Tuesday, August 28, 2018

Heart Burn: Are we treating for too long?


Heart burn is a common phenomenon that can be characterized by a burning sensation in the throat, and chest. Heartburn is relatively easy to treat with a variety of OTC and prescription products. Proton Pump inhibitors (PPIs) are the premier drug class for treating heart burn, and have had a reputation for being benign drugs, until recently.

New evidence is emerging about long term use of PPIs showing correlations between opportunistic infections, pneumonia, and malabsorption of nutrients.1,2 The current recommendation for PPIs for heartburn is 8 weeks, but the reality is many patients surpass this time-frame.

Health care providers should be striving to limit PPI therapy duration in patients to avoid these complications until more information is available.

Difficulty Ceasing?

In patients that have surpassed the recommended 8-week therapy duration, there are two main barriers that make it difficult to terminate therapy.

One of the barriers stopping PPIs therapy cessation is patient preference. Most patients are not optimistic about stopping their PPI therapy, because of how well they work.

The second barrier that causes issues with cessation of PPI therapies is the perceptions of health care providers.  PPIs have been available since 1988, and many healthcare professionals view them as safe drugs. Since most health care professionals view them as harmless, they are less likely to intervene with patients using PPIs long term.


Who does this affect the most?

Although long durations of PPI therapy should be a concern for all patients, it is especially troublesome in older adults. Older adults are more prone to infection, and are more likely to suffer from nutritional deficiencies. Long term PPI use in older adults also adds an extra layer of issues due to drug interactions. To limit this potential harm, it is important to always address any PPI use in older adults.


What can we do?

The best way to decrease complications of long term PPI use in heartburn patients is to play a more active role in product selection, and therapy duration discussions.

Tips:

1) Recommend lifestyle interventions such as exercise, weight loss, and limiting meals before bed.3

2) Consider other drug classes first before PPIs when dealing with mild & moderate cases of heartburn.

3) Discuss with patient and prescribers expected duration of therapy prior to PPI initiation.

4) Investigate any patient prescribed PPIs for longer than 8 weeks and discuss possible taper options.

5) Attempt to taper patients on long term PPIs at least once a year using a combination of life style modifications and other drugs to help.

Quick Tip: Never stop a PPI abruptly due to risk of rebound hyperacidity.

Although PPIs are used mostly to treat minor ailments, it is important to remember the associated risk with long term use. 

Hopefully these tips will be helpful for everyone, because I am signing off.
I hope you have enjoyed my posts & are excited for the next student blogger.

Sincerely,

Derick Oduro

References:

1) Trifan, Anca, et al. “Proton Pump Inhibitors Therapy and Risk of Clostridium Difficile Infection: Systematic Review and Meta-Analysis.” Advances in Pediatrics., U.S. National Library of Medicine, 21 Sept. 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5643276/. 

2) Heidelbaugh, Joel J. “Proton Pump Inhibitors and Risk of Vitamin and Mineral Deficiency: Evidence and Clinical Implications.” Advances in Pediatrics., U.S. National Library of Medicine, June 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC4110863/. 

3) Ness-Jensen E, Lindam A, Lagergren J et al. Weight loss and reduction in gastroesophageal reflux. A prospective population-based cohort study: the HUNT study. Am J Gastroenterol 2013;108(3):376-82.

Tuesday, August 14, 2018

Recalls and Shortages: Knowledge is Power

In today's digital age information is readily available quickly, which can be both positive and negative.  

Health Canada recently recalled Valsartan, a drug for hypertension due to carcinogenic contaminants. As one would expect, this caused a lot of panic among the public. Working in a community pharmacy at the time, I remember getting several frantic calls from frightened patients about this recall. Several patients were displeased that we did not contact them first. The most common calls however, were patients trying to confirm if any of their other medications were being recalled. This panic could have easily been avoided if patients were aware of the resources available to them. 

Health Canada provides updates on its website and app, both of which are underutilized by health care professionals and patients. The website and app provide updates on Health Canada’s decisions for recalls and shortages pertaining to food, consumer goods, vehicles, and drugs.  
Importance of Accuracy? 
Since information spreads quickly in the digital age, it is important to get accurate updates, especially in regards to drugs. 

A game of broken telephone often occurs when news breakscausing misinformation to spread. A great example would be the Valsartan recall. Health Canada had the entire list of Valsartan products being recalled along with their strengths, and manufacturers. Many news outlets simplified this to the drug name, Valsartan and its primary indication, blood pressure. Many patients simplified this to a medication for blood pressure when contacting their family and friends. This led several people down an emotional roller coaster only to find out their drug was not affected. 

Why does this matter? 
Providing patients with these resources provides a reputable source for information on drug recalls and shortages. Well-informed patients are less likely to make rash decisions or panic. The goal is not to stop patients from contacting their health care providers, but to provide better tools for self-care. Self-care is an integral part of health maintenance. Drug recalls and shortages are a common occurrence, and it is difficult to relay this information to patients. Arming patients with these tools for recalls and shortages promotes self-care and limits the harm that misinformation causes. Hopefully this is something that you will strongly consider for yourself and your patients. 

Thanks for your time & catch you next week, 

Thursday, August 2, 2018

Toenail Fungus: Wow, that's a lot on your plate

The issue?

Toenail fungus is not the most fun topic, but it is something we must talk about, especially when nail infections  currently effects 6.4% of Canadians.1 This is approximately 2.3 million cases of nail fungus in Canada, most of which are toenail infections. Toenail fungus is usually preceded by athlete's foot, but it can occur independently. Toenail infections can cause several complications and should be treated promptly. A common issue with toenail infections is the aftermath after a successful treatment.

There are two terms used to define a successful treatment for toenail fungal infections. A mycological cure refers to the eradication of the fungi at the nail. A complete cure is defined by the eradication of fungi at the nail and the appearance of a healthy-looking nail. Most successful treatments of toenail fungus end with mycological cure, leaving patients with discolored and thickened nails. 

The hard part?

Unfortunately, the medications available for treating toenail fungus are not great at achieving complete cures. Topical antifungals and oral antifungals are the preferred therapy for treating toenail infections.

Efinaconazole and Ciclopirox are the two available topical therapies for the treatment of toenail fungus and have a respective 17% and 8.5 % complete cure rate.2 Achieving these cure rates are difficult because it requires patient's to be compliant with once daily usage for 48 weeks. 

The oral therapies Itraconazole and Terbinafine have the advantage of a lower duration of therapy (12 weeks) but come with unwanted drug interactions. Oral antifungals are notorious for their plethora of drug interactions, which can effect people taking medications for:
  • Depression
  • Pain
  • Migraines
  • Blood Pressure
  • Heart rate
  • Cholesterol
  • Psychosis
  • Anxiety
  • Sleep Deprivation
  • Urinary Incontinence
  • Heart Burn

Since several drug interactions exist it is difficult to treat most patients without risk of interactions. All this extra risk coincides with a higher cure rate, but not much. Terbinafine has the highest complete cure rate for oral antifungals commonly used. When used optimally, it’s complete cure rate is 38%.2

Good hygiene:

Low complete cure rates are a reason for concern for fungal toenail infections. Good hygiene practices can decrease the risk of contracting a fungal infection.

Hygiene Practices:
  • Wearing shoes that minimize humidity. Preferable shoes made of canvas or leather.
  • Avoid sharing toe nail clippers, towels, and other foot care devices with individuals
  • Keep nails clean and short
  • Avoid being bare footed in publicly shared spaces such as swimming pools, nail salons, gym locker rooms.
  • Dry feet immediately after washing
  • Wash feet with soap and water every day
  • Change socks worn each day, and even more frequently for physically activity individuals or those with a propensity to sweat
  • Wear socks preferably made of acrylic, cotton, polypropylene or wool.

Quick Tip: All these hygiene practices are valid for preventing both nail and foot fungal infections.

Although the mycological cure rate is respectable for most antifungals, the complete cure rate is usually low. Hopefully this will keep you on your toes, and get you to make the appropriate changes to your daily routine to decrease your risk.

Thank you for your time, and have a nice long weekend!

Derick Oduro 

References:
1) Gupta AK, Gupta G, Jain HC et al. The prevalence of unsuspected onychomycosis and its causative organisms in a multicentre Canadian sample of 30,000 patients visiting physicians' offices. J Eur Acad Dermatol Venereol 2016;30(9):1567-72.

2) Gupta AK et al. J Cutan Med Surg. 2015 Sep-Oct;19(5):440-9. doi: 10.1177/1203475415581310. Epub 2015 Apr







Monday, July 30, 2018

Impacted Earwax: "I’m sorry, could you repeat that?"


We have all had congested nostrils before, but have we all experienced congested ears? The goal of this post is to explain how cumbersome ear congestion can be, and how to help anyone caught in this sticky situation.  

Common Reasons for Build-Up: 
Before we talk about what we can do for congested ears, let us first discuss what causes earwax build up. There are many factors that cause earwax build-up in a person including old age and anatomical anomalies.1 The most common cause of earwax buildup for younger individuals is ear hygiene practices, primarily the use of cotton swabs.2 Placing objects into your ear canal pushes earwax back and impedes the natural cleaning mechanism of the ear causing a build-up. Once enough ear wax has collected it can cause: 

    • Ear discomfort (mainly ear fullness & itchiness) 
    • Hearing loss 
    • Chronic Cough 
    • Ear infections 

What’s Next? 
These symptoms can affect one's ability to function in their daily activities, so it is important to treat for quick relief. Cerumenolytic products are the primary option for treating impacted earwax. Cerumenolytics work by either softening the impacted earwax or lubricating the ear canal. Currently there is no evidence suggesting any cerumenolytic product to be superior.2 Therefore, a recommendation based on practice experience or patient preference is the most suitable approach. Cerumenolytic products do not work instantly and may take up to 7 days to provide relief. For those who would prefer their hearing restored promptly, ear irrigation is an option. 

Quick Tip #1: Some cerumenolytic products contain peanut oils, always double check a patient's allergy status before recommending a product. 

Ear irrigation is the finishing move for removing troublesome earwax. It can be difficult to complete without assistance but the technique is relatively simple. Ear irrigation is not recommended for individuals with a current or past perforated tympanic membrane. Although pharmacist cannot view a patient's ear canal to confirm if the tympanic membrane is still intact, a perforated tympanic membrane presents differently than impacted earwax. 

Quick Tip #2Patients can use both cerumenolytic products and water irrigation together. For patient’s that opt for this it is recommended to use a water based cerumenolytic 10-30mins prior to water irrigation. 

Differentiating between the two1: 
Symptoms
Impacted Earwax
Perforated Tympanic Membrane
Pain
Unlikely, unless ear is also infected.
Yes.
Pain is sudden and sharp.
Itchiness
Yes
Refer if rash is present.
None.
Hearing status
Gradually fades, may become better through jaw movement.
Suddenly occurs.
Discharge
Unlikely, unless ear is also infected.
Yes.

If a patient presents with any of the signs favoring a perforated membrane or infection they should be referred.  Using cerumenolytic products and water irrigation should relive most patients' symptoms within 1-5 days. If relief is not obtained by this point a patient should be referred to a physician.  
  
Quick Tip #3: If, a patient already has lost their hearing in one ear prior to current circumstances refer patient immediately. 

Impacted earwax is a nuisance that can disturbs anyone’s ability to function in their daily life. Although physicians can clear out earwax for patients providing, this knowledge can help decrease those visits. 

Thank you & hope to see you next post, 

Derick Oduro 

References:
1) Ely JW, Hansen MR, Clark EC. Diagnosis of ear pain. Am Fam Physician 2008;77:621-8. 
2) Schwartz SR, Magit AE, Rosenfeld RM. Clinical Practice Guideline (Update): Earwax (Cerumen Impaction). Otolaryngology– Head and Neck Surgery. 2017. Vol 156: S1-S29.