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Monthly Archives: January 2015
Lately we have heard stories of Pharmacists not doing their job correctly. To be exact, in a survey of a sample of pharmacies, it was discovered that medications that are kept in the pharmacy but did not need a prescription, there was insufficient or completely absent counselling on behalf of the pharmacist. These medications are in a special class in that they can only be sold in a pharmacy, behind the counter of the dispensary, and the customer must ask for the medication in order to be screened for interactions with existing medications and medical conditions, as well as proper use of the medication so that it is safely used and gives the best results.
Although there were arguments that the sample size used in this observation was too small to make an overall conclusion, just 50 pharmacies, and that the study was not scientific, showing even one pharmacy not counselling this type of medication is not good. As pharmacists we don’t shoot for a certain percentage of jobs done correctly across the country in the run of a day. We more importantly look at any incidence of improper counselling and try to better ourselves by looking at why we didn’t do our job correctly. Undoubtedly spurred on by a few recent reports of dispensing errors across the country, this survey began in BC and spread across the country based on the results in that one province. Trust me, when a pharmacist makes a mistake, it hits them like a ton of bricks, regardless of the outcome.
This nationally broadcast report was fuelled by a week long buildup that caught the eyes of pharmacists and general public alike. Word began to spread in the New Year about the story and certainly when it finally came to air, there was a huge reaction from those who watched it. Many pharmacists chimed in. Initially claiming unfair reporting in that it made pharmacists look completely inept. Others claimed that the story completely avoided the good that pharmacists do that is totally ignored for the most part. This was followed by examples of what we do as pharmacists every day. The reporter afterwards quickly claimed that the show was more about quotas imposed on pharmacists to increase script count than exposing pharmacists not doing their job correctly. It was certainly a perception of mine leading up to the program and certainly after watching the program that the latter was the case.
As someone that works for an independent in a small community, the concept of pressure imposed by quotas for increased prescription count is definitely foreign to me and one I must admit I had never heard of before. Pharmacists interviewed for the program claimed that this pressure to increase script count was responsible for other parts of their job slipping, including counselling these behind the counter medications and focussing properly on the filling and checking process. Let’s suppose this were true, and maybe it is. Then obviously it is something eroding pharmacy that needs to be addressed. These pharmacists interviewed pointed to the problem of non pharmacists now able to own pharmacies – something new over the last couple of decades. The profession of pharmacy is certainly not against change, but the change we have seen over the last 20 years has absolutely lead to great things, but in some cases has also lead to the erosion of the profession.
Before I graduated from the College of Pharmacy in 1993, things were strict. You kept things professional by not being able to advertise “free prescription delivery”, you couldn’t connect any incentive to a prescription like “points” for your prescription purchase or bonuses for transferring your prescription file to a pharmacy, you couldn’t say “accurate prescription filling” because it was unprofessional and implied someone else had inaccurate prescription filling, among other strict rules. Gradually, we saw big box stores start to include incentives to their employees when they had their prescription filled at their banner, then drug plans that are affiliated with the pharmacy with restrictions that you are covered when you get your prescription filled only at that pharmacy chain and no other. While on the subject of third party plans, in my opinion the most dramatic effect overall in the pharmacy business today, we have seen a very gradual undermining of the pharmacy business because dispensing fees and reimbursement to pharmacy from the third party plan has not grown with what is reality in dispensing. Dispensing has become a volume business in order to show a real profit. In fact we are starting to see decreases in dispensing fees from third party plans. In a lot of ways I feel these plans are a part owner in my business.
A sweeping move initiated by provincial governments across the country was a huge hit to the bottom line of pharmacies, like Nova Scotia’s Fair Drug Price Act. A move that seemingly made sense to the general population in that it aimed at lowering prescription prices by coming up with an imaginary dollar value for various popular generic medications, regardless of what the pharmacy paid for it. This move came about from the practice of generic companies giving rebates for purchases, a common practice in many types of business. The government saw this as their money. These were the main dollars we used to run the programs of our pharmacy and the dollars we used for donations and community programs that came to us for help. Very quickly this money was gone. In effect, this attempt by the government to lower prescription drug prices was accomplished on the backs of the pharmacies in the provinces. Our communities are now realizing the effect of lack of income in their community pharmacies. Before too long, we saw other third party plans jump on this bandwagon, and gone were more dollars we used to run health programs we conceived on our own for the health our community.
Enter the expanded scope of practice. We as pharmacists were allowed now to write prescriptions in certain cases of minor ailments, extend existing prescriptions, do med reviews, injections, adaptation of prescription, and order and interpret lab tests. The reason was we can charge for these services to make up for what we were losing on the other end with rebates. Definitely this is an honourable theory: make money for actually doing something that helps with the health of our patients. The problem being that there was now no money to run these new services anymore and most plans weren’t on board with paying for them .
One might argue, “then why not just drop your affiliation with third party plans?” Then we could set our own prices bases on our own pharmacy needs and staff levels . Small town low volume stores could have better control over their income and not allow third party plans to control what they earn on a prescription. Instead of getting paid 12 dollars for a prescription that costs 15 dollars to fill, you could charge what you paid for the drug and a fee that allows the dispensary to make money on its own regardless of the front shop. Well we do this because it allows our patients to afford their medications and they probably fill more prescriptions for their health when they have coverage, not to mention that all pharmacies not dropping plans means patients shop for pharmacies that take these plans.
This brings us back to the original issue of why are we dropping essential counselling and why are we too busy to catch interactions? Well perhaps the pressure we should be looking at isn’t the pressure to fill more prescriptions, it’s the pressure imposed by third party plans on the pharmacy whereby they don’t make enough on each prescription to pay for itself in the first place. Maybe this is the reason for the “quota” being imposed on pharmacies to fill more. The lack of reimbursement forces any pharmacy to scratch for more prescriptions since they cannot afford to hire the staff to run these extra programs and give time to the pharmacist to do their work of not only bettering health, but preventing harm from meds.
To top off the issue of missed interactions because of lack of time, consider the thought process involved with each and every prescription when the possibility of the patient dying from the medication exists each time a prescription is filled. The side effect of any medication is death and there are so many side effects and potential warnings on any given medication it would take an hour to explain them all to each patient. On top of that, the sheer volume of prescription interactions with other meds or disease states makes the evaluation of these interactions an art that is not just based on book smarts, but also on clinical experience. If there is a 0.00001 chance of a dangerous interaction occurring do you call the doctor, alert the patient and change the drug? Is the evaluation of these interactions a black and white science or is it based on followup with the patient on their overall health and history. Recently I wrote a blog on a type of interaction called prolonged QT interval ( http://stonespharmasave.com/blog/?p=694 ) that describes the complex evaluation involved with just one interaction. There are thousands of such interactions to evaluate for each fill and you reset your brain when you fill the next prescription. If I give you a prescription there is a very slight chance you might leave the pharmacy, take the medication, have an adverse reaction or interaction with another medication and die. Perhaps I will be on the evening news for not telling the patient this. Do I tell you this? Not necessarily. But if I evaluate the probability of this reaction occurring then I am in a better position to act on it. When we take off in an airplane do we sign off on the fact that it might crash? There is inherent risk in taking any medication. It’s our job to make sure you have the best possible medication and outcome from that medication.
Getting back to the lack of counselling in these behind the counter medications – guilty. We accept that. The more pharmacy and pharmacies are left to be run by corporations (big box stores and third party plans) and not pharmacists, the more and more this profession will erode and show up on more undercover specials.
Lets just jump to the main recommendation: reduce your estrogen dominance and eat more fiber. As a pharmacist I see the problem of gall bladder issues A LOT. Every day it seems there is someone out there waiting for an appointment with the specialist to further evaluate the problem. The symptoms include:
- Pain or tenderness under the rib cage on the right side
- Pain between shoulder blades
- Stools light or chalky colored
- Fatty stools
- Indigestion after eating, especially fatty or greasy foods
- Burping or belching
- Feeling of fullness or food not digesting
- Diarrhea (or alternating from soft to watery)
- Constipation or frequent use of laxatives
- Headache over eyes, especially right
- Bitter fluid comes up after eating
- Constipation or frequent use of laxatives
Unfortunately the stress of experiencing gall bladder issues is intensified when the patient thinks they are having a heart attack. Of course it is important to determine that this is not happening so close investigation of the symptoms and pattern are important as is followup with your doctor.
So why reduction of estrogen dominance so key in dealing with your gall bladder and what is estrogen dominance anyway. While we’re at it, what is the gall bladder for in the first place? The gall bladder is a small thumb sized hollow organ located under the liver. It’s main job is the storage of bile or gall which is produced in the liver. In response to a fat containing meal, the gall bladder releases bile into the intestines and with the help of pancreatic enzymes, emulsifies the fat for absorption into the bloodstream. This is quite a simplified description but basically this is what this organ does.
It takes just a simple understanding of plumbing to understand what causes a gall bladder to act up: constricted flow and thickened secretion. What causes the flow to constrict? Well it turns out that estrogen dominance, a common topic of discussion with me results in a constriction of the Sphincter of Oddi, which controls the flow of bile out of the gall bladder. Estrogen dominance is an imbalance between the amount of estrogen compared to progesterone in your body, and just in case you’re a guy and think this doesn’t apply to you, the truth is you most likely have estrogen dominance as well. How do you know if you have it? Well for men,
- Prostate enlargement – benign prostate hyperplasia / hypertrophy (BPH) and the risk of prostate cancer.
- Urination – difficulty, increased frequency. Constricted urethra.
- Erectile dysfunction.
- Low libido.
- Adiposity (fat build-up) and the redistribution of fat. Estrogen stimulates the production of fat cells. However, fat cells also make a small amount of estrogen, causing a vicious cycle.
- Muscle development reduced.
- Body hair reduced.
- Veins become less prominent.
- Breast growth (man boobs).
- Sweat and body odour changes.
- Skin thinning.
Estrogen dominance in women,
- Mood swings, depression, irritability, anger, forgetfulness, inability to focus thoughts, panic attacks.
- Aches and pains, sore bones.
- Disrupted periods. Early, late, high/low blood flow.
- Low energy.
- Weight gain. Fat tends to deposit around the hips, abdomen, and thighs. Estrogen stimulates the production of fat cells. However, fat cells also make estrogen and so a vicious cycle starts.
- Low libido.
- Headaches or migraines.
- Decreased thyroid function (low body temperature and sometimes thinning hair).
- Fluid / salt retention, bloating (oedema) or weight gain due to fluid retention.
- Weak bladder control.
- Fibromas (fibroid tumours).
- Heart palpitations, chest pains.
- Food cravings.
- Insulin resistance / poor blood sugar control / hypoglycaemia.
- Blood clotting, reduced blood vessel tone.
- Breasts. Cyclical breast tenderness – tender or painful, feeling fuller or swollen, particularly in the pre-menstrual week. Use of progesterone cream on days 12 -26 of the menstrual cycle will balance the estrogen dominance. It usually takes three months of use to cure this problem.
- Cancer – increased risk of endometrial or breast cancer.
- Fibrocystic breast disease. Non-cancerous changes and lumps in the breast tissue. They can cause discomfort, varying in relation to hormonal influences from the menstrual cycle. Fibrocystic breast disease affects 30-60% of women.
These are pretty typical symptoms but they often go hand in hand with gall bladder inflammation. So how to you treat this estrogen dominance and allow your progesterone to relax the sphincter that may be causing the gall bladder associated pain? Well it turns out progesterone cream is perfect for both men and women. Also effective is zinc which blocks the conversion of testosterone to estrogen in both men and women. Lowering the fat content in your body will help also as this is the main source for this conversion. Other things can help like avoiding external sources of estrogen, or xenoestrogens in the environment that act like estrogen when introduced to your body. These include herbicides, pesticides, fertilizers, plastic drinking bottles, and heavy metals. Eating organic food and using organic products in the home can help with the avoidance of such ingredients. Supplements like Calcium-d-Glucarate, DIM and I3C also help to lower estrogen dominance symptoms as does exercise. Another great way to lower estrogen dominance is through the use of fiber. Fiber not only helps with gall bladder discomfort by decreasing estrogen and therefore estrogen dominance, it also helps to prevent the recirculation of cholesterol that is used in bile production.
A big problem with ongoing bile problems is the production of biliary sludge, a noticeable thickening of the bile with crystals of cholesterol monohydrate crystals and calcium bilirubinate granules. These can come together to form gallstones but even without that action the thickened bile makes for restricted flow of the bile through the bile duct. This is reminiscent of what happens in a sinus infection, thickening secretions obstruct flow and increased bacteria (in the case of the gall bladder, E.Coli, Klebsiella and enterococcus) result causing inflammation. There is a close relationship between the gall bladder and the bacteria in the intestines and these bacteria can work there way backward to the gall bladder when the Sphincter of Oddi is relaxed, but the “precipitating” factor is the sludge production.
Try reducing estrogen dominance and above all increase your fiber. These will help with many more issues than just gall bladder. Food sensitivities also can increase the incidence of gall bladder attacks so finding the offending agent with the appropriate test can help tremendously.
Without a doubt one of the more prominent medical issues to watch for not only with individual drug administration, but with drug interactions as well is the problem with Long QT Syndrome. It appears that over the last 20 years this crops up more and more. The issue with this syndrome is that most people don’t know if they have this medical problem or not. Although some people have had themselves hooked up to an EKG at some point in their life for an unrelated issue and this problem would have been caught, most haven’t and when this drug/disease or drug/drug interaction pops up, we are left wondering how to deal with the problem.
In measuring the electrical activity of a heartbeat, a typical sinus rhythm should show up. There are distinct landmarks on the graph: P,Q,R,S,and T.
The interval between Q and T is the time it takes for the electrical impulse to flow through the lower chambers of the heart until the heart is ready for its next beat. If this interval is longer than normal, it is called Long QT syndrome.
One of the frustrating things is that this syndrome is that it may not be present all of the time. It may only be present during times of stress, exercise, cold water on the face such as when swimming, auditory stimuli, when you are startled, it may be during the night when sleeping, or it may be caused by certain medications. This syndrome may be inherited or acquired. Theses patients often have no symptoms. They may have a history of fainting, seizures, or an abnormal heart rate at times. The danger is that the syndrome can lead to cardiac arrest or sudden death.
Not everyone metabolizes or handles drugs the same way. In some of our testing procedures we find that some of us metabolize some medications very fast or very slow. Some take a medication for sleep that gets metabolized so fast it can never work to put them to sleep. Others metabolized so slowly that they are completely hungover in the morning from one pill at bedtime. This shows that we are all different when it comes to our response to medications and how some people will experience long QT from one drug and some don’t or that a long QT side effect occurs from a drug/drug interaction in one person and not another.
These individuals should also avoid the following agents:
Anesthetics or asthma medication (eg, epinephrine, lidocaine)
Antihistamines (eg, diphenhydramine)
Antibiotics (eg, macrolides (azithromycin(4)), quinolones, trimethoprim and sulfamethoxazole, pentamidine)
- Antidepressants (tricyclic, citalopram, trazodone, venlafaxine)
Cardiac medications (eg, quinidine, procainamide, disopyramide, sotalol)
Gastrointestinal medications (eg, domeperidone (1), metoclopramide(3))
Antifungal medications (eg, ketoconazole, fluconazole, itraconazole)
Psychotropic medications (eg, tricyclic antidepressants, phenothiazine derivatives, butyrophenones)
Potassium-loss medications (eg, indapamide, other diuretics; medications for vomiting/diarrhea)
Risk factors for drug induced LQT syndrome and TdP include: female gender, concomitant cardiovascular disease, substance abuse, drug interactions, bradychardia, electrolyte disorders, anorexia nervosa, and congenital Long QT syndrome, elderly population, history of fainting or seizures. Careful selection of the medication and identification of patient’s risk factors for QTc prolongation is applicable in current clinical practice.(2) At www.crediblemeds.org there is an invaluable source that is updated regularly to help the clinician evaluate the dispensing of an offending drug so that you and the physician aren’t left guessing on the potential seriousness of the interaction. Registration is free but it is a great resource to have in your back pocket.
This is certainly an important interaction to be able to evaluate and share with the physician. Being able to make recommendations makes you a valuable member of the healthcare team
So many complaints can overlap many different causes when it comes to hormones. What about these symptoms?
thinning muscles, impaired social status, exhaustion and long recovery times, erectile dysfunction, low self esteem and self confidence…well that sounds like low testosterone.
chronic anxiety, depression, poor sleep, weight gain…wait, that could be adrenals.
light sleep…maybe melatonin?
intolerance to cold, more fatigue ?…thyroid
In fact, all of these issues may be a sign of low growth hormone (GH). And GH can effect levels of other hormones and vice versa. What can you do to increase this (remember as always testing of the deficiency is key)? Initial treatments plan involves the most common recommendations for good health, adequate sleep, maintain ideal weight, eat organic, avoid alcohol and caffeine, avoid sugar, and all excess and refined carbs, avoid stress, get sufficient amino-acids (protein)and eat paleo. Feeling better already? Why not add Niacin, argentine, glutamine. As well, maintaining adequate levels of testosterone, estrogens, progesterone, thyroid hormone, melatonin and adequate insulin secretion all help with GH levels. You’ll have to check back on previous blogs on how to do this, but it’s not all about actual hormone replacement therapy necessarily.
Just a glimpse into how intertwined your hormone levels are, and sometimes the levels of the hormones can be deceiving because you may actually be part of the population that gets more hormones into your cells where they actually work, or maybe your sex hormone binding globulin is off, the protein that binds with hormones and carries them around until they separate and then the hormone gets to work. This is why symptoms are so important to determine an action plan for dealing with hormones.
The World Health Organization has released statistics that relate the most common causes of death in relation to overall income for a country. Believe it or not, HIV/AIDS is the second leading cause of death among low income countries. Also in these countries, almost 1/2 of the deaths in children under the age of five occurred within the first 28 days of birth. Causes of death for these infants are taken for granted in western societies, diarrhea, pneumonia and malaria are major causes of death in parts of the world with the lowest income. And let’s not forget tuberculosis, a disease that is making a comeback due to the length of time required to treat, not to mention the cost. Fully 1/3 of all deaths in low income countries are from these above mentioned causes. To add to these deaths is the increased percentage of maternal deaths – moms that pass away during childbirth, because of pregnancy related medical issues or medical problems related to the birth of their child after birth. Premature births are also a major contributor to death in this population.
However, in contrast to the infectious diseases mentioned above, the higher income countries death rates showed that 87% of deaths were non infectious disease related deaths. 70% of people in high income countries die at the age of 70 or higher in contrast to 20% in low income countries. What are we dying from in higher income countries? Ischemic Heart Disease and Stroke, collectively known as cardiovascular disease. Only 1 in 100 deaths is among the age group of 15 years old and younger in western societies, compared to 4 in 10 for lower income countries.
What does this all tell us? Well people in these low income countries still die of heart disease and stroke. We just live longer in higher income countries because of the healthcare and medications available that allow us to fight these diseases. Certainly medications have drastically lowered the main causes of death here that are common for the low income countries like communicable diseases and childhood deaths. We may die of accidental causes more in western type societies. As a pharmacist I can tell you if I take away the number of prescriptions that are for infection, cardiovascular disease medications amount for a significant proportion of medications. Psychoactive meds perhaps second, acid lowering meds close behind (which brings to light the issue of gastric cancer in western societies as compared to lower income countries). As I have blogged before, the medications are only a small part of it, as is evidenced in the difference in life expectancy between the US and Canada. Life expectancy in Canada is notably higher than the US even though we have the same medications available, just different healthcare models. Healthcare in Canada is free for the most part except for medications. I think the main reason is diet, as many states have similar life expectancy to Canada except for the Southern states, which have quite a different diet than the rest of the country and skew that country’s total life expectancy to a lower number.
So how long can we expect to live as humans? Absolutely one of the greatest achievements of the 20th century was the increase in lifespan for those on the planet. We have extended lifespan by nearly 40% in the last century. Definitely getting a human past the age of 15 is a huge hurdle in extending this timeline. In the next 50 years, the percent growth in our population is expected to be exponential in the 85 and older group compared to those that are younger. All of the above mentioned factors of medication, research, healthcare models, and so on have certainly helped and perhaps knowledge of nutrition, but food has been the downfall of how we die. Not only cancer but other obesity related issues can be chalked up to our diet in some way or another. Exposure to other toxins daily due to our lifestyle has drastically changed in the last 60 years as well. Our lifespan has increased but our disease state that ends our life has changed. Seemingly, when someone moves from Rural China to North America, the reason for dying changes within a generation or two.
The timing of our decline and ultimate death is encoded deep in our genes. I am always quick to argue that your genes can be controlled to prevent disease but ultimately there is something more powerful going on that we can’t yet override. There seems to be a clock or sensor in our genes that says, “time to wind down”, or “you are no longer able to contribute to the reproduction of the species”. These genes are interfered with less in lower income countries with less availability to medication or healthcare. Diet, exercise and lifestyle are free to impose their natural forces on DNA unhindered by medicine. Even if we avoid disease, if that is possible, we still can’t live forever. Why is that?
The telomere theory of agin does a good job to explain this. Telomeres are located at the end of our DNA strands. As our cells divide, the DNA replicates so each new cell has its own DNA. Telomeres are disposable caps at the DNA strands. As DNA divides there is always a point where the division of DNA occurs before the actual end of the DNA strand. Small amounts get clipped at the end with each cell division. Telomeres are the buffers that contain “throw away” pieces with each cell division. Now imagine how much of this finite buffer is left when you are 80 compared to 20 years old. At that point we start clipping useable pieces of DNA with each cell division after using up the telomere buffer during your lifetime. At that point we actually have defences to stop division of that cell so mutant cells or cancer won’t develop. The bad side is that we don’t duplicate a cell like that anymore and it dies. Antiaging medicine has focused on keeping the length of these telomers as lengthy as possible to maintain healthy cell division.
This is an over simplified method of aging. How do we prevent the shortening of telomeres and therefore heart disease, cartilage loss? Antioxidant support, astralgus, B,D and C vitamin and mineral support, a good diet, organic food, lack of stress, and as much a we hear that multivitamins are useless, a study has shown that telomeres are on average 5% longer in those that take multivitamins as opposed to those that don’t. Dropping inflammation with omega 3 is also helpful and green tea, curcumin, quercetin, resveratrol, mixed tocopherols (vitamin E mix) also have shown promise.
So we can debate the effect of money on cause of death for a given country, but in the end, even if we prevent disease, we aren’t living forever. Keeping the degradation of telomeres at bay not only prevents longterm disease, but extends lifespan even more. Don’t agree with these nutrition recommendations? Just start by eating better and exercise more.
There are few non-traumatic causes of death that happen as suddenly and without prior knowledge of any ill health more than myocardial infarction or a heart attack. Certainly there are disease states or signs ahead of time that put you at risk for such an event. Smokers (including secondhand smoke), high stress lifestyle, heavy metal exposure, air pollution, increased fat or sugar, diabetes, chronic infections, lack of exercise…does this fall into the heading of a 12 year old? Sure it does. In fact science has shown us that atherosclerosis has its beginnings in this age group. Although we typically don’t screen this age group for any diseases unless symptoms arise, studies have shown that 1 in 6 teens already have atherosclerotic plaque in their coronary arteries.
So what is this atherosclerosis and what makes it such a ticking time bomb in so many of us? It is something that affects half of us (at least in this continent). For reasons that are not completely understood, a fatty streak develops with the help of the above mentioned triggers, perhaps on a damaged or oxidized piece of endothelial cells which lines the inside of the blood vessel. This causes the immune system to respond with white blood cells congregating to this area. Cholesterol in the blood accumulates and a deposit begins to form in the lining of the blood vessel. Calcium and fiberous tissue builds up forming a plaque and a noticeable hardening of the area occurs where the elasticity of the blood vessel is compromised. As blood flows through the vessel, it expands and contracts and makes the plaque more unstable and prone to rupture. A plaque can be stable or unstable. Unstable plaques have more normal macrophages and foam cells (fat laden macrophages). A fiberous cap develops that can rupture and expose the contents like collagen to the blood supply. This results in a clot forming and breaking off, only to get lodged in a smaller blood vessel and the blood supply is blocked, like in the blood vessels supplying the heart or brain. Or maybe the plaque grew to the point that it blocked off the vessel without rupturing at all.
So what does this have to do with a 12 year old. All of this happens so slowly it can start at that age or earlier. Plaques can change size and shape in only 6 weeks but the foundation of this structure have its beginnings in a child’s circulatory system. We work so hard and pay so much in trying to eliminate cigarette smoke and to keep it from children today as opposed to 40 years ago – which is great. Why not recognize the impact a sugary drink has on this highly influential blood vessel. Removing sugary drinks from my pharmacy had many reasons, not the least of which are diabetes and obesity. Sudden death from a heart attack later on in life with no warning should be a motivating factor in cutting back on or removing these beverages from everyone’s diet.