Nutrient and Weight Control Drugs By Linda Self

1. Nutrient and Weight Control DrugsBy Linda Self B

2. Nutritional Deficiency States • Cancer • AIDS • Renal failure • COPD • Heart failure

3. Impact of Malnutrition • Susceptibility to infection • Weakness and fatigue • Impaired wound healing • Impaired growth and development in children • Edema • Anemia

4. Nutritional Products • Liquid enteral products • IV fluids • Pancreatic enzymes • Vitamins • minerals

5. Nutritional Products • Liquid enteral products--Variety of preparations for nutritional supplementation and for those with special conditions • Enteral feedings are preferable to TPN due to maintaining GI integrity, less risk for infection and less expensive • IV fluids used for hydration, specially prepared intravenous products to meet all nutritional needs

6. Nutritional Products • Pancreatic enzymes—amylase, protease, lipase are required for absorption of CHO, protein, and fat • Pancrelipase used as replacement therapy in deficiency states incl. cystic fibrosis, chronic pancreatitis, pancreatectomy, and pancreatic obstruction • Vitamins—insufficient dietary intake to meet requirements

7. Dietary Reference Intakes • RDA—recommended dietary allowance is the amount estimated to meet the needs of approximately 98% of healthy children and adults in a specific age and gender group • Tolerable Upper Intake Level—UL. Maximum intake considered unlikely to pose a health risk in almost all healthy persons in a specified age group • With vitamins—D =50mg; E =1000mg; pyridoxine =100mg • With minerals—UL should not be exceeded due to toxicity

8. Vitamins • A—vision, growth, bone development, skin and mucous membranes • E—antioxidant in destruction of certain fats, may increase absorption, storage and duse of vitamin A • K—essential for normal clotting • D—instrumental in bone health

9. Vitamins • Fat soluble==A, D, E, K • Water soluble==B complex and C • Supplements exert same physiologic effects as fr. foods • No Rx needed • Should not exceed recommended amounts of Vit. D, E, folic acid and vitamin A • Large doses of all minerals are toxic • Antioxidants—may affect free radicals, inconclusive studies regarding outcomes

10. Vitamins • Cyanocobalamin—B12—needed by all body cells incl. RBCs, nerves, metabolism of CHO, proteins and fats. Pernicious anemia. • Folic acid—metabolism of all body cells, normal RBCs and growth. Megaloblasticanemias, neural tube defects . Grains, fresh green vegetables. • Niacin—B3—coenzyme in many metabolic processes; fat synthesis; tissue respiration. Grains, legumes. Pellagra (skin, mucous membranes, asthenia, psychosis) • Pyridoxine—B6—needed for conversion of tryptophan to niacin; helps release glycogen from liver and muscle tissue; helps maintain cellular immunity; functions in metabolism of CNS

11. Vitamins • Riboflavin—B2—role in production of RBCs, corticosteroids and gluconeogenesis. Milk products, leafy green vegetables and dry yeast. Dermatoses, glossitis, cheilitis. • Thiamine—B1—coenzyme in CHO metabolism, essential for energy production. Affects brain utilization of glucose. Dry yeast, wheat germ, nuts, legumes, vegetables. Beriberi (neurologic, cerebral and CV abnormalities).

12. Vitamins • Vitamin C—needed for formation of skin, bone, teeth, cartilage, wound healing, metabolism of iron and folic acid, resistance to infection. Found in fruits and vegetables. Scurvy-bleeding of gums,joints, skin; anemia, loosening of teeth

13. Mineral--Electrolytes • 22 minerals necessary for human nutrition • Calcium and phosphorus in bone development • Sodium (fluid balance), potassium (acid-base), magnesium(nerve conduction), chlorine (fluid and lyte balance, acid base balance) and sulfur (component of proteins, insulin, B vitamins, some amino acids) • Trace elements: chromium, cobalt, copper, fluoride, iodine, iron, selenium and zinc—human nutrition • Manganese, molybdenum, nickel, silicon, tin and vanadium –normal growth and function of connective tissue

14. Minerals cont. • Chromium—affects glucose utilization • Cobalt—component of B12 • Copper—component of enzymes, RBCs • Fluoride—bones and teeth • Iodine—thyroid • Iron—enzymes, component of hemoglobin • Selenium—function of myocardium and other muscles • Zinc—enzymes, necessary for cell growth, for use of vitamin A

15. Electrolyte—mineral imbalances • Deficiencies usually related to inadequate intake or unusual losses (vomiting, diarrhea, gastric suction, laxative abuse) • Most excesses r/t excessive intake or impaired renal excretion

16. Cation-Exchange • Kayexalate (sodium polystyrene sulfate) to treat hyperkalemia. Orally or rectally, combines with potassium in the colon.

17. Chelating Agents (metal antagonists) • Exjade (deferasirox) oral iron chelator for those who require frequent blood transfusions. Untreated iron accumulation from the transfusions can lead to heart failure and liver failure. 2007 warning of renal failure, neutropenia, thrombocytopenia. • Desferal (deferoxamine) parenteral to remove excess iron from storage sites. Combines with iron and is excreted by kidneys. Hemachromatosis, hemosiderosis due to hemolytic anemias.

18. Chelators • Cuprimine (penicillamine) chelataes copper, zinc, mercury and lead which form soluble complexes and are excreted in urine. Use in Wilson’s Disease; cystinuria (AA) metabolic disorder resulting in calculi; to lead poisoning and RA • Chemet (succimer) for binding with lead in children.

19. Iron preparations • Oral ferrous salts include sulfate, gluconate and fumarate • Adverse effects include nausea, discolored stools, constipation • Contraindicated in hemosiderosis, hemochromatosis, multiple blood transfusions, anemias not iron deficiency in nature, PUD, inflammatory intestinal disorders • Iron dextran—IV. Anaphylaxis.

20. Magnesium • Magnesium oxide or hydroxide for mild hypomagnesemia • Magnesium sulfate parenterally for pronounced Mg++ Deficiency, convulsions associated with pregnancy and prevention of low magnesium in TPN • Contraindicated in renal impairment or in comatose

21. Potassium • Hypokalemia • Can be secondary to dietary problems, diuretics, those receiving only IV fluids • Contraindicated in renal failure and in those on potassium sparing diuretics and spironolactone • IV must be diluted well, infused slowly (often at 10 mEq/hour) to prevent cardiotoxicity. Monitor EKG.

22. Zinc • Zinc sulfate and gluconate are OTC • Component of multivitamins • Metabolized in liver and excreted in feces

23. Enteral feedings • Maintain GI tract and immune system functioning • NG, OG • Jejunostomy • Percutaneous endoscopic gastrostomy • Nasointestinal tubes • For feedings into stomach—intermittent feedings • For feedings into jejunum or duodenum, continuous feeding • Potential complication is aspiration

24. Enteral Feedings • Pulmocare • Amin-Aid for those in renal failure • Nepro for those on dialysis • Suplena—lower in protein and some electrolytes for renal patients not on dialysis • Hepatic Aid II—protein restricted in liver failure • Fluid restrictin as in 1.5kcal/mL

25. Parenteral Support • Central or peripheral administration • Can give 5-10% peripherally • Fat emulsions can be given peripherally or centrally; no filter • Vitamins, sometimes insulin • Aminosyn-RF • HepatAmine—special form. of amino acids • Cautious use of lipids r/t hypertriglyceridemia • Large doses Vit. C can cause stones • Monitor fluid and electrolytes • Monitor blood sugars

26. Parenteral Support • In liver failure—need Vit. A, B6, folic, riboflavin, B12, pantothenic acid and thiamine • Niacin is contraindicated • Extreme caution with iron dextran

27. Drugs to aid Weight Management • Overweight ==BMI of 25 to 29.9kg/sq. meter • Obesity==BMI of 30 or more • Desired BMI is 18.5 to 24.9 kg/sq. meter • Waist size >35 inches in women and >40 inches for men is another risk factor

28. Obesity • More common in women, minority groups and poor people • Associated with serious health risks • Cancer of breast, colon, endometrial • Central obesity greatly contributes to breast cancer (androstenedione to estradiol) • Cardiovascular disorders—hypertension, insulin resistance, hyperlipidemia, central adiposity

29. Obesity • Diabetes mellitus—impaired glucose tolerance, insulin resistance. Hyperinsulinemia, impaired lipid metabolism, hypertension

30. Obesity • Osteoarthritis • Sleep apnea • NASH • Increased complications of pregnancy • Infertility in men • Gestational diabetes • Metabolic syndrome—HDL (40,50), BP 135/85 or higher, serum glucose >110, central adiposity

31. Obesity • Decreased physical activity • Sedentary jobs and recreational activities • Large portion sizes • Fast foods • Fast pace • Depression • Medications can cause obesity • children

32. Medications affecting weight • Antihistamines such as loratadine and diphenhydramine increase appetite • Beta blockers decrease BMR, increase fatigue and decrease exericise tolerance • Statins • Steroids • PPIs may increase appetite • Hormonal contraceptives—fluid and sodium retentin • Mood stabilizing medication—lithium with expected wt. gain up to 22#

33. Medications and weight gain • Antiepileptics—phenytoin, valproic acid, carbamazepine, gabapentin, lamotrigine. Slow metabolism and increases appetite. • Antidiabetic drugs—insulin, sulfonylureas, glitazones. • Antidepressants—SSRIs and TCAs. • Antipsychotics-Zyprexa and Clozaril cause gain in 40%. Risperdal less and Seroquel even less. Can even affect glucose tolerance.

34. Drugs for treating obesity • Reserve for those with BMIs of 30 kg per sq. meter or greater • Sensible diet • Physical activity • Behavioral modification

35. Drugs for weight reduction • Side effects—phenylpropanolamine, fenfluramine, ephedra • Current meds-Adipex, Didrex, Meridia • Affect dopamine and norepinephrine in brain

36. Adipex--phentermine • Most frequently prescribed adrenergic anorexiant • Schedule IV • Short term use< 3 months • Contraindicated in hypertension, CV disease or drug abuse • Caution in anxiety or agitation • Adverse effects: nervousness, dry mouth, constipation, tachycardia and hypertension

37. Meridia--sibutramine • Schedule IV • Inhibits reuptake of serotonin and norepinephrine • Causes increased satiety, decreased food intake and faster metabolism • May be used for longer period of time • Cautious use in glaucoma, impaired hepatic function and a history of drug abuse • Contraindicated in CV disorders hypertension • Common SE: HA, insomnia, htn, tachy, anxiety

38. Xenical—Alli (orlistat) • Decreases absorption of dietary fat (binds to gastric and pancreatic lipases making them unavailable to break down fat) • Blocks 30% of fat ingested • Improves cholesterol levels • Side effects include oily spotting, fatty stools, fecal incontinence and increased defecation • Prevents absorption of fat-soluble vitamins A,D, E, K

39. Herbals • Few studies to validate efficacy • Glucomannan—”feel full”, laxative effect, can cause hypoglycemia • Guarana—found in energy drinks, caffeine; contraindicated in those with CV problems, worsens GERD • Laxative and diuretic herbs—aloe, rhubarb root, Super Dieter’s Tea

40. Weight loss programs • Atkins • South Beach • Weight watchers • Jenny Craig

41. Serotonin syndrome • Neuroleptic syndrome • Malignant hyperthermia

42. Neuroleptic Malignant Syndrome • Rare but potentially fatal reaction that can occur hours to months after initial drug use • S/S develop 24-72h • Characterized by fever, muscle rigidity, agitation, confusion, tachycardia, delirium, respiratory failure and acute renal failure • Associated with antipsychotic meds such as Haldol, Geodon, Abilify, Seroquel, Thorazine • Treatment: stop antipsychotic, give dantrolene (muscle relaxant) and amantadine or bromocriptine (dopamine stimulators)

43. Malignant Hyperthermia • A severe form of pyrexia that occurs during the use of muscle relaxants and general inhalation anesthesia in persons with an inherited autosomal dominant trait. • Characterized by skeletal muscle rigidity, fever, hypercarbia, metabolic acidosis, and cyanosis. • Fatal in 70% of patients. • Treat with Dantrium (dantrolene)—IV during acute episode • Must watch liver functions • Incompatible with saline and D5W

44. Serotonin Syndrome • Potentially serious drug-related condition seen in patients taking two or more drugs that increase CNS serotonin levels; the most common combinations involve MAO inhibitors, SSRIs , SNRIs and TCAs. Also can be caused by demerol, dextromethophan, and Zofran • Presents with muscle rigidity, tremors,fever, nausea, rapid heart rate, agitation and seizures. • Stop drugs, supportive care