Q: Since I started a new medicine, my food doesn’t taste right. Is there anything I can do about this?
Our ability to taste foods and drinks enhances our enjoyment of socializing with special foods and savoring favorite flavors, but as we age we start to lose our ability to taste sweet and salt, and that can affect our food choices.
The worse a medicine tasted the more potent they were believed to be, leading to the phrase, “a bitter pill to swallow”. Medicines also have the power to change how our food tastes and smells, with 250 medicines documented to affect how we taste or smell.
There’s also a difference between the taste of something on your tongue, and its characteristic flavor. If you’ve ever had a bad cold or sinus infection which suppressed your sense of smell, you may have noticed that your food and drinks didn’t have their own particular flavor.
Taste is a complex process. We have several different types of cells and nerves inside our mouth and nose receiving signals from foods and drinks that come in contact with them. These signals are then carried to the brain where they are interpreted and identified. This is how we can tell the difference between the heavenly smell of a fresh baked cinnamon roll and the tang of spoiled milk.
Think about your favorite flavor of ice cream. What makes it taste so good? You have three types of receptors working together to create that taste sensation: your taste buds, some other taste receptors found in your mouth, and smell receptors in your nostrils. Each of these handles a different type of sensation.
Found on your tongue, soft palate, and the back of your mouth where you swallow, your taste buds have 4 different types of taste receptor cells, each picking up only one type of taste: sweet, salty, sour or bitter. The other taste receptors in your mouth are not only on your tongue but all along the lining of your mouth, and these taste receptors can sense stinging, burning, cooling and sharpness. People who wear dentures report that they don’t taste food as well since they started wearing them. This is because the taste receptors on the roof of their mouth are now covered up.
What causes taste disturbance? Medications are a common culprit but they aren’t the only one. Medical conditions such as cancer, or poor oral health such as severe tooth decay, an abscessed tooth, and gingivitis can affect the ability to taste. Either radiation or chemotherapy for cancer can also change taste perception.
Medicines can alter taste in several ways, either by tasting bad or changing how you taste. Liquids come in contact with more of your taste buds than a tablet, creating a more intense taste experience. To give our new doctors-in-training an appreciation of why kids have to be coaxed into taking their medicine, my clinic hosts a Taste Test of several liquid medicines every spring. It’s appalling how awful some of them taste.
Another way medicine can affect your ability to taste is by causing your mouth to be dry. Taste and smell receptor cells need moisture to function; taste buds and other taste receptor cells are continually bathed in saliva, and mucus protects the scent receptors in your nose.
Antibiotics and cancer chemotherapy drugs top the list of drugs that can give you a “bad taste in your mouth”. Unfortunately, the drugs most commonly used to treat breast cancer are some of the worst offenders at changing taste and flavor. These drugs diffuse throughout your body, even into your saliva and mucus. That metallic taste in your mouth? When you notice a “funny” (metallic, bitter or sour) taste in your mouth, it’s because you are actually tasting the drug itself as it contacts your taste buds!
Chemotherapy agents also affect taste by destroying your taste and smell receptor cells. Chemotherapy and radiation treat cancer by attacking any rapidly dividing cells. Taste receptor cells are renewed every 10 days, and smell receptor cells are regenerated every 30 days, making them very susceptible to damage from both chemotherapy and radiation treatment.
What can you do about your funny taste in your mouth? Sugarless gum with xylitol, or sugarless lozenges can help dry mouth symptoms and chase away an unpleasant taste. Sips of water or ice chips can also help mask weird tastes. If this doesn’t help, speak up and let your doctor know about this so that you can discuss other medicine options that you could take instead.
Every Monday afternoon I see patients in a small town clinic. Last week it was time to see Elsie, one of my favorites for her monthly check of her blood thinner medicine. She had raised 12 children, was 83 years old and a widow. Ron, one of her 6 sons had driven her to her appointment because he was concerned about her. Every time I see Elsie, I ask her the same questions. Today was no different.
“Any new medicines since I saw you last?” I asked, as I glanced at my laptop with her chart on the screen.
“Why, yes. I saw the heart doctor and he increased one of my medicines. Ron knows which one it is…” as she looked across at her son sitting in the chair to my left in our exam room.
“When was that?” I asked.
“Oh, about 2 weeks ago, now,“ replied Elsie.
“Okay, then. Is it the one that starts with an L? That’s the only other heart medicine I see here on your list of medicines. It shows here that you’ve been taking one tablet of 5mg lisinopril twice a day.”
Ron nodded, and when I asked if he knew what her dose was changed to, he handed me a folded paper that read: “Increase lisinopril 5mg to two tablets twice daily”. He then looked across the room at his mother. “Ask her what you can take for allergies.”
“Dr. Louise, can you recommend something for allergies? I’ve tried the usual stuff but nothing seems to help.”
“What kind of allergy symptoms are you having, Elsie?”
“Just a cough.”
“Are you coughing anything up?”
“Well, no. Just a dry tickle.”
“That cough keeps you up at night, Mom.”
“Well, it may not be allergies after all, Elsie. I’m really glad you said something about it.”
I sent a message to her family doctor about her new cough symptoms since the medication adjustment and it was addressed the very next day with a medication change.
A couple of hours later, I was talking with radio personality Dottie Kaufman. She told me how she had spent 3 months and over $200 seeing an allergy specialist for a dry cough that had caused big problems for her on her radio show. The specialist couldn’t help her, so she continued to put up with it. One day, she was talking to a pharmacist who connected her cough symptoms with a prescription medicine she had started right before the cough showed up. The name of the medicine was lisinopril. Within days of stopping her lisinopril, Dottie’s cough vanished and has never returned.
My father was diagnosed with diabetes at age 78, and his family doctor started him on 3 pills: one for his blood sugar, one for his cholesterol, and one to protect his kidneys. A couple of weeks later while we were talking on the phone, he asked me about them. The medicine he was taking for his kidneys was lisinopril. I asked, “Dad, have you noticed any coughing?”
“No. I feel just fine.” “That’s great, Dad! Be sure to mention it to your doctor if you notice any nagging, tickly type of cough, ok?”
Nine months later my dad had his left knee replaced and I came to stay overnight with him after his surgery so he wouldn’t have to go to a nursing facility. But he wasn’t taking lisinopril any more. Instead, he was on losartan, which is what doctors usually switch to if the lisinopril causes any side effects.
Dad did fine at his starting dose of lisinopril, but, just like Elsie, he developed a nagging cough when his doctor increased the dose. He was changed to the losartan and hasn’t had any further problems.
Lisinopril belongs to a group of drugs called ACE Inhibitors, which are all related to each other and have the word fragment –pril in their generic name, like ramapril and lisinopril. One of the most commonly prescribed drugs in America, lisinopril is given to lower blood pressure, strengthen the heart in congestive heart failure, and to reduce the potential for kidney problems in diabetes. However, it is also notorious for causing a chronic dry cough. One out of every 4 people started on an ACE Inhibitor will develop a cough similar to those described by Elsie and Dottie.
If you have just started a new medicine, speak up if you notice any unusual symptoms. There are lots more strategies for taking your medicine safely in my book, Why Dogs Can’t Eat Chocolate: How Medicine Works and How YOU Can Take it Safely.
Q: I think my pills are making me sick. Is there anything I can do to avoid this? If I throw up right after I take them, should I try again?
You are not alone. As a pharmacist, one of the most common complaints I hear is, “These pills make me sick!” They’re right. Queasiness, cramping of your stomach or intestines – what doctors call “gastrointestinal distress”, or “GI distress” – is the most commonly reported side effect reported with medicines. In fact, either nausea or GI distress has been reported with every single prescription medicine.
If there were a Hall of Fame of drugs that cause nausea and vomiting, the medicines most likely to be in there would be antibiotics, pain medicines, and cancer chemotherapy drugs. Here are some tips to help reduce the GI distress and risk of vomiting from these and other medicines:
Tip #1: Take your medicine with food in your stomach or a full glass of water or milk. Taking it just after finishing your meal instead of at the beginning of it is even better, as there is more food in your stomach to dilute out any distressing effects on your innards.
Tip #2: If an antibiotic is causing nausea or vomiting, ignore any advice about taking the medicine on an empty stomach (gasp!) and take it with crackers or a snack, but not a full meal. Don’t worry, your stomach won’t blow up! You’ll lose a little of the antibiotic because of the food, but it’s much better to get most of your medicine inside you than to upchuck the whole thing before it even has a chance. If you try this and it still doesn’t help, contact your doctor as soon as possible. An antibiotic can’t help you if you can’t keep it down, and delaying treatment can lead to serious consequences.
Tip #3: Take the medicine at night, so you sleep through the queasiness. This is helpful with oral contraceptives or with prenatal vitamins because “morning sickness” during the first trimester of pregnancy can make it challenging to keep food and vitamins down. It can also be helpful with pain medicines.
Tip #4: Ask your pharmacist if there is a delayed-release or specially coated formulation designed to minimize stomach distress that can be requested from your doctor.
Tip #5: Ask your pharmacist if you could safely split your pills into more than one dose and take them several hours apart, like with breakfast and dinner. Some pills can be split safely; others need to be switched to a smaller size pill and given in separate doses.
Chemotherapy drugs top the list of drugs that cause severe queasiness and vomiting. You’re more likely to experience nausea or vomiting during chemotherapy if you are younger than 50 years old, are female, have had nausea during a pregnancy, are prone to motion sickness, or have had nausea during previous chemotherapy. Depending on the treatment regimen, multiple anti-nausea medicines are used together, including pills, dissolving or melt-in-your-mouth tablets, skin patches, rectal suppositories, and injections.
Tip #6: Anti-nausea medicine works best when taken ahead of time. If you’re planning to go salmon fishing on a charter out of Westport, it’s best to take your motion sickness medicine at least 30 minutes before boarding the boat, not when you realize you’re about to heave your breakfast over the side.
If you do vomit after taking your medicine, what should you do? If it’s an antibiotic or pain medicine, go ahead and try it again, but make sure you’re taking it with food and a full glass of fluid. If you end up losing your medicine a second time within 30 minutes, contact your doctor, because if you can’t keep your antibiotic or your pain medicine down, it won’t be able to help you.
If it’s been more than 30 minutes since you took your medicine, then you may have gotten just enough medicine absorbed that taking another dose right away could be an overdose. If your medicine is for your heart, your blood pressure, or anxiety, contact your doctor or pharmacist first before repeating the dose.
Q: I’d like to try taking fish oil, but I get confused with all the different products available. How do I choose a good quality supplement at a reasonable price?
With hundreds of plant and animal based products available, not only as individual agents but also in various concentrations and combinations, making a choice among so many can seem overwhelming. And if you find it for sale in a health food store, pharmacy aisle or website, it must be safe and effective, right?
Not necessarily. Unlike a manufacturer of pharmaceuticals, a dietary supplement manufacturer has very few rules to worry about. Before a prescription medicine can be sold in the United States the manufacturer has to provide documentation to the Food and Drug Administration (FDA) that their particular drug or drug combination is reasonably safe and effective and manufactured according to established standards of purity and quality. Manufacturers of dietary supplements can just make a bunch of product, put a label on it and immediately start selling it. This lack of regulations has encouraged an explosion of natural products made for and marketed to the general public.
It wasn’t always this way. In 1994 Congress passed the Dietary and Supplement Health and Education Act, creating the dietary supplement industry practically overnight. Products that qualify to be considered a “dietary supplement” are treated more like a type of food than a medicine, which means they have very few rules the manufacturer has to follow. This has resulted in significant differences in standards of manufacturing and unacceptable variations in the quality and potency of products available.
Fortunately, there’s now a way to determine whether the bottle of supplement you are interested in purchasing has been manufactured according to good manufacturing standards, similar to the stringent requirements of prescription and non-prescription drugs. Remember the Good Housekeeping Seal of Approval? In 2001 a similar sort of validation called USP verification was started to address the problem of uneven quality of dietary supplements.
When a manufacturer can show that their product is made with the same standards used by pharmaceutical manufacturers, they earn the right to put the USP Verified mark on the label of that product. Those standards are decided on by a group called the United States Pharmacopeial Convention, also called the USP., in 2001 the USP started a new program to address the uneven quality of dietary supplements.
The USP is a non-profit organization created in 1820 by a small group of 11 physicians dedicated to ensuring the purity, identity, strength and quality of foods, medicines and dietary supplements. With nearly 200 years of experience in establishing quality manufacturing standards, this independent scientific group is entrusted by the FDA with creating and standardizing standards for quality in manufactured medicines, food ingredients, and dietary supplements.
According to the USP website at www.usp.org, the USP Verified mark on a label of a supplement indicates that it contains only the ingredients listed on the label in the amount and potency specified, that it doesn’t contain any harmful levels of specific contaminants, will break down and release its active ingredients into the body within a specified amount of time, and has been manufactured according to the FDA’s current Good Manufacturing Practices using sanitary and well-controlled conditions and procedures.
When you are shopping for fish oil, look for the USP Verified seal on the label, which assures you that the product is made according to good manufacturing standards.
To see what the seal looks like and to review supplements that already have earned the USP Verified designation, go to www.usp.org/usp-verification-services/usp-verified-dietary-supplements. One surprise that I found was that the Kirkland Signature brand of fish oil carried by Costco stores is USP Verified.
Q: My sister was just diagnosed with breast cancer. I quit taking my estrogen pills but the hot flashes and night sweats came back. Is there anything I can switch to that won’t increase my risk of breast cancer?
First, please talk to your doctor as soon as possible about your sister’s diagnosis and how it affects your own risk for breast cancer. Additional screening tests may be recommended for you.
Menopause brings many changes, such as night sweats, “hot flashes”, trouble sleeping, fatigue, thinning of your bones, and vaginal dryness. Taking supplemental estrogen can relieve these annoying symptoms and keep your bones strong, but also increases your risk of developing blood clots, breast cancer or having a heart attack.
Stopping your estrogen all at once can make these menopausal symptoms come roaring back. Tapering off estrogen is usually gentler and easier than just stopping it. Some years ago there was a study called the STAR trial (Study of Tamoxifen And Raloxifene), in which the women participating in it first had to stop taking their estrogen replacement medicine. The method that seemed to work best was skipping one day of estrogen in the first week, skipping two days of estrogen in the second week, skipping three days in the third week, and continuing that pattern until the ladies were off their estrogen completely .
The way the STAR trial tapered the estrogen was different than you might think. Instead of evenly spacing the skipped doses, they had the study participants skip Sunday’s dose in Week 1, Sunday and Monday’s doses in Week 2, Sunday, Monday, and Tuesday’s doses in Week 3, and so on. It really surprised me that it works fine either way you do it – by skipping estrogen pills bunched up in a row on Monday, Tuesday and Wednesday, or by spreading the skipped days out to Monday, Wednesday and Friday.
If you experience “hot flashes” or other breakthrough symptoms during your taper, I suggest going back to your previous week’s dose and staying on that for 2 to 4 weeks before trying to taper down again. Instead of doing only 1 week at each level, try staying at the level for 2 to 4 weeks before dropping another dose, then 2 to 4 weeks at the next lower level, and so on until you are completely off of the estrogen.
When we tell our medical provider we have “hot flashes”, the doctor knows what we mean, but that’s not what their medical books call it. I think it’s funny that the medical term used in textbooks for what we call a “hot flash” is a “hot flush”. When I think of a “hot flush” I see a high stakes poker game or a toilet bowl cleanser commercial with Mr. Clean clad in tight black leather pants.
After you have tapered off estrogen, what now? That depends on why you were taking estrogen in the first place. The two major benefits of taking estrogen are reducing menopause-related symptoms (the night sweats, “hot flashes”, and vaginal dryness) and preventing bone loss and future hip fractures from osteoporosis.
Adding a little bit of soy to your diet or taking the herbal product Remifemin® (a formulation of black cohosh) may help reduce “hot flashes”and night sweats. In order to prevent bone loss and osteoporosis you should talk to your doctor about prescription medicines that can protect your bones while decreasing your risk of breast cancer.
Prescription medicines called selective estrogen receptor modulators, or SERMs can act just like estrogen in some areas of your body while blocking the effects of estrogen in other areas. I call these “designer estrogens” because they are designed to mimic the benefits of estrogen supplementation and work in some tissues while having no effect on other parts of your body.
There are two SERMs available in the United States: Evista®, also called raloxifene, and tamoxifen. Evista® is prescribed to prevent and treat osteoporosis in postmenopausal women who can’t or shouldn’t take estrogen, either because they’ve had a blood clot, a stroke, or because of a high risk of developing invasive breast cancer. You can estimate your breast cancer risk at the National Institutes of health (NIH) website: www.cancer.gov/bcrisktool.
The older SERM, tamoxifen, is given to both men and women who have had breast cancer in after surgery or radiation to decrease the risk of a recurrance. Tamoxifen is also prescribed for breast cancer that has come back or has spread to other areas of the body.
October is Breast Cancer Awareness month. Please discuss your risk of breast cancer and osteoporosis with your medical providers, who are your partners in developing a strategy for prevention and early detection of breast cancer.
A nice lady named Joyce contacted me a couple of weeks ago. She had bought my book Why Dogs Can’t Eat Chocolate: How Medicines Work and How YOU Can Take Them Safely and it had given her the courage to ask some tough questions about the medicine she was taking for prevention of breast cancer.
A few years ago Joyce’s mammogram showed a lump that proved to be cancerous, and she underwent a lumpectomy, followed by 35 radiation treatments over the next 7 months.
After completing the surgery and radiation for her breast cancer, her oncologist started her on a medicine called anastrozole, the generic version of Arimidex® to help prevent a recurrence of her breast cancer. They planned for her to take it for 5 years and she had been taking it for almost 2 and half years with no problems.
“I had been doing just fine, until this spring. I thought my allergies were acting up. I’d sometimes see little red dots on the inside of my arms, which eventually faded away. Then something changed. The tips of my ears started to tingle, feel hot, and turn a fiery red color. But I could make that go away by taking an antihistamine, so I continued to think it must be just a bad year for my allergies.”
“By the first of August the rash had spread from my ear tips to my neck, though I still got relief by taking my antihistamine. And when the rash spread to my thighs I was one week away from leaving on a wonderful trip to Scotland and I began to worry. What if the rash continued to spread? I didn’t want to cancel my special trip but I surely didn’t want to be miserable on it either.”
“I was reading your book Why Dogs Can’t Eat Chocolate and got to the part where you encouraged us to Be A Squeaky Wheel and to SPEAK UP, not give up. I wondered, “Could my rash be related to my breast cancer medicine? I’ve taken it without any problems for over 2 years.”
As I listened to Joyce, with her on schedule to leave for Scotland in only 5 days, I advised her to go ahead and stop the medicine but also to call her doctor immediately and explain her situation. Her rash was getting worse, and yes, her Arimidex® could be the reason. If it was caused by the medicine she needed to stop taking it.
“Joyce, please call your doctor and make an appointment as soon as possible to discuss what has been happening, so she can advise you on what other options you have. She needs to know that you are having these symptoms, so she can help you. You did the right thing by speaking up.”
I heard back from Joyce a couple of weeks ago, after she returned from her trip. “The rash went away the day I stopped that medicine and has never come back. I had a wonderful time on my trip, and I didn’t need to take any antihistamines,” she wrote. “I saw my doctor the week after I got back and she told me I had done the right thing to stop the medicine. We discussed it and she started me on a different medicine that’s for the same thing, and I have had no problems taking it so far. Hopefully I can complete my last two and a half years of treatment with this new one”.
“I really appreciate you and your Why Dogs book because it gave me the courage to speak up about my symptoms instead of just putting up with them. You gave me the encouragement I needed to go talk to my doctor about my problem and ask for something else. Thank you.”
“By the way, I was interested in your article on skin treatment to prevent radiation burns and thought you might want to pass on this tip to your readers that I got from my radiologist in Seattle. He recommended I buy the purest aloe Vera juice I could find and to apply it to the skin area after each radiation treatment (never before, just after). I looked around and found some pure aloe juice at Trader Joe’s. I used it after every treatment and never had any discomfort after any of my treatments.”
