Role of vitamin d and statin induced muscle pain

by James Ketterer, PharmD

Statins are a class of drugs used to lower cholesterol and decrease the risk of cardiovascular events. They work by inhibiting an enzyme from completing an early step in the body’s process of synthesizing cholesterol. Statins are among the most commonly prescribed medications in the country. Approximately 1-2% of patients on statins report experiencing muscle pain. This pain can present itself in a variety of ways but most often results in flu-like aches and pains. The muscles may feel stiff or sore like the feeling after working out. This usually effects the larger muscles of the body such as parts of the back or thighs. This side effect is often responsible for patients discontinuing the use of these drugs.

Does Vitamin D Play a Role in Statin-induced Muscle Pain?

Do statins cause muscle pain? The exact cause of this phenomenon is not completely understood, but many researchers have hypothesized that vitamin D levels may play a role. Vitamin D is mainly produced in the skin from sun exposure. However, this source is not active. The liver and kidneys are responsible for activating the vitamin D which then plays a role in facilitating intestinal absorption of essential nutrients as well as balancing bone health homeostasis. Vitamin D deficiencies often present with similar muscle pain as those found as a side effect in statins.

Some researchers have theorized that statins could reduce vitamin D levels because certain types of cholesterol carry vitamin D and when the cholesterol is reduced, less vitamin D could be transported. On the other hand, many have theorized that since both vitamin D and statins are metabolized by the same enzyme in the liver, the use of statins could delay metabolism of vitamin D, thus increasing levels in the blood.

Muscle Pain in Clinical Trials

Clinical trials and various other studies and reports have yielded mixed results on muscle pain in statin users with low compared to high levels of vitamin D. A large analysis of these trials showed that more studies resulted in statin users having higher levels of vitamin D on average. One retrospective study divided statin users into 4 groups, 1 being the lowest vitamin D levels and 4 being the highest. Group 1 was 1.21 times more likely to develop muscle pain than group 4. Another study showed statin users with vitamin D levels of less than 15 ng/mL were 1.9 times more likely to experience muscle pain compared with non-statin users. The statin users with higher levels of vitamin D did not have higher risk for muscle pain compared with non-statin users.

When a patient experiences what is believed to be the side effect of a drug, they are often taken off of the drug to see if the symptoms resolve. If they do resolve, sometimes the patient is started back on the drug to see if the symptoms return. This a referred to as a “rechallenge”. One chart review showed that returning vitamin D levels to a sufficient level before a rechallenge in statin users who had experienced muscle pain, increased their tolerability to statins.

Do Vitamin D Supplements Help Reduce Statin-induced Muscle Pain?

Some studies have given vitamin D supplements to statin users experiencing muscle pain. While these studies were uncontrolled, they did show improvement in muscle pain in nearly 90% of patients.

These are just a few of the examples of research looking at the correlation between stain use and vitamin D levels as a possible cause of muscle pain. While nothing is definitive at this point, patients on statins that are experiencing muscle pain may want to explore vitamin D supplementation as a possible resolution plan. The benefits of statins are well documented in patients with heart risks. Any side effects should be attempted to be overcome before giving up on the statin and assuming it is the cause.

References:

Gregory, Philip J. ” Vitamin D and Statin-Related Myalgia”. Medscape. 2017. Web. 10 Mar. 2017.

Simvastatin.  Micromedex Solutions.  Truven Health Analytics, Inc. Ann Arbor, MI.  Available at: http://www.micromedexsolutions.com.  Accessed March 20, 2017.


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low carb high fat diet metabolic syndrome - wellrx image

by James Ketterer, PharmD Candidate
University of Arizona College of Pharmacy

A Low Carbohydrate High Fat diet (defined as either less than 26% of total energy intake coming from carbohydrates or less than 130 grams of carbohydrates per day) may not be the best dietary choice for everyone. Defined as either less than 26% of total energy intake coming from carbohydrates or less than 130 grams of carbohydrates per day. It has, however, been shown to be as safe and effective, if not more so, than High Carbohydrate Low Fat diets, for people with high cholesterol, diabetes, and non-alcoholic fatty liver disease. In fact, clinical studies have shown that Low Carbohydrate High Fat (LCHF) diets effectively lower blood sugar, triglycerides, insulin, and saturated fat. They also can help reduce blood pressure and weight and even increase levels of good cholesterol which could eliminate the need for damaging cholesterol medicines.

Reducing Hunger, Lowering Daily Calories

LCHF diets inherently increase the relative amount of protein and fat consumed per day. These diets are primarily made up of leafy green vegetables, nuts, fish, eggs, seeds, unprocessed meats, dairy, and plant oils. While it may seem counter-intuitive that consuming more fatty foods would cause weight loss, this is not the case. LCHF diets have been known to decrease hunger resulting in an overall decrease in daily caloric intake. It has also been proposed that LCHF diets provide a specific metabolic advantage by encouraging ketosis and ketone burning. This doesn’t go without scrutiny as LCHF is often referenced as a fad diet. As with all lifestyle and diet changes, we strongly encourage any such changes to be done under the supervision of a physician..

A 24-week clinical study looked at 363 overweight and obese patients who chose to start either a LCHF diet or a ‘low calorie, high nutritional value’ diet. In the 102 patients with Type 2 Diabetes, weight loss was significantly greater (−12.0% vs −7.0%) and their A1C and fasting blood glucose levels decreased significantly more with the LCHF diet. More patients on the LCHF diet were able to decrease or discontinue their diabetic medication as well.

A Decrease in Cardiovascular Risks

The increase in dietary fat consumption in LCHF diets has led to many misconceptions. One of the biggest concerns is risk for developing cardiovascular disease. However, several studies have shown that LCHF diets actually decrease cardiovascular risk more than HFLC diets. The increase in dietary protein has led some to worry that kidney function could be impaired. To date there has not been any evidence to suggest these negative effects occur in people with normal kidney function including diabetics. The most common side effects that do occur are fatigue, headache, and muscle cramps. Most people that experience these effects, do so within the first few weeks of adapting to the diet, then these events subside. The most common failure of all diets is lack of adherence. Studies have shown that people find it no more difficult to adhere LCHF diets than to others, and some people may even find it easier due to the hunger reducing effects.

The individual responses to dietary strategies may change from person to person, but LCHF diets have been proven to be a safe and effective option for improved health outcomes, especially in patients with metabolic syndrome.

References

Noakes, Timothy David and Johann Windt. “Evidence For The Prescription Of Low-Carb High-Fat Diets”. Medscape. N.p., 2017. Web. 22 Feb. 2017.

 

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ScriptSave WellRx - Statins and Liver Damage

by: James Ketterer, PharmD Candidate
University of Arizona College of Pharmacy

If your doctor has said you have high cholesterol, it’s likely that you’ve heard or read about about the potential side effects of statin drugs and their impact on liver.

Doctors often prescribe statins for people with high cholesterol levels to lower their total cholesterol and reduce their risk of a heart attack or stroke. While statins are highly effective, they have been linked to muscle pain, digestive problems and mental fuzziness in some people and may rarely cause liver damage.

Cholesterol and triglycerides are lipids (fats) that are stored in the body and serve as a source of energy. Lipids, together with proteins and carbohydrates, are the main components of living cells. When lipid levels in the bloodstream are too high or low, this condition is called dyslipidemia. The most common types of dyslipidemia are:

  • High levels of low-density lipoprotein (LDL or “bad”) cholesterol
  • Low levels of high-density lipoprotein (HDL or “good”) cholesterol
  • High levels of triglycerides

You may have heard stories of people who have experienced devastating liver damage from their use of drugs like atorvastatin (Lipitor), rosuvastatin (Crestor) and simvastatin (Zocor). Less than 3% of patients on statins report muscle pain while less than 0.5% report rhabdomyolysis (A breakdown of muscle tissue that releases a damaging protein into the blood).

Recently, the risk of statin-induced liver injury has become a hot topic, since this class of drugs is metabolized by enzymes in the liver. Liver injury has a broad definition, but generally includes, at minimum, highly elevated liver enzymes which are directly correlated with liver function and often a precursor to various liver diseases.

Statin Studies

While studies on the safety of these drugs have included thousands of patients, it’s difficult to determine if something like liver injury is one of the side effects of statin drugs, or happening for some other reason. Drug-induced side effects are more commonly identified after a drug hits the market and patients and physicians begin reporting problem cases to the drug manufacturers.

There have been a few studies around the world that have looked at drug-induced liver injury. A study in Iceland identified 96 patients with drug-induced liver injury. Three of those 96 were due to statins (1 with simvastatin and 2 with atorvastatin). During the trial, over 27,000 people were treated with simvastatin and over 7,000 with atorvastatin. That means that 1 out of 27,000 people on simvastatin and 1 out of 3,500 people on atorvastatin had drug-induced liver injury in Iceland over that 2 year period. Of all statins, simvastatin and atorvastatin are responsible for most reported incidents of liver damage, but this is likely just due to the fact that they are prescribed the most.

The Spanish Hepatotoxicity Registry identified 858 cases of drug-induce liver injury. Of those cases they attributed 47 (5.5%) of them to statin use. The total number of patients on statins was not available.

One of the latest studies from the USA ran from 2004 to 2014, examining drug-induced liver injury identified 1188 cases. They determined that about 2% could be contributed to statin use.

A Swedish study compared the reported statin-induced liver injuries to the total number of statin users (based on sales) and found that 1.2 people experience liver injury due to statins per 100,000 users of statins.

A Rare Occurrence

Outside of these large studies, there have been case reports of patients experiencing liver injury following an increase in dosage of their statins. These are few and far between, and are corrected by decreasing or discontinuing the medication. Some of these patients have been restarted on statins and experienced the same liver problems, confirming the drug as the cause. People that experience statin induced liver injury have a generally positive prognosis. These injuries are usually short-term and reversible. One study of interest that looked at 298 patients whom had experienced drug-induced liver injury and found that only 7 of them had any signs of liver problems one year later.

While there’s a lot of information on the safety of statins in the media, the truth is that side effects of statin drugs, including livery injury, are very rare. That’s not to say that they don’t occur, but rather that the benefits in patients with cardiovascular risk, even those with underlying liver problems, substantially outweigh the potential risks.

 

References

Björnsson, Einar S. “Hepatotoxicity Of Statins And Other Lipid-Lowering Agents”. Medscape. N.p., 2017. Web. 9 Mar. 2017.

Simvastatin.  Micromedex Solutions.  Truven Health Analytics, Inc. Ann Arbor, MI.  Available at: http://www.micromedexsolutions.com.  Accessed March 2, 2017.

 

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ScriptSave WellRx - Heliobactor Pylori stress image

Heliobacter pylori Eradication and Antibiotics

by: Derek Matlock
Pharm.D. Candidate 2017
Washington State University

Heliobacter pylori is a bacteria highly prevalent worldwide and is closely linked to duodenal ulcers (which affect the upper section of your small intestine), gastric ulcers, and peptic ulcer disease. It is also linked to an increased risk of developing gastric cancer in an infected person. Despite being more common in developing countries with poor socioeconomic conditions, the American College of Gastroenterology states that 30-40% of the U.S. population is infected with H. pylori, putting them at risk for conditions such as peptic ulcer disease — which affects the stomach lining — and gastric cancer.

Anitbiotics for Ulcers?

Numerous research studies and testing have not only supported these correlations, but they have also demonstrated the benefits of eradication using medications, specifically antibiotics, for patients suffering from complications of H. pylori.

Prior to the discovery of H. pylori, lifestyle factors such as smoking, eating spicy and acidic foods, and stress, were considered the major causes of ulcers. Thus, the main treatment choices were popular acid suppressing medications such as ranitidine (Zantac®) or omeprazole (Prilosec®). These medications can help improve ulcer-related pain and symptoms, and might even heal the ulcer, but they do not treat the underlying H. pylori infection. Without treating the infection, symptoms and complications are likely to reappear.

Triple Therapy for Ulcers

After the discovery of the bacteria causing these conditions, appropriate antibiotics have been able to eliminate the infection in the majority of individuals, thus resolving the infection and its complications. The following antibiotic regimens are being used, and the triple therapy is the most common.

  1. Triple therapy: Omeprazole 20 mg twice daily + Clarithromycin 500 mg twice daily + Amoxicillin 1,000 mg twice daily or Metronidazole 500 mg twice daily
  2. Concomitant quadruple therapy: Omeprazole 20 mg twice daily + Clarithromycin 500 mg twice daily + Amoxicillin 1,000 mg twice daily + Metronidazole 500 mg twice daily
  3. Bismuth quadruple therapy: Omeprazole 20 mg twice daily + Bismuth subsalicylate 262 mg four times daily + Tetracycline 500 mg four times daily + Metronidazole 250 mg four times daily

Although the triple therapy remains an effective choice, a preference for quadruple therapies may soon become more common, as the risk for patients to fail treatment due to antibiotic resistance becomes a growing concern in the science community.

As the United States prevalence of H. pylori continues to decline, the resistance to antibiotics, specifically Clarithromycin, makes the infection more difficult to treat. As a patient, it is essential to inform your doctor about any recent antibiotics you may have taken, as this may help in the selection of a better treatment option.

References:

  1. American College of Gastroenterology Guideline on the Management of Heliobacter pylori Infection
  2. CDC: Heliobacter pylori Fact Sheet for HCPs
  3. Medscape: Heliobacter pylori Infection
  4. WebMD: What is H. Pylori?

 

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generic aspirin tablets

by: Rick Lasica, BS
University of Arizona College of Pharmacy PharmD Candidate, Class of 2017

Many people take aspirin occasionally to provide relief from various conditions (e.g. pain, inflammation, fever, headaches), but what about taking a low-dose aspirin every day for prevention reasons? As with all medications, aspirin poses various benefits and risks that need to be taken into consideration before you start taking it. Studies have shown that certain individuals would benefit the most from taking a low-dose aspirin and others shouldn’t take it at all.

Why Take Low Dose Aspirin?

Our bodies make cells called platelets, which help stop us from bleeding uncontrollably. In order to stop this unnecessary bleeding, a blood clot is formed. In this case, the blood clot is beneficial, but sometimes blood clots are formed when they aren’t needed, which have the potential to lead to a heart attack or stroke. Aspirin is a non-steroidal anti-inflammatory drug (NSAID) commonly referred to as a “blood thinner” because it stops platelets from working together to form a blood clot.

Even though aspirin has many potential benefits, it also has many side effects, some serious, that might occur. Most importantly, it can increase your risk of bleeding, both inside and outside of your body. This might be noticed through your gums bleeding while brushing your teeth, any unexplained bruising on your body, or black/tarry stools. Other side effects that might occur are ringing in the ears, nausea/vomiting, dizziness, or yellowing of the eyes/skin.

The United States Preventive Services Task Force (USPSTF) recommends that people aged 50-59 years with an increased risk of heart problems who have never had a heart attack or stroke in the past would likely benefit from taking a daily low-dose aspirin in order to help reduce the chance of one from happening. Also, people who have had a heart attack or stroke are at an increased risk of having another one, and would likely benefit from it as well.

However, you should never start taking aspirin, or any medication, before talking with your physician or pharmacist about it. They will make an assessment of your condition and weigh the benefits and risks of you taking it and make the ultimate decision of whether or not you should take it as part of your daily regimen. Certain people should not take aspirin if they have had any serious bleeding events, are on certain medications, have a high fall risk, or have specific medical conditions. So, next time you interact with your doctor or pharmacist, ask them if they think it is appropriate for you to take a daily low-dose aspirin.

References:

  1. United States Preventive Services Task Force Recommendations on Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer
  2. WebMD: Aspirin
  3. FDA: Safe Daily Use of Aspirin

 

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ScriptSave WellRx diabetes check image

by:
Jeshvi Manhar, 2017 PharmD Candidate/ Sapna S. Patel, PharmD

ScriptSave WellRx - sound alike-look alike medications and diabetes imageSound-Alike/Look-Alike Medications are very important to identify and help reduce medication errors. There is a list of several medications starting with the letter “T” that have become available to treat diabetes. This may lead to confusion among patients and physicians, so it’s important YOU understand how to safely recognize and use your diabetes medication to minimize problems and possible complications.

Tradjenta® decreases the amount of sugar your liver makes and increases the amount of insulin your pancreas makes. This medicine is the easiest to differentiate, since it is an oral tablet taken once daily.

Tanzeum® and Trulicity® are in the same class of medications called GLP-1 Receptor Agonists. These medications are injected under the skin but, they are not the same as insulin! They decrease your blood sugar by releasing more insulin and slowing down your body’s digestion. The easiest way to differentiate these medications from insulin is that Tanzeum® and Trulicity® are injected under the skin once a week without regard to meals.

Now, let’s discuss the three medications that are insulin: Toujeo® U-300, Tresiba® U-100, and Tresiba® U-200. Insulin works by allowing blood sugar to move into the cells and be used as energy. Toujeo® and Tresiba® are considered long acting insulin and are injected under the skin once daily without regard to meals. These medications are not interchangeable! Toujeo® U-300 is the concentrated form of Lantus®. Toujeo® U-300 is 3 times the concentration of Lantus®! It would be easy to inject the wrong dose (especially when switching from one medication or concentration to another). Tresiba® U-200 is twice as concentrated as Tresiba® U-100! Toujeo® U-300, Tresiba® U-100, and Tresiba® U-200 are all packaged in green boxes, making them look alike. Before injecting your medication, take measures to ensure you know what the name and concentration of your medication is, what the box, pen and/or needle looks like, and how your medication should be used correctly. If in doubt, ask your pharmacist about the brand you’re buying and study the label before using the medication.

GENERAL INJECTION TIPS:

  1. Using 29 gauge 5mm pen needles for under the skin injection may cause less pain
  2. Roll the pen between the palm of your hands before use to decrease discomfort or pain
  3. Common injection sites are stomach and thigh
  4. Make sure to rotate injection sites to prevent buildup of fatty tissue and pain
  5. Wipe injection site with alcohol wipe then wait for a few seconds before injecting to reduce stinging
  6. Be sure to safely dispose and use a new needle prior to each injection to prevent infection.

 

Reference:

LexiComp®, 2.20.17, JM PharmD Candidate at OSU College of Pharmacy/SSP PharmD

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Tradjenta,
Trulicity,
Lantus,

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ScriptSave WellRx - diabetes glucose monitor check image

by:
Cherokie S. Boyd
Pharmacy Intern P1
SinfoniaRx Florida

What a time to be a person with diabetes! These days there are more medications on the market than ever to help you control your diabetes. But how do you know which medication is right for you?

Of course you should always consult your physician or your local pharmacist for medical advice. However, here is some information about these new medications so that you don’t feel out of the loop.

Some of the current insulin medications that you are used to are Lantus, Humalog, and NovoLog. These medications deliver the hormone insulin to your blood so that insulin can tell your cells to take in more glucose. This keeps your blood sugar down.

Then there are oral medications, like Metformin and Januvia. They both work by making your liver produce glucose less often. Metformin also makes your body more sensitive to the insulin that is already made in your body, while Januvia works to help your body increase insulin production. All of that keeps your blood sugar down.

Now we have the new kids on the block. The GLP’s (glucagon-like peptides), sometimes referred to as Incretin mimics. The GLP’s that are available by brand name are Victoza and Saxenda, Byetta and Bydureon, Tanzeum, and Trulicity. These medications work in three ways.

  • They increase the hormone incretin which triggers your pancreas to make its own insulin
  • They inhibit the hormone glucagon which is responsible for telling your liver to make more blood glucose
  • They make you feel fuller for longer by delaying gastric emptying, which helps you lose weight.

Now that last point is what has caught most people’s attention. It is true that some of these GLP’s can be used for weight loss, too. If you have type 2 diabetes, you know that losing weight is a benefit to help control blood sugar in overweight patients. These medications in particular can also affect your natural insulin production, which means you can get a lower dose of your insulin medications. It’s a win-win! But these medications are not to be used as a first line of defense against your diabetes. These medication’s main claim to fame is that they lower your A1C by 1% in most patients.

Your A1C is a blood test you get at the doctor’s office. It’s a measurement that can detect how well your blood sugar is being controlled over a period of 3 months. Usually you want this result to be somewhere under 7%. This reflects that your blood sugar is being controlled for a longer amount of time. Controlled blood sugar limits your risk for complications such as nerve pain and kidney problems.

Did I mention that these GLP medications can cost you around $700 a month? Not to worry. If these medications sound like something you want to add to your regimen don’t hesitate to talk to your doctor about them. They might be on your health plans insurance formulary, or you might qualify for a prescription discount with the ScriptSave WellRx savings program. Compare it to your insurance copay. It may be cheaper!

Keeping your diabetes in control can be a struggle. Never forget the amazing impact that a diet full of vegetables can have for your body. Keep your body moving. Ample exercise each week is another natural way that you can get your prescribed insulin dose lowered.


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ScritpSave WellRx image of a healthy diet

by Benita M. Daniel
University of Arizona, College of Pharmacy
PharmD Candidate, Class of 2017

The beginning of the New Year is often the time to set new goals and resolutions for the upcoming year. It’s an exciting time to start new resolutions that will help you succeed in the coming year. One of the most common New Year’s Resolution is to lose weight, stay healthy, and save money.

Fad diets are typically known for the potential to achieve rapid weight loss, even without the integration of any physical activity. However, it is important to keep in mind that these diets are harmful to the body since it usually restrict one’s nutritional intake. A healthy approach to losing weight is to include a well-balanced diet with physical activity.

Here are some of the examples of fad diets that were popular mainly in the year of 2016:

Military Diet Substitutes – This rigorous diet only allows the consumption of 13 specific food items such as peanut butter, grapefruit, eggs and bananas. It is commonly referred to as a crash diet.

Atkins 40 – This strict diet regimen focuses on a net carbohydrate intake of 40 grams per day. It’s a low carbohydrate diet with very little sugar intake and avoids all types of refined carbohydrates. It’s important to keep in mind that the recommended daily intake of carbohydrates is around 250 grams.

Mono Diet – This diet typically focuses on the consumption of a single food group. For instance, Taco diet, Pizza diet and Chicken Nugget diet.

Ketogenic Diet – This high fat diet calls for at least 70 percent of fat intake per day, in addition to less than 10 percent of carbohydrates and 20 percent of protein. This diet emphasizes on plant based beneficial fats, rather than the saturated animal fats such as cheese, cream and butter.

These diets might promise fast weight loss, however, it is significant to note that the consumption of a single food group or ingredient does not adequately provide all the nutrients that are essential for the body. It is vital to focus on well-proportioned diet that includes all food groups: protein, dairy products, vegetables, fruits, and legumes with a moderate consumption of fats and oils. Additionally, it is important to remember that the long-term effect of fad diets can be dangerous to the body and cause potential complications.

Potential complications that could occur from following a highly restrictive diet are:

  • Vitamin deficiency – Most diets often do not include food groups that are rich in vitamins and essential elements. It is important to ensure that you receive the essential elements and vitamins that are vital for body functions and to prevent any long-term chronic condition. For instance, Calcium is an essential element that plays a key role in bone growth and in preventing chronic conditions such as osteoporosis.
  • Improper long-term weight control – Most people tend to have a tough time following through fad diets due to its strict regimen. Furthermore, it is also noted that most people who achieve the goal through rapid weight loss often quit immediately upon reaching the goal due to the high restrictions associated with it.
  • Increased levels of cholesterol and triglycerides – Certain diets that consists of high-fat diet such as ketogenic diet can sometimes lead to increased levels of cholesterol, which may require treatment with cholesterol medications, like Crestor (rosuvastatin) or Zocor (simvastatin).
  • Ketosis – This can occur when you consume a high-protein and low carbohydrate diet. It is essential to meet the daily-recommended intake for carbohydrates in order to avoid some of the side effects such as headache, constipation, fatigue and dizziness.

Some ways to achieve a healthy lifestyle and to ensure safe and appropriate weight loss include:

  • Create a meal plan that focuses on a balanced diet that incorporates all food groups including fresh fruits and vegetables, lean meat, whole grains, legumes with moderate consumption of beneficial fats derived from fish and plants and minimal consumption of saturated animal fats. It is also key to avoid any consumption of processed foods, like pre-packaged meals or lunch meat. Those foods can be extremely high in sodium.
  • Focus on portion control by limiting the serving size per meal rather than avoiding major food groups
  • A healthy balance to weight loss is incorporating physical activity that is equal to the amount of calories you eat. The Centers for Disease Control (CDC) recommends a healthy routine to lose weight that includes at least 150 minutes of moderate intensity aerobic exercise every week.
  • It’s important to consult your physician or a dietitian before starting any new diet.

References:


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ScriptSave WellRx image - save on diabetic glucagon kits

by Benita M. Daniel
University of Arizona, College of Pharmacy
PharmD Candidate, Class of 2017

Weakness, anxiety or irritability, a general sense of confusion — these are signs of low blood sugar, or hypoglycemia. It often happens when diabetics take too much insulin.

Hypoglycemia happens to many people with diabetes, and it can be serious or even fatal.

Severe hypoglycemic episode, also referred to as insulin shock, can occur when the body has too much insulin that can lead to low blood sugar levels.

The possible causes for insulin shock include:

  • Overdose of insulin
  • Long interval time between each meals
  • Exercising without eating
  • Consumption of alcohol without eating food

If you’re experiencing a hypoglycemic episode, don’t panic. Most incidents of low blood sugar and can be treated at home.

One of the fastest, most effective treatments is with a glucagon injection. Glucagon is a natural hormone that is produced by the pancreas in response to high levels of insulin in the blood. The administration of glucagon injection is indicated for emergency uses only especially in patients who are experiencing severe hypoglycemic symptoms.

Severe hypoglycemia often results when early low blood sugar symptoms are untreated. It is recommended to use Glucagon if you experience:

  • Irritability
  • Tremor
  • Excessive sweating/hunger
  • Seizures
  • Weakness
  • Confusion
  • Unconsciousness

Glucagon pen injections are typically dispensed in Glucagon Emergency kits that contains a vial of glucagon (powder form), syringe with attached needle containing the sterile diluting agent with instructions on how to mix it prior to administration. It is important to ensure that you and your family including close relatives are properly instructed on how to use glucagon injection in the case of an emergency. A detailed instruction for use is provided by the manufacturing company. Since, glucagon products are currently available in market primarily in powder form, it is necessary to make sure that these necessary steps are taken prior to the administration of glucagon injection:

  • Inject the diluting agent contained within the syringe into the glucagon vial/bottle
  • Gently swirl the glucagon vial/bottle until it is a clear liquid. It is important to make sure that glucagon is not administered until it has a clear and water-like consistency
  • Using the same needle as before, draw up all the contents within the glucagon bottle
  • Sterilize the preferred injection sites: buttock, arm or thigh with an alcohol swab. Insert the needle into the injection site immediately after the reconstitution occurs.
  • If the patient does not respond to the first dose of glucagon, call 911 and physician and administer another dose of glucagon
  • After the administration, make sure to discard any remaining unused contents of the injection since the glucagon is typically unusable.

It is critical to treat the early signs and symptoms of hypoglycemia in order to prevent the progression of severe symptoms of hypoglycemia. Here are some helpful tips to help you prevent low blood sugar levels or hypoglycemia:

  • Identify early signs and symptoms of low blood sugar levels
  • Carry glucose tablets or sugary snacks such as candy or regular soft drink
  • Make sure to take insulin doses after each meal
  • Avoid exercising for longer periods of time without eating any sugary snacks
  • Avoid drinking alcohol without eating
  • Test blood sugar levels regularly as recommended by the doctor in order to ensure blood sugar levels are within goal.
  • Ask your doctor for glucagon injection if in case of emergency

There have been recent developments of newer agents such as Glucagon pens (G-pens) that are currently in Phase 3 of Clinical trials. As per the manufacturing company, Xeris Pharmaceuticals, “Glucagon pen is a highly stable, ready-to-inject glucagon solution as an alternative to the existing glucagon emergency kits and to provide various products addressing the broader problems of hypoglycemia in both the diabetic and non-diabetic population.”

Glucagon pens are prefilled auto-injectors that will activate immediately with the contact of the human skin and works in similar methods to that of an Epi-pen.  Additionally, it does not require multiple steps prior to the administration of the medication to ensure the patient receives the active form of glucagon.

The elimination of the reconstitution will help in the fast and efficient administration of glucagon and this can prevent further complications of hypoglycemia including coma. G-pens seems to be a promising area of research and it will be fascinating to see the positive outcomes that would result due to the development of Glucagon pens.

Recheck your blood sugar after 15 or 20 minutes. If it’s still low, take another 15 to 20 grams of a quick-acting sugar, and eat something if you can. If your sugar level stays low after 2 hours or if your symptoms don’t get better, seek medical attention.


References:

http://www.healthline.com/health/diabetes/insulin-shock#Overview1

http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html?loc=lwd-slabnav

http://pi.lilly.com/us/rglucagon-ppi.pdf

http://www.xerispharma.com/pipeline


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Glucagon Emergency Kits,
Celebrex (celecoxib), or
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photo ScriptSave WellRx vitamin supplements

by Sandra Leal, PharmD, MPH, CDE, FAPhA

The US supplement industry is a $30 billion dollar business.1 The Council for Responsible Nutrition estimates that almost 70% of US adults use dietary supplements.2 Before I continue, I must state that I do not have any conflicts of interest and rest assured, although I am a pharmacist, I do not support ‘Big Pharma’ when it comes patients unnecessarily being prescribed medication.

Personally, I use caution when it comes to dietary supplements for one simple reason – they are not regulated like prescription medications. The FDA is the administration that regulates the approval and use of prescription medication. What this means is that on a prescription bottle labeled with a specific amount of ingredients, you can be certain that the actual amount in a given tablet, capsule, cream, suppository, solution, etc. is between about 95% and 105% of what the label actually states. As an example, if you are prescribed to take a tablet that is 100mg in strength, then you can be certain that the amount is between 95mg and 105mg of that medication.

On the contrary, dietary supplements are regulated by the Dietary Supplement Health and Education Act of 1994. Since they are not regulated like drugs, companies that manufacture and produce dietary supplements are able to put whatever claims they want on their bottles. It is possible and highly likely that what is stated on the supplement label is not what is in the actual tablet or capsule. In fact, the New York Attorney General and the Federal Trade Commission have recently filed suit against Prevagen for their claims of memory boosting.

Moreover, many weight loss dietary supplements contain botanicals and plant-derived ingredients that can cause and make health problems worse. Sometimes, these supplements can interact with prescription medicines that you are prescribed. St. John’s wort, in particular, can negatively interact with a number of medications, including Statins (Crestor, Simvastatin), Warfarin (Coumadin), and Tricyclic antidepressants, like Elavil or Pamelor.

I believe there are great health benefits and medicinal properties of nutraceuticals, however there is a great need for credible research and evidence before I would be comfortable recommending these products to my patients. Throughout my years of practice, I have found that many patients do not consider dietary supplements, OTC products, and vitamins as medications. I would recommend that the next time you have an appointment with your doctor, inform him/her of everything you take, even those that you purchase in a store or online, just to ensure that they are safe for you and do not interact with your prescription medications.

The next time you think of taking a supplement, remember that right now you have no way of knowing for sure what’s really in your supplement bottle. And despite the promising on the labels, the pills probably won’t make you any healthier (unless you have a medically diagnosed deficiency), and they might even be hurting you.

 

References:

  1. http://www.vox.com/2016/3/10/11179842/dietary-supplements-medical-evidence
  2. http://www.crnusa.org/CRNPR14-CRNCCSurvey103014.html
  3. http://annals.org/article.aspx?articleid=1789253
  4. http://www.iflscience.com/health-and-medicine/23000-people-us-end-er-annually-because-supplements

For the best Rx price on Crestor (rosuvastatin), Zocor (simvastatin), Lipitor (atorvastatin) and other statins,
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