Trailing Thoughts

Avastin, which is a monoclonal antibody, has been approved by the FDA to use to for colon cancer. Unfortunately this drug is not a cure, but a time extender. When it is given with standard chemotherapy, it can extend a patients life up to 5 months. This does not seem much, but it is a hope for some of the people suffering with the disease.
The FDA updated their website, making it easier to use and to find information about prescription drugs…. you can either get to it from www.fda.gov or follow the link: http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm
This website will also contain information about some OTC products and discontinued drugs.

Psoriasis is a noncontagious chronic skin disease that is relatively common. Psoriasis is diagnosed when there is a defect in th enormal cycle of skin development. It looks like raised red skin patches that is covered by a silverish-white flaky buildup. These patches can have pain associated with them, and some even bleed. Currently 1 to 3% of the world’s population suffers from psoriasis. It effects both men and women equally. No one knows the cause, but it is mainly associated with either genetic predisposition or evironmental issues. Some of these environmental issues that can trigger an attack are: mechanical, ultraviolet, or chemical injury to the skin, stress, smoking, changes in hormones, alcohol, obesity, or medications.
The medications that are known to possibly induce psoriasis include the antimalarial drugs, lithium, beta-blockers, quinidine, some NSAIDS, ACE-Inhibitors, tetracycline, and withdrawal of systemic corticosteriods.
What happens in psoriasis? Well the cycle to make new skin is going faster than normal, and the cells move up to the surface faster, they do not have a chance to differentiate, so they present as inflammed, red scaly skin. This process activates T cells, which provides the exaggeration of the immunological process, helping the skin stay red and inflammed.
There are several types of lesions associated with psoriasis, but the most common one is chronic plaque psoriasis and they are usually found on the elbows, knees, the butt, or scalp, but can appear anywhere. Psoriasis also affects the nail beds. It can cause a separation between the nail from the nail bed, and other problems, including discoloration. Additionally, psoriasis can cause arthritis.
Unfortunately modern medicine did not come out with a cure yet. The only treatment available is suppressive, that is trying to prevent outbreaks of events of psoriasis. There are a variety of topical treatments, including phototherapy. The topical medications used include corticosteroids, anthralin, crude coal tar (OTC, T/Gel), vitamin D analogs, retinoids, salicylic acid and emollients( OTC, like some Curel products). The drugs most often used to treat psoriasis are methotrexate, cyclosporine, acitretin, Amevive, and raptiva.
As mentioned earlier, there is no cure for psoriasis, but fortunately there are many people out there looking for a cure and there are a lot of investigational drugs being considered for the treatment of psoriasis.
As today seems like the day to talk about skin conditions, and with the weather becoming nicer and more and more people are going into the woods and other areas where poison ivy, etc, are found, I will take a few minutes of how to treat it. Trust me, in the summer, about 90% of the questions asked to pharmacists deals with poison ivy.
Poison ivy, oak, and sumac are the most common cause of allergic reactions in the US. Poison ivy is a vine found mainly east of the rocky mountains ( Toledo and the surrounding areas have a lot of it growing) while poison oak is more common west of the rocky mountains, and is usually a shrub. Poison sumac is mainy found in peat bogs or swampy areas as a small tree or shrub. It is common in southern canada and the eastern states. These plants all share a common oil, which is called Urushiol. This oil is present in most of the plant including the leaves, stems, and roots. Contacting this oil directly ( touching a plant) or indirectly (petting your dog, clothing that came in contact with the plant, etc. ). Airborn urushiol particles (from burning the plant) can also can an allergic reaction. Normally the rash does not appear until a person’s second contact with the oil.
When it does occur, it is a red itchy blistering rash that appears within 2 days after coming in contact with the oil. The blisters will start crusting over after a few days and then within 10 to 21 days, the rash completely heals.
Prevention is the key when possible– so remember, “leaves of 3, let them be” (poison ivy and oak are arranged in groups of 3) while poison sumac is arranged in groups of 7 to 13. When the oil, urushiol is exposed to air, it blackens in color… so this appears as plants with drops of black enamel on them. When they cannot be avoided, protect by covering as much as possible. Where long pants and long-sleeved shirts, vinyl gloves, etc… and when you are done contacting the poison plants, be very careful of how you take your clothes off and do not let them touch anything, like the couch or your seats in the car… and wash the clothes separately from the rest of your clothing…. don’t forget about the shoes and the shoestrings or any other object that came in contact with the poison plant.
If you do come in contact with the plant wash the exposed area ASAP! ( the best is within 30 minutes). Soap and water is the best or you can spend some money and get special poison ivy soap… when these are not available, cool water can work, but be very complete and rinse a long time…
Well, now that you have the rash, what can you do? Cool bathes, with or without oatmeal or baking soda, and then applying a OTC hydrocortisone cream ( 1% is the strongest available over the counter). Calamine lotion is not very helpful, it turns you pink… but it can help dry the rash. Do not use it on open blisters though. If you have trouble sleeping look into taking a benadryl capsule… this can help with the itch and is the active ingredient found in most of the over the counter sleep aids (50mg is the recommended dose to sleep).
Contact your doctor if the rash gets worse or it effects the eyes, genitals, or large areas of the face.

Working in a retail pharmacy, I am aware of the high costs for prescriptions. It really upsets me when I know people are choosing between food and their medication…. But is the cost really that high compared with the benefits new technology brought us?
It appears that Europeans are spending 60% less per capita than Americans on prescription drugs. So this is a good thing right? Or is there a hidden cost? There are more drug innovation in the US. Though many of the clinical studies are not based in the US, most of the money for drug innovation comes from the US. The US has come up with 81 new drug molecules, compared to the 44 the Europeans developed in a 4 year period. Additionally, in the US, there is an increase in high- value jobs created in the pharmaceutical industry, compared to Europe which is good for the US economy.
At one point in time, both the US and European research and development expenditures were equal. But the US spends more now, and this is resulting a “brain drain” in Europe. Many of the European drug innovators moved to the US.
The Europeans are also delayed with the best cutting edge technologies, the time it takes to launch a new drug in Europe is approximately 33% longer than the time it takes in the US.
These might not seem like good reasons to say that the high costs of prescription drugs are well founded, but it is something to consider.
There is no answer to solve the issues of the high costs for drugs. It takes a lot of money and time to develop a drug that can be used. The answer is not reducing the cost, but controlling the issues. The government should get involved, but how is the question. Once they start to limit innovation, American will lose the edge that it has on the cutting edge of prescription drug development.
This is just my opinion after reading an article on the costs of prescriptions in the US. It still breaks my heart to see people not able to get the needed medication. This is a whole other issue to address later.

I have a few different programs that I have purchased to have for my rotations this semester and I would like to share my opinions on the different software options.
First, the most bang for the buck: Tarascon Pharmacopoeia. This software is only about 30 dollars and has a lot of great features. It has some common calculations, and a drug interaction tool too. They organize the drugs by class or by an index, which makes finding the right drug easier. I especially like that this program will give average pricing. They also provide a small list of reference websites.
In addition to this I would download Archimedes, a free medical calculator offered by Skyscape. This is an excellent product, and the best thing is that it is free…. I have used this many times during my rotations and it has an extensive formula database.
I did not purchase Lexi-comp and I sort of regret it. It has a nice collection of books, but it is expensive (over $300). But it has many things that others have, but it is easier to find information.
I did purchase a few books from handheldmed.com instead. This is a nice source, but it was incomplete. They had a special that you can purchase 5 books for about $200. I got the Merck Manual, 5 minute clinical consult, Taber’s Cyclopedic Medical Dictionary, A to Z Drug Facts, and Davis’s Guide to IV Medications. I personally have not used this as often as I thought. I use Taber’s the most. Having a medical dictionary is a great thing to have for all of those unfamiliar terms. But if I did it differently I would have purchased Lexi-comp. The reader provided by handheldmed is not a good reader. It is easy to use and everything, but I get a lot of errors and I have to restart the PDA.
I also purchased PDR Drugs, Applied Therapeutics, ABC Lab Data, and Essential Diagnosis from Skyscape. These were pretty expensive also, but I needed a few additional sources. PDR Drugs is a really great book. It is organized well and it is easy to find information. The only problem is that it is not all inclusive. ABC Lab Data is also nice, but I would try to see other options about lab tests.
Applied Therapeutics is good for NAPLEX study purposes. I thought it is a great book, but it is heavy to carry around and so this is a good alternative. The problem here is the case study questions are not included in the Pocket PC version.
MICROMEDEX is the best software option if you belong to an institution that uses this because you can get it free. The University of Toledo provides access to this. It is pretty awesome because it comes with treatment overviews for some conditions, a herbal information database, toxicology information, drug information and interaction tools. This is organized well and has a special heading for dosing adjustment, which is important when you are checking for renal adjustments.
Well these are just my opinions of the software as I actually use them for my rotations. Hopefully this review can help guide others looking to purchase reference materials.

There are so many food products available currently that have sort of claim, fat free, low fat, etc… now the new biggie is “heart healthy”. Some of these things you have to read the label carefully to see if they are really misinterpreting something. On the other hand, some new additions can do what they claim… like Minute Maid Heart Wise juice added plant sterols to help block cholesterol absorption. It claims if you drink 2- 8ounce glasses can decrease the LDL cholesterol (the “bad” cholesterol) from 5 to 17%. Additionally soluble fiber, like Cheerios, or even oatmeal, can help reduce cholesterol by blocking cholesterol absorption. The recommended dose is about 3 grams of soluble fiber, which is about 3 servings.
Stopping the saturated fats can help reduce the LDL cholesterol… eat soy or nuts instead. Not all nuts mind you, but some that are recommended are peanuts, almonds, walnuts, pecans, hazelnuts, or pistachios. These nuts have high levels of polyunsaturated fats and a handful a day can lower the cholesterol 5 to 10%.
It is well known that fish high in omega-3 fatty acids are good for us and seem to reduce the risk of heart disease. Salmon is one fish with a high amount of omega-3 fatty acids.
Of course there are medications that help reduce cholesterol. We can help them work better if they are taken at the proper time. It is usually recommened that patients should take their statin in the evening because at night, most of a persons cholesterol is produced at night. Mevacor, Altocor, Zocor, and Lescol are the ones that this is recommended for… but it would not hurt to take the others, like Lipitor, Crestor, or Pravachol in the evening… but they can be taken at any time of the day, which is due to the fact that they have a little longer half life.
Most people with kids normally will have ipecac syrup on hand just in case the child poisons himself with something… but it is not recommended any longer. It does not improve the outcome in the event of a poisoning. In fact, some cases were worse because of Ipecac. First, it is not very reliable. It depends on the time of ingestion of the poison and when the ipecac is given. At this point, it only clears about 30% of the poison. It also can cause persistant vomitting so when you get to the ER, it is difficult to treat and delays the appropriate treatment.
It is abused often by people with eating disorders, which is not good, because continued, chronic use of Ipecac can cause cardiac toxicity….If a poisoning does occur, call 1-800-222-1222. This number willl connect you to the closest poison control center. Also, get to the ER as soon as possible…. talk to your doctor what are the best ways to prevent accidental poisonings.

Peptic ulcer disease is a group of disorders of the upper gastrointestinal tract (duodenal or gastric) which form “bleeding” lesions that are dependent on acid and pepsin for their formation. Patients with ulcers normally have the symptoms of epigastic pain occuring 1 to 3 hours after they finish eating and the pain is relieved by antacids or more food. Sometimes the pain can last for weeks and months and then disappear. GERD is gastroesophageal reflux disease and is defined by chronic symptoms caused by mucosal damage produced by abnormal reflux of the stomach (gastric) content. Heartburn is the classic symptom here… sometimes it is so severe and can radiate to the neck, back or throat. Eating foods high in fat can cause the GERD to be worse, additionally bending over or laying down may bring on the symptoms. Belching and increased salivation, and regurgitation are also classic symptoms.
What can you take for these symptoms when an antacid is just not cutting it? Well there are 2 types of medications, which are the PPI (proton pump inhibitors) and the H2RA (H2 receptor antagonist). PPIs will suppress gastric acid secretion specifically by inhibiting the H+-K+ ATPase enzyme system of the secretory surface of the gastric parietal cell. What does this mean? Basically this means that you are stopping acid production before it starts. H2RA suppress gastric acid secretion by reversibly blocking histamine2 receptors on the surface of the gastric parietal cell. Now what does this mean? To sum up, it means it competes with acid formation and will block some of the acid from forming.
What are the PPIs available? Prilosec (Also available over the counter) Nexium, Prevacid, Aciphex, Protonix… when taking these it is best to take them before eating and it may take a few days before the full power of the medication is seen. PPIs are best for treating ulcers, while H2RA are recommended for GERD.
The H2RAs include Tagamet, Zantac, Axid, Pepcid. When you are taking these make sure you talk to your pharmacist about drug interactions (especially Tagamet). They interfere with the CYP enzyme system and can cause some drugs to act differently on your body. Also, to get the full effect of your medication, avoid antacids 1 to 2 hours before and after you take the pill. With this class, it does not matter when you take the medication, with or without food.
Remember these are not miracle drugs that will start working instantaneously. You need to take them on a daily basis and not a “as needed” basis to get these medications to work for you…. Both of these classes can cause diarrhea, headache or nausea, but they are generally tolerated well.
Before I get off the subject I briefly want to mention the differences between Prilosec and Prilosec OTC. There is not a big difference, but they are different salts (and 1 is a tablet and 1 is a capsule). Personally, though all the literature does not support using Prilosec OTC as the prescription Prilosec, when it comes to saving money, where the big issues are, I would not recommend the prescription. It will cost you about 5 times more for a 30 day supply if you get the prescription. To me, the difference is not worth it, though there is no long term studies backing my claim…. if you need a PPI and have insurance, it is most likely that you will be put on Prilosec because it has a generic available….get the prescription in this case, because the data is there…. This might not be an option with some insurance companies that are making doctors switch their patients to the OTC formulation because it is cheaper for them… these are other issues all in itself…..

Here is some good news for constant gum chewers. Big Red gum is the gum of choice for people interested in killing 50% of the odor killing bacteria in the mouth. This is only found in Big Red, because of a natural oil that is used to flavor the gum. The cinnamic aldehyde plant extract used in the gum, after chewing it for 20 minutes, can kill 50% on anaerobic bacteria in the saliva.
As my campaign for colon cancer screening, I came across a newer option for screening. It is a fecal immunochemical test that can be used at home to detect blood in the stool, for people that may be concerned about colon cancer but cannot bring themselves to talk to their doctor about it. I have not seen it in local stores, but I assume they can be ordered by your local pharmacy. Next time I am at work and think of it, I will have to check if it can be ordered.