What Were They Thinking?

Mr. Blackwell has his Hollywood “Worst Dressed List” of celebrities whose desire to make a bold personal statement exceeds their fashion sense, creating an outfit so outlandish that you wonder, “What Were They Thinking?”

Instead of Nobel prizes, we also have their counterpoint: Ig Nobel prizes. These dubious distinctions are awarded to people whose achievements “cannot or should not be reproduced”. In 2000, the Ig Nobel Computer Science prize was awarded to Chris Niswander of Tucson, Arizona, for his ingenious invention of PawSense, a computer software program to protect your computer from cats. Able to detect when a cat is walking across your computer keyboard, it blocks dangerous cat typing, and help train your cat that your keyboard is OFF LIMITS.

Don’t forget the Darwin Awards, those lists of unfortunate souls whose jaw-dropping exploits and not-quite-death-defying stunts were preceded by these famous last words, “Hold my beer, and WATCH THIS!” Tragically, they leave grieving friends, relatives, and the rest of us wondering, “What Were They Thinking?”

It’s time to recognize similar outstanding contributions in the field of medicines and supplements. When a new remedy leaves you scratching your head and asking yourself, “What Were They THINKING?”, you could nominate them for a WWTT Award.

There are 2 products that are being introduced to treat itching: one called Allegra® Cooling Relief and another called Allegra® Intensive Relief. They are non-prescription creams that can be applied to the skin 3-4 times a day to relieve itching.

Why would they be nominated for a WWTT Award?

Because neither of these products contain any Allegra®. You can buy non-prescription Allegra® as tablets in two formulas: regular which is taken twice a day, and a 24-hour, which is longer acting. Both of these contain the generic medication fexofenadine, which is the active ingredient found in the prescription version of Allegra®.

But Allegra® Cooling Relief and Allegra® Intensive Relief don’t have ANY fexofenadine in them. Instead, they have diphenhydramine.

One reason for nominating Allegra topical for a WWTT is that diphenhydramine is the generic name for Benadryl®, not Allegra®. We look at the name on the box and think, “Allegra®. Okay, I’ll try it. You would assume that the same ingredient that’s sold as tablets of Allegra is going to be in the skin cream. Wrong!

Several years ago, several anti-itch products that contained Benadryl® were introduced as being relief for itching. Several problems with them showed up.

Problem #1: Hallucinations occurred in children and adults using Benadryl cream for chicken pox blisters.

Problem #2: Side effects such as hallucinations, agitation, abnormal tongue movements, even seizures were reported in both children and adults who used the cream and then also took oral tablets or Benadryl® syrupfor relief of their itchy skin.

Problem #3: Side effects from Benadryl® given as a cream or gel also were reported when added to broken skin. When you apply a cream onto your skin, only a small amount is absorbed, and only into the immediate area. Applying a cream to broken skin is different. Like the Panama Canal cuts a path that goes from the Atlantic to the Pacific Ocean, when your skin has a cut, deep scrape or blisters, the medicine can move right into your blood stream.

Problem #4:
When it was first released the Benadryl® gel was packaged in a container that didn’t look quite like a tube of ointment or cream.  It also contained menthol, and several children were given it by mouth instead of on their skin, causing side effects from both menthol and diphenhydramine.

Whether you use Allegra® or Benadryl® cream, gel or lotion on your skin, the FDA has labeled them with the same cautions.

If you choose to use a cream, gel or ointment containing diphenhydramine on your skin please be careful to avoid using it in cases of chicken pox (varicella) or over large areas of your body, and never apply it to broken skin.

One more caution about using either Benadryl® or Allegra® cream, gel, or ointment for itching. Do not use the topical cream in addition to taking it by mouth as a tablet, capsule or liquid. You may be surprised to find out that Nytol® and Sominex® have formulas containing 50mg tablets of diphenhydramine.

If you talk to a pediatrician, they will tell you that diphenhydramine cream or gel is not very effective for itching. Benadryl® Syrup or its generic is far more likely to work. For chicken pox, use calamine lotion or cool compresses moistened with water. Moisturizers can help tame the intense experience of itching. If skin is not cut, scraped or scratched, either 0.5% or 1% hydrocortisone cream, lotion or ointment can be used safely, even in children.

Allegra® Cooling Relief and Allegra® Intensive Relief with diphenhydramine instead of fexofenadine: “ What WERE They Thinking?”

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Conquering Queasiness On A Cruise

Q:  I’m going on a cruise to Alaska this summer. Which motion sickness medicine should I take with me?

Even if you’ve never had trouble with motion sickness before, packing something to deal with seasickness is a smart idea.

You have several remedies to pick from: ginger root, over-the-counter remedies such as Dramamine® or Bonine®, and a prescription-only scopolamine patch called Transderm-Scop®. These differ from one another in 3 ways: how long the protective effect lasts, what type of side effects they can cause, and whether or not you actually will experience any side effects. Unfortunately, there’s no way to predict whether any medicine will give you side effects, so it’s best if you try it on yourself long before your ship casts off.

Ginger root is the safest option for preventing motion sickness. It has no side effects and is the best choice for children and pregnant women. I wish my parents had known about using ginger – it would have saved me so much misery riding in the back seat of my parents’ station wagon. Discovering it as an adult totally transformed my travel experience.

Ginger should be taken at least 30 minutes before you’ll need it to start working. Each dose is only effective for 4-6 hours, so be prepared to redose several times during the day. You can buy ginger as crystallized chunks of root (cooked with sugar) in the spice aisle, but if its intense hot/sweet taste is not for you, ginger capsules are widely available in the health food section of most grocery stores.

There are 2 antihistamines used for motion sickness prevention available without a prescription: meclizine and dimenhydrinate. Meclizine is my personal choice. It’s available as Bonine® and Dramamine® Less-Drowsy Formula in 25mg tablets, and also as generic meclizine in 2 different strengths, 12.5mg and 25mg. Meclizine works for 24 hours and is taken once a day. It can cause some drowsiness, but how much will vary from person to person. Most people don’t notice much drowsiness, but if you are one of the unlucky ones, one tablet can put you to sleep for the day! Also, watch out, neither antihistamine mixes well with alcohol causing significant drowsiness or confusion.

Buying Dramamine® for motion sickness can be confusing because it comes as two different products: Original and Less-Drowsy. The Less-Drowsy formula contains meclizine; the Original Formula has a shorter-acting antihistamine called dimenhydrinate. Your body turns dimenhydrinate into diphenhydramine, which you may recognize as the generic name of Benadryl®. Benadryl® commonly causes drowsiness and is even sold as a sleeping pills like Sominex-2 and Tylenol-PM. Just like Benadryl®, dimenhydrinate only lasts 4-6 hours, which means you’ll need to redose during the day.

The last motion sickness medicine is Transderm-Scop®, a small, round tan-colored patch applied behind your ear. This prescription-only patch contains scopolamine and lasts for 3 days, longer than any other motion sickness medicine. Scopolamine side effects include dry mouth, blurred vision, dizziness, confusion and even hallucinations, something you definitely want to check out BEFORE you’re depending on it to keep down your dinner. It also shouldn’t be cut or given to a child.

On a trip back home to Seattle from Orlando some years ago I lost track of how long it had been since my last dose of ginger because of the time changes heading westward. I didn’t realize the ginger had worn off until we hit turbulence heading over the Cascade Mountains on the last 30 minutes of the flight. After the very bumpy and utterly miserable descent into Seattle, I vowed to find another option. Today I take meclizine on every trip, although I also pack crystallized ginger pieces if I’m going on a boat. My small tube of chewable meclizine called Bonine® is easy to pack and I keep it refilled from a bottle of 100-count generic 25mg chewable tablets at home. Meclizine is my miracle motion sickness remedy because I only have to chew one tablet a day and I’ve never had drowsiness or any other side effects from it.

Whether you choose to take ginger, meclizine or a scopolamine patch on your cruise, be sure to try it out before you go to avoid getting on the wrong ship because of blurry vision, snoozing your vacation away in your cabin or seeing dancing elephants on the ceiling. Bon voyage!

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The Orange Juice and Banana Sticker

Q: There’s a bright yellow sticker on my prescription bottle suggesting I eat a banana or drink a glass of orange juice every day while on that medicine. If I do that, can I stop taking my huge potassium pills every day?

You must be talking about the little label that says “It may be advisable to drink a full glass of orange juice or eat a banana daily while taking this medication.” It’s meant to encourage you to eat foods that contain potassium.

One of the most important minerals in your body is potassium. Potassium helps you regulate the acid-base balance in your blood, make proteins from amino acids, build muscle and balance your heart’s electrical activity. Some medicines do what they do by pulling water and minerals like sodium and potassium out of your body. Because they make you urinate a lot more than usual they are also called “water pills” or diuretics. Pharmacists add this particular sticker to prescription bottles of “water pills” to encourage getting more potassium in your diet.

It’s especially important to keep your potassium level balanced if you take the heart medicine digoxin, as too much or too little potassium in your blood could trigger abnormal heart rhythms with serious, even deadly results. Your doctor can track your potassium level by testing your blood and if it’s too low give you supplemental potassium.

How does the potassium in your blood drop too low? From the foods you do or do not eat, by vomiting, or by taking prescription diuretics. Diuretics are medicines that are also called “water pills” because they remove water from your body by making you urinate more frequently. Diuretics such as furosemide, hydrochlorothiazide, and chlorthalidone work by removing fluid from your lungs and reducing swelling in your hands or feet. The medicine pulls water out of your body but along with it goes sodium, potassium and magnesium. A diuretic can be combined with another medicine to prevent excess potassium loss and balance things out.

Potassium is measured in two ways: by mg and by mEq. Most prescription forms of potassium are labeled as mEq and are available as either 10mEq or 20mEq tablets.

Depending on our food choices, we take in between 40 to 150mEq potassium every day. Eating a medium-sized banana gives you 12mEq of potassium. An 8-ounce glass of orange juice contains 7mEq. Leafy green vegetables and foods that grow on vines are particularly good sources of potassium, as are milk and yogurt. One potato with the skin has 21mEq potassium. More information on potassium content of foods go to is available at http://www.health.gov/dietaryguidelines/dga2005/document/html/appendixB.htm#appB1.

Many prescription potassium pills are BIG and hard to swallow, leading some folks try non-prescription versions instead. One common non-prescription form is potassium gluconate with 595mg (99 mg of potassium) in each tablet.

How does 99mg of potassium compare to the prescription strength of 10mEq? In each mEq, there is 39mg of potassium, whether it comes as potassium chloride or gluconate. One potassium gluconate tablet with 595mg of potassium gluconate gives you 99mg of potassium or 2.5mEq. It takes four tablets of non-prescription potassium gluconate to equal the potassium in one prescription-only tablet of 10mEq potassium chloride.

Getting enough potassium is important, but not everyone needs more of it. People with kidney problems do not eliminate potassium easily, and taking certain heart medicines like lisinopril or spironolactone can increase the amount of potassium in your body up to dangerous levels, especially you are also taking a potassium supplement.

Do you have to drink a full glass of orange juice or eat a banana every day for your potassium? Not really; in fact, the potassium found in foods doesn’t work as well as potassium chloride when correcting low potassium levels from vomiting or taking a diuretic. Salt substitutes such as NoSalt® or Morton Salt Substitute® are a particularly concentrated source of potassium, containing 15-20mEq in each ¼ teaspoonful. Switching from using table salt (containing sodium chloride) to a salt substitute containing potassium chloride can dramatically increase your potassium intake.

People getting kidney dialysis should avoid foods with high amounts of potassium and avoid using salt substitutes because they cannot easily remove potassium from their bodies. For the rest of us, using a salt substitute is one of the least expensive ways to get more potassium.

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Taking Medicines On Time

As Jenny stepped on the bathroom scale she held her breath. If the glowing red numbers at her feet weren’t lying, she’d gained another pound!

Ten months ago the cramps and diarrhea of her Crohn’s disease were out of control so her rheumatologist at the Virginia Mason clinic in Seattle started her on a new medicine called prednisone. Taking it every day had solved her intestinal problems, but at a price: a raging appetite along with ballooning hips, puffy cheeks and sinking self-confidence.

They’d tried to cut her prednisone dose back several times but each time the cramps and bloody diarrhea came roaring back. Finally she’d had enough and went back to Virginia Mason to insist they take her off the prednisone no matter what before she turned into the Incredible Hulk.

Her doctor agreed. “But this time, before we try to taper it let’s move half of your prednisone dose to the evening first.”
“But I’m already taking the prednisone in the evening.”
“What? When did you start taking it in the evening?”
“I started taking it in the morning but it really upset my stomach so I ended up switching it to dinnertime instead.”
“No wonder we couldn’t get your prednisone dose down!”

Who knew taking a medicine at a certain time could be so important?

How about you? Are you taking your medicine at the “right” time? With some medicines it can make a big difference in how effective the medicine is or how much you are bothered with side effects. Some medicines should be taken on an empty stomach to help you absorb each dose, while others are best taken with food to avoid stomach upset. And a few medicines are more potent if taken at a particular time of day.

When instructed to take a medicine on an empty stomach you should take it at least 30 minutes before eating or 2-3 hours afterward. The thyroid replacement medicine levothyroxine and the stomach acid blocking medicine omeprazole work best if you take them first thing in the morning, about 30 minutes before breakfast.  With the bone building medicines alendronate (Fosamax®) or risendronate (Actonel®) even plain coffee can interfere with getting it into your body.

Most medicines should be taken with food. Stomach upset is the most common side effect reported by people taking medicine in clinical trials, where they keep track of every possible side effect. Unless told otherwise, it’s much easier on your stomach to take medicines with food, especially antibiotics, vitamins and minerals. Many antibiotics can cause nausea, cramps and vomiting if they’re all alone in your stomach. A common diabetes drug called metformin (Glucophage®) is notorious for causing nausea and diarrhea. The popular pain medicines naproxen (Aleve®) and ibuprofen (Motrin®) are very irritating to the stomach, causing cause stomach pain and even bleeding if taken without food or a full glass of water to dilute their irritating effect.

Some cholesterol medicines are more potent if you take them late in the day. Medicines like atorvastatin (Lipitor®) or simvastatin (Zocor®) called “statins” are examples of this. Statin medicines work by blocking the last step needed to make cholesterol, and because your body makes cholesterol at night, statin medicines drop your cholesterol better if you take them in the evening or at bedtime.

Why did Jenny have trouble tapering her prednisone when she took it in the evening? Your body makes an important hormone called cortisol. Cortisol helps you respond to stress, and you make more of it or less of it depending on how much is needed and how much is already in your body. If you take prednisone your body “sees” it as having extra cortisol around so it decreases the amount it makes the next day. As you continue on prednisone over time your body makes less and less cortisol, which can leave you vulnerable when you need large amounts of cortisol quickly to response to stress like a serious infection. When stopping prednisone it can take weeks to months for your body to recover from its lowered cortisol production.

Taking prednisone in the morning minimizes the impact it has on your own cortisol production, making it easier to taper the dose. After moving her prednisone dose from dinnertime to breakfast Jenny was finally able to get off it completely. And now she smiles when she sees the red glowing numbers on her scale each week.

What time is the best time for you to take your medicine?

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Can You EAR Me Now?

One week before my daughter Maureen’s 3rd birthday she started tugging at her left ear. When I tried to see into her ear, she wouldn’t let me, so the following week I asked our pediatrician to take a look. He looked into each ear with the otoscope, and then told me, “she has external otitis – an irritation of her ear canal. It needs to be cleaned out.”

As they flushed out her ear canal I was AMAZED at what came floating out: 3 balls of fuzz the exact color of our living room carpet, 2 rolled up wads of white paper, another 2 balls of carpet colored fuzz and a small white button! Her ear itched and she kept trying to relieve the itching by sticking things into it.

The medical name for earwax is cerumen, based on the Latin word cera, which means wax. But cerumen isn’t really wax, it’s a sticky liquid secreted by the cells in the skin lining your ear canal designed to protect your eardrum by trapping dirt and dust before they can irritate or damage it.

For some people, earwax just flakes away and never causes them any trouble. Then there are the REST of us. Problems with earwax are one of the most common reasons people make appointments to see their doctor. Cerumen can build up against the eardrum, causing hearing loss, ear pain and interfering with hearing aids. Trying to remove it by sticking cotton-tipped swabs or bobby pins up your ear canal only forces it further inside your ear canal, leading to pressure, pain and impaction.

If swabs can’t do it, how do you remove earwax? By softening it first. Making cerumen more pliable makes it easier to dislodge when flushing it out. Unfortunately there isn’t any consensus of what type of eardrops are most effective. A systematic review of studies done on earwax removal using several different types of eardrops showed no difference between them.

The leading product purchased in the United States for earwax is Debrox®, a 6.5% solution of carbamide peroxide. According to a 2013 OTC survey funded by US News and World Report and Pharmacy Times, 86% of American pharmacists surveyed recommend Debrox® drops to their customers.

Carbamide peroxide reacts with earwax to release oxygen, creating foam that liquefies the cerumen and helps it to be rinsed away. Like many people, when I use Debrox® I can hear crackling and popping sounds and can feel a distinct tickling sensation in my ear.

Another eardrop product that we used to recommend for earwax was Cerumenex®, which contained triethanolamine to emulsify cerumen. Introduced in 1958, it was withdrawn in 2008 due to reports of permanent hearing loss or irritation after only one application. When further investigation proved the risk was real Cerumenex® was discontinued.
Docusate sodium (Waxsol®) drops are used to soften earwax in the UK. Docusate sodium, also known as Colace® is a stool softener that pulls liquid into hard stool to make it softer, and does the same thing to impacted cerumen. Most surfactants work just like liquid detergent. If you ever taste docusate, either as a liquid or syrup, it’s like washing your mouth out with liquid dish soap. Yuk!!

In our clinic we use a two-step process: first, docusate liquid in the ear for 1-3 days, then flush with warm water. One way you can try docusate at home is to poke a hole in the end of a capsule and squeeze out its contents into your ear canal, repeating up to three times a day for one or two days. Remove your now-softened earwax by flushing GENTLY with warm water in a bulb syringe or by tipping your head up during a warm shower. Dry afterward with a hair dryer on a low setting.

If, like me, you suffer from excess cerumen, here are some DONT’s:
DON’T clean earwax from your ear canal with a cotton-tipped swab, bobby pin or rolled napkin.
DON’T use eardrops if you have ear pain, bleeding or any discharge from your ear; instead, contact your doctor.
DON’T use a Water Pik® or similar apparatus to flush out your ears.
Don’t use cold water to flush out your ears. It can cause problems with your balance.

More information is on earwax and ear care is available at www.webMD.com.

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Are You Getting Enough Calcium?

Q: Which calcium supplement? Which one is best?

This issue strikes close to home with me because my mother fractured her wrist, then her hip and eventually died from complications from osteoporosis. Those of us who are over 50 years of age, female, post menopausal, have a family history of osteoporosis or a slight build are more likely to develop thinning bones that could lead to fractures along with permanent disability, like my mother suffered.

Many Americans are aware that calcium and vitamin D are critically important for building strong bones but may not realize how our muscles, nerves and blood vessels also depend on calcium in order to work properly. If your body doesn’t have enough calcium it will go looking for more, and the easiest place to get it is from your bones. Without adequate calcium in your diet or in supplements your body will use your skeleton as a calcium ATM until something gives – your hip breaks or your backbone collapses.

Most bone-building medicines work by reversing this process, strengthening your bones by putting calcium back into them. If you are taking a prescription medicine such as alendronate (Fosamax®), Actonel® (risendronate) or Boniva® it’s important to have enough calcium in your body so these medicines can do their job.

How much calcium is enough? 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 used to recommend more for postmenopausal women but backed off when increased heart attacks started showing up in older women taking daily calcium supplements.

Do you even need a calcium supplement at all? Unlike taking calcium in a pill, eating calcium-rich foods does not increase your chances of having a heart attack. Most Americans get about 300mg of calcium daily from their diet, mostly from beans, nuts, and green vegetables. In addition, you’ll get an additional 300mg of calcium for every 8-ounce glass of milk, fortified orange juice, yogurt, or 1.5 ounces of cheese you consume.

Broccoli, cabbage, kale, turnip greens, and salmon are good sources of calcium. Eating spinach can interfere with calcium absorption, so it isn’t a good choice if you are trying to increase calcium in your diet.

If you are over 50, you’ll probably need a little help from a calcium supplement to protect your bones from becoming calcium ATM. Calcium citrate and calcium carbonate are the most common calcium supplements to choose from.

6 Tips To Improve Your Calcium Intake:

1.    Eat more servings of vegetables.  8 ounces of broccoli has 60mg of elemental calcium and 8 ounces of kale has nearly 100mg. Spinach is not a good choice for calcium because it also contains oxalates that interfere with calcium absorption. Eating foods rich in calcium reduces your risk of heart attack, while taking supplements can increase it.

2.    Take supplemental Vitamin D to help your body absorb calcium.
Vitamin D is 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 also contain Vitamin D.

3.    Choose calcium citrate if you take any medicines for stomach acidity, heartburn or stomach ulcer. Taking Prilosec® (omeprazole), Prevacid® (lansoprazole), Zantac® (ranitidine) and other medicines like these reduces the acid level in your stomach. Calcium carbonate needs plenty of stomach acid to be absorbed but calcium citrate doesn’t.

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

5.    Always take a calcium supplement with meals. Calcium is better absorbed when it is in your food (like broccoli) or if you take your supplement with food.

6.    Maintain an adequate water or fluid intake to avoid kidney stones.  Calcium is not very soluble in water, and taking calcium supplements can cause painful crystals or stones inside your kidney. Calcium citrate is less likely to do this than other calcium supplements. If you’ve had kidney stones in the past talk to your doctor before starting a calcium supplement.

May is National Osteoporosis Month. More information about calcium in your diet and how to keep your bones strong is available from the National Osteoporosis Foundation at www.nof.org.

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