Clinician's Corner

March 2017

"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.

TREATMENT

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

OVER THE COUNTER PRODUCTS

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

NASAL SALINE (Ocean):
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.

Administration:
  • 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.

OXYMETAZOLINE (Afrin)
  • 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.

TYPES OF HUMIDIFIERS
"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

CAUTION with Rx ANTI-TUSSIVES

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.

WARNINGS/ PRECAUTIONS/ ADVERSE EFFECTS:
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.

OPIOID DERIVATIVES
(CODEINE & HYDROCODONE)

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.

DXM ABUSE:
  • 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”.

EFFECTS of EXCESSIVE DXM INTAKE:
  • 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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