Category Archives: Nutritonal Supplements

Why the Pharmacy OTC Section Will Be a Growing Target for Evidence Based Medicine Trolls
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The front store of the pharmacy has traditionally been where the pharmacist and patient relationship grows to a level beyond where it would be with just prescription counseling alone. It affords to pharmacists a selection of products that empowers the lay public to take some sort control of their health in almost any way they choose. With certain selective issues (or perhaps a wider selection in their minds), they can bypass the waiting room of the physician, the poking and prodding, the embarrassing questions, the waiting at the pharmacy counter – all gone with just a wave of the hand from the OTC aisle to the pharmacist peering down to you from his or her stoop in the dispensary.

The general public questions this type of medical treatment very little, partially because of the level of trust that is consistently demonstrated towards pharmacists, or perhaps because most of what is available to choose from in this realm has been virtually unchanged in its ingredient list for decades. In fact I am willing to bet that if I were to walk through the aisles of my neighborhood pharmacy on the day I was born nearly 50 years ago, aside from a few struggles with brand names and a few recognized products that have been discontinued, the ingredient list on most items in the entire store would be much the same as my store today. This brings with it a level of trust in these products by the public, sometimes a false sense.

Back then many of these products were put there in the front store without a whole lot of randomized placebo controlled double blinded/crossover trials (RCT’s) that brought most of the prescription medications to market and back 50 years ago there was little debate as to their effectiveness. The pharmacist recommended it and you took it and it worked. That was that. The path that each product took to land on the shelves of your pharmacy each has a story and history of their own.

There is a growing concern that pharmacists are now selecting items for patients that have little backing scientifically. For example, one of these families of products, known as homeopathic, is one of them. Back 50 years ago you may have even spotted one of these in your neighborhood pharmacy. Now before I go any further I’ll end your guessing of my views of homeopathy: I don’t think it really does much of anything for anybody. For those of you still reading, because you’re in agreement of that last statement, just hold on a second. If we are slamming this mode of treatment because we feel the studies don’t back it or because there is nothing in the actual dosage form, that is fair enough. The supplement aisle is another category that brings about much criticism, and for the record, I have a different belief in this category (just not fanatical in like everyone should have all of them). But as “evidence based” practitioners, in all fairness we need to apply this to the entire store.

Applying our strong standard of evidence to everything else, we look with our magnifying glass at all other products: cough medicines, constipation relief, lice remedies, pain relief selections, antacids and reflux relief meds, skin creams, acne relief, teeth whitening (ok maybe not available in the 60’s), hemorrhoid relief, bug spray, lozenges, lip balm, and lots more. Can you quote or summarize the randomized controlled history for these categories? Perhaps can you find evidence against what you are recommending that product for? Acetaminophen for lower back pain? Cough syrup for someone with a common cold. You can check out a fuller explanation of these categories here .

So getting back to our original claim slammed against us: Why do we sell these items that obviously have some doubt as to their effectiveness? As a pharmacist I am always striving to supply what people want to use for their health as long as it does not harm their health in taking it. Secondly it should be effective. The order of these two is important. My community wanted organic food so that’s what I got in to sell at the pharmacy. Removed 12 feet of magazines and replaced it with organic, gluten free, non gmo. Does it harm them? No. Is it effective for what they are taking it for? Maybe. Maybe not. But it does not harm them.

When Cold FX was going through it’s court case on the claims it was making I voluntarily removed it from my shelves. When the case ruled in their favor I brought it back – much to the delight of my customers who had been asking for it for weeks and months. Is it safe – yes, and is it effective – who the hec knows. I push vaccines, but I also sell Muco Coccinum and stress that you cannot rely on that to prevent the flu or much of anything else. I sell probiotics but screen those with suppressed immune system who cannot safely take them. I ensure that it is used safely first and if it is effective for their gut health, immune health, skin health or mental health then so be it. I try to guide them with the studies I have available to me but first and foremost it must be used safely. That means the product won’t interact with their medication or medical condition or result in them omitting proper established treatment for their condition especially should it be serious or life threatening. No one should be curing cancer or treating their heart disease in this part of the store, but if they have a drug induced lowering of vitamin B12 then I’m their guy. If they are looking to prevent a cold they feel might be coming on with Zinc tablets then great (something I take).

The point of all this is most if not all of new drug research is targeted towards bringing new prescription medication to market, not OTC drugs. While it’s true that some prescription medication may trickle down to OTC status (and thankfully this should have RCT’s to back them up, which is great) not much groundbreaking in the OTC field happens for the most part. Recently I have seen a new product come out for varicose veins and one for vaginal dryness, but for the most part we are stuck with what we have out there, and it’s not an area where we test existing products on new indications, nor do we really go testing a lot of the current indications for existing products that they are sold for (perhaps with a few exceptions). Unfortunately the vitamin/supplement and herbal market is always pushing the boundaries of what science thinks will happen if you take pill A and what an RCT says. What this means is going forward we will be left with an aging pool of products, a number of which have questionable efficacy for the indication they are being sold for and a growing list of products that have the same backup. This pool may have some new additions here and there but the old standards stay around.

Complaining about a select group of these items such as homeopathy is noble, but is kind of two faced when we don’t slam other pharmacists that sell all the other products that have similar lack of actual evidence to back them up. Particularly when the pharmacist is following the law. Being a pharmacist is not being a doctor. We can now prescribe for minor ailments in my area, but the pharmacists today didn’t invent this front store they have available to them. A pharmacist’s recommendation may not always be the same as a doctor’s recommendation, or the same as another’s recommendation, but it should be as safe.

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The Continuum of Evidence Based Medicine
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image002Should Pharmacists be blasted for selling what some call alternative therapies or products that are not “evidence based”? These criticisms can blindside unsuspecting Pharmacists trying to do what they can for their patients regardless of the fact that they are making a profit from it or not. What makes it more difficult is the way in which these criticisms are delivered, especially when delivered in an offensive type of online statement like most opinions are delivered today. It makes one grow thick skin if they wish to continue. As a pharmacist myself, I can reflect on the strong personal feelings we have towards our patients, especially in small community pharmacies. Not that many other health care professionals don’t have this deep feeling of ownership in their patient’s heath, it’s just that as pharmacists, the frequency we see these people is just so much higher, either in person or on the phone. We are one of the most if not the most accessible in their health care team and we answer a lot of questions from them, gladly.

Not only are we seeing these people regularly for health related concerns, but we also see them in passing when they need milk or a greeting card. In short, they feel and we feel like we see them more than some of our own family members sometimes. Couple this with the utter vastness of concerns this patient has and relies on us for.

Quite often these questions fall within the 80% of questions we hear every day. Prescription medications, interactions, side effects, screening what should go on to the doctor and what doesn’t need to, and OTC issues like supplements, cough and cold, pain relief, skin ailments, self treatable infections of all kinds, preventative measures, weight loss advice, and many more. During Med Review interviews, we uncover medical issues not being addressed fully or at all. There are medical issues that are treated in ways that the patient would prefer were treated a different way, either due to current side effects, potential side effects, interactions, or for the simple reason that they just want to be on fewer medications.

Now some may consider this an environment that sets up a scenario for a trap of giving the patient something that hasn’t been proven with studies of thousands and thousands of test subjects in randomized controlled trials. There has been no drug rep with glossy handouts showing graphs and impressive relative change overshadowing a less impressive absolute change in results. Perhaps the pharmacist has no idea of any studies that might exist for anything at their OTC disposal, no numbers needed to treat are at their fingertips (however unimpressive even Rx values for NNT are).

The truth is, a lot of these OTC treatments, even though we are taught them in Pharmacy school as recommended treatments, don’t have all that much in the way of studies to prove they work as I pointed out in a previous blog . This starts the slippery slope of evidence based to non evidence based medicine. This is a continuum rather than a conscious switch. As pharmacists who see the direct results of these recommendations daily, we begin to realize what the term “evidence based” means. It includes the evidence they see every day. Some refer only to large centre, many subject, randomized controlled trials for their definition of this term. Of course this is the basis of our scientific and medical knowledge and has extended lifespan many years. These people however may also recommend some things in what is known as off label use of some medications where the evidence is less plentiful. This is outlined in a recent blog: http://stonespharmasave.com/blog/?p=796 . The statistical method is a gift that helps us weed out chance encounters from truth (http://stonespharmasave.com/blog/?s=statistics ) . Anecdotal evidence can be notoriously prone to incorrect conclusions as it sidesteps statistics in its conclusions. Sometimes we just don’t have these studies available to us and must rely on smaller studies or a physiological basis for a recommendation.

I see this with topical pain compounding all the time. Repeated successful results with a scientific basis and numerous small studies and numerous anecdotal reports drive more recommendations and more feedback. This spreads to physicians that may be skeptical on how these products work. With one patient with a favourable results they become more comfortable in writing again. If a patient tries a prescription medication and it doesn’t work is the Doctor a quack?  Of course not.  Evidence based becomes what you see before you in your little world, regardless of what online bullies think, as long as your first priority is to keep the patient safe.

 

Graham MacKenzie Ph.C.

Stone’s Pharmasave

Baddeck N.S.

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In Case You’ve Just Thrown Out All Of Your Supplements.
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Just in case you are being drawn in by the overwhelming attempt to draw you away from anything that is labeled as a supplement, be weary of one red flag: a claim that “there are no studies showing any effectiveness”. No studies. Not even one. Not a single, solitary inkling of any positive outcome in any way, from any dose or for any medical benefit whatsoever. And this is for a multitude of molecules and a whole list of medical conditions. Imagine the possible permutations. How many combinations of supplements and medical issues are possible? It boggles the mind. And not even one slight benefit from any one of these naturally occurring entities – regardless of what we are eating. The one exception is when a Physician diagnoses a deficiency based on the pooled data of all sick and well patients’ blood levels.  It almost seems impossible to believe.

Equally difficult to believe is the incredible effort that is out there to make people believe this. In social media it is hard to estimate how little of one’s mind is actually firing when we read article after article. What part of the brain that deals with reasoning and logic is getting numbed with this type of activity. Who knows? In any case there are many that take advantage of this and take an unsuspecting reader by the hand, down the garden path and have them walk away with an opinion that they normally wouldn’t.   The same authors, over and over again pen an “evidence based” look at supplements. These articles hand-pick studies, many of them well done, to pad their argument. They may claim that you are falling to the charlatans that are looking to grab your money for the promise that you will live longer. Is it not strange that we have list of people that are always are for or always against supplements? Beyond, rickets, scurvy and beriberi we should be ok. With the exception of B12, Iron, Folic acid, Calcium and maybe thiamin, we have found there isn’t much use in supplementing beyond the normal standard North American Diet (which we all know is stellar to say the least).  Our staggering increase in obesity rates suggest this way of eating has unhealthy issues.   Consistently this is done without even a small open window of the opposing side having any effect at all.

Don’t get me wrong. There are those who exist at the other end of the spectrum as well. The ultra gurus that give supplements a bad name by overselling any supplement to anyone that will buy one. Neither side is being truthful, or helpful to the overall health of the reader. Our scientific method has proven over hundreds of years to be a good system of separating chance from true cause and effect. Although not perfect, it works like a puzzle in that the more pieces we develop from well designed and executed studies, the better an overall picture we get. Some pieces frustrate us because they seem to go against previous pieces. We try to explain everything based on one piece, or a few recently found pieces. This only leads to frustration as we claim to be experts on the more recent studies that seem to completely discount anything earlier. Some find it hard to try and explain studies that don’t gel with their opinion. Rather than trying to explain how it is part of the whole picture, they discount it as a bad study. To further cloud the argument, there are statements of supplements that don’t have what they claim on the label, or contain ingredients that shouldn’t be in the supplement. There are issues of hospitalization, side effects and interactions with supplements – all true, but take away from the argument of the actual supplement doing what it is claimed to do.

Take for example the case of the supplement known as Omega-3. As of late the “unbiased” forum has been quite active in trying to deter anyone from trying it for whatever reason. Well written articles too. And they aren’t really lying for the most part. Well for the most part. Studies are out there that claim Omega 3 isn’t good for heart attack prevention, for cholesterol, but use painfully low levels of omega 3 and claim that omega 3 is useless when no effect is found. This effect is compounded when incorrect titles are put on the study and carried on in the media.

So, to even out the argument, the studies that didn’t exist in these one sided, unbiased, “stay away from your pharmacist trying to sell something they are recommending so it must be bad” stories include these:

 

Omega 3 and cardiac sudden death

Cardiovascular risk and the omega-3 index. von Schacky C, Harris WS. J Cardiovasc Med (Hagerstown) 2007;8 Suppl 1:S46-9.

 

Blood levels of long-chain n-3 fatty acids and the risk of sudden death. Albert CM et al. N Engl J Med 2002;346:1113-1118.

Dietary intake and cell membrane levels of long-chain n-3 polyunsaturated fatty?acids and the risk of primary cardiac arrest. Siscovick DS et al. JAMA 1995;274:1363

 

Omega 3 and cardiovascular disease

http://www.medscape.com/viewarticle/764574

 

Omega 3 and pain relief, inflammation

http://www.ncbi.nlm.nih.gov/pubmed/16531187

http://www.ncbi.nlm.nih.gov/pubmed/9028717

http://advances.nutrition.org/content/2/4/304.full

http://www.ncbi.nlm.nih.gov/pubmed/18362100

http://www.ncbi.nlm.nih.gov/pubmed/16531187

 

Omega 3 and autoimmune

http://www.ncbi.nlm.nih.gov/pubmed/12480795

 

Omega 3 and Child behavior/Spelling in school

.http://pediatrics.aappublications.org/content/115/5/1360

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0043909

http://www.medscape.com/viewarticle/808285#vp_1

.  http://www.ncbi.nlm.nih.gov/pubmed/23056476

 

 

Omega 3 and insulin resistance

http://www.nature.com/srep/2014/141021/srep06697/full/srep06697.html

http://www.ncbi.nlm.nih.gov/pubmed/3320694

http://www.ncbi.nlm.nih.gov/pubmed/18348080

 

Omega 3 and dyslipidemia

 http://www.medscape.com/viewarticle/764574_3

  http://www.medscape.com/viewarticle/789642

 http://www.medscape.com/viewarticle/764574_3

http://www.ncbi.nlm.nih.gov/pubmed/19356403

http://www.ncbi.nlm.nih.gov/pubmed/21684546

 

 Omega 3 and anticoagulant and anti arrhythmic

 http://www.medscape.com/viewarticle/789359

 

 

So keep in mind that if we knew all there was to know about just this one supplement, there wouldn’t be a need for any further studies on it and we would all be experts on it. The truth is somewhere in between those that claim supplements are the thing to replace all conventional medications and everyone needs them all , and those that claim supplements are completely useless. To claim that it is just iron, B12, Calcium, and folic acid are the only necessary supplements makes very little sense given the vast knowledge we have from years of scientific study.

 

Graham MacKenzie, Ph.C.

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Your Pharmacy is Most Likely an Alternative, Complimentary, Off Label, Patient Centred One
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Most Pharmacists rely on the foundation that their “evidence-based” mantra is being followed. A simple Google search shows us that:

“Alternative medicine is any practice that is put forward as having the healing effects of medicine, but does not originate from evidence gathered using the scientific method, is not part of biomedicine, or is contradicted by scientific evidence or established science.”

Just in case you were wondering, Google defines biomedicine as “a branch of medical science that applies biological and other natural-science principles to clinical practice. The branch especially applies to biology and physiology”.

This last one is important as we shall see, because it opens the window for recommendations to be made even in the absence of placebo controlled randomized trials (but yet remain outside of the realm of alternative medicine). It allows biochemistry and physiology and biology to guide recommendations to patients, even though direct studies on humans measuring an effect compared to placebo are lacking. For example, if you are thirsty, drink water or you will eventually die. There really are no such studies to prove this but we believe it anyway. Fair enough. Let’s agree on this for a minute or two as we look at our “go to” recommendations we do every day in the pharmacy.

In 2012 the International Journal of Pharmacy Practice published a research paper that looked into the effect of evidence-based training on Pharmacists everyday recommendations. It found that Pharmacists did not routinely utilize evidence-based resources when making decisions about OTC medicines and some felt uncomfortable discussing the evidence-base for OTC products with patients. (1)

In fact most pharmacists go by three things when making OTC recommendations, what they were taught in school (since most OTC ingredients don’t really change all that much from year to year or decade to decade), what they learn through continuing education and what they see works in their patients over time (also known as clinical experience). This is why I gave up recommending OTC teeth whitening products.   I do however recommend specialized toothpastes for sensitive teeth even though I have never read one independent RCT on either subject – because I routinely hear results from many customers. (2)(3)

These are simple recommendations that on the surface seemed to be a great idea. Not that the success of OTC teeth whitening grew into an urban myth to me but it really didn’t seem right to recommend something I had no scientific proof to back me up and make a profit on it plus lacked the positive feedback from my customers. Perhaps that is alternative therapy?

It’s part of every retail pharmacist’s day, stepping out from behind the dispensary counter and making recommendations that draws from the vast pool of for the most part, unchanging static list of ingredients in the front store. I draw a fair share of comments that claim some recommendations I make are “alternative” or “complimentary”, sometimes referred to as CAM therapies. The definition of this term seems to change with whomever makes up the argument. Some arguments against CAM are certainly legitimate, and some include categories that show some effectiveness but are not mainstream. Some involve treatment, cure or prevention of Health Canada Schedule A disorders, which include many conditions that we try to help daily – we just can’t advertise the products as such. They include obesity, hypertension, diabetes, acute anxiety and others. Either way, there are some regular recommendations made by Pharmacists daily that said Pharmacist assumes is proven to work based on mainstream suggestions, but are you making recommendations based on the same science that backs up the prescriptions you hand out daily. Furthermore, if these therapies do not meet these same evidence based standards, are they automatically shuffled into the CAM category or is there another category they might be moved into? Perhaps urban myths make mainstream otc pharmaceutical suggestions.   Lets look at what the current literature says about common therapies. Are there any studies at all that back up what you are suggesting to your customer as fact? If there are studies, do they have the power to the same? If not, what is your rationale for making these recommendations and at what point do we call the recommendations as alternative or not evidence based. In fact, pharmacists do not always rely on the definition of evidence based in making an OTC recommendation.

Cough Therapy

Turning to the Cochrane Data Base, there are a few reviews for common OTC cough medications. In reviewing 29 trials involving 4835 people (adults and children – studies were current up to March 2014), the Cochrane Library stated “ We found no good evidence for or against the effectiveness of OTC medications in acute cough”.  In a 2006 statement, the American College of Chest Physicians stated that its recommendation for cough due to cold was to treat with an antihistamine/decongestant combination. (4)(5) Also, the findings of using codeine or antihistamines for cough showed neither was superior to placebo. A study in the Archives of Pediatrics and Adolescent Medicine found that in Parent reported cough response to buckwheat honey, a DM cough syrup flavored with honey and a placebo, the honey alone treatment was superior to the DM syrup or the placebo in children. (6)(7) Popular cough syrups that use pine needle oil and Canadian Balsam in a capsicum tincture are popular in all pharmacies but lacking evidence.

 

Narcotics for pain

Marketing by drug companies has been quite successful in the widespread use of narcotics today. In fact when various types of pain are treated with opioids, NSAIDS, and acetaminophen, narcotics’ recommendations often fall at the bottom. Dental pain, while often treated with narcotics, has been shown by the Cochrane Database to be treated more effectively with combination ibuprofen and acetaminophen and back pain has also been shown to have more favorable outcomes when treated with non-opioid medications. (8) Historically pharmacists police OTC meds, sometimes blind while trying to keep patients restricted to a days supply. This is now going to be easier with the dawn of the Drug Information System (DIS) in Nova Scotia, giving more real time data than the triplicate prescription monitoring system. Logging in OTC codeine products allows pharmacists to see in real time the profile of the patient at other pharmacies that are also on the system.

It is becoming more and more clear that opioids are to be the exception rather than the rule when it comes to most pain relief. Terminal conditions involving pain are a clear indication for opioids. The numbers needed to treat are typically higher in the opioids compared to the non-opioid medications and in acute pain to chronic pain conditions the opioids are not preferred unless absolutely necessary. Jumping to OTC codeine has not proven to be the answer with most patients based on science.

 

Antacids

Next to cough and cold, and analgesics, acid suppressing agents are a main staple in a pharmacist’s OTC toolbox. Three main categories are antacids, H2-blockers and PPI’s, all available OTC. Most pharmacists may be under the impression that when these are given, they help neutralize acid in the stomach in their own way and relieve reflux symptoms, and that’s that. It turns out these three medications have differing effects that must be kept in mind to help the patient. Antacids have a role in neutralizing acid in the esophagus transiently but do not significantly affect the pH in the stomach. As a result it has been found that in cases of chronic heartburn, repeated administration of antacids commonly result in erosive esophagitis. For this reason it is important to recommend them only in cases of GERD that is temporary or intermittent in nature and to realize that ulcer healing will be minimal. With the H2 blockers, there is a tolerance that can develop rather quickly with these medications that unfortunately is not dose dependent and there is also a secondary analgesic effect on the tissue of the esophagus. (9)

The key in OTC recommendations is recognizing the strengths and the limitations of each of these medications. Simply giving an antacid for a patient with “heartburn” without knowing the exact details of frequency goes against the indication for that suggestion. Monographs for these medications state a six week course and should not be used long-term for acid suppressing agents. It is important to not continue to give antacids too frequently in order to prevent further damage to the esophagus. In fact there is no evidence to support long-term treatment with H2 blockers or PPI’s.

 

Head Lice

While it was something pharmacists had suspected for years, it has now been shown in clinical trials that the effectiveness of the pediculicide known as permethrin has dropped from 99% in 1996 to 25% in 2009. In 2010 this effectiveness was estimated to be 18% as opposed to 46% for isopropyl myristate, which is now a popular alternative for head lice. This is a case of staying on top of current literature.   (10)   Although something may have been proven to work before, it may not have the same effectiveness now and is continued to be used assuming older data is still appropriate.

 

Chronic Constipation

One of the most commonly recommended laxatives for both occasional and chronic constipation as well as narcotic induced constipation is senna. There are no well designed randomized placebo controlled trials for senna and for the most part I think most pharmacists are unaware of this and go by clinical results in making this recommendation. Also no known studies comparing stand alone efficacy of docusate over placebo exist. Fiber, fluids and exercise show surprisingly little results unless the patient is deficient in any of them. (11)

One of the common arguments against alternative therapy is not so much a lack of studies, but a lack of what is considered quality studies by the one against alternative therapies. Sometimes it is what the majority of us do that removes something from alternative. While there are no lack of studies on nicotine replacement therapy OTC in smoking cessation there are many limitations to many of the studies (12). This is a common argument against treatments that are considered alternative.   At some point however we need to treat somehow and we see clinical results, based on science (RCT or biology) and we use this to guide our recommendations safely.

 

Having said all this, the point is from our experience most over the counter meds really do work for their intended uses. If we required iron clad prescription drug quality studies to flip through on all of our front shop recommendations, we may very well cut the front store medicine section in half, not to mention the prescription medications that are prescribed off label. Certainly a lot of the cosmetic anti-aging and skin cream products would fall away. We also must remember that although we counsel based on past results with patients, we still make recommendations based on our education. Being against alternative medicine, whatever your own definition, may mean supplements, nutraceuticals, hormone therapy or herbal products to you. Maybe you consider selling vitamins as alternative. Some bad examples of irresponsible alternative therapy have painted all therapies with the same brush, and some reported side effects and hospitalizations of patients using alternative therapies fail to mention hospitalizations of patients on conventional medicine. As pharmacists, we value what is considered modern medicine but it’s not all that is out there that works. We must be considered the drug expert in all therapies, whether they are proven and safe to completely unproven and unsafe and everything in between in order to make an informed recommendation. Perhaps “evidence based” is a point we try to achieve but never completely reach until we change our definition of what it is. Based on how we defined alternative medication at the start of this article, perhaps alternative therapies are not as uncommon in pharmacies as is claimed by those that are against them.

 

 

 

 

References

 

1) Lezley-Anne Hanna and Carmel Hughes; The influence of evidence-based medicine training on decision-making in relation to over-the-counter medicines: a qualitative study; International Journal of Pharmacy Practice Volume 20, Issue 6, pages 358–366, December 2012

2) Demarco FF, Meireles SS, Masotti AS. Over-the-counter whitening agents: a concise review. Braz Oral Res. 2009;23 Suppl 1:64-70

3) Ilze Maldupa, Anda Brinkmane, Inga Rendeniece, Anna Mihailova ;Evidence based toothpaste classification, according to certain characteristics of their chemical composition ; Stomatologija, Baltic Dental and Maxillofacial Journal, 14:12-22, 2012

4) Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD001831.

5) Smith SM, Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev. 2008;(1)

6) Paul IM, Beiler J, McMonagle A, Shaffer ML, Duda L, Berlin CM Jr Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents Arch Pediatr Adolesc Med. 2007 Dec;161(12):1140-6.

7) An De Sutter. There is no good evidence for the effectiveness of commonly used over-the-counter medicine to alleviate acute cough ; Evid Based Med 2015;20:98 doi:10.1136/ebmed-2014-110156 Systematic review

8) Dr Donald Treater M.D. Evidence for the Efficacy of Pain Medications. National Safety Council (NSC.org)

9) McRorie, J. W., Gibb, R. D. and Miner, P. B. (2014), Evidence-based treatment of frequent heartburn: The benefits and limitations of over-the-counter medications. American Assoc Nurse Prac, 26: 330–339

10) Sanofi-Pasteur , Evidence Based Management of Head Lice 2014

* (Sanofi-Pasteur is a manufacturer of ivermectin lotion)

11) Lawrence Leung, MBBChir, FRACGP, FRCGP, Taylor Riutta, MD, Jyoti Kotecha, MPA, MRSC, and Walter Rosser MD, MRCGP, FCFP Chronic Constipation: An Evidence-Based Review . Journal of the American board of family medicine July-August 2011 Vol. 24 No. 4 pp 436-451

12) Nicotine Replacement Therapy for Smoking Cessation or Reduction: A Review of the Clinical Evidence [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2014 Jan 16. SUMMARY OF EVIDENCE.

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Zinc levels and Erectile Dysfunction and Low Libido
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With the erectile dysfunction (ED) market expected to reach 3.4 billion dollars (USD) by 2019, this is a lucrative area to invest in, and not much grabs the attention of a guy watching a commercial during a Monday night football game than the promise to easily cure this problem with one pill as needed.  But is this the answer for everyone?  What causes ED?  For the guy with no apparent risk factors like depression or diabetes, hypothyroidism, injury or stress issues, erectile dysfunction or loss of libido (which don’t necessarily go hand in hand) can be confusing and frustrating for a guy as well as his partner.

What if we look at erectile dysfunction as something that can be addressed as a condition other than a “pill for every ill”.   What if we actually look at a nutrient level that directly correlates to a medical condition and follow the science to give a directive on its recommendation?  Well it turns out taking a simple zinc supplement won’t help 100% of the time, but it certainly helps some of the time.

There are two things that need to be looked at in recommending a supplement for a medical condition: what is the physiology of the medical condition and what is the pharmacology of the supplement you are using.  There then is a search for a link between the two that leads to a tie in with a therapeutic approach.  In some ways this is like a logic course that says A causes B, B causes C therefor A causes C.  We then must apply this to the scientific method and finally the ultimate test: clinical response and safety.  This is often made out to be the gold standard for our typical Rx meds that I dispense every day, but often ridiculed when it crosses the barbed wired “nutraceutical” boarder.  If it is a nutrient then we must be getting the right amount in our food after all right?  Regardless of 1)what the real amount is in the food we eat, not to mention 2)the depletion that may be taking place of that nutrient due to a prescription drug we are taking (an absolute science based cause and effect) – we blindly accept what our food has in it and the level our bodies maintain – this is an incorrect assumption.  In fact it is quite ironic that the anti-nutraceutical court is still hanging onto this assumption when both are established by science.

So what causes erectile dysfunction?  Sometimes it is a circulation problem.  Sometimes it is a low testosterone issue.  Sometimes it is not.  Testosterone (T) supplementation can help ED and low libido in cases of low T and even if there is a normal T level at baseline, ED can be helped.  In cases where thyroid under or overactivity is causing T levels to be less than optimal.  Aging is also a problem as T levels drop after mid 20’s and as adipose tissue increases and aromatase enzyme conversion of T to Estrogen correspondingly increases.  This causes an unfavorable E:T ratio which equates to low T.

When men are given supplemental testosterone it can have positive effects on erectile dysfunction as well as the “grumpy old men” syndrome of low energy, loss of drive, low libido, and loss of endurance as well as “man boobs”.  Zinc has a direct effect on the two main enzyme systems that act on testosterone: conversion of testosterone to estrogen via aromatase and the conversion of testosterone to DHT by 5 alpha reductase.   Zinc blocks the testosterone to estrogen pathway leading to more testosterone.  It turns out that only at really high zinc levels does zinc inhibit the 5 alpha reductase enzyme so when we give mild to moderate zinc supplements, DHT actually increases because there is more testosterone to feed into this pathway.   This actually benefits things because DHT has 2-3 times the times the androgen receptor affinity than testosterone.  In any case, we see an increase of testosterone and androgenic activity from DHT with zinc supplements and whether a guy has low or normal T to begin with, there is a positive change in erectile dysfunction and libido in some men due to the increased androgenic activity and less estrogen pulling in the opposite direction.  Conversely we see testosterone levels drop when a diet is low in Zinc as well as a drop in DHT.  It is important to note that this effect of increased testosterone with zinc supplementation, while well established, does not always lead to an improvement of ED and increased Libido.

Clinically I have seen these results in doses of just 20 mg twice daily.   It is important to note that prolonged zinc supplementation can lead to lowered copper levels so it is not advisable to continue this therapy unless it is in a cyclical nature.  For those on long term zinc there are combination products with Zinc and Copper.   In cases where some prescriptions that lower zinc are given, like acid lowering meds, thiazide diuretics and ACE inhibitors, or in renal dialysis patients, this chronic monitoring of zinc may lead to longer term supplementation.

So, in establishing physiology, pharmacology, clinical results and safety, zinc is a good choice when you look at cost and side effect profile as well as ease of availability and interaction profile with other meds and other medical conditions.  Having said all of this, there is no bulletproof evidence out there guaranteeing that increasing your zinc consumption either in food or via a supplement will improve ED or increase libido.  Even if a patient experiences an increase in testosterone from such a supplementation, this is not a certain gateway to resolution of theses symptoms as there is more to it than just one hormone level.  However for those that are experiencing problems in these areas, it is certainly worth a try for them.  The patient should be mindful however that supplements should be treated like any other medication and trying to increase your testosterone shouldn’t be done without consultation with your doctor and pharmacist.  You should also check for any interactions with any meds or medical conditions before trying any supplement as well.

 

Khedun SM1, Naicker T, Maharaj B. Zinc, hydrochlorothiazide and sexual dysfunction. Cent Afr J Med. 1995 Oct;41(10):312-5.

 

Prasad AS1, Mantzoros CS, Beck FW, Hess JW, Brewer GJ Zinc status and serum testosterone levels of healthy adults. Nutrition. 1996 May;12(5):344-8

 

Chang CS1, Choi JB, Kim HJ, Park SB Correlation between serum testosterone level and concentrations of copper and zinc in hair tissue.  Biol Trace Elem Res. 2011 Dec;144(1-3):264-71.

 

Jalali GR1, Roozbeh J, Mohammadzadeh A, Sharifian M, Sagheb MM, Hamidian Jahromi A, Shabani S, Ghaffarpasand F, Afshariani R.  Impact of oral zinc therapy on the level of sex hormones in male patients on hemodialysis.  Ren Fail. 2010 May;32(4):417-9.

 

Michael F. Leitzmann, Meir J. Stampfer, Kana Wu, Graham A. Colditz, Walter C. Willett and Edward L. Giovannucci Zinc Supplement Use and Risk of Prostate Cancer  journal of the National Cancer Institute. Volume 95 , Issue 13 pp 1004-1007

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What’s worth more? A favorable statistical p value or clinical results?
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testpostWith the recent talk of p-values and their value in scientific journals it brings to light an important interpretive tool in efficacy of therapies, clinical experience.  P value is the chance of getting a positive response in a scientific study when there is no real effect after all, also known as a false positive.  The smaller this number, the better the certainty that what you are observing is truly an effect of what you are studying.  This number often is given as p .05 meaning that only 5% of the time would you see this happen by chance, the rest of the time it is a true effect of what you are studying.  Put another way, you can say that you are rejecting the “no effect” assumption, and come to the conclusion that drug A has effect B on the body and claim that your results are statistically significant.

This has been the backbone of science forever to determine if what you are seeing is not a fluke.  On closer examination though this value may not be as strong as we first thought.  Don’t get me wrong, it is an awesome way to reduce bias in a study and the best we have to weed this out as long as we don’t play around with this p value after our calculations are done.  What if we applied this 5% theory to a supplement that was being tested for a certain condition.  If we wanted to try 100 supplements for a given condition and only one of these supplements actually did something to improve the condition, we would find 5 supplements that appeared to help (false positives) and one extra that actually did, the one effective supplement in the bunch.  Of the six supplements you came away with thinking worked for the condition, really only one worked.  This means that out of those six conclusions that claim to help the problem, only 1 in truth really does.  You are incorrect 83% of the time in your determination of effective products even though you successfully eliminated 94 ineffective products!  Imagine, a randomized, placebo controlled trial with a p value of 0.05 with this kind of result.

Retractions of published papers also appear to be on the rise and after being involved myself this past year in a scientific study, there really is a lot of pressure felt by the authors to get published in a scientific journal.  It’s almost like a final approval by the cool kids in class and seems to psychologically give a stamp of approval on your work not only to the authors that did the study, but by the public and scientific community that will read or hear about the study.  If you aren’t published, there is almost a sense of failure felt towards the whole project, regardless of how astounding the results are.

This brings us to the world of the front line where these products are actually handed out to the public, the Pharmacy.  Many times I see products written on prescription that work exactly the way they are supposed to but sometimes they fail miserably.   Regardless of how many studies were done on a drug, if a patient paid $100 for it and it didn’t work, they really don’t care how many studies were done or what the p value was; they are out $100 and they now need to fork over more money for another product.  This doesn’t mean the studies that brought this to market were bad, it’s just that they were some of the outliers in the results that didn’t respond to the drug.

When you deal with supplements you often are labeled and dare I say it with  “alternative therapy”, you are always searching for these studies.  They are often small studies but you still look for them.  The same is true for pain compounding.  It is not difficult to be labeled a quack or a charlatan when you try to help someone that doesn’t seem to fit into the regular modern medicine model or wants to try another way first.   Nothing replaces clinical experience in determination of a product’s net worth and if studies are done correctly your results should mimic the studies you originally read.  Keep in mind that this may mean a 70% success rate as determined by the studies.   It is only when you see something work before your own eye(s) that makes you comfortable suggesting it more.  Those products that showed promise in studies and it doesn’t pan out with your patients, these products fall away rather quickly.  When you deal with people that are paying out of pocket for something, you know it is working when they come back for more to spend more money on.  I have had physicians steer away from a product because of one or two bad experiences with it with their own patients.  As always, patient safety is key with any product.  Will this therapy harm this patient based on their existing meds, allergies or medical condition?   Will it cause a dangerous delay in treatment with another more proven product?  These are important questions to as when a patient looks for an alternative medication.

Clinical experience with pain compounding creams has completely change the thinking of a lot of physicians I deal with at the pharmacy level.  Many of these doctors haven’t read even one of the studies I have on the response rate of this type of therapy but when they took a leap of faith with just one patient, then another and another, they realized the value of a therapy they were not taught in school.  When I get in my car and turn the key, a lot goes on to start the car and keep it running.  I haven’t read any studies on car engines but I do it because it seemed to work for others and it works for me for the most part as well.

False positives and subjective results can happen this way as well, but when a patient that was previously addicted to hydromorphone prefers a pain cream or an addition of omega-3 with their pain medication, it helps to alleviate thoughts that they are pretending the pain went away.   As one palliative care physician said to me, “If the placebo effect is 30% on drug X, I’ll take that kind of response rate”.  When there are doubts as to the effectiveness of a well-designed trial, clinical experience acts as an effective filter to refine one’s beliefs.

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What causes “expensive urine”? Vitamins or the Prescription drugs that deplete them?
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testpostPerhaps one of the biggest blanket statements against the nutraceutical/supplement movement is the claim that “vitamin and mineral supplements do nothing more than cause expensive urine”.  This is a claim most of us have heard before and certainly for busy pharmacists, physicians and the public in general that may not have the time to fully research the topic, a claim that might be true.  After all, we can’t be experts on everything and it’s always easier to grab a catchy headline and adopt it as our “go to” statement and move on to the next topic that may come up in counselling.

Even as a pharmacist, keeping up to date on all pharmacy topics, changes in position statements, and heaven forbid – reading a readily available study or a number of studies on just one topic is a daunting task.  Our path is made simple for us when an “expert group” comes out with a statement on the best practice guideline for anything, even if there are flaws with the statement and how they mesh with current studies.  But who is it that makes these recommendations on supplements?  No one really.  Here is an area where self-education is key.

As a disclaimer, I am one that believes in the value of carefully selected supplements and that each individual deserves a review of what their needs are for individual supplements.  This was taught to me in my Pharmacy Degree in University and I have continued to follow up on it for over 20 years since then.  Claims that I am out for a quick buck have rolled off my back a long time ago and are as baseless as a claim that I am out for a quick buck because I sell prescription medication.

In the same University level I was introduced to the fact that many if not all prescription medications can deplete us of specific nutrients, a fact that is often lost on a busy pharmacist’s thought process when filling 200 prescriptions a shift.  After all, isn’t it more important that we make sure the prescription is paid for fully by the third party plan?  Or that we comb through a profile for interactions so we don’t end up harming the patient or on a national “news” program uncovering how we missed something and caused harm to the patient?  Or maybe we are so focused on counseling the patient to make sure our job is done to the letter.  Maybe we are preoccupied with a chocolate bunny getting stolen in aisle three?  Granted these uncover important parts of a pharmacist’s job but it is just as important to review with a patient and make them aware of long term effects of the medication they are taking.  This includes nutrient depletions from taking prescription medications.  It turns out some of the side effects of long term meds may be a result of these depletions.  Some may be weary of being accused of gouging a customer for extra money when they pick up their prescription when they suggest this but there is sound science to back you up.

As always it is important to get as many nutrients from food as possible in the diet.  Due to variations in end product vitamin and mineral content due to growing conditions, food processing, storage and cooking, the final intake of these nutrients is a variable that can make it difficult to get sufficient replenishment from food alone, particularly when a depleting agent is being administered concurrently.

Some documented examples of these depletions include:

1)  Recommendation of a probiotic in a patient on an antibiotic or several rounds of antibiotics.  I have seen diarrhea cured with the administration of a good quality probiotic.  Our health begins in the gut and probiotics are the first line of protection on the lining of this organ system.  Aside from this, antibiotics have a depleting effect on a long list of multivitamin ingredients and those that have taken several antibiotics over a few years may do well to supplement even short term to replenish these stocks.

2)   Oral contraceptives – how many of your patients are on these? Of these patients how is their diet?  Magnesium depletion that can lead to thrombosis, breast cancer protecting selenium that can be depleted, folate depletion leading to neural tube defects in newborns either in OC failure or when a woman comes off an OC,  B2 depletion that has been shown to cause headaches – a side effect we often see from OC’s, B6 depletion that can lead to decreased serotonin and altered mood in OC users, not to mention B12, vitamin C, E and zinc depletion are all shown to be significant in OC users.  http://www.europeanreview.org/wp/wp-content/uploads/1804-1813.pdf

3)  Statins – perhaps one of the most famous depletion in this group of drugs is the CoenzymeQ10.  This depletion was so recognized in early trials of the statins a patent was actually given for a combination statin and CoQ10 product, which was never used.  http://www.functionalmedicineuniversity.com/statin-CoQ10.pdf  Endothelial stabilization and a decrease in the inflammatory cascade are shown with higher levels of CoQ10 and this is precisely what elevated cholesterol levels cannot use in a plaque formation.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2671099/     http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4176102/    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3271709/

The presence of the muscle pain in statin use has also been tied in with CoQ10.  More studies would be helpful in completely putting this to rest as would vitamin D level depletion statins and muscle pain connection.

There are many other examples of nutrient depletion from medication use.  These include ACE inhibitors, Chemo drugs, anticonvulsants, NSAIDS, antidepressants, antipsychotics and many more.  A more complete list is included on our website to give a starting point for recommendations at http://www.stonespharmasave.com/drug_depletions.html

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Rebuttal of MacLean’s Article on Vitamins

Nothing wakes up my sense of rebuttal more than an article that tries to sway the population in a way that misleads them.  After a stint away from writing on my blog to cover some more important issues (not that writing on a blog is unimportant) with my Pharmacies, this article was revealed to me.  Entitled, “The Hard To Swallow Truth About Vitamin Pills”, it was a scathing, one sided, article in MacLean’s magazine by Christopher Labos, a cardiologist and medical journalism freelancer.

http://www.macleans.ca/society/health/the-hard-to-swallow-truth-about-vitamin-pills/?utm_content=bufferf2b2d&utm_medium=social&utm_source=facebook.com&utm_campaign=buffer

I find it amusing how day in and day out my customers refer to pharmacists as “medication experts”, after all we did study nothing more than drugs and drug monographs for years in school; yet when a physician speaks about anything I am “an expert on”, it automatically trumps my opinion.  Is the issue we can’t be trusted because we sell something we are recommending?  To be clear, vitamins and minerals are no different than any medication I give out every day, otc or rx.  In the Canadian accredited University I went to, Dalhousie University, we spent hours upon hours listening to lectures on evidence based vitamin information and therapeutics – because it would be us as pharmacists that would handle the questions and recommendations on that topic.  Physicians are in a group of the most educated people this country has and we owe our lives to their expertise.  Vitamins however are not part of that expertise.  As written by a physician, this article refers to scurvy and rickets right off the bat.  This is the focus and extent of vitamin education in med school.  It also acknowledges the selected use of folic acid, B12, vitamin K and iron (not a vitamin but we can include minerals in the discussion all the same).  Essentially, one would take away from this article that no other deficiency exists.

There is an elementary discussion of water soluble vitamins not being stored and fat soluble ones being over-stored and a colorful graph of the alarming amount of dollars the United States spends on vitamins – which supplies nothing towards proof of what vitamins do or don’t do, just alarm the reader.  There is also a fear mongering claim that “vitamins might actually increase people’s cancer risk”.  Now there is a media savvy way of grabbing attention.  Any pharmacist knows that beta-carotene is not to be used in smokers as it increases cancer risk.  This article points that out but leaves the reader still thinking, “wait a minute, vitamins can cause cancer”.  There is also the statement made that high doses of Vitamin E are linked to prostate cancer in men.  The proper educational remark would be that Vitamin E is a mixture of 8 stereoisomers (tocopherols and tocotrienols) and that most if not all studies of “Vitamin E” use just one: d-apha-tocopherol.  It’s like a “hormone” study using medroxyprogesterone and calling it a “progesterone study”.  This is why I give the mixed form of Vitamin E when asked by a customer.

The gamma and delta tocotrienols of this antioxidant have shown anti proliferative effects against breast cancer, liver cancer, colon cancer, gastric adenocarcinoma, prostate cancer (yes prostate cancer) and lung cancer and are actively involved in apoptosis (programmed cell death that is key to preventing cancer from developing).  http://www.ncbi.nlm.nih.gov/m/pubmed/25480449/

http://www.biomedcentral.com/content/pdf/1472-6882-14-469.pdf

This was not mentioned in this article that clearly had an agenda to psychologically sway the reader into thinking vitamins are deadly.  The key point that was missed was that medications need to be taken correctly to work in a beneficial manner.  Not only does vitamin E, when used correctly not cause cancer, but it helps treat some cancers.  The article also states that a dose of 400 IU of Vitamin E is 20 times what you get with your diet and 20 times more than you need.  This assumes we all get the exact amount of vitamin E from our diet every day, which coincidentally is the exact amount of Vitamin E you need as per what the Canadian Recommendations say.  Dietitians of Canada recommends that most Canadians can get the Vitamin E they need from foods

http://www.dietitians.ca/Your-Health/Nutrition-A-Z/Vitamins/Food-Sources-of-Vitamin-E.aspx

This is true, but are they getting that level?  In fact there are claims now that the average US citizen gets exactly half of the dietary reference intake of this vitamin especially in the elderly population and there is no mention of causes of vitamin E depletion or causes of depletion of any micronutrient that requires supplementation for that matter.

The claim that Vitamin C has no protective effect on cancer is very misleading as there are studies out there that claim the exact opposite for various types of cancer, but no benefit for others.  http://ajcn.nutrition.org/content/53/1/270S.long

A physician owes it to the population to present a fairly discussed topic and not one that paints vitamins with one brush in all cases.

Graham MacKenzie Ph.C.

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6 Medications you should revisit with your doctor
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imageModern medicine is a field that involves following guidelines. As pharmacists, we see a lot of repetition. Eighty per cent of our day seems to involve the same classes of drugs as the previous day. With added pressures of extra duties over the last few years, it can become a busy environment where you struggle to remind yourself of the clinical nature of your job. This includes the possibility of discussing with patients whether the medication they’re picking up is still appropriate for them. Here are common examples of medication groups that are worth reviewing with your patients.

Acid lowering medications (PPIs, H2 antagonists) I put this first because at least half of your patients have probably been taking one for more than the recommended six weeks. The human body was not designed for chronic gastric acid suppression. If you look back you will probably see that this patient has been on this medication for years. Nutrient depletions with this class include beta-carotene, boron, calcium, chromium, copper, folic acid, iron, phosphorus, selenium, thiamin, vitamins B12, C, D, E, K and zinc. It makes it hard to maintain bones, digest food, absorb nutrients, activate digestive enzymes and maintain normal flora in the gut. A new study shows an increased incidence of interstitial cystitis in patients on this long term. You might better solve the patient’s heartburn by removing the offending food agent or, perhaps, decreasing gastric pH in order to increase lower esophageal spincter tone. They may feel awful if they come off it too quick, so I suggest slow tapering. In a televised interview, I explained how to use the acid increasing theory to treat heartburn:

OTC codeine products Here is a product line I wish would go away or be moved to prescription status. I can’t recall any of the many customers that get this product that are new to it. The volume of acetaminophen alone is probably harming their liver, but the addiction to codeine leaves the pharmacist as a police officer and judge as to when they got it last and why they are on it in the first place. In an email I recently sent to Health Minister Rona Ambrose, I urged her to rethink the status of this medication and shared a discussion I had with NIHB on how they were concerned about the addiction from this class on the native population. Unfortunately, I received an impersonal form-type letter back that attempted to educate me on the various drug classes in the country and how they felt all was well with this type of medication as far as a risk/benefit ratio goes. For now, we keep patients to 100 tablets every two weeks, maximum, and this is a population that does not want to talk about their use of this medication. I often find it helpful to discuss their pain or use of this drug.

Daily ASA therapy Twenty years ago, this therapy was certainly in vogue. In fact, even today it is a valuable tool for those at risk of a heart attack. It is one of my favorite medications that became famous without any real studies to back it up and is probably the most off label use medication in use today and is recommended by position statements from various groups. There are, however, many out there that just put themselves on this medication without first seeking the advice of their physician. If your patient has had a heart attack or is at risk of having one, has had a stent put in or bypass surgery, has coronary artery disease, is over 50 or 60, respectively, with high blood pressure or is a diabetic who smokes, then they should be on this therapy. Otherwise, the risk of bleeding versus the benefit of reducing a heart attack is not generally worth it, not to mention the risk of kidney damage from chronic ASA administration. If you fill this prescription or see your patient buying it, you may easily uncover the good from bad reasons they are taking it and steer them to their physician for a re-evaluation. They may have just been put on it years ago for no good reason.

Sedatives (sleeping pills, anti-anxiety medications) Whether it is for sleep or anxiety, these medications are ubiquitous. We may not know why the patient was put on the daytime sedative originally, but quite often they have been taking it for a while. Patients often rely on sleep medications when they work. You owe it to them to question their use without causing further anxiety or uncomfortable vibes. In one patient who approached me with the goal of coming off of her lifelong benzodiazepine, I went back to the root causes of anxiety in some of these people. The body senses when an abnormal process happens internally and responds to it with adrenalin. It turns out Susanna (who proudly asks us to use her name with this story whenever I can) was having glucose regulation issues. Her glucose would drop and her cortisol would spike, causing a corresponding increase in anxiety. When we changed her diet using a low glycemic index and more frequent, smaller meals and added chromium for hypoglycemia, her anxiety dropped off to a level where she could manage tapering off of diazepam. Oh, and she also went gluten free, (sorry, all you anti-gluteners, but when she added this to her lifestyle she claimed it helped). In the end, she stopped 40 years of needless sedative use. She does use Relora periodically now for the odd bout of anxiety. In regards to sleeping pills, the change in sleep architecture over long-term use is not what the brain or body was designed to live with and may be what causes increased depression in sedative users, especially in the elderly. A discussion of proper sleep hygiene can help these patients come off of these medications.

Other opportunities While these are the most common chances to have an impact by revisiting commonly refilled medications, other potential opportunities to investigate your patient’s health exist with statins and the cholesterol/inflammation discussion, bisphosphonates and duration of use and side effects, ADHD meds and their over use in North America, progestin/CEE use, unmonitored iron therapy, overuse of antibiotics, use of antidepressants without a real diagnosis and a refresher on the Beers Criteria for your elderly patients. As a pharmacist we need to remind ourselves that refilled medications mark a path that we are taking our patients down (good or bad) and deserve a thought process that can have a beneficial effect on the patient’s wellbeing, even if it results in that patient coming off of the prescription.

Graham MacKenzie PhC Stone’s Pharmasave

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Agave Nectar Practice Safe Sweetening

image1Agave Nectar – The Biggest Lie In “Health” Food Sugar is bad… yeah, yeah. High Fructose Corn Syrup (HFCS) is even worse… yeah, yeah, yeah. We’ve heard all that and most of us are well programmed by now to look for “healthier” options. One such sweetener that’s been heavily promoted in recent years as a healthy option is Agave Nectar. Interestingly enough agave is actually the plant from which tequila is made. Agave nectar is the sweetener made from the agave plant and is known in Mexico as aguamiel, or “honey water.” In recent years agave nectar has become among the preferred sweetener of many health conscious consumers, weight loss advocates, doctors, and natural foods cooks alike–mostly because of it’s favorable glycemic profile.

To understand what that means and why it is so misinformed let’s briefly over view sugar and the glycemic index. Sugar is comprised of two basic parts: glucose and fructose. Glucose is absorbed directly into the bloodstream very quickly and is the foundation behind the glycemic index. The Glycemic Index (GI), ranks foods based on how much your blood glucose increases in the hours after eating certain foods. The faster they hit the bloodstream, the higher the GI load. Fructose is metabolized very differently than glucose. While every cell in the body can use glucose and it’s absorbed directly into the blood, fructose can only be metabolized by the liver which means when fructose is consumed it’s first transported to the liver where it must be converted to glucose in order to be put to use. All this extra processing time means fructose takes longer to hit the bloodstream and raise blood glucose levels giving it a relatively low glycemic index.

So basically, the more fructose in a sugar, the lower the GI load. The lower the GI load the more favorable the GI profile. But it’s not that simple. From a previous article I wrote on sugar regarding the lower GI index of fructose: “With all the hype surrounding the importance of the glycemic index of food, you may be tempted to think that’s a good thing. It’s not. Having blood sugars go up for a short time isn’t that bad, but having them chronically elevated (high all the time) is a recipe for disaster. The fructose content of a sugar is actually a much bigger problem than its glycemic index. Excess fructose in our bodies doesn’t sit around in our cells ready to be useful for anything in the way that glucose does (as glycogen). Rather when excess fructose is consumed cells begin getting damaged, the liver gets overloaded and immediately begins turning it into triglycerides which (as mentioned above) get stored as fat, both externally and internally–on and around our organs.

The excess triglycerides created when you eat fructose also increase insulin resistance, thereby boosting insulin production to very high levels which can contribute to the development of diabetes. As well, since insulin triggers the hormonal response that tells your brain you’re full and fructose doesn’t elicit this reaction so it’s easier to overeat when consuming too much fructose.” Dr. Robert Lustig, Professor of Pediatrics in the Division of Endocrinology at the University of California, San Francisco has been a pioneer in decoding sugar metabolism. His work has shown: After eating fructose, 100 percent of the metabolic burden rests on your liver. But with glucose, your liver has to break down only 20 percent. Every cell in your body, including your brain, utilizes glucose. Therefore, much of it is “burned up” immediately after you consume it and much gets stored in your muscles as glycogen, ready to be as energy when needed. By contrast, fructose is turned into free fatty acids (FFAs), VLDL (the damaging form of cholesterol), and triglycerides. These get immediately stored as fat. The fatty acids created during fructose metabolism accumulate as fat droplets in your liver and skeletal muscle tissues, causing insulin resistance and non-alcoholic fatty liver disease (NAFLD). Insulin resistance progresses to metabolic syndrome and type II diabetes.

Fructose is the most lipophilic carbohydrate. In other words, fructose converts to activated glycerol (g-3-p), which is directly used to turn FFAs into triglycerides. The more fructose you eat the more g-3-p you have, the more g-3-p you have, the more fat you store. Glucose does not do this. Consuming fructose is essentially consuming fat–and not the good healthy kind that makes us our hair and skin pretty, the kind that sits directly on our butts and jiggles! The metabolism of fructose by your liver creates a long list of waste products and toxins, including a large amount of uric acid, which drives up blood pressure and can cause gout. Glucose suppresses the hunger hormone ghrelin and stimulates leptin, which suppresses your appetite. Fructose has no effect on ghrelin and interferes with your brain’s communication with leptin, resulting in overeating.

The fact is there are major differences in how your body processes and responds to these two types of sugar but the bottom line is despite the lower GI index of products higher in fructose excess of this type leads to increased belly fat, insulin resistance, and metabolic syndrome — not to mention the long list of chronic diseases that directly result. What does all this have to do with agave nectar? Well, now that we know how bad excess fructose is let’s sum up: Table sugar is about 50% glucose and 50% fructose. HFCS, you know, the one that’s SO badly demonized and we’ve all been warned to stay far away from? That’s about 45% glucose and 55% fructose. The higher fructose content of high fructose corn syrup (see that, it’s right there in the name) is one the main reasons it’s considered so much unhealthier than regular sugar. –> Agave nectar is 70-90% fructose. ?It’s even worse than HFCS–by a long shot.

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