When Good Supplements Go Bad (Alpha Lipoic Acid)

by on May 11, 2009

I just saw an interesting case of a lady with a rapid heart beat, chest pains, clean cath. She was taking the dietary supplement Alpha Lipoic Acid (ALA), prescribed to her for peripheral neuropathy. It’s actually got some clinical evidence that’s it’s effective for treating diabetic neuropathy, but there is a downside. In high doses, it causes arrhythmia, rapid heart beat and other cardiac issues (a quick search on Google Scholar shows many articles that mention this).

Alpha Lipoic Acid is an antioxidant. It is an important factor in the Krebs cycle (remember that?), producing energy and helping our bodies to utilize sugars. I read one Internet article that called it the “ultimate antioxidant” because it helps the body to utilize other antioxidants, and would even help diabetics with blood sugar control (scholarly evidence suggests that it can cause hypoglycemia, so maybe that guy was on to something). Diabetes Care (25(4):1160-7 1995) found that it improves nerve blood flow, reduces oxidative stress and improves distal nerve conduction in diabetic neuropathy.

Typical doses for diabetic complications 300 to 600 mg daily. Higher than 50mg doses aren’t recommended unless you’re under the care of a physician.

My point is not to become a pusher of ALA. The point is that most of us would look at a dietary supplement like that and shrug and move on. We wouldn’t even think to research the potential complications of that supplement. But, just because something is natural and not found behind the counter doesn’t mean it can’t interact, cause problems or possible injure someone (for example, mixing St. John’s Wort and warfarin or certain HIV drugs can lead to potentially deadly complications).

As the economy gets worse and more and more people decide to self treat, we’re going to see more herbal supplements being used. A lot of those, especially in combinations with prescription drugs, are unknown. It’s up to us to be vigalant and assemble the information we know and make educated assessments about what we don’t know.

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Clopidogrel (Plavix) and Omeprazole (Prilosec)

by on May 4, 2009

I’ve been meaning to press publish on this post for a while. It was one of the first posts I started on back in February.  I might as well do it now, because I know there are still questions about PPIs and Plavix.

Studies that came out earlier this year had significant data that showed patients taking Plavix and a PPI had decreased Plavix effectiveness which lead to increased events.  The risk of reinfarction within 90 days was 27% greater than among those taking clopidogrel only.

In essence, the PPI made them poor metabolizers of Plavix. The studies postulate that it’s because of a CYP interaction.

I don’t think anyone knows all the answers, but it seems Protonix is the new PPI of choice for people who are taking Plavix + Aspirin.  Omeprazole, the most commonly prescribe PPI, is the worst offender.  Protonix is not metabolized through CYP2C19.

The better choice may be not prescribing a PPI at all in patients who don’t need one.  It’s common practice to prescribe a PPI in patients taking Plavix and aspirin, because of the potential for GI problems/gastric bleeding.  Because of these studies, this recommendation might change.

Cimetidine interferes with almost everything, and it also interacts with Plavix on the same CYP2C19 that omeprazole does, so that’s not an option.

The original studies are pay to read, but here’s a free resource that sums them up excellently: Medscape: Plavix and PPIs

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Pharmacists and the Swine Flu (H1N1)

by on May 1, 2009

I’m not going to write much about the swine flu, because I think the media has blown it out of proportion already. People are already in a bit of a panic about it.  So, I’ll just supple some resources for answers to the many questions we’ve all been getting about it.

A great resource for pharmacist that includes checklists and drug lists for pandemics, including pandemic flu, is located on the ASHP website: A Pharmacist’s Guide to Pandemic Planning. It’s a nice guide and something to bookmark.  You never know when it will come in handy.

For this “pandemic,” I think the best thing pharmacist can do is calm people down.  It’s way too soon to panic.  Give people the facts.  Good hygiene, good health habits and common sense flu prevention are the best defenses we have right now.

The CDC should be a primary resource for health care professionals and patients, and most of their literature is facts without the hype.  I like their “Swine Flu and You” handout.  Here’s a quote from it:

Like seasonal flu, swine flu in humans can vary in severity from mild to severe. Between 2005 until January 2009, 12 human cases of swine flu were detected in the U.S. with no deaths occurring. However, swine flu infection can be serious. In September 1988, a previously healthy 32-year-old pregnant woman in Wisconsin was hospitalized for pneumonia after being infected with swine flu and died 8 days later. A swine flu outbreak in Fort Dix, New Jersey occurred in 1976 that caused more than 200 cases with serious illness in several people and one death.

So far, there have only been 109 cases and 1 death.  Over 30,000 people from typical influenza every year.  Approximately 5% to 20% of U.S. residents get the flu and more 200,000 are hospitalized for flu-related complications each year.   This type of pandemic is nothing new.

If you really want to get intense about it, here are 100 resources for preparing for pandemic flu.  Some of the resources, especially links in the kids and families section, are worth pointing people to.   I know some will not be comforted by the “common sense hygeine” guides and will demand more preparedness information.  These resources have something for people with any type of information demand.

Good luck!

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NEJM Investigates Anti-epileptics in Pregnancy

by on April 22, 2009

Anti-epileptics have been shown to cause birth defects and developmental defects in children when taken during pregnancy.  However, previous studies on the effects of valproate on IQ had small, retrospective samples .  In this month’s Journal, interim results of the largest prospective study to date of long-term cognitive development in children exposed in utero to antiepileptic-drug monotherapy are discussed.

The findings indicate that children who were exposed to valproate in utereo had significantly lower IQs than children exposed to carbamazepine,  lamotrigine and phenytoin.

The study also found that discontinuing valproate after a woman finds she is pregnant is probably too late.  Women on valproate should be counseled about the importance of pregnancy planning, because the defects on cognition probably occur within the first 2-3 months of pregnancy.

Carbamazepine is generally the preferred drug for women of child bearing age.  For generalized epilepsies, the journal recomends trials of lamotrigine or valproate doses below 800 mg per day.

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Cooking Oil Smoke & Cigarette Smoke Trigger Similiar Response

by on April 19, 2009

An interesting study came out a few days ago.  I guess it can be used to educate patients a little, but is mostly just interesting.  Researchers tested response to common air pollutants including cigarette smoke, wood smoke and cooking oil smoke.  They found that secondhand exposure to these products triggered a similar response, but the most interesting thing to me is how quickly that response was triggered.

This study briefly exposed people to low levels of common pollutants and measured their cardiovascular and cardiorespiratory responses (including heart rate variability, breathing and blood pressure). Forty healthy non-smokers (21 women, 19 men) whose average age was 35 participated.   They were exposed to the three types of smoke while they sat in a 10-by-10-foot chamber. The researchers cleared the air in the chamber after each trial.

The results showed that exposure to smoke changed affected cardiovascular function, particularly in men. Women tended to have a greater parasympathetic response.  The exposure response times were as little as 10 minutes in some cases.

The take home points are:

  • Cardiovascular responses during brief exposures were similar to those found during longer or higher-level exposures
  • Air pollutants tested all had similar responses
  • Men have a stronger sympathetic nervous system (”fight or flight”) response to pollutants than women

Something to think about this earth day.  It’s also something to think about the next time you’re exposed to second hand smoke and think it’s only for a short time so it should be just fine.

I don’t have a link to the study, but here’s a link to a the synopsis:  American Psychological Society. It will be presented at that conference.

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How Much Meat is Too Much?

by on March 28, 2009

An article released on March 23 in the Archives of Internal Medicine reveals that, surprise, Americans eat too much meat.  We’ve heard all of that before.  The surprising thing was that this article also found that those consuming white meat had a decreased risk of both total mortality and cancer mortality.  White meat included chicken, turkey and fish, as well as poultry cold cuts, canned tuna and low-fat sausages and hot dogs made from poultry.

Over the 10 year follow-up period from 1995 to 2005, there were 47,976 male deaths and 23,276 female deaths. The scientists found that individuals in the highest group of red meat intake tended to consume a slightly lower amount of white meat but a higher amount of processed meat compared with those in the lowest group.

There are some flaws in the study.  Generally, those who eat more red meat also tend to be less concerned about health already (overweight, low activity), so it’s hard to say if it’s the meat or the lifestyle that causes the increased in mortality.  On the other hand, several other studies have linked high red meat consumption with high levels of cancer.  However, the cooking process contributes to the carcinogen content of some meats, and that was not taken into account in this study.

How Much Is Too Much?

According to this study, based on a 2000 calorie/day diet, men eating 4.8 ounces (136.2 grams) of red meat daily had a 31% increased risk of mortality over a given decade than men that consumed just 0.7 ounces (18.6 grams). Women eating 4.6 ounces (131.8 grams) of red meat daily had a 36% increased risk of mortality over a given decade than women who consumed just 0.6 ounces (18.2 grams).

The study group recommends limiting red meat to 500 grams, or 18 ounces per week, to reduce the risk of cancer.

What Can We Do?

The more studies that come out on the “Western Diet,” “The Medittarian Diet,” “The French Paradox” or anything to do with food, the more we see that “excess” is the bad thing, and not one food. Even though the study may be a little flawed, that message is not.

We live in a country where portions get bigger and bigger, and so do people.

Pharmacists have a unique role in healthcare because we see most patients at least once a month.  They only see their physcians every few months (sometimes only twice a year).  While most patients know that “excess” is bad, most patients don’t understand what excess is.

Too often, we tell patients, “Don’t eat [food].” but we rarely say, “You can eat…”  It’s important for us to counsel interested patients not only on what to avoid, but what to eat.  Just for comparison purposes, 1.5 ounces of meat is about two slices of lunch meat.  Patients should get less than 3 ounces of red meat everyday.

The Heart and Stroke Foundation recommends selecting lean meat and alternatives, trimming visible fat from meats, removing skin from poultry and using cooking methods such as roasting, baking or poaching that require little or no added fat.

What About Grass Fed Beef?

Depends on who you ask!  Many say that grass fed beef is higher in omega-3 fatty acids and lower in omega-6 fatty acids, that corn-fed beef.  It’s also supposed to be high in micronutrients and vitamins, and low in saturated fat. The verdict is still out on its benefits (or detriment) to your health, so I would still recommend moderation. Gourmet had a nice editorial on this article comparing grass vs. corn-fed animals, that talks about some of the problems with corn-fed animals.

You often hear people who raise grass-fed beef touting that the switch from grass-fed to corn-fed animals was the start of the obesity epidemic.  However, around the time of that switch was when portion sizes started to increase.  You be the judge on which was more to blame.

Bottom Line

Portion control and exercise are still the most important aspects of diet, rather you eat red meat or not.  There are such things as fat, unhealthy vegetarians, and healthy carnivores.

Grass-fed beef may be healthier, but it doesn’t give you free reign to eat all you want.  I think sometimes people hear something is lower fat or “healthy” and think that means they can eat all they want.  The same goes with white meat. It was found to be healthy, but that does  not mean you can eat a whole chicken in one setting.   A 4 oz portion of meat  is about the size of deck of cards.

Portion control is, in my opinion, still the most important thing for us all to understand.

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Vitamin D Deficiencies and Requirements

by on March 26, 2009

In the past few days, a few articles on vitamin D have come out.  Spring is the perfect time to talk about vitamin D, since most of us are getting more sun exposure now than we did in the winter.

What did the articles say:

The first one patients will be talking about, because it is being talked about on everything from NPR to USA Today.  It found that Americans don’t get enough vitamin D (actual study in the Archives of Internal Medicine). Several commentators have brought up that the data is older and other journals have found fault with the assay technique.

Another was published on WebMd, so patients may see it too. It found that vitamin D lowers cut bone and said that perhaps the RDA needed to be raised.

Current standards set by the Institute of Medicine are 200 IU per day for children up to age 13, 200 IU per day for men and women aged 14-50, 400 IU per day for men and women aged 51-70, and 600 IU per day for men and women aged 71 and older.  The study used 770 IU daily, but the WebMd article suggests somewhere between 1,000 and 2,000 units daily.

What Pharmacists Should Know:

I do believe that Americans don’t get enough vitamin D, but I think the Annals article has been misinterpreted by the media (imagine that) in a way that could be harmful to patients.  Many of the articles that talk about the study mention the blocking effects that clothing and sunscreen have on vitamin D.

It is true that sunscreen and clothing block vitamin D formation, but they also protect against skin cancer.  It’s the “dangerous” UV-B rays that form vitamin D.  There’s no getting around the exposure.

We need to tell patients that wearing sunscreen is essential if they will be swimming, sunning or anything for a long period of time.

Sources vary on how much sun exposure you need for adequate vitamin D formation.   It also varies based on climate, cloud cover, time of day, skin tone . . . there is no one size fits all.  The low number I found referenced was 10 minutes of exposure three times a week for a person with light skin in southern latitudes.

One presentation found that, in higher latitudes, sunning yourself in the morning or late afternoon causes burning before you get adequate vitamin D production.  Sunning between 10 am and 2 pm during summer months (or winter months in southern latitudes) for 20-120 minutes, depending on skin type and color, will form adequate vitamin D before burning occurs. (Vitamin D Production by Natural and Artificial Sources).

Another caveat: eighty-five percent of your body needs to be exposed to the sun before you can make adequate vitamin D.  Not hard for those strutting string bikinis, but for most of us, exposing 85% of ourselves to the sun is an issue.

Bottom line:  You probably are not going to get enough vitamin D from the sun before you expose yourself to increased skin cancer risks or a severe sun burn.

Vitamin D From Food

I know I’m a pharmacist and I should be recommending people take a vitamin D tablet, and that can be a great alternative, but I prefer to get nutrients from food whenever possible.   That’s the way our ancestors did it.

Recommend people eat more fish, especially fish like salmon, mackerel, tuna, sardines and herring.  Fish is almost a miracle food, lean, high in omega 3s for joints, your heart, your brain.  Everyone should eat more of it.  Most milk and dairy products have been fortified with vitamin D.  Vitamin D is found in egg yolk, some fortified cereals and animal organs like liver (which our ancestors at a lot).
Take Home

These findings are believable, but do not mean that we should all strip down and run around with no sunscreen.  Eating sensibly is a far more effective way to get your vitamin D.  If you cannot or will not eat a variety of vitamin D sources, taking a tablet is a viable alternative.

If you want to learn more about vitamin D than any one human needs to know, you can check out The Miracle of Vitamin D, which is a great and well referenced article on vitamin production and utilization.  I also found a nice visual aid about how vitamin D is made by the skin and one more study (J Steroid Biochem Mol Biol. 2007 March; 103(3-5): 631–634) that showed even the sun drenched Hawiians can use supplementation.

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iPhone & iTouch Applications for Pharmacists

by on March 1, 2009

I love my iPhone and it has replaced my PDA as my source for clinical information.

Here are some of the programs I find most useful along with some of the programs that my retail pharmacist colleagues find useful too.  I’ve also tried to include some things geared towards students.

Drug information:

  • Epocrates (Free-$149): Probably not the best iPhone drug info software, but more than sufficient for most practitioners.  The free version has interactions and drug information.  The paid version ($149/year) has a bunch of added stuff, including IV compatibility and treatment guidelines.  I use Epocrates free and have never found anything I didn’t need at hand.
  • Lexi’s ($119-299): Lexi’s paid version has information superior to Epocrates paid version and not much more ($119-299), however I do not have either on my iPhone.  For a student, Lexi is a must have. It has great information.  For a practitoner, it may information overkill, depending on how comfortable you are.  I get by fine with just Epocrates Free.
  • Drugs.com iPhone Application (Free): A bit clunky at times, this is a great, free secondary resource.  It depends on the Internet, so it can be slow.

Clinical Information:

  • Skyscape (many different apps, range in price): Skyscape makes some of the best software for handheld devices. It’s elegant, easy to use and it all works together.  I fell in love with their Labs 360, which gives detailed information about almost every lab test a hospital can do, as a student, and even though I barely use it now it is still on my iPhone.  They also have clinical guidelines and diagnostic guides for almost every speciality.  Their DrDrugs is ok, but I wouldn’t recommend it over Epocrates.  In order to download any of their software, you must download the Skyscape Medical Resources Application (Free) that contains Archimedes (a calculator), RxDrugs (drug info) and MedAlert (med alerts).
  • ObWheel (Free):  Simple application, but works great.  For those who need more full featured application, Perfect OBWheel is only $1.99.
  • MedAbbreviations ($0.99):  The 0.99 application is just fine.
  • ICD9-Lite (Free): Best free ICD9 application.
  • Australian Therapeutic Guidelines ($9.99 for iSilo + subscription fees): Therapeutic Guidelines for everything from antibiotics, analgesia, cardiology, neurology and more.  These have high reviews but since they’re Australian, I’ve never referenced them.
  • PubMed OnTap (free-$2.99): Search pubmed.  The free version only returns 5 results.

Calculators/Charts:

  • MedCalc (Free): Medical calculator with large selection of equations.
  • Vaccines (Free): Vaccine schedule.  DoctorCalc also has a patient tracker (not that great, imho), ACLS guidelines, sedation guidelines and more.
  • CardioCalc (Free): Calculations specific for cardiovascular disease.


For Students:

  • ECG Guide ($4.99): Great cardiology application for those who read EKGs, but not frequently.  I know pharmacist don’t normally read ECGs, but I keep this on my iPhone because I work in a cardiac facility and it’s good to at least pretend I remember that unit from Pharmacy School.  It gives you quizzes and info on what various rhythms look like.
  • Netter’s Anatomy ($39.99): Netter’s Anatomy allows you to carry the bestselling reference for human anatomy on your iPhone or iPod touch. Navigate through images with the flick of a finger, pinch to zoom, and tap to test your knowledge of muscles, bones, vessels, viscera and the joints. Use study mode to explore images at your own pace and quiz mode to test yourself on what you know. Modality also makes USMLE flashcards for your iPhone/iPod touch.
  • Lytes ($2.99): Easy to use program that lets you enter an electrolyte imbalance and then tells you reasons for the imbalance and how to correct it.

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Basic Pharmacy References – Stuff You Should Already Know

by on February 23, 2009

This section is mostly for students and it’s things I bookmarked when I was a student. It’s very basic information, but I hope it helps someone.

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Drugs in Pregnancy & Lactation

by on February 20, 2009

I don’t see many pregnant patients where I practice so some of the most unnerving questions I get are about pregancy and kids. That’s stuff that I can never remember and you don’t want to take the chance and guess.

My favorite reference is probably SafeFetus. It has information for professionals and consumers and it is quick to reference.

For Professionals

There are literally hundreds more, but I won’t list them all. The point of this site is to share the best references I’ve found, not the MOST references I’ve found. If you have a favorite that I’ve missed, please comments.

For Patients

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