OTC Medications, Getting Too Much of a Good Thing

The availability of over-the-counter (OTC) medications, that at one time could only be obtained by prescription, has allowed thousands of people to treat minor illnesses on their own.  This benefits consumers by avoiding unnecessary doctor visits and offering a less expensive alternative to
prescription drugs. It is important to remember, however, that just because a medication has become available without requiring a prescription, it still carries all of the risks that it had previously. It has been estimated that up to 200,000 Americans are hospitalized each year because of inappropriate use of OTC medications.

The blame for this inappropriate usage is due to a number of factors. Sometimes, the consumers using these medications do not carefully read the instructions for use. Doctors, not realizing that patients are taking certain OTC medications, may prescribe medications containing the same agent resulting in overdosage. Additionally, once a prescription medication becomes available OTC, manufacturers may be less conscientious about pointing out potential side effects when advertising their product.
In today’s Health Tip, we’ll look at some of the most commonly used OTC medications and risks involved if not taken appropriately.

Acetaminophen---(Tylenol, Dayquil, Midol, Excedrin, others)  Acetaminophen is one of the most commonly taken medications. Taking too much at any one time, however, can have serious health consequences. In the U.S., overdosing on acetaminophen is the leading cause of acute liver failure.  More than 600 prescription or OTC medications contain acetaminophen, so it is important to carefully read labels in order to see if you could be taking it from multiple sources.  If an OTC form of acetaminophen is taken along with a prescription medication containing acetaminophen (Percocet, Vicodin, Lortab, others), one could quickly exceed the adult maximum of 4000 mg dosage per day.

Nasal decongestants (Afrin, Neo-Synephrine. others) These OTC nasal sprays work by constricting the blood vessels in the nose.  This can be of great benefit with the common cold by reducing swelling, irritation and sniffling.  Nasal decongestants are generally safe when used for only 3 to 4 days.  Used longer than that, however, they can cause a condition in which the nasal passages become even more swollen that they were originally (rhinitis medamentosa).  Also, in some people, overuse of nasal sprays can raise heart rate and blood pressure.

 Ibuprofen ---(Advil, Motrin) Ibuprofen is in a class of drugs known as non-steroidal anti-inflammatory drugs (NSAIDs) which also includes aspirin and Aleve (Naprosyn).  When used for longer than necessary or at too high a dosage, NSAIDs can cause stomach ulcers or kidney problems. Children and teens under 18 should not take aspirin for a febrile illness because it has been linked with a rare but potentially fatal condition called Reye's syndrome.

Proton Pump Inhibitors (PPIs)  (Prevacid, Prilosec, Zegerid)  These OTC products are marketed primarily for treating frequent heartburn. Taking PPIs for a long period of time has been linked with an increased risk of osteoporosis and fractures, particularly involving the spine, hip, and wrist.  Also the low-acid environment in the stomach caused by PPIs is linked to the development of vitamin B12 deficiency which can cause nerve damage.

Multisystem Cold Medications  (Delsym Multi-Symptom, Tylenol Cold Multi-Symptom, Theraflu Multi-Symptom, others)  The active ingredients in these products vary depending on the symptoms they are designed to treat. Most of them contain some combination of pain medication, decongestant, antihistamine, and/or cough suppressant.  The decongestant (pseudoephedrine, phenylephrine, oxymetazoline, etc.) included in these medications can be a particular concern for people who have high blood pressure.  As mentioned previously, with so many different medicines containing acetaminophen, care must be taken to avoid overdosing.  Multisystem cold medications can simplify treatment of a cold, but in many cases it is better to direct treatment toward specific symptoms, e.g. gargling with salt water for sore throat or using a nasal decongestant for stuffy nose.

Many other OTC medications, including laxatives and antihistamines, pose risks when taken inappropriately. While their availability has been a benefit to medical consumers, it must be realized that like any other medication, OTC products also carry a risk for causing serious side effects.

Om, My Aching Back!—Yoga for relief of low back pain

According to a 2006 report released by the Centers for Disease Control (CDC), one in four U.S. adults say that they suffered a day-long bout of back pain in the past month, and 1 in 10 say the pain lasted a year or more.  Standard treatment recommendations for acute low back pain currently include the use of medications (Tylenol, NSAIDs, muscle relaxers, etc.), advice to remain as active as possible, application of heat, and spinal manipulation (Chiropractic care).  With this treatment, the great majority of cases of acute pain resolve with no long-term consequences.  In some cases, however, the pain lingers and becomes chronic in nature.

What is chronic low back pain? The causes for chronic back pain—defined as pain that lasts more than three months—often remain unidentified with limited treatment options. Possible exceptions to this are when symptoms, such as fever, loss of bowel or bladder control, pain when coughing, or progressive weakness in the legs are present. Those symptoms could indicate that the chronic back pain is due to a serious condition, such as inflammatory arthritis, herniated disc, infection, fracture, or cancer.  In the majority of cases, surgery is not thought to be an appropriate treatment option.

Since treatment options are limited for most chronic low back pain sufferers, many have turned to alternative and complementary therapies in search of relief.  These therapies include acupuncture, spinal manipulation, Pilates, massage therapy, and yoga. While there is little evidence for the benefit of yoga in the management of acute lower back pain, there is a growing body of research supporting the use of yoga in the treatment of chronic back pain.

Which yoga practices appear to help? Yoga is a mind/body practice with historical origins in ancient Indian religion. Various schools of yoga exist, but most have in common the blending of meditative practices, breathing techniques and physical postures to achieve strength, flexibility, and inner peace. Many people practice yoga in order to maintain their health and well-being, improve physical fitness, and enhance their quality of life, but yoga also has an application in the treatment of specific health conditions such as chronic pain, anxiety, and hypertension. One type of yoga that has been evaluated specifically in the treatment of chronic low back pain is a method based on the teachings of B.K.S. Iyengar (pronounced eye-en-gar). This is a form of hatha yoga that places emphasis on the physical alignment of the body in its poses. The Iyengar method employs the use of props, such as pillows, blocks and chairs to help the student achieve perfect alignment in a gradually progressive manner.

What is the evidence for the benefits of yoga?  A meta-analysis (pooling data from multiple studies) looked at 10 randomized controlled trials to assess the effectiveness of yoga in the treatment of chronic low back pain. The parameters that the researchers sought to asses included: 1) relief of pain, 2) reduction in disability, and 3) health-related quality of life.  Following an analysis of the data, strong evidence for short- and long-term relief of pain and moderate effectiveness in regard to reduction in back pain-related disability was found.  No effect on health-related quality of life was noted.

A more recent study, funded by the National Center for Complementary and Alternative Medicine (NCCAM) that was not included in the meta-analysis mentioned above, looked at the effect of Iyengar yoga on chronic back pain. The researchers were also interested to see if practicing yoga had an effect on depression or the use of pain medications among study subjects. The researchers conducting this study concluded that Iyengar yoga decreased functional disability, pain, and depression in people with chronic low-back pain. A second NCCAM-funded study found that once-weekly yoga classes relieved pain, improved function, and reduced the need for pain medication in low-income populations with chronic low-back pain.

The predominance of scientific evidence indicates that people with chronic low back pain stand to benefit from practicing yoga. The Iyengar School of yoga may be particularly appropriate since it appears to take more gradual approach in performing its poses.  Of interest also is that no adverse events from practicing yoga were reported from any of the studies mentioned. In order to achieve best results, it is advisable to practice yoga under the guidance of a qualified teacher.

Photodynamic therapy of skin lesions

Photodynamic therapy (PDT) is gaining acceptance as a convenient and relatively complication-free method of treating precancerous skin lesions on the face. These lesions, known as actinic keratoses (AKs), are primarily caused by damage from UV radiation from the sun. If left untreated, some of these AKs will eventually develop into squamous cell cancer (SCC). PDT, application of a chemotherapy cream (5-FU), and cryotherapy (freezing) are all effective methods of treating AKs in order to prevent the development of SCC.

How does PDT work? PDT, also known as ALA/PDT, involves the use of a photosensitizing drug (one that becomes active when exposed to light) along with a light source. In the U.S., the most common photosensitizing drug for this purpose is aminolevulinic acid (ALA) which is marketed under the trade name Levulan®. When applied to the face and absorbed by AK cells, the precancerous cells become highly sensitive to light. With exposure to FDA-approved light sources (Blu-U and ClearLight) a reaction occurs that destroys the AK cells.

What does a typical PDT session involve? PDT for sun-damaged facial skin is performed on an outpatient basis and usually requires only one treatment session. A typical treatment session involves the following steps:                     

1. The face is rigorously cleaned with alcohol or acetone in order to remove oil from the skin.
2. The photosensitizing medication (ALA) is applied to the entire face and up to an hour is allowed for the medication to "activate" the skin lesions.
3. Following an incubation period the treated skin is exposed to the light source for around 17 minutes.
4. After treatment, it is recommended to avoid exposure to sunlight for up to 48 hours.

What are potential after effects of PDT? During treatment, most patients experience sensations of heat, tingling, or burning. An expected after effect of PDT is redness of the skin similar to sunburn. In some instances, temporary blistering and severe pain may occur. The skin appearance returns to normal within 2 to 3 weeks.

Are there other benefits to PDT? Following treatment, aging-related skin damage such as skin lines and blotchy pigmentation may also be improved. While used primarily for treating sun-damaged skin, PDT is used for other skin conditions, such as acne and rosacea. Additionally, PDT is starting to be used in the treatment of certain cancers, even those involving internal organs, such as the esophagus and lung.

What are the alternatives to PDT? PDT is the relative "new kid on the block" in the treatment of sun-damaged facial skin. Prior to its introduction, most AKs were treated individually with cryotherapy (freezing) or with the topical application of a chemotherapy medication, 5-flurouracil (5-FU). A drawback to cryotherapy is that only visible AKs can be treated. With PDT, even those AKs that have not yet progressed to the point of being seen are addressed. Topical chemotherapy treatment for AKs involves daily applications for weeks and can be associated with severe skin reactions.

The number of skin cancers related to sun exposure has increased annually for many years. PDT is emerging as an important modality to treat precancerous AKs in order to prevent the development of many of these cancers. Advantages of topical PDT are that the method is non-invasive, effective, and generally gives a good cosmetic outcome.

Could I be Depressed?

The diagnosis of depression includes several subgroups including major depression, dysthymia and minor depression. Taking these three entities into consideration, it has been estimated that as many as one-in-five patients seen in primary care offices are depressed.
The diagnosis of major depression is based on exhibiting five or more of the following symptoms for a period of at least 2 weeks:

• Low or irritable mood most of the time
• A loss of pleasure in usual activities
• Trouble sleeping or sleeping too much
• A big change in appetite, often with weight gain or loss
• Tiredness and lack of energy
• Feelings of worthlessness, self-hate, and
  guilt
• Difficulty concentrating
• Slow or fast movements
• Lack of activity and avoiding usual activities
• Feeling hopeless or helpless
• Repeated thoughts of death or suicide

Dysthymia, sometimes considered to be “chronic depression” has symptoms that are less severe than major depression but may have been present for a much longer period of time. Minor depression is similar to major depression except it only has two to four of the symptoms mentioned above.
In spite of how common depression is in the general population, it frequently goes undetected and untreated.  The U.S. Preventive Services Task Force (USPSTF) has found that screening performed during doctor’s visits increases the identification of depressed individuals.
A number of different screening tests for depression are used by doctors in the primary care setting. Most of these are self-administered, meaning that the patient completes a questionnaire that asks about various symptoms and physical signs that could indicate depression. Specific tests, such as the Beck Depression Inventory and the Zung Self-Rating Depression Scale, include around 20 questions and are “graded” in order to determine if depression is present, and if so, how severe is it.
More recently, a 2-question depression screening tool was found to have close to the same accuracy as the more extensive questionnaires. Answering “yes” to both of the following questions about mood and pleasure from activities usually found to be enjoyable makes the diagnosis of depression likely: 

1. "Over the past 2 weeks, have you felt down, depressed, or hopeless?"
    
2. "Over the past 2 weeks, have you felt little interest or pleasure in doing things?"

This 2-question tool is felt to have fairly good sensitivity (correctly identifying people with depression) but only fair specificity (correctly identifying people who aren’t depressed). In other words this screening test did a good job of detecting people who were truly depressed but tended to over diagnose those in whom depression was not a significant issue. For this reason, when the answers to both questions suggest that someone is depressed, a more formal psychological investigation is needed.
Physical problems are not the only reason for seeing the doctor. If you recognize several of the depression symptoms mentioned above or answer “yes” to the 2-question screening test, a visit to your doctor to discuss your feelings is in order.  In addition to advising screening for the depression, the USPSTF also found that treating depressed adults with antidepressants, psychotherapy, or both is effective in reducing symptoms and improving productivity.  Large-scale studies have, in fact, shown that following initiation of treatment approximately two thirds of individuals achieve remission from their depression within a year.