Choline Magnesium Trisalicylate

Nutrients Depleted:
Folic Acid, Iron, Potassium, Sodium, Vitamin C

U.S. Brand Names:Tricosal®, Trilisate®

Use: Management of osteoarthritis, rheumatoid arthritis, and other arthritis; salicylate salts may not inhibit platelet aggregation and, therefore, should not be substituted for aspirin in the prophylaxis of thrombosis

Pregnancy Risk Factor and Implications: C

Contraindications:Bleeding disorders; hypersensitivity to salicylates or other NSAIDs; tartrazine dye hypersensitivity, asthma

Dietary Considerations:
Alcohol: Combination causes GI irritation, possible bleeding; avoid or limit alcohol. Patients at increased risk include those prone to hypoprothrombinemia, vitamin K deficiency, thrombocytopenia, thrombotic thrombocytopenia purpura, severe hepatic impairment, and those receiving anticoagulants.
Food: May decrease the rate but not the extent of oral absorption. Drug may cause GI upset, bleeding, ulceration, perforation. Take with food or large volume of water or milk to minimize GI upset.
Folic acid: Hyperexcretion of folate; folic acid deficiency may result, leading to macrocytic anemia. Supplement with folic acid necessary.
Iron: With chronic use at doses of 3-4 g/day, iron deficiency anemia may result; supplement with iron if necessary.
Magnesium: Hypermagnesemia resulting from magnesium salicylate; avoid or use with caution in renal insufficiency.
Sodium: Hypernatremia resulting form buffered aspirin solutions or sodium salicylate containing high sodium content. Avoid or use with caution in CHF or any condition where hypernatremia would be detrimental.
Curry powder, paprika, licorice, Benedictine liqueur, prunes, raisins, tea and gherkins: Potential salicylate accumulation. These foods contain 6 mg salicylate/ 100g. An ordinary American diet contains 10-200 mg/day of salicylate. Foods containing salicylates may contribute to aspirin hypersensitivity. Patients at greatest risk of aspirin hypersensitivity include those with asthma, nasal polyposis, or chronic urticaria.

Warnings/Precautions:Use with caution in patients with impaired renal junction, erosive gastritis, or peptic ulcer; avoid use in patients with suspected varicella or influenza (salicylates have been associated with Reye's syndrome in children less than 16 years of age when used to treat symptoms of chickenpox or the flu). Tinnitus or impaired hearing may indicate toxicity; discontinue use 1 week prior to surgical procedures.
Elderly are a high-risk population for adverse effects from nonsteroidal anti-inflammatory agents. As much as 60% of elderly can develop peptic ulceration and /or hemorrhage asymptomatically. Use lowest effective dose for shortest period possible. Tinnitus may be a difficult and unreliable indication of toxicity due to age-related hearing loss or eighth cranial nerve damage. CNS adverse effects may be observed in the elderly at lower doses than younger adults.

Adverse Reactions:Greater than 10%experience:
Gastrointestinal: Nausea, heartburn, stomach pains, dyspepsia, epigastric discomfort

1% to 10% experience:
Central nervous system: Fatigue
Dermatologic: Rash
Gastrointestinal: Gastrointestinal ulceration
Hermatologic: Hemolytic anemia
Neuromuscular & skeletal: Weakness
Respiratory: Dyspnea
Miscellaneous: Anaphylactic shock

Less than 1% experience: Insomnia, nervousness, jitters, occult bleeding, prolongation of bleeding time, leukopenia, thrombocytopenia, iron deficiency anemia, hepatotoxicity, impaired renal function, bronchospasm

Overdose/Toxicology:Symptoms of overdose include tinnitus, vomiting, acute renal failure, hyperthermia, irritability, seizures, coma, and metabolic acidosis. For acute ingestion, determine serum salicylate levels 6 hours after ingestion. Nomograms, such as the "Done" nomogram, may be helpful for estimating the severity of aspirin poisoning and directing treatment using serum salicylate levels. Treatment is based upon symptomatology.

Choline Salicylate

Nutrients Depleted: Folic Acid, Iron, Potassium, Sodium, Vitamin C.

U.S. Brand Names: Arthropan® [OTC].

Canadian Brand Names: Teejel®

Use: Temporary relief of pain of rheumatoid arthritis, rheumatic fever, osteo-arthritis, and other conditions for which oral salicylates are recommended; usejul in patients in which there is difficulty in administering doses in a tablet or capsule dosage form, because of the liquid dosage form.

Pregnancy Risk Factor and Implications: C

Contraindications: Hypersensitivity to salicylates or any component or other nonacetylated salicylates.

Dietary Considerations:

Warnings/Precautions: Use with caution in patients with impaired renal function, erosive gastritis, or peptic ulcer; avoid use in patients with suspected varicella or influenza (salicylates have been associated with Reye's syndrome in children less than 16 years of age when used to treat symptoms of chickenpox or the flu).

Adverse Reactions: Greater than 10%: Gastrointestinal: Nausea, heartburn, stomach pains, dyspepsia, epigastric discomfort. 1% to 10%: Central nervous system: Fatigue Dermatologic: Rash Gastrointestinal: Gastrointestinal ulceration Hematologic: Hemolytic anemia Neuromuscular & skeletal: Weakness Respiratory: Dyspnea Miscellaneous: Anaphylactic shock Less than 1%: Insomnia, nervousness, jitters, occult bleeding, prolongation of bleeding time, leukopenia, thromboctytopenia, iron deficiency anemia, hepatotoxicity, impaired renal function, bronchospasm.

Overdose/Toxicology: Sumptoms of overdose include tinnitus, vomiting, acute renal failure, hyperthermia, irritability, seizures, coma, metabolic acidosis. For acute ingestions, determine serum salicylate levels 6 hours after ingestion; the "Done" nomogram may be helpful for estimating the severity of aspirin poisoning and directing treatment using serum salicylate levels. Treatment can also be based upon symptomatology.

Corticosteroids

Nutrients Depleted: Calcium, Folic Acid, Magnesium, Potassium, Selenium, Vitamin C, Vitamin D, Zinc.

U.S. Brand Names: Acticort 100®; Adlone® Injection; AeroBid®-M Oral Aerosol Inhaler; AeroBid® Oral Aerosol Inhaler; Aeroseb-Dex®; Aeroseb-HC®; A-hydroCort®; AK-Dex®; AK-Pred® Ophthalmic; Ala-Cort®; AlaScalp®; Alba-Dex®; Alphatrex®; Amcort®; A-methaPred® Injection; Anucort-HC® Suppository; Anuprep HC® Suppository; Anusol® HC-1 [OTC]; Anusol®; HC-2.5%[[OTC]; Anusol-HC®; Suppository; Aristocort®; Aristocort®A; Aristocort®Forte; Aristocort® Intralesional; Aristospan® Intra-Articular; Aristospan® Intralesional; Articulose-50® Injection; Atolone® Azmacort™; Baldex®; Betatrex®; Beta-Val®; CaldeCORT®; CaldeCORT® Anti-Itch Spray; Celestone®; Celestone® Soluspan®; Cel-U-Jec®; Cetacort®; Clocort® Maximum Strength; CortaGel® [OTC]; Cortaid® Maximum Strength [OTC]; Cortaid® With Aloe [OTC]; Cort-Dome®; Cortef®; Cortef® Feminine Itch; Cortenema®; Cortifoam®; Cortizone® -5 [OTC]; Cortizone® -10 [OTC]; Cortone® Acetate; Cutivate™; Dalalone L.A.®; Decaderm®; Decadron®; Decadron® -LA; Decadron® Turbinaire®; Decaject-L.A.®; Decaspray®; Dekasol-L.A.®; Delcort®; Delta-Cortef® Oral; Deltasone®; Delta-Tritex®; depMedalone® Injection; Depoject® Injection; Depo-Medrol® Injection; Depopred® Injection; Dermacort®; Dermarest Dricort®; DermiCort®; Dermolate® [OTC]; Dermtex® HC With Aloe; Dexair®; Dexasone L.A.®; Dexone®; Dexone L.A.®; Dezone® Deprolene®; Deprolene®AF; Diprosone®; D-Med® Injection; Duralone® Injection; Econopred® Ophthalmic; Econopred® Plus Ophthalmic; Eldecort®; Elocon® Topical; Flonase®; Flovent®; Flutex®; Gynecort® [OTC]; Hemril-HC® Uniserts®; Hexadrol®; Hi-Cor-1.0®; Hi-Cor 2.5®; Hydrocort®; Hydrocortone® Acetate; Hydrocortone® Phosphate; HydroSKIN®; Hydro-Tex® [OTC]; Hytone®; I-Methasone®; Inflamase® Forte Ophthalmic; Inflamase® Mild Ophthalmic; Kenacort®;Kenaject-40®; Kenalog®; Kenalog-10®; Kenalog-40®; Kenalog® H; Kenalog® in Orabase®; Kenonel®; Key-Pred® Injection; Key-Pred-SP® Injection; LactiCare-HC®; Lanacort® [OTC]; Liquid Pred®; Locoid®; Maxidex®; Maxivate®; Medralone® Injection; Medrol® Oral; Methylone®; Meticorten®; Metreton® Ophthalmic; M-Prednisol® Injection; Nasacort®; Nasacort®AQ; Nasalide® Nasal Aerosol; Nasarel™; Nutracort®; Ocu-Dex®; Orabase® HCA; Orasone®; Pandel®; Pediapred® Oral; Penecort®; Predair®; Predaject®; Predalone T.B.A.®; Pred Forte® Ophthalmic; Pred Mild® Ophthalmic; Prednicen-M®; Prednisol® TBA Injection; Prelone® Oral; Procort® [OTC]; Proctocort™; Psorion® Cream; Pulmicort Turbuhaler®; Rhinocort®; Scalpicin®; Solu-Cortef®; Solu-Medrol® Injection; Solurex L.A.®; S-T Cort®; Sterapred®; Synacort®; Tac™-40; Tegrin®-HC [OTC]; Teladar®; Triacet™; Triam-A®; Triam Forte®; Triderm®; Tri-Kort®; Trilog®; Trilone®; Tristoject®; U-Cort™; Valisone®; Westcort®.

Canadian Brand Names: Apo® -Prednisone; Betnesol® [Disodium Phosphate]; Bronalide®; Diprolene® Glycol [Dipropionate]; Elocom; Entocort®; Jaa-Prednisone®; Novo-Prednisolone; Novo-Prednisone; Occlucort®; Pulmicort®; Rhinalar®; Rhinaris®-F; Rhoprolene; Rhoprosone; Syn-Flunis-olide; Taro-Sone; Topilene; Topisone; Wimpred.

Use: Adrenocortical hormone replacement insufficiency; used in rheumatic, autoimmune, dermatologic, collagen-vascular and other inflammatory diseases. Used in the treatment of hypercalcemia, as immunosuppressive agents including use in organ transplantation. Management of respiratorydiseases including asthma, neoplastic diseases, and allergic disorders. Selected agents have been used in postherpetic neuralgia, meningitis, alcoholic hepatitis, and adult respiratory distress syndrome.

Pregnancy Risk Factor and Implications: B; Some corticosteroids are known to enter breast milk/use caution.

Contraindications: Hypersensitivity to individual corticosteroid agents or formulation, fungal infections, serious infections (Note: There are specific exceptions to this general contraindication such as bacterial meningitis in selected patients).

Dietary Considerations:

Warnings/Precautions: Withdrawal of therapy must be done gradually, use may retard bone growth, use with caution in patients with hypothyroidism, cirrhosis, hypertension, congestive heart failure, diabetes mellitus, ulcerative colitis, thromboembolic disorders, and patients at risk for peptic ulcer disease. Use the lowest possible dose for the shortest possible period of time. Adverse effects may be particularly common in the elderly.

Adverse Reactions: Signs and symptoms of systemic hypercorticism and suppression of the adrenal-hypothalamic-pituitary axis may occur when used for prolonged periods. Cushingoid appearance, muscle weakness, and osteoporosis may result. Individual corticosteroids may vary in their potential to cause specific adverse effects. The listing below provides only a general indication of the spectrum and frequency of adverse reactions to corticosteroids. Greater than 10%: Central nervous system: Insomnia, nervousness Gastrointestinal: Increased appetite, indigestion. 1% to 10%: Dermatologic: Hirsutism Endocrine & metabolic: Diabetes mellitus Ocular: Cataracts, glaucoma Neuromuscular & skeletal: Arthralgia Respiratory: Epistaxis Less than 1%: Edema, hypertension, vertigo, seizures, psychoses, pseudotumor cerebri, headache, mood swings, delirium, hallucination, euphoria, acne, skin atrophy, bruising, hyperpigmentation, Cushing's syndrone, pituitary-adrenal axis suppression, growth suppression, glucose intolerance, hypokalemia, alkalosis, amenorrhea, sodium and water retention, hyperglycemia, peptic ulcer, nausea, vomiting, abdominal distention, ulcerative esophagitis, pancreatitis, muscle weakness, osteoporosis, fractures, muscle wasting, hypersensitivity reactions.

Overdose/Toxicology: Symptoms of intoxication include cardiac disturbances, CNS toxicity, bronchospasm, hypoglycemia, and hyperkalemia. The most commn cardiac symptoms include hypotension and bradycardia. Atrioventricular block, intraventricular conduction disturbances, cardiogenic shock, and asystole may occur with severe overdose, especially with membrane-depressant drugs (eg, propranolol). CNS effects include convulsions and coma. Respiratory arrest (commonly seen with propranolol and other membrane-depressant and lipid-soluble drugs). Treat symptomatically. Cardiac and hemodynamic monitoring may be necessary.

Methotrexate

Nutrients Depleted: Calcium, Folic Acid, Magnesium, Potassium, Selenium, Vitamin C.

U.S. Brand Names: Folex® PFS; Rheumatrex®

Pharmacologic Class: Antineoplastic Agent, Antimetabolite

Use: Treatment of trophoblastic neoplasms; leukemias; psoriasis; rheumatoid arthritis; breat, head and neck, and lung carcinomas (cancers); osteosarcoma; sarcomas; carcinoma of gastric, esophagus, testes; lymphomas

Pregnancy Risk Factor and Implications: D (high risk); Enter breast milk/contraindicated.

Warnings/Precautions: The U.S. Food and Drug Administration (FDA) currently recommends that procedures for proper handling and disposal of antineoplastic agents (like Methotrexate) be considered.
 
May cause photosensitivity type reaction. Reduce dosage in patients with renal or hepatic impairment; drain ascites and pleural effusions prior to treatment; use with caution in patients with peptic ulcer disease, ulcerative colitis, pre-existing bone marrow suppression. Monitor closely for pulmonary (lung) disease; use with caution in the elderly.
 
Because of the possibility of severe toxic reactions, fully inform patient of the risks involved. Do not use in women of childbearing age unless benefit outweights risks; may cause hepatotoxicity, fibrosis, and cirrhosis, along with marked bone marrow depression. Death from intestinal perforation may occur.
 
Toxicity to methotrexate or any immunosuppressive is increased in elderly; must monitor carefully. For rheumatoid arthritis and psoriasis, immunosuppressive therapy should only be used when disease is active and less toxic, traditional therapy is ineffective. Recommended doses should be reduced when initiating therapy in elderly due to possible decreased metabolism, reduced renal function, and presence of interacting diseases and drugs.
 
Mehtotrexate penetrates slowly into 3rd space fluids, such as the pleural effusions or ascites, and exists slowly from these compartments (slower than from plasma).

Adverse Reactions:
 
Greater than 10% Occurrance of any one or more of the following:
  Cardiovascular: Vasculitis
 
  Central nervous system (with I.T. administration only):
     Arachnoiditis: Acute reaction manifested as severe headache, nuchal rigidity, vomiting, and fever; may be alleviated by reducing the dose.
     Subacute toxicity: 10% of patients treated with 12-15 mg/m² of I.T. MTX may develop this in the second or third week of therapy; consists of motor paralysis of extremities, cranial nerve palsy, seizures, or coma. This has also been seen in pediatric cases receiving very high dose I.V. MTX (when enough MTX can get across into the CSF).
     Demyelinating encephalopathy: Seen months or years after receiving MTX; usually in association with cranial irradiation or other systemic chemotherapy
 
  Dermatologic: Reddening of skin
 
  Endocrine & metabolic: Hyperuricemia, defective oogenesis or spermatogenesis
 
  Gastrointestinal: Ulcerative stomatitis, glossitis, gingivitis, nausea, vomiting, diarrhea, anorexia, intestinal perforation, mucositis (dose dependent; appears in 3-7 days after therapy, resolving within 2 weeks)
 
  Hematologic: Leukopenia, thrombocytopenia
 
  Renal: Renal failure, azotemia, nephropathy
 
  Respiratory: Pharyngitis
 
1% to 10% Occurrance of any one or more of the following:
  Cardiovascular: Vasculitis
 
  Central nervous system: Dizziness, malaise, encephalopathy, seizures, fever, chills.   Dermatologic: Alopecia (hair loss), rash, photosensitivity, depigmentation or hyperpitmentation of skin.
 
  Endocrine & metabolic: Diabetes
 
  Hepatic: Cirrhosis and portal fibrosis have been associated with chronic MTX therapy; acute elevation of liver enzymes are common after high dose MTX, and usually resolve within 10 days
 
  Hematologic: Hemorrhage
 
  Renal: Renal dysfunction: Manifested by an abrupt rise in serum creatinine and BUN and a fall in urine output; more common with high-dose MTX, and may be due to precipitation of the drug. Prevention is best treatment by aggressively hydrate with 3 L/m²/day starting 12 hours before therapy and continue for 24-36 hours; alkalinize the urine by adding 50 mEq of bicarbonate to each liter of fluid; keep urine flow over 100 mL/hour and urine pH>7.
 
  Respiratory: Pneumonitis associated with fever, cough, and interstitial pulmonary infiltrates; treatment is to withhold MTX during the acute reaciton.
 
  Neuromuscular & skeletal: Arthralgia
 
  Ocular: Blurred vision
 
  Other Details: Anaphylaxis, decreased resistance to infection
 

Overdose/Toxicology: Symptoms of overdose include any of the above adverse reactions.