A pharmacist's look at the supermarket and beyond

Month: June 2015

Heroic Pharmacy

I’m just back from attending the Annual Meeting of the Arizona Pharmacy Association and the last session that I attended is still rattling around in my head. Martha (Martie) Fankhauser is making good use of her so-called retirement by advocating for a more sane approach to health. She has devoted much study to the ecosystem of our bodies and brains and speaks eloquently of the need to keep some important realities in mind when treating our patients. Basically, she notes 1) the need to have a regular intake of protein (being sure to get all nine essential amino acids), fatty acids, complex carbohydrates, vitamins and minerals, and water. These nutrients provide the building blocks for our physical structures and our neurotransmitters, with the whole process being fueled by carbohydrates; 2) exercise improves the the release of neurotransmitters that contribute to our well-being; 3) during sleep we produce and store neurotransmitters for use during the next day; 4) a healthy endocrine system with the correct balance of hormones helps to properly control our physiology.

It seems that the more we learn of the role that nutritional and lifestyle choices make in disease and drug therapy effectiveness, the more we can glimpse a better pathway to health. It’s really quite amazing that deficiencies of vitamin B-12, folate,iron, or vitamin D may manifest in a variety of negative effects beyond the familiar anemias or bone density issues. Martie showed how many of the enzymes that are needed to synthesize neurotransmitters require these vitamins to function. She also reminded us that despite its name, vitamin D, is actually a hormone. Ergocalciferol, or D2 is less effective than cholecalciferol, D3. Martie is not a fan of the 50,000 unit per capsule that many of us dispense, more often D2 than D3. She prefers a more modest daily intake of about 400 units of D3.* Kind of tucked away in all this is one of the reasons that not all cholesterol is bad. Our bodies convert 7-dehydrocholesterol to cholecalciferol when our skin is exposed to UVB light. That’s D3, humans don’t make D2, so if you are buying a supplement, look for D3 or cholecalciferol.

She pointed to a whole host of issues with nutrients, vitamins and minerals that cry out for pharmacist to learn more about and become better able to help patients take better care of their bodies. I was struck by the courage of her convictions and her heroic stance to educate the health care community and our patients. This is a huge paradigm change for most of us practitioners. Our focus is too often to take a pill, and when we don’t get the desired response, take a different pill or even worse, another pill. Before you know it, we have a patient taking handfuls of drugs every day, some of them working against others. That’s polypharmacy at its worst. There is little in our system of care to help to undo this approach. The economy of health care is dependent on the prescribing of treatments and in modern medicine those treatments are drugs and all too seldom corrective measures in diet and exercise. This is of particular note in the area of behavioral health.

Martie mentioned the example of serotonin, the neurotransmitter considered to be critical to a good mood and sense of happiness. Our body requires the essential amino acid tryptophan in order to produce serotonin. The entire class of antidepressants called SSRIs (Selective Serotonin Reuptake Inhibitors) work by preventing serotonin being reused by our nerve cells. The theory is that by blocking the reuptake, there will be a higher concentration of serotonin to act upon the nerve receptor that improves our mood. As we learn more and more of the physiology involved, it become apparent that this approach is not without its flaws. So having more serotonin in the synapse sounds great but, the longer it stays in that space and not reuptaken into the storage vesicle, the more apt it is to diffuse away from the area of activity or be dismantled into inert by-products that are eliminated (some serotonin may be converted to melatonin to help regulate or sleep cycle). It’s easy to see that if the patient does not have a source of tryptophan, then no new serotonin will be produced. All the SSRIs in the world will not work if there is no serotonin in the neuron! Some sources of tryptophan are red and white meats (beef, pork, chicken), fish and other sea creatures, eggs, and dairy products. Yes! It’s OK to eat eggs again! Other neurotransmitters like dopamine and norepinephrine have analogous biochemical properties and pathways that we are discovering.

Martie has her work cut out for her but her passion for this subject is winning people over every day. It’s a tough challenge. It is difficult to undo the status quo. Patients, caregivers, and providers are too ready to seek an easy answer in a capsule or tablet. Half the commercials on the evening news are for prescription drugs. Expensive prescription drugs. I’ve said many time that I strive mightily to have my pharmacy students think things through before “going to the literature.” They have been taught the pathophysiology of the body and the pharmacokinetics of drugs, but little time is spent on presenting a complete picture of healthy physiology and the pharmacodynamics of the drugs we supply. I just love that Martie pointed out that these are often pharmacodynamic problems. In other words, it’s not what the body does to the drug (pharmacokinetics), its how the drug affects our entire physiology (pharmacodynamics), our bodies and our brains.

This is a huge mountain to not only climb, but to completely relocate! The healthcare industry will need to be overhauled with a new focus on prevention and healthful behaviors, including a fair payment model for those of us that may guide patients to better health (and so less cost in treatments and other interventions), while medical and pharmacy schools must be willing to rely less on the “literature,” where studies are mostly funded by pharmaceutical manufacturers, and more on basic research into physiology and pharmacodynamics. We must find unique ways of disseminating the information that scares the beejeezus out of Big Pharma and Big Med. It seems all our information sources are bought and paid for by the entities that are making billions from the status quo. Pharmacists must be willing to demonstrate that their value is in creating healthier, happier patients, not shoveling more drugs into these patients. We must have the courage to speak up just as Martha Fankhauser is doing. I’ll repeat what she quoted at the start of this talk, “knowledge is power.” Grab that knowledge and use that power. Your patients will love you for it.

There was so much information crammed into her presentation that I am still processing it all. I appreciate all that Martha Fankhauser has done for the profession of pharmacy and I am thankful that we have such a dedicated believer who has the strength of her convictions to be a change advocate for all of us. Such is the practice of heroic pharmacy and Martie is truly one of our heroes.

I do have a few key points left to make, some that are new and some that you may have seen here before…

Remember the three main components of health: Nutrition, Exercise, and Sleep. Patients, ask your pharmacist for any nutritional advice based on the drugs that you are taking.
But, don’t forget the importance of touch and movement. Touching, hugging and yes, sex, are all important to a healthy human being. As far as movement goes, I am reminded to tell all you youngsters that I had to walk across four yards of shag carpet just to change the channel. Do you even know how to change the channel without using the remote? Get up off your ass and move! If it helps, you don’t have to call it exercise. Maybe you’ll sleep better!

Here are the essential amino acids:

The ONLY way to get these protein building blocks is from what you eat. You’ll recall that tryptophan, for instance, is best obtained from animal sources. If you are a vegetarian, please consider adding whey to your diet, it will add the essential amino acids, including tryptophan, that you may not be getting in sufficient amounts. I know it is dairy-sourced, but it can contain up to 10 times the amount of biologically available (you can absorb it) tryptophan when compared gram for gram with even the best plant protein sources. Whey provides all nine essential amino acids. I have no interest in any company selling whey, I do occasionally recommend it to patients that are vegetarian or perhaps lacking sufficient dietary protein.

Avoid nicotine, alcohol, caffeine. I suggest complete avoidance of nicotine (yes, even e-cigs), and drastically limiting your intake of caffeine (check your beverages, it could be hiding in there), and restricting your use of alcohol to a glass of wine less than once a day.

If you think you are a victim of polypharmacy, ask your pharmacist to do a comprehensive review of all of your current meds and supply him or her with a list of non-prescription products and supplements that you use. Allow time for the response to be prepared for you. If you are both pharmacist and patient and are taking a multitude of drugs, ask a trusted colleague to do the med review. You can even make it anonymous.

Changing your evil ways does not have to be a huge undertaking, it can begin with baby steps and be a wonderful journey towards health and happiness.

Always remember that knowledge is power, but not as powerful of love. Love somebody, love yourself.

Thanks for sharing, Martie! I’m waiting for your book!

* My recall of this talk wasn’t quite as good as it may seem. Martie contacted me to say, “I would recommend a higher daily dose of vitamin D3 based on a blood level and most adults need a total daily dose of 5000-6000 IU D3 if they can’t synthesize it via the skin. Some may need higher doses based on risk factors.”

Where my pill at?

Are we on the verge of a new male contraceptive?

The demand is there, coming from both men and women, although there is still that concern that men could not be trusted to take a pill every day. Research in the area of male contraceptives is underfunded compared to the more attractive and lucrative areas related to form and function. Enhancing libido and genitalia attract many more dollars than looking for a male contraceptive. Besides, don’t women already have that taken care of?

I first wrote about non-barrier male contraceptives in a Pharmacy Times article in October of 1995, predicting that a male contraceptive pill was coming soon, or, “at least by the next millennium.” The new millennium is here and there may be some new options beyond the condom for men willing to take the responsibility of baby prevention into their own hands, as it were. That reminds me of the poor guy whose only date was with his right hand… he always got Valentine’s Day confused with Palm Sunday.

You can read the original article and other predictions on this page.

The Chinese and the Brazilians have considered gossypol, a cottonseed component, as a male contraceptive. At first things looked pretty successful as the gossypol pill provided a very high degree of contraception, reportedly by blocking enzymes necessary for sperm to mature. Problems arose when frequent hypokalemia and rates of permanent infertility proved unacceptably high. Brazil almost got the gossypol pill, Nofertil (subtle Brazilians!) on the market at about the same time my PT article appeared. The FDA considers it a toxic substance and spends some time and money making sure it does not turn up in animal feed. It’s still being looked at as a kind of chemical vasectomy for its ability to cause permanent infertility.

In India, they have been working on a reversible contraceptive for men that involves a direct injection into the scrotum. Vasalgel (TM), a polymer, is injected into the vas deferens, preventing sperm from traveling beyond the epididymis. A product called RISUG (TM), Reversible Inhibition of Sperm Under Guidance, has been used by Indian men for over 15 years. Although the R stands for reversible, the reversing process has only been tried on animals, not “officially” on humans. The hope is that the newer polymer Vasalgel is more easily reversed and has been licensed for study in the US. Other polymers have been used in China and elsewhere to plug the vas deferens.

The search for a male hormonal birth control pill is ongoing but may have been abandoned. Most hormonal choices that may limit or stop the production of viable sperm are not good candidates for oral use, either being quickly destroyed by stomach acid and digestive enzymes or simply not being absorbed into the bloodstream. That means the needle is most likely guys, although their may be something in a couple non-hormonal drugs that seem to reduce male fertility.

Dibenzyline (phenoxybenzamine), for pheochromocytoma and Mellaril (thioridazine), a behavioral drug both seem to have a peculiar effect on male orgasm. Relax guys, you’ll still have an orgasm, but it will be a cum-free cum. Here’s the rub: Many drugs, notably α-adrenergic antagonists, have effects on contractility of the vas muscles and thus normal ejaculation. It’s a common side effect of these drugs. Normally, sperm and seminal fluid are propelled through the vas by the orchestrated contraction of both longitudinal and circular muscles. It’s quite a trip, starting in your balls and passing up and behind your bladder, right through your prostate, up the shaft of your penis and into the loving environment provided by your partner. Anyway, phenoxybenzamine and thioridazine are particularly good at blocking the contraction of the longitudinal muscles and allowing the circular muscles to contract. The net effect is to close down the highway. We’re trying to take advantage of a side effect here, so much research still needs to be done. Yet studies are ongoing to find more specific agents that will have targeted effect with few side effects. This is also an area being examined to find a drug for premature ejaculation. The calcium channel blocker, nifedipine. is also being looked at because it was observed that men taking it had altered sperm that have a diminished capacity to latch onto the egg.

It’s illuminating to see that there are a huge number of articles (mine included) in the past few decades promising a male contraceptive pill and still nothing has reached the market. Perhaps we are chasing unicorns.

Good News Re: Triclosan

Seems that all those voices expressing concern about the dangers of triclosan have finally hit home. Checking supermarket shelves, I am hard pressed to find an antibacterial soap that still uses triclosan. There are still plenty of “antibacterial” soaps. The new darling of this department is benzethonium chloride. Benzethonium chloride is widely used in hospitals as it has been shown to be highly effective against MRSA. Even for routine cuts and scrapes it has proven to be a better germ killer than Neosporin, or Polysporin. Speaking of MRSA, 58% of MRSA infections found in the community began in a public setting after a person had been in a health care facility. That’s a pretty good reason to avoid hospitals, or at least be sure to use extreme precautions if you must visit.

Anyway, back to benzethonium chloride, an inorganic compound that is bactericidal which is superior to bacteriostatic, both of which can be called antibacterial. As it sounds, batericidal means it kills bacteria while bacteriostatic means it stops bacteria from reproducing. Bacterial reproduction, by the way, requires no partner. I’m not so sure we need to use it on humans, but I do see usefulness on inanimate surfaces, at least until something better and safer comes along.

There are tiny amounts of this substance in the products on supermarkets, yet I still worry that this can still be a toxic substance. Why do we need that extra ingredient when science tells us that washing with soap and warm water is the best disinfectant around. Do soaps labeled “antibacterial” sell that much better? Do people NOT wash up with warm or hot water? In any case, the CDC says: “The substance is toxic to aquatic organisms. It is strongly advised that this substance does not enter the environment.” So why the Hell are we adding it to hundreds of products to be used in and on humans and drained away into our waters?

Consumers did a great job of getting triclosan out of these products by letting manufacturers know we disapproved by our voices and our purchasing choices. I think its time to do it again. End this love affair with redundant antibacterial chemicals.

Previous Triclosan posts are here and here.

Hitting the Applesauce

I’ve had this applesauce idea bubbling in my brain for a while and today I enlisted student pharmacists Katie and Angela to help make some sense of the variety of nutritional info provided.

I am in the habit of buying unsweetened, of no sugar added applesauce, usually the store brand. Out of curiosity, I compared the Kroger product to Mott’s and found that per 1/2 cup the Mott’s claimed 50 calories, while the Kroger label stated 60 calories for the same amount. I wondered if the difference might be in the sweetness of the apples used or perhaps even how much water was added.

Here are the nutritional panel for each product and Musselman’s for good measure:

No sugar added

No sugar added

Mott's No sugar added

Mott’s No sugar added

Musselman's NSA

Musselman’s NSA

Quite a mixed bag, huh? Look at that low sugar content for Musselman’s, and yet calories are still 50, while the Kroger sauce has less sugar than Mott’s but more calories. We wondered if the difference was in other factors such as fiber or water content, but everything we checked was inconclusive or paradoxical.

Check out this rough experimental experiment of water content. We simply plopped a tablespoonful of two different sauces on a paper towel and observed how the water was wicked away from the product. Not terribly exact, I’ll grant you, but you can tell the Kroger sauce seems to be wetter. If you look at the actual product, you can see that the Mott’s is smoother and more consistent in appearance.

After 5 minutes

After 5 minutes

After 30 minutes

After 30 minutes

texture difference

texture difference

The Kroger sauce has visible pieces of fiber which are presumably “insoluble” fiber.

I’ve decided that the nutrition info is really just an estimate and the manufacturer or distributer can put what numbers they like as long as they are within reason (or FDA guidelines). In any case, the proof is in tasting and I can say that the Kroger actually had a better apple taste when it first hits the tongue while the Mott’s was tarter and had a more even distribution of small apple morsels. I prefer the Kroger even with the visible brown pieces of fiber lurking within.

I’ll tell you that the sweetened versions of applesauce range from 90 to 110 calories per 1/2 cup and are sweetened with high fructose corn syrup. The Kroger Simple Truth product, touts organic apples and the sweetened version uses organic sugar, and comes in at 80 calories per 1/2 cup. That’s not too much higher than unsweetened sauce for those of you that might enjoy a sweetened applesauce.

Students + Seniors = Synergy

Being a preceptor to student pharmacists is a rewarding and exciting opportunity. It’s a great way to add a new dimension that enhances an already dynamic workplace. In our community pharmacy, students can have a meaningful impact on our staff and our patients. Learning is much more effective when the results of ones efforts can be seen in a happier work environment and happier, healthier patients.

I enjoy seeing the interaction between pharmacy technicians and student pharmacists, with techs teaching navigation our software, workflow design, and best practices, while student pharmacists soak all that up and then contribute through all facets of our workflow. Counseling patients, calling providers and claims processors, and directly assisting patients are all efforts that contribute to our success. We strive to put student pharmacists in situations where a synergy can develop that creates a higher level of service and therefore a higher level of patient care. Here is one example of a synergistic activity:

Students outside of the pharmacy

Students outside of the pharmacy

The first Wednesday of each month is Senior Wednesday at Fry’s. Seniors benefit from an extra discount and it a very busy time in all departments throughout the store.  
I find it beneficial to all parties when student pharmacists patrol the OTC aisles, helping folks find specific products, discussing generic alternatives, answering dosing questions, explaining dosage form differences, and generally advising our patients on their OTC selections. 

Katie helps

Katie helps

May I help?

May I help?

It’s a great time to focus on the students’ listening skills and putting that didactic learning to practical use. 
Patients benefit from the good information provided, often saving their limited dollars, and appreciate the extra care that they receive from Fry’s.  My staff notices that our workflow improves as we can focus on prescription preparation and dispensing. 
Looks very interested but knew immediately arms should be unfolded!

Looks very interested but knew immediately arms should be unfolded!

When students are not available on Senior Wednesday, my staff is often leaving their pharmacy tasks to assist these clients with their OTC needs. 
Ready to assist!

Ready to assist!

What a great experience!

Special thanks to Kaitlyn (Katie) Uchimura, student pharmacist, Midwestern University College of Pharmacy, Glendale, AZ

Special thanks to William (Will) Kennedy, student pharmacist, University of Arizona College of Pharmacy, Tucson, AZ