rho chi review series - rx study guides...pharmacology and addiction behind nicotine? binds...

Rho Chi Review Series

▪ List exclusions for self-care for:

▪ Generalized muscle pain –

▪ Soft tissue injury (muscle, ligaments, tendons) –

▪ Acute lower back pain –

▪ Osteoarthritis –

▪ Chronic neurologic pain -

▪ List exclusions for self-care for:

▪ Generalized muscle pain – if its caused by systemic infection, chronic condition, or medication

▪ Soft tissue injury (muscle, ligaments, tendons) – if joints are deformed/abnormal w/ movement

▪ Acute lower back pain – if >6 weeks

▪ Osteoarthritis – if not diagnosed by PCP

▪ Chronic neurologic pain – if not diagnosed by PCP

▪ The following types of pain are excluded from self care. What conditions can be causing these types of pain?

▪ Redness and warmth around a joint:

▪ Pelvic/abdominal pain:

▪ Pain accompanied by systemic symptoms:

▪ Pain that goes down L arm into jaw:

▪ If area is swollen/tender/warm:

▪ If pain follows food intake:

▪ If pain occurs after long period of immobilization:

▪ The following types of pain are excluded from self care. What conditions can be causing these types of pain?

▪ Redness and warmth around a joint: Infection (inflamed arthritis)

▪ Pelvic/abdominal pain: pelvic inflammatory disease, STI, pyelonephritis, appendicitis

▪ Pain accompanied by systemic symptoms: infection, myocardial infarction

▪ Pain that goes down L arm into jaw: myocardial infarction

▪ If area is swollen/tender/warm: DVT

▪ If pain follows food intake: ulcer, gastritis

▪ If pain occurs after long period of immobilization: DVT

Fill-in-the-Blank

▪ PQRST stands for _______________________

▪ Pain lasting for more than _____ days, should see PCP

▪ Pain persists for more than _______ days after starting self-care, see PCP

▪ See PCP is pain is in back and causes loss of _______

▪ See PCP if woman is _______

▪ See PCP is child is less than _________ years old

▪ See PCP if pain ____________ over time

▪ See PCP is pain gets better but then ________ over time

Fill-in-the-Blank

▪ PQRST stands for Precipitating Factors, Quality, Region, Severity, Time

▪ Pain lasting for more than 10 days, should see PCP

▪ Pain persists for more than 7 days after starting self-care, see PCP

▪ See PCP is pain is in back and causes loss of bowel/bladder function

▪ See PCP if woman is pregnant

▪ See PCP if child is less than 2 years old

▪ See PCP if pain gets worse over time

▪ See PCP is pain gets better but then recursover time

What does RICE stand for? For what type of pain would a patient use this method?

What does TENS stand for? For what type of pain would a patient use this method?

RICE – use for acute musculoskeletal injuries Rest

Ice

Compression

Elevation

TENS – use for chronic musculoskeletal injuries Transcutaneous Electrical Nerve Stimulation

Pharmacologic Treatment

▪ Describe how each group of counterirritants work and list some ingredients in each group

▪ Normally you don’t want to use a combo product with ingredients from the same group. Which two ingredients are an exception to this?

▪ List at least 3 counseling points for topical analgesics

▪ What is an additional counseling point to tell patient’s about capsaicin


▪ Describe how each group of counterirritants work and list some ingredients in each group▪ Group A – produces redness/warmth

▪ Methylsalicylate, turpentine oil

▪ Group B – produces cooling▪ Camphor, menthol

▪ Group C – vasodilates ▪ Methyl nicotinate, histamine dihydrochloride

▪ Group D – produces redness/warmth ▪ Capsaicin (substance P depletors)

▪ Normally you don’t want to use a combo product with ingredients from the same group. Which two ingredients are an exception to this? Camphor and menthol

▪ List at least 3 counseling points for topical analgesics ▪ Don’t apply to broken skin

▪ Don’t use w/ heating pads or bandages. Keep coverings loose

▪ D/c if pain, swelling, or blistering occurs

▪ What is an additional counseling point to tell patient’s about capsaicin ▪ May have initial increase in pain and burning

before the analgesia takes effect

CAN YOU EXPLAIN THE PHARMACOLOGY AND

ADDICTION BEHIND NICOTINE?

Binds nicotinic acetylcholine receptors in

body

Initially, causes an increase in BP,

HR, O2 consumption,,

stimulates respiration, and causes skeletal

muscle relaxation

Later, release of dopamine in

ventral tegmental area of midbrain

and nucleus accumbens are associated with

feelings of “pleasure and

reward”

Receptors in brain begin to

become sensitized

throughout day, requiring more cigarettes at

increased frequency

What is the most effective way to treat smoking addiction?

COMBINATION OF COUNSELING AND MEDICATION IS MORE EFFECTIVE THAN EITHER ALONE

Offer treatment to all except:

Pregnant women

Teenagers

Smokeless tobacco users

Light smokers

Nicotine patch (OTC)

Nicotine gum and lozenges (OTC)

Nicotine inhaler (Rx)

Nicotine nasal spray (Rx)

Patient still gets nicotine to avoid symptoms of withdrawal, but without all the harmful additives in cigarettes

▪KNOW DOSING

▪When you start with Step 1 vs. when you start with Step 2

▪Difference between Step 1 and Step 2

▪Counseling points

Nicotine Patch

▪ Start with Step 1 if >10 cigs/day

▪ 21 mg (4-6 weeks) → 14 mg (2 weeks) → 7 mg (2 weeks)

▪ Start with Step 2 if </= 10 cigs/day

▪ 14 mg (6 weeks) → 7 mg (2 weeks)

▪ Can continue taking if still struggling with quitting

▪ Apply to hairless area – upper arm, upper chest, hip

▪ Rotate site

▪ Can leave on when shower

▪ If falls off, replace with new one

▪ Can remove at bedtime if giving vivid nightmares

▪ Skin irritation main side effect

▪ Nausea and headache → dose too high

*Only NRT that’s once a day

▪Know how to determine which dose to start at

▪Know daily maximums

▪Know counseling and side-effects

NRT: Gums and

Lozenges

▪ If first cigarette is w/in 30 min of waking ▪ Start with 4mg dose

▪ Otherwise, start with 2mg dose

▪ Try getting pt to use 9 pieces/day for first 6 weeks

▪ Maximums per day▪ Gum = 24 pieces

▪ Lozenges = 20 lozenges (or 5 lozenges in 6 hr period)

▪ Don’t eat/drink 15 min before use ▪ Acidic foods can decrease absorption of the

nicotine

▪ Chew and park method: chew until feel a tingle, park in cheek until tingling stops, then repeat

▪ Side effects: Nausea, dyspepsia, flatulence, hiccups, heartburn, mouth soreness

▪ Has _________ flavor

▪ Use caution in patients with ________________

▪ Do not eat/drink for _____________ before use

▪ Absorbed across _____________

▪ Maximum cartridges per day: ________

▪ Side effects: ________________________________

▪ Has menthol flavor

▪ Use caution in patients with reactive airway disease

▪ Do not eat/drink for 15 minutes before use

▪ Absorbed across oropharyngeal mucosa

▪ Maximum cartridges per day: 16

▪ Use for max of 3 months

▪ Side effects: cough, throat irritation, rhinitis, headache, dyspepsia

What is the adverse effect we are most worried about for patients using the nasal spray ?

▪ BIGGEST potential for ADDICTION

▪ Due to rapid absorption of nicotine, giving patient that “buzz” feeling

▪ Should only be used for 3 months

▪ Try and use at least 8 doses/day (max of 40/day)

▪ Tilt head back when using. Don’t inhale or sniff

▪ Can get initial peppery feeling in throat, sneezing watery eyes, runny nose, cough

▪MOA?

▪Dosing?

▪Side effects?

▪Adjust for poor renal function?

▪ MOA: Binds α4β2 nicotinic receptors ▪ Gives low agonist effect while competitively

inhibiting with nicotine and reducing the “buzz” patient’s get from smoking

▪ Dosing: Pt. starts 1 week prior to quit date ▪ 0.5 mg daily for days 1-3 ▪ 0.5 mg BID for days 4-7▪ 1 mg BID for day 8 – end of tx

▪ For CrCL< 30 mL/min, max dose is 0.5 mg BID. Hemodialysis max is 0.5 mg daily

▪ Side effects: Nausea, headache, vivid dreams, constipation, dry mouth, suicidal thoughts

▪MOA?

▪Dosing?

▪Side effects?

▪Adjust for poor renal function?

▪ MOA: Increases levels of dopamine and norepinephrine in brain

▪ This decreases nicotine cravings and withdrawal symptoms

▪ Dosing: 150 mg daily for 3 days → 150 mg BID

▪ Can choose quit date 1-2 weeks after starting therapy

▪ Separate doses by 8 hrs

▪ Use 150 mg daily in renal failure

▪ 150 mg q other day in hepatic impairment

▪ Many drug interactions compared to Chantix

▪ Can’t use with MAO inhibitors

▪ Can’t use with drugs that lower seizure threshold – benzos, systemic steroids, alcohol, theophylline

▪ CAN INCREASE RISK OF SEIZURE (esp w/ alcohol)

Chantix blocks nicotine from binding to receptor, so using a short acting NRT wouldn’t be effective

Long acting therapy give steady dose of nicotine while short acting agent gives acute titrated dosing (if pt feels they need more of a “kick”)

Ex.) Patch + gum/lozenge Ex.) Bupropion SR + gum/lozenge

Breathing difficulty

Rapid heartrate

Ringing in ears

5 A’s

• Ask – how often they smoke

• Advise – urge to quit

• Assess – is pt ready to quit?

• Assist – give pt tx advise

• Arrange – follow-up w/pt

STAR

• Set quit date

• Tell support group

• Anticipate challenges

• Remove tobacco from environment

General Infant

Information

▪ When should an infant be double their birth weight? Triple?

▪ An infant should have a 50% increase in length by the time they are ______ years old and 100% increase in length by the time they are _______ years old

▪ State the RDA for full-term infants birth-6 months, full term infants 6 months-12 months, and pre-term infants

▪ At what age is a baby able to start digesting more complex foods like cereal and baby food?

▪ Until what age is a baby typically breast fed?

▪ How long can breast milk be kept in the fridge? In the freezer?

▪ What are some incidences in which breast feeding is contraindicated?

General Infant

Information

▪ When should an infant be double their birth weight? Triple? Double by 4 months old, triple by 12 months old

▪ An infant should have a 50% increase in length by the time they are 1 years old and 100% increase in length by the time they are 4 years old

▪ State the RDA for full-term infants birth-6 months, full term infants 6 months-12 months, and pre-term infants ▪ Full term 0-6 months: 110 kcal/kg/day

▪ Full term 6-12 months: 80 kcal/kg/day

▪ Preterm: 130 kcal/kg/day

▪ At what age is a baby able to start digesting more complex foods like cereal and baby food? 4-6 months old

▪ Until what age is a baby typically breast fed? 6 months old ▪ How long can breast milk be kept in the fridge? In the

freezer? 96 hours fridge. 3-4 months freezer

▪ What are some incidences in which breast feeding is contraindicated? HIV-infected mom, mom using certain meds, active TB, galactosemia

Formula Nutrition

▪ What percent of total calories should come from carbs?

▪ What is the main carb in formula and what two simple sugars is this broken down to in the body?

▪ What are some reasons for primary lactase deficiency? Secondary?

▪ What is the main form of fat in formula? What percent of calories should come from fat?

▪ What are protein requirements for infants 0-6 months old and 6-12 months old?

▪ Which two types of protein are used in formula and in what ratio should they be given?

Formula Nutrition

▪ What percent of total calories should come from carbs? 40-50%

▪ What is the main carb in formula and what two simple sugars is this broken down to in the body? Lactose, broken down into glucose and galactose

▪ What are some reasons for primary lactase deficiency? Secondary? Primary is lactose intolerance and premature birth. Secondary is due to malnourishment and gastroenteritis

▪ What is the main form of fat in formula? What percent of calories should come from fat? Triglycerides. At least 30%

▪ What are protein requirements for infants 0-6 months old and 6-12 months old? ▪ 0-6 months: 2.2gm/kg/day

▪ 6-12 months: 1.6gm/kg/day

▪ Which two types of protein are used in formula and in what ratio should they be given? Whey and casein in a 60%40 ratio

▪ What are fluid (water) requirements for:

▪ First 10 kg -

▪ 10-20 kg –

▪ How many calories are in standard infant formulas?

▪ What is the vitamin D recommendation in the first year of life and which infants should be supplemented with this? What about after age 1 ?

▪ What are iron recommendations for:

▪ Full term infant breastfed –

▪ Premature infant breastfed –

▪ Partially breastfed –

▪ Formula fed –

▪ What is a sufficient amount of fluoride supplementation?

▪ What are fluid (water) requirements for: ▪ First 10 kg – 100 ml/kg/day

▪ 10-20 kg – additional 50 ml/kg/day for each kg above 10 kg

▪ How many calories are in standard infant formulas? 20 cal/oz

▪ What is the vitamin D recommendation in the first year of life and which infants should be supplemented with this? What about after age 1 ? 400 IU/day, all infants. 600 IU/day after age 1.

▪ What are iron recommendations for: ▪ Full term infant breastfed – 1mg/kg/day starting at 4

months old

▪ Premature infant breastfed – 2 mg/kg/day starting at 1 month old

▪ Partially breastfed – if > 50% breastfed, same dosing as above

▪ Formula fed – Iron fortified formula is sufficient

▪ What is a sufficient amount of fluoride supplementation? Pea sized amount of fluoridated toothpaste

▪ When comparing human milk, cow’s milk, mile-based formula, and soy-based formula, which has the highest renal solute load?

▪ What is the whey:casein ratio in cow’s milk?

▪ State if the following formulas are milk-based or soy-based?▪ Similac –

▪ Prosobee –

▪ Enfamil –

▪ Carnation –

▪ Isomil –

▪ Why are soy-based formulas good for lactose intolerant infants

▪ What is the purpose of casein-hydrolysate-based formulas?

▪ What is the benefit to whey-hydrolysate-based formulas?

▪ How can you add calories without adding volume to formula?

▪ When comparing human milk, cow’s milk, mile-based formula, and soy-based formula, which has the highest renal solute load? Cow’s milk▪ What is the whey:casein ratio in cow’s milk? 20% whey 80% casein

▪ State if the following formulas are milk-based or soy-based?▪ Similac – milk-based

▪ Prosobee – soy-based

▪ Enfamil – milk-based

▪ Carnation – milk-based

▪ Isomil – soy-based

▪ Why are soy-based formulas good for lactose intolerant infants? Uses corn starch, tapioca starch, or sucrose as the carb source

▪ What is the purpose of casein-hydrolysate-based formulas? Easier to digest for infants with GI disturbances▪ What is the benefit to whey-hydrolysate-based formulas? Tastes better than the casein-

hydrolysate formula

▪ How can you add calories without adding volume to formula? Add a fortifier (like vegetable oil)

What would you recommend if infant is constipated?

How should you warm up formula?

Which formula type tends to taste best?

What are things to monitor if infant isn’t eating/fussy to ensure it’s nothing serious?

What would you recommend if infant is constipated? Give extra 4 oz of formula a day. Honey can cause botulism and plain water doesn’t do anything

How should you warm up formula? Allow to warm to room temp; don’t use microwave

Which formula type tends to taste best? Enfamil

What are things to monitor if infant isn’t eating/fussy to ensure it’s nothing serious? Height, weight, head circumference, hydration status, development

▪ How many ounces should you feed an infant:

▪ Birth – 2 weeks:

▪ 3 weeks – 2 months:

▪ 2 months onward:

▪ How often do you usually have to feed an infant? What about with a premature infant?

▪ For powdered formula, if you desire 20 kcal/oz, how many ounces of water do you need to add per scoop of formula?

▪ What is the benefit of nursery water over tap water?

▪ How long can you keep a reconstituted powder formula in the fridge?

▪ How long can reconstituted formula be kept at room temperature?

▪ When can an infant start drinking cow’s milk? When is 2% milk recommended? What about 1% milk?

▪ How many ounces should you feed an infant: ▪ Birth – 2 weeks: 2-3 oz/feed

▪ 3 weeks – 2 months: 4-5 oz/feed

▪ 2 months onward: 6 oz/feed

▪ How often do you usually have to feed an infant? What about with a premature infant? Every 4 hours. Every 2-3 hours for premature infant

▪ For powdered formula, if you desire 20 kcal/oz, how many ounces of water do you need to add per scoop of formula? 2 ounces of water per 1 scoop

▪ What is the benefit of nursery water over tap water? Supplemented with fluoride but tap water has fluoride in it as well, so no real benefit

▪ How long can you keep a reconstituted powder formula in the fridge? 24 hrs

▪ How long can reconstituted formula be kept at room temperature? 2 hrs

▪ When can an infant start drinking cow’s milk? When is 2% milk recommended? What about 1% milk? At 12 months old. Recommend 2% in infants at risk for obesity at age 1 y/o. otherwise, most infants start at 2 years old with 1% milk

▪ Vitamins are organic/inorganic (CHOOSE) molecules

▪ Minerals are organic/inorganic (CHOOSE) molecules

▪ What are some functions of vitamins and minerals in the body?

▪ List the fat soluble vitamins

▪ List the water soluble vitamins

▪ List major minerals. What is the major function for most minerals?

▪ List trace minerals

▪ Vitamins are organic molecules

▪ Minerals are inorganic molecules

▪ What are some functions of vitamins and minerals in the body? Can act as cofactors in biochemical reactions, help with cell growth/differentiation, help breakdown carbs/proteins/fats for energy, and can act as hormones

▪ List the fat soluble vitamins: A, D, E, K

▪ List the water soluble vitamins: B1, B2, B3, B5, B6, Biotin (B7), Folate (B9), B12, and Vitamin C

▪ List major minerals. What is the major function for most minerals? Sodium, potassium, phosphorous, chloride, magnesium, calcium. They play usually a structural or membrane functional role in the cell

▪ List trace minerals: Iron, zinc, copper, manganese, selenium, chromium, iodine, fluorine, molybdenum

▪ Match the medication with the type of vitamin/mineral deficiency it causes:

▪ Loop diuretics

▪ Thiazide diuretics

▪ Corticosteroids

▪ H2 blockers

▪ PPIs

• A. Decrease in sodium, potassium,

magnesium, phosphate. Increase in

calcium

• B. Vitamin B12 malabsorption

• C. Decrease in vitamins A, C, and D

• D. Decrease in sodium, potassium,

calcium, magnesium, and thiamine

▪ Match the medication with the type of vitamin/mineral deficiency it causes:

▪ Loop diuretics (D)

▪ Thiazide diuretics (A)

▪ Corticosteroids (C)

▪ H2 blockers (B)

▪ PPIs (B)

• A. Decrease in sodium, potassium,

magnesium, phosphate. Increase in

calcium

• B. Vitamin B12 malabsorption

• C. Decrease in vitamins A, C, and D

• D. Decrease in sodium, potassium,

calcium, magnesium, and thiamine

What are the three claims a dietary supplement label can make?

What are the five claims an FDA approved drug label can make?

Decide what type of claim each of the following statements can be categorized as:

• Calcium builds strong bones

• Three grams of soluble fiber from oatmeal daily in a diet low in saturated fat and cholesterol may reduce the risk of heart disease

• Diets low in saturated fat and cholesterol that include 25 grams of soy protein a day may reduce the risk of heart disease

• Consuming at least 3 or more ounce-equivalents of whole grains per day can reduce the risk of several chronic diseases

What are the three claims a dietary supplement label can make? Health claim, structure/function claim, nutrient claim (know these)

What are the five claims an FDA approved drug label can make? Diagnose, cure, mitigate, treat, or prevent a disease

Decide what type of claim each of the following statements can be categorized as:

•Calcium builds strong bones – structure/function claim

•Three grams of soluble fiber from oatmeal daily in a diet low in saturated fat and cholesterol may reduce the risk of heart disease – health claim

•Diets low in saturated fat and cholesterol that include 25 grams of soy protein a day may reduce the risk of heart disease – health claim

•Consuming at least 3 or more ounce-equivalents of whole grains per day can reduce the risk of several chronic diseases – nutrient claim

▪ Match the dietary reference intake with it’s proper definition:

▪ Recommended dietary allowance

▪ Adequate intake

▪ Estimated average requirement

▪ Tolerable upper intake limit

• A. Maximum daily intake

before adverse events occur

• B. Level of daily intake that

is assumed to provide

sufficient nutrition

• C. Average intake that

would meet the daily

nutritional needs of 50% of

the population

• D. Average daily amount

needed that meets the

nutritional needs of the

majority of the population

▪ Match the dietary reference intake with it’s proper definition:

▪ Recommended dietary (D) allowance

▪ Adequate intake (B)

▪ Estimated average (C) requirement

▪ Tolerable upper intake limit (A)

• A. Maximum daily intake

before adverse events occur

• B. Level of daily intake that

is assumed to provide

sufficient nutrition

• C. Average intake that

would meet the daily

nutritional needs of 50% of

the population

• D. Average daily amount

needed that meets the

nutritional needs of the

majority of the population

▪ What is the main role of calcium in the body?

▪ What are 3 indications for calcium supplementation?

▪ What are some risk factors for calcium deficiency?

▪ Does calcium carbonate or calcium citrate have a higher % elemental calcium?

▪ With which formulation do you need to take it with food?

▪ Which formulation is better if you’re also taking a PPI?

▪ What are common adverse effects?

▪ What can excessive supplementation lead to?

▪ Using calcium supplementation to PREVENT weak bones/fractures is only recommended in what population ?

▪ What is the main role of calcium in the body? Used in forming and maintaining bone and well as an intracellular signaling molecule

▪ What are 3 indications for calcium supplementation? Preventing osteoporosis (calcium maintenance levels), preventing glucocorticosteroid induced osteoporosis, and hypocalcemia ▪ What are some risk factors for calcium deficiency? Menopause, female athletes,

corticosteroids, loop diuretics, lactose intolerance, vegetarians, and women who have amenorrhea

▪ Does calcium carbonate or calcium citrate have a higher % elemental calcium? Calcium carbonate▪ With which formulation do you need to take it with food? Calcium carbonate

▪ Which formulation is better if you’re also taking a PPI? Calcium citrate

▪ What are common adverse effects? GI upset (diarrhea, constipation, stomach pain)

▪ What can excessive supplementation lead to? Kidney stones

▪ Using calcium supplementation to PREVENT weak bones/fractures is only recommended in what population ? Nursing home residents with vitamin D deficiency and low calcium intake

RDA Calcium

Male Female Pregnancy Lactating

19-50 years old

51-70 years old

70+ years old

• Fill in the following tables

Tolerable Upper Limit Calcium


19-50 years old

RDA Calcium


19-50 years old 1000 mg 1000 mg 1000 mg 1000 mg

51-70 years old 1000 mg 1200 mg

70+ years old 1200 mg 1200 mg


Tolerable Upper Limit Calcium



What are the main roles of vitamin D in the body?

What are 2 indications for vitamin D supplementation?

• What are some risk factors for vitamin D deficiency?

What are the available vitamin D products OTC?

What are some adverse effects that can occur with excessive supplementation?

▪ What are the main roles of vitamin D in the body? Help with calcium absorption, calcium/phosphorous metabolism, neuromuscular function, cell growth, immune function

▪ What are 2 indications for vitamin D supplementation? Vitamin D deficiency and for community dwelling adults >65 y/o at risk for falls to prevent fracture▪ What are some risk factors for vitamin D deficiency? Elderly pts, obesity, fat

malabsorption, low fat diet, having darker skin

▪ What are the available vitamin D products OTC? Cholecalciferol (D3) and ergocalciferol (D2)

▪ What are some adverse effects that can occur with excessive supplementation? Weight loss, calcifications (kidney stones)

Tolerable Upper Limit Vitamin D


>/= 9 years old

RDA Vitamin D


19-50 years old


Tolerable Upper Limit Vitamin D


>/= 9 years old 4000 IU (100

mcg)

4000 IU (100

mcg)

4000 IU (100

mcg)

4000 IU (100

mcg)

RDA Vitamin D


19-50 years old 600 IU (15 mcg) 600 IU (15 mcg) 600 IU (15 mcg) 600 IU (15 mcg)

▪ What are the main roles of iron in the body?

▪ What are 2 indications for iron supplementation?

▪ What are some risk factors for iron deficiency?

▪ What are the names of the iron salt forms available OTC?

▪ Is ferrous iron or ferric iron more soluble?

▪ Which formulation has the highest percent elemental iron? Which has the lowest?

▪ Does one formulation have better absorption over another?

▪ What is the advantage of ferrous sulfate exsiccated?

▪ Which formulation is best for patients with severe GI side effects?

▪ What is the main adverse effect of supplemental iron ?

▪ What are some reasons you would be cautious giving a pt. OTC iron?

▪ Fill in the blanks for the following counseling points:

▪ Take iron at a separate time than consuming ________ or using an _________

▪ Acidic food/drinks ___________ absorption

▪ Tea and milk __________ absorption

▪ You may experience _________ stools

▪ What are the main roles of iron in the body? Helps to produce hemoglobin and neurotransmitters

▪ What are 2 indications for iron supplementation? Iron deficiency anemia, and chronic anemia ▪ What are some risk factors for iron deficiency? Heart failure, pregnancy, heavy bleeding during menstruation, GI disorders, cancer,

donating blood frequently

▪ What are the names of the iron salt forms available OTC? Ferrous sulfate, ferrous gluconate, ferrous citrate, ferric sulfate, ferrous fumarate, carbonyl iron▪ Is ferrous iron or ferric iron more soluble? Ferrous iron

▪ Which formulation has the highest percent elemental iron? Which has the lowest? Carbonyl iron has 100% elemental iron. Otherwise, ferrous fumarate has the highest percent. Ferrous gluconate has the lowest

▪ Does one formulation have better absorption over another? For the most part, the salt forms have similar absorption. The amount of iron absorbed is more dose dependent than salt dependent.

▪ What is the advantage of ferrous sulfate exsiccated? Has a slower release. Better for GI side effects

▪ Which formulation is best for patients with severe GI side effects? Carbonyl iron. Has a slow continuous release over 1-2 days

▪ What is the main adverse effect of supplemental iron ? GI upset ▪ What are some reasons you would be cautious giving a pt. OTC iron? Elderly and pediatric pts use caution. Pts with existing GI disease

or who have had frequent blood transfusions

▪ Fill in the blanks for the following counseling points: ▪ Take iron at a separate time than consuming dairy or using an antacid

▪ Acidic food/drinks increase absorption

▪ Tea and milk decrease absorption

▪ You may experience black/dark stools

Tolerable Upper Limit Iron


>/= 19 years old

RDA Iron


19-50 years old


Tolerable Upper Limit Iron


>/= 19 years old 45 mg 45 mg 45 mg 45 mg

RDA Iron




▪ What are the main roles of magnesium in the body?

▪ What are 3 indications for magnesium supplementation?

▪ What are some risk factors for magnesium deficiency?

▪ What are the names of the magnesium salt forms available OTC?

▪ Does one formulation have better absorption over another?

▪ Which two formulations have a slow onset of action?

▪ Which formulation has the fastest onset of action?

▪ Which formulations are used to treat constipation?

▪ Which formulations are used to treat dyspepsia?

▪ Why are magnesium gluconate and chloride preferred over oxide?

▪ Which formulation should be taken on an empty stomach?

▪ What are the main adverse effects of supplemental magnesium ?

▪ What are some serious effects that can occur from excessive intake?

▪ What are the main roles of magnesium in the body? Bone structure, muscle/nerve function, blood glucose control, and heart rhythm

▪ What are 3 indications for magnesium supplementation? Constipation, dyspepsia, hypomagnesemia

▪ What are some risk factors for magnesium deficiency? GI disease, type 2 diabetes, older age, alcohol dependence

▪ What are the names of the magnesium salt forms available OTC? Magnesium oxide, sulfate, lactate, aspartate, citrate, chloride, hydroxide, carbonate, and trisilicate

▪ Does one formulation have better absorption over another? Magnesium gluconate, lactate, and aspartate absorbed better than chloride. Absorption is not correlated with percent elemental magnesium

▪ Which two formulations have a slow onset of action? Magnesium carbonate and trisilicate

▪ Which formulation has the fastest onset of action? Magnesium hydroxide

▪ Which formulations are used to treat constipation? Magnesium citrate, sulfate, and hydroxide

▪ Which formulations are used to treat dyspepsia? Magnesium hydroxide, carbonate, and trisilicate

▪ Why are magnesium gluconate and chloride preferred over oxide? Good absorption and less diarrhea associated with them

▪ Which formulation should be taken on an empty stomach? Magnesium gluconate

▪ What are the main adverse effects of supplemental magnesium? Diarrhea, nausea, and cramps. Risk of accumulation in pts with renal dysfunction

▪ What are some serious effects that can occur from excessive intake? Muscle and respiratory paralysis and complete heart block

Tolerable Upper Limit Magnesium


>/= 19 years old

RDA Magnesium


19-30 years old

31-50 years old


Tolerable Upper Limit Magnesium


>/= 19 years old 350 mg 350 mg 350 mg 350 mg

RDA Magnesium





Combined Estrogen/Progestin

Emergency Contraceptive Pills

▪ Using COCs (combination oral contraceptives) as a form of emergency contraception is known as the _______ method

▪ Which form of progestin and which form of estrogen are used for this method?

▪ What is the mechanism of action for these pills in preventing pregnancy?

▪ For how long after intercourse is this method still considered effective?

▪ How should the pt take these pills (how many pills and how many times in a day)?

▪ What are the main adverse effects of this method?

▪ What are contraindications to COCs?


▪ Patients should use barrier method for _____ days after intercourse

▪ If pt vomits within ____ hours of taking the dose, they may need to repeat the dose

▪ Pt can restart their hormonal contraception after the next ______ or the day after they have taken the _________

Combined Estrogen/Progestin

Emergency Contraceptive Pills

▪ Using COCs (combination oral contraceptives) as a form of emergency contraception is known as the Yuzpe method

▪ Which form of progestin and which form of estrogen are used for this method? Levonorgestrel OR norgestrel. For estrogen, ethinyl estradiol

▪ What is the mechanism of action for these pills in preventing pregnancy? Inhibit or delay ovulation. Progestin thought to thicken mucus and prevent sperm from reaching egg while also thinning endometrium. Both hormones also thought to prevent the LH surge

▪ For how long after intercourse is this method still considered effective? Up to 120 hours (5 days)

▪ How should the pt take these pills (how many pills and how many times in a day)? Can take up to 6 pills (should take at least 5) for one dose. Should take one dose q 12 hours for one day

▪ What are the main adverse effects of this method? Nausea, vomiting, tender breasts, irregular menstrual bleeding, headache

▪ What are contraindications to COCs? Known/suspected pregnancy, hx of cancer, risk of thromboembolism, hepatic disease, hypersensitivity, undiagnosed uterine bleeding

▪ Fill in the blanks for the following counseling points: ▪ Patients should use barrier method for 7 days after

intercourse

▪ If pt vomits within 3 hours of taking the dose, they may need to repeat the dose

▪ Pt can restart their hormonal contraception after the next menstrual period or the day after they have taken the emergency contraception

Progestin-Only Emergency Contraception

▪ What is the age requirement to purchase an OTC progestin-only emergency contraceptive?

▪ What formulation of progestin is used in these products?

▪ What are the eight OTC progestin-only contraceptive products available?


▪ For how long after intercourse is this method still considered effective by FDA standards? If it has been longer than this, can the pt still take this drug?

▪ What are the main adverse effects?



▪ If pt vomits within ____ hours of taking the dose, they may need to repeat the dose

▪ Pt can restart their hormonal contraception after the next ______ or the day after they have taken the _________

▪ Recommend a pregnancy test if it has been greater than ______ days since last period

Progestin-Only Emergency Contraception

▪ What is the age requirement to purchase an OTC progestin-only emergency contraceptive? There is no age requirement

▪ What formulation of progestin is used in these products? Levonorgestrel

▪ What are the eight OTC progestin-only contraceptive products available? Plan B, Take Action (generic Plan B), Next Choice, My Way, EContra EZ, Opicon, Aftera, Fallback Solo

▪ What is the mechanism of action for these pills in preventing pregnancy? Inhibit or delay ovulation

▪ For how long after intercourse is this method still considered effective by FDA standards? If it has been longer than this, can the pt still take this drug? 3 days by FDA standards, but can recommend for patients up to 5 days after intercourse

▪ What are the main adverse effects? Nausea, vomiting, tender breasts, irregular menstrual bleeding, headache, fatigue, stomach pain


▪ Patients should use barrier method for 7 days after intercourse

▪ If pt vomits within 2 hours of taking the dose, they may need to repeat the dose

▪ Pt can restart their hormonal contraception after the next menstrual period or the day after they have taken the emergency contraception

▪ Recommend a pregnancy test if it has been greater than 21 days since last period

Ulipristal Acetate

▪ The brand name of this product is ________

▪ True or False: This product is available OTC

▪ What is the advantage of this product over other the progestin-only products?


▪ For how long after intercourse is this method still effective?



▪ If pt vomits within ____ hours of taking the dose, they need to call PCP

▪ Pt can restart their hormonal contraception _____ days after taking this drug

▪ Recommend a pregnancy test if it has been greater than ______ days since last period

Ulipristal Acetate

▪ The brand name of this product is ella

▪ True or False: This product is available OTC. False, this is Rx product only

▪ What is the advantage of this product over the progestin-only products? It is more effective at preventing pregnancy

▪ What is the mechanism of action for these pills in preventing pregnancy? They act as a selective progesterone receptor modulator. Inhibits or delays ovulation

▪ For how long after intercourse is this method still effective? 120 hours (5 days)

▪ Fill in the blanks for the following counseling points: ▪ Patients should use barrier method for 7

days after intercourse

▪ If pt vomits within 3 hours of taking the dose, they need to call PCP

▪ Pt can restart their hormonal contraception 5 days after taking this drug

▪ Recommend a pregnancy test if it has been greater than 21 days since last period

▪ How many days after intercourse should this be implanted if ovulation time is unknown? How many days after intercourse should this be implanted if ovulation occurred >72 hrs after intercourse?

▪ What is the mechanism of action for this IUD in preventing pregnancy?

▪ What are some advantages of the copper IUD over other contraceptives?

▪ What are some adverse effects of this treatment? What are risks/contraindications?

▪ How many days after intercourse should this be implanted if ovulation time is unknown? 5-7 days.

▪ How many days after intercourse should this be implanted if ovulation occurred >72 hrsafter intercourse? Up to 8 days

▪ What is the mechanism of action for this IUD in preventing pregnancy? Produces an inflammatory response. Copper diminishes motility of sperm and causes atrophy of the endometrium

▪ What are some advantages of the copper IUD over other contraceptives? Most effective method. Provides birth control for 10 years. Non-hormonal.

▪ What are some adverse effects of this treatment? What are risks/contraindications? Can be painful (back pain, uterus pain) can cause tearing of endometrium. Heavy periods with spotting. Vaginal infection or discharge. Pelvic inflammatory disease. Contraindicated for people with pelvic disease, frequent infections, and cancer (uterine and cervical)

Put the emergency contraceptives in order of most to least effective

Are these treatments

considered an abortifacient?

Which treatment is recommended for women who are breast-feeding?

Can these be used as routine birth

control?

Put the emergency contraceptives in order of most to least effective

Are these treatments

considered an abortifacient?

Which treatment is recommended for women who are breast-feeding?

Can these be used as routine birth

control?

• Copper IUD >

ella >

progestin-only

> Yuzpe

method

• No they do not

cause an

abortion. They

wont work if

you’re already

pregnant

• Progestin-only

pills

• No these should not

be used as routine

birth control.

Emergency

contraceptive only

Atopic Dermatitis:

Etiology

▪ What are some questions you would want to ask a pt who may be experiencing atopic dermatitis?

▪ What is the hallmark symptom?

▪ What is the atopic triad?

▪ Explain the hygiene hypothesis

▪ What types of genetic and environmental risks are there for atopic dermatitis?

▪ What is the main pathological mechanism of this disease?

Atopic Dermatitis:

Etiology

▪ What are some questions you would want to ask a pt who may be experiencing atopic dermatitis? When did the symptoms start? What makes it better/worse? Is it localized or spreading? What medical conditions do your parents have (if a child)? Does anyone else in the household have a rash? Is the child alert and oriented?

▪ What is the hallmark symptom? Inflammation with pruritus

▪ What is the atopic triad? Asthma, allergic rhinitis, atopic dermatitis. Many times, if a patient has one of these conditions they will end up developing all of them

▪ Explain the hygiene hypothesis: Children who have less germ exposure are more likely to develop atopic dermatitis and other allergies

▪ What types of genetic and environmental risks are there for atopic dermatitis? Low Th1 and high Th2 levels, FLG protein dysfunction, very hot or very cold weather, food allergies, environmental allergens

▪ What is the main pathological mechanism of this disease? Impaired epithelial barrier

Atopic Dermatitis: Diagnosis

▪ Match the following symptoms of atopic dermatitis with the age group that usually presents with those symptoms:

▪ Very itchy, red popular skin lesions mostly around the cheeks and chin

▪ Lichenification (thickening) of the skin along with crusting. Located mostly on folds, bony protuberances, and forehead

▪ Lichenification (thickening) of the skin along with crusting. Located mostly upper eyelids, hands, arms, legs, and neck

• A. Adulthood

• B. Infancy

• C. Childhood

Atopic Dermatitis: Diagnosis

▪ Match the following symptoms of atopic dermatitis with the age group that usually presents with those symptoms:

▪ Very itchy, red popular skin lesions mostly around the cheeks and chin (B)

▪ Lichenification (thickening) of the skin along with crusting. Located mostly on folds, bony protuberances, and forehead (C)

▪ Lichenification (thickening) of the skin along with crusting. Located mostly upper eyelids, hands, arms, legs, and neck (A)

• A. Adulthood

• B. Infancy

• C. Childhood

What are some complications that can occur if AD goes untreated?

Non-pharmacologic treatments:

• What type of clothing should be worn?

• How often should pts bathe and what temperature should the water be?

• What topical products should be utilized after bathing?

• List some common irritants and allergens

What are some complications that can occur if AD goes untreated? Skin infections and viral infections.

Non-pharmacologic treatments:

• What type of clothing should be worn? Loose clothing with soft cotton fabric

• How often should pts bathe and what temperature should the water be? Bathe for 5 min once or twice a day with lukewarm water

• What topical products should be utilized after bathing? Scent-free moisturizers

• List some common irritants and allergens:

• Irritants: soaps and detergents, cigarette smoke, wool, dust, perfumes/cosmetics

• Allergens: pollen, mold, animal dander, food allergens

Atopic Dermatitis:

Topical Corticosteroids

▪ If using this as a maintenance therapy, what potency should you use?

▪ If using as short-term therapy, what potency should you use? What if the areas are lichenified?

▪ How long is “short-term therapy”?

▪ What is the difference between ointments, lotions, and creams? Which would be best for dry skin?

▪ What strengths of hydrocortisone are available OTC?

▪ What areas should this NOT be used on?

▪ How many days should patients self-treat with this before seeing a doctor is no symptom improvement?

▪ When is the best time to apply this?

Atopic Dermatitis:

Topical Corticosteroids

▪ If using this as a maintenance therapy, what potency should you use? Low potency

▪ If using as short-term therapy, what potency should you use? What if the areas are lichenified? Medium-high potency. Should use highest potency is area lichenified

▪ How long is “short-term therapy”? 1-2 weeks

▪ What is the difference between ointments, lotions, and creams? Which would be best for dry skin? Ointments are more oil based and greasy/ Lotions are more water based. Creams are in between. Ointments are the most effective at keeping moisture in the skin, so these should be used for dry skin

▪ What strengths of hydrocortisone are available OTC? 0.5-1%▪ What areas should this NOT be used on? Around the

eyes, mouth or nose. Don’t use on broken skin

▪ How many days should patients self-treat with this before seeing a doctor is no symptom improvement? 7 days

▪ When is the best time to apply this? After bathing

What is an indication for using a topical antihistamine vs a topical corticosteroid?

When can oral antihistamines be considered?

What strengths of hydrocortisone are available OTC?

• What areas should this NOT be used on?

• How many days should patients self-treat with this before seeing a doctor is no symptom improvement?

What is an indication for using a topical antihistamine vs a topical corticosteroid? Excessive itchiness

When can oral antihistamines be considered? If itching is keeping patient up at night; to help them sleep

What strengths of hydrocortisone are available OTC? 1-2%

• What areas should this NOT be used on? Brown, blistering, or oozing skin

• How many days should patients self-treat with this before seeing a doctor is no symptom improvement? 7 days

What are the systemic treatments available? Are these Rx or OTC?

Are topical calcineurin inhibitors OTC or Rx?

• Are these considered first line treatment?

• What is the age requirement for these agents?

• What is the concern with long-term use?

When would patients be indicated for phototherapy?

What are the systemic treatments available? Are these Rx or OTC? Systemic steroids, cyclosporine, azathioprine, methotrexate, mycophenolate. Rx only

Are topical calcineurin inhibitors OTC or Rx? Rx only

•Are these considered first line treatment? These are second-line. Topical corticosteroids are first-line

•What is the age requirement for these agents? 2 y/o and up

•What is the concern with long-term use? Systemic absorption has risk of cancer

When would patients be indicated for phototherapy? When they are not controlled on any of the topical therapies

Contact Dermatitis: Diagnosis

▪ What are the two subtypes of contact dermatitis?

▪ What are diagnosis criteria for the two subtypes? How many office visits are needed to confirm diagnosis?

▪ How can you distinguish between the two subtypes?

▪ Which requires previous exposure to irritant?

▪ Which is localized?

▪ Which lasts longer?

▪ Which has more burning/pain? Which has more itchiness?

▪ List some common irritants and allergens

Contact Dermatitis: Diagnosis

▪ What are the two subtypes of contact dermatitis? Allergic dermatitis and irritant dermatitis

▪ What are diagnosis criteria for the two subtypes? How many office visits are needed to confirm diagnosis? Need an identification of a specific allergen for allergic dermatitis. Need chronic recurring symptoms with an irritant to diagnose irritant dermatitis. Need at least 3 office visits

▪ How can you distinguish between the two subtypes? ▪ Which requires previous exposure to irritant?

Allergen dermatitis

▪ Which is localized? Irritant dermatitis

▪ Which lasts longer? Allergen dermatitis

▪ Which has more burning/pain? Which has more itchiness? Irritant dermatitis is more painful with burning. Allergic dermatitis has more itchiness

▪ List some common irritants and allergens: ▪ Irritants: fiberglass, bandage adhesives, tobacco,

garlic, benzoyl peroxide

▪ Allergens: poison ivy/oak, metals, rubber, certain fragrances or preservatives

Contact Dermatitis: Treatment

▪ You can use a cold compress to treat which areas?

▪ What is the mainstay of therapy? With which subtype would you need to use a higher potency?

▪ What other treatment options are available?

▪ Calamine, hydrocortisone, zinc, benzyl alcohol, and pramoxine are common ingredients in topicals used to treat which allergic dermatitis?

▪ How long does it usually take for contact dermatitis to resolve? What are some complications that can occur?

▪ When would you need to refer pt to their MD?

Contact Dermatitis: Treatment

▪ You can use a cold compress to treat which areas? Areas with broken, oozing skin

▪ What is the mainstay of therapy? With which subtype would you need to use a higher potency? Topical corticosteroids. Need higher potency with allergic dermatitis

▪ What other treatment options are available? Oral steroids and antihistamines

▪ Calamine, hydrocortisone, zinc, benzyl alcohol, and pramoxine are common ingredients in topicals used to treat which allergic dermatitis? Poison ivy

▪ How long does it usually take for contact dermatitis to resolve? What are some complications that can occur? 2-3 weeks. Can end up getting bacterial infection

▪ When would you need to refer pt to their MD? ▪ Problem lasting > 7 days

▪ If pruritus is severe

▪ If no symptom improvement or rash gets worse with OTC tx

▪ If a large area is affected or rash is around eyes/ears/nose

▪ If there are underlying medical conditions

▪ What are some causes of dry skin?

▪ Water content is decreased in which layer of the skin?

▪ Are traditional soaps or synthetic cleansers better for dry skin?

▪ Vehicles:

▪ How do occlusives help to moisturize the skin?

▪ How do humectants help to moisturize the skin?

▪ How do emollients help to moisturize the skin?

▪ Which vehicle is best for patients with atopic dermatitis?

▪ Are synthetic or natural humectants recommended?

▪ What are examples of emollients and when should they be applied?

▪ What are some tips to tell patients for bathing to prevent dry skin? How many times a day should moisturizers be used?

▪ What is the purpose of topical corticosteroid use for dry skin? How many times a day can this be used?

▪ What are some causes of dry skin? Low humidity, excessive bathing with hot water, certain detergents, physical damage to the skin, dehydration, certain systemic disorders

▪ Water content is decreased in which layer of the skin? Stratum corneum

▪ Are traditional soaps or synthetic cleansers better for dry skin? Synthetic cleansers

▪ Vehicles:

▪ How do occlusives help to moisturize the skin? Provide oily layer on skin to prevent water loss

▪ How do humectants help to moisturize the skin? Increase water-holding capacity of skin

▪ How do emollients help to moisturize the skin? Fill spaces of skin with oil droplets to smooth skin

▪ Which vehicle is best for patients with atopic dermatitis? Occlusives

▪ Are synthetic or natural humectants recommended? Natural humectants

▪ What are examples of emollients and when should they be applied? Creams, lotions, and ointments. Apply after bathing

▪ What are some tips to tell patients for bathing to prevent dry skin? How many times a day should moisturizers be used? Bathe for short periods of time (<5 min) at most twice a day. Use lukewarm water. Use moisturizers at least 3x/day

▪ What is the purpose of topical corticosteroid use for dry skin? How many times a day can this be used? Helps with itching. Can use 2-4x/day

Diagnosis

▪ What two types of acne are considered non-inflammatory?

▪ What four types of acne are considered inflammatory?

▪ Acne is a disorder of the ________ gland.

▪ What is the difference between white-heads and black-heads?

▪ What causes inflammatory acne to occur?

▪ When does acne usually start? At what age does it usually resolve?

▪ How do you treat acne in infants?

▪ What are some questions you would want to ask a patient who presents with acne? Onset at what age requires medical evaluation?

Diagnosis

▪ What two types of acne are considered non-inflammatory? Whiteheads (closed comedones) and blackheads (open comedones)

▪ What four types of acne are considered inflammatory? Papules (redness), pustules, cysts (deeper lesions), nodules (raised red areas that are firmer)

▪ Acne is a disorder of the pilosebaceous gland.

▪ What is the difference between white-heads and black-heads? White heads do not pierce the surface of the skin. Blackheads do. When melanin comes into contact with oxygen it turns black

▪ What causes inflammatory acne to occur? Proinflammatory mediators released in response to bacteria and comedones

▪ When does acne usually start? At what age does it usually resolve? At the onset of puberty. Usually resolves by mid-20s

▪ How do you treat acne in infants? Will self-resolve, do not need to treat

▪ What are some questions you would want to ask a patient who presents with acne?▪ Age, how long they’ve had the acne which areas are

affected, have you tried anything yet, are you on other medications, what is your occupation, any new cosmetic products?

▪ Onset at what age requires medical evaluation? If it is a NEW onset when pt is >20 years old

Non-Pharmacologic

Treatment

▪ Don’t pick at the lesions

▪ Avoid touching the face/affected areas

▪ Wash area at most twice daily. Use non-drying soaps

▪ Shampoo daily to decrease oil in hair

▪ Match the treatment with the type of properties it possesses (each treatment may have multiple answers)

▪ Benzoyl peroxide

▪ Adapalene

▪ Salicylate

▪ Sulfur

▪ Estrogens

▪ Anti-androgens

▪ Spironolactone

▪ Isotretinoin

▪ Topical retinoids

▪ Oral antibiotics

▪ Topical antibiotic

▪ Azelaic acid

• A. Reduces sebum production

• B. Keratolytic/comedolytic

• C. Antimicrobial

• D. Anti-inflammatory

▪ Match the treatment with the type of properties it possesses (each treatment may have multiple answers)

▪ Benzoyl peroxide (B,C,D)

▪ Adapalene (B,D)

▪ Salicylate (B)

▪ Sulfur (B)

▪ Estrogens (A)

▪ Anti-androgens (A)

▪ Spironolactone (A)

▪ Isotretinoin (A,B,C,D)

▪ Topical retinoids (B,D)

▪ Oral antibiotics (C,D)

▪ Topical antibiotic (C,D)

▪ Azelaic acid (B,C,D)

• A. Reduces sebum production

• B. Keratolytic/comedolytic

• C. Antimicrobial

• D. Anti-inflammatory


▪ Match the acne type with the appropriate treatment (may need to use more than one answer):

▪ Comedonal (non-inflammatory)

▪ Mild mixed and papular/pustular

▪ Moderate mixed and papular/pustular

▪ Nodular (nodules <0.5cm)

▪ Nodular (nodules >0.5cm and conjoined)

• A. Oral antibiotic

• B. Topical retinoid

• C. Topical antibiotic

• D. Oral isotretinoin

• E. Benzoyl peroxide


▪ Match the acne type with the appropriate treatment (may need to use more than one answer):

▪ Comedonal (non-inflammatory) (B)

▪ Mild mixed and papular/pustular (B+C)

▪ Moderate mixed and papular/pustular (B+A+/-E)

▪ Nodular (nodules <0.5cm)

(B+A+/-E)

▪ Nodular (nodules >0.5cm and conjoined) (D)

• A. Oral antibiotic

• B. Topical retinoid

• C. Topical antimicrobial

• D. Oral isotretinoin

• E. Benzoyl peroxide

Adapalene

▪ What strengths/formulations are available OTC? Which are available Rx?

▪ What type of acne is this the first line treatment for?

▪ How many times a day is this administered? What should you do if the treatment is not fully effective: Increase dose or increase frequency?

▪ How long can this take to be effective?

▪ What is one counseling point you can give patients so they protect themselves from photosensitization?

Adapalene

▪ What strengths/formulations are available OTC? Which are available Rx? OTC is 0.1% gel (Differin). Rx are 0.1% cream/lotion/solution and 0.3% gel

▪ What type of acne is this the first line treatment for? Non-inflammatory

▪ How many times a day is this administered? What should you do if the treatment is not fully effective: Increase dose or increase frequency? Once a day. Increase the dose not the frequency

▪ How long can this take to be effective? 4-12 weeks

▪ What is one counseling point you can give patients so they protect themselves from photosensitization? Wear sunscreen daily

Benzoyl Peroxide

▪ What strengths/formulations are available OTC?

▪ Are the higher strength formulations more effective than the lower strengths?

▪ Which vehicle is the most effective?

▪ What is a counseling point you can tell patients about using a benzoyl peroxide face wash?

▪ What type of acne is this the first line treatment for?

▪ Which strength should therapy be initiated on? What is something the patient can do to assess if they have sensitivity to the treatment?

▪ How many times a day is this administered? What should you do if the treatment is not fully effective: Increase dose or increase frequency?

▪ What are common adverse effects to this treatment?

Benzoyl Peroxide

▪ What strengths/formulations are available OTC? 2.5-10%. Gels, lotions, washes, creams▪ Are the higher strength formulations more effective than

the lower strengths? Yes, up to 5%. The 10% formulation has no more efficacy than the 5% formulation

▪ Which vehicle is the most effective? Gel

▪ What is a counseling point you can tell patients about using a benzoyl peroxide face wash? Leave on face for 5-10 min before washing off

▪ What type of acne is this the first line treatment for? Mild-moderate inflammatory acne

▪ Which strength should therapy be initiated on? What is something the patient can do to assess if they have sensitivity to the treatment? Initiate on 2.5% once a day. Can do a test spot on the skin for a few days before using the treatment all over the area

▪ How many times a day is this administered? What should you do if the treatment is not fully effective: Increase dose or increase frequency? Once a day. If 2.5% once a day is ineffective, increase to twice a day. If this still ineffective, then consider increasing the strength

▪ What are common adverse effects to this treatment? Allergic contact dermatitis (seen with even low doses), irritation/erythema (dose-related), can bleach clothing

• How many times a day should pt use it?

• What are some adverse effects of this tx?

What type of acne is salicylic

acid used for?

• How many times a day should pt use it?

• What are some adverse effects of this tx?

What type of acne is

sulfur used for?

• How many times a day should pt use it? Once daily

• What are some adverse effects of this tx? Slight irritation. Concern for systemic absorption and sensitivity to salicylates (aspirin)

What type of acne is salicylic

acid used for?

• How many times a day should pt use it? 1-3 times a day

• What are some adverse effects of this tx? Has odor and stains. Can actually cause worsening of acne

What type of acne is

sulfur used for?

▪ Which topical antimicrobials are used for acne?

▪ Why is it important to utilize another treatment option in addition to antimicrobials for acne?

▪ What should choice of topical antimicrobial be based off of?

▪ What is the drug of choice for oral antibiotics? What other options are available?

▪ What is an adverse effect associated with cyclines?

▪ What is an adverse effect that can occur in women?

▪ Is it more effective to use both topical and oral antimicrobials together?

▪ Which topical antimicrobials are used for acne? Erythromycin and clindamycin. Sometimes dapsone

▪ Why is it important to utilize another treatment option in addition to antimicrobials for acne? To protect against antimicrobial resistance

▪ What should choice of topical antimicrobial be based off of? Cost. Efficacies are basically the same

▪ What is the drug of choice for oral antibiotics? What other options are available? Doxycycline is drug of choice. Other options are tetracycline, minocycline, and erythromycin

▪ What is an adverse effect associated with cyclines? Photosensitivity

▪ What is an adverse effect that can occur in women? Yeast infections

▪ Is it more effective to use both topical and oral antimicrobials together? No. these should not be used together

Topical Retinoids (Rx)

▪ Which topical retinoids are available to treat acne? Which one is OTC?

▪ What type of acne is this treatment appropriate for?

▪ What are common adverse effects with these?

▪ What can you tell patients to help them avoid adverse effects (especially photosensitivity)?

Topical Retinoids (Rx)

▪ Which topical retinoids are available to treat acne? Which one is OTC? Tretinoin, adapalene, tazarotene, azelaic acid. Adapalene 0.1% gel is OTC

▪ What type of acne is this treatment appropriate for? Non-inflammatory, or mild-moderate inflammatory acne

▪ What are common adverse effects with these? Skin irritation, drying, erythema, photosensitivity

▪ What can you tell patients to help them avoid adverse effects (especially photosensitivity)? Can start with spot testing. Then every other day treatment before going to daily treatment. Tell them to wear sunscreen daily

Isotretinoin

▪ What type of acne is this treatment first line for?

▪ What dermatologic, ophthalmologic, musculoskeletal, and CNS adverse effects can occur? What are some counseling points to tell patients to help with these?

▪ Which labs need to be taken at baseline, after initiation, and after dose increases?

▪ Which labs need to be monitored if pt is experiencing severe muscle/joint pain?

▪ What are the risks of this medication in pregnancy?

▪ Which patients must enroll in the iPledge program?

▪ What is the maximum days supply a patient can get with one prescription?

▪ How long must the patient agree to not donate blood?

▪ How often do female patients need to take a pregnancy test? How many forms of contraceptive must they be on?

Isotretinoin

▪ What type of acne is this treatment first line for? Severe nodular/cystic acne

▪ What dermatologic, ophthalmologic, musculoskeletal, and CNS adverse effects can occur? What are some counseling points to tell patients to help with these? Very drying on the skin. Photosensitivity, tell pt to use sunscreen daily. Dry eyes, suggest artificial tears for pt to use. Joint and muscle pain; usually not severe. Headache, fatigue, and mood changes.

▪ Which labs need to be taken at baseline, after initiation, and after dose increases? Lipids, LFTs, and CBC.

▪ Which labs need to be monitored if pt is experiencing severe muscle/joint pain? Erythrocyte sedimentation rate (ESR) and creatinine kinase (CK).

▪ What are the risks of this medication in pregnancy? Congenital abnormalities, miscarriage, stillbirth

▪ Which patients must enroll in the iPledge program? ALL patients must enroll▪ What is the maximum days supply a patient can get with

one prescription? 30 days

▪ How long must the patient agree to not donate blood? Throughout treatment and for one month after treatment is stopped

▪ How often do female patients need to take a pregnancy test? How many forms of contraceptive must they be on? Pregnancy test every month. Must be on 2 types of contraceptive

▪ Match the various pathogens with the vector that transmits it ▪ Malaria parasite

▪ Zika virus

▪ Yellow fever virus

▪ Plague bacteria

▪ West Nile virus

▪ Lyme disease bacteria

▪ Deng fever virus

▪ Japanese encephalitis virus

▪ African sleeping sickness parasite

▪ Rocky mountain spotted fever bacteria

A. Mosquito

B. Tick

C. Biting Flies and

Fleas

▪ Match the various pathogens with the vector that transmits it ▪ Malaria parasite (A)

▪ Zika virus (A)

▪ Yellow fever virus (A)

▪ Plague bacteria (C)

▪ West Nile virus (A)

▪ Lyme disease bacteria (B)

▪ Deng fever virus (A)

▪ Japanese encephalitis virus (A)

▪ African sleeping sickness parasite (C)

▪ Rocky mountain spotted fever bacteria (B)

A. Mosquito

B. Tick

C. Biting Flies and

Fleas

Highlight which ingredients are US EPA registered active ingredient:

• DEET, 2-undecanine, Picaridin, cedar oil, peppermint oil, oil of lemon eucalyptus/p-methane-3,8-diol, citronella oil, IR3535, soybean oil, geranium oil, catnip oil

What is the difference between registered and unregistered ingredients?

Highlight which ingredients are US EPA registered active ingredient:

• DEET, 2-undecanine, Picaridin, cedar oil, peppermint oil, oil of lemon eucalyptus/p-methane-3,8-diol, citronella oil, IR3535, soybean oil, geranium oil, catnip oil

What is the difference between registered and unregistered ingredients? Registered ingredients have been evaluated for safety and efficacy. Unregistered ingredients just safety

DEET

▪ Strengths vary from ____% to _____%

▪ After which strength is there little to no added benefit? What is a risk for higher strength formulations?

▪ Where can DEET be applied? What is the duration of protection?

▪ In what conditions would a patient need to reapply more frequently?

▪ What are some side effects of this? What is an important counseling pt to tell patients?

▪ What is the youngest age this can be recommended in?

DEET

▪ Strengths vary from 5% to 100%

▪ After which strength is there little to no added benefit? What is a risk for higher strength formulations? After 50% there isn’t much added benefit. Risk for systemic absorption

▪ Where can DEET be applied? What is the duration of protection? On skin or clothes. Lasts 2-5 hours

▪ In what conditions would a patient need to reapply more frequently? High temperature, water exposure, heavy sweating

▪ What are some side effects of this? What is an important counseling pt to tell patients? Skin/eye irritation, odor, may stain certain surfaces. Tell patients not to use on broken skin

▪ What is the youngest age this can be recommended in? 2 months

▪ Match the insect repellant with it’s correct description:

▪ Can be used on skin and clothing. Similar to DEET but with less toxicity, odor, and staining

▪ Can be used on skin and clothing. Short duration of protection

▪ Can be used on skin and clothing. Protects for 5 hours against mosquitoes and 2 hours against ticks

▪ Gives 6 hours of protection against mosquitos. Should not be used in children less than 3 y/o

▪ Short duration of protection. Candles made from this aren’t very effective

▪ Protects against mosquitos and black flies; not ticks. Lasts 7-15 hours

• A. Oil of Lemon Eucalyptus

• B. Picaradin

• C. Catnip oil

• D. 2-undecanone

• E. IR353

• F. Citronella oil

▪ Match the insect repellant with it’s correct description: ▪ Can be used on skin and clothing. Similar to

DEET but with less toxicity, odor, and staining (B)

▪ Can be used on skin and clothing. Short duration of protection (E)

▪ Can be used on skin and clothing. Protects for 5 hours against mosquitoes and 2 hours against ticks (D)

▪ Gives 6 hours of protection against mosquitos. Should not be used in children less than 3 y/o (A)

▪ Short duration of protection. Candles made from this aren’t very effective (F)

▪ Protects against mosquitos and black flies; not ticks. Lasts 7-15 hours (C)

• A. Oil of Lemon Eucalyptus

• B. Picaradin

• C. Catnip oil

• D. 2-undecanone

• E. IR353

• F. Citronella oil

Counseling on Insect

Repellants


▪ Do not apply to __________ skin

▪ Spray in an ________ area

▪ Wash treated skin with ______ and ______ when you return indoors

▪ Do not apply directly to the _______. Spray on hands and apply to this area

▪ Do not use chemical repellants on children younger than ____________

▪ Do not apply to child’s __________. Use your own __________ to apply the repellant to the child’s face

▪ Children less than __________ should not apply the repellant to themselves

Counseling on Insect

Repellants


▪ Do not apply to broken/open skin

▪ Spray in an open area

▪ Wash treated skin with soap and water when you return indoors

▪ Do not apply directly to the face. Spray on hands and apply to this area

▪ Do not use chemical repellants on children younger than 2 months old

▪ Do not apply to child’s hands. Use your own hands to apply the repellant to the child’s face

▪ Children less than 10 years old should not apply the repellant to themselves

Other Insect

Repellants

▪ Are combination sunscreen with insect repellants recommended?

▪ List some products that are ineffective

▪ How do you use permethrin? Is it effective against ticks? What are some toxicities that can occur from this?

▪ Does standing next to someone who is wearing DEET help protect you as well?

Other Insect

Repellants

▪ Are combination sunscreen with insect repellants recommended? No. usually you have to use sunscreen more, don’t want to get excessive absorption of the pesticide. Separate pesticide and sunscreen applications by 1 hour

▪ List some products that are ineffective: chemical wristbands, electronic repellants, thiamine, garlic

▪ How do you use permethrin? What are some toxicities that can occur from this? Use for clothing only. Spray on clothes, let dry before wearing. Can last for 5 washes. Is effective against ticks. Can give eye/skin irritation.

▪ Does standing next to someone who is wearing DEET help protect you as well? No, can actually make mosquitos more attracted to you

▪ Match the following terms with their correct definition:

▪ Beneath the enamel. When exposed, can stimulate nerves to hot, cold, and acidic food

▪ Soft tissue that covers/protects roots of the teeth

▪ Hard calcified tissue that covers the dentin. Made of non-living cells

▪ Part of tooth inside the bone socket

▪ Visible part of the tooth

▪ Soft tissue in center of tooth which contains nerves, blood vessels, and connective tissue

▪ What are certain special populations that may need extra care when it comes to oral health?

• A. Enamel

• B. Crown

• C. Gums

• D. Pulp

Chamber

• E. Dentin

• F. Root

▪ Match the following terms with their correct definition:

▪ Beneath the enamel. When exposed, can stimulate nerves to hot, cold, and acidic food (E)

▪ Soft tissue that covers/protects roots of the teeth (C)

▪ Hard calcified tissue that covers the dentin. Made of non-living cells (A)

▪ Part of tooth inside the bone socket (F)

▪ Visible part of the tooth (B)

▪ Soft tissue in center of tooth which contains nerves, blood vessels, and connective tissue (D)

▪ What are certain special populations that may need extra care when it comes to oral health? Older patients, infants, patients with diabetes, patients who smoke

• A. Enamel

• B. Crown

• C. Gums

• D. Pulp

Chamber

• E. Dentin

• F. Root

Which parts of the teeth do dental caries primarily impact?

What are risk factors for the development of dental caries?

What are three ways to prevent the development of dental caries?

Which parts of the teeth do dental caries primarily impact? Tooth enamel and dentin

What are risk factors for the development of dental caries? Dry mouth, gum recession, tobacco use, orthodontics

What are three ways to prevent the development of dental caries? Mechanical (brush/floss), chemical (product to prevent plaque), and dietary (avoid cariogenic foods)

Fill in the blanks for the following counseling points:

• Recommend trying to brush teeth at least _______ times a day

• Brush at a ______ degree angle from the gum line

• Try and brush for at least ______ minutes

• When flossing between the gum and the tooth, it is important to hold the floss against the _______ while moving in a C-shape up and down

Which type of bristles are preferred for a toothbrush? Why?

Who might benefit from an electric toothbrush?

How often should a toothbrush be replaced?

Fill in the blanks for the following counseling points:

• Recommend trying to brush teeth at least two times a day

• Brush at a 45 degree angle from the gum line

• Try and brush for at least two minutes

• When flossing between the gum and the tooth, it is important to hold the floss against the tooth while moving in a C-shape up and down

Which type of bristles are preferred for a toothbrush? Why? Soft bristles because less damaging to enamel and gums

Who might benefit from an electric toothbrush? Elderly disabled, pt with difficulty in dexterity, pt that has orthodontic device

How often should a toothbrush be replaced? Every 3 months

▪ What should you use before using a fluoride rinse/gel?

▪ How long do you need to rinse with a fluoride rinse

▪ How long do you need to leave a fluoride gel on?

▪ How long should you wait to eat/drink after using?

▪ Match the following toothpaste ingredients with it’s purpose:

▪ Prevents cavities A. Triclosan (Colgate Total)

▪ Control tartar B. Sodium fluoride

▪ Antiplaque/antigingivitis C. Baking soda, titanium dioxide

▪ Whitening D. Zinc chloride, zinc citrate

▪ Mouthwash has two indications. What are they?

▪ What should you use before using a fluoride rinse/gel? Fluoride toothpaste

▪ How long do you need to rinse with a fluoride rinse? 1 minute

▪ How long do you need to leave a fluoride gel on? 1 minute

▪ How long should you wait to eat/drink after using? 30 minutes

▪ Match the following toothpaste ingredients with it’s purpose:

▪ Prevents cavities (B) A. Triclosan (Colgate Total)

▪ Control tartar (D) B. Sodium fluoride

▪ Antiplaque/antigingivitis (A) C. Baking soda, titanium dioxide

▪ Whitening (C) D. Zinc chloride, zinc citrate

▪ Mouthwash has two indications. What are they? As a cosmetic and for plaque control

Mouth Conditions

▪ What causes gingivitis? Is it reversible?

▪ How do you prevent it?

▪ What is halitosis? What can you use to treat it?

▪ What is xerostoma?

▪ What conditions can increase the risk for this?

▪ What are ways to treat/prevent this?

Mouth Conditions

▪ What causes gingivitis? Is it reversible? Accumulation of supragingival bacterial plaque. Yes it is reversible

▪ How do you prevent it? Same way you prevent cavities

▪ What is halitosis? What can you use to treat it? Bad breath. Use zinc salts and chloride dioxide

▪ What is xerostoma? Dry mouth

▪ What conditions can increase the risk for this? Sjogren’s syndrome, depression, diabetes, Crohn’s disease

▪ What are ways to treat/prevent this? Chew sugarless gum, fluoride treatment, avoid caffeine, alcohol, and acidic foods. Can use Biotene (15 mL rinse for 30 seconds)

▪ Which type of toothache indicated reversible damage? Which indicates irreversible damage?

▪ Why does tooth hypersensitivity occur? What ingredient is used to treat this?

▪ What is the most common issue associated with poor denture hygiene?

▪ What are some ingredients in denture cleaners?

▪ What are recurrent aphthous stomatitis more commonly known as?

▪ What causes them? Is this curable?

▪ What can be used to treat this? What are some common ingredients in this?

▪ What is herpes simplex labialis more commonly known as?

▪ What causes these? Where are they usually located?

▪ What are symptoms? How are these different than symptoms of aphthous stomatitis?

▪ What are three treatment options for this? How should they be used?

▪ Which type of toothache indicated reversible damage? Which indicates irreversible damage? Intermittent short sharp pain indicates reversible. Pain without stimulation indicates irreversible damage

▪ Why does tooth hypersensitivity occur? What ingredient is used to treat this? Dentin becomes exposed and dentin tubules become stimulated. Potassium nitrate 5% used to treat this, along with avoiding very hot or very cold foods/drinks

▪ What is the most common issue associated with poor denture hygiene? Chronic atrophic candidiasis

▪ What are some ingredients in denture cleaners? Phosphoric acid, sodium bicarbonate, calcium carbonate

▪ What are recurrent aphthous stomatitis more commonly known as? Canker sores

▪ What causes them? Is this curable? Caused by stress and local trauma. Not curable

▪ What can be used to treat this? What are some common ingredients in this? Orajel. Benzocaine, menthol, hydrogen peroxide

▪ What is herpes simplex labialis more commonly known as? Cold sores

▪ What causes these? Where are they usually located? Herpes simplex virus I. Junction of oral mucosa and skin of lip and nose

▪ What are symptoms? How are these different than symptoms of aphthous stomatitis? Burning, itching, tingling. Canker sores are more painful and located primarily on the oral mucosa

▪ What are three treatment options for this? How should they be used?

▪ Abreva (docosanol 10%) - use as soon as you feel the cold sore coming. Can use 5x/day until gone. Use no more than 10 days

▪ Anbesol (benzocaine) – use on affected area for no more than 2 days

▪ Carmex lip balm – apply to affected area. Do not use for cold sores for more than 10 days

Toothache

Mouth soreness

Fever or swelling

Loose teeth

Bleeding gums without trauma

Broken or knocked out teeth

Severe tooth pain

Trauma to the mouth

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