Archive For: Medications

Pain Management: The New Approach

Fewer Pills, Lower Doses, More Vigilance: The New Approach to Pain Management

It’s hard to imagine a medical crisis more widely discussed, dissected and debated in the last two years than opioid abuse. As a result, clear action steps have been taken, including retooling of the 2016 guidelines for opioid-prescribing protocols – dosage recommendations, follow up assessments and ongoing monitoring were reconsidered and adjusted. In short, for patients with chronic pain not from cancer, nonpharmacological treatment and non-opioid medications should be evaluated first, and opioids used only when:

  • other alternative therapies have not provided sufficient relief, and
  • pain is adversely affecting a patient’s function and/or quality of life, and
  • potential benefits of opioid therapy outweigh

Following are details on the newest developments, and how they may impact the way you’re treated for pain, from hospital bed to physician office.

Minimize and customize dosage. Not surprisingly, the dosage recommendations for exercising caution are lower than in earlier guidelines, beginning with even relatively low doses (20-50 morphine milligram equivalents (MME) per day). The lowest effective dose, for the shortest period needed, will be used to treat acute pain. In most cases, even pain following surgery does not require opioids for more than three days. Several high-profile institutions have changed their opioid prescribing guidelines following surgery.

At Johns Hopkins, a panel of health care providers developed recommendations for the number of five-milligram oxycodone pills needed after almost two dozen common procedures, finding that some required none, while the maximum of 20 pills was appropriate for others. The prescribing limits were designed to help prevent patients from receiving unnecessary opioid pills after surgery and ultimately face a one-in-16 risk of becoming a long-term user.

“Prescriptions for pain meds after surgery should be custom tailored to the operation and a patient’s needs and goals, but the hope is that these guidelines will help reset ‘defaults’ that have been dangerously high for too long,” the study’s author reported in a recent Journal of the American College of Surgeons.

An open discussion. It is now acknowledged that opioids present a risk to all patients, and risks must be clearly presented when starting therapy. These range from common (constipation, nausea) to serious (respiratory problems, opioid use disorder, overdose).

Establish realistic treatment goals. It’s essential to realize there’s no cure for chronic pain, but work toward pain relief to improve function and quality of life. “SMART” goals – specific, measurable, attainable, relevant and time-limited – should be set at the start to determine end points and be continually reassessed.

Continual monitoring. Opioids should only be continued after confirming that clinically meaningful improvements in pain and function were realized without significant risks or harm. In regular checks, patients will be asked to rank their pain, and level of interference with their enjoyment of life and general activity. A 30 percent improvement from baseline scores would be needed to continue the therapy. Reassessments are recommended within a few weeks after starting, and at least every three months throughout the course of treatment.

Not recommended for elderly patients. A body of evidence shows possible harm from long-term opioid use in older patients, who metabolize medications more slowly and so may be prone to side effects such as respiratory and cognitive impairment. UCLA Comprehensive Pain Center experts advise a multidisciplinary approach using psychological support, physical therapy and other complementary therapies.

Proper disposal of unused opioids. Noting that a large part of the opioid abuse crisis was spurred by people taking medications not prescribed to them, new guidelines emphasize not leaving unused pills in the medicine cabinet “just in case.” Patients are advised to dispose of them as quickly and appropriately as possible.

New approaches to addiction. According to a recent editorial in Mayo Clinic Proceedings, looking beyond the “supply side” issue to target the “demand” side of opioid use is critical to addressing why patients were initially drawn to using opioids. The authors recommend screening for depression and other psychiatric disorders which are often the impetus for patients to over-use opioids. Other studies posit that as many as 65 percent of overdoses reported at poison control centers were actually suicide attempts, underscoring the need for comprehensive psychological evaluation and treatment.

Optimize use of non-opioid therapies. A growing list of options includes:

  • Acetaminophen (Tylenol®) or ibuprofen (Advil®)
  • Muscle relaxants
  • Anti-inflammatories
  • Cognitive behavioral therapy – a psychological, goal-directed approach in which patients learn how to modify physical, behavioral, and emotional triggers of pain and stress
  • Exercise therapy, including physical therapy
  • Medications for depression or seizures
  • Interventional therapies (injections)
  • Exercise and weight loss
  • Alternative therapies such as acupuncture

Did You Know?

70–80% – 70-80% Percentage of opioid pills prescribed after surgery not used by patients

Source: Johns Hopkins

The Painful New Reality of Opioid Prescriptions

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Nothing erodes the quality of life faster than pain and unfortunately more than half of American adults report they live with it on a chronic, recurring basis. That makes it easy to understand why, when seemingly safe, effective opioid drugs became widely available in the 1990s, they were quickly embraced by physicians and patients. Considered one of the most promising developments in pain management in decades, opioids such as oxycodone (OxyContin, for example), hydrocodone (Vicodin) or meperidine (Demerol) had already proved highly effective on a short-term basis to treat acute pain. The mechanisms were clear: opioid molecules travel through the bloodstream into the brain, attach to receptors on the surface of certain brain cells and trigger the release of dopamine in the brain’s reward and pleasure center.

However, what was not known was how patients reacted to these medications when taken daily for weeks, months and years to treat chronic conditions ranging from headaches and stubborn lower back pain to neuropathy, fibromyalgia and severe degenerative joint disease. As use of opioids for chronic pain (defined as lasting longer than three months) became widespread, reports of unwanted side effects emerged, along with doubts about long-term efficacy and optimal outcomes. Most alarmingly, the potential for abuse and addiction materialized into a full-blown crisis, evidenced by stark statistics like these:

  • Opioid prescriptions increased 7.3% from 2007-2012; by 2013, 1.9 million people were reported to be abusing or dependent on opioids. As many as 25% of people prescribed opioids on a long-term basis struggle with addiction.
  • 165,000 Americans died from overdosing on prescription opioids from 1999-2014, climbing from 3 deaths per 100,000 people to 9; the highest rates were seen among 25 to 54-year-old white Americans.

Clearly, sweeping changes were needed, and in response, new recommended guidelines for safer pain management were issued by the Centers for Disease Control (CDC) last spring, and received
strong endorsement from well-respected organizations including the American Academy of Pain Medicine and the American College of Physicians (ACP). According to ACP, the recommendations are “reasonable, based on the best available evidence, and find the right balance between educating about the hazards of opioids while recognizing special circumstances where such medications may be an important part of a treatment plan.” The recommendations specify best practices for dosage levels and usage, and raise awareness of the risks posed to all patients by the drugs. Please note that these are recommendations only and may be altered at the discretion of the physician treating you to fit your unique needs. These include:

  • Non-pharmacologic and non-opioid therapy are preferred for chronic pain. Opioid therapy should be used only if expected benefits for both pain and function are anticipated to outweigh risks.
  • If opioids are used, they should be combined with non-pharmacologic and non-opioid pharmacologic therapy, as appropriate.
  • Physicians should establish treatment goals with their patients before starting opioid therapy, including realistic and clinically meaningful goals for pain and function, and an ‘exit strategy’
    should the therapy need to be discontinued.
  • Use immediate-release opioids instead of extended-release/long-acting opioids.
  • Use the lowest effective dosage, and carefully reassess individual risks and benefits when increasing dosage to ≥50 morphine milligram equivalents per day.
  • Prescribe immediate-release opioids for acute pain in no greater quantity than needed for the expected duration of pain – three days or less will often be sufficient, more than seven days will
    rarely be needed.
  • A frank physician-patient discussion regarding the risks and benefits of opioids should take place before starting therapy. An evaluation of benefits and harms should be scheduled within one to four weeks of starting opioid therapy, and repeated at least every three months. If benefits do not outweigh harms of continued therapy, physicians should explore alternatives (see sidebar) with patients and work with them to gradually taper off to lower doses and ultimately discontinue use.

Unlocking the Genetic Code: Spotlighting Pharmacogenomics

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This is the first in a series exploring some of the most promising advances inspired by the Human Genome project. From the burgeoning field of pharmacogenomics to consumer genetic testing such as 23 and Me, the time from discovery to application is progressing rapidly. We’ll look at some of the latest thinking and its impact on personalizing medicine in the future.

To boil down a complex subject to its very human goal, pharmacogenomics means using genomics to get the right dose of the right drug to the right patient at the right time. There is tremendous variability in individual response to drugs, and a large percentage of adverse drug reactions may be due to genetic variables that are just beginning to be really understood.

It’s important to note that while significant progress has been made, the actual use of pharmacogenomics in primary care may be many years away and unlikely to impact the way in which your physician currently prescribes medications for you. However, as research continues to accumulate, the medical community is hopeful that this information will someday help guide prescription decision-making in a much more precise and personalized way.

Did You Know?

1957 – Dr. Arno Motulsky suggests that individual differences in drug efficacy and adverse drug reactions are at least partially attributable to genetic variations

2008 – The Food and Drug Administration releases a table listing genomic biomarkers with established roles in determining drug response

Sources: The National Human Genome Research Project, UptoDate,, JAMA

What we know now

Slightly different, but normal, variations in the human genetic code can yield proteins that work better or worse when they are metabolizing different types of drugs and other substances. Even small differences can have a major effect on a drug’s safety or effectiveness for an individual patient. Your drug-metabolizing enzymes may be set to act in a completely different way than a friend of similar height and weight because phenotypes range from ultrarapid and rapid metabolizers to normal, intermediate and poor metabolizers.
Consider this example from the National Institutes of Health: The liver enzyme known as CYP2D6 acts on 25 percent of all prescription drugs, including the pain reliever codeine. There are more than 160 versions of the CYP2D6 gene, and many of these vary by only a single difference in their DNA sequence. People who manufacture an overabundance of CYP2D6 enzyme molecules metabolize the drug very rapidly, and as a result, even a standard dose can be too much. Conversely, those who carry a CYP2D6 gene that results in a slowly metabolizing enzyme may not experience any pain relief. Armed with this kind of information, a physician may be able to prescribe different types of pain relievers for both of these patients.
The Food and Drug Administration now includes pharmacogenomic information on the labels of some medications, with details on risk for adverse events and side effects, effectiveness for people with specific genome variations, genotype-specific dosing and mechanisms of drug action (the specific biochemical interaction through which a drug substance produces its pharmacological effect). This may eventually help physicians make the right individual patient choices for drugs that include pain relievers, antidepressants, antivirals, statins and blood thinners.
A number of barriers, which includes the lack of clear, evidence-based guidelines, need to be overcome before personalized drug therapy becomes a routine component of mainstream medicine. For now, pharmacogenetics testing is successfully being used in treatment of specific genetically influenced tumors, and for certain medications for cystic fibrosis, inflammatory bowel disease and HIV…important first steps in this promising field.

Defining Terms

  • Pharmacogenomics: A field of research focused on understanding how genes affect individual responses to medications.
  • Pharmacogenetics: Sometimes used interchangeably with pharmacogenomics, it’s actually a subcategory that refers to the role of genetic variation on response to a drug; can be inherited through the germline or acquired as in a tumor.
  • Pharmacokinetics: How a drug moves through an individual’s body, from absorption and distribution through excretion. Blood and urine tests determine where a drug goes and how much of the drug or a breakdown product remains after the body processes it.

Prescriptions: Take Exactly as Directed

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Look inside your medicine cabinet at your prescription bottles and ask: Have I read the label, stickered warnings and instructions? Have I discarded medications past their expiration dates? The Centers for Disease Control (CDC) reports that 80 percent of patients do not take their medications as prescribed. The prevalence of non-adherence to prescription directions has been cited as “America’s other drug problem” by the CDC. The agency estimates more than 125,000 people die annually from problems related to prescription medications, in part due to failure to read or follow label instructions. This number has the potential to increase dramatically over the next few decades, with the growing numbers of seniors, who are prescribed medication most frequently. Currently, 76 percent of Americans 60 and older use two or more prescription drugs, and by age 65, 42 percent take at least five medications weekly.

At every age, it is crucial to know the details about any medication prescribed to you. Consider these commonly asked questions, and you will understand why reading the fine print is essential.

Why do I need to finish an antibiotic? Probably the most common instance of non-compliance is taking fewer or partial doses of an antibiotic, which may allow the resistant bacteria to not only survive, but thrive. Taking a full course of antibiotics is the only way to kill all the harmful bacteria. Additionally, if the first course does not work, subsequent treatments may be more costly, with possible serious side effects.

What happens if I take more or less than prescribed? If you miss a dose, or take less because you feel better, the effectiveness may be reduced and can result in flare-ups of the condition—only if the prescription indicates ‘as needed’’ should you modify the dose. In most cases, experts advise returning to your regular medication schedule, but not to take two doses to make up for the dose you missed, as that can cause unintended side effects. Be careful not to take an extra over-the-counter pain relief pill (acetaminophen) for an intractable headache, as the narrow safety margin places many people “close to a toxic dose in the ordinary course of use,” according to the FDA.

Why do some medications need to be taken with food and others on an empty stomach? Stomach upset, a common side effect, can be lessened by taking a drug with meals, as indicated. For some medicines, the opposite is true, and ingesting food beforehand can delay or decrease absorption of the drug. If ‘take on an empty stomach’ is directed, take the medication first thing in the morning and wait 30 minutes before eating to give the body time to absorb it.

Why is the time of day important? Certain drugs are more effective or better tolerated with specific timing, according to new AARP research. Taking statins at bedtime is advised as cholesterol production in the liver is highest after midnight and lowest in the morning and early afternoon. Pain medications used for osteoarthritis are best swallowed four to six hours before the pain is anticipated to be at its worst. Asthma patients gain the most relief by taking oral medication in the mid-afternoon and inhaled steroids in late afternoon to prevent attacks most commonly experienced at night.

Why can’t I have alcohol with prescription medication? Consumption of alcohol when taking a prescription medication may cause nausea, headaches or fainting. It can also exacerbate medication’s effects, causing you to feel sleepy or lightheaded, and making it harder to concentrate and perform certain tasks.

Why can’t I drive or operate heavy machinery? Some drugs, like those for anti-anxiety, can dull alertness and slow reaction time, while stimulants can impair judgment. Common side effects of medication—drowsiness, dizziness, blurred vision, excitability—all point to the need to stay off the road.

Why should certain foods be avoided? Some medications may not work as well when taken with specific foods. For example, grapefruit contains a compound that affects the way a number of medications are metabolized by the liver and should be avoided or limited as indicated. When taking the frequently prescribed blood thinner warfarin (Coumadin), doctors recommend keeping your diet consistent, particularly with regard to your intake of leafy green vegetables which may impact blood levels.

Can I take drugs after the expiration date? Discard outdated drugs, which may not have full potency, particularly ones in solution or that require refrigeration. Take particular note of medications such as insulin, oral nitroglycerin, biologicals, blood products and epinephrine. Medications with preservatives, such as eye drops, may be unsafe past expiration, as bacterial growth can occur.

New technology can help, such as electronic pillboxes and smartphone apps, or simply use the tried and true pillbox.

Food/Drug Interaction Awareness

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For some of us, an increase in the use of prescription drugs might be a rite of passage as we age. For others who live with a chronic illness, taking several prescription drugs daily is routine. In any circumstance, patients should be knowledgeable about their own medication’s possible side effects, as well as how each drug interacts not only with other medications but also with foods and beverages.

For example, the liver makes proteins with the help of Vitamin K, which form blood clots. Warfarin, commonly known by the brand name Coumadin, is a blood thinner prescribed to block the effects of Vitamin K, thus making it more difficult for blood to clot. Vitamin K can be found in vegetables, fruits, dairy products, beverages, meats and fish, and fats and oils. Because warfarin and Vitamin K work against each other, what you eat could impact warfarin’s effect. Foods containing high amounts of Vitamin K include broccoli, Brussels sprouts, cabbage, mayonnaise and canola oil. It is not necessary to avoid foods with Vitamin K, but rather to keep your diet consistent. A sharp increase or decrease in Vitamin K may require your medication to be modified. Typically, patients taking warfarin have their blood tested periodically to measure clotting time, and dosages may be adjusted accordingly.

Statins, drugs that lower blood cholesterol levels, block the action of a chemical in the liver that is essential for making cholesterol. Eating grapefruit or drinking grapefruit juice can interfere with the statin drugs Zocor (simvastatin), Mevacor (lovastatin), and Lipitor (atorvastatin). Grapefruit or grapefruit juice…as little as one glass or one grapefruit, can interfere with enzymes in the stomach, which in turn prevent them from breaking down these statins. This causes a high accumulation of the drug in your body and could cause liver or muscle damage. Patients taking a statin usually have their blood tested after six weeks and then annually or more frequently to monitor for potential liver or muscle damage.

The class of antibiotics known as tetracyclines is commonly prescribed for treatment of some infections. Drinking or eating dairy products, such as milk or cheese, or taking calcium pills or iron supplements, can interfere with most “cycline” drugs’ effectiveness. These medications are absorbed mainly in the stomach and can bind with calcium, which slows their absorption into the bloodstream. For optimum effectiveness, patients are advised to take cycline medication about one hour before or two hours after consuming calcium rich foods.

There are frequently warnings on prescriptions that say, “avoid alcoholic beverages while taking this medication.” Just how dangerous is having a drink when our prescription bottle warns us otherwise? Amy Peak, PharmD, Director of Drug Information Services for the College of Pharmacy and Health Services at Butler University, says that, “A glass of wine at dinner when you are taking a pain medication might cause you to become groggy more quickly. Drinking a glass of wine and then driving even a short distance home while groggy impairs your ability to react, and that’s a problem.”

Caffeinated drinks like coffee, tea and soda when mixed with some medications, including oral contraceptives or certain antibiotics, can alter how caffeine is metabolized. This causes higher concentrations of this stimulant in the body, resulting in an increased impact of caffeine’s effects (shaky hands, rapid heart rate and inability to sleep). If you are taking medication for high blood pressure and drink a lot of coffee, the combination can inhibit the drug’s effectiveness.

When any new medication is prescribed, be clear on dosage, side effects and any possible interactions. Prescription drugs are accompanied by a “Personal Prescription Information” flyer that delineates side effects and interactions beyond what is indicated on the container.

Statins – Offering a viable option for improving a cholesterol profile

With heart disease the single leading cause of death in America and stroke the third leading cause, the use of statins offers many patients viable treatment and prevention options not previously available.

Controlling your cholesterol level is an important factor in maintaining good health. Cholesterol contributes to heart disease, which can lead to strokes and heart attacks. The World Health Organization estimates that almost 20 percent of all strokes and over 50 percent of all heart attacks can be linked to high cholesterol. But despite the very best efforts at healthy eating and regular exercise, people with a genetic predisposition have bodies that make too much cholesterol no matter what they eat. Certainly, a healthy diet helps, but taking a statin turns down the body’s ability to make new cholesterol.

Statins are a class of drugs prescribed to lower blood cholesterol levels. These drugs block the action of a chemical in the liver that is necessary for making cholesterol. Cholesterol is important for metabolizing fat soluble vitamins like A, D, and E, helping manufacture bile, which helps digest fats. It is also critical for building and maintaining cell membranes. Too much cholesterol in your blood can clog arteries, causing them to narrow or in the most severe cases, blocking them. This can lead to heart attacks and stroke. In some instances, statins can also help the body reabsorb the problematic plaque that has built up on the arteries, thereby preventing further blockage and reducing the chance of a heart attack.

There are many different brands of cholesterol medication, but as yet there is no convincing evidence that any one medication is better than another. Some of the well known medications currently prescribed include Lipitor (atovastatin), Zocor (simivvastatin) and Mevacor (lovastatin). Generic versions, which are less costly, also are available for prescription and may be appropriate in certain situations.

Are statins right for you? When prescribing a statin, physicians consider other risk factors including: family history of high cholesterol or heart disease; degree of activity in your lifestyle; blood pressure; age—55 or older for men, 60 or older for women; general health condition; diabetes; weight; smoking; and narrowing of the arteries in the neck, arms or legs.

If it is determined that statins are a good option for you, a specific dose will be prescribed. Depending on the severity of your high cholesterol, the dose and brand can vary. Once you begin taking a statin, you may need to continue taking it indefinitely. Some people make significant lifestyle changes, lowering their cholesterol enough to go off statins if their doctor advises it.

There can be side effects and risks that come with taking statins as with any prescription drug. Together we will weigh the risks along with the anticipated benefits from taking statins. Common side effects include muscle and joint pain, nausea, diarrhea and constipation. Some people can tolerate statins well, and even those who experience some of the side effects may see them go away over time as their bodies adjust to the medication. Please consult with our office or your pharmacist on whether or not statins may adversely interact with any of your other medications.

It is wise to be aware that a more potentially severe side effect includes liver damage. Statins work by interfering with the production of cholesterol in your liver. As a result, statin use may cause an increase in liver enzymes. We strongly advise having a blood test several weeks after beginning this drug to check liver function, and then periodic blood tests to continue monitoring liver enzymes. If an increase in liver enzymes becomes severe, patients may need to discontinue statin use because this can result in permanent liver damage. Keep our office apprised of any unusual or persistent pain that you may experience if you start taking statins.

Research continues into the impact of statins on our bodies. Some investigation has already shown other benefits beyond lowering cholesterol, including their anti-inflammatory abilities that stabilize the lining of the blood vessels. This could contribute to lower blood pressure and reduced risk of blood clots. Very importantly, statins apparently decrease the potential rupture of plaque on the blood vessel linings, which is one of the most common causes of stroke and heart attack.

There is also early indication that statins may help prevent diseases not related to the heart, including reduced risk of arthritis and bone fractures, some forms of cancer, dementia and Alzheimer’s disease and kidney disease.

Statins hold great potential for improving the health of people with chronic high cholesterol who are at risk for increased incidences of heart attack and stroke. If you would like to discuss whether this medication option is a good one for you, please call our office to make an appointment.

Aspirin? Tylenol? Advil? Aleve?…What’s the difference?

You’ve no doubt heard the question, “Does anyone have an aspirin?” Most of the time, people don’t have a particular brand in mind, just as people ask for a Kleenex when they want a tissue or Xerox when they want to make a copy. But, with aspirin-like products – Bayer, Bufferin, Motrin, Advil, Tylenol, Aleve and others – there are clear differences and their desired effects and disadvantages can be significant.

Acetylsalicylic acid/aspirin (Bayer, Bufferin)

Aspirin was the first over-the-counter pain reliever to be mass produced. In 1900, aspirin was sold as a powder, and by 1915 the first aspirin tablets were made. Aspirin is used to treat headaches, to quell minor aches and pains, and to reduce inflammation. However, it can cause stomach upset, heartburn, and it is also an anticoagulant (blood thinner) which means that people on certain medications, such as Coumadin, should not take pain relievers containing aspirin. That said, aspirin is still the most common over-the-counter pain reliever, available in both brand names and generic versions. Importantly, it is now playing a positive role in the prevention and treatment of heart disease because it is an anticoagulant.

Ibuprofen (Motrin, Advil)

Ibuprofen belongs to a class of drugs called non-steroidal anti-inflammatory drugs (NSAIDs). Ibuprofen is chemically similar to regular aspirin and functions in the body in a comparable way. So how is it different from aspirin? Most importantly, it is usually less irritating to the esophagus and stomach. For patients with ulcers or acid reflux disease, for example, ibuprofen may be the better product. It is also prescribed frequently to reduce menstrual cramps, inflammation from arthritis, sprains, etc. with better results than aspirin.

Naproxen (Aleve)

Although some patients use this medication for headache relief, it is most effective as an anti-inflammatory medication. For arthritis, sprains, sunburn and other inflammation-based pain, naproxen seems to be one of the best products in the over-the-counter pain-reliever marketplace. In comparable doses, it also has a longer-lasting effect in the body, tending to last 8-12 hours rather than 4-8 hours. Note: always be careful to follow dosing instructions. This strong medication can cause serious gastrointestinal problems, sometimes without warning and at any time while you are taking this medication. It is always wise to check with our office before selecting this medication.

Acetaminophen (Tylenol)

All of these aspirin-like products are definitely not the same…as exemplified by acetaminophen. This pain reliever lowers fevers and usually soothes headaches, but is not useful or effective as an anti-inflammatory aid. One of its major benefits is that it causes very few problems with the digestive tract overall, making it the best headache treatment for people with any stomach sensitivities. It is also safer for people on blood-thinning medications, for hemophiliacs, and for children. However, taken regularly over a prolonged period of time, or taken in excessive doses, acetaminophen can be toxic to the liver. The usual dosage for pain relief and its overdose amount are not incredibly different, therefore acetaminophen is sometimes considered to be more dangerous than aspirin, arguing that it is easier to overdose unintentionally.

In summary, make certain to read the ingredients label of these and all over-the-counter medications, to see what else it is partnered with and whether there are additional side-effects. There are various combinations of acetaminophen, ibuprofen and aspirin available – cough and flu, sinus, etc. If you take certain products together you may accidentally take too much of one type of medication. For example, if you take Tylenol and a cough medication in combination, make sure the cough medicine does not also contain acetaminophen. Inadvertently you may be exceeding the recommended dosage.

It is always important to read the drug product labels very carefully. Some, such as aspirin products, have been linked to Reyes Syndrome and should never be administered to children or teenagers with viral or flu-like symptoms. Others, such as Aleve, recommend that you avoid alcohol and prolonged exposure to sunlight. All of these over-the-counter pain relievers may interact with certain prescription medications that you may already be taking. If you have any questions or concerns about which of these over-the-counter medications may be best for your symptoms, please call our office and we will be happy to talk with you about your options.


Shingles Vaccine

You’ve probably had chickenpox. Perhaps your parents even exposed you to the virus as a small child, when you were likely to have a mild case and be done with it. However, the virus remains dormant in your body throughout your lifetime, and could reappear at any time as a painful disease called “shingles” (medical term herpes zoster).

Shingles can be very unpleasant, starting as a skin rash and often erupting with blisters. Its symptoms usually last a week or ten days, sometimes longer, and may include severe pain, chills, fever, headaches, and an upset stomach. About a million Americans get shingles each year, and they all have had chickenpox or received the chickenpox vaccine. It is estimated that half the people who reach age 85 will get shingles at some point. As people age, they become more susceptible to the disease and it can be more severe.

The good news is there is now a shingles vaccine. Approved by the FDA in 2006, the vaccine has been successful in helping prevent the disease. Some of your friends have probably already had the shingles shot, and you may be wondering if it is right for you.

The Centers for Disease Control and Prevention (CDC) recommends it for people age 60 and older, with some exceptions. You should not get the vaccine if you have a weakened immune system or if you have ever had an allergic reaction to gelatin, neomycin, or any of the vaccine’s other ingredients. Other reasons to avoid the shot include a history of certain cancers or tuberculosis, or if you are undergoing radiation or chemotherapy.

Studies show the vaccine prevents shingles in about half the people vaccinated. However, even when it doesn’t prevent the disease itself, it usually reduces the pain and severity of the disease, including permanent scarring and skin discoloration. Importantly, it helps inhibit a lingering and debilitating condition called “postherpetic neuralgia” that affects some 20 percent of shingles patients, can last months, and may even become chronic.

The shingles vaccination involves a single injection of a live, weakened virus. Because it is a live vaccine, side effects might include headache as well as tenderness, redness, swelling, and pain at the injection site. If you develop a rash from the vaccine, it is possible to transmit the virus to a susceptible person, who may get chickenpox but not shingles.

If you are age 60 or older, have had chickenpox, and don’t believe you have any health issues that would prevent you from being a candidate, I recommend that you consider the shingles vaccination. If you have any questions, please call my office and I will be happy to talk further with you. As mentioned earlier, even if you receive the injection and still get shingles, the vaccine could help you avoid more serious complications.

Patients Inquire…

Since shingles is a herpes virus, is it related to other herpes disorders, such as cold sores or genital herpes?

The answer is “No.” The only connection is that each of these conditions is a form of herpes, defined as “a viral disease causing skin eruptions.”

Medications – What you should know!

Here are some common medication questions—with answers!

Are generics and branded drugs identical?

Patients wonder why generics don’t look or taste the same as branded drugs, and they worry about generics’ side-effects. According to the Food and Drug Administration (FDA), “The active ingredient (in generic drugs) is chemically the same as the branded counterpart.” Regarding appearance, they cannot look identical because in the United States, trademark regulations prevent the sale of generic drugs that look exactly like the brand-name drug. Also, inactive ingredients such as flavors and preservatives, and the manufacturing process may differ. Side effects and treatment efficacy may vary based on these and other subtle differences. So while these drugs are not exactly identical, generics will often be recommended when they are available. Most patients will ask for the generic prescription option, since it is almost always a cost savings.

Not all drugs have a generic counterpart. In being your own health care advocate, I suggest if the pharmacist offers a generic substitution, check with our office to determine what is most appropriate for you.

What about off-label drugs?

In the United States new drugs are tested in three phases of clinical trials (research studies) before they are approved for use by the general public. The clinical trials are done to prove that the drug effectively treats a certain medical condition, works the way it is supposed to, and is safe when used as directed. When the FDA is satisfied that the drug is safe and effective, it works with the maker of the drug to create the drug label. This is not an actual label that sticks onto a container, but a report of very specific information. The FDA also must approve this report, which is made available to physicians and pharmacists who prescribe and dispense the drug. The drug label contains information about the drug, including the approved doses and how it is to be given to treat the particular medical condition for which it was approved. When a drug is used “off-label” it is most commonly given for a different disease or medical condition than described in the FDA-approved label. Or, it may be given by a different route, or in a different dosage.

For example, most of us are familiar with the benefits of Botox Cosmetic as a facial wrinkle treatment. Botox injections for migraines were discovered accidentally during clinical testing for Botox Cosmetic. When test patients who normally suffered from headaches reported fewer facial lines and fewer migraines, Botox began its progression from popular cosmetic treatment to medical remedy.

Botox injections for migraines are currently in Phase III of their clinical studies. While the treatment has not yet been FDA-approved for migraines, these injections for headaches are commonly administered by physicians as a viable treatment option. This is considered off-label use. When doctors discover that an off-label use works well, it can become the “standard of care.”

Is it OK to split pills in half?

The answer is – sometimes. Generally, a pill that is twice your normal dosage costs about the same as the smaller dose. So, by splitting double-dose pills in half, your savings could be substantial. The pills best suited to splitting – and according to some medical professionals, the only pills – are those scored down the middle, making them easier to divide. But splitting only works well for certain medications, and numerous reports warn that some pills should never be split. Examples include: longacting, extended- or continued-release tablets or capsules, any capsules that contain powders or gels, birth control pills, and chemo therapy drugs. If you are thinking about splitting your pills, talk to my office about which of the medications you take can be split safely… and be sure to purchase an inexpensive pill-splitting device rather than using a knife.

What are the effects of medication on taste?

Some drugs cause food to taste differently, or they can cause a metallic, salty, or bitter taste in your mouth. Clinical studies have implicated over 250 drugs that can alter taste sensations. And, while it is not known exactly how these medications influence taste, it has been established that medications can have an impact on taste through decreased secretion of saliva. This side effect from certain medications can also lead to problems with chewing and swallowing food. In turn, some patients decrease their food intake, which can be dangerous for many people—especially those who are older or who already have health problems. If your symptom is significant, please call our office as sometimes there can be alternative solutions.

Is it safe to take drugs that have expired?

Today the general consensus from pharmaceutical professionals is that most expired drugs are safe to take for a limited period of time after the expiration date. The expiration date on both prescription and non-prescription medication signifies that the drug will remain at full potency up until that date. However, this does not mean that drugs past this expiration date are necessarily unsafe to use or are spoiled. Before taking a pill beyond the expiration date, keep in mind that liquid medications and medications that have been stored in a warm, moist environment degrade more quickly than solid medications that have been stored in a cool dry place. All of the above being stated, use your own good judgment. The wisest choice with an expired drug is to call your pharmacy and ask before you take even one dose. After all, good health is a collaborative effort!