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(message from) Drug Free Kids Canada

Considering the recent announcement by the federal government to legalize and regulate the sale of cannabis for recreational use, DFK Canada is taking the lead in educating the public about this substance and the risks for teens of early consumption.

News release

The booklet — Cannabis Talk Kit – Know how to Talk With Your Teen — was developed by DFK with the support of the Canadian Centre on Substance Use and Addiction (CCSA) and Health Canada (Talking about drugs).

Parent/physician resources:

Brochure (Download the pdf)

TV messages (YouTube): English and French

Website: https://www.drugfreekidscanada.org/  

Weight Loss

Obesity (BMI > 30 kg/m2) is prevalent in one-in-four adult Canadians and one-in-10 children.

Excessive body weight contributes to hypertension, type 2 diabetes, cardiovascular disease, dyslipidemia, arthritis, cancer, sleep apnoea, chronic pain, depression, and dementia.

The Framingham Study estimated that overweight and obesity account for ~26% of cases of hypertension in men and ~28% in women. A 2009 systematic review found that even for patients with BMI of <35 kg/m2, a weight loss of only 3 kg was associated overall with reduced blood pressure

Although higher BMIs and wider waist circumferences (more than 94 cm, or 37 inches, in men and more than 80 cm, or 31.5 inches, in women) predict obesity risk, the Edmonton Obesity Staging System (EOSS) is a more accurate predictor of long-term mortality.

Obese children are likely to become obese adults and genetics account for over 75% of BMI.

BMI tends to increase during most of adult life, peaking at age 60, as resting metabolic rate declines by approximately 150 kcal/day per decade. The primary focus of obesity management is to prevent further weight gain.

Most weight loss programs fail because the body takes corrective steps to counteract weight loss once it has become accustomed to a certain weight. The body tries to defend its highest weight. For every 10 pounds of weight lost, the resting metabolic rate drops by 3%. During prolonged periods of fasting, the metabolic rate also slows dramatically.

Diet and Exercise

what you should know before you start a weight loss plan

The recommended rate of weight loss is 1-2 lbs per week and the initial goal is to lose 5-10% of body weight. This can be achieved by consuming 500-1,000 fewer kcal per day (myFitnessPal). Reducing calories will lead to similar weight loss at 2 years irrespective of the specific diet chosen. The general principles involve increasing  intake of vegetables, fruits, high-fiber and whole-grain foods while restricting dietary sugar and sugar-sweetened beverages.

Medications

Prescription treatment for obesity in Canada includes 3 drugs, liraglutide (0.6 mg to 3mg/day injection), orlistat (120 mg three times daily with meals), and naltrexone HCL/bupropion HCL (8 mg/90 mg titrated up to two tablets twice daily). They are approved for use in patients with an initial BMI >27 kg/m2  in the presence of weight-related comorbidity, and who have failed a previous weight management intervention or who have a BMI of 30 kg/m2 or more.

In a 56-week study using liraglutide, 33.1% of patients had lost more than 10% of their body weight and 63.2% had lost at least 5% of their body weight. During a 4-year study using orlistat, 73% of patients lost ≥ 5% and 41% of patients lost ≥ 10% of their body weight after 1 year. After 4 years, 44.8% and 21% of the patients treated with orlistat lost ≥ 5 and ≥ 10% of body weight respectively.

Both medications cause gastrointestinal side-effects.

In patients on naltrexone HCL/bupropion HCL for up to 52 weeks, the average weight loss from baseline across four studies was approximately 11–22 lbs (5–9 kg). Clinical trials evaluating naltrexone HCL/bupropion HCL report 4 times more weight loss than placebo and a mean loss of 5.4% in body weight over 56 weeks.

Bariatric surgery is considered with a BMI ≥ 40 or ≥ 35 kg/m2 in the presence of comorbid conditions. There are various types of surgeries: Roux-en-Y gastric bypass, biliopancreatic diversion, gastric banding or vertical sleeve gastrectomy may be performed.

Important components of weight management include mental health, sleep apnoea treatment, and pain control to encourage physical activity.

Both diet and physical activity are important for long-term weight management.

Do you have Binge Eating Disorder (BED)?

You can take a screening test here: Binge Eating Scale

  • Are there times when you feel that your eating is out of control?
  • Do you have any concerns about your eating behaviour?
  • Do you ever eat in secret because you are embarrassed by how much you are eating?
  • Do you eat sometimes when you are not hungry?

BED is defined as recurrent episodes of binge eating, on average, at least once per week for three months with a sense of lack of control and feelings of distress but there are no inappropriate compensatory behaviours (these are found in bulimia nervosa- Eating Disorder Diagnostic Scale).

Not all emotional eating is abnormal (sugar stimulates the limbic system in the same manner in which cocaine does). About 2.8% of the general population suffers from BED, women are more likely to be affected than men, and there are often coexisting mental health problems.

The treatment of BED starts with behavioural and psychotherapy (Treatment for Binge Eating Disorder)

Lisdexamfetamine dimesylate is the only approved prescription treatment for moderate to severe (3 or more episodes per week) binge eating disorder in Canada. It is started at 30mg per day and increased by 20mg per week to the target of 50-70mg. It is not a good choice for patients with cardiovascular disease (it is a stimulant that will increase blood pressure and heart rate), glaucoma or on antidepressants. Other drugs are used off-label (antidepressants; anticonvulsants; substance abuse treatments i.e., acamprosate, baclofen, naltrexone; atomoxetine; liraglutide; orlistat).

Should you stop your heartburn medication?

Proton pump inhibitors (PPIs) are medications used to control frequent heartburn, gastroesophageal reflux disease, and inflammation of the food pipe (esophagitis). The common PPIs are omeprazole (Losec ® ), esomeprazole (Nexium® ), lansoprazole (Prevacid®), dexlansoprazole (Dexilant® ), pantoprazole (Tecta® , Pantoloc ® ), and rabeprazole (Pariet® ).

Gastroesophageal reflux disease needs 4 to 8 weeks of treatment and peptic ulcers 2 to 12 weeks.

Adults 18 years of age and older who have continuously used a PPI for longer than 4 weeks should ask their doctor about deprescribing.

Deprescribing involves decreasing the dose, stopping the medication, or using it “on-demand” (as needed only).

It is best to discuss this decision with a doctor

Certain conditions such as Barrett’s esophagus, severe esophagitis, or bleeding gastrointestinal ulcers may require ongoing use. Patients who use regular daily doses of nonsteroidal anti-inflammatory drugs (NSAIDs) may also need to use a daily PPI to protect the gut.

Reflux symptoms are sometimes caused by other medications (e.g., acarbose, anticholinergics, beta-agonists, benzodiazepines, caffeine, digoxin, calcium channel blockers, erythromycin, estrogen, alcohol, narcotics, nicotine, nitroglycerin, orlistat, progesterone, theophylline).

How to stop

Stopping your PPI suddenly may worsen acid reflux symptoms due to a “rebound hypersecretion” effect. The withdrawal effect lasts for 2-4 weeks and can be blunted by decreasing the PPI dose by 50% for a few weeks or increasing the interval between doses to every 2 or more days. Sometimes an alternative medication like ranitidine can be substituted in.

Why would you want to stop your PPI?

Although PPIs are generally very well-tolerated, they can lead to uncommon side-effects such as diarrhea, vitamin B12 deficiency, magnesium deficiency, gut infections (Clostridium difficile, Salmonella and Campylobacter), hip fractures, and pneumonia.

 

Link:

http://www.open-pharmacy-research.ca/wordpress/wp-content/uploads/ppi-deprescribing-algorithm-cc.pdf

Chronic idiopathic urticaria/chronic spontaneous urticaria

Acute urticaria (hives) is often caused by viruses or allergy. Chronic urticaria (hives) lasts longer than  6 weeks and is thought to be autoimmune. Urticaria is itchy, comes and goes, and can move around. The eruptions are spontaneous or inducible by exercise (exercise-induced anaphylaxis and cholinergic urticaria), water (aquagenic urticaria), coldness (cold urticaria), or sunlight (solar urticaria). One-third to two-thirds of cases are associated with angioedema (swelling beneath the skin). If a patient is on an ACEI drug, this must be stopped. Urticaria usually resolves in 24 hours and angioedema in 72 hours. Severity is measured by the weekly urticaria activity score (UAS7). If individual lesions last over 24 hours, a skin biopsy may be required.

The treatment algorithm starts with a second generation antihistamine like cetirizine (10-40mg/day), desloratadine (5-20mg/day), fexofenadine (120-480mg/day), or loratadine (10-40mg/day). These drugs can be increased up to four times the standard dose. Montelukast can be added and exacerbations may be treated with an oral steroid.

Omalizumab and cyclosporine are third-line therapies initiated at the specialist level.

Resources:

www.itchingforanswers.ca

www.skintolivein.com

www.optionsinciu.ca

CIU Tracker App on App store and Google play

Over-The-Counter

A recent survey among physicians and pharmacists have identified the top over-the-counter brands recommended by Canadian professionals.

Adult allergies: Reactine

Children’s allergies: Benadryl

Nausea: Gravol

Children’s painkiller: Tylenol

Painkilling cream: Voltaren

Scar/stretch mark therapy: Bio-Oil

Sunscreen: Ombrelle

Wart treatment: Compound W

Cold sore cream: Abreva

Vaginal lubrication: Replens

Antibiotic cream: Polysporin

Antibiotic eye and ear drops: Polysporin eye and ear drops

Dry eye drops: Systane

Vaginal yeast infection cream: Canestan

Vaginal yeast infection pill: CanesOral

Iron supplement: Feramax

Laxative: Lax-A-Day

Lice treatment: Nix

Natural cold remedy: Cold-FX

Pregnancy test kit: First Response

Blood Glucose Monitor: OneTouch

Blood Pressure Monitor: Omron

Hand Dermatitis (eczema)

Hand dermatitis (eczema) is associated with irritants or allergies and can be triggered or aggravated at work (occupational dermatitis). Many patients are employed as healthcare workers/nurses, hair stylists, restaurant servers/staff, bakers, or printers.

There are 3 types of hand dermatitis: irritant, allergic, and atopic.

Chronic hand dermatitis lasts at least three months or incurs two relapses in a calendar year. Alitretinoin, cyclosporine, high potency topical corticosteroids, and phototherapy are indicated in Canada for the treatment of chronic hand dermatitis. (Acitretin, azathioprine, methotrexate even soriatane are sometimes used.)

Itchiness is a symptom of both allergic and atopic hand dermatitis. Irritant hand dermatitis often has little or no itchiness.

Common irritants include friction, dryness, moisture, and chemicals (e.g., hand disinfectants, germicides, detergents, ink, dyes, solvents, etc.). When these offending exposures are in the working environment, symptoms develop gradually, show little improvement on weekends, but marked recovery with extended periods away from work.

Allergens like latex, animal fur/dander, perfumes, and food are also be implicated. This is often characterized by redness, blistering, and severe itchiness. Work exposure usually improves on weekends, symptoms disappear on vacation, but recur soon after returning to work. A patch test can confirm the diagnosis.

Atopic dermatitis is frequently unrelated to occupation and a family history of allergy is common. It can involve the flexor surfaces of the wrists, the nails, and the “snuff box”. Blisters are often seen and the skin can turn thick and leathery (lichenification).

The mainstay of hand dermatitis treatment is topical corticosteroids.

Moderate potency corticosteroids are sometimes used for 4-8 weeks (2 weeks if dorsal location) to manage mild-to-moderate chronic hand dermatitis. Severe chronic hand dermatitis uses a potent topical corticosteroid for 4 to 8 weeks (2 weeks if dorsal location) or super-potent topical corticosteroid for 2 weeks.

When moderate chronic hand dermatitis is not improved by prevention strategies, emollient therapy, and a high potency topical corticosteroid of 2-week duration, it is treated as severe and phototherapy/oral treatment is considered. An oral treatment is alitretinoin but pregnancy must be avoided (pregnancy prevention program).

Treatment should be combined with moisturizing therapy and hand protection (eg, gloves), which should continue after discontinuation of corticosteroids.

In hyperkeratotic dermatitis, salicylic acid 20% or urea 5–10% is sometimes prescribed to smooth the skin and help with treatment penetration.

Topical steroids— Potency

Low

  • Desonide 0.05%
  • Hydrocortisone 0.5%, 1%, 2.5%
  • Hydrocortisone acetate 0.5%, 1%, 2%

Medium

  • Betamethasone valerate 0.05%, 0.1%
  • Clobetasone butyrate 0.05%
  • Diflucortolone valerate 0.1%
  • Fluocinolone acetonide 0.01%, 0.025%
  • Hydrocortisone valerate 0.2%
  • Mometasone furoate 0.1%
  • Triamcinolone acetonide 0.025%, 0.1%, 0.5%
  • Prednicarbate 0.1%

High

  • Amcinonide 0.1%
  • Betamethasone dipropionate 0.05%
  • Fluocinonide 0.05%
  • Halcinonide 0.1%
  • Desoximetasone 0.05%, 0.25% •

Ultra-high

  • Beclomethasone dipropionate 0.05% in base containing propylene glycol
  • Clobetasol propionate 0.05%
  • Halobetasol propionate 0.05%

RESOURCES

Diabetes

Patient task list:

  • Have HbA1C tested every 3 months
  • Annual eye examination
  • Annual foot examination
  • Intermittent cholesterol levels, ECG, kidney function
  • DASH diet if no kidney disease
  • Quit smoking
  • Exercise at least 150 minutes per week (moderate-intensity exercise) and resistance training (three times per week)
  • Prioritize at least 7 hours of sleep per night

Intervention Targets

  • The traditional HbA1C target is <7%
  • An HbA1C target ≤6.5% will decrease the risk of eye disease (retinopathy), kidney disease (nephropathy), and nervous system disease (neuropathy).
  • The blood pressure target is <130/80 mmHg
  • LDL-Cholesterol target is <2 mmol/L
  • Patients with a BMI ≥25 should aim for reduction of body weight by 5 to 10%

Patient resources: http://www.diabetes.ca


Doctors secrets …

Pre-diabetes is associated with a 5-fold increased risk for future type 2 diabetes. Metformin reduces the risk of future diabetes in pre-diabetic patients by 25 to 30%

Step 1 Rx = start metformin (if GFR >45 and monitor B12 in chronic use), stop if GFR <30

If the A1C is >7.5%, the patient will likely need dual treatment. If HBA1C >9%, start dual treatment. If the A1C is >8% despite dual treatment, the patient likely needs basal insulin. Consider insulin when HBA1C >10% and symptomatic.

Add additional agent if not in target >3/12 e.g SU, TZD, (edema, HF, bone fracture, weight gain risks), DPP-4-i (avoid if Hx of pancreatitis), SGLT-2-i, thiazolidinedione, GLP-1-RA( avoid if FH of medullary thyroid carcinoma, MEN2, pancreatitis, gastroparesis), basal insulin. CVS outcomes reduced with Liraglutide (GLP-1), empagliflozin (SGLT-2). Watch for euglycemic DKA in SGLT-2 inhibitors. Watch for CCF with saxagliptin, alogliptin (DPP-4); (if pre-existing CCF or CKD). Avoid dpp4-i + GLP-1-RA.

 

– Insulin

Start 10U (or 0.1 to 0.2U/kg) of basal and increase dose by 10-15% (or 2-4U) once or twice weekly until FBG in target. NPH is cheapest. If HBA1C <8% or hypoglycaemia- decrease dose by 4U (or 10-20%). If insulin does >0.5U/kg and not at target, need to start adding basal

– Rapid insulin

Start 4U per meal (0.1U/kg, or 10% of basal dose)- consider decreasing basal dose by same amount of starting mealtime dose. Increase 1-2U (10-15%) once or twice weekly. Hypoglycemia- decrease 2-4U (10-20%)

– Premixed insulin

divide basal dose into 2/3am and 1/3 pm. Increase 1-2U (10-15%) once or twice weekly to target. Hypoglycemia- decrease 2-4U or 10-20%. Can increase to TID dosing if failure to control.