Outsmarting Osteoarthritis

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by: Mylo Wells, , PharmD Candidate, 2018, University of Iowa College of Pharmacy

Bone chilling cold is often used to refer to the low temperatures that have been experienced in the Midwest this winter season. For people with osteoarthritis this takes more of a literal meaning as changes in the weather can cause worsening of symptoms associated with arthritis. In the United States 30 million people currently deal with the aches and pains that come along with this condition. Symptoms range from sharp pain usually brought on by physical activity to constant dull or aching pain that may limit activities of daily living. If you have arthritis, below are some treatment options that will help to provide some relief and may have you ready to shovel your walk the next time it snows.

Where to Start

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Physical activity has been shown to decrease pain and improve function by nearly 40% in adults with arthritis. Moderate physical activity for 150 minutes per week is recommended to be beneficial for arthritis symptoms. This can be as simple as walking, biking, swimming or gardening for 30 minutes 5 days a week. It is okay to break up the 30 minutes of activity into more than one session per day if necessary. Weight loss that may accompany the physical activity also helps to decrease pressure on the affected joint(s) also providing relief.

Next Steps

Medication therapy is the next place to turn when partial or no relief is obtained with physical activity. There are several options both over the counter and prescription only. The best choice depends on where the arthritis is occurring and some patient specific factors including things such as age.

Topicals

For mild arthritis pain, topical agents are considered the safest options for most patients of any age. They are good options for hand and knee arthritis and in some cases effective for back and hip.

Counterirritants provide modest pain relief but are not considered effective for relieving severe pain. These typically contain menthol and camphor as active ingredients and are available over the counter.

-Icy Hot, Tiger Balm Arthritis Rub and Biofreeze are some common medications in this category.

Salicylates provide modest pain relief as well. They have mild anti-inflammatory effects and are often used in combination with counterirritants. Formulations are available over the counter.

-Aspercreme, Bengay and Sportscreme are common topical salicylates.

-Thera-gesic creams, Bengay Ultrastrength Cream, Icy Hot Cream are common combination products.

Capsaicin is derived from chili peppers. It creates a heat sensation on the skin and reduces levels of “substance P”-a substance secreted by nerve endings that binds with pain receptors. This is considered effective for deeper joints like the hip and back and is available over the counter.

-Capzasin and Zostrix are common capsaicin contain products

 

Lidocaine blocks transmission of nerve messages of pain to the brain. It helps to reduce sensation or numb painful stimuli. It is contained in topical preparations as well as patches. It is commonly used for back and hip associated arthritis. It is available over the counter and at higher concentrations as prescription only. In patients with cardiac issues it should generally be avoided due to possible systemic absorption.

-Salonpas, Aspercreme w/ Lidocaine and Lidoderm are all common products which contain lidocaine.

Topical NSAIDs have anti-inflammatory effects so they are helpful in reducing inflammation and pain in the arthritic joint. These are a top choice for people who are 75 or older. They are available as a prescription patch, gel or topical solution. Considered effective for moderate to lower level severe joint pain. Diclofenac is the active ingredient in these preparations.

-Voltaren Gel, Flector Patch and Pennsaid are the three available options in this category.

Oral Medications

Oral options can be used alone or along with topical medications. They are considered to provide moderate to severe pain relief. Not all oral medications are safe for every age group or people that may have other health conditions. Oral medications can be used to help treat most types of arthritis including hand, knee, hip and back.

Acetaminophen provides analgesic effects but little anti-inflammatory action. It is most effective when taken on a scheduled basis. This is not a good option for people with liver damage or people who frequently consume alcohol.

-The recommended dose for arthritis is 1000mg four times daily. The maximum daily limit is 4000mg in 24 hours so it is important not to exceed this dosage.

Oral NSAIDs provide analgesic and anti-inflammatory effects. They are generally taken on a scheduled basis but can be used on an as needed basis as well. These are not a good option for people with kidney damage or who have bleeding disorders/are on anticoagulant therapy. Also, people who are 75 or older should try topical products before using oral NSAIDs. If long term use is necessary, GI protective therapy may be used to prevent the development of ulcers. There are over the counter and prescription medications available.

-Recommended ibuprofen dosage is 1200 to 3200 mg/day divided in 3 to 4 doses.

-Recommended naproxen dosage is 375 or 500 mg orally twice daily which may be adjusted up or down based on clinical response. A dose of 1500mg per day is considered the maximum safe dose for prolonged use.

-Meloxicam, diclofenac, celecoxib and other prescription NSAIDs can also be used for arthritis.

Duloxetine is generally used as an anti-depressant medication but has been shown to be beneficial in arthritis. It can be used alone or in combination with other treatment options including oral NSAIDs. It is considered the second line oral medication option. Duloxetine is prescription only.

-The effective dose for arthritis is 60 to 120 mg once daily.

Injections

Intraarticular glucocorticoid injections are steroid injections placed in the joint. These are administered in patients with moderate to severe pain and in those who have not had success with or cannot use other treatment options.

Treatment Options That Have Not Been Shown to Be Effective

Opioids-do not use

Hyaluronans (hyaluronic acid)

Nerve Stimulation

Glucosamine and chondroitin-okay to use, just lack of evidence

Other Nutritional Supplements-okay to use, just lack of evidence

Last Line

Many people can help control their arthritis symptoms with exercise and/or medications. For those that have severe pain with no relief surgery is an option. Knee and hip replacements are major surgeries which take months of time and physical therapy to recover from but do often help those who received little or no relief from other options.

The next time you stop by the pharmacy, make sure to ask one of the pharmacists what they would recommend for treatment of your arthritis symptoms so you can get back to activities you enjoy this winter and spring.

References

Deveza MD, Bennell PhD. Management of knee osteoarthritis. Hunter D, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on January 15, 2018.)

Centers for Disease Control and Prevention. (2018). Arthritis. Retrieved from https://www.cdc.gov/arthritis/index.htm

Arthritis Foundation. (2018). Arthritis Medication. Retrieved from http://www.arthritis.org/living-with-arthritis/treatments/medication/

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Vitamins & Minerals: Who should take what?

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by: Stephen Vavroch, PharmD Candidate, Class of 2018, University of Iowa College of Pharmacy

Micronutrients are chemicals that are essential in minuscule amounts for our bodies to maintain their normal functions through basic metabolism. Micronutrients include vitamins and minerals. Most vitamins and minerals are obtained from the foods we eat. However, lack of dietary diversity or unhealthy eating can result in a deficiency that may require supplementation.

Taking a multivitamin doesn’t make you healthy

The main source of your vitamin and mineral intake should come from the foods you eat. Supplementation may help in certain cases, but unless you are deficient in a particular vitamin or mineral, there is very little research supporting supplementation in the prevention or treatment of chronic diseases. The old saying, “too much of a good thing” also applies to vitamins. Certain vitamins like vitamins A, B9, and E can result in harmful effects when taken in excess. There are certain populations that can benefit from taking certain vitamins and minerals, however. These populations include infants and children, pregnant women, and midlife and older adults.

Infants and children

The American Academy of Pediatrics recommends vitamin D and iron supplementation in infants that are breastfed. 400 IU of vitamin D and 1 mg/kg/day of iron are the recommended daily doses. Supplementation should continue until the child consumes regular vitamin D-fortified whole milk and iron-containing foods. Infants getting formula usually do not require additional supplementation because vitamin D and iron are often included. Children consuming a healthy diet should get all of the vitamins and minerals they need from the food they eat, so supplementation is not usually necessary.

Pregnant women

Folic acid (vitamin B9) should be consumed by women of childbearing age and throughout pregnancy to prevent neural tube defects in developing fetuses. These women should be consuming at least 0.4 mg of folic acid per day to reach the recommended daily dose. Women at higher risk of neural tube developmental defects may need higher amounts of folic acid. Prenatal vitamins often come with the recommended amount of folic acid, along with several other vitamins/minerals important during pregnancy including vitamin D, iron, and calcium.

Midlife and older adults

As people age, they become less efficient at absorbing certain micronutrients. Specifically, adults over 50 years old may not absorb vitamin B12 as adequately as they did in their youth. Calcium and vitamin D are also recommended in this population to promote bone health. 1000 mg of calcium and 600 IU of vitamin D are the daily recommended amounts in premenopausal women and men aged 50 to 70 years, and that daily recommendation increases to 1200 mg of calcium and 800 IU of vitamin D in postmenopausal women and men over the age of 70.

Regular multivitamin use is not recommended in the average healthy adult population due to the limited research regarding its benefit in chronic health outcomes. With minimal adverse effects, the risks associated with taking a daily multivitamin are relatively low, however. A healthy and well-balanced diet should be the primary source of your micronutrient content and taking a multivitamin does not count as an appropriate substitute. For a listing of the different vitamins, their potential uses, and what foods to find them in, refer to the attached handout.

  1. Manson J, Bassuk S. Vitamin and Mineral Supplements. JAMA. 2018;319(9):859.

Guide To Over-The-Counter Cough Relief

Man Coughing
By: Christopher Petersen, University of Iowa College of Pharmacy, 2018 PharmD. Candidate

A cough is an important reflex for your body’s natural way to get mucus and other foreign material out of the lungs. Cough is the most common symptom for which people seek medical care and Americans spend more money annually on over-the-counter (OTC) cough and cold products than any other category of OTC products.

Selecting The Appropriate OTC Cough Medication:

With so many OTC cough medications; choosing the drug that is best for you depends on the nature and cause of the cough. There are typically two different kinds of coughs; one is described as wet because with this type of cough mucus is coughed up. Clear mucus is often indicative of bronchitis where colored mucus may suggest a bacterial infection. The other kind of a cough is described as dry or hacking. Dry coughs may be associated with viral infections, acid reflux, heart disease, and can be a potential side effect from other medications.

Wet Cough Recommendations: Guaifenesin

Brand: Mucinex, Robitussin Mucus + Chest Congestion

Guaifenesin is a protussive (expectorant) that works by changing the texture of the mucus in the lungs and it increases the amount of mucus removed by coughing.

Dry Cough Recommendations: Dextromethorphan

Brand: DayQuil Cough, Delysm 12 Hour Cough, Robitussin Long-Acting Cough Gels

Dextromethorphan is an antitussive (cough suppressant). These work to control or stop the cough by decreasing the likelihood of coughing. Stopping a wet cough may lead to a bacterial infection since the bacteria remains in the lungs.

Nonproductive Cough Recommendations: (First-Generation Antihistamines)

Brand: Benadryl (diphenhydramine), Chlor-Trimeton (chlorpheniramine)

Many people do not think to use antihistamines for cough relief. Antihistamines are relatively low cost medications that work by increasing the tolerance for not coughing. They are most often used for deceasing coughs associated with a runny nose or allergies. Mucus running down the back of the throat from the nose is often the cause the cough. The drying effects of antihistamines decrease the mucus in the nose and therefore it is less likely for one to cough.

Combination Products: Dextromethorphan and Guaifenesin

Brand: Robitussin Cough + Chest Congestion DM, Mucinex-DM, DayQuil Mucus Control

Recommendations for dextromethorphan and guaifenesin in combination are debated among medical professionals. Some say that using dextromethorphan will suppress the cough and therefore one will not cough up the mucus. This may get rid of the beneficial effects of guaifenesin. Others say that dextromethorphan will decrease the urge to cough and therefore reduce the amount of coughing; when one does cough the guaifenesin will work to increase the amount of mucus coughed up.

Multi-Symptom Combination Products:

Brand: (DayQuil/NyQuil, Robitussin Multi-Symptom Cold, Tylenol Cold + Flu, Mucinex Multi-Symptom Cold & Fever, Advil Cold & Flu, Alka-Seltzer Plus Flu)

 These products often contain similar active ingredients including an analgesic (pain medication), cough suppressant, nasal decongestant, and an antihistamine. These products have been marketed very well and may seem convenient. Combination products can potentially lead to drug interactions, side effects, and may worsen certain medical conditions. More active ingredients in a product means that you have more potential for side effects. It is recommended to select the product with only the ingredients that are necessary to treat your symptoms. Ask your pharmacist what product may be best for you if you are unsure of what the ingredients in a product.

Dosage Formulations: Liquid, Tablet, Capsule etc.

Cough products are available in a variety of dosage formulations and all have similar effects. It is generally recommended that you select the dosage formulation that is most convenient for you. Ask your pharmacist if the product you are looking for is available in the dosage form that you prefer.

What Else Can I Do?

Drinking water soothes the throat, loosen mucus, and helps prevent dehydration. Using cough drops may reduce coughing by relieving throat irritation. Humidifiers increase the moisture in the air, which may decrease airway irritation. Humidifiers work well for babies and young children (< 6 years of age) as cough medications have not been proven to be effective in this population. Mucus in the nose may be the cause of the cough in babies and a nasal bulb may be used to clear their mucus.

When To Seek Further Medical Attention:

  1. Cough that lasts longer than 7 days or keeps coming back
  2. Children < 4 years old
  3. Cough that produces colored mucus or blood
  4. Cough that may be a side effect of a certain class of medication (angiotensin converting enzyme inhibitors: lisinopril, enalapril, benazepril, captopril)
  5. Cough that is accompanied by a fever >102
  6. Cough associated with a chronic medical condition, such as COPD, asthma, heart failure, or chronic bronchitis
  7. Cough that worsens as a cold or flu resolves
  8. Cough associated with breathing in dust or particles
Tietze, K. J. (2015). Chapter 12: Cough. In Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 18th Edition. Washington, District of Columbia: American Pharmacists Association. doi:10.21019/9781582122250.ch12

Ask Your Pharmacist: Should I take Advil or Tylenol for pain?

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Pain is one of the most common symptoms that people seek to relieve by self-treating with over-the-counter (OTC) products. Pain is also a symptom that causes many people seek further medical attention. You may ask yourself, should I go to the doctor or can I take an over-the-counter pain medication?

Before you decide to take medication to relieve your pain, check this list to determine if going to the doctor for further evaluation is appropriate.

Seek Medical Attention If You:

  1. Have severe pain (pain of ≥6/10 on the pain scale)
  2. Have pain that lasts 10 days or more
  3. Have pain that continues despite 7 days of the use of a topical (cream, ointment, gel) pain reliever
  4. Notice an increased intensity or change in character of the pain
  5. Have pelvic or abdominal pain (other than menstrual pain or cramps)
  6. Also have nausea, vomiting, fever, or other signs of infection or disorder
  7. Have a visually deformed joint, abnormal movement, weakness in any limb, numbness or suspected fracture
  8. Are pregnant
  9. Are looking to treat pain in someone <2 years of age

Self-Treatment:

There are only a few brands, but many generic OTC pain relievers. The following is a chart to help you determine which products have the same active ingredients. Ask your pharmacist what generic pain reliever is equivalent to the brand that you are familiar with and if that product is appropriate for you.

Brand ($$$) Generic ($)
Tylenol Acetaminophen
Advil, Motrin Ibuprofen
Aleve Naproxen

Acetaminophen is the most commonly used pain reliever in the world. It may be a good choice to treat headaches, arthritis pain, and fever. Acetaminophen is typically safe for healthy individuals when taken in small to moderate doses. In large doses acetaminophen can lead to liver failure or death.

Ibuprofen and naproxen are medications from the same class that are used to treat pain and swelling/inflammation. For example, menstrual cramps, headaches, toothaches, backaches, arthritis, muscle sprains, and gout are all short-term medical conditions that are associated with pain and swelling that can be reduced by ibuprofen and naproxen.

Ibuprofen and naproxen should be used for the shortest amount of time and at lowest dose possible to provide pain relief. Long-term use may lead to heart issues, high blood pressure, stomach/ intestinal bleeding and kidney damage.

Many people think that these pain medications are completely so they commonly used without recognizing the potential risks. Generally, they are safe to use, but not for everyone. You should consult your pharmacist when selecting an over-the-counter pain medication if you are taking one of the following medications or if you have one of the following medical conditions in order to avoid drug interactions or complications to your medical condition.

When to Avoid Ibuprofen or Naproxen:
Medical Condition Also Taking
·      High Blood Pressure
·      Kidney Disease
·      Heart Failure
·      After a Heart Attack
·      Stomach Ulcers
·      Asthma
·      Over 65 years of age
·   ACE inhibitors: (lisinopril, enalapril, benazepril)
·   ARB: (losartan, olmesartan)
·   Beta Blockers: (metoprolol, bisoprolol, carvedilol, atenolol)
·   Diuretics: (hydrochlorothiazide [HCTZ], chlorithalidone, triamterene)
·   Anticoagulants: (warfarin, Xarelto, Eliquis, Pradaxa, Saavaysa)
·   phenytoin
·   alendronate
·   digoxin
·   methotrexateAny other prescription NSAID: (meloxicam, piroxicam, diclofenac, celecoxib) Use caution if you also taking aspirin
When to Avoid Acetaminophen:
Medical Condition Also Taking
 

·      Liver Disease
·      Alcoholism

·   warfarin
·   ≥3 alcoholic drinks/day
·   Other medications containing acetaminophen:
Ø  Common ingredient in OTC sleep aids and cough/cold products
Ø  Ingredient in many prescription pain medications (opioids)
Any other medication containing acetaminophen – the maximum total daily dose of acetaminophen from all medications is 4000 mg 
   *The list of medical conditions and medications above is not a complete list. You should talk to your pharmacist about other any questions or concerns regarding this list.*

 

 

 

E-cigarettes – What You Need to Know

by: Cole McKenzie, University of Iowa College of Pharmacy, Class of 2018

E-cigarettes entered the market in the United States back in 2006 and their use has dramatically increased over the years.  The many uncertainties question e-cigarettes safety and whether they help tobacco users stop smoking. There is question about long-term health effects as well as public health concerns about the effects e-cigarettes are having on smoking prevalence and access for adolescents.

What is an e-cigarette?

An e-cigarette consist of a refillable cartridge containing a liquid, an atomizer (vaporization chamber with a heating element), and a battery. When a user inhales an e-cigarette the atomizer heats the liquid which creates a vapor that duplicates tobacco smoke, but is not. As a result of how e-cigarettes work, “vaping” is a common term used to describe when an individual uses an e-cig.

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©2017 UpToDate® E-cigarette

So what’s the problem with e-cigarettes?

Currently, the United States FDA is not regulating them, so consumers of e-cigarettes are unaware of what exactly they are inhaling. The main components found in the liquid of e-cigs are nicotine, propylene glycol or glycerol, and flavoring. Chemical analysis of products available in the US has shown inconsistency with the manufacturer’s package labeling. Some products said to be nicotine-free have been found to contain nicotine, whereas others that have claimed to have a specified amount ended up containing higher concentrations. Toxic metals such as tin, lead, nickel, and chromium have also been found in e-cigarette liquids.

Another area of public concern is that unlike conventional cigarettes, e-cigs are able to be sold with different flavorings. With over 7,000 flavors available it should come as no surprise that it appears e-cigarettes are attracting the youth, many of which who are not already smoking. Data and surveys predict that from 2011 to 2014, e-cigarette use in high school students has increased from 1.5 to 13.4 percent.

Surveys have shown that a majority of e-cigarette users are made up of current conventional smokers of cigarettes. This majority of users view e-cigarettes as a tool to help them quit conventional cigarettes or reduce their use. At this point e-cigarettes are still too new to the market to determine if they could be a useful tool for people trying to quit conventional cigarette smoking. There are also the additional health concerns of inhaling e-cigarette’s contents and their alarming rise of use among the adolescent population. It will be interesting to see whether e-cigarettes will continue to expand and whether congress will begin to push for more regulations.

National Immunization Month

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August is National Immunization Awareness Month (NIAM). NIAM was established to highlight the importance of vaccination for people of all ages. Additionally, it was put in place to encourage people to ensure that they are up to date on the vaccines that are appropriate for their age. Vaccination is vitally important as it has helped eradicate and lower the severity of many diseases that once were a serious threat.

What is a vaccine?

The first vaccine was developed by Edward Jenner when he was able to help provide protection against smallpox by inoculating people with the cowpox virus. Since then, many more vaccines have been able to be developed, and as a result, many diseases have been eradicated. A vaccine is able to pass what is called active immunity to an individual, and they will be able to avoid contracting a disease. Some vaccines have dead forms of the virus or bacteria and others have low concentrations of the active virus. While most vaccines are given as shots, other vaccines have been made to be a flu mist or even as a solution that patients can drink.

Do vaccines cause autism?

No! In 1998, Andrew Wakefield published a study that established a link between MMR and autism, which received a lot of publicity and caused a lot of widespread concern. The study was poorly done, and a lot of other aspects of the published study were incorrectly attempted. The journal that published the article retracted the article, and Wakefield and all other involved with the study were guilty of several ethical violations. Since then, CDC has issued multiple statements stating that there is no link between vaccines and autism.

How do I figure out what vaccines I need?

First, obtain a record of your immunizations from your doctor. Additionally, the state usually keeps track of the immunizations that you have received as well through a program that pharmacies and providers can access. Once you have this information, you can discuss options that are appropriate for you with a pharmacist or other healthcare provider. The CDC has recommended schedules available online (see first link listed under additional resources).

What if I don’t see a doctor regularly? Where else can I receive vaccines?

Pharmacists are now able to administer all vaccines to patients over the age of 18 without a prescription. It may be a good idea to double check with your pharmacy to see if they have the vaccine you need in stock.

Additional Resources:

2017 Vaccine Schedules for Adults and Children: http://www.cdc.gov/vaccines/schedules/

CDC Vaccine Website: http://www.cdc.gov/vaccines/parents/index.html

National Immunization Awareness Month Page: http://www.cdc.gov/vaccines/events/niam.html

 

Obstructive Sleep Apnea: An Overview

By: Quinton Franklin, University of Iowa College of Pharmacy, Class of 2018.

Obstructive sleep apnea, otherwise known as OSA, is the most common sleep related breathing disorder with an estimated 26% of adults aged 30-70 having obstructive sleep apnea. Despite the large prevalence, an estimated 80% of moderate or severe OSA cases go undiagnosed. OSA can also have a large impact on your health, causing fatigue, impaired concentration, daytime sleepiness, increased blood pressure, severe gastric reflux, depression and irritability, brain damage, and even sudden death. Given the high prevalence, frequently missed diagnosis, and consequences of untreated OSA, it is important to be educated on OSA and how it is treated.

What is Obstructive sleep apnea?

Obstructive sleep apnea is a sleep disorder where the airway is completely blocked leading to a cessation of breathing. In OSA, loud snoring can be caused due to the increased effort needed to make air pass through the blocked airway and into the lungs. Complete airway obstruction can be due to the structure of the face, leading to components of the mouth such as the tongue, palate, and tonsils completely blocking the airway. The risk of OSA is increased in men, obesity, increasing age, abnormalities of the face and upper airway and those with a family history of OSA.

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How do I know if I have obstructive sleep apnea?

Unfortunately, OSA does not have an easy and specific diagnostic test. If you suspect that you have OSA, or have symptoms such as waking in the night, excessive snoring or cessation of breathing reported by a partner, daytime sleepiness, wake to excessively dry mouth. or other signs of poor sleep, It is important to let your healthcare provider know. Depending on their decision you may be asked to participate in a sleep study, where you will be monitored overnight to check for the presence and frequency of blocked breathing during your sleep.

How is Obstructive sleep apnea treated?

Thankfully obstructive sleep apnea is easily treatable through a variety of methods. OSA can be treated through weight loss if needed, modifications to sleep posture, decreased sedative use, or by way of a continuous positive airway pressure device or CPAP.

What is a CPAP?

A CPAP helps to keep the airway open by way of pressure gradients, increasing the amount of air delivered to the lungs. For best results, it is important to find a CPAP mask that fits snug onto your face, and that is not too loose or tight and to use your CPAP daily. In addition, it is important to keep your CPAP clean and properly maintained, as dirty CPAP machines decrease effectiveness and can cause bacterial infection.

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Here at NuCara we employ several respiratory therapists to help you select a CPAP device, mask, supplies, and give further instructions and tips on how to use your device. For more information, look to our website http://www.nucara.com.