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/