OTC Exam 2 Study Guide

Nutrition/Vitamins: Klucken
Understand importance of nutrition and reasons for supplementation What is the preferred source of nutrients? Food Why? Better absorption What are the risks of nutritional deficiencies? Compromised growth and development Contribute to chronic diseases Exacerbate aging process What are some of the dangers of supplementation? Delay medical care Risk of ADRs with exceeding recommended intake Drug-nutrient interactions List various etiologies of nutritional deficiency What is the stages that causes of nutritional deficiencies? Inadequate intake Decreased absorption Increased metabolic requirements Medications Lack of knowledge Inadequate synthesis or absorption Depletion of nutrient stores Biochemical changes Physical manifestations of deficiency Morbidity and mortality

Be familiar with supplement dosing and labeling What is the intent of supplementation? Maintain present status Prevent deficiencies Replenish compromised stores Treat medical conditions What are the four DRI categories? EAR: Estimated ave (half) requirements RDA: reference daily intake AI: adequate intake (lacks data) UL: tolerable upper intake What is the importance of supplement labeling? Indicates %DV List three problems that result because supplements are not regulated by the FDA. Potential disparity of contents vs. label Do not require proof of safety or efficacy Do not require inspection of production What does USP labeling indicate has been verified? Ingredients and amounts Effective disintegration and dissolution for absorption Absence of harmful contaminants Safe, sanitary, well-controlled manufacturing

Appreciate diverse clinical presentation of various deficiencies What are the difficulties identifying nutritional deficiencies? symptoms not present until deficiency occurs symptoms overlap with other deficiencies What are the stages of evolution of nutritional deficiency?

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OTC Exam 2 Study Guide

VITAMIN DEFICIENCIES
Condition Vitamin A Deficiency Symptoms Night Blindness (usually first symptom) Dry/hardening of the skin Infections Cause Excess excretion of Vit A Fat Malabsorption (little absorption of fat due to drugs or condition) Non-Pharm Treatment Natural Sources of Vitamin A Pharmacological Vitamin A Supplement (Must be medically diagnosed) Refer for any vitamin A deficiency because OTC supplement without diagnosis is only intended to: Maintain present status Prevent deficiency Replenish compromised stores (not intended for self-treatment of vitamin deficiencies_ Vitamin D Supplement (Must be medically diagnosed) Refer for any vitamin D deficiency because OTC supplement without diagnosis is only intended to: Maintain present status Prevent deficiency Replenish compromised stores (not intended for self-treatment of vitamin deficiencies)

Vitamin D Deficiency

Rickets Osteoporosis Muscle Weakness Increased Risk of Falls Colon, prostate, breast cancer

Inadequate intake GI Disease Chronic Renal Failure Inadequate sunlight Long-term Phenytoin Therapy Liver/Kidney Dysfunction

Natural Sources of Vitamin D

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Vitamin E Deficiency

Neurological Abnormalities Muscle pain, ache, cramp, numbness or sense of fatigue (intermittent claudication) Muscle weakness Hemolytic anemia

OTC Exam 2 Study Guide Premature, low birth weight Fat Malabsorption

Natural Sources of Vitamin E

Vitamin K Deficiency

Unusual Bleeding Prolonged PT (time it takes for blood clot to form) Osteoporotic Fractures

Reduction in gut flora that produces Vit K Malabsorption syndromes Bowel resections Liver Disease Antibiotic therapy

Natural Sources of Vitamin K

*DO NOT TAKE WITHOUT PHYSICIAN DIAGNOSIS* Vitamin E Supplement (Must be medically diagnosed) Refer for any vitamin E deficiency because OTC supplement without diagnosis is only intended to: Maintain present status Prevent deficiency Replenish compromised stores (not intended for self-treatment of vitamin deficiencies) Vitamin k Supplement (Must be medically diagnosed) Refer for any vitamin k deficiency because OTC supplement without diagnosis is only intended to: Maintain present status Prevent deficiency Replenish compromised stores (not intended for self-treatment of vitamin deficiencies)

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Vitamin C Deficiency

Vitamin B12 Deficiency

Fatigue Capillary Hemorrhages Swollen/Bleeding Gums Bone Changes Scurvy (vitamin C deficiency) Macrocytic Anemia Neurologic Symptoms Macrocytic anemia Neurologic Symptoms Neural tube defects Pellagra (Niacin deficiency) Dermatitis Diarrhea Dementia Beriberi (Thiamin Deficiency) Neuromuscular symptoms: peripheral neuritis, weakness Wernickles encephalopathy Cardiac Dysfunction Lack of coordination Nystagmus (Dancing eyes) Confusion Bone deformities Osteomalacia Convulsions

OTC Exam 2 Study Guide Inadequate intake of perishables (fruits and vegetables)

Natural Source of Vitamin C

Vitamin C Supplement

Folic Acid Deficiency

Malabsorpion Atrophic gastritis (inflammation of stomach mucosa) Malabsorption Alcoholism Liver Disease Malnourishment (diet high in corn) Alcoholism

Natural Source of Vitamin B12 Natural Source of Folic Acid Reduce amount of alcohol from diet Natural source of niacin Reduce amount of alcohol from diet

Vitamin B12 Supplement

Folic Acid Supplement

Niacin Deficiency

Niacin Supplement (try not to recommend this supplement, use nonpharm) Thiamin Supplement

Thiamin Deficiency

Inadequate Diet Alcoholism Prolonged Diarrhea

Natural Source of Thiamin Reduce alcohol

Calcium Deficiency

Malabsorption Hypoparathyroidism Vit D Deficiency Renal Failure

Natural Source of Calcium

Calcium Supplement

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Iron Deficiency

Iron Deficiency Anemia (IDA) Pallor(pale appearance) Fatigue Neuromuscular iriitability Increase CNS stimulation: Delirum and convulsions Hypocalcemia and Hypokalemia (low potassium) cannot be corrected unless Magnesium is within normal levels

Magnesium Deficiency

OTC Exam 2 Study Guide Blood Loss Malabsorption Inadequate diet Erythropoietin (EPO) w/o iron supplementation GI losses Renal losses

Natural Source of Calcium

Iron Supplement

Natural Sources of Magnesium

Magnesium Supplement

OTC SUPPLEMENTS
Drug Vitamin A Retinoids: retinol Carotenoids: alphacarotene, beta-carotene) Natural Sources Dark green vegetables Red, Orange, or deep yellow vegetables and fruits Liver, Liver fat, egg yolk Indication Normal Growth and Development Bone development Proper organ function Eye health Epithelial cell mucous secretions Dosing Not Important for this exam Interactions Warfarin: increase in anticoagulation Cholestyramine, colestipol, mineral oil: decrease absorption of Vitamin A Exclusion Anyone who is on blood thinners Smokers have an increased risk of cancer,CVD, and death w/ Beta-Carotene People at risk for bone fractures Pregnancy: increase risk of birth defect/liver abnormalities

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Vitamin D Cholecalciferol (D3) naturally occurring Ergocalciferol (D2) food additive Calcitriol Active form of Vit D that aids in absorption of calcium Natural Sources UV Light Milk, egg yolk, liver, salmon, tuna, sardines, milk fat Vitamin E Tocopherols Tocotrienols Natural Sources Wheat germ Vegetable Oils Margarine Green Leafy Vegetables Milk Fat Egg Yolk Nuts

Proper bone/mineral formation Increase calcium and phosphate absorption Improves renal reabsorption of calcium Maintains serum calcium and phosphorous levels

OTC Exam 2 Study Guide 600-800 IU/day Max Dose: 4000 IU /day (100mcg/day) (1mcg = 40 IU Vitamin D)

Phenytoin, carbamazepine, barbituates: increase metabolism of Vit D Cholestyramine, colestipol, mineral oil: decrease absorption of Vit D

Patients at risk of hypercalcemia Patient at risk of kidney stones Patient at risk of renal failure Patients with cancer

Antioxidant Hemebiosynthesis (Creates heme groups which carry oxygen) Steroid metabolism Collagen formation Prevents stretch marks

15mg/day Max Dose: 1000mg/day **@ 400 IU/day can cause death in some patients**

Warfarin: Increase coagulation Cholestyramine, colestipol, mineral oil: decrease absorption of Vit E

Do not take without medical referral Patients @ risk of Chronic Heart Failure (CHF) Patients @ risk of hemorrhagic stroke May cause fetal loss

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Vitamin K Phytonadione (K1) vegetables Menaquinone (K2) Product of bacterial metabolism (produced in the gut) Menadione (K3) synthetic (3x potency) Natural Sources Liver Vegetable Oil Spinach Kale Cabbage cauliflower Vitamin C Ascorbic Acid Natural Sources Green & Red Peppers Broccoli Spinach Tomatoes Potatoes Strawberries Citrus Fruits Kiwi

Promotes the synthesis of clotting factors Activates clotting factors Activate coagulation protein C & S Activation of osteocalcin - bone mineralization

OTC Exam 2 Study Guide Not needed for this exam

Warfarin: Decreased anticoagulation Broad Spectrum Antibiotics reduce vitamin K via gut Flora Vit A & E: reduce vit K activity Cholestyramine, colestipol, mineral oil:Decreased absorption of Vit K

Do not take if you are on blood thinners **NEED DOCTOR EVALUATION IF YOU ARE AT RISK FOR STROKE OR CHF**

Reducing agent Help absorption of nonheme iron (ferric -> ferrous) Claims to prevent and treat common cold (unsupported)

Not important for this exam

Cholestyramine, colestipol, mineral oil:Decreased absorption of Vit C

Rare side effects: Nausea, stomach cramps, diarrhea, nephrolithiasis Creates acidic urine

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Vitamin B12 Cobalamin Cyanobalamin (Pharmaceutic Form most stable) Natural Sources Liver Meat Poultry Oysters Clams Dairy Products Folic Acid Folate Folic Acid (Synthetic: better absorption) Natural Sources Liver Lean Beef Wheat Whole Grain Eggs Fish Dry

Bone marrow CNS GI Tract Fat Protein Carbohydrate Metabolism DNA synthesis Folate Metabolism Myelin Formation DNA Synthesis RBC Maturation

OTC Exam 2 Study Guide Not important for this exam

***Metformin***, colchicine, anticonvulsants, ascorbic acid, antacids, antibiotics: Decreased absorption of Vit B12

N/A

400mcg/day (1g/day treatment) **Recommended for women of child-bearing age in addition to dietary intake due to the fact it is too late to take it by the time you find out your pregnant**

Dihydrofolate reductase inhibitors antibiotic (methotrexate, trimethoprim): Decreased absorption/activity

N/A

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Niacin Nicotinic Acid (Vitamin B3) Natural Sources Lean Meats Fish Liver Poultry Grains Eggs Peanuts Milk Legumes

Aerobic Respiration (etransfer agent) Lower Triglycerides (TG) and LDL (Bad Cholesterol) Increase HDL (Good Cholesterol) **only effective @ high doses which can cause other side effects**

OTC Exam 2 Study Guide Not important in this exam

Hypoglycemic: decreases effect of hypoglycemic medication Probenacid (Gout): decreases the effect of probenacid

Thiamin Vitamin B1 Natural Sources Legumes Whole grain/cereal/bread Wheat Germ Pork Beef

Myocardial Function Nerve Cell Function Carbohydrate Function

Amount of thiamine needed is associated with the amount of carb intake

Diuretics: Increased excretion

Do not take if you have low blood sugar levels Do not take if you are taking Gout medication May worsen asthma Do not use if you have peptic ulcer disorder may cause GI upset Causes flashing warming of the skin can be treated with aspirin 325mg if taken prior to niacin RISK OF HEPATOXICITY Do not take if you are at risk for Liver problems Patients who are on diuretics

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Calcium Calcium (40%) Carbonate 650mg: depends on stomach acid Calcium (21%) Citrate 950mg:No effect on stomach acid, do not need to take w/ food Calcium (9%) Gluconate 500mg Calcium (18%) Lactate 650mg Natural Sources Dairy Products Sardines Clams Oysters Turnip Greens Mustard greens

Bone and Teeth formation Regulates muscle contraction and relaxation

OTC Exam 2 Study Guide 1000-1200mg/day Max Dose 2-3g/Day Calcium (40%) Carbonate 650mg: 4 tabs = 1g Calcium (21%) Citrate 950mg: 5 tabs = 1g Calcium (9%) Gluconate 500mg: 22 tabs = 1g Calcium (18%) Lactate 650mg: 12 tabs = 1g **you need 500mg per dose is the most optimal dose**

Corticosteroids, antacids: Decrease absorption of calcium

Levothyroxine: decrease absorption of levothyroxine Tetracyclines (Doxycycline, Minocycline) & Fluoroquinolones (Cipro, Levofloxacin, Ofloxacin, Macrolides) : Decrease absorption of antibiotic

Do not take calcium carbonate if you have achlorhydria (gastric acid is low in the stomach) Do not take calcium if you are on antibiotics that require acidic stomach environment Do not take calcium if you have thyroid disorder

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Iron Ferric = not absorbable Ferrous = absorbable Ferrous (%) salt: amount of salt/amount of iron Ferrous (20%) sulfate 325mg/65mg Ferrous (33%) fumarate 60mg/20mg Ferrous (12%) gluconate 225mg/27mg Natural Source Liver Meat (well-absorbed) Egg Yolk Legumes (poorly absorbed) Whole or enriched grains Magnesium Natural Source Whole-grain cereal Tofu Nuts Legumes Green vegetables

Regulation oxygen and electron transport

OTC Exam 2 Study Guide Take 200mg of Ascorbic Acid (Vitamin C) for every 30mg of elemental iron to help absorption Take with food (food decreases absorption of iron by 50%)

Antacids: decreased absorption of iron

Levothyroxine: decrease absorption of levothyroxine Tetracyclines (Doxycycline, Minocycline) & Fluoroquinolones (Cipro, Levofloxacin, Ofloxacin, Macrolides) : Decrease absorption of antibiotic

May cause GI Upset (take w/ food) Constipation Black Tarry Stools (be careful if you are susceptible to GI bleeds since you will not be able to distinguish when it is occurring) DO not take if you are taking levothyroxine Do not take if you are on antibiotics that needed acidic stomach acid **VERY TOXIC TO CHILDREN**

Bone structure formation Enzymatic function Nerve Muscle electrical potential

Not needed for this exam

Levothyroxine: decrease absorption of levothyroxine Tetracyclines (Doxycycline, Minocycline) & Fluoroquinolones (Cipro, Levofloxacin, Ofloxacin, Macrolides) : Decrease absorption of antibiotic

Do not take if you are taking levothyroxine Do not take If you are taking antibiotics that require acidic environment Can cause diarrhea Patient at risk of hypermagnesemia w/ renal failure

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OTC Exam 2 Study Guide

Obesity/Nutrition Dearing
How do you calculate BMI? What diets are not recommended and why? Crash Diet: too low in caloric intake (<800Kcal/day) Atkins Diet: Too low in carbs and high in protein cardiac problems Slim Fast 3-2-1 Plan: too low of caloric intake, too rapid of weight loss and added sugar Nutrisystem or Jenny Craig: food taste like cardboard and most expensive

What is a common problem about herbal products being used for diet? **Prolly wont need to know this for test** Chromium: No supporting evidence o DDI: Hypoglycemic agents, levothyroxine (77 other drugs) Bitter Orange: No supporting evidence o DDI: Stimulant and inhibitor of CYP 450 3A4 substrate MAOIs, midazolam, Nardil, Parnate (MAJOR!) Caffeine, dextromethorphan, felodipine, indinavir (moderate) St. Johns Wort: No supporting evidence o DDI: Inducer of CYP 450 3A4 Alprazolam, amitriptyline, birth control, cyclosporine, digoxin, Gleevac (MAJOR!) Ginseng: No supporting evidence o DDI: Warfarin, digoxin, alcohol, pheneizine Green Tea: No supporting evidence Pyruvate: Conflicting evidence Chitosan: Conflicting evidence o DDI: Warfarin (Moderate) Dandelion: Insufficient evidence

Overestimates of non-Hispanic blacks, edematous (swelling or enlargement of body parts) patients, body builders, patients with muscle wasting, vertically challenged patients Underestimate in Asian populations Must measure waist circumference

When do you REFER? Severe Obesity (BMI is greater or equal to 40) Pregnancy or Breast Feeding Less than 18 years of age or greater than 65 years of age History of Cardiovascular disease, dyslipidemia, diabetes, or Hypertension Eating Disorders

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Condition Obesity

Symptoms Cardiovascular Diabetes Osteoarthritis/Joint Disease Cancer Sleep Apnea Polycystic Ovary Syndrome Erectile Dysfunction Irregular Menses or Infertility Psychosocial

OTC Exam 2 Study Guide Cause Genetic Environmental (Primary): Reduce physical activity + abundant food supply Medical Condition Medication: anticonvulsants, antidepressants, antipsychotics, hormone Race/Ethnicity Socioeconomics and Educational Achievement Age Dose/Directions N/A

Nonpharm Treatment At least 30 minutes of moderate exercise most days of the week 400Kcal burn per day in women Weight Bearing exercise Support system Eat off 9 dinner plate Change diet to reduce daily caloric intake by 500-1000 caloris per day (equates to 1-2lbs weight-loss per week) Change in occupation

Pharmacological Weight Watchers Mediterranean Diet Orlistat (Alli) Sensa SlimScents Psyllium

Treatment Weight Watchers Easy to use Online tools Point Based system (if you dont use your points you lose them NO SAVING!) Mediterranean Diet Healthy diet with splash of olive oil and red wine 9% reduction in mortality 11% Cardiovascular risk reduction 5% neoplastic (new growths) disease

Indication Safe and healthy lifestyle change for weight loss

Interactions N/A

Exclusion N/A

Safe and healthy lifestyle change for weight loss

N/A

N/A

N/A

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Orlistat Lipase inhibitor Inhibits the absorption of dietary fats

Long-term weight loss management aid Need to accompany a change to healthier diet (low in fat) and exercise Expected weight-loss of 5-10 lbs within 6 months May also lower LDL cholesterol and blood pressure 6 month weight loss system Does not need to change diet or starve themselves Two monthly containers shipped to patients and new blend of tastants per month Three pens that are rotated constantly Does not require patients to eat special meals or starve themselves

OTC Exam 2 Study Guide 60mg TID Take within 1 hour of eating a meal (if meal does not contain fat the omit dose) MVI to be taken 4-6 hours after or 2-4 hrs prior to taking orlistat

Vit ADEK: decrease absorption of Vit ADEK Lipophillic Drugs (amiodarone,valproic acids): may affect efficacy of lipophilic drugs

Sensa Tastants that trick your brain and stomach into thinking you are full through sense of smell

Sprinkle on any food you eat

N/A

Patient taking warfarin due to decrease in vitamin K absorption Patients with osteoporosis due to decrease in vitamin D absorption Patients with gallbladder problems Chronic malabsorption syndrome May cause GI upset if fatty foods are ingested Expensive patients may not be able to afford

SlimScents Dietary pens that are inhaled through nose before meals

Psyllium **FIBER** Non-digestible carb and lignin (fiber) Favorable effects on obesity, and improved lipid and hypertension control

Inhale gently three times in EACH nostril 5-6 minutes before you eat and 5-10 minutes after you eat OR everytime you feel the least bit hungry Sniff at least 10 times in each nostril per day 20-38 gram per day

N/A

Expensive patients may not be able to afford A little bit more expensive than sense

Hypoglycemic agents: may affect efficacy of hypoglycemic agents

N/A

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OTC Exam 2 Study Guide

Menstruation/PMS/Contraception Masters
What is the Mentrual Cycle? Menarche: First period ~ 12 years old Average cycle last 28 days 30-80mL of blood loss Ovulation occur on Day 14 of the cycle Product that MAY help PMS Caffeine/Pamabron Ammonium Chloride Chastetree Berry 20-40mg ZE440 Extract Most studied likely effective Black Cohosh 4080mg BID Do not take if you have these conditions PUD, Anxiety/insomnia Renal or liver impairment Hormonesensitive cancers, Invitro fertilization (increase fertility) Hormonesensitive cancers Alzheimers disease, bipolar disorder, schizophrenia, infertility Do not take if you are on these drugs MAOI, xanthine meds Oral contraceptives, hormone therapy, dopamine agonists & antagonists

Referrals for Dysmonorrhea Severe dysmenorrhea and/or menorrhagia (abnormal, heavy, prolonged menstrual period at regular intervals) Dysmenorrhea symptoms are inconsistent with primary dysmenorrhea (onset after age of 25, and dysmenorrhea pain at times other than onset of menses) History of Pelvic inflammatory disease (PID), infertility, irregular menstrual cycles, endometriosis (cell from uterus grows in other parts of the body) and ovarian cysts Use of intrauterine decides (IUD) Allergy to aspirin or NSAIDs; intolerance to NSAIDs Active GI Disease (PUD, GERD, Ulcerative colitis) Bleeding Disorders

Referrals for PMS Severe PMS or PMDD (Premenstrual dysphoric disorder: severe form of PMS) Uncertain pattern of symptoms (timing in relationship to menses), particularly for emotional/psychological symptoms Onset of symptoms coincident with use of Oral Contraceptives hormone therapy Contraindication to specific agents

Chemotherapy agents (doxorubicin, docetaxol) Antidepressants (SSRI, TCA St. Johns wort or MAOI), narcotic analgesics, OTC digoxin, dextromethorphan, antidepressant Oral contraceptives, warfarin, AIDS drugs Anticoagulants and Ginkgo helps antiplatelet agents, insulin, with breast pain seizure threshold-lowering and fluid retention drugs, thiazide diuretics ***Lactating women should not use herbals*** Natural Family Planning **NOT LISTED ON OBJECTIVES** Calendar method/cycle beads Basal body temperature: slight increase @ ovulation due to LH surge Cervical/Saliva changes: Peak fertility cervical mucus thins leaf pattern in saliva test Symptothermal method Lactational Amenorrhea Method: Exclusively breast feeding decrease likelihood of pregnancy within 6 months of giving birth Ovulation Prediction Test: Detects LH Surge

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OTC Exam 2 Study Guide Condition Primary Dysmenorrhea Symptoms Cyclic pain at onset of menstruation Cramping Nausea/Vomiting Fatigue Weakness Nervousness Dizziness Diarrhea Headache Cause Prostaglandins and leukotrienes lead to strong uterine contraction and vasoconstrictions Nonpharm Treatment Sleep Hot Bath Heating Pads **very effective** Exercise Reduce exposure to smoke Loose clothing Pharmacological NSAIDs **First line** o Ibuprofen o Naproxen Acetaminophen **Second Line** o Minimal effect on PG Aspirin **Not effective** o Little effect on PG (less than acetaminophen) o Increases menstrual flow** Midol Acetaminophen physical symptoms NSAIDs for physical symptoms Pamprin Pyridoxin Vitamin B6 Vitamin E 400 IU/day for breast tenderness Calcium 600mg BID Magnesium helps irritability Diuretics ** no use because PMS is fluid distribution NOT fluid retention* o Ammonium Chloride o Caffeine o Pamabrom

Prementrual Syndrome

Physical Symptoms o Fatigue o Abdominal bloating o Breast tenderness o Appetite changed/food cravings o Headache o GI upset Emotional Symptoms o Irritability o Sadness o Anger o Depression o Anxiety o Oversensitivity o Nervousness

Cyclic disorder physical and emotion changes during luteal phase Hormone levels: estrogen and progesterone Serotonin involvement

Education Dietary modifications (reduce simple sugars and salty foods) Exercise Stress management

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Toxic Shock Syndrome Severe multisystem illness inflammatory response to enterotoxin produced by bacteria

Occurs within 2 days of onset of menses, during menses or withing 2 days after menses MOST DISTINCT AND REQUIRED FOR DX: Rash: Sunburn like and does not itch ~ 10day for onset o Desquamation of palms and soles High Fever flu like symptoms

OTC Exam 2 Study Guide Tampons Contraceptive barrier (sponge) Bacteria can be on hands Topical Oral Contraceptives Caused by S. aureous and S. pyogenes

Prevention: use of sanitary pads Use low absorbency tampons Wash hands before use of tampons Follow directions on tampons box Do not leave tampon in overnight for longer than 8 hours During the day do not use for more than 6 hours Interactions Alcohol: increase risk of bleeding Anticoagulants: increased risk of bleeding Phenytoin: increase phenytoin levels Aspirin: decrease antiplatelet effect (take aspirin 30 mins before or 8 hours after) Alcohol: increase risk of hepatotoxicity Warfarin: increased INR levels

REFER: THERE IS NO OTC TREATMENT DO NOT USE NSAID: Worsens the disease process

Drug NSAIDs: prostaglandin inhibitor Ibuprofen 200-400mg Naproxen 220-440mg

Indication Physical symptoms of PD and PMS Anti-inflammatory First line of therapy for Primary Dysmenorrhea

Dosing Ibuprofen 200-400mg q 4-6H (max: 1200mg) Naproxen 220-440mg q8-12H (max: 660mg)

Acetaminophen 6501000mg

Physical symptoms for PD and PMS Little effect on prostaglandin Only used for Primary dysmenorrhea if NSAIDs cannot be taken

Acetaminophen 6501000mg q4-6h (max dose 4000mg)

Exclusion Naproxen: DO NOT USE FOR CHILDREN UNDER 12 DUE TO REYES SYNDROME Patients that are on anticoagulants **use alternate therapy** Patients who drink regularly (more than 3 drinks per day) Cannot tolerate NSAIDs Refer back to previous exam material

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Aspirin

Little effect on PG

OTC Exam 2 Study Guide Not important

n/A

Ammonium Chloride Caffeine

Pamabrom Derivative of theophylline Midol and Pamprin Acetaminophen Pamabrom Pyrilamine (antihistamine) Condoms Latex Polyurethane Lamb skin Female Condoms (DO NOT RECOMMEND WITH MALE CONDOM)

Treatment of PMS Diuretic Inhibits renal tubular reabsorption of sodium and water Diuretic: Treatment for fluid retention Treatment of PMS Diuretic Combination of pain reliever, diuretic and antihistamine

TID (max: 3g no more than 6 days) 100-200mg q3-4H

N/A

MAOI (depression meds) Xanthine (Gout Meds) Theophylline (treats asthma) MAOI (depression meds) Xanthine (Gout Meds) N/A

Last line do not use cause of increase in menstrual flow DO NOT USE IN PATIENTS UNDER 15 DUE TO REYES SYNDROME Renal or liver impairment PUD Anxiety Insomnia PUD Anxiety Insomnia N/A

50mg QID In combination products N/A

Contraception

N/A

N/A

Latex allergies -> use polyurethane or natural skin Lamb skin DOES NOT prevent STD prevention DO NOT USE OIL BASED LUBRICANTS Degrades LATEX condoms DO NOT WEAR Female condom for more than 8 hours

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Vaginal Spermicides Films Foams Gels Suppositories Todays Sponge Contraceptive Barrior Spermicide Semen absorbant

Contraception

OTC Exam 2 Study Guide Films: Need 10-15 min 3 hours to dissolve

N/A

contraception

Plan B One Step Levonorgestrel 1.5mg Approved for women of all ages DOES NOT END PREGNANCY

Emergency contraception ONLY FDA approved to work if taken within 72 hours ~ if within 120 hours would be appropriate to sell but counsel!

Plan B Generic Levonorgestrel 0.75mg TWO PILLS Available for women 17+ OTC Under 17 = RX only DOES NOT END PREGNANCY

Emergency Contraceptive ONLY FDA approved to work if taken within 72 hours ~ if within 120 hours would be appropriate to sell but counsel!

Moisten with tap water Effective IMMEDIATELY Must remain in place 6 hours AFTER intercourse Effective for 24 hours REMOVE BY 24 HOURS Take 1 pill as soon as possible after unprotected intercourse or contraception failure Most effective if taken within 3 days Should start menstrual cycle within 1 week (3 weeks if irregular) Refer if menses does not occur Take 1 tablet ASAP after unprotected intercourse or contraceptive failure Take Second dose 12 hours later Will still be effective is 2nd dose is forgotten Should start menstrual cycle within 1 week (3 weeks if irregular) Refer if menses does not occur

N/A

Does not protect against STI Increase risk of contracting HIV/AIDS due to irritability of vaginal canal More effective in women who have not given birth Increased risk of HIV and cervical infections Increase risk in TSS Does not protect against HIV/AIDS Most Common AE: o Nausea o Abdominal Pain o Fatigue o Headache DO NOT TAKE IF YOU HAVE UNDIAGNOSED VAGINAL BLEEDING Does not protect against HIV and AIDS Most Common AE: o Nausea o Abdominal Pain o Fatigue o Headache DO NOT TAKE IF YOU HAVE UNDIAGNOSED VAGINAL BLEEDING

N/A

N/A

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OTC Exam 2 Study Guide

Vaginal Infections and Atrophic Vaginitis Adams

Referral for Vaginal Infection Pregnancy Girls less than 12 years old Fever or pain is present in the lower abdomen, back, or shoulder Medications that predispose (lead) to Vaginal Candidiasis o Corticosteroids o Antineoplastics Medical disorders that can predispose to Vaginal Candidiasis o HIB o Diabetes Recurrent Vaginal Candidiasis o More than 3 vaginal infection per year or vaginal infection in the past 2 months ODOROUS DISCHARGE IS AUTOMATIC REFERRAL TO DOCTOR

What is a pH testing device and what are its limits Press application for women with normal periods DO NOT USE WHEN MENSTRUATING DO NOT URINATE OR TOUCH THE APPLICATOR Intercourse = Wait 2 days before using, Spermicide/Lubricant? = wait 3 days before using Will only tell you if you have vaginal candidiasis high pH must refer to doctor

Referral for Atrophic Vaginitis Symptoms of severe vaginal dryness or dyspareunia Symptoms that are not localized (widespread) Vaginal Dryness or dyspareunia not relieved by use of personal lubricants after 7 days

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Condition Bacterial Vaginosis

Vaginal Candidiasis

Symptoms Odor is present Thin Discharge Itchiness is uncommon pH level of vaginal fluid is high (above 4) Dysuria is not present (difficulty peeing) Dyspareunia is not present (difficulty having sex) Odor is not present Cottage cheese discharge Itchiness pH level of vaginal fluid is within normal range (3.5-4) Dysuria is present Dyspareunia is present Odor is present but may not notice Frothy Discahrge Itchiness pH level of vaginal fluid is high Dysuria is present Dyspareunia is present

OTC Exam 2 Study Guide Cause Bacterial Infection

Nonpharm Treatment Refer

Pharmacological Refer

Fungal infection

Parasitic Infection

Trichomoniasis

Decrease sucrose and refined carbs Lactobacillus acidophilus prevention of recurring VC Sodium bicarbonate sitz bath Consider switching meds that predispose VC Refer

Miconazole Butoconazole Clotrimazole Tioconazole

Refer

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Atrophic Vaginitis

Dryness Itching Irritation Burning Dyspareunia o Vaginal bleeding or spotting Decrease in vaginal lubrication Inflammation

OTC Exam 2 Study Guide Hormonal changes Menopause Postpartum/breastfeeding Radiation and chemotherapy Medications o Fertility o Chemo/Radiation Meds o Cancer o Endometriosis: uterus tissue found in other parts of the body Dosing 3 for typical patients 7 if it is a recurring 1 for noncompliant Cream for external/internal (may cause leakage) - USE SANITARY NAPKIN Suppository or Tablet for day time/internal

Oral Sex

Water Based Vaginal Lubricants during sex Symptoms when not having sex use o Monistat Soothing Care Itch Relief Cream o Monistat Soothing Care Chafing Relief Powder-Gel o Monistat Cool Wipes

Drug Miconazole Monistat - 1, 3 , 7

Indication Vaginal Candidiasis

Interactions Warfarin: can cause internal bleeding

Exclusion If patient is on warfarin then lab work must be performed within the next 1-2 days to prevent/detect internal bleeding

Butoconazole Mycelex -3 Femstat - 3

Vaginal Candidiasis

**takes 3 days to start see relief in symptoms, complete resolution by 7 days** See Above

Warfarin: can cause internal bleeding

If patient is on warfarin then lab work must be performed within the next 1-2 days to prevent/detect internal bleeding

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Clotrimazole Gynelotrimin 3, 7 Mycelex - 7

Vaginal Candidiasis

OTC Exam 2 Study Guide See Above

Warfarin: can cause internal bleeding

Tioconazole Vagistat -1, 3

Vaginal candidiasis

See Above

Warfarin: can cause internal bleeding

Water Base Vaginal Lubricants Monistat Soothing Care Itch Relief HC 1% External Monistat Sooth Care Chafing Relief Powder-Gel Dimethicone Monistat Cool Wipes

Atrophic Vaginitis during sex Atrophic Vaginitis Anti-Itch Used during the day for atrophic vaginitis symptoms Atrophic Vaginitis Cool Effect down there Used during the day for atrophic vaginitis symptoms Atrophic Vaginitis Irritation down there Used during the day for atrophic vaginitis symptoms

2 tsp (finger length) inserted into vaginal tract or externally Not important

N/A N/A

If patient is on warfarin then lab work must be performed within the next 1-2 days to prevent/detect internal bleeding If patient is on warfarin then lab work must be performed within the next 1-2 days to prevent/detect internal bleeding Patients who do not see relief when using OTC products for 7 days! N/A

Not Important

N/A

N/A

Leave in underwear to provide relief

N/A

N/A

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OTC Exam 2 Study Guide

Alopecia Adams
Referral for Alopecia Less than 18 years old Pregnancy or breast feeding Recent discontinuation of oral contraceptives Hair loss in patient with no family history of hair loss Hair loss in patient with positive hair-pull test Hair loss related to history of endocrine dysfunction (chemotherapy, medication use) and dietary deficiencies Sudden or patchy hair loss Evidence of fever or inflammation (occurring 3-6 months before hair loss begins) Skin lesion that indicate autoimmune disease or infection Scaling, sunburn, or other damage to scalp Broken-off hair shafts that resemble those caused by fungal infection or trichotillomania Loss of eyebrows or eyelashes Changes in nails Women with sudden or severe hair loss o Due to hyperandrogenism Postpartum women with hair loss Minoxidil Patient Counseling Points **was not on objectives** Initial Effect o Might see minor hair loss Effectiveness o Works best when you FIRST notice hair loss Hair Stimulation o Turns Vellus (Thin) -> Terminal (thick) Hair o Using 2% form: see improvement @ 4 months o Using 5% Form: see improvement @ 2 months Therapeutic Endpoint Hair o 2%: Must use for one full year to see full effect o 5%: must use for 4 months to see full effect Discontinuation o Hair density returns to pretreatment

Positive Hair Pull Test

10% = excellent 25% = average person 35% = Concern **SHOULD NOT SEE ANY ROOTS***

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Condition Telogen effluvium resting hairs (no root)

Symptoms Loss of resting hairs (no root attached

Anagen Effluvium growing hairs (small hairs attached to root) Nonscarring Alopecia Androgenic Alopecia Alopecia areata: auto immune hair loss Cosmetic Hair Damage Trichotillomania

Androgenic Alopecia o No inflammation o Hair loss is gradual o Men: subtle then fluctuates, onset after puberty, duration: 15-25 years, o Men area of hair loss : frontal hairline, vertex, occipital and temporal o Women area of hair loss: Frontal parietal region Hair loss leads to scarring

OTC Exam 2 Study Guide Cause Stress Illness Hormonal Medications o Anticoagulants o B-Blockers o Ace-I o Amphetamines o Retinoids o Propylthiouracil o Carbamazepine Chemotherapy agents Bromocriptine Androgenic Alopecia: genetic disorder **WE CAN TREAT THIS** Alopecia areata: auto immune hair loss, head to toe hair loss Cosmetic Hair Damage: Perms, color Trichotillomania: psychiatric condition

Nonpharm Treatment

Pharmacological

Androgenic Alopecia: o Wigs o Hair Weaves o Sprays o Colorants o Perms o Topical HairBuilding Products o Surgical Transplantation

Androgenic Alopecia o Minoxidil

Scarring Alopecia (due to medical conditions)

Discoid Lupus Erthmatosus Syphllis Sarcoidosis Lichen Planus

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Drug Minoxidil 2%: Men and Women 5%: Men only

Indication Androgenic Alopecia Cutaneous blood flow to the root prolongs the anagen phase and reduce telogen phase

OTC Exam 2 Study Guide Dosing 1mL BID WASH HANDS Wait 2-4 hours before styling Wait 2-4 hours before any activities that can cause product to be rubbed off

Interactions N/A

Exclusion N/A

Durable Medical Equipment Adams

Counseling Points for Crutches Correct fitting NEVER use topmost hole in a crutch Axillary rest needs to rest 2-3 fingers below armpit Use at 30 degree angle Grip for axillary crutch needs to be at wrist @ resting position When using stairs: USE THE HAND RAIL! Rubber grip needs to be in good shape Stairs o Going up: legs first the crutch o Going down: crutch first then leg Gaits Hemiplegic Gait o One crutch o Crutch is used on good side o Good leg first o Then bad leg + crutch move forward Two Point Gait o Opposites o Left Foot + Right Crutch o Right Foot + Left Crutch Three Point Gait o Most common o Crutch forwards then swing legs forward Four Point Gait -> usually ends up using walker or wheelchair o One movement at a time o One leg, then one crutch etc o Most stable!

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Equipment Forearm Crutches

Platform Crutches

Axillary Crutches Most common Canes

Indication Long term patients that need support for a long period of time Requires good grip Requires good wrist People without inadequate grip People who cannot deal with wrist compression People who cannot deal with axillary pressure Requires good grip Requires arm strength Need safety blanket Four point or quad is most stable People w/ good grips, arm strength, leg strength Assist blood flow Reduce swelling in feet and ankles Help relieve pain and fatigue in legs 40+ circulatory insufficiency Women of child bearing age Workers who do prolonged sitting or standing

OTC Exam 2 Study Guide Directions

Interactions

Exclusion Bad wrist Bad grip

Use on good side

Bad axillary Bad grip Bad arm Patients that need actual support Bad arms Bad wrist Bad legs Patients who need 50 mmHg Should get RX Does not have usual leg size

Hose Usually need to be referred to get correct sizing OTC = lower grade support hose Moderate (mild tiredness) o 10-20mm Hg Firm (begin to feel pain) o 20-30mm Hg Heavy (Severe) o 30-40 mm Hg & 4050mm Hg 27 | P a g e

OTC Exam 2 Study Guide

Opthalmic Disorders/Contact Lenses - Falter

Referrals for Opthalmic Disorders Eye pain Blurred vision not related to self-treatment Use of contact lenses (only if glasses are not an option) Chemical or heat exposure Light sensitivity Symptoms persist for more than 72 hours Symptoms of the infection of the eyelids **SUMMARY** What we can treat o Dry Eyes o Allergic Conjunctivitis o Loose Foreign Material (Minor) o Minor Eye Irritation o DIAGNOSED Corneal edema Preservatives Causes irritation BAK, benzethonium chloride, thimerosal are common preservatives Preservative Free contains disappearing preservatives: purites, sodium perborate o Needs to be disposed of sooner

Pro and Cons of Contacts Should be pretty self-explanatory

Referral for Contacts Vision Changes Deep Aching Pain Last Exam > 1 yr ago Interactions between lenses and systemic Meds

Eyelids Can only treat if its an allergic reaction to cosmetic or soaps -> discontinue new cosmetic or soap + cold compress and take oral antihistamine -> if not resolved in 72 hours see medical doctor

Counseling w/ Contacts Stay with one contact lens solution Do not use hard and RGP lens solution on soft lens Do not use water to wash lens case. Use solution Polyquaternium -1 and poly aminopropyl biguanide are preferred preservatives o If preservative free discard solution bottle after 30 days

Patient Counseling Avoid dry dusty places Use humidifiers Reduce Looking at computer screen Remove contact lenses How long to wait for the following o Solution to Suspension 5 minutes o Solution to Ointment 10 minutes minimum Only keep bottle for 30 days then dispose

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Condition Dry Eyes

Symptoms Mildly Red Gritty Feeling Affects both eyes Red Watery discharge Itiching Blurry vision Puffy eye lid Affects Both Eyes Red Watery Discharge Contagious Affect ONE or BOTH eyes Tearing Irritation Uncontrollable blinking Affects One Eye Red Gritty Feeling One or Both Eyes Pain Irritation Tearing Photophobia One or Both Eyes

OTC Exam 2 Study Guide Cause Reduced blinking allergens

Nonpharm Treatment Reduce look @ comp screen

Allergic Conjunctivitis

Avoid Allergens Keep windows and doors closed Air filters

Pharmacological Artificial Tears Nonmed Ointments If symptoms persist after 7 days refer Decongestants Antihistamines Antihistamine + Mast Cell Stabilizer

Viral Conjunctivitis

Object in eye

Cold Compress Proper Hygiene

Refer May use artificial tears or ocular decongestants

Loose Foreign

Irrigation

Sterile saline Refer if loose object does not go away

Minor Eye Irritation

Exposure to sun, smog or chlorine

Refer irrigation

Chemical Burn

Chemicals

Artificial eyes Nonmed ointments Zinc Sulfate 1-2gtts up to QID Refer

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Blepharitis

Hordeolum (stye) Corneal edema

Inflammation Crusty eyelids Red Scaling Loss of eye lashes Itching/burning One or Both eyes Infection of one of the glands of the eyelid Affects one eye Seeing Halos/starbursts Eyes appear cloudy One or both eyes

OTC Exam 2 Study Guide Bacterial infection of the eyelid

Eyelid hygiene Lid scrub

Refer lubricants

Bacterial infection of the gland of eye lid Over wear of contacts

Refer Warm compresses 3-4x daily for 5-10mins Refer if undiagnosed

Refer Refer if undiagnosed 2% saline solution 4x/day. If symptoms persist after 7 days: 5% ointment qhs IF SYMPTOMS STILL PERSIST ANOTHER 7 DAYS: 5% saline 4x/day + 5% Ointment IF SYMPTOMS PERSIS MORE ANOTHER 7 DAYS GET YO BUTT TO THE DOCTOR Exclusion Preservative sensitivity o Cause for irritation

Drug Artificial Tears

Nonmed Ointments

Indication Dry Eyes Allergenic Conjunctivitis Decreases tear evaporation and increase stability of tear film Dry Eyes Allergenic Conjunctivitis

Dosing Mild: 1-2x /day Mod-Severe: 3-4x/day Use sparingly

Interactions

BID if combination use @ night Use sparingly

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OP Decongestants Phenylephrine Naphazoline* Terahydrozoline* Oxymetazoline **Preferred** OP Antihistamines + Decongestant Pheniramine (+Naph) o Naphcon-A o Opcon A o Visine A Antazoline (+Naph) OP Antihistamine + Mastcell Stabilizer Ketotifen Zaditor Alaway

Eye Pressure Dilation via systemic effects w/ Phenylephrine and Oxymetazoline Allergy and congestion

OTC Exam 2 Study Guide 1-2 gtts 4x a day Tetra: q 4 hours **Only for 72 hours**

Patients with angle closure glaucoma Pregnancy

1-2 gtts q 6-8H

**only for 72 hours**

Patients with angle closure glaucoma

Safe for ages 3+

1gtt q8-12H

N/A

N/A

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OTC Exam 2 Study Guide

Otic Disorders Falter

When do you refer? Signs of infection; Pain due to ear discharge Ear surgery in past 6 weeks Bleeding, trauma, or ruptured tympanic membrane Children under the age of 12 presence of tympanostomy tubes Hypersensitivity to ingredients Unable to follow administration directions Presence of boil(s) anywhere other than auricle or multiple boils Symptoms Pressure or feeling of fullness in ear Gradual hearing loss Cause Ear wax blocking ear canal Nonpharm Treatment Stop Use of Q tip Moist wash cloth draped over finger and get any excess out in outer portion of ear for excessive cerumen May be able to release water by tilting head downward Indirect heat from blow dryer on low setting Self-Resolving Warm compresses Topical antibiotics Pharmacological Carbamine Peroxide 6.5% o 5-10 drops for 15 minutes then rinse ear with warm water w/ otic bulb CAM Agents Isopropyl Alcohol 95% + Glycerin 5% Isopropyl Alcohol 95% + acetic acid (vinegar) 5% (50:50 mixture) Self-Resolving

Condition Excessive/Impacted Cerumen

Water-Clogged Ears

Boils

Wetness or fullness in ear Gradual Hearing Loss Leads to inflammation, itching, pain, infection, Swimmers ear <REFER Opens in 2 weeks with discharge contents

Bacterial infection

Red papule, develops into pustule

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