Self-Care for Central Nervous System Function

Case 1: Antiepileptic Medications and Dental Health

Q: A 24-year-old man presents to the pharmacy with concerns about his dental health. He has recently starting taking phenytoin for a seizure disorder, and his neurologist counseled him about this medication’s numerous adverse effects (AEs). The patient is most concerned about the possibility of developing dental issues. He reports no known drug allergies and a medical history significant only for generalized seizures and seasonal allergies. In addition to phenytoin, the patient takes ibuprofen and loratadine, as needed. How should this patient be counseled regarding the dental AEs of antiepileptic medications, particularly phenytoin?

A: Gingival overgrowth, or gingival hyperplasia, is an AE associated with the use of several medication classes, including antiepileptic drugs such as phenytoin.¹ Although the pathophysiology of this disorder is not completely understood, it is thought to be multifactorial, likely involving epithelial and submucosal tissue changes. Poor dental hygiene, gingival inflammation, and accumulation of dental plaque are risk factors for disease.¹ General counseling points for the dental health of patients on antiepileptic drugs or other medications that may predispose them to gingival enlargement (eg, cyclosporine, calcium channel blockers) should focus on the maintenance of routine dental hygiene and plaque control with daily brushing, flossing, and periodic professional cleaning.^1,2 Encourage the patient to follow up with a dental health professional if he develops any new dental complaints or changes in his dental health.

Case 2: Natural Remedies for Anxiety Relief

Q: A 35-year-old woman presents to the pharmacy seeking advice on stress relief. She has recently started a new job and reports suffering from anxiety related to it, which makes it difficult for her to concentrate at work and to fall asleep each evening. Otherwise, she reports feeling well and does not have any medical problems or allergies to medications. She is interested in a holistic approach to managing her anxiety and would like a recommendation for herbal medications that may help alleviate her symptoms. What suggestions for natural anxiety relief and education on self-care for anxiety can the pharmacist provide?

A: According to the National Institute of Mental Health, anxiety disorders are the most common type of mental illness in the United States, affecting an estimated 28.8% of adults at some point in their lifetime.³ Additionally, women are 60% more likely than men to suffer from these types of disorders, which can include posttraumatic stress disorder, obsessive-compulsive disorder, phobias, and generalized anxiety.³ Although medical evaluation and prescription-only pharmacologic interventions are usually considered in treating anxiety disorders that are interrupting an individual’s daily life, self-care and lifestyle interventions, such as avoidance of alcohol, participation in routine physical exercise, proper nutrition, and smoking cessation, if applicable, can play an important role in self-management of anxiety symptoms.⁴ Cognitive behavioral therapy and counseling are other nondrug interventions that may improve this patient’s ability to cope and to manage her on-the-job stresses.

Regarding dietary and herbal supplements for anxiety, although kava has long been recognized for its effects in promoting relaxation, the FDA has issued warnings regarding the potential for supplements containing this ingredient to increase the risk of severe liver injury.⁵ At this time, recommending lifestyle interventions and relaxation therapy may help this patient cope with her anxiety. If her symptoms persist or become more frequent or debilitating, she should be instructed to consult her primary care provider.

Case 3: Treatment-Resistant Depression

Q: A 43-year-old woman approaches the pharmacist with a request for information regarding herbal treatments for depression. On questioning, she reports suffering from severe depression for several years and has been feeling particularly down over the past few months, which she attributes to the recent loss of a loved one. She is currently seeing a psychiatrist but does not feel that her prescribed medications are helping. A review of her medication profile reveals she has taken sertraline, escitalopram, quetiapine, aripiprazole, and valproic acid at different times over the past year. She has also periodically taken 2 or 3 of these medications in combination with each other, but they have not provided relief. Are herbal supplements indicated for alleviating this woman’s symptoms of depression? What education should she receive?

A: Patients with symptoms of major depressive disorder that are refractory to treatment with 2 or more antidepressant medications may be suffering from treatment-resistant depression.⁶ It would be reasonable to ask this patient about her participation in psychotherapy or counseling, in addition to obtaining a thorough history about the timeline in which she used the medications in her profile. Encourage her to follow up with her psychiatrist or mental health provider and to explain her persisting symptoms, if she has not done this already. In lieu of herbal or natural remedies, ascertain her adherence to prescribed therapies and ensure that she has consistently taken her medications for an adequate duration to realize their effectiveness.

Case 4: Hyperglycemia and Schizophrenia

Q: A 70-year-old woman comes to the pharmacy counter to speak to the pharmacist about OTC treatment options for preventing diabetes. The woman is a caregiver to her 38-year-old son, who was recently given a diagnosis of prediabetes. She would like to know if there are supplement or dietary modification recommendations she can give him to prevent diabetes. Her son has a history of schizophrenia, hypertension, and high cholesterol. He currently takes olanzapine, hydrochlorothiazide, lisinopril, rosuvastatin, and valproic acid. She would like to pick up a supplement or diabetic nutrition bar, but she is not sure which would be best. What information can you give this woman regarding her son’s condition?

A: Potential consequences of using atypical antipsychotic medications include metabolic AEs, such as insulin resistance, hyperglycemia, diabetes mellitus, weight gain, and dyslipidemia; however, the risk of these abnormalities may vary among agents within this class. Although the pathophysiology of antipsychotic-induced diabetes has not been completely elucidated, it is thought that weight gain, coupled with alteration of pancreatic beta-cell function, is a likely contributory factor. Counsel this woman to discuss her son’s prediabetes with his mental health provider. Atypical agents within the class of medications he takes that are less likely to cause weight gain or hyperglycemia could be considered or prescribed. Reasonable lifestyle modifications to discuss include physical exercise (at least 30 minutes per day, if medically cleared) and a diet of lean meats, low-fat dairy, healthy fats, and whole fruits and vegetables, along with reduced carbohydrates. Additionally, remind her that metformin, a medication typically used to treat diabetes, may help prevent metabolic changes associated with her son’s medications and slow the develop of diabetes.⁷

Dr. Bridgeman is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. Dr. Mansukhani is a clinical assistant professor at the Ernest Mario School of Pharmacy, Rutgers University, and a transitions-of-care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey.

References:

• Mejia LM. Drug-induced gingival hyperplasia. Medscape website. emedicine.medscape.com/article/1076264-overview?pa=EsLGSG3VSteoBpFBHdToxkt0VysHCpoJmQd7Zzw%2FVhsddmUvV64Rt5uX4FSgUja2kmqv2rQ%2BqGQ912rFh5TcMYdHiuSJDifRp%2BEZ0GL%2FEKg%3D. Updated December 9, 2016. Accessed February 16, 2017.
• Gum disease. MouthHealthy website of the American Dental Association. mouthhealthy.org/en/az-topics/g/gum-disease. Accessed February 16, 2017.
• Any anxiety disorder among adults. National Institute of Mental Health website. nimh.nih.gov/health/statistics/prevalence/any-anxiety-disorder-among-adults.shtml. Accessed February 17, 2017.
• Prevost RR. Pharmacy review: lifestyle approaches to anxiety and depression. Am J Lifestyle Med. 2007;1(3):185-187. doi: 10.1177/1559827607300012.
• Safety, kava (Piper methysticum). FDA website. www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm154577.htm. Updated August 20, 2013. Accessed February 15, 2017.
• Depression (major depressive disorder): treatment-resistant depression. Mayo Clinic website. mayoclinic.org/diseases-conditions/depression/in-depth/treatment-resistant-depression/art-20044324. Published July 24, 2014. Accessed February 18, 2017.
• Wu RR, Zhao JP, Guo XF, et al. Metformin addition attenuates olanzapine-induced weight gain in drug-naïve first-episode schizophrenia patients: a double-blind, placebo-controlled study. Am J Psychiatry. 2008;165(3):352-358. doi: 10.1176/appi.ajp.2007.07010079.