Hydration Status As a Health Indicator in the Community Setting: How to Identify, Counsel, and Treat At-Risk Patients by Nicole Van Hoey, Pharmd

CONTINUING EDUCATION

Hydration status as a health indicator in the community setting: how to identify, counsel, and treat at-risk patients by Nicole Van Hoey, PharmD

May 1, 2019 (expires May 1, 2022) Activity Type: Application-based To earn continuing education credit: ACPE Program 0207-0000-19-005-H01-P; 0207-0000-19-005-H01-T

Upon successful completion of this article, the pharmacist should be able to: 1. Describe the mechanisms of electrolyte and mineral imbalance associated with the body’s normal and abnormal hydration status. 2. Identify specific risk groups who require special attention in the identification, treatment, and prevention of dehydration, and explain why these patients are at risk. 3. Assess the range of dehydration symptoms in case-based presenta- tions of particular outpatient risk groups. 4. Compare simple fluid replacements with sports drinks and oral rehydration solutions with regard to electrolyte and sugar compositions and effectiveness.

Upon successful completion of this article, the pharmacy technician should be able to: 1. Identify electrolyte and mineral changes that occur during dehydration. FREE ONLINE CE. To take advantage 2. List symptoms of mild, moderate, and severe dehydration. of free continuing pharmacy educa- 3. Name three patient populations at higher risk of dehydration, and tion (CPE) for this program, pharma- explain why. cists and pharmacy technicians must 4. Explain why oral rehydration solutions are considered better than achieve a passing score of 70% on sports drinks or juice for most cases of dehydration. the online continuing education quiz for the program. If a passing score is not achieved, one free reexamination is permitted. To take this test, go to www.ncpalearn.org. This activity is listed under Online Activities. If you have not registered with this site, you must do so before being able to access the CE Center. You will receive immediate online test results and credits will be posted to CPE Monitor NCPA® is accredited by the Accreditation Council for Pharmacy Education as a provider within six weeks. To obtain your CPE of continuing pharmacy education. NCPA has assigned 1.5 contact hours (0.15 CEU) of continuing education credit to this article. Eligibility to receive continuing education Monitor e-Profile ID, please go to credit for this article expires three years from the month published. www.cpemonitor.com to register.

www.ncpanet.org/ap 37 INTRODUCTION In health care, dehydration is often characterized as a EUVOLEMIA AND DEHYDRATION DEFINED concern that dominates non-industrialized countries, The hydration status maintained at a steady state, called particularly in relation to outbreaks of severe diseases euvolemia, refers to the measured amount of total fluid such as cholera. Indeed, the Centers for Disease Control volume throughout the body. Dehydration is defined sim- and Prevention’s Global Water, Sanitation, and Hygiene ply as a loss of body fluids and essential minerals that is arm, or WASH, highlights diarrhea as a common illness greater than intake. Typically, loss is constant every day but global killer. However, patients and health profes- and is accounted for as urine and feces (1-2 L and <1 L, sionals often are surprised to learn that dehydration is respectively) and sweat or skin evaporation and respi- a concern in the 21st century even in the United States. ration (0-1 L). Fluid leaves the extracellular fluid spaces In fact, three quarters of U.S. adults who come to your first and is replaced with normal intake — usually 1-3 L pharmacy may be chronically dehydrated. From 2005 to of drinks and up to two liters of food (especially fruits 2010, U.S. adults were reported to drink only 39 ounces and vegetables) daily. A fluid deficit (hypovolemia, or of water daily (and even less in those with older age dehydration) occurs in outpatients across a wide range and lower education levels). That insufficient daily fluid of ages and conditions and is observed more often than intake, for many adults, causes symptoms of electro- excess intake (hypervolemia, or overhydration). lyte imbalance that can result in serious consequences when unaddressed. The “homeostatic range” of this highly balanced fluid system is extremely narrow. A net fluid loss of only 1.5 In an ambulatory setting, certain risk groups are more percent is enough to trigger the first symptoms of mild likely to experience dehydration. The difficulty associ- dehydration, which is loosely defined as < 5 percent ated with this condition is not in the treatment, but in fluid loss, as the body moves fluid from cells into the the identification of dehydrated status, especially when blood to keep the blood volume constant and maintain mild to moderate. Symptoms at these stages are easily blood pressure. Moderate and severe dehydration fol- missed or attributed to other chronic conditions. Phar- low at a loss of 5 percent to 10 percent, and 10 percent macists can learn to identify subtle signs of dehydration or more, respectively. in high-risk groups during routine interactions, and can then promote appropriate self-care and rehydration Although it is an often-overlooked clinical measure, hy- therapy or referral as needed for best management. dration status can reflect acute bodily stress and uncon- Pharmacists remain valuable and accessible resources trolled chronic disease, and an imbalance in hydration to answer questions about hydration options for patients can easily cause acute adverse effects and irreversible already involved in self-care. long-term damage. Dehydration causes range from the overlooked mundane to surprisingly complex reasons, BACKGROUND ranging from the inability to provide self-care, a lack of Maintenance of the body’s fluid content is one of the water access, intense or prolonged exercise, and more. body’s most basic functions, but it is also highly specific. Some general reasons for dehydration despite normal The volume of fluid in the blood vessels must remain intake may include, for example, extra skin loss through constant to support safe and efficient actions in the burn damage or even sweat; GI loss through diarrhea organ, muscle, and even cellular levels. The mechanism and vomiting, including excess GI fluid loss as a result of homeostasis, or steady-state balance that maintains of laxative abuse; and genitourinary loss as a result of adequate hydration for the body is sensitive and complex. chronic disease, diuretic products, or additional causes Fluid regulation relies on proper activity in the nervous, of osmosis in the kidneys. renal, and gastrointestinal systems, as well as hormonal influences from the pituitary and adrenal glands. ELECTROLYTE BASICS As water is absorbed primarily through the digestive Water provides essential protections in the body. Along tract, the homeostatic system that maintains fluid with regulating temperature and transporting oxygen volume acts without conscious effort to contribute to and minerals, and dispensing waste, it lubricates joints, the total body volume to maintain the optimal amount of forms the bulk of bodily secretions, and maintains cell fluids throughout the body. The kidneys adjust urine out- structures in organs. One of its most basic constant put in response to small variations of the intake-output protections is that of a barrier, as an important compo- balance to maintain euvolemia. Fluid comprises differ- nent of the skin. Overall, 50 percent to 65 percent of a ent proportions of our body weight: blood is 80 percent person’s total body weight is water. fluid, muscle is 70 percent fluid, and fat is only up to 25

38 America’s PHARMACIST | May 2019 percent fluid. The body’s fluid is dispersed unevenly thirst is enough to make healthy adults drink fluids and through the blood, intracellular spaces, and extracellular avoid further consequences. Similarly, urine at a euvole- fluid spaces that are comprised of plasma, lymph, and mic state is pale yellow or colorless, because water is interstitial spaces. For example, a 150-pound man has its primary component. Darkening shades of yellow to approximately 40 liters of total body water with approxi- orange reflect progressively less adequate amounts of mately 25 liters found inside cells, approximately 7 liters body water. in interstitial spaces, and approximately 10 percent of the total (almost 4 liters), in blood. Range of symptoms Symptoms of dehydration begin with mild dehydration at The constant fluid balance maintains not only blood 1.5-2 percent loss and expand to severe dehydration as volume but also of the appropriate concentration of 10 percent loss is reached; they can develop and prog- electrolytes, which are minerals dissolved in the blood ress quickly across the gastrointestinal, urinary tract, that promote proper cell and organ function. Sodium, po- circulatory, musculoskeletal, nervous systems and more. tassium, magnesium, and chloride are just a few of these Table 1 describes common symptoms as they progress important electrolytes. Sodium, present in the blood and from mild to severe dehydrated state. the extracellular fluid, regulates total body water and extracellular fluid concentrations, muscle excitability, Beyond thirst, symptoms indicative of mild dehydration nerve function, and cell permeability. Chloride maintains are fatigue, irritability, reduced alertness, lower urine the acid-base balance, contributes to gastric juices, and output, constipation, and headache. Because these symp- helps maintain osmotic pressure. Potassium is found toms can be nonspecific and difficult to associate with mainly intracellularly, and it regulates intracellular water fluid volume, low urine content and dark urine (in addition content and cell activity, particularly in muscle cells. Ad- to thirst) are key identifying symptoms at this stage. ditionally, appropriate potassium concentrations in the blood are essential for proper cardiac muscle activity. Sometimes, physical symptoms remain unnoticed when internal organs are chronically deprived of enough water. Both over-hydration and dehydration can change the Benefits of increased fluid intake were observed even concentration of these vital minerals and lead to signs without diagnosed dehydration in a study of 140 women and symptoms of organ damage. The central nervous with chronic cystitis and low daily fluid intake (defined system is particularly sensitive to changes in total body as < 1.5 L/day baseline). The women experienced fewer sodium levels, and symptoms of high or low sodium — infections and needed antibiotic treatments less often often some of the first symptoms of dehydration — are when they increased their fluid intake above the baseline. thirst and neurologic changes, such as confusion. In the presence of hypovolemia (particularly when caused by At moderate dehydration, worse symptoms develop insufficient intake to replenish fluid loss), hypernatremia as more water is moved from cells and extracellular can develop, because the total body water volume is spaces to the blood. Symptoms at this stage progress depleted relative to the total body sodium content. to reduced skin elasticity, dry mouth, dizziness, muscle weakness, and cramps. Without treatment, moderate Reasons for hypovolemia that can lead to high sodium dehydration and electrolyte imbalance can lead to include GI disorders, skin burns, renal disease, and loop increased heart rate, palpitations, lack of sweat, and diuretics (which inhibit sodium resorption in the neph- hypotension. As dehydration continues, tissues dry out, rons to increase water clearance). Hydration therapy to shrivel, and malfunction as blood volume decreases. The restore both the lost electrolytes and fluid is essential to lower blood volume often results in increased electro- reinstate proper balance. lyte concentrations, a state known as hyperosmolarity. Hypernatremia in particular reflects a moderate or worse DEHYDRATION SYMPTOMS dehydrated state. Hypernatremia is defined as serum First symptoms sodium level >145 mEq/L and indicates a total body Because water’s effects in the body are broad, dehydra- water deficit relative to sodium content, usually because tion symptoms range across body systems. However, of inadequate fluid intake or excess loss. two initial symptoms are used in outpatient settings to reliably recognize even mild dehydration: thirst and urine Severe dehydration is a medical emergency that almost color. Thirst is the body’s first defense against fluid loss: always requires hospitalization and intravenous fluids its purpose is to trigger intake that replenishes the small for safe correction of volume and mineral imbalances. loss before additional symptoms develop. Typically, Patients experience hypotension, increased heart and www.ncpanet.org/ap 39 Table 1: Symptoms of progressive dehydration by body system

System Mild Dehydration Moderate Dehydration Severe Dehydration

Gastrointestinal Thirst, constipation Thirst and hunger, dry Parched mouth mouth

Urinary tract Darker color to urine, Notable lower urine Little to no urine output slightly lower urine output output or frequency

Cardiovascular/ Increasing heart rate Decreased pulses, Low blood pressure, circulatory rapid heart rate, thready pulse, rapid respiratory rate; rapid heart rate and dizziness respiratory rate

Musculoskeletal Dry and itchy skin Slightly wan or Fewer tears, lack of and skin sunken skin, muscle sweat, shriveled skin weakness, reduced sweating

Nervous/mental Fatigue, low alertness, Irritable, listless Altered mental state status headache

respiratory rates, and fever. Damage to organs, especial- pharmacists have the opportunity to intervene in the ly the brain, occur during severe dehydration when water care of patients who have mild to moderate symptoms leaves brain cells and leads to a hyperosmolar central — those that bring the patient to the pharmacy but that nervous system setting. Untreated, delirium, confusion, the patient might not associate with fluid intake or loss. seizures, and shock will develop and may be irreversible. Controlled fluid replacement and identification of the un- In an outpatient setting, confusion can be the best indi- derlying cause are key to both treatment and prevention. cator of severe dehydration. AT-RISK POPULATIONS In an outpatient setting, the progressive symptoms of de- In the clinic, dehydration as a clinical condition ultimate- hydration, rather than laboratory electrolyte values, form ly has many causes and risk factors. Some are surpris- the basis of a preliminary diagnosis. Mild and moderate ingly commonplace. Identifying patients with mild to conditions may be less noticeable but should not be moderate dehydration — and the possible underlying disregarded: up to 500,000 Americans in 2004 alone were causes — is the challenging first step of pharmacist in- hospitalized for treatment of dehydration, predominantly tervention that prevents worse consequences and repeat from emergency admissions, and many more were likely dehydrated episodes. Certain populations should be undiagnosed and untreated. monitored closely because of their increased likelihood for hydration imbalance. Focusing on these special pop- Although mild to moderate dehydration usually can be ulations helps guide the pharmacist’s assessment and reversed with basic outpatient rehydration, symptoms treatment evaluations. Key groups who warrant extra may recur when an underlying chronic cause — span- fluid monitoring because of increased dehydration risks ning a wide range of possibilities from pregnancy to can be identified more easily in the pharmacy by asking malnutrition — is not addressed properly. Independent open-ended, identifying questions.

40 America’s PHARMACIST | May 2019 ELDERLY are more likely to be hospitalized for dehydration, and Patients older than 65 years of age have multiple the lack of hydration and awareness risk pressure ul- important risk factors for dehydration. The body water cers and urinary tract infections as well as more serious content of elderly adults naturally lowers with increas- kidney damage and blood clots in the lower extremities. ing age, so this population already has a poorer ability Acute, transient, and reversible problems with atten- to replenish early fluid loss. Although such fluid loss tion, cognition, and consciousness occur in up to 10 in other age groups triggers thirst, the elderly are more percent or more of elderly hospital admissions. Up to likely to have a diminished thirst mechanism. Thus, 50 percent of elderly patients can experience delirium elderly have a twofold baseline risk for dehydration: during a hospital stay. One of the major causes of this less flexibility to maintain homeostasis, and a lower delirium — besides drug or infection — is unnoticed or likelihood of natural replenishment. In this setting, undocumented dehydration. reduced intake alone, especially when cumulative, can lead to dehydration. Unlike the cognitively healthy elderly, those with dementia may become agitated when more drinks are offered Other risks for this population focus on accessibility and or may become uninterested with the amount of water medication use. Even otherwise healthy older adults can needed to stay hydrated. Suggested approaches to forget to drink sufficient quantities of fluids each day. increase intake here include the following: Sometimes barriers are as small as glasses or pitchers • Increase the amounts of high-fluid foods in the diet that are stored out of reach, or pain when swallowing. instead (such as watermelons, lettuce, tomatoes). Suggestions to combat these common issues may rely on • Offer flavored drinks for more variety. the individual, but others can involve family or friends: • Vary the temperature (hot tea or soup, slushed ice) • Encourage extra fluids through increased social visits. to add interest throughout the day. • Leave out clean, filled pitchers and a glass for easy • Consider different textures (popsicles, milkshakes) access each day. that may attenuate the dulled or changed taste • Place notes throughout the house as reminders to sensations. drink water. • Schedule drinks on a paper calendar or set electron- Elderly populations also experience higher rates of ic alarms on a drinking schedule. chronic diseases that affect fluid volume, as heart and kidney functions slowly become less efficient. For Initial symptoms specific to elderly patients with un- example, older patients with chronic kidney disease derlying malnourishment and related dehydration as may develop dehydration and hypernatremia when the inpatients or outpatients include lethargy, a quiet and kidneys become unable to concentrate urine. Patients withdrawn demeanor, or paradoxically hyperalert and with chronic kidney disease also can experience an agitated states, although the mechanisms behind these accumulation of urea in the kidneys, which osmotically changes remain unclear. pulls water out of the blood through diuresis.

Good questions to ask and observations to make about Even when healthy enough to live independently, the typ- elderly patients who approach you in the pharmacy ically higher medication burden in the elderly population include the following: also complicate dehydration concerns. Drug plasma lev- • Do you have a usual routine for meals and drinks? els in elderly patients may be affected by the hydration • How often do you drink glasses of water or juice status, because drugs levels in the serum may become during the day? more concentrated in dehydrated patients whose kid- • Does the patient’s hair, lips, or skin look dry? neys are not sufficiently clearing drugs. Several narrow • Has their demeanor changed from what you have therapeutic index drugs are more common in elderly seen before? patients (such as warfarin, digoxin, or amiodarone). • Are they buying over-the-counter products to treat Along with basic dehydration care for elderly patients, dry mouth? drug assessments to adjust doses during and after treatment for dehydration are warranted. Adults with dementia offer a bigger challenge: These patients may be unable to maintain personal care alone Many of these medications also contribute to dehydration and are at risk of dehydration and overall malnourish- by increasing urine output intentionally or unintentional- ment, and they often remain untreated until the condi- ly, too. Examples of medications that increase diuresis in- tion causes severe morbidity. Elderly dementia patients clude antipsychotic agents, diuretics, and antihistamines. www.ncpanet.org/ap 41 Diuretics (for example, loop diuretics such as furose- • Begin fluid replacement before exercise: at 2-4 mide) and antihypertensive drugs that combine diuretics hours before, individuals should drink 400-600 ml with other agents to reduce blood pressure or control of water, which can lower the heart rate during symptoms of congestive heart failure can remove too exercise and delay or prevent dehydration during much fluid over a prolonged treatment period. Some physical activity. antipsychotic agents also contribute to dehydration by • During exercise, aim for fluid replacement of up to increasing urine output as a side effect of their intended 1 liter of isotonic fluid every hour. To achieve this, use. When patients are otherwise healthy, the risk of individuals should maintain intake of 150 to 350 mL fluid imbalance is easily overlooked. However, the long (6-12 ounces) three times per hour during activity. duration of treatment for cardiac conditions and psychot- • All recommended fluid intake should increase ic disorders increases the risk of an underlying fluid im- (according to thirst and urine indicators) if exercise balance. Prescription or OTC antihistamines may mask takes place outdoors because of the risk of addi- early symptoms of dehydration (such as thirst) because tional fluid loss that results from ambient and body of their primary mechanism of action, which inhibits temperature differences. gastric secretions, saliva, and sweat. PREGNANT WOMEN AND INFANTS ATHLETES During pregnancy, women experience a shift in body A sometimes-surprising cause of symptoms from dehy- fluid volumes and distributions, and blood volume may dration at any age is exercise, because increased activity increase as much as 50 percent. The fluid required to naturally increases fluid loss as a result of increased maintain homeostasis in themselves, and a growing sweat, increased respiratory rate, and higher than usual fetus, increases throughout the pregnancy, and up to 25 energy loss. Therefore, even athletes who are traditional- percent of a woman’s added weight during the last two ly viewed as fit individuals are actually at a great risk for trimesters can be attributed to fluid. The extra hydration volume flux and improper fluid and electrolyte replace- needed to support this dramatic increase in fluid require- ment to offset their greater losses. ment can easily remain unnoticed and unaddressed.

The intensity, frequency, and duration of physical In addition to these basic changes, many women experi- exercise all affect hydration status. Athletes performing ence bouts of prolonged nausea and vomiting during their short, intense workouts can rapidly develop moderate first trimester, which increases the likelihood of dehydra- dehydration and hypernatremia. Increasing the intensity tion. A small percentage of pregnant patients develop hy- of workouts can rapidly increase carbohydrate metabo- peremesis gravidarum, or HG, a condition of uncontrolla- lism, with its associated water loss. People who exercise ble vomiting associated with pregnancy. HG is an extreme multiple times per week also should be aware that fluid form of the anticipated nausea and vomiting of pregnancy, loss will accumulate during the week, thus greater fluid and it can last beyond the first trimester. HG can lead to intake likewise should continue throughout the week to ketosis, weight loss of at least 5 percent of weight, and offset the extra loss. dehydration with associated electrolyte abnormalities.

Endurance athletes, such as cross-country runners, risk Pregnant patients should be encouraged to drink at least dehydration in another way, by slowly failing to maintain 8-10 glasses of water daily to maintain adequate fluid intake. fluid intake during the prolonged activity. In these par- After delivery, nursing women should drink a glass of water ticular settings, athletes also can risk drinking too much with each meal and with each nursing session, at least. water to compensate for their endurance sport without also replacing electrolytes, putting them at risk of hypo- At the other end of the age spectrum, newborns and in- natremia, during which cells and brain tissue swell with fants experience a high risk of dehydration symptoms and extra water. morbidity. Their total fluid volume-to-body area ratio is quite low compared with adults, and this population can- During regular exercise, athletes should observe the fol- not share or voice their thirst or other initial symptoms. lowing guidelines from the American College of Sports Medicine and the American Dietetic Association: The biggest risk of dehydration in this young population • Take in 0.5 to 0.7 g of sodium per liter of fluid during a occurs when vomiting and diarrhea develop, causing an 2-3 hour activity, in part to replace sodium and in part acute and drastic imbalance from water and electrolyte to increase the urge to drink. Sodium requirements can loss. In fact, in the United States, gastroenteritis remains increase over longer activity, to 0.7 to 1.2 grams/liter. the biggest cause of dehydration in pediatric patients. In

42 America’s PHARMACIST | May 2019 the U.S. pediatric population alone, gastroenteritis caused CHRONICALLY ILL electrolyte imbalances that caused lead 1.5 million Any illness that chronically decreases the ability to drink outpatients to seek treatment in 2009. In the same year, or interest in drinking is a risk. Some chronic diseases dehydration from gastroenteritis alone led to 200,000 hos- associated with poor hydration control are diabetes mel- pitalizations and 300 deaths in the pediatric population. litus, diabetes insipidus, Addison’s disease, heart failure, chronic kidney disease, and mental illnesses. Pediatric complications from dehydration are usually related to low blood sugar (hypoglycemia) and hypernatre- DIABETES mia (serum sodium concentrations >145 mEq/L, just as in Blood glucose has a unique role in the mechanism adults). Although serum sodium levels may be measured of dehydration. Osmotic pressure leads to diuresis in children at risk for dehydration, outpatient evaluation of fluids, which follow glucose out of the blood and to identify a child who is dehydrated often relies first on intracellular space into the kidneys. In uncontrolled or clinical questions and a physical examination. undiagnosed diabetes, excess glucose (typically > 180 mg/dL) is cleared by renal excretion. Polyuria is often Physical signs of mild dehydration in newborns and a symptom of undiagnosed diabetes mellitus and infants include an abnormal respiratory rate, changes in poses the greatest risk of dehydration, when extreme- skin turgor, and skin scaling. However, a few outpatient ly high glucose concentrations may develop without questions directed at the caregiver also can rule out being addressed. dehydration despite gastric illness: • Is oral intake normal? Diabetes-related dehydration also is one of the most • Is there no diarrhea? common causes of hypernatremia in adults. The fluid • Is there still urine output? movement into the kidneys and high urine output • Is there normal tear production during crying? dehydrates intracellular fluid compartments and leaves the total body water hyperosmolar (with a high sodi- If the answers to any of these questions (especially the um-to-water ratio in the serum). An added risk occurs last two) are yes, dehydration is unlikely. because serum sodium levels do not accurately reflect hypernatremia when water moving from intracellular ACUTELY ILL fluid to the blood also floods the extracellular spaces. Acute GI illness in any age is a dehydration risk. Acute damage to any part of the GI tract and oral cavity can Patients already diagnosed with diabetes or insulin in- negatively affect fluid volume as well, because patients sensitivity should pay extra attention to changes in thirst are less likely to eat and drink. Examples include a sore or urination, because increases in these two markers throat from bacterial and viral infections, cold sores and are signs that blood glucose concentrations might be canker sores, and acid reflux damage that limits food high, causing early symptoms of dehydration. Safe re- intake. These patients should be educated about the hydration, such as consistent but slow intake of 1/2-cup importance of scheduled fluid intake during acute illness amounts every hour, can prevent dehydration symptoms to counter dehydration risks. at the same time that insulin needs are addressed.

Any skin trauma, such as damage that occurs with MENTAL ILLNESSES second or third-degree burns or burns that affect a large Adults with mental illnesses who are not stabilized body-surface area, removes the body’s natural protective on a treatment program may refuse food, water, or defense against moistures loss. As a result, the body medication when hospitalized for their conditions. experiences more evaporative loss than usual. This, Even outpatients may resist efforts to establish an along with blood loss associated with the damaged skin, intake schedule, and adults with bipolar, depressive, quickly leads to dehydration. and manic conditions may be less likely to maintain their basic needs, and those with obsessive disorders Finally, patients receiving chemotherapy have overlap- may be unable to perform adequate self-care tasks in ping risks for dehydration from excess fluid loss and a timely manner. In some cases, patients with mental inadequate intake. These patients may develop mild illnesses may not be able to recognize basic triggers, dehydration from nausea and vomiting side effects, such as the thirst sensation. For patients who are diag- and this loss can be compounded by poor fluid intake nosed with mental illnesses, evaluation of their daily that results from diminished appetite, mouth sores, and routine should include a focus on their food and water mucocutaneous fungal infections like thrush. intake, at least. www.ncpanet.org/ap 43 SITUATIONAL RISKS Alcohol, caffeine, and over-the-counter drug or supple- Along with these defined risk groups, some situational ment use are main factors in these changes. risks of dehydration exist across populations. Factors as disparate as weather, skin condition, supplement Social drinking, though the volume of fluid intake may use, and body weight or gender can change a person’s appear adequate for euvolemia, is likely to induce dehy- baseline risk. dration and electrolyte depletion. Alcohol inhibits antid- iuretic hormone, which leads to increased diuresis and Weather exposure urination that worsens fluid loss. Dehydration associated Although heat and fever both increase fluid loss through with binge drinking of alcohol may be compounded by sweating and are documented dehydration risks, winter nausea and vomiting that occurs when toxic levels of cold actually can be worse for dehydration. Water loss alcohol irritate the gastric lining. increases naturally as vapor through exhalation in cold, dry air; evaporated water from sweating, which increases Likewise, dieting increases the susceptibility to hydration with the weight of extra clothing, goes unnoticed. The imbalance. Cleanse diets that rely on deprivation can lack of observed sweat in cold weather also dampens the induce or prolong dehydrated states, and any diet that likelihood of noticing thirst, even during exercise, and severely restricts one aspect of balanced intake can the thirst response itself decreases by up to 40 percent upset the fluid balance as well. Low-carb diets in partic- as a result of blood vessel constriction. Many other con- ular are associated with dehydration, because fluids are tributors play into cold risks. For example, cold-induced stored and carried into the body together with carbo- diuresis, in which the kidneys conserve water and urine, hydrates. When carbohydrate intake is restricted, fluid changes the body’s fluid distribution and a person’s intake also suffers. Therefore, moderate amounts of ability to interpret urine output as a sign of dehydration. carbohydrate intake can increase absorbed water Also, increased alcohol intake that occurs during winter amounts and prevent dehydration during dieting. holiday parties can be dehydrating. Finally, a number of dietary supplement products and Skin barrier concerns herbs can induce dehydration either intentionally or as Skin care for dryness is a frequent question of outpa- an adverse effect. Many, including energy drinks, coffee, tients in the pharmacy. Dry skin counseling should sodas, diet shakes, and diet and energy pills, contain trigger an assessment of overall hydration, too. Preven- caffeine or other stimulant chemicals such as taurine tive hydration and moisture protect against infection and or ephedra. These products often are initiated during other dermatologic problems and should not be taken midlife to treat or prevent common conditions such as for granted. weight gain, and their stimulants increase urine output. The risk of medication misuse leading to dehydration is The stratum corneum (the outermost epidermis lay- especially high because patients are likely to self-med- er) contains 10-30 percent water to provide a flexible icate for long time periods with these nonprescription and elastic skin barrier. Its main purpose, though, is to products and often self-restrict fluids and foods at the minimize water loss. Thus, problems with the stratum same time. Similarly, herbal products — such as parsley, corneum reflect underlying hydration concerns. Skin ap- celery seed, watercress, and dandelion — are used to pears dry as soon as this layer’s hydration dips below 10 reduce weight or bloating but typically rely on diuretic percent. Symptoms include scaling, itchiness, redness, activity. Laxatives likewise increase dehydration by defi- reduced flexibility, roughness, flaking, and peeling. These nition as a result of increased fluid expulsion. Particular changes are more likely in the elderly, too, who are more attention should be paid in the outpatient setting to likely to have lower fluid levels in the skin as a baseline. notice purchases of or questions about these products, and counsel patients on their safest uses. Pharmacists can counsel patients of all ages to maintain essential skin hydration with emollients (lipid barriers), Gender and body weight occlusive ointments like petrolatum that seal in mois- Basic differences of fluid storage and body size can be ture, and humectants such as glycerin that increase the generally applied, as well. These broad characteristics skin’s water absorption. can increase the risk of dehydration even more when other risks exist. For example, fat holds less water than Dietary choices muscle, so obese patients carry more weight in propor- The simple choices that adults make throughout a day tion to their total body water content than lean patients. can greatly affect their hydration level unknowingly. In women, too, the average smaller total body water

44 America’s PHARMACIST | May 2019 content (compared with that of men) results in part Because fluid status and balance are so important to because of size differences and in part because women overall good health, though, pharmacists should not carry more of their weight as fat tissue, which holds hesitate to counsel any patient with an identified or even less water. When these two populations lose the same suspected cause of dehydration about healthful fluid and volume of water as patients who are leaner or have larger electrolyte intake. Much dehydration prevention can be bone and muscle build, they will lose a greater percent- addressed through changes to activities of daily living. age of their total body water and will not have as much Outreach to every patient can include the following fluid stored in intracellular spaces to replenish the fluid suggestions to encourage adequate fluid intake: lost from blood vessels in early dehydration. • Drink water when you feel hunger, because that sensation is often mistaken for thirst. Travel considerations • Remember to drink water before, during, and after a Travel broadly increases the risk of dehydration to workout of any duration. varying degrees. First, any traveler without established • Carry reusable water bottles throughout each day. hydration habits can experience thirst and mild dehy- • Select decaffeinated over caffeinated coffee or dration from not packing or obtaining enough water on sodas. a trip. Advance preparation to carry a refillable bottle • Start and end each day with water. or even to pack powdered electrolytes is an easy way to • Drink water at restaurants instead of sodas, teas, prevent this situation. or alcohol. • Follow a water intake schedule, or keep filled Although traveler’s diarrhea can develop anywhere, pitchers throughout the house, in extreme cases of some locations are considered high-risk countries by poor self-care. the CDC Yellow Book, including many parts of Asia, the Middle East, Africa, and Central and South America. If patients think they are drinking enough, remind them Here, infection from polluted water is more likely, and of a few easy rules of thumb: drink eight 8-ounce glasses the resulting diarrhea sets the scene for serious effects of fluids daily; drink up to half your body weight in fluid of dehydration — especially when clean water remains ounces. (For example, a 150-pound person could drink unavailable. Up to 50 percent of travelers to high-risk up to 75 ounces daily). Alternatively, aim for a healthy countries experience some level of dehydration. The best baseline of about six glasses of water by drinking a little advice for this population is again to plan ahead, which bit all day long. If patients are bored with just water, should include bringing safe water and electrolyte solu- remind them that intake includes all sources of water, and tions as well as antidiarrheal medications. even soups count. Fruits and vegetables with high water content include melons and strawberries, applesauce, Finally, military personnel experience multiple travel-as- cucumbers and celery, zucchini, and even tomatoes. sociated risks. Along with higher risks of evaporated sweat loss because of extra clothing layers and carrying BASIC TREATMENT OPTIONS packs, these adults are in endurance settings that may The treatment for dehydration sounds simple: rehydra- not allow enough time to recover from the imbalance. tion. However, treatment options vary widely within this In 2010, more than 1,700 occurrences of dehydration basic premise. The goals of rehydration are to restore were documented in overseas military. The rapid loss of the circulating blood volume first, then to replace the vital electrolytes is a particular danger in this group: the interstitial fluid volume, and finally to maintain the fluid decreased mental and physical performance capabilities balance (euvolemia). During therapy, the rehydration at 5 percent dehydration was measured as equivalent to treatment of choice should replace ongoing losses until a dangerous blood-alcohol level of 0.10. This group, too, the cause is resolved (for example, until diarrhea ends). needs not only sufficient fluids but also electrolytes to Ultimately, the patient should resume a normal diet of maintain optimal health. liquids and solids.

COUNSELING PEARLS: LIFESTYLE ADAPTATIONS Outpatient treatment options for mild to moderate dehydra- Identifying and treating dehydration in an outpatient tion can be broken down into three potential fluid catego- setting is a valuable but challenging tasks, because ries: water, sports and energy drinks, and oral rehydration symptoms can appear nondescript or unimportant, solutions. The restoration of euvolemia in severe dehydra- because patient populations at risk are so variable, and tion is the maintenance of isotonicity: the osmolarity of the because dehydration is still considered a condition more water, or the proportion of its electrolyte contents. Isotonic prevalent in non-industrialized countries. body fluid contains 200 to 320 milliosmoles (mOsm) of www.ncpanet.org/ap 45 electrolytes per kilogram of water. Inpatient rehydration American Council on Fitness recommendations for basic therapy for severe dehydration strives to rebalance electro- water intake during moderately intense workouts: lyte concentrations as well as total body volume. • Drink up to 20 ounces of water 2-3 hours before exercising. Although intravenous fluids to treat severe dehydra- • Drink eight ounces approximately 30 minutes before tion rely on precise measures of electrolyte osmolar exercise or during the warm-up period. quantities and proportions, outpatient treatment is less • Drink up to 10 ounces of water every 20 minutes of specific and does not involve laboratory measures of exercise. serum electrolytes. Instead, outpatient treatment and • Drink eight ounces of water within 30 minutes of evaluation rely on physical signs of improvement. completing exercise.

WHEN IS WATER ENOUGH? WHEN ARE SPORTS DRINKS OKAY? Water is considered the most basic fluid replacement, of Sports drinks, such as Gatorade, are marketed to course, but it is sufficient only for mild dehydration, be- athletes, especially because of their need to replenish cause it does not contain electrolyte replacement. Water minerals, not just fluid volume. These products offer nu- is the best option to prevent dehydration, though, and to trients such as sodium, chloride, potassium, and useful maintain euvolemia after other types of hydration ther- calories. However, they are often high in sugar and may apy. Additional benefits of water are its lack of calories, contain added sodium or caffeine without advertising sugars, or herbal stimulants (such as caffeine). Indirect these ingredients clearly. Although sports drinks can dietary sources from broths, fruit and vegetable juices, be used during fevers, vomiting, and diarrhea to replace and herbal teas that are predominantly water do con- electrolytes, they are not intended for this purpose, and tribute to fluid intake goals. However, they contain many their osmolar content is not formatted specifically to fit other ingredients in non-standardized quantities that can these needs. In fact, a 2016 study of various drinks in affect a patient’s health. For example, broths and juices hydrated adult men measured the ability of these drinks may contain high amounts of sodium or sugar, respec- to maintain hydration, as determined by urine output and tively, which can disrupt electrolyte levels or pull water calculations. In the study, sports drinks (and caffeinated into the urine. Conversely, fluid replacement with clear energy products or sodas) appeared only as effective sodas or teas may not contain a sufficiently proportional as water (and less effective than milk, orange juice, and amount of sodium. Caffeinated drinks of any kind also oral rehydration solutions) at hydrating and maintaining increase urination, making them a double-edged sword hydration in this group of active adults. in the treatment of even mild dehydration. Moderate caffeine intake (defined as 200 to 300 mg or 2-4 cups of Sports drinks are probably most useful in healthy, hy- coffee or tea daily), though, is considered acceptable drated individuals during high-intensity exercise, which daily use for adults. burns calories and carbohydrates rapidly, especially if it lasts for more than one hour. The carbohydrate calories One baseline recommendation for fluid intake is, for in these drinks can prevent hypoglycemia during an most people, six glasses of fluid daily (6-8 ounces each). intense workout, and the added electrolytes can maintain All food and drink in a day contribute to the total fluid healthy activity longer than just water. However, sports intake, even when they also carry a detriment (like caf- drink intake should be dosed carefully. For example, feine). It is important to remember that individual fluid sports drinks serving sizes should be checked before needs vary slightly, so one patient’s baseline may be use and the optimal hourly intake during exercise should more or less than six glasses of fluid daily. The pres- remain capped at 60 g of glucose. Also, patients should ence of thirst and hunger, which can be mistaken for use sports drinks that do not contain caffeine and should thirst, is the primary indicator to adjust intake above this note the sodium content, which may differ significantly basic recommendation. If any reasons for a higher risk between brands. Patients with hypertension, in partic- of dehydration exist, a higher baseline also should be ular, should select a sports drink that contains lower considered. Generally, if urine remains light to colorless, sodium content. Conversely, endurance athletes, who hydration can be considered sufficient. risk over-hydration that induces hyponatremia, should be more attentive to the sodium content of their sports drink Just as there is no single daily intake guideline that fits and of their total fluid intake during exercise. A general every person, there is no one-size-fits-all recommen- guideline for these athletes is to drink no more than 400 dation for increasing fluid intake during exercise. In to 800 mL/h of sports drinks, a rate that can prevent de- addition to checking urine color, adults can observe the hydration without adversely lowering sodium levels.

46 America’s PHARMACIST | May 2019 Energy drink products (large volume or 2-ounce shots), without increasing the glucose content. Marketed rice- are distinct from sports drinks, both from advertising and based products may be certified as gluten free, also, for food content perspectives. Energy drink products are not patients with severe gluten sensitivity or celiac disease. recommended to prevent or treat dehydration or to rehy- drate after physical activity. These products are predom- ORS products as a standardized replacement of water inantly caffeine and related stimulants, such as guarana and essential electrolytes are recommended for rehy- and taurine, that are intended to give the body a short- dration therapy by the World Health Organization, the lived jolt. These are marketed to adults who are healthy CDC, and the American Academy of Pediatrics for mild and want a “pick me up,” not to those trying to stay to moderate dehydration in children with any cause of hydrated. In addition to their stimulant ingredients, energy gastroenteritis. In general, ORS can be initiated more drinks often have high sugar levels and are considered quickly than IV therapies and can be re-administered as particularly unsafe in pediatric and teenage populations. necessary at home or in any doctor’s clinic. There is no apparent difference in the efficacy of IV fluids or ORS for BEYOND BASICS: ORAL REHYDRATION SOLUTIONS treatment of mild to moderate dehydration and electro- When water is no longer enough, mild to moderate lyte loss. In fact, ORS was established as equally effec- dehydration can be treated safely and efficiently in the tive as IV fluids in pediatric patients with gastroenteritis outpatient setting with replacement options that contain after four hours of therapy. electrolytes in addition to fluids. These oral rehydration solutions, also known as ORS, are specially formulated ORS products are available worldwide, are simple to to mimic the body’s homeostasis. Unlike water or sports use, are affordable, and have little to no complications or drinks, ORS products are designed to replace specific drug interactions. Even patients who receive ORS during quantities of electrolytes (particularly sodium and potas- a hospitalization or ER visit experience benefits of oral sium) plus a standardized amount of carbohydrates. therapy versus IV. Parents are more satisfied with care, it is noninvasive, ER stays are reduced, and prolonged DEVELOPMENT PREMISE AND FEATURES hospital stays are avoided. The premise of ORS is osmosis of water with solutes (such as glucose). Glucose provided in the liquid product FORMULATIONS AND PRODUCTS increases the absorption of both water and sodium ORS products were first developed in the 1960s, when across the small intestine and into the body, thus clinicians observed that glucose increased the absorp- increasing the volume of retained fluid more than water tion of water from the intestines of patients with chol- alone, even during ongoing diarrhea and vomiting when era-related diarrhea. During a cholera outbreak, patients water alone would pass directly through the intestines who drank only water often lost the same amount of fluid too quickly for absorption. An ORS product with a through diarrhea (sometimes up to 1,000 mL/hour). Water sodium-to-glucose ratio of 1:1 is sufficient to increase alone did nothing to restore blood or intracellular volume. the absorption of electrolytes in the intestine, which With the addition of glucose, morbidity and mortality then increases water absorption across the intestinal from acute diarrhea decreased drastically in children, lumen into cells. A glucose concentration of just 50 mM from 5 million before effective rehydration to only 1.3 increases jejunal sodium absorption 4-fold and water million after implementation of ORS. The oral rehydration 6-fold. The same glucose concentration increases sodi- salts advocated for the treatment of cholera-related diar- um and water absorption to 3-fold each in the ileum. rhea eventually became used for numerous GI conditions globally, including rotavirus and traveler’s diarrhea. Hyperosmolar glucose formulations (concentrated fluids with sodium and glucose) are still considered the best Today’s products, called low-osmolarity formulas, are options for the most absorption of water, although the substantial revisions of the 1990s efforts and average 245 actual content of carbohydrates and sodium have been mOsm/L—the recommended osmolar concentration for adjusted over time. Formulations often contain 20 mEq both adult and pediatric populations according to WHO- of potassium as well. Although glucose is the traditional UNICEF. The new formulas contain approximately 13.5 carbohydrate source, rice starches are effective and are G/L glucose and 75 mEq/L sodium. They minimize the becoming more common in some marketed products as risk of high stool output in children and are associated they become easier to package. Other starch additives with lower vomiting rates. (such as from corn) have been used in experimental ORS products as well. One goal of these starch-based Despite its success worldwide, ORS use in the United products is to improve the colonic absorptive capacity States has lagged behind global advancements. www.ncpanet.org/ap 47 One dominant reason is that awareness of ORS availabil- • For mild dehydration, use 50 mL/kg over four hours, ity, correct use, and importance in mild to moderate by spoon, cup, or oral syringe. This works out to a dehydration still remains inadequate. Pharmacists may rate of 1 mL/kg every five minutes, as tolerated, and find that U.S. adults prefer sports drinks or even caf- can be performed at home, resuming 30 minutes af- feinated energy products when hydration with ORS is ter any episode of vomiting. After four hours, if urine suggested. Educating patients about when to use ORS, output is normal, maintenance and loss-replace- especially in lieu of water or sports and energy drinks, ment with ORT every two hours for up to the next 24 includes teaching patients to recognize progressive hours is acceptable. symptoms of dehydration (such as dark urine or lack of • Treatment of moderate dehydration follows a similar sweat or tears) as they develop and to recognize dangers pattern with higher volumes: ORT over four hours of the alternative products. Also, pharmacists can stock a should begin at 100 mL/kg, and should be initiated with variety of ORS products in the pharmacy to recommend a health professional at first (such as clinic, office, or to these patients during dehydration and as a preventive ER) before continuing treatment at home. Maintenance on-hand measure, especially for high-risk groups. at home should still be given every two hours. Howev- er, if vomiting persists, with an estimated loss of 25 per- BRANDS AND DOSES cent of the hourly administered ORT volume, then the Commercial products today in the U.S. typically contain treatment is considered unsuccessful, and the patient 50 mEq/L sodium, less than the 90 mEq/L recommended should be taken to the ER for consideration of severe by WHO for cholera-specific loss, but near the approxi- dehydration and intravenous fluid treatment. After eu- mate loss of sodium that occurs during, for example, a volemia is restored, pediatric patients are encouraged rotavirus infection. Also, these products usually contain to resume eating, which can assuage diarrhea. approximately 25 g/L dextrose, to avoid hypoglycemia in infants, and 30 mEq/L of sodium bicarbonate to re- Although a highly specific dosing algorithm, developed duce vomiting and to correct a potential acidosis in the by Holliday Segar, is available to calculate exact ORS small total body water volume of children. The different quantities in children, it is more frequently used for inpa- available ORS products aim to provide tolerability by tient hydration therapy and severe hydration. Outpatient taste and texture, and ideal efficacy in different delivery ORS dosages may be simplified for patients as follows: vehicles. Examples include Pedialyte, Ceralyte, Recover for mild to moderate dehydration: give 1 ounce per hour ORS, and H2ORS. Variations are slight and often center in an infant, 2 ounces per hour in a toddler, and 3 ounces on the form of carbohydrate used. Common formulations per hour in older kids. For ongoing loss, an estimate of 10 are premixed liquids, ready-to-freeze ice pops, and pow- mL/kg for every loose stool, or 2 mL/kg for every episode dered single-use packets. of emesis, can be a simple dose for parents to follow.

ORS products for use in the United States are typically In the 21st century, old and new U.S. brands alike have dosed by fluid volume according to age, level of dehydra- aimed to increase awareness of dehydration and reach new tion, and response to therapy. Most available dosage rec- at-risk populations. For example, Pedialyte, a longstanding ommendations focus on children with an acute GI illness; ORS brand, now advertises on its website the benefits general recommendations exist for older patients as well. of use after drinking alcohol. Drip Drop, developed by a physician to provide WHO rehydration standards in more For acute mild to moderate dehydration in children or acceptable flavors and dosage forms (including a powder adults, WHO recommends the following quantities of stick), is now advertised to military personnel and avid ORS within the first four hours of the onset of dehydra- exercisers. The product Normalyte, developed by U.S. phar- tion, by age: macists, is diet-conscious. Users dissolve one packet in • 2-4 year olds: 800 to 1,200 mL 500 mL of drinking water for a lower-calorie ORS option. It • 5-14 year olds: 1,200 to 2,200 mL only has 27 calories compared with 50 calories in Pedialyte • Age 15 years and older: 2,200 to 4,000 mL to replace (and more than 100 calories in most sports drinks), and lost fluids. However, these doses can vary according the packets are free of gluten and artificial sweeteners. to the level of diarrhea and its cause, which changes Hydralyte advertises toward athletes with the claim of the sodium content in the stool. lower sugar than sports drinks. As the number of brands available to U.S. consumers increase, pharmacists can The AAP suggests more specific guidelines for children encourage ORS use that is tailored to specific risk groups, during and just after acute vomiting or diarrhea from with a goal of increasing the acceptance of these products gastroenteritis: instead of sports or energy products.

48 America’s PHARMACIST | May 2019 Table 2: ORS examples

Product Pedialyte Normalyte Hydralyte WHO contents Low-Osmolar Formulation

Sodium 45 mEq/L 37 mEq/500 mL 45-60 mEq/L 75 mEq/L

Potassium 20 mEq/L 10 mEq/500 mL 20 mEq/L 20 mEq/L

Glucose 2.5 g/dL 6.75 g (37 0.6 ounces/L 13.5 g/L mEq)/500 mL

Osmolality 250 mOsm/L — 245 mOsm/L 245 mOsm/L

ORS CAUTIONS save money and make solutions at home, they should The negative characteristics of ORS products are few point out safe and accurate resources. Both The World but can be prohibitive. Poor taste is a significant rea- Bank (http://siteresources.worldbank.org/INTHSDEP/ son that patients avoid these treatments, and limited Resources/1148855-1430226362890/Oral_Rehydration_ selection or availability in the pharmacy also may be a Solutions.pdf) and the Rehydration Project (https://re- problem. Also, cost can be a deterrent to many patient hydrate.org/solutions/homemade-ors.pdf) offer recipes populations, especially those most in need, such as pa- that combine adequate electrolyte balance, lower sugar tients who remain unvaccinated and develop rotavirus. or calorie content, and affordability compared with marketed products. A small subset of patients should not use ORS without physician supervision. These patients most often have Whether your clinic sees mostly middle-aged adults with pre-existing chronic diseases: chronic conditions, elderly independent and assisted • Congestive heart failure or other cause of fluid living residents, or in-their-prime athletes and travelers, restrictions dehydration is a relevant health indicator. Scanning • Impaired urine output, such as with kidney diseases patients and their questions or prescriptions for signs of and dialysis treatments possible volume depletion in early stages can fend off • Sodium sensitivity as a result of hypertension more severe hydration issues in the long term. • Severe dehydration (which requires immediate assessment and treatment with IV fluids) or age CASES younger than 1 year (who should be referred to a Elderly populations pediatrician) H.D., a 75-year-old patient at your pharmacy, is being treated for hypertension that is well-controlled on his current A final option for interested patients is to make their regimen. About five months ago, H.D. started Exelon for own ORS formulations to have on hand at home. As the prevention of Alzheimer’s disease progression. His awareness about adequate hydration increases, home- cognitive decline to date has been slight, and he always made versions of rehydration solutions are being de- picks up his refills on time. H.D. lives independently. How- veloped, too. Note that these at-home recipes typically ever, his daughter (a primary caregiver in the past) recently lack preservatives, though, and that inherent risks exist moved from his town to another state for work. When H.D. in calculating personalized electrolyte concentrations. approaches the counter to pick up his refill and a multivi- Counseling should encourage caution about the recipe tamin, you notice that his hands are dry and peeling, and source. If pharmacists believe that their patients aim to that he is slow to respond to your conversation. Could www.ncpanet.org/ap 49 H.D. be experiencing symptoms of dehydration? What are for, participates in, and ends his cross country meets, you some questions you could ask to ascertain his risk? also recommend replacing caffeinated and sugary cola products with water or, if he insists on the preference, ap- You ask H.D. about his daily diet and self-care routine. propriate serving sizes of sports drinks that replenish elec- When questioned, he admits to feeling tired and slow in trolytes without the added stimulants and sugars. At the the past few weeks. He denies hunger or thirst and says conclusion of your interaction, you use the latest research that he “eats when he is hungry.” He wants a vitamin so to emphasize the potential for oral rehydration solutions to that he gets nutrients without worrying about meals. He benefit him — especially during intense exercise — even noticed that he rarely gets up to use the restroom any- more than appropriately selected sports drinks. more, and he has few visitors to his home. Although H.D. seems tired, he does not seem confused or agitated during Mid-life risk the conversation. You suspect at least mild dehydration A.F., age 42 years, is a new patient in your pharmacy. She because of his dry skin, fatigue, and low urine output. In has transferred medications for year-round environmental addition, H.D. is likely to have an impaired thirst mech- allergies and an antidepressant. A prescription for oral anism and poor self-care, given his dementia and lack of contraceptives is on hold while she nurses her 4-month- a caregiver or regular visitors. You point out to H.D. the old baby. She admits to frequent dieting and using OTC importance of regular fluid intake in staying healthy and weight loss pills before her pregnancy and is considering avoiding cognitive decline, and the usefulness of social restarting them after she stops breastfeeding. She has a interactions to remember to eat and drink regularly. You follow-up visit at her health clinic next month, because suggest immediately increasing fluid intake on a schedule, she had gestational diabetes, and she wants to discuss starting and ending each day with a glass of water, and her fatigue and headaches, which seems more extreme keeping water bottles available around the house for easy than she expected after having a baby. You take some time access. You also encourage H.D. to visit his physician to to counsel A.F. on her medications, weight loss, nursing, check his electrolytes, evaluate his hydration status more and diabetes. What hydration-related topics should you formally, and suggest possible social groups in the com- point out to her? munity he can join. A.F. has numerous acute and chronic risks for under- Athlete case lying dehydration. In addition to her underlying risk for G.T. is a 23-year-old university student whose family reg- diuresis-related symptoms, such as thirst, from chronic ularly uses your pharmacy. When G.T. is back at home on antihistamine use, A.F. is at risk for poorer self-care a school break, he stops in to ask about energy supple- because of her history of depression. Her past dieting ments. He is carrying a large sports drink bottle that has and OTC drug use are risk factors for dehydration that been refilled with a cola product. You are aware that G.T. could become relevant again if she resumes either a low- was on his high school lacrosse team, but you learn today carb diet or a stimulant weight-loss product. Her recent that he has joined the university’s cross country program pregnancy and current nursing status both increase her as well. He is training for the upcoming relay meets and fluid requirements as well, and her likely chronic fluid-loss wants to increase his energy. Do you have concerns about state suggests dehydration as the cause of her noticeable G.T.’s hydration today or in the future? What suggestions fatigue and headaches. Finally, A.F.’s history of gestational can you give him as he increases his physical activity? diabetes puts her at risk for undiagnosed hyperglycemia and diabetes after her pregnancy, which can increase urine G.T. is an apparently fit young adult, but he risks developing output and lead to even more severe dehydration. dehydration by not preparing adequately for his new exercise routines and meets, which are more intense than his You point out to A.F. the multiple reasons that her fluid past physical activity, and by making less-than-ideal regular volume could already be low and explain that increas- hydration choices. You can suggest to G.T. that intense and ing fluid intake will improve her energy and weight loss endurance sports activities in particular require increasing (because thirst is often mistaken for hunger that leads to fluid intake before, during, and after exercise to prevent overeating), will quickly assuage the severity of her fatigue dehydration and provide optimal energy, and that proper and headache, and will protect her from dehydration if she hydration will support his exercise regimen more success- does develop high blood sugar postpartum. If A.F. affirms fully than high-calorie, high-sugar energy drinks or supple- that she experiences thirst, low urine output, dry skin, or ments. You also counsel G.T. that intense exercise outdoors other signs of dehydration now, you should recommend increases fluid loss even more. When G.T. seems interested hydration therapy options, including oral rehydration in learning more about how to stay hydrated as he prepares solutions and a practical approach to maintaining daily

50 America’s PHARMACIST | May 2019 fluid intake while busy at home with a new baby, and suggest that A.F. follow up about her hydration and CE electrolyte status at her upcoming clinic visit. ■ QUIZ

Nicole Van Hoey, PharmD, is a freelance medical writer and editor in Arlington, Va. Continuing Education Quiz Select the correct answer.

1. Hydration status involves: a. A constant balance of volume intake and loss from excretions and insensible (nonmeasured) losses such as perspiration. b. A constant flux of volume that is evenly distributed throughout the blood and extracellular spaces. c. Regulation from only the pituitary system. d. Regulation predominantly from the cardiopulmonary system.

2. Fluid composition of different body compartments is: a. Evenly distributed across the blood, muscle, and fat. b. Dispersed predominantly into body fat. c. Absent from muscles. d. Distributed into intracellular spaces as well as extracellular fluids of plasma, lymph, and more.

3. A regular patient in your pharmacy has developed a viral infection and has a sore throat. She comes to you for cough drop recommendations. In addition, you ask which questions to ascertain adequate fluid maintenance during her acute illness? a. Have you been drinking one 12-ounce glass of water every 10 minutes? b. Have you noticed whether your urine is clear to colorless or a darker color? c. How often do you urinate each day? d. Two of the above e. All of the above

4. The patient admits to low urine output, dry skin, and fatigue in addition to headache and thirst she associated with her cold. She also states that she takes an OTC antihistamine every day for allergies. Which of the following could you recommend to her? a. Go home and sleep off the virus to reduce fatigue and headache. b. Increase fluid intake by drinking two more cups of coffee every morning. c. Increase fluid intake by drinking a baseline of at least six glasses of fluid daily and increasing other sources of fluids (such as broths or decaffeinated teas) to replace lost fluid and prevent worse dehydration. www.ncpanet.org/ap 51 d. Immediately begin a course of oral rehydration solu- c. Gatorade may be used to prevent dehydration, and the tion, maintaining an intake of at least 500 mL each goal intake to prepare for exercise is no more than 60 hour. grams of glucose per hour. d. Both b and c 5. When a fluid deficit occurs and causes mild dehydra- e. All of the above tion, liquid in the extracellular compartments are shifted into the ___ to maintain _____ and _____. 10. How can undiagnosed diabetes lead to dehydration? a. Blood, cellular volume, blood pressure a. Increased glucose in the blood pushes water into the b. Cells, cellular volume, osmotic pressure intracellular spaces to lower the serum water level. c. Blood, blood volume, blood pressure b. Increased glucose in the cells pulls water into the d. Cells, blood volume, pressure intracellular spaces to lower the serum water level. c. Increased glucose in the blood overflows into the pan- 6. Sodium is an essential electrolyte for ___ function, but creas and leads water there to accumulate. increased concentrations greater than ___ that develop d. Increased glucose in the blood enters the kidneys during dehydration can cause ____. to be cleared as polyuria develops, and water in the a. Cardiac contractions, 145 mEq/L, myocardial infarction blood follows the glucose by osmosis into the urine. b. Kidney, 75 mEq/L, kidney stones c. Skin, 75 mEq/L, scaling 11. A regular patient who is obese by body mass index d. Nerve and muscle, 145 mEq/L, neurologic changes measures, takes a loop diuretic from his cardiologist, and enjoys downhill skiing, visits your clinic before a 7. Mild dehydration begins with a net fluid imbalance week-long ski resort trip. Which of the following describe of only approximately ___ percent, and its primary early his dehydration risks? symptom is ___. a. Obesity, because fat holds less water than muscle; a. 1, confusion medications that increase urine output; and hypergly- b. 1.5, lack of tears cemia associated with diuretic use that pulls water c. 2; thirst into the urine d. 2.5; thirst b. Obesity, because fat holds less water than muscle; medications that increase urine output; and decreased 8. Which of the following statements about dehydration thirst response and less-noticeable, but increased, risks is incorrect? skin and respiratory fluid loss during intense outdoor a. Obese patients are at lower risk than lean patients exercise in the cold because they have extra body weight and, thus, fluid c. Obesity, because fat holds onto water more than mus- storage. cle does, and medications that increase urine output b. Women are at higher risk than men because they have d. Medications that increase urine output; indoor exer- chronic health conditions, such as diabetes, that com- cise preparation that increases the fluid deficit before plicate the body’s ability to maintain euvolemia. skiing c. Women have a lower risk of dehydration during pregnancy, because their body volume shifts and fluid 12. A young mother approaches you to ask for cola syrup, needs decrease. because her 6-month-old has had vomiting and diarrhea d. Infants who have rotavirus infection have higher risks for the past five hours. How can you quickly assess the of severe dehydration than children with stuffy noses infant’s hydration status? from a cold virus. a. Ask if the baby is still sweating. b. Ask if the diarrhea volume is more than 500 mL. 9. A person comes to your pharmacy to buy Gatorade c. Ask if the baby still has tears when she is crying. and salt pills and mentions his upcoming half-marathon. d. All of the above You overhear him at checkout and intervene with which of the following counseling points? 13. What do you recommend to this baby’s mother? a. Marathon running carries a high risk of dehydration a. Make a replacement hydration solution at home with in part because large volumes of fluid are lost through cola syrup and ginger ale for sugar replacement. sweat and exhalations during outdoor exercise. b. Try giving the baby extra water in a bottle. b. Salt pills actually are dangerous to use at any time, c. Give approximately 4 ounces per hour of Pedialyte, as because they provide electrolytes without extra fluid to an ORS option, and re-evaluate the next morning. maintain the proper balance of both.

52 America’s PHARMACIST | May 2019 d. Begin ORS treatment a contact the pediatrician, be- 19. Why are current low-osmolarity formulations for oral cause her infant is younger than 1 year of age. rehydration solutions preferred? e. Both C and D a. They help children retain more water during rotavirus infections. 14. Which of the following patients may be most unlikely b. They improve fluid distribution by avoiding high to maintain euvolemia independently? amounts of electrolytes. a. An adult patient with bipolar disorder who has a his- c. They minimize the risk of high stool output and high tory of stopping her medications but lives in a group rates of vomiting. home d. Both A and C. b. A pregnant woman who makes it to all of her OB/GYN appointments 20. Currently available ORS products are hyperosmolar c. An elderly patient living alone with congestive heart products that contain approximately: failure and chronic kidney disease a. 90 mEq/L sodium and 200 mOsm/L. d. An elderly patient with mild dementia living with his b. 75 mEq/L sodium and 245 mOsm/L. daughter and son-in-law as caregivers c. 40 mEq/L sodium and 350 mOsm/L. d. 75 mEq/L sodium and 350 mOsm/L. 15. Prevention of dehydration during exercise relies on: a. 4 L intake before and 2 L intake after, and no fluid 21. GI loss replacement guidelines by ___ suggest an intake during exercise. ORS composition of ______and a dose replacement b. 500 mL intake before and 500 mL during, but only volume of ___ for patients age 5 to 14 years. carbohydrate-heavy foods after exercise. a. CDC, 60 mM sodium every two hours c. 8 ounces 30 minutes during warm-up times, up to 10 b. WHO, 75 mM sodium and 245 mOsm, 1,200 to 2,200 ounces every 20 minutes during exercise, and 8 ounc- mL es within 30 minutes after exercise c. WHO, 50 mM sodium and 275 mOsm, 200 mL/h d. Fluid avoidance before exercise to avoid nausea, and d. CDC; 75 mM sodium every six hours 500 mL each during and after exercise 22. Rehydration options available over the counter are 16. What are three primary indicators to patients to now available: increase fluid intake before dehydration begins to affect a. With lower calories. organ function? b. Without sodium. a. Thirst, low urine output, and dark urine color c. As multi-use dissolution packets. b. Light urine, low urine output, and hunger d. In only one flavor. c. Confusion, thirst, and hunger d. Dark urine, confusion, and thirst 23. Despite the potentially lower cost associated with homemade rehydration recipes, the following risks exist: 17. In addition to patients with GI illnesses, what groups a. Homemade preservatives taste worse than those in might consider ORS use? brand name products. a. Chemotherapy-treated patients experiencing nausea, b. Without a reliable resource, homemade products vomiting, and thrush could contain inappropriate or even unsafe amounts of b. Patients who train for high-intensity exercises who electrolytes. want to avoid sports drinks c. Homemade recipes actually cost more than premade c. Patients who are in the military and stationed overseas solutions. d. All of the above d. Two of the above

18. By the 1960s, when the first standardized ORS prod- 24. As awareness about oral rehydration solutions in the ucts were developed, clinicians were aware that: United States increases, the products are increasingly a. Glucose safely improves the flavor of the water, so marketed toward which of the following groups? people will drink more. a. Endurance athletes in elementary school b. Glucose plus water is less likely to induce vomiting b. Military personnel than water alone. c. Adults who drink alcohol c. Glucose added to water increases intestinal absorption d. Two of the above of water (eg, in cholera) better than water alone. e. All of the above d. All of the above www.ncpanet.org/ap 53