Archive for August, 2016

How To Get Better Pharmacy Care

Being a patient in a hospital is a dangerous place to be because it puts you at risk of being harmed by a medication error. That’s because more doses of medicine and more powerful medicines are given to people who are sick enough to need hospital care.

No matter how much we try, we are all human, and mistakes will be made. Our best hope is to catch these medication errors before they get to the patient by training staff to be alert, building in safeguards that flag potential problems, and by clear communication between the pharmacy staff who fill each medication order and the nursing staff administering it to the patient.

There are two main systems hospitals use to provide medicines to patients: centralized and decentralized distribution systems. In a centralized system the pharmacy is in the basement and pharmacists work inside its walls. Nursing sends new medication orders down to pharmacy and receives them without ever seeing or talking to a pharmacist.
A decentralized system puts pharmacists on the floors or units, usually right next to nursing stations. Pharmacists and nurses work side-by-side to interpret orders that are sent along to the central pharmacy for filling.

In my 12 years as a hospital pharmacist I’ve worked in both decentralized and centralized pharmacy systems and there is a significant difference between them. In a centralized system, nursing and pharmacy have an adversarial relationship, where in a decentralized pharmacy system pharmacy and nursing respect and value each other. My observation is that in centralized pharmacy systems the only time nurses communicate with the pharmacy is by phone when things go wrong, like when they can’t find the next dose of their antibiotic or have run out of pain medicine. The nurse calls the pharmacy in frustration, complaining about how she doesn’t have the medicine and the pharmacy learns to dread getting called by nurses.

Decentralized pharmacies put pharmacists and nurses side-by-side, and the face-to-face contact fosters less blame and more cooperation. Pharmacy helps nurses find missing doses of medicines clarify orders and in general are seen as heroes instead of the problem.

The most striking difference between the two systems is in detecting and resolving potential medication errors. Nursing is the last link between a medication order and the patient. The nurse administering a medicine is the last opportunity to find a mistake or error before it gets to the patient. Let’s be honest here. Because we are human it’s not possible to completely eliminate medication errors. The best we can do is to recognize an error and correct things that aren’t right before they harm an innocent patient.

In a centralized system if a nurse notices something that “doesn’t seem quite right” they will tend to avoid calling the pharmacy, as the pharmacy already thinks they call too much and complain. Instead, they will let it go. In a decentralized system a nurse facing the same “not quite right” feeling will call over the pharmacist, saying, “Hey, could you take a look at this? What do you think?”

There’s a similar situation faced by older Americans when it comes to getting their prescriptions. Centralized pharmacy services are provided by mail-order pharmacies and decentralized services by local pharmacies.

Outside of a hospital, the last link in the chain of a medication error is YOU. Like hospital nurses in a decentralized pharmacy system, using a local pharmacy gives you the opportunity to develop a relationship with a pharmacist or pharmacists. When you see things that don’t make sense to you, you are more likely to ask the pharmacist for help than if you get your medicines through the mail.

Here are 5 tips on getting the safest pharmacy care:

1.    Look for non-mail order options in your benefit plan and choose local whenever you can.

2.     Keep a complete list of all of your medications, and share it with all of your providers, not just your doctors. Take it to your dentist, chiropractor, and each pharmacy that you use. Keep everyone in the loop avoids dangerous duplication or risky combinations of medicines.

3.    Establish a relationship with at least one pharmacist so that you feel comfortable asking them questions. This is an absolutely critical skill as our medications become more complex and more powerful and more dangerous.

4.    If you see something you don’t understand about the medicine please SPEAK UP. ASK! Mail-order pharmacies tend to discourage people questioning things. By not asking questions you are passing up an opportunity to discover a mistake before it gets to you.

5.    Insist on 90-day supplies from your doctor for your regular medicines. This limits the number of times a pharmacy is filling your prescriptions and reduces the possibility of an error,as you get only 4 or 5 refills a year instead of 11 or 12..

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How To Fight Athlete’s Foot Fungus and Win

Q:        My husband has battled athlete’s foot for years. Is there something he can do or use to get rid of it for good?
Your husband has a lot of company out there. Nearly 1 out of every 5 Americans have some type of fungus infection of their skin or nails, and the most common type is athlete’s foot. Athlete’s foot is caused by a type of fungus called tinea. The medical name for the infection is determined by the affected area, for example, tinea of the feet is called tinea pedis or “athlete’s foot” and tinea of the groin is called tinea cruis or “jock itch.

Fungus like the tinea organisms love warmth, moisture, and darkness. People who wear tight shoes and whose feet sweat a lot make it much easier for tinea to get established and reproduce. Not drying between your toes after bathing or showering encourages tinea to spread across toes, nails and even from one foot to the other.

In order to contract athlete’s foot the tinea fungus has to find a way to get into your skin and set up camp. Getting blisters on your feet or cracks in the skin between your toes is an open invitation. Taking good care of your feet and keeping the skin of your feet intact can help keep you from getting infected in the first place.

If you already have athlete’s foot, what can you do? The most important thing is to make it as difficult as possible for the fungus to multiply, discouraging it to spread and making it easier for anti-fungal remedies to kill it off.

The biggest opportunity to make a difference in your husband’s athlete’s foot symptoms is to decrease the amount of moisture next to his feet. People who sweat a lot or who are in contact with wet clothing for long periods of time are much more likely to get fungal infections like athlete’s foot (tinea pedis) or jock itch (tinea cruis).

How can he keep his feet dry? One way is to wear sandals with open toes if at all possible. Feet that are open to the air don’t tend to sweat as much and the sunshine on their feet also discourages the growth of tinea.

Wearing loose shoes and changing his socks frequently will also help keep his feet drier. Some people prefer wearing running socks designed to wick moisture away and reduce getting blisters. Putting powder on his feet before he puts on his socks also helps absorb moisture.

Which remedies are best to treat athlete’s foot? There are several effective options that don’t require a prescription. My personal recommendation is terbinafine 1% gel. It used to be prescription only but now is available over-the-counter (OTC) as Lamisil AT® gel. You can also buy it as the cream, but I prefer the gel because it is less moisturizing than the cream.

When you go to buy an anti-fungal product because the company that sells Lamisil® AT gel has several anti-fungal agents sold under the Lamisil® name, not just terbinafine. Lamisil AF® cream contains the anti-fungal clotrimazole, Lamisil AF® powder aerosol contains the anti-fungal miconazole, and Lamisil Ultra® cream has butenafine. Another anti-fungal, tolnaftate, is available both as a generic and as the brand name Tinactin®.

Here are 4 Tips to treating Athlete’s foot successfully:

1.    Before applying the anti-fungal product, dry your feet well, especially between your toes.

2.    Apply the gel or cream to the affected area twice a day for a minimum of two weeks, until your symptoms completely go away. Don’t use powder by itself because it’s not powerful enough to eradicate the fungus. If your symptoms don’t completely resolve then continue treating twice a day and keep your feet as dry as possible. Wearing sandals without socks can be very helpful.

3.    Once your symptoms disappear continue treating twice a day for another two weeks. This is very important because it helps make sure the fungus gets completely shed out of your skin. If you leave any tinea fungus inside the skin layers of your feet they can start multiplying and before you know it you’ll be right back where you started.

4.    Once your athlete’s foot symptoms have gone and you’ve treated it for 2 MORE weeks, THEN switch to your maintenance program. Using a powder or spray powder 1-2 times a day helps control moisture as well as discourage the fungus from coming back.

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Does Drawing Salve Really Work?

Last week my phone rang as I was cleaning up the dinner dishes. Picking it up, I heard my neighbor’s voice on the other end. “Hi, Jerianne. How’s it going?”

“Fine, Louise. This is going to sound odd, but I was calling to see if you might happen to have some drawing salve I could borrow.”

“Actually, I DO. I found it when I was clearing out my Dad’s medicine cabinet a couple of years ago and kept it because I’d never seen a tube of drawing salve before. It has ichthammol in it. Is that what you’re looking for?

“Yes, exactly! Joe and I were in Mexico last week and today he noticed a red, swollen bump behind his left knee. It looked to me like some sort of tick embedded in his skin, so I used tweezers on it. I pulled some of it out but there are still some black things sticking out, maybe its legs? Ugh! We’re going to the doctor tomorrow but I wanted to put some drawing salve on it tonight to help the swelling and redness. Can I borrow your salve?”

“Sure. Come on down.”

Five minutes later I handed over my half-used tube of ichthammol, NF ointment. “Let me know how it works for you, okay?”

I’d kept that beat up tube of dark stinky ointment because you just don’t see that stuff much any more, and I wanted to find out more about it.

What does “drawing salve” do? The purpose of a drawing salve is to help a boil to come to a head so it can be drained. Another use is to “draw” splinters or other small foreign objects up to the surface of the skin where they can be removed by tweezers. Drawing salves are usually dark and often stinky. You put a small amount of a dark, stinky, and sticky ointment on a bandage then apply it to the area right over the splinter or boil, leaving it on overnight and reapplying if needed in the morning.

My neighbor was looking for ichthammol or ichthyol, which she was familiar with from her experience growing up around horses. Today when people talk about using drawing salve they mean an ointment containing ichthyol or ichthammol.

Ichthyol was discovered in the 1880s from shale deposits found around the Tyrol region of the Alps. Layered between the veins of this shale are layers of rock decorated with dramatic and detailed fossils of animals and fish. Called “oil-stone” or “stink-stone”, Rudolph Schroter found that when crushed and combined with steam, the shale, also called “oil-stone” or “stink-stone produced a distinctive oil high in sulfur. Schroter named the oil Ichthyol, or “fish oil” from ichthys, the Greek word for fish because of the beautiful and detailed imprints of fossilized prehistoric fish in the rock formations that surrounding the veins of shale.

Ichthyol became a major success. In the late 1880s Dr. Paul Gerson Unna, a famous German physician used ichthyol extensively in his remedies for skin problems. Ichthyol contains approximately 15% sulfur and has anti-inflammatory and anti-infective properties. Applied as an ointment, it softens the skin, allowing splinters and boils to come to the surface more easily.

Ichthyol is still mined and produced by the Ichthyol Company of Hamburg and used today, but under different names. The most common are ichthyol, ichthammol, ammonium bituminosulfonate and ammonium bituminosulfate. My old tube contains ichthammol USP, which is made by mixing ichthyol oil with a small amount of lanolin then combining that mixture with petroleum jelly or white petrolatum to make a 20% ichthammol ointment.

Jerianne called a couple of days later, thanking me for letting her borrow my ichthammol ointment. She’d put a dab of the smelly ointment on a Band-Aid® then applied it to the inflamed area behind Joe’s knee. When she peeked at it the next morning the redness was totally gone and the swelling had nearly disappeared. The doctor removed the rest of the mysterious bug parts and it was healing well.

You can find ichthammol ointment at your local veterinary supply or on the internet. Rite-Aid has its own house brand of ichthammol ointment, which also works well. It isn’t a commonly used product these days, so if you don’t see it on the shelf, ask the Rite-Aid pharmacist if he or she can special-order a tube for you.

Watch out for ointments from China. There is ammonium bituminosulfate from China that does not contain ichthyol or ichthammol and doesn’t seem to work as well, either. The real stuff is dark reddish brown and smells like fresh asphalt.

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Which is the Best Antihistamine For You?

Q: Every summer my nose runs and my eyes itch from my allergies. Claritin® has worked for me in the past but for some reason this year is different. I tried Allegra®, but it’s not helping, either. What other antihistamines could I try?

Antihistamines work by keeping histamine locked away inside your body. Histamine is a compound that triggers inflammation and is stored in special cells in your body called mast cells. When you come in contact with something you’re allergic to, your mast cells open up, spilling out histamine and triggering the symptoms we associate with an allergic reaction: stuffy or runny nose, itchy eyes and sinus pressure.

Because they work by preventing histamine from escaping from your mast cells, antihistamines work best if you take them at least 1 hour BEFORE being exposed to what sets your allergies off.
Which antihistamine you should try depends on which one will work best for you and how drowsy it makes you. There are 2 main categories of antihistamine medicines to choose from: sedating ones and non-sedating ones. The sedating antihistamines are older drugs that often cause drowsiness and dry you out. This drying action can actually help relieve your runny nose and watery eyes. Newer antihistamines don’t drowsiness but may not be as effective at drying up a runny nose.

Some antihistamines relieve allergy symptoms better with some people than with others. Many people have to try more than one before they find the one that works best for their allergy symptoms while causing the least drowsiness.

How important to you is avoiding drowsiness? Older antihistamines cause at least some drowsiness in most people. If this is a concern for you, start with the newer antihistamines because they cost little to no drowsiness.

One of the best antihistamines to try first is loratadine, also known as Claritin® and Alavert®. It’s taken only once a day, and rarely causes drowsiness. If loratadine isn’t helping you, another newer non-sedating antihistamine is Allegra®, or fexofenadine, available in either twice a day or once a day versions.

If either of those is not working for you, try cetirizine (Zyrtec®). It’s more likely to cause you some drowsiness compared to Claritin® or Allegra® but because it’s more drying than either of them it can help dry up your runny nose. You only have to take it once a day and it causes minimal drowsiness.

If Claritin®, Allegra® or Zyrtec® aren’t giving you enough relief, you can try one of the older sedating antihistamines. The most powerful is Benadryl® also known as diphenhydramine. It helps with serious allergic symptoms but will cause drowsiness in most people. In fact, you can buy diphenhydramine as a sleeping pill without a prescription as Tylenol PM® or Sominex II. Benadryl® needs to be taken 3 to 4 times a day for best results. Some people take it just at night and substitute another antihistamine during the day.

There are other older antihistamines still available, including chlorpheniramine, brompheniramine, and triprolidine. Triprolidine causes less drowsiness than the other older antihistamines and seems to have the most drying action as well. Surgeons used to avoid having their nose drip while doing surgery. Its main drawback is that it’s only available as Actifed®, a combination with the original formulation of Sudafed®. I really like how effective it is for runny nose, watery eyes and nasal congestion.

4 Tips on how to choose an antihistamine:

1. Take a dose of your antihistamine BEFORE you come in contact with what you are allergic to, if possible. That way you’ll get better results than if you wait until your nose stuffs up and your eyes start itching.

2.  If you have to drive or use machinery, choose one of the newer non-sedating antihistmines like loratidine (Claritin®), fexofenadine (Allegra®) or cetirazine (Zyrtec®) first.  Everyone is a little different in how they react to a medicine.

3. If your first antihistamine choice doesn’t help you, try another one. It’s not unusual to get good results with one yet very little relief from another.

4. An antihistamine can be purchased as a single agent or combined with other medicines, like a decongestant. I recommend you avoid the Sudafed PE® that is sold on the shelf which contains phenylephrine because it is not as effective as the original formula of Sudafed® containing pseudoephedrine. If you need a decongestant for a stuffy nose I recommend the original version of Sudafed®, available from your pharmacist.  You will need to bring photo identification to purchase it. Triprolidine/pseudoephedrine (Actifed®) is a good choice for runny and stuffy nose symptoms.

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