Thursday, April 17, 2008

An Idea

A group of endocrinologists should start a metal band called Thyroid Storm.

Just Pissing It Away

It's been quiet in my corner of the blogosphere, but I lay the blame squarely on the fact that my latest round of exams has kept me extremely busy. Ths plus side of all this is that I get to come back to lots of news, all ripe for comment!

Like this article published today analyzing a couple studies from early 2000 about certain drugs prescribed for high blood pressure being potentially tied to bone loss, particularly in older men.

Most of the time, our sound bite-focused media doesn't get the whole story out there. This article is no exception.

Diuretics are commonly called "water pills," particularly by older people. I really, really hate that term. It isn't even remotely appropriate for describing how diuretics function. I suppose that the analogy comes from the idea that drinking more water causes increased urination, and taking diuretics causes increased urination; hence, diuretics are "water in pill form," except that that totally fails to explain how they work to lower blood pressure. Normally I don't think it's necessary for patients to know the mechanisms of action for the drugs they take--such details are excessively complicated. But we strive to explain things in the simplest way we can without sacrificing accuracy. Antidepressants, for example, are said to "balance or correct problems in brain chemistry." This is simple, but true at the base level.

Diuretics don't add anything to your body, and they certainly don't hydrate you. They have varying mechanisms of action, but what they really do is increase the body's excretion of certain elements that float around in the body in ion form. Sodium, potassium, and calcium are three good examples--they are commonly called "electrolytes," especially if you like reading the labels on your sports drinks. Generally, sodium loss is desirable in patients with high blood pressure. All of these ions must be present in proper concentrations for the body's various functions to work properly. Too much and too little are both bad. Diuretics are a convenient way to get rid of excess electrolytes.

The diuretic the article is talking about is furosemide, though there are other diuretics in the same family that have the same effect. Furosemide flushes out sodium, potassium, and calcium by preventing the kidneys from re-absorbing it at a specific point (the loop of Henle, if you're curious). Many patients on furosemide are also prescribed potassium supplements to counter the potassium loss. The calcium loss is not as frequently addressed, but it really should be; then again, most people don't get enough calcium anyway.

But saying diuretics in general are responsible for worsening bone loss is not only alarmist, it's false. Hydrochlorothiazide, or HCTZ, actually results in calcium retention. Sometimes this is a problem, as it can cause calcium levels in the blood to get too high. But for some patients with high blood pressure who are also at risk for osteoporosis, HCTZ is a great drug; it helps them retain extra calcium, improving bone density! This doesn't mean that everyone at risk for osteoporosis should be on HCTZ; increasing dietary calcium and vitamin D are a much better idea. But when treating patients with high blood pressure, it is often best to use drugs that "kill two birds with one stone." Likewise, it doesn't mean that patients at risk for bone loss shouldn't get furosemide. This is what trained physicians and pharmacists are for--evaluating the complicated mess of risks, benefits, and drug interactions that make modern medical therapy so difficult to manage.

And that's the bottom line--medicine is complicated. One 200-word article in a newspaper is never going to explain all the ins and outs of any particular treatment or drug; that's why scholarly journal articles are long, detailed, and extensively referenced. So consider very carefully where you get your information; chances are that if it was packaged for the general public and sold at the newsstand, you're not getting the whole story.

Friday, April 11, 2008

Really Delayed Ambulance Chasing

A few months ago I was in a minor vehicular accident when traffic ahead of me slowed to a complete stop on the highway. A pickup truck swerved across three lanes and cut in front of me; my eye still on the truck, I failed to notice that the cars ahead had stopped, so I wound up rear-ending a fellow motorist at about five miles per hour as I failed to come to a complete stop. The total damage done was a slight scratch on my front bumper and a tiny imprint the shape of my car in the poor guy's fender. Neither party was injured, so the police didn't even file a full report, just a non-investigated accident form for the both of us as a way of formally exchanging information.

Fast-forward to today, nearly four months later.

When I got home from class, I was told that someone had called about my insurance. Since the other driver had (about a month after the accident) apparently smelled money and tried to claim an injury, I figured that this was about the resolution to that case.

Nope. It was a chiropractor's office.

They were trying to convince me to schedule an appointment in the event that I was having "headaches, backaches, or other pain problems" as a result of the "accident." "It can take several weeks or months for problems to develop," noted the woman on the phone. "This is because at the time of the accident your body is full of all kinds of chemicals."

Right. It still is, as a matter of fact, and I bet I know more about them than she did. Moving on.

I was polite to her; there was no reason to be otherwise, and I declined her offer to make me an appointment for a chiropractic evaluation.

This is all just a story--an anecdote. But I've never seen any other "doctors" having to resort to cold-calling patients from accident records to solicit them as patients. Chiropractors have more in common with ambulance-chasing lawyers than with physicians; the only way most of them are going to get any business is with colorful advertising or by dubious phone-farming.

In retrospect, it might've been somewhat humorous to suggest that I had developed allergies or diabetes since the accident. I wonder what the representative on the phone would've told me if I asked what they could do about it at the office?

Monday, April 7, 2008

Alarmist Media Soundbites Annoy Pharmacy Student

Let it be known that there are few ideas that cannot be expressed in a more entertaining way by using AP-style headlines.

There's been a lot of talk about how common medication errors or overdoses occur in hospital settings, particularly in children. A good bit of this can be attributed to the recent heparin mix-up involving Dennis Quaid's children. This particular error, fortunately, caused no deaths, unlike some previous errors in Indiana a year or two ago. The Quaids have every right to be upset--and they have every right to campaign to make the issue more visible. Medication errors are serious business, and hospitals should do everything in their power to prevent them from happening.

That said, the issue is being way over-hyped by the media.

According to the first link, one in fifteen children admitted to a hospital--about 7.3%, or 540,000 children across the United States each year--is harmed by a medication error. These are the figures that are being pitched around by the media in multiple places.

But these figures are misleading and alarmist. What a shock! Here's the study they're citing.

Part of the issue is the definition of an adverse drug effect. According to the Washington Post:

More than half of the problems cited involved overdoses or allergic reactions to painkillers.

The "or" in that sentence complicates the issue, but here's a simple statistic. The two biggest classes of pain medication are NSAIDs like ibuprofen and opioids like morphine or codeine.

True opioid allergy is exceedingly rare. In fact, less than 1% of the population is estimated to be allergic to opioids. Likewise, only about 1% of the population is estimated to be allergic to NSAIDs (though NSAIDs may precipitate problems in some patients with asthma).

This means that if the numbers reported are accurate and 11 out of 100 children hospitalized experience an adverse effect, only one of those is truly allergic to the drug in question--and there's nothing that can be done about that, short of avoiding the drug. Unfortunately, patients without a history of an allergic reaction are not going to discover the allergy without being exposed to the drug. This seems largely unavoidable. So what about the other ten kids? If the Post is correct, all of them recieved some kind of overdose.

Let's take a look at the actual study:

Twenty-two percent of all adverse drug events were deemed preventable...ninety-seven percent of the identified adverse drug events resulted in mild, temporary harm. [emphasis mine]

Mild, temporary harm? What kind of harm?

The most common adverse drug events identified were pruritis [itching] and nausea, the most common medication classes causing adverse drug events were opioid analgesics and antibiotics


Even patients not truly allergic to opioids may react with what is called a pseudoallergy. Where a true allergic reaction is a result of inappropriate overactivity of the immune system, pseudoallergy reactions are a result of sudden histamine release, causing flushing, itching, sweating, or hives. This is a well-documented side-effect of opioids. Is it totally preventable? Sure--by not giving opioids! Of course, this is why using the lowest effective dose of a drug is always a good idea--unlike true allergies, opioid pseudoallergies are dose-dependent, so higher doses increase the probability of a reaction. The good news is that antihistamines can be used to reverse the majority of these symptoms.

Antibiotics, conversely, wipe out friendly bacteria in the digestive tract, which is commonly accepted to be a cause of antibiotic-induced nausea and diarrhea. Other factors include the direct effect of the drug on the digestive tract, but decimating gut flora isn't doing anyone any favors. Some antibiotics are worse than others, but nausea is extremely common with antibiotic therapy--and, again, there's basically nothing that can be done about it.

At this point, the question should not be "how many children suffer adverse drug reactions?" This statistic is too simple to have any predictive power, especially when including mild or easily reversed side-effects that are extremely common (and predictable) or associated with the use of particular drugs. We should be more concerned with medication errors than minor adverse reactions. A patient getting a thousand-fold overdose of heparin is serious. A child getting a stomachache as a side-effect of antibiotics is not. So let's turn the statistics around--only 3% of adverse reactions were serious. A full 97% were mild and/or reversible. That sounds like good news to me!

I've come to expect that the media is going to spin everything they report to make it sound infinitely worse than it actually is--bad news sells. But the last thing we need is parents panicking about medication errors and being afraid to take their children to the hospital. Vigilance on the part of both parents and healthcare providers is good. Panic--and subsequent distrust--is not. Distrust of medical professionals is one of the main factors that turns patients to supporting woo.

And since I can't resist plugging my own profession, let's not forget that well-trained pharmacists are crucial players in reducing medication errors.

At Least He Didn't Need any Narcan

This is what happens when I get too busy to catch up on blogs for a few days--I miss gems like this post on the Bad Idea Blog.

Zero Tolerance has struck again: eight-year-old Eathan Harris was recently suspended for the dastardly crime of realizing that Sharpie markers smelled sort of neat.

"Zero tolerance" policies in schools have always been taken to positively baffling conclusions. However, they certainly fulfill their function--allowing school teachers and administrators to resolve every problem that might come up via knee-jerk reactions without having to think or reason. Some of the policies occasionally make sense at the most fundamental level, but they inevitably get stretched way beyond reasonable limits:

Student expelled for bringing a butter knife to school.
Another student expelled for possessing Tylenol. Tylenol!
Boy expelled for having two soft pellet guns in his car. What were "school authorities" doing searching his car in the first place?

It's no wonder schools have so much trouble imparting the merits of critical thinking to their students--their administrators don't seem to get it, either.

A Total Waste

According to a recently released report, lack of health insurance results in higher death rates.

A report issued Friday by Families USA, the national organization for health care consumers, concludes that nearly three people die each day in North Carolina because they don’t have health insurance.

The Families USA report says people without health insurance are more likely to delay seeking care because of the high bills, which means disease such as cancer are diagnosed at a later, more deadly stage.


I believe that this sort of thing speaks for itself. The cost of healthcare is astronomical--and it is quite simply unaffordable for the uninsured. By contrast, the insured in this country have an exceedingly poor grasp of the real cost of medical treatment, simply because they've been insulated from it by copays and percentages. Most people have some tenuous grasp on the idea that treatment for life-threatening illnesses is costly--treatments for cancer, for example, or any major surgery. But if outpatient pharmacy is any indication, most patients think that $50 is a "really expensive" drug product and they start complaining about how their insurance clearly didn't cover anything.

For some reason, telling them that the real cost of the medication is $250 doesn't change their tune.

What more can I say? I live in one of the richest countries in the world, but we have the poorest health outcomes per dollar spent. Despite the fact that America is the "first-world," people die from treatable illnesses because they can't afford to seek medical care until it's too late.

Thursday, April 3, 2008

How to Torture a Pharmacist

Get him or her to optimize your medication regimen when you have multiple diseases, one of them is a seizure disorder, and you absolutely need to take phenytoin.

This just in: Phenytoin sucks.

I don't mean in the sense that it is a bad drug. It is quite effective. It's just really, really, really, really annoying.

An Open Letter to my Pharmacy School

Please quit sending me emails about the veterinary therapeutics course. Last I checked, it was illegal for non-vets to prescribe medications for non-human animals. What, exactly, is the point of studying how to treat diseases in animals when animals are considered to be outside both our scope of practice and the scope of practices of physicians we work with? In my state, at the bare minimum, pharmacists aren't even allowed to sub brand-generic on vet prescriptions. What's the point?

I will note that I get a lot of calls from a local vet's office when I'm at work, but most of the time the questions being asked are about drug product availability; sometimes pet meds come in dosages or concentrations that human meds don't, and it can be difficult to approximate the doses. My cat's bladder infection was treated with what amounted to an Augmentin 50 mg/5 mL suspension; the least concentrated form available for humans is 200 mg/5 mL, so trying to dose the cat would've been practically impossible considering that she was getting about one milliliter of the stuff anyway. And I feel really bad for the family at our pharmacy who apparently splits the tiny-ass 2.5 mg Norvasc tablets in half.

Actually, the most confusing veterinary puzzle is the cat who uses an albuterol inhaler. If I ever see the owner at the store I'm going to ask how in the world that works.

Wednesday, April 2, 2008

Flagellating a Long-deceased Equine

How much more of this are we going to have to take?

Vaccines do: Prevent potentially fatal or crippling diseases.

Vaccines don't: Cause autism.

Seriously. Only in a wealthy, priviledged country like America do people have the time and resources to blame medical care for ruining the lives of their children. People in third-world countries will quite frequently do anything to get medicine, vitamins, or vaccinations to prevent or treat polio, rickets, malaria, or any number of other diseases that have been effectively eradicated in the first-world--eradicated thanks to medical science, not ambulance-chasing lawyers seeking thimerosal settlements.

Let me restate that. People are spending hundreds of court-hours and millions of dollars in legal fees trying to prove that a medical intervention that people across the globe are dying to get their hands on harmed their children.

Is this really about protecting children? Or is it about reaching into corporate America's deep pockets and snagging a piece of the autism settlement pie with your sticky fingers?