New drugs need time to be tested
By Dr. Anthony Policastro
New drugs are always coming on the market. Each time a new medication comes out, the manufacturer sends representatives to physicians' offices. Those representatives explain why their new medication is better than what the physicians have already been using. However, there is no way for physicians to know all the ins and outs of every new medication. For that reason, the sales pitch frequently sounds appealing. For example, there is a new ADHD medication about to be offered in January 2103. I have already received the brochures from the manufacturer. The new medication is a liquid preparation. Right now there are only two ADHD medications that come in a liquid preparation. Both of them are short acting and they need to be given every four hours. The new medication is meant to be given once daily. For that reason, the sales pitch is that this is a liquid ADHD preparation that only needs to be taken once daily. The name of the medication is Quillivant XR. The pitch will be that we now have a long acting drug that does not require a child to swallow a pill. However, a look at the information behind the drug tells a completely different story. For example, some of the current medications come in a capsule that can be opened and poured onto applesauce. Another medication can be dissolved in water and taken that way. There is also a patch that can be used if the child has issues with oral medications. Thus, there is not really a problem getting children to take ADHD medication at the present point in time. For that reason, we really do not have a need for a long acting liquid preparation. That being said, there might be some circumstances in which having such a preparation would be useful. For example, a younger child may not be able to swallow pills or capsules. They may not want to take medication in applesauce. They might not want to drink a glass of water containing a medication. They might pull a patch off. So far, I have not seen a child like this in my practice but that does not mean that there is not one of them out there somewhere. For that reason, we might think about using this new medication for a younger child that does not take liquid medication. The problem is that the new medication is labeled to be used in children above age 6. That makes it much less useful for the children who cannot take pills. In addition, the current recommended treatment for children under age 6 is behavioral management not medication. A second issue has to do with the fact that the liquid preparation is something called a suspension. A solution is a preparation in which the material is dissolved in the liquid. Salt water is a good example. In a suspension the material is not really dissolved. It is in the liquid but will settle out if left standing for too long. For that reason, it needs to be shaken to spread the medication throughout the liquid. If this does not happen, it creates two problems. The first is that at the beginning of the bottle most of the medication is settled at the bottom so the patient does not get enough of it. At the end of the bottle, once the top layers of liquid are gone, the medication is now concentrated. The result is that the dose is too high. The manufacturer has addressed this in the package insert. It reads as follows: "Before administering the dose, vigorously shake the bottle of Quillivant XR for at least 10 seconds, to ensure that the proper dose is administered." This statement is also in bold and underlined for emphasis. The expectation is that every time the medication is given the parents will vigorously shake the bottle for at least 10 seconds. While some parents will certainly do that, I do not expect that to be typical. In the office, I have no way of knowing who is going to do this and who will not. For that reason, I would be better off assuming that the directions will be poorly followed. Otherwise, if the patient gets overdosed at the end of a bottle, I am likely to get asked how I could have let that happen. The third issue has to do with the fact that the medication is metabolized differently depending on the age of the individual. They did blood levels of the medication in four patients who were between the ages of 13 and 15. The blood levels were similar to those found in adults taking the medication. They then did blood levels in three patients between the ages of 9 and 12. They found that the blood levels were twice what they were in adults taking the same dose. There are several issues here. The first is that they looked at very few patients. The second is that in the real world, you do not check blood levels of these medications. Therefore, how do you know what blood level of medication you have for a child about 12-13 years of age? Is it equal to the adult dose? Is it twice the adult dose? Is it somewhere in between those two levels? Time will tell us that answer. The bottom line here is similar to what I tell patients for any new drug to come onto the market. We need to wait until this medication has been in use for a while. That is when we will discover the best way to use it. The first group of individuals to take it will be the ones to tell us what the actual directions for taking it need to be. While all of this is true for this one particular medication, you can be sure that there are similar things to be said about any other new medication. Unlike buying the latest gadget, it may not be good to be the first one on your block to try the new medication. Are all of the medications you are taking really helping you?
Submitted by Visiting Angels More often than not, medicinal healthcare for seniors is built around managing symptoms, rather than finding and treating a root cause; or the root cause was found, and was being managed, but new symptoms arose over time, and led to additional prescriptions. Unfortunately, multiple prescriptions often lead to even more new symptoms. "One third of all seniors are taking five or more prescription medications daily," reported the Journal of the American Medical Association in 2008. Clearly, overmedication is a serious problem demanding consideration. If you're presently taking several prescription medicines, you should look beyond the pharmacists' and manufacturers' advice about mixing meds, which are based on clinical studies of a large population of strangers, and consider how multiple chemicals may be affecting you personally. When I see a care recipient pull out a long list of prescription medicines, or carry out a box filled with a rainbow of different pills, it's impossible not to wonder if they're all working together for good, or causing harm. We're a non-medical care provider, and I have no training in pharmacology, but it's difficult to ignore the connection between what the care recipient is telling me, and the large amount of medication they're showing me. According to Dr. Andrew Duxbury, a geriatric medicine specialist, adverse reactions to medications represent the No. 1 health problem facing the elderly today. There are numerous reasons for the wide-spread phenomenon, including:
- Metabolic changes: As we age, absorption rates slow, medications may stay in the body longer causing higher risks of toxicity.
- Overmedication: Leads to worse drug interaction issues and increased side effects such as dry mouth, dizziness, depression and balance problems, leading to falls.
Our caregivers at Visiting Angels provide medication reminders, and closely monitor changes in the symptoms of our care recipients, and we let families know as difficulties arise. By educating our clients, and encouraging them to ask the right questions, we do our best to reduce the risks of multiple medications.
- Missed doses: Missed doses of necessary meds can cause unpleasant or dangerous side effects.
- Blood thinners and blood pressure medications: Anything that directly affects blood flow directly affects the speed and volume at which the chemistry in medicines reaches their targets. Blood thinners are notorious for upsetting how other medications work, and should be monitored often and closely. Here are some basic preventative solutions:
- Twice annual doctor visits: Visit your primary physician at least twice annually and bring all of your medications with you.
- Do your own research: Most medicinal research is performed on adults younger than 65, and these are published and distributed for doctors. Seek out studies focused on seniors and, if they apply, bring them to the attention of your physician.
- Centralize control: When you have an assortment of specialists, they may not be independently aware of your history. They likely do look for drug interactions, but they're usually simply checking an adverse interaction database and not considering your detailed history and present conditions. Make sure your most trusted physician is well aware of all of your medications and changing circumstances.
- Natural medications: Consider what "natural" remedies are available for everything from pain to blood pressure. Dietary changes and herbs may be just as effective, with fewer side effects. Discuss these with your doctor. Do not substitute these for prescription medicines without physician's approval and close monitoring.
- Proper dosing: Use a pill storage device that makes it easy to follow daily dose instructions. For those with memory issues, make sure the primary caregiver closely monitors medications and leaves notes for others who provide respite care.
About Visiting Angels David Forman is president of Visiting Angels of Sussex, which provides living assistance services beyond medication reminders, including hygiene assistance, meal preparation, appointments, errands and shopping, light housekeeping and companionship. Call 329-9475 for a free in-home assessment. More information can be found at visitingangels.com/sussexde.
First health impact assessment Delaware Greenways and the Environment and Policy Committee of Delaware's Coalition for Healthy Eating and Active Living (DE HEAL), in partnership with the Division of Public Health and other agencies, will be conducting the first health impact assessment (HIA) in Delaware. This has the potential to change the way that land use and transportation planning decisions are made in Delaware. Delaware's first HIA will analyze plans for the Fort DuPont Redevelopment Project near Delaware City. The team will examine how different master plan alternatives are likely to impact health through pathways such as transportation equity, accessibility to neighborhood resources, and exposure to flooding and pollution. For more information, visit www.delawaregreenways.org.
Hospice plans grief workshop Delaware Hospice will hold a grief workshop, "Coping with the Holidays," on Tuesday, Dec. 4 from 5:30 to 7 p.m., at the Millsboro office. Participants will learn strategies to help cope with the universal challenges presented by the holiday season. Discussion will include topics such as anticipations and expectations of family and friends; dealing with the multitude of emotions; the impact of death on the entire family unit; dealing with special occasions; honoring your loved one during the holidays; and giving yourself permission to participate or not to take part in special events. There is no fee for this workshop which is offered as a community service by Delaware Hospice but registration is required. Register by contacting Midge DiNatale, GC-C, at 302-416-0581 or firstname.lastname@example.org.
Go Red for Women 2013 The Southern Delaware Go Red For Women will be held on Friday, Feb. 8, 2013. Tickets, which are $35 each, include extensive health screenings, $10 gift card from Macy's, guest gift bag and lunch, entertainment that includes fashion show and silent auction. Table sponsorships are $1,000 and exhibitor sponsorships are $1,500. The event begins at 10 a.m. with lunch and the program starting at noon. For more information, visit www.heart.org/southerndegoredluncheon.
NMH offers CPR classes Nanticoke Memorial Hospital will offer community CPR classes to anyone interested in learning CPR at the Nanticoke Training Center located on Water Street in Seaford. Participants will learn how to perform the basic skills of CPR on adults, children, and infants and how to help an adult, child, or infant who is choking and use of the AED. This classroom-based, video, and instructor-led CPR course offers families, friends, and community members the opportunity to learn CPR and need a course completion card. Classes are open to participants ages 12 and up. This program is specifically designed for those who prefer to learn in a group environment with feedback from an instructor. Cost is $40. Payment and registration is required by no later than five business days prior to the class. Late registrations may be accepted if seating is available. To register and to obtain a listing of class dates/times, contact the Nanticoke Memorial Hospital's Training Center office at 629-6611, ext. 8919. Pre-registration is required.
Tobacco cessation classes Bayhealth's seven week Tobacco Cessation program offers support and guidance to help you quit using all tobacco products. The series of classes began Tuesday, Nov. 6 and is held every Tuesday for seven weeks, ending on Dec. 18. The class will be held from 5 to 6:30 p.m. in the Rehab Conference Room at Bayhealth Milford Memorial. This series of classes offers strategies to improve your lifestyle through behavior modification, diet, stress reduction, exercise and nicotine replacement therapy. The "quit week" is the fourth week of the program. This program is free to all Delaware residents. Call 1-877-453-7107 to register. You must be at least 18 to register and be able to attend all sessions. For more info, or to register for the next series, call Bayhealth Clinical Educator Terry Towne, MSN, RN-BC, NE-BC, at 744-6724.