Pharmacogenomics pharmacogenetics image

by Leah Samera, PharmD Candidate, Class of 2018

As with most things, when it comes selecting a drug regimen for the treatment of chronic disease, one size does not fit all. If you take medications, you may have wondered why that is the case. One reason is because of pharmacogenomics.

Pharmacogenomics refers to “the entire spectrum of genes that interact to determine drug efficacy and safety.” In practice, many people may use the terms pharmacogenomics and pharmacogenetics interchangeably.

Pharmacogenetics, however, also refers to variants of one gene that affect drug response. The study of both pharmacogenomics and pharmacogenetics can help to optimize drug therapy and minimize drug toxicity based on an individual’s genetic profile.

What is a gene?

A gene is a series of codons that specify a particular protein. Genetic variation may result in altered protein sequence and function or in altered protein levels. This is significant, because these proteins can have an effect on how your body interacts with medications.

How do pharmacogenomic variations affect drug response?

The impact of pharmacogenomic variations on drug response have traditionally been divided into four categories:

  1. Those that affect drug pharmacokinetics. Pharmacokinetics refers to how a medication moves through a person’s body, i.e., how the drug is absorbed, distributed, metabolized, and eliminated.  An example of a genetic variation that affects pharmacokinetics is one in which drug metabolism is altered, subsequently affecting plasma concentration.
  2. Those that effect on pharmacodynamics. Pharmacodynamics refers to a person’s therapeutic response to a medication; this depends on a medication’s affinity and activity at its site of action. An example of a genetic variation that affects pharmacodynamics is one in which binding of a drug to its receptor is reduced, thereby decreasing therapeutic efficacy.
  3. Those that affect idiosyncratic reactions. An idiosyncratic reaction is an adverse reaction to a medication that is both rare and unpredictable. An example of a genetic variation that affects idiosyncratic reactions is one in which the likelihood of a hypersensitivity reaction to a certain drug is increased.
  4. Those that affect disease pathogenesis or severity and response to specific therapies. Pathogenesis refers to the origination and development of a disease. An example of a genetic variation that affects pathogenesis is a specific molecular defect related to the development of certain malignancies for which there are targeted therapies.

How can the study of pharmacogenomics help to optimize your drug therapy and minimize side effects?

Organizations like 23andMe allow people to “access, understand, and benefit” from the study of pharmacogenomics. With their simple home-based saliva collection kits, all you have to do is order their Health + Ancestry service; register, and spit into, the provided tube; and mail the kit back to their lab via the pre-paid package. Next, their lab extracts, processes, and analyzes the DNA from the cells in your saliva. Within 6 to 8 weeks, you get an email notifying you that you can view your results in your online account and discover what your DNA says about you. By sharing those results with your healthcare providers, they then can use that information to ensure that you get the most benefit from your medications while minimizing the risk of side effects.

References:

  1. Cavallari LH, Lam Y. Pharmacogenetics. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill; . http://accesspharmacy.mhmedical.com.ezproxy4.library.arizona.edu/content.aspx?bookid=1861&sectionid=146077703. Accessed September 12, 2017.
  2. Roden DM. Pharmacogenetics. In: Brunton LL, Knollmann BC, Hilal-Dandan R. eds. Goodman & Gilman’s: The Pharmacological Basis of Therapeutics, 13e New York, NY: McGraw-Hill; . http://accesspharmacy.mhmedical.com.ezproxy4.library.arizona.edu/content.aspx?bookid=2189&sectionid=167889559. Accessed September 12, 2017.
  3. Tantisira K, Weiss ST. Overview of pharmacogenomics. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 13, 2017.
  4. Our Mission. 23andMe.com. https://mediacenter.23andme.com. Accessed September 13, 2017.
  5. How it works. 23andMe.com. https://www.23andme.com/howitworks. Accessed September 13, 2017.
  6. Our science. 23andMe.com. https://www.23andme.com/genetic-science. Accessed September 13, 2017.

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Anxiety medications and children photo

by Jenny Bingham, PharmD

Across the United States, the rate of antidepressant use in children is rising. It has led to prescription costs exceeding $100,000 in the four states with the highest antidepressant prescription rates for children: Colorado, Florida, Pennsylvania, and Texas.

As the number of antidepressant prescriptions rise, it’s only natural that parents will have a growing number of questions about those medications. Here’s a list of common questions other parents have had when starting pharmacotherapy for their child’s anxiety and/or depression:

How many pills will my child have to take?

The simplest answer is, it depends. Pharmacists are trained to know FDA approved indications for mental health medications. By incorporating pharmacists into the healthcare team, they can help find medications that have dual purposes and decrease the amount of pills in the regimen. Talk to your pharmacist about the medications and if there are alternatives.

How will pharmacotherapy affect my child?

Each patient responds differently to medications. Whereas some patients that are prescribed a common first-line antidepressant (fluoxetine) and tolerate it well, others may have an entirely different reaction. Certain medications can have negative side effects, including:

  • shaking
  • drowsiness
  • weight gain
  • insomnia
  • dizziness
  • dry mouth
  • blurred vision
  • bleeding, and,
  • constipation.

These side effects can be extremely detrimental to a child’s quality of life. It’s important to have open communication with your healthcare provider to ensure that side effects don’t get in the way of medication adherence, school performance, or self-esteem. Current literature provides clinicians a wide variety of information about which side effects are more prominently reported in individual cases. This database of knowledge helps further individualize therapy and avoid potential side effects.

What risks are associated with pharmacotherapy?

Parents should be aware of the potential for abuse, especially with commonly prescribed anxiety medications (ex. alprazolam) that are rated as controlled substances.

Adolescents are at an increased risk of suicidal ideation when initiating certain medications. Family members must be educated on how to monitor, identify, and report these to the provider.

One must also consider the risks of not seeking appropriate treatment, like self-medication with illicit drugs, tobacco, and alcohol. Self-medication can unfavorable effects on one’s mental and physical health.

Are there alternatives to pharmacotherapy?

If a parent decides against using medications, trained therapists can provide alternative options, if appropriate. Cognitive behavioral therapy is a common tool that incorporates education, relaxation exercises, coping skills, stress management, and assertiveness training.1

Other approaches include: interpersonal therapy, motivational interviewing, dialectical behavior therapy, supportive therapy, and family therapy. These tools can also be used in combination with medication to improve depression and anxiety. Parents should work closely with their physician to determine if this is a safe option as monotherapy.

Final Thoughts

Decisions about using medications to treat anxiety and/or depression in children must be catered specifically to the patient. It is imperative for health care providers to approach this sensitive topic as a group, including the patient and parents. Pharmacists are a great resource for optimizing medication effectiveness and reducing pill burden.

References:

  1. Beck JS. Cognitive Behavior Therapy: Basics and Beyond, 2nd ed, Guilford Press, New York 2011. p.391.

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Dry eye treatment eye drops

by Kali Schweitzer, PharmD candidate 2018
University of Arizona College of Pharmacy

For many people, dry eyes may only be a minor inconvenience. But for those who experience chronic dry eye, it can be a major problem, causing extreme discomfort. Left untreated, dry eye can have long term effects on your vision as well as your quality of life.

What causes dry eyes?

Dry eye occurs when you do not produce enough tears or if you are not producing quality tears.  As a result, there is not enough lubrication for the eye, leading to the gritty, burning, and irritated feeling that is most often associated with this condition.  There are a variety of things that may cause dry eye, including:

  1. Dry climate
  2. Wind
  3. Exposure to smoke
  4. Age
  5. Gender
  6. Certain medications and medical conditions.

For some, dry eye may be unavoidable, which is when finding an effective treatment that is not too costly becomes very important. In fact, one study found that the average direct cost for a patient seeking medical care for dry eye was $738 per year, and the cost to society per patient per year was over $11,000. So, the question is, what are your options if you are one of the millions of people in the United States who suffer from this condition?

Over-the-counter treatment for dry eyes

The key to managing dry eye symptoms and avoiding spending a fortune on prescriptions is to take advantage of the various over-the-counter options available.

The most popular over-the-counter treatment for dry eye is artificial tears, which help to lubricate the eye when you do not have enough tears of your own. There are many different varieties of artificial tears in the pharmacy aisle, and the most important distinction between them is that some are preservative-free while others are not. The preservative-free options tend to be more costly, but they are better for those who have more chronic symptoms because they are less likely to irritate the eyes following frequent use.

Another option that is available without a prescription is an omega-3 fatty acid supplement, which helps to increase tear production. Depending on what your doctor determines to be the cause of your dry eyes, they may have other recommendations for you that do not require a prescription for dry eyes.

Home treatment for dry eyes

In addition to over-the-counter medications, there are a number of other things you can try to prevent and/or reduce the symptoms of dry eyes. Some suggestions include blinking regularly, wearing sunglasses outside to protect your eyes, and drinking more water. If eyelid inflammation contributes to your dry eye symptoms, you may consider gently washing your eyelids, which can be done using a mild soap. Applying a warm compress over your eyes may also provide relief.

When do you need a prescription for dry eyes?

If prescription treatment does become a necessity, your doctor will discuss the different options with you. The ones most commonly used are Restasis (cyclosporine), which reduces inflammation, and Xiidra (lifitegrast), which helps you make more, quality tears. Another option is Lacrisert (hydroxypropyl cellulose), which is inserted between the eyeball and lower eyelid and slowly dissolves to release a lubricating substance. For now, these are only available as brand name medications, therefore price may be a barrier depending on your insurance coverage.

Finding the right dry eye treatment

Whether you seldom experience dry eyes or if you have constant symptoms, finding the right treatment is crucial. Dry eye can be irritating, costly, and even life-altering if not controlled. By working with your doctor, your pharmacist, your insurance company, and even prescription savings companies like ScriptSave, you will be in a better position to control your symptoms and save some money in the process.

References:

  1. Yu J, Asche C, Fairchild C. The Economic Burden of Dry Eye Disease in the United States: A Decision Tree Analysis. 2011 April. 30(4):379-387.
  2. https://www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/dry-eye?sso=y
  3. http://www.mayoclinic.org/diseases-conditions/dry-eyes/basics/lifestyle-home-remedies/con-20024129
  4. Micromedex

 

 

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Pharmacist help manage epilepsy drugs

by Jenny Bingham, PharmD

Choosing the correct medication to treat epilepsy is a multifaceted process. Pharmacists can have a huge impact on the patient’s therapeutic response as a valued member of the healthcare team. 1

Medications used to treat seizures are called anti-epileptic drugs. Pharmacists review reams of information to ensure medication safety and suitability. The three primary concepts involved in this evaluation include:

  1. Pharmacogenetics – the role of genetic differences on an individual’s response to a drug.
  2. Pharmacokinetics – how a drug moves through the body.
  3. Pharmacodynamics – an individual’s therapeutic response to a drug.

It is important to assess for drug interactions

When medications interact with one another it is called a drug-drug interaction. Medications can enhance the effects of another drug (agonize). They can also block the effects of another drug (antagonize).

Monitoring for kidney or liver function

Medications are either metabolized in the liver or kidneys. If an individual has impaired organ function or damage, it changes how the body responds to that drug. Some medications, like Carbamazepine and Phenytoin may have more of an impact than Gabapentin.

Medications that are metabolized in the liver have an affinity for certain enzymes:

  • If a medication induces a particular enzyme, it can increase the body’s metabolism of it. The result is decreased serum concentration levels, or decreased effects.
  • If a medication inhibits, it can decrease the body’s metabolism of it. The result is an increased serum concentration level. Individuals might experience increased side effects when this happens.

What to expect for the duration of treatment

The goals of treating seizures are:

  1. Improve the patients quality of life; and,
  2. Decrease seizure frequency.

An individual’s type of seizure and previous medical history dictate how long they must take anti-epileptic drug. Patients should only make changes to their medication as directed by their provider.

In general, there is no one size fits all approach to treating seizures. However, pharmacists can prevent medication-related issues by performing a comprehensive safety evaluation as a member of the healthcare team.

References:

  1. Koshy S. Role of pharmacists in the management of patients with epilepsy. Int J Pharm Pract. 2012 Feb; 20 (1):65-8.
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noacs - warfarin alternatives

by Kali Schweitzer, PharmD candidate 2018
University of Arizona College of Pharmacy

Not so long ago, a diagnosis of atrial fibrillation (AFib), deep vein thrombosis (DVT), or pulmonary embolism (PE) meant that a prescription for the blood thinner, warfarin (Coumadin), was likely coming your way. In recent years, multiple other blood thinners have become available, and you may have wondered if any of them could be right for you.

What are NOACs?

The NOACs, or novel oral anticoagulants, are a new breed of blood thinner that have arrived on the market within the last ten years. This class of medications includes:

How are NOACs Different from Warfarin?

Multiple clinical trials comparing these alternative warfarin medications have all shown that the NOACs are just as effective as warfarin, and that they have a similar (or lower) risk of bleeding. Warfarin has been around for decades and has been proven to be both safe and effective at preventing blood clots, but it’s no secret that it has its problems. Here are some key differences to note when comparing the newer anticoagulants with warfarin and when deciding what is right for you:

  1. Warfarin requires frequent trips to the lab to have your INR (international normalized ratio) checked. Also referred to as PT time, Prothrombin time is a blood test that measures how long it takes blood to clot, or how well the medication is working. You may potentially need to change your dose to increase or decrease the clotting time. NOACs do not require lab monitoring or frequent dose changes.
  2. NOACs do not have the high potential to interact with food or other medications like warfarin does, meaning there are fewer restrictions. This means no more worrying about how much salad you can eat on a day-to-day basis, or if you are allowed to have that glass of grapefruit juice in the morning. It is still recommended, however, to check with your doctor or pharmacist before starting any new medications, as there are still some medications that may increase your risk of bleeding when taken with the NOACs.
  3. NOACs begin working quickly, while warfarin may take up to a week to start working. Because of this, patients with a DVT or PE starting warfarin may require “bridge” therapy with heparin or enoxaparin (other fast acting blood thinners) to prevent clots while waiting for the warfarin to take effect. This “bridge” therapy is not necessary with the NOACs.
  4. Unlike warfarin, not all of the NOACs have a reliable reversal agent if you were to begin bleeding. With warfarin, if your INR becomes too high or if you are having signs of bleeding, you may be given vitamin K, or phytonadione, to reverse its effects. Currently, Pradaxa is the only NOAC that has an approved reversal agent, called Praxbind (idarucizumab). While bleeding is rare while on the NOACs, the lack of reversal agent is something to keep in mind when deciding which medication may be right for you.
  5. NOACs may not be appropriate if you have decreased kidney and/or liver function. Your doctor will review your labs and information to determine if your kidneys/liver are functioning well enough for you to take one of these medications.

The recent approval of the NOACs has provided prescribers and patients with more options to choose from when a blood thinner is necessary. Because these medications are still relatively new, there is a lot left to learn about their use and limitations, so they may not be appropriate for everyone. It is always important to discuss any questions or concerns with your doctor when starting any of these medications or when switching from one to another.

 

References

Leung LLK, Direct oral anticoagulants and parenteral direct thrombin inhibitors: Dosing and adverse effects. In: UpToDate, Mannucci PM (Ed.), UpToDate, Waltham, MA.

Hanley CM, Kowey PR. Are the novel anticoagulants better than warfarin for patients with atrial fibrillation? Journal of Thoracic Disease. 2015;7(2):165-171. doi:10.3978/j.issn.2072-1439.2015.01.23.


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Emergency Preparedness - medications, ScriptSave WellRx

by Leah Samera
University of Arizona College of Pharmacy
PharmD Candidate, Class of 2018

Ready, a public service campaign designed to educate and empower citizens to prepare for emergencies such as natural and man-made disasters, proclaims September to be National Preparedness Month (NPM). In the aftermath of Hurricane Harvey and in anticipation of Hurricane Irma, you may be wondering how to go about preparing for such events. This is especially important to consider if you have a chronic disease or condition.

Illness Follows Disaster

Studies have found that upwards of 70% of the Hurricane Katrina survivors had at least one chronic condition. Additionally, 58% of the visits to emergency treatment facilities in New Orleans after Hurricane Katrina were due to illness, 24% of which were associated with chronic diseases. The research on disasters’ effects on chronically ill patients only serves to reinforce the fact that these emergency situations can lead to both exacerbation and death from chronic illnesses due to direct stress of the disaster, interruption of care, or both.

Emergency Plans and Kits

Organizations like the American Red Cross recommend having an emergency plan and kit prepared for use during a disaster. Some obvious items that should be included in such a kit are water, food, and first aid supplies. However, it is also critical that you have a 7-day supply of your medications on hand as well as any other tools or devices used for your health such as hearing aids with extra batteries, syringes, blood pressure cuffs, et cetera. In order to have at least a 7-day supply of your medications, you must order refills of your prescription medications as soon as you are able rather than before you run out. It is best to keep these items together and in a location that is easy to get to in an emergency.

Planning Ahead

Medications should be stored away from heat, light, and moisture; if possible, keep them in their original bottles and store the bottles in a waterproof bag or container. If you have medications such as insulin that need refrigeration, have a freezer pack and cooler available. It is also important to stay up-to-date on all immunizations, including tetanus, especially if you have diabetes. Additionally, because the stress of these disasters can exacerbate your conditions, it is best to also make appropriate lifestyle changes such as restricting salt intake if you have high blood pressure or learning the carbohydrate counting approach if you have diabetes.

Other Handy Emergency Items

Other items that you should have handy in case of an emergency include any over-the-counter medications you may need like pain relievers, as well as your medication list and insurance card. It is important to keep an up-to-date medication list that not only catalogs the names of your current medications but also their strengths, indications, directions, and prescribers; any bad or allergic reactions you may have had to medications in the past should also be documented. Your prescription benefit card may be needed for approval of an emergency supply if you run out of or lose your medications, or if your medications get damaged or contaminated.

In the event that you end up requiring medications and health resources:

  • RxOpen.org maps open and closed pharmacies, American Red Cross shelters, and infusion centers in areas affected by disasters.
  • The charity Direct Relief provides free prescription drugs and medical supplies to low-income patients at community health centers or clinics.
  • Keep a list of nearby pharmacies and hospitals as well as their phone numbers.

By doing what you can to prepare for disasters, you can lower your risk of exacerbations of your health conditions. As the theme for NPM states: “Disasters Don’t Plan Ahead. You Can.”

References:

  • National Preparedness Month. https://www.ready.gov/september. Accessed September 7, 2017.
  • Kessler RC, Hurricane Katrina Community Advisory Group Hurricane Katrina’s impact on the care of survivors with chronic medical conditions. J Gen Intern Med. 2007;22(9):1225–1230. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219784. Accessed September 8, 2017.
  • Sharma AJ, Weiss EC, Young SL, et al. Chronic disease and related conditions at emergency treatment facilities in the New Orleans area after Hurricane Katrina. Disaster Med Public Health Prep. 2008;2(1):27–32. https://www.ncbi.nlm.nih.gov/pubmed/18388655. Accessed September 8, 2017.
  • Be Prepared for an Emergency. Be Red Cross Ready! http://www.redcross.org/get-help/prepare-for-emergencies/be-red-cross-ready/get-a-kit. Accessed September 7, 2017.
  • Emergency Preparedness for Prescription Medications. http://www.mayo.edu/pmts/mc6000-mc6099/mc6012-39.pdf. Published 2016. Accessed September 7, 2017.

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pill boxes medication adherence

If your doctor has prescribed a medication for you, you want to be sure you’re getting the most benefit from that drug. Medication adherence is important to get the most benefit from the medications used to treat your condition. The causes of non-adherence, when a patient either accidentally or knowingly does not take medications as prescribed, can be complex. Non-adherence is often the result of cost; patients who simply can’t afford their medications. However, good habits and a good understanding of the medication can also be a big part of adherence, and can help you stick to your medication schedule.

Medication Adherence

World Health Organization defined adherence as “the extent to which a person’s behavior – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.” The concept that healthcare professionals manage medical conditions is true only in case of hospitalized patients. The bottom line is, medications don’t work in patients who don’t take them, or don’t take them as prescribed.

In an outpatient setting, the healthcare professionals’ role is limited to providing products (medications and/or monitoring devices) and educational tools. Taking medications, on time and properly, is left up to the patient or their in-home caregiver. There are several techniques to help you remember to take your medications as prescribed and manage their own medical condition. As the patient, you have the ultimate control for safe and effective treatment.

Two Steps to Medication Adherence
Adherence to medication can be achieved in two simple steps; understanding and behavior changes. Understanding includes knowledge of your medical condition and how your prescribed medication can help to manage it. Here are a few helpful websites:

  1. http://www.patienteducationcenter.org/ – The health-related content on the website is provided by Harvard Medical School. Medical conditions are listed alphabetically from A to Z.
  2. https://medlineplus.gov/ – Produced by the National Library of Medicine, provides reliable information on medical conditions, drugs, herbs, and supplements.
  3. https://www.wellrx.com/ – ScriptSave® WellRx allows you to search for the lowest prices on prescription medications at nearby pharmacies, and provides overviews of the medications. Our Ask a Pharmacist phone line lets you talk to a pharmacist about prescription medicines, dosing, or medication interaction questions. Registered members have access to a free suite of personal wellness tools in the Medicine Chest, including:
  • Ask a Pharmacist
  • Pill Reminders
  • Refill Reminders
  • Medication Information (in both English and Spanish)
  • Medication Videos
  • Mood-tracking (to review side effects, etc.)
  • Price-check and Pharmacy Locator

Behavioral changes mean finding ways to stay on track with your medication schedule. Finding the right tool or a combination of methods that fit best your lifestyle is key to medication adherence. Here are some ways to stay on track:

  1. Integrate your medication to your daily routine, such as brushing your teeth or watching your favorite TV show.
  2. Set one/multiple daily alarm using a clock, mobile phone, or computer.
  3. Ask a family member and/or friend give you a call remainder.
  4. Pill boxes are another way to organize your scheduled medications. Pill boxes are available in different forms that allow you/your caregiver to fill them daily, weekly, or even monthly.
  5. Medication charts can be developed by own or with the help of a healthcare professional. Keep an updated chart with medication names, dose, when you take them, and what are you taking them for. You can refer to the chart if you get confused with your medications.
  6. Plan ahead for medication refills and mark a calendar to make sure you always have your medication when necessary.
  7. If you have a smart phone, the free ScriptSave WellRx app can be used to remind you to take your medications, refill your medications, and track how the medications make you feel.

We hope these tips on medication adherence have helped. Download our free app from the iOS app store or the Google Play Store, and get registered to take advantage of our free medication adherence tools. If you’re struggling to afford your medications, visit www.WellRx.com to compare the cash price at pharmacies near you. You may find prices lower than your insurance co-pay!


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Behavioral health medications for anxiety or depression - image

Jenny Bingham, PharmD
University of Arizona College of Pharmacy

There are a number of mental conditions that shape mood and behavior. Any condition that affects a person’s thinking, feeling or mood, falls into a medical classification of Behavioral Health.  Such conditions may affect someone’s ability to relate to others, or maintain reasonable function every day. Each person may have different experiences, even if they have the same diagnosis as someone else.

Depression is the most common behavioral health condition in the general population1. Without treatment, depression can lead to decreased quality of life2, increased suicidal thoughts, and overall worsened health outcomes. The most common method of treating depression is to target serotonin and how the body uses it.  Serotonin regulates mood and ultimately is what makes you feel happy. When we have low serotonin levels, you can feel depressed or anxious. Antidepressants each have their own unique mechanism of action that are specific to certain neurotransmitters in the brain.

Anxiety can affect our ability to function due to excessive worry. Without treatment, anxiety can also lead to a worsened quality of life and can even be debilitating for some patients3. Anxiolytics are the medication class used to treat anxiety. The most common method of treating anxiety is to target serotonin and/or norepinephrine.  Norepinephrine is responsible for motor action, cognition, the body’s alert system, and feeling energetic.  When we have low norepinephrine, it is harder to cope with every day stressors and things that are beyond our control.

How do these medications work?  

These medications are often classified as reuptake inhibitors. They target the neurotransmitters serotonin and norepinephrine, to name a few.  Medications prevent the body from recycling these neurotransmitters. By preventing them from being recycled too soon, it allows the body a better chance to use them to improve mood and/or relieve anxiety.

What can you do to make them work better for you?

We know that the body needs certain building blocks to make serotonin and norepinephrine. An important concept to remember is that no matter how many medications are prescribes to treat these conditions, they don’t stand a chance at being effective without the right precursors; an interesting concept in today’s world. The majority with these conditions take more than one medication.

Step 1: What is your protein source?

The greatest building blocks for serotonin are things that you might already have in your kitchen.

Complete proteins are the main precursor for tryptophan, which is later turned into serotonin. You might think that tryptophan only comes from turkey on Thanksgiving, but did you know that you can also get it from eating beef, venison, buffalo, pork, fish, shellfish, cheese, cottage cheese, milk, yogurt, and eggs? 

The building blocks for norepinephrine are also found in your kitchen.

In addition to eating complete proteins, it’s also important to eat incomplete proteins as well. You can find these in nuts, grains, beans, legumes, and soy.

Step 2: What else is included on your meal plan?

When we think about serotonin building blocks, key vitamins play an important role as well.

  • Vitamin B6. Great nutritional sources of this vitamin are found in whole grains, vegetables, and nuts.
  • Vitamin B12. This vitamin is found in meats, fish, liver, and milk.
  • Folic acid and Vitamin D3 are often found in fortified foods.
  • Omega-3 Fatty Acids are found in fish, dairy, and grains.

Step 3: Don’t forget about your supplements and vitamins.

Over-the-counter supplements can help you fulfill your dietary need of the vitamins mentioned above. But, there is a caveat.  Did you know that you can actually take “too much” of a vitamin? When in doubt always review your supplements and medications with your pharmacist for safe use.

As a patient, take comfort knowing that you can control how well your medications work for you. You are the rate limiting factor in the equation. These simple modifications can make a world of difference with managing depression and anxiety. After all, the best investment you’ll ever make is in yourself.

References:

  1. Kessler RC, Ormel J, Petukhova M, et al. Development of lifetime comorbidity in the World Health Organization world mental health surveys. Arch Gen Psychiatry 2011; 68:90.
  2. Daly EJ, Trivedi MH, Wisniewski SR, et al. Health-related quality of life in depression: a STAR*D report. Ann Clin Psychiatry 2010; 22:43. 
  3. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:617.

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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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Congress just unveiled their long-awaited replacement plan for the Affordable Care Act (ACA, or Obamacare). Unfortunately, it’s likely to leave a huge hole in insurance coverage for many in the U.S.While America waits for the final “yay or nay” from Congress, a recent study from the Kaiser Family Foundation (KFF) makes note of how many are already struggling with healthcare costs,making it difficult to for those trying to find low-cost prescriptions.

Cutting Back to Pay Bills

According to the study, 43 percent of adults with health insurance report problems affording their deductible, and 29 percent say they have difficulty paying medical bills. Among those citing trouble paying their medical bills, more than 70 percent have cut back on vacations, spending on food, clothing or basic household consumer items. We feel these people should get assistance when it comes to paying for the prescription drugs they need. That’s why ScriptSave helps consumers find low-cost prescriptions at pharmacies near them—for free.

Making cuts to pay for medical bills - finding low-cost prescriptionsRising Prescription Drug Costs

The national association, America’s Health Insurance Plans (AHIP), has completed a study showing the majority of health insurance premiums are going towards the cost of prescription drugs.3

For those facing high out-of-pocket costs for prescription meds due to an insurance gap or high premiums, a free download of the ScriptSave WellRx prescription savings card might help. As a patient, the card (or mobile app) won’t cost a penny to use. If it helps, great—enjoy the benefit of a lower-cost medication. If not, then it didn’t cost you anything. That said, our average savings rate is 45% (with reports of savings up to 80%*), and the ScriptSave WellRx program is contracted with over 62,000 pharmacies, nationwide. You might be surprised to find out you’re eligible for low-cost prescriptions with your ScriptSave WellRx card.

ScriptSave’s long-standing mission has been to close the gaps in prescription coverage, and has a 20-year history of working with health plans and pharmacies to provide consumers with discounts on prescribed medications.

If you need to lower your prescription drug costs, ScriptSave WellRx offers help to everyone – regardless of income, age, or insurance coverage. Sign up today and save a little extra money next time you pick up your prescriptions.

 

References:

1 http://www.npr.org/sections/health-shots/2017/03/07/519001659/7-things-to-watch-in-the-gops-american-health-care-act

2 http://kff.org/health-costs/poll-finding/data-note-americans-challenges-with-health-care-costs/

3 https://ahip.org/health-care-dollar/

 

* Average and up to savings percentages are based on all discounted prescriptions that were run through the ScriptSave WellRx program in 2016. Discount percentages represent savings provided off of pharmacies’ retail prices for consumers who do not have a discount program and pay cash.


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