Can't Swallow That?

Difficulty swallowing, known medically as "dysphagia", is a very common complaint. In fact, up to nearly a quarter of patients seen in primary care settings will suffer from this problem. Dysphagia is definitely more common in the older population, whether they are in nursing homes or living independently.

What causes dysphagia? The most common cause depends on the age. In small kids, there may be structural problems present from birth that may need surgical correction. In adults, however, the cause is often something that can be fixed more simply, with medications and/or behavior changes.

Smoking, excess alcohol, and obesity all tend to increase stomach acid refluxing back up into the esophagus, which can cause pain or difficulty in swallowing. Reflux, also known as GERD (Gastro Esophageal Reflux Disease) is a very common cause of dysphagia that is seen in otherwise healthy people. Quitting smoking, stopping excess alcohol and weight loss can all improve symptoms, as well as taking medications that reduce acid production.

Medications such as NSAIDS (like ibuprofen), potassium supplements, antibiotics and osteoporosis medications can all cause problems with swallowing, so both diagnosis and treatment of dysphagia in this case may involve stopping prescription medications.

• Let me take this opportunity to caution against "DRY SWALLOWING" pills. I cringe when I see people grab an ibuprofen and swallow it without a drink. Every time you take a pill or capsule, swallow it along with at least a half glass of liquid. Dry swallowing can essentially "scrape" or chemically irritate the lining of your esophagus. And please, let gravity help you get that pill all the way to your stomach- don't lie down for at least five or ten minutes after you take medications.

Less commonly, the more serious causes of dysphagia are to blame, including cancers, strokes, neurologic disorders such as Parkinson's Disease, advanced infections, or scarring from prior trauma or radiation.

BOTTOM LINE: Don't ignore trouble swallowing, especially if it persists or is getting worse. Schedule an appointment with your family doctor!

Is it a New or Old Weight Loss Drug?

This month I am talking about obesity & weight loss. By our human (and American) nature, we would all like a quick fix to solve our weight issues. This summer, the FDA approved not one, but TWO new weight loss drugs.  My last blog addressed lorcaserin (Belviq), and today's focus is really something old in a new package.

Qsymia was FDA approved in July 2012, and it is a combination of two older drugs that have been used independently to help with weight loss: phentermine and topiramate. Phentermine is an appetite suppressant, and was half of the infamous fen-fen (a diet pill combo that was removed from the market once its use was associated with the development of pulmonary hypertension (a damaging condition in the lungs) and heart valve issues. Phentermine by itself is still approved for "short term" use- a few weeks- as an appetite suppressant, but there is limited efficacy and safety data available. Topiramate was originally classified as an anti-seizure medication, but indications now also include migraine prevention. Physicians and patients were generally pleased to see that a side effect of topiramate is weight loss (to the point where I have had patients without frequent migraines ask if I will prescribe this drug "just in case"!)

Qsymia combines these two drugs, and showed significant weight loss at one year- an average of 8.9%.
Both drug components are  at much lower doses than the individual drugs are typically prescribed, which hopefully will limit side effects. Indications for this new drug are for patients who have a BMI>30 (defined as obese) OR if they are overweight (BMI>27) AND have high blood pressure, diabetes, or high cholesterol.

If you meet those qualifications and are interested in trying this new drug, don't rush to your doctor quite yet! Qsymia is not yet in pharmacies, though it is anticipated to be in "certified pharmacies" next month (September 2012).

BOTTOM LINE: The newly approved weight loss medication, Qsymia, combines two older medications and may prove to be significantly effective in helping treat obesity, but it is not available quite yet. 

Doctor, this COUGH won't go away!

Did you know that a lingering cough is one of the most common reasons people head to see their family doctors? With most "colds", after you get past the headaches, and stuffy nose part, you find yourself coughing. Sometimes it's a minor "clear your throat" type of cough, while other times, it's the crazy fits of coughing that keep you from sleeping.

Is there anything that can be done for a cough that wont go away? Absolutely, and that is the point of today's blog. "Cough" literally makes the top ten list every year for reasons to visit your doctor. After many upper respiratory viruses, coughs will linger... for up to SIX weeks! A cough does NOT mean you definitely need an antibiotic- in fact, typically, you do NOT. However, a cough that is not managed with over the counter medicines should be addressed by your physician. Coughing all day long at school or work (or keeping up your spouse with coughing all night) is NOT a good plan!

What can your doctor do? First of all, they do need to rule out any secondary infection such as a pneumonia. If you are a week into your symptoms, and suddenly you feel a ton worse and develop a fever, this might be a bacterial infection setting up shop AFTER the virus cleared the way past your body's defenses. More commonly, though, you may have developed some over-reactive airways and may benefit from some inhalers or other asthma-style of medicines. A prescription cough syrup used at night may help with the nighttime exacerbations, and your doctor can remind you of some traditional home remedies such as cool mist humidifiers that may help. Finally, sometimes a cough comes from other sources, such as acid reflux or sinus drainage, which require different treatments.

BOTTOM LINE: See your doctor to evaluate coughs that get worse after a respiratory illness, or that wont go away- don't expect antibiotics, but know there are other treatment options!!

Having Trouble Taking All Your Medications?

Today I'd like to say a few words about medications. Often physicians need to prescribe multiple medications for the same patient. One is each morning, another twice a day, a couple are "as needed" and yet another is recommended at bedtime. One must be taken with food, and another is restricted to an "empty stomach". Before you know it, our patient is supposed to take a half a dozen pills per day- at different times, and with different restrictions- and then we wonder why they are "noncompliant"!

In a perfect world, pills would not interact with each other or with meals, and they could be given once per day. In reality, many medications do not play well in the stomach together, and must be separated. What can we all do? Well, the basic pill box that has a separate compartment for each day is lovely. Don't feel you need to qualify for Medicare before you purchase one! I tell all my patients that there is a good reason "the pill" comes in a dispenser that is labeled by day. How many times have you wondered, "gee, did I take my pill today?" Well, the same is true for vitamins, calcium supplements, and prescription medications of all sorts.

Find a pill dispenser that works for you! If you have multiple medications, consider one that actually reminds YOU! There are wonderful contraptions that you can set up with a week or more of pills, and then an alarm will go off up to four times per day, letting you know that your pills are ready for you!

The picture above is the one I used for my memory-challenged father for several years with great success.

BOTTOM LINE: Don't rely on your memory- find a pill dispenser that works for you to simplify and increase your success with medication compliance!

You can find this pill dispenser at the online Alzheimer Store ; I have no financial ties to them, just really appreciate how this tool simplified MY life and improved my Dad's consistency with medications!

ADD- Is Zinc the answer?

We are always looking for more and better solutions to Attention Deficit Disorder, so I was pleased to read a study published last month in the Journal of Child and Adolescent Psychopharmacology, entitled Zinc for attention-deficit/hyperactivity disorder: placebo-controlled double-blind pilot trial alone and combined with amphetamine, that looked at the role of ZINC in treating ADD. There have been some studies published in other countries that suggest supplemental dietary zinc may improve symptoms of ADD. This pilot study was small (as pilot studies should be) including just over 50 children.

The kids received zinc or placebo alone for the first two months, and there was no consistent, statistically significant advantage to taking zinc alone (vs. placebo). Then, the children were randomized to receive either zinc plus amphetamine (such as Ritalin) or a placebo plus the amphetamine for the next five weeks. Here is where the results are encouraging. Although the symptoms of inattention were not better for the kids who received the zinc plus amphetamine, the good news is that those receiving the zinc supplement required 37% less amphetamine to receive the same results compared with those taking amphetamine plus placebo.

Simply restated, the zinc seemed to help the amphetamine work more efficiently, so that a LOWER DOSE of the amphetamine achieved the desired results. Why is this important? Because lower effective doses mean LESS SIDE EFFECTS. So, should you rush out and buy zinc to supplement your child's ADD medications? No, I wouldn't do that based on a study with only 50 kids. However, while we're waiting for future studies with more significant numbers, why not be sure your child is meeting the recommended daily allowance for zinc? (~10mg per day for teens) What foods contain the most zinc? Seeds (pumpkin, sesame, watermelon), wheat germ, chocolate and peanuts. Hmm...maybe Snickers had the right idea! Or a healthier choice would be to head for the hummus (made with tahini- sesame seed paste.)

BOTTOM LINE: Zinc may help reduce the amount of amphetamine medication needed to improve symptoms of ADD.

Where Did My Favorite Cold Medicine Go?

Today the FDA (US Food & Drug Administration) is removing many allergy, cough and cold products from the shelves of your pharmacy. If you have a favorite that has worked for you, perhaps you should stock up. What's going on? Well, it turns out that there are a ton of drugs out there that lack FDA approval, yet doctors and patients alike are unaware.

Why does it matter? Our FDA actually does a great job of collecting and reacting to adverse events related to medications, acting swiftly to remove products that could cause danger. Though there are not oodles of reports with this group of products, there are enough, especially considering that because most are over-the-counter, adverse events are much less likely to be reported.


Frankly, as I went through the list, I was very surprised that some drugs that I have previously written prescriptions for (like Entex PSE and Bromfed) are NOT FDA approved. The main reason I don't routinely recommend herbal treatments is their lack of FDA regulation, which means there is no guarantee of the amount of ACTIVE product in each tablet or capsule. Turns out, this could be true for any of these allergy, cough & cold remedies as well. Additionally, in the past couple of years, pediatric recommendations have changed greatly, especially for kids younger than two years. Many of these medications do not issue any such precautions.

Here are a few, but go to the FDA website for a full list: Accuhist DM, Aerohist, Allerx, Aquatab, Bromfed, Biotuss, Brovex, Carbodex, Deconamine, Duravent, Entex, Guaifenesin, Histex, Lodrane, Rescon, Ru Tuss, ZCof, etc.

Note that the Triamic brand and Robitussin brand are NOT on the list.

BOTTOM LINE: Go to the FDA WEBSITE and scan the list to be sure YOUR upper respiratory medicine of choice is NOT on the list!

Glucosamine and Chondroitin- the Latest Research!

Okay, on the list of drugs to keep in your medicine cabinet, there are two you might want to remove...unless YOU feel relief from them. For years, doctors have been recommending glucosamine and chondroitin for relief of the aches and pains associated with arthritis. A large meta-analysis was recently published in the British Medical Journal entitled Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis. The study evaluated nearly 4000 patients, across ten separate trials.The questions were whether or not these medications provided (A) pain relief and/or (B) any improvement in narrowing of joint space (that is part of the visible decline in arthritic joints, as seen on xray.)

Unfortunately, neither end point was observed. As such, the recommendations from this study are that doctors not encourage patients to try these medications, and that health insurers should not cover the cost of these drugs.
On the flip side, the study recognized that there were no dangerous side effects of glucosamine or chondroitin, so if patients subjectively feel they are getting relief, the use of these drugs need not be discouraged.

BOTTOM LINE: The latest evidence shows that glucosamine and chondroitin do NOT improve pain from hip and knee arthritis, nor do they delay progression of disease.

Coming Up or Running Out- the GI Drugs in the Cabinet

Finishing up what doctors keep in their medicine cabinets, I need to include the GI (gastrointestinal) emergency stash- drugs for throwing up and diarrhea.
For one or two episodes of vomiting, we simply cautiously hydrate with sips of gatorade and wait and see. However, for those occasional wicked stomach viruses that cause nonstop puking all night, we reach for a prescription that we keep on hand- phenergan (promethazine). This drug comes in suppositories as well as pills, and we know when a family member is ready to deal with a suppository, they really need it! Note that phenergan makes you sleepy, which is often a desired side effect, but it also can be addictive- this is for infrequent intense nausea, not for daily use!

What about the other end? No prescription here, we simply keep OTC liquid and pill forms of Imodium. The most important thing with diarrhea is to stop dairy products for a couple days, as you become temporarily lactose intolerant after a day of loose stools.
We also keep a bottle of acidophilus (probiotics) tablets for preventative use when someone is on an antibiotic (to avoid diarrhea from killing off the good bacteria in the gut.)
This is perhaps the least frequently used part of the medicine cabinet, but desperately desired when the occasion arises.

BOTTOM LINE: Phenergan and Imodium make up the gastrointestinal portion of our medicine cabinet.

Stop that Itch! Medicine Cabinet Staple # 5

I am focusing on what medications doctors keep in their home cabinets, and the next item on the list is not a pill, but a cream: HYDROCORTISONE cream or ointment. This is a steroid- not the pump you up/Arnold Schwarzeneggerr type steroid- this is the anti-inflammatory steroid. Grab this when you need to stop an immediate irritation on the skin, such as bug bites or poison ivy. If you've got something new, red and itchy on your skin, very likely this cream will help!
Having said that, know that there certainly are infections or other skin conditions that will not improve with steroid cream, and indeed can be made worse. Obviously, if your itchy rash is not rapidly improving, see your doctor!

This is not something to use on your face or other tender parts, however. Limit your use primarily to your extremities (arms, legs, fingers and toes) and trunk (back, chest and belly). Steroid creams are also not for long-term use, as they can cause thinning and damage to the skin if used chronically.

BOTTOM LINE: For insect bites & stings, and other new itchy "things", try some over-the-counter strength topical steroid cream.

Doctor Preferred Medicine #3- Ibuprofen

Okay, back to what drugs doctors keep in their home medicine cabinets... The first drug I mentioned was aspirin, then diphenhydramine (benadryl), and today-ibuprofen. I have to confess that this is without a doubt the most used medication in our house. Now, I do not believe in medicating every ache or even temperature, but when one of us is in pain or has a high fever, ibuprofen is our drug of choice.
When the kids were little, we kept liquid ibuprofen around (for fevers and teething primarily) but now happily, everyone in our family can swallow pills, so we have a bottle of caplets.

Ibuprofen has many trade names- Advil and Motrin being the most popular, I believe. They offer capsules, gel caps, tablets and liquids. Generic ibuprofen typically works just as well, though some people prefer name brands for taste or texture. (We buy generic.) Ibuprofen is a Non-Steroid Anti-Inflammatory Drug, NSAID for short. This class of drug works well for muscle aches, joint pains, tooth pain, post-operative pain, menstrual cramps, headaches and fevers. For chronic problems such as arthritis, longer acting preparations may be more appropriate.

Many people pop NSAIDs like candy- not a good idea! Yes, we often prescribe ibuprofen at higher doses than the OTC label recommends, but that is for acute, short-lived problems. Taking NSAIDS at high doses can be a danger to your kidneys, and do NOT use these daily for extended periods without consulting your physician. Also, be aware that NSAIDS can cause fluid retention, which may raise your blood pressure, and they can irritate the stomach lining (leading to ulcers.) Wow- that sounds like a commercial, but those are real precautions.

BOTTOM LINE: Keep a bottle of ibuprofen in your medicine cabinet for muscle aches, joint pains, fevers, headaches, etc.- this is a "go-to" drug for many minor maladies, but must be used with caution.

Drug #2 in My Medicine Cabinet

This week I'm talking about what most doctors keep in their own medicine cabinets. The first drug was ASPIRIN, which I discussed yesterday- how appropriate for Labor Day, right? What's next?

Diphenhydramine, better known as BENADRYL. This drug is probably the best known antihistamine. We use it for it's good effects- fighting allergic reactions- AND for its major side effect: SEDATION. Did you realize that benadryl is the sleep-inducing agent in all the "PM" medications (like tylenol PM and advil PM)? All they do is add some benadryl to the well known pain medication.

I tend to keep benadryl both in the liquid and in the tablet form, in case we have someone who cannot swallow pills (either young or old!) who needs immediate antihistamine for what may be a serious allergic reaction- to a bee sting, or food, or even medication.

Of note, I do NOT keep the topical benadryl preparations around for itchy rashes- I use topical steroids (hydrocortisone) for that type of problem, as they are more effective.

So, itchy & sneezy and can't sleep? Benadryl is a great choice, unless you feel too hung over from it in the morning. Some people (like myself) feel groggy way longer than the suggested 8-12 hours after taking benadryl.

BOTTOM LINE: Item number two in my medicine cabinet is diphenhydramine (trade name, Benadryl).

What's in YOUR Medicine Cabinet?

Ever wonder what doctors keep inside their medicine cabinets for their families? Well, my friends (and patients) have definitely asked me, so I thought this week I would share with you my answer. Before I launch into the first ingredient, however, let me encourage you to head directly to YOUR cabinet and THROW AWAY EVERYTHING THAT IS EXPIRED! Just like you should check your smoke detectors a couple times per year, you should also take a look in your stash of medical supplies and toss everything that is expired. Yes, I realize that tiny bottles of prescription medications (especially eye drops, for example) can cost a small fortune, but the only thing worse than "wasting" them by not finishing them is depending on them to work later, when their potency is gone. Don't wait till someone is having a bad allergic reaction to discover your benadryl is long expired!

So, what's the first medication on my list? ASPIRIN- yep, good old-fashioned aspirin. Actually, I keep the enteric coated aspirin, because it's easier on the stomach, but you get the picture. Why do we have aspirin in our cabinet? Not for headaches, though it certainly could be used for that malady. We keep it for several reasons:

1. Heaven forbid a grownup in our home (or neighbors') appears to be having a heart attack- the FIRST response is to have them swallow an aspirin.
2. Studies show that an adult aspirin a couple times per week reduces the incidence of colon polyps (and therefore, hopefully colon cancer, which runs in our family.)
3. Before sitting on a plane or going for a long car ride, a single aspirin can help prevent blood clots from forming in your legs (DVTs- deep vein thromboses.)

BOTTOM LINE: Throw away ALL expired medications, and start your family's medicine cabinet supply list with ASPIRIN.

Medications, medications, medications!

Okay, it's obviously a play off of "location...location", but hey, if it gets your attention, then I've done my job! I want to say a few words about medications. First of all, to physicians. Many times we need to prescribe multiple medications for our patients. One is daily, another twice a day, and yet another may be before meals and bedtime. Before you know it, our patient is supposed to take a half a dozen pills per day (and then we wonder why they are "noncompliant"!)

In a perfect world, pills would not interact with each other or with meals, and they could be given once per day. In reality, many medications do not play well in the stomach together, and must be separated. What can we all do? Well, the basic pill box that has a separate compartment for each day is lovely. Don't feel you need to qualify for Medicare before you purchase one! I tell all my patients that there is a good reason "the pill" comes in a dispenser that is labeled by day. How many times have you wondered, "gee, did I take my pill today?" Well, the same is true for vitamins, calcium supplements, and prescription medications of all sorts.
Find a pill dispenser that works for you! If you have multiple medications, consider one that actually reminds YOU! There are wonderful contraptions that you can set up with a week or more of pills, and then an alarm will go off up to four times per day, letting you know that your pills are ready for you!

The picture above is the one I used for my memory-challenged father for several years with great success.

BOTTOM LINE: Don't rely on your memory- find a pill dispenser that works for you to simplify and increase your success with medication compliance!

You can find this pill dispenser at the online Alzheimer Store ; I have no financial ties to them, just really appreciate how this tool simplified MY life and improved my Dad's consistency with medications!