Pharm Ch 24 - Natural/Herbal Products and Dietary Supplements, CHAPTER 24 (Natural/Herbal Products and Dietary Supplements)

The ______ requires that the following phrase must be included on each natural product's label: "This product is not intended to diagnose, treat, cure or prevent any disease".

DSHEA

Herbal products are regulated by the _______________, which exempts vitamins, mineral and botanical products from meaningful FDA regulation.

Dietary Supplement Health and Educations Act (DSHEA)

A minor consequence of a lack of standardization is the variability of the quantity of the known or supposed active ingredients.

FALSE. A MAJOR consequence of a lack of standardization is the variability of the quantity of the known or supposed active ingredients.

T/F: Manufacturers are required to prove that their products are safe or effective.

FALSE. Manufacturers are NOT required to prove that their products are safe or effective.

T/F: Don't treat herbst products as drugs

FALSE. TREAT herbst products as drugs

Responsibility for proof of misleading labeling is in the hands of the _____

FDA

The ____ will allow a qualified health claim if there is scientific evidence to support it.

FDA

Oral ulcers, lip irritation, swelling, and gingival bleeding have been reported with use of _______

Feverfew.

______, ______, and ______ can increase the risk for bleeding when taken in conjunction with antiplatelet drugs or anticoagulants.

Garlic, ginkgo biloba, and feverfew

____________ standards were introduced by the FDA to ensure that dietary supplements are devoid of adulterants, contaminants and impurities and that package labels accurately.

Good manufacturing practice (GMP)

_____ products are marketed as dietary supplements in the US and are not required to comply with safety and efficacy regulation imposed on drugs products

Herbal

_________ contains ephedrine and can increase the heart rate when given with sympathomimetic drugs.

Ma huang

_______ cannot make claims of curing conditions, but they can make claims of improving structure or functions.

Manufacturers

_________ is a nonprescription product. Proposed mechanism of action is unclear, but it is thought to affect pulpal nerves in some way to deaden pain.

Oil of cloves (eugenol)

(TABLE 24.2 - Herbal supplements & implications): Cranberry =

Opioid analgesics, antidepressants, some antibiotics.

(TABLE 24.1 - Adverse effects and implications): Feverfew =

Oral mucosal irritation, ulcerations.

_________, an herbal supplement used to treat mild depression, causes xerostomia.

St. John's wort

_________ is the process by which one or more active ingredients of an herb are identified and all batches of the herbs produced by a single manufacturer contain the same amount of active ingredient specified on the label.

Standardization

Consumers expect that all prescription and nonprescription drug products are standardized and that what is printed on the label is actually in the drug in the container.

TRUE

Consumers may not expect the same level of standardization with an herbal supplement because herb supplements are considered food products, or they may just assume that such standardized has taken place.

TRUE

FDA with mandatory recall authority for all foods, including dietary supplements, expands facility registration obligations and requires the FDA to issue new dietary ingredients guidance.

TRUE

If a patient is taking conventional drugs and herbal supplements and a perceived drug interaction occurs, it is difficult to determine what was actually responsible for the effect, it will be difficult to obtain accurate information on possible interactions.

TRUE

It is unclear what benefit separating the information from the product would serve other than having gotten the act passed.

TRUE

Little information regarding drug interaction with herbal supplements. The purity and potency of a product is unknown, the dose is not standardized, package labeling is incomplete or inaccurate, or the product may contain more than one active ingredient.

TRUE

Patients do not always report supplement use

TRUE

These products cannot have labels such as "for treatment of hypertension". The labels can contain claims of effects on the structure or function of the body.

TRUE

Xylitol antibacterial effects inhibit the ability of microbes to adhere to and grow in plaque.

TRUE

- Package labeling should also include booth active and all inactive ingredients present in the formation. - These regulations require manufacturers of herbal supplements to test their products for purity and provide accurate labeling information for consumers.

TRUE/TRUE

The US FDA must prove a product is _______

UNSAFE

______ is a naturally occurring sweetener derived from plants that can be extracted from birch bark, raspberries, plums, and corn fiber.

Xylitol

(TABLE 24.2 - Herbal supplements & implications): Black cohosh, butterbur, echinacea purpurea =

acetaminophen, NSAIDS, macrolide antibiotics, azole antifungals.

(TABLE 24.1 - Adverse effects and implications): Coenzyme Q10, echinacea, milk thistle, pomegranate, wormwood =

allergic reactions

(TABLE 24.2 - Herbal supplements & implications): Dong quai =

antihypertensive, opioids, benzodiazepines, CNS depressants, barbiturates, aspirin warfarin.

Acemannan hydrogel was found to be as effective as both prescription and nonprescription products in healing _____ _____

aphthous ulcerations

(TABLE 24.2 - Herbal supplements & implications): Coleus forskolin, goldenseal, gotu kola, hawthorn, melatonin, nettle root, passion flower, valerian root =

benzodiazepines, barbiturates, CNS depressants, opioids.

Herbal products can interact with _______ drugs, leading to disastrous results. Risk for toxicity and reduced therapeutic effect.

conventional drugs

All herbal products must be labeled as _____ supplements.

dietary

Tongue numbness and taste changes with the use of ______

echinacea.

The FDA issued a regulation prohibiting the sale of all dietary supplements containing _______ _________ and warned consumers to stop taking the product.

ephedrine alkaloids

(TABLE 24.1 - Adverse effects and implications): Chaparral, comgrey, kava =

hepatotoxicity, bleeding.

(TABLE 24.2 - Herbal supplements & implications): Yohimbe =

indirect-acting sympathomimetics

(TABLE 24.2 - Herbal supplements & implications): St john's wort =

induces the cytochrome P-450 isoenzymes, many drugs interactions

Other aspects of the DSHEA prevent the use of therapeutic claims on the _____

label.

Requirement is that information about the product must be physically separate from the _____ product.

natural

(TABLE 24.2 - Herbal supplements & implications): Guar gum =

penicillins.

(TABLE 24.1 - Adverse effects and implications): Niacin, yohimbe =

postural hypotension.

(TABLE 24.3 - Recommends for discontinuing herbal supplements): Kava and ephedra =

stop 24 hours prior to procedure

(TABLE 24.3 - Recommends for discontinuing herbal supplements): Ginkgo =

stop 36 hours prior to procedure

(TABLE 24.3 - Recommends for discontinuing herbal supplements): St John's wort =

stop 5 days prior to procedure

(TABLE 24.3 - Recommends for discontinuing herbal supplements): Garlic and ginseng =

stop 7 days prior to procedure.

(TABLE 24.1 - Adverse effects and implications): Ephedra =

tachycardia, hypertension.

(TABLE 24.2 - Herbal supplements & implications): Bilberry fruit, bromelain, chamomile, cordyceps, coenzyme Q10, evening primrose, garlic, ginger, ginseng, gingko, feverfew, guggal, horse chestnut, kava, licorice, oil of cloves. Turmeric =

warfarin, heparin products, aspirin, clopidogrel, NSAIDS.

5. Patients with asthma should bring their fast-acting __________ inhaler to be used prophylactically or in the management of an acute asthmatic attack in the dental office. a. α-Agonist b. β1-Agonist c. β1-Antagonist d. β2-Agonist e. β2-Antagonist

β2-Agonist A fast-acting β2-agonist should be available to manage an acute asthmatic attack in the dental office. Signs of asthma include shortness of breath and wheezing. REF: p. 277

Many consumers consider herbal products to be nontoxic or free of side effects because they are often called ________ ________

"natural" remedies

The most common adverse oral and dental effects of herbal medications include:

- dysgeusia - gingival hyperplasia - intraoral hemorrhage - necrosis - oral candidiasis - oral ulceration - stomatitis - tooth discoloration - xerostomia.

They include essential oils (EOs) that are used in mouth rinses:

- thymol - eucalyptol or menthol - xylitol - acemannan - oil of cloves - triclosan

Increased gingival bleeding with 1- _______, and oral and lingual dyskinesia with the use of 2-_____

1- ginkgo 2- kava

42. Orally inhaled corticosteroids produce an immediate benefit in an acute asthma attack.

ANS: False Although the steroids produce no immediate benefit in an acute asthmatic attack, they hasten recovery and decrease morbidity in these patients. REF: p. 281

39. A spacer is often placed between the metered dose inhaler and the mouth to decrease the amount of drug delivered to the lungs.

ANS: False The spacer increases the amount of drug delivered to the lungs. REF: p. 279

40. Nonchlorinated hydrofluoroalkane (HFA) propellants do not deplete the ozone layer.

ANS: True Chlorofluorocarbons, which have ozone-depleting properties, have been phased out as propellants in MDIs. They have been replaced by the nonchlorinataed HFA propellants that do not deplete the ozone layer. REF: p. 279

38. Researchers have suggested that oxygen be limited to less than 3 L/min for patients with severe COPD.

ANS: True Other literature recommends that oxygen by nasal cannula be used during a dental appointment for patients with severe COPD, especially if pain or stress is anticipated. REF: p. 278

41. One common mistake that many asthmatics make is to rely on their albuterol inhaler and omit using their steroid inhaler.

ANS: True The reason this mistake occurs is because the albuterol gives an immediate response. REF: p. 279

12. The first line of treatment for intermittent asthma is a: a. Short-acting β2-adrenergic agonist b. Long-acting β2-adrenergic agonist c. Corticosteroid d. Mast cell degranulation inhibitor e. Methylxanthine

ANS: a A short-acting β2-adrenergic agonist is the first line of treatment for intermittent asthma. Short-acting β2-agonists are the drugs of choice for the emergency treatment of an acute asthma attack. These agents should be used primarily for the treatment of acute problems, not for the management of normal breathing function. REF: p. 279

3. Asthma may be precipitated by: (1) allergens, (2) exercise, (3) stress a. 1, 2, 3 b. 1, 2 c. 1, 3 d. 2, 3

ANS: a Asthma may be precipitated by allergens, pollution, exercise, stress, or upper respiratory tract infection. REF: p. 277

30. Which of the following adverse reactions is common to all of the currently marketed H2-blocking agents? a. Abnormal liver function tests b. Thrombocytopenia c. Slurred speech d. Gynecomastia

ANS: a Correct: Cimetidine, ranitidine, and famotidine all can cause this adverse reaction. Incorrect choices: Others are adverse effects of cimetidine, but neither ranitidine nor famotidine. REF: p. 285

16. Which one of the following drugs can result in oral candidiasis? a. Fluticasone b. Phenytoin c. Acetaminophen d. Metoprolol e. Omeprazole

ANS: a Correct: Fluticasone is a corticosteroid that is inhaled for patients with asthma and respiratory problems. Corticosteroids are known to result in oral candidiasis; therefore make sure the patient rinses after using his or her inhaler. Incorrect choices: Phenytoin is for seizures and can cause gingival hyperplasia. Acetaminophen is an analgesic. Metoprolol is a selective beta-blocker used to treat high blood pressure. Omeprazole is a proton-pump inhibitor used to treat ulcers and gastroesophageal reflux disease (GERD). REF: p. 281

2. Patients with __________ asthma experience symptoms less than two times a month, and the symptoms do not interfere with normal activity. a. Intermittent b. Mild persistent c. Moderate persistent d. Severe persistent

ANS: a Correct: Intermittent asthma is characterized by the presence of symptoms less than two times a month, and the symptoms do not interfere with normal activity. Incorrect choices: Persistent asthma occurs anywhere from more than twice a week to all day long. Persistent asthma can cause minor limitations of normal activities, and severe persistent asthma can severely limit the patient's normal activities. REF: p. 276

35. The following are actions of metoclopramide except for one. Which one is the exception? a. Decreases peristalsis by acting directly on smooth muscle of the gastrointestinal tract b. Blocks the action of dopamine c. Accelerates gastric emptying time d. Increases the tone of the lower esophageal sphincter

ANS: a Correct: Metoclopramide stimulates motility of the upper gastrointestinal tract and increases peristalsis in the duodenum. Incorrect choices: Others are all actions of metoclopramide. REF: p. 286

22. Which of the following medications is used to treat persistent asthma and the bronchospasm associated with chronic bronchitis and emphysema? a. Theophylline b. Ipratropium c. Omalizumab d. Cromolyn

ANS: a Correct: Theophylline is used to treat persistent asthma and the bronchospasm associated with chronic bronchitis and emphysema. Bronchodilation is the major therapeutic effect desired. Incorrect choices: Ipratropium is a short-acting anticholinergic available for oral inhalation for people with COPD. Omalizumab is the first in a new class of medications introduced to treat asthma due to allergens. Cromolyn is effective only for the prophylaxis of asthma and not for treatment of an acute attack. REF: p. 282

32. Magnesium sulfate should be used with caution in patients with renal impairment because hypermagnesemia has been reported in patients with renal disease. a. Both the statement and the reason are correct and related. b. Both the statement and the reason are correct, but not related. c. The statement is correct, but the reason is not. d. The statement is not correct, but the reason is correct. e. Neither the statement nor the reason is correct.

ANS: a Magnesium from magnesium sulfate may be absorbed into the body. This magnesium will not be properly excreted through the kidney from patients with renal impairment, and the level of magnesium in the body may become abnormally high. REF: p. 286

7. Which of the following groups of medications are considered first-line treatment for COPD? a. β-adrenergic agonists b. Anticholinergics c. Methylxanthines d. Leukotriene (LT) antagonists

ANS: b Anticholinergics are considered first-line treatment for chronic bronchitis and emphysema, but β-adrenergic agonists and methylxanthines are also used to produce bronchodilation in these patients. In many instances, patients receive a combination metered-dose inhaler (MDI) with an anticholinergic drug and a β2-adrenergic agonist. REF: p. 278

1. Asthma is characterized by __________ airway obstruction and is associated with reduction in __________ airflow. a. Reversible, inspiratory b. Reversible, expiratory c. Irreversible, inspiratory d. Irreversible, expiratory

ANS: b Asthma is characterized by reversible airway obstruction and is associated with a reduction in expiratory airflow. Inflammation occurs a few hours later, resulting in an increase in secretions in the lungs and swelling in the bronchioles. REF: p. 276

11. Which of the following statements represents the primary disadvantage of the use of MDIs? a. The inhaled dose cannot be properly measured. b. They are difficult to use properly, and they can be abused. c. The onset of action is unpredictable. d. The bronchodilator effect is less than that of a comparable oral dose.

ANS: b Correct: Disadvantages of MDIs are that they are difficult to use properly (particularly for children) and they can be abused, with a resultant decrease in response. Incorrect choices: The inhaled dose can be accurately measured. The onset of action is rapid and predictable (versus unpredictable response with orally administered agents). The bronchodilator effect is greater than a comparable oral dose. REF: p. 279

33. Which of the following agents is the drug of choice for NSAID-induced ulcers? a. Ranitidine b. Misoprostol c. Omeprazole d. Metoclopramide

ANS: b Correct: NSAIDs inhibit PG synthesis, and PGs have a protective effect on the stomach lining. Misoprostol is a PGE2 and can replenish the PG in the stomach. Incorrect choices: Ranitidine and omeprazole reduce the symptoms of NSAID-induced ulcers but do not prevent the ulcers. Metoclopramide is not indicated for the treatment of ulcers. REF: p. 286

31. Which agent inhibits the H+/K+ ATPase found at the surface of the gastric parietal cell? a. Ketoconazole b. Lansoprazole c. Misoprostol d. Famotidine e. Metronidazole

ANS: b Correct: Proton-pump inhibitors, such as lansoprazole, inhibit the gastric H+/K+ ATPase as their mechanism of action. Incorrect choices: Ketoconazole is an antifungal agent. Misoprostol is prostaglandin E2-alpha PGE2. Famotidine is a histamine2 receptor antagonist. Metronidazole is an antibacterial agent. REF: p. 285

36. Many drugs have a potential to be abused. Certain gastrointestinal drugs such as emetics __________ and have been abused by patients with __________. a. Antiemetics, low blood sugar b. Laxatives, bulimia c. Nitroglycerin, familial hypercholesterolemia d. Antispasmodics, diabetes

ANS: b Correct: Some patients with bulimia abuse emetics to induce vomiting and abuse laxatives to induce bowel movements. Incorrect choices: For other patients, no connection has been established among the drug, the disease, and abuse. REF: p. 286

21. __________ is the least toxic of all asthma medications. a. Omalizumab b. Cromolyn c. Theophylline d. Fluticasone e. Zileuton

ANS: b Cromolyn is the least toxic asthma medication. It is currently available in a metered-dose form as in the other inhalation agents. REF: p. 282

23. A significant drug interaction occurs between theophylline and __________ that can result in toxic serum levels of theophylline. a. Aspirin b. Erythromycin c. Nifedipine d. Clomiphene

ANS: b Erythromycin can increase the serum levels of theophylline, and toxicity may result. REF: p. 282

8. The drive for ventilation is stimulated by a(an) __________ in the normal person. a. Depression in the partial pressure of carbon dioxide (PaCO2) b. Elevation in PaCO2 c. Depression in the partial pressure of oxygen (PaO2) d. elevation in PaO2

ANS: b In the normal person, the drive for ventilation is stimulated by an elevation in PaCO2. The PaO2 can vary widely without stimulating ventilation in the normal patient. REF: p. 278

19. LTs are used to manage patients with __________ that is not controlled by β2-agonists and corticosteroid inhibitors. a. Emphysema b. Asthma c. Chronic bronchitis d. Acute bronchitis

ANS: b LTs manage asthma that is not controlled by β2-agonists and corticosteroid inhibitors. Zafirlukast and montelukast are leukotriene receptor antagonists. They are not as effective as the corticosteroid inhalers. Both are effective taken orally. REF: p. 281

9. The ventilation of a patient with COPD is driven by a(an): a. Increase in PaO2 b. Decrease in PaO2 c. Increase in PaCO2 d. Decrease in PaCO2

ANS: b Patients with COPD experience a gradual rise in PaCO2 over time. Because this mechanism becomes resistant to changes in PaCO2, a new stimulus emerges, the PaO2. The patient's ventilation is then driven by a decrease in PaO2. REF: p. 278

34. Sucralfate can be thought of as a "bandage" for ulcers because it inhibits the action of pepsin and absorbs the bile salts. a. Both parts of the statement and the reason are correct and related. b. Both parts of the statement and the reason are correct, but not related. c. Both parts of the statement are correct, but the reason is not. d. Both parts of the statement are not correct, but the reason is correct. e. Neither the statement nor the reason is correct.

ANS: b Sucralfate can be thought of as a "bandage" for ulcers because it combines with proteins, forming a complex that binds preferentially with the ulcer site. Sucralfate also inhibits the action of pepsin and absorbs the bile salts. However, the physical form sucralfate takes and the physical protection it provides the ulcer site make it akin to a bandage. REF: p. 286

27. __________ is a concern when administering local anesthetics with sulfiting agents as a preservative for the vasoconstrictor. a. Tardive dyskinesia b. Bronchoconstriction c. Tachycardia d. Emesis

ANS: b Sulfiting agents in local anesthetic agents with vasoconstrictor can lead to bronchoconstriction. REF: p. 283

13. Albuterol is a bronchodilator that can be administered via an MDI. It is recommended in prophylactically treating (preventing) chronic asthma. a. Both statements are true. b. Both statements are false. c. The first statement is true, the second statement is false. d. The first statement is false, the second statement is true.

ANS: c Albuterol is a bronchodilator administered via inhaler. However, it is recommended to treat acute asthma attacks, not in the prevention of asthma. One major mistake that many asthmatics make is to rely on the albuterol inhaler and omit using the steroid inhaler. REF: p. 279

37. Use of which laxative is able to interfere with the absorption of the fat-soluble vitamins (A, D, E, and K)? a. Bisacodyl b. Dioctyl sodium sulfosuccinate c. Mineral oil d. Magnesium sulfate

ANS: c Correct: Because mineral oil is a hydrophobic oil, fat-soluble vitamins can dissolve in it, and their absorption into the body will be impeded. Incorrect choices: The other choices are all laxatives, but they do not interfere with the absorption of fat-soluble vitamins. REF: p. 287 TRUE/FALSE

20. Which of the following agents prevents the antigen-induced release of histamine from sensitized mast cells? a. LT modifiers b. Corticosteroids c. Cromolyn d. Methylxanthines e. Anti-IgE antibodies

ANS: c Cromolyn prevents the release of histamine from sensitized mast cells, apparently by preventing the influx of calcium provoked by IgE antibody-antigen interaction on the mast cell. REF: p. 282

29. Which histamine-2 (H2)-blocking agent has been associated with dry mouth and taste alterations? a. Cimetidine b. Ranitidine c. Famotidine d. Meclizine

ANS: c Incorrect choices: Cimetidine and ranitidine are H2-blockers that do not cause xerostomia or taste alterations. Meclizine does cause xerostomia, but is an anticholinergic, not an H2-blocker. REF: p. 285

4. In status asthmaticus, patients have persistent life-threatening: a. Tachycardia b. Stomach ulcers c. Bronchospasm d. Electrolyte imbalance

ANS: c Patients have persistent life-threatening bronchospasm in status asthmaticus despite drug therapy. REF: p. 277

26. Pseudoephedrine __________ is used systemically as a nasal decongestant. a. An α-adrenergic agonist b. A β-adrenergic agonist c. An α-adrenergic and β-adrenergic agonist d. Neither an α-adrenergic nor a β-adrenergic agonist

ANS: c Pseudoephedrine is both an α-adrenergic and a β-adrenergic agonist and is used systemically as a nasal decongestant. REF: p. 282

28. Which of the following gastrointestinal drugs is used to treat nausea? a. Mineral oil b. Loperamide c. Lansoprazole d. Prochlorperazine e. Ranitidine

ANS: d Correct: Prochlorperazine is used to treat severe nausea. Incorrect choices: Mineral oil is a lubricant that is used to treat constipation. Loperamide is used to treat diarrhea. Lansoprazole is used to treat ulcers and GERD. Ranitidine is used to treat ulcers and GERD. REF: pp. 284, 286-287

25. Which of the following statements is true of omalizumab? a. It is a recombinant humanized monoclonal antibody b. It prevents IgE from binding to mast cells and basophils c. It is administered by inhalation d. Both a and b are true. e. Both b and c are true.

ANS: d Correct: omalizumab is the first in a new class of medications introduced to treat asthma caused by allergens. It is recombinant humanized monoclonal antibody that prevents IgE from binding to mast cells and basophils, thereby preventing the release of inflammatory mediators after allergen exposure. Incorrect choices: Omalizumab is administered by subcutaneous injection every 2 to 4 weeks. Adverse reactions include pain and bruising at the injection site. REF: p. 282

14. Which of the following drugs used to treat respiratory diseases carries a black box warning about a higher risk of asthma-related deaths as a result of a high number of asthma related deaths reported with salmeterol therapy during a clinical trial? a. Mast cell degranulation inhibitors b. Anti-immunoglobulin E (IgE) antibodies c. Short-acting β2-agonist d. Long-acting β2-agonist

ANS: d Long-acting β2-agonists carry a black box warning. They are best administered in a fixed-dose combination in the same inhaler with an inhaled corticosteroid. REF: p. 281

10. If a patient with COPD is given oxygen and the PaO2 rises, the stimulant to breathing is: a. Markedly stimulated b. Slightly stimulated c. Slightly depressed d. Removed

ANS: d The stimulant to breathing is removed if a patient with COPD is given oxygen and the PaO2 rises because the patient's ventilation is driven by a decrease in PaO2. The possibility of inducing apnea exists. REF: p. 278

6. Which of the following respiratory diseases is(are) associated with irreversible airway obstruction? a. Asthma b. Chronic bronchitis c. Emphysema d. Both a and b e. Both b and c

ANS: e Chronic obstructive pulmonary disease (COPD) is characterized by irreversible airway obstruction, which occurs with either chronic bronchitis or emphysema. REF: p. 278

17. Which one of the following recommendations would you not make to your patients with asthma? a. Bring your inhaler (albuterol) to the dental appointment. b. Rinse after using your corticosteroid inhaler. c. Avoid erythromycin. d. Avoid aspirin. e. Avoid acetaminophen.

ANS: e Correct: Acetaminophen and weak narcotic analgesics are probably permissible for asthmatics. Incorrect choices: Definitely have all asthmatics bring their inhaler to the dental appointment and keep it within reach. Given that corticosteroids can promote the growth of oral Candida, patients should rinse with water after using the inhaler. If the patient is taking theophylline, then erythromycin can cause toxicity by inhibiting its metabolism and increasing theophylline's blood levels. Aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), and strong opioids should be avoided in patients with asthma. REF: pp. 281, 283

24. The drug of first choice for emphysema is: a. Albuterol b. Zileuton c. Theophylline d. Beclomethasone e. Ipratropium

ANS: e Correct: COPD occurs with emphysema. Ipratropium is the drug of choice for long-term management of COPD. Incorrect choices: Albuterol may be used along with ipratropium in some cases but is not drug of first choice for emphysema. Theophylline may also be used in cases of emphysema. Zileuton is a leukotriene synthesis inhibitor that is a second-line asthma drug. Beclomethasone is a corticosteroid used in asthma. REF: pp. 281-282

18. Which of the following statement is true of LTs? a. LTs produce bronchodilation and decreased bronchial hyperreactivity b. LTs are produced by cells of inflammation c. LTs produce increased secretion of mucus and mucosal edema. d. Both a and b are true. e. Both b and c are true.

ANS: e Correct: LTs are produced by cells of inflammation and produce increased mucus secretion and mucosal edema. Incorrect choices: LTs produce bronchoconstriction and increased bronchial hyperreactivity. REF: p. 281

15. Which of the following drugs is the most effective long-term treatment for control of symptoms in all patients with mild, moderate, or severe persistent asthma? a. LT modifiers b. Cromolyn c. Long-acting β2-agonists d. Theophylline e. Corticosteroids

ANS: e Inhaled corticosteroids are the most effective. Randomized, controlled clinical trials have demonstrated that inhaled corticosteroids are more effective than LT modifiers, long-acting β2-agonists, cromolyn, or theophylline in improving pulmonary function, preventing symptoms and exacerbations, reducing the need for emergency room visits, and decreasing the number of asthma-related deaths. REF: p. 281

_____ ______ is an extract of the aloe vera plant leaf that has immunomodulating properties.

Acemannan hydrogel

(TABLE 24.1 - Adverse effects and implications): Angelica, clove, feverfew, garlic, ginkgo, ginseng, red clover, high dose of vit E =

Bleeding