Anticholinergic effects of medications are factors in autonomic control of the lower esophageal sphincter function. Changes in sphincter control often lead to gastroesophageal reflux disease (GERD), a chronic disease with a prevalence of up to 25% for adults. This effect is a consideration in the treatment of depression, the fourth-leading disease burden. Lower esophageal-sphincter changes are well documented in association with tricyclic antidepressants. The newer medications, selective serotonin-reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, are often used as first-line agents. This case report reviews the emergence of GERD in association with the use of newer agents. The patient, a 55-year-old woman, presented to her primary care physician with complaints of low energy, dysphoric mood, and anhedonia of several months' duration. Trials of citalopram and escitalopram were associated with reports of persistent nausea and gastric reflux unresolved by changes in dosing schedule or positioning. Over-the-counter omeprazole on an as-needed basis was added. Ultimately, the patient was successfully managed with desvenlafaxine for dysphoric mood and low energy and scheduled administration of omeprazole for GERD. The adverse drug reaction was evaluated using the Naranjo Adverse Drug Reaction Probability Scale. This methodology indicated a probable relationship (score of 7 out of 12) between initiation of antidepressant therapy and the presentation of GERD symptoms. When evaluating patient response to medication, inquiring about new-onset symptoms may help assess pharmacotherapy, identify potential medication-related effects such as the anticholinergic profile, evaluate the need to add an antisecretory/antispasmodic agent, or consider an alternative treatment strategy.

Objective: To describe the effects of performance-enhancing supplements and caffeine on the blood pressure (BP) of an adolescent male. Case Summary: An adolescent male presented to his primary care provider for a preseason athletic physical. On physical exam, his BP was 162/90, exceeding the 99th percentile for his age. It had been elevated during the previous 2 yearly physicals. He was referred to the Pediatric Preventive Cardiology Clinic for follow-up. Illegal substance use and renal trauma were ruled out. During the evaluation, the patient acknowledged using energy drinks and performanceenhancing supplements, the majority of which were caffeine-based. His intention was to continue the use of supplements, so lisinopril was initiated. On follow-up, however, the patient reported supplement discontinuation, intermittent medication adherence, and lower home-based BP readings. He was subsequently lost to follow-up. An objective causality assessment revealed that the adverse drug event was probable. Discussion: When working with adolescent patients, it is particularly important to conduct an in-depth interview reflecting lifestyle choices. Use of performance-enhancing supplements and caffeine for adolescent athletes has been well reported in the literature. Adolescent use of supplements may be driven by misguided beliefs and lack of knowledge about potentially detrimental health effects, such as altered heart rate and elevated BP. Little evidence-based research is available to provide treatment guidance for clinicians regarding potential effects. Conclusions: A thorough patient history, including specific questions probing for any recent or chronic use of nutritional supplements, including energy drinks, will help identify substances that may contribute to BP variations. Even mild BP elevations in adolescents should lead clinicians to further investigate supplement use and include specific questions on any product use within the past 24 hours, several days, or longer. Adolescents may not consider the potential for adverse health effects when ingesting performance-enhancing supplements or energy drinks.

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Purpose To illustrate opportunities for pharmacists as resources for community-based healthcare professionals that may be at-risk for occupational exposure to toxins of illicit methamphetamine (METH) manufacturing while providing case management services to community-based patients. Summary Pharmacists can serve as a resource with education and protocol development for minimizing the hazards of healthcare professionals, including pharmacists, at-risk for exposure to the toxins of METH manufacturing while providing community-based case management. The illicit production of METH requires solvents for extraction and purification and often results in the release of a number of harmful, and potentially deadly, chemicals and gases. For community-based healthcare professionals, risk factors include direct contact and inhalation. Community-based healthcare professionals providing case management services to patients involved in the production of METH are at-risk for exposure. Examples of an occupational exposure and how the pharmacist can serve as a resource to these providers are provided. Conclusions When conducting home- or community-based services, healthcare professionals may inadvertently experience health-related consequences and injuries because of exposure to hazardous wastes created by and used in the production of METH. The pharmacist can provide education and protocol development to help healthcare professionals identify hazards of exposure to the toxins of the manufacturing of METH, identify signs and symptoms of METH use, and identify signs and symptoms of toxin exposure.