Master of Science in Nutrition and Dietetics Student at King's College
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Biochemistry of nutrition II
Cystic Fibrosis
For this reflection, I decided to complete IUSM CME Course 3: Gastrointestinal Manifestations of Cystic Fibrosis (CF).1() I used to think that CF was solely a pulmonary disease and did not realize how common and devastating gastrointestinal (GI) manifestations can be in exacerbating CF symptoms and disease progression. I did not realize that because modulator therapy has increased the lifespan of CF patients, GI manifestations have become much more common.(2) I learned that common gastrointestinal problems in CF patients include gastroesophageal reflux disease (GERD), constipation, distal intestinal obstruction syndrome (DIOS), acute and chronic pancreatitis, abdominal pain, bloating, gas, small intestinal bacterial growth (SIBO), constipation, bowel obstructions, and chronic liver disease.(2) Sadly, many of these GI issues may create significant morbidity for CF patients.(2) I had forgotten about the possibility of “silent” reflux, which occurs when patients have documented GER on reflux testing but no obvious symptoms.(2) Not only did this course remind me that this condition exists, but I was shocked to learn that ~60% of adult CF patients may suffer from asymptomatic reflux.(2) Learning this taught me to pay extra attention to supraesophageal manifestations such as hoarseness, sinusitis, coughing, and throat clearing as these may be symptoms of silent GER.(2) I did not realize that CF patients with GER may have more severe lung disease and more frequent respiratory exacerbations than those without GER.(2) Alarmingly, I learned that some CF patients may have chronic heartburn and regurgitation symptoms but not have any evidence of pathologic reflux when tested.(2) Additionally, I learned that high fat diets slow gastric emptying, which can exacerbate GER.(2) I automatically recognized this as a vicious cycle because the normal recommended diet for CF patients are a high-calorie, high-fat diet to offset issues with pancreatic insufficiency, malabsorption, and weight loss yet this same diet can exacerbate GER.(2) I learned that some dietary and lifestyle modifications that can be made to reduce reflux events and/or symptoms include losing weight (if overweight), avoiding caffeinated beverages, avoid eating late at night, elevating the head of bed, and to stop smoking.(2) I am glad I learned about how GER impacts CF patients as untreated reflux in CF patients can be devastating by exacerbating CF disease. Lastly, when different types of reflux testing were mentioned, there was one sentence that stood out to me. This sentence stated that the medical provider must always “choose the optimal test to answer the clinical question.”(2) I tend to overthink things, but this simple sentence reminded me to always think about how to answer the clinical question, regardless of what scenario I am in. I did not realize that CF patients may also suffer from intestinal obstruction, but learned that 5% of CF patients each year suffer from Distal Intestinal Obstruction Syndrome (DIOS) and that if a CF patient has suffered from DIOS in the past, they are at a higher risk in the future.(3) I also did not realize that roughly 50% of CF patients suffer from constipation, but that polyethylene glycol (PEG) solutions are recommended as treatment. As a future RD, learning about the impacts that DIOS and constipation have on CF patients taught me to remind these patients to stay adequately hydrated and physically active, if they are able.(3) Additionally, if the CF patient can safely consume fiber, I would also recommend fiber consumption to help decrease the risk of DIOS and constipation. I was shocked to learn that a history of meconium ileus as a neonate predisposes CF patients to future obstructive bowel issues.(3) Additionally, I realized the importance of understanding DIOS because medical therapy is successful >90% of the time if DIOS is caught and treated early and aggressively.(3) Prevention is key, and as a future RD, I must recognize this potential risk factor. Though it is outside of my scope of practice to make a DIOS diagnosis, as this is the job of a gastroenterologist, I can at least recognize the signs and symptoms to make a proper referral to a gastroenterologist if needed. As an IBD patient, I am very familiar with colonoscopies. However, I did not realize that CF patients must get screened for colon cancer starting at age 40.(3) I was almost speechless when I read that colon cancer screening should not be done for CF patients who have a life expectancy of <10 years.(3) I automatically thought, unless the CF patient is at the end stage of their disease, how would we truly know if they have a 30 Pediatric and Adult CF GI providers.(2) This made me realize that it may be difficult for a CF patient to see a gastroenterologist that is familiar with their disease and understands disease nuances. I used to think that medical nutrition therapy with a Registered Dietitian was standard care for CF patients so was incredibly shocked to learn that nutrition is often an overlooked component of CF-related care.(4) I could not understand how this is possible in such a high-risk patient population. I learned that a multidisciplinary team is involved in the event of nutritional failure and automatically thought that perhaps nutritional failure may be avoided if nutrition is not overlooked in the first place. Prior to going through these moduIes, I was most unfamiliar with pancreatic disorders in CF patients. I was shocked to learn that 60% of CF infants are pancreatic insufficient, and almost 90% are pancreatic insufficient by age one.(5) I also learned that in order to avoid undesirable nutrition impacts and negative nutrition related pulmonary outcomes, a low-fat diet must not be used in CF patients with pancreatitis.(5) This is important and underscores the importance of individualized medical nutrition therapy with a Registered Dietitian who specializes in CF. Additionally, I did not realize that liver cirrhosis is the third leading cause of death in CF patients and the primary cause of death after lung failure.(6) From a nutritional perspective, I learned that a behavioral therapist may be helpful for CF children who struggle to consume enough calories or that enteral therapy may also be an appropriate choice, depending on the situation.(4) I also did not realize that CF patients require between 110% and 200% more caloric needs than the healthy population, which again underscores why each CF patient should receive MNT by an RD.(4) I still find it hard to accept that nutrition is often overlooked as standard care, though this was mentioned in this course, so it must be true. My question is, why is nutrition overlooked? Overall, this course taught me that CF patients truly suffer throughout their lives and must be cared for by a well-equipped multidisciplinary team. It is necessary to ensure these patients are receiving quality multidisciplinary care so they can live the best quality of life available. To help prevent nutritional failure, it is important that healthcare providers that are caring for CF patients (i.e. pulmonologist, endocrinologist, primary care provider, etc) recognize the importance of MNT provided by a dietitian to help keep CF patients as nutritionally healthy as possible. References 1. Indiana University. IUSM CME Course 3: Gastrointestinal Manifestations of Cystic Fibrosis. Accessed March 30, 2024. https://iu.instructure.com/courses/1936850 2.Indiania University. Module 1: Gerd and Dysmotility. Accessed March 30, 2024. https://iu.instructure.com/courses/1936850/pages/1-dot-1-gerd-and-dysmotility?module_item_id=21117226 3. Indiana University. Module 2: Disorders of the Large Intestine. Accessed April 1, 2024. https://iu.instructure.com/courses/1936850/pages/2-dot-1-disorders-of-the-large-intestine?module_item_id=21117232 4. Indiana University. Module 3: Optimal Nutritional Status. Accessed April 1, 2024. https://iu.instructure.com/courses/1936850/pages/3-dot-1-optimizing-nutritional-status?module_item_id=21117238 5. Indiana University. Module 4: Disorders of the Pancreas. Accessed April 1, 2024. https://iu.instructure.com/courses/1936850/pages/4-dot-1-disorders-of-the-pancreas?module_item_id=21117243 6. Indiana University. 5.1 Advanced Topics. CF Associated Liver Disease. Accessed April 1, 2024. https://iu.instructure.com/courses/1936850/pages/5-dot-1-advanced-topics-cf-associated-liver-disease?module_item_id=21117248
Reflection
Much of this semester was spent learning about Cystic Fibrosis (CF). I completed a very large, in-depth case study and dietary analysis of a 22-year-old CF patient. I will not post my completed case study or dietary analysis as future dietetics students may be assigned a similar patient/case study. However, if you’d like to discuss either the case study or dietary analysis, you can send me a message via my “Contact” tab. It truly helped to learn about nutrition recommendations and interventions in CF patients. Individualized medical nutrition therapy (MNT) is very important for CF patients. When working on my dietary analysis and while also working on my nutrition prescription recommendations, I gathered information from three different CF guidelines, which were the Nutrition Guidelines for Cystic Fibrosis in Australia and New Zealand, the ESPEN-ESPGHAN-ECFS Guidelines on Nutrition Care for Cystic Fibrosis, and the Academy of Nutrition and Dietetics 2020 Cystic Fibrosis Evidence Analysis Center Evidence-Based Nutrition Practice Guidelines.(1,2,3) I am glad to now know that these guidelines exist to use as a reference and to help me make the best clinical nutritional decision should I see CF patients as a future registered dietitian. It was interesting to learn that a high fat, high calorie diet isn’t necessarily the “go-to” anymore and that the Dietary Guidelines for Americans is recommended, if appropriate for the patient.(2) It was also important to learn the CF guideline recommendations for vitamin(s) A, D, E, and K. Additionally, I was not aware that current CF guidelines recommend that CF patients consume 6,000 mg/day of sodium and 1,000 mg of calcium.(1,2) This underscores the importance of understanding and knowing the nuances for CF nutrition interventions. I will, of course, stay up to date on the current evidence-based guidelines for CF patients, and now know what resources to go to! Overall, I am thankful to have learned so much about CF in both the case study, dietary analysis, and modules completed. I chose to complete the IUSM CME Course 3: Gastrointestinal Manifestations of Cystic Fibrosis (CF).(4) I learned so much through this course, as stated in my posted reflection above. References 1. The Thoracic Society of Australia and New Zealand. Nutrition Guidelines for Cystic Fibrosis in Australia and New Zealand – August 2017. Accessed 24 April, 2024. https://thoracic.org.au/wp-content/uploads/2021/06/NHMRC-NutritionGuidelines-CF-ANZ-final-web.pdf 2. Wilschanski M, Munck A, Carrion E, et al. ESPEN-ESPGHAN-ECFS guideline on nutrition care for cystic fibrosis. Clin Nutr. 2024;43(2):413-445. doi:10.1016/j.clnu.2023.12.017 3. McDonald CM, Alvarez JA, Bailey J, et al. Academy of Nutrition and Dietetics: 2020 Cystic Fibrosis Evidence Analysis Center Evidence-Based Nutrition Practice Guideline. J Acad Nutr Diet. 2021;121(8):1591-1636.e3. doi:10.1016/j.jand.2020.03.015 4. Indiana University. IUSM CME Course 3: Gastrointestinal Manifestations of Cystic Fibrosis. Accessed March 30, 2024. https://iu.instructure.com/courses/1936850
Enteral Nutrient Drug Interactions
Prior to watching the "Enteral Nutrient Drug Interactions" video, I had never considered how the use of medications may impact nutrient absorption from enteral nutrition (EN).(1) I was familiar with drug nutrient interactions (DNI) in the form of prescribed medication and oral food intake but had never considered how this applies to patients on EN. It was helpful to learn that DNI can be clinically significant in that it may result in a change in medication efficacy or decrease nutritional absorption in EN patients.(1) I did not realize that the populations most at risk for DNI include individuals on multiple medications, patients on continuous EN, malnourished patients, patients in the ICU, and patients that experience altered GI function.(1) In hindsight this makes total sense, but it is not something I intuitively thought about until now. I also had not really thought about physical DNI, in which medications are mixed within the enteral formula, or put directly into the feeding tube. Thinking back to my chemistry days, it makes sense that a precipitate may form in the EN formula, which may reduce bioavailability of either the drug(s) and/or nutrients.(1) I am not sure if I would have thought of this prior to seeing a precipitate form; but I assure you I would have been extremely alarmed had I seen a precipitate form in a feeding tube or within formula while working in a clinical environment. I am thankful to have learned how to avoid physical DNIs so this does not happen to me “in real life” with a real patient in a clinical environment. I was relieved to learn that physical DNIs can be avoided by not directly mixing medications into EN formula and to ensure that the feeding tube is properly flushed prior to administering the medication and flushed after administering the medication.(1) This underscores the importance of the healthcare team collaborating with the dietitian as I assess physical DNI may easily occur if a complacent nurse does not fully understand how a medication may interact with EN. Learning about Physical DNIs also alerted me to always check for medications when scrolling through the electronic medical record, especially for all patients on tube feeds so I can ensure the nurses and physicians are aware of such interactions. If in doubt, I will always consult with the pharmacist on staff. I also learned about pharmaceutical DNIs, which occur when a medication is administered differently than the manufacture intended.(1) I would like to believe that if I saw a healthcare professional crush up a medication and mix it with enteral formula I would intervene. However, if I had not learned about physical DNI and was unfamiliar with pharmaceutical DNIs, I am not sure I would intervene due to not knowing the dangers this may pose. I now know exactly what I would do and would immediately intervene as crushing up a medication and giving it via feeding tube may be life-threatening for the patient, especially in extended-release medications – as the entire dosage, which was designed to be given over time, may be absorbed all at once.(1) This again taught me the importance of being familiar with different medications, to contact the pharmacist if I am in doubt or have questions, and to always talk about how drugs are administered with nurses for patients on EN. I also learned about pharmacokinetic DNIs, which occurs when a drug alters absorption, distribution, metabolism, and excretion of EN.(1,2) I learned that this can be prevented by ensuring medication and EN administration does not occur at the same time and to ensure the drug is administered in the appropriate location for proper activation.(1) However, this again highlights the importance of the pharmacist, nurse, prescribing physician, and dietitian collaborating and working together to minimize adverse events from occurring.(2) I also learned about five common DNI medications, which include Phenytoin, Levodopa, Warfarin, Levothyroxine, and Fluoroquinolone and how to properly avoid a DNI from occurring.(1) While reviewing the Enteral Nutrition and Medication Interactions guide by Roberts and Ziegler that displayed in the video, I became curious about other DNI medications not mentioned in the video. I found that EN must stop 2 hours prior to and 2 hours after Dolutegravir administration and that Carbamazepine should be absorbed via gastric access.(3) However, I learned that if Carbamazepine is administered via post-pyloric route, EN should stop two hours before and two hours after medication administration.(3) I am glad to have learned about this as it has really highlighted to me the importance of understanding what medications are used, why they are used, and how to avoid a DNI from occurring. I have committed to myself that when I am a new RD, I will look up every medication an EN patient is on to ensure it is safe to administer as I do not want to be responsible for any adverse events and never want to cause patient harm. I decided to look up an article mentioned by the video authors, titled Preventing Errors When Drugs Are Given Via Enteral Feeding Tubes.(4) One sentence that really stood out to me stated “Health care practitioners should not assume that a medication intended to be taken by mouth can be safely administered through a feeding tube.”(4) This sentence truly sums up the entire Enteral Nutrient Drug Interactions video as well as drives the point home that if a patient is given a medication and is receiving EN, the RD must stand a watchful eye to ensure a DNI does not occur. Though medication administration is outside our scope of practice, administering EN is not. We are equally responsible to ensure patient safety and must always collaborate with the healthcare team to ensure harm does not come to the patient. Lastly, I will ensure I am always familiar with the step-by-step guide provided in The Enteral Nutrition Practice Recommendations from ASPEN so I never forget a step. Again, I do not want to be responsible for harm coming to a patient so will always be extra diligent. Overall, I learned so much from the Enteral Nutrient Drug Interactions video. I now know that when I am working with EN patients, I will read through their medical record, or electronic medical record, and find what drugs they are on to double-check for possible enteral DNIs. I will also collaborate with the nurses administering the medication to ensure proper procedures occur and are passed down throughout nursing shifts. I will also thoroughly communicate with the interdisciplinary healthcare team, to include nurses, dietitians, physicians, pharmacists, to decrease the risk of adverse events. References 1. Dietitians in Nutrition Support. Enteral Nutrition Drug Nutrient Interactions. YouTube. May 21, 2021. Accessed April 6, 2024. https://www.youtube.com/watch?v=sRMk6tDFWcU&t=1s 2. Peng Y, Cheng Z, Xie F. Evaluation of Pharmacokinetic Drug-Drug Interactions: A Review of the Mechanisms, In Vitro and In Silico Approaches. Metabolites. 2021;11(2):75. Published 2021 Jan 27. doi:10.3390/metabo11020075 3. Dietitians on Demand. Down the tube: Balancing enteral nutrition and medications. April 19, 2022. Accessed April 6, 2024. https://dietitiansondemand.com/balancing-medications-and-enteral-nutrition/ 4. Grissinger M. Preventing errors when drugs are given via enteral feeding tubes. P T. 2013;38(10):575-576.
Reflection
As mentioned above, a powerful sentence every registered dietitian and healthcare professional should commit to memory is “Health care practitioners should not assume that a medication intended to be taken by mouth can be safely administered through a feeding tube.”(1) I learned a great deal about drug nutrient interactions (DNI) and their potential impacts on patients who are on enteral nutrition (EN). Additionally, I learned how medications should safely be administered to EN patients. It was also important to learn about physical DNI, pharmaceutical DNI, and pharmacokinetic DNI as I was unfamiliar with these terms and definitions prior to the start of this semester. Learning about the five common DNI medications and how they should be administered to EN patients was also important to know, and I ended up creating a little note card that I can refer to during my future clinical rotations. Ideally, I’d like to memorize these prior to my clinical rotations. However, I made a small note card as well. I have also saved the step-by-step guide provided in The Enteral Nutrition Practice Recommendations from ASPEN, and will check for updates, especially before staring my clinical rotation. Lastly, though administering medication is outside the RD scope of practice, it is imperative that RDs collaborate with the multi-disciplinary healthcare team to ensure that drug nutrient interactions (DNI) are not occurring. References 1. Grissinger M. Preventing errors when drugs are given via enteral feeding tubes. P T. 2013;38(10):575-576.
Antacid Food/Nutrient-Medication Interactions
Reflection
I decided to build an infographic for my Antacid Food/Nutrient-Medication Interactions (FNMI) project. Prior to completing this project, I was not familiar with antacid FNMI, yet learned a great deal through this experience! I now know what resources to use and where to go to find in-depth FNMI information. I chose to create an infographic for my antacid patient/client education material as infographics are not something I create often. I wanted to challenge myself to create clear, concise, and useful FNMI education material. I hope I achieved this goal. As an IBD patient, I was familiar with FNMI of Entocort (Budesonide), Azathioprine and 6-Mercaptopurine (6-MP). Grapefruit should not be consumed with these medications, though I was never informed by my healthcare provider about this. Overall, this project not only taught me how to check for various FNMI, but also taught me that I must be familiar with such topics as a future Registered Dietitian. I want to hear from you! Send me a message via the “Contact” tab and let me know what you think about my Antacid FNMI Infographic!