Consumer Q & A

When you become ill, your blood sugars may increase even if you haven’t changed how much you eat or your diabetic medications. Furthermore, if you are unable to eat and drink, are vomiting, have diarrhea or are sweating (e.g. because of fever), you may experience dehydration. Some medications are best avoided during times of dehydration.

Have a SICK DAY PLAN in place at all times. This plan should be created with your doctor, nurse practitioner or diabetes educator in order to set guidelines about what to do if you become ill. The plan should include information about when to stop certain medications, how and when to monitor glucose levels and ketones, and when to contact a health professional. An example of a plan template is available from RxFiles.

If you are ill but are able to eat and drink normally, continue to take your medications as prescribed. Monitor glucose levels more often than you usually do and contact your healthcare provider if they go higher or lower than normal.

If you have been ill for more than 24 hours and are eating or drinking less than usual or are experiencing vomiting or diarrhea, consult a healthcare professional to discuss adjusting or temporarily stopping some of the following:

 Blood Pressure Medications

  • Diuretic or "Water" Medications
  • Oral Diabetic Medications
  • Insulin Medications
  • NSAID (non-steroidal anti-inflammatory) Medications

Unless specified in your individual SICK DAY PLAN, do not stop any medications without consulting a healthcare professional first. Continue to monitor your glucose levels more than usual throughout the day and follow healthcare professional recommendations in regard to adjusting your medications if you have an abnormal high or low.

If you have temporarily stopped any of your medications due to illness, they may be restarted when you are eating and drinking normally again and are not dehydrated.

If you have any doubt or questions, please call your pharmacist or medSask [1-800-665-3784 (SK); 306-966-6378(Saskatoon)].


Appendix 8: Sick-Day Medication List. Diabetes Canada. Available at  

Stay Safe When You Have Diabetes and are Sick or at Risk of Dehydration. Diabetes Canada. Available at 

Type 2 diabetes and sick days: medications to pause. RxFiles Drug Comparison Charts. Saskatoon, SK: University of Saskatchewan. [accessed 12 Mar 2020]. Available from:


There is not any conclusive evidence that allergy pills lose their effectiveness when taken over time, but there may be some reasons why this is reported by allergy sufferers.

Allergic reactions can range from nasal congestion, to runny eyes and noses, to rashes and hives. Antihistamines are the mainstay for treating allergies and work most effectively when taken every day before and while, someone is exposed to allergens such as pollens that cause hay fever.

Older medications or first generation antihistamines such as diphenhydramine (e.g. Benadryl) or chlorpheniramine (e.g. Chlortripolon), can cause drowsiness and are taken 3 to 4 times a day, whereas the new, second generation antihistamines cause less drowsiness and only have to be taken once or sometimes twice a day. The newer antihistamines available without a prescription include cetirizine (Reactine), desloratadine (Aerius), fexofenadine (Allegra), and loratadine (Claritin). These are sometimes combined with a decongestant such as pseudoephedrine or phenylephrine to help relieve the symptoms of nasal congestion.


Some possible reasons that antihistamines may appear to not be working as well as previously include:

  • Starting the antihistamine after exposure to allergens, instead of taking them before coming in contact. For seasonal allergies it’s best to start early in the season before allergens are known to circulate. To avoid reactions to animal dander, it’s best to take the antihistamine before contact with the animal.
  • Coming in contact with higher concentrations of allergens than normal, such as high pollen counts. In this case a previously effective dose may not be sufficient. Speak to your pharmacist about a safe dose to take.
  • Using a combined decongestant/antihistamine product. Oral decongestants can have adverse effects such as rapid heart rate, insomnia, tremor and irritability and should not be used regularly for long-term therapy. They should be used with caution or not at all with diabetes, high blood pressure, certain heart conditions, thyroid conditions, glaucoma and with some medications. Check with your pharmacist for appropriate products.
  • Using nasal sprays that contain decongestants. These are effective for short term use, but when used for more than 3 - 5 days, the nasal tissue can develop a tolerance to the drug. When it is stopped congestion may come more strongly than before. This is known as rebound congestion.

 Starting or adding a nasal spray which contains a steroid such as triamcinolone (e.g. Nasacort Allergy) or fluticasone (e.g. Flonase) has been shown to be an effective treatment to help relieve nasal symptoms of seasonal allergies. These can be used throughout allergy season.

There’s no problem switching to a different antihistamine as all are shown to be effective and none are specific to a certain cause of allergic reactions.  However, there is no need to switch if your allergies are controlled with the product you use.

1. deShazo RD, Kemp SF. Pharmacotherapy of allergic rhinitis. Corren J, ed. UpToDate. Waltham, MA: UpToDate Inc. (Accessed 27 Apr 2020).
2. Small, P., Keith, P.K. & Kim, H. Allergic rhinitis. Allergy Asthma Clin Immunol 14, 51 (2018).
3. Oral antihistamines lose their effectiveness when taken chronically. Rumor vs truth. Canadian Pharmacist’s Letter. July 2005.
4. RxTx[Internet]. Ottawa (ON): Canadian Pharmacists Association; 2020. Keith PK. Allergic rhinitis; [updated August 2019; cited 27 Aprr 2020]. Available from: (subscription required).
5. May JR, Dolen WK. Management of Allergic Rhinitis: A Review for the Community Pharmacist. Clinical Therapeutics. Volume 39, Issue 12, December 2017, Pages 2410-2419.
6. Clinical Resource, Managing Seasonal Allergies. Pharmacist’s Letter/Prescriber’s Letter. April 2020.




CBD (cannabidiol) and THC (delta-9-tetrahydrocannabinol) are two components of the cannabis (marijuana) plant. Cannabis is a plant which contains more than 400 cannabinoid substances of which CBD and THC are the most well-known. THC is responsible for the high that occurs with cannabis use, so the lower the THC concentration, the less likely the product will produce these effects. The most common side effect of CBD is sedation or drowsiness.

Depending on the levels of THC and CBD and the concentration of other compounds in the product, the interaction potential with other drugs will vary. Some interactions may cause added effects and some may lower the effectiveness of one or more of the compounds. (1 - 5)

Adverse effects related to CBD/THC include rapid heartrate, drowsiness, dizziness, dry mouth, dry or red eye, constipation, increased appetite, decreased reaction time, anxiety and confusion. (1)

Some over the counter (OTC) drugs that might increase the adverse effects of CBD/THC include omeprazole (for heartburn), fluconazole (for yeast infections), pseudoephedrine and phenylephrine (decongestants in many cold medications), antihistamines (for allergy) and alcohol.

Some OTC drugs that might have increased adverse effects when combined with CBD/THC include ibuprofen and naproxen (anti-inflammatories)l increased levels of these drugs might present as stomach pain, an increased risk for stomach ulcers and an increased risk of bleeding.  (3- 5)

Herbs and supplements that might interact negatively with cannabis products and increase the risk of bleeding, include danshen, garlic, ginger, ginkgo, Panax ginseng and others.

Herbs and supplements that cause drowsiness and may interact with cannabis products include 5-HTP, poppy, catnip, hops, kava, St. John’s wort, valerian and others. (5)

Always check with your pharmacist before starting a new prescription medication,  an OTC product or an herb/supplement if you also use cannabis products. There are many well documented interactions that could put you at risk for adverse effects.


  1. CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2020 [updated 2018 Apr; cited 2020 Mar 9]. Cannabis [CPhA monograph]. Available from: eCPS (subscription required) 
  2. Cannabinoids: Overview.
  3. Brown JD, Winterstein AG. Potential Adverse Drug Events and Drug-Drug Interactions with Medical and Consumer Cannabidiol (CBD) Use. J Clin Med.2019 Jul 8;8(7). pii: E989. doi: 10.3390/jcm8070989.
  4. Antoniou T, Bodkin J, Ho JMW. Drug interactions with cannabinoids. CMAJ 2020; 192 (9): E206. Available from
  5. In: Natural Medicines. [Database on the Internet]. Somerville (MA); Therapeutic Research Center; 2020 [cited 10 Mar 2020]. Available from: Subscription required to view.




Hemorrhoids are swollen veins that occur in the anus and rectum, much like varicose veins occur in the legs. They are caused by pressure or straining while going to the bathroom or during pregnancy when added weight presses on these veins, the blood pools and sometimes causes them to protrude into the anal area. Hemorrhoids can be itchy or sore and can sometimes bleed. Any rectal bleeding should be assessed by a doctor. The incidence of hemorrhoids peaks at 45 – 65 years of age. They occur equally in men and women.

Hemorrhoids without any symptoms do not require treatment.

The first step to preventing hemorrhoids is to prevent constipation, which is the most common cause. The best way to prevent constipation is to increase fiber intake to 25 – 30 grams a day, either in the diet or by taking supplements which contain fiber such as over-the-counter (OTC) Metamucil or Benefibre. This should help to keep the stool soft and make it easier to pass without straining. Increasing fluid intake to at least 6 to 8 glasses of water a day may also help. You can calculate your daily dietary fiber intake with an online calculator such as:

When hemorrhoids do occur, Epsom salt baths, cleansing the area and applying creams or ointments containing zinc, witch hazel, local anaesthetics, shark liver oil or hydrocortisone may provide relief from pain and itching. These are recommended as first-line at-home treatments for hemorrhoids.

Natural health products which are taken orally and have shown some effectiveness for treating the symptoms of hemorrhoids are known as phlebotonic agents. The citrus bioflavonoids (derived from citrus fruits) diosmin and hesperidin are phlebotonic agents and are found in over-the counter (OTC) products for hemorrhoids such as Venixxa and Hemovel. The exact mechanism of action of these ingredients is not known, but they may strengthen the blood vessels and decrease inflammation. These ingredients may also cause some thinning of the blood and so are not recommended for anyone taking anticoagulant medications. The dosing for these products is specific to each one so read the product label.

If symptoms don’t improve within 7 days, assessment by a doctor is recommended.



  1. eCPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; 2020. Chan J. Hemorrhoids. In: Minor Ailments [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2020 [updated Sep 2018; cited 2020 Jan 20]. Available from: Subscription required to view.
  2. Hesperidin. In: Natural Medicines [database on the Internet]. Somerville (MA): Therapeutic Research Center; 2020 [cited 2020 Jan 20]. Available from: Subscription required to view.
  3. Diosmin. In: Natural Medicines [database on the Internet]. Somerville (MA): Therapeutic Research Center; 2020 [cited 2020 Jan 20]. Available from: Subscription required to view.




Why can’t my pharmacy supply me with the medication I need? They say it is shorted by the manufacturer.


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.

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.

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.


  1. Canadian Healthcare Network
  2. Canadian Pharmacist’s Letter; September 2010; Vol: 26

The herpes zoster (HZ) virus, which causes chickenpox on first infection, remains in the body and can show up decades later as shingles. The increase in the likelihood of herpes zoster (shingles) starts around 50 to 60 years of age and continues to increase with age. The lifetime incidence of shingles infection is estimated to be about 30% in the general population and may be higher among those living to 85 years or older.

The most common complication of shingles is postherpetic neuralgia (PHN), a nerve pain that persists after the rash is gone and can last from weeks to years. The nerve pain can be severe enough to interfere with sleep and normal daily activities. The risk of developing PHN is higher in people over 50 who have a severe shingles infection with an extensive area of rash. If shingles does occur in a previously vaccinated person, the incidence of PHN is less than in someone who contracts shingles and has not been vaccinated. In those who aren’t vaccinated, PHN occurs in approximately 43 in 10,000 people, whereas in those who are vaccinated, the number drops to approximately 5 in 10,000.

In Canada, there are 2 vaccines for HZ prevention: Zostavax II® (Live Zoster Vaccine, LZV), and Shingrix® (Recombinant Zoster Vaccine, RZV). Health Canada recommends the Shingrix vaccine for healthy people over 50 years of age even if they have been previously immunized with Zostavax or have had a previous episode of shingles. The Shingrix vaccine can be given any time after Zostavax or after an episode of shingles has resolved and the rash is no longer present. People who are immunocompromised or with chronic health conditions may be able to receive the Shingrix vaccine after assessment on a case-by-case basis. The Shingrix vaccine is given in 2 doses, the second being given 2 to 6 months after the first dose. The need for a booster has not been established, but with Shingrix, the efficacy remains consistent at 85 – 93% for at least 4 years after the second dose.

Zostavax vaccine has lower effectiveness and is only recommended if there is some reason not to give Shingrix such as a shortage or allergy to components of the vaccine.


  1. Herpes Zoster (Shingles) Vaccine: Canadian Immunization guide.
  2. eCPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2019 [updated 2019 March 5; cited 2019 May 10]. Shingrix [product monograph]. Available from: or Also available in paper copy from the publisher.


Babies need special consideration when they are going to be exposed to the sun. Their skin is more sensitive and doesn’t have a well-developed protection system. The Canadian Dermatology Association has tips for children under the age of 1 year:

  • Keep babies out of direct sunlight under cover or in a heavily shaded spot.
  • Limit sun exposure especially between 11:00 am and 3:00 pm.
  • Although you can use sunscreen on babies under 6 months, it is preferable to avoid the sun and use protective light clothing and hats. To date, there is no indication that there is any toxicity from absorption of sunscreen ingredients in babies.
  • For babies over 6 months, sunscreen can be applied to areas not covered by clothing. Avoid the eye and mouth areas.
  • Use a product with an SPF (Sun Protection Factor) of 30 or higher.
  • Contact a doctor if a child under 1 year gets a sunburn.

 A sunscreen with SPF of 30 is twice as protective as an SPF of 15. Products with SPF greater than 50 provide only a slight increase in the protection from UV radiation which causes burns.

Oil-based sunscreens containing zinc oxide and/or titanium oxide are minimally absorbed and less likely to cause allergic reactions or sensitivity than those containing other chemicals.

The Canadian Dermatology Association has a comprehensive list of sunscreens that are considered to meet their standards. It is available at:

Prepared by J. Macpherson BSP; reviewed by C. Bell  BSP
medSask, February 2019


1. Canadian Dermatology Association.
2. Sunburn. Lyn Guenther. Compendium of Therapeutic Choices. March 2017.
3. Baron E. Selection of sunscreen and sun-protective measures.  Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc.   (Accessed  08 Jan 2019)


Sambucol® Original Syrup contains 1.83 grams of elderberry fruit extract per 5 ml (1 teaspoonful).(1)

Elder flowers and berries are used as flavouring and in wine making. Traditionally, alternative medicine treatments for the common cold and the flu often included elderberry extracts. The evidence for the effectiveness of elderberry for this purpose is limited to only a few reliable human studies.(2-4) One small study used the specific elderberry fruit extract that is found in Sambucol® Anti-Viral Flu Care (NPN 80021894) at a dose of 15 ml (1 tablespoonful) four times a day for 5 days. Flu-like symptoms began to improve on average about 3 to 4 days earlier than without treatment.  As with prescription anti-flu medication, it should be started within 48 hours of the first symptoms of illness.(5) Although this is a promising finding, the study only included 60 participants. Much larger studies are needed to confirm the results.(4)

Other formulations and combinations with echinacea, may shorten the length of illness, but again there are no reliable studies confirming this.(6)

Elderberry should never be prepared as an at-home treatment. The leaves, stems and uncooked, unripe fruit contain cyanide-producing chemicals which are toxic and can cause serious side effects. People with autoimmune disorders, such as multiple sclerosis, rheumatoid arthritis or lupus, and those who are on immunosuppressing drugs should avoid using elderberry because it might stimulate disease activity. This is a theoretical interaction, but until more research is done, the possibility of the interaction cannot be ruled out. The safety of elderberry use beyond 12 weeks is unknown. There are no known interactions with food or other herbal supplements. Some people with allergies to grass pollens might have a reaction to elderberry containing products.(2)

There is no safety information regarding use during pregnancy and breastfeeding.(2)

A 230ml bottle of Sambucol® Original Syrup contains fifteen doses of 1 tablespoon (15 ml) and would last 4 days at the dose used in the study, so cost may be a factor.

Sambucol may reduce influenza symptoms if taken within 48 hours of when symptoms begin. If used according to the directions and precautions, it would appear to be safe for most people based on the available, albeit very limited, information.


  1. Health Canada. Licensed Natural Health Products Database.  Ottawa, ON: Health Canada; [cited 28 Dec 2018].  Available from: Medicines Comprehensive Database. Available by subscription;
  2. Elderberry. In: Lexi-Comp Online™, Natural Products Database, Hudson, Ohio: Lexi-Comp, Inc.; 2018; cited 28 Dec 2018.
  3. Vlachojannis JE, Cameron M, Chrubasik S. A systematic review on the sambuci fructus effect and efficacy profiles. Phytother Res. 2010 Jan;24(1):1-8
  4. Zakay-Rones Z, Thom E, Wollan T, Wadstein J. Randomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections. J Int Med Res 2004;32:132-40.
  5. Tiralongo, E, Wee, S, Lea, R. Elderberry supplementation reduces cold duration and symptoms in air-travellers: a randomized, double-blind placebo-controlled clinical trial. Nutrients 2016; 8(4):182.


Do I need a machine to clean my CPAP machine mask and tubing? I have seen ads for cleaning machines but they are quite expensive so I wonder if they are necessary.


There are some parts of a continuous positive airway pressure (CPAP) machine that need to be cleaned daily, some weekly and some parts need to be replaced every few months. Daily cleaning or thorough rinsing of the mask, tubing and water chamber is recommended. Once a week the chamber should be soaked in a 1 part vinegar: 3 parts water solution followed by rinsing with distilled water. More frequent and thorough cleaning should be done if the user has been ill. The chamber may need to be replaced about every 6 months or sooner. (1, 2)

A 2013 study to determine if the presence of bacteria in the reservoir of the CPAP machine caused sinus infections, showed that, although bacteria were present, there was not an increase in sinus infections.(3)

The advantage of a machine to clean the CPAP machine is that the parts do not have to be disassembled. However, if you’re willing to spend a few minutes each day to rinse the equipment and allow it to air-dry, you do not need to buy an expensive machine. (4)

Prepared by J. Macpherson BSP; reviewed by K. Jensen MSc, BSP
medSask, September 2018.


  3. Chin CJGeorge CLannigan RRotenberg BW. Association of CPAP bacterial colonization with chronic rhinosinusitis. J Clin Sleep Med. 2013 Aug 15;9:747-50. doi: 10.5664/jcsm.2910.

The type of cough will determine the treatment that works best. If the cough started with a cold or flu and has lasted less than 3 weeks it is classified as an acute cough. The treatment with the best evidence of effectiveness for this type of cough might be found in your kitchen:

  • Drinking more fluids and using a cool mist humidifier are recommended as first-line treatments.
  • One to two teaspoonsful of honey, has been shown to be helpful to relieve cough for adults and children over 1 year old. (Don’t give honey to Infants less than 1 year of age as they are at risk of a rare infection from spores that may be present in honey.)

On the other hand, over-the-counter (OTC) cough medicines containing dextromethorphan (DM) and/or guaifenesin have not been shown to consistently reduce the severity of an acute cough or the length of time it lasts. DM-containing products should be avoided with some prescription medications for pain and depression. Check with your pharmacist before using OTC cough products medicines if you are unsure about the risk of interaction. OTC products for cough and colds are not recommended for children under 6 years old. (1) One study appears to show that lozenges containing menthol may actually prolong and worsen some coughs. (2)

A cough that lasts longer than 3 weeks is subacute (3 – 8 weeks) or chronic (>8 weeks).  The most common causes of subacute and chronic cough are postnasal drip, asthma, and acid reflux or gastrointestinal reflux disease (GERD). Certain prescription medications used to treat high blood pressure, specifically those classed as angiotensin converting enzyme (ACE) inhibitors can cause a cough in a high percentage of people taking them. Switching to a different class of blood pressure medication is needed if the cough continues.

In other cases treating the underlying cause first, may “cure” the cough. In the case of postnasal drip resulting from allergies, avoiding allergy triggers and using antihistamines and / or steroid nasal sprays may be effective in treating the postnasal drip and stopping the cough. Prescription items may be needed if the cough does not respond to these treatments.

If the cough accompanies asthma, then standard prescription treatments for asthma with steroid inhalers and bronchodilators should help.

Acid reflux or heartburn can cause irritation in the throat which may cause coughing. Treatment with acid suppressor medications such as OTC ranitidine (Zantac©, generics) or OTC omeprazole and lifestyle changes will often help decrease the irritation and the cough. (3)

When these measures do not work to completely resolve a cough after a reasonable amount of time, then consultation with your doctor or nurse practitioner is recommended. (5)

Prepared by J. Macpherson; reviewed by K. Jensen
medSask, Sep. 2018


  1. Clinical Resource, Treatment of Cough in Adults. Pharmacist’s Letter/Prescriber’s Letter. January 2018.
  2. Can menthol-containing cough drops worsen a cough? Whetsel, Tara. Pharmacy Today. August 2018. Volume 24, Issue8, Page 14. (18)31078-8/
  3. UpToDate - Evaluation of subacute and chronic cough in adults. Silvestri, RC, Weinberger, SE. Ed Barnes, P, Talmadge EK.
  4. UpToDate - Treatment of subacute and chronic cough in adults.  Silvestri, RC, Weinberger, SE. Ed Barnes, P, Talmadge EK.
  5. Wilcox, Pearce. Chronic Cough in Adults. In: Therapeutics. [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2018 [updated May 2018; cited 2018 Sep 12]. Available from: Also available in paper copy from the publisher.

Melatonin is a hormone produced in the pineal gland in the brain. It helps to regulate the sleep-wake cycle, also known as circadian rhythm. Its production is increased in response to darkness and decreased in response to light, suggesting that as light fades in the evening melatonin levels increase and we fall asleep more easily.  Melatonin levels may be ten times higher at night than in daytime. Levels are highest in children under four years of age and then decline gradually as we get older. (1, 2)

As we age, our natural circadian rhythm, normally about a 24 hour sleep-wake cycle, may change, and most people tend to get sleepy earlier and wake up earlier. This is known as “phase advancement”. If older adults spend less time in bright daylight because they have fewer opportunities to be outside (living in care homes, not able to go outside on their own) their production of melatonin may be less than it was when they were younger.

Changes in sleeping patterns may contribute to mental decline and dementia. Disturbances in circadian rhythms and altered melatonin production are more common in patients with dementia. People with Alzheimer’s disease (AD) tend to be active at night which can be distressing for caregivers. “Sundowning”, where behavioural changes are most noticeable in late afternoon or early evening is related to abnormal circadian rhythm and is frequently seen in dementia patients. (3, 4, 5)

Melatonin may be helpful for insomnia in older adults because they are likely to be melatonin deficient.(1) The dose of melatonin should be the lowest dose that is effective to induce sleep. Higher doses can lead to a prolonged duration of action, which carries over to the following day and may increase unsteadiness upon waking as well as daytime drowsiness. Lower doses seem more effective on all aspects of sleep and do not interfere with core body temperature. When higher than normal doses are used for a long period of time, the melatonin receptors in the brain can become desensitized and not respond to the normal levels produced by the pineal gland.

A dose of 0.3mg up to a maximum of 1mg to 2mg of immediate-release formulations of melatonin is recommended as adequate for older adults. This dose, when taken preferably about 1 hour before bedtime, seems to best mimic the normal circadian rhythm and avoid undesirable prolonged action and higher than normal levels of melatonin in the body. (6, 7)

Prepared by J. Macpherson; reviewed by K. Jensen
medSask June 2018


  1. Melatonin [Monograph]. Natural Medicines online. Available at (by subscription). Accessed June 2018.
  2. Ariel B Neikrug, AB, Ancoli-Israel, S, Sleep-wake disturbances and sleep disorders in patients with dementia. Goldstein,CA,  Benca, R, ed. UpToDate. Waltham, MA: UpToDate Inc. (Accessed June , 2018).
  3. Tranah GJ, Blackwell T, Stone KL, Ancoli-Israel S, et al. Circadian activity rhythms and risk of incident dementia and mild cognitive impairment in older women.  Ann Neurol. 2011 Nov; 70(5):722-32.
  4. Al-Aama TBrymer CGutmanis I, et al.  Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial.  Int J Geriatr Psychiatry. 2011 Jul;26(7):687-94.
  5. Human Aging and melatonin. Clinical relevance. Touitou, Y. Experimental Gerontology. Volume 36, Issue 7, July 2001, Pages 1083-1100. doi: 10.1002/gps.2582. Epub 2010 Sep 15.
  6. Vural EMvan Munster BCde Rooij SE. Optimal dosages for melatonin supplementation therapy in older adults: a systematic review of current literature. Drugs Aging. 2014 Jun;31(6):441-51.
  7. Wurtman, R. Physiology and available preparations of melatonin. Cooper, DS, ed. UpToDate. Waltham, MA: UpToDate Inc. (Accessed June, 2018.)



Medical attention and antibiotic treatment are only needed if :

1.  Infection with Lyme Disease is suspected:

  • the attached tick has been identified as a “deer” tick AND
  • the tick has been attached for ≥ 36 hours AND
  • there is a high rate of Lyme disease infection in the local tick population.  (That is not the case in Saskatchewan)

2.  Lyme disease symptoms appear.


Most ticks found in Saskatchewan are “wood or dog” ticks and are found in long grass. The ticks that can carry Lyme disease are “deer” ticks and are found in wooded areas.  Most deer ticks seen here have been carried in by migrating birds.   Only a very small percentage of deer ticks (< 1%) carry the bacteria that can cause Lyme disease. There have been occasional sporadic cases of Lyme disease reported in Saskatchewan but most of these are related to travel to areas where Lyme disease is more common, such as British Columbia, Ontario, and parts of the U.S. 

To identify the tick:

  • Remove attached tick as soon as you find it.
    • Using fine-nosed tweezers, grab the head and mouth as close to the skin as possible.
    • Pull up slowly with steady pressure until the tick is completely removed from the skin.
    • Do not twist or jerk the tick.
    • Make sure the whole tick is removed.
    • Wash the area with soap and water or disinfect with alcohol or household antiseptic.
    • Avoid using nail polish, petroleum jelly, or heat to make the tick detach from the skin.
    • Ticks may be saved in an empty pill vial (or similar) and pictures sent in for testing to the eTick online system or taken to the physician if symptoms develop.
    • To tell the difference between the wood tick and the deer tick see:Blacklegged (deer) ticks -

To determine length of attachment: 

  • estimate time from possible exposure (when last in a wooded area?)
  • how engorged was the tick? Even if a tick is attached, it must have taken a blood meal to transmit Lyme disease. At least 36 to 48 hours of feeding is required for a tick to have fed and then transmit the bacterium that causes Lyme disease. After this amount of time, the tick will be engorged (full of  blood). An engorged tick has a globular shape and is larger than an unengorged one.  See link above for pictures.

Lyme disease symptoms:

It is important to note that some people with Lyme disease may have no or minimal symptoms. Others may suffer severe symptoms. As well, some people may not develop symptoms until weeks after the initial bite.

  • A typical sign of early Lyme disease is an expanding skin rash.  It can occur at the site of the infected tick bite, usually in 7 to 14 days. The rash can appear as early as 3 days or as late as 30 days. It can persist up to 8 weeks.  The rash is not usually painful or itchy, but it may be warm to the touch. About 50% of the rashes have a bull's eye appearance but may also be:
    • solid orange to red color
    • blue-purple in color
    • crusted
    • blistering
    • Fever
    • Fatigue
    • Headache
    • Joint aches and pains

Preventative Measures:

  • Wear clothing that covers as much of your skin as possible and wear light coloured clothing to make the ticks easier to spot.
  • Tuck pants into socks and wear shirts that fit tightly around your wrists.
  • Use an insect repellent with DEET.
  • Avoid the long grass-stay in centre of hiking trails.
  • Keep your pets out of the wooded areas and long grass.
  • Check yourself, your children, and your pets for ticks before coming indoors.
  • On return from a tick-infested area, remove your clothes, shower, and check well for ticks.
  • Wash and dry all clothes on the hottest setting to kill any remaining ticks.

Prepared by Dorothy Sanderson BSP; reviewed by Karen Jensen MSc, BSP
medSask, posted May 2015, updated May 2017 and Jul 2022


  1. Tick Fact Sheet - How to keep your family safe - SunCountry Health Region. Available at . Accessed May 2015.
  2. Government of Canada - Information for health professionals on Lyme disease. Available at disease: For health professionals - Canada.carofessionnels/index-eng.php . Accessed 28 Jul 2022.
  3. Government of Saskatchewan - Lyme Disease. Available at: Lyme Disease | Diseases and Conditions | Government of Saskatchewan. Accessed 28 Jul 2022
  4. Onyett H. Lyme disease in Canada: Focus on children. Canadian Paediatric Society , Infectious Diseases and Immunization Committee. Paediatr Child Health 2014;19(7):379-83. Available at . Accessed May 2015.
  5. PL Detail-Document, Stepwise Approach to Lyme Disease: From Tick Bite to Treatment. Pharmacist’s Letter/Prescriber’s Letter. July 2014.
  6. Hu L. Evaluation of a tick bite for possible Lyme disease. In UpToDate online database. Available at (with subscription). Accessed May 2015.



It depends on the medication and how long after taking it the vomiting occurred. In general, if vomiting occurs within 15 minutes of taking the medication, or if there are undissolved pills or capsules visible in what you throw up, the dose can be taken again.

After an hour enough of most drugs will have been absorbed to make re-dosing not necessary. However,  if vomiting occurs between 15 and 60 minutes, it is not so clear-cut. There are some things you should take into account before deciding what to do in this situation.

Most medications that are taken by mouth are absorbed into the body from the small intestine, so they must pass through the stomach first. Some characteristics of the medicine and the illness being treated may determine whether another dose should be taken:

  • Liquids are more quickly absorbed than tablets and capsules because tablets and capsules have to dissolve first before the drug is released and can be absorbed. Some formulations do not dissolve in the stomach at all, but have coatings that allow them to pass through into the intestine before releasing the drug.
  • Food, especially fatty food, slows stomach emptying and the rate of drug absorption, which explains why taking some drugs on an empty stomach speeds up absorption.
  • If the risk of missing a dose outweighs the risk of getting too much of the drug, then it is important to give another dose if vomiting occurs within an hour. This would include medications for HIV AIDs, birth control pills and some antibiotics used for just a short course of treatment.
  • 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 (referred to as a narrow therapeutic window) and when getting a bit more of the drug could result in too high a dose with serious adverse effects. A few examples of drugs which should not be taken again after vomiting are digoxin, warfarin, phenobarbital, long-acting opioids (pain-killers), methotrexate, cyclosporine, theophylline, and some anti-seizure medicines.

If you have any doubt you should call your pharmacist or medSask [1-800-665-3784 (SK); 306-966-6378(Saskatoon)].


Prepared by J.Macpherson BSP; reviewed by K.Jensen BSP, MSx
medSask April 2018


  1. Redosing of selected medications after vomiting. Pharmacist's Letter/Prescriber's Letter 2009;25(9):250909. 
  2. Drug Absorption. Merck Manual online.
  3. Buxton IO, Benet LZ. Pharmacokinetics: The Dynamics of Drug Absorption, Distribution, Metabolism, and Elimination. In: Brunton LL, Chabner BA, Knollmann BC. eds. Goodman & Gilman's: The Pharmacological Basis of Therapeutics, 12eNew York, NY: McGraw-Hill; . Accessed April 17, 2018.

T-scores are the measurements which determine the strength of your bones when you are screened and tested for osteoporosis. Osteoporosis is the weakening of the skeleton which happens when bone cells break down faster than new cells can replace them. This increases the risk of breaking bones especially in the spine and hip. Bone mineral density (BMD) screening measures the thickness and strength of your bones and helps to determine your risk for fractures.  The BMD is most commonly measured at the wrist, shoulder, spine and hip bones.  When bone density is low, there is an increased risk that you will suffer a fracture from a minor fall.

In Canada, it is recommended that both men and women have a BMD test done when 65 years of age or older. People younger than 65 should be tested only if they have risk factors for fractures.

Osteoporosis Canada, available at: is a good resource for information on risk factors and testing.

The T-score is calculated by comparing the BMD measurement of the patient to that of an average, healthy 30 year old woman or man. A T-score of −1.0  or higher is considered normal.

A BMD between -1.0 and -2.5 is called osteopenia. If you are in this range you are at risk of developing osteoporosis.

The World Health Organization has defined osteoporosis as a T-score of - 2.5 or lower.

Figure 1: Bone Density T-scores (American Bone Health.


Depending on your T-score and your risk of fracture, which can be calculated with a formula called the FRAX tool, you may benefit from treatment either with drugs or other measures or both to help stop bone loss.  (1, 2)

Lifestyle measures which may help to reduce bone loss include: adequate calcium and Vitamin D intake, weight-bearing and other exercise, smoking cessation, fall prevention counseling, and avoidance of excessive alcohol use. (2, 3)

Osteoporosis Canada recommends daily supplementation of Vitamin D with 400 to 1000 IU daily for adults 19 to 50 years of age, and 800 to 2000 IU daily for adults over 50 years of age.

The recommendation for daily calcium intake from diet and supplements is 1000mg for adults 19 to 50 years of age and 1200mg for adults over 50 years of age. The Ostoeporosis website has a list of calcium-rich foods, which can help to estimate your daily intake and decide whether you need to take a supplement.  (4, 5)

Prepared by J. Macpherson BSP; reviewed by K. Jensen MSc, BSP
medSask, Your Medication Information Service

April 2018


  1. CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association: c2018. [Updated 2017 Nov]. Osteoporosis. Hanley, DA. Available from: or Also available in paper copy from the publisher.
  2. OSTEOPOROSIS (OP): Treatment Comparison Chart. RxFiles. Available at (Accessed March, 2018.)
  3. Rozen, HN, Drezner, MK. Overview of the management of osteoporosis in postmenopausal women. Mulder, JE, ed. UpToDate. Waltham, MA: UpToDate Inc. (Accessed March, 2018.)
  4. PL Detail-Document, Vitamin D in Adults: FAQs. Pharmacist’s Letter/Prescriber’s Letter. March 2016.
  5. Calcium and Vitamin D. Osteoporosis Canada. Available at March, 2018.)
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 medSask (information below). 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
Tel: 306-966-6378 (Saskatoon); 1-800-665-3784 (Saskatchewan)
December, 2012. Updated Jul 2022


  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 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.

Which thermometer is best will depend on the situation, the age of the person being tested, the ease of use and the accuracy needed.

  • Digital thermometers are easy to read, inexpensive and accurate. They can be used orally, rectally or under the arm. Disposable covers are available so that they can be used by more than one person and at more than one site.
  • Ear thermometers give quick results, but must be positioned correctly for an accurate reading and are often more expensive than digital thermometers.
  • Forehead or temporal thermometers are easy to use, but are also more expensive. 
  • Pacifier thermometers are an option for infants 3 months and older, but must remain in the mouth for 6 minutes for an accurate reading.
  • Colour-changing strips which are placed on the forehead or in the armpit are inexpensive and give fast results, but are not usually very accurate.
  •  Mercury thermometers are no longer used as they pose a danger if breakage occurs and the mercury vapour is inhaled.  (1)

The usual sites of measurement are the mouth (oral) the rectum (rectal), the armpit (axilla) and the ear (tympanic membrane). Each of these sites has its own range of normal values. See chart. (2, 3) Temperature measurement from the rectum, mouth or tympanic membrane reflects core temperature.

Normal body temperature is generally considered to be 37ºC (98.6ºF), but can vary with age, time of the day, level of activity, and phase of the menstrual cycle, among other factors. (2, 3)

Although errors can occur with any method, rectal measurement is recommended in Canada as the gold standard for the most accurate temperature reading in children 5 and under. Oral measurement is recommended in children over 5 years.  Axillary temperature can be used for screening low-risk children of all ages while tympanic temperature measurement can be used as a screening tool for low-risk children 2 years and older. (3)

 Range of Normal Body Temperatures from various sites

Site of measurement




36.6° - 38°C

 97.9° - 100.4°F


   35.5° - 37.5°C

95.9° - 99.5°F


   34.7° - 37.3°C

94.5° - 99.1°F


35.8° - 38°C

  96.4° - 100.4°F

Source: Canadian Paediatric Society, 2015. Fever and temperature taking. For more information, visit

Prepared by J. Macpherson BSP; reviewed by K. Jensen MSc, BSP
medSask November, 2017


  1. Canadian Pharmacist’s Letter - Professional Resource, Thermometer Comparison. Pharmacist’s Letter/Prescriber’s Letter. November 2016.
  2. Ward, MA.  Fever in infants and children: Pathophysiology and management.  In UpToDate online database. Available at (with subscription).  Accessed August 2017.
  3. Langley, JM. Fever in Children. Peer Review Date: June 2014. Date of Revision: May 2017.



If I think I have an eye infection, do I need to see a doctor or will over-the-counter (OTC) antibiotic eye drops work?



Up to 60% of cases of pink eye (conjunctivitis) will get better with no treatment in 1 to 2 weeks. Conjunctivitis can be caused by allergies, viral infections or bacterial infections. Antibiotics are only helpful if the cause is bacterial, in which case treating with antibiotic eye drops may shorten the length of time, prevent recurrence, help prevent  more serious outcomes, decrease discomfort and  help to stop the spread to others. (1)

Bacterial infection is more common in children, while viral infection is more common in adults. The discharge from a bacterial infection is thick and globular (round drops) and may be yellow, white, or green. It forms continuously throughout the day.  Antibiotic eye drops, either OTC (e.g. Polysporin®) or prescription eye drops used up to four times daily for 4 to 5 days are usually effective.

Viral or allergic conjunctivitis, on the other hand, usually produces a stringy, watery discharge. There is no specific treatment for conjunctivitis caused by common viruses. Some people will get relief from symptoms using decongestant eye drops (e.g.Visine®, Clear eyes®), but these do not cure the infection. Limit use of these products to no more than three days to prevent rebound symptoms.  Antihistamine eye drops may be helpful for allergic conjunctivitis.  Ask your pharmacist for help in choosing the best product for your eye condition (2)

Eye infections are highly contagious for up to 3 days. Before and for 24 to 48 hours after starting treatment avoid close contact with others.  Each eye should be cleansed with a single tissue, wiping from the inner corner outward. The eyelashes should be cleansed as well, using warm water and diluted baby shampoo or eyelid wipes such as Lid-Care. (3)

Ask yourself the following questions to determine the need to see a healthcare professional:

1. Is vision affected?

If you can’t read ordinary print you should be assessed by a doctor or nurse practitioner (NP)

2. Does it feel like there is something in your eye and does it stop you from keeping your eye open?

If the sensation is one of having “sand in your eye” or a scratchy feeling, but you can keep your eye open without discomfort then you can probably treat it with an over-the-counter (OTC) eye drop or eye ointment.

If you can’t keep your eye open then you should see a doctor or NP as soon as possible as this could be a sign of more serious injury to your eye.

3. Are your eyes sensitive to bright lights?

This is known as “photophobia” and you should see a doctor or NP.

4. Have you had an injury to the eye?

If you’ve accidentally poked your eye or been hit with blunt force such as by a fist or a ball you should see a doctor or NP.

5. Do you wear contact lenses?

If there is discharge and your eyes are red, you should consult your optometrist, NP or doctor.

6. Are your eyes crusted shut in the morning?

If there is a white, thick discharge that continues throughout the day and is more than just tears, you should talk to your pharmacist, doctor or NP. (4)

Prepared by J. Macpherson BSP; reviewed by K. Jensen MSc, BSP
medSask, August 2017


  1. Jackson, W.B.  Red Eye. In: Therapeutics [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2016 [updated June 2017; cited 2017 July ]. Available from:
  2. Jacobs, D. Conjunctivitis. In: UpToDate, Trobe, J. (Ed), Waltham, MA. (Accessed July 2017.)
  3. Reference: Anti-infective Guidelines for Community-acquired infections. 2013 Edition.
  4. Jacobs. D. Evaluation of the red eye. In: UpToDate, Trobe, J. (Ed), Waltham, MA. (Accessed July 2017.)



Prevagen has been widely advertised as a memory aid but there is no reliable evidence to support this effect. In January 2017, the United Sates Federal Trade Commission charged the manufacture with false advertising for claiming Prevagen is a memory booster (1) The manufacturer is fighting the charges.(1) 

The product website states that Prevagen is a dietary supplement that has been clinically shown to help with mild memory problems associated with aging. This information, however, is followed by a disclaimer which says: “These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.”(2)

The “clinical” information referred to was a study sponsored by the Quincy Bioscience LLC (Limited Liability Company), manufacturer of Prevagen and the main investigator is Kenneth C. Lerner, a patent attorney employed by Quincy Bioscience LLC. The involvement of the manufacturer in the study makes its objectivity somewhat suspect. In addition, one of the authors of the safety study referenced on the website is D.L. Moran, Director of Manufacturing Sciences for Quincy Bioscience LLC. His name comes up as one of the authors in more than one of the journal papers cited on the website. (2)

Prevagen contains a substance derived from jelly fish (active ingredient apoaequorin, a calcium-binding protein). There is no proof that apoaequorin is effective for any of the conditions for which it has been promoted, including amyotrophic lateral sclerosis (ALS), memory, cognitive function and sleep quality. (3) There are currently no clinical trials investigating this substance. (4)

As we get older, calcium-binding proteins found naturally in our brains tend to decrease and intracellular (unbound) calcium increases. A lower level of these binding proteins is associated with Alzheimer’s disease as well as with normal aging. It is theorized that Prevagen supplies these proteins to the brain where they can bind excess calcium thus protecting the brain cells. When infused directly into the brains of rats, apoaequorin did appear to afford some protection to brain cells; however since it is a protein, when taken by mouth in tablet or capsule form it would be broken down by stomach acids before being absorbed and would not reach the brain in an active form. (5.6.7)

Over 2000 side effects associated with PrevagenÒ have been reported with at least 26 considered serious. (7) This supplement should be used with caution in people with pre-existing conditions such as seizure disorders or who have previously suffered a stroke.

The product sells for approximately $40 per month online with a recommendation by the company to give at least 90 days to see results.(2) Prevagen has not been approved for sale in Canada.(8)

Prepared by J. Macpherson BSP; reviewed by K. Jensen MSc, BSP
medSask, August 2017


  1. Fox M. Jellyfish memory supplement Prevagen is a hoax, FTC says. NBC website. Available at Accessed August 2017.
  2. Prevagen® | The #1 Selling Memory Supplement in Drug Stores. Prevagen website. Available at . Accessed August 2017.
  3. Apoaequorin [Monograph]. Natural Medicines online. Available at (by subscription). Accessed August 2017.
  4. Clinical Trials. Available at Accessed August, 2017.
  5. Oh MM, Oliveira FA, et al. Altered calcium metabolism in aging CA1 hippocampal pyramidal neurons.  J Neurosci. 2013 May 1;33(18):7905-11.
  6. Yamaguchi M.  Role of regucalcin in brain calcium signaling: involvement in aging.
  7. Integr Biol (Camb). 2012 Aug;4(8):825-37. doi: 10.1039/c2ib20042b. Epub 2012 May 31.
  8. Canadian Pharmacist’s Letter. PL Detail-Document, Prevagen for Memory. Pharmacist’s Letter/Prescriber’s Letter. November 2015.
  9.  Licensed Natural Health Product Database. Health Canada. Available at Accessed August, 2017.

EpiPens have been in the news recently because of dramatic price increases.  This is particularly a concern since often they are not used before the expiry date supplied by the manufacturer. 

A recent study examined the concentration of 40 unused, expired Epipens (no discoloration) and found that 65% of the EpiPens and 56% of the EpiPen Jrs still had at least 90% of the labeled concentration of epinephrine. One EpiPen that had a listed expiry date of 50 months earlier still had 84% of the stated amount of epinephrine.

This was only one small study, but in light of its findings, keeping an out-of-date EpiPen for backup may be a good option for some people.  There is no evidence that EpiPens become harmful after their expiry date.

Prepared by D. Sanderson, BSP; reviewed by K. Jensen BSP, MSc
medSask, August 2017


Cantrell FL, Cantrell D, Wen A, et al. Concentrations in EpiPens After the Expiration Date. Annals of Internal Medicine letter (Free abstract)


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


  1. UpToDate - Selection of sunscreen and sun-protective measures
  2. Sunscreens - Accessed June 2014.
  3. 3. Insect Repellents -  Accessed June 2014.
  4. UpToDate - Prevention of arthropod and insect bites: Repellents and other measures
  5. Insect Repellents - . Accessed June 2014.
  6. CDC –  Accessed June 2014.
  7. Skin Cancer foundation –  Accessed June 2014. 


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


  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.
  3., accessed June 1, 2011
  4. Using Sunscreens, 07/08/2010, Texas Tech University Health Sciences Center,

Of the almost 3000 types of spiders that live in North America only a very few have strong enough biting appendages to pierce human skin and most have too little venom to cause a reaction.

Unless you can catch the “suspect” for identification or witness the culprit in action, your bite is probably not from a spider. Most spiders bite humans only when they are threatened with being fatally crushed between skin and some object. About 80% of suspected spider bites have been found to be due to ants, fleas, bedbugs, ticks, mites, mosquitoes and biting flies. 

Spiders considered a health threat to humans: The following spiders of concern might be found living in Canada or could be transported to Canada (on fruit, for example):

  • Widows (Western black widow)
    • Found in Western USA from Canada to Mexico
    • Shiny black spider with red area on body
    • Habitat is in clutter around houses, gardens, sheds
    • Rarely found indoors

  • False black widows
    • Found in Southeastern USA, Pacific coast, Colorado, British Columbia
    • Chocolate brown color with tan stripes or markings on abdomen
    • Do not have red markings
    • Habitat is in clutter around houses, gardens, sheds
    • Occasionally found indoors in cupboards and undisturbed areas
  • Recluses
    • Found in USA, Midwest and southern states extending westward, no regular Canadian habitat
    • Non-descript brown spiders
    • Recluses have three pairs of eyes, monochromatic abdomen and legs, and fine hairs on legs
    • Habitat is mostly inside homes in attics, basements, cupboards and outdoors in rock piles and under tree bark, not in live vegetation 

Treatment of spider bites: Spider bites usually result only in a mild reaction producing a single, small, red sore. Any severe reaction from a spider bite is usually delayed from 1 to 8 hours.  Skin, eye, or mucous membrane irritation can occur after contact with prickly hairs from large spiders such as tarantulas or wolf spiders. If possible, capture the spider that bit you so that it can be identified. Most spider bites can be managed similarly to other bug bites (see below) except in the following situations: 

  • Seek medical care if you develop fever, blood in the urine, rash, or joint pain within 48 hours after a confirmed brown recluse bite.
  • If a black widow bite is confirmed, an antivenin is available to treat symptoms such as muscle cramps, paralysis or seizures. 

Recommended general treatment for bug bites:

  • Clean the area with soap and water
  • Apply a cold compress
  • Apply anti-inflammatory, anti-itch creams such as hydrocortisone
  • Take pain relievers (e.g. Acetaminophen) or anti-inflammatories (e.g. Ibuprofen, naproxen) by mouth if needed
  • Take antihistamines by mouth for itching (e.g. Diphenhydramine, cetirizine)

Prepared by Jean Macpherson BSP, Reviewed by Karen Jensen MSc, BSP
medSask, May 2017


  1.  How to Identify and Treat Spider Bites. HealthLine website. Available at: Accessed May 2017.
  2. Barish R, Arnold T. Spider Bites. In Merck Manual online. Available at Accessed May 2017.
  3. Vetter, RS,  Swanson, DL. Approach to the patient with a suspected spider bite: An overview. In: UpToDate, Wiley, JF (Ed), Waltham MA, 2017. Available by subscription from 
  4. PL Detail-Document, How to Manage Bites and Stings. Pharmacist's Letter/Prescriber's Letter. June 2012.
  5. Al-Agroudi MA, Ahmed SA, Morsy TA. Intervention program for nursing staff regarding approach to a patient with a spider phobia and/or bite. J Egypt Soc Parasitol. 2016 Apr;46(1):167-78.



Ticks are found in long grass and bushy, wooded areas.  If possible, avoid walking your dog in these environments.  Always check your dog thoroughly after being outside.  Ticks can be found anywhere on the dog, but they prefer dark areas such as under the collar, on or in the ears, between toes and under the tail.1,2,3

If you find a tick attached to the dog, remove it as soon as possible.  Using tweezers or a special tick removal tool such as a “Tick Key”, grasp the tick as close to the skin as possible. Very gently, pull straight upward, in a slow, steady motion. This will prevent the tick’s mouth from breaking off and remaining in the skin. Do not use alcohol or petroleum jelly in hopes of persuading the tick to back out on its own. These things often don’t work and may cause the tick to inject more saliva into the wound.  Ticks have a very hard shell and are hard to kill.  Placing the tick in a small container of alcohol will ensure its dead and yet enable you to save it for identification purposes – if desired.  Once the tick is removed, clean the area with soap and water and apply a small amount of topical antibiotic ointment such as Polysporin®.  Wash your hands thoroughly.1,2,3

Your veterinarian can supply several products that repel and/or kill ticks:

K9 Advantix II - This is an oil that is applied to the dog’s skin once/month.  It both repels and kills ticks. 

Disadvantages: the oil can discolor the dog’s fur and may rub off on anything that comes in contact with it.  The medication may be dangerous for young children and is toxic to cats.  Possible side effects include itching and redness of skin and hair loss.4

Nexgard - This a flavoured chew given by mouth once a month.  The tick must bite the animal for it to be effective.  The tick is killed within 48 hours of attachment.

Disadvantages : It does not repel ticks. Tick must bite before the medication can work. Because it is taken internally, side effects include vomiting, itching, diarrhea, lethargy and lack of appetite are possible. 5

Bravecto - This is a flavoured chew given by mouth every 12 weeks.  It is convenient since you don’t have to give a dose each month.  In Saskatchewan one dose per year may cover the worst of the tick season.  The tick is killed within 48 hours of attachment.

Disadvantages: Does not repel ticks.  Tick must bite before the medication can work. Possible side effects include: vomiting, diarrhea, gas, lack of appetite and increased thirst. 6

Prepared by Dorothy Sanderson BSP. Reviewed by Karen Jensen MSc, BSP
medSask, May 2017


  1. Ticks. Wascana Animal Hospital website. Available at (Accessed May 2017)
  2. Ticks 101. U of S Veterinary Medical Centre. Available at (Accessed May 2017)
  3. Flea and Tick Preventatives. Caring Hands Animal Hospital. Available at (Accessed May 2017)
  4. Bayer Animal Health website. Available at (Accessed May 2017)
  5. Nexgard website. Available at (Accessed May 2017)
  6. Bravecto website. Available at (Accessed May 2017)

Antibiotic creams or ointments are not necessary unless a cut or scrape becomes infected and are recommended by a healthcare professional. Most minor cuts, scrapes, and superficial burns will heal within a month with very little or no scarring depending on the cause and depth of the injury. Antibiotics taken by mouth are indicated for animal bites, deep puncture wounds or wounds involving the palms and fingers, but are not necessary for other types of clean, non-bite wounds in healthy adults.

Common complications of wounds are infection and scarring, (1) To reduce the chance of complications, follow these guidelines for treating minor cuts and wounds (1, 2):

  • Clean the wound with drinkable tap water and mild soap to remove dirt from the site. Don't use hydrogen peroxide or rubbing alcohol directly on the wound as they can be irritating and interfere with healing.
  • Use running water, if possible to clean the wound. A squirt bottle or large syringe wiith no needle works well.
  • Apply gentle pressure on the wound using gauze or a clean cloth to stop the bleeding. Apply pressure for 10 minutes (15 minutes if the person is taking blood thinners). If bleeding continues then assessment by a professional is required.
  • Remove any pieces of dirt or other material (such as glass, metal or gravel) from the wound area. Use a pair of tweezers soaked in rubbing alcohol or rub gently with a clean gauze pad.
  • Apply a bandage or gauze dressing. Topical antibiotics are usually not needed.
  • Change the dressing daily or more often if it becomes dirty or damp.
  • When changing the dressing, check for signs or symptoms of infection such as:
    • red, puffy areas around the site that are tender to touch
    • red streaks coming from the wound
    • throbbing pain in the wound area
    • pus (creamy yellowish-grey fluid)
    • fever, chills or tender lumps or swelling in your armpit, groin or neck
    • See your doctor, nurse practitioner or pharmacist if you notice any of the above.
  • The dressing can be removed after 48 hours if the wound is healing well.

Tap water is commonly used in the community (non-medical setting) for cleaning wounds because it is easily accessible, efficient and free. There is no evidence that using tap water increases the risk of infection. However there is not strong evidence that cleansing in itself increases healing or reduces infection.(3)

In the absence of tap water, boiled and cooled water or distilled water can be used as wound cleansing agents. (3) Although other solutions are acceptable, a normal saline (salt) solution is best as it is non-irritating and does not interfere with normal healing.(1)

Prepared by Jean Macpherson, BSP; reviewed by Karen Jensen, MSc, BSP
medSask; Your Medication Information Service March 2017


  1. Kleiman N. Minor Cuts and Wounds. In RxTx, CTMA. Revised April 2016. Accessed February 2017. Available at Accessed February 2017.
  2. Cuts and Grazes. St. John’s Ambulance. Available at Accessed March 2017.
  3. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst. Rev. 2012 Feb 15;(2):CD003861. f.

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


  • 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.



  • 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


  • 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
  • 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.
  • 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.


  • 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


  • Hepatitis A usually gets better in a few weeks without treatment.
  • It is recommended to get lots of rest and avoid drinking alcohol
  • Your doctor may suggest medicines to help relieve your symptoms, or medicines you may want to avoid. If symptoms persist, especially if you are an older person, then you should see a doctor again.
  • When you recover, your body will have learned to fight off a future hepatitis A infection. However, you can still get other kinds of hepatitis.
  • Hepatitis B usually is not treated unless it becomes chronic.
  • Chronic hepatitis B is treated with drugs to slow or stop the virus from damaging the liver, to reduce transmission to others and to prevent long-term complications such as cirrhosis and cancer.
  • Treatment should continue until the virus is no longer at detectable levels in the blood and for a period after to ensure it has been effective. Treatment may be life-long in some cases.
  • A liver transplant may be necessary if chronic hepatitis B causes liver failure. Liver transplantation surgery replaces a failed liver with a healthy one from a donor.  Medicines taken after surgery can prevent hepatitis B from coming back.
  • Usually, hepatitis C does not get better by itself.
  • If untreated the infection can last a lifetime and may lead to scarring of the liver or liver cancer.
  • Previous treatment with anti-viral drugs was effective for only about 15 to 25 percent of cases.  
  • Antiviral therapy of HCV changed with the development of new drugs called direct-acting antivirals. The choice of drug and length of treatment depends on the type of HCV.  Treatment can last from 8 weeks up to 24 weeks and is expensive, but usually well-tolerated.
  • The goal of treatment in HCV is to eradicate the virus so that it is undetectable in the blood 12–24 weeks after the end of treatment
  • Because other hepatitis viruses and alcohol use are associated with faster progression of the disease, health experts advise people with hepatitis C to avoid drinking alcohol and to be vaccinated against hepatitis A and hepatitis B viruses.
  • Serious cases may need a liver transplant.
  • Further development of the anti-virals will endeavor to shorten the length of treatment, use fewer drug combinations and reduce costs.

Prepared by Jean Macpherson BSP.  Reviewed by Karen Jensen MSc, BSP
medSask: Your Medication Information Service
June 5, 2013
Updated February 2017


  1. MedlinePlus. Hepatitis A. Available at Accessed  May, 2013
  2. MedlinePlus. Hepatitis B. Available at Accessed  May 2013.
  3. MedlinePlus. Hepatitis C. Available at Accessed  May 2013.
  4. Cheney, Catherine P. Overview of hepatitis A virus infection in adults. In: UpToDate, Hirsch, MS (Ed), UpToDate, Waltham, MA, 2012.
  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. 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 Accessed May 2013.
  7. Overview of the management of hepatitis B and case examples. Lok, ASF. In UpToDate online database. Available at (with subscription). Accessed  March 2016
  8. RxTx – Viral Hepatitis – authors Peltekian,KM, Hirsch, G. Revised May 2014. Accessed March 2016
  9. Overview of the management of chronic hepatitis C virus infection. Chopra, S, Pockros,P. In UpToDate online database. Available at (with subscription). Accessed March 2016.

Some preliminary studies suggest turmeric might be beneficial for osteoarthritis.  (1)  However, claims that the substances found in turmeric help to reduce inflammation (swelling, redness, tenderness) are not supported by strong evidence. More comprehensive studies are needed to determine whether turmeric is useful and what doses are safe and effective.


Turmeric is a yellow spice which comes from a plant in the ginger family. It is used to flavour or colour curry powders, mustards, and other foods. The active component of turmeric is curcumin, which may have anti-inflammatory effects (i.e., reduce swelling, redness, tenderness) and antioxidant effects (i.e., protect cells from damage caused by toxins in the body).

However, most of the studies investigating turmeric have been on small numbers of people and have not been compared to placebo (people not taking turmeric). Curcumin is poorly absorbed, which means that very little of it reaches the tissues to have much effectiveness. (2, 3).

Turmeric is considered generally safe at usual amounts found in food, but it may cause side effects such as heartburn, especially when used in larger amounts. It has been used safely in several clinical trials lasting up to 8 months.

A typical dose for osteoarthritis is about 1 to 2 g/day of turmeric extract. A 1 g dose is equivalent to about 3 to 18 teaspoons (15 to 90 mL) of ground turmeric spice. Taking this with food increases the amount absorbed. (4)

Although the studies for arthritis are limited, there's even less evidence for using turmeric for diabetes, depression, inflammatory bowel disease, cancer, and other conditions. (1)

Prepared by Jean Macpherson BSP. Reviewed by Karen Jensen MSc, BSP
medSask, February, 2017


  1. Professional Resource, Turmeric. Pharmacist’s Letter/Prescriber’s Letter. December 2016.
  2. Turmeric comes on strong. University of California, Berkeley Wellness Letter.  Volume 33. Issue 1. October 2016.
  3. Turmeric. In: National Center for Complementary and Integrative Health. Available at:  Accessed January, 2017.
  4. Turmeric monograph. In: Natural Medicines Comprehensive Database online. Available by subscription at Accessed Jan, 2017.


Do I need antibiotics before I have my teeth cleaned at the dentist office?  I used to get a prescription every time, but I’ve heard that you don’t need them anymore.


Most people do not need to take antibiotics before having their teeth cleaned or other dental procedures.(1)(2)(3)(4)  Recent evidence has shown that antibiotics are usually not necessary in these situations and using antibiotics that aren’t needed may make them less effective when they are needed.

The reason for taking antibiotics before dental procedures (this is called prophylaxis) is to kill bacteria that cause endocarditis. Bacteria can get into the circulation as a result of dental work that causes bleeding. Rarely these bacteria may attach to damaged areas in the heart or heart valves and cause an inflammation called endocarditis which can lead to more damage of the heart valves and life-threatening complications.

It is now known that endocarditis is more likely to occur from exposure to random germs than from a standard dental exam or surgery.  Normal, healthy heart valves are resistant to bacterial infections from the circulation. (1)(2)(3) Only people considered at high-risk of serious complications from infection should receive antibiotics before dental procedures that may cause bleeding of the gums (cleaning, extractions, draining an abscess, etc.)  People with any of the following heart conditions are at high risk:

  • artificial (prosthetic) heart valve
  • previous endocarditis infection
  • certain types of congenital heart defects
  • heart transplant complicated by heart valve problems

The Canadian Dental Association (CDA) does NOT recommend routine antibiotic prophylaxis for patients with total joint replacements or orthopedic pins, plates, or screws who are having dental procedures.(2)

Patients with orthopedic implants should maintain good dental hygiene and oral infections in patients with prosthetic joints should be treated promptly. (4)

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen MSc, BSP
medSask, Dec. 2016


  1. Mayo Clinic Staff. Endocarditis. In Mayo Clinic online. Available at Accessed November 2016.
  2. 2.        .PL Detail-Document, Antibiotic Prophylaxis for Dental Procedures: An Update. Pharmacist’s Letter/Prescriber’s Letter. October 2015.
  3. Endocarditis prophylaxis. In: Dynamed online database. Available at (by subscription). Accessed November 2016.
  4. Berbari  E, Baddour LM. Epidemiology and prevention of prosthetic joint infections.  In: UpToDate, Sexton, D (Ed), Waltham MA, 2016. Available from  (Subscription and login required.)

That depends on what you are taking. Some medications should not be mixed with alcohol at all, while one or two alcohol drinks may be fine with others.

Medication and alcohol combinations which could be risky:

  •  Central nervous system drugs. If you take any drugs known to cause central nervous system (CNS) depression or slow down brain activity, alcohol should be avoided. These types of drugs are often called sedatives, tranquilizers, mood-stabilizers or sleeping pills and may be used to treat anxiety, insomnia and other conditions.  Since ethanol (ethyl alcohol) can also cause a slowing of brain activity, this effect can be stronger when taken with other drugs that have the same effect.

  • Opioid or narcotic pain medicines (e.g. codeine, morphine and others), are also CNS depressants and alcohol should be avoided while taking these. Blood alcohol levels, even within the legal driving limits, may be very unsafe in the presence of other CNS depressants.

  • Combining sedatives or narcotics with alcohol is an increasingly common cause of overdose and death.

  • Extended, slow or controlled release (e.g. those with XR, SR or CR in the name). These drugs might be a problem if alcohol alters the special formulation that allows the drug to be released slowly or affects the way the stomach absorbs the drug. This might result in “dose-dumping”, a higher than prescribed or dangerous amount of drug getting in to the bloodstream. Check with your pharmacist if you are unsure about the formulation of your particular medication.

  • Antihistamines. These are drugs such as diphenhydramine (Benadryl), chlorpheniramine (Chlortripolon) and dimenhydrinate (Gravol) which often cause CNS side effects such as drowsiness. Alcohol should be avoided with these until you know how they affect you.  Other “non-drowsy” antihistamines such as loratadine (eg, Claritin), cetirizine (eg, Reactine), deslopratadine (Aerius) and others may be a safer alternative with alcohol.

  • Antidepressants. These are drugs such as amitriptyline (Elavil), nortriptyline and MAOIs (monoamine oxidase inhibitors) which can cause CNS depression side effects and should be used cautiously alcohol especially when the prescription is first started.  MAOI’s (Parnate, Nardil) have dietary restrictions as well as alcohol restrictions, so avoidance is advised.  Bupropion (Wellbutrin) can make a person more sensitive to alcohol intoxication as well as increase the risk of seizures when combined with alcohol.  Other anti-depressants such as fluoxetine (ProzacÒ  and other related SSRIs or SNRIs) appear to be safer with alcohol.

  • Antidiabetic medicine: Acohol can affect blood sugar and when taken with anti-diabetes medications or insulin, the levels can become unpredictable, causing highs or lows. Alcohol taken with metformin can also cause lactic acidosis (a build-up of lactic acid in the blood).  Use alcohol cautiously and with moderation if you have diabetes.

  • Antibiotics: In most cases alcohol is OK with antibiotics. An exception would be the antibiotic metronidazole (Flagyl) which can cause a potentially serious reaction when alcohol is taken while using the drug and for up to 3 days after stopping the drug. Antifungal medications such as ketoconazole (Nizoral)can cause the same reaction.

  • Acetaminophen (e.g. Tylenol): An occasional drink is usually OK but if you have 3 or more drinks a day you should avoid acetaminophen because the combination can damage your liver.

  • Ibuprofen, naproxen (e.g. Advil, Aleve) and other NSAIDs (e.g. diclofenac, Celebrex, Toradol and others): These drugs can cause bleeding of the stomach lining. Alcohol, especially if you have three or more drinks daily, can worsen this problem because it also can cause bleeding in the digestive tract.

  • Blood thinners: Drinking alcohol can increase the risk of falls and bleeding. Caution is advised when taking “blood thinners” and other drugs that affect clotting such as warfarin, dabigatran (Pradaxa), clopidogrel (Plavix) and others (e.g. Xarelto, Eliquis).  

  • Blood pressure medicines: An occasional drink is probably OK if you are on blood pressure medicines. Some can cause a temporary drop in blood pressure when you stand up from a lying or sitting position and alcohol could worsen this effect increasing the risk of falling. The effect of beta –blockers such as metoprolol can increase with alcohol causing temporary increases or decreases in blood pressure.

  • Varenicline (Champix): Combining alcohol with the smoking-cessation drug varenicline (Champix) can increase drunkenness, willingness to fight and memory loss. Use alcohol with caution if you are on this medication and especially if you have side effects while on it.
Prepared by Jean Macpherson BSP; reviewed by Karen Jensen
medSask, December 2015
  1. Canadian Pharmacist’s Letter -PL Detail-Document, Alcohol and Drug Interactions. Pharmacist’s Letter/Prescriber’s Letter. December 2015.
  2. Lexicomp Online Interactions available at
  3. UpToDate. Prescription drug misuse: Epidemiology, prevention, identification, and management. Accessed December 2015.

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.

Alcohol has many effects on the body that contribute to the hung-over feeling. Dehydration due to alcohol results in headaches, muscles pains, fatigue and irritability. Alcohol causes inflammation of the stomach lining and increases gastric acid production leading to abdominal pain, nausea and vomiting. It can also lower blood sugar and disrupt sleep cycles. These disruptions in body rhythms produce a “jet lag” effect.

If you are going to drink, try to limit the amount to one or fewer drinks per hour 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.

Food of any kind before indulging in alcohol helps to lessen hangover symptoms, 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.

Treatment of hangover

  • Drink lots of water to replenish fluids and dilute toxins. Hangover symptoms will usually abate over 8 to 24 hours. There is no evidence that sports drinks are more effective than water for a hangover.
  • Caffeine is commonly used to counteract the fatigue and malaise associated with hangover condition, but can also contribute to the dehydration.
  • Carbohydrates in the form of toast or crackers and fruit juices increase blood sugar and may help reduce fatigue and irritability.
  • Eggs and high protein foods contain an amino acid known as cysteine which may help detoxify the harmful by-products of alcohol in the body.
  • 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.
  • Do NOT drink more alcohol (“hair of the dog”). It may provide temporary relief but only prolongs the hangover process.

The following are signs and symptoms of alcohol poisoning that require emergency medical treatment:

  • Confusion, dazed feeling
  • Unconsciousness
  • Persistent vomiting
  • Seizures
  • Irregular or slow breathing (less than eight breaths a minute)
  • Blue-tinged skin or pale skin
  • Low body temperature (hypothermia)

Prepared by Jean Macpherson BSP, December 14, 2009
Updated December 16, 2014


  1. Swift R, Davidson D. Alcohol hangover; mechanisms and mediators. Alcohol, Health and Research World 1998;22:54. Available at Accessed 14Dec2009
  2. Perry L. How hangovers work. Available at Accessed 14Dec2009.
  3. Weise J, Shlipak M, Browner W. The alcohol hangover. Ann Intern Med 2000;132:897, Available at Accessed 14Dec2009.
  4. Mayo Clinic. Hangovers. Available at Accessed 15Dec2014
  5. Pittler M, Verster JU, Ernst E. Interventions for preventing or treating alcohol hangover: systematic review of randomised controlled trials. BMJ 2005;331:1515. Available at Accessed 15Dec2014.

In the united Stated, the manufacturer of Tylenol®, Neil Consumer Healthcare, has reduced the daily limit for adults and children over 12 years of age to 10 tablets of Tylenol® Regular Strength (3250mg) or 6 tablets Tylenol® Extra Strength (3000 mg) per 24 hours.(1) Health Canada has reviewed  the safety of acetaminophen and decided not to change the current dosing recommendations (see below) but instead has asked manufacturers to provide clearer instructions on acetaminophen packaging to emphasize the following:

  • the importance of using the lowest effective dose
  • not exceeding the recommended daily maximum in a 24-hour period
  • using these products for no more than five days for pain or three days for fever
  • not mixing them with alcohol if drinking three or more drinks in a day. (2)

Adult Acetaminophen Dosing (3,4)

The total amount of acetaminophen taken in a day from all sources should not exceed 4,000 mg (4.0 grams) for adults and children aged 12 years and older. Over 24 hours, this equals:

  • 8 extra strength pills (each pill contains 500 mg) or
  • 12 regular strength pills (each pill contains 325 mg)

Pediatric Acetaminophen Oral Dosing (3,4)

When possible, the dose of acetaminophen should be based on a child’s weight: 10 to 15 mg/kg/dose.  This dose can be given every 4 to 6 hours up to a maximum of 5 doses in 24 hours. When weight is unknown, the following doses based on age may be used (3):



Dose of Acetaminophen
(Tylenol, Tempra, store brands)

0-3 months

2.7-5.3 kg  [6-11 lbs]

40 mg/dose

4-11 months

5.4-8.1 kg  [12-17 lbs]

80 mg/dose

12-23 months

8.2-10.8 kg  [18-23 lbs]

120 mg/dose

2-3 years

10.9-16.3 kg [24-35 lbs]

160 mg/dose

4-5 years

16.4-21.7 kg [36-47 lbs]

240 mg/dose

6-8 years

21.8-27.2 kg [48-59 lbs]

320 mg/dose

9-10 years

27.3-32.6 kg [60-71 lbs]

400 mg/dose

11-12 years

32.7-43.2 kg [72-95 lbs]

480 mg/dose

Ibuprofen is another over-the-counter medication used to treat pain and fever. The dosing interval of ibuprofen may be different than that for acetaminophen depending on the dose. Check the directions on the package. Take the lowest effective dose for the shortest time needed to reduce the risk of adverse effects. If the medication upsets your stomach, try taking it with food or milk. If you have heart or blood pressure conditions, take ibuprofen only on the advice of your healthcare professional. (5)

 Adult ibuprofen dosing (6)

For adults and children over 12 years old, the dose is 200mg every 4 hours or 400 mg every 6 to 8 hours. The total amount of ibuprofen taken in a day from all sources should not exceed 1200mg. Over 24 hours this equals:

  • 3 extra strength tablets or capsules (each pill contains 400mg)
  • 6 regular strength tablets or capsules (each pill contains 200mg)

Do not take for more than 3 days for fever or 5 days for pain unless directed to do so by a physician.

Pediatric ibuprofen Dosing (7)

When possible, the dose of ibuprofen should be based on a child’s weight: 4-10 mg/kg/dose. (5)

Give one dose every 6 to 8 hours as needed. The maximum single dose is 400 mg/dose, and the maximum daily dose is 40 mg/kg/day up to 1200 mg/day.  When weight is unknown, the following doses based on age may be used:



Dose of ibuprofen
(Advil, Motrin, store brands)

6-11 months

5.4-8.1 kg [12-17 lbs] 

50 mg

12-23 months

8.2-10.8 kg [18-23 lbs] 

75 mg

2-3 years 

10.9-16.3 kg [24-35 lbs] 

100 mg

4-5 years 

16.4-21.7 kg [36-47 lbs]

150 mg

6-8 years 

21.8-27.2 kg [48-59 lbs]

200 mg

9-10 years

27.3-32.6 kg [60-71 lbs]

250 mg

11-12 years

32.7-43.2 kg [72-95 lbs]

300 mg


Prepared by Jean Macpherson BSP; reviewed by Karen Jensen MSc, BSP
medSask. November, 2016


  1. CPL - PL Detail-Document, Treating Fever in Children. Pharmacist’s Letter/Prescriber’s Letter. November 2013.
  2. Stronger, clearer labels for over-the-counter acetaminophen products to further address the risk of liver damage. In: Health Canada website. Available at Accessed Nov. 2016.
  3. Revised Guidance Document: Acetaminophen Labelling Standard. In: Health Canada website. Available at Accessed Nov. 2016.
  4. Acetaminophen general monograph. In: RxTx CPS database. Available at (by subscription). Accessed Nov. 2016.
  5. Ibuprofen monograph. Lexi-Comp OnlineTM, Hudson, Ohio: Lexi-Comp, Inc. Accessed Nov. 2016.
  6. Advil monographs. In: RxTx CPS database. Available at (by subscription). Accessed Nov. 2016.
  7. Farindi A. Pediatric ibuprofen oral dosing. In Medscape online database. Available at Accessed Nov. 2016.

No, giving children acetaminophen (e.g. Tylenol®, Tempra®) or ibuprofen (e.g. Advil®, Motrin®) before getting immunizations is not recommended.  These medication do not appear to reduce the pain of the injection, but has been shown to decrease the immune response to some immunizations. Although the significance of this is not known, it’s best to wait until after getting a vaccination to give a pain reliever and then only if needed. (1, 2) There is no evidence that these medications prevent febrile seizures. (3)

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen MSc, BSP
medSask, November 2016


  1. CPL - PL Detail-Document, Treating Fever in Children. Pharmacist’s Letter/Prescriber’s Letter. November 2013.
  2. Falup-Pecurariu O. Effects of prophylactic ibuprofen and paracetamol administration on the immunogenicity and reactogenicity of the 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugated vaccine (PHiD-CV) co-administered with DTPa-combined vaccines in children: An open-label, randomized, controlled, non-inferiority trial. Hum Vaccin Immunother. 2016 Aug 19:0. [Epub ahead of print]
  3. Canadian Immunization Guide: Part 1 - Key Immunization Information. Available at (Accessed Oct 30, 2016)


I was diagnosed with chlamydia and prescribed one dose of an antibiotic to cure it. How long after taking the antibiotic can I engage in sexual activity?


To ensure that transmission does not recur, abstinence from sexual activity for one week following treatment is recommended.

For gonorrhea, chlamydia, syphilis, and Trichomonas, sex partners should be notified, examined, and treated for the specific STI (sexually transmitted infection).

Even though you took the antibiotic as a single dose, it will remain present in sufficient levels in the body throughout the entire life-cycle of the organism to completely cure the infection. Patients should only resume having sex after symptoms have resolved and sex partners have been treated. Check with your nurse practitioner or doctor to see if they wish to follow up to make sure the infection is cleared. For other STI’s the treatment may be for a longer period of time and require taking an antibiotic more than once a day for a week or more.


  1. Swygard, H, Seña,A, Cohen, M. Treatment of uncomplicated gonococcal infections. In: UpToDate, Hynes, N (Ed), Waltham MA, 2016. Available from  Subscription and login required
  2. Anti-infective Review Panel.  Anti-infective guidelines for community-acquired infections. Toronto: MUMS Guideline Clearinghouse; 2013.


I was diagnosed with a urinary tract infection (UTI) and prescribed MacroBID® 2 days ago. Then I had my wisdom teeth removed and they were infected so I was prescribed amoxicillin today. Is it OK to take two antibiotics at the same time?


Not all antibiotics work against all bacteria and in this case there is an indication for both antibiotics. The bacteria that cause tooth infections are not usually susceptible to MacroBID® while most urinary tract bacteria are resistant to amoxicillin nowadays. Therefore, in your situation it is reasonable to take both antibiotics in order to clear up both infections.

You may get extra nausea and/or diarrhea from the combination. If the diarrhea is severe – more than 4 episodes of diarrhea in 24h – talk to your doctor about the situation.


  • Anti-infective Review Panel.  Anti-infective guidelines for community-acquired infections. Toronto: MUMS Guideline Clearinghouse; 2013.


I have a heart problem and am scheduled for some dental work.  I have a prescription for cephalexin to be taken 2 hours before my dental appointment.  I am allergic to penicillin and I’ve been told that I should be careful about taking other antibiotics like cephalexin. What is the risk that I will be allergic to this as well?


There is a slight risk that you may have a cross reaction. You should talk to your dentist if s/he is not aware of your allergy, especially if your penicillin allergy causes severe effects (swelling around the mouth and throat, difficulty breathing, seizures, loss of consciousness, etc.)  Your dentist may wish to change your prescription to a different antibiotic.

Penicillin allergy is the most commonly reported drug allergy. Although the rate of cross reactivity between penicillins and cephalosporins, including cephalexin, used to be considered to be as high as 50% (based on studies from the 1960’s and 1970’s), it is now thought that the early (first generation) cephalosporins may have been contaminated with trace amounts of penicillin. The rate of cross reaction has been stated to be 8% to 10%, however newer (second and third generation) cephalosporins have chemical structures that are less similar to penicillin and therefore have a lower risk of cross reactivity. Although current studies suggest that the actual rate of cross-reactivity between penicillins and cephalosporins is probably less than 1%, among patients who report penicillin reactions, between 0.17% and 8.4% will react if given a medication like cephalexin.

Another consideration is that people with a penicillin allergy are more likely to have multiple drug allergy syndromes and may be up to three times more likely to have an adverse reaction to any drug.


  1. Penicillin-allergic patients: Use of cephalosporins, carbapenems, and monobactams. In UpToDate, Adkinson, F (Ed) UpToDate, Waltham, MA, 2016. Available at Subscription and login required.
  2. Cross-reactivity of sulfonamide drugs. Pharmacist's Letter/Prescriber's Letter 2010; 26(6):260601

Probiotics may help prevent diarrhea due to antibiotics. Continue taking probiotics during treatment and for up to 2 weeks afterward.

There is some concern that taking antibiotics might decrease the effectiveness of some probiotics.

Since probiotic preparations usually contain live and active organisms, simultaneously taking antibiotics might kill a significant number of the organisms. Separate administration of antibiotics and probiotic preparations that contain bacteria (e.g. bifidobacteria and lactobacilli), as well as oral antifungal medications and probiotics that contain yeast (e.g. Saccharomyces boulardii.), by at least 2 hours.


  1. Natural Medicines Comprehensive Database. Available by subscription at
  2. 2. PL Detail-Document, Comparison of Common Probiotic Products. Pharmacist’s Letter/Prescriber’s Letter. July 2015.

Heart failure (HF), sometimes called congestive heart failure (CHF) occurs when the heart muscles become weak or damaged and can no longer pump blood efficiently or cannot relax sufficiently to allow blood to flow back into the heart from the lungs. This can be the result of previous heart attacks or high blood pressure (hypertension) and since people now live longer with these conditions, the number of people with heart failure is on the rise. It is estimated that there are about 600,000 Canadians currently living with heart failure.

HF is characterized by specific symptoms such as shortness of breath and fatigue, and signs such as fluid retention and swelling (edema). Although there is no cure, there are treatments and lifestyle changes which can help improve the condition and quality of life. These include exercising, reducing salt in your diet, reducing stress and losing weight, (1, 2)

Certain herbal supplements and non-prescription products can be risky with heart failure and should be avoided. These include:

  • Effervescent (dissolving) tablets which contain over 500mg of sodium per tablet. Some examples are: Alka Seltzer, Eno fruit salts, Redoxon (effervescent Vitamins C & B, calcium). Always check labels for sodium content. (3)
  • Licorice root. When used in amounts commonly found in foods, licorice has Generally Recognized as Safe (GRAS) status in the US. However, eating licorice daily for several weeks or longer can cause severe adverse effects including high blood pressure, low potassium, changes in heart rate and even heart attack in otherwise healthy people. Although consuming 20 grams or more licorice daily is more likely to cause these effects, smaller amounts have also caused problems when taken long-term for months to years. (4)
  • Aconite or Wolfsbane. Aconite root contains toxic compounds that are strong, fast-acting poisons that affect the heart and central nervous system, causing paralysis and death. All species of this plant are dangerous. Aconite can cause nausea, vomiting, dizziness, muscle spasms, hypothermia, paralysis of respiratory system, and heart rhythm disorders. It can also be absorbed through the skin in amounts sufficient to cause poisoning.
  • Hawthorne. Hawthorne is often found in combination products recommended for the heart. It may reduce blood pressure and decrease heart rate, but it can interact with other medications used in heart failure and its use is not recommended. (4)
  • St. John’s wort. When St. John’s wort is used with digoxin (Toloxin®), a common prescription treatment for some types of heart failure, it can decrease blood levels and therapeutic effects of digoxin. St. John's wort can reduce digoxin levels by 25% after 10 days in healthy people. Its use should be avoided in heart failure. (5)
  •  Yohimbine. Yohimbine is a prescription drug in Canada and should be used only under the supervision of a health care professional. The use of products containing yohimbine can result in serious adverse reactions, particularly in people with high blood pressure, or heart, kidney or liver disease. Side effects associated with yohimbine include increased blood pressure and heart rate, anxiety, dizziness, tremors, headache, nausea and sleep disorders. (4)
  • Other herbal supplements that can affect heart rate and should be avoided include: green tea, lily-of-the-valley and motherwort.
  • Supplements that can interact with other drugs used to treat HF and that should be avoided include: danshen, black cohosh, dong quai, garlic, ginkgo, ginseng, gossypol and saw palmetto. (3, 5)

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen MSc, BSP
medSask, October 2016


  1. Heart and Stroke Foundation of Canada. Heart Failure. Available at Accessed October 2016.
  2. Mayo Clinic. Heart Failure. Availablet at Accessed October 2016.
  3. Professional Resource, Medications and Supplements with Adverse Effects in Heart Failure. Pharmacist’s Letter/Prescriber’s Letter. September 2016.
  4. Health Canada. Five unauthorized products seized from Keebo Sports Supplements in Winnipeg may pose serious health risks. Available at Accessed October 2016.
  5. Natural Medicines Comprehensive Database. Available by subscription at

The decision to whiten teeth should only be made after consulting a dentist.  The options for whitening range from toothpastes that contain whiteners to at-home whitening products to dentist-office bleaching treatments. The products you can buy without a prescription are generally safe when used as directed and for the suggested amount of time.

Teeth may appear less than white because of surface stains or because the dentin layer below the outer enamel is not white. Since the enamel is translucent and the dentin layer is varying shades of yellow, it will affect the appearance of the teeth. Coffeetea, red wine, sports drinks, hard candy, berries and tomato sauce are all foods that can cause tooth discoloration. (1, 2)

Whitening toothpaste

Some common ingredients in tooth whitening pastes include peroxide, calculus control agents called pyrophosphates, and polishing substances such as silica and baking soda. (3) The effects of whitening toothpastes usually are not dramatic. They can’t change the natural color of your teeth or lighten a stain that goes deeper than a tooth’s surface. Removing deeper stains and changing the color of the internal tooth structure requires a bleaching product. When used twice a day, whitening toothpaste takes about two to six weeks to whiten the teeth. (1, 2)

Dental Bleaching Products

Over the counter (OTC) dental bleaching products usually contain hydrogen peroxide. (3) For most people, bleaching is safe, easy, and inexpensive. Hydrogen peroxide–impregnated polyethylene whitening strips can be used at home to bleach teeth or to maintain already whitened teeth. With darker stains, the best results are achieved by using a combination of dental office and home bleaching systems. Most patients will require periodic re-treatment.

The most common adverse effect of these bleaching products is sensitivity. Approximately two thirds of patients have short-term, minor tooth sensitivity to cold and may also have gum irritation. Tooth surfaces, especially exposed roots or enamel surfaces with defects, are porous and are more likely to develop cold sensitivity. (4)

None of the teeth whitening options currently available are permanent.  Food, drink and aging, will cause your teeth to darken again. Whatever whitening method chosen, eventually you will need to repeat the process if you want to maintain the whiteness of your teeth long-term. (1)

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen MSc, BSP
medSask, September 2016



  1. Sheridan P. Dental Specialties, Mayo Clinic, Rochester, Minn. Available at Accessed Sept. 2016.
  2. Canadian Pharmacists’ Letter. PL Detail-Document.  A Look at Tooth Whiteners. Pharmacist’s Letter/Prescriber’s Letter. December 2013.
  3. Plaque and tartar control. In: Available at Accessed Sept. 2016.
  4. Patel D. Tooth Discoloration Treatment & Management. In: Medscape online. Available at Accessed Sept. 2016.

Resistance to the most commonly used treatments for head lice appears to be emerging in Canada. Although a 1% permethrin creme rinse (e.g. Nix, Kwellada-P) or a pyrethrin shampoo (e.g. R & C Shampoo) is still recommended as first-line treatment, alternative products such as dimeticone and isopropyl myristate are proving to be as or in some cases more effective if they are used properly according to the package directions. These products can be considered if resistance to first line treatments is a known problem in your location, if first line treatment fails (live lice in hair 48 hours after treatment), or if you have concerns about using insecticides on young children. (1)

Dimeticone (e.g. NYDA) is reported to be a successful non-insecticide approach to lice infestations. It is a silicone-based product which when sprayed on dry hair, flows into the breathing system of lice, then thickens and suffocates the lice. According to two studies, more subjects treated with dimeticone were lice free nine days after treatment than those who were treated with permethrin.

Another product, isopropyl myristrate (Resultz), dissolves the outer skeletons of lice and appears to be at least as effective as insecticides. (1, 2)

Dimeticone and isopropyl myristrate are well tolerated and no serious side effects have been reported.  Because of the way these products work, it is hoped that lice will be less likely to become resistant to them. (3)

No matter which treatment is chosen, using a nit comb to remove eggs from the hair shafts after treatment is still necessary to prevent recurrences.

Several other remedies including enzymes which are claimed to affect the outer skeleton of the lice and cause premature molting and death are advertised for treatment of head lice.  There is no evidence in the scientific literature to support these claims.  These products are advertised as non-toxic to humans, but caution is advised especially if there is not full disclosure of all product ingredients. (4)

For an overview of head lice and its treatment go to: and enter “lice” in the search field.

Prepared by Jean Macpherson, BSP; reviewed by Karen Jensen MSc, BSP
medSask, September 2016


  1. Canadian Pharmacist’s Letter - PL Detail-Document, Non-insecticide Lice Treatments. Pharmacist’s Letter/Prescriber’s Letter. April 2012.
  2. Kolber M, Pierse M, Nickonchuk T.  The louse is (no longer) in the house. Canadian Family Physician. Tools for Practice. Vol 62: April• 2016.
  3. Dumont Z, Rutherford L. Head lice: Picking out truth from myth Pharmacy Practice 2012;28:18.
  4. Head lice control. On: Beyond Pesticides website. Available at Accessed August 2016.

Recent studies give more weight to the suggestion that what we eat can affect our brains. Once a brain disorder such as Alzheimer’s disease (AD) is diagnosed, effective treatments are limited at best. It would therefore make sense that preventing or at least delaying the onset would be preferred.

Improving cardiovascular (heart) health may reduce the risk of dementia. Diets that are high in plant-based foods and oils that are low in saturated fats have been associated with a variety of health benefits, including lowering the risk of heart disease. One diet that features this pattern of eating and these types of food is the Mediterranean diet.  Conclusive evidence however, of the beneficial effect of diet on dementia is lacking. (1)

The Mediterranean diet emphasizes:

  • Eating primarily plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts
  • Replacing butter with healthy fats such as olive oil and canola oil
  • Using herbs and spices instead of salt to flavor foods
  • Limiting red meat to no more than a few times a month
  • Eating fish and poultry at least twice a week (1,2)

It appears that specific areas of the brains of people with Alzheimer’s disease and other dementias are smaller than those of people who not affected by these diseases. Magnetic resonance imaging (MRI) scans have shown there is a correlation between an increase in the severity of dementia and a decrease in the size of the whole brain and the thickness of specific areas of the brain such as the cerebral cortex.  The cortical area of the brain plays a key role in memory, attention, perception, awareness, thought, language, and consciousness. (3)

A study of MRI scans that measured these areas of the brain in elderly participants showed that people who had followed a Mediterranean style diet and taken supplemental B vitamins, had wider measurements than those who ate less beneficial foods with higher percentages of calories from carbohydrates and sugar. The difference between the brain matter in the two groups is equal to about five years of aging.

These findings suggest that a healthy diet that is high in fish and vegetables is associated with larger cortical thickness in several brain regions and might help us maintain brain function and delay the onset of dementia disorders. (4, 5)

There are other things you can do that may keep your brain and heart healthy. As more is understood about what role these factors play in Alzheimer’s disease risk, health experts recommend that all adults:

Although scientists do not yet know for sure if these healthy habits can directly prevent or delay Alzheimer’s disease, it’s important to note that these habits have many benefits for overall health and well-being. (1, 6)

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen MSc, BSP
medSask, August 2016


  1. Press, D, Alexander, M, Prevention of dementia. In UpToDate online database. Available at (with subscription). Literature review current through: Jul 2016. This topic last updated: Mar 16, 2016. Accessed August 2016.
  2. Mayo Clinic Staff. Patient Care and Health Information. Mediterranean diet: A heart-healthy eating plan. In Mayo clinic online. Available at:  Accessed August 2016.
  3. Kiho I et al. Variations in cortical thickness with dementia severity in Alzheimer's disease. Neuroscience Letters. Volume 436, Issue 2, 9 May 2008, Pages 227–231. Available at
  4. Brooks M. Mediterranean Diet Linked to Larger Brain Volume.  Medscape Medical News - Neurology. October 22, 2015. Available at .   
  5. National Institute on Aging. Preventing Alzheimer’s Disease: What do we know. Available at . Accessed August 2016.
  6. National Institute on Aging. Preventing Alzheimer’s Disease: What do we know. Available at . Accessed August 2016.

Gout is a type of arthritis that causes severe pain, redness, warmth and swelling in joints. It is caused by a build-up of uric acid crystals in the blood. In people with gout, the body doesn’t get rid of uric acid as quickly as in people who don’t have gout. Uric acid is a chemical produced when the body breaks down substances called purines.  Purine occurs naturally in the body, but certain foods can  increase uric acid levels either because they contain relatively high amounts of purines or because they interfere with the uric acid elimination process.

Gout attacks occur most often at night and usually affect a single joint such as the base of the big toe or the knee. Men are more likely to get gout at a younger age, but it becomes increasingly common in women after menopause.  Fortunately, gout is treatable, and there are ways to reduce the risk that attacks will recur. (1, 2)

The period after an attack of gout has cleared up is called the intercritical period. The time between episodes varies, but most untreated people will have a second attack within 2 years.

Prevention of a recurrence can be aided by addressing some lifestyle changes during the intercritical period. These might include identifying causes of increased uric acid (hyperuricemia) such as food choices, alcohol consumption, body weight and also management of any health issues such as high blood pressure, diabetes, high cholesterol, kidney disease and heart disease. Medications which lower uric acid (for example, allopurinol) and anti-inflammatory medications (for example, naproxen or indomethacin) may also be used during this time to help decrease the likelihood of another attack. (3)

Gout has been associated for centuries with overindulgence in meats, seafood and alcohol. In the past, the recommended diet focused on eliminating all foods that had moderate to high amounts of purine. The list of foods to avoid was long, which made the diet difficult to follow. More recent research has shown a clearer picture of the role of diet in gout management. Some, but not all, foods with purines should be eliminated. Other foods can be included in your diet to help control uric acid levels.

The general principles of a gout diet are the same as those for a balanced, healthy diet.

Although diet isn't likely to lower the uric acid concentration in the blood enough to treat gout without medication, it may help decrease the number of attacks and limit their severity. In general, losing weight lowers the risk of gout and reduces stress on joints.

  • Eat more fruits, vegetables and whole grains, which provide complex carbohydrates. Studies show that vegetables high in purines do not increase the risk of gout attacks. A diet based on lots of fruits and vegetables can include high-purine vegetables, such as asparagus, spinach, peas, cauliflower or mushrooms. Beans or lentils, which are moderately high in purines, are acceptable and a good source of protein.
  • Add protein with low-fat or fat-free dairy products, such as low-fat yogurt or skim milk. These are associated with reduced uric acid levels.
  • Limit daily proteins from lean meat, fish and poultry to 4 to 6 ounces (113 to 170 grams).
  • Cut back on saturated fats from red meats, fatty poultry and high-fat dairy products.
  • Include 8 to 16 cups (2 to 4 litres) of fluids a day with at least half of that as water. Coffee (regular caffeinated) consumption in moderation may help reduce the risk of gout, but drinking coffee may not be appropriate for other medical conditions.
  • Avoid foods such as white bread, cakes, candy, sugar-sweetened beverages and products with high-fructose corn syrup.

  • Avoid organ and glandular meats such as liver, kidney and sweetbreads, which have high purine levels.
  • Avoid the following types of seafood, which are higher in purines than others: anchovies, herring, sardines, mussels, scallops, trout, haddock, mackerel and tuna.
  • Limit use of alcohol - no more than 2 drinks per day for a male or one drink per day for a female. The breakdown of alcohol in the body is thought to increase uric acid production. In addition, alcohol contributes to dehydration. Beer in particular is associated with an increased risk of recurring attacks of gout, distilled liquors to some extent as well.. The effect of wine is not as well understood, so moderation is recommended. (4)
  • Avoid all alcoholic beverages if gout attacks are frequent or if gout is not well controlled.

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen MSC, BSP
medSask, July 2016


  1. UpToDate - Becker MA,  Clinical manifestations and diagnosis of gout. Romain PL, (Ed), UpToDate, Waltham, MA, 2015. Available at (by subscription). Accessed June 2016.
  3. UpToDate - Becker MA,  Prevention of recurrent gout .In:UpToDate. Romain PL, (Ed), UpToDate, Waltham, MA, 2015. Available at (by subscription). Accessed June 2016



Common warts are caused by a virus and are spread by direct skin-to-skin contact. They are small, raised growths which may be a different colour than the surrounding skin. They may contain black dots which are small, clotted blood vessels.

Warts around the fingernails are called periungual warts. Plantar warts are on the soles of the feet and flat warts are usually on the hands, face and lower legs.

Children, young adults and people with weakened immune systems are more likely to develop warts. They are also more common among certain occupations such as handlers of meat, poultry, and fish. You can also get infected by touching surfaces that have the wart virus on them, which is why they often occur in people who go barefoot around pools, locker rooms, or gyms.

Warts usually go away on their own, but may take a year or more to disappear and may reoccur. Many people want to remove them because they find them bothersome or embarrassing. (1, 2, 3)

The treatment for common warts depends on the location of the wart and patient preference. First-line treatments are:

  • over-the-counter salicylic acid formulation applied on the wart at home
  • cryotherapy (often called “freezing”) with liquid nitrogen in a doctor’s office or at home

More recently, the use of duct tape or adhesive tape as a treatment has gained popularity. (2, 4)

Salicylic Acid

Salicylic acid (SA) applied to a wart works by slowly peeling away virus-infected skin. It may also help stimulate the immune system to react to the mild irritation, which in turn helps clear the infection. Effective treatment may take weeks or even months.

Various salicylic acid products are available without prescription in different strengths ranging from 17% to 40% and different formulations (solution, cream, gel, plasters and patches). These products are convenient to use, usually inexpensive, and do not cause pain if applied properly. They are most useful for plantar warts and sensitive body parts where cryotherapy would be painful. Plantar warts should be treated with the higher strength salicylic acid (up to 40%).

Package instructions should be followed exactly for the treatment to work. Before applying the SA product, the warts should be soaked in warm water for five minutes and then an emery board or pumice stone should be used to scuff and remove any dead skin. To avoid spreading the virus, it is suggested that a disposable emery board be used and thrown away after each use. The SA preparation should then be applied on the wart for the recommended time (as per package instructions). SA in liquid form should be applied every day and SA patches reapplied every 48 hours for up to 12 weeks. If the warts are not cleared after the recommended treatment time then a doctor should be consulted. (4)


Cryotherapy can be used instead of salicylic acid or if salicylic acid isn’t effective.  It appears to work by causing irritation and tissue destruction which stimulates an immune response against the wart virus. One disadvantage of cryotherapy is the pain it often causes and because of this, it is used mostly to treat warts in older children and adults and often avoided in young children.

Liquid nitrogen, which freezes tissues to -196°C, is the most common agent used by doctors for cryotherapy. The treatment may take multiple visits to the clinic.  Home use cryotherapy systems consisting of dimethyl ether and propane (DMEP) are also available. These agents freeze tissue to only

 -57°C and do not freeze as quickly as liquid nitrogen. They appear to be almost as effective as treatments done in doctors’ offices, if applied properly.

After application of these products, a blister forms under the wart. The frozen skin and wart should fall off after about ten days. Contact with the blister fluid should be avoided as it may result in spreading the wart.   OTC cryotherapy should only be repeated three times, usually at ten day intervals.  (2, 4)

Duct Tape

There is conflicting evidence as to whether or not duct tape treats warts effectively. Although the mechanism by which it works is unclear, it is suggested that covering the wart deprives the virus of oxygen and that the adhesive causes irritation, which stimulates an immune response to the virus, much the same as SA and cryotherapy.

Silver duct tape appears to work best because of the type of rubber-based adhesive on the tape. It is applied directly to the wart and removed six days later. The skin should then be soaked  in warm water for 10 to 20 minutes, scrubbed with an emery board or pumice stone and left open to the air overnight. The cycle is repeated the next morning and every following six days for up to two months. One study showed that warts completely resolved in 85% of patients treated with duct tape and 60% of patients treated with cryotherapy. (2, 4)

Other treatments

A few alternative treatments have been reported to work for some people, but there is no reliable evidence to show they are as or more effective than salicylic acid and cryotherapy.

  • Zinc – available as an ointment you apply to the wart or as an oral pill taken by mouth. The oral, pill form may be effective in people who have a zinc deficiency.
  • Silver nitrate – available as a solution or ointment to be applied to the wart.
  • Smoke – Some people showed benefit from treating their wart in a "smoke box" with smoke from burnt leaves of a type of poplar tree called Populus euphratica.

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen MSc, BSP
medSask, June 2016


  1. Mayo Clinic Staff. Diseases and Conditions. Common warts. In Mayo clinic online. Available at Accessed May 2016.
  2. Goldstein B, Goldstein A, Morris-Jones, R. Cutaneous warts. In UpToDate online database. Available at (with subscription). Literature review current through: Apr 2016. This topic last updated: Nov 10, 2015. Accessed May 2016.
  3. Dynamed. Verruca vulgaris. Available online at (by subscription). Accessed 09Jan2015.
  4. Treatment of cutaneous warts. Pharmacist's Letter/Prescriber's Letter 2010;26(7):260717.

Most medications remain active and safe to use for many years depending on how they are stored, BUT any medication taken after its expiry date is done so at the consumer’s risk. The manufacturer will not take responsibility for the effect or safety of a drug used after its expiry date.

The expiry date is important information for certain medications in order to be sure they will be effective. Talk to your pharmacist before using an expired product.

Background: An official definition of the manufacturer’s expiration date is the “date after which ideally stored medications in the unopened manufacturer’s storage container or in most circumstances, the opened and intact manufacturer’s storage container, should not be used. Manufacturers will usually set an expiry date of 2 to 3 years from the day the drug is made. The drug manufacturer must have evidence that until that expiry date, the drug is active at the strength stated on the label and is safe for use. This avoids the need for the manufacturer to do longer term testing for stability and may help make up for variability in storage conditions after a product is purchased and opened. (1, 2)

There are certain medications and dosage forms that should be replaced by or used before their expiration dates. Some drugs have shorter expiry dates because they break down more easily and are more sensitive to storage conditions. Examples are: epinephrine, nitroglycerin, insulin, antibiotics in liquid form, and eye drops.

Epinephrine used for allergic reactions (Allerject, Epipen) loses a significant amount of strength for each month past the expiry date, therefore epinephrine products should always be replaced before they expire. However, if there is a situation where epinephrine is needed and the only product available is outdated, it can be used as long as there is no discoloration or particles in the liquid. The benefit of using the outdated product is greater than the risk of a lower dose or of no epinephrine treatment at all. Follow-up as soon as possible at a hospital is required for anyone with an anaphylactic reaction, even if treatment is successful. A second occurrence of the allergic reaction happens in a high percentage of cases within 8 hours of the first episode.(3)

Drugs with a narrow therapeutic index should not be used after their expiry dates. A narrow therapeutic index means that a drug’s blood level needs to be within a precise range to be effective while at the same time avoiding adverse effects. Examples of such drugs are: carbamazepine (Tegretol), phenytoin (Dilantin), phenobarbital, digoxin (Lanoxin or Toloxin), theophylline (Theolair or Uniphyl) and warfarin (Coumadin).

Even if an expired drug is still within guidelines for strength after the expiry date, it may not be appropriate to use if there have been any changes in the health condition for which it was first prescribed. (1) Check with your pharmacist or doctor.

Prepared by Jean Macpherson, BSP.  Rreviewed by Karen Jensen MSc, BSP
medSask, May 2016


  1. Canadian Pharmacist’s Letter - PL Technician Tutorial, Drug Expiration Dates. Pharmacist’s Letter/Pharmacy Technician’s Letter. March 2015.
  2. Expired Medications May Maintain Potency for Decades.  Medscape. Oct 08, 2012.
  3. Estelle F, Simone R, et al.  Outdated EpiPen and EpiPen Jr autoinjectors: Past their prime? J Allergy Clin Immunol 2000; 105(5): 1025-1030 

Many people experience leg cramps at night while asleep and sometimes even while resting and awake. Nighttime or nocturnal leg cramps are usually harmless and are often related to muscle or nerve tiredness. (1) The cramps are caused by uncontrolled spasms of the muscle in the calf (back of the leg), the foot or the thigh. They occur suddenly, are painful and disturb sleep. (2, 3)

While leg cramps can affect anyone, they occur more frequently in older people (up to 50 % of seniors report episodes and pregnant women ( up to 50 % experience muscle cramps during the second half of pregnancy). (2, 4)

The actual cause is unknown, but cramps are sometimes set off by a movement such as pointing the toe down while lying in bed. This shortens the calf muscle, leading to cramping of the muscle. Vigorous activity or unaccustomed use of muscles at an earlier time in the day is sometimes followed by nighttime leg cramps. (5) Although as yet unexplained, cramps happen more often in mid-summer and less often in mid-winter. (6) Sitting for long periods, inappropriate leg position during sitting, and standing for long periods of time on concrete floors is associated with a higher incidence of leg cramps. (2)

Prevention / Treatment

Women who have leg cramps during pregnancy should discuss preventive measures and proper diet with their doctor to ensure they are getting all the required nutrients.

For other people, these types of cramps can sometimes be prevented by regular stretching of the affected muscles.  Calf muscles can be stretched by standing about 2 ½ feet from a wall and by leaning into the wall while keeping  back and legs straight with heels on the floor. This position should be held for 10 to 15 seconds and repeated two or three times a day and again before bed. Alternatively, when lying down, flexing or pulling the toes toward your head while keeping your legs as straight as possible will help stretch the calf muscles.

Stretching, as above, is often the best treatment when a cramp occurs. You can also try:

  • walking or jiggling the affected leg followed by elevating it in bed with a pillow
  • taking a hot shower or bath
  • massaging and icing the muscle. (5)

 Other strategies which may help to stop nocturnal cramps include:

  • wearing proper, comfortable shoes
  • keeping the bed covers at the foot of the bed loose and not tucked in
  • drinking adequate fluids throughout the day to avoid dehydration
  • making sure you are getting the recommended daily amount of calcium and Vitamin D (see Table 1 and 2 below). (2, 5)

If the above measures don’t work and nighttime cramping becomes frequent and is not sufficiently helped by stretching and massage, you should see your doctor to rule out other causes and to discuss other safe medical or prescription preventions and treatments.

Table 1: The Daily Reference Intakes for calcium8

Age group

Recommended Dietary Allowance (RDA) per day

Tolerable Upper Intake Level (UL) per day

Infants 0-6 months

200 mg

1000 mg

Infants 7-12 months

260 mg

1500 mg

Children 1-3 years

700 mg

2500 mg

Children 4-8 years

1000 mg

2500 mg

Children 9-18 years

1300 mg

3000 mg

Adults 19-50 years

1000 mg

2500 mg

Adults 51-70 years


1000 mg
1200 mg


2000 mg
2000 mg

Adults > 70 years

1200 mg

2000 mg

Pregnancy & Lactation
14-18 years
19-50 years



1300 mg
1000 mg



3000 mg
2500 mg

  • There is no additional health benefit associated with calcium intakes above the level of the new RDA.
  • Total calcium intake should remain below the level of the new UL to avoid possible adverse effects.
  • Long-term intakes above the UL (Upper Level)  increase the risk of adverse health effects, such as kidney stone
  • Consider total calcium intake from both dietary and supplemental sources. To figure out dietary calcium, count 300 mg/day from non-dairy foods plus 300 mg/cup of milk or fortified orange juice.

Table 2: The Daily Reference Intakes for vitamin D8

Age group

Recommended Dietary Allowance (RDA) per day

Tolerable Upper Intake Level (UL) per day

Infants 0-6 months

400 IU  (10 mcg)

1000 IU (25 mcg)

Infants 7-12 months

400 IU  (10 mcg)

1500 IU (38 mcg)

Children 1-3 years

600 IU (15 mcg)

2500 IU (63 mcg)

Children 4-8 years

600 IU (15 mcg)

3000 IU (75 mcg)

Children and Adults

9-70 years

600 IU (15 mcg)

4000 IU (100 mcg)

Adults > 70 years

800 IU (20 mcg)

4000 IU (100 mcg)

Pregnancy & Lactation

600 IU (15 mcg)

4000 IU (100 mcg)

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen MSc, BSP
medSask, April 2016


  1. Mayo clinic staff. Night leg cramps. In Mayo Clinic online. Available at Accessed 11Sep2015.
  2. Winkelman JW. Nocturnal leg cramps. In: UpToDate, Romain, PL (Ed), UpToDate, Waltham, MA, 2015. Available at (by subscription). Accessed 11Sep2015.
  3. Nocturnal Leg Cramps. In Dynamed online database. Available at (by subscription). Accessed 11Sep2015.
  4. CPL: How to prevent nighttime leg cramps. Pharmacist's Letter/Prescriber's Letter 2010;26(6):260606.
  5. Muscle Cramps. In Available at Accessed 11Sep2015.
  6. Garrison S, et al. Seasonal effects on the occurrence of nocturnal leg cramps: a prospective cohort study. CMAJ. 2015 Mar 3;187(4):248-53. doi: 10.1503/cmaj.140497. Epub 2015 Jan.
  7. Calcium and vitamin D supplementation: who needs it? Pharmacist's Letter/Prescriber's Letter 2011;27(1):270102.
  8. What are the new DRIs for Calcium? Health Canada. Available at Accessed 11Sep2015.

The use of saline nasal sprays and rinses (known as nasal irrigation) is routinely recommended for relieving symptoms of colds, allergies and sinus congestion.  Familiar product names are hydraSense®, Otrivin Saline®, NeilMed Sinus Rinse®, Neti Pot and others. These products are easy to use and can be purchased without a prescription, but is there any evidence that they are useful for treating these conditions? 


A review of studies showed that the length of time required to recover from a cold was not shortened by the use of nasal irrigation, but that there may be relief of some symptoms, such as runny nose and mucous thickness. (1, 2) 

Allergy (hay fever):

A study of the usefulness of saline rinses in children with inflamed sinuses from allergies, showed that nasal irrigation significantly improved runny nose, nasal congestion, throat itching, sleep quality symptoms, and nasal air flow. Another study found that the beneficial effects of nasal irrigation were greater when used with steroid nasal sprays such as fluticasone (Flonase®) and mometasone (Nasonex®), or others.

Nasal irrigation is particularly helpful when there are crusted nasal secretions due to chronic, thick drainage. The nasal passages can be cleansed with saline before using the steroid sprays to help increase the amount of medication that actually reaches the lining of the nose. 

A study of pregnant women found saline irrigation helped to improve nasal symptoms of allergy. This is particularly helpful for women who want to avoid unnecessary medications while pregnant. (3)

Chronic sinusitis:

Chronic sinusitis is defined as an inflammation of the sinuses and linings of the nasal passages, which lasts for 12 weeks or longer.

At least 2 of the following 4 symptoms must be present for the diagnosis of chronic sinusitus:

  • Pre and/or post-nasal drainage of mucous (runny nose or post-nasal drip)
  • Nasal obstruction (plugged nose)
  • Facial pain, pressure, and/or fullness
  • Decreased sense of smell (4)

Nasal saline irrigation can be useful for allergic and chronic rhinosinusitis, improving symptoms by about 30%. (1) Chronic sinusitis cannot be "cured" in most patients, so therapy is intended to reduce symptoms and improve quality of life.

Washing the nasal cavities with saline reduces postnasal drainage, removes secretions, and rinses away allergens and irritants. Saline washes can be used immediately before other intranasal medications so that the lining of the nose is freshly cleansed when the medications are introduced. (4, 5)

Directions for use

There are a number of devices available, including squeeze bottles, sprays,  bulb syringes and Neti pot containers and all are effective provided the system delivers enough of the solution (>200 mL per side) into the nose. Nasal irrigation with warmed saline can be used as needed only, or once or twice daily for increased symptoms. It carries little risk if properly performed, with minor adverse effects, such as nasal burning and irritation.

Patients can make their own irrigation solutions or buy commercially-prepared solutions or kits.

To make a solution that is close to isotonic (0.9%) use one teaspoonful salt in three cups water (720 mL).

One-half teaspoonful of baking soda is often added to improve tolerability. It is important that the solutions be prepared from sterile or bottled water, as there have been reports of amebic encephalitis due to rinses with tap water that was contaminated. Although rare, it is usually fatal. Irrigation devices can also become contaminated with the bacteria present in the patient's nasal cavities, although it is not clear that this causes any significant problems. However these devices should be cleaned as directed after each use and replaced regularly (3, 5, 6)

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen BSP, Msc
medSask, March 2016


  1. Sexton, D and McClain, M. The common cold in adults: Treatment and prevention. In UpToDate online database. Available at (with subscription). Accessed March 2016.
  2. Alberta College of Family Physicians - Tools for Practice #155. Authors: Emma Huang BScPharm, G Michael Allan MD CCFP. Available online at:
  3. deShazo, R and Kemp, R. Pharmacotherapy of allergic rhinitis. In UpToDate online database. Available at (with subscription). Accessed March 2016.
  4. Hamilos, D. Chronic rhinosinusitis: Management. In UpToDate online database. Available at (with subscription). Accessed March 2016.
  5. Saline nasal irrigation and use of neti pots. Pharmacist's Letter/Prescriber's Letter 2010;26(1):260105.
  6. Patel, Z and Hwang, P.Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment. In UpToDate online database. Available at (with subscription). Accessed March 2016.

None of the detox and cleanse methods have any reliable evidence of effectiveness in removing toxins or preventing diseases. Some can be dangerous depending on how they are used, how often they are used and whether they are being used in place of proven medical treatments.


New Year’s resolutions to lose weight and get healthy, may lead people to try “detoxes” or “cleanses”.  Along with food and calorie restrictions, these may involve products which contain ingredients that claim to help the liver, the kidneys and the colon rid the body of accumulated wastes and chemicals. They are advertised as agents to help lose weight, boost energy and remove toxins. (1)

Promotors claim toxins don't always leave our bodies properly in the form of sweat, urine or feces, but instead hang around in the digestive, lymph, and gastrointestinal systems as well as in skin and hair. They suggest that this can cause problems such as inflammation and allergies. (2)

Cleanses taken by mouth are made up of herbs and dietary fiber. They have no proven benefit and can be expensive. 

Liver cleanses usually contain milk thistle and other ingredients.  Milk thistle alone at doses of up to 600mg/day appears to be safe, but may cause diarrhea, upset stomach and allergic reactions. (1, 3) 

Colon (large intestine) cleanses usually contain fiber, laxatives and herbs and are sometimes used along with probiotics to restore healthy digestive system bacteria. While fiber and exercise will usually work for constipation, when taken in the doses used for cleansing they can lead to diarrhea, resulting in fluid loss and electrolyte (mineral) imbalances. 

Rectal use of cleansing enemas or colonic irrigation often consists of pumping large amounts of liquids into the colon via a tube.

Rectally administered coffee enemas used for detoxification have been linked to at least three deaths. Two of these deaths were related to severe electrolyte imbalance, and a third was associated with infection. (1, 3, 4)

Healthy detox diets usually encourage eating organic foods with high nutrient and high fiber content. Elimination of foods containing “toxins” such as alcohol, caffeine, processed sugar, certain grains, and some dairy foods and meats are proposed to help the body recover from over-indulgence. 

Some detox regimens suggest avoiding solid foods (e.g. juice fasting) or eating higher quantities of single foods (e.g. grapefruit diet). These will sometimes combine the diet with herbal supplements or rectal enemas and can last for days to weeks. Some are safe in the short-term, but long-term fasting can result in nutrient and protein deficiencies. (1) 

People who have certain medical conditions should not try any of these fads without first checking with their medical doctor, in particular:

ANEMIA: People with iron or vitamin deficiency anemia should avoid detoxification programs that restrict foods that provide these nutrients. Dietary restriction of these nutrients could worsen anemia.

CRITICAL ILLNESS: Patients with serious illness such as cancer should avoid detoxification programs that restrict eating adequate amounts of food or restrict certain groups of food. Diseases could worsen if necessary nutrients are restricted.

ENDOCRINE DISORDERS: People with diabetes, thyroid disorder, or other endocrine disorders should avoid detoxification programs that require dramatically changing food and calorie intake without appropriate medical supervision. Substantial dietary changes could potentially worsen these conditions or require changes in treatment.  (3)

Prepared by Jean Macpherson BSP, reviewed by Karen Jensen BSP, MSc
medSask, January 2016


  1. Colon and liver detoxification. Pharmacist's Letter/Prescriber's Letter 2010;26(2):260211.
  2. What is a detox diet? Teen Health. Available at Accessed January 2016.
  3. Milk thistle In: Natural Medicines Comprehensive Database. Stockton, CA: Therapeutic Research Faculty. Available at  (by subscription).
  4. Barrett S. Questionable cancer therapies. Quackwatch online. Available at Accessed January 2016.

Hair loss can be the result of heredity, hormonal changes, medical conditions or drugs. Whatever the cause, hair loss can be distressing. In some cases it can be slowed down or reversed, while other times appearance can be managed with cosmetic hair products.

Background: Of the 100,000 to 150,000 hair follicles on the head, most people will lose between 50 and 100 hairs a day. Hair breakage can also affect the appearance of fullness. Hair care practices that damage the hair shaft such as wearing tight braids, cornrows or ponytails for long periods can contribute to breakage and even to bald spots (alopecia). Chemical treatments such as perms, straighteners or bleaching can cause breakage and inflammation of hair follicles that can lead to hair loss. If scarring occurs, hair loss may be permanent.

The most common type of hair loss is androgenic alopecia (male and female pattern hair loss) caused by an excess in a hormone that destroys scalp hair follicles. In women, this may occur gradually with aging particularly after menopause. 

When hair loss is the result of a medical condition or is stress-related, treating the condition may help to restore a healthy head of hair. Most women who experience hair loss after childbirth will gradually recover their normal hair thickness within about 15 months. Hair loss that is caused by a drug (examples below) may get better the longer the drug is taken or may reverse if the drug is stopped. When hair loss is due to some types of chemotherapy (cancer treatment), re-growth usually starts about two months after the drugs are stopped. If you think a medication you are taking might be causing hair loss, talk to your pharmacist or doctor about it. 

Low levels of zinc, iron, biotin, lysine, or vitamin D or diets that are too low in calories or protein can also cause hair to thin. Nutritional supplements may help over time if a person has a deficiency. 

Minoxidil 5% (Rogaine® and generics) foam is the recommended non-prescription treatment for androgenic alopecia in both men and women. With this treatment, some people experience hair regrowth, a slower rate of hair loss or both. The effect might not be noticeable for 2 to 4 months and full results might not be seen for a year. An increase in the amount of hair that falls out may start within 2 to 6 weeks of beginning to use minoxidil. This is normal and should stop with continuous use. If hair loss continues for longer than 2 weeks, it is recommended to stop using the product. 

The foam is massaged into the affected area of the scalp once a day and left on for at least 4 hours.

Minoxidil treatment must be ongoing to retain benefits. Possible side effects include scalp irritation, unwanted hair growth on the adjacent skin of the face and hands, and rapid heart rate (tachycardia).

Natural products: A small study found that a mixture of lavender, thyme, rosemary, cedarwood, jojoba and grapeseed oils, improved hair growth. The mixture was applied daily for 7 months. However, more studies are needed to confirm that this product is effective. There is not enough evidence to recommend other herbal compounds for restoring hair growth.

Low-level laser therapy (LLLT) for hair growth in both men and women seems to be safe and somewhat effective. The theory behind this is that  laser light of certain wavelengths can stimulate hair  follicles to re-enter and maintain the growth phase. There are few scientific studies that document the degree of effectiveness of lasers on hair growth, however there appears to be a low incidence of adverse effects, aside from a short-term increase in shedding at the beginning (first 1-2 months) of therapy. LLLT should not be used by anyone with melanoma or skin cancer as it could increase the growth of cancerous lesions. Equipment for at-home laser therapy can cost up to $1000 and treatment must be ongoing to maintain effectiveness.

Table 1: Drugs associated with hair loss in ≥ 5% of patients


Comments/Brand Names

ACE Inhibitors  - class of drugs to lower blood pressure

Reported more often with ramipril


Warfarin – may affect  >50% of people with high doses



Most likely with terbinafine (Lamisil®) and fluconazole (Diflucan® and others)


Indinavir (Crixivan®) may affect  up to 10% of people

Aromatase Inhibitors

Anastrozole (Arimidex®) and exemestane (Aromasin®)


Timolol most likely – others rarely

Chemotherapy drugs

Percentage varies depending on type of drug

Cholesterol Lowering Drugs

Lovastatin (Mevacor® and others) most likely  - others rarely


Cyclosporine (Neoral®), leflunomide (Arava®), mycophenolate (Cellcept®),

Tacrolimus (Prograf®) – up to 28%


Intron®, Pegasys® and others

Mood stabilizers

Carbamazepine (Tegretol® and others), lithium (Lithane® and others), valproic acid (Depakene® and others),

divalproex (Epival® and others)


Acitretin (Soriatane®), isotretinoin (Accutane® and others)


Novaldex-D and others
































Prepared by Jean Macpherson BSP; reviewed by Karen Jensen BSP, MSc
medSask, January 2016


  1. Shapiro, J, Otberg, N, Hordinsky, M. Evaluation and diagnosis of hair loss. In UpToDate online database. Available at (with subscription). Accessed December 2015.
  2. Hair Care and Hair Growth. RxTx – Minor ailments. Available from: (by subscription).  Date of Revision: November 2014.  Accessed online December 2015.
  3. Pomeranz, M.The skin, hair, nails, and mucous membranes during pregnancy. In UpToDate online database. Available at (with subscription). Accessed December 2015.
  4. 4.. Mayo Clinic Staff. Diseases and Conditions. Hair loss. In Mayo Clinic online database. Available at  Accessed December 2015.
  5. Natural Product Effectiveness Checker. Natural Medicines Comprehensive Database. Available online by subscription. Accessed December 2015.
  6. Avci, P., Gupta, G. K., Clark, J., Wikonkal, N. and Hamblin, M. R. (2014), Low-level laser (light) therapy (LLLT) for treatment of hair loss. Lasers Surg. Med., 46: 144–151. doi: 10.1002/lsm.22170.
  7. Lúcio Frigo et al. The effect of low-level laser irradiation (In-Ga-Al-AsP - 660 nm) on melanoma in vitro and in vivo. BMC Cancer 2009; 9: 404. Published online 2009 Nov 20. doi:  10.1186/1471-2407-9-404.
  8. Canadian Pharmacist’s Letter - Drugs associated with hair loss. Pharmacist's Letter/Prescriber's Letter 2011;27(2):270215.

Use of oral decongestants, antihistamines, and nasal decongestant sprays prior to flying or diving may reduce obstruction around the Eustachian tube and allow for easier pressure equalization. Pseudoephedrine tablets taken 30 minutes prior to flight may reduce the ear discomfort caused by changes in air pressure during take-off and landing. The nose spray decongestant oxymetazoline is somewhat less effective. These can be used together but we suggest trying pseudoephedrine first. If you still have ear pain, you can use the nose spray in combination with pseudoephedrine.

Other measures that might help include:

  • Swallowing frequently or using the Valsalva maneuver (blowing into your nose while holding your nostrils closed and keeping your mouth shut to open the Eustachian tube or using the Valsalva maneuver (positive pressure against a closed nasal airway) helps to even out the pressure in your ear.. Doing this frequently during take-off and landing can prevent large pressure differences from forming and prevent any damage to your ears. Chewing gum or sucking on hard candies helps for adults, sucking on a bottle or nursing helps for infants.
  • Ear plugs designed to slow down the pressure changes from flying are available in drug stores and most airports. These allow the pressure change to take place more gradually. Their benefit, however, has not been clearly demonstrated.
  • Avoid sleeping during takeoff and landing.

Mild cases of dandruff may need nothing more than daily cleansing with a gentle shampoo. Although a relatively stable condition, dandruff can worsen with poor hygiene or in a dry winter environment. More stubborn dandruff may require treatment with medicated shampoos or corticosteroid products.

Dandruff is the mildest form of a condition called seborrheic dermatitis (seborrhea). It generally affects just the scalp and does not cause inflammation. Seborrhea, in comparison, is an inflammatory skin condition which causes red patches and scaling of the scalp as well as other oily areas of the body such as the face, upper chest and back.  It occurs in about three percent of the population, most commonly in infants up to three months of age (“cradle cap”) and in adults 30–50 years of age. It tends to affect men more than women. In some cases seborrhea is associated with a yeast-like fungus called Malassezia which may be present on the scalp and cause inflammation.

Dandruff symptoms are easy to spot: white, oily looking flakes of dead skin on your hair and shoulders, and possibly an itchy, scaly scalp. Although uncommon in childhood (especially in children younger than 10), dandruff usually begins between ages 10–20 years, and affects up to 40% of men and women over age 30. It isn't contagious and is rarely serious.

Recommended treatment of dandruff and mild seborrhea of the scalp for ages 12 years and over:

  • Dandruff may improve in a moist environment so using a humidifier especially in winter may help.
  • Initial treatment using a regular, non-medicated shampoo at least 3 times a week may be all that is needed to control symptoms and improve the appearance of the hair.
  • If this is ineffective, the next step is to try an antifungal shampoo. The antifungal ingredients available without prescription are ketoconazole (e.g. Nizoral), selenium sulfide (e.g. Selsun Blue products and others) and zinc pyrithione (e.g. Head and Shoulders products and others).
  • To be effective, the shampoo must be massaged into the scalp thoroughtly and left on for 3 to 5 minutes before rinsing.  Once the dandruff is under control, which may take 2 to 4 weeks, use of the antifungal shampoo once a week may help to avoid a recurrence.
  • If you have a lot of redness or itching, inflammation may be present. Ask your pharmacist or doctor if a corticosteroid cream such as 0.5 – 1% hydrocortisone (Cortate, etc.) or clobetasol butyrate (Spectro eczema cream) would be helpful. Either of these may be used once or twice daily for 1 to 3 weeks to reduce symptoms and then stopped once the symptoms are under control. This treatment can be repeated after a rest period if needed.
  • If there is still no response, the next step to try would be products containing salicylic acid and/or sulfur. These have minimal antifungal activity but are sometimes effective because of their keratolytic (softening and peeling action) and antiseptic actions. Coal tar shampoo is mildly effective for seborrhea because it reduces local swelling and inflammation, relieves itching and is keratolytic and antiseptic. It has little antifungal activity. Coal tar is messy, can stain blond or grey hair and has an unpleasant odour. It is used once daily to once weekly. (1, 3)

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen MSc, BSP
medSask, November 2015


  1. Dandruff and Seborrhea. RxTx – Minor ailments. Available from: (by subscription).  Date of Revision: November 2014.  Accessed online November 2015.
  2. Sasseville, D. Seborrheic dermatitis in adolescents and adults. In UpToDate online database. Available at (with subscription). Accessed November 2015.
  3. 3. Mayo Clinic Staff. Diseases and Conditions. Dandruff. In Mayo Clinic online database. Available at, Accessed November 2015.

Cradle cap (yellowish, greasy scales on a baby’s scalp)  will usually clear up on its own in a few months. It can be treated by washing the baby's scalp daily with a mild baby shampoo and loosening the scales with a small, soft-bristled brush before rinsing off the shampoo.

 If the scales don't loosen easily, rub petroleum jelly or a few drops of mineral oil onto baby’s scalp. Let it soak into the scales for a few minutes, or hours if needed. Then brush and shampoo the hair as usual. If you leave oil in the hair, the cradle cap may get worse.

 Once the scales are gone, wash your baby's hair every few days with a mild baby shampoo to prevent scale buildup. 

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen BSP, MSc
medSask, December 2015


  1. Dandruff and Seborrhea. RxTx – Minor ailments. Available from: (by subscription).  Date of Revision: November 2014.  Accessed online November 2015.
  2. Sasseville, D. Cradle cap and seborrheic dermatitis in infants. In UpToDate online database. Available at (with subscription). Accessed November 2015.

Cetaphil Gentle Cleanser has been shown to be effective in a few small studies. (1-3) The first-line treatment recommended for head lice is still 1% permethrin (Nix, etc.) or pyrethrins (R&C, etc.).(4) These products should be reapplied in 7 to 10 days even if labels say otherwise. Other non-prescription products such as Resultz (isopropyl myristate) or Nyda (dimeticone) are available in Canada if the first-line options are not effective (4). Some evidence suggests they work as well as permethrin; however, since they are newer there is less evidence for effectiveness and safety. Nit combing after a treatment is always recommended regardless of which product is used because none are 100% effective at killing the eggs (4).

 Cetaphil Gentle Cleanser is an alternative that can be tried if other treatments have failed or if people want to avoid insecticides. When used, the hair should be carefully inspected for new lice for a few weeks to ensure the product was effective. It is suggested that treatments be repeated for at least three weekly cycles (5).

 Cetaphil Gentle Cleanser works by coating the lice and plugging their breathing openings so that they suffocate. It must be used exactly as recommended (see below) in order to be effective (5). Products like Cetaphil that suffocate live lice are not very effective in killing the eggs, so the lice problem returns as soon as the nits hatch, requiring additional applications of the product.

 In clinical studies, Cetaphil Gentle Cleanser was applied to the scalp, the hair combed to spread the product along each hair shaft, then blow-dried to coat the lice in a shrink-wrap-like layer. The dry lotion was left on the hair and scalp for a minimum of eight hours. This procedure was repeated twice at one week intervals for a total of three applications (1-3).

 Lice and their nymphs can survive for up to three days away from humans, as can their eggs, although the eggs  require scalp temperature to hatch. Extensive housecleaning is not necessary if a family member has lice. They are spread by head to head contact. They can move quickly, but do not jump or fly. Items that have been in contact with the hair should be washed in hot water (66oC) and dried in a hot dryer for 15 minutes, or stored in a plastic bag for two weeks. There is no medical reason for keeping children with lice home from school because by the time lice are spotted, the child has been infected for over a month (4).

Prepared by Jean Macpherson; reviewed by Karen Jensen and Terry Damm
medSask, November 2015


  1. Perlman D. A Simple Treatment for Head Lice: Dry-On, Suffocation-Based Pediculicide.  Pediatrics 2004;114(3) e275.
  2. Barker S, Altman P. A randomized, assessor blind, parallel group comparative efficacy trial of three products for the treatment if head lice in children – melaleuca oil and lavender oil, pyrethrings and piperonyl butoxide, and a “suffocation” product. BMC Dermatol. 2010;10:6. doi: 10.1186/1471-5945-10-6.
  3. Grieve K, Lui A et al. A randomized, assessor-blind, parallel-group, multicentre, phase IV comparative trial of a suffocant compared with malathion in the treatment of head lice in children.Australas J Dermatol. 2010 Aug;51(3):175-82. doi: 10.1111/j.1440-0960.2010.00622.x.
  4. Detail-Document, Management of Head Lice. Pharmacist’s Letter/Prescriber’s Letter. September 2015.
  5. Nontoxic head lice treatment. Available at

Essential oils are thought to be safe and usually well-tolerated when used short-term by inhalation. Some including bergamot, bitter orange, juniper, lavender, lemongrass, peppermint, ginger, Roman chamomile, and rosemary have been safely used when diluted and applied over small areas of unbroken skin. However, they can sometimes cause irritation of the skin, especially used at full strength.

Some, such as bergamot oil, can make the skin more likely to sunburn which increases the risk of skin cancer.

Applying large amounts of highly concentrated oils to a large surface of the skin or on broken skin can result in more of the oil being absorbed into the body which increases the chance of serious side effects.(2)

Essential oils may be unsafe when used orally. Oral use of essential oils is fairly uncommon; however, it does occur.  Some essential oils can cause severe side effects when ingested in large undiluted amounts, including convulsions and kidney failure.

When a substance is taken orally, inhaled or absorbed through the skin, it brings up the question of interactions with prescription and over-the-counter (OTC) products. In general, the interactions between essential oils and other products are considered moderate when the oils are used topically or inhaled. However, caution is advised particularly with blood thinners such as warfarin. Some essential oils such as wintergreen can increase the risk of bleeding even when applied on the skin. Lavender can theoretically have additive effects when used with drugs for blood pressure as well as when used in combination with drugs that are taken for sleep. (2)

Aromatherapy is "the science of using highly concentrated essential oils or essences distilled from plants in order to utilize their therapeutic properties" (1) In aromatherapy, the essential oils are usually vapourized by heating or by adding the oil to a hot bath. Sometimes the oil is applied topically such as during massage, or to a specific areas such as the scalp or a painful joint. Less commonly, essential oils are taken orally (by mouth).

The vapourized essential oils of aromatic plants are believed to bring about effects such as feelings of relaxation and stress relief. Molecules from the vapour bind to receptors in the nose, which send signals to the brain. The effects of a particular odor can depend on psychological factors such as emotions, previous experiences, and expectations. Some constituents of vapours may pass into the bloodstream via the lungs and some might cross the blood-brain barrier and act directly on brain neurons. Inhaled aromas are thought to act much more quickly compared with application to the skin or taking them by mouth.

Clove oil has been used for the topical treatment of toothache because it contains eugenol which is sometimes used in dentistry for its pain relieving and antiseptic properties. The results of one study showed that clove oil gel is equally effective as benzocaine for local anaesthetic effect. (3)

There is some evidence that applying lavender oil in combination with the essential oils from thyme, rosemary, and cedarwood in a mixture of carrier oils (jojoba and grapeseed) has some benefit in promoting hair growth in people with alopecia areata, an autoimmune condition causing hair loss.(4)

 If you are unsure about interactions with your medication, check with your pharmacist before using any essential oil.  Be careful not to use more than the amount recommended on the package.

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen BSP, MSc
May, 2015


  1. Simkin, P, Klein, MC. Nonpharmacological approaches to management of labor pain. In:UpToDate, Lockwood, (Ed). UpToDate, Waltham MA, 2015. Accessed April 2015.

  2. Aromatherapy monograph. In: Jellin JM, editor. Natural medicines comprehensive database online.

  3. Stockton, CA: Therapeutic Research Faculty; c1995-2015 [cited 2015 April 27]. Available from:

  4. Hay, IC,  Jamieson, M, Ormerod, AD.  Randomized Trial of Aromatherapy. Successful Treatment for Alopecia Areata.  Arch Dermatol. November 1, 1998, Vol 134, No. 11 1998; 134(11):1349-1352. doi:10.1001/archderm.134.11.1349.

  5. Algareer, A, Alyahya, A,  Andersson, L. The effect of clove and benzocaine versus placebo as topical anesthetics.  Journal of Dentistry, Volume 34, Issue 10, November 2006, Pages 747–750. doi:10.1016/j.jdent.2006.01.009


Probiotics are live microorganisms used to replace or supplement the  “good” bacteria in the bowel.  Probiotics are most often obtained from cultured dairy products such as yogurt or kafir or from supplements. (1)

There is growing evidence that probiotics may help diarrhea, depending on what is causing the diarrhea. The probiotics that have the best evidence for benefit are species of Lactobacillus, Bidfidobacterium and Saccharomyces boulardii. These may be found alone or in various combinations in probiotic supplements. They are commonly promoted to strengthen the immune system and supply the intestines or vagina with beneficial germs. Their beneficial effects may include providing a protective barrier to the walls of the intestines and altering conditions to favour growth of good bacteria. (2, 3)

Diarrhea is most likely to respond to probiotics if diarrhea is caused by:

  • Radiation to the lower abdomen and pelvis (used to treat cancer)
  • Antibiotics used to treat infections (kill normal bacteria found in the intestines and vagina as well bacteria causing infections)
  • Overgrowth of the intestinal tract by a bacteria called Clostridium difficile (C.dif)
  • Stomach infection by a bacteria called Helicobacter pylori (H.pylori)
  • Acute infectious diarrhea caused by viruses, bacteria or parasites
    • Traveler’s diarrhea (may be caused by eating or drinking food and liquids contaminated with fecal material). Symptoms include diarrhea, cramps, and nausea that if untreated typically last from 2 to 6 days but can last for as long as a month.  

Diarrhea associated with Irritable Bowel Syndrome (IBS) may respond somewhat to probiotics.

Diarrhea that occurs with conditions such as Crohn’s disease and ulcerative colitis does not seem to have a significantly favourable response to probiotics. (3)

To treat Antibiotic-Associated Diarrhea, take probiotics at least 2 hours after taking an antibiotic, otherwise the antibiotic can wipe out the probiotic organisms. The probiotic should be taken for the entire antibiotic course and up to a week afterward. (2)

To prevent Traveller’s Diarrhea, begin taking probiotics five days before travel and continue for the duration of trip. (2)

Long-term and intermittent use of probiotics for any reason appears to be safe for adults and children over 2 months of age. (2) However, use cautiously if you have a weakened immune system or if you are taking medication that affects your immune system.(3)

Prepared by Jean Macpherson, BSP; reviewed by Karen Jensen BSP, MSc
medSask, March 2015


  1. Sartor, R B. Probiotics for gastrointestinal diseases. In: UpToDate, Lamont, JT (Ed), UpToDate, Waltham MA, 2015. Accessed March 2015.
  2. Canadian Pharmacist’s Letter - PL Detail-Document, Comparison of Common Probiotic Products. Pharmacist’s Letter/Prescriber’s Letter. July 2012. Accessed March 2015.
  3. Clauson, ER, Crawford P, What you must know before you recommend a probiotic. J Fam Pract. 2015 March;64(3):151-155. Nellis Family Medicine Residency Program, Nellis Air Force Base, Nev.
  4. Forrester A. Gastrointestinal Conditions: Diarrhea. In e-therapeutics Complete – Minor Ailments. [Internet]. Ottawa (ON): Canadian Pharmacists Association; updated April 2013. Available from: Also available in paper copy from the publisher. Accessed March 2015.

Current evidence finds that homeopathic remedies are no more effective for cough and cold than treatment with a placebo (a product with no active ingredients).1 They are rated as likely safe when taken by mouth or applied to the skin appropriately.2 Most homeopathic preparations contain little or no active ingredient. Therefore, it is unlikely that most homeopathic products will reduce cough and cold symptoms; on the other hand, it appears unlikely they will cause any harmful effects. 

Since 2008 Health Canada has required the warning, "Do not give to children under 6”, be included on all cough and cold products that have certain active ingredients including: anti-histamines to treat sneezing and runny nose; anti-cough medications called anti-tussives: expectorants that loosen mucus; and decongestants to clear nasal passages. These medicines also require clear labelling for dosing for children 6 to 12 years, childproof packaging, and inclusion of a dosing device (such as a measuring cup or spoon) for all liquid forms. Although these non-prescription (OTC) medicines have been used for cough and cold for many years, there is little evidence to show that they are effective in children.3,4

So, what about the products on the pharmacy shelf that say they can be used for children under 9?

These are generally homeopathic products.5 Homeopathy is a pre-scientific practice based on two principles: “like cures like”, that is, the best treatment for a patient is a substance that, when given to a healthy person, produces symptoms similar to those of the patient; and “potentization,” which holds that multiple dilutions (adding water or other liquid to reduce the concentration of the active substance) and “succussions” (shakings) make the product increasingly more active because the liquid retains a “memory” of the initial substance. 5

Homeopathic preparations generally begin with minerals, plants, or animal substances that are crushed, mixed with a water or alcohol solution, and then potentized, usually well past the point at which any of the original substance remains. The resulting diluted liquid is applied to a sugar pill and allowed to dry or given in the liquid form with a dropper and applied to the tongue. 5

Homeopathic products are not regulated as closely as prescription medications and may contain other substances that could be harmful to certain people.5 Look for the DIN-HM, or Homeopathic Medicine number, on products sold in Canada. This number indicates that Health Canada has assessed the product for safety and quality.6 Homeopathic remedies should not replace medicines prescribed by your doctor for serious illnesses.

What can I give my child if they have a cough or cold?3,7

The cough and cold medications available treat the symptoms only, not the infection causing the symptoms. Here are a few safe ways to help your child get some relief from symptoms:

  • Encourage rest
  • Give lots of fluids, such as water, unsweetened juice, or clear soup.
  • Use saline drops or sprays to clear nasal passages. These can be purchased over the counter or made at home by mixing ¼ to ½ teaspoon of table salt and a pinch of baking soda into 8 ounces of tap water (use within 24 hours). Nasal aspirators, devices which suck mucous out of the nostrils, can be used for infants and small children.
  • Use a cool-mist humidifier or vapourizer to keep the air moist. This may help relieve cough and congestion.
  • Soothe a sore throat with a cold drink, popsicles or ice cream. Older children can gargle with warm salt water.
  • Give acetaminophen or ibuprofen if needed for discomfort caused by mild fever.

Keep in mind that symptoms of a cold will usually go away in about 6 to 10 days. If they don't, if symptoms worsen, or if your child appears sick and you are worried, consult a health care provider.3

Prepared by Jean Macpherson BSP Reviewed by Karen Jensen BSP, MSc
medSask, February 2015


  1. Atwood, KC. Homeopathy. In UpToDate, Aronson, MD (Ed) UpToDate, Waltham, MA, 2015. Available at  by subscription. Accessed 09Feb2015.
  2. Homeopathy monograph. Natural Medicines Comprehensive Database. Available online by subscription. Accessed February 9, 2015.
  3. Children’s cough and cold medications: FAQ. Available at .  Accessed 15Feb2015.
  4. Health Canada. Warning – Cough and Cold Medicine for Children. Available at Accessed 15Feb2015
  5. Weekes C. Think ‘approved’ homeopathic cold, flu remedies are safe? Available at Accessed 15Feb2015.
  6. Health Canada. About Natural Health Product Regulation in Canada.Available at Accessed 20Feb2015.
  7. Canadian Paediatric Society. Caring for Kids – Colds in Children. Available at Accessed 20 Feb2015.

Symptoms of dry skin (xerosis) are scaling, itching and cracks in the top layers of skin. In most cases, skin becomes drier as we age, not because it lacks oil, but because it lacks water. Extreme environmental conditions can overwhelm the skin's natural protective barrier, causing water to evaporate. This is an important reason for dry skin among people who live in sunbaked desert climates and in cold-weather climates where excessively dry outdoor air and dry, heated indoor air also can cause dry skin.

Dry skin treatments are aimed at replacing and retaining water in the skin.  When natural oils in the outer layer of skin are decreased the skin loses water.  Although most cases have an environmental cause, certain diseases such as eczema and psoriasis can also significantly affect skin’s moisture balance.  

Often itchy, dry skin is caused or worsened by cold weather and frequent bathing. The best way to prevent and treat dry skin problems is to moisturize. Moisturizers provide a seal over your skin to keep water from escaping.

 General Self-Care Guidelines: 

  • Take a bath or shower no more than once daily. More frequent bathing can make the skin lose water.
  • Use lukewarm (not hot) water.
  • Limit bath and shower time to 15 minutes.
  • Avoid harsh deodorant soaps (or limit their use to armpits, groin, and feet).
  • Use non-soap cleansers, such as Aveeno® or Cetaphil® or mild soaps such as Neutrogena® or Dove®
  • Pat (don't rub) the skin dry after bathing.
  • Use a humidifier in the bedroom during the cold, dry seasons to help prevent dry skin.

 Dry, rough, red skin:

  • Apply moisturizer immediately after bathing, while the skin is still moist and then apply several more times a day.
    • Thicker moisturizers such as Eucerin®, Cetaphil® or barrier creams work well to retain moisture in the skin.
    • When choosing a moisturizer, look for oil-based creams and ointments, which work better than water-based lotions.
    • Fragrance-free creams or ointments are preferred.
    • If your skin symptoms have not improved after 7 to 10 days of treatment with moisturizers, step up to treatment with preparations containing higher concentrations of alpha-hydroxy acids (such as glycolic acid 10 % or lactic acid 5 % to 12 %) or urea (up to 10 %).
    • If you have difficulty deciding which product is best for you, ask your pharmacist for advice.

 Itchy skin:

  • Products containing colloidal oatmeal (Aveeno® and others) are useful to help reduce itchiness.
  • If itchiness is very bothersome, apply over-the-counter cortisone cream 0.5% to affected areas once or twice daily for up to 7 days. Check with your pharmacist or doctor if itchiness continues to be a problem or worsens.


  • Topical antibiotics can be applied immediately to any cracks in the skin to help prevent infection.
  •  If signs of infection appear (increased redness, warmth, swelling, etc.), talk to your pharmacist or doctor. 
Prepared by Jean Macpherson, BSP; reviewed by Karen Jensen MSc, BSP
January 2015



Serotonin (also sometimes called 5-HT) is a chemical produced by the body and found in the stomach and intestines, in the blood and also in the brain. It has many jobs in the body from helping to regulate the digestive system, blood pressure, body temperature and lung function, to affecting mood and behaviour (1).

Serotonin syndrome can occur when levels of serotonin build up in the body. It is a rare condition that can be caused by certain prescription drugs, illegal drugs and also some herbal supplements. The risk goes up when increasing doses of medications which affect serotonin or when combining these types of medicines. 

Too much serotonin causes symptoms that can range from mild (shivering and diarrhea) to severe (muscle stiffness, fever and seizures). See Table 1 below for complete list of symptoms.  Severe serotonin syndrome can be fatal if not treated.

Symptoms of serotonin syndrome usually occur suddenly, within 24 hours of starting a drug, adding a drug, changing a dose or overdosing:

  • 50% of patients will have symptoms within 2 hours
  • 75% of patients will have symptoms within 24 hours
  • rarely can occur up to six weeks after stopping a long-acting drug (4)

Milder forms of serotonin syndrome usually go away within 24 to 72 hours of stopping medications that increase serotonin. In some cases medications to block the effects of serotonin already in your system can be used. However, symptoms of serotonin syndrome caused by some antidepressants could take several weeks to go away completely, because these medications remain in your system longer.

If you take any drugs or supplements that may cause serotonin syndrome (see Table 2 below), talk to your doctor or pharmacist about possible risks.  Often the benefits of combining certain drugs will outweigh the risks but be aware of the possibility of serotonin syndrome and watch for symptoms especially during the first couple of days of treatment.

If your doctor prescribes a new medication, make sure he or she knows about all the other medications and supplements you're taking, especially if you receive prescriptions from more than one doctor. 

Contact your doctor or go to an Emergency Department if you develop any of the symptoms listed in Table 1. Take a list of your medicines with you including vitamins and supplements. (2)


Table 1: Symptoms of Serotonin Syndrome

  • agitation
  • confusion
  • diarrhea
  • fever
  • incoordination
  • muscle rigidity
  • myoclonus (muscles twitching)
  • seizures (3)
  • shivering
  • sweating
  • tremor


Table 2: Drugs and supplements which can contribute to serotonin syndrome

Drug category


Antidepressants - Selective serotonin reuptake inhibitors (SSRIs)

Citalopram (Celexa), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil) and sertraline (Zoloft)

Antidepressants - Serotonin and norepinephrine reuptake inhibitors (SNRIs),

Trazodone, duloxetine (Cymbalta) and venlafaxine (Effexor)

Antidepressant / Tobacco addiction

Bupropion (Wellbutrin, Zyban)

Antidepressant - Monoamine oxidase inhibitors (MAOI)


Antimigraine medications - Triptans

Almotriptan (Axert), naratriptan (Amerge), sumatriptan (Imitrex)

Antimigraine medications - other

Carbamazepine (Tegretol) and valproic acid (Depakene)

Pain medications

cyclobenzaprine (Flexeril), fentanyl (Duragesic), tramadol (Ultram)

Mood stabilizer


Anti-nausea medications

Granisetron (Kytril), metoclopramide (Reglan), droperidol, ondansetron (Zofran)

Over-the-counter cough and cold medications

Dextromethorphan (Delsym, Mucinex DM, others)

Herbal supplements

St. John's wort, ginseng and nutmeg

Illicit drugs

LSD, ecstasy, cocaine and amphetamines

Produced by Jean Macpherson BSP, medSask medication information consultant. Reviewed by Karen Jensen MSc, BSP
January, 2015.


  1. Boyer, EW. Serotonin syndrome. In UpToDate, Traub, SJ (Ed) UpToDate, Waltham, MA, 2015. Avabilable at by subscription. Accessed 09Jan2015.
  2. Mayo Clinic Staff. Serotonin syndrome.  Available at Accessed 09Jan2015.
  3. Dynamed – Serotonin syndrome. Available online at (by subscription). Accessed 09Jan2015.
  4. Canadian Pharmacist’s Letter - PL Detail-Document, Facts about Serotonin Syndrome. Pharmacist’s Letter/Prescriber’s Letter. October 2014. 

Moderate use of alcohol is considered safe for people taking anticoagulants (blood-thinners)  if they have normal liver function.1,2,3  Anticoagulants taken by mouth include warfarin, dabigatran, rivaroxaban and apixaban.4 Moderate use is one drink per day for adult women and two drinks per day for adult men. One drink is a 12-oz beer, a 4-oz glass of wine, or a 1.5-oz glass of distilled spirits e.g. whiskey, vodka, gin.5

People taking anticoagulants should avoid consuming large amounts of alcohol over a short period a time (i.e., binge drinking). In the case of warfarin, this slows the elimination of warfarin from the body and increases the likelihood of bleeding. For all anticoagulants, intoxication increases the risk of falling which is also a risk for bleeding.1

If there is a substantial change in alcohol intake, lab values for INR (measure of how quickly blood clots) should be checked frequently.   Any signs of bleeding including pain, swelling, headache, dizziness, weakness, prolonged bleeding from cuts, increased menstrual flow, nosebleeds, bleeding of gums from brushing, unusual bleeding or bruising, red or brown urine, or red or black stools should be reported to the doctor immediately.6

Prepared by Karen Jensen MSc, BSP. Reviewed by Terry Damm, BSP
December, 2014


  1. Coumarin and related drugs + alcohol. In: Baxter K (ed), Stockley’s Drug Interactions. [online] London: Pharmaceutical Press. Available at (by subscription). Accessed on 15Dec2014.
  2. Warfarin. Micromedex 2.0.  Truven Health Analytics, Inc. Greenwood Village, CO.  Available at:  Accessed 15Dec 2014.
  3. Alcohol-related drug interactions. Pharmacist’s Letter/Prescriber’s Letter 2008;24(1):240106.
  4. Douketis J, Bell A et al. Approach to the new oral anticoagulants in family practice. Part 2: addressing frequently asked questions. Can Fam Physician 2014;60:997-1001. Available at Accessed 15Dec2014.
  5. Warfarin – ethanol. Interactions Checker. Available at . Accessed 15Dec2014. 


Is the flu shot really effective? I’ve heard of people who get sick with the flu even though they have had the flu vaccination.


The effectiveness of the vaccine can vary from 60 to 85 per cent. It is more effective in people who are young and healthy, but may be less effective in older people. However, if a person gets the flu after influenza vaccination, it is usually a milder illness and less likely to require hospitalization.  Antibodies to prevent influenza develop within 2 to 3 weeks after immunization in most healthy children and adults.

The National Advisory Committee on Immunization (NACI) states that healthy people aged 5-64 years benefit from influenza vaccination. Evidence also shows that flu vaccines benefit people of all ages and NACI now recommends flu shots for everyone  6 months and older, with particular focus on people at high risk of influenza-related complications or hospitalization and people capable of transmitting influenza to those at high risk.

It is estimated that between 10-20% of the population becomes infected with influenza each year. Rates of infection are highest in children aged 5-9 years, but rates of serious illness and death are highest in children under 2 years, people older than 65 years, and people with underlying medical conditions.

Aside from common reports of sore arms, low fevers and achiness after a flu shot, severe reactions are extremely rare in Canada. Those who have recently had a mild illness, with or without a fever, can still get the influenza vaccine.

Prepared by Jean Macpherson BSP; reviewed by Karen Jensen MSc, BSP
October 2014


  1. Government of Saskatchewan -
  2. Saskatoon Health Region -
  3. Saskatoon Health Region -
  4. Public Health Agency of Canada -


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

  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.

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


  1. Dental Care: Teething. Minor Ailments in e-therapeutics Complete online. Available from: (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 (by subscription). Accessed August, 2014.
  4. Health Canada Licensed Natural Health Products Database.  Available at Accessed August, 2014.
  5. Managing Discomfort Caused by Teething. J Can Dent Assoc 2013;79:d141  

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


  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 Accessed July 2014.
  3. Swimmer’s Itch. HealthLinkBC File #52 Available at Accessed July 2014.
  4. Swimmer’s Itch FAQs.  Centers for Disease Control and Prevention. Available at Accessed July 2014.

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


  1. Mayo Clinic. Swimmer’s Ear. Available at Accessed June 25, 2014.
  2. Goguen, LD External otitis: Pathogenesis, clinical features, and diagnosis. In UpToDate, Park, L (Ed), UpToDate, Waltham, MA, 2014.

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


  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 (requires log-in and registration.

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


  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.

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


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

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


  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 Accessed April 17, 2014.
  4. Acetaminophen monograph. Micromedex Healthcare Series. Reprotox. Greenwood Village, CO: Truven Health Analytics, 2014. Available at 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. Jamieson, DJ, Rasmussen, SA. Influenza and pregnancy. In: UpToDate, Barss,V (Ed), UpToDate, Waltham, MA, 2014. Available at by subscription. Accessed April 17, 2014.

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)


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.


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 


  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.
  6. 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
  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.

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


  1. DynaMed [Internet].  Ipswich (MA): EBSCO Information Services.  Minor burns [Updated 2013 May 20; cited 2014 March 28] Available from 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

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


  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 Accessed December, 2013.
  5. Pawsitive thinking. (2013, November). Wellness Letter. University of California, Berkeley, Volume 30 (Issue No. 3). P.1-2.


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 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):


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 in billions for the struggling healthcare system. (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


  1. Health Canada.  Biopharmaceutics Classification System Based Biowaiver.  Accessed online Dec 2013.
  2. Canadian Generic Pharmaceutical Association.  Bioavailability and Bioequivalence – What Are They?  Accessed online Dec 2013.
  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.
  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.
  7. Health Canada.  Comparative Bioavailability Standards: Formulations Used for Systemic Effects.  Accessed online Dec 2013.
  8. Deloitte.  Measuring the Return from Pharmaceutical Innovation 2012. Accessed online Dec 2013.
  9. Canadian Generics Pharmaceutical Assocation.  Accessed online May 20019.
  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.[tt_news]=175484#5911JFP_Article4-tab1
  13. Gregory M. Peterson.  Generic Substitution of Antiepileptics: Need for a Balanced View.  Accessed online Dec 2013.

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.


  1. UpToDate, Mechanisms, causes, and evaluation of orthostatic and postprandial hypotension.
    Accessed Dec 2012.
  2. MayoClinic, Accessed Dec 2012.

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 Some probiotics have storage requirements that specify temperature ranges or refrigeration to ensure stablility.To make sure that you get all the benefits from the follow the storage instructions on the label. If cool stroage is going to be a problem, then consider buying a probiotic which doesn't need to be kept cool. Room temperature is considered to be 15 - 25 degrees Celsius. 10
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

• 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

• 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

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.

Bismuth subsalicylate (e.g.Pepto Bismol):524 mg (2 tablets) or 30 mL suspension 4 times a day generally taken for the duration of the trip (Maximum recommended is 3 weeks) can be used as prevention for TD. Taking medication this often may be inconvenient, but it is a option if risky foods can't be avoided. Side effects include black tongue or stool, nausea, constipation, and tinnitus (ringing in the ears). It should be avoided in pregnancy, children, aspirin allergy, kidney disease, gout, and in patients taking anticoagulants, probenecid, methotrexate, or other salicylates. 11

Vaccine: An oral vaccine called Dukoral®, is not routinely recommended because evidence suggests it is not effective for prevention of travelers’ diarrhea. However, it may be considered for people who are going to destinations with suboptimal sanitation and hygiene, backpackers, travelers participating in adventure tours, those decreased immunity such as HIV with low CD4 count  and travelers with a history of repeated, severe travelers’ diarrhea. 12 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.


  1. International Association for Assistance to Travelers. Available at . Accessed Apr. 1, 2012.
  2. Health Canada. Travel Health. Minimizing your risk. Available at 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: 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 Accessed Apr. 15, 2012
  9. C-Health. Pepto-Bismol monograph. Available at Accessed Apr. 15, 2012.
  10. Comparison of Common Probiotic Products. Pharmacist’s Letter/Prescriber’s Letter. July 2015
  11. Travel medicine. Canadian Pharmacist's Letter; May 2013; Vol: 20
  12. PL Detail-Document, Prevention of Travellers’ Diarrhea. Pharmacist’s Letter/Prescriber’s Letter. December 2014.


How can I tell if a medication or vitamin product sold on the shelf has gluten in it? I have celiac disease (gluten intolerance ).


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


  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. (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. ( accessed March 8, 2010)



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.


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