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Self Care Pharmacy Blog

Archive for November, 2013

 

Dietary Supplements: Encourage or Evict?

Monday, November 18th, 2013

by Elizabeth Ledbetter

The Children’s Hospital of Philadelphia (CHOP) declared in early October 2013 that it will ban most dietary supplements from its pharmacy.1 This is because the U.S. Food and Drug Administration (FDA) does not regulate these products in the same way that they regulate prescription drugs. Because the safety and efficacy of dietary supplements have not been clinically tested by the FDA and cannot be guaranteed, CHOP is doing what they call a “clean sweep” in their pharmacy. They will continue to carry only a select few key vitamins, minerals, and amino acids that have been verified by the U.S. Pharmacopeia Convention (USP).1  

It is difficult to argue with the stance that this hospital is taking because their motivation is respectable. They do not want to recommend products to their patients that have not been thoroughly tested for safety and efficacy. Unfortunately, the decision seems to be a bit rash, and I agree with the author when she writes, “…any approach to healing or prevention should be integrative, malleable, and cautiously open-minded.”1 CHOP seems to be taking a closed-minded approach as they essentially eliminate the potential for disease treatment and prevention through supplements.  In my opinion, dietary supplements do not need to be evicted from our pharmacies just because the same prescription drug tests are not being performed on these products.  Adverse events related to dietary supplements are not near as numerous as those related to prescription drugs.  There were 489 adverse events related to dietary supplements reported in the 2012 fiscal year compared with over 300,000 adverse events related to prescription drugs.2,3

I have worked as a technician in a community pharmacy for two years, and I consistently see a large number of customers purchasing dietary supplements.  I will be the first to admit that I do not believe these customers are doing aimless supplement shopping. When I have encountered patients who need help finding a dietary supplement on the shelf they will inquire, “My doctor told me to purchase some ____________. What aisle is it in?” or, “I’ve been doing some research on __________. Do you carry that here?”  Most often, when a customer is purchasing a dietary supplement, he or she is making the final product choice.  I believe that this responsibility motivates customers to do research on dietary supplements and talk to their doctor about potential benefits and risks.

The stance that CHOP has taken on dietary supplements does not change the recommendations I will make in the future.  CHOP’s stance does, however, motivate me to do thorough research on commonly recommended supplements before I am in the position to make a professional recommendation.  I will be happy to make research-grounded recommendations as a pharmacist, yet I will also remind my patients that they need to be cautious when using dietary supplements because the risks and side effects are not known as well as those of prescription drugs.

Although I disagree with the stance that CHOP has taken in banning dietary supplements, there is evidence that supports the thoughts behind their reasoning. In regards to the concern of regulation, admittedly, dietary supplements have no pre-market approval process.4 They may be freely sold until the FDA objects as a result of adverse event reporting.4 The FDA even states on their website, “Generally, manufacturers do not need to register their products with FDA or get FDA approval before producing or selling dietary supplements.”5 In addition, CHOP decided to ban dietary supplements because their safety and efficacy cannot be guaranteed.  One study that examined clinical study reports suggests that the common dietary supplement dehydroepiandrosterone (DHEA) might even be harmful, as it has shown to lead to increased breast cancer risk in postmenopausal women.6 This study reinforces the threat of potential health risks associated with dietary supplements.

I cannot help but agree with the author of this article when she writes, “It baffles me that the same serious [pharmaceutical research] is not given to natural alternatives, which stand not only to help but may also do less harm.”1 Although we still lack the research necessary to recommend dietary supplements with 100% confidence, it is impossible to ignore the potential benefits they could have in preventing disease. So what is the best option: should pharmacies move toward eliminating their dietary supplement sections?

 References

1 Imus D. Is Philadelphia hospital’s ban on supplements a slippery slope? Fox News. October 23, 2013.  Available at: http://www.foxnews.com/health/2013/10/23/is-philadelphia-hospital-ban-on-supplements-slippery-slope/. Accessed October 31, 2013.

2 U.S. Food and Drug Administration. Number of mandatory adverse event reports from the dietary supplement industry entered into CAERS in the month. 2012. Available at: http://www.accessdata.fda.gov/FDATrack/track?program=cfsan&id=

CFSAN-OFDCER-Number-of-mandatory-adverse-event-reports-from-dietary-supplement-industry-entered-into-CAERS. Accessed November 15, 2013.

3 U.S. Food and Drug Administration. FAERS Patient Outcomes by Year. June 30, 2012. Available at: http://www.fda.gov/drugs/guidancecomplianceregulatory
information
/surveillance/adversedrugeffects/ucm070461.htm. Accessed November 15, 2013.

4 Borneman J. The Regulation of Homeopathic Drugs as Complementary and Alternative Medicine Products: The Role of the Homeopathic Pharmacopoeia of the United States. American Journal Of Homeopathic Medicine [serial online]. Winter2007 2007;100(4):258-264. Available from: Alt HealthWatch, Ipswich, MA. Accessed October 29, 2013.

5 U.S. Food and Drug Administration. Dietary Supplements. August 28, 2013. Available at: http://www.fda.gov/Food/DietarySupplements/default.htm. Accessed October 31, 2013.

6 Stoll B. Dietary supplements of dehydroepiandrosterone in relation to breast cancer risk. European Journal Of Clinical Nutrition [serial online]. October 1999;53(10):771-775. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed October 30, 2013.

Older Persons in Rural Areas Prefer Self Care

Monday, November 18th, 2013

By Jessica Davis, PharmD Student at Cedarville University

Many older adults live in the same areas that their parents and grandparents and many generations before them have lived. During the time that these families have lived there, many traditions have been passed down to younger generations, including practices of self care and thoughts about health care providers. Research has shown than many older adults believe that they can treat an illness themselves, or that their behaviors determined their health (1). One reason that older adults turn to self care instead of health care professionals is that their “perceptions about health contain components which most medical professionals would not take into account.“ (2)

This article explains the findings of a research study that looked at the preference of older adults in rural areas and what they believed about their ability to treat themselves. Surprisingly, nearly 60% of those who were surveyed said that they could control their health by their own actions, and nearly 20% of those surveyed said that they could treat an illness without any other help from a health care provider. (1) Many of those surveyed turned to vitamins, supplements, home remedies and other self care therapies in order to care for themselves. The survey did not show what motivations were behind using these methods, but other research shows that the reasons why older patients turn to self care methods are because “a positive valuation of complementary treatment, the ineffectiveness of orthodox treatment for their complaint, concern about the adverse effects of orthodox medicine, concerns about communication with doctors and, of less importance, the availability of complementary medicine. “ (3) This article says that health care providers need to learn more of these tactics in order to better help those patients who believe modern health care will not work for them, or to warn the patient of possible side effects to their own self care therapies. (4)

I would recommend that health care providers keep an open mind and look into any self care methods that a patient would like to try. Another research study reported patients use “health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life.” (4) The findings of one research study showed that many healthcare providers do not know or understand the perceptions of health that many older rural adults believe. (2) This article also emphasizes the importance of health care providers knowing and understanding the use of alternative self care options by older rural patients.

I do agree with this article that older patients may want to use home remedies and other aspects passed down to them from previous generations, and that this often happens more with older patients than younger patients. Many older patients do not like going to a physician or taking medications, but that they do see the need for it. I do agree with the article in the thought that when a health care provider is faced with a patient who wishes to use a home remedy or a nonprescription drug therapy, that the health care provider should do the research and learn how to incorporate this in the best way possible to treat the patient or thoroughly explain to the patient about why the self care therapy would not work. I will think about this more when making recommendations to patients. Alternative options to medications may work better for what the patient believes, but I would also explain what medication options they could also use.

The most important point to take away from this articles and the research done in this field is that if a patient wants to use a method of self care, that they should fully describe the method to their health care provider to make sure that it will not interact poorly with their prescription medications or with their disease states.

When discussing self-care options with your health-care provider, what should you be asking them about the “home remedies that you use? Here are a few points that you should bring up to them:

  • What do they think about the use of home remedies and what do they know about the ones you like to use often.
  • Will any of your home remedies interfere with any conditions you have or with any of the medications you are currently taking.
  • Are they willing to take the time to research and talk with you about the pros and cons of home remedies instead of prescription medications?

References

1. Bell, R. A., Grzywacz, J. G., Quandt, S. A., Neiberg, R., Lang, W., Nguyen, H., ,…Arcury, T. A. (2013). Medical Skepticism and Complementary Therapy Use among Older Rural African-Americans and Whites. Journal of Health Care for the Poor and Underserved, 24(2), 777-787.

2. Goins R, Spencer S, Williams K. Lay meanings of health among rural older adults in Appalachia. The Journal Of Rural Health: Official Journal Of The American Rural Health Association And The National Rural Health Care Association [serial online]. 2011 Winter 2011;27(1):13-20. Available from:MEDLINE with Full Text, Ipswich, Ma. Accessed October 10, 2013.

3. Vincent, C. and Furnham, A. , Why do patients turn to complementary medicine? An empirical study. British Journal of Clinical Psychology, 1996;35: 37–48. doi: 10.1111/j.2044-8260.1996.tb01160.x

4. Astin JA. Why Patients Use Alternative Medicine: Results of a National Study.JAMA. 1998;279(19):1548-1553. doi:10.1001/jama.279.19.1548.

 

 

 

New Study Raises Concern about the Herbal Supplement Industry

Saturday, November 16th, 2013

By Jacob Coleman,  PharmD Student Cedarville University

If you’re a college student like me, you may be wondering what the hype is about vitamins and herbal supplements. These types of products are becoming increasingly popular among American adults, and a college education is just one predictor of dietary supplement use.1 Herbal products alone have grown 15% in the U.S. marketplace in terms of dollars generated in the past year.2 If you’re like me and have even a mild case of physician-phobia, you might prefer to self-treat your ailments before seeking professional help. Most likely you are not like me in having tried to self-treat broken bones before—this is not recommended, as two weeks of Ibuprofen is hardly the cure for dislocated fingers. This tendency towards self-treatment has increased the demand for quality dietary supplements. When the common cold strikes or college stress keeps us awake, one of the most popular solutions is the use of herbal supplements. Unfortunately, the regulation of dietary supplements is a step below the regulation of prescription and non-prescription drugs. Where numerous tests for safety and efficacy are required before drugs can be marketed, the Food and Drug Administration does not require thorough examination of supplements before they are sold. With $60 billion in annual revenues through over 1,000 manufacturers producing more than 29,000 herbal supplements, there is tremendous need for effective products and honest advertising and labeling.3

An article in The New York Times titled Herbal Supplements Are Often Not What They Seem describes the reliability of herbal supplement labeling in U.S. and Canada. The article cites a study from BMC Medicine where researchers examined product labeling to see how well it corresponded with what ingredients were actually in each pill.

The researchers analyzed the contents of 44 bottles of popular herbal supplements from 12 manufacturers, using a technique called “DNA barcoding.” The results revealed that most of the products contained components of plant species not included in the package labeling and only about half actually contained the labeled active ingredient.  One-third even contained other plant species substituted for the labeled active ingredient. For example, one product labeled as black cohosh, a common treatment for menopause symptoms, actually contained a related plant, Actaea asiatica, which can be toxic in humans. In the end, only 2 of the total 12 manufacturers had products that contained the actual label ingredients without contamination. Without mentioning the names of the manufacturers, the results exposed substantial labeling fraud in the herbal supplement market.2,4 The New York Times article discussed the need for regulation of the dietary supplement market while recommending caution to consumers.

The article presented numerous arguments against the herbal supplement industry, citing the lack of integrity in herbal supplement products. I found the article’s argument very compelling and agreed with the need for more FDA involvement in the dietary supplement industry. Aside from the study reference in the article, a variety of other research studies have found similar results, revealing a deficiency in herbal supplement reliability.5,6

file000785313090It is already hard to determine whether or not herbal supplements are effective. Having to find out if herbal products even contain the labeled active ingredient makes self-treatment even more difficult. Countless studies have been done to determine the effectiveness of herbal supplements. If we can’t trust the specific herbal products used in controlled experiments, how can we trust the results of these experiments? The information in this study makes me wonder how accurate my perception of the herbal supplement market is. Where I have been told a particular supplement is ineffective, maybe the manufacturer is the root of the ineffectiveness. Researchers and consumers alike looking to determine the efficacy of particular herbal ingredient should use caution in choosing where they obtain their materials.

There are, however, a few limitations to this study’s approach to determining product quality. DNA barcoding can only determine which ingredients are in a product. It cannot determine the potency of an ingredient or even how much of the available ingredient will even be broken down in the stomach and absorbed into the body. Unfortunately, the names of the manufacturers tested were not included. Because of this, the study invites misleading opinions about the entire herbal supplement without providing helpful information about which product brands to stay away from. Not only is this unhelpful, I don’t think it makes any sense why the researchers would choose to exclude the list of supplements and manufacturers tested. I would very much like to know which product brands in this study were dependable. Without these specifics, the article invites skepticism and can only recommend caution without specific advice concerning which product brands to purchase.

Have you ever taken an herbal supplement? Have you noticed some herbal supplements work better than others depending on the manufacturer?

References

  1. Krinsky, D. L., et. al. (2011) Handbook of Nonprescription Drugs. Washington, DC: American Pharmacists Association.
  2. Newmaster S. G., Grguric M., Dhivya S., et. al. DNA barcoding detects contamination and substitution in North American herbal products. BMC Medicine, 2013, 11:222  doi:10.1186/1741-7015-11-222. Available at http://www.biomedcentral.com/1741-7015/11/222. Accessed November 11, 2013.
  3. Perry, Susan. Herbal supplements often contain substitutes, fillers and contaminants, study finds. MinnPost, November 6, 2013. Available at http://www.minnpost.com/second-opinion/2013/11/herbal-supplements-often-contain-substitutes-fillers-and-contaminants-study-f. Accessed November 11, 2013.
  4. O’Connor, Anahad. Herbal Supplements Are Often Not What They Seem. The New York Times. November 3, 2013. Available at http://www.nytimes.com/2013/11/05/science/herbal-supplements-are-often-not-what-they-seem.html. Accessed November 11, 2013.
  5. Lockwood GB. The quality of commercially available nutraceutical supplements and food sources. Journal of Pharmacy and Pharmacology. 2011;63(1):3-10.
  6. Soller RW. The regulated dietary supplement industry: Myths of an unregulated industry dispelled. HerbalGram. 2012(93):42-57.

A Spoonful of Sugar Helps the Memory Go Down?

Saturday, November 16th, 2013

By Zachary Wallace, PharmD Student Cedarville University

Circulating sugar within the bloodstream is key in the regulation of several brain functions. This is believed to be a result of glucose (the primary sugar used for bodily functions) “acting in the brain [by] altering neural metabolism, neural activity, or neurotransmitter synthesis [i.e. epinephrine].1” As we age, ability to retain information declines partly because humans become deficient in these neuroregulators of memory. It stands to reason that tests in both rat models and humans were conducted to determine if glucose plays a role in reversing age-related memory deficits. Herein resides the striking nature of an article published on MedlinePlus that supports lower blood glucose levels for cognitive performance. The article is intriguing because previous studies have already demonstrated the positive effects of glucose administration to enhance memory in the elderly and even in other populations.1,2,3

file000894312228Controversial in nature, this article is based upon recent online publication of literature from the American Academy of Neurology (10/23/13). The objective of the study was to determine the effect(s) of higher blood sugar levels on memory performance. 141 individuals (without diabetes, excessive consumption of alcohol, or mental impairment) with an average age of 63 were included in testing procedures that measured size of the hippocampus as well as other indicators of memory performance. The volume and structure of the hippocampus were measured because this portion of the brain is primarily responsible for processing information involved in both short-term and long-term memory. Data from the study indicated an increase in hippocampus size as well as overall memory performance as a result of lower blood sugar levels. From the content of the article, it appeared that a stance was taken towards supporting further research rather than deciding the data was fully conclusive. This can be deduced from quotes contained within the article that emphasized lower blood sugar level “could be a promising strategy” and “strategies such as lowering calorie intake and increasing physical activity should be tested.4

When analyzing the literature associated with the article, I am yet to be convinced of anything more than need for further research. Claims in the scientific world that go against prior knowledge studied in-depth have a steep burden of proof to overcome. It would be wrong to suggest following traditional guidelines solely because they have been well-established, yet this does call for a thorough examination of data beyond this one trial to successfully counteract previous research. In this article’s specific case, I am further reluctant to immediately accept the newfound data because basic physiology of the human body includes use of glucose as the primary source of energy for the brain. Why would decreased levels of glucose lead to better performance since the supply of energy would be diminished?

Despite my hesitant disagreement, I could use this potential correlation of lower glucose levels and memory performance to assist in my self-care goals for patients. Lowered blood sugar already has a plethora of health benefits for patients, and this added potential for cognitive enhancement may be the extra measure that entices a patient to follow an appropriate dietary and exercise routine. Those with a family history of neurologic disorders such as Alzheimer’s may be particularly interested. I do not, however, recommend making any blanket statements to patients regarding efficacy of lower blood sugar until further research is conducted. This is especially true when considering some limitations to the study.

Outside of the fact that literature supporting the study’s findings appears to be nearly nonexistent, the Neurology study faces several challenges in collection of data.5 Though not specific to this study, it is important to note the difficulty of measuring memory through testing procedures. Threats to validity include variables such as cognitive difficulty of the testing method and inherent memory capacity of participants. Additionally, measurement of hippocampal volume remains controversial in regards to its direct correlation to memory ability.6 Since the study partially relied on hippocampal volumes to measure memory, this could be a large flaw to its design. Another issue that needs addressed in future studies is the type of sugar, for example do natural sugars such as fruit have the same effect as artificial sugars?

Regardless of this study’s results, seeking to make healthy lifestyle changes remains a top priority in both the prevention and treatment of several disease states. Since lowering blood sugar levels is one of these targeted changes irrespective of its chance to improve memory, should this study’s results even impact treatment of patients?

 

References:

  1. Korol DL, Gold PE. Glucose, memory, and aging. Am J Clin Nutr. 1998;67(4):764S-771S.
  2. Gold PE. Role of glucose in regulating the brain and cognition. Am J Clin Nutr. 1995;61(4 Suppl):987S-995S.
  3. Owen L, Finnegan Y, Hu H, Scholey A, Sünram-Lea S. Glucose effects on long-term memory performance: duration and domain specificity. Psychopharmacology [serial online]. August 15, 2010;211(2):131-140. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed November 11, 2013.
  4. Preidt, R. Lower Blood Sugar Levels May Aid Memory, Study Suggests. Medline Plus. Oct. 23, 2013. Available at http://www.nlm.nih.gov/medlineplus/news/fullstory_141829.html. Accessed Nov. 10, 2013.
  5. Floel A, Kerti L, Witte V, Winkler A, et al. Higher glucose levels associated with lower memory and reduced hippocampal microstructure [Published online before print October 23, 2013] Neurology doi: 10.1212/01.wnl.0000435561.00234.ee.
  6. Van petten C. Relationship between hippocampal volume and memory ability in healthy individuals across the lifespan: review and meta-analysis. Neuropsychologia. 2004;42(10):1394-413.

 

 

Keeping Kids While Traveling: Medicate or Not?

Saturday, November 16th, 2013

By Jesse Hickey, PharmD Student Cedarville University

 Parents often use self-care methods and OTC medication to help control a child’s behavior, especially when faced with situations where the child needs to be quiet.  However, this off-labeled use of medication for its side effects can be dangerous.  The main side effect most parents look for is drowsiness.  Some adults know what medications to use for self-care, but children are essentially blind to what their parents give them.  Unfortunately, it seems like the parents are unaware of the risks themselves.  According to an article, “Should parents drug babies on long flights”, some parents are using diphenhydramine (Benadryl®) to put their children asleep.  A parent referenced in the article stated, “Children accept their parents’ handouts without question not knowing the potential risk.”1 Parents want their infants or toddlers to be comfortable and to help with jetlag.  In American society today, many people understand that diphenhydramine will cause drowsiness or sleepiness in most patients and people use it all the time for this reason.  Therefore, many parents already have an underlying assumption that diphenhydramine is a safe and effective drug to put babies or toddlers asleep.  Not all parents, however, feel the same way about the use of these medications.  Some parents feel that the use of these medications is an abuse of parental power.1  The stance of the article seemed to fair against the use of medications due to multiple reasons suggested by parents and doctors.  In a clinical study on diphenhydramine’s effects on children, the researchers noted the drug’s ability to cross into the blood brain barrier causing a more potent effect on the central nervous system.2  Therefore, diphenhydramine can stimulate the central nervous system causing irritability, restlessness, and nervousness.2  Furthermore, using this drug irresponsibly can be deadly because children have also died by the misuse of the drug.3

First generation antihistamines such as diphenhydramine are well known for their drowsiness effects.3  One parent noted, however, that their child could not fall asleep and felt miserable throughout the trip similar to the clinical trial noted earlier.1 The use of diphenhydramine to drug a child is not only an abuse of parental power but, furthermore, a misuse of a drug.  Parents should also be aware of the child’s tolerance of the drug.  The article noted that the worst place to have a reaction is in the air away from medical attention.1  When diphenhydramine is used for its intended purpose to stop an allergic reaction, the use of the medication is much safer.  Diphenhydramine is a well-established antihistamine that is still a great option when used appropriately for allergic reactions.3  I believe parents need to be simply aware that a drug should not be used for its side effects but simply for its intended use.  The chances of having an adverse effect outweigh the need to sedate a child.  Other methods can be used to help a child sleep or keep them busy during a trip such as keeping the child up before the trip or even giving them something to do to keep them occupied.  If the child is still restless on the plane, try using soft, mellow music to encourage sleeping and avoid distracting sounds.

Unfortunately, Morris’s article and clinical studies have certain limitations that need to be addressed.  No studies have researched how many parents actually give their children diphenhydramine for drowsiness.  Furthermore, this article does not address if all the parents understood how to dose their child’s medication by weight.  Without the proper dosing, parents could be overdosing their children causing some of the reactions addressed earlier.  Another online article by Pediatrician Jennifer Shu, Is it safe to sedate my baby for travel, discussed the same issue with diphenhydramine and came to similar conclusions.4  She suggested against the use of diphenhydramine for drowsiness due to the possibility of hyperactivity.4  She also stated, “Even more important is that, with any medication, there can be dangerous side effects, such as a fast or irregular heartbeat, seizures, and changes in blood pressure.”4  If there are so many negative effects possible with misusing diphenhydramine for its side effects, why aren’t health care providers more involved in addressing this issue to parents?

 

References

 

  1. Morris R. Should parents drug babies for long flights? April 2, 2013. http://www.bbc.co.uk/news/magazine-21977785.  Accessed September 27, 2013.
  2. Chae KM, Tharp MD. Use and safety of antihistamines in children. Dermatologic Therapy. 2000;13(4):374-383.
  3. Berardi R, Ferreri S, Hume A, et al. Disorders related to colds and allergies. In: Handbook of Nonprescription Drugs. Vol 17. 17th ed. American Pharmacists Association; 2012:195.
  4. Shu J. Is it safe to sedate my baby for travel? Baby Center: Expert Advice. http://www.babycenter.com/404_is-it-safe-to-sedate-my-baby-for-travel_7263.bc. Accessed September 27, 2013.

Can Zinc Really Stop a Cold in its Tracks?

Sunday, November 10th, 2013

By Laura Cummings, PharmD Student Cedarville University

‘Tis the season for the spread of the common cold. While not always severe, the congestion, cough, and other cold symptoms are often irritating and can detract from focus and productivity, which drives many cold sufferers to seek a quick solution at the first sign of symptoms. One option that has gained popularity in recent years is zinc lozenges, but have they been scientifically proven effective?

In her article “Do some foods or supplements actually help treat a cold?” Leslie Beck explores several non-drug options commonly used in an attempt to reduce the duration and/or severity of the common cold.1 One treatment that she discusses is zinc lozenges. I agree that some zinc lozenges are scientifically supported as effective, however I disagree with her recommendation of zinc gluconate and zinc citrate lozenges specifically. Furthermore, the article does not include citations to facilitate further research by interested readers.

Although the exact mechanism of action of zinc is still under investigation, researchers have determined that it exerts its effects on the body’s cells rather than directly on the viral cells themselves. This is because the irritating symptoms associated with the common cold are due to an overreaction of the body’s immune cells. Therefore, inhibition of these cells by zinc allows the effective elimination of the virus from the body to occur, while simultaneously reducing the excessive immune effects that cause symptoms such as a runny nose, sneezing, cough, and congestion.2

Science et. al. analyzed 17 randomized controlled clinical trials testing for the treatment effects of various types and dosage forms of zinc on the common cold, when compared with placebo.3 The most commonly supported conclusion was that high-dose zinc acetate treatment was capable of shortening a cold by about two and a half days in adults. It is important to note that zinc gluconate and zinc sulfate did not show similar effectiveness, nor did any zinc treatment used in the treatment of colds in children. Although Science et. al. did not suggest the reasoning behind this, Prasad et. al. have proposed that this is due to increased bioavailability of the acetate form.4 Another suggested conclusion was that zinc was capable of reducing the severity of cold symptoms as rated by patients on graded scales. However, the studies also revealed that side effects of oral zinc can include bad taste and nausea. Another systematic review conducted by Singh helped solidify the specific recommendations for therapy.5 Through the analysis of 18 randomized controlled clinical trials, the authors were able to conclude that in order to be most effective, zinc therapy should begin within 24 hours of the onset of symptoms and should consist of lozenges containing ≥ 75mg of zinc.

So what does this mean practically? When you begin experiencing cold symptoms, stop by the OTC aisle to pick up some 75mg zinc acetate lozenges. Start taking them within 24 hours of the first symptoms and continue as directed on the box (typically every 2-3 hours while awake) until symptoms are gone. You may experience side effects of bad taste and nausea, in which case you can choose to discontinue therapy if you determine that the side effects of zinc outweigh its ability to shorten your cold. This treatment should shorten the duration of your cold by at least 2 days and may decrease the severity of the cold while it lasts.

Have you tried zinc for colds in the past? Did you find it effective?

References

  1. Beck, Leslie. Do some food or supplements actually help treat a cold? The Globe and Mail. Oct. 14, 2013. Available from http://www.theglobeandmail.com/life/health-and-fitness/ask-a-health-expert/do-some-foods-or-supplements-actually-help-treat-a-cold/article14842492/. Accessed November 2, 2013.
  2. Hendley J. The host response, not the virus, causes the symptoms of the common cold. Clinical Infectious Diseases: An Offiial Publication Of the Infections Diseases Society Of America [serial online]. April 1998;26(4):847-848. Available from MEDLINE with Full Text, Ipswich, MA. Accessed November 6, 2013.
  3. Science M, Johnstone J, Roth D, Guyatt G, Loeb M. Zinc for the treatment of the common cold: a systematic review and meta-analysis of randomized controlled trials. CMAJ: Canadian Medical Association Journal=Journal De L’association Medicale Canadienne [serial online]. July 10, 2012;184(10):E551-E561. Available from MEDLINE with Full Text, Ipswich, MA. Accessed November 2, 2013.
  4. Prasad A, Fitzgerald J, Bao B, Beck F, Chandrasekar P. Duration of symptoms and plasma cytokine levels in patients with the common cold treated with zinc acetate. A randomized, double-blind, placebo-controlled trial. Annals of Internal Medicine [serial online]. August 15, 2000;133(4):245-252. Available from MEDLINE with Full Text, Ipswich, MA. Accessed November 6, 2013.
  5. Singh M, Das R. Zinc for the common cold. Cochrane Database Of Systematic Reviews. [serial online]. June 2013;(6) Available from CINAHL Plus with Full Text, Ipswich, MA. Accessed October 19, 2013.

Supplement or Not?: Evidence Against Vitamin D to Build Bones

Saturday, November 9th, 2013

By Sarah Myers, PharmD Student Cedarville University

Osteoporosis has become an increasingly common health problem around the world.  This metabolic bone disorder results in approximately 1.5 million fractures annually as a result of decreased bone mineralization1.  An estimated fifty percent of women and twenty percent of men will develop osteoporosis during their lifetime2.  These high rates of osteoporosis development lead many concerned individuals to seek preventative care to prevent bone loss.  One of the most common supplements used for the prevention of osteoporosis is vitamin D, the sunshine vitamin3.  Because of its role in dietary calcium absorption, consumers commonly seek vitamin D for preventing and slowing the progression of bone loss.  In fact, a recent study suggests that almost half of older adults age 50 and older take a vitamin D supplement4.  Is there ample evidence to support this widespread use of vitamin D, though?

The article entitled More Evidence Against Vitamin D to Build Bones in Middle Age highlights a recent study that evaluates the beneficial claims that are associated with vitamin D when used for preventative bone health among healthy, middle-aged consumers.  This meta-analysis was performed using 23 randomized controlled trials that compared vitamin D supplementation among adults 20 years of age and older.  A total of 4,082 healthy participants were included in the meta-analysis; 92% of which were female.  Baseline serum levels of 25-hydroxyvitamin D, which is the metabolized form of vitamin D3 found within blood circulation, were provided by most studies for a baseline vitamin D level for participants.  The 23 studies varied in duration from 6 months to 5 years.  The majority of the trials used a daily vitamin D supplement, while some studies had participants supplement weekly or monthly.  Additionally, two of the studies dosed by intramuscular injection.  Doses of vitamin D varied from less than 500 international units (IU) to 800 IU daily.  A meta-regression was performed and showed that differences in participant age, duration of study, number of participants, 25-hydroxyvitamin D concentration, vitamin D dose, sex, baseline bone mineral density, and the type of BMD measuring machine would not interfere significantly with the analysis.

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The analysis compared changes in bone mineral density (BMD) from the start of each study to the end of each study.  Bone mineral densities were measured in 1 to 5 different sites, including the lumbar spine, femoral neck, total hip, trochanter, total body, and forearm.  The analysis found only six statistically significant changes in bone density after vitamin D supplementation and four of the six were found only in one location—the femoral neck.  Interestingly, two studies had significant changes that resulted in decreased bone mineral density compared to placebo.  The study notes that three of the studies with positive vitamin D outcomes started with participants having a lower 25-hydroxyvitamin D level than average, which may have resulted in more measurable responses to the vitamin D supplements.  The findings of this study suggest that except for a slight advantage in the femur bone of some study participants, no significant change in bone mineral density was observed throughout the skeleton of those who took the daily-recommended dose of vitamin D.  The study researchers concluded that unless individuals have specific risk factors for vitamin D deficiency, taking the vitamin is not beneficial because it largely functions to maintain calcium concentrations in blood and not the bone3.

I think the aforementioned article adequately addresses a topic that presents many different perspectives from healthcare providers, pharmacists, and consumers.

I share a similar perspective regarding the recommendation of vitamin D.  A limited number of studies focus on supplementing vitamin D in healthy, non-at-risk, middle-aged adults and therefore, a lack of evidence for its beneficial properties in preventing the development of osteoporosis limits its recommendation.  The article coincides with the current standard of care promoted by The U.S. Preventative Services Task Force, which released a statement earlier this year concluding that men and pre-menopausal women should not be recommended to supplement with vitamin D because of insufficient evidence of its benefits5

Some studies suggest daily doses of vitamin D are beneficial in preventing fractures but it is important to note that the majority of available research solely focuses on older, post-menopausal women who have an increased risk of fracture or vitamin D deficiency.  In patients with these risk factors, vitamin D supplementation has been suggested to be beneficial at decreasing risk of fractures.  Limited research exists that focuses on vitamin D supplementation in healthy, middle-aged adults who are not also supplementing with calcium.

I think it is important to remember that the prime period for bone mass fortification is during the childhood and adolescent years4.  With American children choosing to engage in more sedentary activities, such as video gaming, over physically active outdoor activities, should the focus of vitamin D rich diets and supplements rather be directed toward children and adolescents?

 

REFERENCES

1 Position Statement: Osteoporosis/Bone Health in Adults as a National Public Health Priority.  American Academy of Orthopaedic Surgeons.  2009.  http://www.aaos.org/about/papers/position/1113.asp. Accessed October 28, 2013.

2 Lanham-New S, Thompson R, More J, Brooke-Wavell K, Hunking P, Medici E. Importance of vitamin D, calcium and exercise to bone health with specific reference to children and adolescents. Nutrition Bulletin [serial online]. December 2007;32(4):364-377. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 7, 2013.

3 Reid I, Bolland M, Grey A. Effects of vitamin D supplements on bone mineral density: a systematic review and meta-analysis. Lancet [serial online]. October 10, 2013;Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 7, 2013.

4 Bailey R, Dodd K, Picciano M, et al. Estimation of Total Usual Calcium and Vitamin D Intakes in the United States. Journal Of Nutrition [serial online]. April 2010;140(4):817-822. Available from: Academic Search Complete, Ipswich, MA. Accessed November 7, 2013.

5 Moyer V. Vitamin D and Calcium Supplementation to Prevent Fractures in Adults: U.S. Preventive Services Task Force Recommendation Statement. Annals Of Internal Medicine [serial online]. May 7, 2013;158(9):691-696. Available from: Consumer Health Complete – EBSCOhost, Ipswich, MA. Accessed November 7, 2013.

6 Bischoff-Ferrari H, Willett W, Dawson-Hughes B, et al. A pooled analysis of vitamin D dose requirements for fracture prevention. The New England Journal Of Medicine [serial online]. July 5, 2012;367(1):40-49. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 7, 2013.

7 More Evidence Against Vitamin D to Build Bones in Middle Age.  NPR  http://www.npr.org/blogs/health/2013/10/12/232028261/more-evidence-against-vitamin-d-to-build-bones-in-middle-age.  Published 12 October 2013.  Accessed 28 October 2013.

Are Americans Addicted to Oreo’s?

Saturday, November 9th, 2013

By Paul Bicknell, PharmD Student Cedarville University

Over-eating is a significant problem in western culture. For evidence, one need merely look at the ever expanding waistline of its citizenry, but evidence from studies also points to the same conclusion. One study that utilized just over 3.8 million US citizens from around the nation as subjects found that roughly 70% of Americans are either overweight or obese1. Other sources demonstrate the dangerous health effects and economic problems that obesity causes2, 3. However, the cause for overeating remains open to debate to a larger extent, and if cause could be established, people could be assisted in a better way to maintain a healthy weight. One key question is if addiction to food is a factor in our chronic weight gain and how much of a factor it is. Particularly high-fat and high-sugar foods are suspect. This was the case in a study performed by faculty and students at Connecticut College that looked at how rats responded to Oreos as compared to rice cakes and how they responded to an injection of Cocaine or Morphine compared to salt water4. They then examined the rats brains to find that their pleasure centers had been activated by the cookies in a similar way to the drugs4. The researchers argued from this that Oreo cookies are as addictive as cocaine and morphine4.

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The implications of this study were analyzed here in the article “Food Addiction: Does the Oreo Study Prove Anything?” published on WebMD5. This article seems to support the existence of food addiction, but calls into question the ability of the study of a food addiction in rats to predict the same degree of addiction in humans5. The article argues to that end that our biological response to satisfying foods has been evolutionarily beneficial, but can and should be dealt with effectively on a higher level then would be possible for rats since it is not needed to as much of an extent in our well-fed modern society5. At the end is listed a few techniques to try to help deal with food addictions, which includes being mindful of hunger and fullness cues and eating without self-judgment, keeping healthy foods stocked up and only eating high-fat/high-sugar foods in small amounts with a meal, eating meals and snacks only at scheduled times, and trying to eliminate stress which is stated to increase desire for unhealthy foods5.

The study was limited in that it did not present clinical data with human subjects. The human brain is far more advanced then the mouse’s, and humans express a higher level of free thought then mice. The researchers also established a common addiction between the drugs and cookies without comparing them to each other, or even to the same control (drugs compared to salt water, cookies to rice cakes), which makes it hard to establish equality in addiction between the two. The article examining the study also was limited in its reference to outside sources, citing expert opinion a few times and one trial other then the one that was being analyzed.

There is, however, scientific evidence to back up a lot of the suggestions that were made in the article to help deal with food addictions. Free choice has been demonstrated to have an effect in eating habits6, so the higher level of free will in humans would create more control. The benefits of being mindful about eating cues were shown to be effective at reducing tendency to binge eat7. Stress is also demonstrated to be a causal factor that can lead to overeating8, which means attempts to decrease stress may also have a beneficial effect on food addictions.

I would say I agree with most of the content of this article. The helpful tips seem to be in agreement with the primary literature. The other points about making too grand of extrapolations from the data that was collected in the Oreo study seem to also be generally in line with scientific thought. The article gave me ideas for how to counsel on overeating that I intend to implement in my practice, but as a whole, they seem to be pretty consistent with established standards for how to deal with a desire to overeat. I might also add that when a patient faces a desire to eat something unhealthy, he or she could first perform a task that needs to be done, and then eat a very small amount of the desired food as a reward, being sure to only eat a small amount.

Some key question emerges from a discussion about food addiction. What else can be done to help patients deal with their desires to eat too much unhealthy food? How should physicians, pharmacists, nurses, or even government regulating bodies be involved or uninvolved in this task?

 

References:

1.  Kapetanakis, V; et al. OP26 By-State Comparison of Obesity Trends in The Adult Population of the United States of America. Journal of Epidemiology and Community Health. 2012;66:A10-A11 doi:10.1136/jech-2012-201753.026.

2. Wang, Claire; et al. Health and economic burden of the projected obesity trends in the USA and the UK. The Lancet. Volume 378, Issue 9793, 27 August–2 September 2011, Pages 815–825.

3. Sorensid, Thorkild; et al. Obesity as a clinical and public health problem: Is there a need for a new definition based on lipotoxicity effects? Biochimica et Biophysica Acta (BBA) – Molecular and Cell Biology of Lipids Volume 1801, Issue 3, March 2010, Pages 400–404.

4.  Student-Faculty Research Shows Oreos Are Just As Addictive As Drugs In Lab Rats. Connecticut College News 10/15/2013.

5.  Jacobsen, Maryann Tomovich. Food Addiction: Does the Oreo Study Prove Anything? WebMD 10/18/2013.

6.  Fleur, S E La; et al. The snacking rat as model of human obesity: effects of a free-choice high-fat high-sugar diet on meal patterns. International Journal of Obesity (27 August 2013) | doi:10.1038/ijo.2013.159.

7.  Kristeller, Jeatn; et al. Mindfulness-Based Eating Awareness Training (MB-EAT) for Binge Eating: A Randomized Clinical Trial. Mindfulnes February 2013.

8. Tsenkova, Vera; et al. Stress Eating and Health Findings from MIDUS, a National Study of US Adults. Appetite Volume 69, 1 October 2013, Pages 151–155

 

The Impact of NSAIDs on Depression in Osteoarthritis Patients

Wednesday, November 6th, 2013

By Anna Smith, Cedarville University PharmD Student

Imagine waking up every morning for the rest of your life with stiff, aching joints. This is what people with osteoarthritis have to go through.  Osteoarthritis is the result of cartilage breakdown in the joints and can result in pain, swelling, and reduced joint motion.1  It is estimated that 27 million Americans suffer from osteoarthritis, which is a chronic condition.  Although there is no cure, medications have helped to relieve pain.2  On top of the daily pain endured, osteoarthritis patients are twice as likely to struggle with depression.3

Fox News recently released an article about a study published by The American Journal of Medicine.  The study found non-steroidal anti-inflammatory drugs (NSAIDs) used to relieve pain from osteoarthritis, such as ibuprofen and naproxen, may also play a role in reducing depression related to osteoarthritis.  The study used approximately 1500 osteoarthritis patients not taking antidepressants.  Patients were either given over-the-counter (OTC) NSAIDs, Celebrex, or a placebo to observe the impact on depression.3  Depression was measured using the Patient Health Questionnaire (PHQ-9) constructed by Pfizer, using a scale of 0-27.  The total points scored in the questionnaire represent different categories of depression, 1-4 being minimal depression, 5-9 as mild depression, 10-14 as moderate depression, 15-19 as moderately severe depression, and 20-27 being severe depression.4  The median score for the patients before treatment was 3, showing scores were low and around the minimal depression range.  Results showed combined data of OTC NSAIDs and Celebrex lowered depression scores significantly more than the placebo (p<0.039).  However, OTC NSAIDs alone did not have a significant impact compared to the placebo in lowering depression symptoms (p=0.087).  With these results, researchers are suggesting NSAIDs may help reduce depression symptoms in osteoarthritis patients.5

Research on the relationship between NSAIDs and depression is lacking.  The only outside source supporting the use of NSAIDs for depression dealt with interferon-induced (IFN-induced) depression.  This article stated interferon-alpha (used for treatment in some chronic diseases and viral illnesses) can cause depression as a side effect.  NSAIDs are known to treat many IFN-induced side effects. The article suggests NSAIDs could play a role in reducing IFN-induced depression.6  Although NSAIDs could possibly reduce this type of depression, they have been found to interact negatively with antidepressants.  A study showed that NSAIDs were linked to increased depression in patients using selective serotonin reuptake inhibitors to treat depression.7  This suggests simultaneous use of NSAIDs and antidepressants may reduce effectiveness of depression treatment.

By looking through outside sources, it is clear the study on NSAIDs easing depression is limited.  First, there is not enough outside literature and research to support NSAIDs playing a role in depression.  Also, the results could have been due to pain relief.  Rather than having a direct method of action in reducing depression, the treatment could have relieved pain and put patients in a better mood.  The study also stated OTC NSAIDs, Celebrex, and placebo all reduced depression scores.  Since patients taking the placebo were also less depressed, this could mean outside factors altered their mood.  Furthermore, the median score of depression on the PHQ-9 scale before treatment was a 3.  With a score of 3, patients are thought to only have minimal depression, which is the lowest depression category on the scale.4  Without having higher scores, I feel that the data does not accurately represent patients who are truly depressed.

Taking the study and outside research into consideration, I would still recommend using NSAIDs for relieving osteoarthritis pain.  These medications can still be effective in the relief of pain.  However, I would not recommend NSAIDs for treating depression since there is currently no evidence that NSAIDs work to treat depression alone.  Since NSAIDs have been shown to interfere with antidepressant treatment, I would also advise caution when recommending NSAIDs to patients taking antidepressants.

I do not agree with the study that NSAIDs play a role in easing depression of arthritis patients.  There are too many limiting factors to the study and not enough supporting evidence.  There was no significant difference observed between OTC NSAIDs and the placebo on lowering depression symptoms.  Also, the participants did not have high depression scores to start out with.  Additional resources do not support a mechanism for NSAIDs lessening depression.

There does not appear to be a significant amount of research on NSAIDs and depression.  The study mentioned by Fox News may lead to new research studies dealing with NSAIDs and depression, which may clarify a direct or indirect correlation.  The link between pain and depression is complex, and depression may only be lessened by NSAIDs due to their influence on pain.  Until further research is conducted, we must ask – do NSAIDs truly play a significant role in reducing depression?

 

 

References

  1. U.S. National Library of Medicine. Osteoarthritis. MedlinePlus. http://www.nlm.nih.gov/medlineplus/osteoarthritis.html. Updated September 27, 2013.  Accessed October 27, 2013.
  2. Arthritis Foundation. Osteoarthritis. Arthritis Foundation. http://www.arthritis.org/conditions-treatments/disease-center/osteoarthritis/. Accessed October 27, 2013.
  3. Ibuprofen may ease arthritis patients’ depression. Fox News http://www.foxnews.com/health/2013/09/26/ibuprofen-may-ease-arthritis-patients-depression/. Published September 26, 2013. Accessed October 27, 2013.
  4. Pfizer Inc.  Patient Health Questionnaire (PHQ-9).  SAMHSA-HRSA Center for Integrated Health Solutions.  http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf.  Accessed November 1, 2013.
  5. Iyengar, RL, Gandhi S, Aneja A, Thorpe K, Razzouk L, Greenberg J, Mosovich S, Farkouh M. NSAIDs Are Associated with Lower Depression Scores in Patients with Osteoarthritis. The American Journal of Medicine. 2013;126(11):1017.e11-1017.e18.http://www.sciencedirect.com/science/article/pii/S0002934313003586. Accessed November 1, 2013.
  6. Asnis GM, De la Garza II R, Kohn SR, Reinus JF, Henderson M, Shah J. IFN-induced depression: a role for NSAIDs. Psychopharmacol Bull. 2003;37(3):29-50.  http://www.ncbi.nlm.nih.gov/pubmed/14608239. Accessed October 27, 2013.
  7. Gallagher PJ, Castro V, Fava M, Weilburg JB, Murphy SN, Gainer VS, Churchill SE, Kohane IS, Iosifescu DV, Smoller JW, Perlis RH. Antidepressant Response in Patients with Major Depression Exposed to NSAIDs: A Pharmacovigilance Study. Am J Psychiatry.  2012;169(10):1065-1072. doi:10.1176/appi.ajp.2012.11091325.

 

The Importance of Acetaminophen Overdose Education

Friday, November 1st, 2013

by Rachel Kunze

Acetaminophen, also known as Tylenol, is a popular analgesic that can be bought over the counter. Like many drugs, acetaminophen has serious health consequences if the maximum dose is exceeded.1 Tens of thousands people each year end up in the hospital due to acetaminophen overdose and 150 of these cases are fatal due to acute liver failure.2 Factors that increase the risk for liver toxicity include long term alcohol use and use of drugs that are broken down by the cytochrome P450 2E1 enzyme system, including acetaminophen.3 A recent article entitled Tylenol’s Risks Not Fully Understood, Poll Shows explored the public’s knowledge on this drug. Shockingly, fifty-one percent of people surveyed were not aware of any warnings with acetaminophen usage. Forty-nine percent incorrectly said that an acetaminophen overdose would cause heart palpitations. Thirty-five percent of those surveyed believed it was safe to take two products containing acetaminophen simultaneously.1 In response to these polling results, the FDA has launched a safety campaign known as The FDA’s Safe Use Initiative in order to raise awareness of acetaminophen’s risk factors.1 This campaign includes a webpage, pamphlets, and a YouTube channel on the risks associated with acetaminophen. Tylenol manufacturers have also taken steps to raise awareness by making posters for doctors’ offices and making a YouTube channel of their own.1 This article only used polls to measure patient awareness, so threats to validity were possible. The article did not explain factors that may have led to a certain survey response, such as a career in health care.

I was surprised to learn that a large percentage of the public was unaware of the safety concerns with acetaminophen. I agree with the article that steps need to be taken to improve patient education on this issue. Despite the safety concerns, this would not change my self-care recommendations. I still see acetaminophen as an effective analgesic, but would take the time to warn my patients about the health risks. One study determined that out of 662 cases of acute liver failure in a hospital, 42 percent of them had to do with misuse of Tylenol.2 I believe that many hospital visits could be avoided if patients were more aware of the safety concerns with Tylenol products. While it may be true that the FDA campaign may reduce the number of hospital visits, I believe that even more should be done. The FDA’s creation of a YouTube channel, for example, will only help if a patient happens to find it on the internet. What about those who do not own a computer? A patient should not have to go out of their way to be educated on a medication, even if it can be bought over the counter.  I believe something should be done in pharmacies to more directly educated patients. Pharmacists should take a direct role in educating patients in person. Flyers that warn about overdoses should be put up next to the acetaminophen products in pharmacies.  This way, a pharmacist can warn the patient on the maximum dosage and what can happen if there is an overdose of the drug. It would not take up too much of a pharmacist’s time and can be a very effective way to educate the public. This is just one possible solution to the issue. Based on the statistics this article gave, are the safety concerns severe enough to take more initiative? If so, should Tylenol maybe become a behind the counter drug so the pharmacy can further monitor its usage? How else can we reduce the number of acetaminophen overdoses?

 

References

[1] Miller TC,  Gerth J. Tylenol’s Risks Not Fully Understood, Poll Shows. ProPublica: Journal in the Public Interest. 2013. Available at: http://www.propublica.org/article/tylenols-risks-not-fully-understood-poll-shows. Accessed October 7, 2013.

[2] Larson A. M., Polson  J., Fontana  R. J., Davern T. J. et. al. Acetaminophen-induced acute liver failure: Results of a United States multicenter, prospective study. Hepatology [serial online]. 2013;42(6): 1364-1372. Available at: http://onlinelibrary.wiley.com/doi/10.1002/hep.20948/full. Accessed October 11, 2013.

[3] Kozer E, Koren G. Management of Paracetamol Overdose: Current Controversies. Drug Safety [serial online]. January 1, 2001;24(7):503-512. Available from: E-Journals, Ipswich, MA. Accessed October 20, 2013.