November 2018

Out in the vitamin aisle are a LOT of questions, and our patients are counting on our expertise!

Last week we covered the regulation of vitamins, this week as we continue “Vitamin Boot camp” we will do an overview of these amazing compounds that sit out front on the shelves of our stores. The first question we will answer is “what does a vitamin do?” Vitamins in general work in the body by 3 different mechanisms:

Who takes them:
  1. Coenzymes: Most water soluble vitamins are co¬enzymes. Remember in biology we learned that an enzyme is a catalyst for biochemical reactions. Co-enzymes are non-protein compounds that are necessary for the functioning of an enzyme.
  2. Antioxidants (Vitamin A, C & E)- are enzymes or other organic substances, that are capable of counteracting the damaging effects of oxidation in animal tissue. They protect tissues from damage by “free radicals”
  3. Hormones (Vitamin A, D, K are hormones) A hormone by definition is internally secreted compound, that affect the functions of specifically receptive organs or tissues when transported to them by the body fluids.
The next question becomes; how much should I recommend for a patient?
  1. RDA: (Recommended Daily Allowance) is the level of intake of essential nutrients that are considered adequate to meet the known nutritional needs of practically all healthy patients.
  2. The DRI (Dietary Reference Intake) also include other reference values such as the Estimated Average Requirement (EAR) , and Adequate Intake (AI). The RDA, EAR, and AI all define nutritional intake adequacy. These are all for healthy individuals.
  3. The Dietary Reference Intakes (DRI) also includes the tolerable upper intake level of vitamins (UL). The UL is defined as the highest level of intake of a nutrient that will not pose risk of adverse health effects to most individuals in the general population.
Vitamin deficiencies… not so much in America, in the USA will see syndromes of vitamin excess rather than deficiency, especially with vitamins A, D, B-6. Vitamin deficiency is usually insidious in nature, with rather non-specific symptoms. Therefore, a physical exam is rarely helpful in diagnosis. Most characteristic physical findings are seen late in the course of the syndrome. For example, swelling of the tongue (glossitis) and dry scaling and cracking of the lips (cheilosis) are seen with deficiencies in many of the “B” vitamins. These abnormalities suggest a nutritional deficiency, but NOT for a specific nutrient.

The following chart is the MDR and dietary sources for the vitamins.

VITAMIN MDR-adults Dietary Sources
Thiamine (vitamin B1) 1.2mg/day Peas, pork, legumes, whole grains
Riboflavin (vitamin B2) 1.1-1.3mg/day Liver, eggs, dark greens, whole grains
Niacin (vitamin B3) 14-16mg/day Liver, fish, poultry, meat, whole grains
Pantothenic acid (vitamin B5) 5mg/day liver, kidney, meats, egg yolk, whole grains, and legumes.
Pyridoxine (vitamin B6) 1.3mg/day Pork, meats, whole grains, greens.
Biotin (vitamin B7) 30mg/day liver, kidney, egg yolk, milk, most fresh vegetables, grains
Folic acid (vitamin B9) 400mcg/day Liver, meats, fish, whole grains, legumes citrus
Cobalamin (vitamin B12) 2.4mcg/day meats, liver, kidney, fish, eggs, milk and milk products, oysters, shellfish
Ascorbic acid (vitamin C) 75-90mg/day Plant foods; citrus is highest
Vitamin-A 3000iu (men)
2300iu (women)
fish liver oils, egg yolks, green leafy & yellow vegetables
Vitamin-D 600iu fish liver oils, egg yolk, fortified milk, synthesized in skin exposed to UV light
Vitamin-E 22.5iu Vegetable oils, wheat germ, leafy vegetables, egg yolk, margarine, legumes
Vitamin K 120mcg leafy vegetables, vegetable oils, liver, & synthesis by intestinal flora


Casimir Funk (1884-1967), a Polish biochemist who is credited with formulating the concept of vital amines, which today we call “vitamins”, and matching them to their deficiency disorders. In 1912 Dr. Funk wrote a book postulating that the diseases of beriberi, scurvy, pellagra, and rickets could be prevented with “vitamines”. He realized that poor nutrition, specifically white rice, lead to disease states which could be manage with appropriate nutrition, such as brown rice.

He is considered the Godfather of the vitamin movement. We have sections in our drug stores that are there due to the efforts of this little recognized researcher, who never received the Nobel prize. Dr Funk elucidated the causes, and therefore the management of four disease states, and was never appropriately honored for his efforts.

Have a great day on the bench!!

Hey doc? Which one of these vitamins should I take??

Vitamins--does everyone need them?

Who takes them:
  • More than one-half of Americans take multiple vitamins either single entity or multivitamins
  • 70% of adults over the age of 65 report taking a vitamin or mineral supplement.
  • Total spent is $12 billion per year.
  • About one in four young children takes an MVM.
  • Adolescents are least likely to take them.
Who regulates them:
The FDA loosely regulates dietary supplements, under the Dietary Supplement Health and Education Act of 1994 (DSHEA ’94).
In June 2007, FDA established dietary supplement "current Good Manufacturing Practice" (cGMP) regulations requiring that manufacturers evaluate their products through testing identity, purity, strength, and composition. Dietary supplementary are: vitamins, minerals, other botanicals, amino acids, enzymes, organ tissues, glandular, and metabolites. These dietary supplements fall under the category of "foods" and not "drugs".

They do NOT need FDA approval before marketing nor do they need to be registered with the FDA before being produced or sold. The manufacturer does not have to prove that the supplement is effective, unlike for drugs. The manufacturer can say that the product addresses a nutrient deficiency, supports health, or reduces the risk of developing a health problem, if that is true. If the manufacturer does make a claim, it must be followed by the statement “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.”

FDA regulates the label content and health claims. Claims that can be used on food and dietary supplement labels fall into three categories: health claims, nutrient content claims, and structure/function claims. Here are some examples of permissible supplement claims:
  • “Supports a healthy immune system”
  • “Builds strong bones”
  • “Maintains bowel regularity”
  • “Decreases blood platelet stickiness”
  • “A good source of Vitamin-C”
Notice no disease state is mentioned, such as “prevents osteoporosis”, or “prevents stroke”. Burden of proof is on the FDA to prove that a supplement is Unsafe, before that product can be removed from the market. It is the responsibility of the manufacturer to ensure product safety and product efficacy.

Reporting by patients and manufacturers:
Starting December 22, 2007, any serious adverse events reported to a dietary supplement manufacturer must be reported to FDA within 15 days of the manufacturer receiving the adverse event report. Adverse drug events can also be reported directly to the FDA via the MedWatch program. https://www.fda.gov/Safety/MedWatch/default.htm

For the next couple of months, we will journey through our vitamin aisle. We are expected to have a high level of expertise with vitamins. Unfortunately, our level of training with respect to over the counter therapies taught in pharmacy school is minimal. I’ll be providing you with the therapeutic uses of each vitamins, as well as uses for vitamins as therapeutic agents. We will also focus on vitamin depletion caused by the prescription products we commonly dispense. I’m not a “vitamin nut” I believe appropriately recommended vitamins are of great value to our patients. Next week we can discuss “at risk” populations and therapeutic dosing of vitamins and supplements.

Good resource to read:
https://www.hopkinsmedicine.org/health/healthy_aging/healthy_body/is-there-really-any-benefit-to-multivitamins

Have a great day on the bench!!

October 2018

SERMS- very specific targets in the woman's body.

As we move through the month of October, we are discussing women’s health issues. The first three units we discussed breast cancer. Last week we discussed raloxifene and tamoxifen, which are SERMS (selective estrogen receptor modifiers). Estrogen receptors are present throughout the body. SERMs act as agonists or antagonists on various estrogen tissue receptors, including breast, bone, endometrium, hypothalamus and coagulation system. We will discuss in detail the three other SERMS, not associated with breast cancer prevention.
  • Nolvadex® (tamoxifen): (BREAST CANCER PREVENTION)is considered first line therapy of estrogen receptor positive breast cancer. Both for pre-menopausal and post-menopausal women. (No effect on vaginal tissue)
  • Evista® (raloxifene): (BREAST CANCER PREVENTION/OSTEOPOROSIS) is for reduction in risk of invasive breast cancer in postmenopausal women with osteoporosis OR if at high risk for invasive breast cancer. (No effect on vaginal tissue)
Osphena (ospemifene) (DYSPAREUNIA) 60mg tablets
Dose: take (1) tablet daily
Mechanism: estrogen agonist on vaginal tissue. Minimal effect in uterine tissue and serves as an estrogen antagonist in breast tissue. Ospemifene may have a positive effect on bone tissue. Up to 45% of postmenopausal women can experience vulvovaginal atrophy due to estrogen loss.
Indications: approved by the FDA to treat moderate to severe dyspareunia (painful intercourse), due to estrogen deficiency of menopause.
Watch for: May make hot flashes worse. Scan for CYP4503A4 interactions
NOTES: expect about 45% of postmenopausal women to experience vulvovaginal atrophy (VVA) due to declining estrogen levels. Symptoms of VVA may include dryness, itching, irritation, and dyspareunia. Diagnosis of VVA is based on symptoms as well as various laboratory findings. Vaginal lubrication decreases and vaginal pH increases. One of the best indicators of VVA is a pH of 5 or higher. On a cellular level, increases in the number of parabasal cells are seen as well as a decrease in the superficial cell layer.
USE: being promoted for its estrogenic effect on vaginal symptoms.

Duavee®: (conjugated estrogens/ bazedoxifene) (MENOPAUSAL SYMPTOMS)
Use: moderate to severe hot flashes and preventing osteoporosis. Estrogen is used for menopausal symptoms & osteoporosis. Bazedoxifene (SERM) is added to inhibit estrogen's endometrial effects (instead a progestin). Must have intact uterus, because SERM reduces risk of endometrial hyperplasia.
BEST USE: women who want to use estrogen for menopausal symptoms but need an alternative to a progestin.

Clomifene (Clomid):
(FERTILITY) is a nonsteroidal estrogen receptor modulator (SERM). It inhibits the negative feedback response on the hypothalamus by bonding to estrogen receptors. This causes an increase in release of FSH (follicle stimulating hormone) and LH (luteinizing hormone). This promotes follicular growth and maturation. Enhancement of the natural hypothalmic-pituitary-ovarian axis is the primary mechanism of action.
Dosage: 50mg daily beginning day 5 of the cycle.

The first SERM available was (Clomid (Clomifene) which was first approved in 1967. Clomid was the first ever drug to "enhance" fertility. It increases the odds of pregnancy from 1.3% to 5.5% per cycle.

Nolvadex (tamoxifen) was released in 1977 for prevention of breast cancer. It wasn't until 1997 when another SERM became available, Evista (Raloxifene) for osteoporosis. Both Duavee (bazedoxifene) and Osphena (ospemifene) were released in 2013.

Have a great day on the bench!!

Breast Cancer Prevention medications available in the community pharmacy

For the month of October our focus is on breast cancer its diagnosis and prevention. This week we discuss our role as community pharmacists in the treatment with drug therapy. Here is a brief review of the two main classes of drug therapy, along with counseling points for those therapies.

Role of Anti-Estrogens: (SELECTIVE ESTROGEN RECEPTOR MODULATORS)

For breast cancer that is estrogen receptor positive, ANTI-Estrogens are the mainstay of treatment. Antiestrogens bind to estrogen receptors and prevent receptor mediated gene transcription, and are therefore used to block the effect of estrogen on the end target. 70-75% of Breast cancer tumors are estrogen receptor positive.

Nolvadex® (tamoxifen): available as tablets 10 & 20mg is an estrogen antagonist, structurally related to the synthetic estrogen diethylstilbestrol (DES) and is considered first line therapy of estrogen receptor positive breast cancer. Tamoxifen is the only “anti-estrogen” that can be used for BOTH pre-menopausal and post-menopausal women.

Side effects include: hot flashes, nausea, skin rash, vaginal bleeding, hypercalcemia, increased bone pain if tumor has metastasized to the bone. Thrombotic events (PE and DVT) cataract formation, uterine cancer.

Dosage: Breast cancer patients: 20-40mg daily (divide dose if more than 20mg) High risk women: use 20mg daily for 5 years.

Evista® (raloxifene) Available as tablets: 60mg
Dosage: 60mg once daily
Indications: Reduction in risk of invasive breast cancer in postmenopausal women with Osteoporosis OR if at high risk for invasive breast cancer.

Adverse effects: Venous thromboembolic potential. (PE, DVT, stroke). May cause hot flashes, muscle aches & pains.

Mechanism: binds to estrogen receptors. Binding results in activating some and blocking other pathways. Effects on bone similar to estrogen therapy. However, it acts as an antagonist on receptors in the breast and endometrium.

Efficacy: seems to be less effective than Tamoxifen for breast cancer treatment.

ROLE of Aromatase Inhibitors for prevention of Breast Cancer
In postmenopausal women and women whose ovaries have been removed, the main source of estrogen is derived from the peripheral conversion of androstenedione produced by the adrenal gland into the female hormones estrone and estradiol. This conversion requires the aromatase enzyme, which also catalyzes the conversion of androgens to estrogens in the ovary of pre-menopausal women and in extra-glandular tissue, including the breast itself, in post-menopausal women. Aromatase inhibitors effectively reduce the levels of circulating estrogens. Indicated only for post-menopausal women.

Side effects: hot flashes, infrequent vaginal bleeding, do not predispose to endometrial cancer. All these drugs are available generically and are rather inexpensive therapies.
  • Arimidex® (anastrozole) available as 1mg tablets dosed once daily.
  • Femara® (letrozole) available as 2.5mg tables dosed once daily.
  • Aromasin® (exemestane) available as 25mg tablets dosed once daily after a meal
Counseling points for breast cancer during drug treament:
  • Drug therapy is used following “adjuvant therapy” which consists of surgery & radiation to “clean up” cancer cells that may have spread beyond breast
  • Goal of hormonal therapy is block estrogen’s growth promoting effect. Continue anti-estrogen therapy for 5 years—patient adherence is paramount!
  • Tamoxifen and aromatase inhibitors are first line. Remember that only tamoxifen can be used in pre-menopausal women.
  • Hot flashes are most common side effect.
Aromatase inhibitors cause less hot flashes that Tamoxifen. SSRI/SNRI’s may be of benefit: Effexor® (venlafaxine) & Celexa® (citalopram) are best choices.

Avoid Prozac® (fluoxetine), Cymbalta® (duloxetine), Wellbutrin® (bupropion) & especially Paxil® (paroxetine) because they decrease formation of active metabolite of tamoxifen, decreasing efficacy of tamoxifen.
  • Teach patients symptoms of venous thromboembolism (tamoxifen side effect):
    • Shortness of breath
    • Chest pains worsen with breathing or coughing.
    • Coughing up blood
    • Pain, tenderness, swelling, warmth, redness in one leg
  • Aromatase inhibitors may cause significant bone loss. Osteoporosis and fractures have been reported. Treat accordingly- drugs like Alendronate (Fosamax®) are a good choice.
We pharmacists should always be preaching adherence for all medications, be it for an antibiotic for a urinary tract infection, or for Type-2 diabetes medications.Adherence for these drugs for the prevention of breast cancer are critical indeed. According to a study women on tamoxifen with an adherence rate of less than 80% (determined by prescription records) had an increased risk of mortality at a median duration of 2.4 years. Adherence makes a huge difference for the breast cancer prevention with tamoxifen or the aromatase inhibitors.

Missing just 6 doses a month can be cause a significant rise in mortality. Recommend any of the adherence apps on a patients phone, set an alarm, and recommend using a plastic pill box to improve adherence. I also recommend enrolling any of these breast cancer patients in your pharmacy's medication synchronization program.

Have a great day on the bench!!

More than wearing a pink ribbon... share this information with your patients (guys too!)

Prevention--Mammograms save lives The newest recommendations from the American Cancer Society recommends all women should begin having yearly mammograms at age 45 and can change to having mammograms every other year beginning at age 55. Women should talk to their health professional if they have any symptoms or changes in their breasts, or if breast cancer runs in their family. Some patients as young as 40 years of age can begin annual mammograms.

Breast Self-Exams- a smaller role in decection
Breast self-exam (BSE) is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away. Benefits of breast exam is minimal whether performed by a health care provider or the patient. Research has shown that BSE plays a small role in finding breast cancer compared with finding a breast lump by chance or simply being aware of what is normal for each woman. Some women feel very comfortable doing BSE regularly (usually monthly after their period) which involves a systematic step-by-step approach to examining the look and feel of one’s breasts. Other women are more comfortable simply feeling their breasts in a less systematic approach, such as while showering or getting dressed or doing an occasional thorough exam. Sometimes, women are so concerned about “doing it right” that they become stressed over the technique. Doing BSE regularly is one way for women to know how their breasts normally look and feel and to notice any changes. The goal, with or without BSE, is to report any breast changes to a doctor or nurse right away. Bottom line: The American Cancer Society does not recommend clinical breast examination (CBE) for breast cancer screening among average-risk women at any age. (source JAMA)

Common Types of Breast Cancer
Ductal carcinoma. The most common kind of breast cancer. It begins in the cells that line the milk ducts in the breast, also called the lining of the breast ducts. Ductal carcinoma in situ (DCIS). The abnormal cancer cells are only in the lining of the milk ducts and have not spread to other tissues in the breast. Has a higher risk of subsequent invasive cancer. Invasive ductal carcinoma. The abnormal cancer cells break through the ducts and spread into other parts of the breast tissue. Invasive cancer cells can also spread to other parts of the body. Lobular carcinoma. In this kind of breast cancer, the cancer cells begin in the lobes, or lobules, of the breast. Lobules are the glands that make milk. Lobular carcinoma in situ (LCIS). The cancer cells are found only in the breast lobules. Lobular carcinoma in situ, or LCIS, does not spread to other tissues. Invasive lobular carcinoma. Cancer cells spread from the lobules to the breast tissues that are close by. These invasive cancer cells can also spread to other parts of the body

Reducing Risk of Breast Cancer
  • Keep a healthy weight and exercise regularly (at least four hours a week).
  • Get enough sleep.
  • Don’t drink alcohol, or limit alcoholic drinks to no more than one per day.
  • Avoid exposure to chemicals that are carcinogenic
  • Reduce exposure to radiation during medical tests like mammograms, X-rays, CT scans, and PET scans.
  • Discuss with prescriber about hormone replacement therapy or oral contraceptives and the risks associated with therapy. Remember for estrogen replacement… lowest possible dose for shortest period of time.
  • Breastfeeding may be protective
What about the guys? (source: American Cancer Society)
  • About 2,550 new cases of invasive breast cancer will be diagnosed in men in 2018
  • Treatment: mastectomy is indicated but follow-up with radiation or chemotherapy is not as definitive as it is for women. Most breast cancer in men is treated the same as in women.
  • About 480 men will die from breast cancer in 2018
  • Overall odds of a male getting breast cancer is 1:833
  • Overall odds of a woman getting breast cancer are 1:8
  • White males are 1/100th as likely to die of breast cancer compared to white women, while black men are 1/70th as likely as black women to die from breast cancer.
Breast cancer treatment including surgery, radiation and chemotherapy have indeed become more specialized in the 37 years I've been practicing. At one time it was the realm of the general surgeon, while today there are surgeons who specialize in breast cancer surgery and reconstruction.

Even the rural hospital in the small town of Tyrone where I live has its own breast cancer treatment center, with outstanding surgeons and radiologists. There are plenty of resources for our female (and male!) population in detection, prevention and treatment of breast cancers. It is our job as health care professionals to see that our patients are encouraged to use these available resources.

Have a great day on the bench!!

We need to do more for our female patients than just wear a pink ribbon!

Breast Cancer Basics

After skin cancer, breast cancer is most common cancer in women, causing more deaths than any malignancy other than lung cancer. The lifetime risk of developing breast cancer in women is 1 in 8 (13%). There was a 7% drop in breast cancer incidence in 2003, probably due to drop in Hormone Replacement Therapy due to publication of the Women’s Health Initiative (WHI) study in 2002. This study established that HRT increases risk of breast cancer.

Breast cancer warning signs and symptoms
  • Breast lumps: Single painless mass that feels solid. Breast pain is not usually a symptom of malignancy, but it can occur.
  • Skin changes: areas of thickening, swelling, depression, dimpling, redness, irritation or unusual appearance on the breast or underarm.
  • Veins on surface of one breast have become more prominent.
  • Nipple discharge: bloody or watery from one nipple only is cause for most concern
  • Nipple changes: turning inward, rash, changes in nipple skin texture.
  • Breast cancer develops in the breast tissue, usually in the milk ducts (ductal carcinoma) or glands (lobular carcinoma)
Factors that increase risk for breast cancer Risk factors for a 2-5 fold increase:
  • Age: 78% of women with invasive breast cancer are 50 or older
  • Inherited genetic mutations: Genes BRCA-1, BRCA-2 have a 60-85% chance of developing breast cancer.
  • Personal history: previous breast biopsy result of atypical hyperplasia increases risk 4 to 5 times
  • Women with breast cancer in one breast have a 3-4 times greater risk of developing a new cancer in the other breast, or the same breast..
  • High dose radiation the chest (Hodgkin’s disease treatment)
  • Family history: 1 first degree relative (mom, sister, and daughter) doubles risk. First degree relatives is 5 times the risk
Risk Factors for a 1.1 to 2 fold increase
  • Race (white women are more susceptible)
  • Use of estrogen
Current or recent use of HRT- risk returns to normal in 5 years after stopping hormone replacement.

Use of oral contraceptives: no increase risk if stopped greater than 10 years ago Prolonged estrogen stimulation
  • Early menstruation (less than age 12)
  • Late menopause (over age 55)
  • Pregnancy: no children, or first pregnancy after age 30.
  • Lifestyle: alcohol consumption: greater than 3 drinks per day.
  • Obesity
Breast cancer receptors:
  1. Estrogen: About 80% of breast cancers are estrogen receptor positive. Cancers grow in response to estrogen. Known as ER positive.
  2. Progesterone: About 65% of the estrogen receptor positive receptor positive breast cancers are progesterone receptor positive. Cancer grows in response to progesterone. Known as PR positive.
  3. Human epidermal growth factor receptor-2: (HER2) – is a protein which promotes the growth of cancer cells. Is not inherited from a parent. It accounts for about 20% of all breast cancers,and are the most rapid growing and aggressive cancers.
Any of these three cancers are treatable, with specific therapy directed at the receptor to help destroy the rapid growing cells.

And now for the really bad news:
Triple-Negative Breast Cancer
Between 10% and 20% of breast cancers are known as “triple negative” because they don’t have estrogen and progesterone receptors and don’t express the HER2 protein. Many breast cancers associated with the gene BRCA1 are triple negative.
  • There are currently no “targeted therapies”, so treatment includes surgery either lumpectomy or mastectomy, followed by chemotherapy or radiation. Chemotherapy is considered to be the “backbone” for TNBC therapy.
  • TNBC is more commonly diagnosed in women younger than 40 years compared with hormone-positive breast cancer. (twice the incidence in some studies versus hormone receptor positive)
  • African American women have a higher incidence than non-African American women.
  • Pre-menopausal women have a higher incidence than that of post-menopausal women
  • One study demonstrated that breast feeding women were at a lower risk for TNBC, however this study has not been duplicated.
  • Prognosis is poorer than women with other receptor positive cancers.
With October being breast cancer awareness month, let's focus on our female patients, and provide them with sound, clinical information concerning breast cancer. Breast cancer awareness should be more than just using those "Breast Cancer Awareness" prescription bags, or wearing a pink ribbon.

Let's pledge to provide our female patients with good information about breast cancer, and encourage them to get their mammograms. As pharmacists we can also do our part to encourage adherence to the medications prescribed for the treatment of the hormone positive breast cancers.

Have a great day on the bench!!

September 2018

Is it time to get out the DDT? What to do when exposed to bedbug infestation!

Bedbugs---what to do when they show up!

Treatment of a bitten patient:
  • Treatment might not be necessary, as the bites usually resolve without any intervention.
  • Oral antihistamines to relieve itching
  • Prednisone, at doses of 40-60mg per day seem to be of little value.
  • Topical corticosteroids seem to be effective Use mild potency such as triamcinolone 0.1% cream on the bites.
  • May have to treat secondary infections.
Prevention:
  • using a hair dryer on end seams of mattress will “chase” the bed bugs out of hiding for detection.
  • Check out hotel/motel rooms and look for bedbugs or their feces before climbing into bed. Be sure to check out the mattress cords and crevices in box springs.
  • Placement of luggage on a luggage rack or away from the bed or upholstered furniture while traveling. Some sources recommend placing luggage in the bathtub, as bedbugs can’t crawl up that slippery surface.
  • Placement of worn garments in a sealed plastic bag to minimize bedbug attraction to worn clothing.
  • It’s no bargain mattress even if the bedbugs are free! Examine carefully garage sales or resale shops (especially bedding items), for bedbugs or bedbug feces prior to bringing them inside the home
  • Rid Home Lice, Bedbug and Dust mite Spray: contains Permethrin 0.5% - might be of benefit to spray areas that are not directly slept on.
Eradication of Bedbugs:
Insecticides and heat treatment are the best options. Combinations of insecticides are generally used to avoid failure due to resistance. Long-lasting residual insecticides may be necessary for heavy infestations. Heat treatment involves use of equipment to heat rooms to a lethal temperature. All stages of bedbugs can be killed at 50°C (122°F) Cold treatment can be successful in the home environment if the freezer is set to 0- degrees F. You must leave the items in the freezer at that temperature for four days

Your Friendly Exterminator says:
(January 2011) We are using Pyrethrins; Also using heat—over 120 degrees will kill bedbugs. Bedbugs are attracted to carbon dioxide (CO2). We have CO2 machines that attract bedbugs, and then get trapped in plastic traps. Note: The EPA says Some bed bug populations have become resistant to pyrethrins and pyrethroids

(August 2018):
use Alpine WSG (Dinotefuran) to treat. This is a broad spectrum insecticide. The exterminator described a huge problem in Altoona Housing projects. He spends more time in the housing projects combating infestation than in hotels. Hotels deal immediately with the problem, and keep things cleaned up afterward. Such is not the case with the residents in the housing projects. Alpine WSG (dinotefuran) is a neonicotinoids are synthetic forms of nicotine and act on the nicotinic receptors of the nervous system by causing nerves to fire continually until they fail. Because neonicotinoids use this different mechanism of action, bed bugs that are resistant to other pesticides will remain susceptible to the neonicotinoid. (source: EPA)

Permethrin spray that we use as a mosquito and tick repellent is designed for clothing and gear and lasts up to 6 weeks. We spray our hiking and gardening clothes every 6 weeks to keep the deer ticks off. Repellent should be applied outdoors and before clothing is worn; hang clothing, spray and let dry two hours (four hours in humid conditions).

We also spray our suit cases with permethrin 0.5% before packing for a trip. Make sure they are closed. Package reads “for clothing and gear” , so it is appropriate to use on our suitcases. Seems like a good idea to keep these critters from hi-jacking a ride back to Tyrone, PA ! That hotel room you just checked into is only as clean as the last guests who left!

Have a great day on the bench!!

Wanna sleep tight? Make sure these little guys don't hitch a ride from the hotel to your bedroom! View this email in your browser

BEDBUG BUG BASICS

BEDBUGS (Cimex lectularius) are wingless insects about the size of an apple seed that feed on warm blooded animals. Bedbugs are nocturnal and hide during the day. Bedbugs are associated with unsanitary conditions but may be found in the cleanest of homes, hotels, or other buildings and have occurred in all social and economic classes. Infestations most often occur where there is a high turnover of occupants, such as hotels, motels, cruise ships, dormitories, apartment complexes, and shelters.

The Care and feeding of bedbugs:
  • Bedbugs feed on a blood meal for about 10 minutes, injecting an anticoagulant. Females need a blood meal at least every 14 days to produce eggs. Females lay one to three eggs per day, and up to 500 eggs in a lifetime. Males also need a blood meal every 14 days to mate.
  • Unlike fleas or ticks, they do not live on their food source. They hide near their host, and bite during the night.
  • Adult bedbugs can live without feeding for 2 or 3 months which makes getting rid of them such a challenge. (Not like lice that are dead in 10 days without a human host)
  • Presentation: The bite reaction usually presents as a red bump (wheal) ranging in size from a few millimeters to 1 centimeter and does not usually have a red puncture mark in the middle. The bites can occur in lines or clusters of three or four.
Where to look:
Around the bed, they can be found near the piping, seams and tags of the mattress and box spring, and in cracks on the bed frame and headboard. If the room is heavily infested, you may find bed bugs:
  • In the seams of chairs and couches, between cushions, in the folds of curtains.
  • In drawer joints.
  • In electrical receptacles and appliances.
  • Under loose wall paper and wall hangings.
  • At the junction where the wall and the ceiling meet.
  • Even in the head of a screw.
The role of DDT

DDT’s history parallels closely the presence of bedbugs. DDT (dichloro-diphenyl-trichloroethane) was developed as the first of the modern synthetic insecticides in the 1940s. Initially used effectively to combat malaria, typhus, and the other insect-borne human diseases among both military and civilian populations. DDT was also effective for insect control in crop and livestock production, institutions, homes, and gardens. DDT was banned in 1972, was considered to be the first victory for the environmentalist movement.

DDT is still present in the environment
  • will accumulate in fatty tissues, and
  • can travel long distances in the upper atmosphere
  • DDT is one of 12 pesticides recommended by the World Health Organization for indoor residual spray programs.
Because of DDT use in the 1940’s, bedbugs were virtually eliminated. After the year 2001, they have made a resurgence, as the DDT has “worked out” of the environment.

Next week we will discuss Treatment and Prevention of Bedbugs.



I, Peter Kreckel of sound mind and body, bequeath this box of DDT to...

When my father-in-law passed away back in 2012, I helped my wife Denise and her sisters clean out his garage. The garage was full of "treasures" like jars of nails, nuts, bolts, tools and even a bumper off of a Corvair! I left with the grand prize that I have pictured here, a box of unopened DDT, that back in the day retailed for $1.99 for a one pound box!

I keep it in my garage, and my wife insists if a bedbug ever finds its way from a hotel into our house, she will be more than prepared to bring it to it's demise! I'm sure it will remain unopened, and when the day comes that Gretchen and her siblings clean out my garage, this family heirloom will move to the next generation!

Good night, sleep tight and thanks to the DDT in my garage, the bedbugs won't bite!!

Have a great day on the bench!!

This should be the last column that leaves you scratching!

SCABIES

Caused by the mite: Sarcoptes scabei . Mostly affects the interdigital & popliteal folds, axillary folds, umbilicus & scrotum. Spread by direct, prolonged, skin-to-skin contact with a person who has scabies. Transmitted through direct contact, and frequently sexual contact. Can survive off a human host 24-36 hours under normal conditions of heat and humidity. Increased humidity prolongs survival off the host.

Clinical presentation:
  • Severe itching and an inability to sleep.
  • Excoriations in the interdigital web spaces, wrists, buttocks, elbows groin & scalp.
Diagnosis:
  • Look for burrows made by the mite, and skin scrapings. Short irregular mark, 2-3 cm long and the width of a hair.
  • The diagnosis of scabies is confirmed by detecting scabies mites, eggs, or feces with microscopic examination.
Permethrin 5% (Elimite) DRUG of CHOICE available in 60 gm tubes

Warnings/Precautions / Adverse Effects
  • Pregnancy category-B
  • Not recommended if nursing.
  • Can be used in children over age 2 months.
  • Caution with asthmatics.
Patient Education
  • Thoroughly massage cream from the head to the soles of the feet. Rarely do scabies affect the heads of adults. They may infest the infants or geriatrics around the hairline.
  • Remove cream by washing off in bathtub or shower after 8 to 14 hours.
  • One application is generally curative. (30gm is sufficient for 1 adult)
  • Patients may experience itching after treatment, rarely a sign of treatment failure. Living mites after 14 days would indicate that re-treatment is necessary
Crotamiton lotion 10% and Crotamiton cream 10%
10% (Eurax®); Crotan® approved by the FDA for treatment of scabies, but due to frequent treatment failures is seldom used.

Ivermectin (Stromectol®) may be a safe and effective treatment for scabies, although not FDA-approved for scabies. Consider for patients who have failed treatment with or who cannot tolerate FDA-approved topical medications for the treatment of scabies. If used for classic scabies, two doses of oral ivermectin (200µg/kg/dose) should be taken with food, each approximately one to two weeks apart.

A patient weighing 75kg (165lbs) would take 15,000mcg or 15 mg. Dose would be five tablets as a single dose.
(SHORTCUT: weight in pounds divided by 33 equals the number of 3mg tablets of ivermectin)

Might be a good option for nursing homes, where head to toe treatment of each patient is impractical. After successful treatment, patients may continue to itch for several weeks.
  • A steroidal cream like Triamcinolone 0,1% cream will help resolve the dermatitis.
  • Short course of corticosteroids, like prednisone will also decrease itching.
  • Oral antihistamines like diphenhydramine (Benadryl) or hydroxyzine (Atarax) might be of some benefit to relieve itching.
  • If no relief of itching, recheck for reinfestation.
Worst of the worst: Crusted scabies or “Norwegian scabies” — occurs only in people with a weakened immune system (such as HIV infection, lymphoma, or other conditions). This condition may also affect older adults or those with Down syndrome. Ivermectin or permethrin 5% are used to treat this condition. Lesions appear as large, crusty red patches or bumps on the skin.

Scabies is another one of those dreaded skin conditions, that after reading this article will leave you scratching. A patient with ordinary scabies may have an average of 12 mites; however, those with crusted scabies (Norwegian scabies) may have thousands of mites. The infestation occurs at all ages, but particularly in children. It is a common public health problem in poor communities and is widespread in many underdeveloped countries.

It can spend a maximum of only 2 weeks without a human host to live upon and when doing so hides out in clothing, bed linens and sleeping bags. Called the “seven year itch” because it used to wax and wane in about seven year epidemic cycles, the little critters are no longer sticking to that schedule and have become more difficult and resistant to former treatments.

I love the shortcut for dosing the ivermectin. I can see that being very helpful if you had a large population to dose such as in a nursing home or large family.

Vince, one of the excellent Physician Assistants I work with at Dr. Gates office, tells me he is a scabies expert because of his time serving in the U.S Army. When we see that scabies thrive in close quarters and can live in sleeping bags without a human host for 14 days, our servicemen are definitely at risk.

Have a great day on the bench!!

Those sneaky little head lice are becoming resistant to over-the- counter products!

Prescription Products for Pediculosis

OVIDE® (malathion)
Mechanism: is an organophosphate cholinesterase inhibitor. Widely used as a lawn and garden insecticide. Has been on, and off the market for the past several years. Has “high” Ovicidal activity. This seems to be the “go to” product when concern of resistance to permethrins. Malathion was first registered as an insecticide in 1956. Became prescription product (Ovide®) in 1982.

Warnings/Precautions /Adverse Effects
  • Flammable!! 78% alcohol. Do not expose to flame or hairdryers or electric curlers.
  • Don’t use if under age 6. May use down to 24 months if resistance is a problem. (AAP) The safety and effectiveness of malathion lotion has not been established by well controlled trials in children less than 6 years old. Malathion is contraindicated in children younger than 2 years of age.
  • Unpleasant odor, due to sulfhydryl groups
Application Information:
  1. Avoid any open flames.
  2. Apply to dry hair, especially back of head and behind ears.
  3. Wash hands after application.
  4. Allow hair to air dry (no hairdryers!)
  5. After 8-12 hours wash hair with non-medicated shampoo
  6. Reapply in 7-9 days only if required.
ULESFIA® (benzyl alcohol lotion)

Mechanism: does not have ovicidal activity. It inhibits lice from closing their respiratory spiracles which allows the product to penetrate lice, causing them to asphyxiate. Can be used on age 6 months and older.

Application Information: As with the other topical agents, two applications of Ulesfia, separated by at least seven days are necessary to eradicate lice. May be a good choice for parents concerned with “pediculicides” NOTE: because it suffocates the lice (a physical action), less likely to develop resistance to this product. I tell my students it is like an ant becoming resistant to a sledge hammer!

NATROBA® (spinosad)

One treatment is usually needed with Natroba ® Repeat in 7 days only if live lice are seen again.

Mechanism: Spinosad causes neuronal excitation and involuntary muscle contractions in lice. After periods of excitation, the lice become paralyzed and die. Use in patients at least 6 months of age.

Dosage: Apply to dry hair. Leave on 10 minutes. Rinse thoroughly. Combing not required.

STROMECTOL (ivermectin) 3mg tablets (usual dose 200mcg/kg)

Mechanism:
Ivermectin binds to glutamate chloride channels in nerve and muscle cells of lice. This leads to an increased permeability to chloride ions resulting in paralysis and death. Based on this mechanism, it would appear that ivermectin is not ovicidal.

Dosage: used for certain parasitic infections (off-label for scabies or lice) use 400mcg/kg. a 15kg child would take about 2 tablets. Repeat dose in 7 days to eradicate any newly hatched lice.

SKLICE (Ivermectin topical)
Can be used in patients 6 months of age and older.
Completely coat hair. Leave on 10 minutes, then rinse well. No combing needed

Lindane
old brand name was Kwell®, now only as a generic. Second-line treatment.

Mechanism: neurotoxic to head lice and their eggs.
Indications: has fallen into disfavor because of potential toxicities, and its efficacy is LESS than other agents available. 45-70% ovicidal

Warnings/Precautions /Adverse Effects/Drug Interactions
  • Patient MUST weigh at least 110 pounds.
  • Do not prescribe more than 2 oz. of product
  • Do not retreat.
  • Black box warning: neurological toxicity. Has caused seizures and deaths.
  • Avoid using in infants, children, and elderly. Must weigh over 110lbs.
  • Pregnancy category-C
  • Caution if using with drugs that lower seizure threshold (theophylline, Wellbutrin, quinolones, antidepressants, meperidine, methocarbamol)
Trimethoprim-sulfamethoxazole —
Combination therapy with topical permethrin (Nix) and oral trimethoprim-sulfamethoxazole (Bactrim) may be more effective than treatment with permethrin alone. The mechanism of action of trimethoprim-sulfamethoxazole may involve the death of symbiotic bacteria in the louse gut that produce B vitamins necessary for louse survival. This combo is 92% effective compared with only 72% efficacy with permethrin alone. By itself Trimeth/sulfa was shown to be 78% effective. With risks of Stevens-John Syndrome, and allergic reactions it is best to reserve this combo for resistant cases.

Head Lice Chart

Brand name Generic Name Minimum treatment age Ovicidal? (kills nits?) Major warnings/precautions
Nix crème rinse Permethrin 1% 2 months of age and older Good activity resistance is becoming a problem
RID/ A-200 Pyrethrins/pipronyl butoxide Over 2 years of age NO Retreat in 7-9 days. Avoid if allergic to chrysanthemums or ragweed.
Ovide Malathion 0.5% Over 6 years of age.
Contraindicated if under age-2 yrs
Partially ovicidal Flammable. No hair dryers
Ulesfia Benzyl alcohol 5% Over 6 months of age NO, it suffocates live lice Retreat in 7 days
Sklice Ivermectin lotion 0.5% Over 6 months of age Prevents newly hatched nymphs from surviving. Single treatment only. No combing needed.
Natroba Spinosad 0.9% Over 6 months of age Kills live lice and unhatched eggs Nit combing not required
Lindane (Kwell) Lindane Must weigh over 110 lbs About 50% ovicidal Second line. Potent neurotoxin. (AVOID!)


Last week we covered the OTC options for Head Lice Control. Although safe and effective, resistance is becoming a problem and sometimes the need to bring out the “big guns” to take care of those pesky bugs.

Keep in mind though, a lot of treatment failures are due to inadequate environmental controls and are not so much as resistance as re-infestation. Other causes might be improper use of the products dispensed be it not completely covering the hair or not leaving the product on long enough.


I was also amazed to learn about using trimethoprim/sulfamethoxazole (Bactrim) for head lice. I have not seen it used as a treatment for head lice, but after reading the literature, it might be an option as resistance keeps popping up. When DDT was banned in the 70's there was a scramble for insecticides to replace that very potent bug killer. My favorite extreme example of drug pricing going crazy is malathion. Malathion is frequently used as an insecticide around the home and garden, in a 50% strength, while the prescription strength is 1/100% as whet we can buy in a hardware store! Of course we cant recommend the lawn/garden product for human use, but this yet another example of how ridiculous the drug prices can be!!

Have a great day on the bench!!


Same ingredient, but when dispensed as a prescription the price goes up exponentially.
ORTHO MALATHION IS NOT FOR HUMAN USE!!!

August 2018

We can treat those pesky head lice without a prescription!

The first line therapy for head lice is over-the-counter...

Permethrin 1% Crème rinse (NIX®):
Made from a natural chrysanthemum extract, pyrethrins are neurotoxic to lice. Permethrin is a synthetic pyrethroid. Was first approved in 1986 by prescription and in 1990 was moved to over the counter. Is available as a 1% crème rinse, which is considered to be first line treatment for head lice. Mechanism: acts on the parasites nerve cell membrane. Resulting in paralysis of the pest. Remains on hair shaft for 14 days, despite normal shampooing. Can be used prophylactically, in “epidemics” where over 25% of the population (family, daycare, or classroom) is affected. Is 70-80% ovicidal. We are seeing an increase of resistance to permethrin. May be used for a child as young as 2 months.

Directions for Permethrin creme rinse:
  1. Wash hair first, with regular shampoo.
  2. Towel dry briskly
  3. Apply a sufficient amount of permethrin crème rinse to saturate hair and scalp (especially problem areas)
  4. Let on hair for NO longer than 10 minutes.
  5. Rinse with water
  6. May reapply in 7 days if necessary. One application is generally curative. However, Permethrin’s adherence to the hair shaft can be affected by conditioners and silicone-based additives present in almost all currently available shampoos. This may impair efficacy of the crème rinse. Many experts routinely advise re-treatment on day-9.
Piperonyl Butoxide (4%), Pyrethrum Extract (Equivalent to 0.33% Pyrethrins) (Rid®

Brand: RID® and other generics are available over the counter
Pyrethrins are naturally occurring pyrethroid extracts from the chrysanthemum flower. Pyrethrins are safe and effective when used as directed. Pyrethrins can only kill live lice, not unhatched eggs (nits). Piperonyl Butoxide/pyrethrin Lice Killing Shampoo is designed to be used on DAY ONE and then again 7 to 10 days later, but not before. To apply the shampoo, follow the directions on the package, including:
  1. Protect child's eyes—Use towels to protect child's eyes from treatment and prevent clothes from getting wet.
  2. Apply Piperonyl Butoxide/pyrethrin Lice Killing Shampoo—Apply thoroughly to DRY HAIR or other affected area. Wetting the hair dilutes the treatment making it less effective.
  3. Let set for 10 minutes—first apply behind the ears and to the back of the neck. Lice can crawl up and down the shaft of the hair very quickly, so it is important to apply the treatment from the roots to the ends of the hair. Allow product to remain on the hair (or other affected area) for 10 minutes, but no longer.
  4. PRECAUTION: A second treatment is recommended 9 to 10 days after the first treatment to kill any newly hatched lice before they can produce new eggs. Pyrethrins generally should not be used by persons who are allergic to chrysanthemums or ragweed. Piperonyl Butoxide/pyrethrin is approved for use on children 2 years of age and older.
For all lice killing shampoos: All topical pediculicides should be rinsed from the hair over a sink rather than in the shower or bath to limit skin exposure and with warm rather than hot water to minimize absorption attributable to vasodilation. Removal of nits immediately after treatment with a pediculicide is not necessary to prevent spread, because only live lice cause an infestation. Individuals may want to remove nits for aesthetic reasons or to decrease diagnostic confusion. Because none of the pediculicides are 100% ovicidal, manual removal of nits (especially the ones within ½ inch of the scalp) after treatment with any product is recommended by some.

RID LICE CONTROL SPRAY (permethrin 0.5%)
Contains permethrin 0.5% (just like the tick repellant for clothing). Spray only those garments and parts of bedding, including mattresses and furniture that cannot be either laundered or dry cleaned. Most agree that this treatment is no more effective than a thorough vacuuming with a Shop-vac. Some sources recommend against using these insecticides at all. Viable nits are unlikely to incubate and hatch at room temperatures which are cooler than a human host; if they did, the nymphs would need to find a source of blood for feeding within hours of hatching. Next week we will discuss the prescription treatment of head lice infestations, and I’ll provide a summary treatment chart.

Last week we covered the topic of head lice, and patient consultation points. This week's discussion focuses on the OTC recommendations we can use for the treatment of head lice. In this week's column are the directions, and counseling points to share with those “slightly” upset caregivers.

Probably our first step is to always reassure the very upset parent, then provide all of the counseling points to insure a successful treatment. Be sure to share last week's column with those parents who seem to be full of misinformation.

Help educate parents and schools that there's no medical reason to keep kids out of school after treatment. Explain that remaining nits or itching doesn't indicate treatment failure, only live lice do.

Have a great day on the bench!!

School opens soon--- time to "brush up" on our lice treatments!

SEPTEMBER IS NATIONAL HEADLICE PREVENTION MONTH!!

With school around the corner, one of the biggest concerns parents have is if their child brings home some unwanted friends, those being of the six-legged variety… head lice! This week we will cover the basics of head lice and next week we can cover the pharmacological treatment.

PEDICULOSIS (LICE): Pediculosis is a skin infection caused by blood sucking lice. They are small flat wingless insects with stubby antennae and 3 pairs of legs that end in sharp curved claws.

There are 3 major types of lice:
  • Head Lice : Pediculus humanus capitis
  • Body Lice : Pediculus humanus corporis
  • Pubic Lice: Pthirus pubis (note: different species than above)
Life cycles of the human louse:
  • All lice need human warmth to survive.
  • Head and pubic lice spend their entire life cycle on the skin of human host.
  • Head & pubic lice deposit their eggs (known as nits) on hair strands, about 1/4th of an inch from the skin. Each louse develops from eggs (nits) that incubate 1 week. When the eggs hatch the nymphs appear the eggs are small and gray white.
  • Each louse survives about 1 month as a mature adult.
  • The female head louse can produce 3-6 eggs per day. Head lice nits can survive 10 days off a body.
  • Nits are easier to find than the live adults. Check around the back of the ears, and the nape of the neck (warmest parts of the body). Nits are cemented to hair shaft, unlike dandruff that can be brushed away.
Non-Pharmacological treatment of lice:
  • Change clothing daily
  • All household contacts should be inspected and treat if necessary
  • Bed linens and clothes should be washed in hottest water (130degrees or hotter), and dried on heated air cycle for at least 20 minutes to kill both the lice and nits. Dry cleaning also kills head lice and nits. Only items that have been in contact with the head of the infested person in the 48 hours before treatment should be considered for cleaning.
  • Wash hairbrushes, combs, toys in hot water (130degrees) for at least 10 minutes.
  • Stuffed animals, pillows and articles that can’t be laundered. Stuff into large trash bag, seal the bag, and hold for 2 weeks.
  • All household items, carpets, chairs & couches should be thoroughly vacuumed. OTC sprays such as A-200 or R&C spray are no more effective than vacuuming
HEAD LICE MYTHS are numerous! The following FACTS should reassure and inform patients and parents!
  • No significant difference in incidence between various socioeconomic classes or races.
  • Hygiene & hair length are NOT contributing factors.
  • Head lice do not fly or jump. They can crawl about 3 feet.
  • Head lice do NOT carry other disease. (Body lice can)
  • Head lice cannot be contracted from pets.
  • Head does NOT have to be shaved to get rid of the lice.
  • Washing head with brown soap is not effective.
  • Head lice are not related to ticks
  • Hair does NOT fall out because of infestation
  • Head lice can occur at any time of the year.
HEAD LICE TRUTHS:
  • Females are more susceptible to head lice infestations.
  • White children are more susceptible that black children in the United States
  • Pruritus occurs as an allergic reaction to lice saliva injected during feeding
No Nit Policy…. NO WAY!!!
From the CDC website---Here’s why “no-nit” policies should be discontinued” Both the American Academy of Pediatrics (AAP) and the National Association of School Nurses (NASN) are in favor of stopping the common practice of “no-nit” policies for the following reasons:
  • Many nits are more than ¼ inch from the scalp. Such nits are usually not viable and very unlikely to hatch to become crawling lice, or may in fact be empty shells, also known as ‘casings’.
  • Nits are cemented to hair shafts and are very unlikely to be transferred successfully to other people.
  • The burden of unnecessary absenteeism to the students, families and communities far outweighs the risks associated with head lice.
  • Misdiagnosis of nits is very common during nit checks conducted by nonmedical personnel.
As we approach the end of August the school buildings that have been quiet for nearly three months are coming back to life. In Central Pennsylvania where we live, the sports page, full of football stories is the harbinger to the first day of school. Kids are getting their backpacks ready, and the first day of school of outfits are hanging in the closet.

The kids are excited, and the parents are looking forward to the first day as well. However one facet of the beginning of school is the return of the six legged critters, head lice.

Nothing upsets and frustrates parents more than when their kids bring home these unwanted inhabitants of the kids hair! I made sure that the generic permethrin creme rinse is stacked up in the front shelves of the store. I sure it wont be there for long!

In the next two weeks we will cover the over the counter lice treatments, followed by the prescription treatments for pediculosis capitis.

Have a great day on the bench!! (you can stop scratching now!)

You'll never flush your toilet again without thinking about this newsletter!

Steatorrhea and Pancreatic Enzymes

Why is fat content of the stool most important:
Healthy people, excrete less than 6 grams of fat per day even if intake is increased to 100 to 125 g of fat/day. Most patients experiencing steatorrhea excrete more than 20 gram of fat per day in their stool. The pancreas normally responds with between 700,000 and 1,000,000 lipase units (USP) per meal.

The activity of the lipase in patients with EPI (exocrine pancreatic insufficiency) is generally 10% of that of healthy individuals. Since all three enzymes (amylase, protease and lipase) are excreted parallel, lipase is used to determine the appropriate dose of pancreatic enzyme supplements.

Absorption: Of all the macronutrients (fat, carbohydrates, and protein), the absorption process of fat is the most complex and tends to be the most sensitive to interference from disease processes.

Calories: Fat is the most calorically dense macronutrient and, therefore, its malabsorption is a critical factor in the weight loss that often accompanies malabsorptive disorders. Protein and carbohydrates contain 4 kcal per gram, while fat contains 9 kcal per gram.

Patients should be followed up in two weeks to assess and titrate PERT (pancreatic enzyme replacement therapy) dose if needed. The dosage should be individualized and adjusted based on:
  • Clinical symptoms
  • Degree of steatorrhea present
  • Fat content of the diet
As unpleasant as this may sound patients need to report the frequency and consistency of their stools, along with the following symptoms:

Clinical Symptom tracker
  • Frequency of diarrhea or loose stoolst
  • Bloating
  • Excessive gas
  • Abdominal pain
  • Rush to bathroom during the night
Stool appearance indicating steatorrhea:
  • Stool color- pale yellow
  • Foul smelling stool
  • Stool floats on top of water, rather than sinking
  • Hard to flush stool
  • Greasy appearance
  • Droplets of oil in your toilet
Degree of steatorrhea present
  • Foul smelling stools (we are aware than no one’s stools smell good, but have your patients report on foul smelling stools)
  • Do their stools float on the top of the water in the toilet bowl?
Fat content of the diet:
Restriction of the fat content to 20gm per day is recommended. If this is unsuccessful, pancreatic enzymes need to be taken. Remember though that fat is an important macronutrient. Medium chain triglycerides (MCTs) can be supplemented to provide extra calories in patients with weight loss and a poor response to diet and pancreatic enzyme therapy

Adherence Of course, before we make any adjustments to therapy, we need to ask the patient about adherence and measure their understanding about the pancreatic enzymes.
  • Remind the patient that PERT should be taken with meals and snacks to aid in digestion
  • Confirm that the total daily dose of PERT is divided among approximately 3 meals and 2 to 3 snacks a day
  • Ensure the patient understands that half of the prescribed enzyme dose for an individualized full meal should be taken with each snack
Self-Care Strategies:
  • Vitamin supplementation, including fat-soluble vitamins A, D, E, and K
  • A nutritionally well-balanced diety
  • Abstaining from alcohol
  • Smoking cessation
Follow up care:
  • After 12 months, 61% of PERT patients are still on their starting dose
  • 67% of patients are under dosed on their PERT
Most of us did it today, and if not, will be doing it tomorrow. Yet most of us feel very uncomfortable discussing our bowel movements let alone listening to someone else’s vivid description of theirs.

As unpleasant as these discussions are, stool consistency is about the only gauge our patients have to assist with appropriate dosing of pancreatic enzymes.

Most of us cringe when we head out to our laxative section, where we often get excruciating descriptions of patient’s bowel movements. When we are monitoring the efficacy of pancreatic enzyme replacement therapy, such descriptions are necessary for clinicians to gauge the success of the therapy.

I'd recommend discussing the contents of this column with all of your patients within the two weeks suggested after a new start. For pharmacists, at the first refill it would be worth discussing specifically adherence, as well as stool appearance. Hey, we're accustomed to hearing such descriptions anyway!

I remember one of my first lower GI consults, after I was recently licensed in 1981. A rough old gent walked into the store and asked me for a “physic” after asking him what he meant, as I’ve never heard that term before. He said “listen buddy I can’t s----” , using the four letter work my Mom would wash our mouths out with soap if she caught us saying that!

The available pancreatic enzymes: Creon® (Abbvie), Zenpep® (Allergan), Pancreaze® (Janssen), Viokace® (Allergan), and Pertzye® (Digestive Care) are currently the only FDA-approved PEPs that are marketed in the United States. They have excellent websites, that have savings programs for our patients. The sales representatives are a wealth of information as well.

Have a great day on the bench!!