The Best Non-Prescription Pain Relievers

Q:             Which non-prescription pain medicine is the best to use?

There are 4 pain medicines you can buy without a prescription: Tylenol®, Aleve® Advil®, and Motrin-IB®. Which would be best for you to use depends on what type of pain you need it for and whether you have certain kinds of medical conditions.

Tylenol® is oldest of the pain medicines available over-the-counter (OTC). Also known by its generic name acetaminophen, Tylenol® is very safe to use as long you avoid taking too much of it. Taking more than 8 Extra-Strength tablets of 500mg acetaminophen or 12 tablets of regular strength or 325mg Tylenol® in one day can permanently damage your liver, especially if you do it frequently.

The other 3 pain medicines you can buy without a prescription are closely related to each other and all work in the same way. The active ingredient in Aleve® is naproxen and the active ingredient in both Advil and Motrin-IB is ibuprofen. Ibuprofen and naproxen are called non-steroidal anti-inflammatory drugs or NSAIDs for short. NSAIDs are powerful painkillers that are quite effective for certain types of pain associated with inflammation: muscle aches, sprains or strains, tension headache, and dental pain.

Pain medicines with anti-inflammatory action like ibuprofen or naproxen are much better than Tylenol® or acetaminophen for menstrual cramps and especially to prevent swelling and pain after a tooth extraction, but it comes with a price. NSAIDs can cause stomach pain and bleeding, interfere with how your kidneys work, or trigger heart failure from retaining excess water.

I recommend naproxen (Aleve®) over ibuprofen because it lasts longer. Naproxen lasts 8-10 hours while ibuprofen wears off in 6 hours. Years ago I tore a ligament in my right wrist while chopping wood in weather 20 degrees below zero. Some people should NOT be allowed to swing an axe, and I’m one of them! Even taking the most potent prescription strength of ibuprofen three times a day I’d wake up in excruciating pain night after night at exactly 3:25 am. After switching to the OTC strength of naproxen I slept blissfully through the night.

Always take an NSAID with a full glass of water or right after a meal to reduce your risk of stomach problems like burning, cramps, heartburn or bleeding ulcers. The extra water or food will dilute the medicine as it dissolves in your stomach, decreasing your chances of developing pain or bleeding.

When taking naproxen or ibuprofen it’s extremely important to drink plenty of water and avoid them if you are having vomiting or diarrhea. NSAIDs can cause problems with your kidneys, especially if you become dehydrated.

If you have a certain type of heart condition called congestive heart failure (CHF), you should avoid NSAIDs completely. Just ONE DOSE of ibuprofen or naproxen can trigger a deadly build up of fluid in your lungs.

If you have stomach or kidney problems, Tylenol® will be the safest medicine for you to treat mild to moderate pain… unless you take too much of it.

Unfortunately, taking more acetaminophen than you should is MUCH easier than you’d think. Following the dosing recommendations on your bottle of Tylenol® is not enough to prevent problems because acetaminophen is already in many commonly prescribed prescription pain medicines like Vicodin® and Percocet®.

You can also end up taking too much NSAID medicine without realizing it. In addition to OTC formulations, higher strengths of ibuprofen and naproxen along with several other prescription-only NSAIDs are widely prescribed as anti-inflammatory medicines. Taking an OTC and prescription NSAID at the same time increases your chances of having side effects like stomach pain, kidney problems or bleeding ulcers.

To choose the best OTC pain medicine for you, follow these guidelines:

1. For muscle aches, sprains and strains, dental pain or menstrual cramps taking an NSAID like ibuprofen or naproxen will usually work much better for you than Tylenol® or acetaminophen. I recommend naproxen because it lasts 8-10 hours, but either naproxen or ibuprofen should help.

2. If you have a stomach ulcer, kidney problems, congestive heart failure (CHF), or are taking a blood thinner, you should stick with Tylenol® or acetaminophen regardless of the type of pain you have, because it’s is a safer choice.

3. Don’t double up on painkillers. Although it’s safe to take an NSAID anti-inflammatory medicine at the same time as Tylenol®, you should NEVER take more than one NSAID at a time or more than one medicine with acetaminophen in it at a time. Ask your pharmacist if you’re not sure if your prescription pain medicine has either acetaminophen or an NSAID in it.

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Brand vs. Generic Medicines: is There Any Difference?

Q: My insurance company stopped paying for the brand name medicine I have been taking for years because it’s now available as a generic. Within 2 weeks of starting on the generic version of my medicine my old symptoms started coming back. My doctor says that it’s the same medicine, but if that’s true, why do I feel different?

Generic medicines are considered equivalent to their brand name counterparts, but they are not identical. The Food And Drug Administration (FDA) requires that generic drugs meet the same standards as brand name products, but they don’t have to match them in every way.

Before they can sell a generic version of a medicine its manufacturer must show the FDA that their product contains the same active ingredient as the brand does at each strength. It comes in. The formulation (tablet, capsule, liquid or injection) and route of administration must also be the same as the original or “innovator” medicine. In addition, its manufacturing processes, quality control and testing must meet the same standards as any branded product. Many generics are actually made in the same facilities as their brand name equivalent.

The generic drug manufacturer must also prove to the FDA that its medicine is bioequivalent to the brand name drug. This is done by having volunteers each take standardized doses of the generic and brand name medicine with blood samples taken after each dose to measure the amount of each in their bloodstream compared to the other one. If the levels of the generic drug in the bloodstream are the same as the levels found when the brand name product is used, it is assumed that the generic drug will work the same in your body.

But there are differences between taking a generic and a brand name medicine. The biggest difference is in the price, with the average generic drug costing 80 percent less than the brand name version. According to a study of generic drug usage done by the US Government Accountability Office, in 2010 alone the use of FDA-approved generics saved $158 billion as prescriptions and in medicines used by hospitals. That’s an average of more than a billion dollars saved every other day.

Although the active ingredients have to be equivalent, the inactive ingredients don’t have to be. And may change the way some people absorb their medicine. For example, tablets contain more than their active ingredient, like meatballs often contain more than just meat. Most tablets of medicine also have diluents or fillers to make up the size of the tablet, similar to rice or oatmeal used in a meatball recipe. Examples of fillers used for tablets are lactose, sucrose, kaolin, starches and cellulose. Then there’s an adhesive compound added to the powdered medicine called a “binder” to help it all hold together, like an egg added to a meatball recipe helps the meat and rice “stick” together as you form it into a ball. And sometimes a dye is added to the powder to color the tablet, which can cause reactions in people who are sensitive to dyes.

Many generic manufacturers use less expensive versions of filler, binder and dyes than the branded medicine, which is perfectly allowable by the FDA as long as the active ingredient is the same concentration as the original product.

There are more extended release generic medicines available now than ever before, and generics for these are harder to get “right”. Even between different brands of similar products, there can be differences in how much of the medicine is released into the body over a period of time. The FDA received complaints about a generic version of Wellbutrin® XL causing headaches, nausea and a return of depressive symptoms in some people. In October 2012 the FDA reversed its approval because of a difference in how the generic was absorbed and asked its manufacturer, Teva to remove it from the market.

If you notice a difference between how you feel when taking a generic medicine and the brand it has replaced, ask your doctor to report it to the MedWatch program that is run by the FDA, which tracks adverse events caused by medicines. Your doctor may also consider adjusting your medicine, changing it to another medication, or asking the insurance company to approve using the brand name product for you because of your bad experience with the generic.

You can find more information about generic medicines at http://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/understandinggenericdrugs/default.htm.

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Can Cod Liver Oil Improve Your Health?

Q: My neighbor swears by cod liver oil and says I should try it. Could it improve my health?

Drinking cod liver oil may help you if you happen to be deficient in either vitamin A or vitamin D. A type of fish oil, cod liver oil is a good source of the fat-soluble vitamins A and D. It also may contain Omega-3 essential fatty acids like other types of fish oil, helping ease achy joints and minor muscle aches.

Although it’s has been around a long time, cod liver oil didn’t start out as a medicine. It was originally a byproduct of the Norwegian fishing industry and commonly used to soften leather and as a hoof dressing for horses. Then in the 1800s German physicians discovered that cod liver oil cured children of rickets, a common disease at that time that caused serious bone deformities. It was also used successfully to treat joint aches, gout and “obstinate constipation”.

According to the United States Pharmacopeia (USP), Cod Liver Oil, USP is “a thin, oily liquid with a characteristic, slightly fishy odor and a definitely fishy taste” made by “steaming the livers of the Atlantic cod, then straining the oil that rises to the top of the vat or kettle”. Cod Liver Oil, USP lists 3 main ingredients: vitamin A, vitamin D and Omega-3 essential fatty acids.

By 1851, cod liver oil was declared “one of the most esteemed remedies currently available”. Doctors recommended it but children hated it and suggestions on how to improve the “fishy” taste of cod liver oil began to show up in medical and pharmacy references. The 19th edition of The United States Dispensary published in 1907 contains this advice for Cod Liver Oil, USP: “It may be taken alone or mixed with some vehicle calculated to conceal its taste and obviate nausea. Peppermint oil has been found to be helpful.” My favorite suggestion, taken from the same source, is to “chew a small piece of orange peel before and after taking the medicine.”

Cod liver oil may improve your health if your diet is low in either vitamin D or vitamin A. Vitamin D is essential to incorporate minerals such as calcium into new bone tissue. A nutritional deficiency of vitamin D causes rickets in children and osteomalacia in adults. In rickets, newly formed bone lacks minerals and is too soft, causing crooked bones and skeletal deformities. In adults, vitamin D deficiency causes weak bones, or osteomalacia. Deficiency of vitamin A can cause growth retardation, night blindness and an increased susceptibility to infections.

Each teaspoonful (5ml) of the official product of cod liver oil as Cod Liver Oil, USP contains 850 USP units of Vitamin A, 85 USP units of Vitamin D, and approximately 1 gram of Omega-3 essential fatty acids at a concentration similar to salmon oil.

The dose of cod liver oil recommended for children is one teaspoonful 3-4 times daily, and one tablespoonful (3 teaspoonfuls, or 15ml) 3-4 times a day for adults. Other formulations of cod liver oil besides the standard version contain extra vitamin A or D that’s been added by the manufacturer. The amount of Omega-3 fatty acids in cod liver oil varies, with formulas using Atlantic cod having the most and those from Pacific cod having little to none. It’s interesting that cod liver oil was considered helpful in chronic rheumatism (joint or muscle aches) because at least one product contained nearly the same concentration of Omega-3 fatty acids as today’s salmon oil supplements.

To reduce the prevalence of rickets in its children the United States began fortifying milk in the 1930’s with added vitamin A and D. Every 8 ounce serving of cow’s milk has 100 international units of Vitamin D which is 25% of its recommended daily intake and 150 units of vitamin A, which is 10% of its recommended daily intake. Today’s ready to eat cereals are also fortified with 10% of the recommended daily intake of both vitamins A and D. Rickets is now very rare in the United States.

Cod liver oil was one of the first effective vitamin supplements available, but thankfully there are more palatable options today to prevent deficiency of vitamin A and D. One tablet of either Centrum Silver® or Flintstones® chewable is today’s modern, and tastier, equivalent.

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Safe Medicine Disposal

Q:        How should I get rid of my old and expired medicines? I don’t want to just flush them down the toilet into our water supply.

You are not alone in having leftover medicines. In fact, nearly one-third of medicines sold to Washington State households go unused every year, according to a report by Take Back Your Meds, a group of over 270 health organizations, law enforcement, local governments and environmental groups. That’s about 33 million containers of unused pills just in the state of Washington. When you think about the rest of the country…Yikes!

Disposing of your unused medicines is a good idea. Keeping unwanted and outdated prescription medicines around your house invites abuse and theft. Removing medicines you no longer need helps keep habit-forming drugs from entering the lives of your children, grandchildren or their friends and keeps you from contributing to the rapidly growing problem of prescription drug abuse.

It’s not just the people you know who are checking out your medicine cabinet. In addition to friends of your children and grandchildren looking for your leftover pain pills, today’s home intruders look for prescription bottles of pain medicines sitting on countertops or stacked up in medicine cabinets, not just for flat screen televisions and laptop computers.

One of the safest ways to dispose of your expired, unused or unwanted medicines is to take them to a site participating in a take-back program. While it seems natural to return your unused medicines to your pharmacy, under federal law, pharmacies, doctor’s offices and hospitals can’t accept any outdated or unwanted prescriptions of controlled substances, such as narcotic painkillers like Vicodin® or medicines for anxiety such as Ativan® (lorazepam).

The Drug Enforcement Administration (DEA) began hosting national prescription drug take back events beginning in September 2010. Twice a year the DEA partners with local law enforcement agencies to give the public another alternative to disposing of their medicines besides putting them in the trash or flushing them down the toilet.

The 12th Annual National Prescription Drug Take Back Day will be Saturday, October 22, 2016, and as with previous national Take Back events you can bring your medicines to participating sites for safe, free disposal, no questions asked.

But now there’s no need to wait for the next Take Back Day. The DEA has encouraged communities to provide local drop box sites authorized by the DEA for year-round safe medication disposal. You can search by zip code, city or county to find the authorized sites closest to you on the DEA website: https://www.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s1.

If you can’t get to a take-back site near you, the Food and Drug Administration (FDA) recommends disposing of any potent pain medicines by removing them from their original containers and flushing them down a sink or toilet. This includes pain pills containing drugs like Vicodin® or hydrocodone, oxycodone, and patches containing fentanyl, also called Duragesic®. Although it seems harmful to the environment to flush them, it’s even more dangerous to leave them in your trash container. Just part of a pill or a used patch of these powerful pain relievers can be lethal to a pet or small child sucking or chewing on it.

Other prescription medicines can be safely disposed of by first removing them from their bottles and boxes and mixing the pills or capsules with something unappealing like kitty litter, coffee grounds, sawdust or even dirt, then placing them in a leak-proof container like a sturdy zip-lock bag before adding them to your trash bin.

Before putting empty prescription bottles into the trash, protect your privacy by marking out any identifying information such as your name, prescription number and drug name with a permanent marker, like a Sharpie®. Sometimes you can just peel the label off and crumple it up.

4 Tips to Safely Dispose of Your Unwanted or Expired Medicines:

1. The best way to dispose of your medicines is to take them to a Take-Back location or event in your community. Many communities hold their own Take-Back events during the year in addition to National Prescription Take Back events held in the spring and fall.
2. If you can’t get to a take-back location or event, remove any potent pain medicines such as hydrocodone, oxycodone, OxyContin®, or fentanyl patches and flush them down the toilet or sink. Don’t leave them in your trash to be found by a child or pet.
3. Mix any non-narcotic prescription pills in with kitty litter, used coffee grounds, or even dirt before placing them into your trash. Using a plastic container with a secure lid or a heavy plastic zip-lock bag helps prevent leakage.
4. Remember to remove or mark out any personal information and drug names before tossing used prescription bottles or boxes into your trash.

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Caffeine as Our Drug of Choice

Every morning at 6am Pacific Standard Time you’ll find me in my kitchen in front of a silver machine concocting a cup of jump-start for my day. My well-used Gaggia Classic espresso machine relieves my caffeine deprivation every morning with an aromatic, high-octane blend of caffeine, water and milk. As I write this my 16-ounce unflavored latte steams by my right elbow.

I’m not alone when performing this ritual of drinking coffee before engaging my brain. 100 million Americans are also daily coffee drinkers and 60% of us consider coffee a mandatory part of our morning routine. There’s even a National Coffee Month each August to celebrate our addiction.

Although Americans purchase a large proportion of the world’s supply of coffee beans and are the home of Starbucks®, Seattle’s Best® and Dunkin’ Donuts®, we aren’t the world’s most dedicated coffee drinkers. In fact, we only rank 25th in per capita coffee consumption, out-caffeinated by the Top 5: Finland, Norway, Iceland, Denmark and the Netherlands.

Coffee is a definitely a worldwide beverage. Green, or unroasted coffee beans are the second most traded and valued commodity in the world, behind only crude oil. We call coffee “Java” because when coffee as a beverage first became popular in the 19th century the highest quality of beans came from the Philippine island of Java.

Why do we love coffee so much? Probably because it naturally contains caffeine, the most widely consumed stimulant in the world. Found in over 60 different plants, caffeine’s effect on the brain can be detected in amounts as low as 10mg, a fraction of the 100mg dose found in an average 8-ounce cup of brewed coffee.

As the most common psychoactive compound ingested in the world, caffeine is found in beverages all around the globe: coffee, tea, a South American drink called mate, and kola nut. Kola nut extract was originally added to carbonated beverages to flavor them, although today soda manufacturers use synthetic sources of flavoring and caffeine in their cola flavored products.

Enterprising entrepreneurs have added caffeine to other things besides soda. Need the pick-me-up quality of caffeine but don’t want coffee breath? Try one of the popular energy drinks like Red Bull® or 5-Hour Energy®. There’s even Stay Alert® chewing gum with 100mg of caffeine per stick, about the same amount found in a good ol’ cup of java. Not interested in drinking a beverage to get your day going? Wired Waffles® brings you 200mg of caffeine per waffle to jump-start your day or you can use their caffeinated pancake syrup.

If the thought of putting caffeine into foods bothers you, welcome to the club. The Food and Drug Administration (FDA) has concerns about the amount of caffeine in foods, particularly since waffles, pancake syrup, gum and candy are attractive to children.

As I sip my morning coffee, I wonder, “Should caffeine be allowed to be added to foods that don’t naturally contain it? Should we let other products besides our traditional beverages provide us with caffeine?”

One consideration is the fact that we vary in our sensitivity to caffeine’s side effects. Some of us can drink a pot of coffee and go right to sleep while others experience side effects like heart palpitations, tremor, anxiety and insomnia after only one cup. Some heart patients are advised to avoid caffeine completely because of the risk of increased blood pressure and heart rate.

The currently recommended limits of caffeine intake are 300-400mg per day in adults and 100mg daily in teens and young adults. The FDA is concerned about whether to approve food products containing caffeine as an additive because little is known about the effects of caffeine in small children, young adults, or in pregnancy.

In 2010 the FDA forced the withdrawal of caffeinated alcoholic beverages like Joose® and Four Loko® because of studies indicating that combined ingestion of caffeine and alcohol could lead to life-threatening situations. The FDA determined that caffeine consumption masks the sensory cues people use to track their level of alcohol intoxication. Young adults drinking the alcohol/caffeine combinations found in products like Four Loko® continued drinking well beyond what they usually drank with blood alcohol levels 2-3 times higher than those drinking beverages containing only alcohol.

You can find more information about caffeine in foods and other interesting topics on the FDA website under Consumer Updates: www.fda.gov/ForConsumers. Just don’t ask me any tough questions before I have my morning cup of Joe…

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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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Taste and Medicines

Q:        My 89 yr. old mother is taking Cipro® 2x/day for 10 days. She is complaining that nothing tastes “right”. She says everything tastes sour. Is it the Cipro®?

Yes, I believe so. She should be able to taste her food again a few days after she completes the course. It’s because there are small amounts of the antibiotic actually in her saliva, which she can taste.

Q:        I am taking Bactrim®, Cipro® and Xarelto®. Have been on antibiotics for 7 months due to staph from spider bite. Everything from sweet to salty and drinks all taste the same. Like bitter or no flavor at all. Did the medicine cause this and can I do anything about it?

Antibiotics are the most likely culprits. Both Bactrim® and Cipro® can cause taste changes. It’s possible that Xarelto® can as well, although we don’t have as much experience with it as the older medicines you are taking. When did the taste change happen? Did you start any new medicines within 2-3 weeks of noticing that effect? Please work with your doctor on solving this; don’t just quit taking your medicine on your own.

Q:        I am taking Eliquis®, losartan, Plavix® and Crestor®. Lately I can’t find a coffee that doesn’t taste tinny or metallic. I am wondering which med is the culprit?

Any of those medicines COULD be the culprit. The best way to narrow it down is starting with the time relationship: When did you notice your coffee was tasting metallic? Which of those medicines was started within the last 2-3 weeks prior to that? If you started taking more than one medicine during that time, you may need to stop one medicine at a time to determine which is the culprit. Please work with your physician on this issue. If you miss even one dose of Eliquis® you are unprotected from a stroke or other blood clot.

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How To Get Rid of Toenail Fungus

Q:     My toenails are getting really thick and yellow. Are there any non-prescription products that can help?

When you have thickened, deformed toenails it’s not just how nasty they look but how they can cut through your socks, cause pain and prevent you from wearing your favorite shoes. All this misery, just from a fungal infection! Fungus that infects your feet through cracks in your skin, then spreading to the cells under your skin where your body forms new toenails, called the nail plate. Once the fungus invades your nail plate your nails start growing out ugly and deformed.

Fungus infection of the toenails, called onychomycosis often starts with one nail affected, usually with little white spots. As it spreads the entire nail becomes white and it spreads to other nails, eventually causing more severe symptoms, like  nails growing out thickened, yellow, discolored, even crumbly. As your toenails grow thicker it’s harder to keep them trimmed, and nails that grow sideways or slant upward wear holes in your socks and make it hard to find shoes that fit.

Treating onychomycosis is often lengthy, frustrating and disappointing. The prescription treatment considered the most effective only cures the infection in 50% of cases. Not only that, but 1 out of every 5 people who do get cured will have a recurrence within 2 years.
Infected toenails take 12 months to grow out, so any successful treatment of  onychomycosis takes a long, long time: a minimum of 3 months for oral treatment and 10-12 months for topical treatment. Topical treatments designed for athlete’s foot are not usually effective on toenail fungus because they only have to affect the skin. When treating a toenail infection you need the treatment to penetrate under the skin and to attack the fungus growing inside the nail plate.

What can you do?
Topical treatments are most successful in mild cases, such as only part of the nail on only 1-2 toes affected. If you have significant thickening and deformed nails, consider prescription strength antifungals. Sometimes the best way to treat severely deformed toenails is to remove them and let them grow back in while you are treating the infection with an oral antifungal like Lamisil® (terbinafine) for 12 weeks.

There are topical treatments for less severe cases of onychomycosis, but they have far less success than a prescription strength oral antifungal and they all need to be used consistently every day for at least 10 months. Filing off some of the nail may also help topical treatments penetrate better into the nail plate.

Some examples of topical remedies for nail fungus include prescription-only Jublia®, non-prescription tolnaftate solution, tea tree oil, and (believe it or not) Vick’s VapoRub®. Another option recommended by some of my fellow pharmacists is soaking your feet daily in full-strength white vinegar for at least 4-6 months.

Even when the fungus has been killed off, don’t be shocked if it comes back. That’s because the conditions that helped the fungus get a toehold on you are often still there: warmth, moisture and darkness.

Here are 5 tips For Fixing Nail Fungus:

1.     Get rid of athlete’s foot by treating it with topical creams or gels that kill off foot fungus. If you don’t eradicate the fungus from your skin, it will re-infect your toenails. Once your skin symptoms have disappeared keep on using the medication twice a day for at least another two weeks. This helps make sure the fungus gets completely shed out of your skin. If you leave any tinea fungus alive inside the skin layers of your feet it can easily multiply and spread, putting you right back where you started.

2.      Keep your feet as dry as possible. Wear loose shoes or sandals and change your socks frequently. Fungus thrives in warm, dark and moist places; your chances of beating the odds and getting a cure as well as avoiding recurrence are greater if you make it as difficult as possible for the fungus to multiply.

3.    When using a topical remedy, filing off some of the toenail on top seems to improve your changes for success.

4.     Apply the nail fungus remedy to the affected nails every day for a minimum of 10 months. If your symptoms don’t completely resolve or they become worse you should consult your doctor for other options. Sometimes removing the nail is the best option.

5.    Try daily vinegar soaks. Soaking your feet in full strength white vinegar every day for at least 6-10 months is an inexpensive option you can try.

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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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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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