January 2018

We'll have lots of educating to do with our patients. FDA labeling changes on fat soluble vitamins are sure to cause lots of confusion.

Hey, are you out of Vitamin D-2000? All I see out here is Vitamin-D 50!!

I was dumbfounded when our OTC manager brought back a bottle of Vitamin-D and asked what this microgram stuff is about? Don't they make Vitamin D-2000 any more??

In May 2016, the U.S. Food and Drug Administration (FDA) announced regulations that require amendments to the existing supplement facts label, which uses units and conversions based on the Recommended Daily Allowances that were established back in 1968. The new regulations will be mandatory in 2019-2020. On Sept. 29, 2017, the FDA released its proposed rule to extend the compliance dates for Supplement and Nutrition Facts Labeling. The agency said it wanted to give manufacturers more time to comply, citing concerns from stakeholders that the current deadlines would not give them enough time to do so. Some of the vitamin companies have made the labeling change, which I’m sure will cause a lot of confusion, both for patients and prescribers. Let’s hope EPIC and other electronic medical records convert soon, as the new nomenclature is appearing on our shelves!

To convert Vitamin A as retinol:
From IU to mcg: IU/3.33 = mcg

(old labeling)
(new labeling)
5000iu 1500mcg (1.5mg)
8000iu 2400mcg (2.4mg)
10,000iu 3000mcg (3mg)

To convert Vitamin A as beta-carotene:
From IU to mcg: IU/1.66 = mcg

(old labeling)
(new labeling)
25,000iu 15,000mcg (15mg)

To convert Vitamin D:
From IU to mcg: IU/40 = mcg

(old labeling)
(new labeling)
400iu 10mcg
800iu 20mcg
1000iu 25mcg
2000iu 50mcg
5000iu 125mcg
50,000iu 1250mcg= 1.25mg

To convert Vitamin E if the product label has dl-Alpha-tocopherol (blended) as the ingredient:
From IU to mg: IU * 0.9 = mg

(old labeling)
(new labeling)
30iu 27mg
100iu 90mg
200iu 180mg
400iu 360mg
800iu 720mg
1000iu 900mg

To convert Vitamin E if the product label has d-Alpha-tocopherol (pure d-alpha) as the ingredient:
From IU to mg: IU * 0.67 = mg

(old labeling)
(new labeling)
30iu 20.1mg
100iu 67mg
200iu 134mg
400iu 268mg
800iu 536mg
1000iu 670mg

I called our primary vitamin vendor, and asked why they made these label changes. She assured me those changes are being made by the FDA's insistence. I asked her if they are providing conversion charts for the pharmacies, and prescribers. She answered, "not that I know of !"

Some of the labels are not "cross referenced" so we might not see both strengths on the label. According to the FDA both micrograms and international units may be on the label. I looked all over for charts for the conversions for the new labeling changes for the fat soluble vitamins.

So in my frustration I created this chart, so you wouldn't have to. Feel free to copy this chart, make shelf talkers out of it, anything to take care of your patients.

The next vitamin representative that comes to my store, will face a very long discussion. I'm all for FDA compliance, but I'm also for excellent patient care! The vitamin companies need to "step up" and assist the health care practitioners in this conversion.

Have a great day on the bench!!

Treatment of diarrhea... should we or shouldn't we??

What goes along with nausea and vomiting?

Why of course it is diarrhea!! Diarrhea, like vomiting is frequently due to a response of the gastrointestinal tract to remove bacteria and toxins. The most frequent problem that diarrhea causes is dehydration. As with vomiting, our goal for patients with gastroenteritis is to prevent dehydration.

This is the time of year we see patients standing in the gastrointestinal section, holding a box of Imodium, and looking our way for some help. Before you pull that box of loperamide off the shelf, I have a few (actually quite a few) questions?
  • How long and how often do you have these episodes?
  • Any other symptoms?
  • Which anti-diarrhea medications have you tried?
  • Characteristics of your stool?
  • Have you changed your diet? Drinking non-chlorinated water?
  • Have you recently traveled to a foreign country?
  • Anyone in your household have diarrhea or can you contribute it to a particular food?
  • What medications are you currently taking?
  • Any medical conditions or chronic illnesses?
Refer to physician immediately if any of the following (source: cdc.gov)
  • Elderly age
  • History of chronic medical conditions or concurrent illness
  • Fever over 102.2 °F
  • Visible blood in stool
  • High output of diarrhea, including frequent and substantial volumes of stool
  • Persistent vomiting
  • Signs consistent with dehydration (e.g., sunken eyes or decreased tears, dry mucous membranes, orthostatic hypotension or decreased urine output)
  • Change in mental status (irritability, apathy, or lethargy)
  • Suboptimal response to oral rehydration therapy already administered or inability to administer oral rehydration therapy
May I check your med list?
Here are some drugs that have the potential to cause diarrhea:
  • Laxatives
  • Antibiotics (broad spectrum)
  • Magnesium salts
  • Propranolol
  • Parasympathomimetics (pilocarpine, cevimeline bethanechol)
  • Metoclopramide
  • Digitalis
  • Colchicine
  • Seldom used drugs: indomethacin, methyldopa, theophylline, misoprostol
What if it is the “Stomach flu”- gastroenteritis:
  • Follow rehydration protocol as for nausea and vomiting. Oral rehydration solutions (Pedialyte®)
  • Antimotility agents such as (diphenoxylate/atropine) Lomotil® or (loperamide) Imodium® should be considered only in adult patients who are NOT febrile or having bloody/mucoid diarrhea. Antimotility agents may reduce diarrheal output and cramps, but do not accelerate cure.
  • Antimotility agents are generally contraindicated for children.
'Tis the season for the big three... nausea, vomiting and diarrhea. I had three different patients today, presenting with flu symptoms. I have yet to dispense Tamiflu® (oseltamivir) which is approved by the FDA for treatment of acute uncomplicated influenza within 2 days of illness onset. Most patients seem to be well past that 48 hour window where oseltamivir is effective, when they seek medical advice.

With Tamiflu's wholesale acquisition cost being over $150.00, and the generic being over $100.00 is it a good investment to treat most of our patients? I'm a believer in re-hydration, management of fever with acetaminophen and of course frequent hand washing!

Refer patients to the physician when appropriate. Be sure to share the information in the past three Clinician Corner Columns with your patients, especially with regard to hydration and introduction of solid foods.

Have a great day on the bench!!

OTC treatment for Nausea and Vomiting--- a lot cheaper than a visit to the Emergency Department!

OTC treatment options for treatment of vomiting...

Now that we have had the big “germ exchange” also known as the holiday season, a lot of patients are coming to ask our advice for treatment of nausea and vomiting. I know of one physician office where they tell the patients to stay home, keep hydrated and stay off work! The nurses won’t even give the adult patients an appointment! We talked in previous columns about the viruses that cause nausea and vomiting.
Last week we discussed the prescription treatment of nausea, so this week we can address the needs of those patients who come to us first for treatment of this quickly spreading viral gastroenteritis. The first concern we will always have is that our patient doesn’t get dehydrated. That must be the first, and only concern we should have. As we discussed before vomiting is our body’s way of getting rid of bacteria, viruses and toxins that shouldn’t be there. Our goal need not so much be stopping of the vomiting, rather the prevention of dehydration.

Signs and symptoms of DEHYDRATION
  • Dry or sticky mouth
  • Lethargy or coma (severe dehydration)
  • Low blood pressure
  • Low or no urine output, concentrated urine that looks dark yellow. (Consult MD if more than 8 hours)
  • Sunken soft spots (fontanelles) on the top of an infant's head. (Consult MD)
  • No tears
  • Sunken eyes
We have a couple of products over-the counter that are traditionally used for nausea. Their efficacy is doubtful.
  • Emetrol®: mixture of dextrose, fructose and phosphoric acid. Is hyperosmolar and works on GI wall to decrease smooth muscle contraction and delay gastric emptying time. Best for food and drink nausea.
  • Cola syrup (Coke®) contains the same sugars and phosphoric acid. Don’t use regular soda, even de-fizzed.
    • 2-12 years old: 5-10 ml every 15 minutes until vomiting stops; not to exceed 5 doses per hour. Not recommended if under 2 years
    • 12 years old: 15-30 mL every 15 minutes until vomiting stops; not to exceed 5 doses per hour
WHO (World Health Organization) ELECTROLYTE FORMULATION:
Available on-line, recipe and dosing. Contains: sodium chloride, potassium chloride, sodium bicarbonate, sugar and water.

Commercially Available Electrolyte Replacements
  • Oral fluids should be replaced quickly, but in a controlled fashion, to prevent the dehydration from becoming more severe. Recommend a teaspoon (5 mL) every five minutes until the patient can tolerate more.
  • Oral replacement should start at 50 to 100 mL/kg with an extra 2 mL/kg for each emesis or 10 mL/kg for each loose stool.
  • Pedialyte®: is an oral electrolyte replacement solution, sold in liters and a variety of flavors: bubble gum, mixed fruit, plain, blue raspberry, cherry punch, grape. Generic formulations are available.
Dosing of Electrolyte Solutions
  • For infants under 1 year of age: Consult your doctor.
  • For children 1 year and older and adults: Begin with small frequent sips every 15 minutes, increasing serving size as tolerated. Continue for as long as diarrhea is present.
  • To maintain proper hydration, 1-2 liters (32 to 64 fl oz) of Pedialyte may be needed per day. Consult your doctor if vomiting, fever, or diarrhea continues beyond 24 hours or if consumption needs are greater than 2 liters (64 fl oz) per day
WHAT TO AVOID: Fluids to be avoided include:
  • hypertonic fruit juices and drinks
  • carbonated beverages and caffeine containing beverages,
  • powered gelatin mixes which can make diarrhea worse, and lack the necessary electrolytes.
  • Even our beloved Gatorade diluted with water, still contains too much sugar for treatment of diarrhea. If anything, recommend sugar free Gatorade (G2®)
The return to solid foods: BRAT diet:
The BRAT diet is a bland-food diet that is often recommended for adults and children. BRAT stands for Bananas, Rice, Applesauce and Toast. The BRAT diet helps recovery upset stomach or diarrhea for the following reasons:
  • It includes “binding” foods. These are low-fiber foods that make stools firmer. It includes bananas, which are high in potassium and help replace nutrients the body has lost because of vomiting or diarrhea.
  • Some clinicians feel this diet lacks adequate protein for long term use.

I remember as a student pharmacist that one of my jobs was pouring "Coca-Cola®" syrup into four ounce bottles. We would buy our Coke syrup in gallon jugs, package them up, slap on a label from the Coca-Cola company onto the amber bottle giving directions for use. Most of the time we would tell patients to dump the Coke syrup over crushed ice and sip slowly.

This activity of bottling up Coke syrup came to a screeching halt after the Tylenol Tragedy of 1982, when tamper resistant packaging was required for Over-the Counter sales. Today we buy it nicely packaged in four ounce bottles from a variety of distributors under the name "Cola Syrup"

With the every sky-rocketing prices of an Emergency Department visit, we pharmacists can save the health system a pile of money by treating vomiting over-the counter. I have a flyer I created on the BRAT diet that I share with my patients. Often when the nausea subsides they start eating a regular diet which seems to aggravate the gastrointestinal tract.

The BRAT diet for a day or so seems to be an easy way to ease back into a normal diet. Keep reminding your patients that effective hand washing is the most beneficial way to prevent viral gastroenteritis.

Wishing you and your family a Health and Happy 2018!

Have a great day on the bench!!

December 2017

Treatment of nausea and vomiting... lots of receptors we can block!

Prescription treatment of nausea and vomiting

Antihistamine-anticholinergic agents (histamine-1 blockers)
Examples: doxylamine (Unisom), diphenhydramine (Benadryl), hyoscyamine (Levsin)

Indication: for mild nausea and vomiting. Are of greater benefit in prevention of nausea arising from motion sickness.

Mechanism: appear to interrupt various visceral afferent pathways, that stimulate nausea and vomiting. Most antihistamines do have anticholinergic activity, and can be useful for nausea and motion sickness.

Adverse effects: Drowsiness, confusion, blurred vision, dry mouth, urinary retention, possible tachycardia in elderly. Increased sedation with alcohol—careful on cruise ships!

Phenothiazines (dopamine blockers)
Examples: promethazine, prochlorperazine, haloperidol

Promotility agents (dopamine blockers)
Example: metoclopramide (Reglan)

Indication: more severe nausea and vomiting. Are inexpensive and are used for long term nausea. Most useful in patients with viral gastroenteritis or those receiving mildly emetogenic doses of chemotherapy.

Mechanism: act on the CTZ (Chemoreceptor trigger zone) by inhibiting dopaminergic transmission. Also decrease vomiting caused by gastric irritants suggesting they inhibit stimulation of peripheral vagal and sympathetic afferents. Metoclopramide (Reglan) has a unique mechanism of action that is to stimulate motility in the upper GI tract. Metoclopramide has a similar side effect profile to the phenothiazines.

Adverse effects: Extrapyramidal reactions, Parkinson-like side effects, hypersensitivity with possible liver dysfunction, marrow aplasia, excessive sedation

5-HT-3 Receptor Antagonist (serotonin blockers)
Examples: ondansetron (Zofran) granesitron (Kytril)

Indication: effective in prevention of chemotherapy induced vomiting. Also, effective for post-op nausea, and radiation induced nausea. Frequently combined with corticosteroids (dexamethasone or methylprednisolone) for maximal emesis control.

Mechanism: mucosal entero chromaffin cells in the GI tract release serotonin which stimulates 5HT3 receptors. This causes vagal afferent discharge, inducing vomiting. With the binding of the 5HT3 receptors serotonin stimulation is blocked and hence vomiting is blocked.

Adverse effects: headache, constipation, Can prolong the QT interval. May cause torsades, ventricular arrhythmias, or sudden death. If given to a high-risk drug to a high-risk patient such as the elderly, women, or those with heart failure, bradyarrhythmias, or low serum potassium or magnesium.

NK-1 receptor antagonist
Example: aprepitant (Emend)

Indication: antiemetic in combination with other antiemetics for nausea with highly emetogenic cancer chemotherapies
Mechanism: selective high affinity antagonist or human substance –P/ neurokinin-1 receptor. Little or no affinity for 5-HT3, dopamine, and corticosteroid receptors. Antagonizes the NK-1 receptor
Adverse effects: Many GI, cardiovascular and CNS effects, diaphoresis and alopecia, drug interactions

Examples: dronabinol (Marinol) , marijuana

Indication: used as an appetite stimulant and antiemetic. Effective in treating nausea caused by chemotherapy, but associated with CNS side effects in most patients.
Mechanism: THC (tetrahydrocannabinol) appears to affect the central cerebral cortex axis. Available as dronabinol. Antiemetic effect associated with a “high” and appears better tolerated in the young.
Adverse effects: Orthostatic hypotension, drowsiness, sedation, dry mouth, euphoria

Keep in mind that the reason we have vomiting is a protective mechanism to keep our body from retaining harmful bacteria, viruses and toxins. Suppression of vomiting should be necessary only after a few days, and dehydration can occur. Next week we will discuss the over-the counter treatments, as well as patient care information for vomiting

I remember when Reglan (metoclopramide) came out in the early 1980's to much fanfare as another treatment option for GERD. It was the first treatment option since the phenothiazines in the 1950's!! It quickly became the "go to" for nausea and vomiting for the oncology doctors. We quickly found out that the 10mg four times daily dose caused a lot of Parkinson like side effects.

I had a neurologist tell me "Pete, before I even check a patient for cogwheel rigidity to diagnose Parkinson's disease, I check the med list and look for Reglan first!" Usually drug induced Parkinsonism presents as a bilateral tremor. Parkinson's disease usually first presents as a tremor on one side, before progressing to the other side.

In the 1990's ondansetron (Zofran) became available. I remember when Zofran was nearly one thousand dollars for a bottle of 30. We only used Zofran for nausea induced by cancer chemotherapy. Today the generics cost the pharmacy less than ten dollars for a bottle of 30 tablets, and I see ondansetron being used for any kind of nausea and vomiting from chemo, nausea of pregnancy to simple GI upset!

Have a great day on the bench!!

Be sure to avoid these "uninvited guests" at your next Holiday Party!!

Vomiting... don't let it ruin your holidays.

Vomiting is a protective reflex that allows us to rid ourselves of ingested toxins or poisons. There are five principle neurotransmitter receptors responsible for vomiting. Gastroenteritis is most commonly associated with the dopamine and serotonin receptors. I have listed examples of drugs that react with those receptors:

Name of Receptor Drug working on that receptor
muscarinic (M1) anticholinergics: dicyclomine (Bentyl), hyoscyamine (Levsin))
dopamine (D2) metoclopramide (Reglan), prochlorperazine (Compazine)
histamine (H1) diphenhydramine (Benadryl) doxylamine (Unisom)
serotonin (5HT3) ondansetron (Zofran), granisetron (Kytril)
neurokinin 1 (NK1) Aprepitant (Emend)

Who invited these guys to my Christmas Party…? Listed below are the three most common viruses implicated in nausea and vomiting.
  • Norovirus (Norwalk-like virus) is common among school-age children. It may also cause outbreaks in hospitals and on cruise ships. It is the most common GI virus.
  • Rotavirus is the leading cause in children. It can also infect adults who are exposed to children with the virus, and people living in nursing homes. Vaccination has greatly reduced this virus
  • Enteric adenovirus: can cause systemic infection
The Christmas Germ Exchange- We exchange presents, cards, food, handshakes, hugs and kisses at Christmas time. We also exchange a lot of bacteria and viruses!
  • Most viruses and bacteria are passed from person to person by unwashed hands. Other potential causes can be:
    • Improper handling of food
    • Improper cooking of shellfish
    • Improper hand washing after toileting
    • Surfaces not properly sanitized after food preparation.
  • A vaccine to prevent rotavirus infection is recommended for infants starting at age 2 months. (Rotavirus is the leading cause of viral gastroenteritis in kids up to 2 years of age)
I have this vomiting …was it something I ate at the party??

Raw seafood Norwalk-like virus, Vibrio, hepatitis A
Raw eggs Salmonella
Undercooked meat or poultry Salmonella, Campylobacter, E. coli (STEC), Clostridium perfringens
Unpasteurized milk or juice Salmonella spp, Campylobacter, E. coli, Yersinia enterocolitica
Unpasteurized soft cheeses Salmonella, Campylobacter, E.coli (STEC) Yersinia enterocolitica, Listeria monocytogenes
Homemade canned goods Clostridium botulinum
Raw hot dogs, deli meat Listeria monocytogenes

GETS YOU SICK (less serious) GETS YOU TO THE HOSPITAL (serious)
Novovirus Clostridium botulinum
Salmonella Listeria
Clostridium perfringens Shiga-Toxin producing Escherichia coli (STEC)
Campylobacter Vibrio
Staphylococcus aureus

Now What Happens??
  • The CTZ (chemoreceptor trigger zone) is located in the 4th ventricle of the brain. It is the major chemosensory organ for emesis, usually associated with chemically induced vomiting. Because of its location, blood-born and cerebrospinal fluid toxins have easy access to the CTZ. It is our defense against ingesting poisons; our brain works to eliminate these toxins form our GI tract. This mechanism frequently “kicks in” during cancer chemotherapy. This mechanism also “kicks in” to eliminate those toxins and viruses that we are exposed to these holidays.
Next week we will discuss treatment of nausea and vomiting.

Hand-washing should be our first line of defense against the bacteria and viruses that can cause vomiting.

Here is what the CDC says about hand washing on their website:

"Hand-washing is like a "do-it-yourself" vaccine—it involves five simple and effective steps (Wet, Lather, Scrub, Rinse, Dry) you can take to reduce the spread of diarrheal and respiratory illness so you can stay healthy. Regular hand-washing, particularly before and after certain activities, is one of the best ways to remove germs, avoid getting sick, and prevent the spread of germs to others. It's quick, it's simple, and it can keep us all from getting sick. Hand-washing is a win for everyone, except the germs."

Source: CDC

Have a great day on the bench!!

Antacid therapy --- not as harmless as we might believe??

Antacids: Warnings, Precautions and Drug Interactions

After last week’s inorganic chemistry lesson, lets get down to the information that impacts our patients! All the reactions had one thing in common, generation of a chloride salt: aluminum chloride, magnesium chloride, calcium chloride or sodium chloride. Many of our patients can experience adverse effects from these mono and polyvalent cations..

Warnings/precautions/adverse effects of antacid therapy.
  • Use calcium carbonate, and magnesium antacids cautiously in renal impaired patients
  • Sodium bicarbonate is contraindicated in hypertension, heart failure, renal disease & edema. Do not use for ulcers. Zegerid OTC contains both omeprazole and sodium bicarbonate.The manufacturer states sodium bicarbonate “protects the omeprazole from stomach acid”, but still it is sodium bicarbonate!
  • Use antacids cautiously in elderly where there is decreased GI motility
  • Aluminum containing antacids cause constipation.Use with caution with patients suffering with dehydration or intestinal obstruction.Caution in dialysis patients.
  • Chronic administration of calcium carbonate should be avoided because of hypercalcemia, and because calcium ions cause further stimulation of acid secretion.Calcium carbonate causes constipation.
  • Magnesium containing antacids may cause diarrhea.
  • Hypophosphatemia and osteomalacia can occur with long term use of aluminum hydroxides, but can occur with short term use in malnourished patients like alcoholics.
Drug interactions with antacid therapy:
  • Tetracyclines & fluoroquinolones are BOTH bound by antacids. Separate tetracyclines by 2 hours, and fluoroquinolones by 4 hours.
  • Enteric coated drugs: coating is destroyed by antacid exposure.
  • Antacids interfere with absorption of: digoxin, cimetidine, ranitidine, anticholinergics, phenothiazines, phenytoin, quinidine and ketoconazole (they require acid for absorption). Separate these drugs from antacids by 2 hours.
  • Separate from Levothyroxine (Synthroid) by 4 hours
After reviewing all of the potential drug: antacid interactions we pharmacists have another opportunity to interact with our patient population in providing expertise. Antacid therapy is not as innocuous as we might believe.

Have a great day on the bench!!

Did you eat too much at your holiday party??

Antacid Therapy

Indications for antacid therapy: Antacids today should be only used short term. Antacids work quickly to treat ulcer pain and heal ulcer. They neutralize gastric acid, which in turn increases Lower Esophageal Sphincter (LES) tone. The LES tone is important to keep the gastric contents from “splashing up” into the esophagus. Antacids inhibit the conversion of pepsinogen to pepsin thus raising the pH of the gastric contents.

Antacids have a rapid onset (5-15min) short duration (30-60minutes). They are ideal for immediate relief of gastrointestinal distress.

Mechanism: reduces concentration and total load of acid in gastric contents. The hydroxide ions or the carbonate ions neutralize the hydrogen ions (H+).

Active ingredients of antacid therapy: the chemistry behind antacid therapy:

Aluminum hydroxide: Al(OH)3 + 3HCl à AlCl3 + 3 H2O. Aluminum hydroxide plus hydrochloric acid produces aluminum chloride and water.

Magnesium hydroxide: Mg(OH)2+2HCl à MgCl2+2H2O. Magnesium hydroxide plus hydrochloric acid produces magnesium chloride and water.

Calcium carbonate: CaCO3 + 2HClà CaCl2 + H2O +CO2. Calcium carbonate plus hydrochloric acid produces calcium chloride, water and carbon dioxide

Sodium bicarbonate: NaHCO3 + HClà NaCl + H2O + CO2. Sodium bicarbonate plus hydrochloric acid produces sodium chloride, water and carbon dioxide

Simethicone is frequently included in antacid formulations as an “anti-gas” agent: Mechanism: silicon polymers that reduces surface tension of gas bubbles embedded in the intestinal mucosa. Simethicone is often added to antacids to reduce gas pain. The gas bubbles then coalesce and then are more easily eliminated through belching (upper GI) of flatulence (lower GI). Simethicone dosages: Children: less than 24 months: 20mg 4 times daily Age 2-12: 40mg 4 times daily Adults: 40-360mg after meals and at bedtime as needed.

I hope you enjoyed this "throwback" to Freshman Inorganic Chemistry!! Next week we can discuss the warnings, precautions and side effects of antacid therapy.

Since Tagamet came out in 1977, what were out patients with peptic and duodenal ulcer disease? I remember my Dad using Pro-Banthine® (propantheline), an anticholinergic which was approved in 1953. Robinul® (glycopyrrolate), another anticholinergic was approved in 1961 and also used to inhibit stomach acid secretion. Pushing doses of these anti-cholinergic drugs did indeed inhibit gastric secretions, but at what a price given all the side effects of dry mouth, blurry vision, constipation, urinary retention, etc.

Antacid therapy was the mainstay for these patients. Most patients always had a bottle of Maalox (mag/alum hydroxide) or Mylanta in their medicine cabinets, work lockers and even in their car.

The standard regimen included one ounce (30ml) one hour before each meal, one ounce after each meal and at bedtime. Patients could go through 7 ounces of antacid per day, and many bought a couple of bottles at a time. Talk about inconvenient dosing regimens.

We can now see how back in 1977 Tagamet (cimetidine) was met with such enthusiasm!

Have a great day on the bench!!

November 2017

Happy 40th Birthday Histamine-2 Receptor Antagonists!!! Hoooray for H2RA's!!!

Tagamet has been around for 40 years...we still love this class of drugs!

Mechanism: competitively inhibits the histamine at parietal cell receptor sites, thus reducing the volume and hydrogen ion concentration of gastric acid secretions.

Indications: Histamine-2 receptor antagonists (H2RA) are preferred to antacids because of compliance, and lack of effect on GI motility. Reasonably effective to treat mild/moderate gastroesophageal reflux disease (GERD). Less reliable for healing erosive esophagitis. May be useful for PUD or hypersecretory states (Zollinger-Ellison syndrome). H2RA work faster than proton pump inhibitors (which may take up to 3 days). The onset of action for the H2RA’s is within one hour and lasts between 6-12 hours.

Drug Year of Rx INTRO-USA Approved OTC Healing Dose Prevention Dose OTC Brand/Strength
Cimetidine (Tagamet®) 1977 June 1995 800mg HS 400mg HS Tagamet HB 200mg
Ranitidine (Zantac®) 1983 December 1995 300mg HS 150mg HS Zantac 75mg, 150mg tabs
Famotidine (Pepcid®) 1986 April 1995 40mg HS 20mg HS Pepcid AC-10
Pepcid AC-20
Nizatidine (Axid®) 1988 May 1996 300mg HS 150 HS Axid-AR-75mg

Counseling Points:
  • All H2RA are listed a Pregnancy Category-B (no proven risk in humans). However, all packages do carry the warning to consult physician if pregnant.
  • Cimetidine (Tagamet): weak anti-androgenic effects; male gynecomastia & impotence at high doses. May cause feminization of male fetus. Even though cimetidine is Pregnancy Category-B, I would never advise a pregnant patient to use this drug.
  • Pepcid Complete contains: Famotidine 10 mg, Calcium carbonate 800 mg, Magnesium hydroxide 165 mg. I don’t recommend calcium containing antacids, because the calcium will stimulate gastric acid release.
  • Axid-R-75mg is not current available.
Drug interactions
Cimetidine reduces hepatic metabolism of drugs metabolized by cytochrome P450 pathway.
  • CYP450*3A4 -simvastatin, Protease Inhibitors (HIV)
  • CYP450*2D6- codeine, fluoxetine etc.
  • CYP450*1A2 – fluoxetine, EtOH, amitriptyline, clopidogrel
  • CYP450*2C9 –ibuprofen, naproxen, glipizide
  • Ranitidine (Zantac) has about 10% affinity for CYP450 3A4 than that of cimetidine, so we expect insignificant drug interactions.
  • Nizatidine (Axid) and famotidine (Pepcid) have no affinity for CYP450 3A4.

Cimetidine (Tagamet®) was the first billion-dollar drug released back in the 1970’s for treatment of stomach ulcers. In 1964, it was well known that histamine stimulated gastric acid release. However the traditional anti-histamines (Benadryl, ChlorTrimeton) had no effect on gastric acid release. I remember in Medicinal Chemistry class back in 1980 the professor discussing how this class of drugs will change the way drugs are developed, since this was one of the first classes of drugs designed based on the discovery of the receptor site, and developing drugs to fit that receptor.

Ranitidine (Zantac®) was introduced in US market in 1983 and was the world's biggest-selling prescription drug by 1987. It has since largely been superseded by the even more effective proton-pump inhibitors, with Prilosec (omeprazole) taking over the acid suppression market for many years.

Have a great day on the bench!!

Lots of information about PPI's... should they even be over the counter??

Sending out this newsletter one day early... Tis the season for overeating... Happy Thanksgiving!

As we discussed last week, there have always been safety concerns with these medications. Denise and I were to a drug company sponsored dinner last week, and I specifically asked one of the local GI docs about “deprescribing PPI’s”. He acknowledged this as a hot topic in the GI arena, but he said that neither he or his colleagues were in any rush to stop this therapy, given the amazing benefits that appropriate PPI therapy brings to our sickest patients. He reminded us about GI bleeds, Zollinger Ellison, NSAID induced gastropathy and Barrett’s esophagitis. Of course, this astute GI doctor sees only the sickest of patients.

I also reminded him that “deprescribing” PPI’s will be a huge challenge, given the fact that they are available over the counter. With the life-saving potential of PPI therapy let’s discuss the adverse effects, and how we can best help our patients.

  • Fracture risk: at higher doses, new research shows increase risk of hip fractures possibly due to impaired calcium absorption. Fracture risk is a greater concern with high dose, and long term (over 1 year) of PPI therapy. Remind patients to take calcium (citrate), vitamin-D, and to exercise. Elderly patients on PPI therapy will benefit by using calcium citrate, because its absorption is less dependent on stomach acid.
  • B-12 deficiency: May also cause a cobalamin deficiency due to protein-bound dietary Vit-B12 malabsorption. Long term PPI use will decrease serum B-12 levels. Keep in mind that our liver has about two years of Vitamin-B12 on board so deficiency may take a while. Folate levels appear to be unaffected.
  • Decreased Magnesium levels: becomes more apparent with long term PPI use. Low magnesium levels can occur three months into PPI therapy, but risk is higher after one year. Patients should watch for muscle cramps, heart palpitations, dizziness, tremors, or seizures.
  • Pneumonia: PPIs increase gastric pH, which may allow more bacterial growth. The resulting change in gastrointestinal (GI) and respiratory flora may increase the risk for infection. The incidence of hospital-acquired and community-acquired pneumonias appears to be increased with PPI therapy.
  • Clostridium difficile: increase in Clostridium difficile infections and diarrhea occur as a direct result of PPI usage. About 42% of patients being treated for C. difficile while taking a PPI will have a recurrent infection within 90 days. Infections may be decreased by limiting PPI use to patients who truly need them
  • Alzheimers : (?) The results of one study showed that of the 2950 patients who were regularly using a PPI had a significantly higher risk for dementia compared with those not taking this drug. Later refuted by a study was published in the Journal of the American Geriatrics Society (2017) which addressed previous studies that suggested that PPI use was linked to increased risk of cognitive impairment in adults aged 75 years or older. For now, Alzheimer's seems to be unlikely caused by PPI use.
  • Renal Failure: Compared with patients who took an H2 blocker (Zantac, Tagamet, etc), PPI users had a 19% increased risk of estimated glomerular filtration rate (eGFR) falling below 60 mL/min/1.73m2 and a 26% increased risk of CKD (eGFR below 60 on 2 separate occasions at least 90 days apart, based on the Chronic Kidney Disease Epidemiology Collaboration equation). Source: www.renalandurologynews.com. The Taiwanese National Health Insurance data did a rather large study of two groups of over 16,000 patients taking and not taking PPI’s. Here is what their observations were:
    • PPI users were 42% more likely to have Chronic Kidney Disease (CKD) than non-users
    • CKD risk rose by 23% with each milligram increase in PPI dose
    • CKD risk rose by 2% per month of PPI use

If you thought about starting Prilosec OTC or any other proton pump inhibitor (PPI) because of holiday over indulgence, after reading this newsletter you might want to reconsider!

In 1982 when Helicobacter pylori was first reported, the world of GI disease was forever changed. Now Americans spend nearly 11 Billion dollars on PPI use, and up to 1/3 is believed to be inappropriate. The numbers are staggering when one sees that only Dexilant (Dexlansoprazole) is the only brand name; the rest are quite inexpensive. The 1200 square foot neighborhood drug store I work in buys its Omeprazole-20 and Pantoprazole -40 in bottles of 1000!

Counseling points:
  • Inform patients that PPI’s take about three to five days to see benefit. It takes that long to “shut down” acid production.
  • If they are buying these PPI’s over the counter, the package specifically says they are to be used only for two weeks at a time, and then no more than three “cycles” per year.
  • Always scan the patient profile looking for Clopidogrel (Plavix). Some of the PPI’s do block the activation of clopidogrel. Pantoprazole (Protonix) is our “go to” PPI for patients taking clopidogrel.
Have a great day on the bench!

We are a little too comfortable with Proton Pump Inhibitors...

Proton Pump Inhibitors and Acid Suppression

As my student pharmacists will tell you that half of my conversations start out with “Back in the old days, when I was your age...” Back then the histamine-2 receptor antagonists (H2RA) were just in their infancy. Physicians and patients rejoiced when we no longer had to use high dose anticholinergics such as Pro-Banthine (propantheline) and Robinul (glycopyrrolate) to suppress stomach acid. General surgeons whose bread and butter were gastrectomy procedures due to stomach ulcers were maybe not quite so excited. Guys like my Dad and Grandfather were delighted, as they both had two previous gastrectomies due to recurrent stomach ulcers. Tagamet (cimetidine) released in August of 1977and became the blockbuster drug of the 1970's, being the first drug to reach one billion dollars in sales. I remember going to the drug store for my Grandpa and spending $27 for one hundred tablets!

A question on my state board licensure exam was “Which of the following drugs is free of side effects, and drug interactions?” The answer was Tagamet! It was sold by one of my all-time favorite drug reps, a gentleman named “Ray”. In June of 1983 Ray met some very stiff competition when Zantac (ranitidine) was approved.

Tagamet was initially approved as four times a day dosing, then changed to 400mg twice daily dosing to compete with Zantac. The battle was on, and Zantac wrestled a good bit of this lucrative business away from the original H2RA. It became apparent that Tagamet after being used by millions of patients, indeed had side effects such as blocking CYP-450-3A4, as well as causing gynecomastia in men by blocking testosterone formation. I hope they changed that state board question!

The very lucrative H2RA market joined by Pepcid (famotidine) and Axid (nizatadine) came to a screeching halt in the 1990's. Omeprazole was first marketed in the United States in 1989 by Astra, now (AstraZeneca), under the brand name Losec. In 1990, at the request of the FDA, the brand name Losec was changed to Prilosec to avoid confusion with the Lasix 20mg (furosemide). As when the FDA intervenes, things often go amiss, and the new name led to confusion between omeprazole (Prilosec) and fluoxetine (Prozac)!!

I remember discussing this new class of stomach acid suppressants with none other than “Ray” the Tagamet salesman. Ray said “no doubt this Losec shuts down stomach acid production better than Tagamet, but the question becomes... how much is too much” Ray said certainly stomach acid does more than causes stomach ulcers, and aids digestion; but what about its protective effect. Possibly could stomach cancers become more common with this drug. No one seemed concerned about this excess acid suppression, obviously Ray had to try to protect his turf. Prilosec buried the competition.

In 2002 the generics were approved by the FDA, and prices dropped like a rock. Insurance companies no longer required prior authorizations, because they were so cheap. Today most pharmacies are lucky to get reimbursed $10 a month! People get prescribed these drugs and are left on them indefinitely. Much to my amazement this powerhouse acid blocker went over the counter in 2003, and was welcomed by all consumers as a cheaper alternative to the prescription variety. Other proton pump inhibitors like Zegerid and Prevacid followed suit., and had their own OTC formulations. Patients didn't even need to consult a physician or a pharmacist. Sure, the FDA required a 14 day limit on the box, and a warning of no more than 3 cycles of 14 tablets per year; as the companies sold these drugs in “warehouse packs”!

Today the focus is “deprescribing” proton pump inhibitors. How do we even begin, when the patients can buy these potentially harmful drugs without a prescription? Next week we will discuss the numerous potential side effects of these commonly (over)prescribed drugs. My salesman friend “Ray” might have been on to something!

How well I remember how the dreaded "stomach ulcers" ravaged my family. My Dad and Grandpa were always plagued by GI ulcers. Both had stomach resections due to "bleeding ulcers". Both took H2RA therapy and did very well on them.

Next week we will discuss the ramifications of long term PPI therapy. If there is EVER a reason for a "behind the counter" class of drugs, the Histamine-2 blockers and Proton Pump Inhibitors should be the first to be regulated.

Have a great day on the bench!

Instead of $800 to treat EACH person, let's use an effective over-the -counter treatment for pinworms!


Mechanism: It is poorly absorbed from the GI tract in humans and acts by paralyzing worms. Pyrantel causes the release of acetylcholine, inhibits cholinesterase, and stimulates ganglionic neurons, acting as a depolarizing neuromuscular blocking agent in pinworms. These actions cause extensive depolarization of the pinworm’s muscle membrane, producing tension of the pinworm's muscles, which causes paralysis and release of their hold to the intestinal wall. They are unable to latch onto the intestinal mucosa, and are passed out in the stool.
  • Pyrantel pamoate is available over the counter as a 50 mg/mL suspension.
  • The dose of pyrantel pamoate for pinworms is 11 mg/kg of base, up to 1 g, given orally as a single dose. The dose should be repeated after two weeks. Package has detailed instructions by weight.The over-the counter products have detailed weight based dosing instructions. Approved for 2 years of age and older. Maximum dose is 1gram.
  • May administer with food, milk or fruit juice, at any time of day. Fasting, purgation, or special diets are not necessary for effective treatment
  • Does not reliably kill pinworm eggs. Give second dose is to prevent re-infection by adult worms that hatch from any eggs not killed by the first treatment.
  • There are numerous brand names, such as: Pin-X , Pin-Rid, Antiminth, Reese’s Pinworm Medicine. Cost is around $15.00 per ounce. Became OTC in 1986
  • Repeated infections should be treated by the same method as the first infection.
  • Treat all household members if more than one is infected. In institutions, mass and simultaneous treatment, repeated in 2 weeks.
  • Good hand washing hygiene! Soap and water after toilet.
  • Best to not allow children to share the same bathwater, reuse or share washcloths. Showering may be preferred to avoid possible contamination of bath water.
  • Clip fingernails regularly, and avoid biting the nails and scratching around the anus.
  • Frequent changing of underclothes and bed linens first thing in the morning is a great way to prevent possible transmission of eggs in the environment and risk of reinfection. Do not shake out bed linens, the eggs can become airborne. These items should be \ carefully placed into a washer and laundered in hot water followed by a hot dryer to kill any eggs that may be there.
  • Clean shared surfaces like doorknobs, toilet seats, and furniture with a disinfectant, such as bleach
  • Pinworm eggs are spread easily and even the cleanest and most careful people can get them. Be sure to re-assure parents and caregivers.

Last week we discussed prescription treatment options for pinworm infestation. We explored treatment options such as Emverm® (mebendazole) and Albenza (albendazole).

Both products were extremely expensive costing as much as $400.00 for initial treatment, followed by a second dose in two weeks. Today we pharmacists can step in and use a very affordable self-care treatment option for our patients.

Just as important as the treatment, is the second follow-up dose as well as the prevention of re-infestation. Treatment failures are rare, and re-infestation is common. Be sure to share these "practice points" wih all of your patients.

Have a great day on the bench!

"Quit scratching down there".... better have a look. It might be pinworms!

PINWORMS - The basics and prescription Treatment.

Pinworm infections are caused by a small, thin, white roundworm called Enterobius vermicularis. This infection affects all people, especially children, institutionalized persons, and household members of persons with pinworm infection. Pinworms are spread by humans, and not by pets!

Mode of transmission: Pinworms are transmitted from fecal to hand to mouth. Eggs may also be ingested by inhalation. The incubation period for pinworms is 1 to 2 months or longer for the adult gravid female to mature in the small intestine.

These eggs are deposited around the anus by the worm and can be carried to common surfaces such as hands, toys, bedding, clothing, and toilet seats. By putting anyone’s contaminated hands (including one’s own) around the mouth area or putting one’s mouth on common contaminated surfaces, a person can ingest pinworm eggs and become infected with the pinworm parasite. Since pinworm eggs are so small, it is possible to ingest them while breathing.

Symptoms: often asymptomatic, but itching around the anus (pruritis ani) is common.

  • Seeing worms in the perianal region 2 to 3 hours after the infected person is asleep.
  • Touch the perianal skin with transparent tape to collect possible pinworm eggs around the anus at first rising. Use tongue blade with double side tape
  • Microscopically test for eggs under the fingernails (since anal itching is a common symptom)
RX Treatment Options
  • Mebendazole (Emverm®-100mg)
    WAC=$369.00 per tablet AWP=$442.80
    • Dose= 100mg as a single dose. A second dose in 2 weeks may be appropriate if needed; both CDC and Sanford Guide recommend a second dose 2 weeks later. Tablets may be chewed, swallowed whole, or crushed and mixed with food.
    • Do not take concurrently with Metronidazole (Flagyl®) due to an increase incidence of Stevens-Johnson’s Syndrome
    • Approved for children 2 years of age and older
    • Emverm.com is a patient friendly website with good information. Also has a $60 coupon available.
  • Albendazole (Albenza®-200mg) currently
    $365.64 for 2 tablets AWP=$438.77/2
    • THIS IS AN OFF LABEL USE: Dose= 400mg (2 tablets) as a single dose. Repeat dose in 2 weeks. It is listed in the Sanford guide as a secondary treatment option.
      • Can be dosed down to 1 year old (200mg/dose)

Pinworm and eggs, from the CDC website. Lots of good patient information for pinworms on the CDC website.

So, as we can see there is only one prescription option that has FDA approval for treatment of pinworms. Next week the pharmacists can “take over” and we will cover a reasonable treatment option, along with patient counseling points for pinworm infections.

Have a great day on the bench!

October 2017

My grandkids Luke and Anna made a big contribution to this column. Antibiotic associated diarrhea happens this time of year.

Cefdinir and Amox/Clav- useful for ear infections - but be sure to "cover their butts"

Now that winter is approaching and respiratory and ear infection season is closely approaching, we pharmacists can be instrumental in prevention of diaper rash. 18-35 percent of all children exposed to antibiotic therapy will develop antibiotic associated diarrhea. The more broad-spectrum antibiotics will cause a higher incidence of diarrhea. Amoxicillin/clavulanate and cefdinir are the pediatrician’s favorites.

Amoxicillin/Clavulanate (Augmentin®) is notorious for causing stomach upset and diarrhea. Most of the gastrointestinal distress can be traced back to the clavulanate component which increase efficacy of amoxicillin by destroying the beta-lactamase that the bacteria produce. By blocking the effect of the beta-lactamase, the amoxicillin can do its job of destroying the bacteria. The problem is there are numerous strengths of amoxicillin/clavulanate, and for pediatric patients we need to dose based on the amoxicillin component at 80-90mg/kg/day (referred to Amox/Clav HD). For illustration let’s assume we have a 37 lb child (16.5kg). The calculated dose would be 1500mg per day.

Drug To get 1500mg amox You get this much clavulanate daily
Augmentin 125/31.25 12 teaspoons 375mg
Augmentin 250/62.5 6 teaspoons 375mg
Augmentin 400/57 3.75 teaspoons 213.75
Augmentin-ES 600/42.9 2.5 teasp 107.25
Augmentin 250/125 6 tablets 750mg
Augmentin 500/125 3 tablets 375mg
Augmentin 875/125 2 tablets 250mg

As you can see from the above chart for a child getting Amoxicillin 1500mg per day (37lb child) would get 107.25mg of clavulanate should the prescriber use Augmentin ES 600, versus 375mg of clavulanate should the prescriber use Augmentin 250/5.

Whenever you are prescribing Augmentin therapy HD (high dose) as is recommended for otitis media, it is critical to use Augmentin ES 600mg/42.9 to minimize clavulanate exposure and decrease incidence of severe GI upset and diarrhea. Always call the prescriber if a child has otitis media, and the prescriber writes for anything other than Amox/clav -ES 600/5ml to minimize the clavulanate exposure and therefore the gastrointestinal side effects. Remind patients to keep the suspension refrigerated at all times, and to use a protective diaper rash paste BEFORE administering the first dose.

Cefdinir (Omnicef®) is a third-generation cephalosporin that causes a lot less gastrointestinal upset. It is dosed at 14mg/kg/day in 1 or 2 doses. Because it is broad spectrum, it can kill off more gut bacteria and cause diarrhea. In infants, especially if they are formula fed, the cefdinir binds to the iron in the milk and can cause a red stool, resembling blood which can greatly upset the parents. Be sure to warn them of this harmless side effect.

Also with Cefdinir, dispense in the box to keep the glass bottle from breaking, give with food, and do not refrigerate. And like amox/clav it carries a 10-day expiration date. Be sure to always give an appropriate measuring device.

Yes, a picture is worth a thousand words!

Imagine a new Mom changing her infants diaper, and seeing these red streaks in the diaper, which could be easily confused for rectal bleeding. Fortunately the Mom was my daughter Gretchen, who is a doctor of Pharmacy, and teaches Clinical Pharmacy Practice at West Virginia University. Her son Luke, was being treated for a case of recurrent otitis media. So dramatic is this specimen, she snapped a picture for me to share with my students and colleagues. The color would even be brighter for a formula fed baby. For comparison, we snapped a picture of my son Phil's daughter Anna's diaper a normal breast fed diaper.

Keep this image in mind when you are either prescribing, or dispensing Cefdinir (Omnicef®)

Special thanks to Luke and Anna for your input (well, I guess output) for this column.

"We interrupt our discussion about diaper rash" ---- Hand, Foot, Mouth Disease is spreading. Be ready to help your patients NOW!

Hand, Foot, Mouth Disease affects...hand, foot and mouth! (of course).

I will delay discussing diaper rash induced by antibiotics because of an “epidemic” that is spreading in our area. Recently, hand, foot, and mouth disease is on the rise with cases affecting local school districts. One of the local school districts ordered cases of hand sanitizers from a local pharmacy. I can’t think of a disease that has a more descriptive name than “Hand, Foot and Mouth Disease” abbreviated HFMD.

Hand, foot, and mouth disease is caused by viruses that belong to the Enterovirus genus, which includes the polioviruses, coxsackieviruses, echoviruses, and enteroviruses.

Coxsackievirus A16:
is the most common cause of hand, foot, and mouth disease in the United States, but other coxsackieviruses can also cause the illness.

Enterovirus 71:
has also been associated with cases and outbreaks of hand, foot, and mouth disease. Less often, enterovirus 71 has been associated with severe disease, such as encephalitis. Patients can be affected with a couple of different enteroviruses.

Patients with HFMD is most contagious during the first week of illness and be contagious for days or weeks after symptoms go away. Adults, may not develop any symptoms, but they can still spread the virus to others. Everyone especially those with direct contact with children and infants must maintain good hand hygiene so they can minimize their chance of spreading or getting infections. Daycares because of their multiple diapering “events” can see this virus spread quickly through a classroom.

Patient Information:
Here’s some useful information about this condition that Karen Quach one of my student pharmacists would like to share.

Hand, foot, and mouth disease is a common childhood infection most often occurring in confined spaces, such as daycares and schools, in the summer and fall months. It is characterized by small sores that can form in the mouth, and on the hands, feet, buttocks, and genitals. This is the main symptom to look out for, and the sores can appear as small red spots, bumps, or blisters. In addition, some children may present with a mild fever. Although this infection is generally mild, it is highly contagious and may cause pain, including painful swallowing.

Hand,Foot,Mouth disease on 15 month old

The infection itself is not treated and should resolve without medicine within one week. Until then, children should maintain adequate fluid intake to prevent dehydration. If needed, over the counter medications such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) can be used to relieve pain. Cool liquids and foods such as popsicles and ice cream may help to numb the pain.

The virus travels in body fluids, including mucus from the nose, saliva, bowel movements, and fluid from the sores. Therefore, the most important method to prevent spread of infection is proper hygiene. Tips include washing hands frequently with soap and water, using alcohol-based hand sanitizers, covering the mouth and nose when sneezing and coughing, properly disposing infected tissues, and disinfecting contaminated surfaces and objects. Additionally, infected children should be kept home when they have symptoms to prevent spread to other children.

We got a request to put together a newsletter about hand, foot and mouth disease because of a local outbreak. Like any good preceptor, I turned the project over to my student pharmacist.

We have two students living with us right now and last week for Pharmacy Month, Gabrielle Dziuba published a newsletter on Poison Prevention. I turned this project over to Karen Quach. She did a stellar job, and we also published her newsletter in the local paper. Her research is the information that contains the patient information.

Karen Quach, PharmD Candidate
University of Pittsburgh School of Pharmacy Class of 2018

Treating Diaper Rash, and saving the money for the college fund!

Treating Diaper Rash--simple as A-B-C-D-E!!!

Diaper rash is almost always caused by Candida albicans, and like any yeast thrives where it is warm, dark and moist. Here are some treatment strategies to help manage diaper rash in our pediatric population. It’s as easy as A, B,C, D & E.

A = air out the skin by allowing the child to go diaper-free, best to do on a hard surface floor for easy clean up. Don’t expose to sun for longer periods of time to prevent possible sunburn.

B = barrier; use a paste or ointment to protect the skin. Protectants: are first line therapy and can be used for protection (anticipated during antibiotic therapy) or treatment. Provides physical barrier to protect skin against irritants and moisture. Also provides lubrication to reduce skin-to diaper friction.

C = clean; Clean area with water—avoid rubbing area. Use a squirt bottle, pat and air dry. If using Baby wipes, they should be free of soaps, dyes, perfume and alcohol.

D = disposable diapers; are best option during an episode of diaper rash, rather than cloth diapers. If using cloth diapers, avoid plastic panties.

E = educate; educate your patients about how to prevent a recurrence of diaper rash

Pharmacologic Measures:
Antifungal agents
  • Don’t use routinely, only when C. albicans is suspected.
  • Characterized by beefy red plaques, with scales and satellite papules & pustules. Pustules are superficial.
  • May use Miconazole and Clotrimazole which are OTC, or Nystatin (Rx-only)

Vusion® (miconazole 0.25%) – is a product for diaper rash. Contains also white petrolatum & Zn oxide. Lower concentration causes less systemic absorption, however higher strength Miconazole has not been shown to cause problems. The cost of a 50gm tube of Vusion diaper rash ointment is $560.00!

“GrandDad Kreckel” has calculated that 90gram of Zinc Oxide + 15g Miconazole 2% will yield a concentration of miconazole .28%. The leftover $550.00 can be applied to the grandkids college fund!

Cholestyramine/Aquaphor -compounded medication for Diaper Rash Cholestyramine is a bile acid sequestrant, and Aquaphor is a greasy vehicle to protect the bottom. Usually made as a 20% paste. INGREDIENTS:
  • Cholestyramine light powder (80% anhydrous) ---------------25gm
  • Petrolatum ointment base (Aquaphor) --------------------------75gm
  • Dispense as 100gm. Good for 180 days.
What not to use: Talc and cornstarch- not recommended due to potential inhalation by the infant. OTC Antibiotic ointments: Over-the-counter antibiotic creams or ointments (such as Neosporin or Bacitracin) are not recommended because neomycin and bacitracin cause allergic reactions.
  • Bacitracin is the 2003 Allergen of the Year (American Contact Dermatitis Society)
  • Neomycin is the 2010 Allergen of the Year (American Contact Dermatitis Society)
Corticosteroids: Hydrocortisone 1% (otc): can be used for moderate to severe diaper rash, or allergic dermatitis. Can be used for up to 2 weeks maximum. Do NOT use stronger corticosteroids (avoid all RX!!)
Peruvian balsam: Butt Paste (Boudreaux Butt Paste) – contains Zn oxide, Peruvian balsam, boric acid, castor oil and petrolatum. (FDA cautions that Peruvian balsam may cause skin sensitivities.)

Treating diaper dermatitis can be challenging and even frustrating for parents. There are a lot of old time remedies that shouldn't be used today, especially being the powders. When you think about the ingredients in the common powders, they can do more harm than good. Talc is actually a mineral, or stone that is pulverized to dust. Corn starch is a "starch" which we remember from biochem class is a string of sugar molecules linked together, which is just like "feeding" the Candida albicans. The talc being a mineral can be inhaled into the child's lungs, and long term exposure can cause damage. Although both do reduce friction between skin folds, they are not recommended for treatment.

I am a huge fan of plain and simple. When Regina, Luke or Anna get diaper rash the miconazole and zinc oxide combination works very well. It is only used when Candida is suspected, and not for prophylaxis.

Next week we will discuss diaper rash, and provide counseling points to parents when giving their children antibiotics.

Have a great day on the bench!!

When the grandkids get diaper rash... GrandDad comes to the rescue!

When Candida albicans affects the grandkids... treatment of diaper dermatitis

This week we continue our discussion of yeast and fungi focusing on Candida albicans, in a different patient population, that is in our infants and diaper wearing toddlers. When we think of the ideal environment for yeast and fungi to grow, we think of warm, dark and moist. What better place to grow than a baby’s diaper! Candida albicans is the most common cause of diaper rash in infants. The fungi take advantage of the warm, moist conditions inside the diaper.

Causes of diaper dermatitis:
  • Too much moisture
  • Rubbing and friction
  • Skin contact with urine and feces
  • Allergic reaction to the diaper material or to creams, powders or wipes

Role of Candida albicans:
  • Infection often occurs after 48-72 hours of active eruption.
  • It is isolated from the perineal area in as many as 92% of children with diaper dermatitis.
  • Other microbial agents have been isolated less frequently, perhaps more because of secondary infections.
  • Peak incidence occurring when the individual is aged 9-12 months
  • Diaper dermatitis is prevalent in 7-35% of the infant population.

  • Wet skin increases the penetration of irritant substances.
  • Superhydration urease enzyme found in the stratum corneum liberates ammonia from cutaneous bacteria.
  • Irritation occurs because:
    • Urease has a mild irritant effect on nonintact skin.
    • Lipases and proteases in feces mix with urine on nonintact skin and cause an alkaline surface pH, adding to the irritation. The bile salts in the stools enhance the activity of fecal enzymes, adding to the effect

  • Change your baby's diaper often.
  • Keep the diaper loose enough to let air reach the skin inside the diaper.
  • Gently clean the affected skin with warm water. Pat gently with a clean, soft towel.
  • Don't use wipes that contain alcohol or perfume.
  • If you use cloth diapers and wash them yourself, use very hot water. Rinse carefully
  • Note: Feces in breastfed infants have a lower pH, and breastfed infants are less susceptible to diaper dermatitis.
  • Broad spectrum antibiotics can cause Candida albicans to overgrow by destruction of “good” bacteria.
    • Amoxicillin/clavulanate (Augmentin®)
    • Third generation cephalosporins
      • Cefdinir (Omnicef®)
        • Recommend topical protection before the first dose of broad spectrum antibiotics

This area of study is of particular interest to me not only as a young pharmacist when we had three kids in four and one-half years, but now we are blessed with three grandchildren!

Our three year old Regina is potty trained but our 15 month old grandson Luke, and 9 month old granddaughter Anna are in diapers, and GrandDad comes to the rescue to treat diaper dermatitis.

This week we covered the basics, and next week we will discuss treatment of diaper rash, and of course what NOT to use! The money we can save in the treatment of diaper rash will go a long ways for their college funds.

Have a great day on the bench!!

September 2017

Our female patients can benefit from these treatment options

Treatment of Vaginal Candidiasis..

The most mentioned vaginal yeast infection that our patients experience is actually the second most common vaginal infection. Candidiasis is the second most common cause of vaginitis symptoms and accounts for approximately one-third of vaginitis cases. Bacterial vaginosis is the most common, but no over-the counter treatment exists. Ten to twenty percent of healthy women of reproductive age have Candida albicans present in the vaginal tract.

Risk Factors for vulvovaginal candidiasis are as follows
  • Patients with Type-2 diabetes, are more prone to candida albicans infections especially if they are not well controlled
  • Patients exposed to antibiotic therapy-25-33 % of females exposed to antibiotic therapy. This is due to the destruction of the normal healthy flora, allowing the overgrowth of candida species. Lactobacillus is of no value in treatment or prevention.
  • Immunosuppressed patients- patients with a less than robust immune system, either due to corticosteroid therapy, or HIV are more susceptible to candida infections.
  • Elevated estrogen levels: patients taken oral contraceptives, or estrogen supplements have a higher incidence.
  • Sexual activity: vaginal candidiasis is not considered a sexual transmitted infection, because it is part of the normal flora. Patients report an increased incidence of yeast infections when they begin sexual activity.

Symptoms: itching of the vulva is the most common sign, remembering that yeast isn’t the only organism that causes itching. Patients may experience vulvar burning, soreness, and irritation. Some patients may experience burning on urination, with the source of the burning being the vulva and not the urethra. Patients may experience dyspareunia as well. Symptoms are often worse during the week prior to menses.


Diflucan® (Fluconazole) (Rx only)
150mg tablet given as a single dose. Fluconazole remains in the vaginal secretions up to 72 hours. Avoid if pregnant.

Miconazole (Monistat®) (OTC) Is available as a cream, or vaginal suppository, or insert
  • Monistat-3: (200mg supp.) 1 supp vaginally at bedtime for 3 nights
  • Monistat-3 (4% prefilled cream 200mg each) vaginally at bedtime for 3 nights
  • Monistat-7: (100mg supp) 1 supp vaginally at bedtime for 7 nights
  • Monistat-7 (2% cream, 100mg each dose): 1 applicatorful vaginally at bedtime for 7 nights. Best treatment option for treatment of patients who are pregnant, or patients with diabetes.
  • Monistat-1 Combo pack: miconazole 1200mg insert plus miconazole cream for application to vulva
CAUTION: potential CYP 4503A4 interactions due to topical absorption of miconazole

Clotrimazole (Gyne Lotrimin®) Available as a cream
  • Gyne-Lotrimin 1% cream: 1 applicatorful vaginally at bedtime for 7nights
  • Gyne-Lotrimin 2% cream: 1 applicatorful vaginally at bedtime for 3 nights
Terconazole (Terazole®) (Rx only) Available as cream or suppository.
  • Terazol 0.4% cream: 1 applicatorful vaginally at bedtime for 7 nights
  • Terazol 0.8% cream: 1 applicatorful vaginally at bedtime for 3 nights
  • Terazol 80mg supp: 1 suppository vaginally at bedtime for 3 nights
Butoconazole (Gynazole®) Rx Only 2% cream 5gm
  • Insert one applicator at bedtime as a single dose. May weaken diaphragms or condoms, due to mineral oil in the formulation.

Women indeed are very proactive in their healthcare,and we pharmacists have the opportunity to guide them through the feminine hygiene aisle.

When Monistat (miconazole) first became available in 1991, there was great concern from gynecologists that these products might be misused. Labeling on these vaginal candidiasis products specifically say " Do not use if you have never had a vaginal yeast infection diagnosed by a doctor."

Patients should really have had a previous diagnosed yeast infection, and be aware of the symptoms before purchase of such a product. Remember that yeast isn't the only condition that itches.

Have a great day on the bench!!

They're in a rush to treat their thrush!

Candida albicans-- a pathogen in our crosshairs...this week!

Now that we have learned how to wipe out the Trichophyton species, especially T. rubrum, we switch to another pathogen that we frequently see on our mucus membranes, Candida albicans, which is more specifically a yeast. Our first mucus membrane we will cover is the oral-pharyngeal cavity.

Candida albicans infection of the mouth is commonly referred to as “thrush”. Candida albicans is a yeast of our normal flora, that is kept “in check” by a variety of bacteria especially Lactobacillus . When the immune system is weakened, or the bacteria are wiped out by antibiotics, Candida albicans can overgrow.

Symptoms: Candidiasis in the mouth and throat is most often seen as white patches on the inner cheeks, tongue, roof of the mouth, and throat. Other symptoms might include: redness or soreness, feeling like cotton in the mouth and loss of taste. Patients may also experience pain while eating or swallowing or angular cheilitis (cracking and redness at corners of the mouth).

Who is at risk: Candidiasis in the mouth, throat, or esophagus is uncommon in healthy adults. People who are at higher risk for getting candidiasis in the mouth and throat include babies, especially those younger than one-month old, and people who:
  • Wear dentures
  • Have diabetes
  • Have cancer
  • Have HIV/AIDS: thrush is one of the most common infections seen in the AIDS population.
  • Take antibiotics or corticosteroids, including inhaled corticosteroids for conditions like asthma
  • Take medications that cause dry mouth or have medical conditions that cause dry mouth
  • Smoke
Treatment of Adults:
The treatment of oropharyngeal candidiasis in patients without AIDS is usually accomplished with local therapy for 7 to 14 days. For topical agents, successful therapy depends on adequate contact time between the agent and the oral mucosa. Options include:
  • Clotrimazole troches or lozenges are dosed at 10mg 5 times a day slowly dissolved in the mouth for about 15-30 minutes. They are effective, however adherence to a five time per day regimen is difficult. Often patients with radiation to salivary glands, or patients with Sjogrens syndrome lack adequate saliva, and might have difficulty getting these lozenges to dissolve. Don’t eat or drink while using.
  • Nystatin suspension 100,000 units/ml swish and swallow 4-6 ml four times daily is effective but has a bitter taste. It also contains sucrose, which can cause dental caries when used over prolonged time periods.
  • Fluconazole tablets: 200mg first dose then follow with 100mg-200mg daily. Best option for topical treatment failures. Has 90% success rate.
Children Doses for Candida albicans eradication:

Nystatin Oral suspension 100,000 units/ml:
  • For older infants: 2 mL four times a day.
  • For premature and low-birth-weight infants: 1 mL four times a day.
  • Because treatment is topical, and maximal contact time improves efficacy, the suspension should be retained in the mouth for as long as possible before swallowing.
  • Infants should avoid feeding for 5 to 10 minutes after administration to keep nystatin from washing out of the mouth.
Fluconazole: available as 10mg/ml and 40mg/ml in 35ml bottles for reconstitution
  • Dose: 6 orally once on the first day (maximum dose 200 mg followed by 3 once per day (maximum dose 100 mg) for a total of 7 to 14 days. Doses are higher for HIV infection.
Prevention of reinfection in babies
  • Sterilize items that are placed in the infant's mouth. Bottle nipples and pacifiers that are to be reused should be boiled after each use.
  • Breast feeding: Topical miconazole or clotrimazole is applied to the nipples to treat the lactating woman. Azoles are preferred over nystatin since there is less resistance of Candida species. Wipe off prior to feeding and reapply after each feeding.

Thrush is treated first line with topical therapy either nystatin or clotrimazole. Reinforce to the patient that is the contact with the inside of the mouth is what will lead to resolution of the yeast infection. Nystatin ahs been round since the early 1950's and still has a place in therapy for Candida albicans only. It has no effect on any other fungi other than C. albicans. Nystatin was discovered in 1950 by Rachel Fuller Brown and Elizabeth Lee Hazen named nystatin after the New York State Health Department in 1954.

These patients do require a lot of patient counseling, and if appropriate an accurate measuring device.

Have a great day on the bench!!

Do your toenails look unsightly? Some of the treatments lack efficacy!

Toenail fungus--persistence is the key to efficacious treatment

Your fingernails and toenails are composed of keratin and adherent connective tissue, the same stuff that your hair is made of. Nails grow at an average rate of 0.1 mm/day (1 cm every 100 days).

Finger nails require 3 to 6 months to re-grow completely while toe nails require 12 to 18 months. Onychomycosis is a fungal infection of the nails, sometimes caused by Candida species, however 80% of the toenail infections are caused by dermatophytes (Trichophyton rubrum), whose name sounds very familiar to us!

Diagnosis is based on clinical exam and history, microscopy, and culture. Back when both oral prescription drugs were expensive and cost over $600 for a course of therapy, the insurance companies required a positive culture for approval. Now that the oral treatments are available generically, that requirement has been lifted.
  • OTC nail lacquers (Fungi-Nail®) treat fungus around the nail, they don't penetrate the nail plate. Don't recommend them due to minimal efficacy. Contains undecylenic acid, and despite its trade name is only for athlete’s feet.
  • Rx products provide best treatment option.
  • Advise patients about possible recurrence.
Treat fingernails for 6 weeks and treat toenails for 12 weeks. (reference: Sanford guide 2017)
  • Terbinafine (Lamisil®)- fewest drug interactions; check liver function; most efficacy: Cure rate: (46%). Side effects include headache, gastrointestinal disturbance (diarrhea and/or dyspepsia), rash and elevated liver enzymes.
    • Dose: 250mg every 24 hours
  • Itraconazole (Sporanox®)– CYP4503A4 interactions; need liver function tests. Cure rate (23%pulse). Side effects include, skin rash, high triglycerides, cardiac side effects and gastrointestinal effects (nausea, bloating, and diarrhea)
    • Pulse Dose: 200mg BID for 1 week/month x 2-3 months
    • or 200mg/ day for 3 months
  • Fluconazole (Diflucan®) Cure rate:(28%), less drug interactions than itraconazole. Frequent relapse, due to poor retention in the nail.
    • Dose: 150-300mg every week for 3-6 months.
  • Ciclopirox (Penlac®) nail lacquer -Complete cure rate (7%)
  • Efinaconazole (Jublia®) nail lacquer- Complete cure rate (17%)
  • Tavaborole (Kerydin®) nail lacquer- Cure rate (<10%)
Vicks Vap-o-rub?
  • A small study of 18 participants, where fifteen of the 18 participants (83%) showed a positive treatment effect. Source: J Am Board Fam Med. 2011 Jan-Feb;24(1):69-74. doi: 10.3122/jabfm.2011.01.100124
  • 5 of 18 (27.8%) had a mycological and clinical cure at 48 weeks;
  • 10 of 18(55.6%) had partial clearance
  • 3 of 18 (16.7%) showed no change.
Since our enemy Trychophyton rubrum is everywhere, re-infection is a possibility if measures are not taken to make the feet an inhospitable environment for this fungus. Fungus breed where it is warm, dark and moist. Here are some points to share with our patients:
  • 1 in 5 “cures” will relapse (20%) within 2 years
  • Keep feet clean and dry
  • Change socks often
  • Antifungal product for feet and shoes.
  • Sports shoes that fit well will reduce microtrauma to the nail plate. Wear sandals when possible.
  • Using communal showers leads to fungal infection, so these should be avoided
  • Care with hygiene is needed to reduce cross-infection between family members
  • Throw out old “creek shoes”.
  • Emollients can be used to avoid cracks in the skin that allow fungus to enter.
Certain-Dri®—Prevention of onychmycosis
  • Contains aluminum chloride-12%.This product stops the feet from sweating, creating the moist environment for the fungus to grow.
  • Water-based and unscented which makes it gentler on skin
  • Should not wash off after bathing or showering, if application instructions are followed. Use only a few times a week.

Onychomycosis treatment varies from practitioner to practitioner. I've seen podiatrists use the Terbinifine 250mg daily for 84 days, with great results. I've seen podiatrists remove the entire nail, and treat with Terbinifine 250mg for 84 days.

I once had a patient tell me that her dermatologist said "I'm not knocking out your liver so you can have pretty toenails." He went on to say "It is a cosmetic condition, and if treated it will come back... just get over it." She went to her podiatrist, he did the necessary blood work, like liver function testing, was treated for 84 days and she has been "fungus free" for over 15 years. She is meticulous about her foot care.

One of the points we want to share with our patients is that re-infection is indeed a possibility, and we should counsel our patients to follow the steps necessary to prevent re-infection.

Have a great day on the bench!!

Another fungus among us...look what the cat (or puppy) brought in!!

What is this rash that looks like a worm??

Trichophyton rubrum is the most common cause (about 47%) of tinea corporis commonly known as “ringworm”. This is the same organism that can also cause jock itch, athlete’s foot, and nail fungus. Tinea corporis usually begins as a circular or oval, scaling patch that is itchy and spreads centrifugally on the smooth skin, (other than the scalp, groin, palms, and soles). The center of the lesion clears while an active, advancing, raised border remains. The result is a ring-shaped plaque from which the disease derives its common name of ringworm. How do I get it? Epidemiology:
  • May result from contact with infected humans, animals, or inanimate objects. Commonly transmitted by kittens and puppies.
  • Occupational risk: farm worker, zookeeper, laboratory worker, veterinarian
  • Environmental exposure: gardening, contact with animals, towels and shared grooming appliances.
  • Recreational exposure: contact sports especially wrestling, contact with sports facilities (gym mats, locker room floors). Interestingly enough the ringworm spread by wrestling has its own specific name: “Tinea corporis gladiatorum” named after the gladiators of Rome.
How do I get rid of it? Treatment of Tinea corporis (ringworm):

  • Terbinifine (Lamisil®): apply once daily for 7 days
  • Clotrimazole (Lotrimin®): apply twice daily for up to 14 days
  • Miconazole (Micatin): apply twice daily for up to 28 days
May be indicated if tinea corporis includes extensive skin infection, immunosuppression, resistance to topical antifungal therapy (azoles and allylamines) , or the comorbid presence of tinea of the scalp or of the nails.
  • Terbinafine (Lamasil®) 250 mg per day for one to two weeks.
  • Itraconazole(Sporanox®) 200 mg per day for one week
  • Fluconazole (Diflucan®) 150 to 200 mg once weekly for two to four weeks
  • Griseofulvin (remember that drug?) seldom used because 4 weeks of treatment are needed.
  • Itraconazole and Griseofulvin are the most expensive treatment options. Fluconazole and Griseofulvin are the longest treatment options.

When I was discussing this column with a fellow pharmacist they asked me the differences between "tinea versicolor" and "tinea corporis". Although they share the name "tinea", both affect the smooth skin, and are caused by a fungus which thrives in hot and humid conditions, there is a huge difference between the two.

Ringworm as we can read from this column ringworm is caused by the Trychophyton genus, where Tinea versicolor is caused by Malassezia furfur. The Malassezia furfur fungus is part of our normal flora, while ringworm is not. We don't get tinea versicolor by spreading from other sources as it is part of our normal skin flora. Versicolor is much harder to control because we harbor it on our skin.

However, once ringworm is eradicated, a patient needs to be re-exposed to get another ringworm infection.

Have a great day on the bench!!

August 2017

Hey doc---I got “gaulded”--- what do you got for that??

Tinea Cruris "jock itch"

Tinea cruris (jock itch) is a dermatophyte infection involving the fold between the upper thigh and groin area. Most common cause is Trichophyton rubrum, other species of tinea may cause jock itch as well. Tinea cruris is far more common in men than women. Often, infection results from the spread of the dermatophyte infection from concomitant tinea pedis, moving up the leg. Tinea on the groin looks like scaly, itchy, red spots, usually on the inner sides of the skin folds of the thigh. Predisposing factors include copious sweating, obesity, diabetes, and immunodeficiency. Infection may spread to the perineum and perianal areas, into the gluteal cleft, or onto the buttocks. Usually the scrotum in males is not involved.

Treatment: first line therapy is topical antifungals, azoles or squalene epoxidase inhibitors. If unsuccessful consider oral treatment.

  • Terbinafine (Lamisil cream):
    • Mechanism- inhibits squalene epoxidase, thus weakening the fungal cell wall
    • For tinea cruris apply once a day for 7 days
  • Clotrimazole (Lotrimin) or Miconazole (Micatin):
    • Mechanism- inhibits ergosterol synthesis.
    • Apply twice daily for 2 weeks.
    • Any of the OTC or Rx azole antifungals are equally effective
“Tightie whities” or boxers?? Cotton briefs hold moisture and keep it against the skin, allowing dark, warm moist conditions that the dermatophytes thrive in. If you choose briefs, say at the gym or running, choose moisture-wicking synthetic materials and be sure to shower and put on a fresh pair after working out. Going “commando” (or naked) would be the best.

Here is a tip… put on your socks before underwear to minimize the chance of the athlete's foot fungus from moving to the groin area.

I remember my first week working in a rural area of Central Pennsylvania. An old woodsman came in and asked me if I could help him. Being that energetic (and inexperienced) pharmacist I said sure. He told me he got "gaulded" , which I thought he said "scalded", and he pointed "down there". Needless to say I've learned a lot about being "gaulded" (tinea cruris) over the past number of years. Back then we didn't have much to help our patients until the antifungals became OTC.

One year at Boy Scout Camp, when I was the Scoutmaster, one of my 6th graders came to me. He said he was "hurting" down there...I asked him to describe what was going on. He said "Mr K it feels like my crotch is on fire" I asked him if he was showering, and he said "every day, but because the showers are not private we are all showering with our swimming suits on, so no one can see our equipment". I left camp, bought a can of clotrimazole spray (in case the other guys got it) and gave it to him, with instructions to not shower in a swimming suit! He was better the next day, and many years after at his Eagle Scout Banquet I presented him with the left over spray.

Have a great day on the bench!!

ATHLETE'S FOOT - Tinea pedis

Athlete’s foot is usually treated topically due to decreased side effects of this route of administration. It is the most common dermatophyte infection, affecting up to 70% of adults. Causative organisms: Trichophyton, Epidermophyton or Microsporum. Infection is usually acquired by means of direct contact with the causative organism in “surface reservoirs”, as may occur by walking barefoot in locker rooms or swimming pool facilities. If unchecked, osteomyelitis can result from mycotic infections of the feet, including tinea pedis. These complications are seen more frequently in patients with diabetes. Diabetics should check their feet every day with a mirror, and look between the toes for signs of athlete’s foot. The fissures between the toes can serve as a major port of entry for Staph aureus, the major cause of osteomyelitis in patients with diabetes, which may lead to amputation.

  • Terbinafine (Lamisil cream):
    • Mechanism- inhibits squalene epoxidase, thus weakening the fungal cell wall
    • For tinea pedis apply twice a day x 7 day. Apply for 2 weeks if bottom/sides of feet are affected.
  • Miconazole (Micatin) or Clotrimazole (Lotrimin):
    • Mechanism- inhibits ergosterol synthesis.
    • Apply twice daily for 4 weeks.
    • Any of the OTC or Rx azole antifungals are equally effective
Unfortunately, athlete’s foot symptoms may linger for up to 4 weeks. Recurrence might be due to previous treatment failure. Because patients experience recurrence 70% of the time, prevention is warranted. Share these prevention tips with your patients:
  • Patients should be advised to wear non-occlusive footwear such as sandals as frequently as possible, but especially in the summer.
  • Wash socks after each wearing in the hot cycle of the washer and dried in the hot cycle of the dryer before wearing again. Athletic shoes also may be sprayed with disinfectants and/or treated with bleach to destroy fungi.
  • During the bath or shower, patients must wash the feet and toes carefully each day. Patients should be taught to dry the feet thoroughly after each bath or shower, paying closer attention to the interdigital spaces.
  • Wait for 10 to 15 minutes after bathing to don socks and shoes to help the feet dry. The goal is to have the feet completely dry other than when bathing.

What about us??? Most of us as business professionals, should wear socks and leather shoes that “breathe” and reduce sweating. We should also change to sandals as soon as we can and wear them until bedtime or go barefoot around the house as much as possible (except for diabetic patients with peripheral neuropathy)

Socks? Wool socks: If your feet are often cold, or you live a in a cold climate (like Central Pennsylvania), wool socks may be a better fit. Wool fibers are both hydrophobic (repels water) and hygroscopic (absorbs water), which is a fancy way of saying that it can absorb or give off moisture. In fact, they - wool fibers - can absorb up to 1/3 of their own weight in moisture before feeling "wet". Merino wool is less like to be itchy. Merino wool socks are more expensive, it is best not to machine wash wool socks. I wear wool socks for extra padding on my feet. The outer layer of wool fibers have a high concentration of fatty acids, which have anti-bacterial properties, and reduce foot odor.

Cotton socks: less itchy, are cheaper and absorb moisture but they saturate quickly and dry slowly. Are cooler on the feet and are machine washable. When cotton socks get damp/wet they will continue to feel cold and damp, which wetness and increased friction may enhance blister formation.

Have a great day on the bench!!

Mechanisms of action are the best clue as to what to recommend for the "fungus among us"!

We pharmacists love our mechanism of actions, and knowledge of where the multitude of antifungals fit in drives our product selection. Below is a chart, that describes the mechanism of actions for efficacious treatment of dermatophytic and candida infections. Although there are other agents available, I am highlighting the most common and most effective agents we use in community pharmacy practice.

Agents used in the treatment of dermatophyte infections.

Oral Azole Antifungals
Impairs the synthesis of ergosterol, the main sterol of fungi membranes, allowing increased permeability and leakage of cellular components. Inhibits fungal CYP-450 14-alpha-desmethylase thereby decreasing ergosterol.
Ketoconazole (Nizoral) (Rx)
Most potent azole blocker of CYP-450. Most drug interactions and side effects of oral azoles. As of 2013 NOT recommended as oral therapy for treatment of dermatophytes.
Fluconazole (Diflucan) (Rx)
Widest therapeutic window. For treatment of thrush and vaginal candidiasis. Not effective for filamentous fungi (aspergillosis).
Itraconazole (Sporanox) (Rx)
May induce heart failure. Caution in cardiac patients.
Oral Antifungal
First antifungal; isolated in 1939, produced from Penicillium griseofulvin. Disrupts spindle formation. Skin infections only. It is deposited in newly forming skin where it binds to keratin precursor cells, protecting the skin from new infection. Therapy must continue until new tissue replaces old diseased tissue.
Griseofulvin (Gris-Peg) (Rx)
Absorption improves with a high fat meal. Takes 2-6 weeks for treatment. (6 months for onychomycosis).
Oral Squalene Epoxidase Inhibitor
These antifungal agents are reversible, noncompetitive inhibitors of the squalene epoxidase. The buildup of squalene is toxic to the cell wall. This causes pH imbalances and malfunction of membrane bound proteins.
Terbinifine (Lamisil) (Rx)
Most often used for onychomycosis (nail fungus). Doesn’t reach effective levels for treatment of skin infections.
Topical Azole Antifungals
Impairs the synthesis of ergosterol, the main sterol of fungi membranes, allowing increased permeability and leakage of cellular components. Inhibits fungal CYP-450 14-alpha-desmethylase thereby decreasing ergosterol. For topical treatment of dermatophytes, no azole antifungal Rx or OTC is superior to another.
Miconazole (Micatin, Monistat)
Topical use for dermatophytes or vaginal yeast infections. Caution with warfarin may ↑ INR, by blocking CYP-450 metabolism and cause bleeding.
Clotrimazole (Lotrimin), Butoconazole(Gynazole)
OTC available for treatment of vaginal yeast infections. Clotrimazole cream for topical dermatophytes.
Ketoconazole (Nizoral), Econazole (Spectazole) (Rx)
Prescription only for treatment of topical dermatophytes.
Terconazole (Terazol) (Rx)
Terconazole contains a triazole ring, a structure developed specifically to improve antifungal activity. Rx only for vaginal candida infections.
Topical Squalene Epoxidase Inhibitors
These antifungal agents are reversible, noncompetitive inhibitors of the squalene epoxidase. The buildup of squalene is toxic to the cell wall. This causes pH imbalances and malfunction of membrane bound proteins.
Terbinifine (Lamisil)
Most effective OTC treatment for dermatophytes.
Topical antifungal inhibiting cell membrane staility.
Binds to trivalent cations (iron and aluminum), which inhibit essential co-factors in enzymes. Can be fungicidal or fungistatic.
Ciclopirox (Loprox, Penlac) (Rx)
Available as cream, gel, suspension, shampoo and nail lacquer.
Topical Anticandidal Agents
Nystatin (Mycostatin) (Rx)
Polyene antifungal binds to ergosterol in fungal membrane causing membrane to become leaky. Only effective for candida (yeast). Too toxic for parenteral use. Used only topically, usually for diaper rash.
Zinc Pyrithione-ZPT (Head & Shoulders)
Shown to significantly reduce the numbers of yeast organisms. Helps prevent the dandruff-causing microbe, Malassezia globosa, from forming scalp irritants, and normalizing keratinization.
Selenium Sulfide (Selsun) 2.5% (Rx)
For treatment of dandruff and tinea versicolor via its anti-Malassezia effect and significantly reduces the rate of cell turnover.

Where is the Undecylenic Acid, Tolnaftate, Absorbine Junior, Gold Bond, etc.? Although I also did leave out some prescription products as well (sertaconazole, oxiconazole, naftifine), this comprehensive guide will treat the topical fungal infections the community pharmacist sees. Our treatment decisions must be dictated by efficacy, cost and of course patient safety. In the upcoming weeks we will be covering specific topical disease states such as tinea pedis, cruris, corporis, thrush, vulvovaginal candidiasis, onychomycosis, and diaper rash. After this "series" we will feel much better treating "the fungus among us"!!

Have a great day on the bench!!

Are you left scratching your head on how to treat dandruff patients?

Treatment options and patient care points for dandruff

Etiology: Dandruff is the most common form of scalp seborrheic dermatitis. We are familiar with the appearance of dandruff, which the scalp shows fine, white, diffuse scaliness without underlying erythema. The rate of turnover of the epithelial cells is about twice the normal rate in patients affected with dandruff. Malassezia (formerly called Pityrosporum) is a “lipid dependent” fungus (yeast) that lives on the scalps of most healthy patients. Sometimes it grows out of control, feeding on the oils secreted by hair follicles and causing irritation that leads to increased cell turnover. The result is many dead skin cells, which fall off, clump together with oil from hair and scalp, and become visible. Unfortunately, they end up on our black tuxedos or cocktail dresses!

Factors influencing overgrowth: increased oil production; hormonal fluctuations; stress; illness; neurological disorders, such as Parkinson's disease; a suppressed immune system; infrequent shampooing and extra sensitivity to the malassezia fungus may contribute to the development of dandruff.

Treatment : The 2017 Sanford Guide recommends two first line treatments for dandruff: ketoconazole 2% or selenium sulfide 2.5%

Nizoral® Ketoconazole 2% Shampoo(Rx) only:
  • Acts by blocking the biosynthesis of ergosterol, the primary sterol derivative of the fungal cell membrane. Ketoconazole weakens the fungal cell membrane.
  • Apply twice a week. Leave on for 5 minutes and thoroughly rinse.
  • Patient Care points: immediate lather hair when starting shower, to let ketoconazole saturate the hair and scalp for 5 minutes to get full benefit. Nizoral® A/D shampoo 1% is the over the counter version
Selenium Sulfide 2.5% (lotion/shampoo)
  • Controls dandruff via its anti-Malassezia effect and significantly reduces the rate of cell turnover.
  • Usually applied twice a week. Thoroughly rinse.
  • Patient care points: Remove jewelry to prevent staining from sulfide. Although this is the most effective treatment for dandruff, the sulfide (“rotten egg”) smell steers patients away from this drug. Selsun Blue 1% is the over the counter version.
Head and Shoulders® Zinc pyrithione (ZPT)
  • Heals the scalp by normalizing epithelial keratinization, sebum production, or both. Also shown to significantly reduce the numbers of yeast organisms. Helps prevent the dandruff-causing microbe, Malassezia globosa, from forming scalp irritants
  • Dosage: Is effective if used three times a week.
  • Patient care points: Don’t alternate between ZPT and non-medicated shampoos.Use only ZPT containing product if using every day.
Neutrogena T/gel: Coal tar based .5%
  • Mechanism: Keratolytic agent which reduces rate of skin cell formation, and also softens keratin; also elicits antiseptic & antibacterial properties
  • Dosage: best if used twice a week.
  • Patient care points: Use caution in exposing scalp to sunlight after applying this product. It may increase your tendency to sunburn for up to 24 hours after application. Does smell like a freshly paved road.

Lots of marketing goes into shampoos for a good reason. Most people need them, and use them every day. Most patients have their favorite, and that is what they stick with.

My "oily skin" and very abundant growth of Malassezia, make me a primary candidate for using a dandruff control. What is my favorite? I don't like the smell (neither does Mrs. Kreckel!) of the selenium sulfide. I have had the best success with ZPT, since I want to use it every day.

Have a great day on the bench!!

Only our fungi get motivated in this hot and steamy weather!

TINEA VERSICOLOR -- Pathology and Treatment

With the very warm weather we have been experiencing, the heat may make us humans feel lethargic. However, the yeast that causes Tinea versicolor gets “supercharged” and grows more rapidly in this heat and humidity. Tinea versicolor is a superficial skin infection -often referred to as “sweat rash” caused by Malassezia furfur (aka: Pityrosporum ovale or Pityrosporum orbiculare) M. furfur can be found in normal skin flora. Under the right conditions yeast converts to the hyphal phase and causes disease. Most often seen in hot/ humid climates, oily skin, hyperhidrosis, hereditary factors, corticosteroid treatment, and immunosuppression. Look around shirt collar lines, under bra’s, folds of skin, armpits etc. and you will see these flat discolored lesions. These lesions don’t change colors with sun exposure; they are lighter in the summer than surrounding skin, and darker in the winter. The lesions will glow yellow/green when lit up with a Wood’s lamp (“black light”).


  • (selenium sulfide 2.5% shampoo (Rx).
Apply a thin layer covering the body surface from the face to the knees once daily for seven days. Leave on skin for five to ten minutes before rinsing. Remind patients to remove jewelry before application, as it may damage jewelry. Apply once a month for 3 applications to help prevent recurrences. Disadvantages: odor of the product which smells like rotten eggs. Some patients a stinging sensation after application
  • Head and Shoulders shampoo (OTC): Zinc pyrithione shampoo(ZPT) applied once daily, leave on for 5 minutes. Apply daily for 2 consecutive weeks.
  • Nizoral® ketoconazole 2% shampoo (Rx) single application for five to ten minutes is effective (80% mycotic cure rate). May be applied up to 3 days.
  • Topical azoles: usually applied daily for 14 days. Examples: Clotrimazole (Lotrimin-OTC) Miconazole (Micatin-OTC), Ketoconazole (Nizoral-Rx), Econazole (Spectazole-Rx)
  • Oral Treatment of tinea versicolor:
    • Fluconazole 400mg as a single dose.Exercise to a sweat, and do not shower for 12 hours.
      • Alternative: 300mg once a week for 2 consecutive weeks (75% cure rate)
    • Itraconazole 400mg every 24 hours for 3-7 days
    • Ketoconazole (??) Oral ketoconazole is no longer approved by FDA as of 2013 for any topical infections due to hepatotoxicity and other safety concerns, such as adrenal insufficiency and multiple drug interactions.
    • Terbinifine (Lamisil) oral tablets are of little value in the treatment.It does not achieve fungicidal levels in the skin.A 1% topical solution applied to the skin was effective in clinical trials.

Relapse rates: Tinea versicolor’s causative agent is “normal flora.” 60% of cases relapse one year after treatment, and 80% relapse after two years. Prophylaxis (especially in warm weather) use selenium sulfide 2.5% or ketoconazole 2% shampoo applied to the entire body for ten minutes once per month is an effective prophylactic therapy.

Tinea versicolor is commonly seen this time of the year. As the heat and humidity increase, so does the activity of our oil and sweat glands! This provides a perfect breeding ground for overgrowth of our normal flora M. furfur.

Because more of our patient's skin is exposed due to our summer clothing and bathing suits, this common dermatological condition is more readily seen, and frequently patients come seeking our advice.

Up until a few years ago, most dermatologists were using Ketoconazole 200mg tablets, taken as 2 tablets after a high fat meal. Patients were told to exercise until a heavy sweat, and then don't shower for 12 hours so the ketoconazole could be exposed to the M. furfur. After the FDA sternly warned practitioners in 2013 not to use ketocnazole for tinea infections, this is no longer used and a whole host of other treatments have been used. Although ketoconazole is still in the 2017 Sanford Guide, it is NOT recommended.

I feel that prevention of recurrence is as important as appropriate treatment of the initial infection.

Have a great day on the bench!

July 2017

The kidney and parathyroid are the big players in calcium and potassium levels.

Potassium and Calcium

The kidney is the major player in potassium homeostasis, regulating about 90% of excretion. K+ balance is maintained by adjusting secretion into the urine in response to dietary intake. Low levels of potassium can result in muscle weakness, adverse effects on the kidneys and cardiac arrhythmias.

Drugs that Lower Potassium Levels

Work in the distal tubule of the kidney. Keep dose under 25mg/day to decrease likelihood of hypokalemia.
Loop Diuretics
Furosemide, Torsemide, Bumetanide
20 mEq potassium per day is sufficient to prevent hypokalemia with diuretics. Use 40-100mEq to correct deficiency
Antipsychotic drugs
(Risperidone and quetiapine)
Can be a concern in the elderly
Carbonic Anhydrase Inhibitors Acetazolamide (Diamox) Mild diuretic that works in the proximal convoluted tubule. A weak diuretic most commonly used for glaucoma and altitude sickness.
Amphotericin B Half of patients will get hypokalemia
Excessive sweating, vomiting and diarrhea. Colon cleansing. Contribute to hypokalemia by K+ loss

Serum calcium is regulated by parathyroid hormone (PTH) and vitamin D. These hormones effect the bone, kidney, and the gastrointestinal tract. Parathyroid hormone decreases calcium excretion in the kidney, increases absorption of calcium in the gut, and increases bone resorption.

Drugs that lower calcium levels

(Alendronate (Fosamax®), Risedronate (Actonel®), Ibandronate (Boniva®) etc)
Block osteoclast re-absorption of bone
Calcitonin (Miacalcin®) Block osteoclast re-absorption of bone
Cinacalcet (Sensipar®) Lowers serum calcium (binds to receptors on parathyroid gland)
Phenytoin (Dilantin®) (and other inducers of Vitamin-D) Phenytoin, being an inducer speeds up conversion of vitamin D to inactive metabolites
Vitamin-D deficiency Blocks absorption of calcium from gut
Corticosteroids Increase renal calcium excretion and decrease gastrointestinal calcium absorption, resulting in reduced serum calcium
Excess phosphate levels (seen in chronic kidney disease) May lead to decrease calcium absorption from the gut.
Low magnesium levels (most commonly due to
alcoholism, malabsorption, and diuretic therapy)
Magnesium depletion can cause hypocalcemia by producing parathyroid hormone (PTH) resistance,

Last week, in response to a request from a Physician Assistant, we covered drugs that caused excessive levels of potassium and calcium. This week we will explore the common causes of deficiency of these two ions. Potassium and calcium are frequently checked in the physicians office, and sometimes drug therapy can be responsible for their low levels.

Have a great day on the bench!!

Remember learning about parathyroid hormone and aldosterone?

Drugs causing Hypercalcemia and Hyperkalemia
One of my former Physician Assistant Students asked me to write my next column about drugs that affect calcium and potassium. Lots of physiological events can cause increases in these two very important cations, as well as drug therapy. Here are the highlights of drugs causing elevated levels of calcium and potassium.


Hydrochlorothiazide, chlorthalidone
Cause calcium retention by increased resorption of calcium in renal tubules.
Calcipotriol (Dovonex ®) Caution with high doses or in patients with severe, extensive psoriasis
Lithium (Eskalith) Usually mild, likely due to increased secretion of parathyroid hormone (PTH). May take 4 weeks post lithium to resolve
Excessive Calcium Supplementation Obviously!
Theophylline toxicity Results in mild hypercalcemia
Vitamin-A intoxication May cause stimulation of bone resorption
Vitamin-D intoxication In the gut increases the absorption of calcium
HYPERPARATHYROIDISM Hypercalcemia from hyperparathyroidism is usually mild, asymptomatic, and sustained for years
MALIGNANCIES Rapidly progressive; a RAPID rise in calcium levels should increase suspicion of malignancy.
RENAL FAILURE Especially if given calcium carbonate or calcium acetate as phosphate binder


Potassium-sparing diuretics
(triamterene, amiloride)
Block directly the K+-Na+ exchange in the collecting tubules.
Aldosterone antagonist (spironolactone/epleronone) Compete with aldosterone for receptor sites
NSAIDs By inhibiting renal function (block afferent vasodilatation of arterioles). May also inhibit renin secretion.
ACE inhibitors
(lisinopril,enalapril,quinapril, benazepril etc.)
By blocking Angiotensin-II, aldosterone is decreased. Aldosterone is responsible for increasing the excretion of potassium.
Angiotensin-receptor blockers
(ARBs) (Losartan, Irbesartan, olmesartan, etc)
By blocking Angiotensin-II, aldosterone is decreased. Aldosterone is responsible for increasing the excretion of potassium.
Non Selective beta-blockers
(propranolol, labetalol)
Interfere with the beta-2-adrenergic facilitation of potassium uptake by the cells. Selective BB like atenolol (mostly ß-1) have minimal effect. All ß-blockers at high dose lose beta selectivity.
Cyclosporine or tacrolimus Due to reduced efficiency of urinary potassium excretion
Trimethoprim-sulfamethoxazole Trimeth blocks apical membrane sodium channels in the mammalian distal nephron, blocking the excretion of K+
Heparin Reversible aldosterone suppression
Ketoconazole Inhibits aldosterone synthesis
Herbs Alfalfa, Dandelion Horsetail, Nettle are high in potassium
Miscellaneous: Pentamidine & Metyrapone Inhibits distal nephron reabsorption of Na+ by blocking apical Na+ channels in a manner similar to "potassium-sparing" diuretic
Potassium supplements in excessive doses Obviously!

So, as we can see many of our commonly used drug therapies can have a significant impact on these two very important ions. The concern becomes even greater in our patients that are elderly or frail.

"The Request line is open"

Do you remember those days of listening to the local AM radio station? How excited we would be when the announcer would say "the request line is open", and we would jam the phone lines with our requests to hear the Beatles, Beach Boys, or Sonny and Cher!!

I have tons of material to share with my column readers, but I also am delighted when I get an e-mail requesting a specific topic that my readers find of clinical interest. Today's column's request came from a practicing physician assistant who wanted a quick column on the drugs that cause changes in calcium and potassium. Next week we can discuss drug therapy that can cause lowering of potassium and calcium.

Have a great day on the bench!!

We always are promoting "covering up" and sunscreen....what happens when our patients don't listen???

  • Most sunburn is self-treatable. Most are usually first or second degree burns. First degree burns are simple redness of the skin. Second degree burns are when blisters appear. Apply cool compresses; frequent cool baths or showers. Pat skin dry with towel. Do not rub.
  • Minor burns can be treated with protectants which reduce dryness of skin, and prevent friction damage.
  • No topical spray will stop the underlying burn process, or stop the formation of blisters.

Let’s talk about the two most common “remedies” for sunburn treatment:
Dermoplast® spray: (Benzocaine 20%) is the most effective topical anesthetic. Using a strength less than 20% is not effective. Benzocaine may cause hypersensitivity reactions (1%)
Solarcaine® gel: (Lidocaine) Caution with broken skin (might precipitate cardiac arrhythmia)
  • Best not to recommend topical anesthetics, due to short duration of effectiveness: max= 45 minutes, and potential for side effects. Do not recommend for small children.

Ibuprofen: Did you notice after a major sun exposure, a day later the redness gets worse? Erythema becomes clinically apparent 3 to 6 hours after exposure, peaks at 12 to 24 hours, and usually subsides at 72 hours. Three hours after UVB exposure, neutrophilic infiltration begins and peaks at 24 hours, and continues up to 48 hours later.
  • Prostaglandins and nitric oxide are most commonly implicated in the delayed erythema reactions that follow within 14-20 hours after exposure and persists for 1 to 3 days. So, by using an oral medication that blocks prostaglandins, like NSAIDS we can arrest the delayed onset erythema (redness).
  • Best option for treatment of sunburn to manage the pain, and slow down the delayed erythema is IBUPROFEN. Start use immediately after a “major” exposure.

Refer to a physician when:
  • If more than 10% of body surface of a child is sunburned, a physician should be consulted.
  • If a patient presents with: fever, headache, confusion, nausea, vomiting chills
  • Secondary infection may develop, leading to scarring.Infection is hard to treat because dead skin is an excellent medium for microbial growth.Signs of infection include increased pain, swelling, redness drainage or pus from blisters.

Does Sunscreen cause Vitamin-D Deficiency? The short answer is “yes”
  • Effective use of a sunscreen blocks the synthesis of Vitamin-D in the dermis. Middle aged and elderly persons who use sunscreens daily have significantly lower concentrations of 25-Hydroxyvitamin D3.
  • The benefits of using a sunscreen, far outweigh the disadvantages of a decrease in Vitamin-D. A local dermatologist told me: “ It is easier to treat Vitamin-D deficiency than skin cancer”

We see a lot of requests for recommendations for sunburn treatment this time of year. Lots of people are looking for aloe gel and other sunburn remedies. The truth is, just cooling down the skin makes our patients feel better, so a spray bottle filled with water is as effective as any topical cooling gel. Topical anesthetics are of short term value, and has risks if the skin is broken or the patient is very young or very old.

Incidence: the estimated sunburn prevalence among all adults in the US was approximately 34 percent. Sunburn occurs more frequently among adolescents and young adults. In nation-wide surveys in the United States, approximately 70 percent of adolescents aged 11 to 18 years and 50 percent of adults aged 18 to 29 years reported at least one sunburn in the previous year.

A lot of patients need our expertise!

Have a great day on the bench!!

Let's look at PREVENTION of Sunburn!

Last week, we discussed the mechanics of sunscreens and product selection. Here are some tips to share with your patients about sunscreens.

UVA Light: is continuous throughout the day and may exceed the intensity of UVB by up to 1,000 fold. UVA light penetrates to the dermis and is responsible for producing tanning, but may also damage blood vessels. UVA causes photo aging which is the dry, scaling, yellow and deeply wrinkled, thinner & more fragile skin. Photo aging is NOT simply an accelerated aging process. UVA exposure is associated with photo-sensitivity, drug reactions, and basal cell carcinoma.

UVB Light: penetrates the epidermis and is responsible for erythema (burn). Most intense between 10am and 4pm. More intense in summer months and higher elevation. A positive effect of UVB exposure is that it induces the production of Vitamin-D in the skin.

Tips for sunburn prevention
  • Avoid long term exposure during peak hours (10am - 4pm)
  • Sunglasses: Make sure they are UV protected. With cheap dark glasses, pupil dilates allowing more harmful UV rays to damage the retina. Better not to wear sunglasses than cheap sunglasses that are not UV protected!!! UV blocking sunglasses also prevent cataracts.
  • Clothing: Hats, long sleeve shirts, and long lightweight pants. A typical summer tee shirt has an SPF of only about 7. Down to 3 if wet. Yes, I was amazed too when I read how little protection a tee shirt offered. It is better than going "unprotected" and re-application isn't necessary! Check out the fabrics "UPF" (Ultraviolet Protection Factor), which indicates what fraction of the sun's unltraviolet rays can penetrate the fabric. A shirt with a UPF of 50, for example, allows just 1/50th of the sun's UV radiation to reach the skin.
  • Hats: Baseball caps leave the ears, neck and lower face unprotected. Wear wide brimmed hats to ensure that the tips of the ears are covered. Take it from a guy who has had two actinic keratosis lesions removed from his left ear!
  • Automobiles: UVB does not penetrate window glass. Windshields have UVA filters, but side windows do not. Consider sunscreen in the car if photosensitive, even if windows are up.

Application and general information for sunscreens
  • Apply 30 minutes before sun exposure and cover all exposed areas evenly and liberally. Figure 1 0z. per adult application in a swimsuit.
  • Water Resistant: The formula retains SPF after 40 minutes of activity in water, sweating or perspiring.
  • VERY Water Resistant: The formula retains SPF after 80 minutes of activity in water, sweating or perspiring.
  • Water resistance claims on the product's front label must tell how much time a user can expect to get the declared SPF level of protection while swimming or sweating, based on standard testing. Two times are permitted on labels: 40 minutes or 80 minutes. Apply frequently!

(June 18, 2012 - FDA.gov)
  • "Broad Spectrum" and "SPF 15" (or higher) not only protect against sunburn, but, if used as directed with other sun protection measures, can reduce the risk of skin cancer and early skin aging. For these broad spectrum products, higher SPF (Sun Protection Factor) values also indicate higher levels of overall protection.
  • Any sunscreen not labled as "Broad Spectrum" or that has an SPF value between 2 and 14, has only been shown to help prevent sunburn. "Skin Cancer/Skin Aging Alert: Spending time in the sun increases your risk of skin cancer and early skin againg. This product has been shown only to help prevent sunburn, not skin cancer or early skin aging."

"What should I wear to the beach??? Well, certainly my readers or patients wouldn't be asking me for fashion advice!! Here is some practical advice to protecting you and your patients from the damaging effects of the sun's rays. Although, we pharmacists are the experts in selecting medications both oral and topical, we can offer advice to our patients with respect to clothing, as well as automobile glass when it comes to sun protection!

I learned a lot putting this column together! Be sure to share these safety tups with your patients.

There is an excellent website I used as a reference: www.skincancer.org

Have a great day on the bench!!"

June 2017

When choosing an SPF, more isn't always better!

Sunscreens - The basics

Skin Protection Factor (SPF) : how the efficacy of a sunscreen is expressed. It is a ratio of the time required to produce minimal redness with a sunscreen, to the time to produce minimal redness without a sunscreen. An SPF of 15 will allow a person to remain in the sun without burning 15 times longer, than if the skin was unprotected.
Minimal Erythema Dose (MED): is the amount of solar radiation to produce minimal skin redness. MED times SPF =Safe Duration of Exposure. The MED is not a standard amount of exposure. It varies from person to person. Dark skinned individuals demonstrate higher MED. Fair skinned individuals (like redheads) have lower MED. Let’s consider two patients:
  1. Fair skin, redhead: Without sunscreen gets red in the sun within 10 minutes.
  2. Dark skinned brunette: Without sunscreen she gets red in the sun in about 30 minutes.
  • If both use a sunscreen with an SPF of 30, the redhead will turn red in 300 minutes (5 hours) while the brunette would turn red in 900 minutes (15 hours). This IS assuming they are applying the sunscreen frequently according to package instructions.
  • Your patients will have varying responses to sunscreens based on their individual skin type.
Chemically: absorb a specific portion of the spectrum thus preventing harmful rays from hitting the skins surface. Examples: PABA, Cinnamates, Ethylhexylsalicylates, Benzopheones. Most sunscreens contain combinations of 2 or 3 of the classes.
Physically: provide a physical barrier to UV radiation and scatter or reflect the harmful rays. Most commonly referred to as “sunblock” Examples: Zinc oxide, red petrolatum, Titanium dioxide. An SPF of at least 15 is recommended for most people by the Skin Cancer Foundation. HOWEVER...
  • Products with SPF over 30 only block UVB slightly more than those of SPF=30. The higher concentration of chemicals increases potential for adverse effects, such as skin rashes. SPF over 30 are labeled as “SPF 30 plus”. An SPF of 30 blocks 97% of the UVB rays.An SPF of 15 blocks 93% of UVB rays. Higher SPF products do increase the likelihood of allergic reactions.
  • By bumping the SPF from 15 to 30, it may offer an extra margin of safety to consumers who do not apply a sunscreen as frequently as indicated.

“An ounce of prevention is worth a pound of cure”, is a well-worn adage we pharmacists use when discussing blood pressure, Type-2 diabetes, and osteoporosis. This adage is even more applicable with summer officially here as of June 21st at 12:24am. With the appearance of much desired sunshine and hence the need to protect our patients from the sun's damaging rays, our expertise is needed. Let's make the summer vacation of 2017 a safe and fun time whether enjoying the mountains of Pennsylvania, the beautiful sands of Myrtle Beach, or wherever your favorite summer destination is! This week let’s describe the basics of sunscreens. We will cover in the upcoming weeks the proper application of sunscreen and the treatment of sunburn.

Oral corticosteroids are great--just make sure they are prescribed long enough!

Treatment of Poison Ivy- the RIGHT way!
Last week we discussed avoiding the Toxicodendron family of plants. I can easily identify the plant, when it appears growing on the side of a tree or along a hedgerow. The challenge becomes when the leaves are chopped up by a weed eater, or a lawnmower! So let’s discuss the treatment of poison ivy when a patient comes into your pharmacy or clinic.

Refer to a prescriber when:
  • Over 25% of body surface area is contaminated, or if any sign of infection.
  • Limited but disabling involvement (hands, face, area around mouth/eyes, or genitals)
  • If patient has history of severe reactions
Treatment of poison ivy-needs at least 14 days!
Have you noticed when a patient gets a methylprednisolone dosepak that after the pack is completed a few days later they come back, and think they got “another batch” of poison ivy? Truth is, it is the original case but the treatment was not long enough in duration, and the patient is experiencing “rebound symptoms”. A six day treatment pack is not adequate.
  • Oral prednisone: 0.5 to 2mg/ kg / day tapered over 14 to 21 day period. Usually start with 60mg per day, and taper down over a 14-21 day period. Using a 21 day regimen will decrease the likelihood of rebound dermatitis.
  • Medrol dosepak (6 day therapy) is not long enough of duration.
Topical treatment of poison ivy
  • Oatmeal baths might be soothing but are not of much value. They might make the tub slippery, and clog the drain!
  • Calamine actually hinders treatment and is of minimal value for poison ivy. It will help with the itching. Hydrocortisone 1% OTC is of limited value—use only in mild cases.
  • Avoid: topical antihistamines, topical anesthetics, topical antibiotics, as well as poison ivy extracts. Jewelweed (Impatiens biflora) extract is promoted for relief of poison ivy, but is of no value.
  • Burows solution is available over the counter: (aluminum acetate): dissolve 1 packet (Domeboro®) in 1 pint of water, and apply as a wet dressing for 15-30 minutes 3 to 6 times daily. This self care product greatly relieves itching.
  • Topical prescription corticosteroids are most effective in early stages BEFORE the blisters form. They will help with itching, and promote drying of the lesions. They are of little value once the blisters form.

We see a lot of poison ivy in our area, and frequently it is treated with a Methylprednisolone six day dosepak. The patients will come back a couple of days after completion of the pack, and think they got into another "batch" of poison ivy. The truth is they were not treated adequately the first time.

I saw such a patient today, her arms slathered with Calamine lotion Her arms were blistered, and she had a prescription for a Methylpred 4mg dose pack, and an 80gram tube of triamcinolone 0.1% cream. After reading this newsletter, it is obvious that all three treatments were wrong. Calamine is worthless, and needs to be scrubbed out; the triamcinolone cream is not recommended since the blisters were present AND the corticosteroid should be given 14-21 days! (Feel free to share this newsletter with your colleagues!)

Poison Ivy--it's all about the oil. Identification is key to prevention!

Poison Ivy: Leaflets three let them be! Hairy vine no friend of mine!
The Toxicodendron (“means poisonous tree”) genus of plants causes more contact dermatitis than all other causes combined. Ten to fifty million Americans develop allergic contact dermatitis to a Toxicodendron annually. In one study 10% of all occupational injuries among seasonal farm, workers in PA and NY were due to poison ivy contact. The genus/species names are as follows:
  • common or northern poison ivy (Toxicodendron radicans)
  • western poison ivy (Toxicodendron rydbergii)
  • eastern poison oak (Toxicodendron toxicarium)
  • western poison oak (Toxicodendron diversilobum)
  • poison sumac (Toxicodendron vernix)
Regardless of the species name all the treatment protocols are the same. Allergic Contact Dermatitis (ACD) has 2 distinct phases.
  • A sensitization phase where a specific hypersensitivity to the allergen is acquired.
  • An elicitation phase during which dermatological response is visible.
Identification of Poison Ivy:
  • Poison ivy is typically a hairy, ropelike vine with three shiny green (or red in the fall) leaves budding from one small stem. “Leaves of three let them be!” and “Hairy vine, no friend of mine”.
  • May have yellow or green flowers and white to green-yellow or amber berries
  • Poison sumac, may be harder to identify because it more often forms leaflets of five, seven, or more that angle upward toward the top of the stem.Poison sumac presents as a woody shrub that has stems that contain 7-13 leaves arranged in pairs
Here’s what happens
  • Urushiol, which is an oleoresin (lacquer) oozes from the broken leaf and stems, causing the characteristic black dots which is oxidized urushiol (due to the enzyme laccase found in the oleoresin) and can be found on plant leaves within 10 minutes of its exposure to oxygen. Urishiol can be transmitted to the patient by contact with the plant, or pets, tools, gloves, shoes and clothing for months. Washing clothes in regular laundry detergent will decontaminate fabrics. Poison Ivy should NEVER be burned, as it vaporizes the oil, causing lung damage.
  • The characteristic wheals and blisters of poison ivy contain serum, and NOT the urushiol. Poison ivy and other poison plant rashes can't be spread from person to person. But it is possible to pick up the rash from plant oil that may have stuck to clothing, pets, garden tools, and other items that have come in contact with these plants.
In summary, make sure your patients are educated about Lyme disease, and are using insect repellents, wearing long sleeve shirts and pants treated with permethrin, and know appropriate tick removal procedures. Have them seek care in case of a tick bite. As you see from this column, untreated Lyme can have some devastating effects on our patients.

When contacted:
When a patient is exposed to a poisonous plant, like poison ivy, oak or sumac:
  • Immediately rinse skin with rubbing alcohol, poison plant wash, or degreasing soap (such as dishwashing soap) or detergent, and lots of water. Professor Pete takes a half bar of Fels Naphtha soap (old fashioned washboard soap) in a nylon stocking, and carries it backpacking or ties it to his canoe seat. The soap is always handy, and never gets soggy.
  • Rinse frequently so that wash solutions do not dry on the skin and further spread the urushiol.
  • Scrub under nails with a brush.
  • Wash exposed clothing separately in hot water with detergent.
  • After use, clean tools with rubbing alcohol or soap and lots of water. Urushiol can remain active on the surface of objects for up to 5 years. Wear disposable gloves during this process.

Leaflets three--let them be!
(Notice the "hairy vine")

I've spent almost 20 years in leadership positions with Cub Scouts and Boy Scouts, and teaching about poison ivy seems to be the one condition that the general public is most misinformed about! First concern people have is about spreading poison ivy, when the rash starts to blister and seep. These lesions contain serum and can't be spread. The only way the rash can occur is direct contact with the urushiol to a sensitized patient. Identification of poison ivy is another teaching moment. Last week in our landscaping in the front of our home, I found a beautiful specimen of poison ivy. I gently removed it with a rake, and put it on the front curb and took a picture, which appears in this edition. I have gotten poison ivy several times while planting flowers at our cemetery. I guess I'm not good at identifying poison ivy when it is chopped up with a weed-eater or lawn mower! People love to dump stuff on their poison ivy lesions that often does more harm than good-- next week we will talk about appropriate treatment of poison ivy, both from the patients standpoint, as well as the prescriber's standpoint.

What happens when the tick bite goes undiscovered or untreated?

Progression of Lyme Disease

As we discussed last week, Lyme disease, caused by the spirochetal bacterium Borrelia burgdorferi, remains the most common vector-borne disease in the United States. Lyme disease was first described in 1977 as "Lyme arthritis" in studies of a cluster in Connecticut of children who were thought to have juvenile rheumatoid arthritis. When some of these kids got ear infections, and were treated with amoxicillin the “arthritis” went away. The multisystem nature of the infection became clear as involvement of other systems was soon identified.

The problem with Lyme disease isn’t so much with the tick we remove, but the one that is never discovered, and inoculates our patient with the Borrelia burgdorferi spirochete. Only about 25 percent of patients with erythema migrans recall the tick bite that transmitted Lyme disease. The characteristic rash erythema migrans (the “bullseye” rash) occurs in 70 to 80% of the cases. We can also say that 20-30% of the time patients do not get the rash. Here is what happens if Lyme disease remains undiagnosed and progresses.

Early Disseminated Lyme disease
Occurs days to weeks after tick bite and left untreated, the infection may spread and see:
  • Additional erythema migrans lesions appear in other areas of the body
  • Neurological consequences:
    • Facial or Bell's palsy (loss of muscle tone on one or both sides of the face)
    • Severe headaches and neck stiffness due to meningitis (15% of patients)
  • Pain and swelling in muscles and the large joints (such as knees) (60% of patients)
  • Shooting pains that may interfere with sleep
  • Heart palpitations and dizziness due to changes in heartbeat (1% of patients)

Late Disseminated Lyme disease
  • Occurs a few months to years post-tick bite
  • Approximately 60% of patients with untreated infection may begin to have intermittent bouts of arthritis, with severe joint pain and swelling. (60% of untreated patients)
  • Affects Large joints (knees) see pain and significant swelling.
In summary, make sure your patients are educated about Lyme disease, and are using insect repellents, wearing long sleeve shirts and pants treated with permethrin, and know appropriate tick removal procedures. Have them seek care in case of a tick bite. As you see from this column, untreated Lyme can have some devastating effects on our patients.

Here is the latest on treatment of Lyme disease with of all things loratadine (Claritin) and desloratadine (Clarinex). Here is what happens:

Loratadine metabolite “desloratadine” blocks BmtA (Borrelia metal transporter A). Desloratadine (which is the brand name “Clarinex”) blocks manganese from entering the cell. Transition metals, including iron (Fe), zinc (Zn), and manganese (Mn), are critical to both bacterial metabolism and virulence.When these metals are blocked it starves the Borrelia burgdorferi and causing it to die in test tubes. Obviously this is way too early in the research phase for us to recommend this to our patients, so we will have to wait and see…..Source: http://www.pnas.org/content/106/9/3449.full

There is lots of information on the CDC website with patient friendly downloads on Lyme disease: https://www.cdc.gov/lyme/toolkit/index.html
(Hey, we pay our taxes, might as well reap some benefits)

Appropriate prophylaxis and treatment of Lyme disease

Lyme Disease - Treatment Options

Let’s assume our patients didn’t adequately follow last week’s prevention tips. We can cover two scenarios. The first we will discuss when a patient finds a tick on their skin, and then remove it. Then we can discuss treatment when the characteristic rash appears.

Pharmacological Prophylaxis of Lyme disease: The Infectious Disease Society of America recommends prophylaxis of a tick bite only when:
  • Attached tick identified as an adult or nymphal deer tick (Ixodes scapularis)
  • Tick is estimated to have been attached for 36 + hours
  • The antibiotic can be given within 72 hours of tick removal
  • The local rate of tick infection with B. burgdorferi is ≥20 percent.
  • Doxycycline is not contraindicated. Don’t give if the patient is pregnant, nursing or a pediatric patient.
Recommended dose: Doxycycline 100mg (2) tablets as a single dose with food. Dispense #2 tablets.

Pharmacological Treatment of Lyme Disease
The first sign of infection is usually a circular rash called erythema migrans or EM. This rash occurs in approximately 70-80% of infected persons and begins at the site of a tick bite after a delay of 3 to 30 days. A distinctive feature of the rash is that it gradually expands over a period of several days, reaching up to 12 inches (30 cm) across. The center of the rash may clear as it enlarges, resulting in a bull’s-eye appearance. It may be warm but is not usually painful. Some patients develop additional EM lesions in other areas of the body Treatment of early erythema migrans: (appearance of red “bulls-eye” rash)
  • Doxycycline (Vibra-tab) 100mg twice daily for 14-21 days. Avoid doxycycline if pregnant or under age 8.
  • Amoxicillin (Amoxil) 500mg three times daily for 14-21 days
  • Cefuroxime (Ceftin) 500mg twice daily for 14-21 days
  • Erythromycin (Ery-tab) 250mg four times daily for 14-21 days (extremely expensive)
Note: 10 days may be as effective as 20 days. (Source: Sanford Guide)

Since pharmacists are indeed the “drug experts” as well as the “cost experts” consider the following:
  • I personally do not dispense the doxycycline capsules, and use only tablets due to the choking hazard of the capsules. Some European countries ban the capsules for this reason. I have had two students in my class say they had esophageal burns due to capsules getting stuck in the throat. Remember to avoid doxycycline in children whose teeth are not fully erupted.
  • Amoxicillin is equally effective as doxycycline, but it needs to be dosed three times a day. Best option for pediatrics and pregnant women. Amoxicillin is still the least expensive treatment for Lyme erythema migrans. Amoxicillin should NOT be used for prophylaxis (as doxycycline is). Amoxicillin might also be a better choice for patients who experience photosensitivity on previous doxycycline therapy.

"As we discussed last week, prevention is indeed key for our patients who are headed to the outdoors. Although we commonly think of Boy Scouts, hikers, campers, and fishermen keep in mind that other outdoor activities such as gardening and even golf may expose patients to deer ticks.

This morning I decided to take my 5K hike through the neighboring farm, and through the woods. My wife reminded to put on my hiking pants, that I previously sprayed with permethrin. The grass was up to my waist in the fields. I saw a big doe (probably hiding her fawn) in the first field. After I got on the road, my pants were soaked with the morning dew, but there wasn't a tick anywhere on my light polyester pants.

One of the first patients I saw this morning was at the minute clinic, and brought a prescription for Doxycycline for 2 of the 100mg tablets. I gave her the flyer from last week, and she said she did have the permethrin, but neglected to treat her clothes this year! She promised me she would spray them when she got home. The lady behind her was listening in and quickly picked a can of permethrin of the shelf and bought it. My wife Denise called and told me she treated a patient with doxycycline for erythema migrans, who never heard of permethrin clothing spray! He was curious when the doxycycline would be "washed out" so he could canoe again, since he had such a photosensitivity rash last time. Amoxicillin might have been a better choice for this patient. So you see we have a lot of educating to do. Even though the IDSA guidelines came out in 2006, and have not changed many clinicians might not be choosing the optimal therapy for their patients."

May 2017

Lyme Disease is in Full Swing in the United States

Lyme Disease

CAUSED: by the bacterium Borrelia burgdorferi and is transmitted to humans by the bite of infected blacklegged ticks (Ixodes scapularis).
SYMPTOMS: include fever, headache, fatigue, and a characteristic skin rash called erythema migrans, which occurs 3-30 days after the tick bite.

THE RASH "Erythema migrans"
  • May occur anywhere on the body, and appears in approximately 70 to 80 percent of infected persons. (Keep in mind that 20-30% of the time there is NO rash.)
  • Begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days)
  • Expands gradually over a period of days reaching up to 12 inches or more (30 cm) across
  • May feel warm to the touch but is rarely itchy or painful
  • Sometimes clears as it enlarges, resulting in a target or “bull’s-eye” appearance

PREVENTION: “An ounce of prevention is worth a pound of cure”- Benjamin Franklin
  • Wear high socks, long pants and long sleeve lightweight shirts. Best if color is white or very light to spot ticks easier. Walk in the center of a trail, and avoid tall grasses in fields and meadows
  • Checking for ticks: Check legs and feet frequently. Know how to spot and identify ticks. Nymphal ticks are as small as a poppyseed. Use bright light and magnifying glass. Check each other in hard to see areas, especially folds of skin.
  • Pets: use a scheduled tick killing shampoo. Brush pet daily outside the house.

  • Bathe or shower as soon as possible after coming indoors (preferably within 2 hours) to wash off and more easily find ticks that are crawling on you.
  • Conduct a full-body tick check using a hand-held or full-length mirror to view all parts of your body upon return from tick-infested areas. Parents should check their children for ticks under the arms, in and around the ears, inside the belly button, behind the knees, between the legs, around the waist, and especially in their hair.
  • Examine gear and pets. Ticks can ride into the home on clothing and pets, then attach to a person later, so carefully examine pets, coats, and day packs.
  • Tumble clothes in a dryer on high heat for an hour to kill remaining ticks

TICK REMOVAL: Removal with tweezers and magnifying glass. Wear gloves place tweezers on head of tick as near skin as possible. Pull slowly, steadily and upward. Don’t twist, squeeze, jerk or crush tick. Save tick in jar or vial. Wash site of removal with soap and water. Do not use matches, petroleum jelly, gasoline, kerosene, nail polish remover.


Deet (N,N-diethyl-3-methylbenzamide) can be used directly to the skin. Use repellents that contain 20 to 30% DEET (N, N-diethyl-m-toluamide) on exposed skin and clothing for protection that lasts up to several hours. Always follow product instructions. Parents should apply this product to their children, avoiding hands, eyes, and mouth.
Permethrin: Use products that contain permethrin on clothing. Treat clothing and gear, such as boots, pants, socks and tents with products containing 0.5% permethrin. It remains protective through several washings. Permethrin is available OTC as a solution for application to clothing. Available Sawyer Clothing Insect Repellant, or Repel Clothing and Gear. Once applied to clothing it remains effective for up to 6 weeks, even after several launderings. Good for clothes that are exposed to tick infested areas. Effective against ticks that carry Lyme disease and Rocky Mountain Spotted Fever. Repellant should be applied outdoors and before clothing is worn; hang clothing, spray and let dry two hours (four in humid conditions).

"In Pennsylvania we love our sports teams, the Eastern Side of the state has the Phillies, Eagles and Flyers; the western side has the Pirates, Steelers and Penguins. These teams over the years have been “#1” in their respective sports. The whole state has its “#1” in statistics too, that being for the third straight year, leading the nation in number cases of Lyme disease.

Now that winter has released its clutches on our country, everyone is headed to the great outdoors either for picnics, hiking, camping and even less enjoyable, gardening and mowing the lawn! Many of our patients are presenting to our pharmacies/offices with questions about Lyme disease. I just sprayed my hiking pants with Permethrin spray!

Lots of good information on the CDC website. Below is a picture of the rash and other Lyme symptoms."

Hey doc.. I have a lot of pain with this tooth. What can I take?

If it's mechanical-- only the dentist can help

Dental pain: Basically, if a mechanical problem exists (broken tooth, ill-fitting dentures, missing fillings, chipped or broken tooth), our patient should always be referred to the dentist. In the meantime, dental pain from a toothache is best treated orally with NSAIDS (ibuprofen, naproxen). Topical treatment is short lived and is not of much use and should be discouraged. Make sure that NSAIDS are appropriate for that patient. One of the more common OTC treatments many patients use is Anbesol which contains phenol and is of no use in treating dental pain. It will however, in high enough dose, cause caustic chemical burns in the mouth. Advise against its use.

Teething pain in babies: recommend acetaminophen or ibuprofen if old enough (over 6 months). Do not recommend benzocaine topical products, homeopathic remedies or heaven forbid rubbing whiskey on the gums (sorry Grandma!). Have patient consult pediatrician for appropriate doses if under two years of age.

Missing fillings, cracked caps, broken off teeth? Don't apply any sort of medication, such as aspirin, or topical anesthetics, directly to the tooth. Bite down on tea bag to stop bleeding. It is best to avoid eating, but if necessary eat only soft foods until patient can be seen by a dentist. To manage pain, apply ice to the face outside the lips or cheek at the location of the injured tooth. Do not apply ice directly to the tooth. Over-the-counter pain meds (Ibuprofen or Naproxen) if appropriate, are effective to minimize pain.

First Aid for Tooth Avulsion- "Knocked out teeth"

Best Choice: For professions around activities where teeth can be knocked out, such as athletic trainers, coaches, school nurses and emergency responders, Save-a-Tooth® is a proprietary product that should be carried to all events. This product keeps the tooth alive and nourishes cells until implantation occurs. About 90% success rate (versus 10%). If no one has this product available, (which is most likely) pick up tooth by crown, not the root. Rinse the affected tooth with water if dirty. Reposition into socket at once (if possible). Do NOT let the avulsed tooth dry-out! It is important to remember that time is extremely important here. After 30 minutes the success rate of tooth reimplantation drops sharply.
  • may hold in mouth next to cheek (Not recommended in cases where there is a fear of the patient swallowing their tooth)
  • drop into glass of milk (Best option if you don’t have Save-a-tooth)
  • see the dentist/endodontist within 30 minutes
"Meth Mouth" is most commonly attributed to the abuse of methamphetamine (crystal meth, crank). This drug is made in meth labs, through the conversion of pseudoephedrine to methamphetamine. According to the American Dental Association, “meth mouth” is probably caused by a combination of drug-induced psychological and physiological changes including, xerostomia (dry mouth), extended periods of poor oral hygiene, frequent consumption of high-calorie carbonated beverages, teeth clenching and grinding (bruxism). The Pennsylvania Dental Association also contends the acidic nature of methamphetamine destroys enamel. (Due to highly corrosive nature of manufacturing process) “Meth mouth” is a misnomer. Not all patients with these blown away teeth are methamphetamine addicts. Meth mouth also describes any chronically using any amphetamine, or any opioid. This condition can also be seen in anorexia/bulimic patients.

What the dentist sees: of the 28 teeth, most adults have (32 minus 4) most patients come in with at least 20 teeth blown away. The challenge is once these patients are in detox with the opioids withdrawn, the exposed nerves become very painful, and patients seek dental help. Generally speaking, dentures are the only viable treatment option.

"We have spent the past thirteen columns meticulously going through all the products in our dental section, gaining a level of expertise that we didn’t have, thanks to the input of Dr. Rodney Messner. We have a lot of products to choose from to help our dental patients, but there are some complaints that we just can’t fix! This column is dedicated to what we can’t fix, and should be immediately referred to a dentist. Unfortunately many of our states do not reimburse dentists adequately and they will lose money seeing these patients that frequently come to our pharmacy with dental issues. A day doesn't go by when we get a prescription for Clindamycin and Ibuprofen from the Emergency Department from our local hospital. These patients are in pain and this is only a temporary fix. Only the expert care of a dentist will be able to remedy their dental problems. We as pharmacists like to help our patients, and sometimes the best advice we can give is to recommend our patients for appropriate dental care. Remember--"Dentistry isn't expensive...neglect is!" "

Dr. Rodney Messner of CherryTree Dental Associates has been most helpful in providing expertise for these columns. His expertise in the treatment of tooth avulsion is most appreciated for this column. We wish him continued success in his practice.

Dr. Rodney A. Messner, DMD

Dry mouth complaints??... before heading to the dental section... check the med list!!!

Treatment and Prevention of Xerostomia

A healthy patient produces saliva at the rate of 0.5ml per minute, approximately 30 ml of (1 ounce) per hour. In a person with xerostomia, the rate is reduced to 0.1ml per minute, approximately 6ml (1 teaspoonful) per hour. Besides adding in chewing and digestion, saliva maintains the pH balance in the mouth by secreting bicarbonate ions, produced in the salivary ducts, which combine with and neutralize the H+ ions produced in the fermentation process. Inadequate production of saliva is a risk factor for dental caries.

The Most Common Causes of Xerostomia:

  • Lesions in the salivary glands or duct obstruction
  • Radiation injury to the salivary glands
  • Sjogrens syndrome: 9:1 female: male ratio. Most common disease affecting salivary gland. These patients also experience dry eyes, dry skin, difficulty in swallowing and swollen inflamed joints
  • Hypertension, alcohol, tobacco, caffeine use
  • Cystic fibrosis
  • Lupus, Crohn's disease, Biliary cirrhosis, HIV

Many Drugs are Commonly Implicated in Causing Xrostomia:

  • Numerous psychotherapeutic agents: benzodiazepines, buspirone, TriCyclic Antidepressants (Elavil), Selective Serotonin Reuptake Inhibitors (Prozac, Zoloft), MAOI (Emsam), Effexor, Wellbutrin. Lithium, Valproic acid, numerous antipsychotics.
  • Antihypertensive agents: clonidine, enalapril, methyldopa, prazosin
  • Diuretics: HCTZ, Furosemide, Spironolactone
  • Anticholinergics: Benztropine, Trihexyphenidyl, Atropine, Dicyclomine, Hyoscyamine.
  • First generation antihistamines: Diphenhydramine, promethazine, hydroxyzine. This is primarily to their anticholinergic side effects.

OTC treatment of Xerostomia: topical treatment of xerostomia is available as "Saliva substitutes".

Saliva substitutes may be most useful before sleep, because viscosity of saliva changes at night; after waking at night with dry mouth symptoms, during telephone conversations, during social and workplace interactions, and in patients with dentures.

  • Contain carboxymethylcellulose and or mucins for lubrication and viscosity.
  • Contain xylitol or sorbitol as sweeteners. Remember sugar alcohols can cause diarrhea.
  • Trade names: MouthKote, Biotene Oralbalance gel, Biotene mouth spray, Salivart, Xero-lube

Patient tips:

  • Sip water and sugar free drinks.Avoid sugary drinks and caffeine
  • Chew Sugarless gum or suck on sugarless hard candies
  • Use a humidifier
  • Breathe through the nose, not the mouth
  • Practice good oral hygiene: brush, floss, see dentist regularly.
  • Treat cracked lips with petroleum jelly or lip balm
  • Eat high moisture foods (Mashed potatoes instead of French fries). Avoid spicy foods

RX Treatment:

Includes the parasympathomimetics or the "cholinergic agonists": pilocarpine (Salagen), cevimeline (Evoxac). Patients may complain of excess sweating and gastrointestinal upset. Patients should be monitored for development of oral candidiasis (thrush).

Special thanks to Dr. Rodney Messner from CherryTree Dental Associates for his review of this column:

Dr. Rodney A. Messner, DMD

Dr. Rod adds:

  • Biotene products seem to be the most popular with my patients.
  • Xerostomia is a very common problem among our older patients. I do see it a good bit in my dental practice
  • Don't forget to advise patients to avoid highly acidic foods/drinks as well due to their erosive effect on teeth. With limited saliva production, these drinks can quickly damage the protective enamel layer.

Clenching teeth---our dentists can help!

Bruxism--again we have to check the med list!!

Bruxism refers to repetitive jaw-muscle activity characterized by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible. stress and anxiety but by sleep disorders, an abnormal bite or teeth that are missing or crooked. The symptoms of teeth grinding include:
  • Clicking or popping jaw joints
  • Eating disorders
  • Enlarged jaw muscles
  • Earache because of proximity of ear canal to TMJ
  • Dull headaches
  • Jaw pain and stiffness on waking
  • Teeth that are painful or loose, due to wearing down of enamel and increasing sensitivity
  • Fractured teeth and excessive tooth wear
Treatment may include mouth guards, and skeletal muscle relaxants.

German researchers did a small study of 69 patients, and concluded that participants with high sleep bruxing activity tend to feel more stressed at work and in their daily life, and, according to the questionnaire, seem to deal with stress in a negative way. Bruxism is a dangerous dental problem that can not only wear down teeth, but also make them sensitive or loose or even fracture them. Besides worn tooth surfaces, which can lead to sensitivity, symptoms can include headaches and a sore jaw.

Causes of Bruxism:

Bruxism presents with multifactorial etiologies many of which remain unclear, but several factors may be involved which include, the use of psychoactive substances (tobacco, alcohol, caffeine, or medications for sleep and depression) increases arousal and leads to problems falling asleep, staying asleep and daytime sleepiness. Mental disorders, anxiety, stress and adverse psychosocial factors are significantly related to tooth grinding during sleep and it has been found that nearly 70% of bruxism occurs because of stress or anxiety.

Pharmacotherapy may contribute to bruxism, believed to be due to lowering dopamine levels. Selective Serotonin Reuptake Inhibitors (SSRI) are most commonly implicated with Citalopram (Celexa), Fluoxetine (Prozac) and Paroxetine (Paxil) being the biggest culprits. Mirtazapine (Remeron) might be a better choice.

TREATMENT (Pharmacotherapy) of BRUXISM
  • STOP the offending medication!
  • Buspirone (anxiolytic) may help with anxiety, without contributing to bruxism
  • Propranolol, Gabapentin, Botulism toxin have all been used.
  • Clonazepam has most evidence, and has the additional benefit of decreasing nighttime leg movements.
Mechanical treatment of Bruxism: Mouth Guards
  • Premade Plastic Mouth Guards-flexible plastic- don’t always fit adequately over the teeth. May be an obstructive hazard
  • "Boil and Bite" Mouth Guards OTC fit better than the pre-made but are more uncomfortable to wear. May interfere with tongue movement.
  • CUSTOM FIT Mouth Guards: made by dental professionals, from soft rubber up to acrylic, for heavy grinding.
  • Occlusal splints (bite guards) have become first line therapy as they protect the teeth from premature wear, reduce jaw muscle activity and the noise of teeth grinding.

Special thanks (once again) to Dr. Rod Messner for his expertise in reviewing this column for content.

Dr. Rodney A. Messner, DMD

April 2017

Might want to grab a bottle of water after reading this column! (it is cheaper however if you drink it out of the faucet!)

Have a soda...and a smile??

Dr. Rod Messner has this to say about soda consumption: "When I was in Dental School at Temple University, one of the professors gave us first year dental students a most discouraging prediction: with every city fluoridating their water the upcoming generation will have teeth that will never dec... most of you will probably starve, as drilling and filling is our bread and butter" . "Since I first heard that statement 32 years ago, one thing has been made very clear to me: Human behavior always trumps good science! The science related to the deleterious effect of regular consumption of soft drinks is good science as well as the voluminous data related to systemic fluoride."

"However, when our patients regularly ingest 6 liters of Mountain Dew per day, (yes 6 liters) no amount of flossing, tooth brushing, or fluoridated mouthrinse is going to help this patient! What we do know about the dental effects of soft drink consumption is that when compared with caries, dental erosion seems to have a much stronger relationship with soft drinks. In order to advise your patients on ways they can reduce dental caries risk, low-calorie and sugar-free foods should be recommended. However, sugar-free soft drinks often have as high an erosive potential as sugar-containing soft drinks."

Dr. Messner provides these great insights, and 32 years since he heard that prediction we Americans are doing very little to decrease soda consumption. Consider the following: According to the New York Times 5% of the federal "food stamp" budget (SNAP) is spent on these soft drinks, while the category of "sweetened beverages" (energy drinks, fruit juices and teas) accounts for 10% of the grocery bill. The Department of Agriculture is coming under fire for "subsidizing the soda industry"

Here is the history of how much soda Americans consume:
  • 1970- Americans consumed 20 gallons soda per year (7-oz/day)
  • 1981- Americans consumed 32 gallons soda per year (11oz/day)
  • 2002- Americans consumed 54 gallons soda per year (20oz/day)
  • 2015- Americans consumed 41 gallons soda per year (14oz/day)
It's called "pop" in the Midwest and most of Canada. It's "soda" in the Northeast. And it goes by a well-known brand name in much of the South. Where I live in Blair County, Pennsylvania is on the edge of the "pop versus soda" line. Folks to our west in Pittsburgh call it "pop" and the folks to our east call it "soda". Horry County, South Carolina, home of PharmCon it is called by a well-known "brand name". Yes there is a website: popvssoda.com !!

  • Larger serving sizes make the problem worse. From 6.5 ounces in the 1950s, the typical soft drink had grown to up to 20 ounces by the 1990s.

Three ingredients in this delicious, fizzy drink cause the problems with our teeth:

  • Sugar: obvious contributor to dental caries. Note that this also includes corn syrup! This we see regularly as one of the top food additives to avoid in our diet for better health!!
  • Phosphoric acid: gives the "bite" to soft drinks. The pH of soda, and our mouths have a lot to do with the destruction of the enamel of our teeth.
  • pH of a soft drink ranges from 2.47-3.35
  • pH in our mouth is normally about 6.2 to 7.0
  • At a pH of 5.2 to 5.5 or below the acid begins to dissolve enamel on our teeth
  • Citric acid: Non-cola drinks contain citric acid which is also harmful to teeth
As far as interprofessional interactions with dentists and pharmacists, Dr. Messner offers the flowing closing comments: "It is necessary to educate out patients about the harmful effects of excessive soft drink consumption and to advise them with the following tips to prevent dental erosion and caries: limiting soft drink intake, choosing low erosive soft drinks, improving their drinking habits, toothbrushing at least twice per day, and avoiding brushing teeth within 1 hour after consuming acidic food, and using a fluoride or a remineralizing toothpaste."
I remember as a kid growing up, seldom was there soda in our house. We had to go to our Grandpa's house for a visit if we wanted such a treat. I remember well the 7 ounce soda bottles, and how there were judiciously passed out to us youngsters. As we discussed last week, about 2/3 of the municipal water supplies are fluoridated and with the large increases in consumption of sugared beverages and soda-pop, we are confident that our fellow health care clinicians in the dental profession will be plenty busy… for a long time! Once again, I want to express my sincere appreciation to Dr. Rodney Messner for his input on this column. With over 30 years of clinical experience, and an extremely busy schedule I'm delighted to have him contribute his expertise to this column. Have a great day on the bench!!

"Keeping teeth strong with fluoride!
Dr. Rod Messner is a huge fan too! "

Fluoride---friend or foe??

How fluoride works: The risk of dental caries is reduced due to the uptake of fluoride by enamel cystallites and formation of fluorhydroxyapatite which is resistant to acid solubilization. Fluoride is anticariogenic because it replaces the hydroxyl ion in hydroxyapatite with the fluoride ion to form fluorapatite on the outer surface of the enamel. Fluorapatite hardens the enamel and makes it more acid resistant. Fluoride also has demonstrated antibacterial activity. Fluoride is most beneficial from birth to age 12 because unerupted permanent teeth are mineralizing at that time. Whether a person receives fluoride supplementation depends on the concentration of the drinking water. Adding fluoride to the water reduces dental caries by 25%. Because of this contribution to public health, the CDC named community water fluoridation one of 10 great public health achievements of the 20th century. The American Dental Association, the American Academy of Pediatrics, the US Public Health Service and the World Health Organization all support fluoridation of water.

Sources of fluoride:
  • Drinking water: About 66% of the US population lives in a municipality with a fluoridated water system. The United States Public Health Service recommends an optimal fluoride concentration of 0.7 milligrams/liter (mg/L). This concentration of fluoride in drinking water is the concentration that provides the best balance of protection from dental caries while limiting the risk of excess fluoride (dental fluorosis).
  • Dentist applied: fluoride based varnishes and gels can be applied directly to the teeth during a dental visit.
  • OTC mouthwashes: Children under the age of 6 years should not use mouthwash, unless directed by a dentist, because they may swallow large amounts of the liquid inadvertently.
  • Rx Gels and toothpastes such as Prevident 5000 and others. Rx products deliver about four times as much fluoride as do the OTC products.

Does it work?

The prevalence of dental caries in at least one permanent tooth (excluding wisdom teeth) decreased from 90% among those aged 12-17 years in the 1960s to 60% among those aged 12-19 years in 1999-2004. Obviously, people should drink municipal water to get the benefits of fluoride! And that includes the astronomical rise in soda consumption… which we can talk about next week... You can check your water supply, or the water supply where you practice at this website: https://nccd.cdc.gov/DOH_MWF/Default/Default.aspx

How to supplement patients whose water supply is not fluoridated:

Water concentration of Fluoride Age of patient Supplementation mg/day
>0.6 ppm of fluoride 6 months - 3 years 0mg
3 years - 16 years 0mg
0.3 - 0.6ppm of fluoride 6 months - 3 years 0mg
3 years - 6 years 0.25mg/day
6 years - 16 years 0.5mg/day
<0.3ppm of fluoride 6 months - 3 years 0.25mg/day
3 years - 6 years 0.5mg/day
6 years - 16 years 1.0mg/day

Patient Care tips for Fluoride supplements
  • Fluoride supplements (oral) are prescription only.
  • All tablet formulations MUST BE CHEWED! Chewing "pulverizes" the fluoride into the enamel of the teeth
  • Milk and other dairy products may decrease absorption.
  • Available as Luride® (sodium fluoride) 0.25mg chew,0.5mg chew, 1mg chew, as well as Luride® solution 0.5mg / ml.
  • Sodium fluoride:2.2mg= yields 1mg active fluoride ion; 1.1mg= 0.5mg active fluoride ion
  • Most recommend fluoride be given at bedtime after kids brush their teeth.
  • Fluoride may be ingested from bottled water or juices that have been fluoridated

Dr Rod Messner says: "Fluoride works! It is safe, and many water systems have been adding fluoride to the water system since the 1950's without any issues except for the decline in caries"

Dr. Rodney A. Messner, DMD

Where I live in Blair County Pennsylvania, we have 30 different water systems. ONLY the Tyrone water system is fluoridated.The major municipalities in our county of Hollidaysburg and Altoona do not fluoridate their water supply. There was a controversy back in 2013 about eliminating fluoride, where the Borough Council voted to eliminate fluoride supplementation. After many meetings, and our local dentists bringing evidence they had accumulated comparing the Tyrone patients to the patients who didn't have fluoridated water and the council reinstated the supplementation of fluoride to our water supply.

"Keeping up the confidence of denture wearers...with safety in mind!"

A look at Denture Adhesives... are they necessary? ...well sometimes

Denture adhesives are pastes, powders or adhesive pads that may be placed in/on dentures to help them stay in place. In most cases, properly fitted and maintained dentures should not require the use of denture adhesives. Over time, shrinkage in the bone structure in the mouth causes dentures to gradually become loose. When this occurs, the dentures should be professionally relined or new dentures made that fit the aging mouth properly. Denture adhesives fill gaps caused by shrinking bone and give temporary relief from loosening dentures. They are effective; however, they are NOT a permanent solution!! If denture is ill-fitting, refer to a dentist.

How they work: The denture adherent holds dentures in place while chewing or speaking. They also form a seal that keeps food particles from sticking between the dentures and gums, which can be a problem with whole grains, or even fiber laxatives like Metamucil.


  • Paste Application: Most patients use too much! Just a "pea-sized" amount in 4-5 locations on denture is plenty. Examples: Fixodent, Polygrip, Effergrip
  • Powders: Easier to clean. Better initial retention but falls sharply within the first six hours. Examples: Fixodent, PolyGrip and Klutch
  • Thin Adhesive Liners are available as wafers or pads less messy or "gooey" to apply : Example: Sea-Bond.
Remind patients to scrub off the adherent each time the dentures are cleaned.

ZINC in Denture adhesives??

  • Active ingredients: polymethyl vinyl ether-maleic anhydride (PVM-MA) zinc and calcium salts with carboxymethylcellulose.
  • The problem becomes: Chronic, excessive ingestion of zinc can result in copper deficiency, which is an established and increasingly recognized cause of neurologic disease, causing weakness and numbness of the extremities.
  • Some marketed denture adhesive creams, including certain Fixodent and Poli-Grip formulations, contain zinc at levels of about 17 to 34 mg/g.

WHAT does the ADA (American Dental Association have to say:

To earn the ADA Seal: Clinical data demonstrating the effectiveness of the denture adherent in providing increased biting force, increased retention, and that the integrity of the dentures is not affected by the adherent. Effergrip®, is the only adherent that has the ADA seal. It has coloring agents, dispersal agents, wetting agents and adhesives: Polymethylvinylether maleic acid calcium, Polyethylene Oxide, Sodium Carboxymethylcellulose (also thickens). It is zinc free.

Dr. Rod says: "I tell my patients that the selection of a denture adhesive is what works best for them. It's a vanilla or chocolate thing. I tell patients to use them, they do help! If they are doing some public speaking or going to a special event…..USE THEM!! Provides an extra level of confidence.”

Dr. Rodney A. Messner, DMD

Pharmacists Role: Remember, a film of saliva helps hold dentures in place. Inadequate saliva flow may cause dentures to be loose. Inadequate saliva flow may be due to prescription and OTC medications, such as anticholinergics (Bentyl®, Levsin®), tri-cyclic antidepressants (Elavil® is the worst), or first generation antihistamines (Benadryl). Treatment options could be changing to Pamelor® (nortriptyline) which is less anticholinergic and using the second or third generation antihistamines like Claritin or Allegra.

Special thanks to Dr. Rodney Messner from Cherry Tree Dental Associates for his practical hints for this column!

"Care and feeding of your dentures! Once again I had to consult an expert!"

Daily care tips for denture wearers:

Don't let dentures dry out...

The teeth of a denture are typically made from various types of resin or porcelain. Place them in a denture cleanser soaking solution or in plain water when you're not wearing them. Never use hot water, which can cause dentures to warp. Dropping a porcelain denture might result in breakage. Most all dentures made today are plastic(acrylic), both the teeth and the pink denture base, very few have porcelain teeth. Many dentures are broken by dropping them in the sink. Also be careful with your beloved pet, dogs love to get a hold of dentures!

Brushing the dentures...

Brushing dentures daily will remove food and dental plaque, and help prevent them from becoming stained. Always brush dentures over a folded washcloth. If the dentures slip out of the wearers hand, a washcloth might prevent breakage. Patients can use special creams for dentures, or any toothpaste. Some sources recommend dishwashing liquid (Dawn works great) or hand soap to clean dentures.

What NOT to do...

Do not use any household abrasives. A regular or denture brush works fine, but patients should not rely solely on denture cleansers. Some dentures have a permanent soft liner, this material requires special care, a patient should not use conventional brushing methods for these. They are given a special solution to clean them with at the time they were given their denture.

Take care of your mouth...

Brush your gums, tongue and palate every morning with a soft-bristled brush before you insert dentures. This stimulates circulation in your tissues and helps remove plaque. Up to half of those wearing dentures will develop a fungal infection called oral stomatitis (candidiasis). But there are some tips you can follow to prevent this infection, as well as keep you smiling, eating, and speaking with confidence

Give your dentures a rest...

Remove dentures out for 6 to 8 hours a day to allow the tissues of your mouth to heal from any soreness or irritation that may have occurred throughout the day. Removing dentures while sleeping is a good way to give the mouth a rest.

Consult your dentist...

See your dentist if dentures break, chip, crack or become loose. Don't be tempted to adjust them yourself — this can damage them beyond repair. Never should a pharmacist recommend a “denture repair kit”, this is best left to the dental professionals to fix any damaged denture. Patients should NEVER super glue their dentures! Most of the time dentists are professionally unable to repair them after they have been glued.

Adjust your eating habits...

Cut foods into smaller pieces to allow better chewing or adding gravies or a pat of butter to soften up some foods for chewing. Chew on both sides of your mouth to avoid dislodging dentures while eating. Avoid chewy types of food like caramel and hard foods like nuts, which can loosen your dentures.

Soaking the dentures...

Alkaline peroxide cleaners are the most common. When dissolved in water become alkaline solutions of peroxides, releasing oxygen for mechanical cleaning. Soak 4-8 hours. Best for new stains and plaque. soaks are useful for inhibiting growth of Candida albicans, which can cause stomatitis. Examples are Polident and Efferdent.
Hypochlorite: (bleach) removes stains, bacteria, fungi. Hypochlorite dissolves plaque, but not calculus when formed. Example: Dentural® Sodium Hypochlorite (0.5% NaOCl solution) is effective in decreasing microorganisms without changing the color of the denture resin.
Avoid persulfate, it may cause allergic reactions. Acid containing solutions. Shorter soaking times recommended. May be used with ultrasonic cleaners. Usually contain citric acid, examples are: Polident®, Stain Away®.

See your dentist...

Just because a patient may not have all their natural teeth, they still have gums, and an oral cavity that needs to be routinely checked by their dentist. A dentist will also check the fit of the denture, which is extremely important as a patient ages, and has changes to the structure that holds the denture. Dr. Rod Messner recommends a once a year checkup. Pharmacists role in medication management: Please note that currently MANY medications, such as anticholinergics, cause varying degrees of xerostomia which adversely effects denture retention.

"We’ve been discussing dentifrices for over a month now, all along the goal is to achieve stronger and healthier teeth. This week we will discuss what happens when things don’t go as planned, and our denture wearing patients come to us for advice. Nearly 69 percent of adults between 35 and 44 have lost one or more permanent teeth, and 26 percent of adults aged 74 are missing all of them. We have a lot of products in our dental aisle that caters to denture wearers, it is time we get familiar with them!"

"Once again Dr. Rod Messner from CherryTree Dental Associates provided his expertise in writing this column."

Dr. Rodney A. Messner, DMD

"He shared with me many practical hints, especially with denture breakage and repair. Since we don't have any pets I never thought of dogs as being a danger to dentures! One of my local pharmacists told me of an elderly patient whose grandchildren hid her dentures, so she would stay for a longer visit!"

March 2017

"Brushing and flossing do the cleaning, but is your breath fresh and 'kissable'?"

Mouthwashes - the finishing touch!

Now that we have brushed our teeth for two minutes with an ADA approved soft toothbrush, with a pyrophosphate free fluoride ADA approved toothpaste, as well as cleaned our inter-dental spaces with appropriate ADA approved dental floss, the question becomes can we get “kiss-ably close”! The final class of dentifrices we can recommend to get more than a peck on the cheek is to try an ADA approved mouthwash!

There are two distinct mouth washes. We have at our disposal those “cosmetic” mouthwashes that just freshen our breath, and the “therapeutic” mouthwashes that actually do something positive for our mouth. Let's briefly discuss “halitosis” and other mouthwashes.

The major contributor to halitosis is the presence of “volatile sulfur compounds”. These volatile sulfur compounds arise from the breakdown of foods, as well as dental plaque and the bacteria associated with oral disease. Hydrogen sulfide (paper mill smell or rotten eggs) and dimethyl sulfide (smell of the ocean) account for about 90% of the volatile sulfur compounds found in breath and are produced by anaerobic bacteria. High protein foods, such as eggs, meat and fish when broken down by the anaerobic bacteria cause the highest concentration of volatile sulfur compounds. These bacteria can live in all of the corners of the mouth, between teeth and in the “nooks and crannies” of the tongue.

Cosmetic mouthwashes: are best defined by what they don't do. They simply leave the mouth with a pleasant taste, but don't deal with the causes of bad breath, kill the bacteria that cause bad breath; or help reduce plaque, gingivitis or cavities.

Therapeutic mouthwashes: rinse for at least 60 seconds, then spit out.
  • Control plaque and gingivitis (chlorhexidine, povidone iodine,cetylpyridium chloride -CPC- and essential oils) Using a mouthwash with povidone iodine, essential oil, CPC or chlorhexidine significantly reduced plaque and reduced bacterial indicators of gingivitis. Cetylpyridium chloride is an antiseptic that kills off the offending bacteria. CPC decreases dental plaque and gingivitis and remains in the oral cavity 3-5 hours. CPC was developed to control plaque and gingivitis without essential oils ie "medicine breath". Chlorhexidine products (Peridex) are prescription only. Chlorhexidine may cause staining of the teeth, which is easily removed by a dental hygienist.
  • Strengthen teeth (fluoride) For added protection against tooth decay, usually contains about 0.05% of Sodium Fluoride (NaF). Fluoride reduces demineralization by strengthening and protecting the enamel on teeth.
  • Whitener (peroxides) bleaching agent, usually hydrogen peroxide or carbamide peroxide. This helps to whiten teeth and remove stains over time. Products that contain 10 percent carbamide peroxide yield approximately 3.5 percent hydrogen peroxide. These products may also cause dentin hypersensitivity.
  • Alcohol levels can be as high as 20%. Best to avoid these with alcoholics as well as teenagers because of potential abuse. May also cause increase in tooth sensitivity by dissolving away the mucus layer that protects teeth.
  • Xerostomia “dry mouth”-- be sure to use sugar free products, as well as alcohol free dental rinses. Dental rinses containing alcohol may cause increased dryness. Because of reduced salivary flow, sugar free products are needed to decrease chance of tooth decay. (such as Biotene® or Oasis® mouth rinse).

"So 1879 was a pretty amazing year, not only did Edison invent the light bulb, and Albert Einstein was born, but Dr. Joseph Lawrence and Pharmacist Jordan Lambert developed Listerine. One hundred years later, Professor Pete would be in Pharmacy School!.

Special thanks to Dr. Rod Messner for reviewing the content of this article."

"Dental floss...not just for corn-on-the-cob season!! We should use it every day!"

Who would ever think DENTAL FLOSS could cause a controversy??

We all have that spool of “nylon yarn” in our bathrooms. Some of us use it a lot more than others. Flossing helps remove plaque by reaching areas that a brush cannot reach, but reports show that as few as 3% to 18% of patients floss daily. By removing debris from these hard-to-reach tooth surfaces we may see a reduction in the likelihood of gum disease and tooth decay. Dental floss was formerly made of silk, today is made of nylon filaments or single strand plastic monofilaments. Look for the American Dental Association Seal of Approval before purchasing dental floss.

To earn the ADA Seal of Approval…
  • The product components are safe for use in the mouth.
  • Unsupervised use of the product by the average patient will not harm hard or soft oral tissues or restorations
  • Tensile strength: high tenacity “nylon yarn” is best because:abrasion resistance of nylon, when drawn over rough surfaces. Elasticity of nylon is greater allowing it to pass through close places and over rough surfaces with less filament breakage.
  • Both Reach® (J&J) and Oral-B dental floss are ADA approved

What floss should I buy:
Simply stated it is the patients choice based on preference, waxed or unwaxed, flavored or not flavored..
  • Large gaps between teeth: Try dental tape or Super Floss, or JJ Reach® woven floss.
  • Tight spaces: recommend a waxed floss or Oral-B Glide®
  • Less mess: disposable flossers or floss in pre-measured strands.
  • Braces or bridges:A spongy floss is worthwhile, but any floss is OK with dental appliances, especially if you have a floss threader. Super floss is also a good choice.

Is flossing worth the effort:
Flossing Controversy: August 2, 2016- New York Times “There is some evidence from twelve studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from 10 studies that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months. No studies reported the effectiveness of flossing plus toothbrushing for preventing dental caries.”
  • ADA response: In this case, while the average benefit is small and the quality of the evidence is very low (meaning the true average benefit could be higher or lower), given that periodontal disease is estimated to affect half of all Americans, even a small benefit may be helpful. The other side of the benefit-risk analysis is an absence of documented harms as well as minimal cost to patients.
  • The Association also released a statement in response to the news story, reiterating its recommendations to maintain oral health, which include "brushing for two minutes, twice a day with a fluoride toothpaste, cleaning between teeth once a day with an interdental cleaner and regular dental visit advised by your dentist." The ADA also stated that interdental cleaners, including floss, "are an essential part of taking care of your teeth and gums.

"Once again, I had to consult my friend the dentist for his input on this column. Dr Rodney Messner of Cherry Tree Dental in Wisconsin helped by making specific brand recommendations for all of the floss products I listed."

Dr. Rodney A. Messner, DMD
Dr. Rod advises: "There is reliable data correlating periodontal disease and heart disease. I have yet to find a dentist that has told their patients there is no need to floss. Flossing does more than just clean the spaces between the teeth-- it might even protect the heart!

"So, this pharmacist will tell you...keep flossing… even when you are not eating corn-on the cob!"

"My dentist friend guided me for this column. Lots of great information that was challenging for me to find! Special thanks to Dr. Rodney Messner."

Hot tea or cold drinks bother your teeth??

Last week we discussed in detail the characteristics of the toothpastes that we sell in our pharmacies. Sensitive teeth, known as “dentin” hypersensitivity occurs when stimulus (hot, cold, chemical or physical) is applied to tooth. Dentin becomes exposed by gingival recession or enamel loss.

Enamel is the hardest surface in our body, which consists of 96% hydroxyapatite which is a combination of calcium and phosphate, the bones in our body contain 70% hydroxyapatite and the dentin in our teeth is also 70% hydroxyapatite. Dentin contains tubules which are an open pathway between pulp, and dentino-enamel junction.

Hot, cold or mechanical stimulus causes increase in fluid flow through tubule, causing pain at the underlying nerve (or pulp). Dentin hypersensitivity is typically found in patients whose dentin has become exposed due to gingival recession, periodontal therapy and most commonly loss of tooth enamel.

As we discussed, tooth abrasion from brushing and toothpaste selection can contribute to the wear and tear on the enamel, which exposes the dentin, and allows pain transmission through the tubules. 55-75% of patients may experience tooth sensitivity during professional whitening treatments.


The most important step in treating dentin sensitivity is to STOP destructive habits such as aggressive or vigorous cross brushing.Use soft toothbrushes!! 50% of all damage occurs the first 20 seconds of brushing – lots of toothpaste, causes lots of abrasion. Review the “Modified Bass Brushing Technique”- a lot of dental professionals have a saying “It is not the brush, it is the brusher!”
  • Consult your dentist, dental hygienist, or pharmacist to recommend a toothpaste with a lower RDA (Relative Dentin Abrasivity).
  • Recommend twice-daily use of a desensitizing dentifrice. Active ingredients include stannous fluoride, strontium chloride hexahydrate, and aluminum, potassium or ferric oxalates and fluorides. While studies show improvement in patients’ perception of pain, the effectiveness of these products at reducing symptoms appears to increase with increased usage. Patients will experience more benefit the longer they use these products.
    • Fluoride dental paste: (Prevident-5000 plus®) written as a prescription, works by forming the precipitate calcium fluoride which plugs the tubules. Remind patients to brush on this dentifrice and do not swallow. Patients should not rinse and spit. Fluoride is an effective agent to control dentin hypersensitivity and to prevent root caries particularly when used in higher concentrations.
    • Potassium nitrate (5%) (KNO3) alters membrane potential along the dental nerves, after passing through dentino tubules. Also helps occlude the exposed dentino tubules, and decreases flow. Potassium nitrate lowers nerve sensitivity, by blocking the synapse between nerve cells, reducing nerve excitation and the associated pain.
    • Strontium chloride hexahydrate (10%) is an effective means for reducing the discomfort and pain caused by thermal and tactile stimuli in patients with dentinal hypersensitivity. Strontium works by exchanging calcium for strontium in biological processes. Strontium also impairs nerve stimulation by changing stimulus transmission. These treatments reduce flow into the dentin tubules by occluding or sclerosing the tubules.
    • Prevident® 5000 Sensitive teeth contains 5% potassium nitrate along with the Sodium Fluoride 1.1% (which is 4 times stronger than OTC toothpaste).
    • If no relief after twice daily brushing for 2 or 3 weeks, recommend a visit to dentist.

"There is so much for us health care professionals to know, that is why we have 'specialties'! For this column, I struggled finding the mechanisms of action for the many ingredients in these toothpastes for dentin hypersensitivity. My dentist friend Dr Rod Messner came to the rescue again this week. His input, again this week was most valuable."

Dr. Rodney A. Messner, DMD
Dr. Rod says: I prefer using fluoride in my practice to desensitize the dentin. I try to stay away from the stannous fluorides because of the metallic taste, compliance usually becomes an issue at some point. Patients just quit using it at some point. Recently I began to prescribe products such as MI paste(GC America) and 3M’s Clinpro 5000, which contains sodium fluoride. Both these products possess regenerative capability. They taste good so compliance is improved.

"Toothpaste-- how to select a dentifrice, and cause minimal problems. I even had a dentist help me with this column..."

Toothpaste ...helping our patients select a product that won't harm their teeth!

Every morning before heading to work, and every evening before going to bed, we put a dollop of this stuff called toothpaste on our toothbrush. Here is what is in it that amazing stuff that makes our teeth so white, and our mouths so sparkling clean:
  • Fluoride to strengthen tooth enamel and remineralize enamel.Fluoride is most commonly available as Sodium fluoride (NaF), stannous fluoride (SnF2), and sodium monofluorophosphate (Na2PO3F).
  • Humectants, such as glycerol, propylene glycol and sorbitol are added to prevent water loss in the toothpaste.
  • Flavoring agents, such as saccharin and other sweeteners improve taste.
  • Thickeners and binders stabilize the toothpaste formula. They include mineral colloids, natural gums, seaweed colloids or synthetic cellulose.
  • Detergents such as sodium lauryl sulfate, sodium N-Lauryl sarcosinate, cause foaming when contacted with water and manual brushing.

The American Dental Association Seal means that:
  • The toothpaste must contain fluoride
  • Must not have any excipients (flavors, sweeteners) that can cause tooth decay
  • Must not be “too abrasive”

“RDA” for toothpaste? We are familiar with the Recommended Daily Allowance for our vitamins, but there is an RDA for toothpaste, which refers to the Relative Dentin Abrasivity. This is a scale the industry uses to make sure the formulations are not too abrasive to the enamel and can expose the very sensitive dentin, either by wearing down the enamel or causing gingival recession.
Pyrophosphate: Tartar control toothpastes cause more problems than good. The pyrophosphates work to decrease tartar formation by binding up the calcium and magnesium in saliva which blocks tartar formation on the teeth. Tetrasodium pyrophosphate is the most common pyrophosphate.
  • These pyrophosphates in the mouth can form an alkaline solution which can cause irritation.
  • Pyrophosphates have such a bitter taste more flavoring agents are used which can cause hypersensitivity.
  • More detergents are added to make the pyrophosphates soluble which also causes hypersensitivity.
  • Patients with reduced salivary flow are at highest risk for hypersensitivity reactions
  • The tartar control toothpaste might make our teeth mores sensitive to hot or cold temperatures.ns

Chances are when any patient has a red ring around his lips or redness inside the mouth, I always ask what type of toothpaste, and most often it is a tartar control toothpaste. Tartar control toothpastes work on the surface of the teeth to block tartar buildup. However, the sub-gingival tartar (below the gums) is the problem! Tartar control tooth pastes cause a lot of hypersensitivity reactions, and only work above the gum line. That is why we must go to the dentist at least every six months to get the sub-gingival tartar removed- our brush and toothpaste doesn’t do the entire job. Do we even need toothpaste? According to the American Dental Hygienist the most important factor in plaque removal is the mechanical action of the toothbrush!

"As a community pharmacist we all have our toothpaste sections. The ingredient panel lists all kinds of compounds, and some of those compounds can cause excess abrasion or even hypersensitivity reactions. Of all the available resources out there not one is more useful than a practicing dentist. One of my friends Dr Rod Messner, who practices in Wisconsin reviewed this newsletter for content. He also pointed out that the RDA numbers are rather proprietary in nature and most manufacturers are not willing to share this information. The RDA scale starts with just a toothbrush equals 4; toothbrush and baking soda=7 and the FDA upper limit is 200. Any number over 150 is considered to be at the "harmful limit." I suggest doing a google search of "RDA toothpastes" and there are several dentist sites with this information. Thanks to Dr. Messner, I will be switching my brand of toothpaste!"

"Check out your toothbrush....might be due for a springtime replacement...I'll take the blue one!"

Four minutes a day we should be grabbing this tool.

Proper brushing twice daily and flossing at bedtime are preventative measures. Next week we can discuss the available toothpastes, so this week we can focus on the toothbrush, which really does all of the work.

Toothbrushes should be soft, to decrease gingival irritation. Soft bristles are best, they can reach tighter spaces, and do less damage to gums. Brush teeth in a circular motion. Floss daily.

REMIND patients to replace their toothbrush about every three months or sooner if the toothbrush bristles show signs of wear. Best to replace toothbrush after any illness. Bristles that are frayed or damaged are ineffective and may harbor harmful bacteria that could increase the risk of periodontal disease. As toothbrushes wear, they lose their effectiveness. Look for the American Dental Association (ADA) seal of approval, which governs sharpness of bristles, bristle retention and other safety parameters.

Yuck! Here are some hygiene tips to consider when caring for your beloved toothbrush:
  • Store your toothbrush in an upright position after each use and allow them to air dry. Storing a moist toothbrush in a closed container promotes microbial growth more so than leaving it exposed to the open air.
  • We all store our toothbrushes on the sink in the bathroom. Toothbrushes do harbor bacteria including fecal coliform bacteria (like E. coli) that can be released into the air when the toilet is flushed or can be spread to the toothbrush when cross contaminated with another bathroom surface.
  • Although probably not necessary, you can disinfect your toothbrush by soaking in Listerine (26.9% alcohol) or hydrogen peroxide 3% solution.

Powered toothbrushes

Both manual and powered toothbrushes are effective at removing plaque. Remember as with manual toothbrushes, to replace the brush head every 3-4 months. Although the powered toothbrushes are more expensive, they might have the following advantages over the manual toothbrush:
  • People who have dexterity problems—like the elderly, people with disabilities, or children
  • Ease of use for patients with dental appliances such as braces
  • A variety of powered toothbrushes that use a different types of head movement (side-to-side, counter oscillation, rotation oscillation, circular, ultrasonic) are available.
  • People brush longer with the powered toothbrush.Most have a two-minute timer to insure brushing duration is adequate.

"We Pharmacists and our Physician Assistants colleagues in the Emergency Department unfortunately see a lot of dental problems. Hardly a day goes by where we are not filling a Clindamycin and Ibuprofen prescription for someone with significant dental decay who was just seen in the ED. Unfortunately neither profession can adequately treat these "mechanical problems" and a trip to the dental office is the only effective resolution.We will spend the next couple of weeks exploring the dental sections in our pharmacies. Prevention of dental problems is truly the key to improving our patients dental health. It all starts with the toothbrush!

The most important rule for toothbrush selection at the Kreckel house is this: I get the blue toothbrush. Mrs. Kreckel is free to buy any color toothbrushes that are on sale, as long as mine is blue!"

February 2017

"Canker sores, what to do when someone pulls down their lip and asks for your advice!"

Canker sores (Aphthous ulcers)

What: Aphthous ulcers are painful, round shallow lesions with a grayish base. Recurrent aphthous stomatitis (RAS) is the most common cause of mouth ulcers. Some patients may have only two to four outbreaks per year, while others may have almost continuous eruptions.

Who: Aphthous ulcers are seen most frequently in childhood and adolescence and decrease in frequency in adulthood. There seems to be a familial tendency. It is not caused by any infectious agent (virus or bacteria).

Why: There seems to be an association between recurrent cases of canker sores and an overactive immune system, so topical immunosuppressant medications (such as topical corticosteroids) are of benefit.
  • Exacerbated by: trauma, hormonal factors, and emotional stress. Avoid trauma to mouth when brushing teeth.Avoid eating “sharp” foods like nacho’s and chips to minimize oral trauma.Cover sharp edges of braces with dental wax.
Over the counter treatment options include:
  • Benzocaine:Zilactin-B as we discussed last week forms a protective film over the lesion, and can be applied every 6 hours. Benzocaine helps decrease the pain, but should be avoided in kids under age 2 because of methemoglobinemia.
  • Peroxyl® rinse (peroxide) to cleanse the sores
  • Deficiency in the “blood building” supplements such as folate (folic acid), vitamin B-6, vitamin B-12 or zinc. Vitamin B-12 sublingual 1000mcg dissolved in the mouth may be effective in treatment/prevention of canker sores. (http://emedicine.medscape.com/article/867080-treatment)
Home remedies include:
  • Applying ice chips directly to the ulcer
  • Rinsing mouth with a baking soda solution: 1 teaspoonful of baking soda to ½ cup of warm water.
  • Dab a small amount of milk of magnesia to the canker sore a few times per day.
If all else fails, Rx treatment of canker sores: Because corticosteroids inhibits cell proliferation and is immunosuppressive, antiproliferative, and anti-inflammatory they are the mainstay for treatment of aphthous ulcers.
  • Dexamethasone elixir 0.5mg/5ml. Rinse and spit out.
  • Triamcinolone dental paste 0.1%
  • Magic Mouthwash: Benadryl/Maalox/lidocaine2% viscous—equal parts
  • Chlorhexidine gluconate mouth rinses reduce the severity and pain of ulceration but do not affect the frequency.
"So we now know that the canker sores are NOT caused by viruses. There seems to be a connection between an "overactive" immune system that causes these to break out. Celiac and Crohn's patients are frequently plagued with canker sores. Patients with frequent complaints should be checked for vitamin deficiencies as well. Recurrent canker sores can be challenging."

Is there any value in OTC cold sore remedies?

"Are our patients throwing away good money on OTC cold sore treatment?..unfortunately the answer is probably "YES"."

Cold sores are a quite common complaint year-round, but seems to become more prevalent this time of the year. Cold sores or herpes labialis are caused by the Herpes simplex virus Type-1 and is abbreviated as HSV-1. Recurrent herpes simplex labialis occurs in 20% - 40% of the US population. It is estimated that 67% of the population are affected by the virus. Although the disease is self-limiting in the immunocompetent, patients seek treatment because of the discomfort and visibility of a recurrent lesion.

The virus: Reactivation of HSV-1 occurs in the trigeminal sensory ganglion. This leads to the occasional breakout of the virus where the site of infection is usually the border of the lips. Patients with oral herpes infection should be informed that HSV-1 can be transmitted through oral sex to their uninfected partner resulting in genital ulcers. 50% of new cases of genital lesions in the developed world are caused by HSV-1


Zilactin® (benzyl alcohol 10%) which is OTC contains hydroxypropyl cellulose which is a bioadhesive that adheres to mucus membranes and may be used to protect lesions from irritants for up to six hours. Remind patients not to peel off the adhesive film. Also, available at Zilactin-B which contains benzocaine 10% is for use inside the mouth to help numb the lesions.

Abreva® contains docosanol needs to be applied five times daily for a maximum of 10 days. Complete treatment resulted in decreased duration of the lesion by only 18 hours.
Mechanism: inhibiting fusion between the herpes virus and human cell plasma membrane. The end result is that the virus can’t enter into the host cells and multiply.

Sunscreens: some patients will experience cold sores when they are exposed to large doses of ultraviolet light. Sunscreens are of great benefit to these patients. Sunscreen should be applied before direct UV exposure.

Emollients/Protectants: white petrolatum, zinc oxide, cocoa butter relieve cracking and dryness. They do nothing to speed up healing. Many OTC products are seen in combination with camphor, thymol and benzocaine. Avoid any products that contain salicylic acid that can further break down the affected skin. Many of these products contain sunscreens as well.

Lysine: dosed as 1000mg one to three times daily may show a decrease of frequency of recurrence and severity of the lesions. Is of minimal value.

What does work: Rx antivirals
I encourage my patients to have on hand (in their medicine cabinet) oral antivirals so they can take at the first sign of tingling (prodromal phase). The oral antivirals are very effective if taken during the prodromal phase. Here are the doses for cold sore prevention.

Drug Name Brand Dispense Instructions
Acyclovir 400mg Zovirax® #20 capsules Dose: Take one capsule five times a day
Famciclovir 500mg Famvir® #3 tablets Dose: Take 3 tablets as a single dose
Valacyclovir 1gm Valtrex® #4 tablets Dose: Take 2 tablets twice daily for one day

"I give my patients a handout with the above chart, and tell them to have their physician or dentist write a prescription for two courses of any of these antivirals. My favorite is Valacyclovir. The patients can begin treatment as soon as they experience prodromal symptoms.

Topical antivirals such as Acyclovir 5% (Zovirax) , Penciclovir 1% cream (Denavir), Acyclovir-5%/Hydrocort-1% (Xerese) must be applied five times daily. They are not as effective as the oral antivirals and cost more than $500 a tube. Do not recommend these products. "

Nasal sprays - three drugs, three different mecanisms of action

Sodium chloride 0.65% in purified water (USP), made isotonic with sodium phosphate/sodium hydroxide, with phenylcarbinol and benzalkonium chloride as preservatives.
  • Use: relief to dry, irritated nasal passages due to colds, allergies, dry air, pollution, smoke, air travel, and use of decongestant/steroidal sprays
  • Patients using saline irrigation show faster resolution of symptoms, less frequent reappearance of rhinitis, and reduced use antihistamines/decongestants.
  • Dosed on an as needed basis. No side effects

CROMOLYN (Nasalcrom)
  • Mechanism: mast cell stabilizer. Mast cells release of histamine and other inflammatory mediators.
  • Dose: one to two sprays three to four times daily. Ages 2 to adult.
  • Adverse effects: minimal if any.
  • Efficacy: less effective than glucocorticoid nasal sprays like fluticasone (Flonase), may be ok for mild allergy.

  • Brief exposure (cat exposure) : 30 minutes before exposure. Efficacy: minutes to a couple of hours.
  • Prolonged exposures (seasonal allergies): four to seven days in advance. Should be used before pollen season.

  • Mechanism: sympathomimetics (alpha adrenergic: vasoconstriction) that act on adrenergic receptors in the nasal mucosa creating vasoconstriction. They shrink swollen mucosa and improve ventilation.
  • Not recommended for kids under 6 years.
  • Dose every 10-12 hours. Maximum of 2 doses per day.
  • Maximum of three to five days to minimize risk of rebound congestion.

Rebound congestion (rhinitis medicamentosa)
  • Cause: “overuse” of topical nasal decongestants, specifically α-adrenoceptor mediated down-regulation and desensitization of response.
  • Presentation: bright red, swollen nasal membranes
  • Treatment: gradually withdraw the nasal decongestant, one nostril at a time.Replace with saline nasal spray until completely withdrawn.Nasal corticosteroids are of great value
  • Oral decongestants, and topical nasal corticosteroids may be of some value. One study showed reversal of rebound congestion with fluticasone.

"We covered corticosteroid nasal sprays last week. This will wrap up our topical nasal section."

Best choice for allergic rhinitis if used correctly!

Topical nasal corticosteroids have emerged as the MOST effective treatment of allergic rhinitis. Glucocorticoid nasal sprays are more effective than oral antihistamines for relief of total nasal symptoms, including blockage, sneezing, discharge, itch and postnasal drip, and. Currently two are available without prescription, with more to make the switch from Rx to OTC.

The Rx product Veramyst (fluticasone furoate) will be making the switch to OTC in February 2017 and will be named Flonase® Sensimist. Although these drugs are extremely effective, and now very inexpensive, proper administration technique is necessary for optimal results. Pharmacist consultation is necessary to achieve patient satisfaction and symptom relief.
  • Mechanism: inhibits the activity of multiple cell types, such as mast cells, basophils, eosinophils, neutrophils, macrophages, lymphocytes, and mediators of the inflammatory response. Decreases capillary leakage and mucosal secretions.
  • Indications: management of nasal symptoms of seasonal and perennial allergic and non-allergic rhinitis.
  • Excellent for relief of pruritus, sneezing, congestion, rhinorrhea.

Warnings/Precautions/Adverse effects
  • Local dryness & irritation.May cause stinging irritation, nosebleeds, sore throat & burning. May cause taste dysfunction.
  • Local infections with Candida have rarely occurred.
  • The growth rate of some children may be slower using these products. It should be used for the shortest amount of time necessary to achieve symptom relief.
  • Adult supervision if used in patients under age 12

Patient counseling points: May feel better in 2 or 3 days, but peak response takes 2-3 weeks. This drug is not to be used “as needed”. It should be used for the entire allergy season.
  • Blow nose first
  • Remove cap
  • Prime bottle (if first use)
  • Shake bottle
  • Tilt head forward and exhale. (“It goes in your nose, look at your toes”)
  • Direct spray toward the ear on the same side. (Use the left hand to spray the right nostril, and the right hand for the left nostril)
  • Place pump into one nostril.Close other nostril with finger.
  • Administer spray in nostril while inhaling slowly and deeply.
  • Do not sneeze or blow the nose for 10-15 minutes after spray administered.

What's available?

Nasacort- Allergy 24 (triamcinolone)
hours first approved 1957. Approved for OTC use in Fall 2013. The liquid vehicle of OTC triamcinolone acetonide nasal spray is alcohol and taste free.
  • Adults and children 12 years of age and older: 2 sprays each nostril while sniffing- once daily.Once improved may decrease to one spray each nostril.
  • Kids 6-12: one spray each nostril. May increase only if needed.
  • Kids 2-6 one spray each nostril daily.Under age-2 don’t use.

Flonase (fluticasone) first available Rx in 1994. Approved for OTC use Summer 2014. First for relief of itchy watery eyes and nasal symptoms. The liquid vehicle of OTC fluticasone propionate contains phenylethyl alcohol.
  • Adults and children 12 years of age and older: 2 sprays each nostril while sniffing- once daily.Once improved may decrease to one spray each nostril.
  • Kids age 4-11: one spray each nostril. Do NOT use in children under age 4.

Flonase Sensimist (fluticasone furoate) will be available soon as an alcohol free and scent free mist.

January 2017

So if a patient needs a humidifer what should I recommend?

Most allergists feel that 30% room humidity is adequate. So, as we discussed last week, a humidity monitor should be purchased before any humidifier is purchased. I did buy one, and much to my surprise, even with all the cooking in our kitchen our winter humidity level is around 28%. Most allergists feel that setting pans of water on the radiators (and change them daily) will provide adequate moisture to a room without soaking carpets, ruining drapes, pictures, and encouraging dust mite growth.

"Cool Mist" These two types of humidifers generally appear to produce the greatest dispersions of both microorganisms and minerals.
  • Ultrasonic, which create a cool mist by means of ultrasonic sound vibrations.
  • Impeller, or "cool mist", which produces a cool mist by means of a high-speed rotating disk.

Two additional types of humidifiers can allow for growth of micro-organisms if they are equipped with a tank that holds standing water, but generally disperse less, if any, of these pollutants into the air. These are:
  • Evaporative: transmits moisture into the air invisibly by using a fan to blow air through a moistened absorbent material, such as a belt, wick, or filter.
  • Steam vaporizer: which create steam by heating water with an electrical heating element of electrodes. "Warm mist" humidifiers are a type of steam vaporizer humidifier in which the steam is cooled before exiting the machine.

Humidifier Care:
  • Change the water in the portable humidifers EVERY day
  • Every 3 days thoroughly scrub out the reservoir. Rinse with Hydrogen peroxide or dilute bleach solution to decrease bacteria and fungi growth (1 part bleach / 9 parts water)
  • Little kids can get "scalded" with the warm steam vaporizers if they get too close. Pharmacists should never recommend a "warm mist" vaporizer especially if there are children in the home. The American Academy of Pediatrics (AAP) recommends the use of a cool mist humidifer. Vaporizers can cause burns if the child gets too close to the steam or accidentally knocks over a device filled with hot water.
  • There is no need to add anything to a warm steam vaporizer. Menthol, camphor (Vicks Vapo-Steam) or benzoin tincture makes the room smell better, but offers no advantage over the increased moisture.These essential oils will ruin a cool mist vaporizer.
  • Only recommend models with an automatic shut-off feature. Should the water reservoir run dry, the device should turn off automatically.
  • Recommend using distilled water in the humidifier. Tap water contains many minerals that can provide a breeding ground for microorganisms inside the humidifier.

"Pharmacists frequently recommend humidifiers for children who are congested or have rhinorrhea. As we discussed in last week’s newsletter excessive humidity may make their allergies worse, especially if they are allergic to dust mites and mold. In this situation, you want to keep humidity levels low. An air conditioner or dehumidifier can help to keep humidity levels low below 50% if possible which is usually needed in the summer.

Since 2001 The World Health Organization (WHO) suggests that neither steam nor cool mist therapy be encouraged in the management of a cough or cold. "

DUST MITES They're everywhere!!!

“Hey doc, what humidifier do you recommend?” We pharmacists get that question a lot especially during this time of year. This column will address “do we even want to recommend a humidifier.”
  • Every homeowner should own a hygrometer that measures temperature and relative humidity. The ideal relative humidity for health and comfort is about 40-50%. A local allergist told me at a presentation, “before you recommend a humidifier, recommend a hygrometer first!”
  • In the winter months, it may have to be lower than 40% relative humidity to avoid condensation on the windows
  • If a parent wants a cool mist humidifier for a child who is congested or has rhinorrhea, keep in mind that it may make their allergies worse, especially if they are allergic to dust mites and mold.
  • Dust mites and mold like high humidity levels, so a humidifier will increase humidity and make allergies worse. Mites contain about 70% to 75% water by weight and must maintain this to reproduce. Their primary source of water for dust mites is ambient water vapor
  • For dust mite control, you want to keep humidity levels low. An air conditioner or dehumidifier can help to keep humidity levels low -below 50% if possible. (30% is adequate)

Meet your friendly dust mite: Dermatophagoides pteronyssinus and D. farinae
  • Adult Mite Lifespan: Up to 3 months; (3 larval stages)
  • Female mites lay about 25 to 50 eggs
  • Mites live in carpet, fabric upholstery, and mattresses.
  • Human skin scale, animal dander and trace nutrients. Mites need to absorb humidity, since they cannot drink water.
  • Dust mite fecal material. Dust mites do not bite, and they are microscopic.
  • Temperature Range: approx. 59°F to 95°F
  • Relative Humidity Range: approx. 55% to 85%

Reducing exposure to dust mites:
  • Use bedding encasements that cover pillows and mattresses with zippered covers, which are impermeable to mites and mite allergens.
  • Wash sheets, pillowcases, and blankets in hot or warm water with detergent or dry in an electric dryer on the hot setting weekly.
  • Use washable, vinyl, or roll-type window covers.
  • Remove clutter, soft toys, and upholstered furniture.Limit stuffed animals to those that can be washed.
  • Where possible, carpets should be removed or replaced with area rugs that can be cleaned/washed.
  • Wash bed linens weekly
  • Avoid down fillings- encase comforters with fine mesh material
  • Reduce humidity level (between 30% and 50% relative humidity per EPR-3)

Excess humidity can also cause:
  • Damage walls, paint, wallpaper, insulation and ceilings
  • Mold growth on household surfaces, which can cause health issues in sensitive individuals
  • Condensation or fog forming on walls or glass surfaces, such as mirrors, pictures or windowpanes.
  • Dampness around the humidifier.
"When I was teaching about dust mite allergens to my class at St. Francis, the girls were "creeped out" when I told them about all of the dust mites that were inhabiting their pillow and mattress. According to Ohio State University , a typical used mattress may have 100,000 to 10 million dust mites inside. Ten percent of the weight of a two-year-old pillow can be composed of dead mites and their droppings. Dust mites are microscopic "garbagemen" that digest all the skin cells that slough off. When you see the "dust" in a sunbeam coming though the window, about 80% is said to be dead skin cells.

Sleep tight tonight, with your newly discovered friends!"

Pseudoephedrine and Phenylephrine

Mechanism: Pseudoephedrine is an Alpha/Beta agonist that directly stimulates alpha-adrenergic receptors of the respiratory mucosa causing vasoconstriction and stimulates beta-adrenergic receptors causing bronchial relaxation. By constricting these swollen vessels in the nose and sinus region, tissue shrinks to allow the normal flow of air and mucus.

Contraindications: breast feeding, bronchitis, closed angle glaucoma, hypertension (uncontrolled), coronary artery disease, MAOI therapy, urinary retention (BPH), peptic ulcer disease. Pseudoephedrine is classified as Pregnancy Category: C

Illicit manufacturing of methamphetamine: Conversion of Pseudoephedrine (or ephedrine) involves hydrogenation of the hydroxyl group on the ephedrine or pseudoephedrine molecule.

Combat Meth Act of 2005
  • Any products containing oral pseudoephedrine, require a signature, and valid photo ID to purchase.
  • The law limits such purchases to 3.6 grams base in any one day and 9 grams base in any 30 day period. Mail order maximum per month is 7.5grams.
  • 3.6gm Pseudoephedrine HCl146 x 30mg tablets
  • 9.0gm= Pseudoephedrine HCl 366 x 30mg tablets

Nexafed® (pseudoephedrine HCl) Mechanism: significantly disrupts extraction and conversion of PSE to meth. Impede® technology’s inactive ingredients and unique polymer matrix form a thick gel that blocks the extraction. In the direct conversion (one-pot) method, Nexafed significantly disrupts the process, so that the meth yield is unsuitable. source: Nexafed.com

Pseudoephredine with Hypertension
  • The effect in patients with controlled hypertension demonstrated an systolic blood pressure increase of similar magnitude (1.20 mm Hg). (probably OK if well controlled)
  • Higher doses and immediate-release preparations were associated with greater BP increases. Women showed less effect on BP or HR. Shorter duration of use was associated with greater increases in SBP and DBP. PSE exerts an indirect effect causing release of norepinephrine from storage sites which may contribute to its decongestant efficacy.
  • Increased heart rate around 3 beats per minute.
  • Arch Intern Med. 2005;165:1686-1694.

What about Phenylephrine?
  • Phenylephrine (PE): direct alpha-adrenergic
  • PE half life: 2.5hrs. PSE half life: 9-16hr
  • Bickerman study showed no more effective than placebo at 10mg dose
  • Source: Pharmacist Letter: 240205

"Any pharmacist working over the past 10 years remembers the legislation enacted on March 9, 2006, to regulate, among other things, retail over-the-counter sales of ephedrine and pseudoephedrine, because of their use in the manufacture of methamphetamine. Pseudoephedrine and ephedrine were moved behind pharmacy counter (BTC); positive identification was needed to purchase these products. Shortly thereafter phenylephrine became abundant out front as the nasal decongestant that didn’t require such restrictions. It has been over 10 years, and not a week goes by where some “meth lab” isn’t discovered."

Lots of guaifenesin in the cough and cold aisle... is it worth recommending??

Guaifenesin- lets look at the evidence...
Expectorants work by increasing mucus hydration to a volume that is more easily expectorated by coughing. Guaifenesin (glyceryl guaiacolate) whose parent compound comes from the guaiac tree was first approved by the FDA in 1952. In 2002 the FDA approved only one extended release formula now made by Reckitt Benckiser to be marketed (Mucinex). Guaifenesin is also found frequently in cough syrups (Robitussin) and most often found in combination with dextromethorphan, antihistamines, decongestants and acetaminophen.

Mechanism: Guaifenesin stimulates the gastric nerve and promotes increased in airway secretions via the vagal nerve. Guaifenesin also has emetic properties, and can cause GI upset and vomiting, especially in high doses. Other proposed mechanisms of action may include a reduction in mucus viscosity or an enhancement of the mucocilliary clearance.

Guaifenesin for COPD: Excess mucus in COPD should focus on the treatment three major symptoms. First, underlying airways obstruction can be treated with both short and long acting beta agonists. Secondly, airway inflammation can be treated with inhaled corticosteroids or oral steroids if necessary. Cigarette smoking cessation is a must to decrease mucus production, as well as the occasional use of methylxanthines (Theophylline) or phosphodiesterase-4 inhibitors (Daliresp). Guaifenesin seems to lack clinical efficacy.

The big picture: Guaifenesin has not been shown to work as an expectorant, as it does not increase the volume of sputum cleared, or as a mucolytic, as it does not alter thickness or stickiness of the sputum. I find that it does cause a fair amount of stomach upset and I usually just recommend adequate hydration.

Water: adequate hydration is important for all patients, especially COPD patients, but over hydration is of no benefit.
SSKI: (Saturated Solution of Potassium Iodide) may decrease the viscosity of mucus. Use limited due to side effects:
  • metallic taste
  • rash
  • hyperkalemia (especially if kidney dysfunction)
  • hypothyroidism if used more than six weeks

"When we journey through our cough aisle we see a lot of single entity and combinations of products containing guaifenesin. Guaifenesin is the only FDA approved expectorant, and the efficacy for this drug is sketchy at best. The FDA is pushing drug companies to do further studies on the OTC products, and I doubt whether this product will stand up if it is intensely researched. In my past thirty-five years, I’ve seen other expectorants fall by the wayside, such as potassium iodide, and iodinated glycerol (remember Organidin?)"

December 2016


BENZONATATE was first approved in 1958 as Tessalon® perles and is available in 100mg and 200mg capsules. Dosed three times daily for a maximum of 600mg per day
MECHANISM OF ACTION: acts peripherally by anesthetizing the stretch receptors located in the respiratory passages, lungs and pleura by dampening their activity. It begins to work within 15 to 20 minutes and its effect lasts for 3 to 8 hours. Has NO inhibitory effect on the respiratory center in recommended dosages.

SEVERE hypersensitivity reactions (bronchospasm, laryngospasm and cardiovascular collapse) have been reported when chewing the capsule instead of swallowing it whole! Choking can occur if capsule is bitten or chewed. I counsel my patients to swallow it whole with a cold glass of water. May cause sedation, headache, dizziness, constipation, nausea and GI upset.
The Medical Letter back in February 2010 reported that of ingestion in children under 10 years of age may be fatal. One or two capsules in a 2-year-old or younger has caused fatalities. May cause seizures, cardiac arrhythmias and death. Remind patients to keep out of reach of small children.


Codeine ( 3-methylmorphine) is the “gold standard” for treating cough; all other anti-tussives are measured against codeine for effectiveness. The dose is 10-20mg every 4-6 hours which is ½ of analgesic dose. Some physicians will prescribe 30 to 60mg per dose due to lack of efficacy of the lower dose. Codeine is available OTC in 28 states, however Pennsylvania is not one of them.

AVAILABLE AS: Guaifenesin/codeine; Promethazine/codeine; Promethazine VC/codeine each contains 10mg of codeine per teaspoonful. Clinicians should not prescribe more than 4-6 ounces at a time to prevent the potential of overdose. Pharmacists should offer to provide a measuring device and encourage patients to use it.

MECHANISM: centrally mediated suppression of cough threshold. Binds to opiate receptors in the cough center. Codeine is a prodrug that is converted to morphine by the hepatic enzyme CYP2D6. However, genetic variability causes some patients to metabolize it too slowly, and others to metabolize it too quickly. Some patients, particularly children and individuals with obstructive sleep apnea, are "ultrarapid metabolizers," who experience sometimes fatal respiratory depression after taking therapeutic doses of the medication, because they convert the codeine to morphine too rapidly.

Warnings: An FDA advisory committee recommended against the use of codeine for treatment of cough in children in December 2015. In September 2016, the American Academy of Pediatrics recommended against using codeine in children either for pain or as an antitussive. Is best not to prescribe codeine for any patient under age 18.
HYDROCODONE: Hydrocodone gets metabolized to an active metabolite hydromorphone (Dilaudid) by CYP2D6 as well. Ultra-rapid metabolizers would expect to see an increase effect and increase in toxicities with hydrocodone.
AVAILABLE AS Hydromet® (hydrocodone/homatropine 5/1.5 per 5ml)) and Tussionex® (hydrocodone/chlorpheniramine 10/8 per 5ml) Again, clinicians should be cautious when prescribing appropriate quantities. When prescribing Tussionex, keep in mind that the 4oz bottle has 24 doses (12-day supply) which most feel is an excessive duration.

Pharmacists should provide a measuring device, and encourage its use.

"We dispense a lot of cough suppressants this time of year, when the OTC preps are ineffective. We have two entirely different cough suppressants available by prescription only. Both are swallowed, but one works centrally and the other locally in the lungs. Remember that cough is only a symptom of an underlying problem, that can range from benign and self-resolving, to chronic or even life threatening, depending on the condition of the patient and comorbid illness. Effective treatment always addresses the underlying cause of the cough."

We know how often this time of year our patients head to the cough and cold section to pick up a preparation with dextromethorphan to control their cough. The history of dextromethorphan (DXM) shows that abuse has always been a problem.

HISTORY: The FDA approved DXM in 1958 and during the 1960s and 1970s, dextromethorphan became available in an over-the-counter tablet form by the brand name Romilar. In 1975, Romilar was taken off the shelves because of frequent misuse, and was replaced by cough syrup to cut down on abuse. Manufacturers began introducing refined DXM products (Robitussin-DM, Vicks-44, ) that were designed to limit recreational use by creating an unpleasant taste if consumed in large quantities. It wasn’t long we remember that the drug companies started marketing a higher concentration, and more pleasant tasting preparation (Delsym). Keep in mind when the recommended dose is taken, DXM has few adverse side effects, and has a long history of safety and effectiveness. Nine states (California, New York, Virginia, Arizona, Washington, Louisiana, Kentucky, Tennessee and New Jersey) now have legislation requiring a patient to be age 18 and show ID before purchasing DXM products.

  • Most common abused: Coricidin HBP (DM-30mg + Chlorpheneramine-4mg), often referred to as “CC” or “triple C” or “Skittles”.Robitussin products can be used, called “Robo-tripping” or “Robo-shakes”.May lead to elevated body temperature and death.
  • Symptoms following ingestion of high doses (five to ten times the normal therapeutic dose) include euphoria, an altered sense of time, paranoia, and disorientation. In addition, tactile, visual, and auditory hallucinations may occur.
  • The effects seen with dextromethorphan abuse are like those seen after phencyclidine (PCP) use, another agent which blocks NMDA receptors.DXM is sometimes referred to as “Poor man’s PCP”.

  • Increased perceptual awareness
  • Altered time perception
  • Feelings of “floating” or dissociation of the body
  • Visual disturbances
  • Tactile, auditory, visual hallucinations
  • Paranoia
  • Disorientation and lack of coordination
  • Slurred speech
  • Impaired judgment and mental performance

Below is a chart I prepared to illustrate the doses needed to cause all the levels of DXM intoxication. As you can see, just one bottle of Delsym (89ml) can get an abuser to dissociative sedation. I am much more concerned about the Delsym and the Coricidin products, because as we all know excess guaifenesin causes nausea and most likely vomiting.

Plateau Dose (mg) Behavior effects Robitussin DM Delsym Coricidin HBP
1st 100-200 Mild stimulation 50-100ml 17-34ml 3-7 tabs
2nd 200-400 Euphoria hallucinations 100-200ml 34-68ml 7-14
3rd 300-600 Distorted visual perception. Loss of coordination 150-300ml 50-100ml 10-20
4th 500-1500 Dissociative sedation 250-750ml 83- 250ml 17-50

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