Frequently asked questions

September 26, 2014
Q. What can I do to avoid getting sick on my winter cruise?
A.

Before your trip, consult with a travel medicine specialist at least one month before travel to ask about:

  • Special vaccines that are recommended for specific destinations.
  • First aid and medical kit containing regular and special medication for the trip – carry in hand luggage.
  • Evacuation and travel insurance to cover health emergencies while abroad. (1)

 

Depending on your destination, some precautions can help you to stay healthy on your trip and arrive home the same way. The most common illnesses acquired on cruise ships are respiratory infections, sprains and strains, seasickness and gastrointestinal (GI) illness often caused by a virus called norovirus (previously called Norwalk virus) (1). Infections that occur on cruise ships can spread rapidly. With multiple ports-of-call and ever-changing staff members, diseases can be brought on board by infected individuals or in contaminated food and water.

 

 

Cruise ships that dock at ports in the United States are inspected for sanitation by Centre for Disease Control (CDC) officials to lessen the risk of gastrointestinal disease outbreaks on board. Travelers can obtain information on whether specific cruise ships meet sanitation standards from the CDC (www.cdc.gov/nceh/vsp/default.htm). (1, 2) Unannounced inspections are conducted on cruise ships travelling in Canadian waters. The inspections are conducted once per year during the cruise ship season which extends from April to the end of October. The results are matched with those from the CDC. Vessel Sanitation Program (VSP) (3)

 

Respiratory infections:

The best prevention for respiratory infections such as the common cold is frequent hand-washing.

Some healthcare workers in Asia wear surgical-type face masks to prevent getting respiratory infections and these masks are increasingly used by travelers for the same purpose. In a study of their effectiveness, there was no difference in the frequency of colds between groups assigned to the mask or no mask. Subjects assigned to wear masks were much more likely to experience headaches while wearing the masks. (4)

 

GI infections:

Noroviruses cause fever and stomach upset including diarrhea and sometimes vomiting. They are very hardy and can withstand temperatures up to 60°C and can survive up to 2 weeks on surfaces such as tabletops. Outbreaks often occur in food service settings and settings in which people are in close contact such as cruise shipsThe most effective prevention is hand washing with soap and water for at least 20 seconds and trying to not come in close contact with people who are ill. (6)

 

Motion sickness:

Motion sickness (sea sickness) is considered a form of dizziness and affects some people more than others. The symptoms of sea sickness include dizziness, nausea, burping, increased production of saliva and sweating. Hyperventilation (rapid, deep breathing) is common and can cause shortness of breath, skin tingling and feelings of impending doom. There isn't a good way to identify people at risk of motion sickness and some who have never had it before, may suffer from it in certain situations such as very rough seas.

 

Some strategies to help include; focusing on an object in the distance such as the horizon if you're on the sea, reserving a central cabin on a cruise ship or if this doesn’t work, trying an over-the-counter medication containing dimenhydrinate (such as Gravol). This is most effective if taken 30 to 60 minutes before travel, so it has time to work. Another option is scopolamine, a transdermal patch applied behind the ear. The benefit of scopolamine is that it lasts for 72 hours. It must be applied about four to twelve hours before travel is started and if another 3 days is required a new patch is applied behind the other ear. It shouldn’t be used longer than 6 days. Side effects for both kinds of medicine include drowsiness, blurred vision, dry mouth and in older adults possibly confusion. Scopolamine should not be used by people at risk of a less common form of glaucoma – angle closure glaucoma.(5)

 

Prepared by Jean Macpherson BSP, reviewed by Karen Jensen BSP MSc

medSask, September 2014

Sources

  1. International Travel Centre. www.saskatoonhealthregion.ca/locations_services/services/International-Travel. Accessed online September 22, 2014.
  2. Leder K, Weller P. Travel advice. In: UpToDate, Sexton, D(Ed), UpToDate, Waltham, MA, 2014. Accessed online September 22, 2014.
  3. Healthy Living. Cruise Ship Inspection Service. www.hc-sc.gc.ca/hl-vs/travel-voyage/general/ship-navire-eng.php. Accessed online September 22, 2014.
  4. McClain M, Sexton D. The common cold in adults: Treatment and prevention. In: UpToDate, Hirsch, M,(Ed), UpToDate, Waltham, MA, 2014. Accessed online September 22, 2014.
  5. Canadian Pharmacist’s Letter - Preventing Travel-Related Illnesses, Volume 2011, Course No. 317.
  6. Norovirus infection. In Dynamed online. EBSCO Information Services. Available at https://dynamed.ebscohost.com (by subscription). Accessed online September 22, 2014.

 

September 17, 2014
Q. Could I get an overdose if I have a hot shower while wearing a drug patch?  
A.

 

Using a heating pad or electric blanket, sitting in a sauna or taking a hot shower or bath while wearing a patch can alter the drug delivery and skin absorption.  This could result in more drug than usual entering the system and an overdose.

 

 

 

Applying drugs to the skin as a method to get them into the body (known as transdermal administration) was not recognized as a possibility until the 1920’s and it wasn’t until 1978 that a patch containing a drug for motion sickness was introduced. When drugs are taken by mouth they pass through the liver which can alter the structure of the chemical, also known as metabolism. Advantages of the transdermal method are that it allows the drug to remain unchanged by not having to first pass through the liver and avoids absorption and irritation problems in the stomach and intestines. This may result in needing lower doses and causing fewer side effects. The steady absorption of drug over longer periods also usually means less frequent dosing.  Not all drugs can be incorporated into transdermal patches; they must be chemically suitable and non-irritating. Currently, drugs available in a transdermal patch are for hormone replacement, contraception, heart disease, smoking cessation, pain and brain disorders such as dementia and Parkinson’s disease. (1)

 

There are some disadvantages to transdermal patches such as skin reactions and less flexibility in doses than oral medications. Some other drawbacks to the use of medication patches are a delayed onset of action, the possibility of external conditions affecting drug release and absorption, and a potential loss of adhesion to the skin which could alter the dose. (2)

 

Transdermal patches are made up of several layers, including an impermeable backing (the layer visible when the patch is applied to a patient’s skin), a drug layer that contains the active ingredients, a rate-controlling membrane that controls the rate that the drug is released onto the skin, an adhesive layer that provides adhesion to the skin, and a protective cover (peel strip) to be removed before the patch is applied to the skin. (2)

 

There are some points to keep in mind when transdermal patches are used:

  • Cutting the patch – Most patches should not be cut. Cutting can lead to inaccurate and sometimes dangerous doses caused by drug leaking from the cut edge. If a lower dose than is available is required, check with your pharmacist, nurse or doctor for instructions on whether it is possible to do it safely.
  • ·         Patches that fall off – Patches should be applied on clean, dry skin. Patches should not be applied to the waistline or on areas where tight clothing can rub the patch off. If a patch falls off, a new one should be applied to a different site, in most cases. Some patches can be taped around the edges if they repeatedly fall off, but shouldn’t be covered completely with tape. Check with your pharmacist if you are having trouble with adhesion.
  • Getting the patch wet – Most patches can be worn while showering, bathing or swimming. Care should be taken when drying off, so that the patch remains adhered to the skin.
  • Dealing with irritated skin – The best way to avoid skin irritation is to change the site of application each time the patch is changed. If needed a mild steroid cream can usually be applied to the irritated site when the patch is changed.
  • External heat – Using a heating pad or electric blanket, sitting in a sauna or taking a hot shower or bath while wearing a patch can alter the drug delivery and skin absorption.
  • Illness – A fever can also affect the dose.
  • Medical tests – Some patches contain aluminum in the backing and this can be a safety concern for people undergoing an MRI. The aluminum can conduct electrical current which can lead to burns, so the patch should be removed before the test.
  • Writing on the patch – Most manufacturers do not recommend writing on patches. Some people do this to remember the date of application or make clear patches more visible, but it may tear the patch or the ink may be absorbed into the drug layer. It is suggested that the use of medical tape applied close to the patch with the required information is a better practice.
  • Changing the patch – the used patch should be removed before applying a new patch as there may still be some drug left even after the recommended time and this can affect the dose.
  • Discarding used patches – After the patch is removed, fold it in half with the sticky sides together. Follow instructions on proper disposal provided with the patch.
  • Contact with the surface – If you inadvertently come in contact with the drug layer, wash the area with water. Hands should be washed with water before and after applying a transdermal patch. (2,3)

 

Prepared by Jean Macpherson BSP, medSask medication information consultant. Reviewed by Karen Jensen BSP, MSc, medSask medication information
Posted September 2014
 

 

Sources

1. Perumal,O., Murthy, S.N., Kalia, Y.N., Turning Theory into Practice: The Development of Modern Transdermal Drug Delivery Systems and Future Trends, Skin Pharmacology and  Physiology, 2013;26:331–342.

2. Durand, C., Alhammad, A., Willett, K., Practical considerations for optimal transdermal drug delivery, American Journal of Health-System Pharmacy, January 15, 2012 vol. 69 no. 2 116-124.

3. PL Detail-Document, Characteristics of Transdermal Patches. Pharmacist’s Letter/Prescriber’s Letter. August 2012.

September 8, 2014
Q. Which teething products are safe to use?
A.

Non-drug therapies for teething:

  • Give the child something hard, smooth and clean to bite and chew on, such as a frozen facecloth.
  • Safe teethers, cooled in the refrigerator before use, can be very effective in reducing symptoms.
  • Rub the back of a small, cold spoon on the gum.  
  • Caution: Avoid long-term contact with very cold items. Do not place anything in the child's mouth that could be a choking hazard.
  • Teething biscuits are not recommended because of their sugar content.

 

Recommended drug therapies:

  • Oral pain relievers such as acetaminophen or ibuprofen can be used at the usual doses recommended for age and weight. These should never be rubbed on the gum.

 

Non-recommended drug therapies:

  • Viscous lidocaine has been associated with serious adverse reactions (including death) in young children being treated for mouth pain, including teething. (3)

 

  • The Canadian Dental Association does not recommend applying any local anaesthetics such as lidocaine or benzocaine to the gums, although several benzocaine-containing products are available without a prescription. These products only numb the area for 30–45 minutes. (1)

 

Benzocaine may disable the gag reflex if swallowed and the baby could choke on food.

 

Benzocaine has also been associated with a rare, but serious condition called methemoglobinemia, which results in the amount of oxygen carried through the blood stream being greatly reduced. In the most severe cases, methemoglobinemia can result in death. It has been reported with all strengths of benzocaine gels and liquids, including concentrations as low as 7.5%. The cases occurred mainly in children aged two years or younger who were treated with benzocaine gel for teething.

 

People who develop methemoglobinemia may experience:

  • pale, gray or blue colored skin, lips, and nail beds
  • shortness of breath
  • fatigue; confusion
  • headache; lightheadedness; and rapid heart rate
  • In some cases, symptoms of methemoglobinemia may not always be evident or attributed to the condition. The signs and symptoms usually appear within minutes to hours of applying benzocaine and may occur with the first application of benzocaine or after additional use and immediate medical attention is required. (2)

 

  • Homeopathic Hyland’s Teething Tablets were voluntarily recalled in 2010. The reason for the recall in Canada and the U.S. was a precautionary measure after the company and the U.S. Food and Drug Administration (FDA) conducted a review of the company’s adverse event reports and manufacturing processes. They have identified manufacturing processes that can be improved to ensure uniformity in dosage of the Belladonna 3X ingredient. According to U.S. FDA testing, Hyland's Teething Tablets may have posed a risk to children. A new formulation is now available according to the company, however there is no evidence that these products are effective for teething . (4)

 

About two-thirds of babies will have signs and symptoms accompanying the emergence of new teeth. Teething begins on average around 5 to 6 months of age.   For a few days before a new tooth breaks through, the gums may be red, irritated, swollen and tender and babies may tend to produce more saliva and drool more than usual. The discomfort this causes may explain the irritability of the child, which may result in agitation, restlessness, crying and trouble sleeping or staying asleep. Other reported symptoms may include a decrease in appetite for solid food, increased thirst, mild increase in body temperature (up to 37.7°C), loose stools, ear rubbing and a stuffed up or runny nose.

Advice for Parents

  • Continue to gently brush and clean the erupting tooth area to reduce the risk of secondary gum infection due to plaque sticking to teeth.
  • Give child chilled teething toys (rings) or cool cloths to chew on. Ensure toys are lead free, washed, kept clean and stored in the refrigerator prior to use.
  • Keep child well hydrated.
  • Seek medical advice if symptoms are serious or persist for more than 24 hours, to rule out upper respiratory infection and other common conditions.
  • First dental visit should occur within 6 months of eruption of first tooth or by age 1. (5)

Prepared by Jean Macpherson BSP, medSask medication consultant. Reviewed by Karen Jensen BSP, MSc, medSask medication consultant.
September, 2014

Sources

  1. Dental Care: Teething. Minor Ailments in e-therapeutics Complete online. Available from: http://www.e-therapeutics.ca (by subscription). Accessed August 2014.
  2. Canadian Pharmacist”s Letter. PL Detail-Document, Safety of Oral Benzocaine Products. Pharmacist’s Letter/Prescriber’s Letter. May 2011
  3. Wright, JT. Anatomy and development of the teeth. In: UpToDate, Torchia, MM(Ed), UpToDate, Waltham, MA, 2014.Available at  www.uptodate.com (by subscription). Accessed August, 2014.
  4. Health Canada Licensed Natural Health Products Database.  Available at http://webprod5.hc-sc.gc.ca/lnhpd-bdpsnh/index-eng.jsp. Accessed August, 2014.
  5. Managing Discomfort Caused by Teething. J Can Dent Assoc 2013;79:d141  

 

July 24, 2014
Q. How can I prevent getting “The Itch” when I go swimming at the lake?
A.

Ways to reduce the risk of catching “the itch”:

  • Shower and towel dry well after swimming
  • Do not swim where risk has been identified
  • Use a pier or dock to enter the water.  Larvae tend to stay near the shore
  • Apply waterproof sunscreen before swimming.  This may help to reduce the number of larvae penetrating the skin
  • Do not attract birds to swimming areas

 The Itch or Swimmer’s Itch is a skin rash that may appear several hours after swimming in lake or pond water (less frequently in salt water) that is infested with schisosome cercariae parasite.  This parasite infects birds and mammals that frequent the water.  Droppings from these animals contain the eggs of the parasite.  The eggs hatch into larvae which infect snails.  The snails release the larvae into the water.  If the larvae come in contact with people, they can burrow under the skin where they die and cause an allergic reaction and a rash. 

 The rash appears within several hours after swimming and can range from a mild irritation to a severely itchy red rash.  A tingling sensation may be felt as the skin dries off and the larvae start to burrow into the skin.  The infection may last from two to five days and symptoms for as long as two weeks.  Repeat infections are usually worse as people become sensitized to the larvae and have a stronger allergic reaction to them.

 Symptoms may go away on their own in a few days.  If the itching is bothersome, these treatments may be helpful:

  • Over the counter hydrocortisone 0.5% cream
  • Anti-itch lotions such as calamine lotion
  • Cool compresses
  • Baths with Epsom salts, baking soda or oatmeal
  • Baking soda paste applied to itchy areas
  • Oral antihistamines (ask your pharmacist to help you select the best one for you)

Try not to scratch.  This worsens the rash and may cause infection.  If signs of infection develop (increased redness, swelling, warmth),  see your doctor for treatment.

 

Prepared by Dorothy Sanderson BSP; reviewed by Karen Jensen MSc, BSP.
Posted July, 2014.

Sources

  1. Mayo clinic. Swimmer’s itch. Available at www.mayoclinic.prg/diseases-condition/swimmers-itch. Accessed July, 2014.
  2. Government of Alberta. Swimmer’s itch. Available at https://myhealth.alberta.ca/health/Pages/conditions.aspx?hwid=abl0355. Accessed July 2014.
  3. Swimmer’s Itch. HealthLinkBC File #52 Available at www.healthlinkbc.ca/healthfiles/hfile52.stm. Accessed July 2014.
  4. Swimmer’s Itch FAQs.  Centers for Disease Control and Prevention. Available at www.cdc.gov/parasites/swimmersitch/faqs.html. Accessed July 2014.

July 23, 2014
Q. My daughter gets swimmer’s ear every summer. What can I do to prevent this?  
A.

Prevention of swimmer’s ear can include the following (1):

  • Keeping ears dry. Drain ear canals by tilting head to side and dry outer ear gently with a soft towel or with a blow dryer turned on low and held at least foot away.
  • A homemade solution of equal parts of white vinegar with either water or isopropyl alcohol can be instilled in both ears before and after swimming.
  • Watch for signs alerting swimmers to high bacterial counts and don't swim on those days.
  • Don’t put foreign objects in your ears. Never attempt to scratch an itchy inner ear or dig out ear wax with a cotton swab or hairpin. This can irritate or break the skin and pack materials farther down the ear canal.
  • Protect your ears with cotton balls when using hair dye

Swimmer’s Ear or otitis externa is an inflammation of the ear canal most commonly caused by a bacterial infection. It can affect any age group, although children 5 to 14 years have the highest incidence and it is estimated that 10% of people will develop it at some point in their life. (2)

It is more common during the summer months. This is because of increased humidity and increased exposure to outdoor water activities, both of which can affect the way that bacteria gain entrance to the ear. (2)

Extra moisture leads to softening of the skin and breakdown of the barrier of ear wax (cerumen) that protects the ear canal from infection. Cleaning too often with cotton swabs can remove the layer of cerumen and scratch the surface skin. If a piece of the swab or tissue is left behind they can harbour bacteria which cause infection. As well, devices such as hearing aids, ear buds and swim caps which cover the ear can increase the likelihood of infection.(2)

The symptoms of swimmer’s ear may occur rapidly and include tenderness of the outer structure of the ear, pain, itching, swelling, redness and possible hearing loss and jaw pain.(3)

Treatment is aimed at stopping the infection and reducing the pain.

  • As long as there is no hole or tear in the eardrum, a solution of equal parts of white vinegar with either water or isopropyl alcohol can be used as an ear drop up to 4 times a day to help to dry out the ear canal and make it less appealing to the bacteria and fungi that cause swimmer’s ear.
  • Children who have tubes in their ears should be seen by a doctor before treating.
  • Prescription ear drops that contain an antibiotic with or without a steroid usually work quickly to stop the symptoms within 48 hours but should be continued for 7 to 10 days.
  • Ibuprofen (e.g. Advil or Motrin) or acetaminophen (e.g. Tylenol) can be taken for pain. (2)

Prepared by Jean Macpherson BSP. Reviewed by Karen Jensen BSP, MSc.

Posted July 2014

 

Sources

1)       Mayo Clinic. Swimmer’s Ear. Available at http://www.mayoclinic.org/diseases-conditions/swimmers-ear/basics/definition/con-20014723 Accessed June 25, 2014.

2)       Goguen, LD External otitis: Pathogenesis, clinical features, and diagnosis. In UpToDate, Park, L (Ed), UpToDate, Waltham, MA, 2014.

June 26, 2014
Q. Do probiotics help a baby with colic?
A.

Since babies with colic are reported to have increased amounts of gas-forming bacteria in their intestines it has been proposed that probiotics might reduce amounts of these organisms in babies’ intestines and help symptoms of colic. Research into the use of probiotics for colic has been rapidly gaining momentum, however the results of recent studies have been mixed. Some studies showed a positive effect on colic with the probiotic strain Lactobacillus reuteri in a select group of breastfed babies (1), but no positive effect in formula-fed babies. (2) Because of the lack of consistent, positive results, probiotics cannot be routinely recommended for babies with colic with any confidence that they will help.(3) 

 All babies, whether or not they have colic, cry more during the first three months of life than at any other time. Most people cannot agree on what constitutes an abnormal amount of crying. The length of time may vary from 42 minutes to 2 hours daily. 

There is no standard definition for the term “colic.” For practical purposes, it is defined as crying for no apparent reason that lasts for more than 3 hours a day and occurs on more than 3 days a week in an otherwise healthy baby less than 3 months of age. Only 35 percent of infants considered to be "colicky" by their mothers met the "rule of three" criteria when parental diaries were kept. Symptoms resolve in 60 percent of infants by three months of age and in 80 to 90 percent of infants by four months of age. (4) 

No single effective treatment for colic exists. Most guidelines recommend parental support and reassurance as the mainstay of management. The use of hypoallergenic (hydrolyzed) formulas for formula-fed babies or elimination of cow’s milk protein from the diet of mothers who are breastfeeding may possibly be effective for some babies, but not all. (2)

 Probiotics are live microorganisms and are similar to the microorganisms that are found in the human gut. They are also called "friendly bacteria" or "good bacteria” and people take them to help to maintain the natural balance of organisms (microflora) in the intestines. (5) 

Most researchers agree that more studies need to be done to determine if any group of babies with colic would benefit from probiotics. Probiotics are unlikely to be harmful, but there is little evidence to support their use.

In an editorial in the British Medical Journal (BMJ), W. Bennett a pediatric professor says, “Because of the lack of good evidence for treating colic, the question might be: “Should we be treating infant colic at all?” A great deal of accumulated clinical experience tells us that children with colic incur no serious long term effects from the disorder, and that symptoms abate with time.” (6)

 

Prepared by Jean Macpherson, BSP. Reviewed by Karen Jensen BSP, MSc
June 2014

Sources

1)       Savino F, Cordisco L, Tarasco V, et al. Lactobacillus reuteri DSM 17938 in infantile colic: a randomized, double-blind, placebo-controlled trial. Pediatrics. 2010 Sep;126(3):e526-33. doi: 10.1542/peds.2010-0433.

2)       Sung, V, Hiscock, H, Tang, MLK, Treating infant colic with the probiotic lactobacillus reuteri: double blind placebo controlled randomised trial. BMJ 2014;348:g2107  

3)      Bennett, WE, Probiotics and infant colic. BMJ 2014;348:g2286.

4)       Turner T, Palamountain S. Infantile colic: Clinical features and diagnosis. In: UpToDate, Torchia, MM(Ed), UpToDate, Waltham, MA, 2014.

5)       Probiotics. In Natural Standard database online. Available at www.naturalstandard.com (requires log-in and registration.

 

June 26, 2014
Q. Can an Aspirin a Day Prevent Cancer?
A.

At this time, guidelines don’t recommend ASA for cancer prevention. They conclude that aspirin-related bleeding risks (especially in the brain and digestive tract) outweigh the benefits when it’s used for cancer prevention. Out of every 247 patients taking aspirin for 6 years, one cancer death is prevented, but 72 serious bleeds occur. (1)

 

Taking a low dose (75 – 100mg) of aspirin (ASA) every day may be of benefit for some types of cancer; however, there are very few studies at this time that show conclusively that ASA should be used for cancer prevention or treatment.

 Some studies show that taking ASA may help lower the chance of getting some types of colorectal and other digestive tract cancers. Small benefits have also been observed for breast and prostate cancer. The results are not consistent and dosages and length of time needed to show a benefit are still unclear.(2) 

  • Recommendations to protect against colon cancer may include a “protective diet” which suggests avoiding processed and charred red meat,
  • Eating vegetables - especially cruciferous such as cabbage and broccoli and folate-containing vegetables – especially leafy green vegetables
  • Limiting calorie intake
  • Avoiding excessive use of alcohol (women: no more than seven drinks per week and men: no more than 14 drinks per week). (3)

 Since there are no updated guidelines, each person should discuss with their healthcare professional, the use of ASA for preventing diseases, the known risks and benefits and how they relate to each person individually. Because of the availability of screening methods such as colonoscopy for early detection of colon cancer, potential benefits of ASA use must be weighed against the potential adverse effects. (4)

In certain hereditary types of cancer conditions (e.g. Lynch syndrome) aspirin does decrease cancer incidence and should be considered a standard recommendation. (5)

 

Prepared by Jean Macpherson BSP and reviewed by Karen Jensen BSP, MSc
June 2014

Sources

1)      Canadian Pharmacist’s Letter - RUMOUR: Aspirin prevents cancer. August 2012 Rumour vs. Truth

2)      Bosetti C, Rosato V, Gallus S, Cuzick J, La Vecchia C. Aspirin and cancer risk: a quantitative review to 2011. Ann Oncol. 2012 Jun; 23(6):1403-15. doi: 10.1093/annonc/mds113. Epub 2012 Apr 19.

3)      Ahnen, DJ, Macrae, FA. Colorectal cancer: Epidemiology, risk factors, and protective factors. In UpToDate: Goldberg, RM, Lipman, TO (Ed) UpToDate, Waltham, MA, 2014.

4)      Chan,A. NSAIDs (including aspirin): Role in prevention of cancer. In UpToDate: Feldman, M (Ed) UpToDate, Waltham, MA, 2014.

5)      Langley, R.E., Rothwell, P.M. Aspirin in gastrointestinal oncology: New data on an old friend. 2014, Current Opinion in Oncology.

June 8, 2014
Q. Can sunscreen and insect repellent be applied at the same time?
A.

For best effect, the sunscreen should be applied first as it needs to be on the skin 15 to 30 minutes before sun exposure (1,2).  Insect repellent is effective immediately and should be applied over the sun-screened area just before or after going outdoors (3,4).

 

It is not recommended to use a single product that combines insect repellent and sunscreen (5).  Sunscreens must be applied liberally and frequently to provide maximum protection while insect repellents should be applied sparingly (1).  Sunscreen should be applied to all areas exposed to the sun (1), while insect repellents should not be applied to the face (3,4).

 

It is recommended to avoid use of insect repellents on skin damaged by sunburn, cuts, rashes or other skin conditions (3,6).  More absorption occurs through damaged skin which can lead to increased inflammation or an allergic reaction (6).  Test any new insect repellent formulation on a small patch of skin first before applying to all exposed areas (5,7).

Prepared by Dorothy Sanderson, BSP; reviewed by Karen Jensen, BSP, MSc.

Sources

1. UpToDate - Selection of sunscreen and sun-protective measures

2. Sunscreens - http://healthycanadians.gc.ca/environment-environnement/sun-soleil/screen-ecrans-eng.php. Accessed June 2014.

3. Insect Repellents - http://healthycanadians.gc.ca/environment-environnement/pesticides/insect_repellents-insectifuges-eng.php.  Accessed June 2014.

4. UpToDate - Prevention of arthropod and insect bites: Repellents and other measures

5. Insect Repellents - http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/life-vie/insect-eng.php . Accessed June 2014.

6. CDC – www.cdc.gov/westnile/faq/repellent.  Accessed June 2014.

7. Skin Cancer foundation – www.skincancer.org.  Accessed June 2014.

June 7, 2014
Q. Should I take an aspirin every day to prevent heart attacks and strokes?
A.

Before starting to take aspirin (ASA) on a daily basis to prevent a heart attack or stroke, you should discuss the risks and benefits with your health care professional (1).  For many people, the benefits do not outweigh the risks of taking ASA daily even at a low dose.

Heart attacks and certain kinds of strokes (ischemic strokes) occur when a blood clot forms and blocks the flow of blood and oxygen to the heart or brain. ASA works by interfering with the blood’s clotting mechanism so these clots do not form.

 For people who have had a heart attack, a stroke or who have coronary artery disease, taking a low dose (81mg – 325mg) of ASA daily has been shown to help prevent a reoccurrence. This is called “secondary prevention”.

Preventing a first-time occurrence of one of these events is called “primary prevention”. In people who have not had a heart attack or stroke and who are at low risk for cardiovascular disease, even if they have a family history of these conditions, taking ASA daily may have more risk than benefit.

 Approximately one first-time serious cardiovascular event is prevented for every 1000 patients on ASA for one year but at the cost of one serious bleeding event for every 1000 patients.  The benefit seems to be even less for women. Treating 1000 women age 45 and up with ASA for 10 years may prevent only 2 or 3 ischemic strokes and even fewer heart attacks (3).

 The specific risks with ASA are that it can cause dangerous bleeding into the stomach or into the brain (hemorrhagic stroke) (2).  The first Canadian antiplatelet guidelines recommend against using ASA routinely for primary prevention in healthy people at low risk.

 Taking ASA for primary prevention may be beneficial for some people.  People at high risk for cardiovascular events, such as those with diabetes and are over the age of 40, and those with end-stage kidney disease; but only if they have a low risk of bleeding. Risk factors for bleeding include being female, having a previous bleeding episode and using medications such as non-steroidal anti-inflammatory drugs (e.g. ibuprofen, naproxen, diclofenac).

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen BSP, MSc

Sources

1)  Hennekens, CH. Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease. In: UpToDate, Saperia GM (Ed), UpToDate,Waltham, MA, 2014.

2) FDA Consumer Health Information – www.fda.gov/ForConsumers/ConsumerUpdates

3) Aspirin for preventing cardiovascular events: who needs it? Pharmacist’s Letter/Prescriber’s Letter 2011; 27(8):270821.

May 25, 2014
Q. If I take acetaminophen while I’m pregnant, is my baby at risk of developing Attention Deficit Hyperactivity Disorder?
A.

Acetaminophen (Tylenol, Atasol,  store-brands) has generally been regarded as the drug of choice for minor pain and fever relief in pregnancy. Two recent studies from Europe have suggested there may be small increase in risk of ADHD (attention-deficit hyperactivity disorder) or similar conditions in children whose mothers take acetaminophen long-term (6 weeks or more), particularly during the last three months of pregnancy; however, more research is needed to confirm this risk (1,2).

 

An increase in major birth defects or miscarriage related to acetaminophen has not been shown (3). There may or may not be a link between acetaminophen and wheezing / asthma in the infant – some studies have shown an association but others have not (4).  Overdose or prolonged use of high doses may result in liver damage to the unborn baby and other adverse effects (3).

 

Acetaminophen still seems safer than other drugs used for treating pain and fever in pregnancy when used in in normal adult doses for short periods of time. It is also a good choice for nursing moms as the amount that babies get from breast milk is less than doses given to babies, and adverse effects are rare. (4)

 

Keep in mind that it is important to treat fever in pregnancy. Fever during the first trimester has been associated with neural tube defects (e.g. spina bifida) and possibly other birth defects. In addition, fever during labor is a risk factor for seizures, brain disorders, cerebral palsy and death in the newborn. (6)

Prepared by Jean Macpherson, BSP, Medication Information Consultant.
Reviewed by Karen Jensen, BSP, MSc, Medication Information Consultant

Sources

 

1)       Liew Z, Ritz B, et al.  Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders. JAMA Pediatr. 2014 Apr 1;168(4):313-20. doi: 10.1001/jamapediatrics.2013.4914.

2)       Brandlistuen R, Ystrom E, et al. Prenatal paracetamol exposure and child neurodevelopment: a sibling-controlled cohort study. Int J Epidemiol. 2013 Dec;42(6):1702-13. doi: 10.1093/ije/dyt183. Epub 2013 Oct 24.

3)       Acetaminophen monograph. Micromedex Healthcare Series. DRUGDEX System. Greenwood Village, CO: Truven Health Analytics, 2014. Available at http://www.thomsonhc.com/. Accessed April 17, 2014.

4)       Acetaminophen monograph. Micromedex Healthcare Series. Reprotox. Greenwood Village, CO: Truven Health Analytics, 2014. Available at http://www.thomsonhc.com/ by subscription. Accessed May 15,  2014.

5)       Canadian Pharmacist’s Letter PL - PL Detail-Document, Analgesics in Pregnancy and Lactation. Pharmacist’s Letter/Prescriber’s Letter. April 2014.

6)       3) Jamieson, DJ, Rasmussen, SA. Influenza and pregnancy. In: UpToDate, Barss,V (Ed), UpToDate, Waltham, MA, 2014. Available at www.uptodate.com by subscription. Accessed April 17, 2014.

 

 

April 4, 2014
Q. Are TENS and ultrasound machines for home use safe and effective?
A.

Are TENS and ultrasound machines for home use safe and effective?

Chronic pain is one of the most common reasons for seeking medical attention and is reported by 20 to 50 percent of people who visit doctors. When conventional methods are not enough, many people look for other ways of treating pain. Ultrasound and TENS (Transcutaneous Electrical Stimulation) are non-drug methods which claim to help various types of pain. (1)

 

TENS

Good scientific research on ultrasound and TENS for pain relief is lacking and there appear to be varying rates of success for different conditions.

 

  • It has been shown to provide some benefit for some people with chronic neck pain (2)
  • TENS may provide short-term relief of pain and morning stiffness in people with osteoarthritis of the knee.  The patients receiving TENS experienced more pain relief and had less need for pain relief medicine; however, these benefits occurred only while using the device. (3,4)
  • It may help to interrupt or mask pain signals caused by phantom pain from an amputated limb. (5)
  • It has been shown to be an effective therapy with minimal side effects in patients suffering from trigeminal neuralgia, a painful disorder of facial nerves not responding to conventional treatment. (6)
  • TENS for treating fibromyalgia has had mixed results, but it may have some short-term benefit. (7)
  • There are no conclusive positive results that there is any benefit to using TENS to treat cancer-related pain, although it has been widely used.(8)
  • TENS is probably effective for reducing pain from diabetic neuropathy (nerve pain). (9)
  • It has shown some benefit for women with painful menstrual periods that do not respond completely to drug therapy.(10)
  • TENS, under medical supervision was shown to be an effective and safe treatment method for lower back pain during pregnancy. (11)
  • There is only limited evidence that TENS reduces pain in labour. It may reduce severe pain and does not seem to have any impact (either positive or negative) on other outcomes for mothers or babies. (12)

 

TENS therapy involves applying electrodes to the surface of the skin and delivering low voltage electrical currents to the area. The electricity is usually generated by a battery-operated device. It is a non-invasive method and can be used by patients in their homes. Most TENS devices offer variable frequency, intensity, pulse duration and type of output (burst or continuous). Regular TENS (high frequency, short pulse duration, low intensity) produces a sensation of prickling or tingling like “pins and needles”  under the electrodes and acupuncture-like TENS produces muscle twitches. (1)

 

TENS can be tested during a home trial or as a supervised trial when working with a physical therapist. Given the uncertainty about the amount of electrical stimulation most likely to help in an individual patient, a serious trial of TENS requires many days and should test various sites and timings of stimulation, as well as a variety of amplitudes, frequencies, and patterns.

 

 

 

People with the following must not use a TENS machine (13, 14):

  • When the cause of the pain is not known or is not diagnosed.
  • Pacemakers or ICD’s (implantable cardioverter-defibrillator).
  • Epilepsy or certain types of heart disease.

 

TENS machines are available in widely varying price ranges and can cost up to hundreds of dollars. Many advertisements make unsubstantiated claims about their effectiveness. A supervised trial by a medical professional or a physiotherapist would be advisable before purchasing one for use at home.

 

Ultrasound

The term "ultrasound" refers to sound waves of a frequency greater than that which the human ear can hear. Ultrasound machines generate sound waves which cause microscopic vibrations in tissues increasing heat and causing a warming effect. It is usually used in combination with other non-drug treatments and its beneficial effect is thought to be due to the heating of deep tissues. (15)

 

Despite being widely used for the treatment of many muscle and pain syndromes, few studies have evaluated the therapeutic effect of ultrasound.

  • Ultrasound therapy may reduce pain and improve function in patients with some types of shoulder pain and may help to aid in muscle relaxation before exercise. (16)
  • It has no proven benefit and is not recommended as a therapy for treating osteoarthritis and is not routinely used. (3)
  • Ultrasound has been used to promote recovery after nerve and tendon injuries.
  • It has been used to treat carpal tunnel syndrome by raising tissue temperature while reducing pain. Deep, pulsed ultrasound has been reported to decrease pain and improve sensory loss, nerve conduction parameters, and strength. (17)
  • It has been used in combination with stretching exercises to reduce pressure when treating bursitis of the hip.(18)

 

Ultrasound without medical supervision should NOT be used for:

  • Patients who have dulled reflexes or decreased sensitivity to pain and heat
  • Pregnant or potentially pregnant patients. (Overheating and damage to the fetus could result. The fetus is at particularly high risk during the first trimester.)
  • Pain in reproductive organs
  • Treatment in the area of the eye
  • Any region of diminished blood flow (except at low intensities for wound healing)
  • The brain, spinal cord or large subcutaneous peripheral nerves
  • Neoplastic (cancerous) tissues as there is some evidence that  temperatures less than 42°C, may stimulate tumor growth or promote spread of the cancer
  • Children 
  • People who have pacemakers or ICD’s
    • Blood vessels in poor condition (the vessel walls may break open)
    • Patients suffering from heart disease (might result in reflex tightening of the blood vessels in the heart)
    • People at risk of blood clots (a partially disintegrated clot could result in blockage of the arterial blood supply to the brain, heart or lungs)

Ultrasound machines are available for use at home and can range in price up to hundreds of dollars. It is important that patients understand how to correctly use their ultrasound machine because improper technique can, at best, reduce the benefits of ultrasound and, at worst, result in tissue damage. (19)

 

Provided by Jean Macpherson, BSP   Reviewed by Karen Jensen BSP, MSc

April 4, 2014

 

 

 

Sources

1)  Rosenquist, EWK. Overview of the treatment of chronic pain. In UpToDate, Rosenquist, EWK (Ed), UpToDate, Waltham, MA, 2014.

2) Anderson, BC, Isaac, Z, Devine, J. Treatment of neck pain. In UpToDate, Rosenquist, EWK (Ed), UpToDate, Waltham, MA, 2014.

3) Kalunian, KC. Nonpharmacologic therapy of osteoarthritis. In UpToDate, Tugwell, P(Ed), UpToDate, Waltham, MA, 2014.

4) Dynamed - Degenerative joint disease of the knee. Accessed March 2014.

5) http://www.mayoclinic.org/diseases-conditions/phantom-pain/basics/treatment/con-20023268

6) Dynamed – Trigeminal neuralgia. Accessed March 2014.

7) Goldenberg, DL. Treatment of fibromyalgia in adults not responsive to initial therapies.  In UpToDate, Schur, PH(Ed), UpToDate, Waltham, MA, 2014.

8) Strada, EA, Portenoy, RK. Psychological, rehabilitative, and integrative therapies for cancer pain. In UpToDate, Abrahm, J (Ed), UpToDate, Waltham, MA, 2014.

9) Feldman, McCulloch, DK.  Treatment of diabetic neuropathy. In UpToDate, Shefner, JM, Nathan, DM, (Ed), UpToDate, Waltham, MA, 2014.

10) Smith, RP, Kaunitz, AM. Treatment of primary dysmenorrhea in adult women. IN UpToDate, Barbieri, R(Ed), UpToDate, Waltham, MA, 2014.

11) Keskin EA1, Onur O, Keskin HL, Gumus II, Kafali H, Turhan N. Transcutaneous electrical nerve stimulation improves low back pain during pregnancy. Gynecol Obstet Invest. 2012;74(1):76-83.doi:10. 1159/000337720. Epub 2012 Jun 21.

12) Dowswell T, Bedwell C, Lavender T, Neilson JP. Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007214. doi: 10.1002/14651858.CD007214.pub2.

13) Risk of interference from transcutaneous electrical nerve stimulation on the sensing function of implantable defibrillators. Holmgren C. Carlsson T. Mannheimer C. Edvardsson N. Pacing & Clinical Electrophysiology. 31(2):151-8, 2008 Feb. [Journal Article] UI: 18233966

14)http://www.patient.co.uk/health/tens-machines

15) Chou, R. Subacute and chronic low back pain: Pharmacologic and nonsurgical interventional treatment. In UpToDate, Rosenquist, EWK (Ed), Rosenquist, EWK (Ed), UpToDate, Waltham, MA, 2014.

16)Dynamed - Impingement syndrome of rotator cuff. Accessed April 2014.

17) Kothari, M.  Treatment of carpal tunnel syndrome. In UpToDate, Shefner, JM,(Ed), UpToDate, Waltham, MA, 2014.

18) Anderson, BC. Trochanteric bursitis. In UpToDate, Isaac, Z, (Ed),  UpToDate, Waltham, MA, 2014.

19) Health Canada. Occupational Health and Safety.  Accessed online March 2014. http://www.hc-sc.gc.ca/ewh-semt/pubs/radiation/safety-code_23-securite/index-eng.php

March 31, 2014
Q. Can honey be used to treat a burn?
A.

Medical grade honey has evidence to support its use in burn management and may shorten the time it takes a burn to heal. (1) Medihoney, an OTC honey dressing which has been sterilized, is available in Canada. Not all honey products are sterile and some may contain clostridium spores and other contaminants. Since not all honeys are the same and do not possess the same therapeutic advantages, do not treat wounds with regular honey sold in grocery stores. The use of butter is not recommended due to the increased risk for infection. (2)

Overview of burn treatment

In general, first and second degree burns may be managed through self-care, unless the burn area is large, involves the eyes, ears, face, hands, feet or mucous membranes (lips, mouth, inside nose) or the patient is elderly, has diabetes, multiple medical conditions, or has a weakened immune system. Chemical, electrical, or inhalation burns require medical attention and should not be treated with self-care. (2)

Burns occur when some or all of the cells in the skin or other tissues are destroyed by heat, cold, electricity, radiation, or caustic chemicals. The most common type of burn in children is from a scald injury; in adults, the most common burn occurs from a flame.  Burns are classified according to the depth of tissue injury:

  • superficial (first-degree)- painful, red and warm, area turns white when touched, no blisters, moist
  • partial-thickness (second degree) - painful, red, moist, with blisters, hair still intact
  • full thickness (third degree) - painless with no sensation to touch, skin is pearly white or charred, dry and may appear leathery
  • involving muscle and/or bone (fourth degree). (3)

Initial treatment of minor burns consists mainly of removing anything covering the burn area, cooling, simple cleansing, and applying a dressing. Medication to treat pain may also be necessary. Check with your doctor to see if you need a tetanus shot (a booster is recommended if it is longer than 5 years since the last shot). The goals of treating minor burns are to relieve symptoms, promote healing by protecting the burn from infection or further injury, and to decrease the risk scarring. (2, 4)

Cooling — After any clothing, jewelry, and loose dirt is removed, burn wounds can be cooled with room-temperature or cool tap water to provide some pain relief and limit tissue injury. Cool running water for about 20 minutes is recommended. Sterile saline or sterile water can be used, but are not necessary. Ice is not recommended as it can reduce blood flow to the area and worsen the injury or slow healing. Applying sterile saline-soaked gauze, cooled to around 12°C (55°F), is another effective means of cooling. (2, 3)  

Cleaning — Burn wounds should be cleaned using only mild soap and tap water. Avoid skin disinfectants such as povidone-iodine as these can hinder healing. Gentle removal of dead skin will help in the healing process. Small blisters can be left intact. Large blisters should be seen by a doctor for assessment. (2, 4)

Pain management – Acetaminophen, ibuprofen or naproxen can be used for pain and should be given regularly for the first day or two. Since a burn can worsen over 24 to 48 hours, it should be reassessed frequently as the severity may have been underestimated at first.  Topical anesthetics such as benzocaine or lidocaine although cooling, are not recommended because they can cause irritation or allergic reactions. (2)

Manage Itching - Itching is a common problem while burns are healing. Antihistamines such as diphenhydramine (Benadryl) or cetirizine (Reactine) can help combat itching. Bathing in water with baking soda or oatmeal may help. Other topical treatments for itching include: aloe vera, petrolatum-based (Vaseline) creams, cocoa butter, mineral oil and oatmeal containing creams (Aveeno). (1) Topical steroids such as hydrocortisone can be applied to unbroken skin or burns that are healing well to help with itching. (2,5)

Antibiotic skin creams - Minor burns without broken blisters or cracked skin do not require a topical antibiotic. A topical antibiotic (e.g. Polysporin, generic brands) should be applied to burns where the skin is broken (e.g., where blisters have opened and exposed a layer of skin underneath). (2,5)

Dressings - Burns heal best in moist, not wet, conditions. To maintain a moist environment, apply a nonsticky dressing or skin protectant such as allantoin, cocoa butter or petrolatum to superficial burns. (5)

For small burns with minor blistering, a hydrocolloid dressing (DuoDERM, TegaDerm,) can be used to protect the burn and keep it moist. (2)

 

Provided by Jean Macpherson, BSP. Reviewed by Karen Jensen BSP, MSc
March 28, 2014

Sources

  1. DynaMed [Internet].  Ipswich (MA): EBSCO Information Services.  Minor burns [Updated 2013 May 20; cited 2014 March 28] Available from http://search.ebscohost.com/login.aspx?direct=true&site=DynaMed&id=113862. Registration and login required.
  2. PL Detail-Document, Management of Minor Burns. Pharmacist’s Letter/Prescriber’s Letter. April 2012.
  3. Rice, PL, Orgill, DP. Classification of burns.  In: UpToDate, Jeschke, MG(Ed), UpToDate, Waltham, MA, 2014
  4. Morgan, ED, Miser, WF. Treatment of minor thermal burns. In: UpToDate, Moreira, ME (Ed), UpToDate, Waltham, MA, 2014
  5. Tenenhaus, M, Rennekampff, H.  Local treatment of burns: Topical antimicrobial agents and dressings. In: UpToDate, Jeschke, MG(Ed), UpToDate, Waltham, MA, 2014

 

January 9, 2014
Q. Can my pet make me sick?
A.

The benefits of pet ownership are well documented from lowering blood pressure to improving symptoms of depression. However, although the risk is small, it is possible for your pet to make you sick. This is mainly a concern for people whose immune systems are impaired, for older adults, children under 5 and pregnant women.

 

Diseases that are transmitted from animals to humans are called zoonoses.  Many of the risks associated with zoonoses can be lessened by good hygiene after handling pets, careful pet selection, and proper pet care. Adult pets are generally safer than younger animals, since they are less likely to be involved in playful activities that include scratching and biting. Children are at highest risk for infection because they are more likely to have close contact with pets and less likely to understand the importance of hand washing after contact with animals.

 

Although both dogs and cats have been implicated in transmission of zoonoses to their owners, risk of transmission from contact is low. Infections which can potentially be contracted from a cat or dog include:

  • Rabies from contaminated saliva entering the blood stream through bites or scratches.
  • Superficial surface skin infections resulting from bites and scratches
  • Fungal skin infections such as ringworm transferred by direct contact with the skin of an infected animal
  • Toxoplasmosis, a disease caused by a parasite acquired by handling cat feces – dangerous for unborn babies if mothers are exposed
  • Salmonella (bacteria which cause food poisoning) from contaminated feces of either cats or dogs
  • Tick borne diseases such as Lyme disease if a pet brings these insects into contact with people.

 

Rodents, including hamsters, gerbils, guinea pigs, mice and rats are becoming more common pets. Ringworm is the most common zoonotic disease spread to humans from rodents and is spread by skin to skin contact. Transmission of infections which enter the body usually occurs through bites or exposure to bacteria in the feces.

 

Pet reptiles and amphibians such as snakes, turtles, lizards, geckos, and frogs can spread Salmonella infections which can cause fever, stomach upset and bloody diarrhea in humans. The organism is present in the feces and on the skin or shells of these animals.

 

Exotic pets such as monkeys, ferrets and hedgehogs can also spread disease to humans, most commonly fungal skin infections from direct contact and E. coli or Salmonella from handling of feces.

 

Some simple precautions can greatly reduce the possibility of your pet making you sick.

  • Pets should be seen by a veterinarian on a regular basis and treated promptly for diarrhea and skin infections
  • Cats and dogs should be vaccinated for rabies
  • Pets should be fed high quality commercial food and should not eat raw meat or eggs. They should not be allowed to eat garbage, feces, or hunt
  • Pets should not be allowed to drink non-potable water such as surface water or toilet water
  • Young pets present a greater risk for disease than older pets, as they are more likely to engage in playful nipping and biting, behavior which may transmit bacteria
  • Owners should wash their hands following contact with their pet or cleaning of their cages.
  • Pregnant women should not handle cat litter boxes.
  • Ringworm and minor skin infections can be treated with over-the-counter products. Ask your pharmacist for help in selecting the appropriate medication.

Prepared by Jean Macpherson, BSP. Reviewed by Karen Jensen BSP, MSC
January, 2014

Sources

References:

  1. Kotton, CN. Zoonoses from dogs. In: UpToDate, Sexton, DJ (Ed),UpToDate, Waltham, MA,2013.
  2. Kotton, CN. Zoonoses from cats. In: UpToDate, Sexton, DJ (Ed),UpToDate, Waltham, MA,2013.
  3. Kotton, CN. Zoonoses from pets other than dogs and cats. In: UpToDate, Sexton, DJ (Ed),UpToDate, Waltham, MA,2013.
  4. Public Health Agency of Canada. Injuries associated with... DOG BITES AND DOG ATTACKS. Available at  http://www.phac-aspc.gc.ca/injury-bles/chirpp/injrep-rapbles/dogbit-eng.php. Accessed December, 2013.
  5. Pawsitive thinking. (2013, November). Wellness Letter. University of California, Berkeley, Volume 30 (Issue No. 3). P.1-2.

December 30, 2013
Q. Can I still get a flu shot for this season?
A.

Saskatchewan health officials are reporting increasing influenza activity in the province.

The 2013/14 flu season started late in Saskatchewan, but has already resulted in hospitalization for some people with severe illness.  The level of influenza activity is expected to increase into the new year.

The Ministry of Health for Saskatchewan is encouraging Saskatchewan residents to get a flu shot if they haven’t already done so, and practice good hand hygiene to help them avoid getting sick.  In Saskatchewan and across Canada, H1N1 is the predominant strain causing illness this flu season.  This strain is included in this year’s flu vaccine. The injectable and nasal mist vaccines are still available and can be ordered through pharmacies, if necessary.

For Saskatoon and area vaccine supply information, please visit www.4flu.ca. If you live outside of Saskatoon, check your health region website or call HealthLine 811 to find out when and where vaccinations will be available near you.

Prepared by medSask, Your Medication Information Service
Updated Jan. 23, 2014

Sources

http://www.saskatchewan.ca/government/news-and-media/2013/december/27/take-steps-to-avoid-flu

http://www.saskatoonhealthregion.ca/your_health/ps_public_health_ip07_about.htm

http://www.health.gov.sk.ca/influenza-flu

https://clients.mckesson.ca

December 10, 2013
Q. Do generic drugs actually work as well as brand name drugs?  I’ve heard on the news (again!) that someone did much worse on a generic drug compared to the brand name drug.
A.

A recent news article, found here, has once again sparked the debate of whether generic drugs are just as good as brand name drugs.  To answer this question, it is important to understand the approval process of drugs in Canada to see how generic drugs come to market.

Health Canada decides which drugs are allowed to be sold in Canada.  Drug manufacturers, whether in Canada or internationally, must prove their product contains exactly what is labelled and abide by strict “Good Manufacturing Practice” guidelines.  Both brand name drugs and generic drugs are subject to the same criteria; there are not two separate approval processes.

Generic drugs must have the same amount of active ingredient as the brand name drug, but are allowed to have different non-active ingredients or “fillers”, which are ingredients that help hold the tablet together, make it easier to swallow, make it gentler on the stomach, or preserve the drug, etc.  If the generic drug is produced with different fillers, then the manufacturer must prove “bioequivalence” – that is, they must prove that the product delivers the same amount of drug to the body over a period of time compared to the brand name product.  In most cases, if the generic drug has the same fillers (and the same amount), a bioequivalence test is not necessary (1).

To perform a bioequivalence test, usually between 30 and 70 healthy people are tested in two groups.  An individual will receive either the brand or generic drug and the amount absorbed is measured.  The procedure is then repeated with the other drug.   If the drugs are absorbed and removed by the body at a similar extent over a period of time, they are deemed bioequivalent (2).  So, what is “a similar extent”?

People commonly claim bioequivalence requirements are too loose, that the amount of active ingredient in a generic drug is allowed to be from “80 to 125%” of that in the brand name product; thus, a possible 45% variance in the active ingredient is allowed.  This is untrue; the “80 to 125%” figure refers to a statistical term called the 90% confidence interval for the “area under the curve (AUC)” (3).  The confidence interval takes into account the absorption and excretion differences between people in the study, and the AUC is a measure of the concentration of a drug over time as it is absorbed into the body and then slowly removed from the body.  Putting it together, this means that when a generic drug is taken, the entire AUC (taking into account the differences between people being studied), must always fall between a small range of values which lie entirely between 80 to 125% of the stated amount, or it fails the equivalency test; practically, this means the actual variance is less than 5% (4), with studies finding an average variance of 3-4% (5). 

The graph below may help illustrate this point (3):

Graph

Only “A” passes the bioequivalence test, since the entire range of AUC values for individuals in the study lie between 80 and 125%.  The rest fail because their range of values cross the acceptable variance.

A variance of 3-4% must be put into perspective; different batches of the same brand name drug are allowed to have the same variance (6), thus, the potential variation from switching to a generic version is no different than the variation of receiving the same brand at different times.

Some argue that since some drugs must be dosed very accurately, the 3-4% variation can be important.  This is true, and so Health Canada has labelled some drugs as “critical dose drugs”, which means the range of AUC values must lie between 90 and 112%, rather than 80 to 125% (7); thus, the range in the graph above would be even tighter, creating an even smaller allowable variance.

Another misconception is that since generic drugs are less expensive than their brand name counterparts, they must be of poorer quality.  When a company develops a new drug, they spend a substantial amount on research and development of the drug, and must perform expensive studies to prove the safety and efficacy of the new drug.  This takes many years and an average of $1.1 billion (8).  The brand name manufacturers are rewarded for this investment with a patent – a time during which no other manufacturer can produce the drug.  The price set by the brand name manufacturer factors in the money spent in research and development.   Once patent expires, the generic drug companies are free to produce the drug.  Since they do not have to invest in research and development they can bring their version of a drug to market for a much lower cost—it has nothing to do with a lower quality product or substandard manufacturing. 

The advantage of generic drugs versus brand name drugs is lower cost. In Canada, since the government helps pay for many people’s medications, when a lower cost version is routinely given, it amounts to significant savings for the struggling health care system; approximately $7 billion was saved in 2010 (9).  Switching to generic medications to save all this money has NOT caused an increase in harm to patients; two large studies show no differences in outcomes when using generic drugs for patients with cardiovascular disease (10) or infections (11).

Certainly, from time to time, there are reports that a switch from one brand to another (from brand name to generic or from one generic to another generic) result in adverse effects.  This means that someone could experience a side effect that did not happen before the switch, or the drug may not work as well--but this is very rare.  Extra caution is suggested when switching between brands of “critical dose drugs” (e.g., anti-seizure drugs, warfarin, lithium, thyroid hormone, etc.) and extended release formulations (12).  If the medication does not seem to be working as well as normal or if side effects appear after a switch, contact your doctor. However, when starting on a new medication, a generic version is just as good as the brand version (13).

If generic drugs are just as good, why are there reports of people doing worse on them?  They may have different fillers, so if the generic version contained something like a sulfite and the brand name did not, an allergic reaction could be possible, though very rare.  More likely, there is significant bias at play; if a person has negative expectations about a generic drug, any issue will likely be blamed on the generic, instead of the real cause.  One has to consider that in almost all cases, no difference is noticed; these cases don’t make it to the news.

For the vast majority of people, generic drugs are just as good as the brand name drugs, and have enormous cost saving potential for our health care system and need to be utilized as much as possible.  Be confident taking a generic medication, as Health Canada has stringent regulations in place to ensure only safe and effective products are marketed.

 

Prepared by Terry Damm, BSP

Reviewed by Carmen Bell, BSP; Darcy Lamb, BSP, MSc; Karen Jensen, BSP, MSc

December 2013

Sources

1.  Health Canada.  Biopharmaceutics Classification System Based Biowaiver.  Accessed online Dec 2013.  http://www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/consultation/drug-medic/bcs_draft_guide_ebauche_ld_scb-eng.pdf

2.  Canadian Generic Pharmaceutical Association.  Bioavailability and Bioequivalence – What Are They?  Accessed online Dec 2013. http://www.canadiangenerics.ca/en/resources/docs/09.16.13%20Bioequivalence2013_Eng.pdf

3. Generic drug variability. Pharmacist's Letter/Prescriber's Letter 2008;24(7):240704.

4. The Canadian Agency for Drugs and Technologies in Health.  Similarities and Differences Between Brand Name and Generic Drugs.  Accessed online Dec 2013. http://www.cadth.ca/en/resources/generics/similarities

5. Davit BM, Nwakama PE, Buehler GJ, et al. Comparing generic and innovator drugs: a review of 12 years of bioequivalence data from the United States Food and Drug Administration. Ann Pharmacother. 2009;43(10):1583-1597.

6. Health Canada.  Good Manufacturing Practices Guidelines.  Accessed online Dec 2013. http://www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/compli-conform/gmp-bpf/docs/gui-0001-eng.pdf

7. Health Canada.  Comparative Bioavailability Standards: Formulations Used for Systemic Effects.  Accessed online Dec 2013.  http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/bio/gd_standards_ld_normes-eng.php#a2.1.1.6

8. Deloitte.  Measuring the Return from Pharmaceutical Innovation 2012. Accessed online Dec 2013.  http://www.deloitte.com/view/en_GB/uk/research-and-intelligence/deloitte-research-uk/deloitte-uk-centre-for-health-solutions/b47f30374ca4b310VgnVCM2000003356f70aRCRD.htm

9. Canadian Generics Pharmaceutical Assocation.  Accessed online Dec 2013. http://www.canadiangenerics.ca/en/

10. Aaron S. Kesselheim, MD, JD, MPH, Alexander S. Misono, BA, Joy L. Lee, et al. Clinical Equivalence of Generic and Brand-Name Drugs Used in Cardiovascular Disease. JAMA. 2008 December 3; 300(21): 2514–2526.

11. Snyman JR, Schoeman HS, Grobusch MP, Henning M, et al. Generic versus non-generic formulation of extended-release clarithromycin in patients with community-acquired respiratory tract infections: a prospective, randomized, comparative, investigator-blind, multicentre study. Clin Drug Investig. 2009;29(4):265-74.

12.  Lewek, P., Karsas, P.  Generic drugs: The benefits and risks of making the switch.  The Journal of Family Practice.  Accessed online Dec 2013.  http://www.jfponline.com/index.php?id=22143&tx_ttnews[tt_news]=175484#5911JFP_Article4-tab1

13. Gregory M. Peterson.  Generic Substitution of Antiepileptics: Need for a Balanced View.  Accessed online Dec 2013.  http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=3603

November 14, 2013
Q. Do I need a prescription to get the shingles vaccine?
A.

Yes, unless you are getting Zostavax™ at a public health clinic such as the International Travel Clinic, you will have to get a prescription from your doctor in order to obtain the vaccine. You must make an appointment in advance if you plan to get the injection at a Travel Clinic.

Shingles is a painful, blistering rash caused by the same virus that causes chickenpox. The chickenpox virus (varicella-zoster) stays in your nerve cells after the chickenpox blisters heal. It may remain dormant for many years and not cause a problem, but in some people it may become reactivated for unknown reasons and cause shingles.

Shingles usually occurs in one part of the body, frequently around bottom of the rib cage.  The rash can last for several weeks and may result in scarring. The nerve pain that comes from shingles can last for months or years after the rash heals. This is known as post-herpetic neuralgia.

The shingles vaccine,  Zostavax™, is recommended for people over the age of 60 years to prevent shingles. The vaccine works by boosting your immune system to reduce your risk of getting shingles and the associated pain and other serious complications.  It reduces the risk of getting shingles from 3.3% to 1.6%.. If you do get shingles even though you have been vaccinated, the vaccine may reduce the pain and length of time the pain from shingles will last.

Many insurance plans do not cover the cost of Zostavax™, it is not on the Saskatchewan Drug Plan Formulary, and is not included in the publicly funded immunization programs. The cost to the patient is about $200 (as of November 2013). If you have an insurance plan that does cover this vaccine, you will require a prescription receipt for reimbursement. Check with your insurance plan to ensure it will cover vaccinations received at a Travel Clinic and what documentation is required for reimbursement.

Because the vaccine must be stored frozen at an average temperature of -15°C or colder until it is ready for injection, not all clinics, physicians’ offices or pharmacies will have Zostavax™ in stock. www.vaccines411.ca  is a useful website which can help you find a location that offers Zostavax™.

Prepared by Jean Macpherson BSP. Reviewed by Karen Jensen MSc, BSP and Carmen Bell, BSP.

Sources

1)       Health Canada Drug Product Database – product monograph for Zostavax available at http://www.hc-sc.gc.ca/dhp-mps/prodpharma/databasdon/index-eng.php
2)       National Advisory Committee on Immunization (NACI). Update on the Use of Herpes Zoster Vaccine. November, 2013.
3)       Albrecht, Mary A. Prevention of varicella-zoster virus infection: Herpes zoster. In UpToDate, Hirsch,MS(Ed), UpToDate, Waltham, MA, 2013
4)       Saskatchewan Prescription Drug Plan. http://formulary.drugplan.health.gov.sk.ca/
5)       Personal communication with International Travel Centre Telephone: 306-655-4780
6)         Zostavax website. http://zostavax.ca/clinic.html

October 16, 2013
Q. Is it true that people with egg allergies can now get the flu shot?
A.

Yes, recent research has proven that most people allergic to eggs can safely receive trivalent inactivated influenza vaccine (Fluviral, Agriflu,  Vaxigrip or FluZone for use in those 6 months and over and Influvac for use in those 18 years and over).

  • People with mild reactions such as hives, or those who tolerate eggs in baked goods may be vaccinated in regular vaccination clinics.
  • Those who have suffered from anaphylaxis with respiratory or cardiovascular symptoms should be vaccinated in a medical clinic, allergy office or hospital where appropriate expertise and equipment to manage respiratory or cardiovascular compromise is present. These individuals should always be kept under observation for 30 minutes.
  • Although likely safe, there is not enough information to recommend live attenuated influenza vaccine (FluMist) for egg-allergic individuals at this time.

In the past, people with known allergic reactions to eggs (hives, swelling of the mouth and throat, difficulty in breathing, drop in blood pressure, or shock) were advised to avoid vaccines manufactured in egg, including influenza vaccines. However, a number of recent studies have found that the influenza vaccine does NOT cause any serious ill effects in most egg-allergic individuals. The benefits of receiving influenza vaccine therefore greatly exceed the small risk for people with egg allergy.

Sources

1)      National Advisory Committee for Immunization (NACI) 2013–2014 flu season recommendations. Available at http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/13vol39/acs-dcc-4/index-eng.php. Accessed October 2013.

2)     Centers for Disease Control and Prevention. Seasonal Influenza (Flu). Available at http://www.cdc.gov/flu/professionals/vaccination/vax-summary.htm

Prepared by Dorothy Sanderson BSP and Karen Jensen MSc, BSP
medSask, Your Medication Information Service
Oct 15, 2013.

August 28, 2013
Q. What would cause my urine to change colour?
A.

Table: Change in Urine Colour and / or Appearance

Urine Colour / Appearance Foods Drugs Medical Conditions Medical Advice
Cloudy white Foods with a high purine content (E.g. anchovies, gravies, kidney, liver, sardines) Not applicable

- Urinary tract infection (UTI)

- Kidney stones

Seek medical advice for confirmation and treatment, especially if symptoms are accompanied by pain or fever

Blue or green

- Asparagus

- Brightly coloured food dyes 

- Some dyes used for testing kidney and bladder function

- Amitriptyline

- Indomethacin

- Cimetidine

- Promethazine

- Propofol

- Triamterene

- Blue diaper syndrome – an inherited condition that causes blue urine in babies

- Urinary tract infections (UTI) caused by certain kinds of bacteria

Seek medical advice for confirmation and treatment if condition persists for longer than 24 hours, is accompanied by pain on urination or fever and if food or drugs cannot be ruled out.

Orange

- Carrots

- Carrot juice

- Vitamin C

- Rifampin

- Sulfasalazine

- Pyridium

- Warfarin

- Dehydration

- Liver or bile duct problems

Seek medical advice if accompanied by lethargy, headache, dry mouth, extreme thirst, rapid heartbeat or light coloured stools

Red or pink

- Beets

- Blackberries

- Rhubarb

- Levodopa

- Chlorpromazine

- Thioridazine

- Propofol

- Rifampin

- Pyridium

- Senna and/or cascara containing laxatives

- Chronic lead or mercury poisoning

- Presence of blood (hematuria)
Seek medical advice if recent consumption of probable food causes cannot be ruled out
Dark brown

- Fava beans

- Rhubarb

- Aloe

- Metronidazole

- Nitrofurantoin

- Methocarbamol

- Senna and/or cascara containing laxatives

- Chloroquine

- Primaquine

- Vitamin B complexes

- Hepatitis

- Jaundice

- Cirrhosis

- Some UTI’s

- Breakdown of muscle tissue
Seek medical advice if recent consumption of probable food causes cannot be ruled out or if accompanied by pain on urination, fever, yellow skin or pale stools
Foamy Not applicable Not applicable

- Occasional foaminess is normal and may be influenced by the speed of passing urine or mild dehydration.

- Persistent foaminess may be a sign of protein in the  urine (proteinuria) and may indicate a UTI or a kidney problem

Seek medical advice if you have persistently foamy urine that becomes more noticeable over time. Testing may be necessary to determine the cause of the problem.

Sources

1) http://www.mayoclinic.com/health/urine-color/DS01026

2) http://www.uspharmacist.com/continuing_education/ceviewtest/lessonid/106254/ Urinalysis: A Guide for Pharmacists.

3) http://www.mayoclinic.com/health/foamy-urine/AN01702

 

Produced by Jean Macpherson, BSP. Reviewed by Karen Jensen, MSc, BSP

medSask Drug Information Consultants

August, 2013

 

July 3, 2013
Q. What are e-cigarettes?  Are they safe?
A.

An electronic cigarette, or e-cigarette, is a battery-run device that mimics cigarette smoking by producing mist for inhalation with the feel, look, and in some countries, the flavor and nicotine content of tobacco smoke. The devices usually use heat to vaporize a propylene glycol or glycerin-based liquid solution into a mist, similar to the way a humidifier works. The mist can be inhaled and exhaled, creating a vapor cloud that looks like cigarette smoke. Because nothing is actually burning, smoking an e-cigarette is odorless, and it doesn’t produce any ash. (1, 2)


Most electronic cigarettes are about the shape and size of a ballpoint pen, although this varies depending on battery sizes. Many e-cigarettes are designed to look like actual cigarettes or cigars, or even pipes. Some models are reusable, with replaceable and refillable parts and some are disposable. (1, 2)

E-cigarettes containing nicotine are not approved for sale in Canada.(3,4) They are however, available in other countries including the United States and people may have tried them while travelling.(3) Products available in Canada may have the same brand names as nicotine-containing products from elsewhere but contain only aromas or flavorings without the nicotine. (2)

Health Canada advises Canadians not to purchase or use electronic smoking products containing nicotine, as these may pose health risks and have not been fully studied for safety, quality and efficacy by Health Canada.(4) E-cigarettes containing nicotine are advertised on the Internet but Canada Customs will seize orders containing these products if the department catches them.

 

Benefits versus risk

The possible benefits or adverse effects of electronic cigarette use are a subject of disagreement among different health organizations and researchers. While many people consider, and e-cigarette manufacturers claim, that these are safer than cigarettes, the effects have not been well studied. (1, 2)

E-cigarettes are advertised as an alternative to regular cigarettes, as they try to give the experience of smoking without the adverse health effects of tobacco smoke. Recent uncontrolled studies, reported that a certain number of smokers have quit smoking using electronic cigarettes.(1,2) This suggests electronic cigarettes may help people stop smoking..

Saskatchewan has one of the highest cigarette smoking prevalence rates in Canada. Prevalence of smoking among 15-19 year olds is higher in Saskatchewan than the national average.(5)

Unless smokers quit, up to half of them will die as a result of their smoking, most of them before their 70th birthday and after years of suffering a reduced quality of life.  (3)

However, concerns have been raised that e-cigarettes may carry health risks of their own, and they could appeal to non-smokers, especially children, due to their novelty, flavorings, and claims of safety.(3,4) For stopping smoking, Health Canada has authorized the sale of several well-studied options, including over-the-counter nicotine replacement products (gum, lozenges, patches, etc.) and prescription medications (Zyban®, Champix®). (6)

The amount of nicotine in e-cigarette solutions varies by manufacturer, as there is no standard dose for each strength category (e.g., low, high). A consumer buying a nicotine-containing product marked as ‘high’ could receive a solution with a different concentration in nicotine from another product marked as ‘high’, depending on the manufacturer. The fatal dose of nicotine is estimated at 30–60 mg in adults and 10 mg in children. Studies have shown that some e-cigarette solutions contain nicotine doses potentially lethal in adults and children. For example, a 5 ml vial of a 20 mg/ml solution contains 100 mg of nicotine. (7)

Reports of unintentional poisoning in children from tobacco (cigarette butts) and smokeless tobacco (chewing tobacco or snuff) products suggest minor toxicity (e.g., vomiting, nausea, and increased heart rate) in most cases.(6) However, the amount of nicotine contained in the 5, 10 or 20 ml vials commonly uses in e-cigarettes, poses a much higher risk of  severe toxicity or fatality in children if taken orally or absorbed through the skin. This is particularly concerning as e-cigarette nicotine solutions come in flavors attractive to children such as chocolate, cotton candy and bubble gum. (7)

Nicotine dependence can start to occur within weeks of occasional tobacco use, so even brief experimentation with nicotine-containing e-cigarettes could promote adolescents' interest in using other tobacco products. (8) Experts rank nicotine ahead of alcohol, cocaine and heroin with regard to the severity of dependence resulting from its use. Those who start to smoke at an early age are more likely to develop severe levels of nicotine addiction than those who start later, and they are at higher risk of adverse health effects in adult life. (5)

E-cigarettes may  be helpful for people trying to stop smoking as they replace some of the habits associated with smoking cigarettes  and could become a tool - if studied more extensively - in the fight against tobacco-related illness and death.(9)

 

Produced by Jean Macpherson, BSP. Reviewed by Karen Jensen, MSc, BSP

medSask Drug Information Consultants

June, 2013

Sources

  1. www.jasperandjasper.com/what-is-in-an-e-cig-pm-29.html. Accessed June 2013.
  2. http://jasperandjasper.ca/about-us-3. Accessed June 2013.
  3. O’Mara NB. Electronic Cigarettes and Hookah Pipes. Canadian Pharmacists’ Letter: PL Detail-Document. Pharmacist’s Letter/Prescriber’s Letter. May 2013.
  4. Health Canada. Health Canada Advises Canadians Not to Use Electronic Cigarettes. Available at http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2009/13373a-eng.php . Accessed June 2013.
  5. Gov’t Sask. Health effects of tobacco. Available at http://www.health.gov.sk.ca/health-effects-tobacco http://www.health.gov.sk.ca/health-effects-tobacco. Accessed Junes 2013.
  6. Health Canada. Drug Product Database. Available at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp . Accessed June 2013.
  7. Cameron JM., Howell DN, White JR et al. Variable and potentially fatal amounts of nicotine in e-cigarette nicotine solutions. Tobacco Control.2013.
  8. Pepper J, Reiter P, Annie D et al. Adolescent Males' Awareness of and Willingness to Try Electronic Cigarettes.  Journal of Adolescent Health, Volume 52, Issue 2, February 2013, Pages 144–150.
  9. Caponnetto P, Russo C, Bruno CM et al. Electronic cigarette: A possible substitute for cigarette dependence, Monaldi Archives for Chest Disease - Pulmonary Series, 2013 (1) , pp. 12-19.

July 3, 2013
Q. Will Yaz ® and Yasmin® increase my chances of blood clots?
A.

A concern with taking oral contraceptives or birth control pills is that they may slightly increase a woman’s chance of developing a venous thromboembolism (VTE). VTE is the development of a blood clot within the veins, usually in the legs or pelvis. The use of all oral contraceptives will increase the chances of developing VTE compared to a woman not taking an oral contraceptive.  

Although the likelihood of developing VTE is rare it is still a serious condition. When identified and treated early, most VTE cases will get better without causing any long term problems. Sometimes the blood clot may break loose and travel to other parts of the body, such as the lungs, becoming a pulmonary embolism, which can be fatal. One out of 100 or 1% of pulmonary embolism cases are fatal (1 & 5).

The risk of blood clots is increased by many other factors including (but not limited to): immobility (not being active, sitting for prolonged periods of time), obesity, pregnancy, smoking, family history of blood clots, and blood clotting disorders. (1)

When considering oral contraceptives, you should be aware of the risks and benefits of these medications. For most women who choose to use oral contraceptives, the benefits usually outweigh the risk. They prevent pregnancy, reduce uterine cyst formation, decrease your chance of developing certain types of cancers such as ovarian and endometrial  They can also help with menstrual symptoms and regularity. (1, 3 & 4) When discussing your oral contraceptive your doctor or pharmacist will ask questions about your health and family history to ensure the best oral contraceptive is prescribed for you.

To get a better understanding of the risk of VTE, The Society of Obstetricians and Gynecologist of Canada have posted a few comparative estimated rates for the development of VTE in woman (1 & 4):

 

Table 1: Rates of Venous Thromboembolism

Women

Number

Percentage

Not taking oral contraceptives

4-5/10,000

0.04 – 0.05% 

Taking oral contraceptives

8-10/10,000

0.08 – 0.1%

Pregnancy

Up to 29/10,000

0.29%

After giving birth (first few weeks)

Up to 300-400/10000

3 – 4%

 

The death rate from oral contraceptive use is 1/100 000 or 0.001% when taking into considerations the values above (1).                                                               

Yaz® and Yazmin® are combination oral contraceptives. This means that they contain a combination of two hormones estrogen and progesterone. The synthetic estrogen is called ethinyl estradiol and the synthetic form of progestin is termed drospirenone. (2)

There has been some controversy over whether Yaz ® and  Yasmin® increases the chances of developing VTE more than other oral contraceptives. The evidence associated with these claims or with the comparison of risk between oral contraceptives is conflicting. (1, 4, & 5) Some studies suggest there is a slight increase in risk of VTE when using the newer generation progestin; however, some studies have also suggested that there is no significant difference between them. (1, 4, & 5) Because of the conflicting evidence, we cannot say that Yaz ® and Yasmin® do or do not have higher VTE risk associated with them in regards to other oral contraceptives.

Our recommendations:

  • If you are currently taking Yaz ® and Yasmin® then there is no need to switch or stop. The risk of developing a VTE when using oral contraceptives is highest in the first few months, so if you have been on it long term, your risk is normal.
  • If you are starting an oral contraceptive for the first time or switching, consider using an oral contraceptive other than Yaz ® and Yasmin®, especially if you are concerned or have other risk factors for VTE.
  • With this being said, Yaz ® and Yasmin® may be appropriate choices for woman with certain conditions, such as acne or excess body hair.

 

If you are taking an oral contraceptive it is good to know the signs and symptoms of VTE (Table 2). If you experience any of these see a doctor as soon as possible.

Table 2: Signs and symptoms of VTE

In the LEG

In the LUNG

Pain in the leg or calf

Sharp chest pain

Increased warmth in leg

Shortness of breath

Swelling in the calf, ankle, or foot

Coughing (possibly coughing up blood)

Red, purple, or blue discoloration in the leg

Rapid heartbeat

Redness of skin

Feeling faint

 

 

Produced by Joanne Fontaine, Pharmacy student, medSask
Reviewed by Karen Jensen MSC, BSP, Carmen Bell BSP; Terry Damm BSP
June 2013

Sources

1. The Society of Obstetricians and Gynaecologists of Canada. Position Statement: Hormonal Contraception and Risk of Venous Thromboembolism (VTE). Available at http://sogc.org/media_updates/position-statement-hormonal-contraception-and-risk-of-venous-thromboembolism-vte/. Accessed June, 2013

2.  Lexicomp. Yaz . Available at www.lexi-com by subscription. Accessed June, 2013

3. Rx files. YASMIN: Hormonal Contraception- Supplement Tables. Available at http://www.rxfiles.ca/rxfiles/uploads/documents/members/CHT-OCs-Color.pdf.  Accessed June, 2013

4. Rx files. YASMIN: Safety Considerations related to Venous Thromboembolism (VTE). Available at http://www.rxfiles.ca/rxfiles/uploads/documents/Yaz-Yasmin-Q-A.pdf. Accessed June, 2013

5. Food and Drug Administration. Updated External Questions and Answers – Ongoing safety review of birth control pills containing drospirenone and a possible increased risk of blood clots. Available at http://www.fda.gov/Drugs/DrugSafety/ucm299348.htm. Accessed June, 2013

6. Patient Health International. Venous Thromboembolism. Available at http://www.patienthealthinternational.com/venous-thromboembolism/facts-and-figures/symptoms?itemId=1620499&nav=yes. Accessed June, 2013

June 13, 2013
Q. Are Omega supplements useful?  I’ve heard a lot about them in the media.
A.

There has been a lot of media buzz for omega supplements, and many people have started taking them for various purposes; but do they actually help any conditions, and which supplements are best?

Navigating the omega supplement aisle is a daunting experience.  There are omega-3, omega-6, omega 3-6-9, alpha-linolenic acid, krill oil, salmon oil, flaxseed oil and many more supplements to confuse a shopper.  Many of the products available are either marketing gimmicks that have no value, or have not been shown to help for most conditions. 

Quick facts:

  • Dietary omega-3 from two to three servings of fatty fish (salmon, mackerel, tuna, sardines, or white fish) per week continues to be recommended for maintenance of good health (1)
  • Fish oil omega-3 supplements may not be as useful for heart health as once suspected
  • Fish oil omega-3 supplements are very safe when taken in doses under 3g per day.  Higher doses can lead to problems and should not be taken without consulting your doctor or pharmacist.
  • Omega-6 and omega-9 are heart healthy fats; however, most people have too much in their diet and excess supplementation can lead to harm.

The following is a review of the safety and effectiveness of various omega fatty-acid supplements.

1) Omega-3 supplements

                Omega-3 supplements have the largest amount of research behind them.  They have been promoted for preventing heart disease and stroke, and may also have a role in treating rheumatoid arthritis, mental health problems and dementia (2,3).  However, there is limited or inconclusive evidence that omega-3 supplements actually help these conditions. Until more reliable information becomes available, omega-3 supplements cannot be recommended for these conditions.

The types of omega-3 fatty acids with the most research in various health conditions are called EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid).  The other types of omega-3 supplements, such as flaxseed oil or other plant sources, do not have as much research behind them.

Fish oil, which provides EPA and DHA, has been used to help prevent strokes or heart attacks, and to also lower triglycerides.  Original research showed a modest improvement in cardiovascular health and a reduction in heart attacks and stroke, especially in a person who had already had a heart attack or stroke (2).

However, a new body of quality research suggests fish oil supplements do not improve heart health or reduce the risk of heart attack or stroke (4,5).  In contrast, one study found higher dietary omega-3 intake from fatty-fish (salmon, mackerel, tuna, sardines, or white fish) reduced the risk of stroke (6).

Fish oils also have been investigated for their use in improving mental health, dementia, and rheumatoid arthritis; the evidence is inconclusive and requires further research (7).

Fish oil supplements are not a substitute for a healthy diet, which incorporates two or three servings of fish per week, since supplements may not have the same heart health benefits as omega-3 obtained through the diet.

If you do choose to take a fish oil supplement, there are some potential side effects and safety issues.  Fish oil supplements most commonly cause a fishy aftertaste or "fishy burp." They can also cause heartburn, nausea, diarrhea or rash, but they are usually well tolerated.  Taking supplements with meals or freezing them seems to help decrease these side effects for some patients.   Doses higher than 3g per day can lead to more harm (such as an increase in LDL cholesterol and an increased risk of internal bleeds if you’re also taking an anti-coagulant medication like warfarin) than benefits, and should not be taken without consulting your doctor or pharmacist (7).

Krill Oil also provides EPA and DHA, but in much lower amounts than other fish oil supplements, and there is also no data showing cardiovascular benefits.  If you want to try an omega-3 supplement, regular fish oil supplements should be tried first.  If there are too many side-effects, then a krill oil supplement can be tried.  Most brands of Krill oil also contain Vitamin A, D and E, so care must be taken to be sure you are not taking more than the safe daily amounts of these vitamins (2).

Alpha-linolenic acid (ALA) is another type of omega-3 supplement and is found in flaxseed oil.  There is very limited evidence ALA supplementation is helpful in cardiovascular disease, although increasing dietary intake of ALA may be useful for heart health (1).  ALA does not replace the EPA and DHA you should get in your diet (2,7).

Omega-3 supplements are often marketed as a miracle pill, but they do not appear to have the benefits they were once thought to have.  Dietary omega-3 from fatty fish continues to be recommended to maintain general health.  If you do choose to take an omega-3 supplement, only omega-3 found in fish oil products might be beneficial, and they are safe supplements to take at doses of less than 3g per day.

2) Omega-6 supplements

                Omega-6 fatty acids come from vegetable oils, soy and nuts.  Omega-6 is a heart healthy fat, but in the typical western diet, most individuals already consume too much, so supplementing more is not necessary; omega-6 in excess amounts found in supplements can be harmful, leading to an increase inflammation, constriction of blood vessels and a possible negative impact on heart health (2). 


3) Omega-9 supplements

                Omega-9 supplements have not been studied as extensively as Omega-3.  The most common source of Omega-9 is olive oil.  The only available evidence suggests if olive oil replaces other fats and oils in the diet, it can have a benefit to cholesterol levels and overall cardiovascular health.  If you are considering using olive oil in your diet, ensure it replaces other oils, rather than adding to other oils (2,7).

Sources

1) Health Canada Food Guide. Accessed online, 2013 April 10.
[http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php]

2) PL Detail-Document, Omega-3 Fatty Acids. Pharmacist’s Letter/Prescriber’s Letter. August 2012.

3) Heather Hutchins, MS, RD.  Symposium Highlights -- Omega-3 Fatty Acids: Recommendations for Therapeutics and Prevention.  Accessed Online, 2013 April 10. [http://www.medscape.org/viewarticle/514322]

4) Kwak SM, Myung SK, Lee YJ, Seo HG. Efficacy of omega-3 fatty acid supplements (eicosapentaenoic acid and docosahexaenoic acid) in the secondary prevention of cardiovascular disease: a meta-analysis of randomized, double-blind, placebo-controlled trialsArch Intern Med. 2012 May 14;172(9):686-94.  Accessed online at: http://www.ncbi.nlm.nih.gov/pubmed/22493407]

5) Evangelos C. Rizos, MD, PhD; Evangelia E. Ntzani, et al. Association Between Omega-3 Fatty Acid Supplementation and Risk of Major Cardiovascular Disease EventsA Systematic Review and Meta-analysis. JAMA. 2012;308(10):1024-1033.  Accessed online at: [http://jama.jamanetwork.com/article.aspx?articleid=1357266]

6) Association between fish consumption, long chain omega 3 fatty acids, and risk of cerebrovascular disease: systematic review and meta-analysis.  BMJ 2012;345:e6698.  Accessed online at: [http://www.bmj.com/content/345/bmj.e6698]

7) Natural Medicines Comprehensive Database.  Accessed Online, 2013 April 10.

June 10, 2013
Q. What are the differences between Hepatitis A, B, and C?  Can they be prevented?
A.

The term hepatitis literally means “inflammation of the liver”. This can be caused by excessive alcohol use and by some toxic substances, but it is most commonly caused by a virus, Hepatitis A, B or C. The following table summarizes the differences between the different types of hepatitis infection.

 

Hepatitis A Hepatitis B Hepatitis C
Cause
  • Hepatitis A Virus (HAV).
  • HAV only results in acute (less than 6 months) infection; chronic infection (continuing for more than 6 months) does not develop.
  • Highly infectious
  • Hepatitis B Virus (HBV)
  • HBV can result in both acute (<6 months) or chronic (>6 months) infection
  • Most people infected with hepatitis B as adults recover fully, even if their signs and symptoms are severe.
  • Babies and children are much more likely to develop a chronic hepatitis B infection.
  • Chronic HBV can lead to scarring of the liver, liver failure or liver cancer.
  • Hepatitis C Virus (HCV)
  • Can result in both acute and chronic infection
  • The acute infection stage clears up on its own without treatment and rarely causes liver failure
  • The risk of chronic infection after an acute episode of hepatitis C is high
  • Periodic testing for infection may be useful in patients who are at high risk for infection
  • Chronic HCV can lead to scarring of the liver, liver failure or liver cancer.

Transmission/

Spread
  • Spread through food or water contaminated by stool from an infected person
  • Eating food prepared by someone with HAV who did not wash their hands after using the bathroom
  • Having anal/oral sex with someone with HAV
  •  Not washing your hands after changing a diaper
  • Drinking contaminated water
  • People are contagious for 2 to 6 weeks before symptoms appear and so can spread the disease before they know they have it
  • Spread by contact with an infected person's blood, semen or other body fluid.   
  • An infected woman can give hepatitis B to her baby at birth
  • Having sex with an infected person
  • Being tattooed or pierced with unsterilized tools that were used on an infected person
  • Getting an accidental needle stick with a needle that was used on an infected person
  • Using an infected person’s razor or toothbrush
  • Sharing drug needles with an infected person
  • Spread by contact with infected blood or body fluids.
  • Most common way people get infected is by needle-sharing during intravenous drug use.
  • An infected woman can give hepatitis C to her baby at birth.
  • Since reliable blood screening procedures became available, the risk of transmission of hepatitis C by blood transfusion is less than one per million units of transfused blood
  • Rarely, the virus can be transmitted through sexual intercourse
Symptoms
  • Appear 2 to 6 weeks after initial infection
  • Abdominal pain
  • Dark urine
  • Fever
  • Joint pain
  • Loss of appetite
  • Nausea and vomiting
  • Weakness and fatigue
  • Yellowing of your skin and the whites of your eyes (jaundice)
  • Appear about 3 months after initial infection
  • Abdominal pain
  • Dark urine
  • Fever
  • Joint pain
  • Loss of appetite
  • Nausea and vomiting
  • Weakness and fatigue
  • Jaundice

Acute:

  • Jaundice is present in fewer than 25 percent. 
  • Additional symptoms are similar to other forms of acute viral hepatitis, including malaise, nausea, and pain in the upper right area under the ribcage.
  • In patients who experience symptoms, these usually last for 2 to 12 weeks.

Chronic:

  • Most people who are infected with hepatitis C don't have any symptoms for years.
  • The most frequent complaint is fatigue
  • Other less common symptoms include nausea, anorexia, muscle and joint pain, weakness, and weight loss.
Prevention
  • Vaccination for Hepatitis A
  • Proper hand washing
  • Heating food to correct temperature
  • Avoiding water and food from possible contaminated areas
  • Passive immunization prophylaxis with serum immune globulin is available pre and post exposure
    • Vaccination for Hepatitis B
    • Preventive treatment may reduce the risk that the virus will infect your body. But the treatment must be given within 24 hours of exposure to the hepatitis B virus.
    • Know the HBV status of any sexual partner and use condoms.
  •  Be cautious about body piercing and tattooing and use a reputable shop
  • Avoid illicit drug use and non-sterile needles
  • Avoid using other peoples razors or toothbrushes if you don’t know their background
    • There is no vaccine to prevent hepatitis C infection.
  •  Know the HCV status of any sexual partner and use condoms.
  •  Be cautious about body piercing and tattooing and use a reputable shop
  •  Avoid illicit drug use and non-sterile needles
  • Do not donate blood, organs or tissue if you know you have Hepatitis C
  • Avoid using others razors or toothbrushes if you don’t know their background
Treatment
  • Vaccination for Hepatitis A
  • Proper hand washing
  • Heating food to correct temperature
  • Avoiding water and food from possible contaminated areas
  • Passive immunization prophylaxis with serum immune globulin is available pre and post exposure
  • Vaccination for Hepatitis B
  • Preventive treatment may reduce the risk that the virus will infect your body. But the treatment must be given within 24 hours of exposure to the hepatitis B virus.
  • Know the HBV status of any sexual partner and use condoms.
  • Be cautious about body piercing and tattooing and use a reputable shop
  • Avoid illicit drug use and non-sterile needles
  • Avoid using other peoples razors or toothbrushes if you don’t know their background
  • There is no vaccine to prevent hepatitis C infection.
  •  Know the HCV status of any sexual partner and use condoms.
  • Be cautious about body piercing and tattooing and use a reputable shop
  • Avoid illicit drug use and non-sterile needles
  • Do not donate blood, organs or tissue if you know you have Hepatitis C
  • Avoid using other peoples razors or toothbrushes if you don’t know their background

Prepared by Jean Macpherson BSP. Reviewed by Karen Jensen MSc, BSP.

medSask: Your Medication Iinformation Service

June 5, 2013

Sources

  1. 1.       MedlinePlus. Hepatitis A. Available at http://www.nlm.nih.gov/medlineplus/hepatitisa.html. Accessed  May, 2013
  2. 2.       MedlinePlus. Hepatitis B. Available at http://www.nlm.nih.gov/medlineplus/hepatitisa.html. Accessed  May 2013.
  3. 3.       MedlinePlus. Hepatitis C. Available at http://www.nlm.nih.gov/medlineplus/hepatitisa.html. Accessed  May 2013.
  4. 4.       Cheney, Catherine P. Overview of hepatitis A virus infection in adults. In: UpToDate, Hirsch, MS (Ed), UpToDate, Waltham, MA, 2012.
  5. 5.       Sanjiv Chopra. Clinical manifestations and natural history of hepatitis C virus infection. . In: UpToDate, Adrian M Di Bisceglie (Ed), UpToDate, Waltham, MA, 2012.
  6. 6.       Crespi, Judy. The A, B, Cs (+ D + E) of hepatitis. Review - American Pharmacists Association Continuing Pharmacy Education. Pharmacy Today 2012; May: 75 – 84. Available at pharmacists.com. Accessed May 2013.

May 21, 2013
Q. Will taking Garcinia cambogia help me lose weight?
A.

There is unclear or conflicting scientific evidence for the claim that Garcinia cambogia is useful for weight loss.  Much of the positive evidence comes from laboratory and animal studies. Reviews of the studies done with people conclude that Garcinia cambogia

  • Does not decrease weight or burn fat in obese people
  • Might cause people to eat less by making them feel full, but more studies are needed to prove this helps people lose weight.

 

Garcinia cambogia is an extremely small, purple fruit that is naturally found in India and Southeast Asia. It is used to flavor food in Thai and Indian cooking. The rind of the fruit is rich in a substance called hydroxycitric acid (HCA). It has been proposed that HCA helps the body burn carbohydrates and fat.

 

It is considered to be safe when used in doses of up to 2800 mg daily for 12 weeks or less. There is no reliable information on its safety in long-term use.

 

Side effects Garcinia cambogia may cause include nausea, upset stomach, and headache.

 

People should use Garcinia cambogia cautiously if they:

  • Have diabetes because it can affect blood sugar levels.
  • Take a ‘statin’ drug, for example, atorvastatin (Lipitor, generics) or rosuvastatin (Crestor) to lower cholesterol as it may increase the risk of having an adverse reaction involving the breakdown of muscle tissue.
  • Have Alzheimer’s disease or other dementia disorders as it may increase production of a chemical in the brain which affects these conditions.

 

Prepared by Jean Macpherson, BSP. Reviewed by Karen Jensen BSP, MSc and Carmen Bell, BSP.

 


Sources

1) Garcinia cambogia monograph. Natural Medicines Comprehensive Database. Available online by subscription. Accessed May 14, 2013

2) Garcinia (Garcinia cambogia), Hydroxycitric acid Natural Standard Professional Monograph, Copyright © 2013 (www.naturalstandard.com). Accessed May 14, 2013.

3) Health Canada. Licensed Natural Health Products Database. Available at http://webprod3.hc-sc.gc.ca/lnhpd-bdpsnh/index-eng.jsp.  Accessed May 20, 2013.

4) Márqueza F, Babioa N, et al. Evaluation of the Safety and Efficacy of Hydroxycitric Acid or Garcinia cambogia Extracts in Humans. Critical Reviews in Food Science and Nutrition 2012;52: 585-594.

April 5, 2013
Q. Do vitamin supplements help prevent or reduce age-related macular degeneration (AMD)?
A.

Quick facts

  • There are not any miracle supplements to help cure or prevent AMD. 
  • No supplements have been proven to prevent AMD.
  • The Vitalux-AREDS® formula may slow the progression of intermediate  to advanced dry AMD, but does not prevent AMD.
  • Vitamins for eye health can potentially be harmful and should not be started without consulting your optometrist, doctor or pharmacist.
  • Improving your diet by increasing fatty fish and vegetable intake may help your eye health.

 

Many vitamin, mineral and herbal products are on the market promoting healthier eyes, enhanced vision, or even treating age-related macular degeneration (AMD).

But is there any truth behind these products?

AMD is a major cause of blindness in adults, leading many people to do whatever they can to prevent the condition.  There are two types of AMD—wet and dry—which influences what supplements are effective.

Dry AMD is more common than wet AMD.  Dry AMD causes vision loss slowly and gradually, and progresses in three-stages: early, intermediate and advanced. In contrast, wet AMD causes rapid distortion and severe loss of vision.  Dry AMD can progress into wet AMD. (2,3)

There is some evidence that supplements can help slow the progression of dry AMD at certain stages; wet AMD cannot be treated with supplements and requires more specialised treatment. (2) 

The following is a review of the safety and effectiveness of different supplements used to treat dry AMD:

1) Omega-3 fatty acids

A few studies have found that dietary omega-3 fatty acids (found in fatty fish like salmon, mackerel, tuna, sardines, or white fish) helped protect against developing the early stages of AMD and progressing to more advanced stages.  However, no studies have been done to show omega-3 supplements help with AMD.  Consider increasing your intake of fatty fish to two servings per week to help with eye health, but supplements are not yet proven (1). 

Omega-3 supplements are very safe when taken in normal amounts of under 2-3 grams of fish oil per day.  Some people experience a fishy aftertaste or ‘fish burp’ while on the supplements.  Others also experience nausea, diarrhea or heartburn, but is generally very well tolerated.  People taking drugs that affect blood clotting, like warfarin, should not take over 3 grams of fish oils per day, as this can increase your risk of bleeding. 

2) Lutein

Lutein, by itself, has been marketed for eye-health.  Few studies have been done with dietary and supplementary lutein.  Dietary lutein was associated with a lower chance of developing wet AMD (2), but a lutein supplement versus a combination supplement or placebo found no improvement (1).  Lutein is found in green, leafy vegetables such as kale, spinach, swiss chard and romaine lettuce.  Try increasing your intake of these vegetables to get the protective benefits of lutein, though there is no proof it will prevent the development of early AMD.  A lutein supplement may not be as effective.

Lutein has an excellent safety profile; no adverse effects have been reported with normal doses of 10mg / day. (5)

3) Anti-oxidants (beta-carotene, vitamin C, vitamin E and zinc)

The above anti-oxidants are found in products such as Vitalux-AREDS® and Ocuvite®.  The Vitalux-AREDS® has been proven to help slow the progression from intermediate to advanced dry AMD, but does not help prevent it from occurring.  If you have dry AMD, the Vitalux formula may benefit you. (1)

Eye vitamin formulations should not be started without consulting your optometrist,  doctor or pharmacist as they can be harmful to certain people. It has been found that vitamin supplement with high doses of anti-oxidants (such as found in Vitalux® or Ocuvite®) may cause more harm than benefit in some patients (4).  One study found patients taking high doses of anti-oxidants had a slightly increased chance of death from all causes (6).  This risk seems limited to supplement anti-oxidants; dietary anti-oxidants have no known risks.  Until more is known about the benefits or drawbacks to anti-oxidants in supplements, they should only be used where they might have a benefit—for those with intermediate or advanced AMD.

 

Prepared by Terry Damm, BSP
Reviewed by: Karen Jensen, BSP and Carmen Bell, BSP
medSask Medication Information Consultants

Sources

1) Age-related macular degeneration: an update. Pharmacist's Letter/Prescriber's Letter 2009;25(7):250719.

2) UpToDate, Age-related macular degeneration: Treatment and prevention

3) National Eye Institute. http://www.nei.nih.gov/health/maculardegen/armd_facts.asp

4) Michael R. Kolber, Tony Nickonchuk. Tools of Practice, Vitamins for age-related macular degeneration (AMD) demonstrates minimal differences

5) Natural Medicines Comprehensive database

6) Bjelakovic G, Nikolova D.  Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev. 2008 Apr 16;(2):

March 15, 2013
Q. What is the best formula to give my baby?
A.

Quick facts:

If breastfeeding is not an option, use a store-bought infant formula for the first 9 to 12 months :

  • First choice  - use an iron-fortified cow milk-based formula
  • Diagnosed allergy to cow milk  -  use a hydrolyzed  protein formula (cow milk protein which has been partially  broken down)
  • Galactosemia (an inherited disorder in which human and/or cow milk is not properly digested) –  use a soy-based formula
  • Animal products prohibited for cultural or religious reasons – use a soy-based formula


Exclusive breastfeeding for baby’s first six months is the ideal method of feeding an infant
, but this may not be possible for personal, medical, or social reasons. The commercial infant formula chosen must be appropriate for the infant, and prepared and stored safely to reduce the risk of illness from bacterial growth.

       Infant formula nutritional composition and additives are set by the Canadian Food and Drug Regulations. Health Canada requires the manufacturer to submit details of the formulation, ingredients, processing, packaging, and labeling for review. Manufacturers must also submit evidence that the formula is nutritionally adequate to support growth and development. 

Cow milk-based regular formulas

These formulas are made from cow milk which has been modified to make it similar to human milk. A store-bought infant formula contains all the nutrients that healthy babies need. Several different brands are available. They may contain a single milk protein or a combination of whole milk protein, casein or whey. There is no evidence that one brand is better than another.

Protein hydrolysate formulas

The only products recommended by the Canadian Pediatric Society for a baby with proven cow milk protein allergy are hydrolyzed protein formulas e.g. Nutramigen, Alimentum. Babies allergic to cow milk are quite likely to have a similar reaction to soy-based formulas. For babies who are highly allergic to cow milk proteins, an amino acid-based infant formula may be recommended.

Soy-based formulas

Soy-based infant formula is indicated ONLY for infants who have galactosemia, a congenital lactase deficiency or who cannot consume cow milk-based products for cultural or religious reasons.  Soy formula is shown to provide normal nutrition and support normal growth in babies’ first year.  The routine use of soy-based formula has not been proven to prevent or manage infant colic, spitting up, fussiness or prolonged crying and does not prevent allergic reactions in healthy or high-risk infants.  Babies allergic to cow milk are quite likely to have a similar reaction to soy-based formulas.

Not recommended for infants less than 12 months:
  • Cow milk (unaltered) and other animal milks, including goat milk, are not appropriate alternatives to breastmilk for babies. They are low in iron, essential fatty acids and other necessary nutrients, contain a less-digestible form of protein and have too many components which could harm infants’ kidneys.
  • Soy, rice or other plant-based beverages, even when they are fortified, are not appropriate as a breastmilk substitute because they are nutritionally incomplete. Consumption of these beverages by babies may result in failure to thrive.
  • Lactose-free cow milk formula still contains a small amount of lactose and should not be used for infants with a confirmed cow milk protein allergy or with galactosemia. (2)
  • Some infant formulas are intended for use only under medical supervision. They include formulas for the dietary management of some medical and digestive conditions and for preterm infants. These products should not be used for healthy term infants and are not generally available at the retail stores.
Because babies are vulnerable to food-borne illness, proper preparation and storage of infant formula is very important to reduce the risk. Sterilization of all infant feeding equipment is recommended. For detailed instructions for parents and caregivers on the safe preparation of infant formula go to the Health Canadians website at http://www.healthycanadians.gc.ca/kids-enfants/infant-care-soins-bebe/nutrition-alimentation-eng.php.

Prepared by Jean Macpherson, BSP. Reviewed by Karen Jensen, MSc, BSP.
medSask Drug Information Consultants
March, 2013

Sources

1) Baby Centre Canada. Find a formula that’s right for you. Available at http://www.babycenter.ca/a1050266/find-a-formula-thats-right-for-you . Accessed Feb. 2013.

2) Canadian Paediatric Society. Caring for Kids. Available at  www.caringforkids.cps.ca.  Accessed Feb. 2013.

3) Health Canada. Recommendations on the use of breastmilk substitutes. Available at http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php#a11. Accessed Feb. 2013.

4) Mayo Clinic. Infant and toddler health. Infant formula: Your questions answered.  Available at http://www.mayoclinic.com/health/infant-formula/PR00058. Accessed Mar. 2013.

5) National Institute Environmental Health Sciences. Final CERHR expert panel report on soy infant formula. Available at  http://ntp.niehs.nih.gov/ntp/ohat/genistein-soy/SoyFormulaUpdt/FinalEPReport_508.pdf.  Accessed Feb. 2013.

February 25, 2013
Q. Can statins cause diabetes?
A.

Health Canada and the US Food and Drug Administration have added label warnings to all statin medications that they can increase blood sugar levels and increase the risk of diabetes.  Understandably, this has many patients concerned if they should discontinue their statin.  Statins are drugs used to treat high cholesterol and/or people at high risk of cardiovascular (heart) disease; some diabetics have an increased risk of cardiovascular disease compared to non-diabetics. Statins include: atorvastatin (Lipitor®), fluvastatin (Lescol®), lovastatin (Mevacor®), pravastatin (Pravachol®), rosuvastatin (Crestor®), and simvastatin (Zocor®).

Quick facts:

  • Statins reduce the risk of heart attack and strokes.  These benefits have been consistently reported in all studies and outweigh the possible harm of higher blood sugar levels and being diagnosed as diabetic
  • Worsening blood sugar control (and the risk of becoming diabetic) is more likely  with higher doses of statins, or more potent statins (atorvastatin, rosuvastatin or simvastatin)higher doses of statins, or stronger statins (atorvastatin, rosuvastatin or simvastatin).
  • A diabetic patient has an even greater life-saving benefit from statins, compared to a non-diabetic patient, despite the potential for slightly increasing blood sugar levels

Reviews of the medical literature indicate diabetes may occur more frequentlylence of diabetes in people who have taken statins.  One report showed a 9% increase (2); another showed 13% (3); and lastly, one showed up to 27% (4).  These numbers can be alarming, but interpreting these results in a balanced way is important.

The above values are relative increases and translate into one extra case of diabetes per 1000 patients in a year; however, statins prevent 9 cardiovascular events (heart attack, stroke) per 1000 patients in a year (1).  This means that when statins are used in the right patients, they prevent 9 times as many potentially life-threatening conditions as compared to causing diabetes.

So what should you do?

If you have a high risk of developing cardiovascular disease, being on a statin is proven to have significant life-saving effects, especially if you also have diabetes (5).  A high risk of cardiovascular disease would mean (6):

  • All people with a history of heart-attack or stroke
  • Diabetics older than 45 if male, or 50 if female, with one other of the risk factors listed  below.
  • People with 2 or 3 of the risk factors listed below.
  • Risk factors for cardiovascular disease
    • Smoker
    • High blood pressure (greater than 140/90)
    • Low HDL cholesterol
    • High LDL cholesterol
    • Overweight (waist circumference: male >40 inches (102 cm), female >35 inches (88 m), or BMI >25 kg/m2)
    • Family history of early heart disease (male <55, female <65)

Your doctor or pharmacist can also perform something called a “Framingham Risk Assessment,” which helps determine your risk of cardiovascular disease and if a statin is the right treatment for you.  If you do have a high risk for cardiovascular disease, remaining on the statin is important.  If your risk is low, you and your doctor can consider  discontinuing the statin and trying life-style changes instead (exercise, weight loss) to improve your cholesterol.

Prepared by Terry Damm BSP. Reviewed by Carmen Bell, BSP and Karen Jensen MSc, BSP
February, 2013.

Sources

1.  PL Detail-Document, Update on Statin Risks. Pharmacist’s Letter/Prescriber’s Letter. April 2012

2. Sattar N, Preiss D, Murray HM, et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet 2010;375:735-42.

3. Sabatine MS, Wiviott SD, Morrow DA, et al. High-dose atorvastatin associated with worse glycemic control: a PROVE-IT TIMI 22 substudy. Circulation 2004;110(Suppl I):S834.

4. Rajpathak SN, Kumbhani DJ, Crandall J, et al. Statin therapy and risk of developing type 2 diabetes: a meta-analysis. Diabetes Care 2009;32:1924-9.

5. UpToDate, Statins: Actions, side effects, and administration

6. Jacques Genest MD1, Ruth McPherson, et al.  2009 Canadian Cardiovascular Society/Canadian

guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular  disease in the adult – 2009 recommendations.

January 25, 2013
Q. Should I be worried if my blood pressure is low?
A. Quick Facts
• Normal blood pressure can range from 90/60 to 140/90. Lower than 90/60 is considered low blood pressure
• Low blood pressure is only a cause for concern if the person experiences symptoms as well: dizziness, unusual fatigue, weakness, headache, chest-pain or fainting upon quickly rising. A doctor should be seen as soon as possible if these symptoms are present.
--------------------------------------------------------------------------------------------
We always hear about the dangers and health risks of high blood pressure, but what about blood pressure that is too low?
Normal blood pressure can greatly range depending on a person’s age and activity level—anywhere from 90/60 to 140/90. Blood pressure less than 90/60 is considered ‘hypotension’, the opposite of ‘hypertension’. (2)
Generally, low blood pressure is not a concern unless a person is experiencing some symptoms along with their low blood pressure. This indicates that their blood pressure is too low for their body. Symptoms of low blood pressure include: (1)
• Dizziness, light-headedness
• Fainting upon quickly rising
• Unusual fatigue
• Weakness
• Headache
• Chest pain
If you experience any of those symptoms, and your blood pressure is lower than normal, you should make an appointment with your doctor as soon as possible. Low blood pressure does not require an emergency room visit, unless symptoms are very severe, such as loss of consciousness or chest pain that does not resolve. (2)

If you have low blood pressure, but feel fine, medical attention is not necessary. You should still mention it to your doctor so he/she can monitor you.
There are many causes of low blood pressure. The most common causes are dehydration and medications, such as diuretics, beta-blockers, and certain types of anti-depressants. (2)
If you are on medications and are concerned about low blood pressure, ask your pharmacist if certain medications could be contributing to your low blood pressure.

Sources
1) UpToDate, Mechanisms, causes, and evaluation of orthostatic and postprandial hypotension.
Accessed Dec 2012.
2) MayoClinic, http://www.mayoclinic.com/health/low-blood-pressure/DS00590. Accessed Dec 2012.

January 10, 2013
Q. I have just started a statin type medication for cholesterol. I have heard that I must now avoid grapefruit products. Is this true?
A. It is true that grapefruit and its juice (fresh or frozen) can either increase or, less frequently decrease the effects of some medications. In fact the number of medications with a known potential to interact with grapefruit has increased from 17 to at least 43 in the last 4 years. There are more than 85 drugs which could theoretically interact with grapefruit.

There are several statins” used to reduce cholesterol. Not all are at risk of interacting with grapefruit. Simvastatin (Zocor and generics brands), lovastatin (Mevacor and generic brands) and atorvastatin (Lipitor and generic brands) are at high risk for interaction which in rare cases can result in severe muscle and kidney damage. When taken at the same time, large amounts of grapefruit juice markedly to very markedly increase lovastatin and simvastatin levels in the body, and moderately increase atorvastatin levels. Smaller amounts of grapefruit juice and separating administration by twelve hours decrease but don’t completely prevent this effect.

The statin medications that don’t interact with grapefruit are pravastatin (Pravachol and generic brands), rosuvastatin (Crestor and generic brands) and fluvastatin (Lescol and generic brands).

What causes the interaction?
Grapefruit contains chemicals (furanocoumarins) which interfere with an enzyme (CYP3A) that breaks down (metabolizes) certain medications in your digestive system. As a result a larger amount of medication is absorbed into your body resulting in a potentially harmful dose. Because the chemicals which cause this effect are natural to grapefruit all forms of the fruit (juice, whole fruit) have the potential to reduce the activity of the enzyme. Seville oranges (often used in marmalades), limes and pomelos also produce this interaction. Sweet oranges such as Navel or Valencia do not contain furanocoumarins and therefore do not produce this interaction.

Usually grapefruit has been consumed every day for 3 to 5 days before an interaction has occurred. Occasionally however, a single serving of grapefruit juice or a whole grapefruit has resulted in an interaction, such as has occurred with the blood pressure lowering medication felodipine. After a single serving of grapefruit the drug concentration of felodipine increased to three times normal. This resulted in dangerously low blood pressure in some people.

Interactions with other medications
Serious adverse events that have been reported due to grapefruit-drug interactions with other medications include heart rhythm problems, heart blockage, kidney failure and blood clots.

The significance of any particular interaction depends on the seriousness of the dose related drug toxicity and the extent to which the drug concentration increases. You may be able to have a grapefruit occasionally or be switched to a medication that has the same benefit to you but does not interact with grapefruit. Check with your pharmacist or phone the Saskatchewan Drug Information Service at 1-800-665-3784 to see if you must avoid grapefruit and its juice with your medication.

Written by: Lisa Hupka, BSP. Reviewed by: Karen Jensen MSc, BSP
January 2013

Sources
1. http://www.pharmacytimes.com/news/ Grapefruit-Can-Dramactically Increase Medication Potency. (accessed Dec.2012 )
2. http://www.mayoclinic.com/health/food-and-nutrition/AN00413 Katherine Zeratsky,R.D.,L.D. Consumer Health. (accesssed Dec.2012)
3. http://www.cmaj.ca/content/early/2012/11/26/cmj.120951 Grapefruit-medication interactions: Forbidden fruit or avoidable consequences? David G.Bailey, George Dresser, and J. Malcolm O. Arnold. November, 26, 2012. (accessed Dec.2012)
4. http://www.medicinescomplete.com/mc/stockley/current/interactions.htm?q=grapefruit&searchButton=Search (accessed Jan. 2013)
5. http://www.canadianhealthcarenetwork.ca/ Grapefruit can interfere with many drugs to cause severe effects or death: study. (accessed Dec.2012)

January 3, 2013
Q. I am taking an antibiotic. Can I have a drink of alcohol?
A. It depends on the antibiotic you are taking. Of the antibiotics which are commonly taken by mouth for such things as fungal infections, ear infections, urinary tract infections, pneumonia and cuts or cellulitis, there are only a very few which cause alcohol-related reactions. As a general rule, alcohol does not reduce the effectiveness of antibiotics.
Avoid drinking any alcohol if you are taking:
• Ketoconazole: Alcohol consumption might cause flushing, headache, and nausea. Avoid alcohol and alcohol-containing drugs for at least 24 to 40 hours after the last dose.
• Metronidazole (Flagyl): Alcohol consumption might cause flushing, headache, and nausea. Avoid alcohol or alcohol-containing drugs while taking metronidazole and for at least 1 day after the last dose.
• Erythromycin (Eryc, Novo-rythro, Erythro-s): These may increase the amount of alcohol absorbed, so be aware that alcohol may have a stronger effect than you are used to.

If your alcohol consumption is greater than the occasional social drink or if you are not certain about taking your medicine correctly you should always check with your pharmacist.

Prepared by Jean Macpherson, BSP, Drug information consultant. Reviewed by Karen Jensen MSc, BSP.
December 2012.

Sources
1) Alcohol-related drug interactions. Pharmacist's Letter/Prescriber's Letter 2008;24(1):240106.
2) Lexicomp Online Interactions
3) Stockley’s Drug Interactions , 9th edition. Online version available at http://www.medicinescomplete.com by subscription.

December 24, 2012
Q. What should I do when my child has a fever?
A. Fever is in not harmful in most cases. In fact, it may help the body to fight an infection. Children older than 3 months of age who are otherwise healthy and acting normally do not need to be treated. If your child is less than 3 months of age, contact your doctor.(1,2)

Fever may be associated with unpleasant symptoms such as headache, drowsiness, lack of energy, chills, shaking, aches and pains.(1,2) Non-drug measures to treat fever symptoms include cooling by removing extra clothing or bedding, increasing fluids, and encouraging rest.(2) Acetaminophen or ibuprofen can be used if your child is very uncomfortable. Recommended doses (1,2) are:
• Acetaminophen 10 to 15 mg/kg (2.2 lbs) every 4 to 6 hours as needed (Maximum five doses/24 hrs)
• Ibuprofen 5 to 10 mg/kg (2.2 lbs) every 6 to– 8 hours as needed (Maximum four doses/24 hrs)

If you are unsure about calculating the dose for your child, ask your pharmacist or call the Drug Information Service. Always use the measuring device provided with the product when giving the medicine to your child. Giving doses at regular intervals may provide better symptom relief than occasional doses.(1,2)

There is no evidence that taking acetaminophen and ibuprofen together or alternating between one and the other is any better at reducing symptoms than taking either medicine alone. Mixing acetaminophen and ibuprofen dosing increases the chance of giving too high a dose of either medicine and is not recommended. (3,4)
Contact your doctor if:
• Fever is more than 40.5 deg C
• Child seems very sick
• Child has stiff neck,
• A seizure occurs
• Child is confused or delirious
• Child is crying without stopping
• Fever lasts for longer than 3 days

Prepared by Karen Jensen MSc, BSP
Saskatchewan Drug Information Service
Tel: 306-966-6378 (Saskatoon); 1-800-665-3784 (Saskatchewan)
December, 2012

Sources
1. Shevchuk Y. Chapter 9: Fever. In Patient SelfCare, 2nd Ed. CPhA, Ottawa, 2010: pg 80-93.
2. Ward M. Pathophysiology and management of fever in infants and children in UpToDate online. Available at www.uptodate.com by subscription. Updated Oct. 1, 2012. Accessed December, 2012.
3. Purssell E. Systematic review of studies comparing combined treatment with paracetamol and ibuprofen, with either drug alone. Arch Dis Child. 2011 Dec;96(12):1175-9.
4. Kramer L, Richards PA, Thompson A et al. Alternating antipyretics: antipyretic efficacy of acetaminophen versus acetaminophen alternated with ibuprofen in children. Clin Pediatr (Phila). 2008;47(9):907.

December 17, 2012
Q. What over-the-counter products can I use when my child has an ear infection?
A. Ear infection (acute otitis media or AOM) in children often occurs after a viral infection such as the common cold. This can disturb the healthy tissues in the nose, throat and ear and allow bacteria to grow. Most of these infections get better on their own. Unnecessary use of antibiotics can be avoided in about two- thirds of children by using the "watchful waiting" approach (waiting 48 to 72 hours to see if symptoms improve before starting an antibiotic). However, you should contact your doctor right away if your child is less than 6 months old, has a high fever (at least 39deg C, 102 deg F), severe ear pain, or looks extremely ill.(1,2)

Pain control: For children older than 6 months with mild symptoms, ibuprofen or acetaminophen can be given for ear pain. Warmed oils placed in ear canal with a dropper and / or applying heat or cold to the ear may provide temporary relief. There is little evidence that natural or homeopathic remedies are of any benefit. If there is no improvement in symptoms in 48 to 72 hours, contacting the doctor is recommended.(1,2,3)

Decongestants / antihistamines are NOT recommended: Nasal sprays and oral decongestants alone or in combination with an antihistamine have not been shown to be effective in helping symptoms or preventing complications of ear infections.

Antihistamines such as diphenhydramine (Benadryl, generics; Chlortripolon, generics) may actually increase the length of time that fluid remains in the middle ear.(1,3)

Effusion (fluid in middle ear): It is common for fluid to remain in the middle ear for up to 3 months after an ear infection. For most children, this condition will go away without any treatment. This most common symptom is hearing loss. If hearing problems last for longer than 3 month, contact your doctor.(4)

Measures that help prevent childhood ear infections(1, 2):
• Ensuring your child gets a flu shot every year and that all other vaccinations are up to date.
• Children who are breastfed for at least 3 months have fewer ear infections in the first year.
• Avoid having your child exposed to tobacco smoke
• Children who do not go to daycare are less likely to get ear infections.

Prepared by Jean Macpherson BSP and Karen Jensen BSP, MSc. Reviewed by Dr. Yvonne Shevchuk, BSP, Pharm D.
December, 2012

Sources
1) Vayalumka, J.V., Infectious Diseases: Acute Otitis Media in Childhood. In: Repchinsky Carol, editor. e-Therapeutics+ [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2012 [updated Oct 2011; cited 2012 Nov. 14]. Available from: http://www.e-therapeutics.ca. Also available in paper copy from the publisher.
2) Treatment of acute otitis media. Pharmacist's Letter/Prescriber's Letter 2009;25(11):251119.
3) Klein J, Pelton S. Otitis media in children: Treatment. UpToDate online database. Updated Nov 29, 2012. Available by subscription at www.uptodate.com. Accessed December 2012.
4) Klein J, Pelton S. Otitis media with effusion (serous otitis media) in children. UpToDate online database. Updated Jan 12, 2012. Available by subscription at www.uptodate.com. Accessed December 2012.

December 10, 2012
Q. Do I have to take my thyroid medicine in the morning?
A. Not necessarily. Thyroid hormone (Synthroid, Eltroxin, desiccated thyroid) is absorbed best from an empty stomach, so for many people it is easiest to take it first thing in the morning and delay breakfast for about 30 to 60 minutes.(1) However, for some people the timing may work better later in the day, especially if other interacting medications also need to be taken on an empty stomach in the morning (1) – such as bone-building drugs (bisphosphonates) like alendronate (Fosamax), risedronate (Actonel) or etidronate (Didrocal). Studies show thyroid medicine is equally, if not more, effective when taken in the evening, 4 hours after the last food of the day.(2-4) Or if you prefer a morning dose, you can take the thyroid medicine 30 minutes after the bisphosphonate.(1) If you take antacids, calcium, magnesium, or iron supplements you should always separate these from your thyroid medicine by at least 4 hours.(1)

If it is difficult for you to schedule or remember to take thyroid hormone doses on an empty stomach, talk to your pharmacist or doctor. Taking the medicine with a meal is better than missing doses.(5) Another option sometimes used is taking a larger dose once weekly.(6) The most important thing is to be consistent – always take thyroid hormone medicine about the same time each day.(1) This way your dose can be adjusted to ensure that your thyroid levels stay in the normal range.

Prepared by Jean Macpherson, BSP and Karen Jensen, MSc, BSP
December, 2012

Sources
1. Canadian Pharmacists’ Letter: PL Detail-Document #281112, Helping patients take levothyroxine. 2012; 28, No. 11.
2. Bach-Huynh T.G., Nayak B., Loh J., et al: Timing of levothyroxine administration affects serum thyrotropin concentration. J Clin Endocrinol Metab 2009;94:3905-3912.
3. Bolk N., Visser T.J., Nijman J., et al: Effects of evening vs morning levothyroxine intake: a randomized double-blind crossover trial. Arch Intern Med 2010;170:1996-2003.
4. Vanderpump M. Pharmacotherapy: hypothyroidism-should levothyroxine be taken at bedtime?. Nat Rev Endocrinol 2011;7:195-196.
5. Zeitler P, Solberg,P. Food and Levothyroxine Administration in Infants and Children. J Pediatr. 2010;157(1):13-14.e1.
6. Grebe SK, Cooke RR, Ford HC, et al. Treatment of hypothyroidism with once weekly thyroxine. J Clin Endocrinol Metab1997;82:870-5.

November 20, 2012
Q. Is it safe to use permethrin (Nix cream, Kwellada-P lotion) to treat a breastfeeding baby for scabies?
A. According to the manufacturer, permethrin should not be used in children less than 2 years of age(1); however, guidelines in Canada, the USA and Britain recommend permethrin 5% cream or lotion as the treatment of choice for scabies in infants 2 months of age and older.(2,3,4) It should be applied to the entire body including the head and face, left on overnight for 8 to 9 hours, washed off and treatment repeated in 7 days.(5) An alternative (but less convenient) treatment is sulfur 7% in petrolatum (Vaseline) applied to the entire body, left on for 24 hours, washed off and reapplied three times.(5) A third line alternative is crotamiton (Eurax) cream. It is not as effective as permethrin and there is less information about its use in infants.(6) Use cotton mitts or socks on the hands of infants and young children to prevent them rubbing the cream or ointment into their eyes.(7)

The mother must also be treated for scabies at the same time.(8) Although the use of permethrin by breastfeeding women has not been studied, it is considered the treatment of choice for breastfeeding women.(9,10,11) Because the drug is not well absorbed through the skin, very little ends up in the breast milk and it is recommended for scabies treatment with no interruption in breastfeeding. (9,10) The manufacturer suggests that breastfeeding could be temporarily stopped while the mother is being treated (1) but this can be very inconvenient and is not necessary. Wash the cream off the nipples before nursing and reapply after the baby is finished feeding. (12)

General information about scabies
Scabies is an infestation of the skin by a burrowing mite Sarcoptes scabiei. This infestation results in extreme itchiness in the areas of the skin where the mite burrows. The itching is usually more severe at night and is caused by an allergic-type reaction to the mite, mite waste and mite eggs. Signs of the burrows or tracks are most common in the folds of the skin, between fingers, in armpits, around the waist, along the insides of wrists, inner elbow, on the soles of feet, around breasts and in the groin, although almost any area of the body can be affected. The burrow is a thin, grayish, reddish, or brownish line that is 2 to 15mm long.

Scabies is spread by close physical contact and, less often by sharing clothing or bedding with an infected person. Therefore all members of a household should be treated if one person has symptoms. Dogs, cats and humans are all affected by their own distinct species of mite. Each species of mite prefers one specific type of host and doesn't live long away from that preferred host. So, humans may have a temporary skin reaction from contact with the animal scabies mite, but people are unlikely to develop full-blown scabies from pets.

Treatment
To reduce the risk of transmission or eliminate reinfestation all contacts of the scabies infested person, even if they have no symptoms, should be treated as well. This includes sexual and close personal or household contacts within the preceding month. Itching can go on for weeks after successful treatment. Continued itching is not necessarily a reason for retreatment. Antihistamines can be used to treat the itching.

Permethrin 5% (Nix, Kwellada-P)
The cream or lotion is applied two times with a week or so between each application. Permethrin is generally considered safe for children and adults of all ages, including women who are pregnant or breastfeeding.

Directions for Use: For External Use Only
1. Discontinue use of other topical medications and cosmetics during treatment.
2. Clean and dry skin.
Note: Do not take a hot bath before treatment.
3. Apply sufficient amounts of Nix dermal cream (30 g tube) or Kwellada-P lotion and thoroughly massage into the whole body, excluding the head and face (except in infants), paying special attention to creases in the skin, hands, and feet, between fingers and toes, underarms and groin as well as under fingernails. Put on clean clothes. Long-sleeved shirts, pants and mittens should be worn by young children to avoid contact with mouth.
4. Leave product on skin for 8 to 14 hours.
5. Wash off by taking a shower or a bath.
6. Change into clean clothes.
7. Scabies will be killed, but itching may persist. This is normal and does not necessarily mean that the treatment has failed.
8. One single application is effective in most cases. If necessary, a second application may be given 7 to 10 days after the first, but only if live mites can be seen or new lesions appear.
9. All clothing, bed linens, and towels used within the 2 days prior to treatment should be machine-washed in hot water and dried on dryer hot cycle for at least 20 minutes, or dry cleaned following treatment. Mattresses which have been used by an infested person should not be used for 48 hours. Toilet seats should be disinfected.

Crotamiton (Eurax)
This non-insecticide medication is applied once a day for two to five days. Your doctor may recommend it if your baby has scabies. Crotamiton is considered safe in pregnancy and breastfeeding. It may not be as effective as permethrin.

Directions for Use: For External Use Only
1. Take a bath or shower before using this medication. Remove scaly or crusted skin by rubbing gently. Then dry with a towel.
2. Massage a thin layer of the cream into skin from the chin down to the toes, including skin folds and creases, between the fingers and toes, and on the soles of the feet. Avoid applying crotamiton on the face, eyes, mouth, vagina, and any skin that is inflamed, raw, or oozing. Trim fingernails short and apply the medication under the nails since the mites often live there. You may use a toothbrush to apply the medication under the fingernails. Immediately after use, wrap the toothbrush in paper and throw it away. Do not use the same toothbrush in the mouth because it may lead to poisoning.
3. Apply the medication again after 24 hours.
4. Change clothing, towels, and bed sheets the next morning after each application. Wash all clothing, towels, and bedding that have been used in the 3 days before treatment and after each application in hot water and dry in a hot dryer (or dry-clean) to kill all the mites and prevent them from returning. Items that cannot be washed or dry-cleaned should be removed from contact with the body for at least 72 hours.
5. Take a bath 48 hours after the last application to remove the medication from your skin.

Prepared by Jean Macpherson BSP and Karen Jensen MSc, BSP (SDIS). Reviewed by Dr. Yvonne Shevchuk PharmD, FCSHP (College of Pharmacy & Nutrition).
November, 2012

Sources
1. e-CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2012. Nix Dermal Cream [product monograph]. Available from: http://www.e-cps.ca. Also available in paper copy from the publisher.
2. Canadian Paediatric Society [website]. Scabies management. Ottawa, ON: Canadian Paediatric Society; 2009. Available from: http://www.cps.ca/en/documents/position/scabies. Accessed Nov. 2012.
3. Centers for Disease Control and Prevention [website]. Scabies. Suggested guidelines. Atlanta, GA: Centers for Disease Control and Prevention; 2008. Available from: www.cdc.gov/scabies/hcp/index.html. Accessed Nov. 2012.
4. United Kingdom National Guideline on the Management of Scabies infestation (2007). Available at http://www.bashh.org/documents/27/27.pdf. Accessed Nov. 2012.
5. Albakri L, Goldman RD. Permethrin for scabies in children. Can Fam Physician. 2010 Oct;56(10):1005-6.
6. Micromedex. Crotamiton monograph. Available at: http://www.thomsonhc.com/micromedex2/librarian/ND_T/evidencexpert. Accessed October, 2012.
7. Pielop J. Vesiculobullous and pustular lesions in the newborn. UpToDate, Waltham, MA, 2012.
8. Goldstein, BG, Goldstein, AO. Scabies. In: UpToDate, Ofori, AO (Ed), UpToDate, Waltham, MA, 2012.
9. Briggs G, Freeman R, Jason S. Permethrin monograph In: Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, e-book 9th Edition. Lippincott Williams & Wilkins, 2011
10. Schaefer C, Peters P, MillerRK. Drugs During Pregnancy and Lactation, Second Edition. New York: Academic Press; 2007.
11. National Library of Medicine. Permethrin monograph. In: LactMed electronic database. Available at http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~cZGEDf:1. Accessed November, 2012.
12. Scabies monograph. In: Patient.co.uk. Available at http://www.patient.co.uk/health/scabies. Accessed November 2012.
13. Mayoclinic. Scabies. Available at: http://www.mayoclinic.com/health/scabies/DS00451/DSECTION=treatments-and-drugs. Accessed October, 2012.

October 30, 2012
Q. I received the flu shot before the recall. Will I get sick?
A. There is much public concern about the recent flu-vaccine advisory from Novartis, and understandably so. Also, many news reports are presenting different information about what the impact of the recall and what it means.

All of Saskatchewan’s supply of flu vaccines is currently from Novartis. The vaccines have NOT been recalled, but distribution and administration have been halted until analysis is complete.

1) Reason for the recall

Protein aggregates were identified in one batch of the vaccines which were NOT distributed. No aggregates have been seen in other batches of vaccines released.

A vaccine is made up of components of the virus we are protecting against. The components are different types of proteins. Sometimes, these proteins can come together and clump up, forming these protein aggregates which can be seen by the naked eye.

The protein aggregate seen in the Novartis vaccine are the expected viral proteins, not contaminants.

2) Safety issues

Protein aggregates have been seen in vaccines before. Even if they are administered to you, they do not pose any safety concerns.

Additionally, in standard vaccination procedure, the provider will look at the liquid in the vial both before and after shaking it. If protein aggregates are present after shaking, that vaccine is not administered—so no one should have been given a vaccine containing protein aggregates.

There is some concern administering a vaccine with protein aggregates could more likely trigger an allergic reaction. However, allergic reactions would be immediate. If you have already received your vaccine, there is no reason to worry.

Approximately 2 million doses of the Novartis vaccine have been given globally, with no reported adverse effects.

3) Effectiveness concerns

Available information suggests protein aggregates DO NOT reduce the effectiveness of the vaccine. Re-vaccination is not necessary. Novartis and Health Canada have thoroughly tested the vaccines, and they are as potent and effective as they should be.

4) Summary and More information

Flu vaccinations have been suspended as a precautionary measure—the vaccines have not been recalled. There are no safety issues identified or expected, and also no effectiveness issues requiring re-vaccination. For more technical information, visit this similar article prepared for health-care professionals: _________________

Sources
1. Novartis, 10 key facts at a glance - Novartis Influenza Vaccines. http://www.novartis.com/downloads/newsroom/product-related-info-center/10-Key-Facts-at-a-Glance-en.pdf

2. Novartis, Q&As with Jeffry Stoddard, Head Global Medical Affairs. http://www.novartis.com/downloads/newsroom/product-related-info-center/QAs-with-Jeffrey-Stoddard-Head-Global-Medical-Affairs-Novartis_en.pdf

3. Novartis, Information for Doctors and Patients. http://www.novartis.com/newsroom/product-related-info-center/influenza-vaccines-information-center/information-for-doctors.shtml

4. Interview with Dr. Paul Hasselback, Vancouver Island Health Authority:
http://www2.canada.com/nanaimodailynews/news/story.html?id=070dfc1e-9e89-4591-ae71-272a1d0e5b69

5. Health Canada notification, http://www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/_2012/2012_162-eng.php

6. Interview with Dr. Allison McGeer; Infectious Disease consultant Mount Sinai Hospital, Toronto:
http://www.cbc.ca/player/News/Health/ID/2297503804/

October 26, 2012
Q. Nix did not work for the head lice on my children. What else can I try?
A. Next to the common cold, head lice affect more elementary school children in North America than all other communicable diseases combined. Head lice do not spread disease, but in some cases they are becoming resistant to the chemicals used to treat them. Topical insecticides are the first line treatments recommended. These include products containing permethrin (e.g. Nix, Kwellada -P), pyrethrins (e.g. R&C Shampoo). When these products fail after proper and repeated use there are alternatives to try which work differently and may be effective. (1, 2)

Isopropyl myristate (trade name Resultz) works by dissolving the outer waxy coating of the louse which causes unchecked water loss and death by dehydration. It also enters and blocks the breathing passages of the louse. Direct contact with isopropyl myristate causes rapid total paralysis of lice within minutes. It is important that all of the lice on the head of the affected person are in contact with isopropyl myristate rinse to ensure effectiveness. (1, 3) The solution is left on for 10 minutes and rinsed out with warm water. The hair can then be combed with the lice comb provided. This whole procedure should be repeated in 7 days. (3)

Dimeticone (trade name NYDA) is the most recent product approved to treat head lice. It works by suffocating lice and their nits. After application, the solution flows into the breathing system of the lice, their nymphs, and even lice embryos in their eggs, and then thickens, thereby suffocating them. (1)
The somewhat oily liquid is sprayed on to dry hair, especially the hair near the scalp and behind the ears (as this is where most lice and nits are found), massaged in until hair is completely wet and then left for 30 minutes before combing hair with the comb provided. Dosage varies depending upon thickness and length of hair. It is then left on the hair and scalp for 8 hours and washed out. The whole process should be repeated in 8 to 10 days. (4)

Both of these new treatments are well tolerated and have cure rates of up to 80% to 97% and therefore are good alternatives to the chemical treatments which have been available for much longer. (2) Because of the way these products work, it is hoped that lice will be less likely to become resistant to them.

Household products (e.g., mayonnaise, petroleum jelly, olive oil, margarine, thick hair gel) and natural products (e.g., tea tree oil, aromatherapy) should not be used because there is little evidence to prove that they are effective or safe.(5)

Prepared by Jean Macpherson, BSP, SDIS consultant; reviewed by Karen Jensen, MSc, BSP, SDIS consultant

Sources
1. PL Detail-Document, Non-insecticide Lice Treatments. Pharmacist’s Letter/Prescriber’s Letter. April 2012.
2. Dumont Z, Rutherford L. Head lice: Picking out truth from myth Pharmacy Practice 2012;28:18.
3. e-CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2012. Resultz [product monograph]. Available from: http://www.e-cps.ca. Accessed October 2012.
4. eCPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2012. Nyda [product monograph]. Available from: http://www.e-cps.ca. Accessed October, 2012.
5. Management of head lice. Pharmacist's Letter/Prescriber's Letter 2008;24(11):241118.

August 24, 2012
Q. What is the best medication to take for recurring or long-term constipation?
A. Constipation is common in people over age 65 and twice as common in women as in men. It can be caused by some health conditions or may be a side effect of some drugs. When other causes have been ruled out ongoing constipation is known as chronic idiopathic constipation. (See Appendix 1) The symptoms are: fewer than 3 bowel movements a week, difficulty completely emptying the bowel and/or hard or lumpy stools. (1)

Nondrug Treatment
People are first encouraged to try to keep a regular bathroom routine, to increase the amount of exercise they get as well as increase the amount of fiber in the diet (25 grams a day for women and up to 38 grams a day for men). With the increase in fiber they should also increase the amount of liquids they drink to at least 1500ml (6 cups ) a day. (2, 3) If none of these suggestions work, then laxatives are recommended.

Drug Treatment
There are three main types of nonprescription medications used to treat constipation: bulk- forming, emollient, osmotic and stimulant. In general, they should be tried in the following order:

1. Bulk- forming laxatives: These are the safest laxatives and can be used long-term. They contain bran, psyllium or guar gum (e.g. Metamucil®, Benefibre®). They may take from 1 to 3 days to work and may cause diarrhea, bloating and gas. These should be taken starting with one dose a day and increased gradually to reduce side effects. It is important to drink at least 1 cup (250ml) of water with each dose and to wait at least 2 hours before or after taking other medications as they may interfere with absorption of other drugs.

Emollients: These are also known as stool softeners. They do not have any laxative action, but may help to prevent hard stools from forming. The ingredients in these products are docusate calcium (e.g. Surfak®) or docusate sodium (e.g. Colace®). These products may take 1 to 3 days to start working.

2. Osmotic laxatives: When bulk-forming products do not work adequately the next step is to try an osmotic laxative such as lactulose (e.g.Laxilose). This causes fluid to be drawn in to the bowel to produce soft stools within 24 to 48 hours. Osmotic laxatives can cause cramping and bloating.
Glycerin suppositories are also osmotic laxatives and work within 15 to 30 minutes. These should be used only up to 3 times a week and may cause irritation around the rectum.

Other osmotic laxatives include PEG or polyethylene glycol-containing products (Lax-a-DAY®, Pegalax®, Restoralax®) and magnesium containing products (e.g. Milk of Magnesia®, Citro-Mag®).

3. Stimulant laxatives are the next step if the previous products do not work. These have ingredients which make the muscles of the large intestine contract to move the stool through and cause a bowel moment. (E.g. Dulcolax®, Senokot®) These laxatives usually work within 6 to 12 hours and are recommended to be taken at bedtime to cause a bowel movement in the morning. These may also cause cramping and abdominal pain. Although it was once thought that using these products for a long time would cause dependence or damage to the intestine, they are now considered safe and effective if used only up to 3 times a week. (1, 2, 3)

If none of these measures work there is a new prescription product for women with chronic constipation called Resotran® which may begin working as soon as 2 hours after taking a dose. A return to normal bowel movements should be expected within 4 to 5 days. (1)

Appendix 1
Some diseases and conditions or secondary causes of constipation:
- Scleroderma
- Diverticulosis
- Colorectal cancer and/or any tumors that press on the intestines
- Irritable bowel syndrome
- Cystic fibrosis
- Diabetes
- Kidney failure
- Hirschsprung’s disease
- Multiple sclerosis
- Parkinson’s disease
- Hypothyroidism
- Stroke
- Spinal cord injury
- Scar tissue formation after surgery
- Narrowing of the bowel (stricture)
- Anal fissures
- Hemorrhoids
- Pregnancy
- Psychiatric or psychological conditions such as depression, dementia, eating disorders, anxiety
- Age

Some drugs that may be associated with constipation:
- Narcotic pain killers – for example, codeine, morphine, hydromorphone
- NSAIDS - for example, ibuprofen, naproxen, ASA
- Antacids and/or antidiarrheal agents which contain aluminum, calcium or bismuth
- Iron preparations
- Antidepressants – for example amitriptyline, paroxetine, venlafaxine
- Some antihypertensive drugs used to treat high blood pressure – for example verapamil, diltiazem, amlodipine, nifedipine, clonidine, methyldopa
- Antinauseants – for example dimenhydrinate, scopolamine, ondansetron
- Antihistamines – for example diphenhydramine, hydroxyzine
- Anti-seizure medications – for example, phenytoin, gabapentin, pregabalin
- Antiparkinson drugs – for example amantadine, levodopa, pramipexole
- Antipsychotic drugs –for example olanzapine, quetiapine
- Diuretics (water pills) – hydrochlorothiazide, furosemide
- Some types of chemotherapy – especially with vinca alkaloids
- Antidiarrheal drugs such as loperamide and resins such as cholestyramine

Prepared by Jean Macpherson, SDIS Drug Information Consultant. Reviewed by Karen Jensen and Carmen Bell, SDIS Drug Information Consultants

Sources
1) Battistella, Maria. Current and Future Therapies for the Management of Chronic Constipation. Available at http://www.canadianhealthcarenetwork.ca/pharmacists/ Accessed May 18, 2012
2) Patient self-care: helping your patients make therapeutic choices. 2nd edition. Published by Canadian Pharmacists Association, Ottawa ON; 2010
3) Satish SC Rao, Narasimha M Palagummi, Constipation in the older adult. In: UpToDate, Nicholas J Talley(Ed), UpToDate, Waltham, MA, Mar 2012. Accessed online May 2012.
4) Chaun,Hugh Therapeutic Choices, Gastrointestinal Disorders: Constipation in Adults. In: Gray Jean editor. eTherapeutics+[Internet].Ottawa (ON):Canadian Pharmacists Association;c2012[Date Revised: March 2012] Available from: http://www.e-therapeutics.ca. Also available in paper copy from the publisher.

June 7, 2012
Q. I have been hearing a lot about Raspberry Ketone being used for weight loss. Is it safe and effective?
A. Raspberry ketone is the chemical that gives raspberries their smell.1 It should not be confused with the ketones that are produced when the human body breaks down fats for fuel.2 The chemical structure of raspberry ketone is similar to a chemical called synephrine which is sometimes included in weight loss products and which can increase heart rate and raise blood pressure.3

There is no reliable evidence for the claim that raspberry ketone helps humans to lose weight.4,5 Two studies done on mice showed that raspberry ketone stopped them from gaining weight when they were fed high fat food, but no studies done on humans have been reported.6,7 Raspberries are known to contain high levels of anti-oxidants and one study in humans showed that it does help to lower levels of oxidants that build up during exercise.8 However, there is no proof that this will result in either weight loss or improved health.

Raspberry ketone is likely safe when used in amounts commonly found in food.4 The safety of larger doses of raspberry ketone has not been established. There is 1 to 4 mg of ketone in one kilogram (2.2 pounds) of raspberries.9 The typical dose of 250 mg of raspberry ketone therefore contains approximately the same amount of ketone as 60 or more kilograms of raspberries – a much larger dose than would be consumed in food. There are some reports of people experiencing heart palpitations (rapid, pounding heart beat) and a reduced effect of warfarin, a blood thinner.1

The raspberry ketone used in supplements is not produced from raspberries but instead is synthesized in manufacturing plants.10 No single ingredient raspberry ketone product has been approved by Health Canada.11 Purity and dose consistency of unapproved products cannot be guaranteed.

Anyone who is allergic to raspberries, blackberries, strawberries and roses may have an allergic reaction to raspberry ketone and should avoid products which contain it.5 Pregnant women should not use raspberry ketone in large amounts as it may affect labour and delivery.3,4 Because there is not enough evidence to show that it is safe, women who are breastfeeding should not take raspberry ketone.3,4 Raspberry ketone should also be avoided by people with certain cancers such as breast, uterine and ovarian cancer and by women with endometriosis and uterine fibroids as it may act like the hormone estrogen and worsen these conditions.3

Prepared by Jean Macpherson, SDIS drug information consultant. Reviewed by Dr. Jeff Taylor, College of Pharmacy & Nutrition and Karen Jensen, SDIS drug information consultant.

Sources
1. Raspberry Ketone for Weight Loss. Article; Canadian Pharmacist’s Letter; May, 2012; Vol: 19. Accessed May 16, 2012.
2. Ketones –urine. MedlinePlus. http://www.nlm.nih.gov/medlineplus/ency/article/003585.htm. Accessed May 16,2012.
3. Bitter Orange (citrus aurantium) Professional monograph, Natural Standard. Available at www.naturalstandard.com with subscription. Accessed May 16, 2012.
4. Raspberry (RED RASPBERRY) monograph. Natural Medicines Comprehensive Database electronic database. Available online by subscription. Accessed April 3, 2012
5. Raspberry (Rubus idaeus) Professional Monograph, Natural Standard. Available at www.naturalstandard.com with subscription. Accessed April 3, 2012.
6. Park KS. Raspberry ketone increases both lipolysis and fatty acid oxidation in 3T3-L1 adipocytes. Planta Med. 2010 Oct; 76(15):1654-8. Epub 2010 Apr 27. Accessed April 3, 2012.
7. Morimoto C, Satoh Y, Hara M, et al. Anti-obese action of raspberry ketone. Life Sci. 2005 May 27;77(2):194-204. Epub 2005 Feb 25. Accessed April 3, 2012.
8. Morillas-Ruiz J, Zafrilla P, Almar M, et al. The effects of an antioxidant-supplemented beverage on exercise-induced oxidative stress: results from a placebo-controlled double-blind study in cyclists.Eur J Appl Physiol. 2005 Dec;95(5-6):543-9. Epub 2005 Aug 31. Accessed April 3,2012.
9. Beekwilder, J.; Van der Meer, I.; Sibbesen, O.Microbial production of natural raspberry ketone. Biotechnol. J. 2007; 2 (10): 1270–1279. Accessed April 3, 2012.
10. Amercian Council on Science and Health. When is a doctor like a scarecrow? When he doesn’t use his brain. Available at http://www.acsh.org/factsfears/newsid.3547/news_detail.asp. Accessed April 20, 2012.
11. Health Canada. Licensed Natural Health Products Database. Available at http://webprod3.hc-sc.gc.ca/lnhpd-bdpsnh/search-recherche.do?lang=eng. Accessed April 20, 2012.

May 7, 2012
Q. What should I take on my vacation to prevent and treat Travellers Diarrhea?
A. The most common illness that people who travel outside of Canada develop is diarrhea, usually called Traveller’s Diarrhea (TD). It is caused by eating or drinking food and water that is contaminated with bacteria, parasites or viruses. Preventing diarrhea in the first place is best, with instructions to “boil it, cook it, peel it or leave it”.1,2

Probiotics: Products containing Lactobacillus or Saccharomyces may be effective in preventing TD.4 These can be bought without prescription in most Canadian pharmacies.4 The suggested dose is two billion organisms daily starting two days before leaving and continued for the length of the trip.7 Do not use probiotics without consulting your doctor if you have a weak immune system caused by conditions such as AIDS, certain cancers, or are undergoing long term corticosteroid treatment.8

Do
• Drink boiled or bottled water, or use water purifiers
• Wash your hands regularly and thoroughly with water and soap or use an alcohol based hand sanitizer, especially before handling food.
• Eat thick skinned fruit that you can peel yourself, such as oranges and bananas.
• Eat well cooked food while it is hot.1,2

Avoid
• Ice cubes in drinks
• Any unpeeled fruit
• Unpasteurized milk and dairy products
• Salads & buffets
• Re-heated foods
• Shellfish and large fish
• Food from street vendors
• Swimming in fresh water1,2

Prevention:
Antibiotics: Using antibiotics to prevent TD in healthy adults and children is not recommended. Taking antibiotics unnecessarily can lead to bacterial resistance and also may make people more likely to get other infections or have reactions to the drugs.3,4

Prevention treatment with antibiotics might be considered for travellers who must stay healthy such as business travellers or international athletes or for people with conditions that place them at higher risk for TD. This would include people with AIDS, immunodeficiency, chronic gastrointestinal disease, kidney disease and diabetes.1,2,3,5 These people may benefit from prescription antibiotics which are started on the first day in the area and continued for 1 to 2 weeks after returning home.

Vaccine: An oral vaccine called Dukoral®, which works against a common cause of TD, is sometimes used. It is available without a prescription in Canada and is taken as 2 doses by mouth at least 1 week apart. Protection takes effect 1 week after the last dose and lasts for 3 months.6

Self-treatment of TD:
Studies have shown that self treatment is effective in rapidly improving TD.3,5 Mild to moderate TD (up to 3 bowel movements per day with no blood in stool and no fever) will often get better within 24 hours with nonprescription antidiarrheal medicines such as loperamide (Imodium, generics) and bismuth subsalicylate (Pepto Bismol, generics).4 Imodium and Pepto Bismol should be avoided in severe TD.4 Pepto Bismol contains an ingredient related to aspirin and therefore should not be used by people with bleeding problems or who are taking blood thinners; pregnant or breastfeeding women; and children with flu like symptoms or chickenpox.9

Severe TD (blood in stool and/or fever) should be treated with antibiotics. Your doctor may prescribe an antibiotic for you to take with you. You can use the medicine if you do get TD. Usually, you will get enough of the medicine to last for three days. If you get better before that, you can stop taking the medicine. If you do not have a fever or blood in your stool, you can take loperamide along with your antibiotic.3,4

If you get TD it is important to avoid dehydration. You can buy oral rehydration salts such as Gastrolyte or Pedialyte to take with you. These are also sold without a prescription in most countries. Mix in distilled or boiled water.3

You should see a doctor if any effects continue for more than 2 weeks after returning home.4

Prepared by Jean Macpherson, Drug Information Consultant. Reviewed by Dr. Yvonne Shevchuk, College of Pharmacy & Nutrition, U of S and Karen Jensen, SDIS.

Sources
1) International Association for Assistance to Travelers. Available at http://iamat.org/getting_ready_travel_health_basics.cfm . Accessed Apr. 1, 2012.
2) Health Canada. Travel Health. Minimizing your risk. Available at http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/life-vie/travel-voyage-eng.php#mi. Accessed Apr. 1, 2012
3) What You Should Know About Travelers Diarrhea. Canadian Pharmacists Letter; May 2007; Vol: 23.
4) Travellers Diarrhea – Treatment and Prevention. Anti-infective Guidelines for Community-acquired Infections 2010 Edition:p102-103.
5) Steeves A, Ford D. Essential intervention: The pharmacists expanding role in travel medicine. Pharmacy Practice July/August 2010.
6) e-CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; Dukoral [product monograph]. Available from: http://www.e-cps.ca. Also available in paper copy from the publisher. Accessed Apr. 1, 2012.
7) Hilton E, Kolakowski P, Singer C, et al. Efficacy of Lactobacillus GG as a Diarrheal Preventative in Travelers. J Travel Med 1997;4:41-3.
8) Health Canada. Licensed Natural Health Products Database. Culturelle monograph. Available at http://webprod3.hc-sc.gc.ca/lnhpd-bdpsnh/search-recherche.do?lang=eng. Accessed Apr. 15, 2012
9) C-Health. Pepto-Bismol monograph. Available at http://chealth.canoe.ca/drug_info_details.asp?brand_name_id=5164. Accessed Apr. 15, 2012.

March 5, 2012
Q. Bedbugs: Why are we hearing so much about them and do they carry diseases?
A. Bedbugs (Cimex lectularius) were almost wiped out in North America in the 1940s because of the widespread use of DDT and other liquid pesticides. Increase in the last 10 years of bedbug infestations may be due to decreased use of these pesticides, increased resistance to common pesticides and increased travel abroad as bedbugs can easily hide in luggage, clothing and personal items. They are found worldwide.(1,2,3)

Bedbugs are flat, oval, reddish-brown, wingless insects about 5 to 9 mm in length. They feed on human or animal blood. Females require a blood meal for egg production and nymphs require a blood meal for growth. Males can go for a year or more between feedings. They feed at night and are attracted by carbon dioxide which we exhale. Bites, if evident are usually on arms, shoulders, neck and legs. Presence of bedbugs is determined by the sighting of live or dead bugs, dark, reddish brown fecal or blood spots on bedding and a sweet musty odor given off by the bugs.(1,2,3)

Seven to eight percent of those bitten will have a reaction to the bites. This appears as red bumps often in clusters of three or four. The reaction may be immediate or delayed for 7 to 10 days. The bites can be extremely itchy. Vigorous scratching which breaks the skin can introduce bacteria normally present on the skin into a wound. A secondary infection may occur especially in diabetics or people who have a weak immune system. Bites can be treated with topical steroids such as hydrocortisone cream, antihistamines and/or moisturizing creams. If symptoms do not improve within one to two days or worsen, talk to your pharmacist or doctor.(1,2,3)

As for bedbugs spreading disease the evidence is somewhat limited. Bedbugs are suspected of transmitting infectious agents, but there are no reports of this actually happening.(4) In order to spread a disease the vector (bedbugs) must be able to acquire an infectious agent, maintain it, and then give it to an animal or human. A recent study in an underprivileged area of Vancouver, B.C. found antibiotic-resistant bacteria in some bedbugs but more research is needed to find out if bedbugs can spread these bacteria through their bites.(5)

Taking a few precautions while travelling is a good way to keep them from coming home with you. For information on how to avoid getting bedbugs and how to deal with them if you bring them home, Health Canada has a good website (www.hc-sc.gc.ca/cps-spc/pest/part/protect-proteger/bedbugs-punaises-lit/index-eng.php). Note that professional help is usually needed in order to rid of bedbug infestations.

Provincial and municipal public health officers are responsible for local health issues. They can provide you with the latest information you need if you find you have bedbugs. Local listings for public health officers are available at www.health.gov.sk.ca/public-health-offices .

Prepared by Jean Macpherson, SDIS drug information consultant. Reviewed by Karen Jensen and Carmen Bell, SDIS drug information consultants.

Sources
1) Canadian Pharmacist’s Letter May/09 Updated August 2011 Bedbugs – Identification,
2) Elston D, Kells S. Bedbugs. In UpToDate online database. Available at www.uptodate.com by subscription and log-in. Accessed Feb. 2012.
3) Health Canada. Bedbugs. Available at www.hc-sc.gc.ca/cps-spc/pest/part/protect-proteger/bedbugs-punaises-lit/index-eng.php. Accessed Feb. 2012.
4) Delaunay P, Blanc V, Del Giudice, P, et al. Bedbugs and infectious diseases. Clinical Infectious Diseases 2011;52:200 – 210.
5) Lowe CF, Romney MG. Bedbugs as vectors for drug-resistant bacteria. Emerging Infectious Diseases Journal 2011;17 Available at http://wwwnc.cdc.gov/eid/article/17/6/10-1978_article.htm.

December 22, 2011
Q. Is saw palmetto a good choice to treat my BPH?
A. Benign Prostatic Hyperplasia (BPH) is fairly common in men older than 50 years. This condition can lead to bothersome lower urinary tract symptoms and may require treatment or surgery. Symptoms such as needing to go to the bathroom more often, hesitancy (delayed starting, or stopping and starting during urination), and urgency (need to urinate right away) are characteristic of BPH. This may not be the case for all individuals with BPH as many don’t have physical symptoms or have only mild symptoms which may not require treatment. (1,2)

In the past there was some theory to suggest that the use of saw palmetto might act to reduce the size of the prostate and thereby be helpful in the treatment of BPH symptoms. It is thought to act similarly as some prescription products, but with a much weaker effect. Past clinical research on saw palmetto is conflicting. This is further muddled by the fact that differences in the strength and purity of products on the market makes it challenging to evaluate3. However, the majority of studies which have reported a positive effect for saw palmetto have been small and poorly designed. Better quality research has failed to find any benefit for saw palmetto for BPH.(4-5) Many experts no longer recommend the use of saw palmetto for BPH.(6-8)

Some patients may still wish to try saw palmetto. In general, it is well-tolerated but there are a few side effects to watch for. Dizziness and stomach related complaints such as nausea, vomiting, constipation, and diarrhea occasionally occur. Choose a product with an NPN number; which indicates the product has been assessed by Health Canada and contains what it claims to contain. Be aware that there may not be any dramatic improvement in symptoms and if any effect is to take place it would take at least 1 to 2 months. If symptoms still continue afterwards then best to consult your physician for prescription therapy.(7)

Answered by Gurpreet Nijjar, BSc, BSP.

Reviewed by Jeff Taylor, PhD, BSP and Karen Jensen MSc, BSP
Posted December, 2011.

Sources
1. UpToDate: Medical Treatment of Benign Prostatic Hyperplasia
2. Dynamed: Benign Prostatic Hyperplasia
3. UpToDate: Clinical Use of Saw Palmetto
4. JAMA. 2011 Sep 28;306(12):1344-51. Effect of increasing doses of saw palmetto extract on lower urinary tract symptoms: a randomized trial.
5. Cochrane Review. April 2010. James Tacklind, Roderick MacDonald, Indy Rutks, Timothy J Wilt. Serenoa repens for benign prostatic hyperplasia.
6. NMCD: Natural Medicines in the Treatment of Benign Prostatic Hyperplasia
7. Canadian Pharmacists Letter. Article; Canadian Pharmacists Letter; November 2011; Vol: 27.
8. Journal Watch. Treating Lower Urinary Tract Symptoms with Saw Palmetto. Available from: http://general-medicine.jwatch.org/cgi/content/full/2011/1006/1

October 12, 2011
Q. I have already had shingles. Does this mean I am immune to future episodes of shingles, or should I still get the vaccine to prevent a recurrence?
A. The increase in the likelihood of herpes zoster ( shingles ) with aging starts around 50 to 60 years of age and increases into late life in individuals older than 80 years of age.

The vaccine, called Zostavax®, protects against the herpes zoster virus, which causes chicken pox at first infection. The body never rids itself of the virus and it can show up again decades later as shingles. Up to 10 in every thousand seniors develop shingles every year. Without the vaccination, 10 percent to 14 percent of them will suffer from neuralgia (severe sharp pain along the course of a nerve). The lifetime incidence of herpes zoster is estimated to be about 20% in the general population and maybe as high as 50% among those surviving to 85 years or higher.

Individuals with prior history of herpes zoster were excluded from the Shingles Prevention Study and therefore the National Advisory Committee on Immunization makes no recommendation for Zostavax® immunization of individuals with a past episode of zoster. Nevertheless they don’t have any safety concerns for people who have already been immunized with the shingles vaccine. Persons with recent episodes (within 3 to 5 years) of herpes zoster have a boost in immunity that is as strong or better than that obtained from the zoster vaccine so they may not benefit from the vaccine, although recurrent zoster has been confirmed in some healthy patients soon after a previous episode. Individuals with a more remote history of herpes zoster may benefit because herpes zoster can recur, but there are no studies to show that getting the vaccine after having shingles actually reduces the risk of getting it again.

Zostavax® was initially approved for ages 60 and up...now the Public Health Agency of Canada recommends it for ages 50 and up.

ZOSTAVAX® reduces the lifetime risk of developing zoster compared with no treatment by 10% in the general population.

Answered by Lisa Hupka, Bsp

Sources
1. Twersky Jack I, Schmader Kenneth, "Chapter 129. Herpes Zoster" (Chapter). Halter JB, Ouslander JG, Tinetti ME, Studenski S, High, KP, Asthana S: Hazzard’s Geriatric Medicine and Gerontology, 6e: http://www.accessmedicine.com/content.aspx?aID=5138293.
2. http://www.phac-aspc.gc.ca/ccdrw-rmtch/2011/ccdrw-rmtcs0211-eng.php. Canadian Communicable Disease Report. Infectious Diseases News Brief - January 14, 2011
3. Canadian Pharmacist’s Letter; May 2011; Vol: 27
4.10.3949/ccjm.75a.08046 Cleveland Clinic Journal of Medicine. January 2009 vol. 76 1 45-48 Who should receive the shingles vaccine? Aparajita Singh, MD, MPH
5. http://www.merck.ca/assets/en/pdf/products/ZOSTAVAX-PM_E.pdf ( accessed October,2011)

September 9, 2011
Q. There are so many wasps around this fall. What should I do if one bites me?
A. Clean the area with soap and water, hydrogen peroxide or alcohol after the stinger has been removed. Cold compresses might be helpful to reduce local pain and swelling induced by insect bites.

Usually no other treatment is necessary, but if swelling, itching or pain occur and are bothersome treatment with a topical analgesic ( benzocaine, lidocaine etc. ), steroid cream ( hydrocortisone ), counter irritant ( e.g. After Bite®) or skin protectant ( zinc oxide, calamine lotion ) is appropriate. Oral pain medications can be used for pain and oral antihistamines can also relieve itching. In patients who are highly sensitive to insect bites, nonsedating antihistamines taken on a regular basis can reduce the subsequent skin reactions such as itching and swelling from insect bites.

Most wasp stings do not become infected, although this can occur. The stings of yellowjackets are more likely to become infected than those of other species . Yellowjackets tend to scavenge around rotting food and presumably carry bacteria on their exterior.

Infection is suspected when redness, swelling, and pain become dramatically worse three to five days after the sting, when typically symptoms should be disappearing. The presence of fever also suggests infection. Mild symptoms can be treated with a topical antibiotic (e.g. Polysporin® ). If symptoms do not improve within 48 hours, you should see a doctor. An oral antibiotic may be needed.

Some people who are allergic to the wasp venom will have a severe reaction to a wasp bite and symptoms may include chest tightness, difficulty breathing, swelling of the tongue, throat, nose, and lips, dizziness, and/or loss of consciousness. Complications may include shock and heart failure. In these cases emergency medical help should be contacted immediately. People who know that they react severely to an insect bite should carry epinephrine ( EpiPen®, or Twinject®) for emergency self-administration. They can also consider venom immunotherapy to desensitize them.

Sources
1. Canadian Pharmacist’s Letter 2008; 24(8):240815.Management of Insect Bites. ( accessed August 31st, 2011 )
2. Medscape Medical News AAAAI, ACAAI Update Stinging Insect Guidelines, Laurie Barclay, MD June 14, 2011 ( accessed August 31,2011 )
3. Theodore Freeman, MD. Bee, yellowjacket, wasp, and other Hymenoptera stings: Reaction types and acute management. UpToDate, Last updated January 2011 ( accessed Sept. 6th,2011 )

July 12, 2011
Q. Can I use products with DEET to repel mosquitoes, ticks and other insects while I am pregnant?
A. The toxicity of the repellent DEET in large doses and the limited information available make it advisable for pregnant women to use only small amounts of this agent. They should avoid DEET type repellents on large areas of their bodies for long periods unless there is a strong reason, such as being in an area with a high risk of malaria, West Nile and/or Lyme disease.

Exposure to DEET can be limited by wearing long sleeved shirts and leg coverings to avoid biting insects and applying this agent only to exposed skin or clothing. Also use mosquito netting, screens on doors and windows and limit the time spent outdoors between dusk and dawn.

However, the repellent DEET (N,N-diethyl-3-methyl-benzamide, also known as N,N-diethyl-m-toluamide) is acknowledged as the most effective repellent. DEET has been used as a repellent for more than 50 years and is estimated to be applied several hundred million times yearly by North Americans alone. Scientific reviews have concluded that, when used as directed, DEET has an excellent safety record.

DEET can be sprayed on clothes, but can damage certain synthetic clothing such as spandex and rayon. Cotton and wool materials are not affected.

The higher the DEET concentration in the repellent formulation, the longer the duration of protection; this relation reaches a plateau at about 30% to 35%. Products with 10% DEET work for about 3 hours and products with 30% DEET work for 6 hours.

When there is a substantial risk of getting a disease from a mosquito or a large mosquito population, it is appropriate for pregnant women to use the concentration recommended for non-pregnant adults. Otherwise, when the purpose is primarily to avoid nuisance bites a lower concentration of DEET is advisable.

Answered by: Lisa Hupka, BSP

Sources
1. www.thomsonhc.com/micromedex2/ Reprotox ( Accessed on July 6, 2011 )
2. Insect Repellents. Canadian Pharmacist’s Letter; July 2010; Vol: 26
3. Christof Schaefer, Paul Peters, Richard K. Miller. Drugs During Pregnancy and Lactation 2nd ed. Elsevier BV; 2007, PG 458-9.
4. Prevention of arthropod and insect bites: Repellents and other measures. UpToDate. ( Accessed on July 6, 2011 )
5. www.cdc.gov/travel/ Travelers’ Health ( Accessed July 6, 2011)
6. The Merck Manual for Health Care Professionals. Malaria. ( Accessed July 6, 2011 )
7. Karen Jensen. Buzz Off - Helping patients select and properly use insect repellents. Pharmacy Practice. June 1, 2011

June 10, 2011
Q. Is it safe to use sunscreens while pregnant?
A. The proven benefit of sunscreen outweighs any potential risks.

Concern has arisen over an ingredient in some sunscreens called retinyl palmitate. It is an inactive ingredient, a type of topical vitamin A. In skin it converts readily to retinoids which are associated with a risk of birth defects in people taking oral acne medications containing them. However, the animal studies which showed birth defects used much higher doses than can be absorbed through the skin. Studies on rats have not shown sunscreen to cause malformations.

The American College of Obstetricians and Gynecologists recommends that pregnant women protect their skin from the sun by wearing sunscreen with SPF ( sun protection factor ) of 15 or more.
Sun exposure will darken dark brown areas around the eyes, nose and cheeks called cholasma or “mask of pregnancy” which some women develop ( about 70% ) during pregnancy. Sun screen and wearing a wide brim hat can prevent these areas from getting darker.

Here are other steps that Health Canada recommends you take to protect against UV exposure:
• If possible, avoid being in the sun between 11:00 a.m. and 4:00 p.m.
• Look for shade, stay under a tree, or use an umbrella.
• During outdoor activities, wear sunglasses to protect your eyes. When the UV index is three or higher, you should also wear protective clothing and a large-brimmed hat.

Topical absorption of sunscreen is minimal. Sunscreen is safe and recommended for use during pregnancy.

Answered by: Lisa Hupka, BSP

Sources
1. Nohynek GJ, Meuling WJ, Vaes WH, Lawrence RS, Shapiro S, Schulte S, Steiling W, Bausch J, Gerber E, Sasa H, Nau H. Repeated topical treatment, in contrast to single oral doses, with Vitamin A-containing preparations does not affect plasma concentrations of retinol, retinyl esters or retinoic acids in female subjects of child-bearing age. Toxicol Lett. 2006 May 5;163(1):65-76. Epub 2005 Oct 21. PMID: 16243460
2. CBC News. Sunscreen benefits beat risks in pregnancy: MDs. Posted: May25,2011. www.cbc.ca/news/health/story/2011/05/25/sunscreen-pregnancy.html
3. http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/life-vie/sun_soleil-eng.php, accessed June 1, 2011
4. Using Sunscreens, 07/08/2010, Texas Tech University Health Sciences Center, www.infantrisk.com

June 3, 2011
Q. Does using sunscreen cause cancer?
A. There is no convincing evidence that using sunscreen causes cancer. There IS strong evidence that using sunscreen prevents cancer. Sunscreens can significantly reduce the risk of cancer of the skin, lips and mouth. Research shows that they do not cause vitamin D deficiency (as previously suggested). Sunscreens have not been demonstrated to adversely affect the health of humans.

UVA rays do not cause sunburns, but they do contribute to skin cancer and sun-related skin aging. Sunscreens, which have been around for more than 70 years, used to just protect against UVB rays, which cause sunburns and skin cancer. It is important to choose a product which protects against both UVA and UVB rays.

UVA filtering and blocking ingredients are oxybenzone, avobenzone ( Parsol 1789 ), titanium dioxide, zinc oxide and ecamsule (Mexoryl SX/XL). Helioplex, a patented combination of avobenzone and oxybenzone with stabilizers, provides protection against the full spectrum of UVA and UVB radiation. Ecamsule itself is photostable, but only covers short UVA II wavelengths. The combination with avobenzone ( absorbs the long UVA wavelengths ) and octocrylene also provides coverage against the full spectrum of UVA and UVB radiation.

The almost universal use of the sun protection factor (SPF) has lured many consumers into thinking that a higher SPF means a better sunscreen. Because SPF is mostly an indicator of UVB protection, it is difficult for consumers and physicians to compare the UVA protection afforded by sunscreens.

In many countries, changes in labeling guidelines will make it easier for consumers and physicians to determine the level of UVA protection provided by sunscreens. The FDA has proposed a UVA star rating, with one star representing low UVA protection and four stars representing the highest available UVA protection in an over-the-counter sunscreen product. Although this rule has not yet been finalized, a small number of sunscreens may have a star rating on the label.

The Canadian Cancer Society recommends the following:
• People reduce their exposure to the sun, particularly between 11 a.m. and 4 p.m. when the sun’s rays are the strongest
• Use a broad spectrum sunscreen ( protection from UVA and UVB rays )
• Choose a product that is water resistant with an SPF of at least 30
• Apply sunscreen liberally and frequently ( every 2 hours ), especially after swimming or sweating

An average size adult needs an ounce (2 tablespoonfuls ) of sunscreen for optimal coverage.

Answered by Lisa Hupka,BSP

Sources
1. Burnett ME, Wang SQ. Current sunscreen controversies: a critical review.Photodermatol Photoimmunol Photomed. 2011 Apr;27(2):58-67. doi: 10.1111/j.1600-0781.2011.00557.x. PMID: 21392107
2. Update on Sunscreens, R. Bissonnette, MD, FRCPC Posted: 11/10/2008; Skin Therapy Letter. 2008;13(6):5-7, www.medscape.com/viewartcile/5829902
3. Canadian Pharmacist’s Letter 2009; 25(6):250606, Sunscreens: Achieving Optimal Protection
4. Canadian Cancer Society. www.cancer.ca ( accessed May24, 2011 )


May 24, 2011
Q. I had heard that calcium supplements can increase the risk of having a heart attack. Is this true? I thought calcium was good for a person!
A. Calcium is important for bone health as they require calcium to maintain strength. Low calcium intake is associated with colon cancer, kidney stones, obesity and hypertension. Just about every cell in the body, including those in the heart, nerves and muscles rely on calcium to function properly.

A recent analysis of calcium supplement use and cardiovascular (heart and blood vessel) risk revealed that calcium supplements with or without vitamin D, modestly increase the risk of cardiovascular events, especially heart attacks.

There does not seem to be a dose response relationship between calcium supplements and the risk of cardiovascular events. Thus even doses of less than 500mg/day might be associated with an increased risk of cardiovascular events similar to doses greater than 1000mg/day. The abrupt change in the concentration of calcium in the blood after supplement consumption seems to cause the adverse effect, rather than it being related to the total calcium dose taken.

Further studies are needed to reassess the role of calcium supplements in osteoporosis management. In the meantime a person should try to get their calcium needs met through their diet. If you are at high risk of fractures, consult your doctor before stopping or reducing your daily calcium supplement.

Dairy products such as milk, cheese and yogurt are excellent sources of calcium. Vegetables (broccoli, cabbage, bok choy, figs ) also provide calcium as do fish products containing bones (sardines and canned salmon), lentils, beans, tofu and almonds.

Calcium loss through the urine is increased by the consumption of excess salt and caffeine. Therefore try to keep salt intake to a minimum and increase calcium in your diet if you consume more than 4 cups of coffee per day.

Adults age 19 to 50 need 1000mg of calcium per day and teenagers and older adults need slightly more.

One cup of milk or low fat yogurt provide approximately 300mg of calcium each. Go to http://ods.od.nih.gov/factsheets/calcium/ to find out how much calcium is provided by the food you eat to help you plan to get the required calcium from your diet. If you have any difficulty in determining how to obtain your daily calcium requirement, please feel free to contact us.

Answered by Lisa Hupka,BSP

Sources
1. www.osteoprosis.ca
2. Calcium, Vitamin D, and Risk of Cardiovascular Events: Discussion www.medscape.com/viewaraticel/741974_2
3. Canadian Pharmacist’s Letter 2011; 27(1): 27012
4. Abrahamsen B, Sahota O. BMJ 2011; 342: D2080 – Do Calcium plus Vitamin D Increase Cardiovascular Risk.

May 2, 2011
Q. My friend is taking pain medication for a chronic condition. Will he become addicted to the medication?
A. The correct use of prescribed medications for pain commonly produces tolerance and physical dependence. Tolerance is the drug-induced loss of effect over time, while physical dependence is the occurrence of withdrawal symptoms after sudden dose reduction or discontinuation of a drug. These are normal body function changes to repeated use of drugs. Tolerance and physical dependence do not imply abuse or addiction. Understanding the difference is important so that patients with pain aren’t denied adequate pain medication simply because they have shown evidence of tolerance or they exhibit withdrawal symptoms if the analgesic medication is stopped abruptly.

Patients with pain rarely develop abuse or addiction problems. The patient who is not vulnerable to addiction will not experience brain reward when using controlled drugs as prescribed and therefore will not misuse prescribed medications.

The onset of abuse or addiction usually happens before the use of prescribed controlled drug use. Individuals who are at risk of addictive disease usually start their addiction through the use of alcohol, tobacco or marijuana in their late teens or early adulthood. Abuse of prescription drugs tends to complicate pre-existing addiction rather than to cause addiction.

Addiction is entirely different than physical dependence and tolerance. Although these changes presumably occur commonly as addiction develops, neither are necessary for addiction to occur, and equally important, neither means that abuse or addiction is occurring.

Inappropriate fear of addiction on the part of patients (or their caretakers) is a common reason for under-use of prescribed medications. A person should not be denied adequate pain relief because of this fear. For treatment of most types of severe pain strong opioid pain medications are the drugs of choice. Some of the problems of dependence and tolerance can be managed by using long acting formulations and gradually reducing the medication, if it is no longer needed.

Answered by: Lisa Hupka,BSP

Sources
1. O’Brien Charles P, "Chapter 23. Drug Addiction and Drug Abuse" (Chapter). Brunton LL, Lazo JS, Parker KL: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 11e: http://www.accessmedicine.com/content.aspx?aID=941547

2. UpToDate- Prescription Drug Abuse. Desktop19.1

3. The Medical Letter. Drugs for Pain. April1, 2010(Issue 92) p.25

March 15, 2011
Q. How can I tell if a medication or vitamin product sold on the shelf has gluten in it? I have celiac disease (gluten intolerance ).
A. In people with celiac disease, the gluten protein in wheat, barley, rye, and triticale triggers an immune reaction that damages the small intestine. (2) Grains such as oats, millet, corn, tapioca, soy and rice don’t have this protein. (2)(3)This damage keeps the body from taking in many of the important nutrients in food. These include vitamins, calcium, protein, carbohydrates, fats and other important nutrients. The body can’t work well without these nutrients. Even small amounts of gluten in foods can hurt people who have celiac disease. (3)

Note that avoiding gluten does not have any known health benefits for people who do not have celiac disease. (3)

In the area of pharmaceuticals, potential sources of gluten contamination come primarily from the addition of the excipient (filler), ingredients added to the active drug in order to make a particular dosage form. (1) Having an understanding of the fillers origin or how they are produced can help a person make an educated assessment of the likelihood of gluten contamination. One of the first key words to look for in the inactive ingredients list is starch. Starch can be derived from several sources including corn, potato, tapioca and wheat. If starch is listed by itself a call to the manufacturer is the only way to confirm the source of the starch. A product with cornstarch can be assumed to be gluten free.(1)

Also watch out for the four dex-ingredients derived from starch (dextrans, dextrose, dextrates, dextrins ). Dextrans come from corn and potato starch, dextrose comes from corn. Dextrates and dextrins can come from any starch source so a call to the manufacturer is necessary to find out if the product contains gluten.(1)

A problem faced by the pharmaceutical manufacturers is the uncertainty of the gluten free status of the raw materials obtained from outside sources. A person looking for gluten free products must also be aware that pharmaceutical companies frequently change the inactive ingredients of their products without warning. If a product says “new and improved” or “new formulation” it is a sign to recheck the gluten status of the product.(1)

Currently in Canada a natural health product can be labelled “gluten free” if it contains a maximum limit of 20 ppm gluten. This would be gluten from wheat, including spelt or kamut, but not barley or rye as they are not used in the preparation of medications.(1) This maximum level is based on good manufacturing conditions aimed at achieving the lowest possible levels of gluten resulting from cross-contamination.(4)

Tolerance to gluten varies among individuals with celiac disease and there are limited clinical scientific data on the amount of gluten required to initiate or maintain an immune reaction in celiac disease patients. Therefore, there is no clear agreement on a safe gluten threshold level.(4)
There are proposed changes to the Food and Drug Act to prevent products which contain trace amounts of gluten, confirmed by testing to be < 20 ppm gluten, from making the claim gluten-free.(4)

The product package insert is a good starting place to look for gluten in medications. Enrolling the help of a pharmacist will also be beneficial or call the Saskatchewan Drug Information Service at 1-800-665-3784, in Saskatoon 966-6378, to help you with the search.

Answered by: Lisa Hupka, Bsp

Sources
1.Steven Plogsted. Medications and Celiac Disease- Tips From a Pharmacist. The Celiac Diet, Series #5. Practical Gastroenterology. January 2007.
2."Gluten-Free" Foods May Be Contaminated: Study. J Am Diet Assoc 2010;110:937-940. www.medscape.com/viewarticle/725315 (accessed March 8, 2011)
3.Gluten Free Diet. May 2010. AAFP conditions A to Z (2010) Stat!Ref ( accessed March 8, 2011)
4.Notice-Labelling of Natural Health Products Containing Gluten. January 2010. www.hc-sc.gc.ca. ( accessed March 8, 2010)

February 2, 2011
Q. Am I still protected if I was late getting the 3rd injection of Hepatitis A and B vaccine? I had the first 2 Twinrix injections 10 years ago and then I had the 3rd shot 6 years later. Was this too far apart for protection from Hepatitis A and B? Do I need to do the series again or get a booster vaccination before travelling to areas where Hepatitis A and B are common?
A. The usual schedule for Twinrix formulations in Canada for people 19 years and over is 3 injections. The first 2 are 1 month apart and the 3rd injection is 6 months after the first. There is also a rapid schedule that involves 1 extra dose for people who will be exposed to high risk situations before they are able to receive the first 2 vaccinations 1 month apart. It is important to have the minimum time interval between injections to develop adequate final antibody concentrations.(2)

Increasing the interval between the first 2 doses has little effect on the development of immunity or final antibody concentration for the Hepatitis B component of the vaccine. The third dose ensures the maximum level of protection but acts primarily as a booster and appears to provide optimal long-term protection.(1)(3)

The effectiveness of 1 dose of Hepatitis A vaccine ( equivalent to 2 doses of Twinrix) is 94% to 100%. Antibody production is considered to be complete after the first dose, however, the vaccine series should be finished to assure long-term protection.(5)

All available data on single and combined Hepatitis A and Hepatitis B vaccines indicates that there is no support for a Hepatitis A or Hepatitis B booster when a complete primary vaccination course is offered to individuals with a competent immune system.(4) Immune system memory has been demonstrated in a number of studies for both Hepatitis A and Hepatits B, with the implication that protection may persist even when antibodies are no longer measurable.(4)(2)

In summary, the last dose in the series is mainly to ensure long term protection and can be done any time after the first 2 doses as long as there is a minimal spacing of 24 weeks from the first dose in the regular schedule and 1 year from the first dose in the rapid schedule.

Answered by: Lisa Hupka, Bsp, February 2, 2011

Sources
1.A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States. MMWR Dec23,2005/Vol.54 http://www.cdc.gov/mmwr/PDF/rr/rr5416.pdf
2. Canadian Immunization Guide 7th ed. 2006 www.phac-aspc.gc.ca (accessed Feb2,2011)
3.High immunogenicity of delayed third dose of hepatitis B vaccine in travellers. Vaccine. 2007 Apr 30;25(17):3482-4. Epub 2007 Jan 11. PMID: 17306910
4. A review of the long-term protection after hepatitis A and B vaccination. Travel Med Infect Dis. 2007 Mar;5(2):79-84. Epub 2006 Jun 19. PMID: 17298912
5. Immunization Action Coalition Ask the Experts http://www.immunize.org/askexperts/experts_hepa.asp ( accessed Feb2,2011 )

January 25, 2011
Q. I never got the flu shot this fall? Can I still get vaccinated?
A. : Yes. In Saskatchewan public drop in clinics for the seasonal influenza vaccine began Oct. 12, 2010. The vaccine is available at no charge to everyone from Oct. 12, 2010 to March 31, 2011. If you missed getting it in the fall at a drop in clinic call 655-4358 in Saskatoon (1) or 766-7000 in Regina (7) to book an appointment or call the health center closest to you.

The 2010 to 2011 flu vaccine will protect against an influenza A H3N2 virus, an influenza B virus and the 2009 H1N1 virus that caused so much illness last season.(6)

All ages benefit from getting the influenza vaccine. Exceptions are anyone under six months of age or with severe egg allergies. These groups should not be vaccinated.(2)(4) Also anyone who had a serious allergic reaction to a previous dose of influenza vaccine or who developed Guillain-Barre Syndrome ( a neurological disorder ) within 8 weeks of a previous influenza vaccine should not receive the vaccine.(2)(4)

Health Canada says between 4,000 and 8,000 Canadians mostly seniors; will die from pneumonia related to flu and many others may die from other serious complications of flu.(4) The following groups of people are at higher risk of complications from the influenza virus, such as pneumonia:
People over 65 or older.
Pregnant women
Children 6 months to 4 years
People severely obese
People of any age who are residents of nursing homes and other chronic care facilities
Anyone with chronic health conditions
Close contacts of persons who are in the high risk of complications groups above should also get vaccinated.(1)(2) Children younger than 6 months are at high risk of serious flu illness, but are too young to be vaccinated. People who care for them should be vaccinated instead. (6)

Antiviral treatment is available and can reduce the duration and severity of illness for a person infected with the influenza virus. Antiviral treatment of influenza is most effective when administered early in the course of illness, and ideally should be administered within 48 hours of onset of symptoms. Antiviral treatment should be started in people with confirmed or suspected influenza who are at a greater risk for complications.(3)

The signs and symptoms of influenza are fever, headache, fatigue, muscle pain and weakness. These symptoms may be accompanied by cough and sore throat. Some people also experience vomiting and diarrhea.(2)(5)(6)

Seek immediate medical attention for the following symptoms in adults:
Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or continuous vomiting
Flu-like symptoms that improve but then return with fever and worse cough (6)

Answered by Lisa Hupka,Bsp. Jan24/2011

Sources
1.Saskatoon Health Region. Seasonal Influenza Vaccine. www.saskatoonhealthregion.ca (accessed Jan. 24. 2011
2. Public Health Agency of Canada. About Season Influenza www.phac-aspc.gc.ca (accessed Jan24. 2011)
3. Medscape Medical News. ACIP Up Dates Guidelines for use of Antiviral Agents for Influenza. Jan 21, 2011 www.medscape.com/viewarticle/736109
4. CBC News. Fighting The Flu. Jan. 14,2011 www.cbc.ca/health/stsory/2009/01/12/f-flu.html
5. UpToDate- Clinical Manifestations and Diagnosis of Seasonal Influenza in Adults. Last literature review version 18.3 Sept.2010
6. Centers for Disease Control and Prevention. Seasonal Influenza. www.cdc/flu/protect/preventing.htm (accessed Jan. 24.2011)
7. Regina Qu’Appelle Health Region. Telephone Directory for Facilities and Services. www.rqhealth.ca/inside/contact_us/phone.shtml (accessed Jan.24/2011)

December 14, 2010
Q. Is acetaminophen a safe medication to take?
A. Acetaminophen is usually safe to take at recommended dosages.

It works by reducing the production of chemicals in the body that enable the body to feel pain as well as cooling the body. While acetaminophen may be helpful to reduce pain and/or fever it will not cure any medical condition.

The normal dose of acetaminophen for pain or fever in adults is: orally 325 to 650 mg every 4 to 6 hours or 1000 mg 3 to 4 times/day; do not exceed 4 g/day.

The normal dose of acetaminophen in children for pain or fever is: Children <12 years: orally 10 to 15 mg/kg/dose every 4 to 6 hours as needed; do not exceed 5 doses (2.6 g) in 24 hours or 75mg/kg/day.
Many people do not know that Tylenol is the brand name for acetaminophen and that overdose of this product can cause serious liver damage, especially when combined with other medications that can also cause damage to the liver.

Early symptoms of overdose can include nausea, vomiting, weakness, and profuse sweating. These usually occur after an ingestion of acetaminophen large enough to cause hepatic ( liver ) toxicity. However, since some patients show few or none of these early signs, in cases of suspected acetaminophen over dose, therapy should begin as soon as possible. A delay period of 24 to 36 hours exists between ingestion and the onset of symptoms of hepatic injury. Some other symptoms of toxicity are abdominal pain, confusion, a general feeling of discomfort, yellowing of skin and eyes, coma and in severe cases death.

If you suspect someone has taken too much acetaminophen phone the poison control center at 1-866-454-1212.

A situation which has potential for overdose is the practice of alternating doses of acetaminophen and ibuprofen for treatment-resistant fevers. There is no evidence that this works better than either product used alone at optimal doses. This is not recommended because of the possibility of confusion as to what medication was given, which could lead to overdose.

Another problem with acetaminophen is that it is added to many cough and cold products as well as other combination pain killers and muscle relaxants. These products may not be made by the company that makes Tylenol and therefore these products will have different names. As a result when people take these medications they may not realize the amount of acetaminophen actually being consumed, unless they have carefully read the ingredients.

To avoid this situation always read the ingredients of over the counter medications and prescription medications. Don’t exceed the dose recommended on the package and don’t take 2 products that both contain acetaminophen. If unsure, ask your pharmacist or phone Saskatchewan Drug Information Services at 1-800-665-3784 in Saskatchewan or 966-6378 if in Saskatoon.

Sources
1.Lexicomp Online
2.Compendium of Pharmaceuticals and Specialties Online
3. Canadian Pharmacist’s Letter; July 2006; Vol: 22
4.http://www.medscape.com/viewarticle/726598_5

December 3, 2010
Q. How much vitamin D should I take each day?
A. : The recommended amount of vitamin D has increased for everyone. The value for this nutrient was first set in 1997. Calcium and vitamin D are two essential nutrients long known for their role in bone health. Since 2000 the public has heard conflicting messages about other benefits of these nutrients, especially vitamin D. The U.S. Institute of Medicine (IOM) released its report of the Dietary Reference Intakes (DRIs) for vitamin D and calcium on November 30, 2010. The review was jointly commissioned and funded by the U.S. and Canadian governments.

Dietary Reference Intakes (DRIs) are recommendations for nutrient intakes based on Estimated Average Requirement (EAR), Recommended Dietary Allowance (RDA), Adequate Intake (AI) and Tolerable Upper Intake Level (UL).

Vitamin D is a nutrient that helps the body use calcium and phosphorous to build and maintain strong bones and teeth. Too little vitamin D can cause calcium and phosphorus levels in the blood to decrease, leading to calcium being pulled out of the bones to help maintain stable blood levels. This can cause rickets in children and osteomalacia (softening of the bones) or osteoporosis (fragile bones) in adults.

However, too much vitamin D can cause too much calcium to be deposited in the body, which can lead to calcification of the kidney and other soft tissues including the heart, lungs and blood vessels.

The IOM finds that the evidence supports a role for vitamin D and calcium in bone health but not in other health conditions.

The IOM expert committee reviewed a number of health outcomes that could potentially be related to calcium and vitamin D, such as cancer, cardiovascular disease, diabetes, and immunity, and found that the evidence was inconsistent and did not demonstrate a cause-and-effect relationship. Consequently, these health outcomes could not be used for the purposes of determining nutrient requirements.

The skin produces vitamin D3 in response to sun exposure. But the American Academy of Dermatology recommends avoiding sunlight and getting vitamin D from food or supplements. The Canadian Dermatology Association offers similar advice
.
The sun is not strong enough to make vitamin D in the skin in southern Canada from November to February...and for an even longer period at higher latitudes.

Few foods contain much vitamin D. Salmon, canned tuna, and fortified milk (100 IU per cup) are among the best sources. Very few foods naturally have vitamin D. Fortified foods provide most of the vitamin D in our diets.
•Fatty fish such as salmon, tuna, and mackerel are among the best sources.
•Beef liver, cheese, and egg yolks provide small amounts.
•Vitamin D is added to many breakfast cereals and to some brands of orange juice, yogurt, margarine, and soy beverages; check the labels.

New Reference values for daily intake of Vitamin D are:

Birth to 12 months 400 IU
Children 1–13 years 600 IU
Teens 14–18 years 600 IU
Adults 19–70 years 600 IU
Adults 71 years and older 800 IU
Pregnant and breastfeeding women 600 IU

New Reference values for daily intake of Calcium are:

Birth to 6 months 200 mg
Infants 7–12 months 260 mg
Children 1–3 years 700 mg
Children 4-8 years 1,000 mg
Children 9–13 years 1,300 mg
Teens 14–18 years 1,300 mg
Adults 19–50 years 1,000 mg
Adult men 51–70 years 1,000 mg
Adult women 51–70 years 1,200 mg
Adults 71 years and older 1,200 mg
Pregnant and breastfeeding teens 1,300 mg
Pregnant and breastfeeding adults 1,000 mg

Total vitamin D intake should remain below the level of the new UL (upper tolerable limit) to avoid possible adverse effects. The UL is the maximum daily intake unlikely to result in adverse health effects. The new UL is 4,000 IU daily for people from age 9 to age 70, whereas the old UL was 2,000 IU daily.

It is preferable that an individual get their recommended calcium from food sources.

Sources
1.http://www.hc-sc.gc.ca/fn-an/nutrition/vitamin/vita-d-eng.php#t4
2.http://www.iom.edu/Reports/2010Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/
3.http://ods.od.nih.gov/FactSheets/VitaminD-Consumer/
4.http://canadianpharmacistsletter.therapeuticresearch.com/pl/ArticleDD.aspx?nidchk=1&cs=&s=PLC&pt=6&fpt=31&dd=250508&pb=PLC&searchid=24065944
5.http://www.osteoporosis.ca/index.php/ci_id/5534/la_id/1.htm
6.http://ods.od.nih.gov/factsheets/Calcium-Consumer/

November 15, 2010
Q. Why can’t my pharmacy supply me with the medication I need? They say it is shorted by the manufacturer.
A. Healthcare professionals are facing a constant stream of short-term back orders and long-term unavailability of products. Canada is currently experiencing shortages of hundreds of generic drugs.

This supply problem can arise from a variety of different causes including:
• Manufacturing issues
• Shortages in raw materials due to natural disasters and regulatory decisions related to the safety, efficacy or quality of a product
• Reduced inventories carried by pharmacies, wholesalers and manufacturers because of pressure to keep inventories low can result in not enough product on hand to buffer a shortage.
• Lower prices can contribute to a shortage. Recent controls in Ontario and other provinces are reducing profit, which then puts pressure on manufacturers to discontinue unprofitable products.
• Competition in the drug market causes manufacturers to discontinue making a drug if they don’t expect to have a reasonable share of the market due to policies like bulk buying or tendering. Some products coming off patent are not being made generic.

Current shortages are blamed on a shortage of raw materials and compliance issues that led to voluntary recalls of certain drugs and slower production times at manufacturing facilities. This in turn created a backlog of unfilled orders, which is expected to gradually disappear as production steps up. Even then, however, the current market and regulatory trends governing pharmaceutical sales are likely to result in ongoing generic shortages.

Health Canada has no authority to require a manufacturer to bring a product to the Canadian market or to maintain adequate supplies on the market to meet the needs of patients.

Possible actions for Health Canada are:
• Prohibit bulk exports of pharmaceuticals as a proactive move.
• Issue compulsory licences if a patent holder is unable to provide a needed product.
• Develop a list of medically essential drugs (possibly following the list provided by the World Health Organization -- WHO), and monitor and track these.
• Allow parallel importation schemes similar to those used in Europe.
• Provide notification of where products are being manufactured.

The Minister of Health intends to table legislation in Parliament, before it adjourns in December, to establish statutory authority to prohibit the export of prescription and other essential drugs from Canada as necessary to protect human health in the event of an actual or potential shortage.

If the medication you are taking becomes unavailable your pharmacist will work with your doctor to find an appropriate alternative until the shortage is resolved. If a substitute drug or different dosage strength/formulation is being used, your pharmacist will educate you about the change and what to expect.

To ensure that your drug therapy is not interrupted, don’t wait until you are out of your prescription(s) before re-ordering. If there is a shortage your pharmacist may need a few days to arrange for and obtain a suitable alternative.

Sources
1. www.canadiahealthcarenetwork.ca
2. Canadian Pharmacist’s Letter; September 2010; Vol: 26
3. http://www.hc-sc.gc.ca

September 27, 2010
Q. I heard on the news today that people on bisphosphonates for osteoporosis have been having long bone fractures and some researchers think it is related to the drug. Is this true?
A. Bisphosphonates have been used successfully for nearly two decades for prevention of fractures in patients with osteoporosis. There is a high level of evidence to suggest it improves bone mineral density, prevents bone loss, and reduces the number of fractures in the spine and hip. Although the short-term benefit of bisphosphonates is well documented, there are concerns regarding the safety of long-term therapy resulting from the effect on bone functions.

The bisphosphonates available in Canada are: alendronate ( Fosamax ), risedronate ( Actonel ), etidronate/calcium ( Didrocal ) alendronate/vitamin D3 ( Fosavance ) and zoledronic acid ( Aclasta ).

The major problem in osteoporosis is fractures (broken bones). Without proper treatment, patients with osteoporosis are more likely to have fractures, commonly of the hip, spine, wrist and shoulder. The occurrence of a hip fracture is one of the ways that osteoporosis can be diagnosed. These are called typical femoral fractures and occur high up on the femoral bone, very close to the hip joint. These often occur after a fall when the hip breaks from hitting the ground. The hip does not hurt before it breaks. The person may or may not be on osteoporosis medications.

Several case series and multiple individual case reports suggest that some femoral shaft (thigh bone) fractures might occur in patients who have been treated with long-term bisphosphonates. Several unique clinical features are emerging which distinguish these fractures from typical femoral fractures which occur in osteoporosis because of the disease process itself. These features are thigh pain and/or groin pain for several weeks prior to the fracture, complete absence of an injury occurring before the fracture, fractures in both legs in some patients, the fracture occurs lower down from the hip ( closer to the middle of the femur ) and most patients with this type of fracture have been on bisphosphonates for more than 5 years. X-rays, including bone scan and/or MRI, might be warranted in patients who have femoral pain to try to find these atypical fractures at an early stage (stress fracture vs complete fracture).

The supposed mechanism is unknown, and more research is needed to identify distinctive characteristics of these “atypical” fractures. There is no rationale to withhold bisphosphonate therapy from patients with osteoporosis, although continued use of bisphosphonate therapy beyond a treatment period of 3 to 5 years should be re-evaluated annually. Women and men at low risk of fracture should discuss with their doctor if they need to continue with the bisphosphonate beyond 5 years.

For women at high risk for vertebral fractures, the National Osteoporosis Foundation (NOF) recommends continuing alendronate for ten years. Eight year data with risedronate indicated good tolerability and safety.
The risk factors that have been demonstrated to be most predictive of fracture are:
1. low bone mineral density ( BMI )
2. advancing age
3. prior history of fragility fracture
4. chronic glucocorticoid use
5. low body mass index (BMI)
6. parental history of hip fracture
7. cigarette smoking
8. excess alcohol intake
Although this recommendation is based on data from women, such treatment approach is also reasonable for men taking bisphosphonates.

Treatment with bisphosphonates reduces the risk of hip and other non-vertebral fractures by 1000 per 100,000 patient years. If a person has osteoporosis they are at high risk of fracture and much more likely to suffer a typical fracture if not treated, than of ever getting one of these “atypical” femoral fractures while on medication. If you have an increase risk of fracture, the benefits of bisphosphonates far outweigh the risks.

The overall incidence of shaft fractures combined is below 30 per 100,000 person-years, so this type of fracture is much less common than proximal femur (hip) fractures. Furthermore, the unique “atypical” fracture type is a subset of all femoral shaft fractures and accounts for less than 1% of all femoral fractures, making it a rare event.

Sources
1. Clinical Orthopaedics and Related Research
DOI: 10.1007/s11999-010-1535-x Femoral Insufficiency Fractures Associated with Prolonged Bisphosphonate Therapy.
Joseph D. Isaacs, Louis Shidiak, Ian A. Harris and Zoltan L. Szomor PMID: 20809164

2. Curr Osteoporos Rep. 2010 Mar;8(1):34-9.
Atypical subtrochanteric and femoral shaft fractures and possible association with
bisphosphonates.
Nieves JW, Cosman F. PMID: 20425089

3. Safety of long-term bisphosphonate therapy. Pharmacist’s Letter/Prescriber’s Letter 2009;25(12):251205.
December 2009

4. Osteoporosis Canada

5. UpToDate – Osteoporotic fracture risk assessment.

6. Clin Endocrinol Metab. 2010 Apr;95(4):1555-65. Epub 2010 Feb 19.
Long-term use of bisphosphonates in osteoporosis.
Watts NB, Diab DL. PMID: 20173017

September 20, 2010
Q. My child vomited 30 minutes after I gave him his medication. Should I give him another dose now or wait until the next scheduled dose?
A. The decision of whether to redose an oral medication after vomiting is based on many factors.

The stomach has a relatively large surface area, but its thick mucous layer and short time in contact with the medication limit absorption. Most absorption occurs in the small intestine. Stomach emptying and therefore drug absorption is affected by many variables. Factors that affect how fast the stomach empties and absorption include the dosage form (liquid versus immediate release versus sustained release tablets), the physical and chemical properties of the drug, and the physiologic characteristics of the person taking the drug. Food, especially fatty food, slows stomach emptying (and rate of drug absorption), explaining why taking some drugs taken on an empty stomach speeds absorption.

You can redose if vomiting occurs within 15 minutes...or if you see the intact drug in the vomit . After an hour, there’s usually no need to redose because the drug is probably already past the stomach. But if vomiting occurs within the 15- to 60-minute window, you must consider the risk versus benefit of repeating the dose.

If the risk of missing a dose outweighs the risk of getting too much of the drug, as with drugs such as HIV meds and birth control pills, then it is important to give another dose if a patient vomits within an hour.

Antibiotics for acute infections, especially with a single dose treatment or short course of therapy, should also be given again if the patient vomits within an hour of administration.

For many drugs it is best to err on the conservative side and not give another dose. This is very important for drugs whose recommended dose is close to the toxic dose (narrow therapeutic window ) and getting a bit more of the drug could result in too much with serious consequences.
Examples of drugs not to redose are digoxin, warfarin, phenobarb, long acting opioids, methotrexate, cyclosporine, theophylline, lidocaine, aminoglycosides and other anticonvulsants.

Always check with a health care professional to be sure of the medication in question.

Sources
1. Redosing oral medications after vomiting. Pharmacist’s Letter/Prescriber’s Letter 200;25(9):250909
2. http://www.merck.com/mmpe/sec20/ch303/ch303b.html
3. Buxton Iain L, “Chapter 1. Pharmacokinetics and Pharmacodynamics: The Dynamics of Drug Absorption, Distribution, Action, and Eliminatio” (Chapter). Brunton LL, Lazo JS, Parker KL: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 11e: http://www.accessmedicine.com/content.aspx?aID=935800

August 3, 2010
Q. How do I know if I have West Nile Disease?
A. West Nile virus is transmitted by infected mosquitoes. In most cases, symptoms of West Nile are mild and infected individuals generally recover spontaneously. Rarely, meningitis and encephalitis can occur. There are no specific treatments for West Nile virus infection.

The typical incubation period for infection ranges from 2 to 14 days. Once a patient recovers, immunity to West Nile virus is thought to be life-long; if reinfection occurs, it is very rare.

The most common symptoms are fatigue, fever, headache, skin rash, muscle weakness, diarrhea, vomiting, pain in your eyes, not feeling hungry, swollen glands (rarely) and/or difficulty concentrating. The rash typically involves the chest, back and arms, and generally lasts for less than one week. Most people who have the mild form of West Nile virus have a fever for 5 days, a headache for 10 days, and feel tired for more than a month.

More severe infections involving the brain and spinal cord may cause: headache, high fever, stiff neck, disorientation, reduced attention to surroundings, tremors and convulsions, muscle weakness and paralysis and coma. People with these symptoms should seek medical treatment. Medical treatment involves supportive therapy such as intravenous fluids if a person has experienced prolonged nausea, vomiting and diarrhea, pain relievers, ventilator support as required, and treatment for the prevention of secondary infections.

In most cases your doctor won’t test for West Nile virus unless you have symptoms of meningitis or encephalitis. Then your doctor will test your blood for antibodies to the virus. If you have these antibodies in your blood, your doctor will know that you have West Nile

Personal protection during the months of August and September includes staying indoors between dusk and dawn when mosquitoes are most active, wearing protective clothing when outdoors (i.e., long sleeves and pants with socks and shoes), and using mosquito repellents. The most effective mosquito repellent for use on skin is N,N-diethyl-m-toluamide (DEET). See http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/life-vie/insect-eng.php for more information on insect repellents.

Removal of standing water in barrels, buckets, gutters and flowerpots, which can be used as breeding sites, also helps to reduce the mosquito population.

Sources
1. UpToDate - Clinical manifestations and diagnosis of West Nile virus infection
2. Canadian Pharmacist Letter 2003; 19(5): 190520
3. http://www.medscape.com/viewarticle/575934_7
4. www.healthwise.net/Saskhealthlineonline

June 23, 2010
Q. Can I use insect repellents with DEET on my children?
A. DEET (N,N-diethyl-m-toluamide) is an effective active ingredient found in many repellent products and in a variety of formulations.

It is available in concentrations ranging from less than 10 percent to more than 75 percent. The effectiveness of DEET plateaus at approximately 30 percent, but higher concentrations provide longer duration of protection. Products with concentrations around 10% are effective against mosquitoes for periods of approximately three hours; a concentration of about 30% percent provides an average of six hours of protection from mosquitoes. Protection is shortened by swimming, washing, rainfall, sweating, and wiping.

For children aged six months to two years, use 10% concentrations applied no more than once daily. Children aged two to 12 can use 10% DEET applied up to three times daily. Adults and children over 12 years of age can use up to 30% concentrations of DEET and reapply if being bitten by mosquitoes, always follow product instructions. Higher concentrations should be reserved for situations in which insect infestation is high, elevated temperatures and humidity may limit evaporation, or time outdoors will exceed three to four hours.

Do not use insect repellents containing DEET on infants under six months of age. Use a mosquito net when the child is outdoors in a crib, playpen or stroller.

Guidelines for using insect repellents:

• Use enough repellent to cover exposed skin or clothing. Don’t apply repellent to skin that is under clothing. Heavy application is not necessary to achieve protection.

• Do not apply repellent to cuts, wounds, or irritated skin.

• After returning indoors, wash treated skin with soap and water. (This may vary depending on the product. Check the label.)

• Do not spray aerosol or pump products in enclosed areas.

• Do not spray aerosol or pump products directly to your face. Spray your hands and then rub them carefully over the face, avoiding eyes and mouth.

• When using repellent on a child, apply it to your own hands and then rub them on your child. Avoid children’s eyes and mouth and use it sparingly around their ears.

• Do not apply repellent to children’s hands. (Children may tend to put their hands in their mouths.)

• Do not allow young children to apply insect repellent to themselves; have an adult do it for them.

Other ways to protect your children against mosquitoes are to have them wear long pants, long sleeved shirts and closed shoes if they are outside when mosquitoes are active. Mosquitoes are most active at dawn and dusk.Wear light-colored clothing, which will help reduce overall attractiveness to mosquitoes.

In comparison trials, DEET is more effective than any other insect repellent. DEET repels mosquitoes for a longer duration than for ticks. When seeking protection against ticks, look for a product that specifies use for ticks.

Sources
1.http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/life-vie/insect-eng.php
2.www.cdc.gov/ncidod/dvbid/westnile/qa/insect_repellent.htm
3.DynaMed
4.Pediatr.Ann. 2004 Jul;33(7):443-53 “Does Anything Beat DEET” PMID: 15298309
5.UpToDate - Prevention of arthropod and insect bites: Repellents and other measures

May 28, 2010
Q. I sat on a high backed chair 2 days ago, just after someone with lice sat on it. Should I use the lice shampoo just in case some lice got on me?
A. : Head lice are tiny, wingless, parasitic insects that live and feed on blood from your scalp. Lice do not jump or fly. Head lice are easily transmitted from person to person with close contact (as occurs within households and classrooms) There is no proven transmission from nonliving carriers, but because head lice and ova have been found on hats, combs, brushes and stuffed animals, it is a good idea to eradicate lice from household items. Machine laundering with or without detergent in hot water (50C) or placing the item in a dryer for 40 minutes has been shown to effectively decontaminate lice and nits. Other unproven but routine recommendations include dry cleaning, vacuuming or sealing items in plastic bags for 3 to 4 days, as lice are unlikely to survive off the scalp for more than 3 days. Nits are also unlikely to hatch at room temperature, since they need the warmth and moisture of the scalp.

The diagnosis of head lice is definite only when crawling lice are seen in the scalp or hair. Detection is difficult since head lice move quickly and most infections involve 10 or fewer lice. Using a fine–toothed nit comb is four times as effective, and twice as fast as visual inspection for the detection of live head lice. The lice are detected by a thorough combing-through of wet hair from the scalp with the fine-tooth detection comb; lice are usually found at the back of the head or behind the ears. Nits are oval, grayish white eggs fixed to the base of hair shafts. Each adult female louse lays 3 to 5 eggs/day, so nits typically vastly outnumber lice and are not a measure of severity of infection. Some people with a lice infestation may not have any symptoms, but the most common symptom people experience is itching of the scalp, neck and ears.

Only persons with live crawling lice should be treated. Close contacts and household members of someone with lice should be screened for lice. Preventative treatment is unnecessary and may contribute to resistance.

If the diagnosis is positive for lice, all topical lice treatments are available as non-prescription products at pharmacies. The product must be reapplied 7 to 10 days following initial treatment.

Sources
1.http://www.merck.com/mmpe/sec10/ch121/ch121e.html#S10_CH121_T001
2.www.pharmacygateway.ca CE Online CCCEP file # 671-1207 “Head Lice Treatment: Is it time for a paradigm shift?” by Penny Miller, B.Sc.(Pharm.), M.A. March 2008
3.http://www.mayoclinic.com/health/head-lice/DS00953

April 9, 2010
Q. How long can a bottle of sun screen be used for?
A. Chemical sunscreens may become less effective over time, and leaving them in high temperatures (eg, car, beach) may speed the process. Manufacturers and others recommend throwing away sunscreen when it has passed the expiration date listed on the bottle. For sunscreen that does not have an expiration date, a typical recommendation is to throw it away after three years, when stored at room temperature. Expired sunscreen may be less effective, potentially reducing the SPF rating and increasing your risk of sunburn.

Bottles of sunscreen shouldn’t last very long if they are being used correctly. To achieve the labelled SPF value a person should apply 2 tablespoons of sunscreen for the full body. The following body parts should have ½ teaspoon each: the face and neck, each arm and shoulder, front of torso, and back of torso. Plus, one teaspoon should be applied to each leg/top of foot. Sunscreen sprays should be sprayed on and rubbed in to ensure uniform coverage.

Apply sunscreen at least 15 to 30 minutes prior to sun exposure and reapply every 2 hours even on cloudy days and after swimming, heavy sweating and towelling off.

For maximum protection from sunburn, skin wrinkling, skin aging and cancer causing UV radiation from the sun use an SPF of at least 15 ( some organizations recommend nothing less than 30 ) on exposed skin every day. You may need a higher SPF if you are fair skinned or plan to be in the sun for a prolonged period or if you anticipate intense sun exposure (eg, while at the beach or skiing ). Snow reflects up to 80 per cent of the sun’s rays, giving you a double dose of radiation when involved in winter sports. Also, use a sunscreen that protects against UVA and UVB radiation.

Other measures that can be used to protect yourself from the sun are to avoid the sun between 10am and 4pm, wear protective clothing like a wide brimmed hat, sunglasses and long sleeves. Protect your lips with lip balm containing an SPF of 30 or higher and re-apply frequently.

Sources
1. Sunscreens: achieving optimal protection. Pharmacist’s Letter/Prescriber’s Letter 2009;25(6):250606
2. UpToDate- Patient Information: Sunburn Prevention
3. http://www.dermatology.ca/sap/safety_resources/sunscreen_faqs/index.html

January 12, 2010
Q. What is the dose of aspirin needed for stroke prevention?
A. : Aspirin is usually administered at doses of 75-325 mg once daily. Higher dose aspirin is not more effective than lower aspirin doses, and some analyses suggest reduced efficacy with higher doses. Because the side effects of aspirin are dose-related, daily aspirin doses of 75-100 mg are recommended for most indications. When rapid blood thinning ( platelet inhibition ) is required, an initial aspirin dose of at least 160 mg should be given. Most common side effects are gastrointestinal and range from painful indigestion ( dyspepsia ) to inflammation of the stomach or peptic ulcers with bleeding and perforation.

The American Diabetes Association recommends the use of aspirin (75 mg to 162 mg per day) as a primary prevention strategy in patients with diabetes who are at increased cardiovascular risk. The Canadian Diabetes Association released their Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada in September 2008. The recommendation states that use of daily aspirin (81 mg to 325 mg) should be based on clinical judgement.

The use of enteric-coated aspirin is not recommended for reducing the risk of gastrointestinal bleeding or dyspepsia. People at high risk of gastrointestinal bleeding or those with dyspepsia caused by antiplatelet treatment should consider measures to protect the stomach ( for example a proton pump inhibitor ). Aspirin should be taken after food to reduce the risk of gastrointestinal adverse effects. A person should seek medical advice if they experience wheezing or dyspepsia symptoms with low dose aspirin.

Although the optimal dose of aspirin is uncertain, there is no compelling evidence that any specific dose is more effective than another, and fewer gastrointestinal side effects and bleeding occur with lower doses (≤ 325 mg a day). We recommend a dose of 50 to 100 mg daily when using aspirin for the secondary prevention of stroke.

Sources
1. www.accessmedicine.com
2. Canadian Pharmacist’s Letter
3. www.cks.nhs.uk/antiplatelet_treatment/management/quick_answers/scenario_antiplate
4. UpToDate – Antiplatelet Therapy for Secondary Prevention of Stroke

December 14, 2009
Q. What can I do to prevent a hangover after drinking alcoholic beverages?
A. Alcohol has multiple effects on the body that contribute to the hang over feeling. It causes dehydration and has many effects that contribute to a headache. Alcohol causes inflammation of the stomach lining and increase in gastric acid leading to abdominal pain, nausea and vomiting. It can cause low blood sugar and disrupts sleep cycles. These disruptions in body rhythms produce a “jet lag” effect.

There is no scientific evidence to support any cure or effective prevention for alcohol hangovers. The most effective way to avoid a hangover is to consume alcohol only in moderation or not at all. If you are going to drink, drink small amounts and alternate with a glass of water to reduce dehydration. Alcoholic beverages that contain few congeners ( biologically active compounds that contribute to the taste, smell and appearance of the alcoholic beverage ) such as vodka, gin and rum are associated with a lower incidence of hangover than are beverages that contain a number of congeners, such as brandy, whiskey, bourbon and red wine.

ASA and other anti-inflammatories, such as ibuprofen or naproxen, may reduce the headache and muscle aches, but should be used cautiously if upper abdominal pain or nausea is present. These are gastric irritants and will compound alcohol induced gastritis. Acetaminophen should be avoided during the hangover period because alcohol metabolism enhances acetaminophen toxicity to the liver.

Putting anything in your stomach prior to indulging in alcohol helps prevent a hangover, but fatty foods in particular stick to the stomach lining longer and therefore slow down the absorption of alcohol into the blood stream. This gives the body more time to process the by products of alcohol.

Bananas, kiwi fruit and sports drinks will help replenish lost electrolytes and the fructose in fruit juice is reported to increase the rate that the body gets rid of toxins.

Eggs and high protein foods contain an amino acid known as cysteine which helps detoxify harmful substances in the body.

Caffeine is commonly used to counteract the fatigue and malaise associated with hangover condition, but can also contribute to the dehydration.

Drink lots of water to replenish fluids and dilute toxins. Hangover symptoms will usually abate over 8 to 24 hours.

Sources
1. http://pubs.niaaa.nih.gov/publication/arh22-1/54-60.pdf
2. http://health.howstuffworks.com/hangover5.htm
3. http://www.annals.org/content/132/11/897.full

November 25, 2009
Q. How long does it take for the H1N1 vaccine to become effective?
A. : After receiving the H1N1 flu vaccine, most people will start to develop
immunity within 10 days with just one dose.

Sources
1. www.phac-aspc.gc.ca/alert/h1n1/
2. www.RxFiles.ca
3. bulletin.healthwise.net/h1n1

November 25, 2009
Q. Is there any reason a person should not get the H1N1 vaccine?
A. The following groups of people only should not receive the H1N1 flu vaccine:
- people who have had a previous anaphylactic ( severe allergic reaction ) to any element of the vaccine , or people with a hypersensitivity to eggs ( eg. hives, swelling of the mouth and /or throat, breathing difficulty )
- people experiencing a high fever
- people who have previously experienced Guillan-Barre Syndrome within 8 weeks of receiving a seasonal flu vaccine
- the H1N1 flu vaccine is not approved for children under 6 month

Sources
1. www.phac-aspc.gc.ca/alert/h1n1/
2. www.RxFiles.ca
3. bulletin.healthwise.net/h1n1

November 25, 2009
Q. Do any medications interact with the H1N1 vaccine?
A. The H1N1 vaccine does not interact with any other medication because it is prepared from an inactivated (dead) virus.
People on immunosuppressive medications (e.g. high dose prednisone, cancer chemotherapy, anti-rejection drugs, etc.) may not mount a full immune response after being vaccinated, but vaccination is especially important for these people because
their weakened immune system makes them more susceptible to contracting the H1N1 virus.

Sources
1. www.phac-aspc.gc.ca/alert/h1n1/
2. www.RxFiles.ca
3. bulletin.healthwise.net/h1n1

November 25, 2009
Q. How is H1N1 influenza treated?
A. Your doctor may prescribe an antiviral such as Tamiflu ( oseltamivir ) or Relenza ( zanamivir ). These medications can reduce flu symptom, shorten the length of illness and reduce serious complications if taken within the first 24 to 48 hours of getting sick.
Getting the H1N1 flu vaccine is the best way for you to protect yourself
and others from getting infected.

Sources
1. www.phac-aspc.gc.ca/alert/h1n1/
2. www.RxFiles.ca
3. http://bulletin.healthwise.net/h1n1


November 25, 2009
Q. How do I know if I have H1N1?
A. The influenza illness usually presents with a sudden onset of cough and fever. In laboratory confirmed cases of H1N1 100% of children under age 2 presented with fever, 90% of pregnant women and approximately 50% of people greater than 65 presented without fever. Fever and cough were present in 70% of the confirmed cases.
Other common symptoms are sore throat, nasal discharge, fatigue, muscle and joint pains, headache and decreased appetite. Sometimes the person may have vomiting, diarrhea and nausea. Is the pandemic H1N1 2009 virus known to be circulating in your
community? You can check at www.phac-aspc.gc.ca/fluwatch/index-eng.php. Indications that you have a severe case and should seek medical help are shortness of breath, chest pain, dizziness, confusion and/or a high fever lasting longer than 3 days.

Sources
1. www.phac-aspc.gc.ca/alert/h1n1/
2. www.RxFiles.ca
3. http://bulletin.healthwise.net/h1n1

September 28, 2009
Q. If I want to stop taking my sleeping pills can I stop all of a sudden or should I go off of them gradually?
A. Withdrawal effects, especially rebound insomnia, are rare after the discontinuation of long-duration benzodiazepines ( flurazepam, diazepam, chlordiazepoxide) and tend to be mild after the discontinuation of intermediate-acting benzodiazepines (lorazepam,temazepam,oxazepam,alprazolam). However, marked rebound insomnia has been reported after the discontinuation of triazolam, a shorter-acting drug, usually lasting one to three nights. In contrast, withdrawal studies of zopiclone have shown little or no rebound insomnia. The rate of withdrawal of benzodiazepines should be individualized, depending on the half-life and dose of the drug, the duration of therapy, and whether the insomnia is acute or chronic. Long acting benzodiazepines are not recommended in the elderly because they cause higher cortical impairment resulting in confusion and falls.

After tapering the medication plan to stop the medication at a low-stress time, e.g., a weekend. Two nights before the planned withdrawal, the patient should shorten the sleep time (while staying on the medication) by 20 minutes. This modest degree of sleep deprivation will promote physiological sleepiness, which should counterbalance any sleep disruption associated with withdrawal. This shortened sleep period should be maintained for one week.

To achieve a good sleep it is important to follow these guidelines referred to as sleep hygiene
1. Keep a regular sleep wake schedule, 7 days per week.
2. Restrict the sleep period to the average sleep time you have obtained each night over the preceding week.
3. Avoid sleeping in, extensive periods of horizontal rest or daytime napping; these activities usually affect the subsequent night of sleep.
4. Get regular exercise every day- about 40 minutes of an activity with sufficient intensity to cause sweating. If evening exercise prevents sleep, schedule the exercise earlier in the day.
5. Avoid caffeine, nicotine, alcohol and other recreational drugs, all of which disturb sleep. If you must smoke do not do so after 7:00 p.m.
6. Plan a quiet period before lights out; a warm bath may be helpful.
7. Avoid large meals late in the evening; a light carbohydrate snack (e.g., crackers and warm milk) before bedtime can be helpful.
8. Turn the clock face away and always use the alarm. Looking at the clock time on awakening can cause emotional arousal (performance anxiety or anger) that prevents return to sleep.
9. As much as possible, keep the bedroom dark and soundproofed. If you live in a noisy area, consider ear plugs.
10. Use the bedroom only for sleep and intimacy; using the bed as a reading place, office or media centre conditions you to be alert in a place that should be associated with quiet and sleep. If you awaken during the night and are wide awake, get up, leave the bedroom and do something quiet until you feel drowsy-tired, then return to bed.
Note: Pharmacologic (or any) interventions will be less effective if these guidelines are not followed. In mild cases of insomnia, sleep hygiene guidelines, practised consistently and together, may be sufficient to reinstate a normal sleep pattern.

Sources
1. eTherapeutics
2. N. Engl J. Med.2005;353(26):2827
3. eCPS

July 31, 2009
Q. When will the new vaccine for shingles be available and who should be vaccinated?
A. The new vaccine for shingles is called Zostavax, and it has had a notice of compliance from Health Canada allowing it to be sold in Canada since August 22,2008. The company that manufacturers the vaccine, Merck Frosst Canada Ltd. ,plans to market it in the fall of 2009.

Zostavax reduces the risk of reactivation of the varicella zoster virus, the same one that causes chicken pox. The shingles vaccine contains about 14 times the amount of weakened chicken pox virus than the vaccine for children. This amount is needed to obtain a protective response in the aging immune system of older adults. Anyone who has had chicken pox is at risk of developing shingles. It most commonly occurs in people over 60 and the risk increases as people age. The virus that has been dormant in the nerve cells, once reactivated, travels from the nerves and follows a path out to the skin. The nerves along the path become inflamed and therefore shingles can be painful. Pain that lasts for months after the rash has healed is called post herpetic neuralgia.

The vaccine is safe and common side effects include: headache, pain, swelling, and itching at the injection site. A small group of recipients also got a rash at the injection site.
A single dose of shingles vaccine is indicated for adults 60 years of age and older to prevent the development of shingles.

Sources
www.fda.gov
www.chop.edu
www.immunize.org.vis
Communication with Merck Frosst Canada Ltd.

December 23, 2008
Q. Can I take my birth control pill continuously? In other words can I skip the 7 days of inactive sugar pills and start taking another pack instead? I’m going on a trip and I want to avoid my period.
A. Yes, but check with your doctor if it is right for you. There is a specific branded product now available called Seasonale®, allowing users to take an active pill once daily for 84 days before taking 7 inactive pills. Taken in this manner, one would expect only 4 periods per year instead of the usual 12. The same can be done with most birth control pills by starting a second pack immediately after finishing the active pills in the first pack (ie. disregarding the inactive sugar pills ). Two packs or more can be run together in this fashion before taking a 7 day pill free break. Again the exact regimen should be decided upon in consultation with your doctor.

Sources
Guilbert E, Boroditsky R, Black A, Kives S, Leboeuf M, Mirosh M, Senikas V, Wagner MS, Weir E, York-Lowry J, Reid R, Trussell J; Society of Obstetricians and Gynaecologists of Canada. Canadian Consensus Guideline on Continuous and Extended Hormaonal Contraception, 2007. J Obstet Gynaecol Can. 2007 Jul;29(7 Suppl 2):S1-32.

August 29, 2008
Q. Can I consume alcohol when taking an SSRI antidepressant?
A. Most manufactueres of SSRIs suggest that concurrent use with SSRIs and alcohol is not advisable. This is likely due to the fact that both alcohol and SSRIs may cause sedation and the effect may be increased when combining the two. Also the risk of alcohol abuse is higher in depressed patients. There are only a few studies examining the interaction between alcohol and some SSRIs. They reveal that there are likely no clinically significant interactions with alcohol and the following SSRI antidepressants: citalopram, escitalopram, fluoxetine, paroxetine and sertraline but there may be some modest increase in sedation with fluvoxamine and paroxetine. Keep in mind, the above information pertains to SSRI type antidepressants only and you should talk to your doctor about consuming alcohol with any antidepressants.

Sources
Stockley's Drug Interactions 8th Edition

August 6, 2008
Q. Can I test my blood sugar using blood from my forearm?
A. Yes you can, but it may not be as accurate as using the finger tip in certain circumstances and only those devices (meters, lancing devices etc.) for which alternate site testing is recommended should be used.

Only use forearm testing before a meal, an insulin dose, or physical exercise, or 2 hours after a meal, an insulin dose, or exercise.

When blood sugar is changing rapidly, for instance, within 2 hours after a meal, an insulin dose or physical exercise, a forearm blood sample will not show this change as quickly as a fingertip sample.

When blood sugar is falling, testing with a fingertip may identify a hypoglycaemic (low blood sugar) level sooner than a test with a forearm sample.

You should use fingertip testing whenever you have a concern about hypoglycemia (insulin reactions), such as when you drive a car, particularly if you suffer from hypoglycemic unawareness (lack of symptoms to indicate an insulin reaction), since forearm testing may fail to detect hypoglycemia. If the results from the forearm do not match how you feel (high or low), test from the fingertip and use those results.

If you want to use an alternate site because of fingertip pain, please see these tips regarding fingertip pain:

http://www.diabetes.ca/Section_About/fingertip.asp

Here are some tips on alternate site blood sugar testing.

For best results from alternate site
testing, individuals should be trained in
proper technique, as follows:

1. The selected alternate site should be
relatively free of hair and cleaned with
soap and warm water.
2. Rub the area vigorously for 5 seconds.
3. The correct end cap to the lancing
device must be used. This is a clear
end cap to allow the user to see the
blood drop form.
4. Press the clear end cap firmly against
the skin for 1 to 2 seconds to help pool
the blood.
5. Release the lancing mechanism and
leave the end cap pressed firmly
against the skin until the blood drop
forms. If necessary, pressure against
the skin may be released slightly and
reapplied to help the blood drop form.
6. Take the strip to the drop allowing the
capillary action to draw in the sample.
7. Make note in a logbook of which alternate
site has been used.

Sources
1. http://www.diabetes.ca/Section_About/fingertip.asp
2. http://www.diabetes.ca/files/Professional%20Pub%20Archives/DiabetesQuarterly/DCJuly-Aug0712Jul07.pdf

March 19, 2008
Q. My friend told me that cinnamon is helpful for diabetes. Is this true?
A. Likely not. Initial research indicated that cinnamon was possibly effective for type 2 diabetics by lowering fasting serum glucose, triglyceride, and cholesterol levels.

However, a recent analysis of the existing evidence indicates otherwise. Currently cinnamon has not been found effective in people with type 1 or type 2 diabetes in improving fasting blood glucose, hemoglobin A1C, or lipid levels. Further research is required regarding the use of cinnamon in preventing diabetes in high risk individuals or those with pre-diabetes.

Currently a study is being conducted in Toronto to assess the impact cinnamon has on fasting blood glucose, insulin, glycosylated hemoglobin (HA1C), triglyceride, total cholesterol, HDL cholesterol and LDL cholesterol levels in people with type 2 diabetes. The results of this study will be able to provide more conclusive evidence regarding the use of cinnamon in type 2 diabetics.

Sources
Natural Medicines Comprehensive Database 2008: Cassia Cinnamon

Baker WL. Gutierrez-Williams G. White CM. Kluger J. Coleman CI. Effect of cinnamon on glucose control and lipid parameters. [Journal Article. Meta-Analysis] Diabetes Care. 31(1):41-3, 2008 Jan.
UI: 17909085

http://clinicaltrials.gov/ct2/show/NCT00479973?term=diabetes+%5BCONDITION%5D+AND+diet+%5BTREATMENT%5D&recr=open&rank=19

November 19, 2007
Q. I would like to give my infant Tylenol drops for fever caused by recent immunizations but I am worried given that some Tylenol products have been recalled?
A. Medications that were affected by the voluntary recall included those with multiple ingredients for cough and cold only. The concern was related to misuse of these multiple ingredient products and potential effects of overdose. Products with only acetaminophen were not affected and can be used safely in those under two years of age as indicated on the label. Always check the label before giving your infant any over the counter medication or ask your pharmacist.

Sources
http://www.ndmac.ca/index.cfm?fuseaction=main.dspFile&FileID=139

November 7, 2007
Q. Is Black Cohosh effective for post menopausal hot flashes?
A. It might be. There are many different treatment options for hot flashes. The most effective therapy is still hormone therapy (1), but there are other non hormonal options for those whom hormonal therapy is not indicated or for those who prefer not to take hormones. Although not approved for use in combating menopausal symptoms, some antidepressants have been shown to be effective including venlafaxine (Effexor®), paroxetine (Paxil®) and fluoxetine (Prozac®) (2). Clonidine is another prescription medication which can be tried although side effects may limit its use (2). Gabapentin, a medication typically used in the treatment of nerve pain, may also be useful (2).

Black Cohosh is an herbal product that may also be tried although there is conflicting evidence about how effective it might be. Some trials show that it is no more effective than placebo pills (1) and others show it is more effective than estrogen or placebo (1). That being said, Black Cohosh is relatively safe, with the most common adverse effect being stomach upset (1). There is some concern of liver toxicity and safety beyond six months is not established (1) therefore liver function tests should be monitored periodically. Jaundice, unusual fatigue and dark urine are symptoms of liver toxicity and should they occur should be reported to your doctor (3).

The North American Menopause Society recommends lifestyle modifications with or without non-prescription therapy (including Black Cohosh) for women who need relief of mild menopausal symptoms such as hot flashes (1).

Sources
1. Menopause, Vol. 11, 16 No. 1, 2004
2. eTherapeutics April 2007 Menopause
3. Canadian Pharmacist's Letter 2004 (7):200714

October 3, 2007
Q. Should I use an herbal colon flush to remove toxins from my body?
A. There are many different "colon flushes" and "herbal detox systems" on the market today with a variety of ingredients. None of them can be recommended. There is no need to flush toxins from the body. The human body has very efficient organs to deal with waste including the liver, the kidneys and the colon itself. Furthermore, depending on the method and ingredients, these "flushes" may have adverse consequences including nausea, vomiting, cramps, dehydration, and electrolyte/mineral imbalances. Depending on the frequency of use, these products may also cause the user to become dependent on the product for normal bowel function. For more information click on the links below.

Sources
1. http://www.acsh.org/factsfears/newsID.194/news_detail.asp
2. http://www.quackwatch.org/01QuackeryRelatedTopics/detox.html
3. http://www.quackwatch.org/01QuackeryRelatedTopics/gastro.html

September 26, 2007
Q. Are generic drugs the same as brand name drugs?
A. Yes. Whether a manufacturer makes brand or generic drugs, they must meet the same standards set by Health Canada. Health Canada is also responsible for evaluating generic drugs. Evaluation is based on comparative studies carried out by the manufacturer. The studies are conducted the same way regardless of the drug or manufacturer. The generic drug must show that it can deliver to the bloodstream the same amount of medicinal ingredient at the same rate as the brand name drug. Sometimes the non-medicinal ingredients are different. These ingredients are responsible for shape and colour of the tablet and have no medicinal properties. If and when a manufacturer changes the non-medicinal ingredients of a drug, they must prove with scientific studies that the different ingredients do not affect the delivery, effectiveness or safety of the drug. Most pharmacies will dispense generic drugs if available for any given product unless requested otherwise by the patient or the doctor.

Sources
http://www.hc-sc.gc.ca/iyh-vsv/med/med-gen_e.html#is

September 21, 2007
Q. I am taking homeopathic products and was wondering if it will interact with my medications?
A. First we need to be clear what we mean by "homeopathic". Homepathic products are different than herbal products. Homeopathy is based on three premises including the law of similars, individuality and small doses. The law of similars theorizes that substances that would normally cause symptoms of side effects at high doses in healthy subjects can be used to treat these same symptoms in very low doses in those who are sick. The premise of individuality states that because everyone presents with different symptoms of the same disease they must be treated differently. Small doses are used in homeopathy because normal doses of these products would be toxic. "Mother tinctures" are often diluted with alcohol or water to such a degree that the original ingredient can't possibly exist but as homeopathic practitioners will argue, it is the "essence" that remains and the "essence" that is active. There is much controversy surrounding the use of homeopathic medicines as the above principles run contrary to the science of medicine, pharmacology and chemisty. Given that the mechanism of action for homeopathic medicines are unknown or unproven, the knowledge regarding drug interactions is also difficult to determine. We can assume that if the ingredient in a homeopathic product is undetectable then drug interactions would be non-existent. Problems may arise if other ingredients such as natural products are added to the preparations and not indicated on the label. If you would like to take a homeopathic product make sure that it has an NPN number on the label which indicates at the very least that Health Canada has verified the quality and safety.

Sources
1. Am J Pharm Educ. 2007 February 15; 71 (1): 07
2. Br J Clin Pharmacol 2007 Sep 15
3. http://www.quackwatch.com/search/webglimpse.cgi?ID=1&query=homeopathy

August 28, 2007
Q. My baby is crying, screaming and turning red in the face when she "poops". I think she is constipated, what can I give her?
A. If your baby is exhibiting these symptoms and still passes a soft stool then your baby may NOT be constipated at all. These symptoms are referred to as infant dyschezia. Infant dyschezia is caused by an inability to co-ordinate abdominal pressure with relaxation of pelvic muscles. The baby cries in an attempt to increase abdominal pressure and is not crying from pain. These symptoms will generally resolve spontaneously as your baby will learn to co-ordinate the defecation reflex. Treating the symptoms may be counter productive as this may interfere with the learning process. If you believe that your baby is constipated and you notice blood in the stool, fever, vomiting or a loss of weight please contact your doctor as this is unlikely "infant dyschezia".

Sources
1. Up to Date 2007: Constipation in Children: Etiology and Diagnosis
2. Paul Hyman, M.D. Accessed Aug 28, 2007. " Childhood Defecation Disorders: Constipation and Soiling." http://www2.kumc.edu/kupedigi/Defecation.htm
3. J Pediatr Gastroenterol Nutr. 1999 Nov;29(5):612-26.

August 15, 2007
Q. I am having difficulties coming off my SSRI antidepressant. Is this normal? What can be done?
A. SSRI antidepressants include (fluoxetine, fluvoxamine, paroxetine, citalopram and sertraline). Yes it is normal to have difficulties coming of these medications but it is important to distinguish between discontinuation symptoms and a re-emergence of depression. Usually this is easy enough for your doctor to distinguish. Discontinuation symptoms generally appear within hours or days of discontinuation and generally include dizziness, headache, nausea, "electric shock" like sensations, and "rushing" sensations in the head. These symptoms will usually respond rapidly to restarting the antidepressant.

The cause of discontinuation symptoms is not completely understood but is thought to result from a temporary deficiency of serotonin in the brain and a temporary deficiency (down-regulation) of serotonin receptors. It may take a couple of weeks for the serotonin and receptors to normalize and discontinuation symptoms to disappear.

Given the proposed mechanism of discontinuation symptoms it is best to reduce the dose of an antidepressant slowly over time rather than to quit taking them outright. There is no clear cut or "best" way to taper an antidepressant. With the exception of Prozac (fluoxetine) most newer antidepressants should be discontinued over several weeks with dose adjustments every 7 days. If withdrawal symptoms occur during tapering, the drug can be restarted and tapered more slowly. Another option is to substitute the drug with Prozac(fluoxetine) which, because of it's long half life, has a "built-in" tapering effect.

Sources
1. American Family Physician Volume 74, Number 3.

August 8, 2007
Q. What can I give my baby for colic? My doctor recommended Lactobacillus.
A. Colic has been defined as crying for more than three hours per day, for more than three days per week, and for longer than three weeks in a baby who is well-fed and otherwise healthy. Although colic can be quite distressing to the parent, it usually resolves on its own but may last up to four months of age. That being said, other causes of crying should be ruled out by the physician before a diagnosis of colic is made. The cause of colic is unclear and effective treatment options are few and far between. Simethicone, the active ingredient found in many over-the-counter anti-gas drops, has been shown to be no more effective than placebo. Similarly, no evidence exists for the effectiveness of various "Gripe Water" preparations and if tried, alcohol/sugar-free products should be used. There is some evidence that a certain species of lactobacillus (lactobacillus reuteri) may be helpful but more research is needed. There is no evidence for other species of lactobacillus. Many non-drug measures such as car-rides, pacifiers, gentle soothing motions, prophylactic holding, et cetera can be tried but are likely not effective. Infant massage and chiropractic techniques have not been shown to be effective and cannot be recommended. Although colic can be very difficult to deal with as a parent, there are no long term effects associated with colicky babies when compared to a non-colicky babies.
July 30, 2007
Q. A friend heard on Canada AM that Fosamax should be discontinued. Is this true? I've had no problems with it. I heard that Fosamax can cause jaw and heart problems and I should stop taking it, is this true?
A. Fosamax is in a class of medications called the bisphosphonates. Bisphosphonates are used to prevent and/or treat osteoporosis. These medications are also helpful in other bone diseases and certain types of cancer. A very rare adverse effect of this class of medication is osteonecrosis of the jaw which is damage to bone tissue of the jaw leading to severe pain, swelling and loose teeth. Although this condition can occur with oral forms of bisphosphonates including Fosamax, the majority of cases have resulted from intravenous forms of these drugs in patients with cancer. The risk or this adverse effect with oral bisphosphonate therapy is considered very low (0.7 case per 100,000 person years exposure). People at higher risk include those taking chemotherapeutic agents, radiation, corticosteroid therapy and those with poor oral hygeine or certain medical conditions like dental problems, anemia and diabetes. Smoking and alcohol use may also increase risk. Most of the time, the benefits of bisphosphonate therapy outweigh the risk of osteonecrosis of the jaw. To help minimize risk, those taking oral bisphosphonates should maintain good oral hygiene and visit the dentist regularly. It is important to let the dentist know about concurrent treatment with an oral bisphosphonate.

Fosamax has also been in the news recently with links to irregular heart beats (arrythmias). Two papers published in the New England Journal of medicine showed an increase in serious arrythmias in those taking Reclast, a once yearly injectable bisphosphonate, and the oral form of Fosamax. Again the risk of Fosamax causing serious arrhythmias appears to be very small and may not be significant. In one trial the risk of serious arrhythmia was 1.5% in those taking Fosamax compared to 1% for those not taking fosamax. At this point the risk seems higher with Reclast. As with osteonecrosis of the jaw, most of the time, the benefits of Fosamax therapy outweigh the very small risk of serious arrhythmias.