cells, affect adrenal gland secretion, increase cortisol levels, many others dosing 200mg – 600mg/day in capsule form, also in tea form PG 429

52 Ginseng - Safety Rare but potentially serious ADRs reported short term < 3 mos., insomnia, edema, HTN tachycardia Steven-Johnson syndrome avoid long-term use as may increase ADRs Interactions anticoagulants (warfarin, ASA); bleeding risk antidiabetic drugs; increased effect immunosuppresants; reduced effect may inhibit CYP2D6 caution in DM, cardiac dz., insomnia Rare but potentially serious ADRs reported short term < 3 mos., insomnia, edema, HTN tachycardia Steven-Johnson syndrome avoid long-term use as may increase ADRs Interactions anticoagulants (warfarin, ASA); bleeding risk antidiabetic drugs; increased effect immunosuppresants; reduced effect may inhibit CYP2D6 caution in DM, cardiac dz., insomnia PG 429

53 Ginseng - Efficacy Meta-analysis by Vogler et al. 16 trials met inclusion criteria most were poor in quality numerous indications studied (energy/exercise capacity, mood, immune function, memory) few beneficial effects seen vs. placebo Probably not the energy pill people want it to be in low-doses, probably wont hurt or help (placebo effect) Meta-analysis by Vogler et al. 16 trials met inclusion criteria most were poor in quality numerous indications studied (energy/exercise capacity, mood, immune function, memory) few beneficial effects seen vs. placebo Probably not the energy pill people want it to be in low-doses, probably wont hurt or help (placebo effect) PG 428

54 Saw Palmetto Extract of fruit from native American tree active compounds: multiple fatty acid compounds Proposed Uses treatment of symptoms of benign prostatic hypertrophy, prostate CA, alopecia? mechanism of action appears to competitively inhibit 5-alpha reductase, preventing conversion of testosterone to dihydrotestosterone, leading to shrinking of prostate –think finasteride (Proscar), dutasteride (Avodart) also has anti-inflammatory process dosing 160mg bid of extract containing 80-90% fatty acids Extract of fruit from native American tree active compounds: multiple fatty acid compounds Proposed Uses treatment of symptoms of benign prostatic hypertrophy, prostate CA, alopecia? mechanism of action appears to competitively inhibit 5-alpha reductase, preventing conversion of testosterone to dihydrotestosterone, leading to shrinking of prostate –think finasteride (Proscar), dutasteride (Avodart) also has anti-inflammatory process dosing 160mg bid of extract containing 80-90% fatty acids PG 428

55 Saw Palmetto - Safety Few common or serious ADRs reported dizziness, n/v/d sexual dysfunction (meta-analysis findings) –0.7% placebo –1.1% saw palmetto –4.9% finasteride Drug Interactions few noted additive effect or ADRs w/finasteride? hormone therapy does not affect PSA levels Few common or serious ADRs reported dizziness, n/v/d sexual dysfunction (meta-analysis findings) –0.7% placebo –1.1% saw palmetto –4.9% finasteride Drug Interactions few noted additive effect or ADRs w/finasteride? hormone therapy does not affect PSA levels PG 428

56 Saw Palmetto - Efficacy Benign Prostatic Hypertrophy Overall data suggests benefits multiple studies up to 48 wks have shown significant improvement in urinary symptoms (nocturia, urine flow) does not appear to affect prostate size symptomatic effects seem comparable to finasteride, less than alpha-blockers –not studied head-to-head w/alpha-blockers Benign Prostatic Hypertrophy Overall data suggests benefits multiple studies up to 48 wks have shown significant improvement in urinary symptoms (nocturia, urine flow) does not appear to affect prostate size symptomatic effects seem comparable to finasteride, less than alpha-blockers –not studied head-to-head w/alpha-blockers PG 430

57 Fish Oil Derived from fatty fish (salmon, sardine, trout) EPA and DHA are essential fatty acids Rx prescription – Omacor change to Lovaza Proposed uses: heart disease, hypertriglyceridemia Mechanism of action: competes with arachidonic acid in the COX and lipoxygenase pathways Dosing: 1 g qd (CHD); 2-4 g/d for TGs Derived from fatty fish (salmon, sardine, trout) EPA and DHA are essential fatty acids Rx prescription – Omacor change to Lovaza Proposed uses: heart disease, hypertriglyceridemia Mechanism of action: competes with arachidonic acid in the COX and lipoxygenase pathways Dosing: 1 g qd (CHD); 2-4 g/d for TGs PG 430

58 Fish Oil - Safety Most common Fishy aftertaste, GI intolerance, loose stools, belching (dose-related) Allergies to fish protein not fish oil Drug interactions Anticoagulants Antiplatelets Increase bleeding risk Does not appear to affect INR Most common Fishy aftertaste, GI intolerance, loose stools, belching (dose-related) Allergies to fish protein not fish oil Drug interactions Anticoagulants Antiplatelets Increase bleeding risk Does not appear to affect INR PG 431

59 Fish Oil - Efficacy Prevention of CHD Retrospective and prospective studies suggest benefits, especially in high-risk patients Hypertriglyceridemia Studies suggest 25-30% reductions in triglycerides with use of higher doses Small increase in LDL and HDL also seen Flaxseed Oil - Also point out that the omega-3s in flaxseed and some nuts are different than the ones in fish. They contain alpha- linolenic acid (ALA) which is the precursor of EPA and DHA. But the amount of EPA and DHA the body converts from ALA is minimal. Diets high in these foods MIGHT help decrease heart disease...but NOT triglycerides. Prevention of CHD Retrospective and prospective studies suggest benefits, especially in high-risk patients Hypertriglyceridemia Studies suggest 25-30% reductions in triglycerides with use of higher doses Small increase in LDL and HDL also seen Flaxseed Oil - Also point out that the omega-3s in flaxseed and some nuts are different than the ones in fish. They contain alpha- linolenic acid (ALA) which is the precursor of EPA and DHA. But the amount of EPA and DHA the body converts from ALA is minimal. Diets high in these foods MIGHT help decrease heart disease...but NOT triglycerides. PG 431

60 St. Johns Wort (SJW) Extract from buds, leaves & flowers of hypericum perforatum active compounds: hypericin, hyperforin Proposed Uses treatment of mild to moderate depression mechanism of action hypericin inhibits COMT & MAO, hyperforin modulates effects of serotonin, inhibits reuptake of various neurotransmitters dosing 300mg TID of extract standardized to 0.3% hypericin content; other doses studies Extract from buds, leaves & flowers of hypericum perforatum active compounds: hypericin, hyperforin Proposed Uses treatment of mild to moderate depression mechanism of action hypericin inhibits COMT & MAO, hyperforin modulates effects of serotonin, inhibits reuptake of various neurotransmitters dosing 300mg TID of extract standardized to 0.3% hypericin content; other doses studies PG 431

61 St. Johns Wort - Safety Some adverse effects reported gastrointestinal, dry mouth, restlessness / insomnia more common also vivid dreams, agitation, mania, dizziness, skin rash, photosensitivity reported ADR profile similar to TCAs, fewer cardiac effects unsafe at high doses Drug Interactions all antidepressants, triptans; Induces CYP450; reduce levels of cyclosporine, HIV meds, OCs, CBZ, warfarin Caution in bipolar, schizophrenia, Alzheimer's Some adverse effects reported gastrointestinal, dry mouth, restlessness / insomnia more common also vivid dreams, agitation, mania, dizziness, skin rash, photosensitivity reported ADR profile similar to TCAs, fewer cardiac effects unsafe at high doses Drug Interactions all antidepressants, triptans; Induces CYP450; reduce levels of cyclosporine, HIV meds, OCs, CBZ, warfarin Caution in bipolar, schizophrenia, Alzheimer's PG 431

62 St. Johns Wort - Efficacy Mild to Mod. Depression widely studied in Europe most evidence suggests as effective as low dose TCAs, possibly as effective as SSRIs recent study reported no benefit; however pts. had more severe depression depression in NOT like the common cold ; self-tx. not safe in my mind Mild to Mod. Depression widely studied in Europe most evidence suggests as effective as low dose TCAs, possibly as effective as SSRIs recent study reported no benefit; however pts. had more severe depression depression in NOT like the common cold ; self-tx. not safe in my mind PG 431

63 Garlic : Cholesterols natural enemy? Tasty spice used heavily in Italian cuisine active compounds: alliin, allicin Proposed Uses hyperlipidemia, hypertension, prevention of atherosclerosis mechanism of action may act as an HMG-CoA reductase inhibitor, may vasodilate and relax smooth muscle, release NO may also reduce oxidation of LDL, inhibit platelet function dosing 600mg – 1200mg in divided doses for HTN, hyperlipidemia –4-6 cloves of wholes garlic/day most trials used garlic powder extract (1.3% alliin) Tasty spice used heavily in Italian cuisine active compounds: alliin, allicin Proposed Uses hyperlipidemia, hypertension, prevention of atherosclerosis mechanism of action may act as an HMG-CoA reductase inhibitor, may vasodilate and relax smooth muscle, release NO may also reduce oxidation of LDL, inhibit platelet function dosing 600mg – 1200mg in divided doses for HTN, hyperlipidemia –4-6 cloves of wholes garlic/day most trials used garlic powder extract (1.3% alliin) PG 431

64 Garlic - Safety Safe w/the exception of social side-effects GI, heartburn, n/v, BAD BREATH Drug Interactions antidiabetic medications risk of hypoglycemia anticoagulants (warfarin, ASA) can increase INR and bleeding risk induces CYP3A4 cyclosporine, saquinivir, OCs Safe w/the exception of social side-effects GI, heartburn, n/v, BAD BREATH Drug Interactions antidiabetic medications risk of hypoglycemia anticoagulants (warfarin, ASA) can increase INR and bleeding risk induces CYP3A4 cyclosporine, saquinivir, OCs PG 430

65 Garlic - Efficacy Hyperlipidemia Meta-analysis by Stevinson et. al in 2002 –13 of 39 trials met inclusion criteria –796 pts., 8-24 wks, 900mg/day most common –overall reduction of 16mg/dl in TC (6% dec.) –small, non-significant changes in LDL, HDL long-term clinical CV benefits unknown Hypertension 7.7 mmHg reduction in SBP after 4 weeks Hyperlipidemia Meta-analysis by Stevinson et. al in 2002 –13 of 39 trials met inclusion criteria –796 pts., 8-24 wks, 900mg/day most common –overall reduction of 16mg/dl in TC (6% dec.) –small, non-significant changes in LDL, HDL long-term clinical CV benefits unknown Hypertension 7.7 mmHg reduction in SBP after 4 weeks Stevinson et. al. Ann Intern Med 2000;133:420-9 Silagy CA et al. J Hypertens 1994;12:463-8 PG 432

66 Melatonin Not an herbal; hormone that control circadian rhythm and sleep-wake cycle Proposed use: treatment of insomnia, jet lag Mechanism of action: stimulates binding of GABA in the CNS; leading to neuroinhibitory effects Dosing: Insomnia: doses range from mg hs Jet lag: mg on day of arrival and continued for 2-5 days Not an herbal; hormone that control circadian rhythm and sleep-wake cycle Proposed use: treatment of insomnia, jet lag Mechanism of action: stimulates binding of GABA in the CNS; leading to neuroinhibitory effects Dosing: Insomnia: doses range from mg hs Jet lag: mg on day of arrival and continued for 2-5 days PG 432

67 Melatonin - Safety Appears safe for short-term use (<2 mo) ADRs Fatigue, drowsiness, anxiety, dizziness Avoid driving within 4-5 hours Drug interactions Medications with CNS depressant effects May increasae BP and impair blood sugar control Potential antiplatelet effects Appears safe for short-term use (<2 mo) ADRs Fatigue, drowsiness, anxiety, dizziness Avoid driving within 4-5 hours Drug interactions Medications with CNS depressant effects May increasae BP and impair blood sugar control Potential antiplatelet effects PG 432

68 Melatonin - Efficacy Insomnia Results are mixed; may improve sleep quality, especially in elderly subjects; may not increase sleep duration Jet lag May reduce symptoms of jet lag when dosed appropriately; efficacy results mixed Insomnia Results are mixed; may improve sleep quality, especially in elderly subjects; may not increase sleep duration Jet lag May reduce symptoms of jet lag when dosed appropriately; efficacy results mixed PG 432

69 Which of the following herbal products does not have the potential to interact with anticoagulant / antiplatelet agents? a. gingko biloba b. ginseng c. garlic d. saw palmetto e. feverfew Which of the following herbal products does not have the potential to interact with anticoagulant / antiplatelet agents? a. gingko biloba b. ginseng c. garlic d. saw palmetto e. feverfew

70 Which of the following herbal products does not have the potential to interact with anticoagulant / antiplatelet agents? a. gingko biloba b. ginseng c. garlic d. saw palmetto e. feverfew Which of the following herbal products does not have the potential to interact with anticoagulant / antiplatelet agents? a. gingko biloba b. ginseng c. garlic d. saw palmetto e. feverfew

71 Coenzyme Q10 Also not an herbal; substance found in all cells active compounds: a.k.a. ubiquinone Proposed Uses Treatment of congestive heart failure, angina, HTN mechanism of action found in higher concentrations in cells of heart, liver, lungs; has powerful antioxidant activity also serves as a co-factor for ATP in oxidative resp., appears to be beneficial in condition assoc. w/low levels of CoQ10 (CHF) dosing 100mg /day in divided doses (50mg BID ) Also not an herbal; substance found in all cells active compounds: a.k.a. ubiquinone Proposed Uses Treatment of congestive heart failure, angina, HTN mechanism of action found in higher concentrations in cells of heart, liver, lungs; has powerful antioxidant activity also serves as a co-factor for ATP in oxidative resp., appears to be beneficial in condition assoc. w/low levels of CoQ10 (CHF) dosing 100mg /day in divided doses (50mg BID ) PG 433

72 Coenzyme Q10 - Safety Few common or serious ADRs reported very rare GI adverse effects noted Drug Interactions warfarin; reduced effect due to similarity to vit. K; antineoplastics; may protect tumor cells synergistic effects w/ anti-HTNs Statins lower CoQ10 levels; clinical signif. not known caution; LFTS, HTN Few common or serious ADRs reported very rare GI adverse effects noted Drug Interactions warfarin; reduced effect due to similarity to vit. K; antineoplastics; may protect tumor cells synergistic effects w/ anti-HTNs Statins lower CoQ10 levels; clinical signif. not known caution; LFTS, HTN PG 433

73 Coenzyme Q10 - Efficacy Treatment of congestive heart failure conflicting data a number of trials have shown benefits in QOL, symptoms, hosp. Rates (poor design) Khatta et al. – more severe disease (class III,IV) –no benefit seen in EF or exercise tolerance in 55 pts. treated for 6 months possibly consider in mild/moderate CHF in pts. already on optimal Rx therapy Angina, Hypertension Minimal benefits seen Treatment of congestive heart failure conflicting data a number of trials have shown benefits in QOL, symptoms, hosp. Rates (poor design) Khatta et al. – more severe disease (class III,IV) –no benefit seen in EF or exercise tolerance in 55 pts. treated for 6 months possibly consider in mild/moderate CHF in pts. already on optimal Rx therapy Angina, Hypertension Minimal benefits seen Tran MT et al. Pharmacotherapy 2001;21: Khatta M et al. Ann Intern Med 2000;132: PG 431

74 ResourcesResources Facts and Comparison: Review of Natural Products good general info., poor on dosing PDR for Herbal Medicines Hard to find unless you know plant names German Commission E Monographs monographs are not referenced, lack substance Natural Medicine Comprehensive Database THE BEST, updated, referenced, thorough Costly ($132.00, book plus 1 year online) www. naturaldatabase.com Facts and Comparison: Review of Natural Products good general info., poor on dosing PDR for Herbal Medicines Hard to find unless you know plant names German Commission E Monographs monographs are not referenced, lack substance Natural Medicine Comprehensive Database THE BEST, updated, referenced, thorough Costly ($132.00, book plus 1 year online) www. naturaldatabase.com

75 When taken orally, all of the following drugs may cause discoloration of soft-contact lenses EXCEPT: a. rifampin b. ferrous gluconate c. tetracycline d. phenazopyridine e. estrogens When taken orally, all of the following drugs may cause discoloration of soft-contact lenses EXCEPT: a. rifampin b. ferrous gluconate c. tetracycline d. phenazopyridine e. estrogens

76 When taken orally, all of the following drugs may cause discoloration of soft-contact lenses EXCEPT: a. rifampin b. ferrous gluconate c. tetracycline d. phenazopyridine e. estrogens When taken orally, all of the following drugs may cause discoloration of soft-contact lenses EXCEPT: a. rifampin b. ferrous gluconate c. tetracycline d. phenazopyridine e. estrogens

77 Which of the following drugs does NOT have significant activity against motion sickness? a. cyclizine b. dimenhydrinate c. diphenhydramine d. meclizine e. pyrilamine Which of the following drugs does NOT have significant activity against motion sickness? a. cyclizine b. dimenhydrinate c. diphenhydramine d. meclizine e. pyrilamine

78 Which of the following drugs does NOT have significant activity against motion sickness? a. Cyclizine (Marezine) - antihistamine b. Dimenhydrinate – (Dramaine) – H1 blocks c. Diphenhydramine – Benadryl – H1 blocks d. Meclizine – (Bonine) – blocks chemoreptor trigger zone e. Pyrilamine – H1 antagonsit Which of the following drugs does NOT have significant activity against motion sickness? a. Cyclizine (Marezine) - antihistamine b. Dimenhydrinate – (Dramaine) – H1 blocks c. Diphenhydramine – Benadryl – H1 blocks d. Meclizine – (Bonine) – blocks chemoreptor trigger zone e. Pyrilamine – H1 antagonsit

79 Which of the following is the best therapeutic substitution for Robitussin AC? a. Robitussin b. Robitussin CF c. Robitussin DAC d. Robitussin DM e. Robitussin PE Which of the following is the best therapeutic substitution for Robitussin AC? a. Robitussin b. Robitussin CF c. Robitussin DAC d. Robitussin DM e. Robitussin PE

80 Which of the following is the best therapeutic substitution for Robitussin AC? a. Robitussin b. Robitussin CF c. Robitussin DAC d. Robitussin DM e. Robitussin PE Which of the following is the best therapeutic substitution for Robitussin AC? a. Robitussin b. Robitussin CF c. Robitussin DAC d. Robitussin DM e. Robitussin PE

81 Oxymetazoline acts as a nasal decongestant by: a. Causing a local anesthetic action b. Blocking at the synaptic ganglia c. Constricting blood vessels by alpha- adrenergic stimulation d. Dilating blood vessels by beta-adrenergic stimulation e. Blocking muscarinic receptors Oxymetazoline acts as a nasal decongestant by: a. Causing a local anesthetic action b. Blocking at the synaptic ganglia c. Constricting blood vessels by alpha- adrenergic stimulation d. Dilating blood vessels by beta-adrenergic stimulation e. Blocking muscarinic receptors

82 Oxymetazoline acts as a nasal decongestant by: a. Causing a local anesthetic action b. Blocking at the synaptic ganglia c. Constricting blood vessels by alpha- adrenergic stimulation d. Dilating blood vessels by beta-adrenergic stimulation e. Blocking muscarinic receptors Oxymetazoline acts as a nasal decongestant by: a. Causing a local anesthetic action b. Blocking at the synaptic ganglia c. Constricting blood vessels by alpha- adrenergic stimulation d. Dilating blood vessels by beta-adrenergic stimulation e. Blocking muscarinic receptors

83 Ingredients in Mylanta include: I. Aluminum hydroxide II. Magnesium hydroxide III. Calcium carbonate a. I only b. III only c. I and II only d. II and III only e. I, II, and III Ingredients in Mylanta include: I. Aluminum hydroxide II. Magnesium hydroxide III. Calcium carbonate a. I only b. III only c. I and II only d. II and III only e. I, II, and III

84 Ingredients in Mylanta include: I. Aluminum hydroxide II. Magnesium hydroxide III. Calcium carbonate a. I only b. III only c. I and II only d. II and III only e. I, II, and III Ingredients in Mylanta include: I. Aluminum hydroxide II. Magnesium hydroxide III. Calcium carbonate a. I only b. III only c. I and II only d. II and III only e. I, II, and III

85 A pharmacist should caution a patient purchasing the dietary supplement glucosamine plus chondroitin if he/she is allergic to which of the following: I. Bisulfites II. Eggs III. Shellfish a. I only b. III only c. I and II only d. II and III only e. I, II, and III A pharmacist should caution a patient purchasing the dietary supplement glucosamine plus chondroitin if he/she is allergic to which of the following: I. Bisulfites II. Eggs III. Shellfish a. I only b. III only c. I and II only d. II and III only e. I, II, and III

86 A pharmacist should caution a patient purchasing the dietary supplement glucosamine plus chondroitin if he/she is allergic to which of the following: I. Bisulfites II. Eggs III. Shellfish a. I only b. III only c. I and II only d. II and III only e. I, II, and III A pharmacist should caution a patient purchasing the dietary supplement glucosamine plus chondroitin if he/she is allergic to which of the following: I. Bisulfites II. Eggs III. Shellfish a. I only b. III only c. I and II only d. II and III only e. I, II, and III

87 Concurrent administration of antacids will increase the plasma level of: I. levodopa II. ciprofloxacin III. warfarin a. I only b. III only c. I and II only d. II and III only e. I, II, and III Concurrent administration of antacids will increase the plasma level of: I. levodopa II. ciprofloxacin III. warfarin a. I only b. III only c. I and II only d. II and III only e. I, II, and III

88 Concurrent administration of antacids will increase the plasma level of: I. levodopa II. ciprofloxacin III. warfarin a. I only b. III only c. I and II only d. II and III only e. I, II, and III Concurrent administration of antacids will increase the plasma level of: I. levodopa II. ciprofloxacin III. warfarin a. I only b. III only c. I and II only d. II and III only e. I, II, and III

89 An ingredient available in OTC products for the eradication of pinworms is: a. miconazole b. polycarbophil c. pyrantel pamoate d. phenazopyridine e. valerian An ingredient available in OTC products for the eradication of pinworms is: a. miconazole b. polycarbophil c. pyrantel pamoate d. phenazopyridine e. valerian

90 An ingredient available in OTC products for the eradication of pinworms is: a. miconazole b. polycarbophil c. pyrantel pamoate d. phenazopyridine e. valerian An ingredient available in OTC products for the eradication of pinworms is: a. miconazole b. polycarbophil c. pyrantel pamoate d. phenazopyridine e. valerian

91 Which of the following is an/are active ingredient(s) in Childrens Dimetapp ND? a. brompheniramine b. brompheniramine and pseudoephedrine c. loratadine d. phenylephrine e. pseudoephedrine Which of the following is an/are active ingredient(s) in Childrens Dimetapp ND? a. brompheniramine b. brompheniramine and pseudoephedrine c. loratadine d. phenylephrine e. pseudoephedrine

92 Which of the following is an/are active ingredient(s) in Childrens Dimetapp ND? a. brompheniramine b. brompheniramine and pseudoephedrine c. loratadine d. phenylephrine e. pseudoephedrine Which of the following is an/are active ingredient(s) in Childrens Dimetapp ND? a. brompheniramine b. brompheniramine and pseudoephedrine c. loratadine d. phenylephrine e. pseudoephedrine

93 THANKS!!!!!


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