Tuesday, December 22, 2015

Times when you could do without (or with) a prescription

You could do without a prescription when you:

Have a common cold & flu

As seasonal common cold is arising from virus (influenza type c), you could hop to your nearest pharmacist to get medications for symptomatic relief. This is because viral cold is usually self-limiting and would recover when your body's immune system wins the virus, unlike bacterial infections which are often more severe. For example: paracetamol for a mild fever, expectorant or suppressant for cough, loratidine for your runny nose...

BUT if your symptoms persist for more than a week, has a fever that does not subside in 3 days, has wheezing or signs of breathlessness or cough up purulent colored phlegm, it's time to pay your doctor a visit. Those may point to a more severe infection such as MERS or even bacterial infections like pneumonia.

Have a wart or corn

You could go for over-the-counter treatments like Duofilm liquid or  corn plasters which both contain salicylic acid. This chemical will make the hardened skin layer peel over time, turning the area white initially.  It works for both corn and warts.
Another otc choice for wart is Wartner, which freezes off the wart. Wart is a viral-induced skin problem. A wart has a cauliflower-like appearance and may gradually grow bigger. Unlike warts, corn can't be freeze-off.
Children or diabetic persons may need doctor's advice before any self-treatment.

Have hereditary hairloss

That is if your parent(s) have hair loss problem as they age and you find yourself in their footsteps, you could hop to the pharmacist to get some hair tonics or this topically applied medication call Minoxidil. It works for both male and female baldness in most cases but if no results is seen within 6 months of use, you would probably want to visit your doctor to seek for alternative.

If you think your hair loss problem is due to dietary deficiency, you could take some hair supplements (usually containing amino acids, collagen and some herbs). If you think you are suffering from some scalp disease which resulted in the hair loss then it is important to first get it treated. People who are taking long-term medications or have any medical condition should first let your pharmacist know before seeking self-treatment.

Have mild-moderate eczema

Eczema is an allergy induced skin condition where there's itching, rashes and possibly dryness (which exacerbates the itch). It can occur at any age and be triggered by food or allergens in the environment.

For mild cases which resolve by themselves, avoidance of allergens and a good moisturizer to protect the skin would usually serve well as prevention measures. For bothersome cases in which you can't identify what things you need to avoid, you could visit a doctor for a skin-prick test. Sometimes to your dismay, it could be things that are hard to avoid eg. haze, dust-mites.

Nevertheless, moisturizer and a soap-free cleansers are the first line of remedy. For moderate cases, you may need anti-histamine tablets and steroid cream in addition for treatment.

For severe or persistent cases, despite self-treatment with the above, you may require stronger prescription therapy from doctor. Once the inflammatory condition has been controlled, you could consider stepping down to self-treatment and prevention. Avoid prolonged use of steroid creams as they could thin the skin or make the area under treatment more prone to skin infection.

Constipation and mild diarrhea

For constipation, you could get laxatives over the counter and they can be broadly classified as for short-term fast relief or for longer term slower relief. The fast relief ones are usually senna tablet, bisacodyl tablet or suppository and enemas. These are not recommended for prolonged regular usage as they can cause dependence (lazy bowel) and abdominal cramps. The slower relief ones but safe for long term use are lactulose, fibres and probiotics. Lactulose and fibres would take about 2-3 days for onset, may be milder in effect and occasionally cause bloating, so you might want to start low and continue them for a while.
Drinking more water, healthy lifestyle and having a balance diet can't be emphasized enough for people who suffer from long term constipation.

Diarrhea may prove a bit more complex in terms of the choice of therapy because it may arise from various causes:
traveller's diarrhea or pathogenic diarrhea, irritable bowel syndrome, medications or colon diseases (cancer, inflammatory bowel disease etc).

Any diarrhea with fever, blood in stool, severe cramps or persisting beyond 2 days should warrant a doctor's visit.

The first-line of treatment is NOT to simply stop the diarrhea but to drink re-hydration salt with enough fluid to prevent getting dehydrated. Taking charcoal pills (available over-the-counter) may help in the initial phase of food poisoning or traveller's diarrhea. If you are certain that your diarrhea is mild or not pathogenic in nature, then you could take Lomotil (diphenoxylate) or Imodium (loperamide) which are medications to reduce your gut movement in stopping the diarrhea. This is because you wouldn't want to have the bacteria or toxins continue manifesting in your intestines or simply mask away the diarrhea without knowing its cause.

For prevention of traveller's diarrhea, you could take probiotics on a daily basis to 'strengthen' your gut. Although it's best to abide by the rules of “boil it, cook it, peel it, or forget it”. Any antibiotic treatment warranted for pathogenic diarrhea would need a doctor's prescription.

Young children, the at-risk group (elderly, diabetic) or anybody with signs of dehydration should seek medical attention promptly.

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Saturday, November 9, 2013

Cautions for thiazolidinediones use - in heart failure or with insulin

Administration of thiazolidinediones with insulin is cautioned. Rosiglitazone is not approved for use with insulin, as stated in the warning section of the package insert.[3] When rosiglitazone is taken with insulin, the frequency of edema increases.

Recommendations and Considerations

Thiazolidinediones (eg. Actos, Avandia) may cause or exacerbate congestive heart failure in some patients.
  • Initiation of these drugs in patients with established NYHA Class III or IV heart failure is contraindicated.
  • After initiation of Actos, Actoplus Met, and Duetact, and after dose increases, observe patients carefully for signs and symptoms of heart failure (including excessive, rapid weight gain, dyspnea, and/or edema). 
  • If these signs and symptoms develop and heart failure is confirmed, appropriate management of heart failure should be initiated.  Discontinuation or dose reduction of Actos, Actoplus Met, or Duetact should be considered.

Information for the Patient

Patients should be informed that Actos, alone or in combination with other antidiabetic agents, can cause fluid retention, which may exacerbate or lead to heart failure. 
  • Patients should be asked to watch for and report to their healthcare professional any signs and symptoms of heart failure, including edema from fluid retention, shortness of breath or trouble breathing, unusually fast increase in weight, and unusual tiredness.
[Source: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124178.htm]

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Thursday, October 24, 2013

Back to updates - Mefloquine, Quinolones, New anticoagulants (Box warnings)

It's time to catch up with more drug news after more than half a year of Marketing study instead of Pharmacy study. @.@

Black Box in the Nutshell...

- it is an anti-malarial medicine which can be purchased directly from the pharmacy

The FDA is advising the public about strengthened and updated warnings regarding neurologic and psychiatric side effects associated with the antimalarial drug mefloquine hydrochloride. The neurologic side effects can include dizziness, loss of balance, or ringing in the ears.  The psychiatric side effects can include feeling anxious, mistrustful, depressed, or having hallucinations.

Neurologic side effects can occur at any time during drug use, and can last for months to years after the drug is stopped or can be permanent.  Patients, caregivers, and health care professionals should watch for these side effects. When using the drug to prevent malaria, if a patient develops neurologic or psychiatric symptoms, mefloquine should be stopped, and an alternate medicine should be used.  If a patient develops neurologic or psychiatric symptoms while on mefloquine, the patient should contact the prescribing health care professional.  Source: http://www.fda.gov/drugs/drugsafety/ucm362227.htm

Quinolone antibiotics
- most side effects are CNS effects, tendonitis, blood sugar changes, and QT prolongation
- quinolone-related nerve damage is very rare but it can persist for a long time even after stopping the antibiotic
- to let doctor know if patients develop peripheral neuropathy such as pain, burning, numbness, etc.

New anticoagulants: Dabigatran, Rivaroxaban, Apixaban
- Increased stroke risk in patients with Atrial Fibrillation if therapy is discontinued due to their shorter half-lives (so their blood thinning effect wears off faster)
- Important to emphasize patient compliance

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Tuesday, November 13, 2012

Insomnia - an overview

"Have you got anything to help with sleep?" - This is one common question that people ask at the pharmacy. A simple question it may sound but there is really more to it than meets the eye...

Here's some questions for you to think about when finding your insomnia remedy:

1) How long have you had the insomnia?

Insomnia can be broadly classified into 3 types: Source: MedicineNet
  • Transient insomnia usually is due to situational changes such as travel, extreme climate changes, and stressful events. It lasts for less than a week or until the stressful event is resolved.
  • Short-term insomnia usually is due to ongoing stressful lifestyle or events, medication side effects or medical conditions and lasts for one to three weeks.
  • Chronic insomnia (long-term insomnia) often results from depression, digestive problems, sleep disorders, or substance abuse and continues for more than three weeks.

 2) The causes...

Is it mood or stress-related?
What medications are you on? Have you just started on a new medication?
Do you have poor sleep habits?
Is there any recent lifestyle changes disrupting your sleep pattern?
Do you have any underlying medical conditions that could be causing your insomnia? eg. heartburn, back pain etc...

Sleeplessness can also be the cause of a mix of physiological and psychological factors. If it is transient sleeplessness, it would often go away with adequate rest and the help of short-term sleeping-aid.

Here are some possible causes and risk factors.

3) What have you tried?

You may have tried things like melatonin, other sleep supplements or even sleeping pills expecting to have a quick remedy. Have you also tried any lifestyle changes eg. exercises or relaxation techniques and environmental changes to aid you in falling asleep? Find out through trial and errors what worked for you and what didn't. Remember there isn't such a thing as one size fits all. Over-reliance on sleeping pills for a 'quick fix' may cause dependence and make insomnia worse in the long run without truely treating the root cause of the problem.

You can read up more here - Sleep Hygiene

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Sunday, November 11, 2012

Stress-induced stomach ulcer

Gastric problem seems to be getting very prevalent these days. Dr. Joseph F. Montague, author of the book Nervous Stomach Trouble - "You do not get stomach ulcers from what you eat. You get ulcers from what is eating you."
To treat stomach ulcer, it is not just about taking medications (of course medications can play a part in reducing your stomach acid and treat any H. pylori infection). It also involves lifestyle adjustments and behavorial treatment such as time management, pacing and relaxing yourself and having regular meals. Also avoid eating food that are very spicy or oily. I ever heard from a doctor who said "The food you most hate to give up is the one that you should avoid when you have a stomach problem."

If you have a gastric problem that persists more than 2 weeks despite a course of gastric medicines or on and off for over 3 months despite medicines and lifestyle changes, you should see a doctor to check against any possibilty of ulcer or H.pylori infection.


Drug interactions to be aware of with gastric medications:
Omeprazole is a cyp2c19 and cyp3a4 enzyme inhibitor. Caution to be exercised when administering with other medicines such as plavix (clopidogrel)

Cimetidine is a multiple cyp enzymes inhibitor which can affect the level of other medicines in the body.
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Top (worst) pharmacy etiquettes

The Angry Pharm-mist's top 5 worst 'etiquette' displayed by customers at the pharmacy.

1) Shout / swear at / threaten the pharmacist when the aphrodisiacs can't be supplied

2) Cut queue without a care that there are other people in the queue before them. "Excuse me, excuse me..."

3) Bargain for prescription medicines supply without having a prescription or a legally valid one - 'I just want one tablet.' (even after telling them where is the nearest doctor they can visit.)

4) Demand that a medication be supplied to them when the pharmacist has deemed it inappropriate to do so for health and safety reasons.

5) Say that they have the prescription or would get one for an emergency supply of medicine the next day and subsequently become un-contactable.


Dear readers, I hope you are guilty of none above. If you are and have no intention of repent, please do not come to the Angry Pharm-mist's shop.

We all want a more gracious society in Singapore and courtesy goes a long way. Thank you.
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