Med Reviews

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

“I can resist anything…..except temptation.”  Oscar Wilde may have hit the nail on the head when it comes to how important self control is.  I was dismayed when I heard how important it was that children be able to resist marshmallows.  There were these series of experiments done in the 1960’s by Walter Mischel.  Four year old children were offered a marshmallow.  They were told they could eat the one marshmallow whenever they wanted, but if they waited 15 minutes, they would get 2 marshmallows.  About 2/3’s of the kids ate the marshmallow right away and about 1/3 waited.  These kids have been followed for years.  They were checked on at age 13, at 18 and are still being followed today.  The 4 year olds who could delay gratification the longest were more successful in life than those who ate the marshmallow right away.  The kids with self control were thinner, had better grades, had better relationships, and were overall doing better at life.  This experiment concerned me so much because I’ve seen my son Eric eat 5 marshmallows at a friend’s bonfire before any of the other kids had choked down one.  When it comes to marshmallows, Eric resists temptation like Oscar Wilde.

It may seem counter intuitive that a four year old resisting marshmallows is a strong indicator of their future success.  Our society doesn’t celebrate self control, but when you think about it, self control is a very useful attribute.  It may also not be immediately obvious, but sitting down with your pharmacist to discuss your medications for 30-60 minutes can be very good for your health.  We call these extended interactions with a pharmacist a medication review.  In a community pharmacy, pharmacists spend most of our time making sure the right medication is in the right bottle for the right patient.  Then we explain how a patient can get the most use out of that medication.  I might tell them to take it with food, or to be careful because it might make them sleepy.  That is an over-simplification, but in general that is what I get paid to do.  In other provinces, pharmacists get paid to do more services for patients such as medication reviews.  And patients find these other services very valuable.  But you don’t have to take my word for it.  The Canadian Association of Retired People or CARP did a study.

Let’s take a step back.  What problems in the health care system did CARP think pharmacists could help with?  As the Canadian population ages, Canadians are living with multiple complex chronic illnesses like diabetes, heart disease and arthritis.  Multiple illnesses in one person often means multiple medications prescribed that person.  When a person has multiple medications, that increases the chances of medication non-adherence.  Medication non-adherence includes things like not taking medications properly, not filling prescriptions at all, missing refills, and skipping doses.  Non-adherence statistics in Canada are alarming.  It is estimated that 50% of patients with a chronic disease are non-adherent with their medications.  Medication non-adherence  leads to an estimated $7-9 billion of annual health care cost in Canada.  Even more frightening, it is estimated that 125.000 people die unnecessarily every year due to medication non-adherence.  One tool available to combat medication non-adherence is a medication review done by a pharmacist.

CARP and Shopper’s Drug Mart looked at Medication Reviews across Canada.  A medication review is an individualized, in-person meeting between a patient and a pharmacist.  It usually takes 30-60 minutes to perform.  During a medication review a pharmacist will discuss how to take each medication.  They will make sure each medication the patient is taking still matches up with a disease/condition the patient has.  For example a patient might not need a stomach acid medication for an ulcer that was healed last year.  The pharmacist will review what each medication is for including over the counter medications, vitamins and herbs.  If the patient is experiencing side effects the pharmacist will give them information about how to minimize them.  If any serious problems with the medications come up during the review, the pharmacist will consult with the patient’s doctor to solve them.

When CARP interviewed Canadians from BC, Alberta and Ontario who recently completed a medication review with their pharmacist, 85% of them were likely to make medication reviews a regular part of their health routine.  The main benefits cited were: preventing and managing adverse drug reactions, ensuring medications were being taken properly, improving medication effectiveness, improving pharmacist-patient-physician communication and having the pharmacist identifying additional clinical services that might benefit the patient.

The CARP study found medication reviews by pharmacists were paid for differently in different provinces.  Alberta had one of the most comprehensive medication review programs.  To have a medication review by a pharmacist paid for, an Albertan must have at least one chronic medical condition and be taking 3 or more prescription medications or be taking insulin.  Most other provinces pay at least something for patients to receive a medication review.  However 2 provinces don’t pay for medication reviews by pharmacists at all.  Those provinces are Manitoba and Quebec.

Recently I was listening to an interview with Walter Mischel, the marshmallow guy.  He said I interpreted the marshmallow results all wrong.  Just because Eric can’t resist a marshmallow (or five) he isn’t doomed.  The important thing is self control can be taught.  Mischel remembered a little girl in his test that ate the marshmallow right away.  He told her next time imagine the marshmallow was a picture.  Then she was able to resist the marshmallow for 15 minutes because in her words, “You can’t eat a picture.”  Maybe we can teach Eric to resist marshmallows.  Right after I learn how to resist beer and donuts.  Oscar Wilde was right.  Maybe I’ll just try to resist something other than temptation.

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca

As always if you have any questions or concerns about these or other products, ask your pharmacist.

CARP Study on Medication Reviews – www.carp.ca/2014/08/26/carp-member-study-calls-enhanced-role-pharmacists-meds-reviews-good-first-step/

CBC’s The Current Interview with Walter Mischel –www.cbc.ca/thecurrent/episode/2014/09/23/the-marshmallow-test-of-almost-50-years-challenging-will-power-shows-self-control-can-be-learned/

Toe Nail Fungus

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy
The Watson Arts center put on their Beer and Cash fund raiser a couple weeks ago.  The beer from Half Pints Brewery in Winnipeg was to die for.  The food from Doug Morley was divine.  But the Johnny Cash’s we have in Dauphin stole the show.  It amazes me how much talent we have here in the Parkland.  I think my favorite Johnny Cash song isn’t one of his originals.  I think I like his cover of Nine Inch Nails, “Hurt” the best.

If you really did have nine inch long toe nails, fungus might be a problem for you.  Toe nails are specialized parts of the skin that protect the ends of our digits.  The nail grows out from the small area inside the white half moon by the cuticle.  It is estimated that 6.5% of Canadians have toe nail fungus.  It is more common in older people.  It is estimated that over 30% of people between the ages of 60 and 70 have toenail fungus.  People with nail problems like having a nail injury or psoriasis near the nail are more likely to get toe nail fungus.    Also people who wear footwear that don’t let the feet breathe, people with poor circulation to their feet, people with diabetes and people with compromised immune systems are more likely to get fungus.  The medical term for toe nail fungus is onychomycosis.  Onchomycosis is caused mainly by dermatophytes.

You can get infected toenails through contact with an infected person or through contact with an infected surface like a bathroom floor where the fungus is present.  It is common to get toenail fungus at the same time as you get athlete’s foot.

Fungus infected toenails look weird, but are not itchy or painful.  In the most common type of toe nail infection, the end and/or sides of the nail get thicken and yellow.  The infection can spread in all the way up to the cuticle and the nail matrix.  Crumbling yellow debris is usually seen under the nail edge.  We think of toenail fungus as just being ugly to look at.  However, there are some non-cosmetic problems that can result from a fungal infection.  The nail fungus can spread to other nails or even other parts of the body like the groin or scalp.  In diabetics, the thickening nail can add extra pressure to the toes and lead to ulcers or sores.  In extreme cases with diabetics, sores on the feet can lead to amputation, but that is rare.

What can be done if you have toenail fungus?  First you should have a doctor have a look at the nail.  There are other things besides fungus that can cause nail problems.  Once a definite diagnosis has been made, you and your doctor need to decide how you want it treated.  In some cases, the infected part of the nail can be removed.  Onychomyconsis can also be treated with medication.  There are both oral pills and topical medications to apply to the nail.

The two most common oral medications for toenail fungus are terbinafine (lamisil) and itraconazole (sporanox).  It is difficult to say which medications work the best because the studies about toenail fungus are very small and not that well done.  The studies usually talk about when the nail is fungus free.  A patient has to remember that even after the nail is fungus free, it will still take months and months for the nail to grow out and the yellow, thick, discolored areas to disappear.  Toe nails can take a year to grow back.

Terbinafine has to be taken every day for 3 months to cure toenail fungus.  Like all antifungals it can cause liver damage but the chances are remote.  Your doctor should test your liver function before you go on it and repeat the liver function test in about 6 weeks.  Depending on where I looked, I saw cure rates with terbinafine at about 46%.

Itraconazole is another antifungal oral medication, but it can be given as pulse therapy.  That means you take the pills everyday for a week and then take 3 weeks off.  You repeat this for 3 months.  This pulse therapy can be more convenient for many people.  Again there is the risk of liver damage and you doctor should check you out.  The cure rates for itraconazole I found were around 23%.

If you aren’t sure you want to get your liver function checked or have your toenail removed there are other options.  Ciclopirox (Penlac) looks like nail polish.  You apply it everyday and wipe off any excess about once a week with nail polish remover.  Again, it will need to be used for about 3 months.  The cure rate I found was about 7%.

There is a new prescription toe nail fungus nail polish on the market.  It is called Efinaconazole (Jublia).  Its cure rate is listed at 17%.

The Dauphin Clinic Pharmacy makes another anti-fungal nail polish.  For better or worse several of the doctor’s have dubbed it “Trevor’s Magic Nail Polish”.  It is made with the anti-fungal fluconazole.  There are no large clinical studies on it, so I have no cure rate to give you, but anecdotally some patients who used it found it worked well.  The big advantage of the fluconazole nail polish we compound over the commercial one is coverage.  If you go over your pharmacare deductible our compounded nail polish is covered while the commercial one is not.

Which ever nail fungus treatment you choose there are some things you can do on you own to help your toenails.  Keep your nails short, dry, and clean.  Keep your feet dry – make sure your feet (including between your toes) are completely dry before putting on shoes and socks.  Wear absorbent cotton socks , and change them at least once a day.  Wear proper fitting shoes and rotate shoes to allow them to dry out between uses.  Don’t go barefoot in damp public places like public showers – wear shower shoes.  People with nail fungus shouldn’t share shoes, socks or nail clippers with others.  If you have diabetes, make sure your blood sugar is under control.  As mentioned we don’t want people with diabetes having their toe nail fungus causing sores and ulcers.

“You could have it all…My Empire of Dirt.  I will let you down.  I will make you hurt.”  Johnny Cash’s cover is better than the Nine Inch Nails original.  Nine Inch nails won’t help your foot health either.  So dry those feet and trim those toe nails.  Don’t let toe nail fungus make you hurt.  Look after your feet and your feet will look after you.

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca

 As always if you have any questions or concerns about these or other products, ask your pharmacist.

 Hurt – Johnny Cash www.youtube.com/watch?v=Bp4UI_FxGLE

Hurt – Nine Inch Nails www.youtube.com/watch?v=AvJKVKglIRs

Restless Leg Syndrome

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

“I’m not as good as I once was, but I’m as good once as I ever was.”  I’m not sure if those words by Toby Keith apply to me anymore.  I had a team of cyclists with me during the MS Bike ride from Dauphin to Clear Lake and back.  I had trained more for this MS Riding Mountain Challenge than I ever had before.  I felt ready.  However, I had trouble keeping up to one team member, Emily, my 12 year old daughter.  This was Emily’s first MS Bike ride and she often left me in the dust.  After the MS Bike Tour, I went out to play Monday Night Hockey.  I thought all that cycling would help my skating.  Nope.  Younger guys were still skating circles around me, and cycling didn’t give me magic hockey skills that I never had before.  On my anniversary, I had to call my wife to kill a big spider in the shower.  I don’t like spiders.  Emily said, “You really aren’t the man of the house, are you Dad?”  I told her I hadn’t been for years.  I had the uncomfortable feeling I couldn’t even see my lost machismo in the rear view mirror anymore.

Another uncomfortable feeling is Restless Leg Syndrome.  Recently, I had a patient come in the pharmacy and tell me her doctor was going to cure her Restless Leg Syndrome with iron pills.  I had never heard of that treatment for RLS before, so I was excited to look it up.

Restless Leg Syndrome (RLS) is also known as Ekbom Syndrome or Willis-Ekbom disease.  RLS gives you the strong urge to move your legs and often unpleasant feelings in the legs like pulling, itching, tingling or aching.  When a person with RLS moves their legs, their symptoms get better, but only for a short time.  Usually the urge to move happens when the person is inactive.  Often the urge to move happens at night.  That means RLS often disturbs people's sleep.  It has been reported that up to 1 in 15 of us will suffer from RLS. 

There is no cure for RLS.  The causes of Restless Leg Syndrome aren't all known either.  However levels of iron and dopamine in the brain seem to be involved.  As early as 1953, Nils Nordlander recognized that treating patients with iron injections could reduce or eliminate RLS symptoms.  He even recognized that iron stores in the tissues could be low even though blood levels of iron were normal.  More recent studies with spinal taps and MRI's have confirmed that the brain can be low in iron even when the rest of the body has normal iron levels.  Dopamine is a brain chemical that is involved in many systems from the reward system to Parkinson's Disease to Schizophrenia.  Even though we know we can make RLS symptoms better when we use drugs that act like dopamine and we can cause RLS symptoms if we block dopamine from doing its job, exactly how dopamine is involved in RLS isn’t completely clear.  It seems there might be lots of dopamine production in the RLS brain, but not enough receptors to respond to the dopamine signal.

Most drugs we use to treat RLS act like dopamine in the brain.  Pramipexole and ropinirole are considered first line treatments.  They are relatively expensive.  They have side effects like nausea, dizziness, sleepiness and in rare cases compulsive behavior like gambling.  Levodopa is a much less expensive treatment, but it has a larger chance of causing augmentation.  Augmentation is when after being on the RLS treatment for several months the symptoms start getting worse again.  Worsening symptoms include symptoms happening earlier in the day than before and symptoms happening just before the next medication dose is due.

Can iron cure RLS?  Iron it isn't a miracle cure for everyone with RLS but in some cases if the RLS patient also has low iron, it can at least reduce symptom severity.  Your doctor should do blood tests to see if your serum ferritin levels are actually low.  If you just take iron on your own, you could get iron overload, and that can be dangerous.  If your ferritin is low, your doctor may recommend oral iron tablets.  Depending on the type of iron, you may have to take it 1 to 3 times per day.  If you take your iron with vitamin C, the iron may be absorbed better.  Any time a text book talks about taking iron tablets, they will say iron should be taken on an empty stomach, an hour before meals.  That is because iron is absorbed best on an empty stomach.  However, iron tablets bother a lot of people’s stomachs.  My compromise with many patients is to tell them to take their iron with the least amount of food possible.  And people shouldn't take their iron pills and their calcium pills together.  Those two minerals will stop each other from getting properly absorbed.  Your doctor will check your ferritin levels again in 3-4 months to see if it is normal.  If not, they may decide to try injectable iron.

Iron isn’t a magic cure all for RLS, but it is an interesting and inexpensive avenue of treatment that you can certainly discuss with your doctor.  And this morning I got to rescue my family from a raging inferno.  Okay Kraft Dinner.  Eric was trying to cook his single serving KD in the microwave.  He forgot to put the water in with the noodles.  First there was a funny burning smell.  Then smoke started pouring out of the microwave.  I took the smoking mess out of the microwave, poured some water over it in the sink and put it out on the deck.  Crisis averted.  Maybe I can enjoy Toby Keith’s song again.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca

 Johns Hopkins Restless Leg Syndrome Center: http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/restless-legs-syndrome/what-is-rls/

Restless Legs Syndrom Foundation: www.rls.org

American Academy of Sleep Medicine: www.aasmnet.org

Cholesterol pills and Diabetes

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

September 11^th. The date is almost a punch line itself. Where were you on September 11^th? I know where I was September 11^th, 1999. I was at Rowendale Baptist Church, just off Pembina Hwy in North Kildonan. I was there with a very pretty girl who got baptized in that Church. She was so nervous that her bouquet was vibrating. Her grandmother said we should have moved up the wedding a few days so our anniversary date would have been 9-9-99. Apparently that was trendy in Germany at the time. “9-1-1” was our own private joke for a couple of years. Then a horrible event forever tainted the date. I think it’s time to take the date back.

Lately, several people have wanted to take their cholesterol medications back to the pharmacy. A very common class of cholesterol medication called statins have been reported to increase the chance of a person getting diabetes. Is this true and does it matter? This goes back to a study in 2008 called JUPITER. It looked a cholesterol pill called rosuvastatin or crestor to see if it could prevent heart attacks, strokes and a bunch of other heart problems in people with normal LDL cholesterol levels and high C-reative protein levels. The answer was yes, but it was only a small benefit. An interesting afterthought was that JUPITER showed that about 6 extra people out of 1000 would become diabetic after 2 years on rosuvastatin. This is where the controversy started.

What is cholesterol? Cholesterol is a naturally occurring substance in the body that is essential for life. If you had no cholesterol in you, you would die. Cholesterol helps form bile acids in your digestive system, hormones in your endocrine system and important components of every cell membrane in your body. Although cholesterol is essential for life, you don’t have to eat any. Your liver can make all the cholesterol you need.

Why does your doctor test your blood for cholesterol if it is essential for life? Why does your doctor care if your cholesterol is too high? Your doctor cares about blood cholesterol levels because if they are too high for too long you have higher chance of getting a heart attack or a stroke. Heart attacks and strokes account for about one third of all the deaths in Canada.

The primary target of cholesterol lowering therapy is something called LDL. If LDL or bad cholesterol is high, we have many, many studies saying that increases the patient’s chance of having a heart attack or stroke. The most common LDL lowering medications are the statins. The statins stop the liver from making as much cholesterol. The statins do a good job of reducing LDL. In fact, if we reduce someone’s LDL with statins we can reduce their chances of heart attacks and strokes by 25% to 35% with five years’ use.

What does all this LDL, and HDL stuff mean? When your liver makes cholesterol, it puts it into the blood stream. Cholesterol is a kind of fat or lipid. Since blood is mostly water, cholesterol doesn’t mix well with it. The liver has to mix the cholesterol with proteins to get it to stay in the blood. This mixture of cholesterol and protein is called a lipoprotein. If you take a blood sample and spin it really fast in a centrifuge, it separates based on density. Different layers in the sample have different densities. Low Density Lipoprotein or LDL is often called “bad” cholesterol because it transports cholesterol from the liver to places like the lining inside the arteries. Through a complicated series of events, these cholesterol deposits can cause blockages that slow or stop blood flow. If blood flow to the heart muscle is stopped, that is a heart attack. If blood flow to the brain is stopped that is a stroke. High Density Lipoprotein or HDL is called “good” cholesterol because it transports cholesterol away from the cells lining the blood vessels. This can decrease the chance of blockages.

Back to statins causing diabetes. There have been other studies confirming that statins cause diabetes effect and some that dispute it. In 2012, the FDA in the US said labels on statin drugs must now warn they might make blood sugar go up. But this effect, even if it is real, probably doesn’t matter. In the original JUPITER trial, by the fact the participants had high C-reactive protein levels and a few other conditions, made them at high risk of diabetes anyway. The placebo group in the JUPITER trial actually had lower blood sugars as measured by H1AC BEFORE the trial started. These are some of the reasons why we are still not sure if this blood sugar raising effect is real. But even if it is, the benefit of lowering LDL cholesterol outweighs the risk of becoming diabetic. In other words being on a statin will prevent more deaths in people with high cholesterol than if those people weren’t on statins even if a small number of them become diabetic.

Yes, there should be more study to see if this statin-diabetes effect is real. Yes, doctors should check the blood sugars of their statin treated cholesterol patients. But no, don’t let a couple media reports scare you away from your cholesterol pill. You are better taking your statin than not. Take back your right to prevent heart attacks and strokes.

I want to take back September 11^th too. No disrespect to victims of terror, but September 11^th was a happy day for many of us. I’ve met many people, young and old, with birthdays on September 11^th. Let’s celebrate them. I know I can’t be the only one with a September 11^th Wedding Anniversary. Let’s reminisce about the last time I made a decision on my own. September 11^th is a happy day for many of us. Let’s remember that.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have this and most other articles published in the Parkland Shopper on our Website. Please visit us at www.dcp.ca

Heart Attack and Stroke Risk calculator: https://www.cvdriskchecksecure.com/FraminghamRiskScore.aspx

For more info on Cholesterol Guideline visit:

http://www.lipidgeneticsclinic.ca/pdf/2009dyslipidemiaguidelines.pdf

Statins and New Onset Diabetes: http://circ.ahajournals.org/content/126/18/e282.full

HEAD LICE

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

“Some gal would giggle and I'd get red.  And some guy'd laugh and I'd bust his head, I tell ya, life ain't easy for a boy named "Sue."”

My friend Munna Zaman has a unique name.  Well I think it is unique.  I've never met any other Munna's.  But he had a story of a family he knew that had much more unusual names.  The father was a physicist so he named his sons Proton, Neutron and Electron.  Fortunately he named his daughter something much more mundane like Lisa.  Over a decade ago I was playing hockey with an RCMP member named Tracy.  He explained that if you met any Tracy's born before 1960, they were all male.  Now they are all female.  I've noticed the same thing with Cameron.  All the Cameron's I knew growing up were male.  Now all the children my kids know named Cameron seem to be female.  As a Pharmacist, I have a definite name bias.  I'd like all children to have a name I can say, I can spell and I know if it is a boy or a girl.  Of course no one asks their pharmacist before naming their kids.

Are head lice by any other name just as itchy?  Head lice are quite common.  Having head lice doesn’t mean someone has dirty hair.  Lice actually seem to prefer clean hair.  Children from 3 to 11 years old are the most affected age group.  Girls seem to be more affected than boys. However, anyone can get lice, regardless of sex, race, age, hair length or socio-economic status. 

What are lice?  Head lice are parasites that live in humans’ hair.  The scientific name for them is Pediculus humanus capitis.  Lice are wingless insects with six legs and range in color from white to brown to dark grey.  They don’t fly and they don’t jump.  A young louse matures in 10-12 days and the adult is 2-4mm long.  They multiply very quickly.  Females lay 7 to 10 oval and whitish eggs attached to the base of a hair shaft every day.  The eggs are called nits.  Seven to ten days later, the nits hatch and are called nymphs.  The whole life-cycle is about 20-30 days.  Lice are transmitted in two main ways.  Lice can be transmitted directly by close contact from one infested scalp to another (e.g. touching heads together).  They can also be transmitted indirectly by sharing personal articles that come in contact with the head (e.g. brushes, hats, etc).  I was surprised to learn the transmission rate.  Apparently lice will only be transferred 10-30% of the time when someone is exposed.  It is believed prolonged head to head contact, ie. over 30 seconds, is required for lice to move from one person to another.  Quick head contact or transfer through inanimate objects like combs, brushes or hats is supposed to be uncommon.   Adult lice need us for their blood meal.  Nits need our head warmth for incubation.  Lice and nits die when away from us humans for 55 hours.

What are the symptoms of having lice?  Most people don't have any symptoms at all.  If a person is going to have symptoms, the most common symptom is itching, especially around the ears and back of the scalp.  This itching is from a mild allergic reaction to the saliva of the louse when it feeds on us.  There can be small sores on the person’s scalp or neck.  If these sores get infected, there can be pus.  How do you recognize head lice?  First you should see nits (the eggs) attached to the base of the hair shafts on the warmer parts of the scalp (the back and sides).  The egg or nit is oval and glued to the hair.  Nits are laid close to the scalp for warmth, usually around the ears and the nape of the neck.  Live nits are brownish in color, and dead ones are whitish.  Nits found more than 0.6 cm from the scalp have grown out with the hair and have either hatched or are dead.  To know for sure that someone has lice, though, you have to see the live adult louse.  Combing with a fine toothed comb is supposed to be 4 times more efficient and twice as fast for finding adult lice as just looking through the scalp. 

One non-drug treatment that can be used to treat lice is wet combing.  Wet combing every 3-4 days with a fine toothed comb can help get rid of lice.  This might not work as well as the lice shampoos, but it is completely safe.  Using vinegar with wet combing should be avoided if using wet combing in combination with one of the lice shampoos as the vinegar can inactivate the shampoo.

The main product used to treat head lice is permethrin (one of the brand names is Nix).  It stays in the hair for up to ten days after use to kill any more lice that hatch.  It is generally the product of first choice because is very good at killing lice, it has low toxicity and it sticks around for about 10 days.  Since no lice treatment kills 100% of the nits, it is recommended that one uses the permethrin again in 7 to 10 days.  Permethrin can cause allergic reactions in ragweed or chrysanthemum sensitive individuals.  There are older products on the market that contain lindane.  Lindane is not as good as permethrin at killing lice.  It doesn’t stick around so you must do a second application in 7-10 days for it to be effective.  About 10% of the lindane actually goes into the rest of your body and it can accumulate with repeated exposure.  It can cause seizures and other neurologic disorders so lindane is not my favorite product. 

There has been talk over the last few years about resistance to treatments like permethrin.  Although resistance has been found in the US and the UK, the Canadian Pediatric Society says none has been proven in Canada.  Because of the resistance fears, there have been new products developed that don’t work like permethrin.  One of these is called Resultz.  It contains isopropyl myristate.  The permethrin in Nix attacks the nervous system of the louse.  Isopropyl myristate is more like a soap.  It dissolves the waxy outer coating on the louse and the louse dehydrates.  The claim is that Resultz kills the louse within ten minutes.  The down side to Resultz is it does not kill the nits or eggs in the hair.  So you absolutely need to do the second treatment in one week.  On the positive side, there is no documented resistance to Resultz.  There were small studies where Resultz killed more lice than permetherin.  One of these small trials was even done in Winnipeg, MB!  I don’t know if I am ready to say Resultz is definitely better than permetherin yet, but it is nice to have another tool in the tool box.

I’m obviously biased, but my favorite alternative to permethrin is called Nice ‘N Natural lice treatment.  We compound Nice ‘N Nature lice treatment at the Dauphin Clinic Pharmacy with a variety of natural oils.  It coats the hair and suffocates the lice.  It smells really nice and customers tell us it works really well.

Treating head lice doesn’t have to as horrible or dreadful as being a Boy Named Sue.  In his famous song , Johnny Cash's character claimed his name gave him, “The gravel in his guts and the spit in his eye.”  Steven Levitt and Roland Fryer, economists, actually did research that seems to indicate that your baby's first name does not affect their economic outcome later in life.  Steven Levitt is one half of the Freakonomics book, movie, website, podcast, etc. and they have an episode about names.  As far as naming kids go, my wife and I were unintentionally very unimaginative.  Eric and Emily.  Two E names.  I hope their names don't harm them.  And I hope their upcoming school year is lice free.

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca

As always if you have any questions or concerns about these products, ask your pharmacist.

Freakonomics Radio – How Much Does Your Name Matter? - http://freakonomics.com/2014/07/31/how-much-does-your-name-matter-a-freakonomics-radio-rebroadcast/

Sun Screen

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

Cassandra was a princess of the Ancient Greek City of Troy.  One day she ran into the Greek God Apollo.  Apollo made some advances.  Cassandra said no.  Apollo cursed her such that she could predict the future, but no one would believe her.  That drove her round the bend.  She was then known as the princess who was beautiful but insane.  You have to stretch the meaning of beauty a little to include my bald head and bloated mid-section, but mornings are driving me around the bend.  I predict that tomorrow morning, and the day after that, and the day after that, etc. our dog Sheldon will need to go outside to relieve himself.  I also predict my son Eric won’t believe me.  Eric will argue.  Eric will make excuses.  Eric will disappear.  Eric will roll around on his bed telling me how unfair it is that his sister never has to walk the dog.  The worst part is: he actually enjoys walking the dog!  Sheldon and Eric always have a good time on the walk.  Eric always comes back happier than when he left.  It is just important to argue first.

My next prediction is that summer is coming.  Really.  I swear.  And many of you won’t protect your skin and will get sun burn and skin damage.  Like Cassandra, I know you aren’t going to believe me, but when you’re outside, use sunscreen.  Too much sun can damage your skin.   And that damage can add up.  Sun exposure can lead to serious problems like skin cancer.

The sun emits radiation across the entire electromagnetic spectrum, from radio waves to X-rays.  The part of the spectrum we are interested in for skin damage are the Ultra-violet wavelengths.  There are 2 types of UV radiation we talk about with skin damage, UVA and UVB.  Sun burn is most often caused by UVB.  UVA & UVB can both cause premature skin aging, and skin cancer.

Sun exposure is a factor in the development of three types of skin cancer.  Basal cell carcinoma is caused by the exposure to UV radiation and is the most common type of skin cancer.  Basal cell carcinoma often affects fair-skinned people with blond or red hair who sun burn easily.  Basal cell carcinoma is usually very easy to treat.  Squamous cell carcinoma, the second most common form of skin cancer, is caused by repeated exposure to the sun over a long period of time.  It can be very successfully treated if it is identified early.  Malignant melanoma is a less common skin cancer.  We believe sun exposure is one of its causes.  If malignant melanoma is found early, it has a high cure rate.  However, if it is not caught early, it can spread to the blood stream and in the worst cases, it can cause death.  If sunscreen is used properly, it has been shown to reduce the number of cases of squamous cell carcinoma, and it may help reduce the risk of malignant melanoma.  There is debate about how well sun screens protect against basal cell carcinoma.

The Food and Drug Administration in the US started to require changes in the labeling of sunscreens in 2012.  Health Canada followed suit in July 2013.  Sunscreens can no longer be labeled “Sunblock”, and they can’t claim immediate protection upon application.  The FDA thinks “sunblock” implies too much protection.  If the sunscreen protects against both UVA and UVB and has an SPF of 15 or greater, it can be labelled as “Broad Spectrum”.  The FDA also won’t allow a sunscreen to claim an SPF of greater than 50 as they feel there is no evidence that numbers above 50 have any real meaning.  Sunscreens aren’t be able to say they are “water proof” or “sweat proof”.  The are only be able to say they are water resistant.  The label must state how long they are water resistant for.  The two labeling options are water resistant for 40 minutes or water resistant for 80 minutes.

Sunscreen shouldn’t be the only defense used to prevent skin cancer.  Here are some practical suggestions.

• Avoid the sun when it is most intense.  This are generally between the hours of 11 am and 4 pm.
• Seek the shade when you are outside for a long period of time
• Wear a hat with a wide brim and long-sleeved shirt.

Like the beautiful Cassandra, I will keep making predictions.  Sheldon will have go out tomorrow morning, and Eric won’t believe me.  I am going to forget a hat at one of Emily’s soccer games and burn my bald head.  One of you will not use sunscreen and a few decades from now will be talking to your doctor about skin cancer treatments.  Come on.  Just once, believe the predictions.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

 We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca

 Canadian Dermatology Association- Sun Safety –www.dermatology.ca/programs-resources/resources/sun-safety/ 

Aerobika

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

Revenge is a dish best served…. Pink.  Don’t get mad.  Get….Pink.   You’ve got to ask yourself one question.  Do you feel lucky, Pink?  Well do ya?  I’m not usually an advocate for vigilante justice.  I’m more a live and let live kinda guy.  Or the best revenge is a life well lived kind of person.  I usually say, “An eye for an eye and the whole world goes blind.”  But not this month.  May is different.  You know that girl who squealed to the boss because your weekly article wasn’t worded right?  Pink ‘em.  You know that guy who stole your girlfriend in highschool?  Pink ‘em.  Or the skip of the curling team you can never beat?  Pink ‘em.  Pink ‘em all and let someone else figure it out.  It only costs $20 to have someone pinked.  I know a team of professionals that can do it efficiently and will leave no trace behind.

There is new device available in the pharmacy that removes mucus efficiently and leaves no trace behind.  It’s called Aerobika.  You breathe into it and it loosens mucus in your lungs with vibrations.

Why would you want to loosen phlegm and mucus?  Certain medical conditions like COPD and Cystic Fibrosis cause the lung to produce too much mucus.  Usually your lungs produce a small amount of mucus.  This mucus traps the small amounts of dirt, dust, bacteria and other things that get sucked into the lungs every day.  Your lungs have little hairs called cilia that move the mucus and all it trapped particles up and out of the lungs.  The cilia/mucus system usually works quite well.

Sometimes things get out of balance.  Some conditions cause the body to produce too much mucus.  This mucus builds up and narrows the airway which makes it harder to breathe.  The mucus just sits there.  This stagnant mucus is a great place to grow bacteria.  This leaves the lungs of people with too much mucus prone to infection.

So how do you remove thick and stagnant mucus from the lungs?  It isn’t easy.  People with CF will actually have people or machines thump on their chest to loosen up the mucus so they can cough it out.  It has been shown that this kind of physical therapy can help people with COPD as well.  However, in practice, it isn’t done for COPD patients very often.

Trudell Medical, out of London, ON, has a cool new device that should help.  It is called Aerobika and it is an oscillating positive expiratory pressure device.  Let’s break that down.  Positive pressure means as you breathe into the device you encounter some resistance.  This resistance creates some pressure inside your lungs which holds the airways open.  When you blow up a balloon, it is the positive pressure that holds the balloon open.  Inside your lungs this positive pressure opens up the small airways that may be blocked by mucus.

The other part of the oscillating positive expiratory pressure device is the oscillating part.  It is really neat when you blow into the Aerobika.  There is a valve inside that switches quickly between higher and lower resistance.  The Aerobika makes a very rapid “thump, thump, thump, thump” noise as you blow in.  This causes waves of low and high pressure inside the airways.  In fact, if I breathe into the device and you put your hand between my shoulder blades, you can feel my chest vibrating.  This vibration inside the lungs loosens and seems to decrease the viscosity of the mucus.  So between the positive pressure opening the small airways and the oscillations loosening the mucus, the lungs are now able to get some of that excess mucus out.  Getting out excess mucus improves breathing and reduces the chance of infection.

Usually you would use the Aerobika twice a day.  You would breathe into it 10-20 times and then perform 2-3 “huff coughs”.  A huff cough helps get mucus out of your lungs.  It is like when you want to breathe on a mirror to fog it up.  You take a short, shallow breath and exhale forcefully with your mouth in an “O” shape.  You would repeat this cycle for 10-20 minutes.  The goal is that you will be coughing up little to no mucus.  If you are coughing up a lot of mucus, your health care professional may tell you to use the Aerobika more than twice per day.   One last neat thing about Aerobika is that if you are using a nebulizer, the Aerobika can hook up to your nebulizer and you can loosen mucus while getting medication.

So is there any evidence that the Aerobika device works?  Yeah, but… There are studies.  Even some really cool looking ones done at the University of Western Ontario.  These ones had patients inhale a special kind of helium that can be seen on an MRI.  This allowed the researchers to show air got into parts of the lungs after 3-4 weeks of Aerobika therapy that didn’t get air pre-treatment.  The problem with all the studies is they are really small.  The ones I saw only had 10-20 patients in them.  In drug trials we are always looking for hundreds or thousands of patient in a trial to show the results were not just a fluke.  So the evidence for the Aerobika is very interesting, but not overwhelming.

The Aerobika also costs some cash.  It runs $80-$90.  Although the evidence for Aerobika isn’t overwhelming yet (I hope more studies are being done) and it costs a little under $100, it is a drug free treatment.  There is very little chance of adverse effects.  You do have to be careful that with all the exhalations you don’t get dizzy and fall, but other than that, there is very little down side to giving one a try.  Aerobika can be bought without a prescription, but you should talk to your doctor first.  The two of you should discuss if this is an appropriate device for you.  Then you will want your doctor, pharmacist, respiratory therapist or other health care professional to go over its use and cleaning with your

The Kinsmen Club of Dauphin is having a fund raiser in May called Flocking.  You call us at 204-638-5892 and give us the name and address of someone in Dauphin.  We charge you $20 and put a flock of pink flamingos on their lawn.  It’s the perfect way to live out your revenge fantasy without hurting anyone.  That person will then get the opportunity to pay the revenge forward to someone who slighted them.  And so on.  So use your negative emotions in a positive way.  Flock someone and help the Kinsmen support the Community’s Greatest Needs.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have most of the articles published in the Parkland Shopper on our Website www.dcp.ca

 Aerobika and the UWO – http://communications.uwo.ca/media/copd/

Aerobika Studies –http://www.trudellmed.com/sites/trudellmed.com/files/pdf/consumer/opep_wtpaper_en.pdf

Aerobika Overview – http://www.trudellmed.com/consumer-health/aerobika-oscillating-pep