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Monthly Archives: April 2015
Modern 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
It’s entertaining to read the back and forth between those adamant about either side of the GMO/non-GMO argument. Although some studies have lead me to think that tinkering with nature at the gene level may have some negative long lasting effects that cannot be undone (maybe) I am not one to plaster all over social media how bad GMO’s are. Along the same lines I cannot bring myself to jumping on the same websites and claiming how these people that are for GMO are wingnuts and probably are antivaxers and all for homeopathy.
Why don’t I do either of these? Well because I took math in elementary school. Mathematically, it is simply impossible to arrive at any conclusion that claims that GMO’s are completely safe long term, for a few generations, either directly to our health or indirectly through the environment. There just hasn’t been enough time to show us. When trans fats were invented in the pre World War 2 era (a time when omega 6 vegetable oils were becoming popular also) we saw a few decades pass where more and more were consuming trans fats. Even when our governments in the ‘70’s were recommending toning it down on these deadly fats, we were still not told to completely avoid them, even though no safe level exists.
So is there a parallel here with GMO or organic food to trans fat and the lesson we learned with them? Who knows? I can tell you who knows, your great great grandson. He is the one who can tell you if millions died as a result of this global experiment with GMO’s or if anything untoward occurred with other plants, insects, or the environment that couldn’t be turned off as a result of this global experiment – or not. Either way, it is difficult to pretend to be an expert on the future especially when there is really no history to compare it to that repeats itself.
In science, the null hypothesis teaches us that there is no relationship between two things unless proven otherwise. We can stick to that and assume that anything we do that hasn’t been tested is safe. Or we can entertain the idea that trans fat has returned – maybe.
There seems to be little tolerance among many otherwise good meaning people for those that have gained weight. With social media I see multiple daily scathing rants on how anyone who tries to help someone lose weight is doing it wrong, raking in money, doing harm. Just eat right and exercise and you’ll be fine they say. Anything else is quackery it seems. How did these people come to be overweight if it is that simple then? Certainly picking up Canada’s food guide and putting on some walking shoes should make us all look the same, with the exact same effort. Seeing an overweight person ignites an elementary school part of our brain that we compare ourselves to others, and when we see someone helping someone lose weight our opinionated know-it-all-about-everything side leaps out. Obesity is a medical condition that deserves the same respect as any other. Trained, well meaning individuals to help them also deserve that respect as well.
As a pharmacist, I see my personal recommendations changed by the patient all the time. Either it tastes bad, the packaging says something strange, their friend said another thing worked for them, etc, etc, etc. As a pharmacist it is my job to give them something that will not waste their money but it is just as important to give them something that will not harm them. I may give them the most proven cough and cold medication but in the end I realize it may not really work for them. I spend more time actually speaking to them about current medical conditions, current medications, allergies and past histories and experiences with other meds. Why do I do this? Because I don’t want the patient harmed with my recommendation. It really only takes me a second to put that all together and make a recommendation and hand them a bottle and say keep in touch. Will it work to their satisfaction? Maybe. Do I lose sleep over thinking if their cough stopped? No. Do I lose sleep wondering if they have a safe medication choice? No, because I cover all that when I gave them the medication.
This is no different with weight loss. I understand that overweight people do not want to be overweight. I understand that they know what bad food and good food is and that they need to move to burn calories. They are like the patient that changes my first recommendation. I can tell them to eat right and exercise and then “take care”, but then I wouldn’t sleep right. They need the motivation and tools to lose weight and obviously the current tools of how to do it aren’t being used. Motivation gained by bringing them to a lower weight safely is the next logical step.
As always, I have said that science has no place for belittling, putting down, threatening, or blaming. I love tracking down studies that show the most effective and safest way to treat people so that I have a second or third choice to give them. Do I have a study for every Health Canada approved item in my pharmacy? Well, no. In fact I don’t pack any studies on dextromethorphan for cough, PEG for constipation, clotrimazole for yeast infection. They probably exist out there. I just don’t have them. Funny how I am never challenged on this type of choice.
Although using terms like “melting fat”, “turning fat to muscle”, or “miracle cure” can take away credibility and I stay away from that, patient safety should be the most important factor.
Agave 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.
When I am asked to “prove” something by showing a study, it reminds me of how backwards we can be when it comes to stacking studies against each other to make a point. We come up with rebuttals like, “the patient size was too small”, “the study is too old” and “the study wasn’t double blinded”. In fact, virtually every study that has ever been done can be debated for some reason or other. As well, it is safe to say that not much has ever been proven of any value or consequence by just one study alone.
Let’s say that a colleague and myself have a disagreement on whether or not chromium has the ability to prevent hypoglycemia. This can start out with a quick exchange of some handpicked positive and negative outcome studies that may be well designed or not or maybe had the power to determine the outcome or not. Maybe a study hid some of the data or the statistical analysis was done improperly. Maybe my colleague had 10 times as many studies compared to mine. Is that what decides the outcome of all of these scientific studies? That one person can scrounge up more studies than someone else? How does that person explain a well-designed study that doesn’t back up his or her argument? Do they quietly pass off the study as a fluke or placebo effect or do they start to see what scientific study is for us – many studies that create a whole picture much like individual pieces of a puzzle make a picture.
Let’s say we have a puzzle. It is a puzzle of a field of green grass on a sunny day with blue sky and some white clouds. It turns out that this picture is a picture of a rabbit sitting in the field, only a very small part of the picture, less than one percent is taken up with the rabbit. This translates into just 2 pieces of the 500 piece puzzle. Let’s say my colleague and I divide the puzzle in two and each take half of the puzzle home with us. We separately lay out the pieces and get a vague idea about what the picture shows. It turns out I have both pieces that make up the rabbit, statistically not what we would expect but it happened. I call my colleague and tell him about the picture we are looking at and how it appears to be one with a rabbit in the field. He says, “that’s crazy, there’s no rabbit in this picture”. He said he’s looked at all of his pieces and no evidence of any rabbit.
So who is correct? Well based on what is in front of each of us, we are both correct. When we both meet to put the puzzle together on one table, the entire picture becomes clear. The puzzle changes from a field on a sunny day to a rabbit on a sunny day. Each piece of the puzzle is a scientific study.
This exercise shows us what the power of a study means, or an analysis of many studies can show. For an infrequent result, the amount of pieces that are required to find the rabbit are large. My colleague arrived at what would be called a negative result and mine was a positive result. In a book called Statistics Done Wrong, (Alex Reinhart) it is described that in a review of studies between 1975 and 1990 in prestigious medical journals, almost a third of these studies yielded negative results. A full 64% of these studies didn’t have the power to determine a 50% difference in the primary outcome they were looking for between treatment groups. When a 25% difference was present, a full 84% of studies didn’t have the power to find this.
As always, I believe that scientific studies are the best thing we have to unlock what we do not know. One study however, can be deceiving when taken as a single data point on a graph. Scientific studies are a group effort.