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Self Care Pharmacy Blog

Will treating a fever lead to wheezing?

November 24th, 2014

By Aric Carroll, PharmD Student

A young child is very susceptible to getting sick, and with that sickness often comes fever. How do most parents treat their child’s fever? The answer for the past few decades has been acetaminophen. In many countries around the world, the first line drug approved for treating fever in children is acetaminophen.1 It has been estimated from one study that up to 75% of all children in Western countries are at some time treated with fever reducing drugs such as acetaminophen.2,3 In the United States acetaminophen use without a physician visit is approved for children as young as 2 years old.4,5 In the past decade, a lot of research has looked at a connection between the rise of acetaminophen use and the rise of asthma in young children.6

A recent study from the Journal of Korean Medical Science (JKMS)9 investigated the relationship between acetaminophen use and asthma prevalence, but took it a step further to try to see why acetaminophen use could be associated with the condition of asthma. The study particularly looked at a specific gene for a receptor in the body called toll-like receptor 4 (TLR4). This is one of the first studies to focus on the combination of TLR4 modification and acetaminophen use and the risk of asthma associated with that combination. In past studies, modification of the gene for TLR4 has been associated with a higher prevalence rate of asthma.7 It has been suggested that modification at this particular gene affects how the TLR4 functions. Modifications may cause the body to work harder at dealing with fine particles that are inhaled leading to physical symptoms associated with asthma.8 The authors of the recent JKMS study acknowledge that TLR4 facilitates the symptoms of asthma by contributing to the release of reactive oxygen species, which are molecules that cause excess stress on the body. This excess stress can then lead to the release of cells that cause inflammation, cause the airways to be inflamed, and cause bronchial hyperresponsiveness (BHR) or tightening of the airways. The study suggests that modification of the TLR4 gene could cause the receptor to be more abundant and lead to greater asthma symptoms.9

The study examined 2, 428 children aged between 8 and 13. The parents of each child were asked to fill out a questionnaire, which included questions about whether the child had used acetaminophen, and whether the child had been diagnosed with asthma. Tests were run on each child to determine a forced expiratory volume after a methocholine challenge, which is an indicator of BHR. Methocholine causes constriction of the airways. BHR to methocholine was defined as a PC20 (the concentration of methocholine re-quired to provoke a 20% reduction in FEV1) ≤ 16 mg/mL. Genetic tests were run on each child to determine modification of the TLR4 gene. The results showed that the use of acetaminophen was associated with risk of BHR; however, it was not associated with actual asthma diagnosis. Modification of the TLR4 receptor was not associated with asthma diagnosis or risk of BHR. A combination of acetaminophen use and TLR4 modification was significantly associated with asthma diagnosis as well as risk for BHR. The study concluded TLR4 gene modification may increase the risk of asthma in children who have used acetaminophen.9

While the study had a very large sample size of children, it had limitations that could have affected the study’s results. The study only looked at acetaminophen use in the past 12 months, but did not take into account whether children had used acetaminophen in earlier years. Also, the study looked at patients with a recall of an actual diagnosis of asthma in the children instead of asking about certain symptoms of asthma such as shortness of breath during physical exercise, wheezing, or increased coughing. Many children may have had symptoms of asthma but had never been diagnosed by a physician. The study also did not in any way establish a relationship between dose or duration of acetaminophen use. Acetaminophen use was defined as if they took acetaminophen longer than 3 days in the last 12 months. This was also solely based on patient recall. These limitations are significant and reduced the generalizability of the study. This type of observational study cannot determine a causative relationship. Thus, this kind of research can only suggest potential risks associated with exposure.

While this study, along with others, have evidence to support a relationship between TLR4 modification and asthma, other similar studies have not found this relationship.10 The conflicting evidence on this specific mechanism makes it hard to conclude one way or another whether TLR4 modification is directly linked to asthma symptoms. Also, at this time there seems to be a lack of sufficient evidence to directly link acetaminophen use to asthma symptoms. More prospective research needs to be done looking at acetaminophen use and its relationship with asthma symptoms specifically in combination with TLR4 gene modification. It may be possible that acetaminophen has a greater adverse effect on children who have a TLR4 gene modification which would increase the risk of asthma specifically in those children. With what evidence is available at this time, it is difficult to say that treating a child with acetaminophen will cause them to develop asthma symptoms.

So, what are your thoughts? Even with this possibility of acetaminophen use in children leading to asthma symptoms, do you think it’s still reasonable for acetaminophen to be used to treat a child’s fever?

References

  1. Gonzalez-Barcala F, Pertega S, Silvarrey A, et al. Exposure to paracetamol and asthma symptoms. European Journal Of Public Health [serial online]. August 2013;23(4):706-710. Available from: Food Science Source, Ipswich, MA. Accessed October 15, 2014.
  2. Jensen J, Tønnesen L, Söderström M, Thorsen H, Siersma V. Paracetamol for feverish children: parental motives and experiences. Scandinavian Journal Of Primary Health Care [serial online]. June 2010;28(2):115-120. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed October 16, 2014.
  3. Sullivan J, Farrar H. Fever and antipyretic use in children. Pediatrics [serial online]. March 2011;127(3):580-587. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed October 16, 2014.
  4. Reducing fever in children: safe use of acetaminophen. FDA Consumer Health Information. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm263989.htm. Published July 21, 2011. Updated June 6, 2014. Accessed October 15, 2014.
  5. Krinsky, D. L., Berardi, R. R., & Ferreri, S. P. (2011). Handbook of nonprescription drugs: An interactive approach to self-care (17th ed.). Washington, D.C: American Pharmacists Association.
  6. Farquhar H, Stewart A, Beasley R, et al. The role of paracetamol in the pathogenesis of asthma. Clinical & Experimental Allergy [serial online]. January 2010;40(1):32-41. Available from: Academic Search Complete, Ipswich, MA. Accessed October 15, 2014.
  7. Fagerås Böttcher M, Hmani-Aifa M, Vaarala O, et al. A TLR4 polymorphism is associated with asthma and reduced lipopolysaccharide-induced interleukin-12(p70) responses in Swedish children. The Journal Of Allergy And Clinical Immunology. September 2004;114(3):561-567. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed October 16, 2014.
  8. Kerkhof M, Postma D, Koppelman G, et al. Toll-like receptor 2 and 4 genes influence susceptibility to adverse effects of traffic-related air pollution on childhood asthma. Thorax [serial online]. August 2010;65(8):690-697. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed October 18, 2014.
  9. Lee S, Kang M, Hong S, et al. Association between Recent Acetaminophen Use and Asthma: Modification by Polymorphism at TLR4. Journal Of Korean Medical Science. March 2014;29(5):662-668. Available from: Science Citation Index, Ipswich, MA. Accessed October 10, 2014.
  10. Hussein Y, Awad H, Shalaby S, Ali A, Alzahrani S. Toll-like receptor 2 and Toll-like receptor 4 polymorphisms and susceptibility to asthma and allergic rhinitis: A case-control analysis. Cellular Immunology [serial online]. 2012;274(1-2):34-38. Available from: Science Citation Index, Ipswich, MA. Accessed October 18, 2014.

Flush Out Your Child’s Allergies!

November 20th, 2014

By Kelly Huston, Pharm.D. Student.

Got allergies? Is your child sneezing and/or have a stuffy, itchy, or runny nose? Flushing the nose out with a saltwater solution may provide some relief. Allergies are the body’s response to a substance that causes these symptoms.1 Because germs can contribute to allergy symptoms, flushing the nose could help by removing germs and by increasing the nose lining’s ability to stop germs from entering the body.2,3 Parents are looking for a simple solution to relieve their children’s allergic symptoms. Rinsing the nose out with a saltwater solution may be the answer they are hoping for.

Currently, self-treating allergies in children less than twelve years old is only appropriate if they have been seen by the doctor. However, if the child is twelve years or older, self-care is appropriate without first seeing the doctor. The best way to treat allergy symptoms in children is to avoid the cause of the allergic reaction. If the child cannot avoid the cause of the reaction, a second option to try before using medications is to flush the nose out with a saltwater solution. If medication is necessary, remember that choosing the medicine focused on relieving your child’s main symptom(s) can greatly help.1

An article published in June 2014 entitled, The Effectiveness of Nasal Saline (seawater) Irrigation in Treatment of Allergic Rhinitis in Children, looked at how effective flushing out the nose with a saltwater solution is at reducing allergy symptoms. The study consisted of sixty-one children between the ages of two and fifteen who were diagnosed with allergies. The individuals were randomly placed in three groups to look at how well fluticasone propionate (a steroid-medication used in the nose), nasal rinsing, and a combination of both methods relieved the symptoms of allergies. The study looked at the ability of each of the three treatments to reduce the symptoms of itchy nose, runny nose, blocked nose, and sneezing. The researchers found that flushing the nose out twice a day had no side effects among any of the children, improved all of the children’s symptoms after three months, and was effective when combined with the nasal medication. They discovered that both flushing out the nose and using the nasal medication caused the children’s symptoms to improve more at four, eight, and twelve weeks, compared to each method done individually. Using both methods made it possible to reduce the amount of medication used to treat the allergies. Using a larger amount of the nasal medication can be costly, but flushing the nose out in combination with this medication may lead to a decrease in the cost of treating allergies. These findings reinforce the idea that flushing out the nose with saltwater can effectively relieve the symptoms of allergies. However, this study is limited. A good scientific study will include a group (called the control group) that does not receive any type of treatment in order to see if the treatment that the other group is receiving is really as good as the researchers think it will be. This study did not have a control group. Another limit of the study was that it only looked at one nasal medication and did not look at other medications used to treat allergies.3 Previous studies have looked at the effectiveness of flushing out the nose. In fact, two studies conducted in the years 2000 and 2012 concluded that flushing the nose is effective at reducing allergy symptoms.4,5

Currently, there are several different methods of rinsing out the nose such as a Neti Pot, battery powered pulse water device, bulb syringe, and squeeze bottle. The proper technique of flushing out the nose is important because, if done inappropriately an infection may result.6 This procedure can be done one to two times a day or as needed to relieve symptoms.7 Individuals should wash their hands and make sure the device is dry and clean before following the procedure below. Specific directions may vary between methods, but they generally include:

  • Over a sink, learn your head sideways and facedown to avoid getting the solution in your mouth.
  • Keep your mouth open, place the spout of the device that is filled with the saltwater solution in the top nostril, so that the liquid comes out the other nostril
  • Once finished, blow your nose. Lean your head to the other side and facedown. Then repeat this procedure for the other nostril.6

Mild side effects may include slight stinging. Stop using this treatment and see the doctor if a headache, fever or nosebleed occurs.6 Also, if this treatment does not improve allergy symptoms, the use of a medication may be an option.1 If concerns or questions come up, please speak with a pharmacist or doctor.

Given this information, will you flush out your nose, or a loved-one’s nose with saltwater solution to relieve symptoms in the future?

References:

  1. Krinsky DL, Berardi RR, Ferreri SP, et al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, D.C.: American Pharmacists Association; 2012.American Rhinologic Society. Nasal/Sinus Irrigation. http://care.american-rhinologic.org/irrigation Updated August 2012. Accessed October 29, 2014.
  2. Chen J, Jin L, Li X. The Effectiveness of Nasal Saline Irrigation (seawater) in Treatment of Allergic Rhinitis in Children. International Journal Of Pediatric Otorhinolaryngology [serial online]. July 2014;78(7):1115-1118. Available from: Academic Search Complete, Ipswich, MA. Accessed October 30, 2014.
  3. Tomooka LT, Murphy C, Davidson TM. Clinical Study and Literature Review of Nasal Irrigation. Laryngoscope, 2000, 110, 7, 1189-1193, John Wiley & Sons. http://onlinelibrary.wiley.com/doi/10.1097/00005537-200007000-00023/full
  4. Hermelingmeier K, Weber R, Hellmich M, Heubach C, Mösges R. Nasal irrigation as an adjunctive treatment in allergic rhinitis: a systematic review and meta-analysis. American Journal Of Rhinology & Allergy [serial online]. September 2012;26(5):e119-e125. Available from:
  5. MEDLINE with Full Text, Ipswich, MA. Accessed October 30, 2014.
  6. U.S. Food and Drug Administration. Is Rinsing Your Sinuses Safe? http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM316649.pdf Published August 2012. Accessed October 27, 2014.
  7. deShazo R and Kemp S. Patient information: Allergic Rhinitis. UpToDate. http://www.uptodate.com/contents/allergic-rhinitis-seasonal-allergies-beyond-the-basics Updated February 2014. Accessed October 30, 2014.

 

The Purple Pill Goes OTC

November 20th, 2014

By Josh Willoughby, Pharm.D. Student

Heartburn is a common health problem that affects 25% of Americans on average each year. It has been reported that in the United States alone, approximately $14 billion is spent annually.[1] Heartburn normally presents itself with a burning sensation in the chest or upper abdomen that moves upward into the throat. There are many different medications for treatment of heartburn, so it is important to know which one is the best option for self-treatment. Recently, the well-known “purple pill” for heartburn became available to patients without the need for a prescription. In late May of 2014, Pfizer Inc. announced the introduction of a new over-the-counter heartburn medication, known as Nexium 24HR.[2] Nexium, the popular “purple pill”, previously had been on the market as a prescription-only medication, but has now made the jump to over-the-counter (OTC), just as competitors Prilosec and Prevacid did years before. The switch to OTC will now allow consumers greater access and more affordable options for treatment of heartburn.

Nexium 24HR is a proton pump inhibitor or PPI, meaning that it blocks acid pumps in the stomach, which are the controlling factors in causing heartburn. PPIs are effective for treating frequent heartburn that occurs at least two days a week. Relief begins in two to three hours, but it may take between one and four days for the maximum effect to set in. Though this medication may have a slower onset of relief compared to antacids, PPIs last the longest out of any OTC heartburn treatment (approximately 12-24 hours). Nexium 24HR currently comes in a delayed-release, enteric coated form, allowing the medication to work in the body where it is needed. Nexium 24HR should be taken 30-60 minutes before meals for full effect. Taking the medication each morning would be the easiest way to ensure that the patient does not forget to take it. It is recommended that the medication be taken once daily for two weeks and then stopped for at least four months. If heartburn continues to occur, contacting the primary physician is suggested.1

Nexium 24HR comes in 22.3 mg strength, compared with the prescription-only 20 mg and 40 mg strengths. Even with the slight difference, compared with the prescription strengths, the 22.3 mg dose is equivalent to 20 mg esomeprazole, the medication’s active ingredient.[3] Nexium 24HR capsules should not be crushed or chewed. This will cause the medication to be released before it reaches the small intestine, where it needs to be activated. Nexium 24HR should not be taken by patients who have trouble swallowing food, are vomiting blood, or have black or bloody stools. Those who have lightheadedness, sweating, dizziness, or chest pain should not take Nexium 24HR and should contact a doctor. Nexium 24HR should not be taken by patients younger than 18 years old. Patients taking warfarin, clopidogrel, cilostazol, antifungals, anti-yeasts, digoxin, diazepam, tacrolimus, HIV medications, or methotrexate should ask a doctor before starting Nexium 24HR.[4]

Since prescription-strength Nexium originally came on the market in 2002, it quickly surpassed the other PPIs in sales through heavy marketing by AstraZeneca. The “purple pill” became the most purchased PPI over its competitors Prevacid (Lansoprazole) and Prilosec (Omeprazole). Based on Consumer Report’s data before the release of Nexium 24HR, Lansoprazole 20 mg and Omeprazole 20 mg (both OTC) were the cheapest effective PPI options.[5] Currently, a box of Nexium 24 HR costs about $18, while Omeprazole 20 mg only costs around $13 for a box of 28 capsules. Clinical evidence has shown no proof that Nexium is more effective than Prilosec (Omeprazole) in treating heartburn. In fact, both medications are nearly identical in their chemical structures. However, research studies have found that Nexium 20 mg and 40 mg are slightly more effective than Prilosec 20 mg in healing the esophagus, but no tests have been done to compare against Prilosec 40 mg.[6]

Because Nexium has not been tested against the higher strength of Prilosec, it remains unknown whether or not it is a better treatment option. Due to the fact that Nexium and generic Prilosec (Omeprazole) are almost identical in structure and have similar effectiveness, one should pause before choosing the more expensive option, Nexium. Most likely due to increased advertising, Nexium has become the preferred PPI on the market over the past decade. However, based on the current scientific and clinical data, I would recommend generic Prilosec OTC (Omeprazole) over Nexium 24HR to patients on the basis of increased cost savings. Paying more for a medication that has not been conclusively proven to be better than another medication is really not in anyone’s best interest. Hopefully, future studies will discover whether or not these medications significantly differ in efficacy, so that both medical professionals and patients alike will be better informed. With this information, what proton pump inhibitor would you recommend or choose for treating yourself and why?

References

  1. Heartburn and Dyspepsia. (2012). In D. Krinsky et al (Ed.), Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care (17th ed., pp. 219-228). Washington DC: American Pharmacists Association.
  2. Pfizer Brings Frequent Heartburn Relief Over-the-Counter with New Nexium 24HR. (2014, May 27).
  3. Esomeprazole (Lexi-Drugs). (2014, May 1).
  4. Nexium 24HR. (2014, May 27).
  5. Consumer Reports, Using the Proton Pump Inhibitors to Treat Heartburn and Stomach Acid Reflux, 1-15. (2013).
  6. Zablocki, E. (2004). Proton Pump Inhibitors are the Preferred Treatment for Ulcers. Managed Healthcare Executive, 48-49.

Eat more, lose more?

November 18th, 2014

By Stephanie Cailor, PharmD Student

You have probably heard the common dietary recommendation that you should eat more fruits and vegetables as a part of a healthy diet. WebMD provides some simple diet tips including one that correlates specifically with this theme. They explain that by “eating more fruits and vegetables, you shouldn’t feel as hungry because these nutrient-rich foods are also high in fiber and water, which can give you a feeling of fullness,” a claim that is supported by much research.1, 2 So how exactly does fiber play a role? Fiber is a component of food that is difficult for the body to digest. Two types of fiber exist: soluble fiber, such as that found in citrus fruits, strawberries, celery, and green beans, and insoluble fiber, found in foods such as broccoli, cabbage, and grapes. Soluble fiber retains water and slows digestion in the stomach and intestines; whereas, insoluble fiber works by adding bulk to the stool in order to speed up the passage of food through the stomach and intestines.3 For this reason,  among others, the World Health Organization recommends that adults eat a minimum of 400 grams of fruit and vegetables per day to prevent health conditions such as obesity.4 To bring this number into perspective, roughly half of each plate should be filled with fruits and vegetables. Further examples and information regarding serving sizes can be viewed at www.choosemyplate.gov/food-groups/.5 While the task of eating more fruits and vegetables may seem simple, is this general recommendation to help lose weight failing to tell us the whole story?

The claim that adding fruits and vegetables to the diet can help with weight management may be correct, but only increasing fruit and vegetable consumption may not lead to weight loss. A recently published meta-analysis reviewed the results of 7 research studies on this subject.6 Each of these studies looked at the impact of increased dietary intake of fruits and vegetables on weight loss; however, none saw a significant effect. One study involving 90 adults utilized an 8 week intervention that added either 0 grams, 300 grams, or 600 grams of fruits and vegetables to daily diet. The study concluded that groups increasing their fruit and vegetable intake lost some additional weight, but the amount was not statistically significant.7 Another study looked at adult women who increased the intake of their fruits and vegetables to 9 servings a day. The body weight of these patients changed very little, with no statistically significant reduction in weight loss over the course of the study.8 There are a few reasons why the included research studies may show the shared conclusion of no significant weight loss due to eating more fruits and vegetables. Some of the studies may not have looked long enough to see the effects of eating more fruits and vegetables on body weight. Others may have not had a large enough increase in fruits and vegetables in the diet to show any weight loss effects. Accordingly, more research needs to be done on this topic before a definitive statement can be made.

Overall, this meta-analysis concludes by stating that while eating more fruits and vegetables does promote a healthy lifestyle, in order to lose weight, other efforts are necessary to achieve desired outcomes.6 For example, adding fruits and vegetables without cutting out other unhealthy foods, primarily those with high calorie counts, will not provide desired weight loss effects.9 Other supporting research emphasizes that significant weight loss results can be seen by reducing caloric intake and balancing the diet with fruits and vegetables.4, 10

As a future pharmacist, I believe that eating more fruits and vegetables as a part of a healthy diet is beneficial due to their overall low caloric content and the fiber they contain. To lose weight, though, it is important to reduce the amount of unhealthy foods in the diet. Being healthy is a lifelong pursuit that does not consist of simply changing one bad habit. Alongside a healthier diet, it is also important to be physically active. For physical activity to provide health benefits, adults should spend 150 minutes per week doing moderate intensity aerobic activity (such as walking) and at minimum 2 days per week completing muscle strengthening activities, which includes strength training or endurance exercises.11 Small steps towards a healthy lifestyle for some people could mean adding one new vegetable to their plate tomorrow or not buying chips at their next trip to the grocery store. Others may choose to take a walk around their neighborhood every day for the next week. What are some unhealthy lifestyle and diet habits that you could change today to help you get on track for weight loss?

References

  1. Smith, M. W. (2014). 15 Best diet tips ever. Available from: http://www.webmd.com/diet/ss/slideshow-best-diet-tips-ever. Accessed on October 17, 2014.
  2. Tohill, B. C. (2005). Dietary intake of fruits and vegetables and management of body weight. World Health Organization.
  3. Dugdale, D. (2012, September 2). Soluble and insoluble fiber: MedlinePlus Medical Encyclopedia Image. Retrieved November 1, 2014.
  4. Amine, E., Baba, N., Belhadj, M., Deurenbery-Yap, M., Djazayery, A., Forrester, T & Yoshiike, N. (2002). Diet, nutrition and the prevention of chronic diseases: report of a Joint WHO/FAO Expert Consultation. World Health Organization.
  5. Dietary guidelines for Americans, 2010. (2010). Washington, D.C.: U.S. Dept. of Health and Human Services, U.S. Dept. of Agriculture.
  6. Kaiser, K. A., Brown, A. W., Brown, M. M. B., Shikany, J. M., Mattes, R. D., & Allison, D. B. (2014). Increased fruit and vegetable intake has no discernible effect on weight loss: a systematic review and meta-analysis. The American journal of clinical nutrition, 100(2), 567-576.
  7. Whybrow S, Harrison CL, Mayer C, James SR. Effects of added fruits and vegetables on dietary intakes and body weight in Scottish adults. Br J Nutr 2006;95:496–
  8. Maskarinec G, Chan CL, Meng L, Franke AA, Cooney RV. Exploring the feasibility and effects of a high-fruit and -vegetable diet in healthy women. Cancer Epidemiol Biomarkers Prev 1999;8:919–
  9. Sacks, F. M., Bray, G. A., Carey, V. J., Smith, S. R., Ryan, D. H., Anton, S. D., … & Williamson, D. A. (2009). Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. New England Journal of Medicine, 360(9), 859-873.
  10. Wing, R. R., Hill, J. O. (2001). Successful weight loss maintenance. Annal Review of Nutrition, 21(1):323-341.
  11. Physical Activity Guidelines Advisory Committee. (2008). Physical activity guidelines advisory committee report, 2008. Washington, DC: US Department of Health and Human Services, 2008, A1-H14.

Training Programs to Prevent ACL Tears Could be the Answer to an Athlete’s Prayers

November 18th, 2014

By Kaysie Brittenham, PharmD Student

Are specialized training programs the solution to the alarming number of ACL (Anterior cruciate ligament) tears among young athletes? ACL tears continue to be a major issue among children and teens participating in competitive sports such as basketball, soccer, volleyball, and gymnastics. There are approximately 200,000 (1 in 1,750) ACL injuries every year, a majority of which occur in patients 15-45 years of age with young females at greatest risk.5 The ACL is one of four important ligaments in the knee. It runs through the center and provides stability when athletes are cutting, pivoting, stopping, or landing from a jump. Ligaments in the knee connect bone to bone at the joint and act like strong ropes to hold the bones together and maintain joint stability. They can tear from the force of a hit or from an awkward movement putting more force on the ligament than it can tolerate.2

ACL injuries have both immediate and long term debilitating effects. After an ACL tear, athletes are often less likely to return to athletics and tend to experience greater problems later on in life. Surgery, lengthy rehabilitation, early development of joint problems, chronic pain, and disability are all possible effects from ACL tears. Additionally, there are many financial, emotional, and psychological effects. Currently, ACL reconstruction surgery uses grafts to replace the ligament. These grafts come from tendons (strong tissues connecting muscle to bone) in the knee or in the back of the leg of either the patient or a deceased donor. The procedure typically lasts no more than a few hours. However, rehabilitation can be quite lengthy. Each person recovers differently, with some experiencing more difficulty than others. Complete recovery typically takes 9 months of rehabilitation. Muscles take a long time to regain strength and the affected knee often requires painful physical therapy to recover range of motion and stability. Sadly, some people are never the same after surgery and continue to experience problems such as a noticeable limp, joint pain, or fear of reinjuring themselves. Despite improvements in surgery and rehab, ACL injury prevention strategies are being stressed more and more. The hope is that these programs will combat the high occurrence of these detrimental injuries. Recent studies have suggested that specific training programs can lower the risk of ACL injury by as much as 70 percent.1 These training programs are believed to strengthen lower leg muscles, improve core stability, and help athletes avoid dangerous knee positions.1

Training programs are being stressed predominantly in young female athletes. “The largest numbers of ACL injuries occur in female athletes ages 15 to 20.”1 In fact, females are 4-6 times more likely than males to experience a torn ACL.3 The prevalence of ACL tears among young female athletes after puberty is thought to be a result of developmental changes. As body size increases, muscles in females do not generally develop and increase in strength as they do in males.1 Additionally, girls tend to jump and land differently than boys. Girls generally use their leg muscles unevenly, land with straight knees, and have legs that differ in strength. “These imbalances, which become more pronounced after puberty, put girls at greater risk of tearing their ACLs.”2 However, with the help of training programs, it is believed that these tendencies can be altered.

Physicians and athletic trainers are stressing the idea of ACL tear prevention. Many believe that specialized training programs, consisting of simple exercises that alter the way athletes run, jump, and land, can significantly reduce the risk of ACL injury. These programs have demonstrated numerous benefits and though they are not one hundred percent effective, initial research shows promise.2 Training programs may only take a few minutes a day to implement and could include a combination of drills such as jogging, skipping, lunging, or other bodyweight exercises.2 Consciously practicing a technique over and over causes muscle memory to kick in when the athlete cannot focus all of their attention on technique.3 One study conducted by Dr. Cynthia LaBella, showed that “a 20-minute program of specialized warm-ups, strengthening drills and plyometrics (explosive jumping exercises) cut down dramatically on ACL injuries compared to girls who did not perform the drills.”2 LaBella’s research has led to the development of KIPP (Knee Injury Prevention Program) which is now one of many ACL injury prevention programs.

Since KIPP’s development, many schools have adopted the program or others similar to it.2 Evidence has shown that multi-component programs are more successful than single-component programs in decreasing the occurrence of ACL injures. Exercises within these programs include plyometrics, balance and core control, strength training, agility training, spatial awareness, and muscle memory training.3 Many programs differ with respect to number and types of exercises and the frequency and duration of training.  A pooled analysis, however, looked at all current studies on these training programs and concluded that the most effective programs combined 3 key components. These included core and lower leg muscle strengthening, plyometrics, and repeated enforcement of proper technique.4 Additionally, the most effective programs trained athletes for a minimum of twice per week for 6 weeks and included preseason and in-season training.4 Though more research needs to be done, evidence suggests there are benefits in utilizing ACL injury prevention programs.

Talk with your doctor if you have questions or are interested in learning more. They can help athletes and parents locate a qualified instructor and provide you with more information.4 Athlete’s tend to have a mindset that they’re invincible, but all it takes is one wrong movement. Is it worth being proactive and possibly preventing such a common and destructive injury? As a future health care provider, I strongly suggest that young athletes, particularly females, consider these training programs. I’ve seen first-hand the negative effects of ACL injuries and greatly support efforts to reduce their occurrence. Additionally, I would recommend that pharmacists encourage patients with possible ACL tears to have it looked at by qualified athletic trainers or sports medicine physicians. Based on their assessment an MRI may then be necessary to confirm a tear. If MRI results demonstrate a torn ACL, it is important for athletes to see a specialized orthopedic surgeon with high success rates in ACL reconstruction.

References

  1. Preidt R. Training Programs Protect Young Athletes From ACL Tears: Report. HealthDay Consumer News Service[serial online]. April 28, 2014: Available from: Consumer Health Complete – EBSCOhost, Ipswich, MA. Accessed October 26, 2014.
  2. Torn ACLs continue to ravage high school athletes. Record, The (Kitchener/Cambridge/Waterloo, ON)[serial online]. September 9, 2014: Available from: Points of View Reference Center, Ipswich, MA. Accessed October 26, 2014.
  3. Laible C, Sherman O. Risk Factors and Prevention Strategies of Non-Contact Anterior Cruciate Ligament Injuries. Bulletin Of The Hospital For Joint Diseases[serial online]. January 2014;72(1):70-75. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed October 26, 2014.
  4. Dharamsi A, LaBella C. Prevention of ACL Injuries in Adolescent Female Athletes. (cover story). Contemporary Pediatrics[serial online]. July 2013;30(7):12. Available from: Publisher Provided Full Text Searching File, Ipswich, MA. Accessed October 30, 2014.
  5. Kim, Jennifer. Anterior Cruciate Ligament Injury. Sports Medicine. http://orthosurg.ucsf.edu/patient-care/divisions/sports-medicine/conditions/knee/anterior-cruciate-ligament-injury-acl/. Last Updated January 2009. Accessed November 9, 2014.

 

Poised Poses for more Z’s

November 17th, 2014

by Rachel Bull, PharmD student

Poor sleep quality is one of the most common health complaints in older adults today.  It is approximated that more than 80% of older adults experience sleep disturbance to some degree, while 50% note the common recurrence of sleep disturbance.1 Insomnia can be defined as, “having trouble falling or staying asleep, waking up too early and cannot return to sleep, or not feeling refreshed after sleeping”.2 The identification of the presence of insomnia is often quite obvious while the cause of the insomnia can be more difficult to identify.  The cause of insomnia can range greatly and is often not the primary disorder rather a response to an underlying issue.  The most common causes of insomnia are stress and anxiety.  Other causes can include a medical illness, poor sleep habits, or other sleep disorders such as sleep apnea and narcolepsy. The standard of care for insomnia is the practice of reestablishing a normal sleep cycle which can be accomplished with sleep hygiene practices such as exercise, a nonprescription sleep aid, or a prescription sleep aid.2 These treatments still pose barriers such as not being completely effective for all patients, therefore alternative treatments for insomnia are still being pursued.  Also, many over the counter sleep aids come with barriers of their own including the body building tolerance against antihistamines which are commonly found in these sleep aids, feeling groggy or unwell the next day, potential medication interactions, and a list of side effects associated with each sleep aid such as dizziness, dry mouth, and daytime sleepiness being the most common among all sleep aids.3 Recently an up and coming trend for treating insomnia has been focused on using the practice of yoga.  Yoga has been found to naturally strengthen the body by improving physical strength and flexibility, reducing stress, improving breathing patterns, and enhancing mental focus.4

A recent publication in Alternative Therapies by Health & Medicine explored the effects of yoga as a treatment for insomnia.1 Alternative therapies, such as yoga, have been proposed to be a safe alternative from the standard of care such as sleep aids and provide a treatment with little adverse events.  This waiting-list controlled trial study was conducted at Shaare Zedek Medical Center in Jerusalem, Israel and looked at how participating in yoga classes twice weekly as well as recommended home-based practices would affect older adults with complaints about insomnia.  The study included 67 participants who were 60 years and older. Sixteen of the participants were assigned to the waiting list control group while the other 43 participants were assigned to the yoga intervention group and 7 participants dropped out for various reasons.  The results concluded that overall the practice of yoga by older adults was shown to be a safe treatment and led to improved sleep quality and duration.  The study found that just 25 minutes of yoga per day for 12 weeks led to improved sleep status. A limitation presented by the authors was that there was not a single method of measuring the outcomes instead a wide range of measuring methods were used.  Another limitation would be the compliance of the participants throughout the study. This was evident with only 10% of participants maintaining the practice compliance level.1

There has been previous research done on this topic over the years. Another study showed yoga can positively affect insomnia by improving sleep efficiency and sleep duration.4 The study provided the participants with yoga training and instructed all participants to maintain daily yoga practice for eight weeks.  The participants kept sleep diaries for two weeks before the yoga practices began and for the entire eight week study to record the amount time spent asleep, number of times they woke up during the night, and the time spent sleeping between waking periods.  The study also noted that the cause of insomnia has commonly been linked to anxiety and depression.4 Another study published in the Indian Journal of Psychiatry found that 60 minutes of yoga daily for 6 months led to improved sleep quality among the elderly aged 60 years and older.5 This study supports the conclusion that the practice of yoga improves sleep quality while noting that further research should be conducted on this alternative therapy because of its great potential to treat insomnia.5

Yoga still offers barriers such as potential injury and the fact that the elderly population should not first attempt yoga on their own without seeking advice from their primary care provider. On the other hand, yoga can be more financially friendly than some medications offered to treat insomnia.  The benefits of yoga naturally target the most common causes of insomnia, which prove to be another reason why the practice of yoga should be utilized as a treatment for insomnia. Yoga can easily be incorporated into a basic lifestyle change by finding a yoga class at a local gym or fitness center or in the peace of your own home by using instructed yoga videos for just 30 minutes a day.

Are these poised poses worth a try? Do you think specifically yoga treats insomnia or simply exercise in general?  Is yoga the answer to your sleepless nights?

 References

  1. Baharav A, Cahan C, Cohen M, Halpern J, Kennedy G, Reece J. Yoga for improving sleep quality and quality of life for older adults. 2014; 20(3):37-38-46.
  2. Melton, C. K. Insomnia, Drowsiness, and Fatigue. In: R. R. Daniel L. Krinsky, Handbook of Nonprescription Drugs An Interactive Approach to Self-Care. Washington, DC: American Pharmacists Association; 2012: 867-876.
  3. Mayo Clinic Staff. Sleep aids: Understand over-the-counter options. Mayo Clinic Web site. http://www.mayoclinic.org/healthy-living/adult-health/in-depth/sleep-aids/art-20047860. Published 12/10/2011. Updated 2014. Accessed 11/15, 2014.
  4. Khalsa, SBS. Treatment of Chronic Insomnia with Yoga: A Preliminary Study with Sleep-Wake Diaries. 2004; 29(4):269-278.
  5. Basavaraddi IV, Gangadhar BN, Hariprasad VR, et al. Effects of yoga intervention on sleep and quality-of-life in elderly: A randomized controlled trial. 2013; 55:364-365-368.

Melting Away the Pounds: The Cold Facts

November 17th, 2014

By: Sara Hill, PharmD Student

As the holidays rapidly approach, more and more people start to think about losing weight for their family functions or maintaining their current weight throughout a food-laden season. However, despite the urge to snap up the first weight loss supplement that we hear advertised, we have to remember the importance of evaluating each product to decide if it is our best option. One supplement that fits that description is Garcinia cambogia, a growingly popular herbal supplement that Dr. Oz and others believe to be a good choice to help us lose weight.

In June, a journal called Phytotherapy Research published a study that researched Garcinia cambogia to determine how effective it truly is. (In case you are wondering, phytotherapy is the use of plants and plant products for medicinal purposes.) The researchers wanted to see if Garcinia cambogia made a difference in several health values, including weight, body mass index (BMI), waist-hip ratio, and percentage of fat mass in the body. The study involved two groups of women whose BMI values were greater than 25 (BMI >25 is considered obese). The first group of women was given Garcinia cambogia for 60 days and put on a diet that reduced their calorie intake. The second group of women was given a placebo and put on a diet that reduced their calorie intake in the same way as the first group of women. After 60 days, the researchers compared the health values of the women who had taken the supplement and those who hadn’t. Although the study identified that G. cambogia helped to lower the women’s triglycerides (a cholesterol marker), the weight, BMI, waist-hip ratio, and percentage of fat mass was not significantly different between the two groups of women.1 Although the study provided useful information, it did not account for ways that different groups of people gain and lose weight. Men and women gain weight differently, as do young people and elderly people. Furthermore, the study only accounts for the lifestyle and diet of a particular geographic location. The diet the researchers chose may not be reasonable for women (or men) in other parts of the world.

This study only contributes to a growing collection of studies examining Garcinia cambogia. Several studies have been conducted on the benefits of taking G. cambogia, but they do not always come to the same conclusion. Studies published in the late 90’s found that G. cambogia did not cause significant weight loss.2 However, studies from 2000 and 2004 shows that G. cambogia actually does lead to weight loss.2

Our decision to take or not to take Garcinia cambogia involves several things. First, we have to know that G. camgobia has not been proven save, although no studies have seen any harmful effects­­3. However, G. cambogia has been on the market before as a part of other weight loss supplements that caused safety concerns. It was one of the key ingredients in several versions of Hydroxycut that were removed from the market because of safety concerns. Furthermore, multiple cases of liver damage have led to concerns that G. cambogia is poisonous to the liver. Yet another case reported that G. cambogia interacts with some prescription medications (like antidepressants) and causes harmful levels of certain compounds in the body. Finally, we must remember that no one has conducted an extensive safety study on G. cambogia to identify the risks that go along with taking it. Without being fully aware how likely we are to be harmed, we cannot compare the risks and benefits and therefore make a fully educated decision.

Second, we have to know if G. cambogia is effective. As we have already discussed, the studies that tested how effective the supplement is do not agree with each other. One possible explanation suggests that some forms of G. cambogia work better because your body can absorb it better than the other forms. When more of the supplement makes it into your body, it can actually have its full effect. The scientists who proposed this reasoning recommend looking for bottles that list G. cambogia in the potassium and calcium salt forms instead of simply one or the other, or a completely different salt altogether. (Please note that the term “salt” here does not refer to standard table salt but to the chemical structure that allows the compound to get into your body. You should look for a product like this one that lists calcium and potassium as the salt forms.) The scientists who evaluated the calcium/potassium form of G. cambogia found positive results, indicating that G. cambogia does lead to significant weight loss.

Finally, our decision to take G. cambogia should include a comparison to standard weight loss methods. Our primary study compared women taking G. cambogia to women not taking it, but both groups of women decreased the number of calories in their diet, and both groups of women lost weight. The standard weight loss methods of diet and exercise should always be our first approach (although they are certainly difficult to accomplish during the holidays). By focusing on eating healthier foods (fewer fatty and fried foods, fewer carbs, and less sugar) in appropriate quantities and spending more time being physically active, you may find that additional weight loss techniques are no longer needed. Supplements like G. cambogia should only become an option once you’ve tried these other weight loss techniques and should be used carefully to meet your specific physical needs.

Because weight loss is often such a pressing concern, we are usually tempted to choose what seems to be the easiest, fastest option. However, due to the concerns presented above, G. cambogia does not seem like the best option. Until further tests examine the safety of the supplement as well as the effectiveness of the particular salt forms, you are probably better off staying away from it.

But what do you think? Would you feel comfortable taking Garcinia cambogia to supplement your weight loss efforts? Would you expect it to be effective?

Works Cited:

  1. Vasques, C.A.R.; Schneider, R.; Klein-Junior, L.C.; Falavigna, A.; Piazza, I.; Rossetto, S. Hypolipemic Effect of Garcinia cambogia in Obese Women. Phytotherapy Research. 2014;28(6):887-891.
  1. Downs, B.W.; Bagchi, M.; Subbaraju, G.V.; Shara, M.A.; Preuss, H.G.; Bagchi, D. Bioefficacy of a novel calcium-potassium salt of (-)-hydroxycitric acid. Mutat Res 2005;579: 149-162.
  1. Chuah, L.O.; Yeap, S.K.; Ho, W.Y; Beh, B.K.; Alitheen, N.B. In Vitro and In Vivo Toxicity of Garcinia or Hydroxycitric Acid: A Review. Evidence-Based Complementary and Alternative Medicine. 2012;1155(10) 12 pages.

Revealing the “Dark” Side of Chocolate

November 14th, 2014

By: Ruth Choi, PharmD Student

 

For centuries, cocoa has been consumed for its pleasurable taste as well as for its health benefits. Today, research attempts to explain how cocoa may be beneficial to our overall health, specifically cardiovascular health. Chocolate- Guilty Pleasure or Healthy Supplement is a review paper that was recently published in The Journal of Clinical Hypertension. In the paper, Latham et al discuss major studies done with cocoa to determine how cocoa acts in the body to produce cardiovascular benefits and whether it can be consumed as a dietary supplement.

The unique diet and health of the Kuna Indians initially sparked research on dark chocolate consumption and cardiovascular health. From the San Blas Islands of Panama, Kuna Indians consume about four 8-ounce cups of unprocessed cocoa drinks per day and have exceptionally low rates of hypertension and cardiovascular disease (CVD) even to old age.1 For instance, the mean blood pressure (BP) was 110/70 mm Hg in the elderly over 65 years.1 Cocoa comes from the Theobroma cacao tree, and a major component of it is flavanol. One of the proposed mechanisms is flavanols are responsible for improving blood flow by stimulating the endothelium of blood vessels to produce more nitric oxide (NO) and increase vasodilation.1 Improving blood flow subsequently reduces CVD risk factors such as hypertension, platelet dysfunction, insulin resistance, and hypercholesterolemia.1. Heiss et al researched the effects of cocoa intake in smokers and found that drinking cocoa high in flavanols (176-185 mg) increased NO levels and reversed endothelial dysfunction.2 One way the body naturally produces NO is through insulin stimulation. Insulin resistance occurs in individuals who do not respond to insulin’s action on blood vessels to produce NO. In a study done by Grassi et al, flavanol-rich dark chocolate proved to decrease BP and insulin resistance and improved blood flow in hypertensive patients.3

Cholesterol also plays a significant role in cardiovascular health. Dark chocolate is thought to increase HDL-C levels, which is the good cholesterol. In a 3-week study done on healthy subjects, Mursu et al found that consuming either 75 g of dark chocolate or flavanol-rich dark chocolate daily increased HDL-C levels by 11.4% and 13.7%, respectively.4 On the contrary, some studies will argue that it is actually theobromines in cocoa that help increase HDL-C levels.1 Further research is needed to determine whether flavanols or theobromines increase HDL-C levels.

Many recent studies show the benefits of cocoa intake on cardiovascular health. Due to its delectable taste, relative safety, and low cost, cocoa-rich dark chocolate is being considered as a health supplement. Major hindrances to its use, however, are the caloric intake and limitations of many of the studies.1 Due to its high caloric, saturated fat, and sugar content, chocolate needs to be consumed with caution, especially in obese patients. Though less palatable, people could consume cocoa-based products with less sugar or saturated fat. Latham et al explain the limitations that are apparent in all of the studies that were reviewed.1 One of the major limitations is the variability in flavanol content in all the studies making it difficult to interpret and compare the results. It also hinders making effective dosage recommendations for patients. Another limitation is the small sample sizes in all the studies making it difficult to generalize the results to a larger, more diverse population. The short duration of the studies is another limitation because it is unknown whether cocoa intake would produce these same results if given long term. Therefore, further research is needed until we can recommend dark chocolate as a health supplement. Nonetheless, one thing you can take away from the research is that you don’t have to feel guilty anymore about eating ‘healthy’ dark chocolate in moderation as part of your dietary lifestyle changes to prevent and treat CVD risk factors.

The Dietary Approaches to Stop Hypertension (DASH) diet recommended by the National Heart, Lung, and Blood institute (NHLBI) consists of eating a diet rich in fruits, vegetables, and low-fat dairy products to improve BP.5 Many supplements also exist that have been significantly proven to have antihypertensive effects. What sounds better, chocolate or veggies?

References:

 

  1. Latham L, Hensen Z, Minor D. Chocolate—Guilty pleasure or healthy supplement? JCH. 2014;16(2): 101. http://onlinelibrary.wiley.com/doi/10.1111/jch.12223/full. Published February 2014. Accessed October 29, 2014.

 

  1. Heiss C, Dejam A, Kleinbongard P, Schewe T, Sies H, Kelm M. Vascular effects of cocoa rich in flavan-3-ols. JAMA. 2003;290(8): 1030. http://jama.jamanetwork.com/article.aspx ?arti cleid=197170. Published August 27, 2003. Accessed October 29, 2014.

 

  1. Grassi D, Necozione S, Lippi C, et al. Cocoa reduces blood pressure and insulin resistance and improves endothelium-dependent vasodilation in hypertensives. HYP. 2005:46(2): 398. http://hyper.ah ajournals.org/content/46/2/398.full.pdf+html. Published July 18, 2005. Accessed October 29, 2014.

 

  1. Mursu J, Voutilainen S, Nurmi T, et al. Dark chocolate consumption increases HDL cholesterol concentration and chocolate fatty acids may inhibit lipid peroxidation in healthy humans. FRBM. 2004:37(9): 1351. http://www.sciencedirect.com/science/ article/pii/S0891584904004551. Published November 1, 2004. Accessed October 29, 2014.
  2. What Is the DASH Eating Plan? National Heart, Lung, and Blood Institute. Available from: http://www.nhlbi.nih.gov/health/health-topics/topics/dash/

 

 

Nicotine Patches Fail Most Pregnant Women

November 14th, 2014

By Kara Bobka, PharmD Student

In 2011, 10% of pregnant women reported smoking during the last trimester.1 Smoking during pregnancy can lead to miscarriages, premature births, placenta problems, birth defects, and infant death.1 The standard treatment for smoking cessation is behavioral therapy, like staying active or chewing gum, and support groups. Nicotine replacement therapy (NRT), such as over-the-counter nicotine patches, provides a way to help pregnant women achieve smoking cessation or stop smoking.2 Nicotine patches are applied directly to the skin, where they release a nicotine source that is then absorbed through the skin to decrease withdrawal symptoms for up to twenty-four hours.2,3 Yet, most recommend wearing the patch for sixteen-hours to give the body a break from nicotine and to decrease the potential for skin irritation.3

Patches fight symptoms of anxiety, cravings, irritability, restlessness, increased appetite, low mood, and poor concentration that are associated with smoking withdrawal. 3 However, two recent meta-analyses4,5 and one well-powered study6 showed that standard NRT doses (15 mg a day) are ineffective with pregnant women smokers when used for eight months or less. To address the effectiveness of NRT in pregnant smokers, a randomized, double blind, multicentre trial in the British Medical Journal (BMJ) confirms nicotine patches are no more effective than placebo at increasing either smoking cessation rates or birth weights even when nicotine doses are adjusted to individuals and given at higher doses. 7  

 What They Did

Berlin et al. randomized 402 pregnant women smokers (≥5 cigarettes per day) from 23 French maternity wards to receive either nicotine or placebo patches.7 All were ≥18 years of age and between 9 and 20 weeks gestation.7 All had to have health insurance. 7 More so, participants were motivated to stop smoking.7

Participants were given a two-week grace period between their initial and first follow-up visit for a chance to either stop smoking or to reduce cigarette consumption (<5 per day) on their own.7 This was necessary because people must be asked to quit smoking before using NRTs.7 Pregnant women can only be prescribed NRTs if they are unable to stop alone.7 Failing to either quit or reduce cigarette use, patients were eligible to continue, where they set a quit date and began the study.7 Smoking cessation was monitored via monthly measurements of saliva nicotine levels.7

Therapy lasted from quit date to the end of pregnancy, where women were either given 16-hour delivery nicotine patches (10-15 mg), similar to those produced in the US, or an identical placebo manufactured specifically for the study.7 For those who received active patches, daily doses ranged between 10-30 mg and were adjusted based on initial saliva nicotine levels.7 Behavioral support was provided at each visit.7

Primary outcomes were complete smoking cessation (self reported and confirmed via spirometry-confirmed carbon monoxide levels ≤8ppm) and birth weight.7 Secondary outcomes were self-reported smoking abstinence and birth characteristics.7

 What They Found

Results demonstrated that 11 of 96 (5.5%) and 10 of 76 (5.1%) women in the nicotine patch and placebo patch groups, respectively, achieved complete smoking cessation (P=0.87).7 42% in the nicotine patch group and 37% in the placebo patch group decreased their consumption of cigarettes by half.7 After two weeks, 62% had smoked again.7 More so, the nicotine patch did not decrease tobacco cravings or withdrawal symptoms or the number of cigarettes smoked.7 Average birth weights of groups did not differ significantly.7 Yet, newborns of mothers who were able to quit had a notably higher birth weight than those who were unable to stop smoking.7

Study limitations included that the subjects were women who smoked at least five cigarettes a day. So, results are hard to generalize to other expecting smokers. More so, the treatment began after the first trimester. It may be more effective to begin treatment earlier since smoking abstinence before 15 weeks gestation has yielded comparable birth outcomes to those of non-smokers.8 Another study conducted in England showed NRT combinations to be effective versus single or no NRT use.9 Despite other findings and its limitations, this study shows a lack of effectiveness of NRTs in pregnant women smokers and thereby a lack of birth characteristics’ improvements.

 What To Tell Patients

Although NRT has been shown to help others quit smoking, its effects on pregnant women remain unclear.   Earlier treatment with NRT during pregnancy may be more beneficial, although no evidence is to suggest that at this point. So, the best way to achieve smoking cessation is via behavioral therapy and support.7

To stop smoking, the Center for Disease Control and Prevention (CDC) recommends five great behavioral therapies. These include: asking family and friends for support; developing a quit plan or joining a quit program; staying busy (Get active. Chew gum. Drink water.); avoiding smoking triggers (Toss cigarettes, lighters, and ashtrays. Avoid caffeine.); and staying positive, yet vigilant.10 To successfully stop smoking, it takes time, but you can! So, reward yourself after the first 24 hours. You deserve it! Your baby will thank you!

If you smoked and wanted to quit, what actions would you take? Would you try a nicotine patch?

 

Bibliography and References Cited

 

  1. Tobacco use and pregnancy. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/reproductivehealth/tobaccousepregnancy/. Published August 5, 2014. Updated 2014. Accessed October 26, 2014.
  2. American Society of Health-System Pharmacists, Inc. Nicotine Transdermal Patch. MedlinePlus: Trusted Health Information for You. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601084.html. Published June 13, 2013. Updated September 24, 2014. Accessed October 26, 2014.
  3. Nicorette® 16hr Invisipatch. Nicorette. http://www.nicorette.com.au/products/16hr-patch. Updated September 29, 2014. Accessed October 26, 2014.
  4. Coleman T, Chamberlain C, Cooper S, Leonardi-Bee J. Efficacy and safety of nicotine replacement therapy for smoking cessation in pregnancy: systemic review and meta-analysis. 2011;106(1): 52-61.
  5. Coleman T, Chamberlain C, Davey MA, Cooper SE, Leonardi-Bee J. Pharmacological Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev. 2012;9:CD010078.
  6. Coleman T, Cooper S, Thornton JG, Grainge MJ, Watts K, Britton J, Lewis S. A Randomized Trial of Nicotine-Replacement Therapy Patches in Pregnancy. N Engl J Med. 2012;336:808-18.
  7. Berlin I, Grangé G, Jacob, N, Tanguy ML. Nicotine patches in pregnant smokers: randomized, placebo controlled, multicentre trial of efficacy. BMJ. 2014;348(1622):1-16.
  8. McCowan LM, Dekker GA, Chan E, Stewart A, Chappell LC, Hunter M, et al; SCOPE consortium. Spontaneous preterm birth and small for gestational age infants in women who stop smoking early in pregnancy: prospective cohort study. 2009;338:b1081.
  9. Brose LS, McEwen A, West R. Association between nicotine replacement therapy use in pregnancy and smoking cessation. Drug Alcohol Depend. 2013;132:660-664.
  10. Tips From Former Smokers. Centers for Disease Control and Prevention. http://www.cdc.gov/tobacco/campaign/tips/quit-smoking/guide/steps-on-quit-day.html. Updated March 24, 2014. Accessed October 26, 2014.

 

Can You Drink Your Way to Good Health?

November 14th, 2014

by Rachel Wilcox, PharmD student

Red wine is often thought to be a good source of antioxidants and is associated with heart health.1 Resveratrol is an antioxidant found in a variety of sources, including red wine, nuts, berries and dark chocolate.2 Antioxidants are believed to be important in either preventing or reducing heart disease, cancer, the effects of aging and increasing the body’s resistance to stress.3,4 Resveratrol acts to rid the body of harmful toxins and some evidence shows that resveratrol may play a role in slowing progression of cancer.2 One current popular antioxidant is Vitamin C, which is found in orange juice and has a daily-recommended intake of 90mg for adult males and 75mg for adult females.5 Although evidence of resveratrol’s benefits may not be as concrete as Vitamin C, resveratrol is gaining popularity in the public eye. In fact, some consumers in the US are going beyond just drinking wine for the supposed benefits of resveratrol and are spending about $30 million dollars each year on resveratrol supplements.1,6 A major problem concerning resveratrol is that there is no FDA approved recommendation for daily intake and current studies provide conflicting evidence about the benefits of this antioxidant.7

A recent article from CNN cites an observational study that investigated the effects of resveratrol on health outcomes such as heart disease, inflammation, cancer and mortality in 783 patients who were 65 years of age or older. 1,6 This study found that resveratrol in red wine was not associated with anti-cancer properties, reducing inflammation or improving heart disease.6 The researchers did note that a limitation of their study was in their sample size. Increasing the amount of patients studied might allow the researchers to find an association between resveratrol and health outcomes.6

There is conflicting evidence for the benefits of resveratrol. Some scientific studies found that resveratrol improved health outcomes while other studies found no benefit. One study looked at the relationship between resveratrol and its effect on protecting a second heart attack in humans. The study describes that resveratrol did thin the blood, which is important for prevention of secondary heart attacks.3 Resveratrol also possesses anti-cancer properties but this study only looked at resveratrol effects in rats and mice.2 On the other hand, several studies show that resveratrol does not live up to the hype. One study showed that resveratrol was only responsible for about less than 5% of the antioxidant activity in wine.4 In fact, their research shows that there was no significant difference in terms of antioxidant benefit between red wine and wine with 10 times the amount of resveratrol added.4 This information brings up an important question. If wine consumption may not provide enough resveratrol to see benefits, should resveratrol supplements be recommended instead? The bottom line answer is probably not. A recent publication from Harvard Medical School explains some of the concerns with resveratrol supplements. One major concern is that there is no safe and effective dose established for these supplements.7 Long-term safety is also an issue since studies have not evaluated what effects resveratrol has on the human body over time.7

Since there is so much conflicting evidence about the benefits of resveratrol and whether moderate portions of wine will even provide the needed amount of resveratrol, I would not recommend drinking wine solely for antioxidant effects of resveratrol. It is also important to weigh the potential benefits of drinking alcohol against any negative consequences. The U.S. health department guidelines strongly recommend that women do not consume more than 1 alcoholic drink per day, and that men consume no more than 2 alcoholic drinks a day.8 Overconsumption of wine and other alcohol can cause liver damage as lead to other serious health issues. Remembering to consume alcohol responsibly and within the recommended guidelines is important to reduce the chances of negative consequences. While alcohol consumption does have drawbacks, it is important to note wine contains many other antioxidants that may be beneficial. I encourage wine enthusiasts and other curious individuals to do more research on different types of antioxidants wine provides and the associated health benefits. One study did find that the health benefits of wine were attributed to many different antioxidant compounds rather than a single compound.4 I also do not recommend taking resveratrol supplements because there may be more effective products on the market with stronger scientific evidence to support the use, such as Vitamin C. What do you think, would you consider taking a resveratrol supplement? What antioxidant supplements have you tried and why?

References

  1. Hudson W. Antioxidant in red wine has no benefit at low doses. CNN. http://thechart.blogs.cnn.com/2014/05/12/antioxidant-in-red-wine-has-no-benefit-at-low-doses/. Accessed October 1, 2014.
  1. Murtaza G, Latif U, Najam-Ul-Haq M, et al. Resveratrol: An active natural compound in red wines for health. Journal of Food & Drug Analysis. 2013;21(1):1-12. Accessed October 2, 2014
  1. Das DK, Mukherjee S, Ray D. Resveratrol and red wine, healthy heart and longevity. Heart Fail Rev. 2010;15(5):467-477. Accessed October 1, 2014.
  1. Xiang LM, Xiao LY, Wang YH, Li HF, Huang ZB, He XJ. Health benefits of wine: Don’t expect resveratrol too much. Food Chem. 2014;156:258-263. Accessed October 2, 2014
  1. Office of Dietary Supplements. Vitamin C. National Institute of Health. http://ods.od.nih.gov/factsheets/VitaminC-Consumer. Updated June 24, 2011. Accessed October 21, 2014.
  1. Semba R, Ferrucci L, Andres-Lacueva C, et al. Resveratrol levels and all-cause mortality in older community-dwelling adults. JAMA Internal Medicine [serial online]. July 2014;174(7):1077-1084. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed October 1, 2014.
  1. Can drinking wine really promote longevity? recent evidence shows the antioxidant resveratrol in wine does not offer a health boost. Harv Health Lett. 2014;39(11):5-5. Accessed October 2, 2014.
  2. Center for Disease Control and Prevention. Alcohol and Public Health. Center for Disease Control and Prevention. http://www.cdc.gov/alcohol/faqs.htm#standDrink. Updated March 14, 2014. Accessed November 9, 2014.