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HERBAL SUPPLEMENTS – TOP TEN June 16, 2005 anaphylaxis, photosensitivity, GIcomplaints decreased INR on warfarin; ? ^ breast cancer risk; decreased thyroidabsorption N, D, abdominal pain, erectile dysfunction Induces cytochrome P405 3A: Decreasedlevels of CCBs, statins, benzodiazepines,erythromycin, and protease inhibitors.
May alter INR with warfarin; increasesurinary oxalate.
AGENTS FOR DIABETES type 2. November 1, 2005 adv ant age s/ 2
disadvantages
cost 30 ds
indications
w hole sale
resistance, or poor control oral ly.
All Type II diabetics should be on a b aby aspirin. Rxo utreach.com gives lowest prices.
1 M etform in dec rease s hep atic gluc ose p rod uction , decr easing intestinal gluc ose a bso rption , and inc reasing insulin sen sitivity). Metform in had a grea ter be nefit in de creas ing mo rtalityand diab etes rela ted en dpo ints versu s insulin or chlorp rop amid e (U KP DS , Lanc et 19 98;3 52:8 54) . 2 M ortformin, glitaz ones, and g lipizide decr ease H gbA 1C by 1-2 %, 0 .5-1.3 %, a nd 1 -2% respe ctively. 3 Thiazolidinediones decrease muscle and hepatic glucose production, increase glucose use by these tissues, and increase insulin secretion.
4 Patients with PCO D are good candidates for glitazones and metformin.
5 If the D M 2 patient is asym ptom atic witho ut ketonuria, fairly lev els of gluc ose o f up to 4 00-5 00 c an be tolerate d and you ca n afford to brin g gluco se do wn gra dually. Don ’t overtre at.
6 Other anti-obesity drugs: Sibutramine (Meridia). Blocks uptake of nor epinephrine & serotonin. Decreases glucose & LD L & increases HD L. Adverse effect: Hypertension.
Rim onabant (Aco mplia ): Ap petite su ppr essant. D ecrea ses gluc ose. A dverse effec ts: anxiety an d dia rrhea . (NE JM 200 5;35 3:21 11, 2 121 .)7. Give an aspirin in all diabetics.
8.D CC T in D M 1:A1 C 7.3% vs 9.1 > v in m icrov ascula r com plicatio ns(neruop athy v6 0% , micro scop ic ablu min, ren al failure v5 4% , retinop athy v4 7% ). F/u:57 % v in M I, CV A,or death(NEJM 2005;353:2643). UKPDS in DM 2 showed similar results; also in UKPDS: BP Control to 142/88 >>v macrovascular complications: v in DM death, CHF, and CVA.
*Trigylcerides are very dependent on glucose control !!! All diabetics should be on a statin and an aspirin. Use Vytorin 10 mg Simvastatin/40 mg Ezetimibe.
1 Statins block HMGCoA reducatse, inhibiting cholesterol synthesis, which increases LDL receptors and LDL catabolism; statins decrease mortality by 35%, niacin decreases mortality, cardiac mortality,and cardiac events; gemfibrozil and cholestyramine decrease cardiac mortality and cardiovascular events.
2 Fibrates enhances lipoprotein lipase synthesis and hence VLDL breakdown.
3 Nicontinic Acid blocks VLDL synthesis and is the only drug known to decrease Lp(a), a prothrombotic and an independent CV risk fator; shown to decrease mortality.
5. Omega 3 FA’s have been shown to reduce overall mortality, sudden death, and infarction, and improve angiograms in RCTs.
6. Check TSH for hypothyroidism, which is correlated with dyslipidemia.
7. Exercise, smoking cessation, weight reduction & loc calorie hi dietary fat will elevate HDL. Drug-related increases in HDL not shown to decrease mortality (NEJM 2005;353:1252). 8.9/05: When to start drugs, to goal: LDL100+ + CVD, to <70/ LDL130+ & no CVD, to <100/ TG>400, to <150/ HDL goal: men>50 & women >40. 9 CYP3RA, inhibited by fibrates, catabolizes statins, except for pravastatin. Glucorinadation for renal excretion of statins is effected by gemfibrozil but not fenofibrate. Therefore, the pravastatin-fenofibrate combination is optimal. Pravastatin or rosuvastatin (Crestor. Cheaper than atorvastatin) are the best drugs to use in liver dis (UTD).
10. Niaspin XR has no hepatotxicity. Use crystalline niacin for lower toxicity.
Left or bilateral
Wo rsening or No relief
of pain with elevation
of testis.
Blue dot in 1/5.
Cremasteric reflex may Impr ove men t of p ain
with elevation of testis.
> 35 y.o., no sexualexposure , oflaxac in only.
Other illnesses:Testicular ruptureTraumaHe noch Sch oenleinPurpura.
He rniaMumps Short Acting
May be safe in patients with HYP & CHF Long Acting: **
FelodipineNicardipine,Isradipine,Nifedipine GITS & CCNisoldipine Long Acting: **
com pare d to c hlortha lidon e in thos e with Avo id in C HF . Acute contro l in A.Fib . Best side effect profile. Gingivalhyperplasia.
Avo id in C HF . Con stipation . Raises dig level b y 50% .Contraind icted in th ose w ithconduction ab norm ality or tho se on betablocker. Gingival hyperplasia.
*Decrease AV node conduction** Use these drugs. OK for angina in heart disease per MK SAP XIII, Don Dye.
(3) Diltiazem, verapamil,atenologl, and metoprolol are recommended for rate control in chronic atrial fibrillation.
Allergic
Irritant induced (pollution, cigarette smoke)
Inflammatory
Anatomic
Hormonal
Rhinitis Medicamentosa
Cystic Fibrosis
Topical decongestants Antihypertensives Antidepressants Cocaine Vasomotor Allerg ic rhinitis: skin testin g for re spo nses to suspe cted a llergens is diagn ostic. Specificity can be demonstrated by binding to a solid-phase antigen via the RAST test (uptake of radiolabeled anti-IgE allergosorbenttechnique (RAST ). RAST is more difficult than skin testing because of the requirement for defined antigens and standardization.
Nose bleed: sit up and lean forward at waist. Ice packs and pressure on nose. Use oxymetazolineintranasally.
Ben zodiaz epines and tricyclics lead the list of medications that predisp ose to falls.
For acne in women, where it is related to androgenic habitus, use combined estrogen + progestin contraceptive. Spironolactone also worksbut does not improve any associated menstrual irregularity. (Q 42, MKSAP 13) Operations and anti-coagulation: if the patien t is alread y on an anti-coa gulant a nd if there is no clo t or prior histo ry of clo t (e.g., if anti-
coagulant is for A.F., which has never thrown an embolus), just hold warfarin for 2 days before surgery. If there is a higher risk, manage by
covering with unfractionated IV heparin until the morning of surgery and discontinue 4 hours prior to surgery (½ life is 1.5 hours); depending
on the risk of bleeding from surgery, you may or may not resume the heparin post op until warfarin becomes therapeutic. Uptodate:
Management of anticoagulation pre and post op.
For patients who are not on an anti-coagulant and who are undergoing immobilizing surgery such as joint replacement (low bleeding risk),you can start warfarin 1 day before the surgery and cover them with unfractionated heparin at therapeutic dose (onset in 30 minutes) aftersurgery until warfarin becomes therapeutic.
I n H o ar se ne ss a nd or c ou gh , w he re th er e is c ir cu msta ntia l e vid en ce of G E RD , 2 mo nth co ur se of P P I c an be su cc essfu l in 90 % .
Asymmetric hearing loss by audiometry may represent cerebellar pontine angle tumor.
Hypertension: effective salt restriction is 4 gm/day; exercise is the greatest contributor to controlling BP. (Q5, MKSAP 13) Hydrochlorothiazide is constipating.
Refer to urologist if PSA > 4.0 or increase in PSA is > 0.75 ng/ml/year.
Po lyurethane co ndo ms are availab le for tho se with late x allergy.
“M orning after p ill” such a s Plan B (p roge stins) can be effec tive if given w ithin 72 hour s of interc ourse . Also, o ne ca n pre scribe ethinylestradiol 10 0 mcg a nd levono rgestrel 0.5 mg im mediately and again in 12 ho urs.
W ith splenome galy asso ciated for exa mple with infectio us mo nonu cleos is, one h as to b e con cerne d ab out rup turing a sp leen d ue tosplenome galy.
For bee stings, decrease risk of stings with light colored clothing and no perfumes.
Ho neybee sen sitivity is not predictive of sensitivity to Vespid s which include wa sps, yellow jackets and hornets.
A severe lo cal skin reaction is not pred ictive of future anaphylaxis.
Have a high index of suspicion for endometrial cancer in women over 40 years of age with continued menses with abnormal uterine bleeding:Vaginal ultrasound has a sensitivity of 92% for endom etrial cancer but endometrial biopsy is more definitive. If cancer is excluded, examinepossibility of hypothyroidism or coagulation disorders such as von Wildebrand’s disease.
Levator a ni syndrome . Rectal pain increase d with sitting. Has no rectal fissures or hemo rrhoids, but a tend er rectum. T reat with hot bathes,NS AID S, mu scle rela xants. Have a high index of suspicion for breast masses that are negative on mammogram even when multiple (multiple fine needle biopsies) andparticularly if non-cystic (excision biopsy).
In de press ion o f the elde rly, nortrip tyline stimula tes app etite mo re than an SS RI.
In pre gnancy or suspect pregnancy, a UTI is treated with amoxicillin or ampicillin.
In scre ening fo r food allergies, sk in prick testing is said to hav e high se nsitivity.
For patients with painful spasms of pelvis and legs, baclofen via permanent epidural catheter can be given.
Psychiatric or soc ial disorders:
Somatization disorder: 8 unexplained symptoms: 4 pain, 2 GI, 1 sexual, 1 neurologic.
Abridged somatization disorder: 4 unexplained symptoms. Occurs in ¼ of general internal medicine
outpatients. Use freq uent non-pa tient-depende nt visits.
Pain disorder: significant pain in one or more sites associated with psychologic factors.
Hypochondriasis is a fear of disease; reassurance is ineffective.
Malingering is intentionally falsifying symptoms.
Conversion disorder: loss of motor sensory function related to social or psychic conflicts. The presentation fits the patient’s
view of the disorder.
After ruling out malingering or serious pathology, the diagnostic categories are embraced by MUS: Medically UnexplainedSymptoms. The management involves:*Reassure that there is no serious disease present.
*Further testing is not required.
*Validate the patient’s perception. it is not “all in your head”.
*Provide a benign somatic diagnosis: e.g., muscle strain.
*”We can’t necessarily cure it but we can take it out of the center of your life.”*Inquire about suicidal thoughts.
*Treat associated psychiatric disorders with appropriate meds. E.G.: GAD or depression with SSRIs.
OCPs:Low dose formulations have fewer overall side effects but may have break through bleeding; but give a trial of 3 months.
If this doesn’t work, try a different progestational agent.
If this doesn’t work and there is still break through bleeding, then you will have to try a higher dose estrogen formulation. If there are acne side effects, use a norgestimate formulation. a particular kind of progestational formulation.
In cases of missed OCPs, the pituitary and ovaries need release from OCP suppression for more than 7 days to produce afertilizable egg. Missing 2 to 4 days of pills at the beginning of menses is worse than during the middle of a menses becausethe pill-free interval is extended in the former but not the latter. Patients should take the most recent missing pill, continue anduse caution. (Q 105, MKSAP 12).
Bladder spasm in MS can result in chronic UTI and staghorn calculi. Fix this with oxybutynin which decreases bladderpressure, reflux, tendency to UTI, and hence calculi. (Q109, MKSAP 12).
The “minor treatment statute” allows for treatment of persons over 14 years of age for STDS, mental health problems,substance abuse, and contraception. Other medical problems may require guardian’s consent where person is a minor. ADHD can be diagnosed in adults if there is a history of onset before age 7 years. There is little development of tolerance totreatment with methylphenidate but improved concentration is not diagnostic of ADHD. Psychostimulants have little abusepotential (Q105, MKSAP 12).
Acupuncture is documented to be effective in the N & V of chemotherapy (MKSAP 12, Q 113).
Uptodate has an algorithm for “Estimation of coronary risk before non-cardiac surgery”. See ACP algorithm and Eagle criteria.
Jaw claudication and bilateral shoulder stiffness can signal TA; RX with prednisone urgently and obtain TA biopsy.
For women with DM 2 contemplating pregnancy, a) obtain UA for protein and creatinine clearance, U/A to r/o UTI, start tightinsulin control perhaps switching to insulin and avoiding oral hypoglycemics whose fetal effects are unclear, and give 0.4 mgfolate.
PPIs and cimetidine may augment traveler’s diarrhea.
In post menopausal women, for vaginal infections, UTIs, and dyspareunia, a vaginal estrogen ring is better than conjugatedestrogen cream because it is less messy and does not effect serum estrogen levels (Q117, MKSAP 13, Primary Care Medicine) Hematuria from BPH can be successfully treated with finasteride (Propecia) a 5 alpha reductase inhibitor, blocking testosteroneto dihydrotestoerone (Q 119, MKSAP 13, Primary Care Medicine) A rise in INR to 1.3 after 2 days of coumadin could represent a patient very sensitive to coumadin; cut the dose in ½ andrecheck in 2 days (Q 113, MKSAP 13, Primary Care Medicine) Treatment of depression in elderly:
>Methylphenidate in the morning and at noon can often be associated with a rapid response with a cost of few side effects.
>Sertraline (Zoloft) and desipramine are for those with primarily psychomotor retardation
>Nortriptyline or nefazodone are more useful for those who display agitation.
For fall prevention, all community based elderly patients receive (1)gait training, (2) exercise, (3) treatment for postural hypotension, and(4) m edica tion rev iew of m edicin es, partiuclarly p sycho tropicmedications (MK SAP 1 3 Upd ate).
Treat be nign p rostatic hyper plasia w ith either the alpha 1 anta gonist,doxa zosin (Card ura) or tamu losin (Floma x), or the five alpha red uctaseinhibito r, finasterid e (P rop ecia, P rosca r) (M KS AP 13 u pda te). Bo thhave equal efficacy in reducing rate of progression. The two togetherare m ore e ffective tha n either a lone in redu cing p rogre ssion. Finasteridc (P ropec ia or Pro scar) and c omb ination therapy alsoreduced urinary retention. Also, finasteride reduces the prevalence ofprostate cancer relative to placebo, although this effect was morepro noun ced in the pr even tion of lo w grad e lesion s. No te that tam sulosin (Flom ax) is also used for B PH and h as pro bab lysimilar effica cy acc ord ing to M SK AP 13 u pda te but w as no t studied inRCT cited in MSKA P 13 U pdate. Also, combination doxazosin plusfinasterid e ma y have similar sid e effects c omp ared with tams ulosinalone.
For alcoh olism, tre atment is AA and m ay be a ssisted b y naltrexo ne (ifnot on opioids), disufluram (if not drinking), acamprosate, ortopiramate.
Length of treatment for DVT/PE:Warfarin Life long: 3+ unprovoked DVT, 2 DVTs with anytype of thrombophilia, or one DVT in an unusual site.
Heparin Life long: DVT or PE secondary to cancer. Warfarin for 12 months: 2 unprovoked PE OR one unprovoked PE with an irremovable risk factor (e.g., ACLA orFactor V Leiden).
Warfarin for 6 months: 1st unprovoked DVT.
Warfarin 3 - 6 months: one DVT with removable risk factor.

Source: http://roushmedicine.com/Herbals&OtherOPD.pdf