Archive for the ‘Medicine’ Category

How To Take Your Thyroid Medicine

Q: My husband takes a thyroid medicine called levothyroxine. He went to his doctor last week because he’d been feeling tired and the doctor told him it’s because he’s taking his thyroid pills wrong. All these years he’s taken it with his other morning pills at breakfast, but now he’s supposed to take it 30 minutes BEFORE his breakfast instead. He’s tried to make the switch but it’s really hard for him to remember to take it first thing in the morning. Is there anything we can do?

Levothyroxine is a very potent medicine; even small changes in the dose can create big differences in how much energy you have. How much levothyroxine you need can depend not only on how much medicine is prescribed by your doctor, but also on HOW you take those pills. Your husband may not be getting the entire dose of his thyroid medicine because food can interfere with the ability of levothyroxine to get into your body.

Like most medicines, in order to do its job levothyroxine must first get into your body. It needs to jump from a pill sitting in an amber prescription bottle all the way into your thyroid gland, where it works to support your metabolism and give you energy.

When you swallow a pill it doesn’t magically dissolve in your stomach and do its thing right then and there. Most medicines need to get into your bloodstream first before they can get to where they need to go and do what they are supposed to do. Although your pills dissolve in your stomach they can’t jump into your body from there. Instead, medicines and nutrients have to leave your stomach and move into your small intestine before they can be launched into your body.

Your small intestine is a busy place. Its walls are covered with blood vessels and specialized cells designed to transport nutrients and medicines into your bloodstream, where they get carried on throughout your body and delivered to where they need to be, like levothyroxine going to your thyroid gland.

The process of medicine going from a pill you swallow to entering your bloodstream is called absorption. Some medicines are better at being absorbed than others. While many medicines are completely absorbed after you take them, other medicines like levothyroxine can run into trouble along the way, resulting in less of it getting into your body and doing its job.

Your husband will get more consistent results from taking his levothyroxine on an empty stomach because food and certain minerals can attach themselves to it and prevent it from making the trip through the wall of his small intestine into his bloodstream and on to his thyroid gland.

But the most important thing of all is taking it consistently, every day, the same way. His doctor will use blood tests to adjust his levothyroxine dose if he needs more.

Here Are 5 Tips For Best Results When Taking Levothyroxine:

  1. Levothyroxine is absorbed best on an empty stomach, either AT LEAST 30 minutes before a meal OR 3-4 hours after you’ve finished eating.
  2. If you have trouble remembering to take your levothyroxine first thing in the morning, try taking it at bedtime instead, as long as it’s been at least 3 hours since your evening meal. Taking it at bedtime may be easier to remember than taking it all by itself in the morning, especially if you take other medicines at the same time.
  3. If you forget to take your levothyroxine before breakfast, go ahead and take it anyway. Don’t worry, your stomach is not going to blow up, your intestines are not going to fall apart and your thyroid is not going to die. If you take levothyroxine with your meal you may not absorb the whole dose but if you skip entirely it you won’t get ANY of it absorbed! And that’s worse.
  4. If trying to take levothyroxine on an empty stomach is too complicated to do, don’t panic. It’s perfectly okay to take levothyroxine with your breakfast or other meal, as long as you take it that way all the time. Many patients are perfectly successful taking levothyroxine because they ALWAYS take it with their breakfast and don’t skip any doses.
  5. If you take calcium or iron supplements, don’t take them at the same time as levothyroxine. These minerals can significantly reduce the amount of levothyroxine that you absorb, so it’s best to separate them by at least 3-4 hours.


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Choosing a Medicine for Your Aches and Pains

Q: There are so many choices out there for aches and pains. Which medicine is best for me?

When you have mild to moderate pain like a headache, sore muscles or aching joints there are 4 pain medicines you can buy without a prescription: aspirin, acetaminophen (Tylenol®), ibuprofen (Advil®), and naproxen (Aleve®). Which one should pick?

Aspirin is the oldest of these four options and is available in two strengths: low dose or “baby” aspirin which are 81mg each and the adult dose of 325mg, which is exactly 4 times the 81mg dose. Many Americans take one aspirin a day to prevent heart problems because of how it works as a blood thinner. If you take any prescription blood thinner medicine like Plavix®, warfarin (Coumadin®), or one of the newer ones advertised on the television, don’t take more aspirin for relief of your headache pain. Since aspirin can upset your stomach it’s best to take it with food or a full glass of water.

Whether sold as Tylenol® or by its generic name acetaminophen, Tylenol® is the most popular and common painkiller sold in America. Although it is safe enough for kids to take, Tylenol® has a dark side: taking too much acetaminophen is deadly to your liver. Being available in over 200 different non-prescription products the popularity of acetaminophen makes it dangerous because its so easy to get too much.

If you take a prescription pain medicine you may already be getting acetaminophen. Look for the abbreviations APAP or ACET on the prescription label, or ask your pharmacist. If you have liver disease, don’t take Tylenol® until you talk to your doctor about whether taking it is safe for you and how much you can safely take for pain.

The other two pain relievers available without a prescription are closely related to each other and also to aspirin. Ibuprofen and naproxen were originally only given as prescription medicines, but now they are available in non-prescription products in addition to their stronger prescription doses. Aspirin, naproxen and ibuprofen relieve muscle aches and swelling better than acetaminophen and belong to a group of medicines called NSAIDs, or non-steroidal anti-inflammatory drugs.

When taking ibuprofen, also known as Advil® or Motrin-IB®, or its close cousin, naproxen, sold as Aleve® be careful to take it with food to avoid stomach pain and bleeding. NSAID medicines can also damage your kidneys, especially if you have kidney problems or take it when you are dehydrated.

Taking too much of an NSAID is particularly dangerous because it can cause stomach bleeding and kidney failure. In addition to the non-prescription NSAID remedies there are several prescription NSAIDs commonly prescribed. Ask your pharmacist if you are already taking a prescription-strength NSAID and if you are, avoid taking the non-prescription versions.

7 Tips for Taking OTC (over-the-counter) Pain Relievers Safely:

  1. For aching muscles and swelling, ibuprofen or naproxen usually works better than acetaminophen. Some people get more relief with one or the other. Ask your pharmacist before taking ibuprofen or naproxen to make sure that you’re not already getting a prescription product doing the same thing.
  2. Avoid taking an NSAID if you already take a blood thinner. Taking 81mg of aspirin daily is ok, though. Ask your pharmacist if you aren’t sure if you are on a blood thinner medicine.
  3. Watch out for taking too much Tylenol®. Healthy adults can take up to 4 grams per day, or the equivalent of 8 tablets of extra-strength acetaminophen. Older adults are should limit their Tylenol® use to 3.1 grams daily, or 6 tablets of extra-strength Tylenol®. If you take a prescription pain reliever ask your pharmacist to find out if it has acetaminophen in it, and how much.
  4. If you take aspirin daily for your heart, talk to your doctor o pharmacist before taking it for pain relief. It’s safer to take Tylenol® or another NSAID like naproxen instead.
  5. You can take both acetaminophen and an NSAID for pain at the same time, as long as you don’t take more than is safe for you. Your pharmacist is a medication expert and can advise you as to which one is best for you.
  6. If you have kidney disease avoid taking ibuprofen or naproxen for mild to moderate pain, and make sure that you stay well hydrated when taking either one.
  7. If you have liver disease, ALWAYS check with your doctor before taking Tylenol® or acetaminophen.


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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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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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Your Medicine and the Sun

It was a beautiful sunny midsummer afternoon, perfect for feeding the ducks. My seven year-old niece Crystal was staying with me, and after finishing our lunch of grilled cheese sandwiches and tomato soup, I loaded my backpack with water and a bag of old bread scraps before setting out for the duck pond at a local park.

Crystal tossed the first bread bits as far as she could. Soon the ducks swam over to gobble up the floating treats, creating squawking competition for each bit of bread. Laughing, she continued pitching the rest of the bread piece by piece into the quacking crowd. Once the bread was gone we headed for the swings, pumping our legs to carry us higher and higher into the cloudless sky.

“Aunt Louise, I feel hot. ”

“Let’s head for that big tree over there, and I’ll get you some water.”

Opening my pack, I fished out a water bottle and turned around to offer it to Crystal, nearly dropping it in shock when I saw her flaming red cheeks and arms. Heading back home, I kept thinking, “She had sunscreen on, so how could she have burned so quickly?”

Once we got home, I zipped into the kitchen to get a damp towel for Crystal’s face. Sitting right next to the sink was her prescription bottle of antibiotic. I’d given Crystal her morning dose right after breakfast and then left it out on the counter to remind me to give her next dose at dinner. Could her medicine have caused her to burn even through her sunscreen?

When my brother had dropped Crystal off the day before I had focused on the dosing instructions printed on the label of her bottle but overlooked the small yellow sticker over on the side that warned about exposure to sunlight. Luckily, her “burn” faded by dinnertime, but I’ve never forgotten how scared I felt.

Exposing our skin to sunshine causes our skin to react, either by “tanning” or “burning”. Sunlight contains ultraviolet radiation; there are wavelengths called UVA and UVB that can trigger skin reactions like rash, itching and even exaggerated sunburn. These effects are called photosensitivity reactions.

Sunburn, skin cancer and accelerated skin changes such as wrinkles and spots called photo aging are caused mostly from exposure to UVB radiation. UVB rays are most intense between 10 in the morning and 4 pm, and help our skin produce Vitamin D. UVA radiation triggers photosensitivity reactions in people taking certain medicines, like Crystal. Normal sunlight has approximately 20 times as much UVA radiation as UVB. Because UVB radiation causes more sunburn, 96% of the rays from tanning beds are UVA wavelengths.

Crystal’s antibiotic increased the sensitivity of her skin to the UVA wavelengths in the sunshine we played in that July afternoon. Back then; the sunscreen she wore protected her against UVB rays, which can cause sunburn, but not against UVA wavelengths, which can trigger photosensitivity skin reactions. Today’s sunscreen products are formulated to protect against BOTH UVA and UVB radiation.

The measure of how much protection a sunscreen product gives is called its SPF (Sun Protection Factor). The bigger the SPF number, the better the protection. For example, if you properly apply a sunscreen with an SPF of 15, you could stay out in the sun 15 times as long without burning as you could without it.

Sunscreens come in two main types: chemical and physical. Chemical sunscreens work by absorbing specific wavelengths of UV radiation before they penetrate your skin, while physical sunscreens reflect and scatter UVA and UVB radiation. The lighter your skin, the more quickly it can burn and the more protection you need.

4 Tips for Taking Medicines That Can Cause Sun Sensitivity:

  1. AVOID tanning beds or going outside into direct sunlight until you finish the medicine. When going outside during the day, cover up with long sleeves and a hat with a brim at least 4 inches wide, or apply sunscreen with UVA and UVB protection.
  2. Apply sunscreen at least 15 minutes before you expect to be outside in the sun. To be most effective, sunscreens need time to bind to your skin.
  3. Don’t skimp when applying sunscreen. The FDA estimates an adult in a swimsuit should use about 4 and 1/2 teaspoonfuls when applying sunscreen to their whole body.
  4. Reapply your sunscreen frequently, especially after swimming, playing in the water or sweating. And don’t forget to reapply sunscreen after drying yourself off with a towel.

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Medication Safety: Question Everything

One of my favorite videos is of a backyard July 4th fireworks display gone wrong: a little dachshund runs up to a lighted Roman Candle, grabs it in its mouth and runs around as fireworks shoot out sideways from the burning tube, scattering the watching crowd. Sometimes getting a new medicine can go sideways on you…

Jane is an 86-year-old just home from the hospital after not being able to catch her breath. At the hospital the doctor diagnosed her with congestive heart failure and changed her water pill to a stronger one to help keep the fluid out of her lungs. She was given a list of her medicines when she was discharged back home and the new medicine was on it, but when I saw her the next day she was starting to have trouble breathing again. Checking her pill bottles, I noticed that she had a new prescription for her old water pill instead of her new one.

“This isn’t the medicine that your hospital paperwork shows you should be taking.”
“I know, but when I asked the pharmacist about it he said that they filled the prescription with exactly what was called in for me. I thought maybe the doctor changed her mind.”
“Maybe. Let me check.”

Calling the pharmacy, I spoke to the pharmacist and discovered that her prescription wasn’t faxed to them but instead was called in.

“Was it called in by the doctor?”
“No, by a nurse at the hospital.”

I then called the doctor who’d prescribed Jane’s new medicine and asked, “Did Jane’s water pill get changed from torsemide back to furosemide?”

“No! I want her taking torsemide, not furosemide. Why?”
“Well, the nurse on the floor called in the new prescription as furosemide. Do you want me to send a new prescription for the torsemide?”
“Yes, please!”

If Jane had taken her paperwork to the pharmacy and showed it to the pharmacist, they wouldn’t have assumed that the doctor changed her mind but instead contacted the doctor to clarify the prescription. Instead, Jane almost ended up back in the hospital with the wrong medicine. She questioned it, but without having the paperwork with her to show the pharmacist, she just assumed the doctor changed it back and accepted the wrong medicine.

Then yesterday, 56 year-old Marjorie came in a for a blood thinner check. She’d gone to the emergency room the previous day with one side of her mouth drooping and trouble talking. Luckily, she got better and the doctors diagnosed a TIA, or transient ischemic attack, due to her blood thinner level being way too low.

“Marjorie, your chart shows that I increased your warfarin dose last week, and changed the tablet size, too. But you’re taking the same dose you were on before.”
“I thought we had changed my dose, but when I picked up my new bottle at the pharmacy the label and tablets inside were different than what you’d told me. I thought you’d changed your mind, so I took it the way the label said.”

When I called Marjorie’s pharmacy they insisted they’d never received any new prescriptions for her, so they refilled her current prescription, which was now the old tablet size and old directions.

“Marjorie, let’s fix this before you really DO have a stroke.”

These days, doctor’s offices send most prescriptions by electronic fax, which records it directly into the patient’s medical chart. Most of these faxes arrive, but when they don’t, it STILL looks like they arrived just fine. With an electronic fax there’s no way to tell the difference between one that arrived at its destination and one that didn’t. I sincerely believe that there’s a black hole in our universe, randomly sucking innocent electronic faxes traveling between doctor’s offices and pharmacies, causing medication mishaps and mayhem.

Here are 3 ways you can protect yourself against your medications going sideways:

1. Make a list of your medicines and update it with any additions and changes. Take it with you whenever you go to the doctor, the hospital, or your pharmacy.

2. If a doctor or other medical provider changes your medicine, get it in writing. Keep this with your current list of medicines and take it to the pharmacy when you pick your prescriptions in case there’s a discrepancy.

3. PLEASE ASK QUESTIONS! Question anything that doesn’t look right to you. With so many people involved and a fax-sucking black hole loose in the universe, omissions and misunderstandings can easily affect your medications. Speak up and question anything that doesn’t look right. Your health and safety may well depend on it.

And watch out for wiener dogs running with fireworks…

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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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