we'll be discussing Enrique, who is our case study.
He is a 58 year old male coming in today complaining of reflux symptoms.
And in this case study we'll be learning how to use the Assess, Educate and
Advise Model.
It may be helpful for you to use the Assess, Educate,
Advise Model that is included in your reading for
this lesson as a reference as we move through the activity.
Next, I would like you to meet Enrique.
Enrique is a 58 year old male who's coming in to see you today with concerns for
reflux.
His symptoms occur several times a month and
often wake him in the middle of the night, causing him to lose sleep.
He's already tried avoiding spicy food and alcohol, but
he still continues to have symptoms.
His primary doctor previously ordered an endoscopy, and
no serious causes for his reflux could be found.
He was recommended to start an acid medicine for his symptoms.
He's here today to see if there are any natural options that may be
helpful for him.
The first step is to asses if Enrique is a good candidate for botanicals.
Based on what you've heard about Enrique so far, do you think he is a good fit for
botanicals?
>> We can already tell that Enrique is definitely interested in botanicals.
And we know this because he specifically was asking about more natural options.
So, so far, it's looking like he could potentially be a good candidate.
Of course, there's more information we're going to need to know, but
at least we know he's interested.
Now let's say Enrique was simply wanting to help manage his reflux symptoms and
he didn't mention any natural options.
If this were the case, I may say something like there are many options that we can
use to help manage your reflux symptoms, some pharmaceutical and some more natural.
Would you be interested in hearing about both of these options?
And if he says, yes, great, and
I can proceed with outlining the botanical versus the pharmaceutical.
Some patients at this point may say no, I'm really not
interested in anything herbal or botanical, I just want the standard drugs.
That's fine too.
Whatever options we discuss however, it's important to go over the risks and
benefits of any options that you are considering for a patient.
So we need to make sure that we do that for Enrique as well.
Well, having an interest in botanicals is always fine for
the first thing to assess, we still need other information about Enrique to
know if he's a really good candidate for botanicals.
What else do you think we might need to know about him?
It's going to be really important that we know what past medical history
Enrique has, as well as what current list of medications that he's taking.
And the reason for this is that a lot of medical conditions may render a patient
not an ideal candidate for botanicals.
We'll be going into this in much further detail in future lectures.
But some things that may be cause of concern are liver disease,
kidney disease, pregnancy, being immunosuppressed from cancer or
other illnesses, or other conditions which we will be going through
that may render a patient not as good of a candidate for botanicals.
Also, it's really important to obtain a current accurate list
of any other medications that the patient may be taking.
And the reason for this is that many botanicals can cause
herb drug interactions and we do not want that.
So for Enrique, we need to further ask if he's on any other medications and
has any other medical conditions.
And, for the sake of this case study, Enrique says he takes nothing else,
no other medications and he has no other major medical problems.
The second step is to educate Enrique about his therapeutic options.
How would you go about doing that?
Whenever possible, I always try to compare and
contrast the botanical versus pharmaceutical options for patients.
If there's perhaps relevant scientific literature, I will briefly discuss that as
well, as well as the pros and the cons of each type of therapy.
This really helps our patient make an informed decision and
it's important that we do this for Enrique as well.
Now in this symptomatic management of reflux there are many medicines,
both pharmaceutical and botanical, that we could try, but for simplicity's sake I'll
just be discussing one pharmaceutical and one botanical option for Enrique.
Pharmaceutical options for
Enrique may include the use of a Proton-Pump Inhibitor, or PPI for short.
A common example of a PPI is Omeprazol, or commonly known as Prilosec.
These. These medicines work by blocking
enzymes in the stomach lining that produce stomach acid and
are frequently prescribed for symptoms of reflux.
Over the counter versions of different PPIs may be available in your country.
For example,
Prilosec OTC can be purchased without a prescription in the United States.
This is a good example of a pharmaceutical option for Enrique.
In contrast to PPIs that shut off all the production of stomach acid, certain
botanicals work in a different mechanism to protect the stomach lining from acid.
Marshmallow is a plant whose roots contain a substance called mucilage
which forms a protective soothing barrier in the gastrointestinal or
GI tract to alleviate the symptoms of reflux.
PPIs work by directly shutting off stomach acid.
They are stronger medicines and will work better for more severe symptoms.
PPIs are taken in pill form, typically on a regular daily basis.
This is convenient for
many patients and helps them not to forget to take their medicines.
Some insurance plans will actually cover the cost of this therapy as well.
In contrast, marshmallow is better suited for mild reflux symptoms.
This is ideal in patients who don't wish to take stronger medicines and
or don't want to take a medicine every single day.
Marshmallow can be taken in pill form, but it can also be consumed in other forms,
such as a tea, and often only taken as an as-needed basis.
Pharmaceuticals tend to produce more side effects than botanicals.
While inhibiting the production of stomach acid can certainly help alleviate symptoms
of reflux, it can also create problems.
Stomach acid is necessary for the absorption of important nutrients, and
it also helps maintain the good bacteria in the GI tract.
Staying on a PPI for a long period of time can lead to nutrient deficiency and
also increase the incidence of diseases such as Sitic Colitis or Pneumonia.
Also when a patient tries to discontinue a PPI after it's been used for
a long time, they typically experience withdrawal reflux symptoms.
I personally experienced this when I tried to wean off my PPI, and
I found it very uncomfortable.
This is in contrast to marshmallow, where really the only major side effect
is that it may impair the absorption of other medicines if taken at the same time.
This is easily avoided if the patient simply takes
any other medications several hours after consuming the marshmallow.
Marshmallow, however, may not be strong enough to alleviate severe symptoms.
In general, pharmaceuticals tend to have significantly more evidence to support
their use than botanicals.
However, certain botanicals do have a body of scientific evidence to support their
use as well.
If you're going to recommend a botanical, you must be familiar with the evidence or
lack thereof regarding its use.
I typically try to sum it up very concisely for patients.
In Enrique's case, I would say something along the lines of PPIs have a strong body
of scientific evidence to support their use in the treatment of reflux.
Marshmallow so far does not have any scientific literature to support its use,
however, this is a plant that's considered very safe, and when used appropriately,
has a long tradition of use of treating reflux symptoms.
You can then offer to answer any questions the patient may have about this.
The final step is to advise Enrique on the best treatment plan for him.
We've already assessed that Enrique is a good candidate for
botanical medicines, and he's expressed an interest in a more natural approach.
His symptoms are mild and he's on no other medications at this time.
After reviewing the pros and cons of both PPIs and marshmallow, Enrique has decided
that he'd like to see if marshmallow will help alleviate his symptoms.
What else should we talk about with Enrique?
Since Enrique has decided to take a botanical, the next thing we need to
think about is a very practical one, how does he want to take it?
And one nice thing about botanicals is that it can be taken in multiple
forms, often.
Certainly if a pill is convenient for him, he can do that.
Marshmallow, in particular, has the benefit of being able to be consumed
as a tea, which many patients really enjoy doing that.
And there are other forms possible.
And we'll be discussing this at length in future lessons,
just how many different botanical preparations there are.
In this particular case,
Enrique has decided to consume his marshmallow in tea form.
And the next thing we need to discuss is recommending a good quality product.
I won't go into those further details now,
because we will be spending an entire lesson on that in the future, but
making sure that he's buying a quality supplement,
quality botanical to help for his symptoms is going to be very, very important.
And then, as always, discussing any safety concerns specifically for
the botanical will be important.
Marshmallow's an extremely safe botanical and the only real,
major safety concern that we need to discuss with Enrique is that he shouldn't
consume it with any other medications within one hour of taking the marshmallow.
In particular, he's not on any other medications, so it's a little bit
of a moot point, but if he needed to take anything like a tablet of Tylenol for
a headache or anything like that,
he should just take that within over one hour of consuming the marshmallow.
Finally, remember to check in with your patient for follow up.
This is important to ensure that Enrique is continuing to use marshmallow effective
and is taking it properly.
If it's not controlling his symptoms, a different regimen may be needed.
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