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2 Goal for this presentation
This webinar is designed for hospice providers who are accepting patients on “natural” products who have a different mindset concerning Functional Medicine: conventional medications. This program will provide an overview of functional medicine which Benefits for the Hospice addresses the underlying causes of diseases or symptoms using a patient- Patient centered approach and what hospice also has in common with this approach. Jenna Head BS, RPH, BCGP We will also explore alternative agents used to palliate common symptoms at end of life, as well as manage side effects of commercially available medications.
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3 4 Webinar Objectives Disclosures
The presenter has no relevant financial relationships with • Define Functional Medicine and compare with manufactures of any commercial products discussed in this presentation. conventional, alternative, and integrative medicine.
• Discuss the nutritional costs of commercially Supplement manufacturers are not allowed to make available medications which can cause a health claims: prescribing cascade. “These statements have not been evaluated by the • Identify commonly used hospice medications with Food and Drug Administration. This product is not natural origins and common drug/natural product intended to diagnose, treat, cure, or prevent any disease.” interactions.
• Explore specific examples of remedies for common There are a vast number of studies on natural products that have been done to study efficacy and drug symptoms that are palliated in hospice. interactions.
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5 6 Different approaches • Conventional Medicine – making diagnosis is endpoint of therapy. Treat symptoms and send patient home. Specialized not holistic.
• Alternative Medicine – any of a range of medical therapies that are not regarded as orthodox by the medical profession, such as herbalism, homeopathy, and acupuncture. Holistic. FUNCTIONAL MEDICINE • Integrative Medicine – a type of medical care that combines conventional medical treatment with complementary and alternative medicine (CAM). CAM therapies treat the mind, body, and spirit. Holistic.
• Functional Medicine – looks deeper to find the root cause. FM looks to see if you are missing something you may need- vitamins, minerals, probiotics or amino acids. It also looks to see if you have something you don’t need such as environmental contaminants, heavy metals, bacteria, fungus, and/or parasites. Holistic.
http://www.ibsgroup.org/other/articles/Understanding_functional_medicine.pdf 5 6
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7 8 Definition of Functional Medicine 4 R’s of Functional Medicine
Remove refers to the elimination of anything that may be in our body or diet • Functional Medicine is a systems-biology-based model that empowers which contributes to poor health. This can include foods, pesticides, food patients and practitioners to work together to achieve the highest additives, unwanted bacteria, fungi, and parasites. expression of health by addressing the underlying causes of disease. Reinnoculation involves the use of probiotic supplements containing lactobacillus acidophilus, bifidobacteria, and other friendly flora. These • Functional Medicine uses a unique operating system and personalized bacteria manufacture vitamins, repel. harmful microbes, and have anti-tumor therapeutic interventions to support individuals in achieving optimal effects. They are easily disrupted by use of antibiotics and the stress of wellness. contemporary living. Replace refers to the addition of supplements to support digestive function and may include: digestive enzymes, bile salts, and/or HCl. Repair refers to the nutritional support that helps quickly regenerate and heal the body.
Jones, DS. Textbook of Functional Medicine. Institute for Functional Medicine. Federal Way, WA: Institute for Functional Medicine; 2010. http://www.ibsgroup.org/other/articles/Understanding_functional_medicine.pdf 7 8
Recognize Interconnectedness 9 10 of conditions and causes
All Functional Medicine is Integrative, but not all Integrative Medicine is Functional
Integrative Medicine: healing-oriented, body/mind/spirit, lifestyle approach that combined Conventional and CAM therapies X Functional Medicine: emphasizes underlying cause of dysfunction, organizes assessment & treatment using FM tools
Jones, DS, Quinn, S.Introduction to Functional Medicine. Gig Harbor, WA: The Institute for Functional Medicine; 2016. Castle, L Riera-Gilley V, PharmD, ASCP Power point presentation Functional Medicine: The impact on the Senior Patient. August 2019. 9 10
12 Functional vs. Conventional
http://www.ibsgroup.org/other/articles/Understanding_functional_medicine.pdf Jones, DS, Quinn, S.Introduction to Functional Medicine. Gig Harbor, WA: The Institute for Functional Medicine; 2016. 11 12
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13 14 Functional vs. Hospice
Functional Medicine Hospice Nutritional Cost of Holistic Holistic Medication and Common Patient Centered Patient Centered Prescribing Cascades Deprescribe medications Deprescribe medications
High Touch High Touch
Focuses on quality of life Focuses on quality of life
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15 16 Resource for Identifying Nutrient Depletion Drug Muggers Definitions Drug Mugger: noun An Over-the-Counter or prescribed medication, food, Suzy Cohen, RPH has devoted her career herb, medical condition, or lifestyle choice that is capable of robbing your to identifying nutrient depletions from body’s natural stores of an important vitamin, mineral or hormone. commercially available medications and offers safer ways to use medications to Usage: Acid blockers are drug muggers of zinc. prevent side effects by effectively Smoking is a drug mugger of Vitamin C. replacing the lost vitamin, mineral or hormone. Drug Mugging: adjective Of or relating to a drug mugger.
Usage: My legs are cramping; I could be suffering from the drug mugging effects of my cholesterol medication.
S Cohen, RPH, Drug Muggers Rodale Publishers 2011
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17 18 Nutrient Depletion Effect of Drugs Nutrient Depletion Effect of Drugs Diseases related to drug mugging Diseases related to drug mugging Depression, osteoporosis, and irregular heartbeat: These can all be caused by a deficiency Cataracts, macular degeneration, liver problems, and high levels of the heart-attack- of the mineral magnesium. Common drug muggers of magnesium include female promoting substance homocysteine: Any of these conditions could be tied to low hormones, diuretics, raloxifene (Evista), anti-inflammatories (NSAIDS), and aspirin. glutathione, a powerful antioxidant needed to get rid of poisons in your body. Acetaminophen is a possible drug mugger of glutathione. Bald patches, loss of taste or smell, erectile dysfunction, and chronic diarrhea: All these conditions may result from zinc deficiency. Common drug muggers for zinc include anti- Weight gain, depression, fatigue, anemia, nerve pain, and a sensation of pins and needles: inflammatories (NSAIDS), antibiotics, antacids, ulcer and heartburn medications, diuretics, Any of these could be related to a deficiency of one or more B vitamins. Your stash gets and estrogen drugs used for birth control and menopause. depleted by female hormones (used for birth control and menopause), alcohol, antacids, ulcer medications, diuretics, raloxifene (Evista), cholestyramine, and diabetes drugs. Leg cramps, muscle spasms, memory loss, and fatigue: Any of these conditions may develop from a deficiency of CoQ10 (ubiquinone). This life sustaining antioxidant gets demolished by hundreds of medications, including statin cholesterol drugs, metformin, antidepressants, beta blockers and diuretics. S Cohen, RPH, Drug Muggers Rodale Publishers 2011 S Cohen, RPH, Drug Muggers Rodale Publishers 2011
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19 20 Prescribing Cascade
For example, there was a man who went to see a cardiologist because he experienced heart palpitations. The cardiologist put him on heart medication. He saw his internist because he had a tremendous amount of leg cramping, and was put on a muscle relaxant. And his psychiatrist put him on an anti-depressant for anxiety. Natural Remedies for The same man saw a functional medicine physician who immediately noticed that all of these symptoms could be due to a lack of magnesium. Magnesium and other Common Symptoms supportive nutrients were given and the man was able to discontinue all other medications. Palliated in Hospice
Another example is patients on Amlodipine and diuretics such as furosemide. A common side of amlodipine is peripheral edema. Review to DC amlodipine and the edema may subside and relieve the need for the diuretic. The diuretics can always cause potassium loss. http://www.ibsgroup.org/other/articles/Understanding_functional_medicine.pdf
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21 22 Dyspepsia, Nausea, Constipation & Diarrhea Chronic Pain, Leg Cramps, Muscle Spasms Constipation can cause nausea so look at treating both Dyspepsia (Heartburn): Calcium Carbonate (Tums), Restless Leg Syndrome: Chelated Iron (prevents constipation) Mylanta/Maalox(magnesium), Peppermint. Muscle/Leg Cramps: Check hydration, Chelated magnesium (lessens chance of Gastroesophageal spasms: Altoids Peppermint/Spearmint lozenges diarrhea), Check potassium if on diuretic, CoQ10 (ubiquinone), Epsom salt baths (magnesium) Gas/Bloating/Flatulence: Activated charcoal (CharcoCaps) Chronic Pain: Vitamin D, Tumeric, Bosweillia, Chlorophyll, Nausea: Ginger Ale, Ginger chews, Sprite Glucosamine/Chrondrotin, Apple Cider Vinegar, Bilberry, Smoking cessation Constipation: Warm prune juice, Aloe Vera juice, Magnesium Citrate, Milk of Magnesia, Senna, Bisacodyl Carpal Tunnel: Vitamin B6,
Diarrhea: Pepto Bismol (bismuth), Probiotics (S Boulardii when on abx) Tingling/Pins and needles neuropathy: B vitamins, Alpha Lipoic Acid
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23 24 Cough, Itching, UTI Prevention, Wounds Insomnia, Anxiety/Restlessness
Cough productive or dry: Normal saline nebs Insomnia: Melatonin, Chelated magnesium, herbal tea, lavender oil on feet Itching: High dose Vitamin C, Oatmeal lotion and baths Anxiety/Restlessness: Chamomile Tea, aromatherapy, Epsom salt bath, Urinary Tract Infection Prevention: D-Mannose, Uqora (entire system with D- Chelated magnesium, music therapy Mannose/probiotics) Fatigue: Folic Acid and B-12 Wound Healing: Zinc, Arginine (Arginaid) Medical Grade Honey (Medihoney) Immune system support: Elderberry, Echinacea, Golden Seal, Lysine, Silver dressings and creams Vitamin D, Vitamin C
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25 26 Supplements that affect clotting These supplements should NOT be taken with any of the antiplatelet/anticoagulant medications due to increase risk of bleeding.
Herbs with Antiplatelet Properties Herbs with both properties Aloe Dong Quai Cranberry Evening Primrose Potential Drug Interactions Feverfew Ginseng Garlic between Drugs and Herbs Ginger Ginko Herbs interfering by other mechanisms Meadowsweet Flaxseed Tumeric Grapefruit White Willow Green tea Oregano Herbs with Anticoagulant Properties Saw Palmetto Chamomile Fenugreek Abebe, Worku Review of herbal medications with the potential to cause bleeding: dental implications, and risk Red Clover prediction and prevention avenues. EPMA Journal 2019 Mar; 10.1007/s13167-018-0158-2 25 26
27 28 Case Study M.R. 81 year old female with Lung Cancer with mets, T2DM, Afib, Iron deficiency, Hypertensive Heart and CKD, fibromyalgia, hyperlipidemia, long term use of nicotine, chronic pain from broken shoulder sustained in fall a few years ago, constipation.
Allergies: Bactrim, Ibuprofen, Lisinopril, Macrobid, Metoprolol, Case Study Oxycodone, Prilosec
Medications: Atenolol, Basaglar, Bilberry extract, Eliquis, Ezetimibe, Glycopyrrolate, Lorazepam, D-Mannose, Morphine, Nystatin, Potassium, Pravastatin, CoQ10, Vitamin B1, Torsemide, Vitamin C, Vitamin D3, Hydrocodone/APAP 5/325, Lactulose, Miralax, Bisacodyl supp, Senokot
Primary Caregiver: Son, who has had lymphoma himself and has studied up on medicine. 27 28
29 30 Chief Complaint Increased shoulder pain: We identified the pravastatin/eztimbe as drug muggers of CoQ10 which can cause pain. Even though he had his mother on CoQ10 supplement, he realized lack of benefit vs risk of side effects and decided to discontinue. He was having to give his mother two hydrocodone 5/325mg sometimes to achieve pain relief but was worried about the APAP dose. His hospice nurse and I collaborated to put Hydrocodone 10/325mg tabs in the home to use for pain >5 and keep hydrocodone 5/325 for pain <5 on a scale of 1-10. Conclusions Constipation due to increase in hydrocodone dosage: Patient was already on Senna. Son stated that he had tried milk of magnesia but that Polyethylene Glycol powder (Miralax) was the only thing that works. The hospice nurse ordered miralax.
I complimented the son on the CoQ10, Vitamin D and Bilberry for pain, D-mannose for UTI prevention, Vitamins C and D for immune support. These supplements do not affect blood clotting since the patient also takes Eliquis.
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31 32 Conclusion Recognizing Drug Muggers is an excellent reason to deprescribe unnecessary medications which are often causing symptoms.
Med D excludes coverage of all supplements except prescription versions such as Potassium and Fish Oil.
Each hospice must decide if they will provide supplements or let the family’s pick them up.
HPS provides recommendation to evaluate benefit of supplements at end of life . THANK YOU Questions? If a patient can no longer swallow, the burden of trying to take vitamins/supplements typically outweighs benefit.
Each medication regimen must be evaluated for drug/herb interactions to prevent adverse events
It is possible for hospice to work with caregivers/patients that wish to use natural supplements for symptom management by providing education and monitoring for drug interactions and side effects.
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