A. The most common illness that people who travel outside of Canada develop is diarrhea, usually called Traveller’s Diarrhea (TD). It is caused by eating or drinking food and water that is contaminated with bacteria, parasites or viruses. Preventing diarrhea in the first place is best, with instructions to “boil it, cook it, peel it or leave it”.1,2

Probiotics: Products containing Lactobacillus or Saccharomyces may be effective in preventing TD.4 These can be bought without prescription in most Canadian pharmacies.4 The suggested dose is two billion organisms daily starting two days before leaving and continued for the length of the trip.7 Do not use probiotics without consulting your doctor if you have a weak immune system caused by conditions such as AIDS, certain cancers, or are undergoing long term corticosteroid treatment.8

Do
• Drink boiled or bottled water, or use water purifiers
• Wash your hands regularly and thoroughly with water and soap or use an alcohol based hand sanitizer, especially before handling food.
• Eat thick skinned fruit that you can peel yourself, such as oranges and bananas.
• Eat well cooked food while it is hot.1,2

Avoid
• Ice cubes in drinks
• Any unpeeled fruit
• Unpasteurized milk and dairy products
• Salads & buffets
• Re-heated foods
• Shellfish and large fish
• Food from street vendors
• Swimming in fresh water1,2

Prevention:
Antibiotics: Using antibiotics to prevent TD in healthy adults and children is not recommended. Taking antibiotics unnecessarily can lead to bacterial resistance and also may make people more likely to get other infections or have reactions to the drugs.3,4

Prevention treatment with antibiotics might be considered for travellers who must stay healthy such as business travellers or international athletes or for people with conditions that place them at higher risk for TD. This would include people with AIDS, immunodeficiency, chronic gastrointestinal disease, kidney disease and diabetes.1,2,3,5 These people may benefit from prescription antibiotics which are started on the first day in the area and continued for 1 to 2 weeks after returning home.

Vaccine: An oral vaccine called Dukoral®, which works against a common cause of TD, is sometimes used. It is available without a prescription in Canada and is taken as 2 doses by mouth at least 1 week apart. Protection takes effect 1 week after the last dose and lasts for 3 months.6

Self-treatment of TD:
Studies have shown that self treatment is effective in rapidly improving TD.3,5 Mild to moderate TD (up to 3 bowel movements per day with no blood in stool and no fever) will often get better within 24 hours with nonprescription antidiarrheal medicines such as loperamide (Imodium, generics) and bismuth subsalicylate (Pepto Bismol, generics).4 Imodium and Pepto Bismol should be avoided in severe TD.4 Pepto Bismol contains an ingredient related to aspirin and therefore should not be used by people with bleeding problems or who are taking blood thinners; pregnant or breastfeeding women; and children with flu like symptoms or chickenpox.9

Severe TD (blood in stool and/or fever) should be treated with antibiotics. Your doctor may prescribe an antibiotic for you to take with you. You can use the medicine if you do get TD. Usually, you will get enough of the medicine to last for three days. If you get better before that, you can stop taking the medicine. If you do not have a fever or blood in your stool, you can take loperamide along with your antibiotic.3,4

If you get TD it is important to avoid dehydration. You can buy oral rehydration salts such as Gastrolyte or Pedialyte to take with you. These are also sold without a prescription in most countries. Mix in distilled or boiled water.3

You should see a doctor if any effects continue for more than 2 weeks after returning home.4

Prepared by Jean Macpherson, Drug Information Consultant. Reviewed by Dr. Yvonne Shevchuk, College of Pharmacy & Nutrition, U of S and Karen Jensen, SDIS.

Sources
1) International Association for Assistance to Travelers. Available at http://iamat.org/getting_ready_travel_health_basics.cfm . Accessed Apr. 1, 2012.
2) Health Canada. Travel Health. Minimizing your risk. Available at http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/life-vie/travel-voyage-eng.php#mi. Accessed Apr. 1, 2012
3) What You Should Know About Travelers Diarrhea. Canadian Pharmacists Letter; May 2007; Vol: 23.
4) Travellers Diarrhea – Treatment and Prevention. Anti-infective Guidelines for Community-acquired Infections 2010 Edition:p102-103.
5) Steeves A, Ford D. Essential intervention: The pharmacists expanding role in travel medicine. Pharmacy Practice July/August 2010.
6) e-CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; Dukoral [product monograph]. Available from: http://www.e-cps.ca. Also available in paper copy from the publisher. Accessed Apr. 1, 2012.
7) Hilton E, Kolakowski P, Singer C, et al. Efficacy of Lactobacillus GG as a Diarrheal Preventative in Travelers. J Travel Med 1997;4:41-3.
8) Health Canada. Licensed Natural Health Products Database. Culturelle monograph. Available at http://webprod3.hc-sc.gc.ca/lnhpd-bdpsnh/search-recherche.do?lang=eng. Accessed Apr. 15, 2012
9) C-Health. Pepto-Bismol monograph. Available at http://chealth.canoe.ca/drug_info_details.asp?brand_name_id=5164. Accessed Apr. 15, 2012.

A. Bedbugs (Cimex lectularius) were almost wiped out in North America in the 1940s because of the widespread use of DDT and other liquid pesticides. Increase in the last 10 years of bedbug infestations may be due to decreased use of these pesticides, increased resistance to common pesticides and increased travel abroad as bedbugs can easily hide in luggage, clothing and personal items. They are found worldwide.(1,2,3)

Bedbugs are flat, oval, reddish-brown, wingless insects about 5 to 9 mm in length. They feed on human or animal blood. Females require a blood meal for egg production and nymphs require a blood meal for growth. Males can go for a year or more between feedings. They feed at night and are attracted by carbon dioxide which we exhale. Bites, if evident are usually on arms, shoulders, neck and legs. Presence of bedbugs is determined by the sighting of live or dead bugs, dark, reddish brown fecal or blood spots on bedding and a sweet musty odor given off by the bugs.(1,2,3)

Seven to eight percent of those bitten will have a reaction to the bites. This appears as red bumps often in clusters of three or four. The reaction may be immediate or delayed for 7 to 10 days. The bites can be extremely itchy. Vigorous scratching which breaks the skin can introduce bacteria normally present on the skin into a wound. A secondary infection may occur especially in diabetics or people who have a weak immune system. Bites can be treated with topical steroids such as hydrocortisone cream, antihistamines and/or moisturizing creams. If symptoms do not improve within one to two days or worsen, talk to your pharmacist or doctor.(1,2,3)

As for bedbugs spreading disease the evidence is somewhat limited. Bedbugs are suspected of transmitting infectious agents, but there are no reports of this actually happening.(4) In order to spread a disease the vector (bedbugs) must be able to acquire an infectious agent, maintain it, and then give it to an animal or human. A recent study in an underprivileged area of Vancouver, B.C. found antibiotic-resistant bacteria in some bedbugs but more research is needed to find out if bedbugs can spread these bacteria through their bites.(5)

Taking a few precautions while travelling is a good way to keep them from coming home with you. For information on how to avoid getting bedbugs and how to deal with them if you bring them home, Health Canada has a good website ( www.hc-sc.gc.ca/cps-spc/pest/part/protect-proteger/bedbugs-punaises-lit/index-eng.php). Note that professional help is usually needed in order to rid of bedbug infestations.

Provincial and municipal public health officers are responsible for local health issues. They can provide you with the latest information you need if you find you have bedbugs. Local listings for public health officers are available at www.health.gov.sk.ca/public-health-offices .

Prepared by Jean Macpherson, SDIS drug information consultant. Reviewed by Karen Jensen and Carmen Bell, SDIS drug information consultants.

Sources
1) Canadian Pharmacist’s Letter May/09 Updated August 2011 Bedbugs – Identification,
2) Elston D, Kells S. Bedbugs. In UpToDate online database. Available at www.uptodate.com by subscription and log-in. Accessed Feb. 2012.
3) Health Canada. Bedbugs. Available at www.hc-sc.gc.ca/cps-spc/pest/part/protect-proteger/bedbugs-punaises-lit/index-eng.php. Accessed Feb. 2012.
4) Delaunay P, Blanc V, Del Giudice, P, et al. Bedbugs and infectious diseases. Clinical Infectious Diseases 2011;52:200 – 210.
5) Lowe CF, Romney MG. Bedbugs as vectors for drug-resistant bacteria. Emerging Infectious Diseases Journal 2011;17 Available at http://wwwnc.cdc.gov/eid/article/17/6/10-1978_article.htm.

A. Benign Prostatic Hyperplasia (BPH) is fairly common in men older than 50 years. This condition can lead to bothersome lower urinary tract symptoms and may require treatment or surgery. Symptoms such as needing to go to the bathroom more often, hesitancy (delayed starting, or stopping and starting during urination), and urgency (need to urinate right away) are characteristic of BPH. This may not be the case for all individuals with BPH as many don’t have physical symptoms or have only mild symptoms which may not require treatment. (1,2)

In the past there was some theory to suggest that the use of saw palmetto might act to reduce the size of the prostate and thereby be helpful in the treatment of BPH symptoms. It is thought to act similarly as some prescription products, but with a much weaker effect. Past clinical research on saw palmetto is conflicting. This is further muddled by the fact that differences in the strength and purity of products on the market makes it challenging to evaluate3. However, the majority of studies which have reported a positive effect for saw palmetto have been small and poorly designed. Better quality research has failed to find any benefit for saw palmetto for BPH.(4-5) Many experts no longer recommend the use of saw palmetto for BPH.(6-8)

Some patients may still wish to try saw palmetto. In general, it is well-tolerated but there are a few side effects to watch for. Dizziness and stomach related complaints such as nausea, vomiting, constipation, and diarrhea occasionally occur. Choose a product with an NPN number; which indicates the product has been assessed by Health Canada and contains what it claims to contain. Be aware that there may not be any dramatic improvement in symptoms and if any effect is to take place it would take at least 1 to 2 months. If symptoms still continue afterwards then best to consult your physician for prescription therapy.(7)

Answered by Gurpreet Nijjar, BSc, BSP.

Reviewed by Jeff Taylor, PhD, BSP and Karen Jensen MSc, BSP
Posted December, 2011.

Sources
1. UpToDate: Medical Treatment of Benign Prostatic Hyperplasia
2. Dynamed: Benign Prostatic Hyperplasia
3. UpToDate: Clinical Use of Saw Palmetto
4. JAMA. 2011 Sep 28;306(12):1344-51. Effect of increasing doses of saw palmetto extract on lower urinary tract symptoms: a randomized trial.
5. Cochrane Review. April 2010. James Tacklind, Roderick MacDonald, Indy Rutks, Timothy J Wilt. Serenoa repens for benign prostatic hyperplasia.
6. NMCD: Natural Medicines in the Treatment of Benign Prostatic Hyperplasia
7. Canadian Pharmacists Letter. Article; Canadian Pharmacists Letter; November 2011; Vol: 27.
8. Journal Watch. Treating Lower Urinary Tract Symptoms with Saw Palmetto. Available from: http://general-medicine.jwatch.org/cgi/content/full/2011/1006/1

A. The increase in the likelihood of herpes zoster ( shingles ) with aging starts around 50 to 60 years of age and increases into late life in individuals older than 80 years of age.

The vaccine, called Zostavax®, protects against the herpes zoster virus, which causes chicken pox at first infection. The body never rids itself of the virus and it can show up again decades later as shingles. Up to 10 in every thousand seniors develop shingles every year. Without the vaccination, 10 percent to 14 percent of them will suffer from neuralgia (severe sharp pain along the course of a nerve). The lifetime incidence of herpes zoster is estimated to be about 20% in the general population and maybe as high as 50% among those surviving to 85 years or higher.

Individuals with prior history of herpes zoster were excluded from the Shingles Prevention Study and therefore the National Advisory Committee on Immunization makes no recommendation for Zostavax® immunization of individuals with a past episode of zoster. Nevertheless they don’t have any safety concerns for people who have already been immunized with the shingles vaccine. Persons with recent episodes (within 3 to 5 years) of herpes zoster have a boost in immunity that is as strong or better than that obtained from the zoster vaccine so they may not benefit from the vaccine, although recurrent zoster has been confirmed in some healthy patients soon after a previous episode. Individuals with a more remote history of herpes zoster may benefit because herpes zoster can recur, but there are no studies to show that getting the vaccine after having shingles actually reduces the risk of getting it again.

Zostavax® was initially approved for ages 60 and up...now the Public Health Agency of Canada recommends it for ages 50 and up.

ZOSTAVAX® reduces the lifetime risk of developing zoster compared with no treatment by 10% in the general population.

Answered by Lisa Hupka, Bsp

Sources
1. Twersky Jack I, Schmader Kenneth, "Chapter 129. Herpes Zoster" (Chapter). Halter JB, Ouslander JG, Tinetti ME, Studenski S, High, KP, Asthana S: Hazzard’s Geriatric Medicine and Gerontology, 6e: http://www.accessmedicine.com/content.aspx?aID=5138293.
2. http://www.phac-aspc.gc.ca/ccdrw-rmtch/2011/ccdrw-rmtcs0211-eng.php. Canadian Communicable Disease Report. Infectious Diseases News Brief - January 14, 2011
3. Canadian Pharmacist’s Letter; May 2011; Vol: 27
4.10.3949/ccjm.75a.08046 Cleveland Clinic Journal of Medicine. January 2009 vol. 76 1 45-48 Who should receive the shingles vaccine? Aparajita Singh, MD, MPH
5. http://www.merck.ca/assets/en/pdf/products/ZOSTAVAX-PM_E.pdf ( accessed October,2011)

A. Clean the area with soap and water, hydrogen peroxide or alcohol after the stinger has been removed. Cold compresses might be helpful to reduce local pain and swelling induced by insect bites.

Usually no other treatment is necessary, but if swelling, itching or pain occur and are bothersome treatment with a topical analgesic ( benzocaine, lidocaine etc. ), steroid cream ( hydrocortisone ), counter irritant ( e.g. After Bite®) or skin protectant ( zinc oxide, calamine lotion ) is appropriate. Oral pain medications can be used for pain and oral antihistamines can also relieve itching. In patients who are highly sensitive to insect bites, nonsedating antihistamines taken on a regular basis can reduce the subsequent skin reactions such as itching and swelling from insect bites.

Most wasp stings do not become infected, although this can occur. The stings of yellowjackets are more likely to become infected than those of other species . Yellowjackets tend to scavenge around rotting food and presumably carry bacteria on their exterior.

Infection is suspected when redness, swelling, and pain become dramatically worse three to five days after the sting, when typically symptoms should be disappearing. The presence of fever also suggests infection. Mild symptoms can be treated with a topical antibiotic (e.g. Polysporin® ). If symptoms do not improve within 48 hours, you should see a doctor. An oral antibiotic may be needed.

Some people who are allergic to the wasp venom will have a severe reaction to a wasp bite and symptoms may include chest tightness, difficulty breathing, swelling of the tongue, throat, nose, and lips, dizziness, and/or loss of consciousness. Complications may include shock and heart failure. In these cases emergency medical help should be contacted immediately. People who know that they react severely to an insect bite should carry epinephrine ( EpiPen®, or Twinject®) for emergency self-administration. They can also consider venom immunotherapy to desensitize them.

Sources
1. Canadian Pharmacist’s Letter 2008; 24(8):240815.Management of Insect Bites. ( accessed August 31st, 2011 )
2. Medscape Medical News AAAAI, ACAAI Update Stinging Insect Guidelines, Laurie Barclay, MD June 14, 2011 ( accessed August 31,2011 )
3. Theodore Freeman, MD. Bee, yellowjacket, wasp, and other Hymenoptera stings: Reaction types and acute management. UpToDate, Last updated January 2011 ( accessed Sept. 6th,2011 )

A. The toxicity of the repellent DEET in large doses and the limited information available make it advisable for pregnant women to use only small amounts of this agent. They should avoid DEET type repellents on large areas of their bodies for long periods unless there is a strong reason, such as being in an area with a high risk of malaria, West Nile and/or Lyme disease.

Exposure to DEET can be limited by wearing long sleeved shirts and leg coverings to avoid biting insects and applying this agent only to exposed skin or clothing. Also use mosquito netting, screens on doors and windows and limit the time spent outdoors between dusk and dawn.

However, the repellent DEET (N,N-diethyl-3-methyl-benzamide, also known as N,N-diethyl-m-toluamide) is acknowledged as the most effective repellent. DEET has been used as a repellent for more than 50 years and is estimated to be applied several hundred million times yearly by North Americans alone. Scientific reviews have concluded that, when used as directed, DEET has an excellent safety record.

DEET can be sprayed on clothes, but can damage certain synthetic clothing such as spandex and rayon. Cotton and wool materials are not affected.

The higher the DEET concentration in the repellent formulation, the longer the duration of protection; this relation reaches a plateau at about 30% to 35%. Products with 10% DEET work for about 3 hours and products with 30% DEET work for 6 hours.

When there is a substantial risk of getting a disease from a mosquito or a large mosquito population, it is appropriate for pregnant women to use the concentration recommended for non-pregnant adults. Otherwise, when the purpose is primarily to avoid nuisance bites a lower concentration of DEET is advisable.

Answered by: Lisa Hupka, BSP

Sources
1. www.thomsonhc.com/micromedex2/ Reprotox ( Accessed on July 6, 2011 )
2. Insect Repellents. Canadian Pharmacist’s Letter; July 2010; Vol: 26
3. Christof Schaefer, Paul Peters, Richard K. Miller. Drugs During Pregnancy and Lactation 2nd ed. Elsevier BV; 2007, PG 458-9.
4. Prevention of arthropod and insect bites: Repellents and other measures. UpToDate. ( Accessed on July 6, 2011 )
5. www.cdc.gov/travel/ Travelers’ Health ( Accessed July 6, 2011)
6. The Merck Manual for Health Care Professionals. Malaria. ( Accessed July 6, 2011 )
7. Karen Jensen. Buzz Off - Helping patients select and properly use insect repellents. Pharmacy Practice. June 1, 2011

A. The proven benefit of sunscreen outweighs any potential risks.

Concern has arisen over an ingredient in some sunscreens called retinyl palmitate. It is an inactive ingredient, a type of topical vitamin A. In skin it converts readily to retinoids which are associated with a risk of birth defects in people taking oral acne medications containing them. However, the animal studies which showed birth defects used much higher doses than can be absorbed through the skin. Studies on rats have not shown sunscreen to cause malformations.

The American College of Obstetricians and Gynecologists recommends that pregnant women protect their skin from the sun by wearing sunscreen with SPF ( sun protection factor ) of 15 or more.
Sun exposure will darken dark brown areas around the eyes, nose and cheeks called cholasma or “mask of pregnancy” which some women develop ( about 70% ) during pregnancy. Sun screen and wearing a wide brim hat can prevent these areas from getting darker.

Here are other steps that Health Canada recommends you take to protect against UV exposure:
• If possible, avoid being in the sun between 11:00 a.m. and 4:00 p.m.
• Look for shade, stay under a tree, or use an umbrella.
• During outdoor activities, wear sunglasses to protect your eyes. When the UV index is three or higher, you should also wear protective clothing and a large-brimmed hat.

Topical absorption of sunscreen is minimal. Sunscreen is safe and recommended for use during pregnancy.

Answered by: Lisa Hupka, BSP

Sources
1. Nohynek GJ, Meuling WJ, Vaes WH, Lawrence RS, Shapiro S, Schulte S, Steiling W, Bausch J, Gerber E, Sasa H, Nau H. Repeated topical treatment, in contrast to single oral doses, with Vitamin A-containing preparations does not affect plasma concentrations of retinol, retinyl esters or retinoic acids in female subjects of child-bearing age. Toxicol Lett. 2006 May 5;163(1):65-76. Epub 2005 Oct 21. PMID: 16243460
2. CBC News. Sunscreen benefits beat risks in pregnancy: MDs. Posted: May25,2011. www.cbc.ca/news/health/story/2011/05/25/sunscreen-pregnancy.html
3. http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/life-vie/sun_soleil-eng.php, accessed June 1, 2011
4. Using Sunscreens, 07/08/2010, Texas Tech University Health Sciences Center, www.infantrisk.com

A. There is no convincing evidence that using sunscreen causes cancer. There IS strong evidence that using sunscreen prevents cancer. Sunscreens can significantly reduce the risk of cancer of the skin, lips and mouth. Research shows that they do not cause vitamin D deficiency (as previously suggested). Sunscreens have not been demonstrated to adversely affect the health of humans.

UVA rays do not cause sunburns, but they do contribute to skin cancer and sun-related skin aging. Sunscreens, which have been around for more than 70 years, used to just protect against UVB rays, which cause sunburns and skin cancer. It is important to choose a product which protects against both UVA and UVB rays.

UVA filtering and blocking ingredients are oxybenzone, avobenzone ( Parsol 1789 ), titanium dioxide, zinc oxide and ecamsule (Mexoryl SX/XL). Helioplex, a patented combination of avobenzone and oxybenzone with stabilizers, provides protection against the full spectrum of UVA and UVB radiation. Ecamsule itself is photostable, but only covers short UVA II wavelengths. The combination with avobenzone ( absorbs the long UVA wavelengths ) and octocrylene also provides coverage against the full spectrum of UVA and UVB radiation.

The almost universal use of the sun protection factor (SPF) has lured many consumers into thinking that a higher SPF means a better sunscreen. Because SPF is mostly an indicator of UVB protection, it is difficult for consumers and physicians to compare the UVA protection afforded by sunscreens.

In many countries, changes in labeling guidelines will make it easier for consumers and physicians to determine the level of UVA protection provided by sunscreens. The FDA has proposed a UVA star rating, with one star representing low UVA protection and four stars representing the highest available UVA protection in an over-the-counter sunscreen product. Although this rule has not yet been finalized, a small number of sunscreens may have a star rating on the label.

The Canadian Cancer Society recommends the following:
• People reduce their exposure to the sun, particularly between 11 a.m. and 4 p.m. when the sun’s rays are the strongest
• Use a broad spectrum sunscreen ( protection from UVA and UVB rays )
• Choose a product that is water resistant with an SPF of at least 30
• Apply sunscreen liberally and frequently ( every 2 hours ), especially after swimming or sweating

An average size adult needs an ounce (2 tablespoonfuls ) of sunscreen for optimal coverage.

Answered by Lisa Hupka,BSP

Sources
1. Burnett ME, Wang SQ. Current sunscreen controversies: a critical review.Photodermatol Photoimmunol Photomed. 2011 Apr;27(2):58-67. doi: 10.1111/j.1600-0781.2011.00557.x. PMID: 21392107
2. Update on Sunscreens, R. Bissonnette, MD, FRCPC Posted: 11/10/2008; Skin Therapy Letter. 2008;13(6):5-7, www.medscape.com/viewartcile/5829902
3. Canadian Pharmacist’s Letter 2009; 25(6):250606, Sunscreens: Achieving Optimal Protection
4. Canadian Cancer Society. www.cancer.ca ( accessed May24, 2011 )

A. Calcium is important for bone health as they require calcium to maintain strength. Low calcium intake is associated with colon cancer, kidney stones, obesity and hypertension. Just about every cell in the body, including those in the heart, nerves and muscles rely on calcium to function properly.

A recent analysis of calcium supplement use and cardiovascular (heart and blood vessel) risk revealed that calcium supplements with or without vitamin D, modestly increase the risk of cardiovascular events, especially heart attacks.

There does not seem to be a dose response relationship between calcium supplements and the risk of cardiovascular events. Thus even doses of less than 500mg/day might be associated with an increased risk of cardiovascular events similar to doses greater than 1000mg/day. The abrupt change in the concentration of calcium in the blood after supplement consumption seems to cause the adverse effect, rather than it being related to the total calcium dose taken.

Further studies are needed to reassess the role of calcium supplements in osteoporosis management. In the meantime a person should try to get their calcium needs met through their diet. If you are at high risk of fractures, consult your doctor before stopping or reducing your daily calcium supplement.

Dairy products such as milk, cheese and yogurt are excellent sources of calcium. Vegetables (broccoli, cabbage, bok choy, figs ) also provide calcium as do fish products containing bones (sardines and canned salmon), lentils, beans, tofu and almonds.

Calcium loss through the urine is increased by the consumption of excess salt and caffeine. Therefore try to keep salt intake to a minimum and increase calcium in your diet if you consume more than 4 cups of coffee per day.

Adults age 19 to 50 need 1000mg of calcium per day and teenagers and older adults need slightly more.

One cup of milk or low fat yogurt provide approximately 300mg of calcium each. Go to http://ods.od.nih.gov/factsheets/calcium/ to find out how much calcium is provided by the food you eat to help you plan to get the required calcium from your diet. If you have any difficulty in determining how to obtain your daily calcium requirement, please feel free to contact us.

Answered by Lisa Hupka,BSP

Sources
1. www.osteoprosis.ca
2. Calcium, Vitamin D, and Risk of Cardiovascular Events: Discussion www.medscape.com/viewaraticel/741974_2
3. Canadian Pharmacist’s Letter 2011; 27(1): 27012
4. Abrahamsen B, Sahota O. BMJ 2011; 342: D2080 – Do Calcium plus Vitamin D Increase Cardiovascular Risk.

A. The correct use of prescribed medications for pain commonly produces tolerance and physical dependence. Tolerance is the drug-induced loss of effect over time, while physical dependence is the occurrence of withdrawal symptoms after sudden dose reduction or discontinuation of a drug. These are normal body function changes to repeated use of drugs. Tolerance and physical dependence do not imply abuse or addiction. Understanding the difference is important so that patients with pain aren’t denied adequate pain medication simply because they have shown evidence of tolerance or they exhibit withdrawal symptoms if the analgesic medication is stopped abruptly.

Patients with pain rarely develop abuse or addiction problems. The patient who is not vulnerable to addiction will not experience brain reward when using controlled drugs as prescribed and therefore will not misuse prescribed medications.

The onset of abuse or addiction usually happens before the use of prescribed controlled drug use. Individuals who are at risk of addictive disease usually start their addiction through the use of alcohol, tobacco or marijuana in their late teens or early adulthood. Abuse of prescription drugs tends to complicate pre-existing addiction rather than to cause addiction.

Addiction is entirely different than physical dependence and tolerance. Although these changes presumably occur commonly as addiction develops, neither are necessary for addiction to occur, and equally important, neither means that abuse or addiction is occurring.

Inappropriate fear of addiction on the part of patients (or their caretakers) is a common reason for under-use of prescribed medications. A person should not be denied adequate pain relief because of this fear. For treatment of most types of severe pain strong opioid pain medications are the drugs of choice. Some of the problems of dependence and tolerance can be managed by using long acting formulations and gradually reducing the medication, if it is no longer needed.

Answered by: Lisa Hupka,BSP

Sources
1. O’Brien Charles P, “Chapter 23. Drug Addiction and Drug Abuse” (Chapter). Brunton LL, Lazo JS, Parker KL: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 11e: http://www.accessmedicine.com/content.aspx?aID=941547

2. UpToDate- Prescription Drug Abuse. Desktop19.1

3. The Medical Letter. Drugs for Pain. April1, 2010(Issue 92) p.25

A. In people with celiac disease, the gluten protein in wheat, barley, rye, and triticale triggers an immune reaction that damages the small intestine. (2) Grains such as oats, millet, corn, tapioca, soy and rice don’t have this protein. (2)(3)This damage keeps the body from taking in many of the important nutrients in food. These include vitamins, calcium, protein, carbohydrates, fats and other important nutrients. The body can’t work well without these nutrients. Even small amounts of gluten in foods can hurt people who have celiac disease. (3)

Note that avoiding gluten does not have any known health benefits for people who do not have celiac disease. (3)

In the area of pharmaceuticals, potential sources of gluten contamination come primarily from the addition of the excipient (filler), ingredients added to the active drug in order to make a particular dosage form. (1) Having an understanding of the fillers origin or how they are produced can help a person make an educated assessment of the likelihood of gluten contamination. One of the first key words to look for in the inactive ingredients list is starch. Starch can be derived from several sources including corn, potato, tapioca and wheat. If starch is listed by itself a call to the manufacturer is the only way to confirm the source of the starch. A product with cornstarch can be assumed to be gluten free.(1)

Also watch out for the four dex-ingredients derived from starch (dextrans, dextrose, dextrates, dextrins ). Dextrans come from corn and potato starch, dextrose comes from corn. Dextrates and dextrins can come from any starch source so a call to the manufacturer is necessary to find out if the product contains gluten.(1)

A problem faced by the pharmaceutical manufacturers is the uncertainty of the gluten free status of the raw materials obtained from outside sources. A person looking for gluten free products must also be aware that pharmaceutical companies frequently change the inactive ingredients of their products without warning. If a product says “new and improved” or “new formulation” it is a sign to recheck the gluten status of the product.(1)

Currently in Canada a natural health product can be labelled “gluten free” if it contains a maximum limit of 20 ppm gluten. This would be gluten from wheat, including spelt or kamut, but not barley or rye as they are not used in the preparation of medications.(1) This maximum level is based on good manufacturing conditions aimed at achieving the lowest possible levels of gluten resulting from cross-contamination.(4)

Tolerance to gluten varies among individuals with celiac disease and there are limited clinical scientific data on the amount of gluten required to initiate or maintain an immune reaction in celiac disease patients. Therefore, there is no clear agreement on a safe gluten threshold level.(4)
There are proposed changes to the Food and Drug Act to prevent products which contain trace amounts of gluten, confirmed by testing to be < 20 ppm gluten, from making the claim gluten-free.(4)

The product package insert is a good starting place to look for gluten in medications. Enrolling the help of a pharmacist will also be beneficial or call the Saskatchewan Drug Information Service at 1-800-665-3784, in Saskatoon 966-6378, to help you with the search.

Answered by: Lisa Hupka, Bsp

Sources
1.Steven Plogsted. Medications and Celiac Disease- Tips From a Pharmacist. The Celiac Diet, Series #5. Practical Gastroenterology. January 2007.
2."Gluten-Free" Foods May Be Contaminated: Study. J Am Diet Assoc 2010;110:937-940. www.medscape.com/viewarticle/725315 (accessed March 8, 2011)
3.Gluten Free Diet. May 2010. AAFP conditions A to Z (2010) Stat!Ref ( accessed March 8, 2011)
4.Notice-Labelling of Natural Health Products Containing Gluten. January 2010. www.hc-sc.gc.ca. ( accessed March 8, 2010)

A. The usual schedule for Twinrix® formulations in Canada for people 19 years and over is 3 injections. The first 2 are 1 month apart and the 3rd injection is 6 months after the first. There is also a rapid schedule that involves 1 extra dose for people who will be exposed to high risk situations before they are able to receive the first 2 vaccinations 1 month apart. It is important to have the minimum time interval between injections to develop adequate final antibody concentrations.(2)

Increasing the interval between the first 2 doses has little effect on the development of immunity or final antibody concentration for the Hepatitis B component of the vaccine. The third dose ensures the maximum level of protection but acts primarily as a booster and appears to provide optimal long-term protection.(1)(3)

The effectiveness of 1 dose of Hepatitis A vaccine ( equivalent to 2 doses of Twinrix ®) is 94% to 100%. Antibody production is considered to be complete after the first dose, however, the vaccine series should be finished to assure long-term protection.(5)

All available data on single and combined Hepatitis A and Hepatitis B vaccines indicates that there is no support for a Hepatitis A or Hepatitis B booster when a complete primary vaccination course is offered to individuals with a competent immune system.(4) Immune system memory has been demonstrated in a number of studies for both Hepatitis A and Hepatits B, with the implication that protection may persist even when antibodies are no longer measurable.(4)(2)

In summary, the last dose in the series is mainly to ensure long term protection and can be done any time after the first 2 doses as long as there is a minimal spacing of 24 weeks from the first dose in the regular schedule and 1 year from the first dose in the rapid schedule.

Answered by: Lisa Hupka, Bsp, February 2, 2011

Sources
1.A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States. MMWR Dec23,2005/Vol.54 http://www.cdc.gov/mmwr/PDF/rr/rr5416.pdf
2. Canadian Immunization Guide 7th ed. 2006 www.phac-aspc.gc.ca (accessed Feb2,2011)
3.High immunogenicity of delayed third dose of hepatitis B vaccine in travellers. Vaccine. 2007 Apr 30;25(17):3482-4. Epub 2007 Jan 11. PMID: 17306910
4. A review of the long-term protection after hepatitis A and B vaccination. Travel Med Infect Dis. 2007 Mar;5(2):79-84. Epub 2006 Jun 19. PMID: 17298912
5. Immunization Action Coalition Ask the Experts http://www.immunize.org/askexperts/experts_hepa.asp ( accessed Feb2,2011 )

A. : Yes. In Saskatchewan public drop in clinics for the seasonal influenza vaccine began Oct. 12, 2010. The vaccine is available at no charge to everyone from Oct. 12, 2010 to March 31, 2011. If you missed getting it in the fall at a drop in clinic call 655-4358 in Saskatoon (1) or 766-7000 in Regina (7) to book an appointment or call the health center closest to you.

The 2010 to 2011 flu vaccine will protect against an influenza A H3N2 virus, an influenza B virus and the 2009 H1N1 virus that caused so much illness last season.(6)

All ages benefit from getting the influenza vaccine. Exceptions are anyone under six months of age or with severe egg allergies. These groups should not be vaccinated.(2)(4) Also anyone who had a serious allergic reaction to a previous dose of influenza vaccine or who developed Guillain-Barre Syndrome ( a neurological disorder ) within 8 weeks of a previous influenza vaccine should not receive the vaccine.(2)(4)

Health Canada says between 4,000 and 8,000 Canadians mostly seniors; will die from pneumonia related to flu and many others may die from other serious complications of flu.(4) The following groups of people are at higher risk of complications from the influenza virus, such as pneumonia:
People over 65 or older.
Pregnant women
Children 6 months to 4 years
People severely obese
People of any age who are residents of nursing homes and other chronic care facilities
Anyone with chronic health conditions
Close contacts of persons who are in the high risk of complications groups above should also get vaccinated.(1)(2) Children younger than 6 months are at high risk of serious flu illness, but are too young to be vaccinated. People who care for them should be vaccinated instead. (6)

Antiviral treatment is available and can reduce the duration and severity of illness for a person infected with the influenza virus. Antiviral treatment of influenza is most effective when administered early in the course of illness, and ideally should be administered within 48 hours of onset of symptoms. Antiviral treatment should be started in people with confirmed or suspected influenza who are at a greater risk for complications.(3)

The signs and symptoms of influenza are fever, headache, fatigue, muscle pain and weakness. These symptoms may be accompanied by cough and sore throat. Some people also experience vomiting and diarrhea.(2)(5)(6)

Seek immediate medical attention for the following symptoms in adults:
Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or continuous vomiting
Flu-like symptoms that improve but then return with fever and worse cough (6)

Answered by Lisa Hupka,Bsp. Jan24/2011

Sources
1.Saskatoon Health Region. Seasonal Influenza Vaccine. www.saskatoonhealthregion.ca (accessed Jan. 24. 2011
2. Public Health Agency of Canada. About Season Influenza www.phac-aspc.gc.ca (accessed Jan24. 2011)
3. Medscape Medical News. ACIP Up Dates Guidelines for use of Antiviral Agents for Influenza. Jan 21, 2011 www.medscape.com/viewarticle/736109
4. CBC News. Fighting The Flu. Jan. 14,2011 www.cbc.ca/health/stsory/2009/01/12/f-flu.html
5. UpToDate- Clinical Manifestations and Diagnosis of Seasonal Influenza in Adults. Last literature review version 18.3 Sept.2010
6. Centers for Disease Control and Prevention. Seasonal Influenza. www.cdc/flu/protect/preventing.htm (accessed Jan. 24.2011)
7. Regina Qu’Appelle Health Region. Telephone Directory for Facilities and Services. www.rqhealth.ca/inside/contact_us/phone.shtml (accessed Jan.24/2011)

A. Acetaminophen is usually safe to take at recommended dosages.

It works by reducing the production of chemicals in the body that enable the body to feel pain as well as cooling the body. While acetaminophen may be helpful to reduce pain and/or fever it will not cure any medical condition.

The normal dose of acetaminophen for pain or fever in adults is: orally 325 to 650 mg every 4 to 6 hours or 1000 mg 3 to 4 times/day; do not exceed 4 g/day.

The normal dose of acetaminophen in children for pain or fever is: Children <12 years: orally 10 to 15 mg/kg/dose every 4 to 6 hours as needed; do not exceed 5 doses (2.6 g) in 24 hours or 75mg/kg/day.
Many people do not know that Tylenol is the brand name for acetaminophen and that overdose of this product can cause serious liver damage, especially when combined with other medications that can also cause damage to the liver.

Early symptoms of overdose can include nausea, vomiting, weakness, and profuse sweating. These usually occur after an ingestion of acetaminophen large enough to cause hepatic ( liver ) toxicity. However, since some patients show few or none of these early signs, in cases of suspected acetaminophen over dose, therapy should begin as soon as possible. A delay period of 24 to 36 hours exists between ingestion and the onset of symptoms of hepatic injury. Some other symptoms of toxicity are abdominal pain, confusion, a general feeling of discomfort, yellowing of skin and eyes, coma and in severe cases death.

If you suspect someone has taken too much acetaminophen phone the poison control center at 1-866-454-1212.

A situation which has potential for overdose is the practice of alternating doses of acetaminophen and ibuprofen for treatment-resistant fevers. There is no evidence that this works better than either product used alone at optimal doses. This is not recommended because of the possibility of confusion as to what medication was given, which could lead to overdose.

Another problem with acetaminophen is that it is added to many cough and cold products as well as other combination pain killers and muscle relaxants. These products may not be made by the company that makes Tylenol and therefore these products will have different names. As a result when people take these medications they may not realize the amount of acetaminophen actually being consumed, unless they have carefully read the ingredients.

To avoid this situation always read the ingredients of over the counter medications and prescription medications. Don’t exceed the dose recommended on the package and don’t take 2 products that both contain acetaminophen. If unsure, ask your pharmacist or phone Saskatchewan Drug Information Services at 1-800-665-3784 in Saskatchewan or 966-6378 if in Saskatoon.

Sources
1.Lexicomp Online
2.Compendium of Pharmaceuticals and Specialties Online
3. Canadian Pharmacist’s Letter; July 2006; Vol: 22
4.http://www.medscape.com/viewarticle/726598_5

A. : The recommended amount of vitamin D has increased for everyone. The value for this nutrient was first set in 1997. Calcium and vitamin D are two essential nutrients long known for their role in bone health. Since 2000 the public has heard conflicting messages about other benefits of these nutrients, especially vitamin D. The U.S. Institute of Medicine (IOM) released its report of the Dietary Reference Intakes (DRIs) for vitamin D and calcium on November 30, 2010. The review was jointly commissioned and funded by the U.S. and Canadian governments.

Dietary Reference Intakes (DRIs) are recommendations for nutrient intakes based on Estimated Average Requirement (EAR), Recommended Dietary Allowance (RDA), Adequate Intake (AI) and Tolerable Upper Intake Level (UL).

Vitamin D is a nutrient that helps the body use calcium and phosphorous to build and maintain strong bones and teeth. Too little vitamin D can cause calcium and phosphorus levels in the blood to decrease, leading to calcium being pulled out of the bones to help maintain stable blood levels. This can cause rickets in children and osteomalacia (softening of the bones) or osteoporosis (fragile bones) in adults.

However, too much vitamin D can cause too much calcium to be deposited in the body, which can lead to calcification of the kidney and other soft tissues including the heart, lungs and blood vessels.

The IOM finds that the evidence supports a role for vitamin D and calcium in bone health but not in other health conditions.

The IOM expert committee reviewed a number of health outcomes that could potentially be related to calcium and vitamin D, such as cancer, cardiovascular disease, diabetes, and immunity, and found that the evidence was inconsistent and did not demonstrate a cause-and-effect relationship. Consequently, these health outcomes could not be used for the purposes of determining nutrient requirements.

The skin produces vitamin D3 in response to sun exposure. But the American Academy of Dermatology recommends avoiding sunlight and getting vitamin D from food or supplements. The Canadian Dermatology Association offers similar advice
.
The sun is not strong enough to make vitamin D in the skin in southern Canada from November to February...and for an even longer period at higher latitudes.

Few foods contain much vitamin D. Salmon, canned tuna, and fortified milk (100 IU per cup) are among the best sources. Very few foods naturally have vitamin D. Fortified foods provide most of the vitamin D in our diets.
•Fatty fish such as salmon, tuna, and mackerel are among the best sources.
•Beef liver, cheese, and egg yolks provide small amounts.
•Vitamin D is added to many breakfast cereals and to some brands of orange juice, yogurt, margarine, and soy beverages; check the labels.

New Reference values for daily intake of Vitamin D are:

Birth to 12 months 400 IU
Children 1–13 years 600 IU
Teens 14–18 years 600 IU
Adults 19–70 years 600 IU
Adults 71 years and older 800 IU
Pregnant and breastfeeding women 600 IU

New Reference values for daily intake of Calcium are:

Birth to 6 months 200 mg
Infants 7–12 months 260 mg
Children 1–3 years 700 mg
Children 4-8 years 1,000 mg
Children 9–13 years 1,300 mg
Teens 14–18 years 1,300 mg
Adults 19–50 years 1,000 mg
Adult men 51–70 years 1,000 mg
Adult women 51–70 years 1,200 mg
Adults 71 years and older 1,200 mg
Pregnant and breastfeeding teens 1,300 mg
Pregnant and breastfeeding adults 1,000 mg

Total vitamin D intake should remain below the level of the new UL (upper tolerable limit) to avoid possible adverse effects. The UL is the maximum daily intake unlikely to result in adverse health effects. The new UL is 4,000 IU daily for people from age 9 to age 70, whereas the old UL was 2,000 IU daily.

It is preferable that an individual get their recommended calcium from food sources.

Sources
1.http://www.hc-sc.gc.ca/fn-an/nutrition/vitamin/vita-d-eng.php#t4
2.http://www.iom.edu/Reports/2010Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/
3.http://ods.od.nih.gov/FactSheets/VitaminD-Consumer/
4.http://canadianpharmacistsletter.therapeuticresearch.com/pl/ArticleDD.aspx?nidchk=1&cs=&s=PLC&pt=6&fpt=31&dd=250508&pb=PLC&searchid=24065944
5.http://www.osteoporosis.ca/index.php/ci_id/5534/la_id/1.htm
6.http://ods.od.nih.gov/factsheets/Calcium-Consumer/

A. Healthcare professionals are facing a constant stream of short-term back orders and long-term unavailability of products. Canada is currently experiencing shortages of hundreds of generic drugs.

This supply problem can arise from a variety of different causes including:
• Manufacturing issues
• Shortages in raw materials due to natural disasters and regulatory decisions related to the safety, efficacy or quality of a product
• Reduced inventories carried by pharmacies, wholesalers and manufacturers because of pressure to keep inventories low can result in not enough product on hand to buffer a shortage.
• Lower prices can contribute to a shortage. Recent controls in Ontario and other provinces are reducing profit, which then puts pressure on manufacturers to discontinue unprofitable products.
• Competition in the drug market causes manufacturers to discontinue making a drug if they don’t expect to have a reasonable share of the market due to policies like bulk buying or tendering. Some products coming off patent are not being made generic.

Current shortages are blamed on a shortage of raw materials and compliance issues that led to voluntary recalls of certain drugs and slower production times at manufacturing facilities. This in turn created a backlog of unfilled orders, which is expected to gradually disappear as production steps up. Even then, however, the current market and regulatory trends governing pharmaceutical sales are likely to result in ongoing generic shortages.

Health Canada has no authority to require a manufacturer to bring a product to the Canadian market or to maintain adequate supplies on the market to meet the needs of patients.

Possible actions for Health Canada are:
• Prohibit bulk exports of pharmaceuticals as a proactive move.
• Issue compulsory licences if a patent holder is unable to provide a needed product.
• Develop a list of medically essential drugs (possibly following the list provided by the World Health Organization -- WHO), and monitor and track these.
• Allow parallel importation schemes similar to those used in Europe.
• Provide notification of where products are being manufactured.

The Minister of Health intends to table legislation in Parliament, before it adjourns in December, to establish statutory authority to prohibit the export of prescription and other essential drugs from Canada as necessary to protect human health in the event of an actual or potential shortage.

If the medication you are taking becomes unavailable your pharmacist will work with your doctor to find an appropriate alternative until the shortage is resolved. If a substitute drug or different dosage strength/formulation is being used, your pharmacist will educate you about the change and what to expect.

To ensure that your drug therapy is not interrupted, don’t wait until you are out of your prescription(s) before re-ordering. If there is a shortage your pharmacist may need a few days to arrange for and obtain a suitable alternative.

Sources
1. www.canadiahealthcarenetwork.ca
2. Canadian Pharmacist’s Letter; September 2010; Vol: 26
3. http://www.hc-sc.gc.ca

A. Bisphosphonates have been used successfully for nearly two decades for prevention of fractures in patients with osteoporosis. There is a high level of evidence to suggest it improves bone mineral density, prevents bone loss, and reduces the number of fractures in the spine and hip. Although the short-term benefit of bisphosphonates is well documented, there are concerns regarding the safety of long-term therapy resulting from the effect on bone functions.

The bisphosphonates available in Canada are: alendronate ( Fosamax ), risedronate ( Actonel ), etidronate/calcium ( Didrocal ) alendronate/vitamin D3 ( Fosavance ) and zoledronic acid ( Aclasta ).

The major problem in osteoporosis is fractures (broken bones). Without proper treatment, patients with osteoporosis are more likely to have fractures, commonly of the hip, spine, wrist and shoulder. The occurrence of a hip fracture is one of the ways that osteoporosis can be diagnosed. These are called typical femoral fractures and occur high up on the femoral bone, very close to the hip joint. These often occur after a fall when the hip breaks from hitting the ground. The hip does not hurt before it breaks. The person may or may not be on osteoporosis medications.

Several case series and multiple individual case reports suggest that some femoral shaft (thigh bone) fractures might occur in patients who have been treated with long-term bisphosphonates. Several unique clinical features are emerging which distinguish these fractures from typical femoral fractures which occur in osteoporosis because of the disease process itself. These features are thigh pain and/or groin pain for several weeks prior to the fracture, complete absence of an injury occurring before the fracture, fractures in both legs in some patients, the fracture occurs lower down from the hip ( closer to the middle of the femur ) and most patients with this type of fracture have been on bisphosphonates for more than 5 years. X-rays, including bone scan and/or MRI, might be warranted in patients who have femoral pain to try to find these atypical fractures at an early stage (stress fracture vs complete fracture).

The supposed mechanism is unknown, and more research is needed to identify distinctive characteristics of these “atypical” fractures. There is no rationale to withhold bisphosphonate therapy from patients with osteoporosis, although continued use of bisphosphonate therapy beyond a treatment period of 3 to 5 years should be re-evaluated annually. Women and men at low risk of fracture should discuss with their doctor if they need to continue with the bisphosphonate beyond 5 years.

For women at high risk for vertebral fractures, the National Osteoporosis Foundation (NOF) recommends continuing alendronate for ten years. Eight year data with risedronate indicated good tolerability and safety.
The risk factors that have been demonstrated to be most predictive of fracture are:
1. low bone mineral density ( BMI )
2. advancing age
3. prior history of fragility fracture
4. chronic glucocorticoid use
5. low body mass index (BMI)
6. parental history of hip fracture
7. cigarette smoking
8. excess alcohol intake
Although this recommendation is based on data from women, such treatment approach is also reasonable for men taking bisphosphonates.

Treatment with bisphosphonates reduces the risk of hip and other non-vertebral fractures by 1000 per 100,000 patient years. If a person has osteoporosis they are at high risk of fracture and much more likely to suffer a typical fracture if not treated, than of ever getting one of these “atypical” femoral fractures while on medication. If you have an increase risk of fracture, the benefits of bisphosphonates far outweigh the risks.

The overall incidence of shaft fractures combined is below 30 per 100,000 person-years, so this type of fracture is much less common than proximal femur (hip) fractures. Furthermore, the unique “atypical” fracture type is a subset of all femoral shaft fractures and accounts for less than 1% of all femoral fractures, making it a rare event.

Sources
1. Clinical Orthopaedics and Related Research
DOI: 10.1007/s11999-010-1535-x Femoral Insufficiency Fractures Associated with Prolonged Bisphosphonate Therapy.
Joseph D. Isaacs, Louis Shidiak, Ian A. Harris and Zoltan L. Szomor PMID: 20809164

2. Curr Osteoporos Rep. 2010 Mar;8(1):34-9.
Atypical subtrochanteric and femoral shaft fractures and possible association with
bisphosphonates.
Nieves JW, Cosman F. PMID: 20425089

3. Safety of long-term bisphosphonate therapy. Pharmacist’s Letter/Prescriber’s Letter 2009;25(12):251205.
December 2009

4. Osteoporosis Canada

5. UpToDate – Osteoporotic fracture risk assessment.

6. Clin Endocrinol Metab. 2010 Apr;95(4):1555-65. Epub 2010 Feb 19.
Long-term use of bisphosphonates in osteoporosis.
Watts NB, Diab DL. PMID: 20173017

A. The decision of whether to redose an oral medication after vomiting is based on many factors.

The stomach has a relatively large surface area, but its thick mucous layer and short time in contact with the medication limit absorption. Most absorption occurs in the small intestine. Stomach emptying and therefore drug absorption is affected by many variables. Factors that affect how fast the stomach empties and absorption include the dosage form (liquid versus immediate release versus sustained release tablets), the physical and chemical properties of the drug, and the physiologic characteristics of the person taking the drug. Food, especially fatty food, slows stomach emptying (and rate of drug absorption), explaining why taking some drugs taken on an empty stomach speeds absorption.

You can redose if vomiting occurs within 15 minutes...or if you see the intact drug in the vomit . After an hour, there’s usually no need to redose because the drug is probably already past the stomach. But if vomiting occurs within the 15- to 60-minute window, you must consider the risk versus benefit of repeating the dose.

If the risk of missing a dose outweighs the risk of getting too much of the drug, as with drugs such as HIV meds and birth control pills, then it is important to give another dose if a patient vomits within an hour.

Antibiotics for acute infections, especially with a single dose treatment or short course of therapy, should also be given again if the patient vomits within an hour of administration.

For many drugs it is best to err on the conservative side and not give another dose. This is very important for drugs whose recommended dose is close to the toxic dose (narrow therapeutic window ) and getting a bit more of the drug could result in too much with serious consequences.
Examples of drugs not to redose are digoxin, warfarin, phenobarb, long acting opioids, methotrexate, cyclosporine, theophylline, lidocaine, aminoglycosides and other anticonvulsants.

Always check with a health care professional to be sure of the medication in question.

Sources
1. Redosing oral medications after vomiting. Pharmacist’s Letter/Prescriber’s Letter 200;25(9):250909
2. http://www.merck.com/mmpe/sec20/ch303/ch303b.html
3. Buxton Iain L, “Chapter 1. Pharmacokinetics and Pharmacodynamics: The Dynamics of Drug Absorption, Distribution, Action, and Eliminatio” (Chapter). Brunton LL, Lazo JS, Parker KL: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 11e: http://www.accessmedicine.com/content.aspx?aID=935800

A. West Nile virus is transmitted by infected mosquitoes. In most cases, symptoms of West Nile are mild and infected individuals generally recover spontaneously. Rarely, meningitis and encephalitis can occur. There are no specific treatments for West Nile virus infection.

The typical incubation period for infection ranges from 2 to 14 days. Once a patient recovers, immunity to West Nile virus is thought to be life-long; if reinfection occurs, it is very rare.

The most common symptoms are fatigue, fever, headache, skin rash, muscle weakness, diarrhea, vomiting, pain in your eyes, not feeling hungry, swollen glands (rarely) and/or difficulty concentrating. The rash typically involves the chest, back and arms, and generally lasts for less than one week. Most people who have the mild form of West Nile virus have a fever for 5 days, a headache for 10 days, and feel tired for more than a month.

More severe infections involving the brain and spinal cord may cause: headache, high fever, stiff neck, disorientation, reduced attention to surroundings, tremors and convulsions, muscle weakness and paralysis and coma. People with these symptoms should seek medical treatment. Medical treatment involves supportive therapy such as intravenous fluids if a person has experienced prolonged nausea, vomiting and diarrhea, pain relievers, ventilator support as required, and treatment for the prevention of secondary infections.

In most cases your doctor won’t test for West Nile virus unless you have symptoms of meningitis or encephalitis. Then your doctor will test your blood for antibodies to the virus. If you have these antibodies in your blood, your doctor will know that you have West Nile

Personal protection during the months of August and September includes staying indoors between dusk and dawn when mosquitoes are most active, wearing protective clothing when outdoors (i.e., long sleeves and pants with socks and shoes), and using mosquito repellents. The most effective mosquito repellent for use on skin is N,N-diethyl-m-toluamide (DEET). See http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/life-vie/insect-eng.php for more information on insect repellents.

Removal of standing water in barrels, buckets, gutters and flowerpots, which can be used as breeding sites, also helps to reduce the mosquito population.

Sources
1. UpToDate - Clinical manifestations and diagnosis of West Nile virus infection
2. Canadian Pharmacist Letter 2003; 19(5): 190520
3. http://www.medscape.com/viewarticle/575934_7
4. www.healthwise.net/Saskhealthlineonline

A. DEET (N,N-diethyl-m-toluamide) is an effective active ingredient found in many repellent products and in a variety of formulations.

It is available in concentrations ranging from less than 10 percent to more than 75 percent. The effectiveness of DEET plateaus at approximately 30 percent, but higher concentrations provide longer duration of protection. Products with concentrations around 10% are effective against mosquitoes for periods of approximately three hours; a concentration of about 30% percent provides an average of six hours of protection from mosquitoes. Protection is shortened by swimming, washing, rainfall, sweating, and wiping.

For children aged six months to two years, use 10% concentrations applied no more than once daily. Children aged two to 12 can use 10% DEET applied up to three times daily. Adults and children over 12 years of age can use up to 30% concentrations of DEET and reapply if being bitten by mosquitoes, always follow product instructions. Higher concentrations should be reserved for situations in which insect infestation is high, elevated temperatures and humidity may limit evaporation, or time outdoors will exceed three to four hours.

Do not use insect repellents containing DEET on infants under six months of age. Use a mosquito net when the child is outdoors in a crib, playpen or stroller.

Guidelines for using insect repellents:

• Use enough repellent to cover exposed skin or clothing. Don’t apply repellent to skin that is under clothing. Heavy application is not necessary to achieve protection.

• Do not apply repellent to cuts, wounds, or irritated skin.

• After returning indoors, wash treated skin with soap and water. (This may vary depending on the product. Check the label.)

• Do not spray aerosol or pump products in enclosed areas.

• Do not spray aerosol or pump products directly to your face. Spray your hands and then rub them carefully over the face, avoiding eyes and mouth.

• When using repellent on a child, apply it to your own hands and then rub them on your child. Avoid children’s eyes and mouth and use it sparingly around their ears.

• Do not apply repellent to children’s hands. (Children may tend to put their hands in their mouths.)

• Do not allow young children to apply insect repellent to themselves; have an adult do it for them.

Other ways to protect your children against mosquitoes are to have them wear long pants, long sleeved shirts and closed shoes if they are outside when mosquitoes are active. Mosquitoes are most active at dawn and dusk.Wear light-colored clothing, which will help reduce overall attractiveness to mosquitoes.

In comparison trials, DEET is more effective than any other insect repellent. DEET repels mosquitoes for a longer duration than for ticks. When seeking protection against ticks, look for a product that specifies use for ticks.

Sources
1.http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/life-vie/insect-eng.php
2.www.cdc.gov/ncidod/dvbid/westnile/qa/insect_repellent.htm
3.DynaMed
4.Pediatr.Ann. 2004 Jul;33(7):443-53 “Does Anything Beat DEET” PMID: 15298309
5.UpToDate - Prevention of arthropod and insect bites: Repellents and other measures

A. : Head lice are tiny, wingless, parasitic insects that live and feed on blood from your scalp. Lice do not jump or fly. Head lice are easily transmitted from person to person with close contact (as occurs within households and classrooms) There is no proven transmission from nonliving carriers, but because head lice and ova have been found on hats, combs, brushes and stuffed animals, it is a good idea to eradicate lice from household items. Machine laundering with or without detergent in hot water (50C) or placing the item in a dryer for 40 minutes has been shown to effectively decontaminate lice and nits. Other unproven but routine recommendations include dry cleaning, vacuuming or sealing items in plastic bags for 3 to 4 days, as lice are unlikely to survive off the scalp for more than 3 days. Nits are also unlikely to hatch at room temperature, since they need the warmth and moisture of the scalp.

The diagnosis of head lice is definite only when crawling lice are seen in the scalp or hair. Detection is difficult since head lice move quickly and most infections involve 10 or fewer lice. Using a fine–toothed nit comb is four times as effective, and twice as fast as visual inspection for the detection of live head lice. The lice are detected by a thorough combing-through of wet hair from the scalp with the fine-tooth detection comb; lice are usually found at the back of the head or behind the ears. Nits are oval, grayish white eggs fixed to the base of hair shafts. Each adult female louse lays 3 to 5 eggs/day, so nits typically vastly outnumber lice and are not a measure of severity of infection. Some people with a lice infestation may not have any symptoms, but the most common symptom people experience is itching of the scalp, neck and ears.

Only persons with live crawling lice should be treated. Close contacts and household members of someone with lice should be screened for lice. Preventative treatment is unnecessary and may contribute to resistance.

If the diagnosis is positive for lice, all topical lice treatments are available as non-prescription products at pharmacies. The product must be reapplied 7 to 10 days following initial treatment.

Sources
1.http://www.merck.com/mmpe/sec10/ch121/ch121e.html#S10_CH121_T001
2.www.pharmacygateway.ca CE Online CCCEP file # 671-1207 “Head Lice Treatment: Is it time for a paradigm shift?” by Penny Miller, B.Sc.(Pharm.), M.A. March 2008
3.http://www.mayoclinic.com/health/head-lice/DS00953

A. Chemical sunscreens may become less effective over time, and leaving them in high temperatures (eg, car, beach) may speed the process. Manufacturers and others recommend throwing away sunscreen when it has passed the expiration date listed on the bottle. For sunscreen that does not have an expiration date, a typical recommendation is to throw it away after three years, when stored at room temperature. Expired sunscreen may be less effective, potentially reducing the SPF rating and increasing your risk of sunburn.

Bottles of sunscreen shouldn’t last very long if they are being used correctly. To achieve the labelled SPF value a person should apply 2 tablespoons of sunscreen for the full body. The following body parts should have ½ teaspoon each: the face and neck, each arm and shoulder, front of torso, and back of torso. Plus, one teaspoon should be applied to each leg/top of foot. Sunscreen sprays should be sprayed on and rubbed in to ensure uniform coverage.

Apply sunscreen at least 15 to 30 minutes prior to sun exposure and reapply every 2 hours even on cloudy days and after swimming, heavy sweating and towelling off.

For maximum protection from sunburn, skin wrinkling, skin aging and cancer causing UV radiation from the sun use an SPF of at least 15 ( some organizations recommend nothing less than 30 ) on exposed skin every day. You may need a higher SPF if you are fair skinned or plan to be in the sun for a prolonged period or if you anticipate intense sun exposure (eg, while at the beach or skiing ). Snow reflects up to 80 per cent of the sun’s rays, giving you a double dose of radiation when involved in winter sports. Also, use a sunscreen that protects against UVA and UVB radiation.

Other measures that can be used to protect yourself from the sun are to avoid the sun between 10am and 4pm, wear protective clothing like a wide brimmed hat, sunglasses and long sleeves. Protect your lips with lip balm containing an SPF of 30 or higher and re-apply frequently.

Sources
1.Sunscreens: achieving optimal protection. Pharmacist’s Letter/Prescriber’s Letter 2009;25(6):250606
2.UpToDate- Patient Information: Sunburn Prevention
3.http://www.dermatology.ca/sap/safety_resources/sunscreen_faqs/index.html

A. : Aspirin is usually administered at doses of 75-325 mg once daily. Higher dose aspirin is not more effective than lower aspirin doses, and some analyses suggest reduced efficacy with higher doses. Because the side effects of aspirin are dose-related, daily aspirin doses of 75-100 mg are recommended for most indications. When rapid blood thinning ( platelet inhibition ) is required, an initial aspirin dose of at least 160 mg should be given. Most common side effects are gastrointestinal and range from painful indigestion ( dyspepsia ) to inflammation of the stomach or peptic ulcers with bleeding and perforation.

The American Diabetes Association recommends the use of aspirin (75 mg to 162 mg per day) as a primary prevention strategy in patients with diabetes who are at increased cardiovascular risk. The Canadian Diabetes Association released their Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada in September 2008. The recommendation states that use of daily aspirin (81 mg to 325 mg) should be based on clinical judgement.

The use of enteric-coated aspirin is not recommended for reducing the risk of gastrointestinal bleeding or dyspepsia. People at high risk of gastrointestinal bleeding or those with dyspepsia caused by antiplatelet treatment should consider measures to protect the stomach ( for example a proton pump inhibitor ). Aspirin should be taken after food to reduce the risk of gastrointestinal adverse effects. A person should seek medical advice if they experience wheezing or dyspepsia symptoms with low dose aspirin.

Although the optimal dose of aspirin is uncertain, there is no compelling evidence that any specific dose is more effective than another, and fewer gastrointestinal side effects and bleeding occur with lower doses (≤ 325 mg a day). We recommend a dose of 50 to 100 mg daily when using aspirin for the secondary prevention of stroke.

Sources
1. www.accessmedicine.com
2. Canadian Pharmacist’s Letter
3.www.cks.nhs.uk/antiplatelet_treatment/management/quick_answers/scenario_antiplate
4. UpToDate – Antiplatelet Therapy for Secondary Prevention of Stroke

A. Alcohol has multiple effects on the body that contribute to the hang over feeling. It causes dehydration and has many effects that contribute to a headache. Alcohol causes inflammation of the stomach lining and increase in gastric acid leading to abdominal pain, nausea and vomiting. It can cause low blood sugar and disrupts sleep cycles. These disruptions in body rhythms produce a “jet lag” effect.

There is no scientific evidence to support any cure or effective prevention for alcohol hangovers. The most effective way to avoid a hangover is to consume alcohol only in moderation or not at all. If you are going to drink, drink small amounts and alternate with a glass of water to reduce dehydration. Alcoholic beverages that contain few congeners ( biologically active compounds that contribute to the taste, smell and appearance of the alcoholic beverage ) such as vodka, gin and rum are associated with a lower incidence of hangover than are beverages that contain a number of congeners, such as brandy, whiskey, bourbon and red wine.

ASA and other anti-inflammatories, such as ibuprofen or naproxen, may reduce the headache and muscle aches, but should be used cautiously if upper abdominal pain or nausea is present. These are gastric irritants and will compound alcohol induced gastritis. Acetaminophen should be avoided during the hangover period because alcohol metabolism enhances acetaminophen toxicity to the liver.

Putting anything in your stomach prior to indulging in alcohol helps prevent a hangover, but fatty foods in particular stick to the stomach lining longer and therefore slow down the absorption of alcohol into the blood stream. This gives the body more time to process the by products of alcohol.

Bananas, kiwi fruit and sports drinks will help replenish lost electrolytes and the fructose in fruit juice is reported to increase the rate that the body gets rid of toxins.

Eggs and high protein foods contain an amino acid known as cysteine which helps detoxify harmful substances in the body.

Caffeine is commonly used to counteract the fatigue and malaise associated with hangover condition, but can also contribute to the dehydration.

Drink lots of water to replenish fluids and dilute toxins. Hangover symptoms will usually abate over 8 to 24 hours.

Sources
1. http://pubs.niaaa.nih.gov/publication/arh22-1/54-60.pdf
2. http://health.howstuffworks.com/hangover5.htm
3. http://www.annals.org/content/132/11/897.full

A. The influenza illness usually presents with a sudden onset of cough and fever. In laboratory confirmed cases of H1N1 100% of children under age 2 presented with fever, 90% of pregnant women and approximately 50% of people greater than 65 presented without fever. Fever and cough were present in 70% of the confirmed cases.
Other common symptoms are sore throat, nasal discharge, fatigue, muscle and joint pains, headache and decreased appetite. Sometimes the person may have vomiting, diarrhea and nausea. Is the pandemic H1N1 2009 virus known to be circulating in your
community? You can check at www.phac-aspc.gc.ca/fluwatch/index-eng.php. Indications that you have a severe case and should seek medical help are shortness of breath, chest pain, dizziness, confusion and/or a high fever lasting longer than 3 days.

Sources
1. www.phac-aspc.gc.ca/alert/h1n1/
2. www.RxFiles.ca
3. http://bulletin.healthwise.net/h1n1

A. Your doctor may prescribe an antiviral such as Tamiflu ( oseltamivir ) or Relenza ( zanamivir ). These medications can reduce flu symptom, shorten the length of illness and reduce serious complications if taken within the first 24 to 48 hours of getting sick.
Getting the H1N1 flu vaccine is the best way for you to protect yourself
and others from getting infected.

Sources
1. www.phac-aspc.gc.ca/alert/h1n1/
2. www.RxFiles.ca
3. http://bulletin.healthwise.net/h1n1

A. The H1N1 vaccine does not interact with any other medication because it is prepared from an inactivated (dead) virus.
People on immunosuppressive medications (e.g. high dose prednisone, cancer chemotherapy, anti-rejection drugs, etc.) may not mount a full immune response after being vaccinated, but vaccination is especially important for these people because
their weakened immune system makes them more susceptible to contracting the H1N1 virus.

Sources
1. www.phac-aspc.gc.ca/alert/h1n1/
2. www.RxFiles.ca
3. http://bulletin.healthwise.net/h1n1

A. The following groups of people only should not receive the H1N1 flu vaccine:
- people who have had a previous anaphylactic ( severe allergic reaction ) to any element of the vaccine , or people with a hypersensitivity to eggs ( eg. hives, swelling of the mouth and /or throat, breathing difficulty )
- people experiencing a high fever
- people who have previously experienced Guillan-Barre Syndrome within 8 weeks of receiving a seasonal flu vaccine
- the H1N1 flu vaccine is not approved for children under 6 month

Sources

1. www.phac-aspc.gc.ca/alert/h1n1/
2. www.RxFiles.ca
3. http://bulletin.healthwise.net/h1n1

A. : After receiving the H1N1 flu vaccine, most people will start to develop
immunity within 10 days with just one dose.

Sources
1. www.phac-aspc.gc.ca/alert/h1n1/
2. www.RxFiles.ca
3. http://bulletin.healthwise.net/h1n1

A. Withdrawal effects, especially rebound insomnia, are rare after the discontinuation of long-duration benzodiazepines ( flurazepam, diazepam, chlordiazepoxide) and tend to be mild after the discontinuation of intermediate-acting benzodiazepines (lorazepam,temazepam,oxazepam,alprazolam). However, marked rebound insomnia has been reported after the discontinuation of triazolam, a shorter-acting drug, usually lasting one to three nights. In contrast, withdrawal studies of zopiclone have shown little or no rebound insomnia. The rate of withdrawal of benzodiazepines should be individualized, depending on the half-life and dose of the drug, the duration of therapy, and whether the insomnia is acute or chronic. Long acting benzodiazepines are not recommended in the elderly because they cause higher cortical impairment resulting in confusion and falls.

After tapering the medication plan to stop the medication at a low-stress time, e.g., a weekend. Two nights before the planned withdrawal, the patient should shorten the sleep time (while staying on the medication) by 20 minutes. This modest degree of sleep deprivation will promote physiological sleepiness, which should counterbalance any sleep disruption associated with withdrawal. This shortened sleep period should be maintained for one week.

To achieve a good sleep it is important to follow these guidelines referred to as sleep hygiene
1. Keep a regular sleep wake schedule, 7 days per week.
2. Restrict the sleep period to the average sleep time you have obtained each night over the preceding week.
3. Avoid sleeping in, extensive periods of horizontal rest or daytime napping; these activities usually affect the subsequent night of sleep.
4. Get regular exercise every day- about 40 minutes of an activity with sufficient intensity to cause sweating. If evening exercise prevents sleep, schedule the exercise earlier in the day.
5. Avoid caffeine, nicotine, alcohol and other recreational drugs, all of which disturb sleep. If you must smoke do not do so after 7:00 p.m.
6. Plan a quiet period before lights out; a warm bath may be helpful.
7. Avoid large meals late in the evening; a light carbohydrate snack (e.g., crackers and warm milk) before bedtime can be helpful.
8. Turn the clock face away and always use the alarm. Looking at the clock time on awakening can cause emotional arousal (performance anxiety or anger) that prevents return to sleep.
9. As much as possible, keep the bedroom dark and soundproofed. If you live in a noisy area, consider ear plugs.
10. Use the bedroom only for sleep and intimacy; using the bed as a reading place, office or media centre conditions you to be alert in a place that should be associated with quiet and sleep. If you awaken during the night and are wide awake, get up, leave the bedroom and do something quiet until you feel drowsy-tired, then return to bed.
Note: Pharmacologic (or any) interventions will be less effective if these guidelines are not followed. In mild cases of insomnia, sleep hygiene guidelines, practised consistently and together, may be sufficient to reinstate a normal sleep pattern.

Sources
1. eTherapeutics
2. N. Engl J. Med.2005;353(26):2827
3. eCPS

A. The new vaccine for shingles is called Zostavax, and it has had a notice of compliance from Health Canada allowing it to be sold in Canada since August 22,2008. The company that manufacturers the vaccine, Merck Frosst Canada Ltd. ,plans to market it in the fall of 2009.

Zostavax reduces the risk of reactivation of the varicella zoster virus, the same one that causes chicken pox. The shingles vaccine contains about 14 times the amount of weakened chicken pox virus than the vaccine for children. This amount is needed to obtain a protective response in the aging immune system of older adults. Anyone who has had chicken pox is at risk of developing shingles. It most commonly occurs in people over 60 and the risk increases as people age. The virus that has been dormant in the nerve cells, once reactivated, travels from the nerves and follows a path out to the skin. The nerves along the path become inflamed and therefore shingles can be painful. Pain that lasts for months after the rash has healed is called post herpetic neuralgia.

The vaccine is safe and common side effects include: headache, pain, swelling, and itching at the injection site. A small group of recipients also got a rash at the injection site.
A single dose of shingles vaccine is indicated for adults 60 years of age and older to prevent the development of shingles.

Sources
www.fda.gov
www.chop.edu
www.immunize.org.vis
Communication with Merck Frosst Canada Ltd.

A. Yes, but check with your doctor if it is right for you. There is a specific branded product now available called Seasonale®, allowing users to take an active pill once daily for 84 days before taking 7 inactive pills. Taken in this manner, one would expect only 4 periods per year instead of the usual 12. The same can be done with most birth control pills by starting a second pack immediately after finishing the active pills in the first pack (ie. disregarding the inactive sugar pills ). Two packs or more can be run together in this fashion before taking a 7 day pill free break. Again the exact regimen should be decided upon in consultation with your doctor.

Sources
Guilbert E, Boroditsky R, Black A, Kives S, Leboeuf M, Mirosh M, Senikas V, Wagner MS, Weir E, York-Lowry J, Reid R, Trussell J; Society of Obstetricians and Gynaecologists of Canada. Canadian Consensus Guideline on Continuous and Extended Hormaonal Contraception, 2007. J Obstet Gynaecol Can. 2007 Jul;29(7 Suppl 2):S1-32.

A. Most manufactueres of SSRIs suggest that concurrent use with SSRIs and alcohol is not advisable. This is likely due to the fact that both alcohol and SSRIs may cause sedation and the effect may be increased when combining the two. Also the risk of alcohol abuse is higher in depressed patients. There are only a few studies examining the interaction between alcohol and some SSRIs. They reveal that there are likely no clinically significant interactions with alcohol and the following SSRI antidepressants: citalopram, escitalopram, fluoxetine, paroxetine and sertraline but there may be some modest increase in sedation with fluvoxamine and paroxetine. Keep in mind, the above information pertains to SSRI type antidepressants only and you should talk to your doctor about consuming alcohol with any antidepressants.

Sources
Stockley's Drug Interactions 8th Edition

A. Yes you can, but it may not be as accurate as using the finger tip in certain circumstances and only those devices (meters, lancing devices etc.) for which alternate site testing is recommended should be used.

Only use forearm testing before a meal, an insulin dose, or physical exercise, or 2 hours after a meal, an insulin dose, or exercise.

When blood sugar is changing rapidly, for instance, within 2 hours after a meal, an insulin dose or physical exercise, a forearm blood sample will not show this change as quickly as a fingertip sample.

When blood sugar is falling, testing with a fingertip may identify a hypoglycaemic (low blood sugar) level sooner than a test with a forearm sample.

You should use fingertip testing whenever you have a concern about hypoglycemia (insulin reactions), such as when you drive a car, particularly if you suffer from hypoglycemic unawareness (lack of symptoms to indicate an insulin reaction), since forearm testing may fail to detect hypoglycemia. If the results from the forearm do not match how you feel (high or low), test from the fingertip and use those results.

If you want to use an alternate site because of fingertip pain, please see these tips regarding fingertip pain:

http://www.diabetes.ca/Section_About/fingertip.asp

Here are some tips on alternate site blood sugar testing.

For best results from alternate site
testing, individuals should be trained in
proper technique, as follows:

1. The selected alternate site should be
relatively free of hair and cleaned with
soap and warm water.
2. Rub the area vigorously for 5 seconds.
3. The correct end cap to the lancing
device must be used. This is a clear
end cap to allow the user to see the
blood drop form.
4. Press the clear end cap firmly against
the skin for 1 to 2 seconds to help pool
the blood.
5. Release the lancing mechanism and
leave the end cap pressed firmly
against the skin until the blood drop
forms. If necessary, pressure against
the skin may be released slightly and
reapplied to help the blood drop form.
6. Take the strip to the drop allowing the
capillary action to draw in the sample.
7. Make note in a logbook of which alternate
site has been used.

Sources
1. http://www.diabetes.ca/Section_About/fingertip.asp
2. http://www.diabetes.ca/files/Professional%20Pub%20Archives/DiabetesQuarterly/DCJuly-Aug0712Jul07.pdf

A. Likely not. Initial research indicated that cinnamon was possibly effective for type 2 diabetics by lowering fasting serum glucose, triglyceride, and cholesterol levels.

However, a recent analysis of the existing evidence indicates otherwise. Currently cinnamon has not been found effective in people with type 1 or type 2 diabetes in improving fasting blood glucose, hemoglobin A1C, or lipid levels. Further research is required regarding the use of cinnamon in preventing diabetes in high risk individuals or those with pre-diabetes.

Currently a study is being conducted in Toronto to assess the impact cinnamon has on fasting blood glucose, insulin, glycosylated hemoglobin (HA1C), triglyceride, total cholesterol, HDL cholesterol and LDL cholesterol levels in people with type 2 diabetes. The results of this study will be able to provide more conclusive evidence regarding the use of cinnamon in type 2 diabetics.

Sources
Natural Medicines Comprehensive Database 2008: Cassia Cinnamon

Baker WL. Gutierrez-Williams G. White CM. Kluger J. Coleman CI. Effect of cinnamon on glucose control and lipid parameters. [Journal Article. Meta-Analysis] Diabetes Care. 31(1):41-3, 2008 Jan.
UI: 17909085

http://clinicaltrials.gov/ct2/show/NCT00479973?term=diabetes+%5BCONDITION%5D+AND+diet+%5BTREATMENT%5D&recr=open&rank=19

A. Medications that were affected by the voluntary recall included those with multiple ingredients for cough and cold only. The concern was related to misuse of these multiple ingredient products and potential effects of overdose. Products with only acetaminophen were not affected and can be used safely in those under two years of age as indicated on the label. Always check the label before giving your infant any over the counter medication or ask your pharmacist.

Sources
http://www.ndmac.ca/index.cfm?fuseaction=main.dspFile&FileID=139

A. It might be. There are many different treatment options for hot flashes. The most effective therapy is still hormone therapy (1), but there are other non hormonal options for those whom hormonal therapy is not indicated or for those who prefer not to take hormones. Although not approved for use in combating menopausal symptoms, some antidepressants have been shown to be effective including venlafaxine (Effexor®), paroxetine (Paxil®) and fluoxetine (Prozac®) (2). Clonidine is another prescription medication which can be tried although side effects may limit its use (2). Gabapentin, a medication typically used in the treatment of nerve pain, may also be useful (2).

Black Cohosh is an herbal product that may also be tried although there is conflicting evidence about how effective it might be. Some trials show that it is no more effective than placebo pills (1) and others show it is more effective than estrogen or placebo (1). That being said, Black Cohosh is relatively safe, with the most common adverse effect being stomach upset (1). There is some concern of liver toxicity and safety beyond six months is not established (1) therefore liver function tests should be monitored periodically. Jaundice, unusual fatigue and dark urine are symptoms of liver toxicity and should they occur should be reported to your doctor (3).

The North American Menopause Society recommends lifestyle modifications with or without non-prescription therapy (including Black Cohosh) for women who need relief of mild menopausal symptoms such as hot flashes (1).

Sources
1. Menopause, Vol. 11, 16 No. 1, 2004
2. eTherapeutics April 2007 Menopause
3. Canadian Pharmacist's Letter 2004 (7):200714

A. There are many different "colon flushes" and "herbal detox systems" on the market today with a variety of ingredients. None of them can be recommended. There is no need to flush toxins from the body. The human body has very efficient organs to deal with waste including the liver, the kidneys and the colon itself. Furthermore, depending on the method and ingredients, these "flushes" may have adverse consequences including nausea, vomiting, cramps, dehydration, and electrolyte/mineral imbalances. Depending on the frequency of use, these products may also cause the user to become dependent on the product for normal bowel function. For more information click on the links below.

Sources
1. http://www.acsh.org/factsfears/newsID.194/news_detail.asp
2. http://www.quackwatch.org/01QuackeryRelatedTopics/detox.html
3. http://www.quackwatch.org/01QuackeryRelatedTopics/gastro.html

A. Yes. Whether a manufacturer makes brand or generic drugs, they must meet the same standards set by Health Canada. Health Canada is also responsible for evaluating generic drugs. Evaluation is based on comparative studies carried out by the manufacturer. The studies are conducted the same way regardless of the drug or manufacturer. The generic drug must show that it can deliver to the bloodstream the same amount of medicinal ingredient at the same rate as the brand name drug. Sometimes the non-medicinal ingredients are different. These ingredients are responsible for shape and colour of the tablet and have no medicinal properties. If and when a manufacturer changes the non-medicinal ingredients of a drug, they must prove with scientific studies that the different ingredients do not affect the delivery, effectiveness or safety of the drug. Most pharmacies will dispense generic drugs if available for any given product unless requested otherwise by the patient or the doctor.

Sources
http://www.hc-sc.gc.ca/iyh-vsv/med/med-gen_e.html#is

A. First we need to be clear what we mean by "homeopathic". Homepathic products are different than herbal products. Homeopathy is based on three premises including the law of similars, individuality and small doses. The law of similars theorizes that substances that would normally cause symptoms of side effects at high doses in healthy subjects can be used to treat these same symptoms in very low doses in those who are sick. The premise of individuality states that because everyone presents with different symptoms of the same disease they must be treated differently. Small doses are used in homeopathy because normal doses of these products would be toxic. "Mother tinctures" are often diluted with alcohol or water to such a degree that the original ingredient can't possibly exist but as homeopathic practitioners will argue, it is the "essence" that remains and the "essence" that is active. There is much controversy surrounding the use of homeopathic medicines as the above principles run contrary to the science of medicine, pharmacology and chemisty. Given that the mechanism of action for homeopathic medicines are unknown or unproven, the knowledge regarding drug interactions is also difficult to determine. We can assume that if the ingredient in a homeopathic product is undetectable then drug interactions would be non-existent. Problems may arise if other ingredients such as natural products are added to the preparations and not indicated on the label. If you would like to take a homeopathic product make sure that it has an NPN number on the label which indicates at the very least that Health Canada has verified the quality and safety.

Sources
1. Am J Pharm Educ. 2007 February 15; 71 (1): 07
2. Br J Clin Pharmacol 2007 Sep 15
3. http://www.quackwatch.com/search/webglimpse.cgi?ID=1&query=homeopathy

A. If your baby is exhibiting these symptoms and still passes a soft stool then your baby may NOT be constipated at all. These symptoms are referred to as infant dyschezia. Infant dyschezia is caused by an inability to co-ordinate abdominal pressure with relaxation of pelvic muscles. The baby cries in an attempt to increase abdominal pressure and is not crying from pain. These symptoms will generally resolve spontaneously as your baby will learn to co-ordinate the defecation reflex. Treating the symptoms may be counter productive as this may interfere with the learning process. If you believe that your baby is constipated and you notice blood in the stool, fever, vomiting or a loss of weight please contact your doctor as this is unlikely "infant dyschezia".

Sources
1. Up to Date 2007: Constipation in Children: Etiology and Diagnosis
2. Paul Hyman, M.D. Accessed Aug 28, 2007. " Childhood Defecation Disorders: Constipation and Soiling." http://www2.kumc.edu/kupedigi/Defecation.htm
3. J Pediatr Gastroenterol Nutr. 1999 Nov;29(5):612-26.

A. SSRI antidepressants include (fluoxetine, fluvoxamine, paroxetine, citalopram and sertraline). Yes it is normal to have difficulties coming of these medications but it is important to distinguish between discontinuation symptoms and a re-emergence of depression. Usually this is easy enough for your doctor to distinguish. Discontinuation symptoms generally appear within hours or days of discontinuation and generally include dizziness, headache, nausea, "electric shock" like sensations, and "rushing" sensations in the head. These symptoms will usually respond rapidly to restarting the antidepressant.

The cause of discontinuation symptoms is not completely understood but is thought to result from a temporary deficiency of serotonin in the brain and a temporary deficiency (down-regulation) of serotonin receptors. It may take a couple of weeks for the serotonin and receptors to normalize and discontinuation symptoms to disappear.

Given the proposed mechanism of discontinuation symptoms it is best to reduce the dose of an antidepressant slowly over time rather than to quit taking them outright. There is no clear cut or "best" way to taper an antidepressant. With the exception of Prozac (fluoxetine) most newer antidepressants should be discontinued over several weeks with dose adjustments every 7 days. If withdrawal symptoms occur during tapering, the drug can be restarted and tapered more slowly. Another option is to substitute the drug with Prozac(fluoxetine) which, because of it's long half life, has a "built-in" tapering effect.

Sources
1. American Family Physician Volume 74, Number 3.

A. Colic has been defined as crying for more than three hours per day, for more than three days per week, and for longer than three weeks in a baby who is well-fed and otherwise healthy. Although colic can be quite distressing to the parent, it usually resolves on its own but may last up to four months of age. That being said, other causes of crying should be ruled out by the physician before a diagnosis of colic is made. The cause of colic is unclear and effective treatment options are few and far between. Simethicone, the active ingredient found in many over-the-counter anti-gas drops, has been shown to be no more effective than placebo. Similarly, no evidence exists for the effectiveness of various "Gripe Water" preparations and if tried, alcohol/sugar-free products should be used. There is some evidence that a certain species of lactobacillus (lactobacillus reuteri) may be helpful but more research is needed. There is no evidence for other species of lactobacillus. Many non-drug measures such as car-rides, pacifiers, gentle soothing motions, prophylactic holding, et cetera can be tried but are likely not effective. Infant massage and chiropractic techniques have not been shown to be effective and cannot be recommended. Although colic can be very difficult to deal with as a parent, there are no long term effects associated with colicky babies when compared to a non-colicky babies.

A. Fosamax is in a class of medications called the bisphosphonates. Bisphosphonates are used to prevent and/or treat osteoporosis. These medications are also helpful in other bone diseases and certain types of cancer. A very rare adverse effect of this class of medication is osteonecrosis of the jaw which is damage to bone tissue of the jaw leading to severe pain, swelling and loose teeth. Although this condition can occur with oral forms of bisphosphonates including Fosamax, the majority of cases have resulted from intravenous forms of these drugs in patients with cancer. The risk or this adverse effect with oral bisphosphonate therapy is considered very low (0.7 case per 100,000 person years exposure). People at higher risk include those taking chemotherapeutic agents, radiation, corticosteroid therapy and those with poor oral hygeine or certain medical conditions like dental problems, anemia and diabetes. Smoking and alcohol use may also increase risk. Most of the time, the benefits of bisphosphonate therapy outweigh the risk of osteonecrosis of the jaw. To help minimize risk, those taking oral bisphosphonates should maintain good oral hygiene and visit the dentist regularly. It is important to let the dentist know about concurrent treatment with an oral bisphosphonate.

Fosamax has also been in the news recently with links to irregular heart beats (arrythmias). Two papers published in the New England Journal of medicine showed an increase in serious arrythmias in those taking Reclast, a once yearly injectable bisphosphonate, and the oral form of Fosamax. Again the risk of Fosamax causing serious arrhythmias appears to be very small and may not be significant. In one trial the risk of serious arrhythmia was 1.5% in those taking Fosamax compared to 1% for those not taking fosamax. At this point the risk seems higher with Reclast. As with osteonecrosis of the jaw, most of the time, the benefits of Fosamax therapy outweigh the very small risk of serious arrhythmias.