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Self Care Pharmacy Blog

Archive for October, 2013

 

Do Artificial Sweeteners Make Us Crave Real Sugar?

Monday, October 14th, 2013

By Julie Cummings, PharmD Student Cedarville University School of Pharmacy

Since Adam took a bite of the apple, we have been self-conscious about our bodies.  Weight management, a good diet and exercise will help the body stay lean.  But what if there is still a problem with diabetes or weight management?  How can one eat better today?  One of the many helpful inventions has been artificial sweeteners.  “Artificial sweeteners are attractive alternatives to sugar because they add virtually no calories to your diet. In addition, you need only a fraction compared with the amount of sugar you would normally use for sweetness”.(1)   They have been used for decades to help with diabetes maintenance and weight management.

Recently, an article about a study on mice and artificial sweeteners called “The Brain Cannot Be Fooled By Artificial Sweeteners – Leading To a Higher Likelihood Of Sugar Consumption Later”  was published on AlphaGalileo’s website.(2) The study was performed at Yale University by Professor de Araujo.  He wanted to study the brain signal that is critical in the choice between artificial sugar and real sugar.   When the body ingests real sugar, the brain sends signals that allow dopamine to rise.  Dopamine is a chemical in the body that makes the person feel “happy”.  When real sugar is broken down in the body into a useable fuel, dopamine is released.  In the study, the mice were given a choice to ingest an artificial sweetener or real sugar.  At the same time, their chemical responses for reward were measured in their brains.  Professor de Araujo found that when the mice were given a choice between real sugar, a substance that required their body to break down for fuel, and an artificial sweetener, they switched to the real sugar instead.  He went on to say that even when the artificial sweetener was sweeter than the real sugar item, they still switched to the real sugar item.  He felt the study would achieve the same results in humans.(2)

The human body is a miraculous invention.  This evidence really doesn’t surprise me that the brain is unsatisfied when not given something it wants.  We see this in instances when our brain is telling us it needs some hydration (water) and our human choice is something other than water, like coffee, tea or soda.  This choice, a lot of times, does not satisfy the brain’s command to hydrate and we remain in a condition of thirst.  A study done in 2010 on the effects of weight gain in children who consumed artificial sweeteners couldn’t find a plausible metabolic effect from the consumption of artificial sweeteners, but concluded that more research should be done on the subject.   Another study, observing girls ages 9 to 10, found the consumption of diet sodas was significantly associated with higher calorie intake.(3)   I do believe that Professor de Araujo may have a point that needs further research.   I would like to see a study performed in adult humans, maybe even with a disease state of diabetes or obesity to truly clarify if these disease states could be affected by the artificial sweetener/real sugar debate.

My thoughts on recommending artificial sweeteners are these:

  1. If the patient’s diabetes or weight management is in control, I would allow my patient to moderately utilize some real sugar with their artificial sweeteners for a trial period.  If they noticed a problem arising with their medical conditions, I would tell them to stop taking the real sugar.
  2. I wouldn’t allow this article to convince me to tell all of my patients to do this.  I may ask them if they notice they are craving “sweet” food or drink items, even though they are utilizing artificial sweeteners.  If they are and are satisfying this craving with binge-full sugar consumption, I would definitely ask them to start mixing artificial sweetener with a little bit of real sugar throughout the day in a more managed fashion.
  3. If my patient is new to the artificial sweetener world, I would rather them use the artificial sweetener for a couple of weeks and ask them to come back or call me about how it is going and then go from there on how to manage their sweetener/sugar intake.
  4. Make sure my patients know the FDA regulates artificial sweeteners and has an acceptable daily intake (different per product) each day for a lifetime.(4)

What would you recommend to your diabetic patient bringing you a box of Sweet-N-Low?  Do you tell her to take it by itself and significantly reduce her sugar intake?   Do you tell her to NOT take artificial sweetener or sugar at all, because she doesn’t need to have anything sweet and see a HUGE reduction in her sugar intake? (She left the pharmacy and probably won’t be back to see that psycho pharmacist, (her words, not mine)!)  Or, do you tell her that there may be a chance that she may need some real sugar with it?

 

References

 

1.  Mayo Clinic Staff. Mayo Clinic Health Information. http://www.mayoclinic.com/health/artificial-sweeteners/MY00073.  Published October 9,2012 Retrieved September 27, 2013.

2.  Wiley. (2013, 9 20). Alpha Galileo Foundation. Retrieved 9 26, 2013, from http://www.alphagalileo.org/ViewItem.aspx?ItemId=134681&CultureCode=en.  Published September 20, 2013 Retrieved September 25, 2013.

3. Brown, R. J., De Banate, M. A., & and Rother, K. I.. Artificial Sweeteners: A systematic review of metabolic effects in youth. International Journhal of Pediatric Obesity, 2010;305-312; doi: 10.3109/17477160903497027.

4. ADAM editorial team). Medline Plus. http://www.nlm.nih.gov/medlineplus/ency/article/007492.htm. Published January 23, 2012 Retrieved September 27, 2013.

Are Magnetic and Copper Bracelets Effective for Arthritis?

Tuesday, October 8th, 2013

By Derrick Chapman, PharmD Student Cedarville University

Magnetic and copper bracelets have become a popular natural remedy for many ailments, most commonly for arthritis and pain.  Advertisements claim these bracelets offer improvements in energy, increases in strength, and relief from pain, as well as many other health issues. The basis for these claims is that electromagnetic cell signaling, disrupted by illness, may be altered and corrected by a magnetic bracelet.2

There were no known scientific studies known supporting the effectiveness of magnetic or copper bracelets. In preparation for their study, the researchers did find one article comparing different strength magnets in arthritic pain relief.  This study did not find an effect to either strengths of magnets that they tested.4 Because minimal research has been done on the actual effectiveness of copper and magnetic bracelets on pain relief, researchers decided to study the effects of different bracelets on pain relief in rheumatoid arthritis patients.  The researchers provided a strongly magnetic bracelet, a weakly magnetic bracelet, a copper bracelet, and a nonmagnetic bracelet.  The researchers had the patients self-report the severity of their pain.  The researchers also examined plasma viscosity and C-reactive protein of the subjects to test for anti-inflammatory effects. None of the bracelets produced any significant effect in either pain relief or inflammation.  The conclusion was that these products do not help with pain and inflammation.4

There were some limitations to the study. The patient was used as their own control.  Pain is a feeling and concept, and therefore had to be measured on a self-reported scale. While very careful measures were taken to blind the study, researchers anticipated that some patients may try to determine on their own if their bracelet was magnetic or not.4 None of these limitations significantly affected the validity in my opinion.  As a student pharmacist, I found this article, as well as the research it presents, very accurate and helpful.  The scientific rationale behind using these products is flimsy at best, and the studies that have tested the efficacy of these products disprove any positive effects. Some of the anecdotal evidence may be due to psychological reasons rather than actual scientific reasons.1 Also, the placebo effect may be due to the fact that arthritis naturally flares and mitigates.  Starting treatment at the height of a flare up may synchronize the treatment with the perceived relief.3

This article and the research it presents have reinforced my decision to not recommend magnetic or copper bracelets to patients.  The research is consistent with the standard care guidelines that over-the-counter analgesics, namely NSAIDs and acetaminophen, are the best treatment options for arthritis pain.  I recognize that some alternative therapies may work mainly because of the placebo effect.  The article, quoting researcher Stewart J. Richmond, introduced an interesting patient counseling issue and ethical concern about the placebo effect. “Is it ethically correct to allow patients to live in blissful ignorance? Or is it better to provide them with the facts?”1 I agree with researcher Stewart J. Richmond that as a healthcare professional I am obligated to be honest with my patients.1 I must provide the unbiased truth on the many products that make false health claims and will only recommend the safest, most effective treatment options.1 However, relief, whether real or perceived, is relief nonetheless and I would not stand in the way of something that works for a particular patient.  However, three things must be in place before use. First, the patient must be informed of the unbiased truth about the product. Second, the patient must not be foregoing necessary medical treatment. Third, the product must not pose a serious risk to the patient. Even though I would not recommend one, I see no reason to discourage use of a magnetic bracelet in a patient who has experienced relief provided those three stipulations are met.

Whether you are a health professional or a patient suffering from arthritis, what are some non-traditional methods you have found to relieve arthritis pain? Have you tried these bracelets and found they work for your pain?

 

References

1.  Bakalar, N. Magnets Fail to Relieve Arthritis Pain. The New York Times.    http://well.blogs.nytimes.com/2013/09/19/magnets-fail-to-relieve-arthritis-pain/?_r=0. Published September 19, 2013. Accessed October 3, 2013.

2.  Hellesvig-Gaskell K. How Do Magnetic Bracelets Work?. LIVESTRONG. http://www.livestrong.com/article/32851-magnetic-bracelets-work/. Published August 16, 2013. Accessed October 3, 2013.

3.  Hope J. If that copper bracelet eases your arthritis, it’s just a trick of the mind: Straps which claim to help chronic illnesses are useless, says landmark study. Mail Online. http://www.dailymail.co.uk/health/article-2422965/Copper-bracelets-straps-claim-help-chronic-illnesses-like-arthritis-useless-says-study.html. Published September 16, 2013. Updated September 17, 2013. Accessed October 3, 2013.

4.  MacPherson H, Bland M, Gunadasa S, Richmond S.  Copper Bracelets and Magnetic Wrist Straps for Rheumatoid Arthritis – Analgesic and Anti-Inflammatory Effects: A Randomised Double-Blind Placebo Controlled Crossover Trial. PLoS ONE. 2013; 8(9): e71529. doi:10.1371/journal.pone.0071529

Nasacort: OTC Status Approve or Disapprove?

Tuesday, October 8th, 2013

By Nathanael Smith, PharmD Student Cedarville University

Allergic Rhinitis (AR) is a systemic disease with prominent nasal symptoms that affects the upper respiratory system, causing symptoms of itching of the eyes, nose and/or palate and sinus pain. AR is a disorder triggered by indoor and/or outdoor allergens that is characterized by the activation of IgE, a inflammatory immunoglobulin.1 Indoor allergens consist of house-dust mites, mold, cockroaches, and pet dander. Outdoor allergens consist of mold spores, pollen, and possible pollutants such as exhaust particles. The allergen enters the body and causes a complex four-phase effect involving histamines and other inflammatory mediators that eventually lead to inflammation and an overproduction of mucus. This disease affects worldwide populations of adults and children. It is estimated that 20% of adults and 40% of children in the United States have this disease, coupled with a steady increase in cases over the past 3 decades.3

 CNBC covered a story about Sanofi SA, a pharmaceutical company, who was attempting to move prescription Nasacort AQ to be an over-the-counter medication. Nasacort AQ is an intranasal corticosteroid (INC) aerosol that provides effective relieve for AR. The FDA advisory panel voted 10-6 for the move of Nasacort, but the FDA has not given the OK to make the switch.4 Sonafi SA wants the approval because Teva pharmaceuticals has won the rights to manufacture the generic.4 This caused a decrease in gross for Sanofi of approximately $275 million dollars, dropping from $375 million to $100 million sales in one year.4 Sanofi is hoping that the switch to a nonprescription medication will increase the revenue for Nasacort and help compensate for the loss of sales.4

The appropriateness of the switch, however, is not based on the revenue that the company can make, but on how effective the medication is and the safety of the medication for self-care use. According to the Journal of Rhinology and Allergy (AJRA), all INCs, such as Flonase, Nasonex, and Nasacort, are equally effective and potentially better at relieving allergic rhinitis in adults and pediatrics as antihistamines. In addition, the AJRA states that INCs are considered the “most effective first-line therapy to improve AR symptoms and burden of disease.” On the flip side, articles opposing INCs becoming OTC medications were written due to the use of new aqueous propellants that caused several side effects such as “dripping down the throat,” and “wet feeling,” along with pharyngitis and nasal burning/irritation.5 To relieve these adverse effects, numerous studies have been done to help make INCs safer including the use of nonaqueous propellants such as hydrofluoroalkane (HFA).5 Now, after numerous studies, INCs have much better side effects, only consisting of throat/nose irritation or dryness, coughing, sneezing, nose bleeds, or unpleasant taste/smell.6 On top of this, intranasal corticosteroids have less side effects than oral antihistamines and are therefore the recommended choice in both adults and children with persistent allergic rhinitis.7

In light of the article background and information regarding INC medications, I agree with this article. INCs, such as Nasacort, are the “gold standard” for choice due to the safety and effectiveness of the medication in treating allergic rhinitis.8 In addition, the American Academy of Family Physicians (AAFP) stated that INCs are the first line option for all mild-moderate persistent AR in children and adults, while antihistamines, such as Zyrtec, Claritin, and Allegra, are more for occasional allergies.9 In addition, INCs were shown in 11 studies to provide greater relief to itching and nasal blockage than oral antihistamines.10 Therefore, this new proposal for Nasacort to be moved to an OTC medication would change my self-care recommendation. My first choice for a patient would depend upon the symptoms the patient was showing. If a patient solely had a complaint of a first-time allergy that occurred at irregular times, I would recommend an oral antihistamine. If the patient, however, showed symptoms of persistent, mild to moderate allergies, or needed a safe, fast relief, then I would first recommend Nasacort. In the end, Nasacort has shown to provide better results and safer action than other allergy medications.   

Intranasal corticosteroids have evolved significantly over the past seven years due to opposition on efficacy. This evolution has brought about safer products that can be the most effective response to allergic rhinitis symptoms. Eventually, Nasacort may become an OTC medication, and pharmacists will need to counsel patients on the proper self treatment, and whether or not the patient should use an INC instead of a different allergy medication.

With this potential switch, do you feel comfortable using Nasacort instead of the common oral antihistamines? Would you suggest this product to a friend or relative that may be suffering from persistent allergies?

 

References:

 

[1] Mucci T, Govindaraj S, Tversky J. Allergic rhinitis. Mt Sinai J Med. 2011;78(5):634-644.

 

[2] Blaiss MS. Allergic rhinitis: Direct and indirect costs. Allergy Asthma Proc. 2010;31(5):375-380.

 

[3] Krinsky, D. Berardi, R. Ferreri, S. Hume, A. Newton, G. Rollins, C. Tietze, K. Scolaro, K. Disorders related to colds and allergy. In: Wolter KY, L., ed. Handbook of nonprescription drugs. 17th ed. ; 2012:190-201.

 

[4] Dooren J. FDA: Sanofi allergy spray ‘good candidate’ for nonprescription switch. WSJ. 2013.

 

[5] Carr WW. New therapeutic options for allergic rhinitis: Back to the future with intranasal corticosteroid aerosols. Am J Rhinol Allergy. 2013;27(4):309-313.

 

[6] Triamcinolone acetonide – nasal, nasacort. Medicine Net.com Web site. http://www.medicinenet.com/triamcinolone_acetonide-nasal/article.htm. Updated 2013. Accessed October 4, 2013.

 

[7] Salib RJ, Howarth PH. Safety and tolerability profiles of intranasal antihistamines and intranasal corticosteroids in the treatment of allergic rhinitis. Drug Safety. 2003;26(12):863.

 

[8] Blaiss MS. Safety update regarding intranasal corticosteroids for the treatment of allergic rhinitis. Allergy Asthma Proc. 2011;32(6):413-418.

 

[9] Sur D, Scandale S, Geffen D. Treatment of allergic rhinitis. AAFP. 2010;81(12):1440-1446.

 

[10] Weiner J, Abramson M, Puy R. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: Systematic review of randomised controlled trials. BMJ. 1998;317(7173):1624-1629.

 

 

Sunscreen: Are You Protecting Yourself Againist Aging Skin?

Monday, October 7th, 2013

By Aaron Le Poire, PharmD Student Cedarville University

We have often sought healthy and youthful complexions throughout history.  One way people have tried to prevent aging is by using creams and lotions to protect themselves from wrinkling and the damaging effects of the sun on the skin.1,2 Exposure to the harmful A and B ultraviolet components of sunlight is one of the leading causes of skin aging and skin cancer.3,4  One of the most common ways used to prevent the aging of skin from the sun is sunscreen.5

Recently, a news article from USA Today was published lauding the benefits of sunscreen based on a study issued in the Annals of Internal Medicine.6 The study, which followed hundreds of people over a four and a half year period, found 24% less skin aging in people who regularly applied sunscreen.7 The researchers studied people who were less than 55 years old because their skin-aging is primarily from the sun and not due to their age.  The study made replicas of the skin on the back of the subject’s hands in order to measure the deterioration of the skin at the beginning and end of the trial.  The study concluded that the regular use of sunscreen by young and middle-aged adults could slow down the aging of their skin from the sun.7

There are other studies that support the same opinion that sunscreen can limit the effects of aging from the sun.8,9  Studies have found sun exposure can damage skin and can be avoided by protecting oneself from harmful UV rays.10 The FDA also suggests that skin aging and cancer can be avoided by the use of sunscreen.11 The difference between this study and others is this particular one actually put those findings to the test in a large-scale trial examining many subjects over a long period of time.  The study was also completed in a sunny part of Australia that is as close to the equator as Florida.6

One of the limitations of the study was one-third of the people enrolled in the study only completed one reading of their skin, usually the first time.  Another limitation of the study could be the use of lotions or moisturizers by the subjects to protect their skin affecting how much it deteriorated over time.  Using less effective sunscreen than what is on the market today is also another limitation of the study.  More research needs to be done to see if newly developed sunscreens help even more with the aging of skin.  There are some studies that could suggest the chemicals in sunscreen could be harmful to the body.  One study found some ingredients in sunscreen to cause genetic damage in mice, but this has not been tested in humans.12 Another study found sunscreen use tied to increased free radicals in the body, which could lead to an increased risk for cancer.13

The trial had a solid study design, as it was a randomized, controlled, clinical trial.  Along with the study design, the location of the study and efforts by the researchers to make sure the people enrolled were complying with the design make the results even more pertinent.  Any study longer than the one in the article is unlikely to be implemented because it would be considered unethical to keep people from using sunscreen for such long periods of time.6

The practice of sun protection as laid out by the FDA includes reducing time in the sun, wearing appropriate clothing such as hats, long pants, sunglasses, and long sleeve shirts.11 Another recommendation is the use of sunscreen.  The sunscreen used should be at least 15 SPF, which is what was used in the study.  It is also recommended to use a water resistant and “broad spectrum” sunscreen that protects against the different types of UV radiation from the sun.  Make sure to apply it evenly to all exposed skin at least 15 minutes before going out and reapply at least every 2 hours.11

Protecting your skin from the sun is very important, not only for it’s appearance but also for preventing the risk of skin cancer.  Sunscreen is one easy way to protect your skin from both aging and cancer.  Studies have shown the effectiveness of sunscreen for protection against UV radiation.8 The study mentioned in the article delivers confirmation of the benefits regular use of sunscreen can have on the aging of your skin over a prolonged time period.

So, do you think this trial provides enough evidence for the beneficial effects of sunscreen? Or do you think sunscreen has too many harmful effects?  Does this evidence change your opinion on how you will use sunscreen in the future?

 

References

 

[1] Brandt FS, Cazzaniga A, Hann M . Cosmeceuticals: current trends and marker analysis. Semin Cutan M ed Surg. 2011;30:141-3. [PMID: 21925366]

 

[2] Yaar M , GUchrest BA. Aging of skin. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, et al, eds. Fitzpatrick’s Dermatology in General Medicine. 5th ed. New York: McGraw Hill; 1999:1697-706.

 

[3] Rabe JH, Mamelak AJ, McElgunn PJ, Morison WL, Sauder DN. Photoag- ing: mechanisms and repair. J Am Acad Dermatol. 2006;55:l-19. [PMID:

16781287]

 

[4] Foote JA, Harris RB, Giuliano AR, Roe DJ, Moon TE, Cartmel B, et al. Predictois for cutaneous basal- and squamous-cell carcinoma among actinically damaged adults. Int J Cancer. 2001;95:7-ll. [PMID: 11241303]

 

[5] Antoniou G, Kosmadaki MG, Stradgos AJ, KaKambas AD. Photoaging: prevention and topical treatments. Am J Clin Dermatol. 2010;l 1:95-102. [PMID: 20141230]

 

[6] Painter K.  Regular sunscreen use slows skin aging, study shows.  USA Today. June 3, 2013.

 

[7] Hughes MC, Williams GM, Baker P, Green AC. Sunscreen and prevention of skin aging: a randomized trial. Ann Intern Med. 2013;158(11):781-90.

 

[8] Gilchrest, B.A.  A review of skin ageing and its medical therapy. Br. J. Dermatol. 1996;135: 867–875.

 

[9] Naylor, M.F. & K.C. Farmer.  The case for sunscreens: a review of their use in preventing actinic damage and neoplasia. Arch. Dermatol. 1997;133: 1146–1154.

 

[10] Taylor CR, Stern RS, Leyden JJ, Gilchrest BA. Photoaging/photodamage and photoprotection. J Am Acad Dermatol. 1990;22(1):1-15.

 

[11] FDA. Sun safety: save your skin! FDA website. 2012 available at http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm049090.htm. Accessed October 1, 2013.

 

[12] Trouiller B, Reliene R, Westbrook A, Solaimani P, Schiestl RH. Titanium dioxide nanoparticles induce DNA damage and genetic instability in vivo in mice. Cancer Res. 2009;69(22):8784-9.

 

[13] Hanson KM, Gratton E, Bardeen CJ. Sunscreen enhancement of UV-induced reactive oxygen species in the skin. Free Radic Biol Med. 2006;41(8):1205-12.