Kristen Marjama, DNP, FNP-BC

Celiac disease (CD) is a chronic condition classified as an autoimmune disorder. Gluten proteins found in barley, rye, and wheat trigger systemic injury primarily to the small intestine, but they can also affect the joints, liver, skin, uterus, and other organs.

The only available treatment for CD is adherence to a gluten-free diet (GFD). The occurrence rate of CD is thought to be underestimated. The reported prevalence of CD in children globally ranges from 0.31% to 0.9% and from 0.4% to 0.95% for adults in the United States.

From 2009 to 2014, those 6 and older undergoing serologic testing for CD with a prior diagnosis of the disease and the use of a GFD, confirmed by direct interview, participated in a National Health and Nutrition Examination Survey study.

Findings suggest that the prevalence of CD has remained stable in the United States, though people are increasingly following a GFD without a confirmed diagnosis.

Here are some thoughts on what may be contributing to the increasing popularity of a GFD:

•    Gluten-free products used to be hard to find but have become more widely available. â€¨

•    Public perception is that GFDs are healthier than traditional diets and may provide benefits for nonspecific gastrointestinal symptoms. â€¨

•    There is an increasing number of individuals with self-diagnosed gluten sensitivity without a diagnosis of CD who have experienced improved symptoms on a GFD.

A number of medications are undergoing early testing to improve the prognosis of CD or to allow patients to consume foods with gluten. But until those are approved, educated patients need to understand the importance of adhering to a GFD. Evidence shows that a GFD will improve symptoms, though there is a lack of convincing evidence that the diet protects against all comorbidities and complications.

How can clinicians improve patient adherence? Adherence is strongly linked to knowledge and understanding. Begin by educating the patient on the function of the small intestine, which is made up of villi that absorb nutrients into the bloodstream. Gluten is a protein that damages villi in patients with CD. Without the ability to absorb nutrients, the body can develop other conditions from malabsorption such as other autoimmune disorders, cancer, infertility, osteoporosis, and thyroid disease.

Showing pictures of abnormal and normal mucosa can help illustrate the effect that gluten has on the small intestine. It is important to also stress with patients that adhering to a GFD improves the potential of healing the mucosa, thus improving the symptoms of CD. Although patients generally feel better on a GFD, not all symptoms will resolve in all patients. For most patients, diarrhea will respond within 4 weeks, but it could take up to 6 months, and a small number of patients will continue to have persistent diarrhea.

Without getting into a detailed lesson in genetics, clinicians can help the patient understand why some people are at risk for getting CD while others are not, that environmental factors only contribute to the risk of CD, and that comorbidities in CD, some of which are not preventable, may occur both before and after diagnosis.

Patients will need detailed information on how to read the labels of processed food and ideally should be given a referral to a dietitian. It can help to focus the patient on a list of grains and other starch-containing foods that are naturally gluten-free: These include amaranth, arrowroot, beans, buck wheat groats (also known as kasha), cassava, chia, corn (maize), flax, gluten-free oats, millet, nut flours, potato, quinoa, rice, sorghum, soy, tapioca, teff, and yucca.

CD can also affect social behaviors. Patients with CD may have to pass on dinner invitations, for instance, if they are afraid that they will not be able to eat the food served. Teenagers for whom belonging to a group and not standing out is of high importance are at higher risk for poor dietary adherence. There is clear evidence that patients with CD are less likely to dine out in restaurants or at friends’ houses because of concerns regarding cross-contamination or inadvertent exposure to gluten.

The Celiac Foundation (celiac.org) provides additional information for patients and health care professionals.

, is a doctorally prepared family nurse practitioner with 9 years of experience in theâ€¨retail health industry. She is the manager of clinic education and professional development at Walmart Care Clinic in Fort Lauderdale, Florida

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The Spectrum of Celiac Disease: Epidemiology, Clinical Aspects and Treatment

3.     JAMA Internal Medicine November 2016 Volume 176, Number 11. Time Trends in the Prevalence of Celiac Disease and Gluten-Free Diet in the US Population: Results from the National Health and Nutrition Examination Surveys 2009-2014. Pages 1716-1718.

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https://celiac.org/live-gluten-free/glutenfreediet/food-options/

Articles

Gluten proteins found in barley, rye, and wheat trigger systemic injury primarily to the small intestine, but they can also affect the joints, liver, skin, uterus, and other organs.

The Nuts and Bolts of Celiac Disease

It is that time of year again, when health care providers see an increase in patient volume because no one has time to be sick. Ah yes, the common

cold that can keep children out of school, athletes out of games, adults out of work, and elderly individuals out of commission and basically disrupt life as we know it. There are more than 100 strains of rhinoviruses that cause the majority of colds.

The common cold typically starts with a sore throat, turns into nasal congestion, a runny nose, and sneezing, and then finishes off with a nagging cough that can last up to 2 weeks. Who has time for this?

The first step in educating patients: Tell them to try not to catch the common cold in the first place. They should be aware that hands carry cold viruses and those viruses can stay on skin surfaces for up to 2 hours. People need to cough into the bend of their elbows and not their hands. And if they do touch their hands, they should not touch their eyes, noses, or mouths. In addition, they should wash their hands before they eat, as cold viruses can live on surfaces such as doorknobs, faucet handles, phones, armrests, and tray tables on planes. And those who happen to stand next to a person with a cold virus who coughs or sneezes a droplet into their eyes, nose, or mouth likely won’t be feeling well within the next 48 to 72 hours.

Treatment is all about controlling the symptoms, and an antibiotic isn’t going to help. Let’s look at this from the patient’s perspective. They head to the OTC cold-and-cough section, only to be met by all sorts of cards to take to the pharmacy for pseudoephedrine, multiple rows of phenylephrine, as well as nasal sprays, antipyretics, and cough medicine. They are asking themselves, “Do I need just guaifenesin or guaifenesin with dextromethorphan or just dextromethorphan? Is it combined with acetaminophen and/or phenylephrine? Do I need something for day and something for night?” Let’s not mention the rows of antihistamines. Health care providers can help patients sort through the multiple available OTC options to treat symptoms of the common cold. Let’s educate patients regarding

treatment options for the most common acute illness in the United States, which is responsible for about 37 million doctor’s office visits every year.

Nasal decongestants, such as pseudoephedrine and phenylephrine, are used for short-term relief of nasal congestion and sinus pressure. What is the deal with pseudoephedrine, and why is it available only behind the counter at a pharmacy? Pseudoephedrine has been used illegally to produce methamphetamine, a highly addictive stimulant. The Combat Methamphetamine Epidemic Act of 2005, which was incorporated into the Patriot Act in 2006, mandated that retailers sell pseudoephedrine behind the counter only, require a photo ID, limit quantities purchased, and keep per- sonal information about the customers for at least 2 years.

Different states have different limitations. State governments have issued additional regulations because of the misuse of methamphetamine. I recently visited Arkansas and had a cold, and I could not purchase pseudoephedrine without identification from that state and was told by the pharmacist that I would need a prescription. Furthermore, certain pharmacies have additional regulations requiring a prescription, no matter what state a person is from. When recommending pseudoephedrine for patients, be aware of the state and pharmacy regulations. Waiting in line at the pharmacy for an OTC medication that can’t be purchased can be frustrating for patients with the common cold. As for effectiveness, results from studies have shown pseudoephedrine to be more effective than phenylephrine in reducing nasal congestion.

Keep in mind that alternative options may be preferred for patients with heart disease, hypertension, thyroid disease, diabetes, an enlarged prostate, or glaucoma.

Dextromethorphan (DXM) is a cough suppressant that is one of the more commonly abused cough and cold medicines. Misused at high doses, it can cause hallucinations and euphoria, referred to by teenagers and young adults as robotripping or skittling.

Interestingly, many brands combine DXM with guaifenesin. However, guaifenesin at high doses

induces nausea; needless to say, the combination brand is avoided by those with the intent to misuse. Patients should not take DXM with antidepressants because of the risk of serotonergic syndrome, which can be life-threatening.

Guaifenesin is an expectorant that works to thin mucous and clear congestion. Patients should know that if they drink a lot of water, this medication will be even more effective.

Saline nasal sprays are a safe and effective remedy to clear nasal congestion. Nasal sprays that contain a decongestant, such as phenylephrine, are also available. Tell the patient that decongestant nasal sprays should not be used for longer than 3 days, to avoid rebound nasal congestion. Very little research has been done on the effectiveness of nasal corticosteroids for the common cold. In my opinion, it may take several days for optimal symptom control, by which time the common cold will have resolved.

Antihistamines block histamine, which is responsible for allergic symptoms that are very similar to the symptoms of the common cold caused by a virus. This prompts the question, “Do antihistamines help relieve symptoms of the common cold?” Let’s review the evidence from 18 trials with 4342 participants reported in 17 different publications.

In adults, there was a benefit on the first or second day of treatment, with 45% feeling better versus 38% on placebo. But there was no difference over the remaining days. The trials in children were smaller and of lower quality, lacking evidence of effectiveness.

We will get through this season together, one cough at a time. Prevention is key. But educating patients about the appropriate OTC treatment options for them specifically can help improve symptoms and reduce the disruptions caused by the common cold.

, is a doctorally prepared family nurse practitioner with 9 years of experience in the retail health clinic industry.

She is the manager of clinic education and professional development at Walmart Care Clinic.

1.     Sexton DJ, McClain MT. Patient education: the common cold in adults (beyond the basics). UpToDate website

uptodate.com/contents/the-common-cold-in-adults-beyond-the-basics

. Updated March 1, 2016. Accessed November 1, 2017.

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bestpractice.bmj.com/best-practice/monograph/252/basics/epidemiology.html. Accessed November 1, 2017.

3.     Legal requirements for the sale and purchase of drug products containing pseudoephedrine, ephedrine, and phenylpropanolamine. US Food and Drug Administration website.

fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm072423.htm

. Updated on September 13, 2016. Accessed November 1, 2017.

4.     Horak F, Zieglmayer P, Zieglmayer R, et al. A placebo-controlled study of the nasal decongestant effect of phenylephrine and pseudoephedrine in the Vienna Challenge Chamber.

2009;102(2):116-120. doi: 10.1016/S1081-1206(10)60240-2.

5.     Cough and cold medicine abuse. National Institute on Drug Abuse website.

drugabuse.gov/publications/drugfacts/cough-cold-medicine-abuse

. Updated May 2014. Accessed November 1, 2017.

6. Drug Enforcement Administration. Dextromethorphan.

deadiversion.usdoj.gov/drug_chem_info/dextro_m.pdf

. Published March 2014. Accessed November 1, 2017.

7. De Sutter AIM, Saraswat A, van Driel ML. Antihistamines for the common cold.

cochrane.org/CD009345/ARI_antihistamines-common-cold

. Published November 28, 2015. Accessed November 1, 2017.

It is that time of year again, when health care providers see an increase in patient volume because no one has time to be sick. 

Treating the Common Cold

The National Health Interview Survey in 2014 estimated that 17.7 million adults and 6.3 million children had asthma.

How are we doing with educating patients on managing asthma? An educated patient is an important key to controlling asthma nationwide. It is important to manage this chronic disease with regularly scheduled follow-up visits, shared decision making, monitoring of quick-relief medication use, and continuing asthma education. Moreover, a written asthma action plan (WAAP) is recommended for every patient with asthma.

Because asthma is a chronic disease with intermittent worsening of symptoms, medication adherence plays an important role in maintaining asthma control and managing these worsening symptoms. Even though study results have shown that WAAPs contribute to improved asthma medication adherence, evidence suggests that as few as 25% of eligible patients have one.

Fewer than 1 in 2 children and 1 in 3 adults are likely to receive a WAAP,

which means that health care providers can have a major impact on helping pa- tients take control of their asthma by making asthma education a priority and utilizing a WAAP.

Children are more likely than adults to learn how to manage their asthma. More than 8 in 10 children, but fewer than 7 in 10 adults, are taught how to recognize asthma symptoms.

Health care providers should keep in mind that not all patients know how to recognize asthma. Therefore, education is essential, and an individualized WAAP can be created to serve 2 main purposes. First, the WAAP is used to inform the patient (or parent/caregiver) how to maintain daily asthma symptom control.

This includes outlining the steps the patient must take to keep asthma from worsening. Second, it provides guidance to help the patient know when and how to treat worsening symptoms.

WAAPs can take varying forms, but the goal should be to use the one that works best for the patient and is easiest for the health care provider to create. WAAPs can either be printed out and then filled in, or some can be completed online before printing; computer-based programs can also help create 5 individualized WAAPs. WAAPs are typically divided into 3 different color zones: green (no symptoms), yellow (having symptoms), and red (having symptoms that aren’t responding to a quick relief medication).

In general, an effective WAAP must contain the following information

Patient’s treatment options: long-term control and quick-relief medications with instructions

Potential precipitating factors and asthma triggers to avoid (if applicable)

What signs and symptoms (or peak flow measurements) indicate worsening asthma

Action points: when, what, and how to take a medication for how long and what to expect

When to seek immediate medical care: Signs of severe exacerbations

Phone numbers for an emergency contact, health care provider, and local hospital

The primary focus of the WAAP can be found in the action points. Patients require education about their medications. Asthma medications can be categorized into 2 classes: long-term control medications and quick-relief medications. Quick-relief medications, such as short-acting beta agonists, are used to treat symptoms and exacerbations. Long-term control medications are used to achieve and maintain control, such as inhaled corticosteroids and long-acting beta agonists. Here are some key education tips for each of these classes of medication.

Use when short of breath; with cough, chest tightness, or wheezing; or if your peak expiratory flow decreases 10% to 20% from the baseline.

List the quick-relief medication name with directions, such as 2 puffs every 4 to 6 hours. Or if severe, consider recommending 2 puffs every 5 minutes up to 20 puffs. If no response in 1 hour, the patient needs to seek immediate medical attention.

It is important for the patient to understand WHY the increased need for the quick relief medication is a red flag and should be reported to the health care provider.

This is not a quick-relief medication, but it helps to reduce exacerbations and can also help to keep patients on a lower dose of the ICS. Dosing typically does not change during an exacerbation, but additional studies are needed to clarify this practice

It is typically used along with an ICS and can also be ordered in combination formulations.

List the medication name with directions accordingly.

Although WAAPs are useful for everyone with asthma, they are particularly important for those who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma. In addition to understanding what the WAAP should contain, it is also helpful to look at the factors that may contribute to the low rate of use or misuse of the WAAP. A study revealed that patients indicated the following reasons for underuse

The health care provider never offered them a WAAP.

The patient did not feel confident about using the WAAP, or did not use it at all.

The patient did not feel that the health care provider believed the WAAP would be effective for self-management.

What can we do to combat these factors? It is not hard to offer a patient of WAAP, yet it does require time and individualization. To help the patient feel confident about using the WAAP, it is important to encourage patient participation in the development of the plan. This will help to ensure the plan is created at the patient’s level of understanding. Health literacy is a common theme in the literature. A need exists for communication in plain language due to barriers for patients with poor health literacy skills. From this perspective, the action plan needs to be written so that it is easily understood by the adult patient, child, or parent/caregiver.

Do we as health care providers believe that the WAAP is an effective tool in empowering patients for self-management? We can demonstrate our belief by asking about and reviewing the WAAP at each visit. For each patient who comes in with a history of asthma, we should be asking if they have a WAAP. Inquire if the patient has any questions about the plan. If patients are being asked these questions at each visit, they are going to get the idea that it’s important! Asking about the WAAP also helps health care providers to gain a better understanding as to how well the patient can identify their own asthma control. It is also an opportunity to identify patient concerns that can be addressed to improve upon their individual self-management strategy. An educated patient can slow the progression of asthma and improve outcomes in our communities.

is a doctorally prepared family nurse practitioner with 9 years of experience in the retail health care clinic industry. Dr Marjama is the Manager of Clinic Education and Profes- sional Development at Walmart Care Clinic.

Her passion is for the provision of high-qual

ity care with a primary focus on education

of evidence-based guidelines. She enjoys speaking at conferences, networking with health care professionals, and was selected this year to participate in the Leadership Program through the American Association of Nurse Practitioners (AANP).

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Asthma Action Plan. CDC website. www.cdc.gov/asthma/actionplan.html. Updated February 14, 2012. Accessed February 23, 2017.

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National Heart, Lung, and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Department of Health and Human Services; National Institutes of Health website. www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report. Published August 28, 2007. Updated April 2012. Accessed June 5, 2015.

Tools for Asthma Control. CDC website. cdc.gov/asthma/tools_for_control.htm. Updated February 27, 2012. Accessed February 24, 2017.

Rank MA, Volcheck GW, Li JT, Patel AM, Lim KG. Formulating an effective and efficient written asthma action plan.

2008;83(11):1263-1270. doi: 10.4065/83.11.1263.

National Heart, Lung, and Blood Institute. Lung Diseases. Asthma Action Plan. Department of Health and Human Services; National Institutes of Health website. www.nhlbi.nih.gov/health/resources/lung. Accessed February 24, 2017.

Kristen Marjama, DNP, FNP-BC

Articles

The Nuts and Bolts of Celiac Disease

Treating the Common Cold

Written Asthma Action Plan