Did you get your flu shot?

Here I am making sure that everyone at Delgado Community College gets theirs!

I wore my boy hair.

Flu shots and all the fixin's

 Actually...I haven't had my flu shot this year. There are two reasons for this:
1. I work alone, and I don't know how I feel about giving myself a vaccine.
2. The preservative-free vaccine isn't available yet and I think it's inadvisable to inject mercury into your muscle every year.


So. Do YOU get the flu shot? Why or why not?

Ask a Pharmacist: What can I do for chronic bad breath?

1. Talk to your dentist in case you have gum disease.
2. Floss twice daily. You can run the floss through some mouthwash before using for extra effectiveness. Pay attention to ill-fitting crowns as you floss: they may need dental work.
3. And if all else fails, you simply use the magic cure. It really is magic, but it's hard to find. I've been recommending Lavoris for years, and I've had women come tell me that it saved their marriage. My own hubby uses it, because he's paranoid about his breath.

It's full of food coloring and sickly sweet, but it really works. Gargle before bed. Oh and don't use the mint flavor, only the cinnamon seems to be effective.
If you can't find Lavoris in a tiny little mom and pop drug store, ask the pharmacist to order it for you.

Ask a Pharmacist: What can take for a sore throat?

Ah, seasons are changing, pollen is wafting, people are sniffling!
One of the common questions I receive this time of year is about sore throats. Nothing is more annoying, yet since a sore throat isn't dire, you still have to go to work and school and act normal. How you should treat it depends on the cause.

1. Scenario one: "I'm getting over a cold, but my cough is always the last thing to go. It's giving me a sore throat."

It sounds like your throat is irritated. While out and about, suck on some Halls Breezers. They're pectin-based, so they coat the throat to soothe it. Alternatively, buy slippery elm lozenges at a health food store. They work well, too. When you're at home you can sip hot water with honey. I don't usually recommend tea since it is an astringent and can dry out the throat and worsen the irritation.

2. Scenario two: "I think I'm dying."

You might have the flu. If you're aching, feverish, and seem to have a severe cold or a flu, you may have a sore throat as part of the infection. The pain is partly due to your immune response in the area, partly from irritation thanks to coughing and mucous build up, and partly due to the overall aches that set in with a flu. Swallowing and talking hurts.
Treat the pain with a lozenge that contains benzocaine, such as Sucrets or Chloraseptic. They actually numb the throat. Avoid sprays; they're messy and hard to apply and wash away with a few swallows.

3. Scenario three: "Swallowing is so painful! It feels like there is a lump in my throat."

First, make sure you don't have strep. Strep symptoms can be similar to a cold or flu, with noticeable throat pain. You may be able to see swelling, redness, or white spots on the uvula, tonsils, and palate. But don't trust your own diagnosis: it's hard to look in a mirror with a flashlight see if your throat is red and sometimes symptoms are non-specific.
If you have a cold or flu and feel that painful swallowing, you need to reduce swelling in the area. There are two prescription options: one is an oral steroid to decrease inflammation; another is a gargle called by various names (1:2:3 rinse or Magic Mouthwash). You have some non-prescription options, too. You can actually make your own gargle for sore and swollen throat and tonsils. Mix 3 teaspoons Maalox liquid with 2 teaspoons Benadryl liquid and one teaspoon Chloraseptic spray (take the spray top off the spray bottle),. Gargle and swish well for at least a minute and spit out. you can repeat every few hours; don't swallow since you'll be loading up on Benadryl. Another remedy is very old fashioned: plain Coca-Cola. Sip some regular coke and notice that it reduces inflammation. And of course, a good old hot toddy helps, too.

4. Scenario four: "I've had this annoying sore, raw feeling in the back of my throat for days."

Most of the time a nagging sore throat is allergy related. Allergies give you sniffles; sniffles give you post-nasal drip; post nasal drip irritates the throat. Drying up the drip usually takes care of the problem. If you have noticed other allergy symptoms, try an antihistamine for a few days. I'm partial to cetirizine (Zyrtec). You may need more than just an antihistamine if you are experiencing a great deal of nasal mucous. One remedy is to use a saline rinse to clear the sinuses out. Try a netti-pot or similar wash. This is not comfortable, but if you keep producing nasal mucous this can help. You can also gargle with salt water to clear out the mucous that collects in the throat.
If you have a cold, sometimes the post-nasal drip is thicker and an antihistamine won't help very much. If you are waking up with a lot of thick congestion and a sore throat, try thinning the mucous with a guaifenesin (Mucinex in the blue box or plain Robitussin). At first your nose will run more and you will have more drainage, but it will help you to clear it out.

5. Scenario five: "I had a long night out/long speech/12 hour meet and greet/opera. Now my throat is sore."

Overuse injuries require rest, hydration, and soothing. Drink tons of water. Milk, especially whole milk, can sooth but don't use it if you're a singer - it prevents mucous breakdown and can effect your singing voice. You can sooth the throat with pectin drops or slippery elm lozenges but don't use regular cough drops.


By the way, I'm now taking real ask a pharmacist questions, and I'm going to go back to my previous posts and find questions from the comments in that section, too. Thanks in advance for the questions!

Ask a pharmacist: Which NSAID should I take? Part II

Well, the time has come to conclude my verbose post on NSAIDS. Where we last left off we had talked about how NSAIDs work, and what side effects are common with NSAIDs.
Now here is the useful part: Which NSAID should you take?

Let's go over them by type.
1. Aspirin. Aspirin gets it's own category, because it is unique. What makes aspirin different (besides the fact that it is sort of natural, as its precursor can be obtained from willow bark, did you know that?) is that its inhibiting mechanism (see last post) is PERMANENT rather than temporary. When aspirin binds to its target, it stays forever. So to overcome the effects of aspirin you actually have to produce more enzymes. That is why aspirin is used to keep the blood thin. People who take a daily aspiring to reduce the risk of heart attack or stroke usually take a enteric-coated tablet that won't dissolve in the stomach. It dissolves in the intestines, so stomach bleeding is less likely.
Technically aspirin falls into the salsalate class, and there are other drugs in this class, but they are used rarely - and generally for irritable bowel syndrome or Crohn's disease.
Do not take an aspirin daily unless directed by your doctor. He will give you a risk assessment to see if you are a candidate for daily aspirin therapy. Remember you are balancing the blood thinning benefits against the possibility of stomach issues, kidney damage, and high blood pressure.
Asthmatics should not take aspirin unless their doctor ok's it - aspirin - and to a certain extent, other NSAIDs - can exacerbate asthma, but not everyone is sensitive to it.
If you have gout, don't take aspirin for it. It will make it worse. 
Don't take other NSAIDS if you're taking aspirin to thin your blood as  the other drugs will counteract these effects.
2.Propionic acids: ibuprofen, ketoprofen, naproxen. These drugs are all available over the counter and as prescription (higher strengths). These drugs are great for short term relief of fever, swelling, cramps, and pain related to inflammation. They are all fairly rough on the kidneys and the stomach (naproxen especially), so use should be temporary - none of this "I take Motrin every day" crap. If your stomach is sensitive, ketoprofen (Orudis) is a good choice. It is milder on the stomach. If your pain is keeping you awake at night, choose Aleve (which contains naproxen), as it has an 8-hour duration of effect; the others will last 4 to 6 hours and you can awaken in pain late at night. Ibuprofen is superior in the class for menstrual cramps and fever reduction. Interestingly, there is not hard and fast data showing that naproxen increases the risk of heart attacks. This may be true or this may be the stats lying to us. I wouldn't let that influence your choice of drug.
3. Acetic acids: diclofenac, etodolac, indomethacin, and sulindac. These are all available by prescription only. They are killer strong and killer rough on the stomach. The first two come in extended release preparations that have longer duration of action. Indomethacin is outrageously good for gout but studies show that it is very hard on the stomach and may be very hard on the heart as well.
4. Napthylalkanones: Nabumetone. Rx only. Excellent for muscular pain, especially when associated with stiffness and tension.
5. Pyrroles: Ketorolac. Rx only. A wonder drug post-surgery: it actually beats our opioids like morphine for pain control. Unfortunately, if used for over 5 days or at a dose greater than 20 mg per day, it is extremely toxic to the kidney and can easily cause kidney failure. It should never be used longer than 5 days. I mean it.
6. Enolic acids: piroxicam, meloxicam. Rx only. My personal favorite class. Both are well-tolerated and can be taken just once a day, as the half-life is over 24 hours. They are wonderful for muscle pain and swelling, especially around the joints since maintaining control of swelling over a 24 hour period is important to allow healing of the joint. What's fantastic about meloxicam is that it is COX-2 preferential. It doesn't select for COX-2, like Vioxx did, but it tends to prefer the COX-2 enzyme, so there is very little stomach upset with this drug.
7. Cox-2 inhibitors. The only one left is Celebrex (celecoxib). Don't take it. It is expensive and no more effective than meloxicam. Incidentally it is a sulfonamide, so don't take it if you have a sulfa allergy.

In closing, runners should take meloxicam, but not before a long run as you risk kidney failure. Crampers should take naproxen or ibuprofen. Gout victims should consider short term therapy with indomethacin. Rich people should take Celebrex.

And any questions, ask me!

Ask a pharmacist: Which NSAID should I take? Part I

I got a few real-life questions for a pharmacist last week, but you know what? They were all about vitamins. I didn't want to talk about vitamins again. So I found an imaginary friend question I liked better (although I will get to those questions. Except maybe the vitamin E one, way to pick a tough topic Termite!) This question is about NSAIDs - those helpful pain and inflammation killers that can be so confusing.

If you run, you probably take NSAIDS for pain and swelling. Actually if you have ever had pain, fever, cramps, or swelling you have probably taken NSAIDS. NSAIDS (non-steroidal antiinflammatory drugs) are agents that reduce pain and inflammation by modifying the COX enzyme pathway. These enzymes facilitate the production of prostaglandins which cause pain, inflammation, and fever. The name "NSAIDS" was chosen ages ago to distinguish them from steroids, which are a completely unrelated type of antiinflammatory.
To understand how NSAIDS work, let's review a little pharmacology.

It's easy, I promise.

First, let's talk about what happens when you are injured. Let's say you shut your thumb in the door. You're hurt, and your cells are hurt. When the door slams, it squishes your cell membranes, and they release a compound called arachidonic acid (with the help of phospholipase-A, an enzyme). This starts what we call the "COX pathway", your body's antiinflammatory response to injury. Arachidonic acid is broken down by the COX enzymes to create several products:  thromboxane, a compound that causes platelets to adhere to each other and cause clots; prostacyclin, a compound that causes blood vessels to enlarge and prevents platelet clotting; and certain prostaglandins, which cause swelling, pain, uterine cramping, and fever. Now right off the bat you probably wonder why your body responds to injury by making compounds that both CAUSE clotting and PREVENT clotting. It's all part of keeping balance during an injury to make sure your blood can bring the healing cells it needs to the injury sight ... yet you won't bleed to death either. The clotting pathway, however, is complex and goes beyond our scope today. So back to NSAIDS. Anyway, these prostaglandins are useful in healing your body, but they cause uncomfortable effects, too. For example, fever is meant to kill bacteria that might have invaded the sight of injury, but we don't always want to deal with fever. So we take drugs to stop these effects. The enzymes that break arachidonic acid down to the prostaglandins that cause inflammation and fever are COX-1 and COX-2. Since COX-2 is produced at the sight of injury and has these results, this is the enzyme we want to inhibit. However, most NSAIDS also inhibit COX-1. Basically they can't differentiate between the two enzymes, so they inhibit both. The problem with that is that while COX-1 can produce inflammatory prostaglandins, we need it for something else. It is present in our gastrointestinal tract at all times, helping to produce different prostaglandins required to maintain the natural mucosal lining in the stomach. If COX-1 is inhibited, these prostaglandins aren't produced, and the stomach becomes easily damaged and upset. Your lining can bleed, severely even.
It would make sense, then, to try to develop a drug that would just stop COX-2, which is only produced by the body at the site of injury. That would spare some side effects. Scientists tried this, and they succeeded. Remember Vioxx? Vioxx, of all the legal claims and law suits? Yeah, there was a problem with COX-2 selective inhibitors. Studies have shown that COX-2 inhibitors increase the risk of heart attack and stroke. I had a 6-paragraph explanation of why this might be so, but it was beyond boring and the conclusion was..."one of these two mechanisms may be the culprit..." so I cut it out. If you want more info, though, email me!
Of course, COX-1 or COX-2 or whatever, all NSAIDS have certain side effects and risks.Before I talk about specific NSAIDS, I'll review the side effects common to all drugs in the class.
Stomach upset: Any drug that reduces COX-1 upsets the stomach and may cause/allow intestinal bleeding. If you have a history of GI bleeding or take other drugs that can cause GI bleeding or have gastric ulcers, avoid NSAIDS.
Blood thinning:  All NSAIDS thin the blood. If you're on a blood thinner you have to discuss NSAID therapy with your doctor; he may allow it but will monitor you more frequently (I have had a patient die from a massive GI bleed due to self-medicating with over the counter ibuprofen. The combination of thin blood and gastric bleeding actually killed him).
Water retention and increased blood pressure: NSAIDS cause your kidneys to hold on to extra water. This will increase your blood pressure and can worsen heart failure, because your heart is burdened with extra fluid to pump.There is more to this, but it is a dry discourse. If you want more info, again, email me.
Kidney damage: NSAIDS can damage the kidney through several mechanisms; mainly they inhibit prostaglandins that allow vessels in the kidney to expand. The tightened vessels prevent the kidney from processing fluids, and the kidney can shut down and fail.
High potassium: It's all connected: the high blood pressure, water retention, and kidney damage are all linked, and they are linked to increased potassium, too (moral of the story: don't mess with your kidneys!). This is usually only a problem for people who already have problems with electrolyte balance or with their kidneys.
Tinnitus: All NSAIDS, but primarily aspirin, can cause ringing in the ears.
Liver failure: Possible with high doses of all NSAIDS. 
Pregnancy/breastfeeding concerns: You may take NSAIDS while breastfeeding. Do not take while pregnant (date shows increased complications when taken during your third trimester).
Who should not take NSAIDs/ask your doctor: Asthmatics, those with a history of stomach ulcer or GI bleeding, people on blood thinners, people with high blood pressure (even on medication since NSAIDs counteract the effects of certain blood pressure drugs - please talk to your doctor), people with heart failure, those who have a kidney disease.

Are you scared yet? Haha. This post is getting horribly long, so I'll leave you with this background and next time I'll go into the differences between different NSAIDS and which are best for which condition.

A note about sources: these posts are my opinion as a pharmacist and based on my training. If I have any fact-checking to do, I generally do it from a variety of reliable sources. If I ever directly use a study or some data, I will reference it. So far these have been too general to require that.