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Ask The Pharmacist is brought to you by YourRxCard.com and Pharmacist Dr. Sam Uretsky . In order to submit your questions please click the image above to fill out your question. We will make every effort to get as many questions as we can answered as well as providing you up to date information from the Health Care world.

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Use of Non-Steroidal Anti-Inflammatory Drugs

A recent review in the journal Spine, evaluated the use of non-steroidal anti-inflammatory drugs for treatment of low back pain. The reviewers concluded that these drugs, which include ibuprofen, naproxene, fenoprofen, meloxicam, nabumetone and lots more, do have some benefit, but don’t expect much from them. They also looked at the studies to try to answer the question that has been asked often enough – which is best. There really doesn’t seem to be a best, they’rr all about the same once the dose is adjusted for differences in potency. The best choice is the cheapest, used in the lowest effective dose in order to minimize side effect. As the doser gets higher, the side effects, particularly the effects on the stomach, become more common and more severe.

Tablets Getting Smaller

The American population is getting older, and manual dexterity declines with age, but for some reason tablets keep getting smaller and harder to pick up. Kitchen tools are made with fatter handles that are easier to hold, and clocks have larger numbers that are easier to read with aging eyes, but pills keep shrinking. They may be easier to swallow, but only if you can get your fingers on them. If the people who have the trademark “Good Grips” came out with a line of pills, they would probably find a market with no trouble at all.

Time Magazine

Time magazine has an interesting report on counter-detailing, focusing on South Carolina’s SCORxE program: South Carolina Offering Prescribing Excellence (yes, that’s the way Time reports it, not SCOPE which seems more logical.) The idea is that the state funded program has pharmacists visiting physicians, offering objective information about drug selection and countering the efforts of corporate representatives to promote more expensive drugs when a generic drug can do the same job at a lower price. The report estimates that every dollar spent on the program saves $2 in drug costs. While South Carolina tends to be a conservative state, and opposition to a program of using state money to counter corporate effort was expected, the program seems to be popular.

But according to Time, there is a major debate going on – should the people doing the counter-detailing work bring pizza?

A Proper Teaspoon

It’s amazing how many parents child-proof their homes, put in latches so that kids can’t get to cleaning supplies, put plugs in electrical outlets and gates in front of stairs – but don’t have a proper medicinal teaspoon. When a prescription calls for giving a child one teaspoonful of a liquid, it does NOT mean take a teaspoon out of the kitchen drawer – it means use an accurate measure. A medicinal teaspoon has 5 milliliters, while household teaspoons may have anywhere from 3 to 6 milliliters.

The best medicinal teaspoons are the ones that look like test tubes with marks on the side. They can be a little bit harder to use, and a lot harder to clean, than some other designs, but they give a more accurate measurement than either the ones that look like spoons or the ones that are packaged with bottles of pediatric medicine.

Save More Than Money – Save Your Life

The purpose of this column is to offer advice about saving money on prescription drugs – which usually reduces to asking questions of your physician and pharmacist. But, there are two other questions you should ask that can save more than money – they may save your life. These are the questions that may prevent prescription errors, and they should be asked before you say good-bye, before you leave the physician’s office, before you leave the pharmacy.

When your physician hands you a prescription, look at it, and read it. If it isn’t clearly written, so that you can read it with no difficulty, as “would you please rewrite this legibly?� You may not recognize the word, you may not be familiar with quadragintesimal either (it means “in forty parts� according to the Hutchinson Dictionary of Difficult Words) but you can read it, and that’s what’s important. Read the prescription aloud to your physician, to be sure you’re reading it correctly. If you can’t read the prescription, don’t assume that anybody else can, because an illegible prescription increases the risk that your pharmacist will make a mistake.

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[Question] Conversion From Ritalin

Question:

Can you recommend a conversion from Ritalin 10mg tid to Focalin?

Answer:

Focalin, Novartis’ brand of dexmethylphenidate (there is a generic product available from Teva Pharmaceuticals) is the dextrorotatory form of methylphenidate (Ritalin, also from Novaris, is the best known brand of methylphenidate) which is used for treatment of attention deficit disorder. If anybody wants a really good discussion of stereochemistry and how it affects drug therapy, here’s a link to a paper that appeared in the Primary Care Companion to the Journal of Clinical Psychiatry but I’ll try to offer an explanation anyway.

Lots of chemical compounds can rotate a beam of polarized light, and lots of compounds exist in two forms, mirror images of each other. These compounds will have the same number of atoms, the same molecular weight, the same formula, but (for want of a better example), like your two hands, they don’t fit in the same glove. The molecular structure that twists a beam of polarized light to the left is called the levorotatory form, and the chemical structure that twists the beam to the right is called dextrorotatory. A mixture of the two forms is called racemic, and because it has equal amounts of the dextro and levo forms of the compound, a racemic mixture won’t bend a beam of polarized light at all.

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Bill To Reduce Medicare Payments Fails

Although the House of Representatives approved HR 6331, a bill that would, among other things, reduce Medicare payments to physicians by 10%, by a lopsided vote of 355 to 59, the bill failed to pass the Senate by a large enough majority to override a threatened Presidential veto.

While the reduction in payments to physicians has been the most obvious provision in the bill, other parts directly affect pharmacy. One provision would require insurance companies to pay valid claims within 14 days of when they’re received. Another part of the bill would change the way the costs of drugs are calculated. Medicare and other insurers pay for prescriptions by paying an estimated price for the drug, plus a fee for the dispensation. These fees, which have to cover the expenses of running the pharmacy – salaries, rent, utilities – have always been low, but there was enough excess in the estimated cost of the drugs to allow pharmacies to operate at a profit. By changing the way the cost of the drugs is calculated, many small and low volume pharmacies, particularly those in rural areas, are expected to become unprofitable. The American Pharmacists Association has estimated that these cuts could force as many as 11,000 pharmacies to close.

The Senate will reopen discussion of the bill when it returns from its Fourth of July recess.

Is It Okay To Take Expired Drugs?

One of the most common questions any pharmacist has to answer is: is it okay to take expired drugs. It’s also one of the hardest questions, with a long answer, because the real answer is “I don’t know� and nobody accepts that even if it is the truth.

It’s important to understand what “:expired� means. It’s not an absolute state, like red light green light – it’s more of a best guess at an estimate. When you take a tablet, the weight of active ingredient isn’t absolute. The label may say “100 milligrams� but it’s actually going to be within a range, something like 90 - 110 milligrams. The exact range will vary from drug to drug, and there are other standards for uniformity, but the thing to keep in mind is that there is a range, and a drug is considered expired when, based on best estimates, it’s at the bottom of its permissible range. Drugs don’t suddenly disappear, so that they’re good on Monday and bad on Tuesday, like a dated supermarket discount. Drugs will normally degrade slowly. That means a drug that has just reached its expiration date is likely to be perfectly good. According to a report in The Wall Street Journal, of March 29,2000, the United States Department of Defense found that it had $1 billion or more of drugs on hand. In order to minimize waste, the military had the United States Food & Drug Administration analyze the drugs. They found that 90% of them were perfectly good even 15 years after they were supposed to have expired. In a published study, the Department of Pharmaceutics of the University of Texas at Austin reported that liquid preparations of metronidazole, an antiinfective agent, which had a labeled expiration date of April 1986, were still had 99.3% or labeled potency when they were assayed in January 1993. According to an article on the web site Medscape.com, Bayer Aspirin is labeled with a 2 to 3 year expiration date, but their own testing shows that the aspirin tablets are still good after 4 years, and they’ve never tested the tablets for more than 4 years.

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Cancer Cures?

The United States Food & Drug Administration is taking action against a number of companies that have been selling unproven “cancer cures”.  False cures have been around for decades, and some were considerably more dangerous than the cancers they claimed to treat.  Others, while not directly harmful, were a waste of money, and kept patients from getting more effective treatments.  The products contain ingredients such as bloodroot, shark cartilage, coral calcium, cesium, ellagic acid, Cat’s Claw, an herbal tea called Essiac, and mushroom varieties such as Agaricus Blazeii, Shitake, Maitake, and Reishi.

The FDA warns patients against any product that makes excessive claims, and gives these examples:

• “Treats all forms of cancer”
• “Causes cancer cells to commit suicide!”
• “80% more effective than the world’s number one cancer drug”
• “Skin cancers disappear”
• “Target cancer cells while leaving healthy cells alone”
• “Shrinks malignant tumors”
• “Avoid painful surgery, radiotherapy, chemotherapy, or other conventional treatments”

“Cancer” is not a single disease, but a collection of different conditions, and not all are dangerous.  Some are so slow growing that they often don’t require treatment, while others can be effectively cured through conventional treatments.  There is no “one size fits all” treatment for cancer, and any product which claims to be effective for all cancers isn’t to be trusted.