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Thursday, November 10, 2011


The View From the Office


Cholesterol Medications: The cholesterol medication with the greatest name recognition, Lipitor, goes generic at the end of this month; it will then be the preferred generic statin medication. Many people should consider changing their cholesterol medication in order to take advance of this more potent, and now finally, less expensive drug for cholesterol.

Drugs for Osteoporosis:  (Fosamax, etc.): The new consensus is that patients should not just remain on these medications forever, once they start. Most experts are calling for stopping the medication after 5 years, unless there is a recent osteoporotic fracture. Some experts recommend stopping after 3 to 5 years and then rechecking a bone density test in 2 to 3 years to see if there is relapse. The problem with taking these medications too long are that you can get a condition called "osteonecrosis of the jaw" (no fun) and/or atypical femoral fractures. All of these drugs are different forms of a chemical called BISPHOSPHONATES, and these stay in the bone for years even after stopping the medication. 
     Prescriber's Letter recommends that everyone take 1200 mg of elemental calcium daily and 800 to 2000 IU of vitamin D3.

SAW PALMETTO is Losing Its Fans: Prescriber's Letter predicts that saw palmetto will fall out of favor for treating symptoms of enlarged prostate (BPH). Two new NIH-sponsored trials now suggest that saw palmetto is NOT better than placebo for BPH symptoms...even at high doses. "In fact, our Natural Medicines Comprehensive Database is downgrading its rating of saw palmetto to "Possibly Ineffective."
     This expert group recommends telling men not to rely on saw palmetto for BPH. Explain that benefits are modest at best. There is no need to be overly concerned, however, if men want to try it, there's no evidence of serious adverse effects.

PROBLEMS with MAGNESIUM and PPI medications (e.g., Prilosec, Nexium, Protonix, Prevacid, Aciphex, etc.): Medications like Prilosec (omeprazole) may lower magnesium levels. These experts recommend checking a blood test for magnesium in patients who have been on PPIs for a long time. Other drugs that can lower magnesium are diuretics for hypertension or heart failure, and some of the cancer drugs like cisplatin. Also, if you are having a problem with either calcium or potassium, consider doing blood tests for all 3 -- calcium, potassium, and magnesium. It will be difficult to correct low calcium or potassium if the magnesium remains low.
     If your magnesium is low and you need a supplement, consider the one that is best absorbed--magnesium lactate (Mag-Tab SR), magnesium chloride (Slow-Mag), or magnesium aspartate (Maginex).  Magnesium oxide is easier to get (Mag-Ox) and has more elemental magnesium than the others, but it is not well absorbed. Better absorption means less diarrhea. You can use IV magnesium sulfate for severe deficiencies. Ultimately, if the magnesium does improve in a patient on a PPI, stop the PPI, and substitute an anti-histamine acid drug like Pepcid.
     Prescriber's Letter  recommends avoiding magnesium supplements in patients with renal insufficiency, which is pretty common in our neck of the woods.

A Guideline to Reduce Your Risk of Ulcer from ANTI-INFLAMMATORY DRUGS:

                 LOW GI RISK      MODERATE GI RISK                HIGH GI RISK

LOW         ibuprofen or     1.Celebrex alone                      1.avoid NSAIDs
CARDIAC   Alleve              2.ibuprofen, etc, + PPI             2.Celebrex + PPI
RISK                                    or Cytotec
                                       3. NSAID + double-dose 
                                           Pepcid or Zantac (etc.)

HIGH          Naproxen        1. Naproxen + PPI or Cytotec     Avoid all NSAIDS
CARDIAC                          2. Naproxen + double-dose 
RISK                                     Pepcid or Zantac, etc.

Note: NSAIDs include all anti-inflammatory drugs except aspirin--e.g., ibuprofen, Advil, Nuprin, Alleve, naproxen, Mobic, Relafen, Clinoril/sulindac, etc.

THYROID MEDICATION: You May Not Need As Much: The fact is that younger people, if their thyroid gland is not producing enough hormone,  need more hormone replacement (levothyroxine) than older people. Younger adults need about 1.7 mcg/kg/day of levolthyroxine but some seniors need only 0.5 mcg/kg/day. I have been seeing several older patients recently who have been on the same dose of levothyroxine for over 10 years, but all of a sudden on a routine thyroid test (TSH), their TSH is too low, indicating they are getting too much thyroid hormone. The explanation of this is just normal aging. After a certain time, we need to reduce the dose a bit. That is why it is so important to check your thyroid blood test (TSH) at least once a year, if you're taking thyroid medicine. Then check it again 6-8 weeks after any dose change, suggest the editors of Prescriber's Letter.

FISH OIL TO LOWER YOUR TRIGLYCERIDES: The rule of thumb is that 1 gram a day of omega-3 fatty acids from fish oil will lower triglycerides by 5 to 10%.  You can go up to 4 grams a day, if you're not having side effects. 

THE NEW DRUG FOR ATRIAL FIBRILLATION: Pradaxa (dabigatran) Can Replace Warfarin: Pradaxa is generally very good news. It is more effective at preventing strokes than warfarin (Coumadin) and it does not require any blood testing. It costs about $240 a month (for twice daily dosing) compared to about $80 (with blood testing) for warfarin. There are, however, a few caveats:
  1. If you are already on warfarin and want to switch to this, you should stop your warfarin, wait until your INR is less than 2.0, then start the Pradaxa.
  2. If you are doing well on warfarin, don't change. Changing will create an increased risk of bleeding, particularly gastrointestinal bleeding.
  3. Missed doses of Pradaxa: Pradaxa lasts in the system for about 15 hours. Thus if you miss a dose, you should take the missed dose as soon as you remember it, but NOT  if your next dose is due in less than 6 hours. That would increase the risk of bleeding.
  4. If you do experience bleeding on Pradaxa, the old remedy of vitamin K which we use for excess bleeding due to warfarin, will not work. You will need a blood transfusion.
  5. Pradaxa is only good for 30 days after the bottle is opened. 
  6. The most common side effects of Pradaxa is upset stomach. Taking it with food, or with an OTC medication like Prilosec or Pepcid or Zantac may help.

Reference: Prescriber's Letter, Vol 18 No 1 January, No 6 June, No 7 July, and No 11, November 2011 

1 comment:

  1. completely useful..good source, thanks anyway!