Download Lisa Sharp-Gomez KNH413 Spring 2014 Drug

Lisa Sharp-Gomez
KNH413
Spring 2014
Drug-Nutrient Interaction Case Study
1) What is depression?
According to Merriam-Webster, depression is “a psychoneurotic or psychotic disorder
marked especially by sadness, inactivity, difficulty in thinking and concentration, a significant
increase or decrease in appetite and time spent sleeping, feelings of dejection and hopelessness,
and sometimes suicidal tendencies.”
2) Dr. Byrd has decided to treat Ms. Geitl with Zoloft, a selective serotonin reuptake
inhibitor (SSRI). Are there any pertinent nutritional considerations when using this
medication?
When taking an SSRI, one should avoid tryptophan supplements as they may increase the drugs
side effects. St. John’s Wort should also be avoided as the combination of the two could cause
serotonin syndrome, an increased level of serotonin in the body which can, if not treated, lead to
death. When taking this drug, care should be taken to avoid consuming grapefruit and certain
other citrus varieties as this can lead to increased circulatory levels of the drug. This drug can
also cause anorexia, which can lead to weight loss. (Pronsky, et al, p 286, 291, 390)
3) How do serotonin reuptake inhibitors (SSRIs) work?
SSRI’s work by preventing serotonin from being reabsorbed at the neural synapses. This allows
serotonin, a neurotransmitter, to remain available in the synapse for a longer period of time and
thus increase the number of neural transmissions possible, thus increasing mood. (Wildman, et
al, p. 152)
4) During the diet history, you ask Ms. Geitl if she uses any OTC vitamins, minerals or
herbal supplements. She tells you her mother suggested she try Hypericum perforatum
(St. John’s Wort) because in Germany, it is prescribed to treat depression. Ms. Geitl did as
her mother suggested, as it is available without prescription in the United States. What is
St. John’s Wort?
St. John’s Wort is a plant indigenous to Europe, but grown worldwide, whose flowers
and leaves are used as a treatment for the symptoms of mild depression. It has also been used to
treat menopause symptoms, somatization disorders and topically for wound healing. (St. John’s
Wort, 2012,NIH.gov)
5) How is St. John’s Wort used in the United States?
In the US, St. John’s Wort is sold as a dietary supplement. “Supplement products without
any reliable scientific evidence of health benefits may still be sold as long as the companies
selling them do not claim the supplements can prevent, treat, or cure any specific disease”(St.
John’s Wort, ,2008, Cancer.org) In the US, St. John’s Wort is most commonly used for
depression and conditions that sometimes go along with depression such as anxiety, tiredness,
loss of appetite and trouble sleeping. There is some strong scientific evidence that it is effective
for mild to moderate depression. (NIH citation) A doctors prescription is not required for this
‘supplement’ in the US as it is in Germany (St. John’s Wort, 2008, Cancer.org) thus anyone can
go to their local Walmart and purchase it.
6) How does St. John’s Wort work as an antidepressant?
St. John’s Wort appears to have several mechanisms which all seem to work together. 1)
It prevents the reuptake of several neurotransmitters, including serotonin, dopamine and
norepinephrine. 2) it seems to increase the density of some receptors in the frontal cortex, thus
increasing the sites at which neurotransmitters can bind, it inhibits certain enzymes in the brain,
thus allowing more dopamine to be converted to norepinephrine. None of these mechanisms
seem to predominate (St. John’s Wort, pharmacologyweekly.com)
7) Does St. John’s Wort have any side effects?
St. John’s Wort does have some side effects. In addition to the potential for causing
serotonin syndrome, it can cause photosensitivity, nausea, constipation, fatigue, dry mouth,
dizziness, headache, drowsiness, and sleep disturbances.(St. John’s Wort, 2008,cancer.org)
There are drug interactions with drugs used to treat mental conditions, certain liver
disorders, heart conditions, HIV/AIDS. St. John’s Wort seems to affect the rates at which these
medications are excreted from the body, thus increasing or decreasing the amounts that remain in
the body and thus altering their effectiveness. (NIH Medline citation)
St Johns Wort can also make birth control pills less effective by increasing the rate at
which estrogen is metabolized and excreted. Ms. Geitl is taking birth control pills, so this should
be of concern to her. (Hall, et al, p. 525-535)
8) How is St. John’s Wort regulated in the United States?
In the US, St. John’s Wort is sold as a dietary supplement, thus is not bound to FDA
regulations. Dietary supplements may be sold as long as the companies selling them do not
claim the supplements can prevent, treat or cure any specific disease. There are no standards for
the quantity of active ingredient that the product must contain. (St. John’s Wort,
2008,cancer.org)
9) How is St. John’s Wort used in Europe?
In Europe, St Johns Wort is also used to treat mild depression, but in many countries,
requires a doctors prescription (St. John’s Wort, 2000, CSPINET.org)
10) Why do you think people are interested in alternative medicine and herbal treatments?
I feel that people are interested in alternative medicine and herbal treatments because
they feel that a ‘natural’ product is better for them and will have fewer side effects than a ‘man
made’ drug. The word natural implies a meaning of being good for you. Well, opium is natural
too...
I also feel that many people perceive alternative medicine and herbal treatments as being
equally effective without the potential side effects of pharmaceuticals. In some cases, I feel that
this is correct, but I also feel that there is a time and place for everything and in some instances,
the pharmaceutical option would be the more effective choice .
11) Because Ms. Geitl is ambulatory, you are able to measure her height and weight. She is
5’11” tall and weighs 160 lbs. You also determine that she is of medium frame. Because
Mrs. Geitl is from Germany, she is used to reporting her weight in kilograms and her
height in centimeters. Convert her height and weight to metric numbers.
She is 180.34cm or 1.8m tall and weights 72.73kg
12) Is Ms. Geitl’s recent weight loss anything to be worried about?
Ms. Geitl’s current BMI of 22.4 is still in the normal range. It has fallen from 23.1, but
again, both are still within normal limits. The fact that she has lost 5 lbs. is not really a concern,
but the fact that she has lost 5 lbs. because she is eating a nutrient and energy poor diet is of
greater concern.
13) Because Ms. Geitl is alert and cooperative, you ask her to compete a Patient-Generated
Subjective Global Assessment (PG-SGA) of Nutritional Status. How would you score her?
Sections
Box 1
Box 2
Box 3
Box 4
Weight loss section (table 1)
Disease section (table 2)
Metabolic section (table 3)
Physical section (table 4)
Total
Score
1
2
4
2
1
0
0
1
11
SGA rating: I rated Ms. Geitl as a B=moderately (or suspected of being) malnourished
14) Using Appendix I, how would you triage nutritional intervention?
Triage is defined by Merriam-Webster as “the sorting of patients (as in an emergency
room) according to the urgency of their need for care.” By using the assessment tool provided in
the PG-SGA, individuals can be placed into groups based on the urgency of their need for
intervention. Those in group A show few deficits and although they may need intervention, it is
not urgent. Those in group B require more urgent intervention to prevent any further
deterioration of their condition. Those in group C require immediate intervention to restore
severe deficits
15) What methods are available to estimate Ms. Geitl’s energy needs?
Energy needs can be calculated using the Mifflin-St. Joer equation, the Harris-Benedict
equation, the American College of Chest Physicians equation, the Penn State 2003 equation, the
Ireton-Jones equation the Swimaner 1990 equation or the FAO/WHO Basal energy estimation
equations. (Nelms, et al pg 60)
16) Calculate Ms. Geitl’s basal energy needs using one of the methods you listed in
Question 15.
Using the Mifflin-St.Joer equation, Ms. Geitl’s energy needs are:
10W + 6.25H-5age – 161 =
10(72.7) +6.25(180.34) -5(20) -161 =
727 + 1127 – 100 – 161 = 1593 round up to 1600
17) What is Ms. Geitl’s estimated energy expenditure?
Multiplying by physical activity level of 1.3 (Nelms, et al, pg 60), Ms. Geitl’s estimated
energy expenditure is 1600 x 1.3 = 2080 kcal per day.
Using the calculation on page 242 of Nelms, Ms. Geitl’s estimated energy expenditure can be
calculated to be:
EER = 354 - 6.91(age) + PA x ((9.36 x wt) + (726 x ht)) =
= 354 - 6.91(20) + 1.12 x ((9.36 x 72.7) + (726 x 1.8))
= 354 - 138.2 + 1.12(1986.8)
= 2200
Both calculations yield results that are fairly close.
18) Evaluate her diet history and her 24 hour recall. Is she meeting her energy needs?
Based on her diet history and her 24 hour recall, she is only meeting about 30% of her
energy needs. She is consuming 600-625 kcal per day, way below what is needed to maintain
basal energy requirements.
It appears that her food choices are nutritious enough– broccoli, chicken noodle soup,
whole wheat, cottage cheese and peaches – but she is not consuming enough protein, fat,
carbohydrates and calories in general.
19) What would you advise?
Until Ms. Geitl’s medication has had a chance to become effective, I would advise the
addition of a nutritional beverage supplement, such as Ensure, to make up for her lack of desire
to eat. I would recommend that she try to drink 4 servings of Ensure Plus per day (350 kcal per
serving) in addition to what she can manage to eat, to make up for her energy intake deficit. She
currently is taking in approximately 600 calories, but needs 2200. Adding 4 supplemental
beverage servings will still leave a 200 calorie deficit, but as she has been prescribed medication,
it is hoped that her normal appetite will be returning. As her appetite returns, the number of
supplemental beverages that she consumes daily can be reduced and ultimately eliminated.
Once the medication has become effective, hopefully, Ms. Geitl would have an increased
desire to eat. It is noted that one of the side effects of Zoloft is anorexia, so progress may be
slow. (Pronsky, et al, p. 291) At this point, I would assist her in learning about what her calorie
needs were and what that would look like - food wise, by helping her plan daily menus.
I would also counsel Ms. Geitl on the requirements to abstain from grapefruit products
and extracts, Seville oranges, tangelos, minneolas, pummelos and exotic oranges as these can
lead to increased therapeutic effects of the medication that she has been prescribed. (Pronsky, et
al, p 390)
20) List each factor from your nutritional assessment and then determine an expected
outcome from each.
Supplemental beverages – The expected outcome of the use of these beverages is to stop
Ms. Geitl’s decent into malnutrition and to provide the calories needed to stop her weight loss
and possibly regain the weight that she has lost already. This will be measured at follow up
visits and will be documented by scale weight.
Education – Once Ms. Geitl’s medications have become effective and she feels the desire
to consume more regular meals, education will provide her the tools to plan, shop for, cook and
eat a well balanced diet with the right number of calories, fats, proteins, carbohydrates, vitamins
and minerals. The effectiveness of this education will be measured by a 3 day recall and by scale
measurements at future visits.
Education will also be effective to help Ms. Geitl recognize which citrus products she can
and cannot consume while taking her prescribed medication.
21) What is your immediate concern regarding this patient’s use of St. John’s Wort?
Two immediate concerns are 1) she is at risk for serotonin syndrome by taking St. John’s
Wort along with Zoloft and 2) the St. John’s Wort can decrease the effectiveness of her birth
control method.
22) Review the initial nutrition note written for this patient. Is this progress note
appropriate? Is it complete? Any errors? Any omissions?
While I agree with the 58g protein requirement, I am not sure how the 2600 was calculated. I
calculated using Mifflin St. Joer, Harris-Benedict and FAO/WHO methods and never came up
with more than 1680 to be multipled by an physical activity factor of between 1.12 and 1.3
(depending on which chart you are using) (Nelms, p. 60)
In the assessment statement, the RD did not address the why. The what – risk of malnutrition
due to not meeting energy or protein needs with her oral intake – is adequately stated, but why
this occurred is not mentioned. That might be something that would be necessary to know if Ms.
Geitl is seen by a different dietitian in the future.
Lastly, in the plan portion of the note, it was mentioned what was going to be done – increase
kcal and protein intake – but there was no mention of how the client was going to accomplish
this. There were no goals set, hence, nothing to measure at a future visit.
References:
Nelms, Sucher, Lacey, Roth; (2011)Nutrition Therapy & Pathophysiology, Belmont, Ca,
Brooks/Cole Cengage Learning
Pronsky and Crowe, Food Medication Interactions, 17th edition(2012), Birchrunville, Pa; FoodMedication Interactions
Depression, (n.d.) retrieved from http://www.merriam-webster.com/dictionary/depression\
Triage, (2014), retrieved from http://www.merriam-webster.com/dictionary/triage
SSRI, (n.d.) retrieved from http://www.mayoclinic.org/diseases-conditions/depression/indepth/ssris/art-20044825
Wildman, Robert, and Denis Medeiros. Advanced Human nutrition. Sudbury, MA: Jones and
Barnett Learning, 2012. 152. Print.
St John’s Wort, (2012) retrieved from
http://www.nlm.nih.gov/medlineplus/druginfo/natural/329.html
St. John’s Wort; (2008)
http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicin
e/herbsvitaminsandminerals/st-johns-wort
St. John’s Wort; (n.d.) http://www.pharmacologyweekly.com/articles/herbal-supplement-StJohn-wort-hypericum-perforatum-mechanism-depression
St. Johns Wort, (2000); https://www.cspinet.org/nah/9_00/stjohnswort.html
Hall, S. PhD; Wang, Z. MD,PhD; Huang, S. PhD; Hamman M. BS; Vasavada, N. MD; Adigun,
A. MD; Hilligos, J. LPN; Miller, M. PhD and Gorski, J. PhD. The interaction between St. John’s
wort and an oral contraceptives, American Society for Clinical Pharmacology and Therapeutics,
2003 vol. 74 no. 6 ,525-535, retrieved from
http://www.fda.gov/downloads/scienceresearch/specialtopics/womenshealthresearch/ucm248342
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