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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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Topical NSAIDs for Aches and Pains

December 5th, 2016. Filed Under: Uncategorized.
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Q: I’ve taken Aleve® or Motrin® for years for my bad knee, but now my stomach burns whenever I take them. My doctor tried me on Celebrex®, which didn’t burn my stomach but didn’t work for me. I’ve already tried Icy-Hot® and capsaicin but they burn my skin. Are there any other creams that could help my joint pain?
Yes. Motrin®, also called ibuprofen, is related to Aleve® (naproxen) and Celebrex® (celecoxib) which are Non-Steroidal Anti-inflammatory Agents, or NSAIDs. In the United States most people take NSAIDs by mouth as tablets, but in the UK and Europe they have used NSAID creams, gels, ointments and sprays for many years.

NSAIDs are very good at treating most types of swelling and pain, whether from a sudden injury like a muscle sprain or strain or a chronic inflammation such as arthritis. Using an NSAID cream or gel directly to your sore muscle or joint can relieve pain and inflammation without the side effects that NSAIDs often cause, like stomach burning, stomach pain, kidney or heart problems. For people who take a blood thinner, using a topical form of NSAID helps avoid an increased risk of bleeding.

You are not alone in noticing side effects from taking an oral NSAID like Aleve® or Motrin®. Many Americans with ulcers, kidney or heart problems could benefit from using an NSAID instead of a dangerous narcotic pain reliever. Sadly, diclofenac is the only commercially available topical NSAID in the United States and it requires a doctor’s visit for a prescription.

With so many other NSAIDs available, why is diclofenac the only one marketed in United States as a cream, gel or spray? I suspect the pharmaceutical companies haven’t bothered to develop or market topical versions of their NSAIDs in America because there’s not enough patent protection to make it profitable.

Another roadblock to the availability of topical forms of NSAIDs is whether it can penetrate the skin. Grinding a medicine up into powder and adding it to a cream or ointment doesn’t guarantee that enough of it will merrily move through the skin to cause a measurable decrease in pain. In some cases, the drug company has decided that the topical version of their NSAID medicine isn’t effective enough to justify the huge investment needed to pursue approval from the Food and Drug Administration (FDA).

Some topical NSAIDs have been shown to ease the acute pain of sprains and strains as well as the chronic pain of osteoarthritis. In September 2012 the Cochran Institute published a review of multiple studies called a meta-analysis on this topic, called Topical NSAIDs for chronic musculoskeletal pain in adults. They collected and evaluated lots of studies done with topical NSAIDs, many of them unpublished work from the files of drug companies. Two NSAIDs stood out as effective in chronic musculoskeletal pain: diclofenac and ibuprofen. Not only that, but diclofenac was shown to be just as effective applied to the skin as in a pill form, and with minimal side effects. Both ibuprofen and diclofenac gel are available without a prescription in the UK and Europe.

While visiting Germany a couple of years ago, I saw Voltaren® gel advertised in the windows of several Apotheks (German pharmacies). The day before we flew home I stopped at a busy Apothek to see if I could purchase some Voltaren®. Pointing at the boxes of gel displayed in their window, I rubbed my elbow and stammered, “Voltaren®, bitte?”

With our daughter Maureen translating, I discovered from the German pharmacist that generic ibuprofen gel had been available in Germany for over 10 years, and neither it nor the Voltaren® gel in the window required a prescription. I walked out triumphantly clutching a tube of each. Too bad the patient information leaflet inside the box was only printed in German.

You can get topical diclofenac in the U.S. in several formulations and brand names, but it is expensive and available only by prescription. Diclofenac comes as Voltaren® 1% gel, applied 4 times daily; Pennsaid® 1.5% solution, applied 3-4 times daily; Pennsaid® 2% solution in a pump applied twice daily; and Flector® 1.3% as a patch applied twice daily. It’s also available as Solaraze® 3% gel for rosacea.

Now, here’s some good news: Voltaren® gel is now available as a generic! This usually means it costs less and will be added to most prescription insurance plans. Check with your doctor for a prescription for generic Voltaren® (diclofenac) 1% gel for your knee pain.

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How To Select An Expectorant

November 28th, 2016. Filed Under: Uncategorized.

When I was at my hairdresser’s last week, he asked me, “I was at the grocery last week looking for Mucinex® but instead of just a couple of choices, I found a whole section of it, all saying Mucinex® on the box! How do I pick the one that’s best for me?”

The original Mucinex® tablets are still out there, containing only one ingredient: guaifenesin, pronounced gweye-FEN-ah-SIN. Guaifenesin works as an expectorant and has been sold for decades as the main ingredient in Robitussin® cough syrup.

Guaifenesin was developed by the A.H. Robbins company in 1949 and introduced as a prescription cough syrup called Robitussin®. By the time I graduated from pharmacy school 30 years later in 1979, Robitussin® was the most popular prescribed cough medicine in the country, with various formulations like Robitussin PE, Robitussin AC, and Robitussin DM. Whether alone or combined with a decongestant, an antihistamine or a cough suppressant, Robitussin was a best seller both as a prescription and non-prescription cough medicine.

Guaifenesin an expectorant. It works by increasing the fluid in your sinuses, throat, and lungs, to help liquefy sticky phlegm and mucus so that you can cough it up and out. Although they are both called cough medicines, an expectorant works differently than a cough suppressant. Cough suppressants dampen down your cough, helping you get much needed rest at night but don’t deal with stubborn gunky phlegm like an expectorant can.

Eventually guaifenesin moved beyond just Robitussin® syrup and as tablets it was sold as the prescription medicines Entex®, Entex LA®, and Entex® PE, a combination of guaifenesin and pseudoephedrine (Sudafed®). These were very popular in relieving symptoms of throat and lung congestion and sinusitis. When the patent protection on them expired, the company applied to the Food and Drug Administration (FDA) to sell the exact same formulations over-the-counter, and Mucinex® and Mucinex-D® were born.

Adding a decongestant to guaifenesin can help with sinusitis and a stubborn, non-productive cough. Mucinex-D® is the non-prescription equivalent of Entex® PE. It’s available right next to the original Sudafed®, and like Sudafed® you’ll need to sign for it.

Robitussin® and Mucinex® each contain guaifenesin. So, which one should you choose? Robitussin® cough syrup contains 100mg/5ml or 100mg per teaspoonful, while Mucinex® has 600mg per tablet and Mucinex® Maximum Strength has 1200mg in each tablet. Robitussin liquid is designed for children over the age of 2 up to age 12. The adult dose of guaifenesin of 1200mg to 2400mg per day is best supplied by taking tablets of Mucinex®.

Mucinex® tablets are available both as short acting and long-acting forms. I recommend buying the 600mg long acting tablets which last 12 hours. Some people get queasiness at the higher doses, so I suggest you the 600mg tablets so you can see which dose is best for you.

If you need an expectorant, avoid Mucinex® Allergy! One of the reasons there are so many products with Mucinex® on them is that companies often take advantage of the familiarity of popular brand names and use those names on related and sometimes even completely unrelated products. This is called “extending the product line” and can create lots of confusion. Mucinex Allergy® doesn’t have any guaifenesin in it at all. Instead it has fexofenadine, the same antihistamine found in Allegra®.

Here are 5 tips when selecting an expectorant:

  1. Mucinex® contains an expectorant, not a cough suppressant. Expectorants work by increasing fluid in your sinuses, throat and lungs to help liquefy thick sticky mucus, but don’t dampen a cough. If you need to cough less, take a cough suppressant instead, like dextromethorphan (Delsym®).
  2. When you have a cough or cold, drink plenty of fluids to help liquefy your secretions. If you suffer from stubborn thick mucus in your throat or lungs, Mucinex® can help thin and liquefying that sticky phlegm, helping you cough it up and out of there.
  3. Adding a decongestant like pseudoephedrine (Sudafed®) to an expectorant like guaifenesin can to help it work even better. I recommend choosing Mucinex-D®, which you’ll need to sign for at the pharmacy counter.
  4. Avoid Mucinex Allergy® unless you have allergies; it doesn’t have an expectorant in it and so it can’t help relievebyour dry cough.
  5. The best Mucinex® to start with is the 600mg long-acting tablets. Use 1-2 tablets every 12 hours. If your stomach bothers you, decrease the dose.



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Do You Need a Vitamin E Supplement?

November 14th, 2016. Filed Under: Uncategorized.

Vitamin E is a fat-soluble vitamin that helps protect your cells from damage. It does this by acting as an antioxidant. Antioxidants counteract the damage to your cells caused by compounds called free radicals, which are produced in your body during metabolism. Free radicals are very reactive compounds. They move around and interact with your cells in ways that can cause cancer, cataracts, heart disease or stroke.

With the 3 leading causes of death in America heart disease, cancer and stroke, there’s lots of interest in finding ways to decrease the risk of these, including reducing the negative effect free radicals have on your cells, either by generating fewer free radicals or increasing the antioxidant compounds available to counteract them.

Would supplementing with Vitamin E, an antioxidant, protect your cells and help reduce the incidence of these 3 top killers? Unfortunately, the results of carefully designed clinical studies clearly show that Vitamin E supplementation does not provide any clear benefit and in fact is associated with an increased likelihood of either dying, having a stroke caused by bleeding into the brain, or developing prostate cancer.

How much Vitamin E do you need? The National Institutes for Health (NIH) recommends that adults get 22.5 International Units (IU) of Vitamin E daily. Although most Americans get only about half that amount from their diet, Vitamin E deficiency is not very common. Vitamin E needs fat for it to be well absorbed, so eating a very low fat diet or having a disease that interferes with digestion or absorption of fat such as Crohn’s disease or cystic fibrosis can increase your risk of being deficient in Vitamin E. Vitamin E deficiency may cause nerve and muscle damage with numbness in your arms and legs, muscle weakness, vision problems and reduced effectiveness of your immune system.

Should you take a Vitamin E supplement?

There are 2 common forms of Vitamin E: alpha-tocopherol and gamma-tocopherol. Vitamin E as alpha-tocopherol exists in higher concentrations in the body than its cousin gamma-tocopherol, and until recently was assumed to be responsible for Vitamin E’s antioxidant effects. Most multivitamins include 30 IU of Vitamin E as alpha-tocopherol, considered to be 100% of the daily requirement for adults by the NIH. High dose Vitamin E supplements of 400 IU contain over 13 times that amount.

While alpha-tocopherol is found in vitamin supplements, gamma-tocopherol is found in foods rich in Vitamin E such as nuts, seeds, oils and green leafy vegetables such as spinach and broccoli.

Recent research has uncovered evidence that the key to the antioxidant potency of Vitamin E is the level of gamma-tocopherol in the tissues and blood, not the amount of alpha-tocopherol. Taking a supplement of alpha-tocopherol will actually DECREASE the level of gamma-tocopherol, suppressing Vitamin E’s beneficial antioxidant action. This may explain why alpha-tocopherol supplements have produced negative instead of positive results in controlled research studies.

One study where Vitamin E supplementation helped is the Age-Related Eye Disease Study, or AREDS. In the 5-year study, a formulation of Vitamins A, C and E combined with zinc and copper including 400 IU of Vitamin E was used. The most severely affected study participants showed a 25% decrease in the progression of age-related macular degeneration (AMD), a common cause of blindness in the elderly. However, for those with mild or no AMD, there was no benefit.

Most Vitamin E supplements contain alpha-tocopherol as either the natural form (d-alpha-tocopherol) or synthetic form (dl-alpha tocopherol). The main difference between them is their potency. The natural (d-alpha-tocopherol) form is 1.5 times as potent as the synthetic (dl- alpha-tocopherol) form. Gamma-tocopherol Vitamin E supplements are now available but it’s too early to know if they can prevent cancer, stroke or heart disease where the alpha-tocopherol form could not.

Should you take a Vitamin E supplement?

  1. YES, if you have age-related macular degeneration. The AREDS formulation is proven to help, such as in PreserVision® AREDS. Another supplement recommended by eye care professionals is Ocuvite®. Ask your eye care professional which would be best for you.
  2. NO, if you are taking a blood thinner like warfarin (Coumadin®), aspirin or clopidogrel (Plavix®). Vitamin E supplementation can actually cause bleeding problems in high doses or in people who take blood thinners.
  3. The BEST way to get the antioxidant benefits of Vitamin E is to eat plenty of green leafy vegetables such as spinach and broccoli.

There’s more information about Vitamin E at

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Which Sweetener Do You Prefer?

November 7th, 2016. Filed Under: Uncategorized.

November is National Diabetes Month, reminding me of candy, sweet treats and sweeteners. Reaching for a packet of sweetener for your cup of coffee or glass of iced tea, which color do you look for? White, pink, blue, yellow, or green? You can choose a white packet containing sugar or various colored packets, each with their own sugar substitute.

We also buy foods that contain sweeteners. One study looked at sweeteners in foods purchased by Americans between the years of 2005 and 2009. The researchers tracked the purchase of “uniquely formulated foods”, meaning foods that did not include any raw foods or food with only one ingredient, such as apples or eggs. This study found that 75% of those “uniquely formulated foods” had some type of sweetener added to them. Yikes!

In that study, sweeteners were divided into two types: caloric sweeteners (CS) and non-caloric sweeteners (NCS). The five most common caloric sweeteners found in the “uniquely formulated foods” in order of most common to least common were corn syrup, sorghum, cane sugar, high fructose corn syrup, and fruit juice concentrate. 53% of baby food formulas, 75% of salad dressings and dips and 78% of vegetable juices contained at least one added sweetener.

The non-caloric sweeteners included saccharine, known as Sweet’N Low® and packaged in pink packets, sucralose or Splenda® which is sold in yellow packets, and aspartame or NutraSweet® available in blue packets. Although NCS sweeteners were found in only 1% of foods and beverages, over the course of the study Americans chose more NCS-containing foods and beverages every year. In 2006 Americans selected food products with NCS 13.3% of the time in 2006, increasing to 15.2% by 2009.

Non-calorie sweeteners have been used for decades as food additives and are considered safe. Research published in the October 2014 issue of Nature magazine shows disturbing new information that may challenge that assumption. Samples of three commonly used non-calorie sweeteners and sugar were given to mice. Aspartame, saccharine and sucralose somehow changed the makeup of intestinal bacteria of the mice while sugar had no effect. But the startling finding was the mice that had their gut bacteria change also showed changes in their ability to handle sugar. In the affected mice, their blood sugars rose higher after they ate and dropped back to normal levels much more slowly, a pattern called glucose intolerance associated with an increased risk of becoming diabetic.

When researchers introduced samples of the changed mice’s gut bacteria into normal mice, the new mice’s gut bacteria changed too. And when it did, so did the same pattern of glucose intolerance occurred. Trying the same experiment on a small group of humans, only a few of them showed changes in their gut bacteria. But the ones who did also showed the same pattern of glucose intolerance seen in the affected mice. Although the effect of these sweeteners on gut bacteria doesn’t happen consistently in humans it could explain why switching from using sugar to a NCS have not had consistently helpful effects in weight reduction or controlling blood sugars in diabetics.

Today, new options like stevia and xylitol join older sweeteners like saccharin, sucralose, and aspartame. Stevia is a calorie-free sweetener from a plant native to South America in the crysthanthemum family, related to ragweed. Originally approved as a dietary supplement to improve blood pressure and diabetes control, stevia was approved for use as a food additive in 2008 and is marketed as the sweetener Truvia®. Often blended with other sweeteners stevia also comes as individual servings in green packets.

Xylitol is a low-calorie sweetener extracted from natural sources such as corn. Because of its protective effect on tooth enamel, xylitol is added to sugarless gum and mints and is marketed as a sugar substitute for baking. Xylitol may be a dentist’s friend but it’s a dog owner’s nightmare. Xylitol is deadly to dogs, causing very low blood sugar, liver damage and liver failure. In dogs, eating xylitol triggers their pancreas to dump out insulin, which drops their blood sugar so low they have seizures. There is no safe dose for dogs; even a small amount can be fatal.

What color packet should you reach for to sweeten your coffee or tea? Non-calorie sweeteners, long considered a safe alternative to sugar might actually cause problems in some of us, and xylitol definitely causes trouble for dogs.

You can also check out Kenneth Chang’s post in the New York Times’ blog Well, as he comments about the effects of some artificial sweeteners in humans here:

And if you have dogs as pets, PELASE say NO to xylitol.

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The Orange Juice and Banana Sticker

June 15th, 2015. Filed Under: Uncategorized.

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

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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The Heat of Heartburn

Q: I take a prescription strength stomach acid medicine called Prevacid® which has helped my heartburn a lot. Now my insurance company is refusing to cover it. When I stop it, all my heartburn symptoms come back. What can I do?

Prevacid® is an acid blocking medicine called a proton pump inhibitor, or PPI. Every time you eat or drink something, a miniature pump called a proton pump shoots gastric acid into your stomach to start digesting that piece of yummy apple pie ala mode you just ate. Prevacid® and other PPIs reduce heartburn and help heal stomach ulcers by reducing the amount of gastric acid in your stomach.
PPIs are our most effective medicines for treating excessive stomach acid and are very good at helping heal ulcers. PPIs can even help prevent ulcers. People taking blood thinners like warfarin or Coumadin® together with pain medicines like ibuprofen or naproxen have less problems with bleeding ulcers if they are also taking a PPI.
Twenty-two years ago while taking the very last capsule of an antibiotic called doxycycline, it got stuck. Extra water didn’t help. I could feel a pressure beneath my breastbone right where that darn pill had stuck. Soon it felt like I was swallowing fire every time I ate or drank anything. The pain kept increasing until I ended up in the Emergency Department diagnosed with an ulcer in my esophagus, all because of a pill dissolving in the wrong place!
The ER doctor started me on a prescription medicine called Prilosec®, the very first PPI available and for the next 6 weeks spicy food was off-limits. I glumly ate yogurt while my family enjoyed the Tex-Mex food at my youngest sister Margaret’s wedding in Austin, Texas.
Is it okay to take a PPI year after year?
It seems to be safe to take a PPI for years instead of just months, but there is a price. Absorbing Vitamin B12, iron, calcium and magnesium depends on having a certain amount of stomach acid. Those who take PPIs longer than a few months risk becoming deficient in these critical nutrients. Long-term use of PPIs is also associated with an increase in bone fractures both in men and women, possibly related to absorbing less calcium.
Stomach acid is one of the most important defenses our body has against foreign organisms. Taking a PPI long-term can lead to increased infections such as pneumonia or a particular organism called Clostridium difficile that causes antibiotic-associated diarrhea.
If you’ve suffered from heartburn when stopping your PPI you are not alone. Between 60-90% of folks taking a PPI for at least 3 months notice symptoms of stomach burning when they stop taking it.
Having heartburn symptoms come back when you stop your Prevacid® doesn’t mean you’re stuck on it for the rest of your life.

Here are 3 approaches to reducing your dependence on a PPI medicine:
1.     If your doctor has no objections, slowly taper the dose down over several months before stopping it. If you take your PPI twice a day, start the taper by decreasing or stopping the evening dose. If you take the PPI once a day, taper by cutting the dose in half or taking it every other day. Stay on the reduced dose for several weeks before trying another decrease.
Taper the PPI dose every few weeks until you are off it completely. If your symptoms come back, start with the last dose you were symptom-free and stay on it another few weeks before trying to taper it. For some people this may take up to 9 months.
2.     Switch to an older stomach medicine like Zantac® or ranitidine to help control your symptoms. Called an H2-blocker, medicines like Zantac® work best when taken at night. Taking a PPI in the morning and rantidine (Zantac®) at night can help keep your symptoms under control while tapering your PPI.
3.    If your prescription PPI taper isn’t feasible or successful, you can switch to a PPI available without a prescription such as Prilosec® OTC or Prevacid® 24HR®. Another PPI has just become available over-the-counter (OTC): Nexium® 24HR.
For occasional fast-acting relief of heartburn, antacids like Tums®, Mylanta® and Maalox® are available in liquid form or chewable tablets. These older antacid products often contain calcium or magnesium, which can interfere with absorbing some prescription medicines. Please check with your pharmacist before taking them.

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How Long To Take A Bone Building Medicine?

Q: My doctor wants me to start taking a medicine once a week to strengthen my bones. How long do I have to take it?

Osteoporosis is a disease in which your bones become thin, weak and more likely to break. It directly affects 10 million Americans and threatens nearly 34 million more, according to Amy Porter, Executive Director and CEO of the National Osteoporosis Foundation (NOF), a health organization dedicated to preventing osteoporosis and broken bones though awareness, education and research.

“Osteoporosis now causes an estimated two million fractures each year and can result in immobility, pain, and other health problems”, says Robert Recker, MD, the president of NOF.

My mother died of complications of osteoporosis. She broke her left wrist when she was 73 years old from tripping in downtown Seattle trying to catch a bus. Four years later she broke her right hip in another fall getting up to go to the bathroom in the middle of the night. Her right leg ended up one inch shorter than her left, causing her discomfort and inconvenience for the rest of her life.

In the United States, one out of every two women and one in four men over age 50 will have an osteoporosis-related fracture in their lifetime. Twenty percent of seniors who suffer a hip fracture will die within one year.

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.

Although complications show up in old age, osteoporosis is a disease of thinning bones that starts in childhood. Up to 90 percent of peak bone mass is built before 18 years of age in girls and 20 years old in boys. At menopause bone loss accelerates; the thinner your bones are to start with, the more likely you’ll eventually experience a fracture.

If you have passed menopause or have taken certain drugs, especially prednisone or corticosteroids, you may have thin bones without knowing it. Testing your bone density helps determine how likely you are to have a bone break in the future. If you are at risk, your bone loss can be slowed with medicine. My mother never knew she had thin bones until she broke her wrist. With screening and bone-building drugs available today she may have avoided the hip fracture that shortened her life.

Bone building drugs like alendronate (Fosamax®), Actonel® and Boniva® are called bisphosphonates. These powerful medicines have complicated directions, which is why most women prefer to take them once a week instead of every day. They must be taken with a full glass of water on a completely empty stomach, and you must stay upright at least 30 minutes afterward, no leaning back or lying down allowed.

The reason you need to keep yourself upright and drink a full glass of water is to avoid irritating your esophagus. The empty stomach is also very important because even with the best conditions only 2-3% of the medicine in each tablet will get absorbed into your body.

But what does get in stays in. These drugs become part of your bone cells and continue to work to build bone for you even after you stop the drug.  How long do you have to take this medicine? That depends, and you and your medical provider should decide together. The current evidence is that if you are taking them to prevent a future fracture, five years may be enough. Both alendronate (Fosamax®) and Actonel® are effective in preventing hip and vertebral fractures for up to ten years, even after you have stopped taking them.

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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Pharmacist Recommendations for Osteoarthritis Pain

July 1st, 2014. Filed Under: Uncategorized.

Q: Which products do pharmacists recommend most for osteoarthritis pain?

Because of collaboration between the publications Pharmacy Times and US News and World Report the general public can find out which products are recommended most by pharmacists by category.

For the past 19 years, Pharmacy Times has invited its pharmacist readers to share their expertise in recommending their favorite brand-name non-prescription products. Over 168,000 pharmacists are asked to submit the over-the-counter or non-prescription products (abbreviated as OTC) in 160 categories.

Together Pharmacy Times and US News and World Report have made the results of this survey available online for viewing at There is even a mobile app for it as well, called “OTC Guide.”

Looking over the category of Oral Arthritis Pain Relievers for the 2013-14 study results I saw there were 5 pain relievers recommended. The top pick in this category is Aleve®, with 33% of the pharmacists’ vote. The next two recommendations were pretty close together which didn’t surprise me because they are the same medication: Advil® was second place with 26% and Motrin®-IB third place at 20% of the vote. My personal favorite for arthritis pain, Tylenol Arthritis® was recommended with 17% of the survey responders and Osteo Bi-flex®(glucosamine/chondroitin) rounded out the group with 4%.

The top 3 products recommended by pharmacists belong to a family of compounds called non-steroidal anti-inflammatory drugs, often abbreviated as NSAIDs.  Aleve®, the generic name of naproxen is also the number 1 prescription NSAID as well. Naproxen 500mg twice daily is considered the gold standard of pain and inflammation relief among prescription NSAIDS like nabumetone, meloxicam, and Celebrex®.

Since they are very similar, why did naproxen get first place? Pain relief from naproxen lasts for 6-8 hours, while ibuprofen often wears of in 4-6 hours. I have a personal preference for naproxen over ibuprofen as well because of my own experience. I took prescription strength ibuprofen while recuperating from ripping a ligament in my right wrist 20 years ago, injured by chopping wood in 15 degrees below zero weather. My ibuprofen wore off at every night exactly at 3:15 am and it took nearly an hour for the next dose to kick in and allow me to go back to sleep. After 2 weeks of this I tried in desperation 2 tablets of OTC naproxen for a total of 440mg and blessedly slept through the night.

Naproxen gets my vote for best relief of muscle pain, but for osteoarthritis pain, #4 in the survey, Tylenol Arthritis® is MY #1 pick. I recommend this medication for anyone taking blood thinners such as aspirin, warfarin (Coumadin®) or clopidogrel (Plavix®) because it doesn’t have the tendency to cause stomach bleeding. It also works all through the night, lasting 8-10 hours. I recommend taking two tablets twice daily, once every morning and again at bedtime.

The tricky thing about Tylenol Arthritis® is it’s popularity. That’s right, it’s TOO popular. Acetaminophen, abbreviated as APAP on prescription labels, is used as an ingredient in over 200 of OTC products and if that were not enough, it’s one of the ingredients in prescription analgesics like Vicodin®, Lortab®, and Percocet®.

Although the product mentioned in the 2013-14 survey is Tylenol Arthritis®, its manufacturer has long-acting acetaminophen product called Tylenol® 8-Hour.  Tylenol® 8-Hour is a brightly colored capsule that contains an extended release formulation of acetaminophen with a similar long acting pattern of pain relief.

Osteo Bi-Flex® are #5 in the current survey. Osteo Bi-Flex® has two ingredients, glucosamine and chondroitin.  I like glucosamine because if you respond to it, it is the most safe of all these options for long term pain relief of arthritis. I have not seen any side effects nor any interactions with other drugs in the 15 years I have used it in my patients taking warfarin as a blood thinner.

Glucosamine may take up to 6-8 weeks for a full effect, and while you are trying it can be expensive. Osteo-Bi-Flex retails for around $30-60 for a month’s supply. If cost is an issue, I have recommended getting it as a powder from a company called Bio-Alternative based in Klamath Falls, Oregon. Their glucosamine powder is a bargain at only $20 per a pound jar, a 6-month’s supply, plenty to see whether you will respond to it.

Curious what other products were recommended in other categories? Check it out at or get the free OTC Guide app.

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