Natroba (spinosad) is a new prescription topical treatment for head lice.   Natroba seems to work better then the OTC Nix (and other OTC permethrin).  Natroba works similarly to Nix, however Nix only kills living lice.  This means you need to wait for the nits (eggs) to hatch then re-apply and kill them too (gross, I know!)  Well, Natroba is thought to kill the nits too -so there is a better chance that there will be no need to reapply!

What’s the hitch?  Well, Nix is OTC and cost ~$15; Natroba is by prescription and cost ~$200!  So, best bet is to use the OTC Nix (or generic) options unless there is resistance in your area (your physician should know) or Nix treatment has failed after 2-3 treatments.

Current available topical treatments for head lice: 

• OTC permethrin (Nix or generic) 
• OTC pyrethrins (Licide or genereic)
• Prescription malathion (Ovide)
• Prescription benzyl alcohol (Ulesfia)
• Prescription spinosad (Natroba). 

If nothing seems to help -ask your physician about prescription oral ivermectin (Stromectol).

What about home remedies?  Cetaphil, Vaseline, mayo, olive oil, tea tree oil, Listerine, shaving hair, vinegar, etc…none have been proven to work and some can be harmful!

What do you swear by to treat head lice?  We would love to hear your input -please leave a comment

Clonidine was actually synthesized in the early 1960’s for use as a nasal decongestant, and then by chance, researchers discovered it decreased blood pressure and heart rate and produced sedation at very low doses. Clonidine has been used in the United States since it was given approval from the FDA in 1974. It wasn’t until September 2010 that the FDA approved extended-release clonidine for the treatment of ADHD in pediatric patients.

Indications

Extended-release clonidine is indicated as monotherapy or as adjunctive therapy to stimulant medications for the treatment of ADHD. It would be used as an add-on to a child’s drug therapy when they have not reached an optimal response to a stable regimen of a stimulant medication. 

Because extended-release clonidine is so new, it has not been systematically evaluated in clinical trials for effectiveness of long-term use. Based on studies, we know the medication is effective for the short-term, but beyond 5 weeks, we have no proof of how well it will work!

Interestingly enough, this extended-release clonidine formulation also exists in the world under the name Jenloga, which is approved for the treatment of hypertension in adults.

How the drug works

Extended-release clonidine is a central alpha-2-adrenergic agonist just like the immediate-release clonidine, so its mechanism of action is the same.  It decreases the release of norepinephrine from nerve cells in the brain leading to a lower firing rate of nerve cells that are responsible for arousal.  The result, a decrease in excessive stimulation found in patients with ADHD.

The controlled-release nature is what makes extended-release clonidine different from its predecessor. It is designed to produce slow, constant absorption for at least 8 hours, unlike the immediate-release formulation. Potential advantages of extended-release preparations are a decrease in frequency of administration, which may lead to improved patient compliance and a therapeutic effect that can be maintained overnight. Also, the peaks in drug concentration that occur after taking an immediate-release dosage form are eliminated, thereby decreasing the occurrence and/or intensity of side effects.    

Side effects and precautions

Extended-release clonidine comes with the same side effects as the immediate-release formulation, but side effects appear to be less intense because the medication’s peak concentration in the bloodstream does not get as high. Side effects to look out for are decreased heart rate and blood pressure, sedation, depression, irritability, constipation, dry mouth and eyes, headache, upper respiratory tract infection, sore throat, ear pain, nightmares, and nasal congestion.

Precautions are similar too! Abrupt discontinuation should be avoided due to the risk of withdrawal effects like increased heart rate, palpitations, tremors, anxiety, insomnia, sweating, and agitation. Parents will still have to follow the advice of the American Heart Association and have their child be carefully screened and monitored for any cardiovascular abnormalities as extended-release clonidine has the potential to cause toxic cardiac effects too. Also, children with kidney insufficiency will need their dose adjusted based on the degree of kidney impairment.

Extended-release clonidine has not been studied in children younger than 6 years old, so it may be best to avoid using this medication in children 5 years of age or younger. 

Similar medications

We’ve already determined that extended-release clonidine is very much like immediate-release clonidine. Guanfacine and extended-release guanfacine (Intuniv) are also central alpha-2-adrenergic agonists commonly used as alternative or add-on treatments for ADHD. They may actually be better options compared to the clonidine alternatives because they have a lower incidence of side effects and appear to stay in the body longer.

Administration guidelines  

Extended-release clonidine is available as 0.1mg and 0.2mg tablets. It should not be crushed, chewed, or broken, but it can be taken with or without food. When starting this medication, it should be initiated at 0.1mg at bedtime. Until the desired response is achieved, dosages should be adjusted in increments of 0.1mg per day at weekly intervals. Doses should be given twice a day, in the morning and at bedtime, with the equal or higher split dosage being given at bedtime. For example, if your child’s total daily dose is 0.3mg, your child would take a 0.1mg tablet in the morning and a 0.2mg tablet at bedtime.

Extended-release clonidine is not to be used interchangeably with the immediate-release clonidine formulation due to lack of clinical data from studies and because they absorb at different rates in the body. 

Recommendations

Extended-release clonidine may sound like a great idea because it’s part of some cutting edge happenings taking place in the pharmaceutical industry nowadays, but it’s also one of the most expensive options for the treatment of ADHD.  Extended-release preparations come with a price! Since it is not first-line treatment for ADHD and because data on its long-term use does not exist yet, I would hold off on giving your child this medication unless you have exhausted all other options.

Up against cheaper, safer, and more effective medications for the treatment of ADHD, extended-release clonidine is going to have an uphill battle in making a difference in the world of pharmacy.  Will the drug make a name for itself?  Only time will tell!

 We received this question in our Submit Your Question page:
Question: I am taking xanax it is really messing with my stomach and am having trouble sleeping and looking for the purest form of benedryl liquid to aid me in sleeping?

Thank you for contacting us!  Xanax can be rough on the belly.  Benadryl is available in multiple forms, including liquid and tablet form.  The actual drug is diphenhydramine.  If you are interested in the liquid form -the “purest” from what is available commercially, would be Children’s Benadryl Dye Free Allergy Liquid.  Although, all liquids It still contains additives and flavoring but is at least free of dye.  It may be “more pure” to take the Dye Free Benadryl gelcaps -they are flavor and color free.

As you probably know, Benadryl (diphenhydramine) is an antihistamine and is used for allergies.  So, it comes along with some side effects, such as dry mouth, dry eyes, possible “hangover” in the morning…  Having said that, up to 90% of Benadryl is used by people to help fall asleep!  If you are new to Benadryl, I would recommend using 12.5mg -25mg 15-30 minutes before bedtime.  You can build from there up to 50mg before bedtime.  Benadryl is not physically addicting.  Take care about the possible “hangover” feeling the next morning and drink lots of extra water!

Can I take Prozac with Coricidin?

Yes and no.  Prozac is okay to take with Coricidin Cold and Flu only.  The rest of the Coricidins contain dextromethorphan which can  interact with Prozac and cause serotonin syndrome.

I ate my Chia Pet’s sprouts on a dare -is that bad?

Not at all!  Actually Chia sprouts and chia seeds are edible and good for your health!  If you want to learn more -please read Chia for Your Health.

Is there a substitute for Xyzal 5mg?

Currently, there is not a generic available for Xyzal 5mg but there are some alternatives.  Xyzal works similarly to Allegra (fexofenadine) which is a prescription antihistamine (available in generic).  OTC generics include Claritin (loratadine) or Zyrtec (cetirizine).  There are also some antihistamine eye drops and nose spray that often are used along with an oral antihistamine.  

A woman asked via email, “I read your article on the Neti Pot.  I’ve always had low blood pressure but just found I am now borderline (140/80). Only change in life is using the Neti Pot daily for 1 year -could that cause it?”

No, there is no known link between use of the Neti Pot and high blood pressure.  Your question does make me wonder what led you to use the Neti Pot daily for the last year -perhaps it is related to the bump in blood pressure…?

Sometimes people are concerned with the “salt water” used in the Neti Pot being able to  raise blood pressure.  This is a false concern because 1.  Very little of the irrigation solution is absorbed into the body and 2. The salt level in the irrigation solution is equal to the body’s salt level so the salt can not pass into the body due to osmotic pressure.

A mom wrote in a recent email, “Can I give my daughter Mucinex for Kids and Children’s Motrin at the same time?”

Yes -it is okay to give the Mucinex and Motrin at the same time.  There are different medications in each.  It is good to ask and be cautious, especially with combination products.

A patient came into the pharmacy this morning and asked, “My doctor told me once I take Nexium for a few weeks, I no longer need to take it on an empty stomach…is that right?”

First, a little background info -Nexium along with Prilosec (omprazole), Aciphex and Prevacid (lansoprazole) -and a couple others- are in a class of drugs called proton pump inhibitor (PPI).  PPIs are used to treat issues related to acid in the stomach (like GERD or heartburn). 

A popular false rumor was started that once a PPI is taken for a few weeks, timing doesn’t matter. 

Untrue!  Just remember,  PPIs are most effective if taken on an empty stomach 30 to 6o minutes before eating.

A dad wrote, “I’ve been surfing (and surfing), looking for an answer to (what I thought) was a simple question, so I’m hoping you can advise: My daughter had an upset stomach (vomiting), so I gave her some Pepto. I then discovered it had expired by about a year. Is there any danger in this? I’ve since thrown it out once I realised, but just wanted some reassurance that there was no serious danger.”

Taking expired Pepto is not known to cause any issues -so I would not worry.  However, Pepto is not good to give to kids under 12 years of age.  Pepto contains bismuth salicylate which is like aspirin.  Aspirin (and Pepto) can cause Reye’s Syndrome in children -it is a very small but serious risk.  There is Children’s Pepto that contains calcium carbonate (like Tums) -and does not have any risk of causing Reye’s.  

If you want some more info on expired meds please read Expired Medications.

To see more random questions and answers, please visit the Question of the Day page.  If you want to ask a random question -please visit our Submit Your Question page.

Metformin was first synthesized back in the 1920s but was not seriously considered for use in treating diabetes until the 1950s.  It took another 40 years for it to be released in the United States for treatment in type 2 diabetes.  It is now first line treatment for diabetes as montherapy or concomitantly with insulin or sulfonylureas. 

Metformin is the only antidiabetic medication still on the market that belongs to the drug class biguanides.  It works by decreasing hepatic glucose production, improving insulin sensitivity and decreasing glucose absorption in the intestines.  This leads to a reduction in fasting glucose levels by 60-70mg/dL, which in turn decreases hemoglobin A1c, a test that measures the average blood glucose over 2-3 months.   Also of interest is that metformin has been evaluated in the treatment of polycystic ovarian syndrome and to help delay early menarche in females.

Metformin is available in an oral solution (Riomet), tablet (Glucophage) and extended release tablet (Fortamet, Glucophage XR, Glumetza).  Metformin tablets and extended release tablets are available in generic. 

The most common side effects during the beginning of treatment are headache, nausea, vomiting and diarrhea.  These are usually transient and will stop after a few weeks of therapy.  Taking doses with meals and starting with a low dose and increasing slowly should help decrease the likelihood of these adverse reactions.  Kids often complain of the “fishy” or “sticky” odor associated with some of the generic tablets.  Additional side effects include flushing, myalgia, rash, sweating and flu-like symptoms.  Sometimes, the outer shell of the extended release tablets may be found in the stool. 

Metformin has a black box warning for lactic acidosis.  It is an extremely rare side effect but if it occurs it is a medical emergency.  Because of this risk metformin should not be used in kids with renal or hepatic insufficiency.  Symptoms of lactic acidosis can include anorexia, nausea, vomiting, belly pain, lethargy and decrease in blood pressure.  The actual incidence is extremely low at around 9 incidences in 100,000 years of therapy.

Metformin can interact with many medications, so it is always best to check with the physician and pharmacist for drug interactions.  Drugs that interact with metformin and are common in kids are cephalexin and corticosteroids. 

Metformin has been approved in kids 10 years and older.  Typical starting dose is 500mg twice daily.  This can be increased to a maximum of 2000mg/day.  Metformin will start working within a few days but maximum effect can take up to two weeks. 

Along with lifestyle changes, metformin is a good option to treat type 2 diabetes in kids.  It has been shown to help with weight loss in patients with diabetes and is one of the few antidiabetic medications that does that regularly cause hypoglycemia.  Metformin is an inexpensive and effective way to help treat type 2 diabetes.  

This is a very fascinating concept to me and one of the reasons why I chose clonidine as the topic of this discussion. The other reason is because an extended-release form of clonidine has recently been approved and will be promoted to help in the treatment of ADHD. Instead of focusing on this new medication called Kapvay (extended-release clonidine), we’re going to stick with the old and learn about the role immediate-release clonidine has in treating ADHD. This will allow us to compare the older version of clonidine to the new extended-release form in our next discussion. 

 Indications

Clonidine has FDA approval for all the conditions mentioned above except for the treatment of ADHD and nicotine withdrawal symptoms in adults, which means it is used as off-label treatments for these purposes. Clonidine is generally used as either an alternative or an add-on to other medications for the treatment of ADHD, so it’s not the top choice for this condition. 

Other off-label or investigational uses include alcohol dependence, heroin withdrawal, vasomotor symptoms due to menopause (i.e. hot flashes), diabetes-associated diarrhea, painful menstrual cycles, and the prevention of migraines. Obviously some of these uses are not so kid specific, but it just goes to show how unique clonidine is with all of its potential roles in the medical field!

Clonidine is available by prescription only in the form of a tablet, transdermal patch, or injection for epidural administration. The tablet form is generally used for ADHD treatment and the epidural is the dosage form used for pain management. 

How the drug works

Clonidine is a central alpha-2-adrenergic agonist that decreases the release of norepinephrine from nerve cells in the brain. Norepinephrine is a chemical that naturally occurs in the nervous system. When the release of this chemical is decreased, the firing rate of nerve cells is reduced within a specific part of the brain that is responsible for arousal, thereby decreasing excessive stimulation found in patients with ADHD.    

Side effects and precautions

Even though clonidine is intriguing in its ability to serve many purposes, it does not come without warning. The American Heart Association recommends that all children should get a thorough cardiovascular exam before initiating clonidine therapy. This recommendation is based on reports of serious cardiovascular adverse events in both children and adults who were also taking normal doses of stimulant medications. Most of these affected patients had underlying structural heart disease. Examples of stimulant medications include methylphenidate, dextroamphetamine, and mixed amphetamine salts (i.e. Adderall), which are considered the first-line treatment of ADHD.

Clonidine therapy should not be abruptly discontinued because your child may experience a rapid increase in blood pressure and overactivity of the central nervous system, which includes increased heart rate, palpitations, tremors, anxiety, agitation, insomnia, and sweating. If your child needs to stop taking oral clonidine, they should be tapered off the tablet gradually over more than 1 week.

Other side effects of clonidine your child may experience include decreased heart rate, decreased blood pressure, sedation, depression, constipation, dry mouth, dry eyes and headache. Also, dosing adjustment may be needed in children with kidney disease.

Similar medications

Guanfacine is also a central alpha-2-adrenergic agonist that is commonly used as an alternative or add-on treatment for ADHD. It actually may be a better option for your child as it stays in the body longer and has fewer side effects than clonidine. There is also an extended-release guanfacine (Intuniv) on the market that is approved for children and adolescents aged 6 to 17 years for once-daily treatment of ADHD.

 Administration guidelines

All things considered, clonidine therapy is pretty straightforward. The tablet can be given with or without food, but if it seems to be bothering your child’s stomach, giving it with food is advisable.

When your child is started on clonidine treatment, their dose should be initiated on the low side and then gradually increased every 3 to 7 days until the target dose is reached. Doses are usually given 3 to 4 times per day. If a dose is missed, give your child the missed dose as soon as possible. If it is almost time for your child’s next dose, skip the missed dose and return to their regular dosing schedule. Definitely do not give them a double dose!      

Recommendations

Clonidine is a less effective option than the stimulant medications for single drug therapy of ADHD, but it is being more frequently prescribed as an add-on to control aggression or to improve sleep. This means you may want to reserve clonidine as an alternative if the stimulant medications are not tolerable or as an add-on if more control of an overaroused, highly active, more aggressive, or easily frustrated child is needed. I would even go a step further by choosing guanfacine over clonidine because it has fewer side effects and because it has the potential of being dosed fewer times per day.   

If your child is started on clonidine and complains of dry eyes, you may offer them relief by giving them artificial tears. Constipation may be avoided by giving them a diet high in fiber, having them drink more liquids, and keeping them active. Lastly, dry mouth may cause cavities so help your child take good care of their teeth and be sure they see a dentist on a regular basis.

Any questions, comments, or concerns?  Let us know by leaving a comment below or e-mail me at Cate@getpharmacyadvice.com. 

Also, definitely grab our free video course on how to save money on your prescription meds by clicking on this link!

Here ya go

Trimethoprim-sulfamethoxazole (Bactrim, Septra, Sulfatrim) is a sulfa antibiotic combo that has been around since the 1960s. It is used in kids most commonly to treat urinary tract infections (UTIs), otitis media, chronic bronchitis, acne and typhoid fever.

Bactrim belongs to the class of drugs called sulfonamides. Bactrim is the most well-known of the group. Others include dapsone (Alczone), sulfadiazine and sulfasalazine (Azulfidine). These are the antibiotics that should be avoided if your child has a sulfa allergy.

Bactrim is available in IV formula, oral suspension (Sulfatrim) and tablets. It is approved for kids 2 months and older. Bactrim is dosed on the trimethoprim portion of the combo. Typical dosing for treating kids ranges from 6-20mg trimethoprim/kg divided into two to four doses a day. Dosing for UTI prophylaxis 2mg trimethoprim/kg once daily or 5mg/kg twice weekly.

Bactrim has an interesting way of fighting bacteria. It uses sequential inhibition. Which means it inhibits two enzymes necessary in the step by step process for bacteria to make folic acid. The sulfamethoxazole inhibits the first enzyme and the trimethoprim inhibits the second. Alone these antibiotics would be bacteriostatic but together they can actually kill the bacteria. On occasion, when taken for a prolonged period of time, this can actually decrease folic acid in humans.  However, this is rare for two reasons –human folic acid enzymes are less sensitive to Bactrim and humans can ingest folic acid.

Common side effects include belly upset, diarrhea, lack of appetite, headache, dry eyes and bladder stones. There are more serious side effects, mostly associated with an allergic reaction – the dreaded sulfa allergy.  An allergic reaction can create joint swelling and liver and kidney issues. Bactrim can also cause Stevens-Johnson syndrome, which includes a blistering rash and flu-like symptoms. Stevens-Johnson syndrome is scary but extremely rare with only about 300 new cases in the States a year and mostly in adult women. To avoid these severe side effects, Bactrim should not be given to patients with a known sulfa allergy or G-6-PD deficiency. If the child develops problems breathing or a rash, stop the antibiotic right away.

 If taking the suspension, it can be stored at room temperature.  Be sure to shake the suspension well before giving dose. If taking the tablets, drink it with a full glass of water to avoid the risk of bladder stones. The medicine can be taken with food if it causes belly upset. Bactrim can interact with quite a few other medications, so check with your child’s physician or pharmacist.

 Bactrim is available in generic so it is reasonably priced. It is a good first line choice for treatment of UTIs and a great option for kids with an allergy to penicillins.

Whadyathink?  Please leave a comment/question!

Azithromycin belongs to a group of antibiotics called macrolides.  Other macrolides include erythromycin (Ery-Tab), clindamycin (Cleocin), clarithromycin (Klaricid) and telithromycin (Ketek).  Macrolides work by preventing bacteria from multiplying and producing proteins that are essential for their growth. The bacteria eventually die or are killed by the immune system.  Macrolides are bacteriostatic. 

Just a note here about antibiotics and the difference between bacteriostatic versus bactericidal antibiotics.  Bacteriostatic antibiotics work by stopping the growth of the bacteria and helping to rid the body’s immune system of the bacteria.  Bactericidal antibiotics actually kill the bacteria. 

Azithromycin is available in tablets, suspension, IV and ophthalmic solution.  The solution is approved for kids over six months. Pediatric doses range from 5-20mg/kg.  Usually, azithromycin is started with a loading dose, so a common script will read as 10mg/kg on day one, 5mg/kg on days two thru five. That is right, typically treatment is for only five days!

In addition to the short duration of therapy, most kids really like the cherry/banana flavouring.  For those kids who are not fans of cherry/banana, azithromycin is easily flavoured at the pharmacy.  Azithromycin liquid is a suspension, which means always shake well.  It can be given with or without food, but with a meal may reduce and belly upset for the child. However, azithromycin should not be given with antacids that contain aluminum or magnesium because the antacid will bind the antibiotic and prevent absorption.  

Once azithromycin is reconstituted at the pharmacy, it can be stored at room temperature or in the fridge for 10 days.  The most common side effects are belly related –nausea, vomiting, diarrhea and belly ache.  Kids may also complain of headache, dizziness and agitation.  Rare side effects include kidney, liver and heart issues.  This may sound quite scary but the side effects are very rare and more likely when used in the IV formulation (which isn’t approved for children).

Oftentimes, I am asked why one antibiotic is chosen over another.  When deciding what antibiotic is best to use, we often consider the severity of the infection, where the infection is, what kind of bacteria is most likely causing the infection, patient specific information –like allergies and age, and price. 

Azithromycin is commonly a good choice for treatment in kids.  Available in generic, it is reasonably priced.  It is well received by both kids and parents and it is effective against many common childhood bacterial infections.

Just like adults, the majority of kids have low levels of vitamin D.   Kids are more likely to be inside and use sunblock, which blocks their ability to get some vitamin D from the sun.  Latino and African American kids have an even higher rate of low vitamin D levels due to darker skin -which blocks out the sun more.  

What do I give the kiddo?  400IU/day from a few months old until adulthood.       

How do you feel about vitamin D and your kids?  Do you give them supplements?  We would love to hear from you!

How do I give them 400IU/day?  Most parent’s turn to fortified milk or formula -1 glass only equals 100IU of vitamin D.  For kids, most multivitamins have 400IU.  For the babies, Tri-Vi-Sol or Poly-Vi-Sol have vitamin D (along with some other good vits).

Why give my kids vitamin D? Potential benefits for cardiovascular health and overall immunity.

I wanted to do a write up about griseofulvin because it is the most used to treat ringworm in kids that need an oral treatment. 

Griseofulvin (Grifulvin) is the current prescription drug of choice.  Griseofulvin was first isolated  in 1938 and yet, over 70 years later, it continues to be first line of treatment.  Griseofulvin is available in microsize suspension and tablets (Grifulvin V) and ultramicrosize tablets (Gris-Peg).  It has been approved in children older than 2 years old.

Griseofulvin works by inhibiting fungal growth and helps protect new skin from being infected. This means it stops the fungal infection from progressing, allowing the infection to clear as the infected skin dies and sheds.  Because it does not kill the fungi, griseofulvin has a long length of therapy.  General ringworm of the body is usually treated for two to four weeks, whereas infections involving the head or feet can be treated for as long as four to 12 weeks.  Yes, that’s right, 2 to 3 months of  treatment.

Griseofulvin is typically given to children in the suspension form because it allows specific weight based dosing.  Both suspension and tablets are best absorbed when taken with a fatty meal.  Peanut butter or ice cream are recommended, which makes administering the medication a bit easier for parents J.  The ultramicrosize tablets may be crushed and mixed with 1 tablespoon of applesauce and taken right away without chewing.

Griseofulvin has a low incidence of serious side effects.  The most common adverse reaction is headache.  Also included are belly upset, oral thrush, sensitivity to sunlight and dizziness.  Rare but serious side effects include liver toxicity and decrease in white blood cells; these often disappear even with continuation of therapy.  Perhaps most interesting and pertinent is the estrogen-like effects that griseofulvin can cause in children.  Estrogen-like effects in children can include bloating, depression, headaches, thyroid interference and impaired blood sugar control- once again serious but rare.

Other antifungal medications used to treat ringworm are terbinafine (Lamisil), itraconzaole (Sporanox) and fluconazole (Diflucan).  These drugs appear to have similar efficacy as griseofulvin but with a shorter therapy cycle, typically four weeks.

It is imperative to treat ringworm in children.  If left untreated, bacterial infections and permanent hair loss can occur.  Griseofulvin remains the drug of choice for treatment of ringworm, however this is mostly based on old information.  Back in the day, griseofulvin was the only treatment option available in generic formulation and was therefore bumped to first in line due to price.  Nowadays, all of the medications have some dosage forms available in generic.  When discussing your child’s treatment plan with her physician, be sure to consider the length of treatment, dosage forms and price of the medications.

What do you think?  Love to hear from you -please leave a comment!

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