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Drug-Nutrient SIM Case Study

Drug-Nutrient SIM Case Study

Clarissa Sumanting

Professor Baird

December 15, 2020

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Drug-Nutrient SIM Case Study

1. What is the Dietary Reference Intake (DRI) for Vitamin K? What is the Daily Value

(DV) for Vitamin K as listed on food and supplement labels?

The DRI for Vitamin K for a 66-year-old female is 90 ug/day.

The DV for Vitamin K as listed on food and supplement labels is 120 mcg.

2. Identify sources of Vitamin K, both from diet and synthesis in the body.

Sources of vitamin K from one’s diet include vegetables and, more specifically, green

leafy vegetables. These include kale, spinach, romaine lettuce, broccoli, and Brussels

sprouts. Smaller amounts of Vitamin K is also present in meat, eggs, dairy foods and

vegetable oils.1 Vitamin K is also synthesized in the body by bacteria present in the

human gut.1

3. Look up Vitamin K levels of the following sample foods in a food composition table

or database: 1 cup of cooked kale, 1 cup turnip greens, 1 cup raw romaine lettuce, 1

cup raw peeled cucumber, 1 cup cooked turnips. How do the Vitamin K levels of

these foods compare to the DRI and DV?

1 cup cooked kale – 1062 mcg of Vitamin K2

1 cup cooked turnip greens – 529 mcg of Vitamin K2

1 cup raw romaine lettuce – 48 mcg of Vitamin K2

1 cup raw peeled cucumber – 10 mcg of Vitamin K2

1 cup cooked turnips – 0.16 mcg of Vitamin K2

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Drug-Nutrient SIM Case Study

In comparison with the DRI of Vitamin K, one cup of cooked kale is almost twelve times

the DRI and 1 cup of cooked turnip greens is about 6 times the DRI. In comparison with

the DV of Vitamin K, 1 cup of cooked kale is 883% of the DV, 1 cup of cooked turnip

greens is 440%, 1 cup of raw romaine lettuce is 40%, 1 cup of raw peeled cucumbers is

8%, and 1 cup of cooked turnips is 0.1%.

4. What is the recommended adjustment in Vitamin K intake in patients on warfarin?

What foods should they avoid or limit?

For patients on warfarin, it is recommended to keep the amount of vitamin K in one’s

diet consistent. If needed, the foods to avoid or limit, as previously stated, are primarily

green leafy vegetables.

5. Is it advisable for her to take a multivitamin? How much Vitamin K is in a standard

“once daily” multivitamin?

The patient may continue to take a multivitamin but, if she plans to do so, she should

take the daily multivitamin consistently and once/day and not occasionally as stated in

her food/nutrition-related history. A once daily multivitamin contains about 80 mcg of

Vitamin K.
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Drug-Nutrient SIM Case Study
6. How would her periodic use of antibiotics affect her INR?

Antibiotics can affect how warfarin acts in the body. Some antibiotics can heighten the

blood-thinning action of warfarin which could result in internal bleeding, whereas other

antibiotics can decrease the warfarin’s ability to “thin” blood and thus lead to the

formation of blood clots.3 This reaction between antibiotics and warfarin ultimately

affects one’s INR.

7. Describe the effects of herbal supplements such as St. John’s wort on medication.

St. John’s wort is an herbal supplement that some individuals may turn to in order to

treat mild to moderate depression.4 Unfortunately, St. John’s wort can weaken or

diminish the effectiveness of prescription medications such as anti-depressants,

oxycodone and warfarin.4

8. Name other food medication interactions for which she is at risk.

Another food-drug interaction that this patient is at risk for is her consumption of

grapefruit juice and its reaction to Simvastatin. Consuming grapefruit or grapefruit juice

will increase the plasma concentration of Simvastatin, increasing the cholesterol-

lowering effect and also increasing the side-effects of this medication. 5

9. Write a PES statement. What is your intervention?

Food-medication interaction (Vitamin K and warfarin) (NC-2.3) related to combined

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Drug-Nutrient SIM Case Study
intake of food and medication as evidenced by reported intake of warfarin with

inconsistent intake of foods rich in Vitamin K.

The intervention will include providing education to the patient about consuming a

consistent amount of foods rich in vitamin K to prevent a food-medication interaction

with warfarin. A list of foods high in vitamin K can also be provided if patient is unaware

of these items.

10. How would you monitor and evaluate the results of your intervention?

The results of this intervention can be monitored and evaluated by a 3-day food log to

ensure her intake of vitamin K foods remains consistent. Additionally, her INR and

changes in her warfarin prescription can be monitored to assess her adherence to this

intervention.
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Drug-Nutrient SIM Case Study

1. Patient Data N.A / 66 y.o. / F

 Patient Profile: N.A is a 66-year-old female referred to an RDN by her
cardiologist due to her multiple changes in warfarin dosage and unstable INR.
 Past Medical History / Past surgical history: HTN, HLD, atrial fibrillation, chronic
UTI
 Patient Current Diagnosis: Warfarin prescribed s/p subcortical stroke with no
neurologic deficits. INR remains unstable.
 Present Medical Status / Diagnosis: Pt has a history of mild subcortical stroke
with no neurologic deficits.
 Socio-economic status: Pt is retired and lives with her husband who does most
of the cooking. Pt does not drink or smoke.
2. Nutritional Assessment
Anthropometric, Diet history, medical history, social history, intake, weight history – weight loss or gain,
NFPE, other disciplines physical findings, documentation
 Anthropometrics:
o Wt. 131 lbs / 60 kg
o Ht. 65 in / 1.65 m
o BMI 22 kg/m2
o IBW 125 lbs / 56.8 kg
o %IBW 105%
o Adj wt. – N/A
o UBW – N/A
o Weight history – N/A
 Labs:
o INR 4.0 sec (H)
o Total Cholesterol 189 mg/dL (WNL)
o LDL 90 mg/dL (WNL)
o HDL 44 mg/dL (L)
o TG 100 mg/dL (WNL)
 Medications
o Simvastatin, Warfarin, Bactrim (periodically), Multivitamin (occasionally)
o History of taking St. John’s wort for depression
 Diet / Allergies
o NKA
 Nutritional Status / Estimated Nutritional Needs (kcal, protein fluids)
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o Based upon 25-30 kcal/kg of current body wt 60 kg
 1500 – 1800 kcal/day
o Based upon 0.8 – 1.0 g/kg of current body wt 60 kg
 48 – 60 g/day of protein
o Based upon 1 mL/kcal:
 1500 – 1800 mL/day
3. Nutrition Focus Physical Exam
 Adequately nourished. Multiple bruises noted, located on her extremities. Pt c/o
of muscle aches.
4. Full assessment / Assessment Summary
 Patient is a 66-year-old female referred to an RDN by cardiologist due to her
several dosage changes in warfarin prescription and unstable INR. Patient is
concerned about a future stroke after a history of mild subcortical stroke with no
neurologic deficits. She currently follows a heart-healthy diet. Patient’s BMI is
indicative of a normal weight. Per NFPE, patient is adequately nourished but has
multiple bruises located on her extremities. INR is elevated, 4.0 seconds. Pt
needs education on food-medication interactions. Current medications are
Simvastatin, warfarin, Bactrim and multivitamin.
5. Nutrition Care Process: Implementation of MNT - Medical Nutrition Therapy
 Nutrition Diagnosis
o Food-medication interaction (Vitamin K and warfarin) (NC-2.3)
 PES
o Food-medication interaction (Vitamin K and warfarin) (NC-2.3) related to
combined intake of food and medication as evidenced by reported intake
of warfarin with inconsistent intake of foods rich in vitamin K.
 Nutritional Interventions
o Diet – Continue with current diet.
 Recommendations
o Recommend patient to keep a food log for a week.
o Recommend coordination with other health care disciplines (MD,
pharmacist).
 Goals / Plan
o Patient to maintain a diet consistent with her vitamin K intake.
o Patient to show an INR lab WNL.
o Patient to have no changes in her warfarin prescription.
 Education (if provided)
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Drug-Nutrient SIM Case Study
o Provide education on the importance of consuming a consistent amount
of foods rich in vitamin K to prevent a food-mediation interaction with
warfarin.
o Provide patient with a list of foods high in vitamin K.
6. Federal Regulations / Billing and coding for MNT
 MNT units 15 minutes for initial assessment. Z79.0 Long-term (current) use of
anticoagulants and antithrombotics/antiplatelets
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Summary of disease

Drug-nutrient interactions are one area in which a Registered Dietitian Nutritionist

(RDN) may assist a patient with. This topic can be organized according to the effect a prescribed

medication may have on a patient’s nutritional status, the effect of nutrients on the action of a

prescribed medication or the role of nutrition therapy in increasing the effect of a medication or

minimizing its side effects.6 For this specific case study, the food-drug interaction involves

vitamin K and warfarin, an anticoagulant.

Warfarin is a commonly prescribed anticoagulant or “blood thinner” to patients who

recently have experienced a myocardial infarction. 7 Warfarin can assist in preventing future

blood clots because it is designed to make blood coagulate slower.7 In comparison, vitamin K is

a clotting factor that causes the coagulation of blood to occur more quickly. 7

Therefore, nutrition therapy focuses on consuming and maintaining a diet consistent in

foods rich in vitamin K in order to not affect the action of warfarin. Any changes in diet that may

be an increase or decrease in vitamin K foods should be informed to the clinic staff. 7 Patients

prescribed warfarin should be educated on foods high in vitamin K and to be alert of any

nutritional supplements that contain vitamin K, such as multivitamins and some calcium

supplements.7 Furthermore, large intakes of vitamin E supplementation may lead to a reduced

absorption of vitamin K as they are both fat-soluble vitamins. 7 This information may also need

to be communicated to the patient.

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Drug-Nutrient SIM Case Study

References:
1. Vitamin K. National Institutes of Health Website.
https://ods.od.nih.gov/factsheets/VitaminK-HealthProfessional Updated June 3, 2020.
Accessed December 15, 2020.
2. Nutrition Calculator. INR Tracker Website. http://inrtracker.com/nutrients/ Accessed
December 15, 2020.

3. Warfarin users, beware of antibiotics. Harvard Health Publishing: Harvard Medical

School Website. https://www.health.harvard.edu/heart-health/warfarin-users-beware-
of-antibiotics Published June 2012. Accessed December 15, 2020.

4. St. John’s Wort and Depression: In Depth. National Institutes of Health: National Center
for Complementary and Integrative Health Website. https://www.nccih.nih.gov/st-
johns-wort-and-depression-in-depth Updated December 2017. Accessed December 15,
2020.

5. Lilja JJ, Neuvonen M, Neuvonen PJ. Effects of regular consumption of grapefruit juice on
the pharmacokinetics of simvastatin. Br J Clin Pharmacol. 2004; 58(1): 56-60. Doi:
10.111/j.1365-2125.2004.02095.x

6. Nelms M, Sucher KP, Lacey K. Nutrition Therapy and Pathophysiology. Boston, MA:
Cengage Learning; 2016.

7. Academy of Nutrition and Dietetics. Nutrition Care Manual. Vitamin K and Prothrombin
Time. https://www-nutritioncaremanual-org.ezproxy.gvsu.edu/topic.cfm?
ncm_toc_id=267358 Accessed December 15, 2020.