House Call, MD

by Tania Houspian, PharmD 2011 | houspian@myhousecallmd.com

You’re fiancé is sick. His nose is running, he’s sneezing every two seconds while concurrently coughing up a lung.  In between all these bodily functions, he still manages to complain about how sick he is.  On your side of the bed, you’re struggling to get a good night’s sleep because you have work early the next morning. You drag yourself out of bed and head to the local 24-hour pharmacy hoping to find something (really anything) to help his symptoms and your chance of getting some sleep.  Instead of finding the remedy to soothe his symptoms, you develop a symptom of your own: a headache.  As you look around the never-ending aisles of drugs, you realize you have no idea where to start.  They all promise to alleviate every symptom under the sun.  What’s the difference between them all?  Your head begins to pound.

Let’s back up the story to the point at which he caught the cold. It’s called the common cold because, well, it’s common.  It’s all around us.  It turns out that there are over 200 viruses that can cause the “common cold.”  So yes, you’re surrounded and outnumbered.  People usually get the common cold by touching the virus (i.e. touching something someone with a cold sneezed on) and then touching their eyes or nose (yes, you can get sick from touching your eyes with infected hands).  We hate to admit it but we are the ones giving the virus a free ride into our bodies.  Another way to catch the virus is by inhaling or swallowing a droplet that someone expelled via sneeze or cough.  Droplets from a sneeze can travel up to 30ft away (impressive and terrifying at the same time) and infect someone on the opposite side of the room. Now you see why your mother always told you to cover your mouth and wash your hands after you sneeze?

So let’s say your fiancé is a teacher and caught the virus from one of his students at school whose mother never taught him to cover his mouth when he sneezes (not a rare scenario since 75% of viral infections are transmitted by children).  About 1-2 days after catching the virus, he started to complain of a sore and scratchy throat. Day 2 started off with a symphony of sneezing and sniffling.  Then there’s the predictable transition in your nose: clear discharge slowly becoming hazy and booger filled later on as the infection progresses.  Day 2 -3 is when things heat up (i.e. you develop a fever).  Children and older adults are more likely to develop a fever while everyone else usually just gets that general feeling we medical professionals call “yuck + aches.”  Days 4 and 5 bring coughing.   Early on, nothing came out when he coughed (called a “dry cough”) but as the cold progressed he started coughing up sticky mucous clumps (predictably called a “wet cough”).  This is the general scheme of how the common cold progresses.  At the same time, every individual is different and every virus is different.  The common cold is also different from the flu which has similar but more severe symptoms that last longer.  The common cold usually last 5-12 days while the flu can last anywhere from 2-3 weeks.

Now lets go through each symptom and outline the medications of choice to minimize the suffering.  Remember, there is no cure for the common cold for many reasons, one of which being the fact that so many different viruses can cause it.  All the recommendations below help reduce symptoms so you can go on with your life (and stop his complaining) while his body fights off the cold but they are not “cures” for the cold.  Your body will take care of that on its own.  When shopping for medications, be sure to look at the Active Ingredients.  This is what you are paying for.  Active ingredients are the components of the medication that work to improve your symptoms.  As you browse, you may begin to notice that many of the medications contain similar ingredients…not a coincidence.  What matters when shopping for the right treatment is the active ingredient, not the fancy name and logo on the front of the box.

Symptom 1: Sore/Scratchy Throat

Complaint: “It hurts to talk. It hurts to swallow. It even hurts to breathe.”

A sore throat can make it hard to drink and eat, both of which are very important in helping your body fight off a cold.  Common components of medications that help soothe a sore throat are Benzocaine, Menthol, Phenols, and Dyclonine. Benzocaine and Dyclonine are painkillers and stop your nerves from feeling the sore throat. Menthols are extracted from peppermint or other mint oils and, similar to phenols, produce a cooling sensation in the throat.  They’re all equally effective and come in two different forms (pick whichever better suits your fancy).

• Lozenges: Hard candies you can suck on which release the medication into your mouth and help relieve the pain.  Some common brands include Halls, Cepacol, or Cholraseptic. You can take one lozenge every 2 hours to relieve the soreness.

• Liquids: Usually sprayed, swished, or gargled then spit out. You can use them up to four times a day.

Whichever formulations you choose, remember to try not to eat or drink for an hour after using the medication since doing so will wash away the medication.

Symptom 2: Runny Nose (or “Sniffles” for the under 10 crowd)

Complaint: “My nose has turned into Niagara Falls and I’ve gone through enough Kleenex to fill a landfill!”

You can either blow your nose or do what you did in second grade (remember taking a big sniff and swallowing your spoils…yum).   You can also try something that will stop the flow (the more socially acceptable approach).  The class of medications usually used to relieve the sniffles is called decongestants.  Decongestants cause your blood vessels to contract so that less fluid is allowed to leak out of the capillaries in your nose and, viola, the sniffles go away.  One problem with decongestants is what is called “reflexive vasodilation.”  When the medication wears off, the blood vessels in your nose dilate causing the return of Niagara Falls.  An unfortunate side effect of temporary relief.  Decongestants come in two forms: topical and oral.

Topical decongestants come in little spray bottles that you insert in your nostril, delivering the medication directly to your nasal capillaries.  Some common topical decongestants are:

• Short-Acting (will relieve runny nose for 4-6 hours)

  • Ephedrine

  • Epinephrine

  • Naphazoline

  • Phenylephrine

  • Tetrahydraoline

• Medium-Acting (8-10 hours)

  • Xylometazoline

• Long-Acting (12 hours)

  • Oxymetazoline (Afrin)

When shopping for your decongestant, take into account how long you want the medication to work.  They are included in many different brand name decongestants so be sure to turn the bottle around and read the back where it tells you the “active ingredients.”  Oxymetazoline is a popular one since it works the longest and can be found as the brand name “Afrin.”  An important note about topical decongestants is that using them longer than 3-5 days will actually cause a condition called rhinitis medicamentosa (fancy word for your runny nose will get WORSE…a much more severe form of reflexive vasodilation).  Take Home Message: don’t over these medications and start to wean yourself off of it after 3 days.

Oral decongestants come in tabs and take longer to work since you don’t apply them directly to your nose.  The two most common ones are Phenylephrine and Pseudoephedrine.  Phenylephrine is shorter acting (about 3 hours) while pseudoephedrine can work for up to 12 hours with one dose.  All pseudoephedrine-containing medications (brand name is usually Sudafed) are stored behind the counter at the pharmacy.  You have to show your ID to prove you’re over 18 and sign a document in order to purchase it.  Why?  It turns out that people have figured out a dangerous way of making an illegal drug using pseudoephedrine and the government would like to discourage such activities.  If you have high blood pressure or are pregnant/breastfeeding, avoid using this product since it causes blood vessels to constrict which is unfavorable in any of those conditions. Also, oral decongestants can cause you to become more alert and energized so avoid taking them close to bedtime…unless you want to pull an all-nighter when you’re sick.  We wouldn’t recommend it.

Symptom 3: Sneezing

Complaint: “AAACHOOOOOO! If I sneeze one more time my head may explode.”

Sometimes a sneeze feels great.   When you’re sick, it just hurts. So what can you do to make them stop?  Antihistamines are typically used for allergies but they also decrease mucous production throughout your body.  Take an antihistamine and you can say goodbye to sneezing, runny nose, itchy throat, and runny eyes. Yes, antihistamines are amazing. The downside is they can be very sedating.

• Most sedation: Diphenhydramine (Benadryl), Clemastine fumarate (Tavist)

• Intermediate sedation: Pyrilamine maleate (Theracof), Pheniramine, Brompheniramine (Dimetapp), Chlorpheniramine (Chlor-Trimeton), and Tripolidine (Actifed)

• Least sedating: Loratadine (Claritin) and Cetirizine (Zyrtec)

If you’re about to go to bed, taking Diphenhydramine may not be such a bad idea since it’ll help you fall and stay asleep.  If you’re about to go to work, Loratadine is the better choice.  It’s all a matter of what you need at that time.

Symptom 4: Fever

Complaint: “I’m hot then I’m cold. I feel like Katy Perry.”

Treating a fever is tricky because a fever can be an indication of a more severe illness than your garden-variety common cold. If you have a fever for more than 24 hours you need to see your doctor.  If you have a fever and you’re taking medications to help reduce it but the fever continues to get worse even after three days of treatment, definitely go see your doctor.  The best medications to take for a fever are Acetaminophen (Tylenol) or Ibuprofen (Motrin, Advil).  They both work equally well to lower a fever.  They both come in many forms including tablets, capsules, liquid capsules, liquids, and suppositories so pick whichever you’re most comfortable with.

Tylenol overdoses are more common than we would hope and are very dangerous (Tylenol can wreak havoc on your liver).   Be sure you are not taking too much and follow the directions on the bottle carefully. The maximum amount you can take is 4000mg (4 Grams) per day. Ibuprofen is safer but it’s recommended that you take no more than 1200 mg a day.

If you have a child with a fever, just go see your doctor.  Fever-reducers are much more complicated and dangerous in children so working with a pro is recommended here.

Symptom 5: Cough

Complaint: “Between sneezing and coughing I have no time left for breathing…which I can’t do anyway since my nose is so stuffed up!”

There are two types of cough (as we previously mentioned): nonproductive and productive. Nonproductive coughs are dry hacking coughs during which time nothing comes out (i.e. nonproductive).  Productive coughs are the ones where you get a nice surprise in your mouth at the end (yup, a gooey ball of mucous). These two types of coughs are treated differently.

For nonproductive coughs, try Dextromethorphan (Robitussin) or Diphenhydramine (Benadryl).  We don’t know how Dextromethorphan works and some doctors claim that it really doesn’t.  It’s one of those medications that has been around for such a long time and used so frequently that nobody bothered to study it.  Diphenhydramine (yes, our friend the antihistamine is back) is actually one of the best treatments for a cough caused by the common cold.  It’s great at bedtime if you want to fall asleep and will prevent you from waking up coughing. No cough and a good night’s sleep sounds pretty awesome to us.

For productive coughs, Guaifenesin (also called Robitussin) is the way to go. Guaifenesin won’t stop your cough but it will make it easier to cough up the mucus in your airway so that you will eventually stop coughing.  Out is better than in.  It’s important to drink lots of water when taking this medication (and when your sick in general).  Drinking water helps the drug loosen up the mucous, making it easier to cough out.  Getting rid of all this mucous will help eliminate the infection as opposed to stopping the cough and keeping the virus-infected mucous in your throat and lungs.

You now know the basic components of just about every cold and flu medication on the market.  There are tons of combination products that mix and match ingredients to suit the limitless permutations of symptoms.  Next time the common cold strikes, turn the bottle around read the ingredients.  You know how to treat each of your symptoms in a much more strategic fashion.  If you forget, you can always ask your friendly and knowledgeable pharmacist (or just print out this article and take it with you to the drug store).

We’ve gone over the most accepted treatments of common cold symptoms.   What about all that other stuff you find in the aisle?

The “Other Stuff”

Airborne

When Airborne hit the market in 1999, who wasn’t swearing that it could cure the common cold?  Nine years later, Airborne Health, Inc. found itself waist-deep in class action law suits for making claims about therapeutic efficacy that it couldn’t support with medical research.  All the lawsuits were settled out of court and Airborne Health, Inc. paid truckloads of money to make the lawsuits go away.  The main problem was that Airborne claimed it could “prevent or reduce the risk of colds, sickness, or infection; protect against or help fight germs; reduce the severity or duration of a cold; and protect against colds, sickness, or infection in crowded places such as airplanes, offices, or schools.”  Not a single clinical trial was done to prove that any part of that statement was correct.  If you’ve checked out their website or commercials, you know that a lot has changed.  Now they only claim that, “The Airborne health formula helps to support your immune system through its blend of vitamins and minerals.”

The verdict?  Their new advertising campaign is much more accurate.  Airborne is simply a combination of vitamins and minerals that your body will generally be getting from a well-balanced diet.  It never hurts to take a multivitamin to compensate for any dietary deficiencies but that’s all Airborne is.  It has higher amounts of specific vitamins, like vitamin C, than your average multivitamin.  The adult tablets have 1000mg (1gram) of vitamin C.  If you took the tablets the way they recommend you do (every 3 hours while awake) you would be consuming up to 5 grams of Vitamin C per day.  Doses that high aren’t necessarily bad for the average person but they can cause kidney stones in certain individuals.  In addition, there is no benefit to taking that much vitamin C (unless you enjoy a good dose of diarrhea which doses that high can cause).  Doses of 2-3 grams per day have been shown to help reduce the duration of cold symptoms but do nothing for the severity of the cold.  Also, Vitamin C does not work as a preventative measure.

The Final Verdict: Sure, go ahead and take airborne as long as you realize you are taking an overpriced yet tasty (yum, pink grapefruit) multivitamin.  Oh, and it’s not a miracle cure.  Did we mention that?

Zicam

Zicam brand makes every form of medication you could ask for.  From nasal swabs to lozenges, they are working hard to please the full spectrum of consumers.  Their line of products called “Symptom Relief” contain the spectrum of medications we discussed earlier (from menthol to Tylenol) so make sure you read the back before you buy any of them.   You may be just able to buy a bottle of Tylenol and a decongestant for less money.  The Zicam uniqueness is found in their line of “Cold Remedy” products.  The active ingredients in this line of products are Zincum Aceticum and Zincum Gluconicum (different forms of Zinc). One line of zinc-containing products (Zicam Cold Remedy Nasal Gel, Zicam Cold Remedy Nasal Swabs, and Zicam Cold Remedy Swabs, Kids Size) was completely removed from the market because they caused people to lose their sense of smell (definitely not a good thing).  These were zinc-containing products that were applied directly to the inside of the nose.  NOTE: If you have any at home, throw it away!  The company is currently considering the FDA’s request to discontinue the product…until the controversy settles, don’t use them.

Back to the other zinc-containing products: The makers of Zicam believe that zinc prevents the rhinovirus (one of the viruses that causes a cold) from invading human cells.  Some studies have found that zinc-containing products can shorten the length of time cold symptoms last and minimize the severity of the common cold if they are taken within 24 hours of symptom onset.  Other studies claim that these initial studies were poorly designed and that zinc does little to help with the common cold.  Who should we believe?   Let’s think about this logically.  If Zicam prevents the rhinovirus from invading human cells but there are over 200 different viruses that cause the common cold, the odds of Zicam helping your particular cold seem slim.  On the other hand, rhinoviruses are the most common cause of the common cold so the odds go up a bit.

The Final Verdict: It really depends the particular virus you have.  If you take Zicam as soon as you develop cold symptoms and you don’t get better, you probably don’t have a rhinovirus.  At this point, refer to all of the medications outlined above that have been proven effective for your cornucopia of symptoms.

You are now officially an informed consumer!  Next time you’re in the pharmacy shopping for treatments for your cold symptoms, flip the box around and strategically target your symptoms of choice with the correct active ingredient.  No need to suffer any longer!  We wish you a sneeze-less, cough-less, and complaint-less night.  Go get some shut eye.

Questions?  E-mail Tania: houspian@myhousecallmd.com

by Tania Houspain, PharmD 2011 | houspian@myhousecallmd.com

It is freezing cold outside, you’re stressed out about finals, and now your good old friend, Herpie (your favorite cold sore), is back.   You and Herpie have been friends for a while now.  You met him at a party in college when you didn’t think it would hurt to share drinks with the guy with the weird bump on his lip.  College is, after all, the time for bad decisions.  You live and you learn.  Now you are so paranoid that you won’t even share a cup with your own mother.  Sadly, though, it’s too late.  You and Herpie have begun an unavoidable lifelong relationship, a relationship that people all over the world are stuck with (note Paris Hilton’s sexy, lip gloss-coated cold sore).  With the medical treatments we have today, there’s nothing you can do to stop cold sores from coming back.  There are, however, a few things you can do to minimize number of cold sores you get and potentially shorten the length of time those annoying cold sores stick around.  Now let’s see if any of the current treatments are good enough to prevent a cold sore.

What causes a cold sore?

Cold sores are caused by a virus called the herpes simplex virus type 1 (HSV1). Yes, I said herpes.  When most people hear herpes they think of the sexually transmitted infection that causes sores in the nether regions (genital herpes) and they’d be right. Most cases of genital herpes are caused by herpes simplex virus type 2 (HSV2) while most cold sores are cause by HSV1 but both viruses can (although much less common) cause sores in the opposite region if the active virus comes in contact with that region (use your imagination here).

How do you “catch” a cold sore?

When you “catch” a cold sore you’re catching a virus.  Viruses are much smaller than bacteria and live inside your cells.  When someone has a cold sore it is caused by the herpes virus in the cells of their lips making a bunch of copies of themselves eventually causing the cells to burst open.  When the cell bursts, it frees the viral particles allowing them to invade more cells and repeat the cycle.  When enough of your cells are burst you get that wonderful oozing area of cells referred to as a cold sore.  Most people can see some redness, feel itchiness and pain over the area in which they are about to get a cold sore. This is caused by the death of your cells in that region.

So where did you get the initial virus?  You can get it anytime you exchange fluids with someone who is infected with the herpes virus and is actively shedding the virus.   Activities like kissing, sharing a cup, sharing utensils, toothbrush, etc.  Cold sores are most contagious when someone has an open blister present on their lips until the point where the blister has completely healed.  At the same time, note that certain people can spread the virus through their saliva even if there is no open blister present.  Maybe hold off on kissing a lot of frogs until you meet prince charming?  We’ll leave that one up to you.

Ok, so why is there no cure for herpes?

That’s like asking why there isn’t a cure for the common cold (also caused by a virus, though not a herpes virus).  Viruses are pesky like that.  Herpes, in particular, has the ability to travel deep into your body and make a home for itself in your nerve fibers.  Once the virus reaches your nerves, it temporarily goes into stealth mode, waiting for the opportune time to resurface.  During this time, the elusive little buggers hide from your immune system and medications.  This is called “Latency” (as seen in the diagram below depicting the virus moving from the epithelial on your lip to your nerve cell where it will lay dormant).  Herpes then rears its ugly head when your immune system gets weaker or is preoccupied with another infection.   It’s like guerilla warfare.  That’s why most people get another cold sore (called “reactivation” of the virus) when they get sick, are stressed out, or are just generally not taking good care of themselves.  Sun damage has also been linked to cold sore outbreaks (so if you find that’s one of your personal triggers, try using a chap stick with at least SPF 15).

Now to the fun stuff: products that may help quickly get rid of or prevent a cold sore that you can find at your local pharmacy and don’t need a prescription to get.

Abreva  (active ingredient: Docosonal)

How it works:  It changes the cell membranes of healthy, uninfected cells. These changes help prevent the cold sore virus from getting into healthy cells so the viral particles can’t spread to new cells. Think of it as dead bolt and home security system for the doors into your healthy cells.

Does it work?:  Yes!  It doesn’t prevent a cold sore but if you start using it as soon as you think you’re getting a cold sore it will shorten the amount of time you have to spend with Herpie.  On average, Abreva shortens the cold sore’s stay by 3 days (so if your cold sore usually hangs around for 7 days it’ll be gone by day 3 if you use Abreva at the first sign of it…remember that initial itching/tingling sensation?).

How to use it:  It comes in a cream and spray that you apply onto the cold sore.  You’re supposed to start applying it at the first signs of a cold (so any redness, tingling, itching, etc near your lips. If you’ve ever had a cold sore you can probably tell your going to get one soon).  If you wait until the blister is fully formed, Abreva will still help but it won’t be as effective as it is if you use it right away.

Note:  This is the only FDA approved drug to shorten the duration of cold sores and speed healing time (when you hear FDA approval you can rest assured that its been thoroughly tested for safety and efficacy before being sold to you).  The rest of the treatments that can be found in your pharmacy have some supporting research but no FDA approval just yet.

Cost:  $18 for each 2-gram tube. Each tube last from 2-3 outbreaks depending on your cold sore. If you’ve got a monster of a cold sore then it may only last through one.

Lysine

How it works: Lysine is an amino acid your body absorbs when you eat eggs, red meat, cheeses, or fish (among many other sources). By increasing the amount of lysine you eat (either through diet changes or taking lysine pills) or applying a lysine ointment directly onto the cold sore it is believed that you disrupt an important ratio of lysine to arginine (another amino acid) that the virus needs to make copies of itself

Does it work?: It’s not FDA approved for treating cold sores but there’s a lot of buzz and research into it. One trial found that 40% people treated with lysine at the first sign of outbreak were rid of their cold sore by day 3.  Pretty awesome if you ask us.

How to use it: There are creams like Lysine+™ that contain lysine as one of the main ingredients that you apply in the same way you apply Abreva at the first sign of a cold sore. There are also pill forms of lysine that you can find in the vitamin section of some pharmacies.  Most sources recommend 1000mg (1 gram) three times a day at the first sign of a cold sore. Some people have found that if they start the lysine pills early enough, they can actually prevent the blister from fully forming (sorry Herpie).

Cost: A tube of Lysine+™ usually costs about $8 for a 0.25 oz tube that will last 2-3 sores. Lysine tabs can range in price depending on the brand (usually around $10) but definitely go for a well-known brand that uses high-quality sources of lysine.

Peppermint Oil (yes, peppermint oil)

How it works: Peppermint oil is thought to have direct viricidal (i.e. virus killing) abilities. How does it do this?  We’re not sure just yet…but if the cold sore goes away, does it matter?

Does it work?: Surprisingly, the answer may be “yes.”  Not enough studies have been done on the subject but it seems like peppermint oil is capable of killing the virus particles that are outside of your cells.  Studies have yet to be conducted on humans or on the exact way to use peppermint oil (dosing, delivery mechanism, etc.) so it’s a little iffy right now.  At the moment its just test tube medicine.  Feeling adventurous?  Might be worth a shot.   People who use it have reported seeing their cold sore disappear faster.

How to use it:  There are no tried and true rules for how to use these oils at the moment but here are some guidelines:

• Use good quality peppermint oil

• Dip a cotton swab in water and then into the peppermint oil (this is to help dilute the oil a little because 100% peppermint oil can be very irritating to your skin)

• Apply on to the cold sore

• Do this a couple of times a day

• DO NOT drink the oil.  It won’t help, we promise.

Note: A lot of other natural products like tea tree oil, eucalyptus oil, and lemon balm are also being investigated as possible treatments for cold sores. If any of them interest you, use them similarly to peppermint oil.

Cost: Greatly varies but like with any natural remedy make sure its good quality and from a source you trust. On average though its pretty inexpensive.

You may have noticed that all these products ask you to start using them at the first sign of a cold sore.  This means that you have to be in tune with your body and recognize how your cold sores develop.  Look for warning signs of your next outbreak.  It’s also a good idea to keep track of the things that triggers your cold sore.  If you get a visitor on your lips every time finals come around or workload gets heavy, then start using one of these products preemptively around the start of finals.

Other products:

The products below are frequently advertised as treatments for cold sores but they don’t contain any ingredients that make them particularly active against the herpes virus.  They’re great for keeping your lips healthy and conditioned (nothing some chapstick with SPF wouldn’t do).  They can also help reduce the pain, itching, and redness caused by the cold sore because a many of them have pain-relieving ingredients.  Unfortunately, there is nothing in them that will get rid of the herpes virus and make the outbreak go away faster.

• Zilactin

• Anbesol

• Blistex Medicated

• Carmex

• Orajel

• Neosporin-LT

• Campho-Phenique

Again, this is a brief review of products that are available.  The world of cold sole- combating “medications” is filled with a ridiculous number of products but the cure has yet to be uncovered.  The Internet is full of people’s home remedies (from toothpaste to bleach) and products popping up claiming to be FDA approved.  Use common sense and a healthy dose of detective skills when considering any product (we don’t recommend using bleach on your mouth.  It seems like the kind of horrible idea that will land you a Darwin Award).  Find out what the product’s active ingredients are and see if those are chemicals you’d want in or on your body.  Activities that undoubtedly help reduce cold sores are staying healthy and dealing with stress in a healthy way.  Also, do your friends and family a favor and try not to introduce them to Herpie.  If you know you have a cold sore developing, don’t share anything that touches your mouth with them.  Until something better comes along, you and Herpie are just going to have to learn to work together…and do your part to shorten his stay!

References:

Abreva New Drug Application. 20-941. FDA Archives. Oct.29.1999

Elish D, Singh F, Weinberg JM. Therapeutic options for herpes labialis: experimental and natural therapies. Cutis. 2005 Jul;76(1):38-40.

Schuhmacher A, Reichling J, Schnitzler P. Virucidal effect of peppermint oil on the enveloped viruses herpes simplex virus type 1 and type 2 in vitro. Phytomedicine. 2003;10(6-7):504-10.

Singh BB, Udani J, Vinjamury SP, Der-Martirosian C, Gandhi S, Khorsan R, Nanjegowda D, Singh V. Safety and effectiveness of an L-lysine, zinc, and herbal-based product on the treatment of facial and circumoral herpes. Altern Med Rev. 2005 Jun;10(2):123-7.

by Tania Houspian, PharmD 2011

You can picture it now: Your New Year’s resolution to get in shape finally realized. You’re on the beach in your Speedo with your muscles glistening in the sun. Ok, maybe that’s not exactly what you are imagining the finished product to look like. Perhaps your New Year’s resolution was geared more towards building bigger muscles and getting in better shape rather than becoming the next World’s Strongest Man (skin bronzer, shaving, and Speedos may not be your style).  Nonetheless, you do want to become more muscular.  If so then creatine is the one supplement all your Google searches for “build more muscle” will undoubtedly produce.  Creatine is possibly the most widely used and talked about dietary supplement in the world of bodybuilding.   It’s definitely something a lot of people come into pharmacies and nutrition stores looking for. The question, of course, is “Does it work?”

Before we answer that question here’s another one: What is creatine?

Creatine is not, I repeat, is NOT a steroid. Creatine is a protein your body (specifically your liver) makes. You also get creatine from foods like meat and fish. The creatine that is made by your liver or that is absorbed from food is then stored in muscles. An average 70kg (154 lbs) person has about 120g of creatine stored in their muscles and metabolizes about 2g of creatine each day (which is easily replenished from your diet or liver).  In the muscles, creatine acts as a battery charger.  In this case the battery is your body’s energy stores called ATP.  When muscles use up ATP to perform an action it is converted into ADP. Creatine is able to convert ADP back into ATP, which can once again be used by your muscles to perform actions.  This is a quick and easy way for the body to create more energy (twice as fast as the bodies normal way of deriving ATP from glucose).  Sounds great, right?  The downside is that the creatine is depleted pretty quickly and the body has to go back to breaking down glucose to make more ATP.  So when an athlete takes creatine, their hope is that it will help their muscles maintain the ATP levels for a longer period of time subsequently allowing them to train longer before becoming fatigued.

Aside from increasing the amount of work your muscles can perform before becoming fatigued, there are other theories about how creatine helps build more muscle:

1. Creatine pulls water into muscle cells via osmosis (remember osmosis from high school chemistry?), helping keep muscle cells hydrated and making your muscles appear rounder and fuller…possibly the origin of the common gym phrase, “Getting swoll”

2. By delaying the muscles’ use of glucose to generate ATP, creatine also helps delay the creation of lactic acid (a byproduct of glucose use). Lactic acid is what makes your muscles burn and causes you to feel sore the morning after a tough workout (yes, lactic acid is to blame for the “I was just hit by a big rig” sensation).

So far we have discussed theories about creatine’s ability to improve muscle building.  What we really want to know is if any of them have been proven.  The answer is yes and no. Given the popularity of creatine as a workout supplement there have been hundreds of studies done to examine its efficacy and safety. The studies reviewed asked participants to consume 20 grams of creatine supplements a day for five days (called creatine loading). Then the subjects were asked to consume 5 grams of creatine per day for 21 days. Theoretically, this would increase the stores of creatine in their muscles. The participants were then asked to perform various exercises and their results were compared to their pre-supplementation results. The studies show that creatine does help increase body mass and it does help increase endurance in short-duration, high-intensity exercises (they specifically looked at number of bench press reps, leg press reps, and vertical jump height). However, creatine did not help the men in long endurance exercises such as running a 12 mile race (creatine actually hurt test subjects in long endurance exercises, possibly because they were carrying around excess body mass).  Creatine also did not decrease the amount of post-workout soreness reported by the subjects. The amount of soreness felt was the same before using creatine and after the supplementation period.

The Verdict: Creatine is not a wonder supplement.  You can’t take it, go to sleep, and wake up with bulging muscles.  It is, however, something you can take if you are serious about working out as it may help you increase your stamina and strength with specific workouts.

Now to the most important information: Is it safe and are there any side affects?

Initially, there were reports of creatine causing dehydration, cramping, and kidney & liver damage.  Athletes taking creatine were subsequently warned to not work out on hot days and to be cautious of any cramping the experienced.  That sounds pretty ridiculous to us: if you’ve ever worked out hard you know that cramping is bound to happen from time to time.  To test out these claims more studies were done. The main study on this subject was performed on 14 football players who were told to consume creatine for 8 weeks.  They chose football players as the athletes to use as guinea pigs…I mean test subjects…because football is considered a high-intensity, short-duration exercise (which is exactly the kind of activity creatine is supposed to aid in).  During the 8-week time period the athletes’ kidney function, liver function, and over health were closely monitored. Their results regarding creatine efficacy paralleled those of other previous studies showing that body mass increased and the athletes’ abilities to perform high-intensity, short-duration exercises did improve.  As far as toxicity goes, no signs of kidney or liver damage were seen in any of the patients.  In addition, none of the football players became dehydrated or had more cramping than they did at baseline.

Before we go waving our “Creatine is Safe” flag, a few things should be pointed out.  First, the studies were done on healthy, young males.  People who have liver or kidney problems to begin with should not further challenge their organs unless they are under the close supervision of a health professional.  Studies have not been done with people who have kidney or liver problems so it is hard to say how it may affect them.  Second, all these studies were short term (8 weeks was the longest one performed) so no one really knows the long-term effects of taking creatine.  Many of the problems initially reported with creatine supplementation could have been due to impurities in the creatine supplement people were purchasing thus it’s always important to buy supplements made by a well known and trusted company (i.e. don’t order it off the web from some no name company just because shipping is free).  In addition, be sure to consume plenty of water when using creatine.  Remember that creatine pulls water into your muscles (and out of your body’s circulation).  You need to make sure that you are replacing this displaced water while using creatine to prevent dehydration.

The Final Verdict: If you are serious about working out and are looking for a supplement to provide you with additional stamina to help you strength train for longer periods of time then creatine may be the way to go.  Some things to keep in mind when shopping around:

1. Most of the studies used creatine monohydrate powder as their creatine source (there are more expensive formulations with fancy names but this formulation seemed to work well in the studies).

2. No consistent standards were set for the loading phase of creatine use but 20 grams per day (split into 4-5 grams doses throughout the day) for 5 days seemed to be the most common approach. Note, however, that consuming that much creatine is going to upset your stomach.

3. It was recommended that the average person who wants to gain body mass should supplement with 2-5 grams of creatine per day when working out.

4. Make sure you’re buying high quality creatine from a reputable manufacturer at a reasonable price.

Now go hit the gym mister.

References:

Bemben M, Lamont H. Creatine Supplementation and Exercise Performance Recent Findings. Sports Med 2005; 35 (2): 107-125

Cancela P, Ohanian C, Cuitiño E, et al., Creatine supplementation does not affect clinical health markers in football players. 2008 Sports Med 42: 731-735 .

Dalbo V, Roberts M, Stout J, et al. Putting to rest the myth of creatine dehydration and supplementation leading to muscle cramps. Br J Sports Med 2008 42: 567-573

Herda T, Beck T, Ryan E, et al. Effects of Creatine Monohydrated and Polyethylene Glycosylated Creatine Supplementation on Muscular Strength, Endurance, and Power Output. 2008. The Journal of Strength and Conditioning Research.

Lopez R, Douglas C, McDermott B, et al. Does Creatine Supplementation Hinder Exercise Heat Tolerance or Hydration Status? A Systematic Review with Meta-Analyses. 2009; Journal of Athletic Training. 44(2), 215-223.

by Tania Houspian, PharmD 2011

There is a tried and true medical procedure that is minimally invasive and takes a few seconds to perform. This procedure will help prevent dozens of diseases and aide in making the entire population healthier. The more people that undergo the procedure, the better it is for the health of the entire population. Like any procedure though, it has its risks. Do the benefits outweigh the risks? Would you choose to undergo this procedure?

That’s a question you always have to ask yourself when choosing to undergo any medical procedure. The risks and benefits need to be weighed.  More importantly the true risks and true benefits need to be weighed. Grandma thinks that her blood pressure medicine gives her gas but, as her children and grandchildren can confirm, Grandma had some serious gas long before she began taking blood pressure medication. Just because two things happen at the same time does not mean that one caused the other.  Correlation does not equal causation.

So what was the procedure we referred to above?

Procedure: Vaccinating Children

Benefit: Vaccines are the single best public health measure ever implemented in our society. They have been proven to prevent many diseases that, in the past, were the leading causes of death in young children.  Think Polio, for example.

Risk: Autism?

One in four Americans believes that vaccines cause autism. When anything becomes that engrained in the minds of a society, it warrants deeper examination. There are two main theories that aided in forming this widespread notion.

Theory #1:

The first mention of vaccines being a possible cause of autism was in 1998 by British gastroenterologist, Andrew Wakefield. Wakefield, along with 12 others, published a paper in which they put forward the theory that the measles virus in the measles, mumps, and rubella vaccine (commonly called the MMR vaccine) caused a “leaky gut.” They concluded that the leaky gut allowed toxic substances into the bloodstream that eventually ended up in the brain. In the paper they recommend separating the three (measles, mumps, and rubella) into separate vaccines. Wakefield called a press conference to let everyone know about his discovery and consequently triggered a panic in Great Britain.

Since then, Wakefield has not exactly been what we would call a respected member of the medical community. Ten of the co-authors on that paper retracted their involvement and have said they do not agree with the conclusions that Wakefield drew in his paper. The General Medical Council is also investigating Wakefield for scientific misconduct, specifically falsifying data.  Oh yeah, and Wakefield also forgot to mention that he was working on introducing a new measles vaccines to the market to compete with the MMR vaccine. Can you say conflict of interest? Hidden motives aside, Wakefield’s research methods have been accused of not only being flawed but also unethical.

Taking into account the fact that Wakefield has been publicly discredited and his paper deemed invalid, you would think this theory regarding the connection between vaccines and autism would have fallen by the wayside…and it hasn’t.  This is because it’s not that simple.  Many people believed Wakefield was on to something even if the science did not match his conclusions. Due to the number of vaccines children receive in the first three years of life (14 vaccines to be exact) many parents felt that there could be a connection.  Once the idea of a risk like this has been introduced, it’s difficult to get the idea out of people’s minds. Simply said, it’s always easier to scare people than to un-scare them.

Theory #2:

In 1999 the US government published a report revealing three childhood vaccines (diphtheria, tetanus, acellular pertussis [a combo called DTaP]; Haemophilus influenzae type b (Hib); and hepatitis B) contained higher levels of mercury than previously thought. Thimerosal is the preservative used in these three vaccines and contains 49.6% ethylmercury by weight. An obscure medical journal took this finding and ran with it, publishing an article (without any scientific validity) saying that autism was a form of mercury poisoning.  This, of course, caused a huge uproar in the United States and propaganda like the image and chart included below (again, without scientific support; note the lack of references for the chart’s information).  In response, the Center for Disease Control reviewed numerous studies all finding that there is NO LINK between autism, vaccines, and mercury. Even though the CDC’s findings showed no connection between mercury and autism, the government still requested vaccine manufacturers to remove the mercury component from all childhood vaccines.  Since 2001, no childhood vaccines have contained mercury.  So let’s say the initial theory published by the obscure medical journal linking mercury and autism was correct (even though all the scientific evidence pointed the other way), then autism rates should have dropped dramatically after mercury was removed from all vaccines in 2001…and parents everywhere would be able to breath a sigh of relief. Well, it turns out that the exact opposite has happened. Autism rates have continued to rise since 2001. This simple fact should be enough to put the mercury-autism theory to rest yet many groups out there continue to vilify vaccines and anyone who dares step up to defend them.

Mercury – Autism Propaganda

Then why the controversy?

So why is it that, even though all the scientific evidence seems to point away from the connection between vaccines and autism, people still believe vaccines cause autism? Personal experience and temporal associations. One of the main driving forces amongst groups who believe vaccines cause autism are parents with children who have autism, which they begin to notice during the same period of time their children are receiving their 14 recommended vaccinations. Many parents first start to notice signs of autism when their children have developmental delays in speech. The MMR vaccine (which, by the way, never contained thimerosal) is given around 12-15 months of age, which coincides with the age most children begin to speak. So it seems that the most likely explanation is coincidence not causation. There are also many children who exhibit signs of autism prior to any vaccinations, further discrediting the link between vaccinations and autism.

What Now?

No one can belittle how difficult it must be for the parents of autistic children to witness their children’s developmental challenges. These parents need an explanation and, with so many people pointing the finger at vaccines, it’s a tempting to jump on the bandwagon. This approach, however, is not helping anyone. The focus of autism research has been and will continue to be on genetic causes of the disease.  This is the research that needs to be supported and perpetuated in order for real answers to be found and for meaningful interventions to be developed.

People seem to have become comfortable with how safe vaccines have made our society and forgotten that the illnesses they prevent can kill their children. These viruses continue to exist throughout the world and, without vaccination, we remain vulnerable to the epidemics they can cause. When Wakefield published his paper in 1998, parents in Great Britain stopped vaccinating their kids. The rate of vaccination dropped to 80% by 2003.  That same year, over 1,000 measles cases were reported in Great Britain. Similarly, in the United States there have been outbreaks of measles, pertussis, and Haemophilus influenzae Type B…all diseases that are preventable through vaccination.

References:

Fombonne,E. Thimerosal disappears but Autism Remains. Arch Gen Psychiatry. 2008 Jan;65(1)15-6

Gross L (2009) A Broken Trust: Lessons from the Vaccine–Autism Wars. PLoS Biol 7(5): e1000114. doi:10.1371/journal.pbio.1000114

Immunize.org, http://immunize.org. December 22,2009.

Miller L, Reynolds J. Autism and vaccination- the current evidence. J Spec Pediatric Nursing. 2009 Jul; 14(3): 166-72.

Thimerosal In Vaccines Questions and Answers. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/QuestionsaboutVaccines/UCM070430#q5. December 26,2009.

by Tania Houspian, PharmD 2011

You bat your lashes and smile seductively at him from across the room. He takes the bait and walks over.  He offers to buy you a drink to which you coyly respond, “Sure” and wink.  What’s this?  Your eye is stuck in the wink position.  You over did the glue when applying your gorgeous fake lashes and now the cute boy is staring at you wondering why you won’t stop winking.  You run to the bathroom and rip off the false lashes wondering why you do this to yourself and if there is an easier way. Well there just might be.  Rumor has it that there is a new drug that can give you the fuller longer lashes you desire without the risk of gluing accidents.  Let’s explore this wonder drug, Latisse, and find out if it’s too good to be true.

Latisse has an interesting history behind it.  Latisse is the brand name for the drug, Bimatoprost. Bimatoprost was initially the active ingredient in another drug called Lumigan, used to treat glaucoma (a disease that affects the eyes of older men and women).  Yes, same drug…different brand name.  So how does a drug used to treat a disease that can lead to blindness turn into a drug that can give us longer, fuller lashes? This is how it went down: Men and women using Lumigan for glaucoma noticed that their lashes were becoming thicker and fuller and reported this side affect to the company.  The drug company realized that this “side affect” might actually be something people without glaucoma would pay to experience.  They reapplied with the FDA for approval of their old drug, Bimatoprost, for this new use. The FDA approved the use of bimatoprost for hypotrichosis, meaning lack of hair growth.

So does Latisse work? All signs point to yes. A number of research studies show that it increases growth of eyelashes. Ok, so how does it work? That question isn’t as easy to answer because there seems to be no conclusive answer. There are, however, three theories:

1. It may prolong the growth phase of hair, allowing it to grow longer. Think of it as prolonging puberty and giving you more time to grow. Not that anyone should endure puberty for longer than they already have to…it was just an analogy.

2. It wakes up any dormant, lazy hair follicles you have and gets them to start producing hair. It doesn’t increase the number of follicles; it just works with what you already have.

3. It increases the production of the substance melanin. Melanin is what your skin produces when it’s exposed to the sun and it causes that golden tan coloring Southern Californians love so much. Like your skin, your hair also contains melanin and an increase in melanin means darker and fuller looking lashes.

No gluing, no fake lashes, and no awkward moments needed.  Like with any drug, there are other things that need to be considered in addition to how it works.  Side affects are always a concern and using a medication appropriately is key to preventing those unwanted effects. There is a specific way Latisse must be applied in order to keep side affects to a minimum.

Here’s what to do:

1. Start with a clean palette. Wash your face, remove any makeup, and take out your contact lenses

2. Place a drop of Latisse solution on a new applicator (60 applicators come with a month’s supply of Latisse)

3. Immediately draw the applicator across where the eyelashes meet the skin starting at the inner part of the eye and sweeping to the outer part (similar to how you’d apply a thin line of eyeliner) on the TOP eyelid only

4. Blot away any extra solution

5. Grab a new applicator and repeat on your other eye

This process should be done once each night.  If you aren’t going to bed right away you can put your contact lenses in 15 minutes after you apply the solution. Pretty simple, right?

Here’s what NOT to do:

• Do not apply Latisse to your bottom eye lid (top eyelid only!)

• Do not put the solution into your eye (it stands to reason that if you don’t have glaucoma you don’t need to decrease the pressure in your eyes)

• Don’t apply it more than once a day thinking it will make your lashes grow even longer. The results you get from applying ten times a day are the same as once a day. All you would be doing by using it more often is increasing the side effects (which we’ll get to shortly) and you would have to buy more bottles of Latisse…which seems silly to us.

Although it would be nice to do this process once, go to bed and wake up the next day with the lashes you’ve been dreaming of, it takes about 2 months for most people to see a difference in their lashes.  Moreover, if you stop using Latisse your lashes will slowly return to their original state of affairs. There are a couple more downsides to using Latisse:

1. It can cause the skin of your eyelids to get darker. Why? That’s right, the extra melanin. Once you stop using Latisse your eyelids should go back to normal color.

2. It can cause your iris to become brown. The iris is the part of your eye that has color already so if you’re a brown-eyed person this may not be an issue. However, if you have blue eyes and like them that way, be careful not to get any of the solution into your eye. Sadly this color change is permanent.

3. There is no guarantee that both of your eyes will respond in exactly the same way.  One eye may grow long gorgeous lashes while the other eye doesn’t quiet reach its full potential.

4. Since it is applied directly on to the eye you may develop eye problems like itching, stinging, redness or vision changes. If you do experience changes with your eyes’ appearance or your vision, stop using Latisse and make an appointment with your doctor to see if Latisse is causing the problem.

Now that you know the good, the bad, and the ugly about Latisse, do you still want to use it?  If you do, make an appointment to talk to your doctor because you need a prescription in order to get it from the pharmacy.  Also note that it costs about $90 for a month’s supply so budget accordingly.  If you’re not turned off by the cost and side affects then go for it and know that the next time a cute boy asks to buy you a drink you can wink worry free.

References:

Bimatoprost New Drug Application 22-369. FDA archives. November 30, 2009

Latisse package insert. Allergan. November 30,2009.