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Libby MachtKNH413 Matuszak3/5/2013Case Study 3: Drug Nutrient InteractionWhat is depression?Depression is a serious medical illness which affects the social, emotional and physical wellness of an individual. Onset of depression includes factors such as biochemistry, genetics, personality and environmental factors. According to the American Psychiatric Association, symptoms include deep feelings of sadness, marked loss of interest or pleasure in activities, changes in appetite resulting in weight changes, insomnia or oversleeping, loss of energy or increased fatigue, restlessness or irritability, feelings of worthlessness or guilt, difficulty thinking, concentrating or making decisions and thoughts of death or suicide. American Psychiatry Association (APA)Are there any pertinent nutritional considerations when using Zoloft, a selective serotonin reuptake inhibitor (SSRI)?Zoloft is the brand name for the generic drug sertraline, an FDA approved SSRI. The nutritional considerations when using Zoloft include the alteration of tryptophan metabolism. SSRIs can also deplete sodium, folic acid and melatonin.NT&P p. 220; SSRI Mayo ClinicHow do SSRIs work?As the name suggests, SSRIs work by selectively inhibiting the reuptake of serotonin. Serotonin is a neurotransmitter released by neurons in the brain. Changing the balance of serotonin helps brain cells send and receive these chemical messages, which in turn boosts mood. These drugs primarily affect serotonin (thus deemed “selective”).SSRI Mayo ClinicWhat is St. John’s wort?Scientifically known as Hypericum perforatum L., it is a shrub-like perennial herb native to Europe, western Asia and northern Africa. It was brought to the US and now grows widely. The flowering tops produce the part of the plant used for herbal remedies.St. John’s wort Mayo Clinic; St. John’s Wort American Cancer Association (ACA)How is St. John’s wort used in the United States?Common uses of St. John’s wort in complementary and alternative medicine include treatment of depression, anxiety and stress, prevention and treatment of infections, reduce serum cholesterol levels, treat breast cancer, treat PMS, treat chronic fatigue syndrome, alleviate fibromyalgia symptoms and reduce memory loss. According to Mayo Clinic, there is strong evidence supporting the use of St. John’s wort for mild to moderate depression. More recent research is underway in the United States. NT&P p. 231; St. John’s wort Mayo Clinic How does St. John’s wort work as an antidepressant?The antidepressant mechanism of St. John’s wort is similar to selective serotonin reuptake inhibitors. The National Institute of Health reported that the bioactive compounds make it a weak inhibitor of monoamine oxidase-A and –B activity and synaptomsomal uptake of serotonin, dopamine and norepinephrine.Butterweck NIHDoes St. John’s wort have any side effects?According to the Mayo Clinic, it is well tolerated at recommended does for up to 1-3 months. Side effects may include upset stomach, skin reactions, fatigue and sedation, restlessness or anxiety, sexual dysfunction, sensitivity to light, dizziness, headache, and dry mouth. It has also been reported that St. John’s word may cause psychiatric symptoms such as suicidal and homicidal thoughts.St. John’s wort Mayo Clinic How is St. John’s wort regulated in the United States?St. John’s wort can be purchased in drug and health food stores in the US. Natural products are regulated by the 1994 Dietary Supplement and Education Act but are not closely monitored by the FDA unlike prescription and OTC medicines. Strength or purity of the active ingredient Hypericin cannot be guaranteed. Companies do not have to show evidence of safety or health benefits to the FDA before selling dietary supplement products.St. Johns wort ACAHow is St. John’s wort used in Europe?St. John’s wort is widely used in Europe for treatment of depression, anxiety, and sleep disorders. It is approved for the treatment of depression and anxiety in Germany but is only available by prescription. It is prescribed more often than Prozac.St. John’s wort ACAWhy do you think people are interested in alternative medicine and herbal treatments?I think people find an appeal to using medication and treatments that are based on all natural ingredients. Patients may be discouraged with limited success from conventional medication and look for alternatives based on the body’s natural defenses. The National Health Interview Survey of 2007 found that 38% of adults use CAM, either together with conventional medicine or in place of it.National Center for Complementary and Alternative Medicine Convert her height and weight to metric numbers.160 # / 2.2 lb./kg. = 72.7 kg.5’11” = 71 in. x 2.54 cm./in. = 180 cm. = 1.80 m. Is Ms. Geitl’s recent weight loss anything to be worried about?Her weight loss of 5 lbs. over three months puts her at 97% usual body weight. Though this isn’t significant for malnutrition diagnosis, her eating patterns indicate that without intervention unnecessary weight loss will only continue. How would you score her based on the Patient-Generated Subjective Global Assessment of Nutritional Status? (See Appendix I)PG-SGA forms are attached. She scored 1 for a decrease in weight, 1 for less than usual intake of normal food but less than normal amount, 4 for no appetite and depression symptoms, and 3 for ability to do little activity and spending most of the day in bed. She scored 0 for worksheets 2 (disease condition such as cancer/AIDS), 3 (fever and steroids), and 4 (physical examination of deficits). She was categorized as SGA-B (Stage B: moderately malnourished or suspected malnutrition) due to her weight loss, definite decrease in intake, presence of nutrition impact symptoms and functional deficit. Appendix PG-SGA p. 784-785 Using Appendix I, how would you triage nutritional intervention?She scored 9 points from boxes 1-4 so her nutritional intervention recommendation indicates a critical need for improved symptom management and nutrient intervention options. With her antidepressant prescription and attention from the RD for nutritional education, her symptoms can be managed appropriately.Appendix PG-SGA p. 784What methods are available to estimate Ms. Geitl’s energy needs?Ms. Geitl’s energy needs can be calculated by equations such as the Harris-Benedict equation, WHO equation, or EER equations. Other methods of estimation for energy needs include indirect calorimetry, doubly labeled water, and direct calorimetry. NT&P p. 241-244Calculate Ms. Geitl’s basal energy needs using one of the methods you listed in question 15.Harris-Benedict equation REE = 655.1 + 9.6 (weight kg) + 1.9 (height cm) – 6.8 (age years)REE = 655.1 + 9.6 (72.7 kg) + 1.9 (180 cm) – 6.8 (20 years)REE = 1559.02 = 1560 kcalNT&P p. 241What is Ms. Geitl’s estimated energy expenditure?Using a physical activity factor of 1.27 for active (young student; though sedentary and fatigued now, energy needs are elevated due to weight loss and to help meet needs for daily activities).REE x PA = 1560 x 1.27 = 1981.2 = 1950-2000 kcal.NT&P p. 242 Evaluate her diet history and her 24-hour recall. Is she meeting her energy needs?She is not meeting her energy needs. Her usual intake and 24-hour recall indicate that she is only consuming around 500-600 kcals. She is not getting enough energy and therefore cannot meet her needs for macronutrients. Her intake of vitamins and minerals would also likely be insufficient due to poor intake of total food and no supplement.Diet HistoryKcalFat (g)CHO (g)Protein (g)Black coffee0000? c. low-fat frozen yogurt1301.52641 ?” square Stouffers lasagna14561581 c. steamed broccoli300421 breadstick1502285Diet cola (2-3 12 oz cans)0000Air-popped popcorn with salt1001183TOTAL55510.5912224-Hour RecallKcalFat (g)CHO (g)Protein (g)2 c. black coffee00001 slice dry whole wheat toast9011552 c. chicken noodle soup14042082 saltine crackers300.54.50.5? c. strawberry gelatin5001201 12 oz. diet cola00002 peach halves6001501 c. low fat cottage cheese18021028TOTAL5507.576.541.5What would you advise?Nutrition diagnosis would include inadequate energy intake (NI-1.4), inadequate oral food/beverage intake (NI-2.1), and inadequate protein-energy intake (NI-5.1). Her prescription for Zoloft and the discontinuation of St. John’s wort should return her appetite to normal. Nutritionally, I would advise her to follow a general, healthful diet, increasing her oral intake of food and beverages with nutrient dense, small additions throughout the day.List each factor from your nutritional assessment and then determine an expected outcome from each.Assessment FactorExpected OutcomeDepression-related lack of appetite- antidepressant prescription ZoloftLift mood; restore ability to participate in daily activitiesPoor oral intake of food/beverage – diet plan, nutrition educationRestore energy intake to recommended 2000 kcal, no further weight lossInadequate protein-energy intakeRestore energy intake to 2000 kcal/day and protein to 58 g/day; no further weight loss; energy to participate in life activitiesWhat is your immediate concern regarding this patient’s use of St. John’s wort?The combination of Zoloft and St. John’s wort should be avoided. Using both increases risk of serotonin syndrome and neuroleptic malignant syndrome. According to the National Institute of Health, serotonin syndrome, or hyperserotonemia, is defined as “a potentially life threatening drug reaction that causes the body to have too much serotonin.” Symptoms may include agitation, diarrhea, tachycardia, hallucinations, increased body temperature, nausea and vomiting. Neuroleptic malignant syndrome is a disorder caused by an adverse reaction to neuroleptic or antipsychotic drugs including symptoms such as high fever, sweating, unstable blood pressure, stupor and autonomic dysfunction. Both of these syndromes develop within the first 2 weeks of treatment so it is crucial Ms. Geitl stops use of St. John’s wort while prescribed Zoloft.Epocrates; Serotonin syndrome NIH; Neuroleptic malignant syndrome NINDS Review the initial nutrition note written for this patient. Is this progress note appropriate? Is it complete? Any errors? Any omissions?The nutrition note is appropriate and complete albeit brief. The initial note adequately covers her anthropometrics and diet history. Adequacy could be improved by including wt loss of 5# over 3 mo and her status as a student studying abroad (family in Germany) and diagnosis of depression 9 months prior to admission. Further plans for intervention should be noted including education on small, energy dense meals and evaluation of resources available for food.ReferencesButterweck, V. (2003). Mechanism of action of St. John’s wort in depression: What is known?. CNS Drugs, 17(8):539-62. Retrieved from . (2012). American Psychiatry Association. Retrieved from nutrient depletions/interactions chart. (n.d.). Phyto Pharmica. Retrieved from malignant syndrome information page. (2007). National Institute of Neurological Disorders and Stroke. Retrieved from . disorders/neuroleptic_syndrome/neuroleptic_syndrome.htmSelective serotonin reuptake inhibitors (SSRIs). (2010). Mayo Clinic. Retrieved from syndrome. (2012). PubMed Health. Retrieved from . John’s wort. (2008). American Cancer Association. Retrieved from . John’s wort. (2012). Mayo Clinic. Retrieved from health/st-johns-wort/NS_patient-stjohnswort What is complementary and alternative medicine?. (2012). National Institutes of Health: National Center for Complementary and Alternative Medicine. Retrieved from : Drug interactions. (n.d.). Epocrates. Retrieved March 2, 2013 from the downloaded iPhone application. ................
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