PBA Health PPOK OPHA - Drug Store News · PDF file1 PBA Health ° PPOK ° OPHA Trusted...

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PBA Health ° PPOK ° OPHA

Trusted Resource: Counseling your Patients on Drug/Nutrition Depletion and Vitamin

Supplementation

By Jeff Robins, R.Ph., FAAFRM, ABAAHP

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Synergy Conference PBA HEALTH • PPOK • OPHA


Trusted Resource: Counseling your Patients onDrug/Nutrition Depletion and Vitamin

SupplementationJeff Robins, R.Ph., FAAFRM, ABAAHP

Owner, Summit Functional [email protected]

0401 0000 17 300 L01 P/TDrug Store News is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.This CPE activity is approved for pharmacists and technicians and is worth 2.0 contact hours (0.2 CEUs)


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Synergy Conference PBA HEALTH • PPOK • OPHASynergy Conference PBA HEALTH • PPOK • OPHA

CPE CODE: THM 639Trusted Resource: Counseling your Patients on Drug/NutritionDepletion and Vitamin Supplementation.


Faculty Disclosures

Jeff Robins

Jeff Robins and the DSN clinical and editorial staff have no actual orpotential conflicts of interest in relation to this activity.

This program shall exhibit fair content balance, providing the audience with information of differentperspectives from which an informed professional opinion can be developed.

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Learning Objectives Pharmacists

• Identify patients who are candidates for drug/ nutrition depletion andvitamin supplementation counseling

• Create a plan to allow time, space and manpower for pharmacistprovided counseling of patients regarding potential nutrientdeficiencies

• List key counseling points for usage and interactions for patientsseeking wellness supplements

• Recommend appropriate supplements for patients with prescriptionand OTC drug induced nutritional depletion


Learning Objectives Technicians

• Identify patients who are candidates for drug/ nutrition depletion andvitamin supplementation counseling

• Create a plan to allow time, space and manpower for pharmacistprovided counseling of patients regarding potential nutrientdeficiencies

• List key factors to consider when referring a patient to the pharmacistfor prescription and OTC drug induced nutritional depletion counseling


Polling Question #1

1. Which classes of drugs may cause drug induced nutritionaldeficiencies?1. Statin drugs2. ACE inhibitors3. Estrogen containing products4. Type 2 Diabetes medication5. All of the above

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Polling Question #2

1. What are the side effects of lowered Co enzyme Q 10 levels?1. Muscle pain and weakness2. Confusion or decreased mental acuity3. Congestive heart failure4. Decreased energy5. All of the above


Why should you talk with your patients aboutDrug Induced Nutritional Deficiencies?

•Provide better healthcare for your patients togrow and rebrand your business


Why should you talk with your patients aboutDrug Induced Nutritional Deficiencies?

• Pharmacies have a built in clientele who are sick and want to be better.• 75% of disease in America is preventable or reversible!• Americans are willing to pay for health

• 50 67% take supplements,• 58 million join health clubs,• 38% use alternative medicine

• Many drugs cause drug induced nutritional deficiencies• 10% of Americans have nutritional deficiencies

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Benefits of Replenishing Drug InducedNutrient Depletions

• Talking to your patients about drug induced nutritional depletion will:• Allow you to prevent or reverse a deficiency

• Potentially greatly impacting your patient’s health.• Assist in simplifying therapy

• The patient may eventually, with the approval of their physician, discontinue medicationsthey no longer need.

• Show you are on the cutting edge of the newer drug/nutritional information.• Build patient confidence in your pharmacy by empowering the patient withinformation they will not get from their provider.

• Create a chance to speak with the patient’s provider exposing them to a newand important therapeutic process


Courtesy of Linus Pauling Institute Oregon State University


Courtesy of Linus Pauling Institute Oregon State University

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Neurotransmitter Production


Neurotransmitter Production


Etiology of A Drug Induced NutritionalDeficiency

• Patient presents with symptoms and is started on a medication.• Medication helps with original symptoms.• DIND starts to have effect on patients body insidious• Over weeks, months or years patient develops another set ofsymptoms or out right disease state due to DIND.

• Patient returns to physician with new symptoms, and is started onanother drug.

• Entire process may start all over again.

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How Drug Induced Nutritional DeficienciesDevelop

• Inhibition of nutrient absorption.• Inhibition of nutrient synthesis.• Alterations in transport of nutrients across membranes.• Increase or decrease in metabolism of nutrients.• Increase or decrease in excretion of nutrients.• Alteration in the body’s ability to store nutrients.


Drug Classes that May Cause DIND

• Antacids• Antibiotics• Anticonvulsants• Antidiabetics• Antifungals• Anti inflammatory drugs

• Antivirals• Bronchodilators

• Decongestants• Cardiovascular drugs• Cholesterol Lowering drugs• Electrolyte Replacements

• Female Hormones

• Oral contraceptives• Laxatives• Psychotherapeutic drugs• Ulcer medications


Cardiovascular DrugsMedication Class and NameExample:

• Statins: atorvastatin,fluvastatin, lovastatin,pravastatin, rosuvastatin,simvastatin

• HMG CoA reductaseinhibitors. Block theconversion of HMG CoAto mevalonate and alsoblocks the production ofCoQ 10.

Symptoms of Depletion:

• Congestive heart failure, highblood pressure, angina, mitralvalve prolapse, cardiac,arrhythmias ,lack of energy,muscle pain and weakness.Generalized weakening of theimmune system.

Nutrient Depleted

Coenzyme Q 10

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• ACE Inhibitors: captopril(Capoten®), enalapril(Vasotec®), lisinopril(Prinivil®, Zestril®),quinapril (Accupril®),ramipril (Altace®)


• Acne, impaired sense of smelland taste, delayed woundhealing, decreased immunity,frequent infections,depression, night blindness,problems with hair, skin andnails, component of insulin,needed for thyroidconversion of T4 >T3.

Nutrient Depleted

Zinc


Importance of Zinc

• Studies show a dramatic increase in urinary zinc excretion and corresponding decrease in zincblood values.

• Zinc is used by the body for auto debridement, and keratinocyte migration to clear and thenbuild soft tissue through the zinc dependent matrix metalloproteinases

• Immunity Killer T cells must have zinc to work.• Zinc is used in over 300 enzymatic processes in the body• The greatest concentration of zinc is found in our brains, the hippocampus responsible formemory and mood

• Zinc deficiency in synapses leads to more NMDA receptors which respond to the excitatoryneurotransmitter glutamate it also decreases the effect of GABA an inhibitoryneurotransmitter. This decreases BDNF (brain fertilizer) and another Nerve growth factor NGF.This process is thought to be a part of seizures, migraines

• Zinc is needed for the conversion of T4 to T3 and it is required for T3 receptor to accept T3.



• Beta Blockers: atenolol,metoprolol, nadolol,carvedilol


• Congestive heart failure, highblood pressure, angina, mitralvalve prolapse, cardiacarrhythmias ,lack of energy,muscle pain and weakness.Generalized weakening of theimmune system.

Nutrient Depleted

Co Enzyme Q10

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• Calcium ChannelBlockers: amlodipine,felodipine , nifedipine,nimodipine, nisoldipine


• Potassium Irregular heartbeat, edema, muscleweakness, fatigue, dizziness,confusion

Nutrient Depleted

Potassium



• Cardiac Glycoside:digoxin


• Magnesium is used in over 300enzymatic processes in thebody, muscle cramps,weakness, insomnia, loss ofappetite, GI disorders, kidneystones, osteoporosis,nervousness, restlessness,depression, anxiety, confusion,fatigue, HBP

• Potassium Irregular heart beat,edema, muscle weakness,fatigue, dizziness, confusion

Nutrient Depleted

MagnesiumPotassium



• Potassium Supplements

potassium chloride


• Fatigue, peripheral neuropathy,tongue and mouthirregularities, macrocyticPotassium Supplements

• potassium chloride

• anemia, depression, confusion,memory loss, easy bruising,dermatitis, loss of appetite

Nutrient Depleted

Vitamin B12

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Diuretic DrugsMedication Class and NameExample:

• Loop Diuretics bumetanide,furosemide

• Thiazide Diureticschlorthalidone indapamide ,hydrochlorothiazidemethyclothiazide

• Potassium Sparing DiureticsAmiloride hydrochloride,spironolactone, triamterene


• Phosphorous is essential forbuilding soft tissue(phospholipids), creatingcellular energy (ATP), coenzymefor enzymatic processes, acts asbuffer, needed for cellular andprotein synthesis

• Vit B1 depression ,memoryloss, muscle weakness,confusion, fatigue, nerveinflammation, rapid pulse rate

Nutrients Depleted

B1, B6, Vit C, Calcium,Magnesium, Zinc,

Potassium

Magnesium, B1, B6,Phosphorous, Potassium,

Zinc, Coenzyme Q10

Calcium, Magnesium


Anti diabetic DrugsMedication Class and NameExample:

• Biguanide Metformin


• Folic Megaloblastic anemia,birth defects, cervical dysplasia,elevated homocysteine,headache, fatigue, hair loss,increased infections.

• B12 Fatigue, Peripheralneuropathy, tongue and mouthirregularities, macrocyticanemia, depression, confusion,memory loss, easy bruising,dermatitis, loss of appetite

Nutrients Depleted

Folic Acid

Vitamin B12


Anti diabetic DrugsMedication Class and NameExample:

• Sulfonylureasglyburide,glipizide, glimepiride


• Healthy bacteria Gas, bloating,constipation, diarrhea, chronicyeast infections, bad breath,decrease immune response,depression, anxiety.

• CoQ10 Congestive heart failure,high blood pressure, angina,mitral valve prolapse, cardiac,arrhythmias, lack of energy,muscle pain and weakness.Generalized weakening of theimmune system.

Nutrients Depleted

Healthy IntestinalBacteria,

Coenzyme Q10

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Antacids/ Anti ulcerative DrugsMedication Class and NameExample:

• H2 Inhibitors famotidine ,cimetidine, ranitidine

• Proton pump inhibitorsomeprazole, lansoprazole,esomeprazole, rabeprazole

• Antacids AluminumHydroxide plusMagnesium


• Iron Anemia, thyroid disorder,weakness, fatigue, hair loss,brittle nails, frequent infections.

• Beta carotene Weaker immunesystem, increase risk of cancer,night blindness, Xerophthalmia,dry rough skin.

• Calcium muscle cramps, heartpalpitations, HBP, brittle andsoft bones, insomnia, leg andback pain.

Nutrients Depleted

Folic Acid, B12, Vit D,Calcium, Iron, Zinc

Beta Carotene, B12,Folic Acid, Calcium,Zinc, Iron

Folic Acid, Vit D, Zinc,Calcium, Magnesium,Chromium, Iron


Osteoporosis DrugsMedication Class and NameExample:

• Bisphosphonatesalendronate,risedronate,ibandronate, etidronate ,zoledronic acid


• Calcium muscle cramps, heartpalpitations, HBP, brittle andsoft bones, insomnia, leg andback pain. Magnesium is usedin over 300 enzymatic processesin the body, muscle cramps,weakness, insomnia, loss ofappetite, GI disorders, kidneystones, osteoporosis,nervousness, restlessness,depression, anxiety, confusion,fatigue, HBP

Nutrients Depleted

Calcium,Magnesium


Antibiotic DrugsMedication Class and NameExample:

• AntibioticsLevofloxacin,Ciprofloxacin Amoxicillin,Penicillin, Erythromycin,Azithromycin


• Biotin Hair loss, B1depression, irritability,confusion, muscle weakness,nerve inflammation,numbness, memory loss, B2dry itchy skin, cheilosis,reddening tearing burning ofeyes,B6 Depression,insomnia, PMS, Elevatedhomocysteine, lethargy

Nutrients Depleted

Biotin, B1, B2, B3,B6, B12, Zinc,Calcium,

Magnesium,Potassium, Vitamin

K, HealthyIntestinal Bacteria

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Hormone DrugsMedication Class and NameExample:

• Conjugated Estrogens

• Bio Identical HormonesEstradiol, Estriol, Estrone

• Oral Contraceptives


• Depression, low energy, lowlibido, osteopenia,osteoporosis, insomnia, moreillnesses, low blood count,heart palpitations, weightgain.

Nutrients Depleted

B6, B12, Vit D,Calcium,

Magnesium, Zinc,Folic Acid


Narcotic/Analgesic DrugsMedication Class and NameExample:

• NSAIDS aspirin,celecoxib, diclofenac,ibuprofen, ketorolac,naproxen

• Opiates hydrocodone,morphine, oxycodone


• Vitamin C Capillary fragility,muscle weakness, tenderswollen joints, easy bruising,gums that bleed easily

• Folic Megaloblastic anemia,birth defects, cervical dysplasia,elevated homocysteine,headache, fatigue, hair loss,increased infections. PotassiumIrregular heart beat, edema,muscle weakness, fatigue,dizziness, confusion.

Nutrients Depleted

Folic Acid, Vit C,Iron, Potassium


How to Get Started with your Patients?

•Order product

•Make space and time to

talk to your patients

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What Kind of Products to Order?

Use product lines that are exclusive to professional practices.

Use products that have a track record of safety.

Use products that are proven to be efficacious.


What Kind of Products to Order?

• Have account representatives who will help grow yourbusiness• Visit other practitioners in your area• Have in store promotions

• Have a profit margin that will allow your company to grow

• Have programs in place to maximize nutritional sales


Which Products to order?

• Multivitamin Capsule form taketwice daily, activated forms ofvitamins

• Coenzyme Q 10 Bioavailableform.

• B complex Activated form of Bvitamins

Probiotics Minimum of 10 billioncultures per capsule.Saccharomyces boulardii

Vitamin D3 5000U provenpotency

Multi mineral supplementBioavailable thru chelatingmineral to an amino acid

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Roadblocks to DIND Consultations

“It’s too expensive.”

“I don’t know enough.”

“I don’t have enough time.”

“I’m not a salesperson.”







Data?

Judgment?

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80/20 Rule


Sizzle

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Where Do You Spend Most of Your Time?

Behind the counter?

In the office?

On the floor with your patients?


DIND consultations take 2 4 minutes

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If you were my mom, I’d tell youto…..


Building your Drug Induced Depletion Team

• Who on your staff will be your ally in this process?• Pick a person who has time to talk to patients.

• If your perfect person is too busy….lighten their load• Look for an employee who:

• Likes or knows about vitamins• Is outgoing• Is compassionate• Is couragous• Is patient service oriented.

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Building your Strategy• To start, pick one or two drug depletions to discuss with your patients.• Get clinical studies to back up your info.

• This builds an irrefutable case for skeptical employees, and patients.

• Do a lunch and learn the first Tuesday of the month to teach about thenew depletions.

• Help employees connect why you are asking you to do this and what they cansay.

• Include 4 to 6 simple sentences explaining:• Which drugs may cause the depletion• The symptoms of depletion• The nutritional product to replenish the depletion


Step into what you have built!The Day is at Hand!

• You lead the way!• Stock the consultation area with:

• The Replete handouts from vitamin company• Studies for the patients• Products to purchase

• Stand by and support your staff until they get the hang of it.• Encourage everyone to keep trying. After 3 or 4 times everyone willhave it down pat.


Practice Points

Drug –induced nutritional depletions are real.

Body functions start to break down without vitamins

Replacing nutrient depletions is easy and inexpensive.

Set your practice apart from your competition by meeting your patient’s needs.

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Polling Question #1

1. Which classes of drugs may cause drug induced nutritionaldeficiencies?1. Statin drugs2. ACE inhibitors3. Estrogen containing products4. Type 2 Diabetes medication5. All of the above


Polling Question #2

1. What are the side effects of lowered Co enzyme Q 10 levels?1. Muscle pain and weakness2. Confusion or decreased mental acuity3. Congestive heart failure4. Decreased energy5. All of the above


Questions

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References1. Centers for Disease Control and Statistics. Health United States 2006. www.cdc.gov/nchs/data/hus/hus06.pdf#093.2. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. JAMA 2002;288:2998-3007.3. Clayton JA, Rodgers S, Blakey J. Thiazide diuretic prescription and electrolyte abnormalities in primary care. Br J Clin Pharmacol 2006 Jan;61:87-95.4. Pak CY. Correction of thiazide-induced hypomagnesemia by potassium-magnesium citrate from review of prior trials. Clin Nephrol 2000;54:271-275.5. Khedun SM, Naicker T, Maharaj B. Zinc, hydrochlorothiazide and sexual dysfunction. Cent Afr J Med 1995;41:312-315.6. Zenuk C, Healey J, Donnelly J, et al. Thiamine deficiency in congestive heart failure patients receiving long term furosemide therapy. Can J Clin Pharmacol 2003;10:184-188.7. Kishi T, Watanabe T, Folkers K. Bioenergetics in clinical medicine XV: Inhibition of coenzyme Q10-enzymes by clinically used adrenergic blockers of beta-receptors. Res Commun Chem Pathol Pharmacol 1977;17:157-164,


References8. Stoschitzky K, Sakotnik A, Lercher P et al Influence of Beta-blockers on Melatonin Release. Eur J Clin Pharmacol. Apr1999;55(2):111-15.9. Langsjoen PH, Langsjoen AM. The clinical use of HMG CoA-reductase inhibitors and the associated depletion of coenzyme Q10: A review of animal and human publications. Biofactors 2003;18(1-4):101-111.10 Crane FL. Biochemical functions of coenzyme Q10. J Am Coll Nutr 2001;20:591-598.11. Folkers K, Langsjoen P, Willis R, et al. Lovastatin decreases coenzyme Q levels in humans. Proc Natl Acad Sci U S A 1990;87:8931-8934.12. Valuck RJ, Ruscin JM. A case-control study on adverse effects: H2 blocker or proton pump inhibitor use and risk of vitamin B12 deficiency in older adults. J Clin Epidemiol 2004;57:422-428.


References13. Russell RM, Golner BB, Krasinski SD. Effect of antacid and H2 receptor antagonists on the intestinal absorption of folic acid. J Lab Clin Med 1988;112:458-463.14. Sturniolo GC, Montino MC, Rossetto L, et al. Inhibition of gastric acid secretion reduces zinc absorption in man. J Am Coll Nutr 1991;10:372-375.15. Yang, YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA 296 (24): 2947-5316. Zhao-Wei Ting R, C Chun Szeto, M Ho-Ming Chan, et al. “Risk factors of vitamin B12 deficiency in patients receiving metformin.” Archives of Internal Medicine Oct 9, 2006: 1975-1979.17. Wulffele MG, Kooy A, Lehert P, et al. Effects of short-term treatment with metformin on serum concentrations of homocysteine, folate and vitamin B12 in type 2 diabetes mellitus: A randomized, placebo-controlled trial. J Intern Med 2003;254:455-463.18. Bottiglieri T. “Folate, vitamin B12 and neuropsychiatric disorders.” Nutrition Review Dec 1996; 54(12): 382-390.,

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References19. Bottiglieri T, M Laundy, R Crellin, et al. “Homocysteine, folate, methylation, and monoamine metabolism in depression.” Journal of Neurology, Neurosurgery & Psychiatry Mar 2001; 70(3): 419.20. Golik a, Zaidenstein R, et al Effects of Captopril and Enalapril on Zinc Metabolism in Hypertensive nutrients.”; Journal of the American College of Nutrition Volume 17, 1998 issue 121. Pennix B,Guralnik J, et al “Vitamin B12 Deficiency and Depression in Physically Disabled Older Women: Epidemiologic Evidence From the Women’s Health and Aging Study”, American Journal of Psychiatry; May 2000; Vol 157 (5) 715-721.22. Modi S, Collins J, Relma D, “ Antibiotics and the Gut Microbiota”; The Journal of Clinical Investigation Oct 2014; Volume 124 issue 1023. C Jernberg, S Lo fmark, C Edlund, J Jansson” Long-term impacts of antibiotic exposure on the human intestinal microbiota”;Microbiology (2010), 156, 3216–3223


References

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Medical Association, Feb 1982; 126(3) 244-24726. Rose D, Strong R, Adams P, Harding P ”Experimental Vitamin B6 Deficiency and the Effect of Oestrogen Containing Oral Contraceptives on Tryptophan and Vitamin B6 Requirements Clinical Science; April 1972, 42(4) 465-47727. Butterworth C,Hatch K, et al, “Improvement in cervical dysplasia associated with folic acid therapy in users of oral contraceptives”, The American Journal for Clinical Nutrition; april 198228. Lindenbaum J, Whitehead N, Reyner F, “Oral contraceptive hormones, folate metabolism, and the cervical epithelium”; The American Journal of Clinical Nutrition; Oct 197529. Brown G, Greenwood J,” Drug and nutrition-induced hypophosphatemia: mechanisms and relevance in the critically ill”; Annals of Pharmacotherapy; May 1994 volume 28 (5) 626-632


References30. Deichmann R, Lavie C, Andrews S,” Coenzyme Q 10 and statin-induced mitochondrial dysfunction” The Ochsner Journal; Spring 2010 10(1) 16-2131. Rao R, Pandurange P, et al Digoxin toxicity with normal digoxin and serum levels: beware of magnesium, the hidden malefactor”; Journal of Emergency Medicine Aug 2013 45(2) 31-3432. Andress D, et al “Antiepileptic drug-induced bone loss in young male patients who have seizures”;

JAMA May 2002 volume 59(5)33.Monteleone P, Maj M, et al “Depressed nocturnal plasma melatonin levels in drug-free paranoid

schizophrenics”; Schizophrenia Research; April 1992, volume 7(1) 77-8434. Barringer T, Kirk J, et al “Effect of a multivitamin and mineral supplement infection and quality of

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;Neurology ; May 2002 vol 58 (9) 1348-1353.36. Brewer G, Dressman J, et al “Effect of intragastric pH on the absorption of oral zinc acetate and

zinc oxide in young healthy volunteers” ;Journal of Parenteral and Enteral Nutrition; Sept 1995 vol 19 (5) 393-397.

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References37. Marcuard S, Albernaz L, et al “Omeprazole therapy causes malabsorption of cyanocobalamin”

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41. Bailey CJ, Wilcock C, Scarpello JH. Metformin and the intestine. Diabetologia 2008;51:1552–1553.

42. Tomkin GH. Malabsorption of vitamin B12 in diabetic patients treated with phenformin: a comparison with metformin. Br Med J 1973;3:673–675.

43. Ting RZ, Szeto CC, Chan MH, et al. Risk factors of vitamin B(12) deficiency in patients receiving metformin. Arch Intern Med 2006;166:1975–1979


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44. Caspary WF, Zavada I, Reimold W, et al. Alteration of bile acid metabolism and vitamin-B12-absorption in diabetics on biguanides. Diabetologia 1977;13:187–193.

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50. Artuch R, Colome C, Vilaseca MA, et al. [Ubiquinone: metabolism and functions. Ubiquinone deficiency and its implications in mitochondrial encephalopathies. Treatment with ubiquinone]. Rev Neurol. 1999;29(1):59-63.


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comp inc 200153. StatisticsFromNationalHealthInterviewSurvey,https://nccih.nih.gov/research/statistics/NHIS54. 50% of Americans Take Vitamins- http://www.gallup.com/poll/166541/half-americans-vitamins-

regularly.aspx55. Adams,S. (April 2012) Why Doctors Regret Their Job Choice? Forbes.com

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