Archive for the 'Medications' Category

FDA Announces “Bad Ad Program”

May 13, 2010

The FDA announced yesterday a new program called the “Bad Ad Program” designed to help health care providers detect and report misleading drug advertisements.  When I read about the new program it immediately brought to mind the various antihistamine advertisements touting how a particular drug works against outdoor and indoor allergens.  The ads basically imply, without specifically saying, that one antihistamine works for all types of allergies whereas another might only work for indoor allergies and another for only outdoor allergies.  I have had many patients ask me if a particular drug that seemed to be working for pollen allergy would also work for indoor allergies such as cat or dust mite allergy. 

The bottom line is histamine is a mediator that is responsible for many of the symptoms of allergies.  If a person is allergic to an allergen and has allergen antibodies (IgE antibodies) circulating in their system directed against a particular allergen, histamine is released by cells in response to the allergen.  Antihistamine medications act against this histamine release regardless of the allergen that is causing the problem.   Antihistamines work for histamine release caused by a food allergy, medication allergy, pollen allergy, dust mite allergy or pet allergy. 

It is completely misleading for a pharmaceutical company to create an ad highlighting the fact that their antihistamine works against indoor and outdoor allergens, since all antihistamines work against indoor and outdoor allergens.  Now, you may ask, how is it that one company can include this in their ad and another can not.  Well, that is actually the FDA’s fault.  The FDA approves each medication for a specific indication.  If the drug company does efficacy studies on an antihistamine using outdoor and indoor allergens, the FDA will approve the medication for both.  If the drug company’s efficacy study for a particular antihistamine only involves pollen, the FDA approves the drug specifically as only being indicated for seasonal pollen allergies (or outdoor allergies) and not indoor allergies.  This does not mean the medication does not work for indoor allergies, and the FDA should know that.  The problem is, drug companies are only allowed to include in their ads information pertaining to the specific FDA approved indication of the medication.   

Note: The content of this blog is for informational purposes only and is not meant as specific medical advice for a specific person.   If you have a medical problem, please contact your doctor.

Can’t I Just Get A Shot Before The Season To Prevent These Allergies?

April 13, 2010

Every once in a while I have a patient who has heard of someone who received one shot and was fine the entire allergy season.  Invariably the story involves an older relative who used to get a shot just before the pollen season and swore it helped for the entire season.  The only medication that could possibly work in that way is a long acting injectable steroid.

The problem is, long acting injectable steroids are associated with way too many potential side effects to warrant using them in this way and for this purpose.  First of all it should be pointed out that these medications stay in your system and provide broad-based anti-inflammatory activity for about three weeks.  Do you really want to be injected with a drug with lots of potential side effects that could stay in your system for three weeks?  The more important potential side effects include: 1)increase in blood pressure, 2)suppression of the natural immune response of the body to infection, 3)suppression of the adrenal gland and 4)alteration in mood ranging from irritability to emotional lability to depression.

I never give injections of long acting steroids to patients with seasonal pollen allergy.   There are many good medications available with excellent side effect profiles that control symptoms in most patients.  Those who have particularly bad symptoms or whose symptoms do not respond to a combination of medications usually do benefits from shots, but not the single shot of a long acting steroid, but the series of shots commonly known as allergy shots.

“Doctor, Do You Believe In The Flu Vaccine?”

January 26, 2010

Each fall when the flu vaccine becomes available I am asked, on a fairly regular basis, “Doctor, do you believe in the flu vaccine?”  Although I am used to being asked that question, I always find it somewhat strange.  I know the person asking the question is really asking me whether or not I think they should get the flu vaccine, or whether or not I think the flu vaccine is effective, or whether or not I think the side effect profile of the vaccine is too high.  But, invariably, they ask if I “believe” in the vaccine.  Nobody would ever ask if I “believe” in the flu, since science has established that the flu exists and that people can get very sick from it.   Not “believing” in the flu would be tantamount to not “believing” that HIV causes AIDS.  It is a matter of scientific fact and not belief (although there are still people out there who actually don’t believe that HIV causes AIDS).  Likewise, it is not really a matter of belief as to whether or not there is a vaccine that can protect against the flu.  It exists, and it is available.

However, the question is being asked and it does have importance since it underscores a strange bias that exists in a segment of the community toward vaccines.  It is a bias that comes from a vocal and hyped “belief” that vaccines can cause all sorts of medical problems, from autism to actually giving people the diseases they are meant to prevent.    It is a bias that comes from the “belief” that an immune system that is bombarded on a daily basis with all sorts of microbes and antigens, somehow can’t deal with being exposed to a few specific antigens in the form of vaccines, even if this targeted exposure is meant to result in a specific protective immune response.   In the age of the internet, these “beliefs” are given credibility in the form of blogs and websites.  On-line, almost everything looks authoritative.  And so, there can be scientific evidence that autism is not linked to vaccinations, and yet, the question will continually be posed on-line and in the lay press.  Pediatricians deal with this issue on an almost daily basis.   Belief systems are important.  I just wish that when it came to science, facts would always trump beliefs.

There is no doubt in my mind that immunizations would be high up on any credible list of the most significant medical advances in the history of mankind.  Their importance is irrefutable.   So, the next time you have a question about the effectiveness of a vaccine or about potential side effects, ask about those things directly.   If you don’t really understand why it is important for you or your child to receive a specific vaccine you should ask about it.   If you are concerned about taking a vaccine that has just been approved, you need to have a conversation with your doctor about that.   If you are unclear as to what the difference is between a live attenuated viral vaccine and and a killed viral vaccine, please ask.  Those are good questions and they are worthy of real discussion.  With the answers you will be able to decide, with the help of your doctor, what is right for you.

Nasal Saline Irrigation

January 25, 2010

Nasal irrigation is an effective way to improve sinus drainage, promote nasal mucosal ciliary function, decrease nasal mucosal swelling and clear the nasal passages of bacteria and allergens.  Saline nasal irrigation can decrease symptoms of chronic sinusitis and reduce the use of medications.  It is an ancient personal hygiene practice used for centuries in parts of Asia and the Middle East.   Before starting nasal irrigation on a daily basis, please see my January 7, 2010 blog entry with some new interesting information.

Traditionally, nasal irrigation is done using a small vessel called a neti pot.  Neti pots can be purchased in select health food stores and through yoga institutes.  Two on-line sources through which you can buy a traditional neti pot that I recommend are: www.sinucleanse.com and www.himalayaninstitute.org.  Although I recommend these two sources for purchase of the neti pot, I do not specifically endorse the various solutions they may also have available to use with the neti pot. 

Instructions: The most important aspect of an effective nasal wash is holding your head in the proper position. Lean over the sink so you are looking directly into the basin and rotate your head to the side so that one nostril is directly above the other. The forehead should remain slightly higher than the chin.  If the forehead is not higher than the chin the saline solution will flow into the frontal sinuses (sinuses above the eyes) and this can cause a headache.  If the forehead is too much higher than the chin, the saline will drain into your mouth.  If you rotate your head too much, the saline may drain into your eustachian tube which will cause you to feel like your ear is a little clogged. 

Gently insert the spout into the upper nostril so that it forms a comfortable seal. Keep your mouth open and raise the handle of the neti pot so that the solution enters the upper nostril and drains out through the lower.  You should be able to comfortably breathe through your mouth during the wash.  You should rinse each nostril with the volume of saline solution that fits into one pot.  When the pot is empty, rotate your head so you are looking into the sink and exhale through both nostrils to clean them of excess mucus and water.

www.himilayaninstitue.org has a good instructional video for proper use of the neti pot. 

Saline Solution for one pot:

Distilled water to fill the pot

¼ heaping teaspoon of plain salt such as kosher salt (not iodized and not sea salt)

A pinch of pure baking soda (sodium bicarbonate) (Optional)

Mix to dissolve salt

Reading Over-The-Counter Cold and Allergy Medication Labels

January 17, 2010

There are many different over-the-counter allergy and cold medications available.  It is often very confusing figuring out what to buy in the drug store with so many different products on the shelves.   The key to making a decision is looking at the active ingredients of the products. The active ingredients are always listed on the label of the medication.  It is much more important to read the active ingredients, than to pay attention to the fancy labels and packaging.

Over-the-counter allergy and cold medications basically contain one or more of five major types of medications: 1)Antihistamines, 2)Decongestants, 3)Pain medications, 4)Cough suppressants and 5)Expectorants.

1. Antihistmines: There are two major types of antihistamines that are available over-the-counter, those that make most people drowsy and those that don’t.  The most common antihistamines available that make most people drowsy are Diphenhydramine, Chlorpheniramine and Brompheniramine.  Diphenhydramine is the active ingredient in Benadryl.  There are two over-the-counter antihistamines that do not cause drowsiness,- Loratadine and Cetirizine. Loratadine is the active ingredient in Claritin and Cetirizine is the active ingredient in Zyrtec.   Cetirizine may cause some drowsiness in a small percentage of people.

2. Decongestants: The major decongestants available in over-the-counter medications are Phenylephrine and Pseudoephedrine.

3. Pain medications: The major pain medications available in over-the-counter cold and allergy preparations are Acetaminophen (the active ingredient in Tylenol) and Ibuprofen (the active ingredient in Advil or Motrin)

4. Cough suppressants: Dextromethorphan is the main cough suppressant you will see in preparations.

5. Expectorants: Guafenisin is the main expectorant you will see in preparations.

Cold and allergy medications that call themselves non-drowsy, usually will not contain a sedating antihistamine.  In fact, they might not contain any antihistamine at all.  If you are mainly taking the product for allergy reasons, you would want to take an antihistamine.  Products labeled HBP (high blood pressure) usually do not contain decongestants since decongestants can cause an elevation of blood pressure.

The amount of each ingredient is indicated on the label in milligrams (mg).  You can compare dosages of specific ingredients milligram for milligram.  For instance, a product that contains 120mg of pseudoephedrine has 4 times as much of that ingredient in it than a product that contains 30mg of pseudoephedrine.  Since pseudoephedrine can cause potential dose related  side effects, your doctor might not want you to be on that higher dose.

You can not compare the milligram dosages of one ingredient with that of another ingredient. It is wrong to think that a higher milligram dosage of one ingredient is stronger than a lower mg dosage of another ingredient.  For instance, 30mg of one medication could be stronger, weaker or equivalent to 5 mg of another medication.  This is true for any class of medication.

It is important to take the medications as indicated on the label or to ask your doctor if you are unsure of how much to take.  It is also important to be careful about combining different products since there might be overlapping active ingredients that could result in taking too much of one medication.  For instance, if you are taking a cold medication that contains acetaminophen, you would want to be very careful about the milligram dosage of acetaminophen in that medication before taking Tylenol along with it.

Daily Nasal Saline Irrigation: Too Much Of A Good Thing May Not Be Good

January 7, 2010

Saline (salt water)  irrigation of the nasal passages can improve nasal mucociliary clearance.   Many patients with chronic nasal and sinus problems use nasal saline irrigation with a neti pot or spray on a daily basis to treat congestion and mucous build up.  A recent study presented at a national allergy and immunology meeting showed that when patients used nasal saline irrigation on a daily basis for a year, they had 60% more acute nasal/sinus infections over the course of the year, compared to not using the nasal saline irrigation on a daily basis.

It is appropriate and most likely helpful to use nasal saline irrigation on an intermittent basis when you have a cold, or are developing a cold, to help improve clearance of already infected mucus.  For this purpose it can be used for a week or 10 days and most of my patients report that it helps.  I prefer the use of a neti pot, rather than a spray, since a neti pot rinses the sinuses with passive flow of the saline whereas a spray introduces an element of positive pressure.

Although the short-term use of nasal saline irrigation can be helpful and should be considered a good thing, this study shows that the daily use of nasal saline irrigation over longer periods of time might be harmful.  It is possible that ongoing enhanced clearance of uninfected “good” mucous might end up making it more likely that an infection develops.

I think this is important information since the lay public and many physicians often assume that they don’t need to worry about bad side effects from a medical intervention that does not involve a “medication” but instead involves a “natural” substance, like salt water.   This study shows that even “natural” therapies can have potential side effects.

One caveat:  This is one study and it should be repeated to assure that the results are accurate.

Say No To Chronic Oral Decongestants

December 29, 2009

Many over-the-counter and prescription allergy medications contain an oral decongestant,- either pseudoephedrine or phenylephrine.   The decongestant is the “D” part of Zyrtec D, Claritin D and Allegra D.   Decongestants are also in many over-the-counter cold medications such as Dimetapp, Contact and Sudafed, to name a few.

The short term use of oral pseudoephedrine or phenylephrine during an acute upper respiratory tract infection is an acceptable option for many people.  The chronic use of this medication for people with allergies is problematic.   From my perspective these medications have too many potential side effects to use chronically.  I see patients on a regular basis who have been on these medications for months or even years.  As a rule of thumb, I do my best to get patients off of these products.

The potential side effects of oral decongestants include increased blood pressure, increased heart rate, palpitations, nervousness, interference with the normal sleep cycle, insomnia, tremor, loss of appetite and urinary hesitancy.  People with heart disease, high blood pressure, enlarged prostates and glaucoma should not use them at all and I think people without these conditions should only use them chronically as a last resort.

Years ago there was another oral decongestant on the market named phenylpropanolamine, which was an active ingredient in many cold and allergy medications.  About 9 years ago the FDA withdrew phenylpropanolamine from the market because of an increased risk of hemorrhagic stroke in woman who took phenylpropanolamine as an appetite suppressant.  Although this side effect has not been seen with pseudoephedrine or phenylephrine, as a class of medications, oral decongestants tend to have significant side effects.

The bottom line is, there are many other classes of medications, as well as therapies that do not involve medications, that are effective for people with chronic nasal congestion.  The use of a product containing an oral decongestant is rarely, if ever, necessary in this setting.