Archive for May, 2015

How To Take Thyroid Medicine

Q: On the bottle of my thyroid medicine it says to take it in the morning on an empty stomach. But sometimes I forget and don’t realize it’s still there until after I’ve eaten my breakfast. Is it safe to take it then?

My mother took the thyroid medicine levothyroxine, and her prescription bottle said to take it 30 minutes before breakfast. Every day she worried about what might happen if she didn’t take it “correctly”. If she took her first bite of breakfast and noticed that her yellow levothyroxine tablet was still sitting on the counter, she’d skip her dose for that day rather than risk getting an upset stomach or worse.

“Louise, what if it CAN’T be safely mixed with food? What if taking thyroid medicine with food in my stomach starts a deadly chain reaction and my stomach ruptures?”

“It’s okay, Mom. Your stomach won’t rupture if you accidently take your thyroid medicine at the same time as your breakfast. If you take it with breakfast what happens is your body might not get all of the medicine in that pill. That’s because food can change how much of the levothyroxine your body absorbs.”

“But the label on the bottle says to take it BEFORE breakfast. Are you SURE it’s safe if I take it later than that? I don’t want to get into trouble.”

“You might get less of your thyroid medicine if you take it with your breakfast, but skipping it completely guarantees you’ll get NONE of the dose. ZERO medicine. That can affect you even more than if you messed up and took it with breakfast.”

Levothyroxine is one of the most commonly prescribed medicines in the United States, and it can be hard to remember to take it first thing in the morning.

Kate struggled to take her pills every day according to the directions on the labels. She’d even set her alarm for 6am just so she could take her levothyroxine in the morning before breakfast. Otherwise she’d forget it completely. She took her regular morning pills right after she finished breakfast, then took her blood thinner warfarin at 5pm and her cholesterol medicine simvastatin at bedtime. She had to remember to take her medicines 4 times a day every day and it felt overwhelming.

“I want to take my medicines like the doctor wants me to, but it’s so hard to remember to take all of them every day.”

I suggested she move her thyroid medicine and her blood thinner to bedtime, the same time she was taking her simvastatin. That way she only had to take her pills twice a day, which would be easier than 4 times a day.

When she started taking her thyroid medicine more consistently she felt more energetic and no longer worries about taking her medicine correctly. “It’s such a relief to have less to remember, and I love having more energy!”

Here are some tips on how to take this common medicine:

  1. There’s nothing that says you must take levothyroxine in the morning. It won’t hurt you if you take it at a different time, like at breakfast or bedtime.
  2. Although levothyroxine is absorbed better if you take it on an empty stomach (30 minutes to an hour before a meal or 4 hours afterward), as long as you take it the same way every time, you’ll get a consistent dose.
  3. Don’t just skip your dose if you forget to take it before you eat. Even some of your thyroid medicine is better than none.
  4. There are some medicines that should be taken 4 hours from levothyroxine: calcium pills, iron pills, or multivitamins with minerals containing calcium or iron. An easy way to do this is to take any multivitamins or supplements with calcium or iron at your lunch or dinner meal.
  5. If you take thyroid medicine, then if you also take medicine for building bones like alendronate (Fosamax®) take the alendronate FIRST, on an empty stomach and your thyroid medicine at least 30 minutes later.

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Pancakes and Mustard

Some things just DON’T go together. Like oil and water…ice cream and ketchup… or pancakes and mustard.

Some medicines just don’t go together either, and can cause serious problems if they’re combined. When 2 drugs should NOT be taken by the same person, it is considered a drug-drug interaction.

One example of a drug-drug interaction is adding a blood thinner medicine to another blood thinner medicine. The most common side effect of taking blood thinner medicines is bleeding, and taking more than one blood thinner at a time increases the possibility of having unusual bruising, a nosebleed, stomach bleeding or even bleeding into a joint.

In general, blood thinner medicines such as aspirin, warfarin (also Coumadin®), Plavix® (also clopidogrel) and newer ones like Pradaxa®, Eliquis® or Xarelto® should NOT be taken together unless your doctor specifically instructs you to do it. However, sometimes it’s necessary to take more than one blood thinner at a time in order to prevent blood clots.

Pain medicines with anti-inflammatory action like ibuprofen or naproxen can relieve muscle pain, swelling and stiffness better than acetaminophen (Tylenol®).  These medicines are called NSAIDs, which is short for non-steroidal anti-inflammatory drugs. Aspirin, naproxen and ibuprofen are the most widely used NSAID medicines because they are available without a prescription. I often recommend naproxen or ibuprofen to relieve muscle aches, swelling, dental pain and menstrual cramps.

One of the most common side effects of an NSAID medicine is bruising and bleeding. If you are already taking a blood thinner and then start taking an NSAID for your headache or backache, it increases the chance you will have serious bleeding. Both NSAIDs and blood thinner medicines can cause bleeding, and taking them together increases the risk. But how much does it do that?

Doctors have known for some time that taking an NSAID medicine while on a blood thinner could increase the risk of having bleeding, but it wasn’t very clear how much. A new study published earlier this month looked at the bleeding risk associated with taking an NSAID together with a blood thinner.

The researchers asked themselves, how much does taking an NSAID affect the chances of having serious bleeding when taken by someone who is already on a blood thinner? To answer this, they looked at bleeding events in two trials: the EINSTEIN-PE trial, with people diagnosed with blood clots in their lung, and the EINSTEIN-DVT trial, with those diagnosed with a blood clot in their leg. Both groups were taking a blood thinner for their clot, either warfarin (Coumadin®) or Xarelto®.

Although all the study participants were cautioned that taking an NSAID could increase the likelihood of them having bleeding, 25% of them did take an NSAIDs during the trial, and those who did had significantly more serious bleeding. The researchers were surprised to find out how much bleeding. Those who took an NSAID were 2.5 times more likely to have a serious bleeding episode and 25% of those bleeding episodes occurred within only eight days of taking the NSAID.

Aspirin, ibuprofen (Motrin®, Motrin-IB®), and naproxen (Aleve®) are the most common NSAIDs because they don’t require a prescription. You can also be prescribed a prescription NSAID medicine for a back strain or dental procedure.

Can you safely take just ONE dose of an NSAID if you are already taking a blood thinner? Possibly. In my mediguide Taking Warfarin Safely I talk about what you can safely take for aches and pains while taking the blood thinner warfarin. It explains, “Occasional use (2 to 3 times a week) of naproxen or ibuprofen for muscle aches or dental pain is usually safe unless you have had stomach bleeding or an ulcer”.

With this new information about increased bleeding risk, if you take a blood thinner then having one dose of an NSAID no more than 2-3 times a week is probably still reasonable. It would be safer for you to avoid taking naproxen or ibuprofen whenever possible and instead substitute acetaminophen (Tylenol®) for aches and pains. Because some things just DON’T go together. Like NSAIDs and blood thinners…chocolate and pepperoni…grapefruit juice and milk…pickles and peanut butter…

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Help for Patches That Itch

Q:     My niece wears a patch for her ADHD and it is working well except for one thing. She complains that “it itches” and wants to pick at the edges. Would it help if I covered it up with a bandage so she can’t scratch at it?
One of the most helpful things about using a patch instead of a pill is the steady amount of medicine you get from a patch. Patches can also help deliver medicines that are hard to get into the bloodstream. Using a patch bypasses the stomach and delivers medicine into your blood through your skin. Some patches are applied daily, such as nitroglycerin and methylphenidate (Daytrana®), most are applied every 3 days (Transderm-Scop®, Duragesic®), and a few such as clonidine (Catapres TTS®) are designed to last a week.
There are two types of medicated patches: reservoir and matrix. The reservoir type has a liquid core surrounded by a membrane controlling how fast the drug moves into the skin.  Newer patches use a matrix that combines the drug with the adhesive into a single layer. Drugs available as a patch include nicotine, methylphenidate, nitroglycerin, estrogen, and the analgesics lidocaine, ketoprofen and fentanyl.
Patches are usually more expensive than the tablet forms of medicine and prescription insurance doesn’t always cover them. Another challenge is getting the right amount of “stickiness” on the patch. It needs to stick to your skin without taking off a couple of layers when you remove it. Finally, because the patch stays on for hours or days, some people develop irritation at the site of the patch.
The most common problem reported with patches is redness and itching where the patch was applied. There are 2 types of skin reactions caused by wearing a patch: irritant dermatitis and allergic dermatitis. Irritant dermatitis can be annoying but there are strategies that can help that. Allergic dermatitis will not get better and you need to stop using the patch.
Irritant contact dermatitis shows up as a red area limited to the exact shape of the patch, and fades over several days after the patch is removed. If you see sharp boundaries of redness when removing the patch, it is most likely irritation.
An allergic reaction to a patch is different. It works like a reaction to poison ivy: first your body comes in contact with the patch. Then days, months or years later, your body decides that some component in that patch is a threat to you, and your immune system goes into action. The trigger could be its active ingredient, the adhesive, or some other component of the patch.
Once your body is sensitized to a compound, future reactions take place pretty quickly. The redness and irritation often spread past the point where a patch has had contact with the skin and the itching can be severe, taking days to calm down after removing the patch.
Nickel allergy is an example of allergic dermatitis. I cannot wear stainless steel or white gold necklaces or earrings for more than a few hours because they cause my entire earlobe to swell, get red and itch, itch, itch!

How can you help someone who is itching from wearing a patch?
1.     First, try to determine whether it is an allergic reaction or not. If in doubt, call the doctor or make an appointment.
2.     Treat your skin gently. Minimize irritation by using lukewarm instead of hot water when bathing or taking a shower, and don’t use rubbing alcohol or other solvents on your skin.
3.     Don’t apply moisturizer to the area right before putting on a new patch, as that can cause the adhesive to fail.
4.     Avoid washing the skin right before applying a new patch, as that can trap soap residue or moisture underneath the patch, causing irritation.
5.     Remove the patch gently and apply a corticosteroid cream to the area, either 1% hydrocortisone or a prescription-strength cream from your doctor. If you have excess adhesive on your skin left from the patch, don’t scrub it off. Instead, wipe it off with Petroleum jelly or Bag Balm®.
6.    Here’s a trick that may help reduce irritation: apply a liquid antacid like Maalox® or Mylanta® lightly to the skin with a cotton ball and let it dry before applying the patch.

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The Sneaky Side Effect

Keith is a former college basketball player and retired physical education teacher who’s still fit and active at 85 years young. When he came in last week he showed me his new bottle of medicine, Vesicare®, a drug marketed for overactive bladder. His urologist had prescribed it to him to decrease the number of times he had to get up during the night to go to the bathroom.
I asked him, “How is it working for you?”
“I was on the 5mg tablets first, but I didn’t notice any difference so the Doc upped it to the 10mg tablets.”
“Are those working better?”
“Not really. I did notice a difference at first, for the first couple days, but then it stopped working. I’m back to getting up just as often as I did before I took it.”
“Are you having any problems or side effects from it?”
“What do you mean?”
“Keith, does your mouth feel dry since you started taking it?”
“How did you know? It helps if I suck on lemon drops, though, and when I drink more water.”

Keith is not alone. It’s estimated that over 30% of people older than 65 years have some degree of dry mouth. Healthy people can make up to 1.5 liters of saliva every 24 hours, but those with dry mouth, also called xerostomia make much less.  Saliva secretion can be decreased by radiation to the head and neck for cancer treatment, autoimmune diseases like Sjogren’s, rheumatoid arthritis, or lupus, or taking certain medicines chronically.

Saliva lubricates your mouth, helping you chew your food and swallow it without choking. It also dissolves some of the compounds in your food and spreads them over your taste buds to help you taste it. The moisture from your saliva also protects the lining of your mouth and teeth from injury and infection. Saliva contains very important antibacterial compounds that prevent tooth decay and gum disease.

Dry mouth like Keith was experiencing is not just a nuisance. It can be painful and costly. The lining of your mouth is more easily damaged when it is dried out. Without enough saliva to rinse them, food sticks to your teeth and tongue, dramatically increasing plaque formation and causing tooth decay and inflamed gums.

If you wear dentures, when your gums get dry they shrink and become more sensitive. The sensation of a dry mouth often triggers sipping or drinking more fluids, which in Keith’s case ended up aggravating the problem the bladder medicine was originally intended to solve. After the first couple of days on his bladder medicine, he found he made just as many nightly trips to the bathroom as before.

If you are experiencing dry mouth symptoms, what should you do?

1.     Review the medications you take regularly. Are one or more of them causing your dry mouth symptoms?
The most common reason to have dry mouth is the medications you take. I call dry mouth the sneaky side effect. It can sneak up on you and create serious dental problems before you realize it. Unfortunately, every medicine marketed for bladder control causes dry mouth, some more than others. Keith drank more water to relieve his dryness, which caused him to urinate more and prevented him from getting relief from his frequent nocturnal bathroom trips.

2.     Avoid chewing or smoking tobacco, because that interferes with saliva production.

3.    Avoid chewing gum or sucking on hard candy sweetened by sugar.
Sugar encourages bacteria in your mouth to produce more acid, which attacks your teeth and gums. I advised Keith to switch to a sugar-free version, like xylitol.  Chewing gum with xylitol may help decrease the risk of caries. Keep it out of reach of your pets, however. In dogs, xylitol triggers a very rapid rise in insulin, causing very low blood sugar and seizures, and can also cause cause liver failure.

4.     If you have to take medicine that makes your mouth dry, try taking it an hour before you eat because eating stimulates saliva production.

5.    Take extra good care of your teeth.
Brush and floss twice a day, using a very soft toothbrush to reduce damaging your mouth. See your dentist regularly.

6.    You can try a saliva substitute, such as a spray or gel. There are also small discs that you can stick to the inside of your mouth where baseball players put chewing tobacco. Over 80% of my pharmacist colleagues recommend a Biotene® product, either the dry mouth relief spray or the clear gel called Oral Balance.

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Calcium and Your Bones

May 4th, 2015. Filed Under: consumer information.
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Q: My doctor says I need to take a calcium supplement. Which one is the best and how much of it do I need to take?

May is National Osteoporosis Awareness and Prevention Month. The National Osteoporosis Foundation (NOF) is encouraging Americans to learn more osteoporosis and how to keep their bones strong and healthy, including getting enough calcium and Vitamin D, doing some weight bearing exercise every day, quitting smoking and asking their doctor or medical provider about bone density testing.

Your muscles, nerves and blood vessels depend on calcium to work properly. If there is not enough calcium in your blood for your muscles and nerves, your body will grab calcium right out of your bones to make it up. Over time, you lose more and more bone until something gives: your hip breaks or your backbone collapses.

How do you know if you are getting enough calcium to prevent this from happening to you? The Institute of Medicine recommends 1000mg daily of calcium for men and women up to age 50, and 1200mg for adults older than 50 years of age. The National Institutes of Health recommends more calcium for postmenopausal women: 1500mg daily for women who are postmenopausal but not taking an estrogen supplement, and 1500mg for all women age 65 and older. These recommended amounts of calcium refer to the actual amount of calcium mineral in each pill, also called elemental calcium. For example each Citracal® tablet contains only 21% of elemental calcium, and Caltrate® has 40% elemental calcium in each tablet.

If you are taking a medicine to prevent or treat bone loss (such as Fosamax® or alendronate, Actonel® or risendronate, Boniva®, or calcitonin nose spray) it’s extra important to get plenty of calcium every day because these medicines work by putting calcium BACK INTO bones. It’s important to have enough calcium in your body so these medicines can do their job.

You’ll get about 300mg of calcium daily from your diet, including beans, nuts, and green vegetables, with an additional 300mg of calcium for every 8 ounce glass of milk, fortified orange juice, yogurt, or 1.5 ounces of cheese you consume. Most men need 600mg and most women will need 600mg to 1200mg daily of a calcium supplement.

Most calcium supplements have either calcium carbonate or calcium citrate, with brand names and generics to choose from. Calcium carbonate is nearly twice as concentrated in elemental calcium as calcium citrate. The most concentrated are TUMS® antacid tablets, available as 500mg, 750mg and 1000mg each. Caltrate®, OsCal®, and Viactiv® each contain either 500mg or 600mg of calcium carbonate. Citracal® has calcium citrate in a variety of strengths, from 200mg to a slow-release form containing 600mg. Citracal® Gummies use tricalcium phosphate.

It’s best to pick a calcium supplement that you are willing and able to take regularly. A bottle of calcium pills sitting on the shelf because they’re too big to swallow won’t help your bones! Here are some tips to help you out:

6 Tips For Selecting A Calcium Supplement:

1.    Most women need 1000-1200mg of elemental calcium as a daily supplement.  That’s two each of calcium carbonate or about four each of calcium citrate for women, and half of that dose for men over 60 years of age. Most calcium supplements show calcium content on the label by a serving size of 2 each.

2.    Take supplemental Vitamin D to help your body absorb calcium.
Vitamin D is now recommended as 600 IU daily for folks up to 70 years of age and 800 IU daily for those over 70. You can also get Vitamin D from salmon (800 IU per 3 ounces), canned tuna (150 IU per 3 ounces), fortified milk (about 120 IU per 4 ounces), and fortified orange juice (80 IU per 4 ounces). Most calcium supplements contain Vitamin D but you can also take it separately.

3.    Maintain an adequate water or fluid intake to avoid kidney stones.  Calcium is not very soluble in water, and can form painful crystals or stones inside your kidney. Calcium citrate is less likely to do this than calcium carbonate supplements; talk to your doctor first before taking calcium if you have had kidney stones in the past.

4.    Choose calcium citrate if you take any medicines for stomach acidity, stomach ulcer, or hiatal hernia. Prilosec® or omeprazole, Prevacid® or lansoprazole, Zantac® or ranitidine, and other medicines like these reduce the acid in your stomach. Calcium carbonate needs an acidic stomach to be completely absorbed; calcium citrate is well absorbed regardless.

5.    If you have trouble with constipation, avoid calcium carbonate.

6.    Take advantage of chewable calcium if you can’t swallow large pills.
If you HATE to take big pills like me (I tend to gag on them or get them stuck partway down), try smaller tablets (Citracal® Petites), caramel-like chews (Viactiv®), or new gumdrop-like “gummies” (Caltrate®, Citracal®).

To find out more about osteoporosis and how you can prevent it from the National Osteoporosis Foundation stop by their website at

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