You may have read that reducing salt intake from food is important for preventing high blood pressure, and kidney disease, but do you know why it is particularly important for people with heart failure?

Heart Failure is a medical condition in which the heart cannot fill with blood or pump blood effectively. When this happens, this creates a backup of blood that is not circulating through the body as it should which is called congestion. This backup can create a pooling of fluid in the legs and lungs, producing the symptoms of heart failure that are most bothersome including:

• Edema – most often swelling from fluid in the legs and ankles
• Shortness of breath – excess fluid in the lungs and poor oxygen exchange

Salt – sodium chloride – is made up of two elements that our bodies require to be kept within normal range. These electrolytes help regulate our water balance, namely our thirst and urination. Some salt is necessary, but most of us are getting too much. The American Heart Association recommends limiting daily sodium intake to 1,500 mg for patients with heart disease. Unfortunately, the average American diet contains about 3,400 mg – more than double the recommendation! To put this in perspective, 1 teaspoon of salt has 2,300 mg of sodium which is an acceptable daily amount for people without heart disease, but patients with heart disease should limit their daily intake to 2/3 of a teaspoon of salt which has 1,500 mg of sodium.

While some sources of salt such as fast food and french fries are more obvious, most of this excess salt actually comes hidden in processed and packaged foods. You might be surprised to learn how much salt is hidden in sweets like cookies or foods that are marketed as healthy like salted nuts. This is why it is important for patients with heart failure to read food labels and be aware of their salt intake.

Common suggestions for reducing salt intake:

• Remove the saltshaker from the kitchen table
• Exchange canned vegetables for fresh or frozen vegetables
• Reduce the times per week that you eat out at restaurants by cooking more at home
• Add flavor to food with spices and herbs or lemon and vinegar

If you are used to a high salt diet try to work in changes gradually. Trying to make all the changes listed above all at once and quit salt cold-turkey can result in cravings which make sticking to your new habits even harder!

Excess sodium intake is especially concerning in patients with heart failure because:

• Heart failure makes you particularly sensitive to fluid backup and retention because the heart is pumping less efficiently
• Certain medications for heart failure work in the kidneys where salt and water are regulated
• Similarly, some salt substitutes contain potassium which is known to interact with certain medications for heart failure. Some potassium can be beneficial for high blood pressure, but potassium can also cause heart problems when used in excess. Do not use salt substitutes before discussing it with your provider.

Self-Monitoring in Heart Failure and When to Call

If you have heart failure, fluid retention can be gradual over time or rapid after a salty meal so it is important to monitor yourself at home. You can self-assess for fluid retention by noting when you feel bloated or by looking and feeling for swelling in your legs and ankles. This can be somewhat subjective, so a more objective measure is your weight. For patients with heart failure it is recommended that you take a daily weight and monitor the trend to assess for fluid retention. Be as consistent in your measurements as possible! Take your weight at the same time each day, ideally naked or with the same clothes on, and keep a record.

If you record a weight increase of more than 3 pounds in a day or 5 pounds in a week it’s time to call your provider. They may want to see you in an appointment for a more throughout assessment or give you instructions on the phone of how to take your medicines. Either way it is best to be proactive and inform your provider of early signs of fluid retention so that the issue does not continue to get worse. Excess fluid is a common reason patients with heart failure are admitted to the hospital. The key is to be proactive and get instructions from you provider before that point.

When it comes to managing salt intake, you we more likely to stick with a change if it is viewed as a long-term lifestyle change rather than a restrictive diet. It takes time to for our tongue to become accustomed to less salt just like it takes time to build new healthy habits.

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What causes snoring?

The auditory phenomena of snoring occurs when tissues in the nose or soft palate in the mouth vibrate against the airway when inhaling or exhaling.

Habitual snoring – snoring every night – is estimated to effect 45% of men and 30% of women. Thus it can be a significant problem, impacting other’s sleep quality in addition to your own.

What health conditions are associated with snoring?

• Obesity
• Alcohol and tobacco use
• Seasonal allergies

Common Solutions for Snoring

• Maintain a healthy weight
• Try sleeping on your side instead of on your back
• If congestion is the problem, try a saline nasal spray before bed
  • You can also ask your pharmacist for a recommendation for allergy medicines or decongestants
• External nasal dilators, such as Breathe Right strips
  • Might help with nose snoring but not open-mouth snoring

Why do healthcare providers become concerned?

When snoring is particularly problematic and persistent, your health care provider may want to conduct further tests to rule-in or rule-out sleep apnea. Apnea is the medical term for a temporary pause in breathing. Your provider might order a sleep study for which you will need to stay overnight. While you sleep, polysomnography techniques will be used to record brain waves, the oxygen level in your blood, your heart rate and breaths per minute, as well as eye and leg movements. All this information together can help assess the quality of your sleep and determine the severity of your sleeping problem.

Obstructive Sleep Apnea (OSA)

OSA is a condition of transient airway blockage while asleep during which the airway is momentarily closed and breathing is cut off. Most patients with OSA will struggle with symptoms of loud snoring, sputtering, gasping, or choking while asleep. Sometimes these will cause someone with OSA to wake up multiple times a night, resulting in poor quality sleep and daytime sleepiness. Morning headaches can also be a painful and problematic symptom.

How can sleep apnea impact other parts of my overall health?

We now know that sleep apnea can result in low oxygen levels and impact other health conditions. These include high blood pressure, atherosclerosis, and diabetes.

• Hypertension – untreated OSA is associated with worsening blood pressure control. Nighttime is usually a period when the body is at rest and blood pressure is lower. Poor breathing can disrupt rest and the natural nighttime decrease in blood pressure, worsening hypertension.
• Atherosclerosis – this refers to the build up of fatty plaques on the walls of blood vessels and arteries. When left untreated, a lifetime of snoring vibrations may thicken and stiffen arteries, especially the carotid arteries on each side of the neck.
• Diabetes – poor regulation of blood sugars is associated with OSA, independent of other factors like weight. Insufficient oxygen leads to inflammation, increasing the risk for metabolic syndrome.

All of this together means that if left untreated, sleep apnea can increase the risk of heart attack and stroke. As you can see, a number of the problems above go hand-in-hand, so your provider may employ a wholistic strategy to reduce the risk of heart attack and stroke from all angles.

Finally, what are CPAP machines?

CPAP stands for continuous positive airway pressure.  It consists of a machine with a mask that is used to keep the airway open and prevent pauses in breathing. A CPAP machine is the cornerstone of treatment for adults with OSA. In large studies, those with sleep apnea find that nightly CPAP reduces the number of apneic events or breathing pauses, improves elevated blood pressure, and increases quality of life. Unfortunately, there is not conclusive evidence that using a CPAP machine reduces the risk of heart attack or stroke; this is why a comprehensive strategy rather than a single intervention is needed to reduce cardiovascular risk.

Do you know someone who snores? Do you have sleep apnea? If so, what are you doing to improve your quality of life and reduce your risk of related health problems?

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A prescription medication (Rx) is converted to over-the-counter (OTC) when a common condition being treated is easily identified by patients and the medicine can be safely used by patients without needing to be monitored by a healthcare provider.

Product Characteristic Requirements

• The consumers can self-diagnose, self-treat, and self-manage the condition
• No health practitioner is needed for the safe and effective use of product
• Product has low potential for misuse and abuse
• Safety margin of benefit outweighs the risks

What steps are required by the FDA?

1. Rx safety and efficacy data can be utilized for FDA review before conversion to OTC
2. Rx prescription label must be translated to consumer-friendly terms
3. Consumer studies must be evaluated to determine usability
   • Label Comprehension Study: can the public understanding the key label messages?
   • Self-Selection Study: can the public select the right product?
   • Actual Use Study: can the public follow the labeled directions?
   • Human Factor Study: can the public use the product correctly?
4. Submit a New Drug Application (NDA)

Who Can Request an OTC Switch?

• Holder of an approved prescription NDA
• Citizen petition

Both scenarios still require full scientific data to support the switch.

Recent examples of products now available over-the-counter without a prescription: 

Pataday Once Daily Relief (olopatadine HCl 0.7%)

• Indication: allergic conjunctivitis
  • Dose: 1 drop into each eye daily
• Administration: do not insert contact lenses within 10 minutes of application and wait 5 minutes before using other eye drops
• Adverse Effects: headache, eye irritation
• MOA: Histamine H1-antagonist
• Compelling reasons to support OTC Conversion:
  • Previously few options for OTC topical antihistamine for the eyes
  • Less systemic side effects such as drowsiness commonly resulting from antihistamines taken by mouth 

Voltaren Gel (diclofenac sodium 1%)

• Indication: arthritis pain
  • Lower extremities: 4 g to affected area up to 4 times a day as needed
  • Upper extremities: 2 g to affected area up to 4 times a day as needed
• Administration: Apply to clean, dry, intact skin. Do not to open wounds, eyes, or mucous membranes. Do not cover with occlusive dressing or apply heat, sunscreens, cosmetics, lotions, moisturizers, insect repellent, or other topicals. Avoid showering at least 1 hour after application and avoid sunlight exposure to affected area. Make sure to apply to entire joint and affected area.
  • Not to be used for more than 21 days or more than 2 body parts at the same time
• Adverse Effects: scaling or dryness where it was applied
• MOA: reversibly inhibits COX-1 and COX-2 enzymes, decreasing inflammation
• Compelling reasons to support OTC Conversion:
  • Previously no OTC topical anti-inflammatory medicine for pain
  • Provides an option for a localized condition such as knee or shoulder pain
  • Safer compared to OTC anti-inflammatory drugs taken by mouth, such as ibuprofen and naproxen, because it avoids side effects such as increased risk of bleeding and stomach ulcers

Prepared By: Allen Su, PharmD Candidate 2021

References: 

Prescription to Over-the-Counter (OTC) Switch List. US Food and Drug Administration.
https://www.fda.gov/about-fda/center-drug-evaluation-and-research-cder/prescription-over-counter-otc-switch-list

Regulatory Approaches for Prescription to OTC Switch. Theresa M. Michele, M.D. US Food and Drug Administration.
https://www.fda.gov/files/drugs/published/Presentation–Regulatory-Approaches-for-Prescription-to-OTC-Switch.pdf

Pataday Drug Labeling & Voltaren Drug Labeling

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Small companion animals, such as cats and dogs, can become infected with external and internal parasites.

External parasites live on the outside of your pet’s body, biting your pet to obtain nutrients from your pet’s blood. Examples of external parasites include:

• Fleas
• Ticks
• Lice
• Mites

Internal parasites are typically worms that live inside your pet’s body. These parasites either feed off your pet’s partially digested food or your pet’s blood. Examples of internal parasites:

• Heartworm
• Tapeworm
• Hookworm
• Roundworm
• Whipworm

HOW DOES MY PET GET PARASITES & HOW DO I KNOW IF MY PET HAS PARASITES?

External parasites are acquired from the environment or contact with infected animals. While you may be able to visually inspect an animal for external parasites, the first sign is often itching and scratching. Fur loss, red bumps, and flea droppings are also common signs of infestation.

Internal parasites are usually acquired from inadvertent swallowing of parasite eggs. Contaminated food, water, soil, or feces are common infection sources. Tapeworms may also be transmitted through the bite of infected fleas. Of note, puppies may acquire parasitic eggs in utero and while nursing. Kittens are also vulnerable to acquiring parasitic eggs from nursing. Many pets show no signs of internal parasite infection; the first sign is often the visualization of worms in the feces.

WHY DOES MY PET NEED PARASITE PREVENTION?

Veterinarians and veterinary societies recommend year-long parasite prevention against external and internal parasites, because infestations can pose serious harm to your pet’s health. In addition, the parasites that infect your pet are zoonic or are vectors for zoonic pathogens. This means that the parasites on or in your pet can infect humans and/or can transmit diseases to humans. (Example: A tick carrying Lyme disease may act as a vector, spreading the zoonic pathogen to humans and pets).

WHAT ARE MY PARASITE PREVENTION OPTIONS?

Most antiparasitic medications are prescriptions that a veterinarian must write for your pet. Your veterinarian will assess your pets individualized needs and will recommend product(s) that best prevent the most common parasites in your area.

Antiparasitic medications are dosed based on species (cat or dog) and your pet’s weight. Most products must be given once a month. There are topical formulations that can be placed on the skin of your pet’s back and oral formulations that are given by mouth. If you have a dog, there is also a once-a-year shot called ProHeart 12 and protects against heartworms. The table below outlines a few common products you might see.

WHAT ARE SOME ADDITIONAL RESOURCES?

The best resource is always your pet’s veterinarian. If you would like to do more research into parasites and parasitic infections in pets, the Companion Animal Parasite Council (CAPC) is a great place to start. CAPC is an independent, non-profit organization of veterinarians that work to investigate and compile evidence-based best practice guidelines to help drive awareness for and prevention of parasitic infections in our pets and families.

Table 1: Select antiparasitic medications available for cats and dogs.

Prepared By: Jennifer Bennett, PharmD Candidate 2021

REFERENCES:

1. Companion Animal Parasite Council. Published 2021. Accessed May 20, 2021. https://capcvet.org/
2. Pets and Parasites. CAPC. Published 2021. Accessed May 20, 2021. https://www.petsandparasites.org/resources/pets-parasites-and-people
3. External Parasites. American Veterinary Medicine Association. Published 2021. Accessed May 20, 2021. https://www.avma.org/resources/pet-owners/petcare/external-parasites
4. Ward E, Barnette C. Internal Parasites in Dogs. VCA Animal Hospitals. Published 2021. Accessed May 20, 2021. https://vcahospitals.com/know-your-pet/internal-parasites-in-dogs

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