Pharmacology: Supplements and Toxicology
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| A manufacturer can product does something: | beneficial, BUT CANNOT MAKE MEDICAL CLAIMS; there are a few exceptions like folic acid, calcium and osteoporosis, sodium and HTN, etc.
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| Nutrient rich products with limited health claims | Nutraceuticals
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| Any modified food or ingredient that may provide a benefit beyond the traditional nutrients it contains Ex: bread with extra fiber in it | Functional Foods
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| Foods that are derived from naturally occurring ingredients Ex: soy has one | Foods that are derived from naturally occurring ingredients (soy has phytoestrogen)
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| made by steeping and soaking herb in water for a few minutes | tea
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| the herb is soaked in alcohol, glycerin or an alcohol-water combination to extract active components | Tinctures
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| A tincture that has been filtered or distilled | Extract
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| herbs are dried, pulverized to a powder, and placed in capsules or shaped into pills | Tablets and capsules
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| An herb is added to an emollient like petrolatum, lanolin, or a proprietary cream | Topical
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| Ginseng: Uses and Adverse | U: stress reliever, performance enhancer, energizer; A: HTN, or HypoTN, estrogen-like effects, HA; Antioxidant effects reduce LDL, may lower blood postprandial glucose in type 2 DM, and improve effectiveness of ABX in acute bronchitis
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| Ginkgo: Uses (3) and Adverse | U: 1) improvement of blood flow 2) Anti-oxidant 3) Blocks effects of platelet aggregating factors A: similar to poison ivy, and can have similar effects and INCREASED bleeding risk
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| 4 specific uses for Ginkgo | 1) claudication 2) Alzheimers 3) Cerebral insufficiency 4) SSRI-induced sexual dysfn
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| Garlic: Use | U: claims improved lipid profile, but study showed no effect
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| Black Cohosh: Use and Adverse | U: Menopausal and PMS Sx, though not proven in NIH study for hot flashes and night sweats. A: liver damage
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| Echinacea: Use and Adverse | U: prophylaxis/Tx of cold and flu Sx (immune system stimulation). Studies mixed on Tx, probably doesn't prevent. A: immunosuppresive w/ continuous use, Rxns in people w/ allergies to daisy family.
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| St. John's Wort (Hypericum): Use and Adverse | U: DEPRESSION (SSRI quality), anxiety, anti-viral (not effective). A: Photosensitive skin rxns, substantial effects on cytochrome P450 system
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| Saw Palmetto: Use and Adverse | U: 5 alpha reductase inhibitor activity (inhibits Test ->DHT), possibly BPH. A: not for use during PREGNANCY
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| Valerian: Use and Adverse | U: Promote sleep and anti-anxiety (Increase GABA levels in CNS) A: withdrawl, potentiate benzos
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| Ma Huang or Ephedra: Use and Adverse | U: bronchial asthma, wt loss, performance enhancer A: CNS stimulation and vasoconstriction, HTN, arrythmias, MI, stroke, seizures, death. CAN BE USED TO CREATE METH
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| Glucosamine: Use and Adverse | U: Tx of osteoarthritis (strengthens cartilage). A: Shellfish allergies, may decrease effectiveness of insulin
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| S-adenosylmethionine- SAMe: Use and Adverse | U: depression, arthritis, liver disease, HD (produce and break down serotonin, dopamine etc). A: dry mouth, N/G/D/HA, SEROTONIN effects
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| Coenzyme Q10: Use | U: acts as anti-oxidant, may decrease BP, helpful post MI.
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| Melatonin: Use and Adverse | U: dementia, jet lag, insomnia, anti-aging. A: impairs gonadal development in children
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| Omega 3s: Use, Deficiency, Adverse | U: Essential for brain fn, reduce inflammation, Significantly lower triglyceride levels, CAD (minimal heart benefit), high BP. D: fatigue, poor memory, dry skin. A: bleeding problems
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| Creatine: Use and Adverse | U: increase in muscle mass, heart muscle strength, body wt, endurance in HF pts. A: Dehydration and rhabdomyolysis, muscle cramps, muscle tears
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| T/F: Although chicken is less expensive, gram for gram, it is less effective than whey protein or amino acid supplement | FALSE, cheaper and more protein; Eat a balanced diet: don't need supplements
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| What are 2 anabolic steroid precursors? What do they convert to? Are they effective? Adverse? | DHEA and Andro; Convert to testosterone; Minimally or not effective; A: liver damage and cause opposite gender features in person and respectively increase prostate or uterine cancer.
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| Phentermine | appetite suppressant; amphetamine like substance w/o habituating properties as it didn’t have as strong of a mental stimulation
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| Locaserin: Use, MOA and Adverse | for chronic weight management in BMI>30 or >27 w/DM2/HTN/Dyslipidemia. 5HT-2c agonist (most control over satisfaction/satiation). A: HA, cognitive impairment, fatigue, hypoglycemia.
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| Qysmia: Use, MOA, Wt loss? Adverse | chronic weight management in BMI>30 or >27 w/DM2/HTN/Dyslipidemia. combines phentermine and ER topiramate (anti-seizure). 20 lbs wt loss/year. A: monitor for suicidal thoughts/behavior, cognition, fatigue, dysgeusia (exacerbates weird metallic taste)
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| Orlistat: Use and Adverse | Alli; U: inhibits pancreatic lipases w/ break down fat molecules. A: Oily, leaky, fatty discharge and lowers absorption of fat soluble vitamins
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| Sibutramine: Use and Adverse | U: inhibits NT reuptake in brain (esp norepinephrine), enhances feeling of satiety. PULLED from US markets but still slipped into conterfeit products. A: Part of fen-phen combination and an amphetamine.
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| Metformin: Use | U: overweight and DM2 (lowers glucose, increase insulin sensitivity, appetite suppressant).
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| Adverse for Stimulant Rx drugs: | Increased BP, HR, nervousness, irritability
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| T/F: Prescription diet drugs work well independantly | FALSE, very minimal results w/o diet and exercise
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| Difference between ephedra and ephedra replacements | Ephedra replacements have no active ingredient and there is no published evidence to support them for appetite suppressing
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| T/F: Xenadrine contains ephedrine and synephrine | False, it USED TO contain those, now it contains heavy caffeine and and other stimulants.
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| First steps on approaching a poisoned patient | Airway, Breathing, Circulation (ABCs)
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| 6 questions you want to ask with a toxicology patient | 1) What? 2) When? 3) How much? 4) How? 5) Why? 6) Anything else?
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| LC50 | The concentration of a toxin or toxicant needed to produce death (lethality) in 50% of the exposed population
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| EC50 | The dose producing an effect (good or bad) in 50%
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| IC50 | The dose inhibiting a physiologic end-point in 50%; great if toxin has several levels of physiologic impact.
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| What is the measure to define carcinogenic effects? | NO MEASURE
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| Delaney Clause | zero tolerance for any agent that caused cancer in humans or animals – mandated removal from the market any food or drug ingredient that had been linked to cancer, even in miniscule amounts.
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| 5 key toxidromes | 1. sympathomimetic
2. serotoninergic
3. opiate
4. anticholinergic
5. cholinergic
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| Serotoniergic Toxidrome: Why, Dx, Tx, Ex | Adverse rxn to serotonergic agents. Dx: 1) high temp, 2) mental status changes, 3) autonomic instability 4) Neuromuscular abnormalities. Tx: Antipyretics and Benzos (for seizures and muscle relaxant); Ex: SSRI OD
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| Anticholinergic Toxidrome: Dx, Tx, Ex | Dx: Dry mucus membranes, mental status changes, flushed skin, mydriasis (very dilated pupils), fever, tachy, hyperprexia, HTN. Tx: Supportive care or cholinergics if they are super tachycardic. Ex: Atropine
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| Cholinergic Toxidrome: Dx, Tx, CNS interaction, Ex | Dx: DUMBELLS (diarrhea, urinatio, miosis, bradycardia, bronchospasm, emesis, lacrimation, limp, salivation/sweating) LOTS OF SECRETING; Tx w/ anti-cholinergics. Entry of cholinergics into the CNS will cause SEIZURES; Ex: pesticides (organophosphates)
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| Opioid toxidrome: Dx, Tx | Dx: respiratory depression, miosis (pinpoint pupils), hypoactive bowel sounds. Tx: naloxilone
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| Sympathomimetics: Dx, Ex | HTN, Tachycardia, hyperpyrexia WITH SWEATING, mydriasis (dilated pupils), anxiety Ex: Cocaine (LIKE anti-cholinergics except SWEATING)
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| What toxins cause bradycardia? PACED | Propanolol, anticholinesterases, CCBs, Ethanol, Digoxin
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| What toxins cause tachycardia? CAAASST | Cocaine, Anticholinergics, Antihistimines, Amphetamines, Sympathoimetics, Solvents, Theophylline
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| What toxins cause hypoventilation? SLOW | Sedatives, Liquor, Opiates, Weed
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| What toxins cause hyperventilation? PANT | PCP, Aspirin, Noncardiogenic pulmonary edema, Toxic metabolic acidosis
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| Bitter almonds | Cyanide
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| Mothballs | Camphor
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| Garlic | Organophosphates, Arsenic
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| Peanuts | Rodenticides
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| Carrots | Water hemlock
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| Rotten eggs | Sulfur dioxide, hydrogen sulfide
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| Wintergreen | Methyl salicylates
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| Gasoline | Hydrocarbons
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| Fruity | DKA, Isopropanol consumption
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| Pears | Chloral hydrate
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| What can cause EKG problems? (5) | Sympathomimetics, BBs, digoxin, CCBs, CO
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| 2 with increased anion gap and increase osmolar gap | 1) Methanol 2) Ethylene glycol
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| What 4 things cause increased anion gap other than methanol and ethylene glycol? | 1) Lactic acidosis 2) Ketoacidosis 3) Salicylate poisoning 4) Chronic renal failure
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| Normal anion gap? | 8-12
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| Coma Cocktail (3) | Dextrose, Naloxone (Txs opiates), Thiamine (malnourishment)
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| T/F: Lavage is TOC with ingestion of corrosives due to risk of perforation | False, CONTRA, replaced with charcoal
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| T/F: Treat the poison first | False, TREAT THE PATIENT NOT THE POISON
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| T/F: Pepto-bismol can cause a salicylate overdose | True, bismuth subsalicylate!
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| Metabolism of Salicylates | Metabolism is first order until serum level reaches 30mg/dL, then it becomes zero order (constant rate)
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| Salicylate overdose Sx (5) | N/V (dehydration), diaphoresis, tinnitius, hyperventilation, hypokalemia
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| Worse the toxicity, worse the | hypokalemia
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| Tx of salicylate overdose (3) | 1) Tx of metabolic acidosis and hypokalemia 2) Activated charcoal (multi-use, best for extended release) 3) Urine alkalization
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| Indications for dialysis in salicylate overdose (7) | 1) Serum levels >100 in acute 2) Levels >60 in chronic 3) Pulmonary edema 4) Renal failure 5) CHF 6) Poor response to Tx 7) Altered mental status/academia
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| Acetaminophen or APAP is the most common annual cause of | 1) Pharmaceutical poisoning 2) Pharmaceutical poisoning death 3) Acute liver failure in US (even more than alcohol!)
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| Max dose of acetaminophen in Peds | 60mg/kg/day
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| Max dose of acetaminophen in adults | 4 grams/day
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| What part of acetaminophen is the most toxic? What does it do? What detoxifies it? | NAPQI (4% of breakdown), binds cellular proteins, altering cell function resulting in cell death. Detoxified by glutathione (which is only produced in a finite amount)
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| What else lowers glutathione? (2) | Ethanol and phenobarbital
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| Acetaminophen overdose phase 1 | “silent overdose”, N/V/Abd pain
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| Acetaminophen overdose phase 2 | hepatic damage (LFT elevated), RESOLUTION OF PHYSICAL Sxs
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| Acetaminophen overdose phase 3 | N/V/abd pain reoccur, LFT maximally elevated, coagulopathy, hepatic necrosis (orange pt), coma -> death
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| Acetaminophen overdose phase 4 | if pts survives 4 days -> recovery phase. LFTs decrease over several weeks.
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| Normogram | guideline for determining who should be treated for a single acute ingestion
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| Tx for acetaminophen? What does it do? | N-acetylcysteine (NAC), donates for glutathione regeneration
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| Greatest benefit for administration w/in how long for acetaminophen | 8 hours, though after 8 hours can work (even up to a few days)
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| Worst part about NAC | Very foul “rotten egg” odor when in liquid form
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| Adverse of IV N-acetylcysteine | anaphylactoid rxn: rash, HypoTN, bronchospasm, death
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| T/F: Tx if any sign of liver injury even w/o Hx of APAP ingestion unless AST/ALT normal | True!
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| T/F: Late presenting sick pts may not have detectable acetaminophen levels | True!
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| What does the rule of 150's describe? | Acute toxic dose:>150mg/kg (also pediatric) or >7.5g. Chronic toxic dose: >150mg/kg/day or 7.5g/day.. Tx indicated if: Level above 150mcg/dL at 4 hours or Ingestion of 150 mg/kg in children
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