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Self Care Pharmacy Blog

Archive for November, 2013

 

Medical Mobile Apps Not Enough to Replace Face-to-Face Consultation

Tuesday, November 26th, 2013

by Lauren Williams, PharmD student

Today’s use of mobile technology heavily influences and expands the way we interact and communicate with others. Not only has it provided us new ways to interact with our friends and family, but it is currently expanding patient access to medical advice and opening the way for innovative interactions with medical professionals. According to the Research2Guidance mobile research specialists, “500 million smartphone users worldwide will be using a health care application by 2015”.1 With the great ease of access to medical information and advice today, self-care is very prevalent. Are patients more likely to skip out on pharmacist consultation and doctor appointments to rely on their easily attained materials and video calls with physicians?

The article, “Study finds dermatology apps useful, but they can’t replace a doctor’s visit”, published by MedCity News, discussed a study on the use and availability of dermatology applications.2 After searching the Apple, Android, BlackBerry, Nokia and Windows app stores for products related to dermatology, researchers reported finding over 200 apps that offered its users medical material, treatment help and guidance to self-diagnosis concerning dermatology. Specifically, they give the users what they need to identify and treat dermatological concerns without having to consult with their pharmacist or visit their doctor. Although these apps increase user accessibility to medical information and advice, researchers are highly concerned that people may be getting the wrong information since only a few of these apps were clearly created by medical professionals. Their other concern was that some patients would value and grow confident in their app facts, and forego actually visiting the dermatologist. Despite these concerns, mobile apps are used not only by patients, but also by health care professionals. Because trusted professionals use these, the FDA has stepped into the picture and declared that they will regulate and set apart medical apps intended for the use of doctors.

I agree with the article that medical apps may be great sources to increase medical knowledge; however, we must approach them with skepticism, recommending users to cross-reference the information and consult with their pharmacist or doctor before beginning treatment options based on apps. I am comfortable with patients self-educating and treating on more minor topics, such as sunburn, but I believe that they should present to their doctor with any more serious concerns, such as a lumpy mole that has changed color, which could indicate melanoma. Common conditions, such as eczema, dry skin, contact dermatitis, insect bites, stings, head lice and sunburn can all be immediately self-treated or referred with consultation from a pharmacist. Pharmacists are easily assessable and qualified to identify self-care exclusion criteria with these dermatological conditions. Some conditions may easily be detected simply by viewing, but others may not be so simple since a biopsy, or other procedure, may be necessary for better understanding. Mobile apps cannot perform biopsies; they cannot give thorough follow-up examinations. Teledermatology, one of the most promising apps, has similar limitations.3 Although the patient and dermatologist evaluate via a live video call, the patient’s interpretation of symptoms may be different from the dermatologist’s interpretation. These mobile apps can only be used so much in self-treatment and self-examination, but they can continue to educate the user.

A study published by University of Florence’s Department of Dermatology asked the question “Is skin self-examination for cutaneous melanoma detection still adequate?” Researchers found that although the largest percentage, 36%, of found melanomas were results of a regular annual skin examination by a dermatologist, the next largest group, 33%, of found melanomas were by self-detection. Because these percentages were so close, one may think that self-detection is just as good as a visit to the dermatologist. This study also concluded “self-detection was associated with a greater probability of having a thick melanoma and, therefore, a poor prognosis (odds ratio 1.56)”. 4 Therefore, I believe that although self-detection with the aid of medical applications is beneficial, it is more beneficial and important to pay a visit to the dermatologist or seek immediate recommendation from a pharmacist.

Using mobile devices for self-care is different from the standard of care, but it is progressive, innovating, and exciting to try. We must always be cautious with any type of progression simply because it often takes us on an untraveled road to new outcomes, studies, and experiments. I believe that the utilization of mobile applications is a part of the natural movement of converging health practices with modern technology. Mobile technology is heavily integrated in our society, so it makes sense that patient care and medical advice is accessible by it.

The point of these applications is to increase medical knowledge, not to replace face-to-face interaction with a medical professional. Do you believe that the designers of these apps are aiming to increase medical knowledge, or to replace face-to-face interaction with a physician or pharmacist? How do you think patients will use them?

References

 [1] Mikalajunaite, E. 500m people will be using healthcare mobile applications in 2015. http://www.research2guidance.com/500m-people-will-be-using-healthcare-mobile-applications-in-2015/. Published November 10, 2010. Accessed November 12, 2013.

[2] Pittman, G. Study finds dermatology apps useful, but they can’t replace a doctor’s visit. http://medcitynews.com/2013/09/study-finds-dermatology-apps-useful-cant-replace-doctors-visit/. Published September 26, 2013. Accessed October 23, 2013.

[3] Brewer A, Endly DC, Henley J, et al. Mobile Applications in Dermatology. JAMA Dermatol. 2013;149(11):1300-1304. doi:10.1001/jamadermatol.2013.5517.

[4] De Giorgi, V., Grazzini, M., Rossari, S., Gori, A., Papi, F., Scarfi, F.,Gandini, S. Is skin self-examination for cutaneous melanoma detection still adequate? A retrospective study. Dermatology. 2012;225(1), 31-6. doi: 10.1159/000339774.

Vitamin B Supplements Can Lower Your Risk of Stroke

Tuesday, November 26th, 2013

by Jessica Amtower, PharmD student

Vitamin B supplements have been known for their many uses. For example, some B vitamins help cells burn fats and glucose for energy, while others help make neurotransmitters like serotonin.1 To get as much benefit as possible, it’s recommended that you need all of the B’s, but they are still beneficial alone. Some B vitamins have previously been noted to possibly lower the risk of stroke. According to the CDC, strokes are the leading cause of death in the United States, killing nearly 130,000 Americans each year—that’s 1 of every 18 deaths.2

CNN recently published an article stating that Vitamin B supplements could potentially help reduce the risk of a stroke.  The study promoting this information was published in the journal Neurology, where researches conducted a meta-analyses from the results of 14 clinical trials involving 54, 913 participants.3 The study concluded that patients taking a vitamin B supplement had a 7% reduced risk of stroke compared to those who were taking a supplement. This reduced risk of stroke was due to lowered homocysteine levels in the blood, which are associated with hardening and narrowing of the arteries as well as increased risk of heart attacks, strokes, and blood clot formation.4 Several meta-analyses have been published since 2010 looking at the effects of therapy to lower homocysteine levels with B vitamin supplementation on vascular disease risk. However, this new study included studies that were omitted from previous reports and adopted stricter inclusion criteria.5

According to an author of the study, Xu Yuming of Zhengzhou, University in Zhengzhou, China, previous studies have conflicting findings regarding the use of vitamin B supplements and stroke or heart attack.6 He states, “Some studies have even suggested that the supplements may increase the risk of these events.” While it was found that participants had a reduced risk of stroke, the supplements did not reduce the severity of the strokes or the risk of death.6 Scientists have admitted that more research needs to be done in the area, but many stroke specialists still feel this is a positive step forward.

Dr. Teshamae Monteith, an assistant professor of clinical neurology at the University of Miami School of Medicine says, “I think this is an exciting study, because we need more treatments for stroke. I believe safe options are necessary, but I don’t think people should start ingesting large amounts of Vitamin B to avoid strokes.” In light of the article background and information regarding supplements and stroke, I would agree with Dr. Monteith in that this is a step in the right direction, but we shouldn’t just start recommending it constantly. Although there is plenty of scientific literature stating that B vitamin supplementation for homocysteine reduction significantly reduced stroke events4, more research is required to solidify these findings. After further research on vitamin B supplements, I would personally recommend them. Vitamin B supplements are beneficial for health issues such as stress, anxiety, depression, dementia, Alzheimer’s disease as well as many others.6 According to the USDA, many Americans don’t get enough B vitamins, as deficiencies in folic acid, B12 and B6 are especially common.1 Many Americans are unaware of these deficiencies only because they are not currently presented in a physical ailment. B vitamin supplements are more helpful than most realize, and aren’t going to cause harm. Water-soluble B’s are found to be very safe. Patients should always check with their primary care physician before adding a dietary supplement to their medication regimens.

When searching for limitations within the research, it was rather difficult to find anything. Typically, with meta-analyses you would look for limitations such as sample size, study methods, or exclusion/inclusion criteria. This study had a rather large sample size of over 54,000 participants, ruling this out as being a possible limitation. The inclusion/exclusion criteria were very broad to include studies where vitamin B was shown effective and studies where it wasn’t. The only thing I can seem to find as a limitation is that B vitamin supplement has yet to be defined as a standard of care when dealing with reduction of the risk of stroke. Practitioners are unaware of any benefit due to it not being a standard of care.

With this newly discovered research, many patients are going to be asking questions about the safety and effectiveness of B vitamin supplements. If these supplements were to truly reduce the risk of stroke, would you take them on a regular basis? As a student pharmacist, and current intern, would you feel comfortable recommending this to patients?

References

  1. Challem J. The Benefits of B Vitamins. In Whole Living: Body and Soul in Balance. http://www.wholeliving.com/134086/benefits-b-vitamins. Published 2005. Accessed November 15,2013.
  2. CDC. Stroke Facts and Statistics. Center for Disease Control and Prevention. http://www.cdc.gov/stroke/facts_statistics.htm. Published October 16, 2012. Accessed November 15, 2013.
  3. Wadas-Willingham V. Vitamin B may lower stroke risk. CNN Health. http://thechart.blogs.cnn.com/2013/09/19/vitamin-b-may-lower-stroke-risk/. Published September 19, 2013. Accessed November 15, 2013.
  4. Yan J., et al. Vitamin B supplementation, homocysteine levels, and the risk of cerebrovascular disease: A meta-analysis. Neurology. September 18, 2013; 81(15):1298-1307. Doi: 10.1212/WNL.0b013e3182a823cc.
  5. Anderson P. Vitamin B Supplements May Lower Stroke Risk. Medscape: Medical Students. http://www.medscape.com/viewarticle/811260. Published September 18, 2013. Accessed November 15, 2013.
  6. Whiteman H. Vitamin B may reduce risk of stroke. Medical News Today. http://www.medicalnewstoday.com/articles/266247.php. Published September 20, 2013. Accessed November 15, 2013.

Exercise to Improve Back Pain

Tuesday, November 26th, 2013

By Gina Mattes, PharmD Student Cedarville University

Today almost 80% of  Americans have back pain, but often the treatments used are ineffective and costly. 1 However, there is another way that people can relieve back pain that is relatively cheap or free and you can do it right at home! Exercise is being proven to be more beneficial for your heart, but it’s also better for pain.1 In an article posted in The New York Times a study was cited that showed even going for a walk every day can help reduce back pain.1 This conclusion was made because there was no statistical difference between the exercise group and the walking group with significant improvement in walking distance from the beginning to the end in both groups.2 The six minute walk test was the main outcome for the study.  Both groups participated in a six-week program that was twice a week. Both groups started with 20 minutes during each session and increased by 5 minutes every week. The walking group spent time on a treadmill starting at a low intensity, increasing intensity, then had a cool down with low intensity at each session. The exercise group focused on active movement and strengthening exercises, beginning with a five minute warm up, low loaded exercise increasing the number of exercise repetitions over the course of the 6 weeks, and a five minute cool-down.2

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Another way to reduce chronic pain The New York Times article proposes is doing yoga. One study showed that yoga for short-term effectiveness helped tremendously, but only moderate outcomes for long-term effectiveness.3 The reason exercise has been helping rather than hurting is because you are strengthening the muscles in your back and abdomen, in doing this you are able to regain function of your back without pain because of the endurance your body has built up.2 In the study presented by the Clinical Journal of Pain Cramer and colleagues looked at 10 randomized clinical studies that collectively had 967 chronic back pain patients that showed strong evidence for short term relief and moderate evidence for long-term relief.3 There is no simple solution or usually a reason for back pain to be occurring, but even if there is no reason for the pain people don’t have to be in pain instead they can go for a walk and build up those muscles. I agree with this article. It’s easier and way cheaper to go outside and walk around the block a few times, going to the gym, or looking up youtube yoga videos to do some yoga and help yourself than taking medications that probably won’t help in the long run.

Studies have show that the standard of care for lower back pain such as steroid shots, has often  been ineffective for chronic pain. 3, 4 Additional evidence shows that people doing yoga to relieve chronic back pain is much more helpful.1,2,3  In a study done by Saper he came up with a 12 week hatha yoga program.5 The study included a 12 week yoga program with each session lasting about 75 minutes, led by a 2 year yoga expert.5 The program was broken up into four, three week segments with each week containing a different theme.5 The participants were strongly encouraged to practice yoga for 30 minutes each day, the participants were given all material needed to practice at home.5 Improvement was evaluated by questionnaires that participants filled out at 6 and 12 weeks of intervention.5 At the end the study showed that participants’ pain decreased resulting in the decrease of using pain medications and muscle relaxants.5 However, the study did have a high number of drop out rates and a low number of follow up at 26 weeks.5 Even with the issues of the study it still shows a significant difference in people who did a yoga program versus the people who did not.5

The increase in studies that exercise in some form helps chronic pain patients long-term are overwhelming. Even a short day trip in a study done in Japan where people went to an amusement park for the day had pain relief, but the relief quickly faded after that day.2,3 This study included several age groups and measured back pain at different times (10 minutes, 1 hour,and 3 hours after arriving), but had a low number of participants in the study making it more questionable.3 In light of this new evidence I would highly recommend to my patients to try and build those lower back and abdomen muscles by going for a walk or maybe even looking up a few easy exercises online instead of jumping to steroid shots. In the end walking around the block would likely be more beneficial to health holistically than medication therapy.

So which would you rather have, going for a walk every day or sitting in the doctor’s office waiting for a shot that may not have long term effectiveness?

References:

1. Reynolds, G. Alternatives for back pain relief. The New York Times. July 18, 2013:MM18. October 21, 2013 http://well.blogs.nytimes.com/2013/07/18/looking-for-alternatives-for-back-pain-relief/?_r=0

2.   Shnayderman I, Katz-Leurer M. An aerobic walking programme versus muscle strengthening programme for chronic low back pain: a randomized controlled trial. Clinical Rehabilitation [serial online]. March 2013;27(3):207-214.

3.   Centre for Reviews and D. A systematic review and meta‐analysis of yoga for low back pain (Provisional abstract). Clinical Journal Of Pain [serial online]. 2013;:450-460.

4.   Staal J, Nelemans P, de Bie R. Spinal injection therapy for low back pain. JAMA: The Journal Of The American Medical Association [serial online]. June 19, 2013;309(23):2439-2440.

5.   Saper R. Yoga for Chronic Low Back Pain in a Predominantly Minority Population: A Pilot Randomized Controlled Trial. Alternative Therapies In Health & Medicine [serial online]. November 2009;15(6):18-27.

6.   Sakakibara T, Wang Z, Kasai Y. Does going to an amusement park alleviate low back pain? A preliminary study. Journal Of Pain Research [serial online]. January 1, 2012;5:409-413.

Could There Be Another Reason to Get Hooked on Fish Oil?

Monday, November 25th, 2013

by Trevor Stump, PharmD student

Fish oil supplements have obtained an impressive track record within scientific literature for improving heart health and lowering triglyceride levels.1 However, the scope of the benefits of these supplements may expand further, as research has recently suggested that the anti-inflammatory effects of omega-3 fatty acids found in fish oil may reduce symptoms of macular degeneration.2 Age-related macular degeneration (AMD) results from damage to the cells of the macula, or central section of the retina, in the eye. This portion of the eye processes close up visual information, so as it deteriorates tasks such as reading or recognizing faces become strenuous. AMD comes in either a dry or wet form, and up to this point, there are no treatment options available for dry AMD. While the cause of the disease is not fully understood, researchers believe that both oxidative stress and inflammation play key roles in its progression.2 As scientists have developed an understanding of the body’s inflammatory response, they have recognized the importance of a certain class of inflammatory mediators known as resolvins, which decrease inflammation by limiting the production of both inflammatory cells and chemicals and inhibiting their transport to sites of inflammation. These mediators are produced through the breakdown of omega-3 fatty acids which are found in large quantities in fish oil supplements.3

A recent article in Natural Standard examines a pilot study conducted to examine the potential for the treatment of dry AMD with high doses of omega-3 fatty acids from fish oil supplements.4 The study, published in PharmaNutrition, gave patients daily high-dose omega-3 fatty acid supplements. The patients were then evaluated for visual acuity using an eye examination every six weeks for six months. The results showed that every patient examined showed at least one line of improvement by the end of the six month period with patients improving by an average of two lines.2 With a 100% improvement rate, this study demonstrates the promise that fish oil supplements provide for the treatment of dry AMD.  [1]

While this article certainly shows fish oil’s potential, the study has its fair share of limitations. The study is classified as a preliminary pilot study, thus it lacked many key aspects needed in a well-designed clinical trial. The researchers involved freely acknowledge these limitations, and explain that better controlled studies will be necessary to make any substantial claims. First, the study sample was too small to provide enough statistical power to get significant results. Furthermore this study did not include a placebo-control group, meaning the researchers had nothing to compare the experimental results to. In addition, the dosage of fish oil administered in this study was relatively high compared to the dosage available over the counter. Because there was such limited control, the conclusions drawn from this study are certainly restricted. As the researchers involved noted, there is a need for further research before any definitive conclusions can be drawn.  While several studies evaluate AMD symptom alleviation from dietary fish intake or fish oil in combination with other products, few if any studies examine fish oil supplements alone for the treatment of AMD. On top of this, up to this point the research that is available has produced inconclusive evidence.5,6,7 Because of the conflicting evidence, I am hesitant to support the claims in the article from Natural Standard. It appears that there is some promise for the use of fish oil in treatment for AMD, but the evidence is clearly insufficient at this point, and further research is necessary before healthcare providers can be confident in its effectiveness for this indication.

While the evidence for fish oil supplements in the treatment of AMD is certainly conflicting, fish oil has been found to have limited side effects, and very few if any serious side effects.8 Since there is no indicated treatment for dry AMD and these supplements have been shown to be well tolerated, the potential reward seems to greatly outweigh any risk involved. In light of this, I could understand the reasons a healthcare provider might recommend the supplement for alleviating dry AMD symptoms. Still, without solid evidence to back it up, any recommendation must be accompanied with patient education on the supplement in order to temper a patient’s expectations. Patients must understand that while the supplement will likely not harm them, it may not help them either. With no other treatment options available, the research behind this promising avenue for the treatment of dry AMD becomes even more important. As research continues, hopefully more conclusive evidence will be produced, giving healthcare providers a better understanding of what to expect from this product.

What do you think? Should healthcare providers recommend fish oil for AMD even though the research is inconclusive?

References

1. 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.

2. Georgiou T, Neokleous A, Nicolaou D, Sears B. Pilot study for treating dry age-related macular degeneration (AMD) with high-dose omega-3 fatty acids. PharmaNutrition. 2013. Accessed November 15, 2013.

3. Serhan CN, Hong S, Gronert K, et al. Resolvins: A Family of Bioactive Products of Omega-3 Fatty Acid Transformation Circuits Initiated by Aspirin Treatment that Counter Proinflammation Signals. Journal of Experimental Medicine. 2002;196(8):1025-1037. Accessed November 15, 2013.

4. Natural Standard. Omega 3 fatty acids may reduce symptoms of macular degeneration. Natural Standard. 2013. http://www.naturalstandard.com/news/news201311006.asp. Accessed November 15, 2013.

5.  Seddon JM, Cote J, Rosner B. Progression of age-related macular degeneration: association with dietary fat, transunsaturated fat, nuts, and fish intake. Arch Ophthalmol. 2003;121(12):1728-37. Accessed November 15, 2013.

6. Sangiovanni JP, Chew EY, Clemons TE, et al. The relationship of dietary lipid intake and age-related macular degeneration in a case-control study: AREDS Report No. 20. Arch Ophthalmol. 2007;125(5):671-9. Accessed November 15, 2013.

7. Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. JAMA. 2013;309(19):2005-15.

8. Villani AM, Crotty M, Cleland LG, et al. Fish oil administration in older adults: is there potential for adverse events? A systematic review of the literature. BMC Geriatr. 2013;13(1):41.

Vitamin D supplements do improve bone health

Sunday, November 24th, 2013

by Jacques Allou, PharmD student

Vitamin D is a fat-soluble vitamin that is naturally present in very few foods. It is available as a dietary supplement, and is also produced inside the body when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis.1

In the past decade, wonderful claims has been made about the role of vitamin D in the prevention and treatment of conditions as varied as osteoporosis, heart disease, cancer, diabetes, dementia, neuromuscular and immune function, and reduction of inflammation.1 Reports from authoritative bodies and reviews show that there is good consensus on the role of Vitamin D in growth and development of bone. Adequate supply of vitamin D is required for efficient calcium absorption and for the maintenance of normal blood levels of calcium and phosphate that are needed for the normal mineralization of bone and bone health.1,2 Not only does vitamin D promote bone growth, it does also protect against cardiovascular disease. In a study published on June 23 in the Archives of Internal Medicine, a team of Austrian scientists revealed that low blood levels of vitamin D appear to have an increased risk of death overall and from cardiovascular.3 A recent consensus panel estimated that about 50 – 60 percent of older individuals in North America and the rest of the world do not have satisfactory vitamin D status, and the situation is similar for younger individuals. Blood levels of vitamin D lower than 20 to 30 nanograms per milliliter have been associated with falls, fractures, cancer, autoimmune dysfunction, cardiovascular disease and hypertension.3   Vitamin D was the leader in dietary supplement sales in 2009, recording 82% sales growth.4

In this recent article by Fox News, Researchers have indicated that Vitamin D may actually do very little to guard against osteoporosis, contrary to popular belief.5 The researchers from the University of Auckland in New Zealand analyzed data from 23 studies involving 4,082 healthy adults with an average age of 59.6  In these studies, bone mineral density – the measure of bone strength and the amount of bone mineral present – was examined at five different sites in the body: lumbar spine, femoral neck, total hip, total body and forearm. They found that adults who took supplements of vitamin D for an average period of two years did not see any improvements in their bone health, apart from a small increase in bone density around their femoral neck.  However, the study authors believe such a small increase is unlikely to be clinically significant.6

I was surprised to learn that. I do not agree with the article because the study has some limitations. There could be a strong possibility that bone mineral density in middle-aged women is a poor predictor of who will eventually have osteoporosis as already suggested by Dr. Clifford.7 It could be that vitamin D and calcium need to be taken together, and that they help only when a person is really low on either or both. Researchers have shown that, even though calcium is the main bone health nutrient, its absorption in the gut and use by bone tissue is dependent on vitamin D. Therefore, regardless of the adequacy of calcium intake, poor vitamin D status will limit calcium absorption.8 This explains why interventions using combinations of calcium and vitamin D produce more consistent results than interventions based on calcium alone.9 The link between vitamin D and calcium has been known for decades, so studying vitamin D alone does not make it appropriate.

My self-care recommendation will not be changed, based on the above discussed limitations. When counseling patients, I will stress that calcium and vitamin D work synergistically, and that foods and supplements containing these nutrients should be eaten or taken regularly as part of a balanced diet.

Half of all people around the world are deficient in vitamin D and therefore at increased risk for serious and potentially fatal conditions.3 What will we do as pharmacists to protect the cardiovascular and bone health of our aging patients?

 

References

  1. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010. http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx   Assessed November 12, 2013
  2. European Food Safety Authority. Scientific Opinion of the Panel on Dietetic Products, Nutrition and Allergies on a request from the Association de la Transformation Laitière Française related to the scientific substantiation of a health claim on vitamin D and bone growth. The EFSA Journal (2008) 827, 1-10. http://www.efsa.europa.eu/en/efsajournal/doc/827.pdf Assessed November 12, 2013
  3. Dobnig H, Pilz S, Scharnagl H, et al. Independent Association of Low Serum 25-Hydroxyvitamin D and 1,25-Dihydroxyvitamin D Levels With All-Cause and Cardiovascular Mortality. Arch Intern Med. 2008;168(12):1340-1349. doi:10.1001/archinte.168.12.1340.
  4. Tousrounis C, Denneby C. Introduction to Dietary Supplements. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 17th Ed Washington DC, American Pharmacists Association Press; 2012: 955-956.
  5. Fox News. Vitamin D supplements do not improve bone health study finds. Fox News. http://www.foxnews.com/health/2013/10/14/vitamin-d-supplements-do-not-improve-bone-health-study-finds/ Published October 14, 2013. Assessed November 1, 2013
  6. Ian RR, Mark JB, Andrew G. Effects of vitamin D supplements on bone mineral density: a systematic review and meta-analysis. The Lancet. 2013; DOI: 10.1016/S0140-6736(13)61647-5.
  7. Shute N. More Evidence Against Vitamin D To Build Bones In Middle Age http://m.npr.org/news/Health/232028261. Published October 12, 2013. Assessed November 1, 2013
  8. Fleet JC, Schoch RD (2010) Molecular mechanisms for regulation of intestinal calcium absorption by vitamin D and other factors. Critical Reviews in Clinical Laboratory Sciences. 47, 4, 181-195
  9. Tang BM, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. The Lancet. 2007; 370, 9588, 657-666.

Effectiveness of Acupuncture on Allergy Treatment

Sunday, November 24th, 2013

By Yeseul Kim, PharmD student

Many people in the world are suffering from allergies and they want some relief from the symptoms whether they are mild or serious. Some are using OTC allergy medications, such as Allegra, Benadryl, and Claritin, for treatment. However, these OTC allergy medications can cause some side effects, such as drowsiness, dizziness, constipation, or dry mouth.1 Therefore, people often try another treatment like acupuncture which may have fewer side effects than OTC medications. According to National Center for Complementary and Alternative Medicine (NCCAM), this therapy originally came from Asian countries and has been studied for over a thousand years for a wide range of conditions.2

The article, “Acupuncture may be antidote for allergies”, from CNN Health, deals with treating allergy patients with the therapy of acupuncture.3 Since some patients have already adopted the acupuncture method for relieving pain, one study tried to evaluate the effect of acupuncture on patient’s allergies. The researchers divided allergy patients into three groups.4 The first group received acupuncture treatments with antihistamines as needed, the second group received fake acupuncture treatments with antihistamines as needed, and the third group did not receive any acupuncture, and only took antihistamines for treatment.4

The study results showed some effectiveness of acupuncture for allergy treatment. The first group took less antihistamines and showed improvement in symptoms.4 There is a placebo effect also as shown in second group, in which some patients improved with fake acupuncture.4 Based on improvement seen in this study, I agree with and support the use of acupuncture in addition to antihistamines for allergy treatment. Another study found similar results and helps increase the validity of this study. The 2008 Berlin allergic rhinitis acupuncture study concluded that “the result of this trial suggests that treating patients with allergic rhinitis in routine care with additional acupuncture leads to clinically relevant and persistent benefits.”5

Although the study reported a higher quality of life for allergy patients after acupuncture treatment, there are some limitations to the study. The researchers noted, “We found that acupuncture led to statistically significant improvements in disease-specific quality of life and antihistamine use after eight weeks of treatment compared with sham acupuncture and with antihistamine alone, but the clinical significance of the findings remains uncertain.”6 Also, acupuncture was less effective on severe allergy symptoms. If patients with severe allergies do not get relief from OTC medication or acupuncture, they may want to try prescription products for their allergies.

Another study, Effect of Acupuncture in the Treatment of Seasonal Allergic Rhinitis: A Randomized Controlled Clinical Trial, found a significant improvement in nasal and non-nasal symptoms between the two types of acupuncture treatments.7 The study concluded at the end that “no side effects were observed for both groups. The results indicate that acupuncture is an effective and safe alternative treatment for the management of Seasonal Allergic Rhinitis.”7

I want to recommend acupuncture therapy with use of antihistamines for allergy patients, even though this is different from the standard of care. The current standard of care is taking antihistamines only for treatment. Several studies have found a positive result in treating allergies and acupuncture is a safe treatment as reported side effects are rare. Acupuncture treatment also contains some placebo effect which I believe is another important mechanism in patient treatment. A positive state of mind largely influences the improvement of symptoms  

Through various research, the efficacy of acupuncture on allergies is proven, but some are still questioning the exact scientific mechanism of how the acupuncture works. Some patients will get better with acupuncture but others will not.  We should think about “What are the factors that can lead to less effectiveness?” and “Should we recommend an acupuncture treatment for a patient before recommending OTC medications to a patient?”

References

 

1. Berardi RR, Kroon LA, McDermott JH et al. Handbook of nonprescription drugs, an interactive approach to self-care. APhA Publications; 2006.

2. Acupuncture: An Introduction. National Center for Complementary and Alternative Medicine Web Site. http://nccam.nih.gov/health/acupuncture/introduction.htm. Updated 2012. Accessed October 30, 2013.

3. Sifferlin A. Acupuncture may be antidote for allergies. CNN.com Web Site. http://www.cnn.com/2013/02/19/health/acpuncture-allergies/. Updated 2013. Accessed October 29, 2013.

4. Benno Brinkhaus, Miriam Ortiz, Claudia M. Witt, Stephanie Roll, Klaus Linde, Florian Pfab, Bodo Niggemann, Josef Hummelsberger, András Treszl, Johannes Ring, Torsten Zuberbier, Karl Wegscheider, Stefan N. Willich; Acupuncture in Patients With Seasonal Allergic RhinitisA Randomized Trial. Annals of Internal Medicine. 2013 Feb;158(4):225-234.

5. Louis PF. Banish allergies with acupuncture: Here’s how. Naturalnews.com Web Site. http://www.naturalnews.com/040305_allergies_acupuncture_studies.html. Updated May 13, 2013. Accessed October 30, 2013.

6. Radford B. Acupuncture for Allergies? Jury’s Still Out. Discovery.com Web Site. http://news.discovery.com/human/health/acupuncture-for-allergies-jurys-still-out-130222.htm. Updated 2013. Accessed October 30, 2013.

7. Xue C, English R, Zhang J, da Costa C, Li C. Effect of Acupuncture in the Treatment of Seasonal Allergic Rhinitis: A Randomized Controlled Clinical Trial. American Journal Of Chinese Medicine [serial online]. January 2002;30(1):1. Available from: Academic Search Complete, Ipswich, MA. Accessed October 31, 2013.

Hand Sanitizer: Effective or Toxic?

Saturday, November 23rd, 2013

by Joseph Newman, PharmD student

Hand sanitizer is often used as a quick and convenient alternative to washing your hands. Whether it is a quick squirt after leaving the gym or the super market, or pulling it out after shaking lots of hands or coughing, it has become one of the most common ways to clean hands and get rid of germs. But is using all of this hand sanitizer actually preventing you from getting the flu or a cold? Is it any more or less effective when compared to washing with soap and water?

In his recent article1 on CNN, Bob Barnett evaluates the use of hand sanitizer and suggests that there are safety and efficacy concerns for hand sanitizers containing triclosan. Barnett states that according to Allison Aiello, an associate professor of epidemiology at the University of Michigan, there is no evidence that products containing triclosan have any benefit and that hospitals won’t use them. He goes on to cite other sources saying that there is little benefit of triclosan-containing products over washing with soap and water. Barnett claims that triclosan can disrupt the endocrine system and reduce muscle strength, as shown in animal studies. He also claims that triclosan does not protect against viruses and fungi. Barnett makes the distinction that alcohol-based hand sanitizers are good at killing bacteria and some viruses and can be used as an alternative to hand washing, but concludes by emphasizes the fact that washing with soap and water is the most effective way to eliminate germs.

I agree with most of this article. According to the World Health Organization, hand washing is “the most important hygiene measure in preventing the spread of infection.”2 I also agree that alcohol-based hand sanitizer is a good idea if you can’t wash your hands. Barnett’s recommendation for hand washing and alcohol-based hand sanitizer is one that is consistent with the standard for self-care in regards to hand hygiene. However, there are some limitations to his article, especially in his evaluation of triclosan-containing products. For one, he only cites a couple different sources. His claims of potentially harmful effects of triclosan and its limited effectiveness cannot be backed up without further research. Furthermore, Barnett says that studies support his claims, but then fails to provide information about or references to those studies.

Upon further research, I found that alcohol-based hand sanitizers are an “appropriate alternative to hand washing for hand cleansing”3 and that they improve hand hygiene practices within the home setting.4 Another study showed that alcohol-based hand sanitizers are safe. In this study, volunteers applied hand-rubs with varying amounts of ethanol onto their hands before being tested for blood concentrations of ethanol and acetaldehyde. According to the study, any alcohol absorbed through the skin was below toxic levels in humans.5 This supports Barnett’s claim that alcohol-based hand sanitizers can be safe and effective. As far as triclosan containing hand sanitizers, the FDA states that triclosan is not known to be hazardous to humans6 and according to one study, is “well tolerated by a variety of species, including human beings.”7 According to this research, it appears as though triclosan is not toxic, contrary to the research that Barnett refers to in his article.

Hand sanitizers that are alcohol-based appear to be safe to use as well as effective at promoting hand hygiene and preventing some illnesses, and while triclosan appears to be non-toxic, there was not very much research available on the effectiveness of hand sanitizers containing that ingredient. So what does this mean for me and you in terms of using these products to prevent colds, the flu and other common diseases? As a pharmacist, these types of questions come up often when discussing over-the-counter treatment of colds. Alcohol-based hand sanitizer can be a very useful tool in self-care of colds to prevent the transmission of germs while on-the-go. However, washing your hands is still the most important measure in preventing the spread of infection.2

So what do you think? Should we continue to use hand sanitizer? Should we switch to only soap and water? Or do you think there should be more research done on this issue?

 

References:

  1. Barnett, B. Is hand sanitizer toxic? CNN. October 16, 2013. Available at http://www.cnn.com/2013/10/16/health/hand-sanitizer-toxic-upwave/index.html?hpt=he_bn3. Accessed November 13, 2013
  2. Hospital Infection Control Guidance. World Health Organization Web site. 2003 Available at: http://www.who.int/csr/surveillance/infectioncontrol/en/print.html. Accessed November 13, 2013
  3. Vessey J, Sherwod J, Warner D, Clark D. Comparing Hand Washing to Hand Sanitizers in Reducing Elementary School Student’s Absenteeism. Pediatric Nursing [serial online]. July 2007;33(4):368-372. Available from: Consumer Health Complete – EBSCOhost, Ipswich, MA. Accessed November 14, 2013
  4. Sandora TJ, Taveras EM, Shih MC, et al. A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home. Pediatrics. 2005;116(3):587-94. Available at http://pediatrics.aappublications.org/content/116/3/587.long. Accessed November 14, 2013
  5. Kramer A, Below H, Bieber N, et al. Quantity of ethanol absorption after excessive hand disinfection using three commercially available hand rubs is minimal and below toxic levels for humans. BMC Infect Dis. 2007;7(1):117. Available at http://www.biomedcentral.com/1471-2334/7/117/. Accessed November 14, 2013
  6. Consumer Updates > Triclosan: What Consumers Should Know. Federal Drug Administration Website. August 29, 2012. Available at http://www.fda.gov/forconsumers/consumerupdates/ucm205999.htm. Accessed November 14, 2013
  7. Bhargava H, Leonard P. Triclosan: Applications and safety, American Journal of Infection Control, Volume 24, Issue 3, June 1996, Pages 209-218, ISSN 0196-6553, Available at http://www.sciencedirect.com/science/article/pii/S0196655396900176. Accessed November 14, 2013

Acupuncture: Treatment for Depression?

Saturday, November 23rd, 2013

by Eric Huseman, Pharm D student

The practice of inserting needles into the body, known as acupuncture, has long been used in China and Japan and is implemented in a variety of styles including classical/tradition acupuncture, trigger point acupuncture, and single point acupuncture.1 An article recently published in Express, a UK based news source, reports that acupuncture may show potential for treating anxiety and depression, offering a new source of hope to those suffering from these mental ailments.2 According to the article’s author, Laura Milne, acupuncture can help reduce anxiety because, as shown in prior research, it acts on parts of the brain known to decrease sensitivity to pain and stress and also serves as a relaxation promoter and a way of deactivating an area of the brain responsible for anxiety and worry, an area referred to in the article as the “analytical brain.”2 However, despite this potential for relief, according to a study conducted by the British Acupuncture Council and Anxiety UK, only ten percent of those suffering from anxiety look to acupuncture for relief.2

While the article itself does not provide much evidence supporting acupuncture’s usefulness in treating anxiety and depression, the British Acupuncture Council’s website (the link to which was provided by the Express article) provides a wealth of information concerning acupuncture and its use in treating a variety of diseases, including depression.3 According to the Council’s fact sheet on depression, some current evidence supports the use of acupuncture as adjunctive or stand-alone therapy for depression, but the current evidence cannot justify the recommendation of acupuncture as stand-alone therapy.4 The Council’s fact sheet also contains numerous summaries of systematic reviews and clinical trials examining the effectiveness of acupuncture in alleviating depression.5

One article examining the efficacy of acupuncture in the treatment of depression is a 2010 Cochrane review by Smith et al titled “Acupuncture for depression.”1 This review included and analyzed thirty separate trials examining the use of various types of acupuncture in the treatment of depression. This review found several instances of evidence that supported the effectiveness of acupuncture either in comparison to a control or as an adjunct to medication therapy.1 However, as acknowledged by the authors, the majority of the trials included in the review carried a high risk of bias.1 The authors concluded that the evidence was not sufficient to demonstrate acupuncture’s benefit over various controls or as an addition to mediation therapy.1 They ended the article by calling for further studies to be conducted using higher quality methods and procedures.1

In evaluating the article written in Express, the information found on the British Acupuncture Counsel’s website, and the review conducted by Smith et al, I do not disagree with the premise that acupuncture may provide a way of alleviating depression. However, I find myself in agreement with Smith et al that I am not yet convinced that acupuncture is a proven method of alleviating depression either as a stand-alone therapy or as an adjunct to medication therapy. As such, I would not feel confident telling my patients that acupuncture would definitely relieve their depression. However, I do not think that pharmacists should hesitate to inform their patients of acupuncture’s potential to help treat their depression as long as they counsel patients not to discontinue their usual course of depression treatment.

As health-care providers, pharmacists should be willing to learn and accept new forms of treatment outside the standard of care when provided with sufficient evidence to do so. Though research has not definitively determined the merit of acupuncture in treating depression, research has show St. John’s Wort to be an effective form of alternative therapy for patients suffering from mild to moderate depression.6 Unfortunately, because St. John’s Wart interacts with numerous medications, including drugs often prescribed for depression such as paroxetine (Paxil®) and sertraline (Zoloft®), the pharmacist must be cautious in recommending it to a patient.6 For patients seeking a more “natural” approach to tradition antidepressant medications, however, St. John’s Wart may be a viable treatment option as long as the pharmacist ensures the patient is not taking any medications that would may interact with this natural product

While one would need to conduct a more thorough review of published literature regarding acupuncture and depression to form a truly authoritative position regarding the use of acupuncture in treating depression, discussing the place of acupuncture and other nontraditional forms of care such as St. John’s Wart in the treatment of depression nevertheless requires pharmacists to take a closer look at alternative methods of medical practice and self-care, respectively. While the pharmacist should certainly evaluate such modes of treatment critically, he or she must constantly accompany this evaluation with the following question: “Am I allowing the evidence to guide my recommendations, or am I letting my preconceived notions of alternative methods of care, whether positive or negative, unduly influence my thoughts?” While providing an honest answer to this question may prove convicting, evaluating all treatment options with as little bias as possible will ultimately result in the best possible patient outcomes.

 

References

  1. Smith C, Hay P, MacPherson H. Acupuncture for depression. Cochrane Database Of Systematic Reviews [serial online]. November 11, 2009;(1)Available from: Cochrane Database of Systematic Reviews, Ipswich, MA. Accessed November 6, 2013.
  2. Milne, Laura. Acupuncture offers new hope in treating depression and anxiety. Express Web site. Available from http://www.express.co.uk/life-style/health/435324/Acupuncture-offers-new-hope-in-treating-depression-and-anxiety. Published October 9, 2013. Accessed November 5, 2013.
  3. Home page. British Acupuncture Council Web site. http://www.acupuncture.org.uk. Accessed November 19, 2013.
  4. Depression: Intro. British Acupuncture Council Web site. Available from http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/depression.html. Last modified December 2, 2013. Accessed November 6, 2013.
  5. Depression: The evidence. British Acupuncture Council Web site. Available from http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/depression.html. Last modified December 2, 2011. Accessed November 6, 2013.
  6. Krinsky D et al. Handbook of Prescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2012.

 

Saturated Fat Not Harmful?

Friday, November 22nd, 2013

By Megan Buck, PharmD Student Cedarville University

In 1970, Ancel Keys’ “seven countries study” correlated the incidence of coronary heart disease and total cholesterol concentrations then observed a correlation between heart disease and saturated fat.1  Due to this study, saturated fat has been held responsible for cardiovascular risks.  Since then, scientists have reviewed several studies and examined the differences between types of fats and cholesterols.  New scientific evidence suggests that the last forty years of convincing people to remove saturated fat from their diets actually increased their cardiovascular risks.2

Aseem Malhotra of Croydon University Hospital in London recently published an article explaining this discovery.  “Saturated Fat Is Not the Major Issue” describes the importance of saturated fat in the diet.  Consuming saturated fat is not harmful, but we should be concerned with overmedicating with statin drugs.2 3  A diet consisting of a maximum of 10% of total nutrients coming from saturated fat has not be proven efficient at reducing cholesterol or reducing cardiovascular risks.  Saturated fat produced large and light-weight (Type A) LDL particles rather than the small and heavy (Type B) particles, the later are likely responsible for cardiovascular disease.2  Also, Malhotra states that studies found processed meats contribute more to coronary heart disease than dairy products and red meat.  Kewick and Pawan’s study showed that a group with a 90% fat-consuming diet lost more weight than groups with 90% protein and 90% carbohydrates, indicating that fat does not have to be terrible in the diet.  Fat-free food is not necessarily healthy because the saturated fat is often replaced with sugar, which is being investigated for lowering HDL cholesterol.  Statins are very popular in the US and UK, partially because the Framingham heart study claimed total cholesterol was a risk factor for coronary artery disease.2

I agree with Aseem Malhotra’s article; he supports his point with the literature.  My search of the literature also yielded a recent meta-analysis and a systematic review that support Malhotra’s conclusion that saturated fat is not the major issue.  Patty W Siri-Tarino et al. performed a meta-analysis to see how reducing saturated fat influenced coronary heart disease (CHD), stroke, and cardiovascular disease and concluded that saturated fat does not increase CHD or cardiovascular disease.The discussion of statin therapy is beyond the scope of this post, however the decision to take a statin should be discussed with a medical provider, some patients may still benefit from a statin if they have already had a heart attack.

A patient can eat foods containing cholesterol without getting a heart attack.5  For example, even though egg yolks have cholesterol, they have thirteen essential nutrients, so they should not be automatically eliminated from the diet.  However, it is noteworthy that people typically do not consume only one nutrient per meal.  Saturated fat should be consumed in context of a balanced meal.  Our bodies crave different foods because of the nutrients in them.  Strictly limiting a person to a diet of a few items would not be my primary recommendation for my patients.

This information will slightly change my self-care recommendation because it differs from the dietary standard of care.  If you have high cholesterol and high cardiovascular risk, you may eat saturated fats, dairy products and red meats but should minimize or avoid intake of trans fats and processed meats.  Red meats are not even particularly high in saturated fat.6  O’Sullivan et al. conducted a meta-analysis which demonstrates that large consumptions of the fat-containing foods of butter, cheese, yogurt, and milk “were not associated with a significantly increased risk of mortality compared” with small consumptions.7  Fat-free foods may not be a better choice than regular-fat foods containing saturated fat because the saturated fat is often replaced with sugar.2  Scientists are currently investigating whether sugar leads to low amounts of the “good” HDL cholesterol and raised triglycerides, or fat in the blood.If you have high blood pressure, I encourage you to limit your caffeine intake.

High cholesterol does not appear to increase risk risk for heart disease.  High cholesterol may be falsely accused for heart disease, further studies need to be identified to determine if statins or any cholesterol lowering therapy is beneficial when targeting cholesterol numbers alone.  Involving the patient in discussion of therapy and treating the whole patient vs. numbers from a holistic approach may be more fruitful.

Does this study affect your current perception of treating high cholesterol?  How would you counsel your patients with high cholesterol after reading this post?  What other foods should be avoided in patients with increased cardiovascular risks?

 

References

  1. Available at: http://www.epi.umn.edu/cvdepi/study.asp?id=12. Accessed November 12, 2013.
  2. Malhotra A. Saturated Fat Is Not the Major Issue. BMJ. 2013;347(oct22 1):f6340. Accessed November 1, 2013.
  3. Available at: http://www.medterms.com/script/main/art.asp?articlekey=33979. Accessed November 2, 2013.
  4. Siri-tarino PW, Sun Q, Hu FB, Krauss RM. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr. 2010;91(3):535-46.
  5. Kresser C. The Diet-Heart Myth: Cholesterol and Saturated Fat Are Not the Enemy. Available at: http://chriskresser.com/the-diet-heart-myth-cholesterol-and-saturated-fat-are-not-the-enemy. Accessed November 5, 2013.
  6. Kresser C. New Study Puts Final Nail in the “Saturated Fat Causes Heart Disease” Coffin. Available at: http://chriskresser.com/new-study-puts-final-nail-in-the-saturated-fat-causes-heart-disease-coffin. Accessed November 5, 2013.
  7. O’Sullivan T, Hafekost K, Mitrou F, Lawrence D. Food Sources of Saturated Fat and the Association With Mortality: A Meta-Analysis. American Journal Of Public Health [serial online]. September 2013;103(9):e31-e42. Available from: Business Source Complete, Ipswich, MA. Accessed November 1, 2013.

Another possible health benefit to taking Aspirin?

Wednesday, November 20th, 2013

By Brittany Santee, PharmD Student, Cedarville University

Aspirin is one of the most used drug worldwide, and this usage has been going on for centuries. It is most known for treating pain, inflammation, and cardiovascular disease.1 Aspirin has been used by many because of it’s ability to reduce the chance of having a heart attack due to it’s anti-platelet activity.2 The American College of Chest Physicians recommends people who reach 50 years old or older who do not have cardiovascular disease should take a daily low dose aspirin.3 But this might not be the only way aspirin can save lives.

Recently Yahoo News posted an article about a study done in Sweden published by the British Journal of Cancer.4 The study looked at how low dose aspirin use affects cancer characteristics. Colorectal, lung, prostate, and breast cancer patients were studied and their cancer progression was recorded as well as if they regularly used aspirin. The patients’ tumor size and progression were then compaired based on regular aspirin use.5

There are some considerations to take when thinking about taking aspirin daily. First, it interacts with the absorption of many vitamins and food substances. Alcohol should not be taken with this medication. If any kind of heart medication is taken, a primary care physician should be consulted because many of these interact with aspirin both in how it is absorbed and how it works. Aspirin may cause stomach ulcers or stomach pain in 6 to 31% of patients.6

So now the question is whether the study done shows enough evidence to start taking a daily dose of aspirin. Looking at the data for metastasis in the lung cancer, it would take treating around 14 people with low dose aspirin to have no distant metastasis (M0) instead of presenting with cancer that has spread to other areas of the body(metastasis-M1). Overall there was around a 20-30% reduction in the odds of metastasis among aspirin users across lung cancer.  The data from the colorectal cancer is very similar.5 The evidence is less clear with hormone based cancers such as prostate and breast cancer, in these patients the study actually shows that tumor progression and tumor size were greater in the patients who were on a low dose of aspirin.  This finding was not statistically significant and compounded by low sample size in the aspirin users group.5 Overall the evidence presented is not something to panic about, further studies are needed to determine if low dose aspirin effects tumor progression and metastasis.

Studies have consistently found aspirin to be beneficial in many different health conditions, but the problem with aspirin is that there are can be serious side effects if it is not used carefully under medical supervision. This limits the studies done because aspirin can’t be given to certain groups in the population. In general the scientific community is aware of the wide range of health benefits that come from regularly taking aspirin. Because the lack of evidence from this study, I would not recommend taking a daily dose of aspirin to lower the risk of tumor progression.

 

References

 

1. Fuster V, Sweeny J. Aspirin: A Historical and Contemorary Therapeutic Overview. 2011. 123(7): 768-778. Avaliable from: http://circ.ahajournals.org/content/123/7/768.full.pdf+html. Accessed October 27, 2013.

2. Centre for Reviews and D. Collaborative meta‐analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients (Structured abstract). Bmj [serial online]. 2002;324:71-86. Available from: Database of Abstracts of Reviews of Effects, Ipswich, MA. Accessed November 18, 2013.

3. Guyatt GH, Akl EA, Crowther M, et al, “Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines,” Chest, 2012, 141(2 Suppl):7-47.

4. Aspirin tied to smaller lung and colon cancer tumours. Yahoo News[serial online]. August 21, 2013:Available from: http://news.yahoo.com/aspirin-tied-smaller-lung-colon-cancer-tumors-130628628.html. Accessed October 27, 2013.

5. Jonsson F, Yin L, Lundholm C, Czene K, Pawitan Y, Smedby K. Low-dose aspirin use and cancer characteristics: A population-based cohort study. British Journal Of Cancer [serial online]. October 1, 2013;109(7):1921-1925. Available from: Scopus®, Ipswich, MA. Accessed October 27, 2013.

6. Lexi-Comp, Inc. (Lexi-DrugsTM). Lexi-Comp, Inc.; November 1, 2013.

7. Berardi RR, Kroon LA, McDermott JH et al. Handbook of nonprescription drugs, an interactive approach to self-care. APhA Publications; 2006.