otc exam 2 study guide

7/27/2019 OTC Exam 2 Study Guide

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OTC Exam 2 Study Guide

1 | P a g e

Nutrition/Vitamins: Klucken

Understand importance of nutrition and reasons for

supplementation

• What is the preferred source of nutrients?

• Food

• Why?

• Better absorption

• What are the risks of nutritional deficiencies?

• Compromised growth and development

• Contribute to chronic diseases

• Exacerbate aging process

• What are some of the dangers of supplementation?

• Delay medical care

• Risk of ADRs with exceeding recommended intake• Drug-nutrient interactions

• List various etiologies of nutritional deficiency

• What is the stages that causes of nutritional deficiencies?

• Inadequate intake

• Decreased absorption

• Increased metabolic requirements

• Medications

• Lack of knowledge

Appreciate diverse clinical presentation of various deficiencies

• What are the difficulties identifying nutritional deficiencies?

• symptoms not present until deficiency occurs

• symptoms overlap with other deficiencies

• What are the stages of evolution of nutritional deficiency?

• Inadequate synthesis or absorption

• Depletion of nutrient stores

• Biochemical changes• Physical manifestations of deficiency

• Morbidity and mortality

Be familiar with supplement dosing and labeling

• What is the intent of supplementation?

• Maintain present status

• Prevent deficiencies

• Replenish compromised stores

• Treat medical conditions

• What are the four DRI categories?• EAR: Estimated ave (half) requirements

• RDA: reference daily intake

• AI: adequate intake (lacks data)

• UL: tolerable upper intake

• What is the importance of supplement labeling?

• Indicates %DV

• List three problems that result because supplements are not

regulated by the FDA.

• Potential disparity of contents vs. label

• Do not require proof of safety or efficacy

• Do not require inspection of production• What does USP labeling indicate has been verified?

• Ingredients and amounts

• Effective disintegration and dissolution for absorption

• Absence of harmful contaminants

• Safe, sanitary, well-controlled manufacturing




2 | P a g e

VITAMIN DEFICIENCIESCondition Symptoms Cause Non-Pharm Treatment Pharmacological

Vitamin A Deficiency Night Blindness

(usually first

symptom)

Dry/hardening of the

skin

Infections

Excess excretion of Vit A

Fat Malabsorption (little

absorption of fat due to

drugs or condition)

Natural Sources of

Vitamin A Vitamin A Supplement

(Must be medically

diagnosed)

Refer for any vitamin A

deficiency because OTC

supplement without

diagnosis is only intended

to:

Maintain present status

Prevent deficiency

Replenish compromised

stores (not intended

for self-treatment of vitamin deficiencies_

Vitamin D Deficiency Rickets

Osteoporosis

Muscle Weakness

Increased Risk of Falls

Colon, prostate, breast

cancer

Inadequate intake

GI Disease

Chronic Renal Failure

Inadequate sunlight

Long-term Phenytoin

Therapy

Liver/Kidney

Dysfunction

Natural Sources of

Vitamin D

Vitamin D Supplement

(Must be medically

diagnosed)

Refer for any vitamin D


supplement without


to:


Prevent deficiency Replenish compromised


for self-treatment of

vitamin deficiencies)




3 | P a g e

Vitamin E Deficiency Neurological

Abnormalities

Muscle pain, ache,

cramp, numbness or

sense of fatigue

(intermittent

claudication) Muscle weakness

Hemolytic anemia

Premature, low birth

weight

Fat Malabsorption

Natural Sources of

Vitamin E *DO NOT TAKE

WITHOUT PHYSICIAN

DIAGNOSIS*

Vitamin E Supplement

(Must be medically

diagnosed)

Refer for any vitamin Edeficiency because OTC

supplement without


to:


Prevent deficiency





Vitamin K Deficiency Unusual Bleeding

Prolonged PT (time it

takes for blood clot to

form)

Osteoporotic Fractures

Reduction in gut flora

that produces Vit K

Malabsorption

syndromes

Bowel resections

Liver Disease

Antibiotic therapy

Natural Sources of

Vitamin K

Vitamin k Supplement

(Must be medically

diagnosed)

Refer for any vitamin k


supplement without


to:


Prevent deficiency








5 | P a g e

Iron Deficiency Iron Deficiency Anemia

(IDA)

Pallor(pale appearance)

Fatigue

Blood Loss

Malabsorption

Inadequate diet

Erythropoietin (EPO)

w/o iron

supplementation

Natural Source of

Calcium

Iron Supplement

Magnesium Deficiency Neuromusculaririitability

Increase CNS

stimulation: Delirum

and convulsions

Hypocalcemia and

Hypokalemia (low

potassium) cannot be

corrected unless

Magnesium is within

normal levels

GI losses Renal losses

Natural Sources of Magnesium

Magnesium Supplement

OTC SUPPLEMENTSDrug Indication Dosing Interactions Exclusion

Vitamin A

Retinoids: retinol

Carotenoids: alpha-

carotene, beta-carotene)

Natural Sources

Dark green vegetables Red, Orange, or deep

yellow vegetables and

fruits

Liver, Liver fat, egg yolk

Normal Growth and

Development

Bone development

Proper organ function

Eye health

Epithelial cell mucoussecretions

Not Important for this

exam Warfarin: increase in

anticoagulation

Cholestyramine,

colestipol, mineral oil:

decrease absorption of

Vitamin A

Anyone who is on blood

thinners

Smokers have an

increased risk of

cancer,CVD, and death

w/ Beta-Carotene People at risk for bone

fractures

Pregnancy: increase risk

of birth defect/liver

abnormalities




6 | P a g e

Vitamin D

Cholecalciferol (D3) –

naturally occurring

Ergocalciferol (D2) –

food additive

Calcitriol – Active form

of Vit D that aids inabsorption of calcium

Natural Sources

UV Light

Milk, egg yolk, liver,

salmon, tuna, sardines,

milk fat

Proper bone/mineral

formation

Increase calcium and

phosphate absorption

Improves renal

reabsorption of

calcium Maintains serum

calcium and

phosphorous levels

600-800 IU/day

Max Dose: 4000 IU /day

(100mcg/day)

(1mcg = 40 IU Vitamin

D)

Phenytoin,

carbamazepine,

barbituates: increase

metabolism of Vit D

Cholestyramine,

colestipol, mineral oil:

decrease absorption of Vit D

Patients at risk of

hypercalcemia

Patient at risk of kidney

stones

Patient at risk of renal

failure

Patients with cancer

Vitamin E

Tocopherols

Tocotrienols

Natural Sources

Wheat germ Vegetable Oils

Margarine

Green Leafy Vegetables

Milk Fat

Egg Yolk

Nuts

Antioxidant

Hemebiosynthesis

(Creates heme groups

which carry oxygen)

Steroid metabolism Collagen formation

Prevents stretch

marks

15mg/day

Max Dose: 1000mg/day

**@ 400 IU/day can

cause death in some

patients**

Warfarin: Increase

coagulation

Cholestyramine,

colestipol, mineral oil :

decrease absorption of Vit E

Do not take without

medical referral

Patients @ risk of

Chronic Heart Failure

(CHF) Patients @ risk of

hemorrhagic stroke

May cause fetal loss




7 | P a g e

Vitamin K

Phytonadione (K1) –

vegetables

Menaquinone (K2) –

Product of bacterial

metabolism (produced

in the gut) Menadione (K3) –

synthetic (3x potency)

Natural Sources

Liver

Vegetable Oil

Spinach

Kale

Cabbage

cauliflower

Promotes the

synthesis of clotting

factors

Activates clotting factors

Activate coagulation

protein C & S

Activation of osteocalcin- bone mineralization

Not needed for this

exam Warfarin: Decreased

anticoagulation

Broad Spectrum

Antibiotics reduce

vitamin K via gut Flora

Vit A & E: reduce vit Kactivity

Cholestyramine,

colestipol, mineral

oil :Decreased

absorption of Vit K

Do not take if you are on

blood thinners

**NEED DOCTOR

EVALUATION IF YOU

ARE AT RISK FOR

STROKE OR CHF**

Vitamin C

Ascorbic AcidNatural Sources

Green & Red Peppers

Broccoli

Spinach

Tomatoes

Potatoes

Strawberries

Citrus Fruits

Kiwi

Reducing agent

Help absorption of non-

heme iron (ferric ->

ferrous)

Claims to prevent and

treat common cold

(unsupported)

Not important for this

exam

Cholestyramine,

colestipol, mineral oil :Decreased

absorption of Vit C

Rare side effects:

Nausea, stomachcramps, diarrhea,

nephrolithiasis

Creates acidic urine




14 | P a g e

Orlistat

Lipase inhibitor

Inhibits the absorption

of dietary fats

Long-term weight loss

management aid

Need to accompany a

change to healthier diet

(low in fat) and exercise

Expected weight-loss of

5-10 lbs within 6months

May also lower LDL

cholesterol and blood

pressure

60mg TID

Take within 1 hour of

eating a meal (if meal

does not contain fat the

omit dose)

MVI to be taken 4-6

hours after or 2-4 hrsprior to taking orlistat

Vit ADEK: decrease

absorption of Vit ADEK

Lipophillic Drugs

(amiodarone,valproic

acids): may affect

efficacy of lipophilic

drugs

Patient taking warfarin

due to decrease in

vitamin K absorption

Patients with

osteoporosis due to

decrease in vitamin D

absorption Patients with

gallbladder problems

Chronic malabsorption

syndrome

May cause GI upset if

fatty foods are ingested

Sensa

Tastants that trick your

brain and stomach into

thinking you are full

through sense of smell

6 month weight loss

system

Does not need to change

diet or starve

themselves Two monthly containers

shipped to patients and

new blend of tastants

per month

Sprinkle on any food you

eat N/A Expensive – patients

may not be able to afford

SlimScents

Dietary pens that are

inhaled through nose

before meals

Three pens that are

rotated constantly

Does not require

patients to eat special

meals or starve

themselves

Inhale gently three times

in EACH nostril 5-6

minutes before you eat

and 5-10 minutes after

you eat OR everytime

you feel the least bit

hungry

Sniff at least 10 times in

each nostril per day

N/A Expensive – patients

may not be able to afford

A little bit more

expensive than sense

Psyllium **FIBER**

Non-digestible carb and

lignin (fiber)

Favorable effects on

obesity, and improved

lipid and hypertension

control

20-38 gram per day Hypoglycemic agents:

may affect efficacy of

hypoglycemic agents

N/A




15 | P a g e

Menstruation/PMS/Contraception– Masters

What is the Mentrual Cycle?

Menarche: First period ~ 12 years old

Average cycle last 28 days

30-80mL of blood loss Ovulation occur on Day 14 of the cycle

Referrals for Dysmonorrhea

Severe dysmenorrhea and/or menorrhagia (abnormal, heavy,

prolonged menstrual period at regular intervals)

Dysmenorrhea symptoms are inconsistent with primary

dysmenorrhea (onset after age of 25, and dysmenorrhea pain at

times other than onset of menses)

History of Pelvic inflammatory disease (PID), infertility, irregular

menstrual cycles, endometriosis (cell from uterus grows in otherparts of the body) and ovarian cysts

Use of intrauterine decides (IUD)

Allergy to aspirin or NSAIDs; intolerance to NSAIDs

Active GI Disease (PUD, GERD, Ulcerative colitis)

Bleeding Disorders

Referrals for PMS

Severe PMS or PMDD (Premenstrual dysphoric disorder: severe

form of PMS)

Uncertain pattern of symptoms (timing in relationship tomenses), particularly for emotional/psychological symptoms

Onset of symptoms coincident with use of Oral Contraceptives

hormone therapy

Contraindication to specific agents

Product that MAY

help PMS

Do not take if

you have these

conditions

Do not take if you are on

these drugs

Caffeine/PamabronPUD,

Anxiety/insomniaMAOI, xanthine meds

Ammonium

Chloride

Renal or liver

impairment

Chastetree Berry

20-40mg ZE440

Extract – Most

studied – likely

effective

Hormone-

sensitive cancers,

Invitro

fertilization

(increase fertility)

Oral contraceptives,

hormone therapy, dopamine

agonists & antagonists

Black Cohosh 40-

80mg BID

Hormone-

sensitive cancers

Chemotherapy agents

(doxorubicin, docetaxol)

St. John’s wort – OTC

antidepressant

Alzheimer’s

disease, bipolardisorder,

schizophrenia,

infertility

Antidepressants (SSRI, TCA

or MAOI), narcotic analgesics,digoxin, dextromethorphan,

Oral contraceptives,

warfarin, AIDS drugs

Ginkgo – helps

with breast pain

and fluid retention

Anticoagulants and

antiplatelet agents, insulin,

seizure threshold-lowering

drugs, thiazide diuretics

***Lactating women should not use herbals***

Natural Family Planning **NOT LISTED ON OBJECTIVES** Calendar method/cycle beads

Basal body temperature: slight increase @ ovulation due to LH surge

Cervical/Saliva changes: Peak fertility cervical mucus thins – leaf

pattern in saliva test

Symptothermal method

Lactational Amenorrhea Method: Exclusively breast feeding

decrease likelihood of pregnancy within 6 months of giving birth

Ovulation Prediction Test: Detects LH Surge




17 | P a g e

Toxic Shock Syndrome

Severe multisystem

illness – inflammatory

response to enterotoxin

produced by bacteria

Occurs within 2 days of

onset of menses, during

menses or withing 2

days after menses

MOST DISTINCT AND

REQUIRED FOR DX:

Rash: Sunburn like and

does not itch ~ 10day

for onset

o Desquamation of

palms and soles

High Fever

flu like symptoms

Tampons

Contraceptive barrier

(sponge)

Bacteria can be on hands

Topical Oral

Contraceptives

Caused by S. aureous and S. pyogenes

Prevention: use of

sanitary pads

Use low absorbency

tampons

Wash hands before use

of tampons

Follow directions ontampons box

Do not leave tampon in

overnight for longer

than 8 hours

During the day do not

use for more than 6

hours

REFER: THERE IS NO

OTC TREATMENT

DO NOT USE NSAID:

Worsens the disease

process

Drug Indication Dosing Interactions Exclusion

NSAIDs: prostaglandininhibitor

Ibuprofen 200-400mg

Naproxen 220-440mg

Physical symptoms of PD and PMS

Anti-inflammatory

First line of therapy for

Primary Dysmenorrhea

Ibuprofen 200-400mg q4-6H (max: 1200mg)

Naproxen 220-440mg

q8-12H (max: 660mg)

Alcohol: increase risk of bleeding

Anticoagulants:

increased risk of

bleeding

Phenytoin: increase

phenytoin levels

Aspirin: decrease

antiplatelet effect (take

aspirin 30 mins before

or 8 hours after)

Naproxen: DO NOT USEFOR CHILDREN UNDER

12 DUE TO REYES

SYNDROME

Patients that are on

anticoagulants **use

alternate therapy**

Patients who drink

regularly (more than 3

drinks per day)

Cannot tolerate NSAIDs

Acetaminophen 650-1000mg

Physical symptoms forPD and PMS

Little effect on

prostaglandin

Only used for Primary

dysmenorrhea if NSAIDs

cannot be taken

Acetaminophen 650-1000mg q4-6h (max

dose 4000mg)

Alcohol: increase risk of hepatotoxicity

Warfarin: increased INR

levels

Refer back to previousexam material




18 | P a g e

Aspirin Little effect on PG Not important n/A Last line – do not use

cause of increase in

menstrual flow

DO NOT USE IN

PATIENTS UNDER 15

DUE TO REYES

SYNDROME

Ammonium Chloride Treatment of PMS

Diuretic

TID (max: 3g – no more

than 6 days) N/A Renal or liver

impairment

Caffeine Inhibits renal tubular

reabsorption of sodium

and water

Diuretic: Treatment for

fluid retention

100-200mg q3-4H MAOI (depression meds)

Xanthine (Gout Meds)

Theophylline (treats

asthma)

PUD

Anxiety

Insomnia

Pamabrom

Derivative of

theophylline

Treatment of PMS

Diuretic

50mg QID

In combination products

MAOI (depression meds)

Xanthine (Gout Meds)

PUD

Anxiety

Insomnia

Midol and Pamprin Acetaminophen

Pamabrom

Pyrilamine

(antihistamine)

Combination of painreliever, diuretic and

antihistamine

N/A N/A N/A

Condoms

Latex

Polyurethane

Lamb skin

Female Condoms (DO

NOT RECOMMENDWITH MALE CONDOM)

Contraception N/A N/A Latex allergies -> use

polyurethane or natural

skin

Lamb skin DOES NOT

prevent STD prevention

DO NOT USE OIL BASEDLUBRICANTS – Degrades

LATEX condoms

DO NOT WEAR Female

condom for more than 8

hours




19 | P a g e

Vaginal Spermicides

Films

Foams

Gels

Suppositories

Contraception Films: Need 10-15 min –

3 hours to dissolve N/A Does not protect against

STI

Increase risk of

contracting HIV/AIDS

due to irritability of

vaginal canal

Today’s Sponge

Contraceptive Barrior

Spermicide

Semen absorbant

contraception

Moisten with tap water

Effective IMMEDIATELY

Must remain in place 6

hours AFTER

intercourse

Effective for 24 hours –

REMOVE BY 24 HOURS

N/A

More effective in womenwho have not given birth

Increased risk of HIV

and cervical infections

Increase risk in TSS

Plan B One Step

Levonorgestrel 1.5mg

Approved for women of

all ages

DOES NOT ENDPREGNANCY

Emergency

contraception

ONLY FDA approved to

work if taken within 72

hours ~ if within 120hours would be

appropriate to sell but

counsel!

Take 1 pill as soon as

possible after

unprotected intercourse

or contraception failure

Most effective if takenwithin 3 days

Should start menstrual

cycle within 1 week (3

weeks if irregular)

Refer if menses does not

occur

N/A Does not protect against

HIV/AIDS

Most Common AE:

o Nausea

o Abdominal Paino Fatigue

o Headache

DO NOT TAKE IF YOU

HAVE UNDIAGNOSED

VAGINAL BLEEDING

Plan B Generic

Levonorgestrel 0.75mg

TWO PILLS

Available for women

17+ OTC

Under 17 = RX only

DOES NOT END

PREGNANCY

Emergency

Contraceptive

ONLY FDA approved to

work if taken within 72

hours ~ if within 120

hours would be

appropriate to sell but

counsel!

Take 1 tablet ASAP after

unprotected intercourse

or contraceptive failure

Take Second dose 12

hours later

Will still be effective is

2nd dose is forgotten

Should start menstrual

cycle within 1 week (3

weeks if irregular)

Refer if menses does not

occur

N/A Does not protect against

HIV and AIDS

Most Common AE:

o Nausea

o Abdominal Pain

o Fatigue

o Headache

DO NOT TAKE IF YOU

HAVE UNDIAGNOSED

VAGINAL BLEEDING




20 | P a g e

Vaginal Infections and Atrophic Vaginitis – Adams

Referral for Vaginal Infection

Pregnancy

Girls less than 12 years old

Fever or pain is present in the lower abdomen, back, or shoulder

Medications that predispose (lead) to Vaginal Candidiasis

o Corticosteroids

o Antineoplastics

Medical disorders that can predispose to Vaginal Candidiasis

o HIB

o Diabetes

Recurrent Vaginal Candidiasis

o More than 3 vaginal infection per year or vaginal infection in the past 2 months

ODOROUS DISCHARGE IS AUTOMATIC REFERRAL TO DOCTOR

What is a pH testing device and what are its limits

Press application for women with normal periods

DO NOT USE WHEN MENSTRUATING

DO NOT URINATE OR TOUCH THE APPLICATOR

Intercourse = Wait 2 days before using, Spermicide/Lubricant? = wait 3 days before using

Will only tell you if you have vaginal candidiasis – high pH must refer to doctor

Referral for Atrophic Vaginitis

Symptoms of severe vaginal dryness or dyspareunia

Symptoms that are not localized (widespread)

Vaginal Dryness or dyspareunia not relieved by use of personal lubricants after 7 days




24 | P a g e

Alopecia – Adams

Referral for Alopecia

Less than 18 years old

Pregnancy or breast feeding

Recent discontinuation of oral contraceptives

Hair loss in patient with no family history of hair loss

Hair loss in patient with positive hair-pull test

Hair loss related to history of endocrine dysfunction

(chemotherapy, medication use) and dietary deficiencies

Sudden or patchy hair loss

Evidence of fever or inflammation (occurring 3-6 months before

hair loss begins)

Skin lesion that indicate autoimmune disease or infection

Scaling, sunburn, or other damage to scalp

Broken-off hair shafts that resemble those caused by fungal

infection or trichotillomania Loss of eyebrows or eyelashes

Changes in nails

Women with sudden or severe hair loss

o Due to hyperandrogenism

Postpartum women with hair loss

Positive Hair Pull Test

10% = excellent

25% = average person

35% = Concern

**SHOULD NOT SEE ANY ROOTS***

Minoxidil Patient Counseling Points **was not on objectives**

Initial Effect

o Might see minor hair loss

Effectiveness

o Works best when you FIRST notice hair loss

Hair Stimulation

o Turns Vellus (Thin) -> Terminal (thick) Hair

o Using 2% form: see improvement @ 4 months

o Using 5% Form: see improvement @ 2 months

Therapeutic Endpoint – Hair

o 2%: Must use for one full year to see full effect

o 5%: must use for 4 months to see full effect

Discontinuation

o Hair density returns to pretreatment




27 | P a g e

Equipment Indication Directions Interactions Exclusion

Forearm Crutches Long term patients that

need support for a long

period of time

Requires good grip

Requires good wrist

Bad wrist

Bad grip

Platform Crutches People without inadequate grip

People who cannot deal

with wrist compression

People who cannot deal

with axillary pressure

Axillary Crutches

Most common Requires good grip

Requires arm strength

Bad axillary

Bad grip

Bad arm

Canes Need safety blanket

Four point or quad is

most stable People w/ good grips,

arm strength, leg

strength

Use on good side Patients that need actual

support

Bad arms Bad wrist

Bad legs

Hose

Usually need to be

referred to get correct

sizing

OTC = lower grade

support hose Moderate (mild

tiredness)

o 10-20mm Hg

Firm (begin to feel

pain)

o 20-30mm Hg

Heavy (Severe)

o 30-40 mm Hg & 40-

50mm Hg

Assist blood flow

Reduce swelling in feet

and ankles

Help relieve pain and

fatigue in legs

40+ circulatoryinsufficiency

Women of child bearing

age

Workers who do

prolonged sitting or

standing

Patients who need 50

mmHg – Should get RX

Does not have usual leg

size




32 | P a g e

Otic Disorders – Falter

When do you refer?

Signs of infection; Pain due to ear discharge

Ear surgery in past 6 weeks Bleeding, trauma, or ruptured tympanic membrane

Children under the age of 12

presence of tympanostomy tubes

Hypersensitivity to ingredients

Unable to follow administration directions

Presence of boil(s) anywhere other than auricle or multiple boils

Condition Symptoms Cause Nonpharm Treatment Pharmacological

Excessive/Impacted

Cerumen

Pressure or feeling of

fullness in ear Gradual hearing loss

Ear wax blocking ear

canal

Stop Use of Q tip

Moist wash cloth drapedover finger and get any

excess out in outer

portion of ear for

excessive cerumen

Carbamine Peroxide

6.5%o 5-10 drops for 15

minutes then rinse

ear with warm water

w/ otic bulb

CAM Agents

Water-Clogged Ears Wetness or fullness in

ear

Gradual Hearing Loss

Leads to inflammation,

itching, pain, infection,

“Swimmer’s ear” <-REFER

Bacterial infection May be able to release

water by tilting head

downward

Indirect heat from blow

dryer on low setting

Isopropyl Alcohol 95% +

Glycerin 5%

Isopropyl Alcohol 95% +

acetic acid (vinegar) 5%

(50:50 mixture)

Boils Opens in 2 weeks with

discharge contents Red papule, develops

into pustule

Self-Resolving

Warm compresses

Topical antibiotics

Self-Resolving

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