May 2018

We dispense a lot of generic antidepressants to our patients. Are there any over-the counter treatment options??

St. John's Wort and treatment of depression

Common Names: St. John’s wort, hypericum, Klamath weed, goatweed.
Latin Name: Hypericum perforatum: flowering tops of St. John's wort are used to prepare teas, tablets, and capsules containing concentrated extracts. St. John's wort consists of the dried, above ground parts of H. perforatum gathered during flowering season near the end of June around the Feast of St. John the Baptist (June 24th). Antidepressant activity of SJW is attribute to its hyperforin content, which is highest in the plant during its flowering season. Hyperforin has strong reuptake inhibitor effects on all four of the mood neurochemicals (serotonin, norepinephrine, dopamine and GABA)

USE: depression, dysthymia, and sleep disturbances.
DOSE: most common regimen is 300mg up to 3 times daily up to 6 weeks Before we even discuss all the ramifications of using this drug, consider the following:
  • Should we even be considering the treatment of depression as “treatable” condition for our patients? Do we have the clinical skills necessary to manage treatment of depression? This pharmacist certainly does not.
  • Before recommending this herbal, remember that inadequately treated depression may become severe and, in some cases, may be associated with suicide.
EVIDENCE
  • The German Commission E has recognized St. John's wort as a "modestly effective" antidepressant. Some sources say it is comparable to low dose SSRI’s (like Prozac) or Tri Cyclic Antidepressants (like Elavil)
  • Doubtful efficacy for the treatment of moderate to severe major depressive disorder
  • Remember: Some studies highlight the ongoing concerns with placebo response rates in antidepressant studies which have recently been estimated to be as high as 35—45%. Almost ½ of your patients will get a positive effect from taking a placebo.
  • Usual dose: The usual dose for mild depression and mood disorders is 300 mg (standardized to 0.3% hypericin extract), 3 times per day, with meals. As with all antidepressants expect about three weeks for benefit.
  • Topical use: some value for treating Herpes labialis. Dynamiclear is a single application product for cold sore treatment. He topical oil may have some value in treatment of psoriasis lesions.
PRECAUTIONS
  • potent photosensitizer- make sure patients are using sunscreen. Risk increases when patients take 2-4 grams of St. John’s Wort extract (contains 5-10mg hypericin)
  • may precipitate manic attack if a patient is bipolar
  • Combining St. John’s wort with certain antidepressants can lead to a potentially life-threatening increase of serotonin, thus precipitating “serotonin syndrome”. Serotonin syndrome symptoms range from tremor and diarrhea, confusion, muscle stiffness, tachycardia (rapid heartbeat), seizures, hyperthermia (high fever), and even death. Dextromethorphan may also precipitate serotonin syndrome when given with antidepressants.
  • Avoid if pregnant or nursing
DRUG: DRUG INTERACTIONS: CYP450-3A4 inducer (expect to decrease levels of interacting drugs), avoid using St. John’s Wort with any drug metabolized by the CYP450-3A4 pathway especially:
  • Warfarin and anticoagulants
  • Phenobarbital and phenytoin
  • Digoxin
  • Other antidepressants
  • Birth control pills
  • Some HIV drugs (NNRTI and Protease inhibitors)
  • Monamine oxidase inhibitors (MAOI)
  • Alprazolam (Xanax) will speed up its metabolism and decrease efficacy by half.
We can tell that by our purchases of generic Zoloft, Prozac, Celexa and Lexapro in bottles of 500 or 1000 that depression is one of the most common conditions we treat in our pharmacies. Although this herb is in the “Top 10” of herbs used in the United States it also made the “Top 4 Herbal Supplements Your Doctor Hates” list by US News and World Report (2/22/12).

If our patient's would insist on counseling or the appropriateness of St. John's Wort the minimum "screening questions" we could ask are: (source: aafp.org)
  • "During the past month, have you often been bothered by feeling down, depressed, or hopeless?"
  • "During the past month, have you often been bothered by having little interest or pleasure in doing things?"
Given the facts of the drug interactions, the placebo effect of treating depression, the potential for serotonin syndrome and even suicide, self-management of depression for our patients is not recommended. Let’s leave the treatment of this condition to clinicians with some level of experience. I'm not recommending that we become amateur psychiatrists!

Have a great day on the bench!!

Most of our migraine patients will do anything to alleviate the severity or frequency of their headaches. This herbal product might be of benefit.

Feverfew... neurologist recommended!

Petasites is a genus of flowering plants in the sunflower family, that are commonly referred to as butterburs and coltsfoots. Tanacetum parthenium, Chrysanthemum parthenium (feverfew, bachelor’s buttons, featherfew) is ranked #19 as the most often used herb in the US. The leaves or flowers, which can be fresh or dried, as well as a tincture are available. The active ingredient parthenolide, has been studied to prevent menstrual cramps, cancer, as well as treat rheumatoid arthritis and migraine headaches. Petasin appears to be a major active compound of petasites hybridus extract. It has inhibitory activities on leukotriene generation in eosinophils and neutrophils. This indicates that it may have anti-inflammatory and anti-allergy properties.

EVIDENCE FOR USE:
  • MIGRAINE HEADACHES: Some research suggests that feverfew may be helpful in preventing migraine headaches; however, results have been mixed and more evidence is needed from well-designed studies. Five trials (total 343 patients) were unable to establish that feverfew is efficacious for preventing migraine. There is insufficient evidence from some controlled clinical trials that feverfew was better than placebo for migraine treatment. Side effects were minimal with only mild and transient adverse events were reported in the included trials. Some of the trials used an alcoholic extract, while trials that used the dried leaves seemed to show more efficacy for migraine treatment.
  • Some studies showed patients reported a decrease in severity and frequents of headaches, as well as a decrease in nausea. American Academy of Neurology and the American Headache Society suggest that a feverfew extract may be effective and should be considered for migraine prevention. Petadolex® is the brand most studied.
  • RHEUMATOID ARTHRITIS: One study found that feverfew did not reduce rheumatoid arthritis symptoms in women whose symptoms did not respond to conventional medicines. It has been suggested that feverfew could help those with milder symptoms. It was found to no more effective than placebo for the treatment of rheumatoid arthritis.
  • CANCER: Did show some anti-cancer effects in lab studies. Human studies are needed.
FEVERFEW PRECAUTIONS:
  • If allergic to other members of the daisy family (which includes ragweed and chrysanthemums) are more likely to be allergic to feverfew.
  • Pregnancy and nursing: NOT recommended during pregnancy, because of its abortifacient properties in early pregnancy.
  • People taking anticoagulants should use feverfew with caution because feverfew may potentiate the activity of anticoagulants such as warfarin
  • Side effects: Common: Minor gastrointestinal distress; oral ulcerations from chewing fresh feverfew leaves; airborne contact dermatitis; exacerbated dermatitis following use of a moisturizer containing feverfew.
Feverfew got its name from the Greeks, who thought it reduced fever, but is of minimal value. In the 1980’s it was frequently recommended along with magnesium and Riboflavin (B2) for the prevention of migraine headaches. Many of our local neurologists start patients with Magnexium Oxide and Riboflavin (B-2) as initial prophylactic therapy.

As we journey through the many herbals that are available to our patients, we wont seen many that are endorsed by traditional medical societies. Feverfew is one exception to that notion. After reading that the American Academy of Neurology and the American Headache Society recommend it's use, I'd feel comfortable recommending it to my patients.

The challenge, as always in the United States, is the lack of standardization of these herbal products. Petadolex® seems to be the product with the most support for efficacy. It is available through our pharmacy warehouses, and retails around $45.00 per month. Most references, particular in Canada require feverfew supplements should be standardized to contain at least 0.2% parthenolide.

Have a great day on the bench!!

Echinacea... might be better for our patients than a Z-pak!

Our next herbal product...Echinacea

Echinacea is one of the top five herbs that our patients have questions about. Many have their own notions on this herbs efficacy. Like all products we sell it does come with a few warnings that might not make it appropriate therapy for a select group of patients. Efficacy seems to be another issue.

Ecinacea comes from the Echinacea angustifolia, or E.purpurea, or E.pallida (American cone flower, Kansas snake root). It is found widely throughout North America and was used by the Native Americans both topically and orally for the treatment of burns, snakebites, pain, cough, and sore throat. All nine species are native to North America. The fresh or dried roots or above-ground parts that are collected at the time of flowering of the Echinacea angustifolia, is what is used in medicinal preparations.

USE:
Echinacea is used today in the prevention and treatment of the common cold to decrease both the duration and severity. According to most current literature, prevention and treatment of common cold is modest at best. Well-designed clinical trials have not proven its benefit in treatment/prevention of upper respiratory infections, including the common cold.

PRECAUTIONS:
  • Allergy to related plants in the daisy family: ragweed, chrysanthemums, marigolds, and daisies.
  • The immune stimulating effects of Echinacea have led to concerns regarding the use of Echinacea in patients with autoimmune disorders. It isn’t known whether Echinacea may exacerbate autoimmune disorders, such as Lupus, Sjogrens syndrome or rheumatoid arthritis. I wouldn’t recommend Echinacea in any of these patients. Patients that have atopic dermatitis have increase likelihood of allergic reactions and should also avoid echinacea.
  • According to one study the authors noted that there were small trends in the direction of a benefit from echinacea—an average half-day reduction in duration, or an approximate 10 percent decrease in severity—the researchers concluded that echinacea, at this dose formulation, does not significantly change the course of the common cold.
  • A 2001 study of 80 adult male and female subjects showed a reduction of duration of cold symptoms from 9 days for the placebo group versus 6 days for the echinacea group. https://www.ncbi.nlm.nih.gov
  • Dose most frequently studied: (The echinacea tablets contained the equivalent of 675 mg of E. purpurea root and 600 mg of E. angustifolia root.) Most common strength available OTC is 400mg capsules.
  • Commission E monographs from Germany: Only two preparations have been approved by the German Commission E. These include the root extract of Echinacea pallida used to support and promote natural powers of resistance of the body, especially infectious conditions (influenza and colds), and the expressed juice of Echinacea purpurea, as a supplemental treatment for upper respiratory and urinary tract infection.
So it seems like Echinacea doesn’t have the evidence that supports our recommendation for treatment or prevention of the common cold. As we with Vitamin C, patients need to be on it chronically to reduce the duration or intensity of the common cold. Antibiotic prescriptions that many prescribers send our way, actually do more harm.

The latest antibiograms from Central Pennsylvania hospitals are showing resistance to Azithromycin (Z-pak) of 50%. Thanks to the indiscriminate use of antibiotics, Azithromycin is ineffective against the most common bacterial pathogen half of the time! All of a sudden now using echinacea for the common cold doesn’t seem like such a bad idea!

Just make sure it is for the right patient. With the lack of standardization of herbal products in the United States, and the fact there are 9 different species of coneflower makes consistency of Echinacea very challenging.

Remember if you treat the common cold it lasts 7 days; if untreated it lasts one week!

Have a great day on the bench!!

April 2018

We have insulin, sulfonylureas, SGLT2 inhibitors, gliptins, alpha glucosidase inhibitors, DPP4 inhibitors and biguanides... how about a sprinkle of cinnamon?

Instead of all those pills, can I take a natural product for my Type-2 diabetes?

Cinnamon fits into both the food and medicinal herb categories. We have our “Cinnamon Toast Crunch” (my kids favorite) cereal for breakfast, and we sell cinnamon in our herbal section to improve glycemic control for our diabetics. Because of the lack of standardization in the United States, and the very conflicting data, I am hesitant to recommend this herbal product. Cinnamon contains coumarins, which in high doses can lead to liver toxicity, when doses exceed 7grams. Here is some background information:

From Cinnamomum aromaticum, a small evergreen tree native to Southern India and Sri Lanka, Malaysia and Madagascar. Cinnamon bark (Cinnamomum verum) is the most common type used in the Western world, as a cooking spice. Bark most commonly used and occasionally, leaves and buds.

Use: Treatment of Type-2 Diabetes. Cassia cinnamon (“Chinese cinnamon”) is believed to be most effective. This type of cinnamon is commonly found in herbal products in pharmacies and health food stores. As of now most believe it is to be used as “adjunctive” therapy, when added to sulfonylurea therapy (8.22% to 7.86% after 12 weeks) in a well-designed study. Seemed to be of some benefit in those with poor glycemic control, by increasing sensitivity at the insulin receptor.

ADA journal article: 60 DM Type-2 patients studied for 60 days: After 40 days, all three levels of cinnamon reduced the mean fasting serum glucose (18–29%), triglyceride (23–30%), LDL cholesterol (7–27%), and total cholesterol (12–26%) levels; no significant changes were noted in the placebo groups. Dose used was 1g, 3g, 6g of cinnamon. (2004 article). Patients took 1, 3 and 6 grams of cinnamon in the study arm. This study was done in Pakistan.

National Institutes of Health: “High-quality clinical evidence (i.e., studies in people) to support the use of cinnamon for any medical condition is generally lacking”

University of Connecticut School of Pharmacy: Diabetes Care. 2008;31(1):41. PRECAUTIONS/CONTRAINDICATIONS:
  • RESULTS: Five prospective randomized controlled trials were identified. Upon meta-analysis, the use of cinnamon did not significantly alter A1C, Fasting Blood Glucose, or lipid parameters. Subgroup and sensitivity analyses did not significantly change the results.
  • CONCLUSIONS: Cinnamon does not appear to improve A1C, FBG, or lipid parameters in patients with type 1 or type 2 diabetes.
CAUTION: Cassia cinnamon contains coumarin, consuming large amounts my lead to liver toxicity.
DRUG/FOOD INTERACTIONS: Cinnamon may reduce the effectiveness of tetracycline antibiotics. PREGNANCY: Use of cinnamon in amounts greatly exceeding those found in foods is not recommended during pregnancy

In 1958 the rate of Type-2 diabetes in the United States was 1%, sixty years later we are approaching the 10% mark. Many of our patients want to take "natural" products to manage their Type-2 diabetes. Most often they inquire about cinnamon, and the results are variable indeed.

Depending on what the patients want to believe they can find evidence supporting claims that cinnamon is useful for Type-2 diabetes management.

There is a plant called goats rue (Latin: Galega officinalis) that is endemic to the temperate climates of Europe and the United States. By studying some of the compounds in this plant the biguanide class was discovered which includes phenformin (D.B.I) which was removed from the market in the 1970's due to lactic acidosis, as well a metformin (Glucophage). Goat's rue was considered an agricultural pest and placed on the "Federal Noxious Weed List" in the United States. Think of that next time you prescribe or dispense metformin!

The newest class of diabetes drugs, the "flozins" or SGLT-2 inhibitors like canaglaflozin (Invokana) also came from a natural product. Phlorizin, a naturally occurring compound extracted from the root bark of an apple tree in 1835 and later identified as a SGLT1 and SGLT2 dual inhibitor, was the precursor to this category of drugs.

Maybe there is an active compound in cassia cinnamon that will be elucidated as a treatment for Type-2 diabetes, but for now tell your patients that it is best to sprinkle their cinnamon on a fresh apple!

Have a great day on the bench!!

Bright yellow and in our spice cabinet, this Indian herb may be beneficial to our arthritis patients.

Turmeric---not just for cooking!

Latin name: Curcuma longa

Common Name: Indian saffron or curcuma which is related to ginger, is grown throughout India, other parts of Asia, and Central America. Turmeric is a major ingredient in curry powder. The medicinal part of the plant used is the dried rhizome.

Primary active ingredients: curcuminoids, which are bright yellow and used to color foods and cosmetics. Turmeric is what gives curry it’s bright yellow color in cooking. The German Drug Codex monograph requires turmeric to contain not less than 3.0% curcuminoids, calculated as curcumin, and not less than 3.0% volatile oil.

Possible uses: osteoarthritis, digestive disorders, and potentially stroke prevention by quelling inflammation in blood vessels,

Possibly effective: Osteoarthritis-- Some turmeric extracts can improve symptoms of osteoarthritis. Taking a specific turmeric extract (Meriva by Indena) 500 mg twice daily seems to reduce pain and improve functionality in patients with osteoarthritis of the knee after 2-3 months of treatment. Patients using this product saw decreased use of NSAIDS.

The University of Arizona Health Sciences secured an NIH grant to conduct studies of turmeric (CLaRA study), where they found turmeric to be effective as an anti-inflammatory, in rheumatoid arthritis patients. Researchers also found that turmeric blocks a protein that causes bone breakdown in these patients.

The rhizome contains an anti-inflammatory and choleretic volatile oil. Anti-inflammatory actions may be due to leukotriene inhibition, as well as COX-2 inhibition. Turmeric has been used as a “digestive aid”; as a choleretic it increases release of bile, therefore it is contraindicated if the patient has gallstones.

PRECAUTIONS/CONTRAINDICATIONS:
  • High doses of turmeric can act as a blood thinner, and also cause stomach upset. Avoid turmeric/curcumin in patients that take blood thinners such as warfarin (Coumadin).
  • Are about to have surgery
  • Pregnant
  • Have gallstones or any gallbladder disease
Dose:
  • Osteoarthritis: In capsule form use 400 mg to 600 mg, three times per day.
  • Rheumatoid Arthritis: 500 mg twice daily.
In last week’s column, I invited all my readers to feel free to e-mail me their request for whatever herb they would like covered. My first response was from one of my pharmacist colleagues who is 87 years old, and still practicing part time. He is a voracious reader, and is a self-proclaimed “nerd” as I am. To respond to this very seasoned pharmacist’s request the first herb we will cover is Turmeric or Tumeric.

Our warehouse has at least 12 different brands of turmeric capsules available, and most cost less than $10.00 per month. This is one herb I will feel comfortable recommending to our arthritis patients, as long as they do not have any contraindications as listed in this newsletter. There seems to be a fair amount of efficacy for this herb, and our questions about its use will be answered when the CLaRA study is completed.

Have a great day on the bench!!

Herbal Therapy-- pharmacists are expected to have some degree of proficiency!

Herbal Pharmacy --- what a challenge!

So often it is difficult to substantiate any benefit from Herbal therapy, while side effects seem to appear rapidly. I find these products to be particularly challenging, given the fact we seem to have better pharmacotherapeutic choices in the prescription department.

Herbals: Challenges for pharmacists
  • our training is very limited- including mine
  • the prescribing community knows even less!
  • consistency of products between distributors and manufacturers
  • At best supporting literature is weak. Frequently we see conflicting studies and results.
Best website I’ve found: National Center for Complementary and Integrative Health.
https://nccih.nih.gov/health
  • For this project I’ve joined the American Botanical Council (ABC) for access to the Commission-E monographs. The cost is $50 per year, which allows you access to this herbal website. You can read about each herb individually, or can look up therapeutic categories, and the herbs that are associated with treatment of that disease state.
Herbal Regulations
  • The FDA loosely regulates dietary supplements, under the Dietary Supplement Health and Education Act of 1994 (DSHEA ’94)
  • Dietary supplementary are considered to be: vitamins, minerals, other botanicals, amino acids, enzymes, organ tissues, glandular, and metabolites. These dietary supplements fall under the category of "foods" and not "drugs".
  • Consequently, scientific data supporting claimed benefit are not always available as for traditional pharmaceuticals. The burden of proof for safety and adulteration of products lays on the Food and Drug Administration (FDA)
  • Consumers should also note that rigid quality control standards are not required for nutraceuticals and substantial variability can occur in both the potency and the purity of these products.
  • Given the regulatory structure for herbal medicines, there is substantial variation in the quality of commercially available products in the United States and elsewhere. Variability in product quality can impact the product's efficacy, safety, and therefore clinical usefulness.
What Germany does so well:
  • Commission-E is Germany’s equivalent to the FDA in the United States.
  • There are 380 monographs evaluating the safety and efficacy of herbs for licensed medical prescribing in Germany. Published in 1998.
  • Official monographs that give the approved uses, contraindications, side effects, dosage, drug interactions and other therapeutic information essential for the responsible use of herbs and phyto-medicines.
  • Up to 70% of German doctors prescribe "phytomedicines"
SAFETY of Herbals: Despite ephedra products comprising only 0.8 percent of all dietary supplement sales in 2001, they were responsible for 64 percent of all herb-related adverse events reported to United States Poison Control Centers during the same year. Fortunately, the FDA banned all products containing ephedra in April 2004. Then the manufacturers substituted bitter orange (citrus aurantium) which contains “synephrine” for ephedra in weight loss products. Synephrine has been associated with serious cardiovascular and neurological side effects.

I think most of us pharmacists would feel better about recommending these herbal products if we had the guidance of the FDA, as do our pharmacists in Germany have with the Commission-E monographs. Until that happens, I will continue to proceed with caution. Patients seem to equate safety with natural products. I always remind my patients that one of our favorite botanicals is “digoxin” from the foxglove plant, knowing that 1mg can stop a person’s heart. Natural does not equate to safety!

Feel free to send me an email, so we can explore in depth herbals you might have questions about.

Have a great day on the bench!!

Fresh fruits and vegetables might be adequate to prevent constipation, but when it comes to opioid induced constipation, a pharmacist recommendation is critical.

Management of Opioid Induced Constipation

Numerous side effects are commonly seen with opioid use such as euphoria, respiratory depression, sedation, GI upset and constipation. Of all the common side effects associated with opioid use, the patient never develops a tolerance to constipation. Opioid induced constipation (OIC) occurs in approximately 40% of patients treated with opioids.
  • Use Rome III criteria (less than 3 BM per week)
  • OIC is dose related. As doses escalate, OIC becomes more prevalent
  • Mechanism: opioids bind to mu receptors in the GI tract inhibiting peristalsis.
Over The Counter:
  • Stool softeners can result in "all mush, no push" simply because there's not enough GI motility. Stool softeners are of little value for OIC.
  • For patients on opioids (hydrocodone, oxycodone, codeine etc.) recommend a stimulant laxative (senna or bisacodyl) to increase GI motility plus docusate if the stool is too hard to pass.
  • OTC Polyethylene Glycol 3350 (MiraLAX) is another excellent choice.
Peripherally Acting Mu-Opioid Receptor Antagonists (PAMORAs)
How they work: preferentially block mu-opioid receptors in the GI tract and do not interfere with the pain-relieving effects of opiates on the mu receptor in the central nervous system.

Methylnaltrexone: (Relistor®)
  • Mechanism: Methylnaltrexone is a PAMORA with a quaternary amine structure, blocking the ability of methylnaltrexone to cross the blood-brain barrier.
  • Indication: Treatment of opioid-induced constipation in patients with advanced illness who are receiving palliative care, when response to laxative therapy has not been sufficient.
  • Warnings/Precautions/Adverse Effects:
    • Contraindicated if known or suspected mechanical gastrointestinal obstruction
    • Discontinue therapy if severe or persistent diarrhea occurs
    • Use with caution in patients with known or suspected lesions of the GI tract
    • May cause gastrointestinal perforation (serious adverse effect)
    • Pregnancy category: B
    • May cause diaphoresis, abdominal pain, flatulence, nausea, dizziness (common adverse effects)
  • Effects can be seen within 4 hours of administration
Relistor® (methylnaltrexone) injection dosage:
cost around $125 for 12mg vial


Injection is based on body weight. Typical dose is 12mg SC once a day for chronic non-cancer pain.
Relistor 150mg (ORAL) tablets cost: $1635.00/month
Dose: 3 x150mg tablets (450mg) daily in the morning half hour before first meal of day

Naloxegol (Movantik®) cost: $314/month
opioid antagonist indicated for the treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain.
Dose: 25mg once daily; if not tolerated reduce to 12.5mg daily. If renal impairment less than 60ml/min, use 12.5mg daily. Take on empty stomach, one hour before a meal or 2-3 hours after a meal.
Drug interactions: Avoid CYP450-3A4 inhibitors (diltiazem, verapamil, erythromycin), or reduce to 12.5mg daily. Avoid grapefruit juice.
STOP all maintenance laxatives before starting Naloxegol, may restart in 3 days if not effective.
  • effective in people who have taken opioid pain medicines for at least 4 weeks
  • if opioid is stopped, stop Movantik®
Naldemedine (Symproic®) cost: $314/month
opioid antagonist indicated for the treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain. Is a derivative of opioid antagonist naltrexone. It has a large polar side chain to prevent penetration into the CNS. Works by blocking opioid receptors in the GI tract.
Dose: 0.2mg tablet once daily, any time of day, with or without food.
Drug interactions: is a substrate of CYP 450 3A4 watch for drug interactions with rifampin (induce). CYP-450 3A4 blockers can cause excessive levels of naldemedine.
Prescription medications for treatment of OIC
  • Methylnaltrexone (Relistor) 12mg SC daily (chronic non-cancer pain)
    • Relistor 150mg tablets 3 tablets in the morning
  • Naloxegol (Movantik) 25mg orally in the morning
  • Naldemedine (Symproic) 0.2mg tablet orally daily in the morning
  • Lubiprostone (Amitiza) 24mcg orally twice daily (see last week’s newsletter)
Opioid induced constipation can be a challenge to treat. So often a clinician will recommend docusate for prevention which for most cases is not adequate to treat OIC. Addition of fiber like Metamucil or Citrucel is a worse choice as lack of peristaltic activity can lead to impaction.

Fresh fruits and vegetables might be adequate for a teenager who has their wisdom teeth extracted to prevent constipation for their acute hydrocodone prescription. However for our patients taking chronic opioids, this newsletter will be of great benefit helping clinicians select appropriate treatment. Stimulant laxatives over the counter are the most economical ways to handle OIC, however for patients receiving higher doses of opioids, prescription treatment might be indicated.

Have a great day on the bench!!

March 2018

We'll explore some of the most expensive treatment options for constipation...of course they are prescription!!

PRESCRIPTION TREATMENT of CIC and IBS-C!

Let’s look at the prescription options for treatment of chronic idiopathic constipation (CIC) and Irritable bowel syndrome constipation predominant (IBS-C)

NEWER TREATMENTS OF CHRONIC CONSTIPATION

AMITIZA® (Lubiprostone) : 8mcg and
24mcg(AWP=445.32)
First approved 2006


Mechanism: Lubiprostone is a locally acting chloride channel activator that enhances a chloride-rich intestinal fluid secretion without altering sodium and potassium concentrations in the serum. By increasing intestinal fluid secretion, lubiprostone increases motility in the intestine, thereby increasing the passage of stool and alleviating symptoms associated with chronic idiopathic constipation. Indication

  • Treatment of chronic idiopathic constipation (CIC) in adults.
  • Treatment of irritable bowel syndrome with constipation (IBS-C) in women over 18 years old
  • Also indicated for opioid induced constipation.
Warnings/precautions/adverse effects
Potential to cause miscarriage (have negative pregnancy test, use contraceptive measures) Pregnancy category: C
May cause nausea, diarrhea, abdominal distention, loose stools, flatulence and vomiting
May also cause headache, dizziness and peripheral edema

Amitiza® (lubiprostone) 24mcg and 8mcg CIC: Dosage: 1 capsule (24mcg) BID with food IBS-C: 8mcg BID for women age 18 and over.

LINZESS® (linaclotide) 72mcg, 145cg and 290mcg caps
(AWP=$464.47)-
First approved:2012


Indication: irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC).

Dose: one capsule each day on an empty stomach, at least 30 minutes before your first meal of the day. Swallow LINZESS capsules whole. Do not break or chew the capsules
Mechanism: guanylate cyclase-C agonist. By increasing the concentration of cyclic guanosine monophosphate (cGMP), linaclotide leads to secretion of chloride and bicarbonate into the intestinal lumen which causes an increase in fluid and GI transit time.
  • For IBS-C, linaclotide should be dosed as 290 mcg once daily on an empty stomach. For IBS-C, Linzess decreases PAIN from IBS-C
  • For CIC, the approved dose is 145 mcg or 72mcg once daily on an empty stomach
  • Do not use in patients less than 18 years of age
TRULANCE® (plecanatide) 3mg tablets ($466.16)
First approved-2017

Trulance (plecanatide) 3 mg tablets is indicated in adults for the treatment of
  • Chronic Idiopathic Constipation (CIC) and
  • Irritable Bowel Syndrome with Constipation (IBS-C).
Mechanism: Except for a single amino acid substitution, Trulance is structurally identical to human uroguanylin. Uroguanylin activity modulates within the changing pH environment of the intestines, coinciding with areas of fluid secretion, and decreases pain sensation.
Dose: 3mg once a day, taken with or without food.

Next week we will discuss the prescription treatment options for opioid induced constipation.

TFiber supplements and stimulant laxatives have been around for a very long time. Many of us “seasoned” pharmacists remember “if not nature---Metamucil” and “Doxidan in the PM for a BM and the AM.” We cant forget to mention "Natural and Gentle Fletcher's Castoria".

And of course every Saturday night Lawrence Welk would be promoting "Serutan--that is Natures spelled backward." There have always been a lot of advertising for laxatives in the media, but our patients always asked for our recommendations.

Since 2006, we have had three new laxatives on the prescription shelves that are indeed effective and very expensive. We've seen ads on TV for Amitiza "move to your own beat" as well as Linzess "ease the pain"-- just ask your doctor!! Just be sure to have enough in your health savings accounts!

Have a great day on the bench!!

When fiber and softeners are not quite enough, we have to "get things moving" with a stimulant laxative.

Sometimes our patient's boels need a little "push"

Laxatives that Result in Soft or Loose stool in 6-12 hours

Bisacodyl (oral) Dulcolax® 5mg 5-15mg daily HS
Senna Senokot® 8.6mg 2HS, max=4 daily
Magnesium hydroxide Milk of Magnesia (400/5) 30-60ml HS


Stimulant agents

Indication: Are effective as initial therapy to treat constipation but should not be used for more than 1 week. Chronic use was believed to lead to cathartic colon, which results in poorly functioning colon, resembling ulcerative colitis. However, most of these cases are reported before 1960 when toxic cathartics were used (podophyllin). Still a subject of controversy whether mild laxatives can be used long term.

Mechanism: Increases propulsive contractions by local irritation or action on the intramural nerve plexus of the intestinal smooth muscle, stimulate secretion of water and electrolytes.

Patient information:
  • Causes discoloration of urine
  • Temporary measure, do not use for longer than one week, without consultation.
  • These agents are often abused.
  • Are excreted in breast milk.
  • May cause harmless melanotic pigmentation of colon
  • May color the urine from pink to brown.
Senokot® (senna) 8.6mg/ tablet.
Dosage: start 2 tablets at bedtime; do not exceed 2 tablets twice a day. Senna is often combined with docusate.

Dulcolax® (bisacodyl) 5mg tablets Dosage: start with 1 tablet at bedtime. Usual adult dose is 2 tablets at bedtime. NOTE: this product is enteric coated do not crush or chew. Do not take within 1 hour of antacids, milk or any product that raises gastric pH.

Magnesium hydroxide

Indication: can be used as an antacid for temporary relief of heartburn, or occasionally as a laxative.

Mechanism: Highly osmotic ions draw water into the intestine and cause an increase in the intraluminal pressure, thereby exerting a mechanical stimulus that increases intestinal motility. Increase cholecystokinin – pancreozymin which is an enzyme that increases the secretion of fluids into the GI tract.

Drug interactions: Oral anticoagulants, Digoxin, Tetracyclines, Quinolones

Patient information:
  • May lead to hypermagnesemia (as much as 20% Mg may be absorbed)—problem if renal impaired. Patients with a CrCl <30 mL/minute should be monitored by serum magnesium levels.
  • Sodium: hypertensive or CHF patients should not receive these on a long term basis due to fluid retention from sodium absorption.
  • May see abdominal cramping, excessive diuresis, Nausea, vomiting, dehydration electrolyte disturbances, incontinence.
  • Milk of Magnesia 400mg/5ml
Is an 8% suspension of magnesium hydroxide Antacid: For the temporary relief of heartburn, upset stomach, sour stomach, or acid indigestion. Laxative: For relief of occasional constipation. Expect results within 30 minutes to 6 hours. Dose: 1 to 2 ounces at bedtime. Shake well before using and follow dose with 8 oz of water.

Thanks to the frequent practice of "cross-branding" we pharmacists should always be consulted before our patients make a laxative purchase. Some companies use their Proprietary name to enhance a whole line of products. I feel Dulcolax is the worst offender as they have the "Dulcolax" name blasted across their softener which actually contains docusate sodium.

Among us older practitioners Dulcolax has always meant bisacodyl. Clinicians should encourage patients to consult the pharmacist before purchasing laxative products. Better yet it is prudent for clinicians to write a prescription for the patient to decrease confusion.

However, I once received a prescription from a physicians office that was computer generated. It said "Dulcolax" (docusate) - take 4 capsules at bedtime the night before the test. I called the physician's office and told them this was the same as "Colace" . The nurse told me, that was the first thing that came up under "Dulcolax". She authorized me to switch it to the bisacodyl product.

You can only imagine how confused our patients can get with this very foolish practice. As I tell my students---"when I become head of the FDA...this is the first thing I will change!"

Have a great day on the bench!!

Sometimes we need more than prunes and psyllium!

Laxatives that cause softening of feces in 1-3 days

Generic Representative Brand Dosage
STOOL SOFTENER
Docusate sodium Colace® 50, 100 50-360mg/day
Docusate calcium Surfak 240mg 50-360mg/day
MINERAL OIL Kondremul® 15-30ml
LACTULOSE Chronulac®, Constulose® 15-30ml
SORBITOL 30-50gm
PEG 3350 soln Miralax® 1 cap 17gm in 8oz water


Stool softeners

Indication: Beneficial in anorectal conditions in which passage of a firm stool is painful. Generally used for prevention of constipation.

Mechanism: Anionic surfactants increase the wetting efficiency of intestinal fluid, thereby softening fecal mass. Facilitates admixture of fat and water to soften stool.
FYI: Docusate is a “soap” and bridges the barrier between the lipid stool, and water. Cut open a capsule, add to a small prescription vial, add water and shake. Looks like dish-washing soap.

Patient information:
  • Take with fill glass of water.
  • Do not take with any mineral oil containing laxatives, as this will lead to the oil’s absorption and cause hepatotoxicity.
Available as:
  • Colace® (docusate sodium) 50mg (rarely used) 100mg (common) 50- 300mg daily in divided doses.AKA : “DOSS”or “DSS””: dioctyl sodium sulfosuccinate
  • Surfak® (Docusate calcium) 240mg dose: one capsule daily.
Emollients (lubricants)
Indication: prophylactically in patients who should not strain (anorectal surgery, MI)

Mechanism: Softens fecal contents by coating them, thereby preventing the colonic absorption of water.

Patient Information:
  • Do NOT give with stool softeners (Colace, Surfak)
  • Avoid in any patient with the potential to aspirate such as GI reflux, as this could cause lipid pneumonia
  • May cause anal leakage leading to anal pruritis. May stain clothes/furniture.
  • If used long term, supplement with fat soluble vitamins (ADEK) as this will impair their absorption.
  • Take on an empty stomach.
Available as:
  • Mineral oil: dose 15-45ml HS
  • Kondremul® (mineral oil emulsion) dose: 30-75 ml at bedtime. This product is a pleasantly flavored marshmallow liquid, and is much more palatable than straight mineral oil.
Lactulose
Chronulac® (Rx only) Indication: useful particularly in elderly patients. Not usually first line. Takes at least 24-48 hours for action.
  • Also used for hepatic encephalopathy to decrease blood ammonia levels.Because colon contents are now more acidic than blood, ammonia migrates from blood to colon, acid colon contents convert NH3 to the ammonium ion (NH4+) trapping it and preventing its reabsorption.Also because of the laxative effect of lactulose, the ammonia spends less time in the colon, decreasing time for absorption to occur.
Mechanism: disaccharide used orally or rectally. Metabolized by colonic bacteria to form lactic acid, formic acid, acetic acid and carbon dioxide. Increase osmotic pressure and acidify the colonic contents, thus increasing stool water content and softening.

Patient information:
  • Give with fruit juice, water or milk to increase palatability.
  • Will cause significant gas, leading to -flatulence, abdominal pain and cramping.
  • May also cause diarrhea and electrolyte imbalances.
  • Because it contains galactose & lactose, use with caution in diabetics.
  • If used over 6 months in elderly measure: electrolytes (K & Cl) & carbon dioxide periodically.
Available as: Chronulac® (lactulose) 10gm / 15ml available in pints and quarts Dosage 15-30ml daily. Increase to 60ml if necessary.

Sorbitol
Not available as a laxative but is available as a sweetening agent for prescription compounding. Along with mannitol, these are alcohol sugars that are used as sweeteners. If your patients are ingesting excessive sugar free candy or gum diarrhea can occur.
Mechanism: similar to lactulose.

Polyethylene glycol laxatives
Indication: Used for colon cleansing before diagnostic procedures or colorectal operations. Can also be used in lower doses for chronic constipation.

Mechanism: is an osmotic laxative that large molecules draw water into the gut, and increased volume results in distention of the intestines, increasing peristalsis and bowel motility, and softening stools.
FYI: the number 3350 is the molecular weight of this particular polyethylene glycol.

Patient information
  • May cause abdominal cramping, flatulence, rectal irritation and incontinence.
Miralax® contains PEG 3350 (this product for long term management of constipation)

Dosage: 1 capful (17gm) in 8 oz of water once daily.
  • Available prescription sizes: 255gm (2 weeks supply) and 527gm as (1 month supply).
  • Caution: some generic caps are “oversized” and have a fill line inside. May cause over dosage—more than 17 grams.17gm= 1 heaping tablespoonful
  • Also available over the counter in 7-day, 14-day and 28-day packaging.
GoLytely, CoLyte, Nu-Lytely: contains PEG 3350, in a 4 liter jug, (approximately 230-240Gm)

The 4L jug should be reconstituted to the fill line early in the morning, then refrigerated. Do not add flavors (unless provided by manufacturer) or colors to the solution. Follow prescribers protocol.
  • Some prescribers give Metoclopramide (Reglan®) to decrease nausea
There is always a lot of opportunities for us to discuss laxative use with our patients. Often the intake of water, fiber supplements, fresh fruits and vegetables on't produce the desired results.

Of all the products we discuss today, docusate (Colace®) and PEG3350 (Miralax®) are the most common we use in the pharmacy. PEG3350 falls nicely into the "softener" category when taken as a 17gm dose once a day. I remember as a much younger pharmacist we had a patient who had multiple sclerosis. She battled constipation for many years.

Her very astute neurologist would have me break down a bottle of the bowel preparation, and she would mix a portion with water and drink it over a 2 day period. In 1999, Miralax was finally released as a single daily dose of 17 grams. In 2006 the Bayer company got FDA approval to sell this product over-the-counter. In 2012 the product became available as a generic.

This laxative is the "go to" for pediatric patients (with a doctors recommendation).

Have a great day on the bench!!

Less than 10% of our patients ingest enough fiber for bowel regularity. What can we do to help them...

An apple a day is a good start!!

The traditional classification of laxatives by mechanism of action is not very useful. Many mechanisms have not been elucidated. Most work by promotion of mechanisms associated with diarrhea, such as electrolyte secretion, decreased water & electrolyte secretion, increased intraluminal osmolarity, and increased hydrostatic pressure in the gut.

Classification is best accomplished by dividing the drugs into categories based on their time to onset of action. for the next couple newsletters we will focus on laxatives that cause soften of feces in 1-3 days

Generic Representative Brand Dosage
BULK FORMING AGENT
Methylcellulose Citrucel® 4-6 gm per day
Wheat Dextrin Benefiber® 2 teaspoon up to 3 times daily
Psyllium Metamucil®, Konsyl® Varies
Polycarbophil FiberLax®, Fibercon® 4-6gm per day


Bulk Forming Agents:

Fiber are natural or synthetic polysaccharide derivatives that absorb water to soften stool and increase bulk, which stimulates peristalsis. Because dietary fiber works in both small and large intestines the onset of action is slow (12-24 hours—up to 72 hours.). Fiber supplements are used to prevent rather than treat constipation. Insoluble fiber does not absorb water; while soluble fiber does. Both help material move through your digestive tract, but soluble fiber can help give stool a softer, bulkier consistency that’s easier to pass.

Metamucil®: is made from ground psyllium husks, from the plantago ovata plant. Adult dose is 1-2 rounded teaspoonful in 8oz of water 1 to 3 times daily. If using the “Orange Smooth-Real Sugar” product the dose is 1 tablespoonful.

Fun Fact: Metamucil website has dosages for
  • For helping feel less hungry between meals
  • For promoting and maintaining digestive health
  • For helping lower cholesterol to promote heart health- (psyllium traps bile acids)
  • For helping maintain healthy blood sugar levels as part of your diet
Patient counseling points:
  • There are Metamucil capsules available, if patients complain of grittiness especially if they wear dentures
  • Make sure patients mix with adequate water
  • Because of fermentation it may cause abdominal cramping, bloating, flatulence, distention, esophageal obstruction, intestinal obstruction, allergic reactions
  • Drug interactions: oral anticoagulants, digitalis, salicylates, tetracycliness
Citrucel®
is a synthetic bulk laxative containing methylcellulose. Methylcellulose is derived from cellulose which comes from the cell walls of green plants. It is less likely to cause fermentation leading to bloating and flatulence.
Dose: 1 tablespoonful 1 to 3 times daily.

Patient counseling points:
  • Available as orange flavor, sugar free and caplets.
  • Be sure to mix with adequate fluids to prevent esophageal obstruction.
  • Mix with cold fluids, avoiding carbonated beverages and milk.
Benefiber®
ingredient: wheat dextrin, which is extracted from wheat starch. Wheat dextrin is a soluble fiber which absorbs water in the intestine to form a viscous liquid which promotes peristalsis and reduces transit time. Helps lower cholesterol (LDL and total cholesterol), reduces risks of coronary heart disease and type 2 diabetes. May be beneficial lowering blood sugar and reducing risk for heart disease.
Dose 2 teaspoonfuls daily, up to 3 times daily. Benefiber® promotes wheat dextrin as a "prebiotic" which are carbohydrates that act as food for beneficial bacteria in the gut. These carbs (or starches) travel undigested to the colon, where they ferment and produce small chain fatty acids that feed the gut flora. Prebiotics encourage growth of good flora and crowd out the "bad flora"

Patient counseling points:
  • Will not thicken in liquid, no taste, no gritty texture.
  • Will not alter taste of food or beverages.
  • May mix with water, juice, coffee, baked goods
  • Patients should avoid if they are gluten sensitive
Calcium polycarbophil (FiberLax®, FiberCon & Equilactin): can be used for both diarrhea and constipation. Is a “stool normalizer”. Polycarbophil absorbs about ten times its own weight of water under acidic conditions, but the swells to 70 times its weight in the neutral pH of the small and large intestines.
Each caplet contains 625mg calcium polycarbophil=500mg polycarbophil
Dose: 2 caplet 1 to 4 times daily.

We discuss another common problem that presents in our clinics, that in many cases can be ameliorated by adequate diet, exercise and hydration. The recommended levels for dietary fiber is 25 grams/day for adult women, 38 grams/day for adult men (consisting of fruits, vegetables, legumes, whole grains)

About 90% of the US population does not consume this level of dietary fiber, averaging only 15 grams/day.

"An apple a day keeps the doctor away" with its 4.4 gm of fiber. You will do better with a pear (5.5gm), or half of an avocado (6.75gm) or best of all 1 cup of navy beans at 19.1 grams! Adequate dietary intake as well as exercise and hydration might be all our patients need.

Have a great day on the bench!!

We do this every morning! You'll see things in a different way next time you flush!

There are different types of constipation!!

We clinicians have a real opportunity to bring comfort to our patients that present to us with constipation. We’ve been all trained to ask about stool frequency, consistency, remitting factors, diet, and exercise but we also need to inquire about the presence of pain. Pain in the belly seems to be the determining factor between Chronic Idiopathic Constipation(CIC) and Irritable Bowel Syndrome Constipation Predominant (IBS-C).

But as always before we act on any such symptom we need to check the medication list for DRUGS frequently causing constipation:
Medications that can affect the color of our stools (feces)

Opioids Calcium channel blockers
Anticholinergics Calcium carbonate
Aluminum antacids Iron supplements
Antidepressants Clonidine
Antipsychotics Sucralfate
Diuretics Cholestyramine


CHRONIC IDIOPATHIC CONSTIPATION (CIC)

Chronic idiopathic constipation is frequently referred to as “functional constipation”. It is estimated that 14% (as many as 35 million) patients may suffer from this condition.
  • Chronic constipation was more common in females, in older subjects, and those of lower socioeconomic status. 58% of patients suffering from CIC are female
  • Chronic constipation has also been linked to impaired quality of life, especially among the elderly.
  • 72% of CIC patients self-treat with OTC medications, while 13% receive prescription therapy.
IRRITABLE BOWEL SYNDROME-Constipation predominant (IBS-C)
Irritable bowel syndrome is defined as abdominal pain or discomfort associated with constipation. This condition is long-lasting and keeps recurring. Patients will have hard or lumpy stools at least 25% of the time, and loose or watery stools less than 25% of the time. It is estimated that 5% (as many as 13 million) patients may suffer from IBS-C. 64% of IBS-C patients are female, and 66% are under the age of 50, therefore this seems to be a “younger woman” problem.
  • Pain is what separates IBS-C from CIC, patients will complain “it feels like a knot in my guts”. 62% will experience abdominal pain.
  • 72% of the patients are constipated, and 59% will have incomplete evacuation on bowel movements
  • 57% of IBS- C patients will self-treat with OTC medications, while 15% will receive prescription medications.
  • OTC meds most often recommended by physicians
    • 52% fiber supplements: psyllium, methylcellulose, wheat dextrin etc.
    • 32% OTC laxatives: senna, docusate, bisacodyl etc.
Next week we will begin discussions of the pharmacological treatment of constipation.

We pharmacists are frequently asked what to recommend for constipation. We all have shelves full of laxatives. For the next couple of weeks we will discuss all of the treatment options for constipation, but first we need to know if we should even recommend a self-care product.

Simply getting the bowels to move might not be adequate treatment for our IBS-C patients. Referral to a gastroenterologist is prudent when there is any type of belly pain or any appearance of blood in the stool.

Have a great day on the bench!!

February 2018

We do this every morning! You'll see things in a different way next time you flush!

The consistency of our patients stools depend on a lot of factors!!

Getting to know your innards:
How long does it take my food to digest? That depends on a lot of factors, depending on the food types we eat, and medications we might be taking to decrease our stomach acid. The pH of your stomach is 1.5 to 3.5, because your stomach excretes about 1.5 liters of gastric acid daily. Fat takes longer to leave the stomach than other foods, sometimes remaining in the stomach for up to six hours. Remember a big meal of a double burger and fries? You feel full for a very long time. Liquids take around 20-30 minutes to exit the stomach. Water and liquids do fill you up, but that effect doesn’t last very long. Complex carbohydrates break down at a slower rate than simple carbohydrates. Proteins take about 1.5 hours to leave the stomach.

Usually, most of a regular-sized meal empties from the stomach within two hours. After that it takes about 6 hours to pass through the small intestine, where bicarbonate is added to the mix to bring the pH to a more neutral 7. Your small intestine as around 22.5 feet long and about 1.5 inches wide. Food enters the large intestine, which is around 5 feet long, for more digestion and absorption of water and essential vitamins. Undigested material gets pushed toward the anus for elimination. It takes an average of 33 hours (almost 1.5 days) for foods to reach from the mouth to the anus.
Once it gets to the end, for elimination our stools can be graded for texture and even color depending on medications being taken: Bristol Stool Scale: is a scale that gastroenterologists use to “classify” our feces. Feel free to see the Bristol Stool Scale charts on-line!
  • Type 1: Separate hard lumps, nut-like in appearance
  • Type 2: Sausage-shaped, but lumpy
  • Type 3: Like a sausage but with cracks on its surface
  • Type 4: Like a sausage or snake, smooth and soft. (most normal stool)e
  • Type 5: Soft blobs with clear cut edge
  • Type 6: Fluffy pieces with ragged edges, a mushy stool
  • Type 7: Watery, no solid pieces, entirely liquid
Medications that can affect the color of our stools (feces)

Color Agents
black Iron, charcoal, bismuth (PeptoBismol)
Red or orange phenazopyridine, rifabutin, rifampin, or antacids with aluminum. Cefdinir interacts with iron in baby formulas, and breast milk
White speckled Antacids with aluminum
Yellow Alli (orlistat) or anything that inhibits fat absorption
Green Chlorophyll, iron or drugs causing diarrhea (antibiotics, laxatives)
Red or black tarry stools GI bleeding due to aspirin, NSAIDs, antiplatelet drugs, or anticoagulants
Pale stools Liver injury from hepatoxic drugs


Most of us seasoned practitioners have our own favorite stories about patients and their vivid descriptions of their bowel movements! Most often when they need a laxative they go to great lengths to describe their consistency of their stools.

When I was first licensed an elderly gentleman came to the pharmacy and asked for a good "physic". He got a blank stare from this newly minted pharmacist. I asked him what he meant, and he said "Kid I need to take a good s---t" What a lesson in vocabulary building!

I have also had patients on wax matrix potassium supplements bring in a "ghost tablet" from their stool to prove to me that the potassium I dispensed wasn't working because it did not dissolve!

For the past 36 years I remember to tell all of my potassium patients about the ghost tablets and this is a normal sighting. My question is why don't the makers of potassium wax matrix tablets make them brown in color, rather than orange (Klotrix®) or bright yellow (K-tabs®) !

Tomorrow morning when you flush the toilet, you will have a greater appreciation for your gastrointestinal tract! Next week we will start covering laxatives.

Have a great day on the bench!!

Not exactly billion dollar GI drugs... but they are still used!

Miscellaneous GI drugs to treat GERD and Ulcers.

We’ll wrap the last of the stomach drugs of the 1980’s three drugs with unique mechanisms of actions.
SUCRALFATE (Carafate®) approved Oct- 1981 Indications: indicated in the short-term (up to 8 weeks) treatment of active duodenal ulcer. Because it does not suppress acid formation or release it is minimally effective for GERD.

Mechanism: a mucosal protectant, nonabsorbable disaccharide containing sucrose and aluminum. It heals chronic ulcers without altering gastric acid or pepsin secretion or significantly buffering acid. It stimulates small-vessel formation, and granulation tissue. It binds to the injured tissue and protects it from pepsin and acid.

Warnings/precautions/adverse effects
  • Constipation, metallic taste, hypophosphatemia (with long term)
  • Compliance problems with QID administration
  • Pregnancy Category: B
Drug interactions – the aluminum salt is responsible for the impairment in the absorption of several drugs:
  • Bind tetracyclines & fluoroquinolones decreasing their absorption
  • Decreases warfarin absorption
  • Decreases digoxin & quinidine absorption
  • Decreases phenytoin absorption
  • Decrease levothyroxine absorption
Counseling points:

Sucralfate should be given on an empty stomach about half hour before meals to “coat” the lining of the stomach.

Reglan® (metoclopramide) approved Dec-1980

Indications: short term use (4-12 weeks) for GERD who fail to respond to conventional therapy. Also, used for diabetic gastroparesis. Metoclopramide (Reglan®) also used off label for improved lactation, by increasing serum prolactin. Generally used in patients with motility disorders, or if patients fail on high dose Proton Pump Inhibitors.

Mechanism: is a dopamine antagonist (blocker) that stimulates motility of upper GI tract, without stimulating gastric, biliary or pancreatic secretions. Appears to sensitize tissues to acetylcholine.

Warnings/precautions/adverse effects (Major)
  • Depression, restlessness, gynecomastia
  • Tardive dyskinesia
  • Extrapyramidal effects--Parkinson like symptoms
  • May cause drowsiness.
  • Pregnancy Category: B
Drug interactions: increases alcohol absorption rapidly absorbed in small intestine. Decreases absorption of: cimetidine, digoxin.

Patient counseling
  • Do not use for more than 12 weeks.
  • Dosed 5mg-10mg four times daily 30 minutes before meals and bedtime
  • Report any signs of tremor. A local neurologist tole me “Pete, before I check a suspected patient for Parkinson’s disease I always check the med list and look for metoclopramide”
MISOPROSTOL (Cytotec® )Approved Dec-1988 Indications: prevention of NSAID gastric ulceration, in patients at high risk for complications (over 60, debilitating disease, history of ulcers) relief of GERD, reduced gastric acid secretions.
Mechanism: has anti-secretory (inhibits gastric acid secretion) and mucosal protective properties. NSAIDs inhibit prostaglandin synthesis, a deficiency of prostaglandins within gastric mucosa may lead to diminished bicarbonate and mucus secretion, contributing to damage of gastric mucosa by NSAIDs. Misoprostol is a prostaglandin that increases bicarbonate, and mucus production, and maintains mucosal blood flow. Is also available combined with diclofenac as a single tablet (Arthrotec®)

Warnings/precautions/adverse effects
  • Abortifacient: black box warning
  • Pregnancy Category-X
  • Diarrhea, abdominal pain up to 40% (usually dose related-take with food)
  • Use Contraceptives in female patients
  • Must have negative pregnancy test in the past 2 weeks.
  • Oral and written warnings.
Drug interactions: none

Back in November we talked about the fact that Tagamet was the first billion-dollar drug. The second drug to reach the billion-dollar drug rank was Zantac.

By 1990 Zantac hit the two-billion-dollar mark. In the 1980’s there was a lot of interest in developing drugs for peptic ulcers, along with gastroesophageal reflux disease.

A lot of us believe that the proliferation of these “stomach drugs” parallels the exponential increase in restaurants and fast food! Think about that the next time you pull the omeprazole, pantoprazole, esomeprazole, lansoprazole, rabeprazole, dexlansoprazole, ranitidine, cimetidine, famotidine and others off the shelf.

Have a great day on the bench!!

Flu season is in full swing... does oseltamivir make your cash register ring???

$100.00 or more for one day of benefit... at best!

Oseltamivir (Tamiflu) has been available for treatment of the flu since 1999. It works by inhibition of neuraminidase. By binding to neuraminidase proteins, oseltamivir prevents flu viruses from spreading from infected cells to other healthy cells. Oseltamivir is a prodrug and is pharmacologically similar to zanamivir. After oral administration, oseltamivir is readily absorbed from the gastrointestinal tract and extensively converted to the active metabolite.

So far this flu season of 2018, influenza viruses have been susceptible to the neuraminidase inhibitor antiviral medications, which also includes zanamivir (Relenza®), and peramivir (Rapivab®).

Indications for use:
  • Patients two weeks of age and older, who have had flu symptoms for 2 days (48 hours) or less. Oseltamivir is effective against both influenza type A and B. Therapy should begin within 48 hours of the onset of symptoms. Oseltamivir may reduce symptoms by 1 day.
  • Prevention of influenza A and B in patients one year of age and older
Warnings/Precautions/ Adverse effects:
  • Nausea, vomiting, headache and pain.
  • Drug interactions: probenecid causes a 2-fold increase due to decreased tubular secretion.
  • CDC warning: November 13, 2006: The FDA approved a labeling supplement to include a precaution about neuropsychiatric events for Oseltamivir (Tamiflu®). Self-injury and delirium has been observed in Japan primarily among pediatric patients. Monitor pediatric patients for signs of unusual behavior.
Representative Products:

Tamiflu® (oseltamivir) 30mg, 45mg, 75mg capsules, (generics are available)
and powder for suspension 6mg/ml: 60 ml per bottle Adults: 75mg twice daily for 5 days. Children: based on body weight If younger than 1 year old: 3 mg/kg/dose twice daily If 1 year or older, dose varies by child’s weight:
  • 15 kg or less, the dose is 30 mg twice a day (suspension: 5ml BID)
  • >15.1 to 23 kg, the dose is 45 mg twice a day (susp: 7.5ml BID)
  • >23.1 to 40 kg, the dose is 60 mg twice a day (susp: 10ml BID)
  • >40 kg, the dose is 75 mg twice a day (susp: 12.5ml BID)
Patients should start the 5-day regimen as soon as possible. Take two doses the first day, no matter when the prescription is received.

The prophylaxis dose is the same as above EXCEPT all doses are given ONCE daily for 10 days. Patients need to be over 1 year of age to receive prophylaxis.

What oseltamivir doesn’t do:
  • It does not prevent bacterial infections
  • It is NOT a substitute for the annual flu vaccine
  • Of no value if started later than 48 hours after onset of symptoms.
APPROACH WHEN TAMIFLU (oseltamivir) liquid is not available: (from the Tamiflu® website) For patients who cannot swallow capsules, TAMIFLU for oral suspension is the preferred formulation.
  • When TAMIFLU for oral suspension is not available from wholesaler or the manufacturer, TAMIFLU capsules may be opened and mixed with sweetened liquids such as regular or sugar-free chocolate syrup, corn syrup, caramel topping, or light brown sugar (dissolved in water).
  • During emergency situations and when neither the oral suspension or the age-appropriate strengths of TAMIFLU capsules to mix with sweetened liquids are available, then a pharmacist may prepare an emergency supply of oral suspension from TAMIFLU 75 mg capsules.
The following chart shows how to make Tamiflu in an oral suspension of 6mg/ml

Total Volume of Prepared Oral Suspension 37.5ml 75ml 100ml 125ml 150ml
Number of Tamiflu 75mg strength
capsules (total strength)
3 capsules (225mg oseltamivir) 6 capsules (450mg oseltamivir) 8 capsules (600mg oseltamivir) 10 capsules (750mg oseltamivir) 12 capsules (900mg oseltamivir)
Amount of water 2.5ml 5ml 7ml 8ml 10ml
Volume of vehicle (Cherry Syrup (Humco);
OR Ora-sweet SF (Paddock Laboratories) OR simple syrup
34.5ml 69ml 91ml 115ml 137ml


STEPWISE DIRECTIONS:
  1. Place specific amount of water in PET or Glass bottle
  2. Separate capsules and pour powder from those capsules into bottle
  3. Gently swirl suspension to ensure adequate wetting of powder
  4. Slowly add specified amount of vehicle. Use only the vehicles listed above. Cap the bottle.
  5. Shake well for 30 seconds. Add shake well label to bottle.
  6. Stability
    1. Refrigeration: Stable for 5 weeks (35 days) when stored in a refrigerator at 2° to 8°C (36° to 46°F).
    2. Room temperature: : Stable for five days (5 days) when stored at room temperature, 25°C
  7. Counsel patient on storage, instruct to shake well, discuss dosing regimen, provide a liquid measuring device.


Remember rimantadine (Flumadine®) and amantadine (Symmetrel®)? High levels of resistance to amantadine and rimantadine persisted among circulating influenza A viruses. Adamantanes are not effective against influenza B viruses. They have not been recommended for treatment of the flu for at least 10 years.

All we have in the prescription department to combat influenza are the neuraminidase inhibitors. I have not dispensed Relenza® (zanamivir) in years. When I see many copays crashing the $100.00 mark, as many of elderly have not met their Medicare-D deductibles, we often put the medication back in stock.

When we see that oseltamavir only shortens the duration by a little over one day, and has to be started within 48 hours of onset, we can see how important influenza vaccines are!

Frequent hand washing, avoiding sick people, covering mouth and nose when sneezing are all practical tips for staying healthy this time of the year. Remember the flu virus can “live” on some surfaces for up to 24 hours. Routine cleaning of surfaces may reduce the spread of flu.

Oseltamivir with its high cost over $100 for many, the narrow window of opportunity, and limited efficacy fo shortening flu by one day, make those flu shots in October very important indeed!

Have a great day on the bench!!

Hand Holding and dry crackers can only go so far in treating hyperemesis gravidarum. Prescription treatment might be warranted

Help for Mom, when she needs it the most! Rx treatment of hyperemesis gravidarum

Last week we discussed using two rather common over the counter medications (with physician’s approval) Vitamin B-6 and Doxylamine. As discussed, this combo could be used instead of the very expensive Diclegis®. However, Diclegis is the only FDA approved drug for treatment of nausea of pregnancy.

The other prescription drugs listed below are being used off label for treatment of nausea and vomiting of pregnancy. This week we can discuss the prescription treatment of nausea of pregnancy, and the more intensive form: hyperemesis gravidarum.

I’m well aware that the FDA is phasing out the traditional pregnancy categories, but they still serve as a guide for many clinicians



DRUG THERAPY FOR NAUSEA OF
PREGNANCY/ HYPEREMESIS GRAVIDARUM
Pregnancy Category Comments
Doxylamine (Unisom®) A Very safe combined with B-6
Pyridoxine (Vitamin-B6®) A First line. Alone or in combo with Doxylamine
Diclegis® 10mg/10mg (doxylamine succinate and
pyridoxine hydrochloride delayed-release tablets)
A Only FDA approved treatment for nausea of pregnancy; not for hyperemesis gravidarum
Dramamine (Dimenhydrinate)
Diphenhydramine (Benadryl)
Meclizine (Antivert/Bonine/Dramamine-II)
B Generally safe- may cause drowsiness. None are considered to be teratogenic
Dolasetron (Anzemet®)
Granisetron (Kytril®)
Ondansetron (Zofran)
B Limited human data- animal data suggests low risk. Zofran –most studied-
Metoclopramide (Reglan®) B Watch Mom for drug induced movement disorder. Monitor baby for extrapyramidal symptoms at birth.
Hydroxyzine (Atarax & Vistaril®) C Caused 5.8% rate major birth defects
Chlorpromazine (Thorazine®)
Perphenazine (Trilafon®)
Prochlorperazine (Compazine®)
Promethazine (Phenergan®)
C All considered as 3rd line agents. Watch for QT prolongation and extrapyramidal effects, and movement disorders.
Corticosteroids C
D-1st trim
Oral clefting first trimester exposure. Last resort.


Ondansetron (Zofran) can be dosed at 4mg every 8 hours, up to a maximum dose of 16mg/dose. Ondansetron can cause QT prolongation, and serotonin syndrome in susceptible patients. As far as the baby goes there is a slight increase in heart defects and cleft palates, but most obstetricians feel the very small risk of these side effects are superseded by all of the well-known problems of prolonged dehydration caused by nausea and vomiting.

According to the American College of Obstetrics and Gynecology (ACOG) prenatal vitamins in the preconception period may reduce the severity of nausea and vomiting in early pregnancy. Most clinicians do not recommend ginger supplements, due to lack of standardization, but will recommend ginger containing food such as lollipops, candy, and tea.

Hyperemesis may lead to dehydration, vitamin deficiency, and weight loss, therefore, adequate hydration, vitamin replacement, nutrition, and antiemetic therapy is critical to avoid maternal morbidity. Most physicians feel the risk of ondansetron therapy is worth the benefit.

So often with our pregnant population when they complain of nausea, reassuaance and dietary modifications may be all that is necessary. Basic recommendations include avoiding stimuli that trigger nausea and vomiting such as sensory stimuli to strong odors, and other sensory stimuli such. Dietary counseling about frequent small meals and avoidance of spicy or fatty foods is appropriate even though the evidence is lacking for such a recommendation.

Most obstetricians are quite comfortable using ondansetron for nausea and vomiting of pregnancy. Now that the generics are so inexpensive obstreticians seldom hesitate to use it if needed. Remember back in 2012, when Zofran 4mg was $22.00 per tablet! We have a lot of reasonable priced medications to treat these women with very safe drugs to insure a happy and healthy pregnancy.

Have a great day on the bench!!

January 2018

Help share the joy with the new mother, and make her tummy feel better too!

Treatment and Prevention of Nausea of Pregnancy

Often referred to as “morning sickness” 75-80% of pregnant patients complain of morning or evening nausea. The peak time for morning sickness is in the first trimester between weeks 5-12 of pregnancy. Most women experience this discomfort, and by adjusting diet or routines, have minimal difficulty as resolution occurs at the beginning of the second trimester.

Hyperemesis gravidarum – the worst kind of morning sickness: 15% of pregnancies experience nausea and vomiting until delivery. Persistent vomiting may cause weight loss, dehydration, starvation ketosis, hypochloremic alkalosis and hypokalemia. This severe vomiting might also lead to transient elevation of liver enzymes.

The exact cause of nausea and vomiting during pregnancy is unknown. However, it is believed to be caused by a rapidly rising blood level of human chorionic gonadotropin (HCG), which is produced in the placenta. High levels of HCG is most common with multiple gestations. High-fat diets and Helicobacter pylori infection also contributes to the incidence and severity of hyperemesis gravidarum. Helicobacter pylori, the bacteria that causes stomach ulcers in the general population, is seen in 90% of the patients with hyperemesis gravidarum.

  • Reassurance and dietary advice is all that is required in most instances.
  • Best to hospitalize patient in private room with bed rest.
  • The hospitalized patient should not eat or drink (NPO) for 48 hours, electrolyte balance and hydration should be maintained by parenteral nutrition.
  • Place patient on “dry diet” plus clear liquids 1 hour after eating.
  • Get plenty of rest.
  • Avoid smells that are bothersome.
  • Eat five or six small meals each day instead of three large meals.
  • Eat small snacks high in protein (such as a glass of milk or a cup of yogurt) throughout the day.
  • Avoid spicy foods and fatty foods.
First line (always weigh risks versus benefits). Most over-the counter products do carry pregnancy warnings, so it is safest to use these products on a physician’s recommendation.

  • Vitamin-B-6 (pyridoxine) 10-25mg every six hours. Most often dosed at night before bed, then additional doses in the morning and in the late afternoon, IF NEEDED
  • Doxylamine (Unisom®) since 25mg is the lowest dose available in the United States, it is reasonable to use 12.5 to 25mg along with the dose of pyridoxine at bedtime, then in the morning and late afternoon if needed. Just make sure the patient is buying the “Sleep-tabs®” which contain doxylamine, and not SleepGels® which contain diphenhydramine.
DICLEGIS: fixed dose combination drug product (Delayed-release tablets containing 10mg doxylamine succinate and 10 mg pyridoxine hydrochloride) direct cost is nearly $700 per 100 tablets Dosage: Take two tablets daily at bedtime. The dose can be increased to a maximum recommended dose of four tablets daily one in the morning, one mid-afternoon and two at bedtime. (cost: $600.00/ 100 tablets). BONJESTA is the same combination, but each tablet contains 20mg of pyridoxine and doxylamine.

Writing this column takes me back 32 years ago, when my wife Denise was pregnant with our second daughter Elizabeth. She was the textbook case for hyperemesis gravidarum. She lost so much weight during her pregnancy, she weighed less after delivery than before she got pregnant!

Of course back in 1986, we didn't have the medications we do today to help control the nausea and vomiting, on an outpatient basis. At her check-up her obstetrician was so disturbed by her weight loss, he admitted her to the hospital, for IV fluids to re-hydrate her. After spending a few days in the hospital she came home, and was able to eat small meals. She never fully got back her appetite until delivery.

Next week we will discuss the prescription therapy for hyperemesis gravidarum. For simple cases of nausea, the pyridoxine and doxylamine may be of great benefit. Many of us seasoned pharmacists remember Bendectin® which was withdrawn by the manufacturer, as they got tired of defending this product in court.

The ingredients in Bendectin, are the same as in Diclegis, which are rated as Pregnancy Category-A: " Controlled studies show no risk or find no evidence of harm" With the physician’s approval we can easily save our patients over $500.00 per month by substituting these over-the-counter recommendations.

Have a great day on the bench!!

We'll have lots of educating to do with our patients. FDA labeling changes on fat soluble vitamins are sure to cause lots of confusion.

Hey, are you out of Vitamin D-2000? All I see out here is Vitamin-D 50!!

I was dumbfounded when our OTC manager brought back a bottle of Vitamin-D and asked what this microgram stuff is about? Don't they make Vitamin D-2000 any more??

In May 2016, the U.S. Food and Drug Administration (FDA) announced regulations that require amendments to the existing supplement facts label, which uses units and conversions based on the Recommended Daily Allowances that were established back in 1968. The new regulations will be mandatory in 2019-2020. On Sept. 29, 2017, the FDA released its proposed rule to extend the compliance dates for Supplement and Nutrition Facts Labeling. The agency said it wanted to give manufacturers more time to comply, citing concerns from stakeholders that the current deadlines would not give them enough time to do so. Some of the vitamin companies have made the labeling change, which I’m sure will cause a lot of confusion, both for patients and prescribers. Let’s hope EPIC and other electronic medical records convert soon, as the new nomenclature is appearing on our shelves!

To convert Vitamin A as retinol:
From IU to mcg: IU/3.33 = mcg


INTERNATIONAL UNITS
(old labeling)
MICROGRAMS
(new labeling)
5000iu 1500mcg (1.5mg)
8000iu 2400mcg (2.4mg)
10,000iu 3000mcg (3mg)


To convert Vitamin A as beta-carotene:
From IU to mcg: IU/1.66 = mcg


INTERNATIONAL UNITS
(old labeling)
MICROGRAMS
(new labeling)
25,000iu 15,000mcg (15mg)


To convert Vitamin D:
From IU to mcg: IU/40 = mcg


INTERNATIONAL UNITS
(old labeling)
MICROGRAMS
(new labeling)
400iu 10mcg
800iu 20mcg
1000iu 25mcg
2000iu 50mcg
5000iu 125mcg
50,000iu 1250mcg= 1.25mg


To convert Vitamin E if the product label has dl-Alpha-tocopherol (blended) as the ingredient:
From IU to mg: IU * 0.9 = mg

INTERNATIONAL UNITS
(old labeling)
MICROGRAMS
(new labeling)
30iu 27mg
100iu 90mg
200iu 180mg
400iu 360mg
800iu 720mg
1000iu 900mg


To convert Vitamin E if the product label has d-Alpha-tocopherol (pure d-alpha) as the ingredient:
From IU to mg: IU * 0.67 = mg

INTERNATIONAL UNITS
(old labeling)
MICROGRAMS
(new labeling)
30iu 20.1mg
100iu 67mg
200iu 134mg
400iu 268mg
800iu 536mg
1000iu 670mg


I called our primary vitamin vendor, and asked why they made these label changes. She assured me those changes are being made by the FDA's insistence. I asked her if they are providing conversion charts for the pharmacies, and prescribers. She answered, "not that I know of !"

Some of the labels are not "cross referenced" so we might not see both strengths on the label. According to the FDA both micrograms and international units may be on the label. I looked all over for charts for the conversions for the new labeling changes for the fat soluble vitamins.

So in my frustration I created this chart, so you wouldn't have to. Feel free to copy this chart, make shelf talkers out of it, anything to take care of your patients.

The next vitamin representative that comes to my store, will face a very long discussion. I'm all for FDA compliance, but I'm also for excellent patient care! The vitamin companies need to "step up" and assist the health care practitioners in this conversion.

Have a great day on the bench!!

Treatment of diarrhea... should we or shouldn't we??

What goes along with nausea and vomiting?

Why of course it is diarrhea!! Diarrhea, like vomiting is frequently due to a response of the gastrointestinal tract to remove bacteria and toxins. The most frequent problem that diarrhea causes is dehydration. As with vomiting, our goal for patients with gastroenteritis is to prevent dehydration.

This is the time of year we see patients standing in the gastrointestinal section, holding a box of Imodium, and looking our way for some help. Before you pull that box of loperamide off the shelf, I have a few (actually quite a few) questions?
  • How long and how often do you have these episodes?
  • Any other symptoms?
  • Which anti-diarrhea medications have you tried?
  • Characteristics of your stool?
  • Have you changed your diet? Drinking non-chlorinated water?
  • Have you recently traveled to a foreign country?
  • Anyone in your household have diarrhea or can you contribute it to a particular food?
  • What medications are you currently taking?
  • Any medical conditions or chronic illnesses?
Refer to physician immediately if any of the following (source: cdc.gov)
  • Elderly age
  • History of chronic medical conditions or concurrent illness
  • Fever over 102.2 °F
  • Visible blood in stool
  • High output of diarrhea, including frequent and substantial volumes of stool
  • Persistent vomiting
  • Signs consistent with dehydration (e.g., sunken eyes or decreased tears, dry mucous membranes, orthostatic hypotension or decreased urine output)
  • Change in mental status (irritability, apathy, or lethargy)
  • Suboptimal response to oral rehydration therapy already administered or inability to administer oral rehydration therapy
May I check your med list?
Here are some drugs that have the potential to cause diarrhea:
  • Laxatives
  • Antibiotics (broad spectrum)
  • Magnesium salts
  • Propranolol
  • Parasympathomimetics (pilocarpine, cevimeline bethanechol)
  • Metoclopramide
  • Digitalis
  • Colchicine
  • Seldom used drugs: indomethacin, methyldopa, theophylline, misoprostol
What if it is the “Stomach flu”- gastroenteritis:
  • Follow rehydration protocol as for nausea and vomiting. Oral rehydration solutions (Pedialyte®)
  • Antimotility agents such as (diphenoxylate/atropine) Lomotil® or (loperamide) Imodium® should be considered only in adult patients who are NOT febrile or having bloody/mucoid diarrhea. Antimotility agents may reduce diarrheal output and cramps, but do not accelerate cure.
  • Antimotility agents are generally contraindicated for children.
'Tis the season for the big three... nausea, vomiting and diarrhea. I had three different patients today, presenting with flu symptoms. I have yet to dispense Tamiflu® (oseltamivir) which is approved by the FDA for treatment of acute uncomplicated influenza within 2 days of illness onset. Most patients seem to be well past that 48 hour window where oseltamivir is effective, when they seek medical advice.

With Tamiflu's wholesale acquisition cost being over $150.00, and the generic being over $100.00 is it a good investment to treat most of our patients? I'm a believer in re-hydration, management of fever with acetaminophen and of course frequent hand washing!

Refer patients to the physician when appropriate. Be sure to share the information in the past three Clinician Corner Columns with your patients, especially with regard to hydration and introduction of solid foods.

Have a great day on the bench!!

OTC treatment for Nausea and Vomiting--- a lot cheaper than a visit to the Emergency Department!

OTC treatment options for treatment of vomiting...

Now that we have had the big “germ exchange” also known as the holiday season, a lot of patients are coming to ask our advice for treatment of nausea and vomiting. I know of one physician office where they tell the patients to stay home, keep hydrated and stay off work! The nurses won’t even give the adult patients an appointment! We talked in previous columns about the viruses that cause nausea and vomiting.
Last week we discussed the prescription treatment of nausea, so this week we can address the needs of those patients who come to us first for treatment of this quickly spreading viral gastroenteritis. The first concern we will always have is that our patient doesn’t get dehydrated. That must be the first, and only concern we should have. As we discussed before vomiting is our body’s way of getting rid of bacteria, viruses and toxins that shouldn’t be there. Our goal need not so much be stopping of the vomiting, rather the prevention of dehydration.

Signs and symptoms of DEHYDRATION
  • Dry or sticky mouth
  • Lethargy or coma (severe dehydration)
  • Low blood pressure
  • Low or no urine output, concentrated urine that looks dark yellow. (Consult MD if more than 8 hours)
  • Sunken soft spots (fontanelles) on the top of an infant's head. (Consult MD)
  • No tears
  • Sunken eyes
We have a couple of products over-the counter that are traditionally used for nausea. Their efficacy is doubtful.
  • Emetrol®: mixture of dextrose, fructose and phosphoric acid. Is hyperosmolar and works on GI wall to decrease smooth muscle contraction and delay gastric emptying time. Best for food and drink nausea.
  • Cola syrup (Coke®) contains the same sugars and phosphoric acid. Don’t use regular soda, even de-fizzed.
    • 2-12 years old: 5-10 ml every 15 minutes until vomiting stops; not to exceed 5 doses per hour. Not recommended if under 2 years
    • 12 years old: 15-30 mL every 15 minutes until vomiting stops; not to exceed 5 doses per hour
WHO (World Health Organization) ELECTROLYTE FORMULATION:
Available on-line, recipe and dosing. Contains: sodium chloride, potassium chloride, sodium bicarbonate, sugar and water.

Commercially Available Electrolyte Replacements
  • Oral fluids should be replaced quickly, but in a controlled fashion, to prevent the dehydration from becoming more severe. Recommend a teaspoon (5 mL) every five minutes until the patient can tolerate more.
  • Oral replacement should start at 50 to 100 mL/kg with an extra 2 mL/kg for each emesis or 10 mL/kg for each loose stool.
  • Pedialyte®: is an oral electrolyte replacement solution, sold in liters and a variety of flavors: bubble gum, mixed fruit, plain, blue raspberry, cherry punch, grape. Generic formulations are available.
Dosing of Electrolyte Solutions
  • For infants under 1 year of age: Consult your doctor.
  • For children 1 year and older and adults: Begin with small frequent sips every 15 minutes, increasing serving size as tolerated. Continue for as long as diarrhea is present.
  • To maintain proper hydration, 1-2 liters (32 to 64 fl oz) of Pedialyte may be needed per day. Consult your doctor if vomiting, fever, or diarrhea continues beyond 24 hours or if consumption needs are greater than 2 liters (64 fl oz) per day
WHAT TO AVOID: Fluids to be avoided include:
  • hypertonic fruit juices and drinks
  • carbonated beverages and caffeine containing beverages,
  • powered gelatin mixes which can make diarrhea worse, and lack the necessary electrolytes.
  • Even our beloved Gatorade diluted with water, still contains too much sugar for treatment of diarrhea. If anything, recommend sugar free Gatorade (G2®)
The return to solid foods: BRAT diet:
The BRAT diet is a bland-food diet that is often recommended for adults and children. BRAT stands for Bananas, Rice, Applesauce and Toast. The BRAT diet helps recovery upset stomach or diarrhea for the following reasons:
  • It includes “binding” foods. These are low-fiber foods that make stools firmer. It includes bananas, which are high in potassium and help replace nutrients the body has lost because of vomiting or diarrhea.
  • Some clinicians feel this diet lacks adequate protein for long term use.

I remember as a student pharmacist that one of my jobs was pouring "Coca-Cola®" syrup into four ounce bottles. We would buy our Coke syrup in gallon jugs, package them up, slap on a label from the Coca-Cola company onto the amber bottle giving directions for use. Most of the time we would tell patients to dump the Coke syrup over crushed ice and sip slowly.

This activity of bottling up Coke syrup came to a screeching halt after the Tylenol Tragedy of 1982, when tamper resistant packaging was required for Over-the Counter sales. Today we buy it nicely packaged in four ounce bottles from a variety of distributors under the name "Cola Syrup"

With the every sky-rocketing prices of an Emergency Department visit, we pharmacists can save the health system a pile of money by treating vomiting over-the counter. I have a flyer I created on the BRAT diet that I share with my patients. Often when the nausea subsides they start eating a regular diet which seems to aggravate the gastrointestinal tract.

The BRAT diet for a day or so seems to be an easy way to ease back into a normal diet. Keep reminding your patients that effective hand washing is the most beneficial way to prevent viral gastroenteritis.

Wishing you and your family a Health and Happy 2018!

Have a great day on the bench!!

December 2017

Treatment of nausea and vomiting... lots of receptors we can block!

Prescription treatment of nausea and vomiting

Antihistamine-anticholinergic agents (histamine-1 blockers)
Examples: doxylamine (Unisom), diphenhydramine (Benadryl), hyoscyamine (Levsin)


Indication: for mild nausea and vomiting. Are of greater benefit in prevention of nausea arising from motion sickness.

Mechanism: appear to interrupt various visceral afferent pathways, that stimulate nausea and vomiting. Most antihistamines do have anticholinergic activity, and can be useful for nausea and motion sickness.

Adverse effects: Drowsiness, confusion, blurred vision, dry mouth, urinary retention, possible tachycardia in elderly. Increased sedation with alcohol—careful on cruise ships!


Phenothiazines (dopamine blockers)
Examples: promethazine, prochlorperazine, haloperidol

Promotility agents (dopamine blockers)
Example: metoclopramide (Reglan)


Indication: more severe nausea and vomiting. Are inexpensive and are used for long term nausea. Most useful in patients with viral gastroenteritis or those receiving mildly emetogenic doses of chemotherapy.

Mechanism: act on the CTZ (Chemoreceptor trigger zone) by inhibiting dopaminergic transmission. Also decrease vomiting caused by gastric irritants suggesting they inhibit stimulation of peripheral vagal and sympathetic afferents. Metoclopramide (Reglan) has a unique mechanism of action that is to stimulate motility in the upper GI tract. Metoclopramide has a similar side effect profile to the phenothiazines.

Adverse effects: Extrapyramidal reactions, Parkinson-like side effects, hypersensitivity with possible liver dysfunction, marrow aplasia, excessive sedation

5-HT-3 Receptor Antagonist (serotonin blockers)
Examples: ondansetron (Zofran) granesitron (Kytril)


Indication: effective in prevention of chemotherapy induced vomiting. Also, effective for post-op nausea, and radiation induced nausea. Frequently combined with corticosteroids (dexamethasone or methylprednisolone) for maximal emesis control.

Mechanism: mucosal entero chromaffin cells in the GI tract release serotonin which stimulates 5HT3 receptors. This causes vagal afferent discharge, inducing vomiting. With the binding of the 5HT3 receptors serotonin stimulation is blocked and hence vomiting is blocked.

Adverse effects: headache, constipation, Can prolong the QT interval. May cause torsades, ventricular arrhythmias, or sudden death. If given to a high-risk drug to a high-risk patient such as the elderly, women, or those with heart failure, bradyarrhythmias, or low serum potassium or magnesium.

NK-1 receptor antagonist
Example: aprepitant (Emend)


Indication: antiemetic in combination with other antiemetics for nausea with highly emetogenic cancer chemotherapies
Mechanism: selective high affinity antagonist or human substance –P/ neurokinin-1 receptor. Little or no affinity for 5-HT3, dopamine, and corticosteroid receptors. Antagonizes the NK-1 receptor
Adverse effects: Many GI, cardiovascular and CNS effects, diaphoresis and alopecia, drug interactions

Cannabinoids
Examples: dronabinol (Marinol) , marijuana


Indication: used as an appetite stimulant and antiemetic. Effective in treating nausea caused by chemotherapy, but associated with CNS side effects in most patients.
Mechanism: THC (tetrahydrocannabinol) appears to affect the central cerebral cortex axis. Available as dronabinol. Antiemetic effect associated with a “high” and appears better tolerated in the young.
Adverse effects: Orthostatic hypotension, drowsiness, sedation, dry mouth, euphoria

Keep in mind that the reason we have vomiting is a protective mechanism to keep our body from retaining harmful bacteria, viruses and toxins. Suppression of vomiting should be necessary only after a few days, and dehydration can occur. Next week we will discuss the over-the counter treatments, as well as patient care information for vomiting


I remember when Reglan (metoclopramide) came out in the early 1980's to much fanfare as another treatment option for GERD. It was the first treatment option since the phenothiazines in the 1950's!! It quickly became the "go to" for nausea and vomiting for the oncology doctors. We quickly found out that the 10mg four times daily dose caused a lot of Parkinson like side effects.

I had a neurologist tell me "Pete, before I even check a patient for cogwheel rigidity to diagnose Parkinson's disease, I check the med list and look for Reglan first!" Usually drug induced Parkinsonism presents as a bilateral tremor. Parkinson's disease usually first presents as a tremor on one side, before progressing to the other side.

In the 1990's ondansetron (Zofran) became available. I remember when Zofran was nearly one thousand dollars for a bottle of 30. We only used Zofran for nausea induced by cancer chemotherapy. Today the generics cost the pharmacy less than ten dollars for a bottle of 30 tablets, and I see ondansetron being used for any kind of nausea and vomiting from chemo, nausea of pregnancy to simple GI upset!

Have a great day on the bench!!

Be sure to avoid these "uninvited guests" at your next Holiday Party!!

Vomiting... don't let it ruin your holidays.

Vomiting is a protective reflex that allows us to rid ourselves of ingested toxins or poisons. There are five principle neurotransmitter receptors responsible for vomiting. Gastroenteritis is most commonly associated with the dopamine and serotonin receptors. I have listed examples of drugs that react with those receptors:

Name of Receptor Drug working on that receptor
muscarinic (M1) anticholinergics: dicyclomine (Bentyl), hyoscyamine (Levsin))
dopamine (D2) metoclopramide (Reglan), prochlorperazine (Compazine)
histamine (H1) diphenhydramine (Benadryl) doxylamine (Unisom)
serotonin (5HT3) ondansetron (Zofran), granisetron (Kytril)
neurokinin 1 (NK1) Aprepitant (Emend)


Who invited these guys to my Christmas Party…? Listed below are the three most common viruses implicated in nausea and vomiting.
  • Norovirus (Norwalk-like virus) is common among school-age children. It may also cause outbreaks in hospitals and on cruise ships. It is the most common GI virus.
  • Rotavirus is the leading cause in children. It can also infect adults who are exposed to children with the virus, and people living in nursing homes. Vaccination has greatly reduced this virus
  • Enteric adenovirus: can cause systemic infection
The Christmas Germ Exchange- We exchange presents, cards, food, handshakes, hugs and kisses at Christmas time. We also exchange a lot of bacteria and viruses!
  • Most viruses and bacteria are passed from person to person by unwashed hands. Other potential causes can be:
    • Improper handling of food
    • Improper cooking of shellfish
    • Improper hand washing after toileting
    • Surfaces not properly sanitized after food preparation.
  • A vaccine to prevent rotavirus infection is recommended for infants starting at age 2 months. (Rotavirus is the leading cause of viral gastroenteritis in kids up to 2 years of age)
.
I have this vomiting …was it something I ate at the party??

Raw seafood Norwalk-like virus, Vibrio, hepatitis A
Raw eggs Salmonella
Undercooked meat or poultry Salmonella, Campylobacter, E. coli (STEC), Clostridium perfringens
Unpasteurized milk or juice Salmonella spp, Campylobacter, E. coli, Yersinia enterocolitica
Unpasteurized soft cheeses Salmonella, Campylobacter, E.coli (STEC) Yersinia enterocolitica, Listeria monocytogenes
Homemade canned goods Clostridium botulinum
Raw hot dogs, deli meat Listeria monocytogenes


GETS YOU SICK (less serious) GETS YOU TO THE HOSPITAL (serious)
Novovirus Clostridium botulinum
Salmonella Listeria
Clostridium perfringens Shiga-Toxin producing Escherichia coli (STEC)
Campylobacter Vibrio
Staphylococcus aureus


Now What Happens??
  • The CTZ (chemoreceptor trigger zone) is located in the 4th ventricle of the brain. It is the major chemosensory organ for emesis, usually associated with chemically induced vomiting. Because of its location, blood-born and cerebrospinal fluid toxins have easy access to the CTZ. It is our defense against ingesting poisons; our brain works to eliminate these toxins form our GI tract. This mechanism frequently “kicks in” during cancer chemotherapy. This mechanism also “kicks in” to eliminate those toxins and viruses that we are exposed to these holidays.
Next week we will discuss treatment of nausea and vomiting.

Hand-washing should be our first line of defense against the bacteria and viruses that can cause vomiting.

Here is what the CDC says about hand washing on their website:

"Hand-washing is like a "do-it-yourself" vaccine—it involves five simple and effective steps (Wet, Lather, Scrub, Rinse, Dry) you can take to reduce the spread of diarrheal and respiratory illness so you can stay healthy. Regular hand-washing, particularly before and after certain activities, is one of the best ways to remove germs, avoid getting sick, and prevent the spread of germs to others. It's quick, it's simple, and it can keep us all from getting sick. Hand-washing is a win for everyone, except the germs."

Source: CDC

Have a great day on the bench!!

Antacid therapy --- not as harmless as we might believe??

Antacids: Warnings, Precautions and Drug Interactions

After last week’s inorganic chemistry lesson, lets get down to the information that impacts our patients! All the reactions had one thing in common, generation of a chloride salt: aluminum chloride, magnesium chloride, calcium chloride or sodium chloride. Many of our patients can experience adverse effects from these mono and polyvalent cations..

Warnings/precautions/adverse effects of antacid therapy.
  • Use calcium carbonate, and magnesium antacids cautiously in renal impaired patients
  • Sodium bicarbonate is contraindicated in hypertension, heart failure, renal disease & edema. Do not use for ulcers. Zegerid OTC contains both omeprazole and sodium bicarbonate.The manufacturer states sodium bicarbonate “protects the omeprazole from stomach acid”, but still it is sodium bicarbonate!
  • Use antacids cautiously in elderly where there is decreased GI motility
  • Aluminum containing antacids cause constipation.Use with caution with patients suffering with dehydration or intestinal obstruction.Caution in dialysis patients.
  • Chronic administration of calcium carbonate should be avoided because of hypercalcemia, and because calcium ions cause further stimulation of acid secretion.Calcium carbonate causes constipation.
  • Magnesium containing antacids may cause diarrhea.
  • Hypophosphatemia and osteomalacia can occur with long term use of aluminum hydroxides, but can occur with short term use in malnourished patients like alcoholics.
Drug interactions with antacid therapy:
  • Tetracyclines & fluoroquinolones are BOTH bound by antacids. Separate tetracyclines by 2 hours, and fluoroquinolones by 4 hours.
  • Enteric coated drugs: coating is destroyed by antacid exposure.
  • Antacids interfere with absorption of: digoxin, cimetidine, ranitidine, anticholinergics, phenothiazines, phenytoin, quinidine and ketoconazole (they require acid for absorption). Separate these drugs from antacids by 2 hours.
  • Separate from Levothyroxine (Synthroid) by 4 hours
.
After reviewing all of the potential drug: antacid interactions we pharmacists have another opportunity to interact with our patient population in providing expertise. Antacid therapy is not as innocuous as we might believe.

Have a great day on the bench!!

Did you eat too much at your holiday party??

Antacid Therapy

Indications for antacid therapy: Antacids today should be only used short term. Antacids work quickly to treat ulcer pain and heal ulcer. They neutralize gastric acid, which in turn increases Lower Esophageal Sphincter (LES) tone. The LES tone is important to keep the gastric contents from “splashing up” into the esophagus. Antacids inhibit the conversion of pepsinogen to pepsin thus raising the pH of the gastric contents.

Antacids have a rapid onset (5-15min) short duration (30-60minutes). They are ideal for immediate relief of gastrointestinal distress.

Mechanism: reduces concentration and total load of acid in gastric contents. The hydroxide ions or the carbonate ions neutralize the hydrogen ions (H+).

Active ingredients of antacid therapy: the chemistry behind antacid therapy:

Aluminum hydroxide: Al(OH)3 + 3HCl à AlCl3 + 3 H2O. Aluminum hydroxide plus hydrochloric acid produces aluminum chloride and water.

Magnesium hydroxide: Mg(OH)2+2HCl à MgCl2+2H2O. Magnesium hydroxide plus hydrochloric acid produces magnesium chloride and water.

Calcium carbonate: CaCO3 + 2HClà CaCl2 + H2O +CO2. Calcium carbonate plus hydrochloric acid produces calcium chloride, water and carbon dioxide

Sodium bicarbonate: NaHCO3 + HClà NaCl + H2O + CO2. Sodium bicarbonate plus hydrochloric acid produces sodium chloride, water and carbon dioxide

Simethicone is frequently included in antacid formulations as an “anti-gas” agent: Mechanism: silicon polymers that reduces surface tension of gas bubbles embedded in the intestinal mucosa. Simethicone is often added to antacids to reduce gas pain. The gas bubbles then coalesce and then are more easily eliminated through belching (upper GI) of flatulence (lower GI). Simethicone dosages: Children: less than 24 months: 20mg 4 times daily Age 2-12: 40mg 4 times daily Adults: 40-360mg after meals and at bedtime as needed.

I hope you enjoyed this "throwback" to Freshman Inorganic Chemistry!! Next week we can discuss the warnings, precautions and side effects of antacid therapy.


Since Tagamet came out in 1977, what were out patients with peptic and duodenal ulcer disease? I remember my Dad using Pro-Banthine® (propantheline), an anticholinergic which was approved in 1953. Robinul® (glycopyrrolate), another anticholinergic was approved in 1961 and also used to inhibit stomach acid secretion. Pushing doses of these anti-cholinergic drugs did indeed inhibit gastric secretions, but at what a price given all the side effects of dry mouth, blurry vision, constipation, urinary retention, etc.

Antacid therapy was the mainstay for these patients. Most patients always had a bottle of Maalox (mag/alum hydroxide) or Mylanta in their medicine cabinets, work lockers and even in their car.

The standard regimen included one ounce (30ml) one hour before each meal, one ounce after each meal and at bedtime. Patients could go through 7 ounces of antacid per day, and many bought a couple of bottles at a time. Talk about inconvenient dosing regimens.

We can now see how back in 1977 Tagamet (cimetidine) was met with such enthusiasm!

Have a great day on the bench!!

November 2017

Happy 40th Birthday Histamine-2 Receptor Antagonists!!! Hoooray for H2RA's!!!

Tagamet has been around for 40 years...we still love this class of drugs!

Mechanism: competitively inhibits the histamine at parietal cell receptor sites, thus reducing the volume and hydrogen ion concentration of gastric acid secretions.

Indications: Histamine-2 receptor antagonists (H2RA) are preferred to antacids because of compliance, and lack of effect on GI motility. Reasonably effective to treat mild/moderate gastroesophageal reflux disease (GERD). Less reliable for healing erosive esophagitis. May be useful for PUD or hypersecretory states (Zollinger-Ellison syndrome). H2RA work faster than proton pump inhibitors (which may take up to 3 days). The onset of action for the H2RA’s is within one hour and lasts between 6-12 hours.



Drug Year of Rx INTRO-USA Approved OTC Healing Dose Prevention Dose OTC Brand/Strength
Cimetidine (Tagamet®) 1977 June 1995 800mg HS 400mg HS Tagamet HB 200mg
Ranitidine (Zantac®) 1983 December 1995 300mg HS 150mg HS Zantac 75mg, 150mg tabs
Famotidine (Pepcid®) 1986 April 1995 40mg HS 20mg HS Pepcid AC-10
Pepcid AC-20
Nizatidine (Axid®) 1988 May 1996 300mg HS 150 HS Axid-AR-75mg


Counseling Points:
  • All H2RA are listed a Pregnancy Category-B (no proven risk in humans). However, all packages do carry the warning to consult physician if pregnant.
  • Cimetidine (Tagamet): weak anti-androgenic effects; male gynecomastia & impotence at high doses. May cause feminization of male fetus. Even though cimetidine is Pregnancy Category-B, I would never advise a pregnant patient to use this drug.
  • Pepcid Complete contains: Famotidine 10 mg, Calcium carbonate 800 mg, Magnesium hydroxide 165 mg. I don’t recommend calcium containing antacids, because the calcium will stimulate gastric acid release.
  • Axid-R-75mg is not current available.
Drug interactions
Cimetidine reduces hepatic metabolism of drugs metabolized by cytochrome P450 pathway.
  • CYP450*3A4 -simvastatin, Protease Inhibitors (HIV)
  • CYP450*2D6- codeine, fluoxetine etc.
  • CYP450*1A2 – fluoxetine, EtOH, amitriptyline, clopidogrel
  • CYP450*2C9 –ibuprofen, naproxen, glipizide
  • Ranitidine (Zantac) has about 10% affinity for CYP450 3A4 than that of cimetidine, so we expect insignificant drug interactions.
  • Nizatidine (Axid) and famotidine (Pepcid) have no affinity for CYP450 3A4.

Cimetidine (Tagamet®) was the first billion-dollar drug released back in the 1970’s for treatment of stomach ulcers. In 1964, it was well known that histamine stimulated gastric acid release. However the traditional anti-histamines (Benadryl, ChlorTrimeton) had no effect on gastric acid release. I remember in Medicinal Chemistry class back in 1980 the professor discussing how this class of drugs will change the way drugs are developed, since this was one of the first classes of drugs designed based on the discovery of the receptor site, and developing drugs to fit that receptor.

Ranitidine (Zantac®) was introduced in US market in 1983 and was the world's biggest-selling prescription drug by 1987. It has since largely been superseded by the even more effective proton-pump inhibitors, with Prilosec (omeprazole) taking over the acid suppression market for many years.

Have a great day on the bench!!

Lots of information about PPI's... should they even be over the counter??

Sending out this newsletter one day early... Tis the season for overeating... Happy Thanksgiving!

As we discussed last week, there have always been safety concerns with these medications. Denise and I were to a drug company sponsored dinner last week, and I specifically asked one of the local GI docs about “deprescribing PPI’s”. He acknowledged this as a hot topic in the GI arena, but he said that neither he or his colleagues were in any rush to stop this therapy, given the amazing benefits that appropriate PPI therapy brings to our sickest patients. He reminded us about GI bleeds, Zollinger Ellison, NSAID induced gastropathy and Barrett’s esophagitis. Of course, this astute GI doctor sees only the sickest of patients.

I also reminded him that “deprescribing” PPI’s will be a huge challenge, given the fact that they are available over the counter. With the life-saving potential of PPI therapy let’s discuss the adverse effects, and how we can best help our patients.

  • Fracture risk: at higher doses, new research shows increase risk of hip fractures possibly due to impaired calcium absorption. Fracture risk is a greater concern with high dose, and long term (over 1 year) of PPI therapy. Remind patients to take calcium (citrate), vitamin-D, and to exercise. Elderly patients on PPI therapy will benefit by using calcium citrate, because its absorption is less dependent on stomach acid.
  • B-12 deficiency: May also cause a cobalamin deficiency due to protein-bound dietary Vit-B12 malabsorption. Long term PPI use will decrease serum B-12 levels. Keep in mind that our liver has about two years of Vitamin-B12 on board so deficiency may take a while. Folate levels appear to be unaffected.
  • Decreased Magnesium levels: becomes more apparent with long term PPI use. Low magnesium levels can occur three months into PPI therapy, but risk is higher after one year. Patients should watch for muscle cramps, heart palpitations, dizziness, tremors, or seizures.
  • Pneumonia: PPIs increase gastric pH, which may allow more bacterial growth. The resulting change in gastrointestinal (GI) and respiratory flora may increase the risk for infection. The incidence of hospital-acquired and community-acquired pneumonias appears to be increased with PPI therapy.
  • Clostridium difficile: increase in Clostridium difficile infections and diarrhea occur as a direct result of PPI usage. About 42% of patients being treated for C. difficile while taking a PPI will have a recurrent infection within 90 days. Infections may be decreased by limiting PPI use to patients who truly need them
  • Alzheimers : (?) The results of one study showed that of the 2950 patients who were regularly using a PPI had a significantly higher risk for dementia compared with those not taking this drug. Later refuted by a study was published in the Journal of the American Geriatrics Society (2017) which addressed previous studies that suggested that PPI use was linked to increased risk of cognitive impairment in adults aged 75 years or older. For now, Alzheimer's seems to be unlikely caused by PPI use.
  • Renal Failure: Compared with patients who took an H2 blocker (Zantac, Tagamet, etc), PPI users had a 19% increased risk of estimated glomerular filtration rate (eGFR) falling below 60 mL/min/1.73m2 and a 26% increased risk of CKD (eGFR below 60 on 2 separate occasions at least 90 days apart, based on the Chronic Kidney Disease Epidemiology Collaboration equation). Source: www.renalandurologynews.com. The Taiwanese National Health Insurance data did a rather large study of two groups of over 16,000 patients taking and not taking PPI’s. Here is what their observations were:
    • PPI users were 42% more likely to have Chronic Kidney Disease (CKD) than non-users
    • CKD risk rose by 23% with each milligram increase in PPI dose
    • CKD risk rose by 2% per month of PPI use

If you thought about starting Prilosec OTC or any other proton pump inhibitor (PPI) because of holiday over indulgence, after reading this newsletter you might want to reconsider!

In 1982 when Helicobacter pylori was first reported, the world of GI disease was forever changed. Now Americans spend nearly 11 Billion dollars on PPI use, and up to 1/3 is believed to be inappropriate. The numbers are staggering when one sees that only Dexilant (Dexlansoprazole) is the only brand name; the rest are quite inexpensive. The 1200 square foot neighborhood drug store I work in buys its Omeprazole-20 and Pantoprazole -40 in bottles of 1000!

Counseling points:
  • Inform patients that PPI’s take about three to five days to see benefit. It takes that long to “shut down” acid production.
  • If they are buying these PPI’s over the counter, the package specifically says they are to be used only for two weeks at a time, and then no more than three “cycles” per year.
  • Always scan the patient profile looking for Clopidogrel (Plavix). Some of the PPI’s do block the activation of clopidogrel. Pantoprazole (Protonix) is our “go to” PPI for patients taking clopidogrel.
Have a great day on the bench!

We are a little too comfortable with Proton Pump Inhibitors...

Proton Pump Inhibitors and Acid Suppression

As my student pharmacists will tell you that half of my conversations start out with “Back in the old days, when I was your age...” Back then the histamine-2 receptor antagonists (H2RA) were just in their infancy. Physicians and patients rejoiced when we no longer had to use high dose anticholinergics such as Pro-Banthine (propantheline) and Robinul (glycopyrrolate) to suppress stomach acid. General surgeons whose bread and butter were gastrectomy procedures due to stomach ulcers were maybe not quite so excited. Guys like my Dad and Grandfather were delighted, as they both had two previous gastrectomies due to recurrent stomach ulcers. Tagamet (cimetidine) released in August of 1977and became the blockbuster drug of the 1970's, being the first drug to reach one billion dollars in sales. I remember going to the drug store for my Grandpa and spending $27 for one hundred tablets!

A question on my state board licensure exam was “Which of the following drugs is free of side effects, and drug interactions?” The answer was Tagamet! It was sold by one of my all-time favorite drug reps, a gentleman named “Ray”. In June of 1983 Ray met some very stiff competition when Zantac (ranitidine) was approved.

Tagamet was initially approved as four times a day dosing, then changed to 400mg twice daily dosing to compete with Zantac. The battle was on, and Zantac wrestled a good bit of this lucrative business away from the original H2RA. It became apparent that Tagamet after being used by millions of patients, indeed had side effects such as blocking CYP-450-3A4, as well as causing gynecomastia in men by blocking testosterone formation. I hope they changed that state board question!

The very lucrative H2RA market joined by Pepcid (famotidine) and Axid (nizatadine) came to a screeching halt in the 1990's. Omeprazole was first marketed in the United States in 1989 by Astra, now (AstraZeneca), under the brand name Losec. In 1990, at the request of the FDA, the brand name Losec was changed to Prilosec to avoid confusion with the Lasix 20mg (furosemide). As when the FDA intervenes, things often go amiss, and the new name led to confusion between omeprazole (Prilosec) and fluoxetine (Prozac)!!

I remember discussing this new class of stomach acid suppressants with none other than “Ray” the Tagamet salesman. Ray said “no doubt this Losec shuts down stomach acid production better than Tagamet, but the question becomes... how much is too much” Ray said certainly stomach acid does more than causes stomach ulcers, and aids digestion; but what about its protective effect. Possibly could stomach cancers become more common with this drug. No one seemed concerned about this excess acid suppression, obviously Ray had to try to protect his turf. Prilosec buried the competition.

In 2002 the generics were approved by the FDA, and prices dropped like a rock. Insurance companies no longer required prior authorizations, because they were so cheap. Today most pharmacies are lucky to get reimbursed $10 a month! People get prescribed these drugs and are left on them indefinitely. Much to my amazement this powerhouse acid blocker went over the counter in 2003, and was welcomed by all consumers as a cheaper alternative to the prescription variety. Other proton pump inhibitors like Zegerid and Prevacid followed suit., and had their own OTC formulations. Patients didn't even need to consult a physician or a pharmacist. Sure, the FDA required a 14 day limit on the box, and a warning of no more than 3 cycles of 14 tablets per year; as the companies sold these drugs in “warehouse packs”!

Today the focus is “deprescribing” proton pump inhibitors. How do we even begin, when the patients can buy these potentially harmful drugs without a prescription? Next week we will discuss the numerous potential side effects of these commonly (over)prescribed drugs. My salesman friend “Ray” might have been on to something!


How well I remember how the dreaded "stomach ulcers" ravaged my family. My Dad and Grandpa were always plagued by GI ulcers. Both had stomach resections due to "bleeding ulcers". Both took H2RA therapy and did very well on them.

Next week we will discuss the ramifications of long term PPI therapy. If there is EVER a reason for a "behind the counter" class of drugs, the Histamine-2 blockers and Proton Pump Inhibitors should be the first to be regulated.

Have a great day on the bench!

Instead of $800 to treat EACH person, let's use an effective over-the -counter treatment for pinworms!

PYRANTEL PAMOATE

Mechanism: It is poorly absorbed from the GI tract in humans and acts by paralyzing worms. Pyrantel causes the release of acetylcholine, inhibits cholinesterase, and stimulates ganglionic neurons, acting as a depolarizing neuromuscular blocking agent in pinworms. These actions cause extensive depolarization of the pinworm’s muscle membrane, producing tension of the pinworm's muscles, which causes paralysis and release of their hold to the intestinal wall. They are unable to latch onto the intestinal mucosa, and are passed out in the stool.
  • Pyrantel pamoate is available over the counter as a 50 mg/mL suspension.
  • The dose of pyrantel pamoate for pinworms is 11 mg/kg of base, up to 1 g, given orally as a single dose. The dose should be repeated after two weeks. Package has detailed instructions by weight.The over-the counter products have detailed weight based dosing instructions. Approved for 2 years of age and older. Maximum dose is 1gram.
  • May administer with food, milk or fruit juice, at any time of day. Fasting, purgation, or special diets are not necessary for effective treatment
  • Does not reliably kill pinworm eggs. Give second dose is to prevent re-infection by adult worms that hatch from any eggs not killed by the first treatment.
  • There are numerous brand names, such as: Pin-X , Pin-Rid, Antiminth, Reese’s Pinworm Medicine. Cost is around $15.00 per ounce. Became OTC in 1986
PREVENTION of REINFESTATION
  • Repeated infections should be treated by the same method as the first infection.
  • Treat all household members if more than one is infected. In institutions, mass and simultaneous treatment, repeated in 2 weeks.
  • Good hand washing hygiene! Soap and water after toilet.
  • Best to not allow children to share the same bathwater, reuse or share washcloths. Showering may be preferred to avoid possible contamination of bath water.
  • Clip fingernails regularly, and avoid biting the nails and scratching around the anus.
  • Frequent changing of underclothes and bed linens first thing in the morning is a great way to prevent possible transmission of eggs in the environment and risk of reinfection. Do not shake out bed linens, the eggs can become airborne. These items should be \ carefully placed into a washer and laundered in hot water followed by a hot dryer to kill any eggs that may be there.
  • Clean shared surfaces like doorknobs, toilet seats, and furniture with a disinfectant, such as bleach
  • Pinworm eggs are spread easily and even the cleanest and most careful people can get them. Be sure to re-assure parents and caregivers.

Last week we discussed prescription treatment options for pinworm infestation. We explored treatment options such as Emverm® (mebendazole) and Albenza (albendazole).

Both products were extremely expensive costing as much as $400.00 for initial treatment, followed by a second dose in two weeks. Today we pharmacists can step in and use a very affordable self-care treatment option for our patients.

Just as important as the treatment, is the second follow-up dose as well as the prevention of re-infestation. Treatment failures are rare, and re-infestation is common. Be sure to share these "practice points" wih all of your patients.

Have a great day on the bench!

"Quit scratching down there".... better have a look. It might be pinworms!

PINWORMS - The basics and prescription Treatment.

Pinworm infections are caused by a small, thin, white roundworm called Enterobius vermicularis. This infection affects all people, especially children, institutionalized persons, and household members of persons with pinworm infection. Pinworms are spread by humans, and not by pets!

Epidemiology
Mode of transmission: Pinworms are transmitted from fecal to hand to mouth. Eggs may also be ingested by inhalation. The incubation period for pinworms is 1 to 2 months or longer for the adult gravid female to mature in the small intestine.

These eggs are deposited around the anus by the worm and can be carried to common surfaces such as hands, toys, bedding, clothing, and toilet seats. By putting anyone’s contaminated hands (including one’s own) around the mouth area or putting one’s mouth on common contaminated surfaces, a person can ingest pinworm eggs and become infected with the pinworm parasite. Since pinworm eggs are so small, it is possible to ingest them while breathing.

Symptoms: often asymptomatic, but itching around the anus (pruritis ani) is common.

Diagnosis:
  • Seeing worms in the perianal region 2 to 3 hours after the infected person is asleep.
  • Touch the perianal skin with transparent tape to collect possible pinworm eggs around the anus at first rising. Use tongue blade with double side tape
  • Microscopically test for eggs under the fingernails (since anal itching is a common symptom)
RX Treatment Options
  • Mebendazole (Emverm®-100mg)
    WAC=$369.00 per tablet AWP=$442.80
    • Dose= 100mg as a single dose. A second dose in 2 weeks may be appropriate if needed; both CDC and Sanford Guide recommend a second dose 2 weeks later. Tablets may be chewed, swallowed whole, or crushed and mixed with food.
    • Do not take concurrently with Metronidazole (Flagyl®) due to an increase incidence of Stevens-Johnson’s Syndrome
    • Approved for children 2 years of age and older
    • Emverm.com is a patient friendly website with good information. Also has a $60 coupon available.
  • Albendazole (Albenza®-200mg) currently
    $365.64 for 2 tablets AWP=$438.77/2
    • THIS IS AN OFF LABEL USE: Dose= 400mg (2 tablets) as a single dose. Repeat dose in 2 weeks. It is listed in the Sanford guide as a secondary treatment option.
      • Can be dosed down to 1 year old (200mg/dose)



Pinworm and eggs, from the CDC website. Lots of good patient information for pinworms on the CDC website.


So, as we can see there is only one prescription option that has FDA approval for treatment of pinworms. Next week the pharmacists can “take over” and we will cover a reasonable treatment option, along with patient counseling points for pinworm infections.

Have a great day on the bench!

October 2017

My grandkids Luke and Anna made a big contribution to this column. Antibiotic associated diarrhea happens this time of year.

Cefdinir and Amox/Clav- useful for ear infections - but be sure to "cover their butts"

Now that winter is approaching and respiratory and ear infection season is closely approaching, we pharmacists can be instrumental in prevention of diaper rash. 18-35 percent of all children exposed to antibiotic therapy will develop antibiotic associated diarrhea. The more broad-spectrum antibiotics will cause a higher incidence of diarrhea. Amoxicillin/clavulanate and cefdinir are the pediatrician’s favorites.

Amoxicillin/Clavulanate (Augmentin®) is notorious for causing stomach upset and diarrhea. Most of the gastrointestinal distress can be traced back to the clavulanate component which increase efficacy of amoxicillin by destroying the beta-lactamase that the bacteria produce. By blocking the effect of the beta-lactamase, the amoxicillin can do its job of destroying the bacteria. The problem is there are numerous strengths of amoxicillin/clavulanate, and for pediatric patients we need to dose based on the amoxicillin component at 80-90mg/kg/day (referred to Amox/Clav HD). For illustration let’s assume we have a 37 lb child (16.5kg). The calculated dose would be 1500mg per day.

Drug To get 1500mg amox You get this much clavulanate daily
Augmentin 125/31.25 12 teaspoons 375mg
Augmentin 250/62.5 6 teaspoons 375mg
Augmentin 400/57 3.75 teaspoons 213.75
Augmentin-ES 600/42.9 2.5 teasp 107.25
Augmentin 250/125 6 tablets 750mg
Augmentin 500/125 3 tablets 375mg
Augmentin 875/125 2 tablets 250mg


As you can see from the above chart for a child getting Amoxicillin 1500mg per day (37lb child) would get 107.25mg of clavulanate should the prescriber use Augmentin ES 600, versus 375mg of clavulanate should the prescriber use Augmentin 250/5.

Whenever you are prescribing Augmentin therapy HD (high dose) as is recommended for otitis media, it is critical to use Augmentin ES 600mg/42.9 to minimize clavulanate exposure and decrease incidence of severe GI upset and diarrhea. Always call the prescriber if a child has otitis media, and the prescriber writes for anything other than Amox/clav -ES 600/5ml to minimize the clavulanate exposure and therefore the gastrointestinal side effects. Remind patients to keep the suspension refrigerated at all times, and to use a protective diaper rash paste BEFORE administering the first dose.

Cefdinir (Omnicef®) is a third-generation cephalosporin that causes a lot less gastrointestinal upset. It is dosed at 14mg/kg/day in 1 or 2 doses. Because it is broad spectrum, it can kill off more gut bacteria and cause diarrhea. In infants, especially if they are formula fed, the cefdinir binds to the iron in the milk and can cause a red stool, resembling blood which can greatly upset the parents. Be sure to warn them of this harmless side effect.

Also with Cefdinir, dispense in the box to keep the glass bottle from breaking, give with food, and do not refrigerate. And like amox/clav it carries a 10-day expiration date. Be sure to always give an appropriate measuring device.




Yes, a picture is worth a thousand words!


Imagine a new Mom changing her infants diaper, and seeing these red streaks in the diaper, which could be easily confused for rectal bleeding. Fortunately the Mom was my daughter Gretchen, who is a doctor of Pharmacy, and teaches Clinical Pharmacy Practice at West Virginia University. Her son Luke, was being treated for a case of recurrent otitis media. So dramatic is this specimen, she snapped a picture for me to share with my students and colleagues. The color would even be brighter for a formula fed baby. For comparison, we snapped a picture of my son Phil's daughter Anna's diaper a normal breast fed diaper.

Keep this image in mind when you are either prescribing, or dispensing Cefdinir (Omnicef®)

Special thanks to Luke and Anna for your input (well, I guess output) for this column.

"We interrupt our discussion about diaper rash" ---- Hand, Foot, Mouth Disease is spreading. Be ready to help your patients NOW!

Hand, Foot, Mouth Disease affects...hand, foot and mouth! (of course).

I will delay discussing diaper rash induced by antibiotics because of an “epidemic” that is spreading in our area. Recently, hand, foot, and mouth disease is on the rise with cases affecting local school districts. One of the local school districts ordered cases of hand sanitizers from a local pharmacy. I can’t think of a disease that has a more descriptive name than “Hand, Foot and Mouth Disease” abbreviated HFMD.

Etiology:
Hand, foot, and mouth disease is caused by viruses that belong to the Enterovirus genus, which includes the polioviruses, coxsackieviruses, echoviruses, and enteroviruses.

Coxsackievirus A16:
is the most common cause of hand, foot, and mouth disease in the United States, but other coxsackieviruses can also cause the illness.

Enterovirus 71:
has also been associated with cases and outbreaks of hand, foot, and mouth disease. Less often, enterovirus 71 has been associated with severe disease, such as encephalitis. Patients can be affected with a couple of different enteroviruses.

Epidemiology:
Patients with HFMD is most contagious during the first week of illness and be contagious for days or weeks after symptoms go away. Adults, may not develop any symptoms, but they can still spread the virus to others. Everyone especially those with direct contact with children and infants must maintain good hand hygiene so they can minimize their chance of spreading or getting infections. Daycares because of their multiple diapering “events” can see this virus spread quickly through a classroom.

Patient Information:
Here’s some useful information about this condition that Karen Quach one of my student pharmacists would like to share.

Hand, foot, and mouth disease is a common childhood infection most often occurring in confined spaces, such as daycares and schools, in the summer and fall months. It is characterized by small sores that can form in the mouth, and on the hands, feet, buttocks, and genitals. This is the main symptom to look out for, and the sores can appear as small red spots, bumps, or blisters. In addition, some children may present with a mild fever. Although this infection is generally mild, it is highly contagious and may cause pain, including painful swallowing.

Hand,Foot,Mouth disease on 15 month old

The infection itself is not treated and should resolve without medicine within one week. Until then, children should maintain adequate fluid intake to prevent dehydration. If needed, over the counter medications such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) can be used to relieve pain. Cool liquids and foods such as popsicles and ice cream may help to numb the pain.

The virus travels in body fluids, including mucus from the nose, saliva, bowel movements, and fluid from the sores. Therefore, the most important method to prevent spread of infection is proper hygiene. Tips include washing hands frequently with soap and water, using alcohol-based hand sanitizers, covering the mouth and nose when sneezing and coughing, properly disposing infected tissues, and disinfecting contaminated surfaces and objects. Additionally, infected children should be kept home when they have symptoms to prevent spread to other children.



We got a request to put together a newsletter about hand, foot and mouth disease because of a local outbreak. Like any good preceptor, I turned the project over to my student pharmacist.

We have two students living with us right now and last week for Pharmacy Month, Gabrielle Dziuba published a newsletter on Poison Prevention. I turned this project over to Karen Quach. She did a stellar job, and we also published her newsletter in the local paper. Her research is the information that contains the patient information.

Karen Quach, PharmD Candidate
University of Pittsburgh School of Pharmacy Class of 2018

Treating Diaper Rash, and saving the money for the college fund!

Treating Diaper Rash--simple as A-B-C-D-E!!!

Diaper rash is almost always caused by Candida albicans, and like any yeast thrives where it is warm, dark and moist. Here are some treatment strategies to help manage diaper rash in our pediatric population. It’s as easy as A, B,C, D & E.

A = air out the skin by allowing the child to go diaper-free, best to do on a hard surface floor for easy clean up. Don’t expose to sun for longer periods of time to prevent possible sunburn.

B = barrier; use a paste or ointment to protect the skin. Protectants: are first line therapy and can be used for protection (anticipated during antibiotic therapy) or treatment. Provides physical barrier to protect skin against irritants and moisture. Also provides lubrication to reduce skin-to diaper friction.

C = clean; Clean area with water—avoid rubbing area. Use a squirt bottle, pat and air dry. If using Baby wipes, they should be free of soaps, dyes, perfume and alcohol.

D = disposable diapers; are best option during an episode of diaper rash, rather than cloth diapers. If using cloth diapers, avoid plastic panties.

E = educate; educate your patients about how to prevent a recurrence of diaper rash

Pharmacologic Measures:
Antifungal agents
  • Don’t use routinely, only when C. albicans is suspected.
  • Characterized by beefy red plaques, with scales and satellite papules & pustules. Pustules are superficial.
  • May use Miconazole and Clotrimazole which are OTC, or Nystatin (Rx-only)

Vusion® (miconazole 0.25%) – is a product for diaper rash. Contains also white petrolatum & Zn oxide. Lower concentration causes less systemic absorption, however higher strength Miconazole has not been shown to cause problems. The cost of a 50gm tube of Vusion diaper rash ointment is $560.00!

“GrandDad Kreckel” has calculated that 90gram of Zinc Oxide + 15g Miconazole 2% will yield a concentration of miconazole .28%. The leftover $550.00 can be applied to the grandkids college fund!

Cholestyramine/Aquaphor -compounded medication for Diaper Rash Cholestyramine is a bile acid sequestrant, and Aquaphor is a greasy vehicle to protect the bottom. Usually made as a 20% paste. INGREDIENTS:
  • Cholestyramine light powder (80% anhydrous) ---------------25gm
  • Petrolatum ointment base (Aquaphor) --------------------------75gm
  • Dispense as 100gm. Good for 180 days.
What not to use: Talc and cornstarch- not recommended due to potential inhalation by the infant. OTC Antibiotic ointments: Over-the-counter antibiotic creams or ointments (such as Neosporin or Bacitracin) are not recommended because neomycin and bacitracin cause allergic reactions.
  • Bacitracin is the 2003 Allergen of the Year (American Contact Dermatitis Society)
  • Neomycin is the 2010 Allergen of the Year (American Contact Dermatitis Society)
Corticosteroids: Hydrocortisone 1% (otc): can be used for moderate to severe diaper rash, or allergic dermatitis. Can be used for up to 2 weeks maximum. Do NOT use stronger corticosteroids (avoid all RX!!)
Peruvian balsam: Butt Paste (Boudreaux Butt Paste) – contains Zn oxide, Peruvian balsam, boric acid, castor oil and petrolatum. (FDA cautions that Peruvian balsam may cause skin sensitivities.)

Treating diaper dermatitis can be challenging and even frustrating for parents. There are a lot of old time remedies that shouldn't be used today, especially being the powders. When you think about the ingredients in the common powders, they can do more harm than good. Talc is actually a mineral, or stone that is pulverized to dust. Corn starch is a "starch" which we remember from biochem class is a string of sugar molecules linked together, which is just like "feeding" the Candida albicans. The talc being a mineral can be inhaled into the child's lungs, and long term exposure can cause damage. Although both do reduce friction between skin folds, they are not recommended for treatment.

I am a huge fan of plain and simple. When Regina, Luke or Anna get diaper rash the miconazole and zinc oxide combination works very well. It is only used when Candida is suspected, and not for prophylaxis.

Next week we will discuss diaper rash, and provide counseling points to parents when giving their children antibiotics.

Have a great day on the bench!!

When the grandkids get diaper rash... GrandDad comes to the rescue!

When Candida albicans affects the grandkids... treatment of diaper dermatitis

This week we continue our discussion of yeast and fungi focusing on Candida albicans, in a different patient population, that is in our infants and diaper wearing toddlers. When we think of the ideal environment for yeast and fungi to grow, we think of warm, dark and moist. What better place to grow than a baby’s diaper! Candida albicans is the most common cause of diaper rash in infants. The fungi take advantage of the warm, moist conditions inside the diaper.

Causes of diaper dermatitis:
  • Too much moisture
  • Rubbing and friction
  • Skin contact with urine and feces
  • Allergic reaction to the diaper material or to creams, powders or wipes

Role of Candida albicans:
  • Infection often occurs after 48-72 hours of active eruption.
  • It is isolated from the perineal area in as many as 92% of children with diaper dermatitis.
  • Other microbial agents have been isolated less frequently, perhaps more because of secondary infections.
  • Peak incidence occurring when the individual is aged 9-12 months
  • Diaper dermatitis is prevalent in 7-35% of the infant population.

Pathophysiology
  • Wet skin increases the penetration of irritant substances.
  • Superhydration urease enzyme found in the stratum corneum liberates ammonia from cutaneous bacteria.
  • Irritation occurs because:
    • Urease has a mild irritant effect on nonintact skin.
    • Lipases and proteases in feces mix with urine on nonintact skin and cause an alkaline surface pH, adding to the irritation. The bile salts in the stools enhance the activity of fecal enzymes, adding to the effect

Prevention
  • Change your baby's diaper often.
  • Keep the diaper loose enough to let air reach the skin inside the diaper.
  • Gently clean the affected skin with warm water. Pat gently with a clean, soft towel.
  • Don't use wipes that contain alcohol or perfume.
  • If you use cloth diapers and wash them yourself, use very hot water. Rinse carefully
  • Note: Feces in breastfed infants have a lower pH, and breastfed infants are less susceptible to diaper dermatitis.
  • Broad spectrum antibiotics can cause Candida albicans to overgrow by destruction of “good” bacteria.
    • Amoxicillin/clavulanate (Augmentin®)
    • Third generation cephalosporins
      • Cefdinir (Omnicef®)
        • Recommend topical protection before the first dose of broad spectrum antibiotics

This area of study is of particular interest to me not only as a young pharmacist when we had three kids in four and one-half years, but now we are blessed with three grandchildren!

Our three year old Regina is potty trained but our 15 month old grandson Luke, and 9 month old granddaughter Anna are in diapers, and GrandDad comes to the rescue to treat diaper dermatitis.

This week we covered the basics, and next week we will discuss treatment of diaper rash, and of course what NOT to use! The money we can save in the treatment of diaper rash will go a long ways for their college funds.

Have a great day on the bench!!

September 2017

Our female patients can benefit from these treatment options

Treatment of Vaginal Candidiasis..

The most mentioned vaginal yeast infection that our patients experience is actually the second most common vaginal infection. Candidiasis is the second most common cause of vaginitis symptoms and accounts for approximately one-third of vaginitis cases. Bacterial vaginosis is the most common, but no over-the counter treatment exists. Ten to twenty percent of healthy women of reproductive age have Candida albicans present in the vaginal tract.

Risk Factors for vulvovaginal candidiasis are as follows
  • Patients with Type-2 diabetes, are more prone to candida albicans infections especially if they are not well controlled
  • Patients exposed to antibiotic therapy-25-33 % of females exposed to antibiotic therapy. This is due to the destruction of the normal healthy flora, allowing the overgrowth of candida species. Lactobacillus is of no value in treatment or prevention.
  • Immunosuppressed patients- patients with a less than robust immune system, either due to corticosteroid therapy, or HIV are more susceptible to candida infections.
  • Elevated estrogen levels: patients taken oral contraceptives, or estrogen supplements have a higher incidence.
  • Sexual activity: vaginal candidiasis is not considered a sexual transmitted infection, because it is part of the normal flora. Patients report an increased incidence of yeast infections when they begin sexual activity.

Symptoms: itching of the vulva is the most common sign, remembering that yeast isn’t the only organism that causes itching. Patients may experience vulvar burning, soreness, and irritation. Some patients may experience burning on urination, with the source of the burning being the vulva and not the urethra. Patients may experience dyspareunia as well. Symptoms are often worse during the week prior to menses.

Treatment:

Diflucan® (Fluconazole) (Rx only)
150mg tablet given as a single dose. Fluconazole remains in the vaginal secretions up to 72 hours. Avoid if pregnant.

Miconazole (Monistat®) (OTC) Is available as a cream, or vaginal suppository, or insert
  • Monistat-3: (200mg supp.) 1 supp vaginally at bedtime for 3 nights
  • Monistat-3 (4% prefilled cream 200mg each) vaginally at bedtime for 3 nights
  • Monistat-7: (100mg supp) 1 supp vaginally at bedtime for 7 nights
  • Monistat-7 (2% cream, 100mg each dose): 1 applicatorful vaginally at bedtime for 7 nights. Best treatment option for treatment of patients who are pregnant, or patients with diabetes.
  • Monistat-1 Combo pack: miconazole 1200mg insert plus miconazole cream for application to vulva
CAUTION: potential CYP 4503A4 interactions due to topical absorption of miconazole

Clotrimazole (Gyne Lotrimin®) Available as a cream
  • Gyne-Lotrimin 1% cream: 1 applicatorful vaginally at bedtime for 7nights
  • Gyne-Lotrimin 2% cream: 1 applicatorful vaginally at bedtime for 3 nights
Terconazole (Terazole®) (Rx only) Available as cream or suppository.
  • Terazol 0.4% cream: 1 applicatorful vaginally at bedtime for 7 nights
  • Terazol 0.8% cream: 1 applicatorful vaginally at bedtime for 3 nights
  • Terazol 80mg supp: 1 suppository vaginally at bedtime for 3 nights
Butoconazole (Gynazole®) Rx Only 2% cream 5gm
  • Insert one applicator at bedtime as a single dose. May weaken diaphragms or condoms, due to mineral oil in the formulation.

Women indeed are very proactive in their healthcare,and we pharmacists have the opportunity to guide them through the feminine hygiene aisle.

When Monistat (miconazole) first became available in 1991, there was great concern from gynecologists that these products might be misused. Labeling on these vaginal candidiasis products specifically say " Do not use if you have never had a vaginal yeast infection diagnosed by a doctor."

Patients should really have had a previous diagnosed yeast infection, and be aware of the symptoms before purchase of such a product. Remember that yeast isn't the only condition that itches.

Have a great day on the bench!!

They're in a rush to treat their thrush!

Candida albicans-- a pathogen in our crosshairs...this week!

Now that we have learned how to wipe out the Trichophyton species, especially T. rubrum, we switch to another pathogen that we frequently see on our mucus membranes, Candida albicans, which is more specifically a yeast. Our first mucus membrane we will cover is the oral-pharyngeal cavity.

Candida albicans infection of the mouth is commonly referred to as “thrush”. Candida albicans is a yeast of our normal flora, that is kept “in check” by a variety of bacteria especially Lactobacillus . When the immune system is weakened, or the bacteria are wiped out by antibiotics, Candida albicans can overgrow.

Symptoms: Candidiasis in the mouth and throat is most often seen as white patches on the inner cheeks, tongue, roof of the mouth, and throat. Other symptoms might include: redness or soreness, feeling like cotton in the mouth and loss of taste. Patients may also experience pain while eating or swallowing or angular cheilitis (cracking and redness at corners of the mouth).

Who is at risk: Candidiasis in the mouth, throat, or esophagus is uncommon in healthy adults. People who are at higher risk for getting candidiasis in the mouth and throat include babies, especially those younger than one-month old, and people who:
  • Wear dentures
  • Have diabetes
  • Have cancer
  • Have HIV/AIDS: thrush is one of the most common infections seen in the AIDS population.
  • Take antibiotics or corticosteroids, including inhaled corticosteroids for conditions like asthma
  • Take medications that cause dry mouth or have medical conditions that cause dry mouth
  • Smoke
Treatment of Adults:
The treatment of oropharyngeal candidiasis in patients without AIDS is usually accomplished with local therapy for 7 to 14 days. For topical agents, successful therapy depends on adequate contact time between the agent and the oral mucosa. Options include:
  • Clotrimazole troches or lozenges are dosed at 10mg 5 times a day slowly dissolved in the mouth for about 15-30 minutes. They are effective, however adherence to a five time per day regimen is difficult. Often patients with radiation to salivary glands, or patients with Sjogrens syndrome lack adequate saliva, and might have difficulty getting these lozenges to dissolve. Don’t eat or drink while using.
  • Nystatin suspension 100,000 units/ml swish and swallow 4-6 ml four times daily is effective but has a bitter taste. It also contains sucrose, which can cause dental caries when used over prolonged time periods.
  • Fluconazole tablets: 200mg first dose then follow with 100mg-200mg daily. Best option for topical treatment failures. Has 90% success rate.
Children Doses for Candida albicans eradication:

Nystatin Oral suspension 100,000 units/ml:
  • For older infants: 2 mL four times a day.
  • For premature and low-birth-weight infants: 1 mL four times a day.
  • Because treatment is topical, and maximal contact time improves efficacy, the suspension should be retained in the mouth for as long as possible before swallowing.
  • Infants should avoid feeding for 5 to 10 minutes after administration to keep nystatin from washing out of the mouth.
Fluconazole: available as 10mg/ml and 40mg/ml in 35ml bottles for reconstitution
  • Dose: 6 orally once on the first day (maximum dose 200 mg followed by 3 once per day (maximum dose 100 mg) for a total of 7 to 14 days. Doses are higher for HIV infection.
Prevention of reinfection in babies
  • Sterilize items that are placed in the infant's mouth. Bottle nipples and pacifiers that are to be reused should be boiled after each use.
  • Breast feeding: Topical miconazole or clotrimazole is applied to the nipples to treat the lactating woman. Azoles are preferred over nystatin since there is less resistance of Candida species. Wipe off prior to feeding and reapply after each feeding.

Thrush is treated first line with topical therapy either nystatin or clotrimazole. Reinforce to the patient that is the contact with the inside of the mouth is what will lead to resolution of the yeast infection. Nystatin ahs been round since the early 1950's and still has a place in therapy for Candida albicans only. It has no effect on any other fungi other than C. albicans. Nystatin was discovered in 1950 by Rachel Fuller Brown and Elizabeth Lee Hazen named nystatin after the New York State Health Department in 1954.

These patients do require a lot of patient counseling, and if appropriate an accurate measuring device.

Have a great day on the bench!!

Do your toenails look unsightly? Some of the treatments lack efficacy!

Toenail fungus--persistence is the key to efficacious treatment

Your fingernails and toenails are composed of keratin and adherent connective tissue, the same stuff that your hair is made of. Nails grow at an average rate of 0.1 mm/day (1 cm every 100 days).

Finger nails require 3 to 6 months to re-grow completely while toe nails require 12 to 18 months. Onychomycosis is a fungal infection of the nails, sometimes caused by Candida species, however 80% of the toenail infections are caused by dermatophytes (Trichophyton rubrum), whose name sounds very familiar to us!

Diagnosis is based on clinical exam and history, microscopy, and culture. Back when both oral prescription drugs were expensive and cost over $600 for a course of therapy, the insurance companies required a positive culture for approval. Now that the oral treatments are available generically, that requirement has been lifted.
  • OTC nail lacquers (Fungi-Nail®) treat fungus around the nail, they don't penetrate the nail plate. Don't recommend them due to minimal efficacy. Contains undecylenic acid, and despite its trade name is only for athlete’s feet.
  • Rx products provide best treatment option.
  • Advise patients about possible recurrence.
Treat fingernails for 6 weeks and treat toenails for 12 weeks. (reference: Sanford guide 2017)
  • Terbinafine (Lamisil®)- fewest drug interactions; check liver function; most efficacy: Cure rate: (46%). Side effects include headache, gastrointestinal disturbance (diarrhea and/or dyspepsia), rash and elevated liver enzymes.
    • Dose: 250mg every 24 hours
  • Itraconazole (Sporanox®)– CYP4503A4 interactions; need liver function tests. Cure rate (23%pulse). Side effects include, skin rash, high triglycerides, cardiac side effects and gastrointestinal effects (nausea, bloating, and diarrhea)
    • Pulse Dose: 200mg BID for 1 week/month x 2-3 months
    • or 200mg/ day for 3 months
  • Fluconazole (Diflucan®) Cure rate:(28%), less drug interactions than itraconazole. Frequent relapse, due to poor retention in the nail.
    • Dose: 150-300mg every week for 3-6 months.
  • Ciclopirox (Penlac®) nail lacquer -Complete cure rate (7%)
  • Efinaconazole (Jublia®) nail lacquer- Complete cure rate (17%)
  • Tavaborole (Kerydin®) nail lacquer- Cure rate (<10%)
Vicks Vap-o-rub?
  • A small study of 18 participants, where fifteen of the 18 participants (83%) showed a positive treatment effect. Source: J Am Board Fam Med. 2011 Jan-Feb;24(1):69-74. doi: 10.3122/jabfm.2011.01.100124
  • 5 of 18 (27.8%) had a mycological and clinical cure at 48 weeks;
  • 10 of 18(55.6%) had partial clearance
  • 3 of 18 (16.7%) showed no change.
Since our enemy Trychophyton rubrum is everywhere, re-infection is a possibility if measures are not taken to make the feet an inhospitable environment for this fungus. Fungus breed where it is warm, dark and moist. Here are some points to share with our patients:
  • 1 in 5 “cures” will relapse (20%) within 2 years
  • Keep feet clean and dry
  • Change socks often
  • Antifungal product for feet and shoes.
  • Sports shoes that fit well will reduce microtrauma to the nail plate. Wear sandals when possible.
  • Using communal showers leads to fungal infection, so these should be avoided
  • Care with hygiene is needed to reduce cross-infection between family members
  • Throw out old “creek shoes”.
  • Emollients can be used to avoid cracks in the skin that allow fungus to enter.
Certain-Dri®—Prevention of onychmycosis
  • Contains aluminum chloride-12%.This product stops the feet from sweating, creating the moist environment for the fungus to grow.
  • Water-based and unscented which makes it gentler on skin
  • Should not wash off after bathing or showering, if application instructions are followed. Use only a few times a week.

Onychomycosis treatment varies from practitioner to practitioner. I've seen podiatrists use the Terbinifine 250mg daily for 84 days, with great results. I've seen podiatrists remove the entire nail, and treat with Terbinifine 250mg for 84 days.

I once had a patient tell me that her dermatologist said "I'm not knocking out your liver so you can have pretty toenails." He went on to say "It is a cosmetic condition, and if treated it will come back... just get over it." She went to her podiatrist, he did the necessary blood work, like liver function testing, was treated for 84 days and she has been "fungus free" for over 15 years. She is meticulous about her foot care.

One of the points we want to share with our patients is that re-infection is indeed a possibility, and we should counsel our patients to follow the steps necessary to prevent re-infection.

Have a great day on the bench!!

Another fungus among us...look what the cat (or puppy) brought in!!

What is this rash that looks like a worm??

Trichophyton rubrum is the most common cause (about 47%) of tinea corporis commonly known as “ringworm”. This is the same organism that can also cause jock itch, athlete’s foot, and nail fungus. Tinea corporis usually begins as a circular or oval, scaling patch that is itchy and spreads centrifugally on the smooth skin, (other than the scalp, groin, palms, and soles). The center of the lesion clears while an active, advancing, raised border remains. The result is a ring-shaped plaque from which the disease derives its common name of ringworm. How do I get it? Epidemiology:
  • May result from contact with infected humans, animals, or inanimate objects. Commonly transmitted by kittens and puppies.
  • Occupational risk: farm worker, zookeeper, laboratory worker, veterinarian
  • Environmental exposure: gardening, contact with animals, towels and shared grooming appliances.
  • Recreational exposure: contact sports especially wrestling, contact with sports facilities (gym mats, locker room floors). Interestingly enough the ringworm spread by wrestling has its own specific name: “Tinea corporis gladiatorum” named after the gladiators of Rome.
How do I get rid of it? Treatment of Tinea corporis (ringworm):

TOPICAL THERAPY
  • Terbinifine (Lamisil®): apply once daily for 7 days
  • Clotrimazole (Lotrimin®): apply twice daily for up to 14 days
  • Miconazole (Micatin): apply twice daily for up to 28 days
SYSTEMIC THERAPY
May be indicated if tinea corporis includes extensive skin infection, immunosuppression, resistance to topical antifungal therapy (azoles and allylamines) , or the comorbid presence of tinea of the scalp or of the nails.
  • Terbinafine (Lamasil®) 250 mg per day for one to two weeks.
  • Itraconazole(Sporanox®) 200 mg per day for one week
  • Fluconazole (Diflucan®) 150 to 200 mg once weekly for two to four weeks
  • Griseofulvin (remember that drug?) seldom used because 4 weeks of treatment are needed.
  • Itraconazole and Griseofulvin are the most expensive treatment options. Fluconazole and Griseofulvin are the longest treatment options.

When I was discussing this column with a fellow pharmacist they asked me the differences between "tinea versicolor" and "tinea corporis". Although they share the name "tinea", both affect the smooth skin, and are caused by a fungus which thrives in hot and humid conditions, there is a huge difference between the two.

Ringworm as we can read from this column ringworm is caused by the Trychophyton genus, where Tinea versicolor is caused by Malassezia furfur. The Malassezia furfur fungus is part of our normal flora, while ringworm is not. We don't get tinea versicolor by spreading from other sources as it is part of our normal skin flora. Versicolor is much harder to control because we harbor it on our skin.

However, once ringworm is eradicated, a patient needs to be re-exposed to get another ringworm infection.

Have a great day on the bench!!

August 2017

Hey doc---I got “gaulded”--- what do you got for that??

Tinea Cruris "jock itch"

Tinea cruris (jock itch) is a dermatophyte infection involving the fold between the upper thigh and groin area. Most common cause is Trichophyton rubrum, other species of tinea may cause jock itch as well. Tinea cruris is far more common in men than women. Often, infection results from the spread of the dermatophyte infection from concomitant tinea pedis, moving up the leg. Tinea on the groin looks like scaly, itchy, red spots, usually on the inner sides of the skin folds of the thigh. Predisposing factors include copious sweating, obesity, diabetes, and immunodeficiency. Infection may spread to the perineum and perianal areas, into the gluteal cleft, or onto the buttocks. Usually the scrotum in males is not involved.

Treatment: first line therapy is topical antifungals, azoles or squalene epoxidase inhibitors. If unsuccessful consider oral treatment.

  • Terbinafine (Lamisil cream):
    • Mechanism- inhibits squalene epoxidase, thus weakening the fungal cell wall
    • For tinea cruris apply once a day for 7 days
  • Clotrimazole (Lotrimin) or Miconazole (Micatin):
    • Mechanism- inhibits ergosterol synthesis.
    • Apply twice daily for 2 weeks.
    • Any of the OTC or Rx azole antifungals are equally effective
“Tightie whities” or boxers?? Cotton briefs hold moisture and keep it against the skin, allowing dark, warm moist conditions that the dermatophytes thrive in. If you choose briefs, say at the gym or running, choose moisture-wicking synthetic materials and be sure to shower and put on a fresh pair after working out. Going “commando” (or naked) would be the best.

Here is a tip… put on your socks before underwear to minimize the chance of the athlete's foot fungus from moving to the groin area.


I remember my first week working in a rural area of Central Pennsylvania. An old woodsman came in and asked me if I could help him. Being that energetic (and inexperienced) pharmacist I said sure. He told me he got "gaulded" , which I thought he said "scalded", and he pointed "down there". Needless to say I've learned a lot about being "gaulded" (tinea cruris) over the past number of years. Back then we didn't have much to help our patients until the antifungals became OTC.

One year at Boy Scout Camp, when I was the Scoutmaster, one of my 6th graders came to me. He said he was "hurting" down there...I asked him to describe what was going on. He said "Mr K it feels like my crotch is on fire" I asked him if he was showering, and he said "every day, but because the showers are not private we are all showering with our swimming suits on, so no one can see our equipment". I left camp, bought a can of clotrimazole spray (in case the other guys got it) and gave it to him, with instructions to not shower in a swimming suit! He was better the next day, and many years after at his Eagle Scout Banquet I presented him with the left over spray.

Have a great day on the bench!!

ATHLETE'S FOOT - Tinea pedis

Athlete’s foot is usually treated topically due to decreased side effects of this route of administration. It is the most common dermatophyte infection, affecting up to 70% of adults. Causative organisms: Trichophyton, Epidermophyton or Microsporum. Infection is usually acquired by means of direct contact with the causative organism in “surface reservoirs”, as may occur by walking barefoot in locker rooms or swimming pool facilities. If unchecked, osteomyelitis can result from mycotic infections of the feet, including tinea pedis. These complications are seen more frequently in patients with diabetes. Diabetics should check their feet every day with a mirror, and look between the toes for signs of athlete’s foot. The fissures between the toes can serve as a major port of entry for Staph aureus, the major cause of osteomyelitis in patients with diabetes, which may lead to amputation.

TREATMENT
  • Terbinafine (Lamisil cream):
    • Mechanism- inhibits squalene epoxidase, thus weakening the fungal cell wall
    • For tinea pedis apply twice a day x 7 day. Apply for 2 weeks if bottom/sides of feet are affected.
  • Miconazole (Micatin) or Clotrimazole (Lotrimin):
    • Mechanism- inhibits ergosterol synthesis.
    • Apply twice daily for 4 weeks.
    • Any of the OTC or Rx azole antifungals are equally effective
Unfortunately, athlete’s foot symptoms may linger for up to 4 weeks. Recurrence might be due to previous treatment failure. Because patients experience recurrence 70% of the time, prevention is warranted. Share these prevention tips with your patients:
  • Patients should be advised to wear non-occlusive footwear such as sandals as frequently as possible, but especially in the summer.
  • Wash socks after each wearing in the hot cycle of the washer and dried in the hot cycle of the dryer before wearing again. Athletic shoes also may be sprayed with disinfectants and/or treated with bleach to destroy fungi.
  • During the bath or shower, patients must wash the feet and toes carefully each day. Patients should be taught to dry the feet thoroughly after each bath or shower, paying closer attention to the interdigital spaces.
  • Wait for 10 to 15 minutes after bathing to don socks and shoes to help the feet dry. The goal is to have the feet completely dry other than when bathing.

What about us??? Most of us as business professionals, should wear socks and leather shoes that “breathe” and reduce sweating. We should also change to sandals as soon as we can and wear them until bedtime or go barefoot around the house as much as possible (except for diabetic patients with peripheral neuropathy)

Socks? Wool socks: If your feet are often cold, or you live a in a cold climate (like Central Pennsylvania), wool socks may be a better fit. Wool fibers are both hydrophobic (repels water) and hygroscopic (absorbs water), which is a fancy way of saying that it can absorb or give off moisture. In fact, they - wool fibers - can absorb up to 1/3 of their own weight in moisture before feeling "wet". Merino wool is less like to be itchy. Merino wool socks are more expensive, it is best not to machine wash wool socks. I wear wool socks for extra padding on my feet. The outer layer of wool fibers have a high concentration of fatty acids, which have anti-bacterial properties, and reduce foot odor.

Cotton socks: less itchy, are cheaper and absorb moisture but they saturate quickly and dry slowly. Are cooler on the feet and are machine washable. When cotton socks get damp/wet they will continue to feel cold and damp, which wetness and increased friction may enhance blister formation.

Have a great day on the bench!!

Mechanisms of action are the best clue as to what to recommend for the "fungus among us"!

We pharmacists love our mechanism of actions, and knowledge of where the multitude of antifungals fit in drives our product selection. Below is a chart, that describes the mechanism of actions for efficacious treatment of dermatophytic and candida infections. Although there are other agents available, I am highlighting the most common and most effective agents we use in community pharmacy practice.

Agents used in the treatment of dermatophyte infections.

Oral Azole Antifungals
Impairs the synthesis of ergosterol, the main sterol of fungi membranes, allowing increased permeability and leakage of cellular components. Inhibits fungal CYP-450 14-alpha-desmethylase thereby decreasing ergosterol.
Ketoconazole (Nizoral) (Rx)
Most potent azole blocker of CYP-450. Most drug interactions and side effects of oral azoles. As of 2013 NOT recommended as oral therapy for treatment of dermatophytes.
Fluconazole (Diflucan) (Rx)
Widest therapeutic window. For treatment of thrush and vaginal candidiasis. Not effective for filamentous fungi (aspergillosis).
Itraconazole (Sporanox) (Rx)
May induce heart failure. Caution in cardiac patients.
Oral Antifungal
First antifungal; isolated in 1939, produced from Penicillium griseofulvin. Disrupts spindle formation. Skin infections only. It is deposited in newly forming skin where it binds to keratin precursor cells, protecting the skin from new infection. Therapy must continue until new tissue replaces old diseased tissue.
Griseofulvin (Gris-Peg) (Rx)
Absorption improves with a high fat meal. Takes 2-6 weeks for treatment. (6 months for onychomycosis).
Oral Squalene Epoxidase Inhibitor
These antifungal agents are reversible, noncompetitive inhibitors of the squalene epoxidase. The buildup of squalene is toxic to the cell wall. This causes pH imbalances and malfunction of membrane bound proteins.
Terbinifine (Lamisil) (Rx)
Most often used for onychomycosis (nail fungus). Doesn’t reach effective levels for treatment of skin infections.
Topical Azole Antifungals
Impairs the synthesis of ergosterol, the main sterol of fungi membranes, allowing increased permeability and leakage of cellular components. Inhibits fungal CYP-450 14-alpha-desmethylase thereby decreasing ergosterol. For topical treatment of dermatophytes, no azole antifungal Rx or OTC is superior to another.
Miconazole (Micatin, Monistat)
Topical use for dermatophytes or vaginal yeast infections. Caution with warfarin may ↑ INR, by blocking CYP-450 metabolism and cause bleeding.
Clotrimazole (Lotrimin), Butoconazole(Gynazole)
OTC available for treatment of vaginal yeast infections. Clotrimazole cream for topical dermatophytes.
Ketoconazole (Nizoral), Econazole (Spectazole) (Rx)
Prescription only for treatment of topical dermatophytes.
Terconazole (Terazol) (Rx)
Terconazole contains a triazole ring, a structure developed specifically to improve antifungal activity. Rx only for vaginal candida infections.
Topical Squalene Epoxidase Inhibitors
These antifungal agents are reversible, noncompetitive inhibitors of the squalene epoxidase. The buildup of squalene is toxic to the cell wall. This causes pH imbalances and malfunction of membrane bound proteins.
Terbinifine (Lamisil)
Most effective OTC treatment for dermatophytes.
Topical antifungal inhibiting cell membrane staility.
Binds to trivalent cations (iron and aluminum), which inhibit essential co-factors in enzymes. Can be fungicidal or fungistatic.
Ciclopirox (Loprox, Penlac) (Rx)
Available as cream, gel, suspension, shampoo and nail lacquer.
Topical Anticandidal Agents
 
Nystatin (Mycostatin) (Rx)
Polyene antifungal binds to ergosterol in fungal membrane causing membrane to become leaky. Only effective for candida (yeast). Too toxic for parenteral use. Used only topically, usually for diaper rash.
Miscellaneous
 
Zinc Pyrithione-ZPT (Head & Shoulders)
Shown to significantly reduce the numbers of yeast organisms. Helps prevent the dandruff-causing microbe, Malassezia globosa, from forming scalp irritants, and normalizing keratinization.
Selenium Sulfide (Selsun) 2.5% (Rx)
For treatment of dandruff and tinea versicolor via its anti-Malassezia effect and significantly reduces the rate of cell turnover.


Where is the Undecylenic Acid, Tolnaftate, Absorbine Junior, Gold Bond, etc.? Although I also did leave out some prescription products as well (sertaconazole, oxiconazole, naftifine), this comprehensive guide will treat the topical fungal infections the community pharmacist sees. Our treatment decisions must be dictated by efficacy, cost and of course patient safety. In the upcoming weeks we will be covering specific topical disease states such as tinea pedis, cruris, corporis, thrush, vulvovaginal candidiasis, onychomycosis, and diaper rash. After this "series" we will feel much better treating "the fungus among us"!!

Have a great day on the bench!!

Are you left scratching your head on how to treat dandruff patients?

Treatment options and patient care points for dandruff

Etiology: Dandruff is the most common form of scalp seborrheic dermatitis. We are familiar with the appearance of dandruff, which the scalp shows fine, white, diffuse scaliness without underlying erythema. The rate of turnover of the epithelial cells is about twice the normal rate in patients affected with dandruff. Malassezia (formerly called Pityrosporum) is a “lipid dependent” fungus (yeast) that lives on the scalps of most healthy patients. Sometimes it grows out of control, feeding on the oils secreted by hair follicles and causing irritation that leads to increased cell turnover. The result is many dead skin cells, which fall off, clump together with oil from hair and scalp, and become visible. Unfortunately, they end up on our black tuxedos or cocktail dresses!

Factors influencing overgrowth: increased oil production; hormonal fluctuations; stress; illness; neurological disorders, such as Parkinson's disease; a suppressed immune system; infrequent shampooing and extra sensitivity to the malassezia fungus may contribute to the development of dandruff.

Treatment : The 2017 Sanford Guide recommends two first line treatments for dandruff: ketoconazole 2% or selenium sulfide 2.5%

Nizoral® Ketoconazole 2% Shampoo(Rx) only:
  • Acts by blocking the biosynthesis of ergosterol, the primary sterol derivative of the fungal cell membrane. Ketoconazole weakens the fungal cell membrane.
  • Apply twice a week. Leave on for 5 minutes and thoroughly rinse.
  • Patient Care points: immediate lather hair when starting shower, to let ketoconazole saturate the hair and scalp for 5 minutes to get full benefit. Nizoral® A/D shampoo 1% is the over the counter version
Selenium Sulfide 2.5% (lotion/shampoo)
  • Controls dandruff via its anti-Malassezia effect and significantly reduces the rate of cell turnover.
  • Usually applied twice a week. Thoroughly rinse.
  • Patient care points: Remove jewelry to prevent staining from sulfide. Although this is the most effective treatment for dandruff, the sulfide (“rotten egg”) smell steers patients away from this drug. Selsun Blue 1% is the over the counter version.
Head and Shoulders® Zinc pyrithione (ZPT)
  • Heals the scalp by normalizing epithelial keratinization, sebum production, or both. Also shown to significantly reduce the numbers of yeast organisms. Helps prevent the dandruff-causing microbe, Malassezia globosa, from forming scalp irritants
  • Dosage: Is effective if used three times a week.
  • Patient care points: Don’t alternate between ZPT and non-medicated shampoos.Use only ZPT containing product if using every day.
Neutrogena T/gel: Coal tar based .5%
  • Mechanism: Keratolytic agent which reduces rate of skin cell formation, and also softens keratin; also elicits antiseptic & antibacterial properties
  • Dosage: best if used twice a week.
  • Patient care points: Use caution in exposing scalp to sunlight after applying this product. It may increase your tendency to sunburn for up to 24 hours after application. Does smell like a freshly paved road.

Lots of marketing goes into shampoos for a good reason. Most people need them, and use them every day. Most patients have their favorite, and that is what they stick with.

My "oily skin" and very abundant growth of Malassezia, make me a primary candidate for using a dandruff control. What is my favorite? I don't like the smell (neither does Mrs. Kreckel!) of the selenium sulfide. I have had the best success with ZPT, since I want to use it every day.

Have a great day on the bench!!

Only our fungi get motivated in this hot and steamy weather!

TINEA VERSICOLOR -- Pathology and Treatment

With the very warm weather we have been experiencing, the heat may make us humans feel lethargic. However, the yeast that causes Tinea versicolor gets “supercharged” and grows more rapidly in this heat and humidity. Tinea versicolor is a superficial skin infection -often referred to as “sweat rash” caused by Malassezia furfur (aka: Pityrosporum ovale or Pityrosporum orbiculare) M. furfur can be found in normal skin flora. Under the right conditions yeast converts to the hyphal phase and causes disease. Most often seen in hot/ humid climates, oily skin, hyperhidrosis, hereditary factors, corticosteroid treatment, and immunosuppression. Look around shirt collar lines, under bra’s, folds of skin, armpits etc. and you will see these flat discolored lesions. These lesions don’t change colors with sun exposure; they are lighter in the summer than surrounding skin, and darker in the winter. The lesions will glow yellow/green when lit up with a Wood’s lamp (“black light”).

TREATMENT OF TINEA VERSICOLOR

  • (selenium sulfide 2.5% shampoo (Rx).
Apply a thin layer covering the body surface from the face to the knees once daily for seven days. Leave on skin for five to ten minutes before rinsing. Remind patients to remove jewelry before application, as it may damage jewelry. Apply once a month for 3 applications to help prevent recurrences. Disadvantages: odor of the product which smells like rotten eggs. Some patients a stinging sensation after application
  • Head and Shoulders shampoo (OTC): Zinc pyrithione shampoo(ZPT) applied once daily, leave on for 5 minutes. Apply daily for 2 consecutive weeks.
  • Nizoral® ketoconazole 2% shampoo (Rx) single application for five to ten minutes is effective (80% mycotic cure rate). May be applied up to 3 days.
  • Topical azoles: usually applied daily for 14 days. Examples: Clotrimazole (Lotrimin-OTC) Miconazole (Micatin-OTC), Ketoconazole (Nizoral-Rx), Econazole (Spectazole-Rx)
  • Oral Treatment of tinea versicolor:
    • Fluconazole 400mg as a single dose.Exercise to a sweat, and do not shower for 12 hours.
      • Alternative: 300mg once a week for 2 consecutive weeks (75% cure rate)
    • Itraconazole 400mg every 24 hours for 3-7 days
    • Ketoconazole (??) Oral ketoconazole is no longer approved by FDA as of 2013 for any topical infections due to hepatotoxicity and other safety concerns, such as adrenal insufficiency and multiple drug interactions.
    • Terbinifine (Lamisil) oral tablets are of little value in the treatment.It does not achieve fungicidal levels in the skin.A 1% topical solution applied to the skin was effective in clinical trials.

Relapse rates: Tinea versicolor’s causative agent is “normal flora.” 60% of cases relapse one year after treatment, and 80% relapse after two years. Prophylaxis (especially in warm weather) use selenium sulfide 2.5% or ketoconazole 2% shampoo applied to the entire body for ten minutes once per month is an effective prophylactic therapy.

Tinea versicolor is commonly seen this time of the year. As the heat and humidity increase, so does the activity of our oil and sweat glands! This provides a perfect breeding ground for overgrowth of our normal flora M. furfur.

Because more of our patient's skin is exposed due to our summer clothing and bathing suits, this common dermatological condition is more readily seen, and frequently patients come seeking our advice.

Up until a few years ago, most dermatologists were using Ketoconazole 200mg tablets, taken as 2 tablets after a high fat meal. Patients were told to exercise until a heavy sweat, and then don't shower for 12 hours so the ketoconazole could be exposed to the M. furfur. After the FDA sternly warned practitioners in 2013 not to use ketocnazole for tinea infections, this is no longer used and a whole host of other treatments have been used. Although ketoconazole is still in the 2017 Sanford Guide, it is NOT recommended.

I feel that prevention of recurrence is as important as appropriate treatment of the initial infection.

Have a great day on the bench!

July 2017

The kidney and parathyroid are the big players in calcium and potassium levels.

Potassium and Calcium

POTASSIUM
The kidney is the major player in potassium homeostasis, regulating about 90% of excretion. K+ balance is maintained by adjusting secretion into the urine in response to dietary intake. Low levels of potassium can result in muscle weakness, adverse effects on the kidneys and cardiac arrhythmias.

Drugs that Lower Potassium Levels

THIAZIDE DIURETICS
Work in the distal tubule of the kidney. Keep dose under 25mg/day to decrease likelihood of hypokalemia.
Loop Diuretics
Furosemide, Torsemide, Bumetanide
20 mEq potassium per day is sufficient to prevent hypokalemia with diuretics. Use 40-100mEq to correct deficiency
Antipsychotic drugs
(Risperidone and quetiapine)
Can be a concern in the elderly
Carbonic Anhydrase Inhibitors Acetazolamide (Diamox) Mild diuretic that works in the proximal convoluted tubule. A weak diuretic most commonly used for glaucoma and altitude sickness.
Amphotericin B Half of patients will get hypokalemia
Excessive sweating, vomiting and diarrhea. Colon cleansing. Contribute to hypokalemia by K+ loss


CALCIUM
Serum calcium is regulated by parathyroid hormone (PTH) and vitamin D. These hormones effect the bone, kidney, and the gastrointestinal tract. Parathyroid hormone decreases calcium excretion in the kidney, increases absorption of calcium in the gut, and increases bone resorption.

Drugs that lower calcium levels

Bisphosphonates
(Alendronate (Fosamax®), Risedronate (Actonel®), Ibandronate (Boniva®) etc)
Block osteoclast re-absorption of bone
Calcitonin (Miacalcin®) Block osteoclast re-absorption of bone
Cinacalcet (Sensipar®) Lowers serum calcium (binds to receptors on parathyroid gland)
Phenytoin (Dilantin®) (and other inducers of Vitamin-D) Phenytoin, being an inducer speeds up conversion of vitamin D to inactive metabolites
Vitamin-D deficiency Blocks absorption of calcium from gut
Corticosteroids Increase renal calcium excretion and decrease gastrointestinal calcium absorption, resulting in reduced serum calcium
Excess phosphate levels (seen in chronic kidney disease) May lead to decrease calcium absorption from the gut.
Low magnesium levels (most commonly due to
alcoholism, malabsorption, and diuretic therapy)
Magnesium depletion can cause hypocalcemia by producing parathyroid hormone (PTH) resistance,


Last week, in response to a request from a Physician Assistant, we covered drugs that caused excessive levels of potassium and calcium. This week we will explore the common causes of deficiency of these two ions. Potassium and calcium are frequently checked in the physicians office, and sometimes drug therapy can be responsible for their low levels.

Have a great day on the bench!!

Remember learning about parathyroid hormone and aldosterone?

Drugs causing Hypercalcemia and Hyperkalemia
One of my former Physician Assistant Students asked me to write my next column about drugs that affect calcium and potassium. Lots of physiological events can cause increases in these two very important cations, as well as drug therapy. Here are the highlights of drugs causing elevated levels of calcium and potassium.

Drugs causing HYPERCALCEMIA

THIAZIDE DIURETICS
Hydrochlorothiazide, chlorthalidone
Cause calcium retention by increased resorption of calcium in renal tubules.
Calcipotriol (Dovonex ®) Caution with high doses or in patients with severe, extensive psoriasis
Lithium (Eskalith) Usually mild, likely due to increased secretion of parathyroid hormone (PTH). May take 4 weeks post lithium to resolve
Excessive Calcium Supplementation Obviously!
Theophylline toxicity Results in mild hypercalcemia
Vitamin-A intoxication May cause stimulation of bone resorption
Vitamin-D intoxication In the gut increases the absorption of calcium
HYPERPARATHYROIDISM Hypercalcemia from hyperparathyroidism is usually mild, asymptomatic, and sustained for years
MALIGNANCIES Rapidly progressive; a RAPID rise in calcium levels should increase suspicion of malignancy.
RENAL FAILURE Especially if given calcium carbonate or calcium acetate as phosphate binder


DRUGS CAUSING HYPERKALEMIA

Potassium-sparing diuretics
(triamterene, amiloride)
Block directly the K+-Na+ exchange in the collecting tubules.
Aldosterone antagonist (spironolactone/epleronone) Compete with aldosterone for receptor sites
NSAIDs By inhibiting renal function (block afferent vasodilatation of arterioles). May also inhibit renin secretion.
ACE inhibitors
(lisinopril,enalapril,quinapril, benazepril etc.)
By blocking Angiotensin-II, aldosterone is decreased. Aldosterone is responsible for increasing the excretion of potassium.
Angiotensin-receptor blockers
(ARBs) (Losartan, Irbesartan, olmesartan, etc)
By blocking Angiotensin-II, aldosterone is decreased. Aldosterone is responsible for increasing the excretion of potassium.
Non Selective beta-blockers
(propranolol, labetalol)
Interfere with the beta-2-adrenergic facilitation of potassium uptake by the cells. Selective BB like atenolol (mostly ß-1) have minimal effect. All ß-blockers at high dose lose beta selectivity.
Cyclosporine or tacrolimus Due to reduced efficiency of urinary potassium excretion
Trimethoprim-sulfamethoxazole Trimeth blocks apical membrane sodium channels in the mammalian distal nephron, blocking the excretion of K+
Heparin Reversible aldosterone suppression
Ketoconazole Inhibits aldosterone synthesis
Herbs Alfalfa, Dandelion Horsetail, Nettle are high in potassium
Miscellaneous: Pentamidine & Metyrapone Inhibits distal nephron reabsorption of Na+ by blocking apical Na+ channels in a manner similar to "potassium-sparing" diuretic
Potassium supplements in excessive doses Obviously!


So, as we can see many of our commonly used drug therapies can have a significant impact on these two very important ions. The concern becomes even greater in our patients that are elderly or frail.


"The Request line is open"

Do you remember those days of listening to the local AM radio station? How excited we would be when the announcer would say "the request line is open", and we would jam the phone lines with our requests to hear the Beatles, Beach Boys, or Sonny and Cher!!

I have tons of material to share with my column readers, but I also am delighted when I get an e-mail requesting a specific topic that my readers find of clinical interest. Today's column's request came from a practicing physician assistant who wanted a quick column on the drugs that cause changes in calcium and potassium. Next week we can discuss drug therapy that can cause lowering of potassium and calcium.

Have a great day on the bench!!

We always are promoting "covering up" and sunscreen....what happens when our patients don't listen???

TREATMENT OF SUNBURN
  • Most sunburn is self-treatable. Most are usually first or second degree burns. First degree burns are simple redness of the skin. Second degree burns are when blisters appear. Apply cool compresses; frequent cool baths or showers. Pat skin dry with towel. Do not rub.
  • Minor burns can be treated with protectants which reduce dryness of skin, and prevent friction damage.
  • No topical spray will stop the underlying burn process, or stop the formation of blisters.

Let’s talk about the two most common “remedies” for sunburn treatment:
Dermoplast® spray: (Benzocaine 20%) is the most effective topical anesthetic. Using a strength less than 20% is not effective. Benzocaine may cause hypersensitivity reactions (1%)
Solarcaine® gel: (Lidocaine) Caution with broken skin (might precipitate cardiac arrhythmia)
  • Best not to recommend topical anesthetics, due to short duration of effectiveness: max= 45 minutes, and potential for side effects. Do not recommend for small children.

Ibuprofen: Did you notice after a major sun exposure, a day later the redness gets worse? Erythema becomes clinically apparent 3 to 6 hours after exposure, peaks at 12 to 24 hours, and usually subsides at 72 hours. Three hours after UVB exposure, neutrophilic infiltration begins and peaks at 24 hours, and continues up to 48 hours later.
  • Prostaglandins and nitric oxide are most commonly implicated in the delayed erythema reactions that follow within 14-20 hours after exposure and persists for 1 to 3 days. So, by using an oral medication that blocks prostaglandins, like NSAIDS we can arrest the delayed onset erythema (redness).
  • Best option for treatment of sunburn to manage the pain, and slow down the delayed erythema is IBUPROFEN. Start use immediately after a “major” exposure.

Refer to a physician when:
  • If more than 10% of body surface of a child is sunburned, a physician should be consulted.
  • If a patient presents with: fever, headache, confusion, nausea, vomiting chills
  • Secondary infection may develop, leading to scarring.Infection is hard to treat because dead skin is an excellent medium for microbial growth.Signs of infection include increased pain, swelling, redness drainage or pus from blisters.

Does Sunscreen cause Vitamin-D Deficiency? The short answer is “yes”
  • Effective use of a sunscreen blocks the synthesis of Vitamin-D in the dermis. Middle aged and elderly persons who use sunscreens daily have significantly lower concentrations of 25-Hydroxyvitamin D3.
  • The benefits of using a sunscreen, far outweigh the disadvantages of a decrease in Vitamin-D. A local dermatologist told me: “ It is easier to treat Vitamin-D deficiency than skin cancer”

We see a lot of requests for recommendations for sunburn treatment this time of year. Lots of people are looking for aloe gel and other sunburn remedies. The truth is, just cooling down the skin makes our patients feel better, so a spray bottle filled with water is as effective as any topical cooling gel. Topical anesthetics are of short term value, and has risks if the skin is broken or the patient is very young or very old.

Incidence: the estimated sunburn prevalence among all adults in the US was approximately 34 percent. Sunburn occurs more frequently among adolescents and young adults. In nation-wide surveys in the United States, approximately 70 percent of adolescents aged 11 to 18 years and 50 percent of adults aged 18 to 29 years reported at least one sunburn in the previous year.

A lot of patients need our expertise!

Have a great day on the bench!!

Let's look at PREVENTION of Sunburn!

Last week, we discussed the mechanics of sunscreens and product selection. Here are some tips to share with your patients about sunscreens.

UVA Light: is continuous throughout the day and may exceed the intensity of UVB by up to 1,000 fold. UVA light penetrates to the dermis and is responsible for producing tanning, but may also damage blood vessels. UVA causes photo aging which is the dry, sc