The current options on the market for oral treatment of erectile dysfunction include:

1) Staxyn (vardenafil -oral disintegrating) -10mg 60 minutes before sexual activity.  Don’t chew, crush or break.  Best to take it without liquids; lasts ~4 hours

2) Levitra(vardenafil)-5-20mg 60 minutes before sexual activity; best to take on empty stomach; lasts ~4 hours

3) Viagra(sildenafil) -the original “blue pill”; 25-100mg 60 minutes before sexual activity; best to take on empty stomach; lasts ~4 hours (for some men it may lasts as long as 8-12 hours)

5) Cialis(tadalafil)-10-20mg 60minutes before sexual activity OR 2.5-5mg daily; take without regard to food; lasts ~36 hours

Common side effects for all of the medications: headache, flushing, runny nose, belly ache and back pain.  There are lots of drug interactions so first check with your physician and pharmacist.  They interact with drugs used to treat BPH and all of these meds should not be used if you are being treated with nitrates.

Studies show that they all work equally well and share most of the side effects.  Cost, ease of use, duration and patient preference help you and your physician decide what drug will work best for you.

Finally, what is the whole 4 hour erection thing all about?  Well, it is called priapism(which if you are a True Blood fan, Jason had a case of priapism during the first season).  It is a prolonged, painful erection lasting more then 4 hours without sexual stimulation.  It is due to blood being trapped and unable to drain from the penis.  It can be permanently damaging to the penis if not treated.  Priapism must be treated by a physician immediately.  Fun fact, priapism can also be caused by scorpion bites!

We would love some comments about which medication you feel works best!  So if you have any questions or comments please contact us!

Diabetes Type 2 Overview and Actos and Avandia -What’s the Deal?!

There has been a lot of controversy of benefits versus risks with these medications -especially Avandia.  For a while now, Avandia has been considered unsafe because it is associated with higher risk of heart attacks and strokes and worsened cholesterol levels.   

Well, for those who are still on Avandia, I am sure you will soon notice it is SUPER difficult to get it any longer.  Due to heart concerns, after mid-November, there is a new program that you and your physician will need to be enrolled in -just to be able to get Avandia.  It is the Avandia -Rosiglitazone Medicines Access Program (this link will take you to Avandia.com).  Only patients that are already on Avandia or have no other options will be able to get the medication through the program.  Avandia will no longer be available at your local pharmacy -ONLY through the program which will mail the medication to your home.

On the other hand, we have Actos (pioglitazone), which was considered the “safe” option.  Now, there are some murmurs about increased risk of bladder cancer with use of Actos.   The risk is really quite small, but best to avoid Actos if you have a history of bladder cancer. 

I hope this clears up why there is no Avandia to be found!  If you have any questions about switching to a different diabetes medicine -please leave a comment.  And if you are part of the Avandia program, we would love to hear how that is going for you!

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.  

I LOVE juice -what do I do?  Take the Allegra at night!  It is actually best to take the daily antihistamines (Allegra, Zyrtec, Claritin) at night.  This is because it is best to take the antihistamine 2-5 hours before being exposed to allergens.  And guess when pollen levels are at their worse?  Usually between 5-10 AM!  So, if Allegra is taken at night, you wake up ready to fight off allergens and free to drink as much juice as you want!

Does it hurt me to drink juice and take Allegra at the same time?  No, nothing bad will happen to you if you drink juice and take Allegra at the same time.  However, drinking juice and taking Allegra at same time can actually decrease the amount of Allegra that is absorbed (up to 50% in one study) -this means the Allegra doesn’t work as well.

What about orange juice, cranberry juice, grapefruit juice, grape juice….? Most of the stuidies have been with grapefruit juice, however what causes the interaction is in all fruit juices -so no juice is “safe”.

How long must I separate drinking juice and taking Allegra?  It is best to separate drinking juice and taking Allegra by at least 4 hours.  It is time dependent -so, if you take it together up to 50% won’t be absorbed, if you wait 2 hours 25% won’t be absorbed, if you wait 4 hours mostly all of it will be absorbed.

Can I just take twice the prescribed dose in order to overcome the loss caused by the orange juice? Not a great choice for a couple of reasons.  First, because it is not an exact science of how much Allegra is absorbed so most likely too much Allegra will get into the body.  This increases the risk of side effects.  And because doubling the dose is not very cost effective!

Is it the vitamin C in the juice that causes the interaction? No it is not the vitamin C that causes the interaction.  It is most likely caused by fruit juices inhibiting an organic anion transporting peptide (OATP1A2).  By inhibiting OATP1A2, the absorption of Allegra is reduced.

Why would Zyrtec advertise for Allegra? I really don’t know…

Which is better -Zyrtec, Allegra or Claritin? All three -Zyrtec (cetirizine), Claritin (loratadine) and Allegra (fexofenadine) are now available OTC and all work well.   Studies show that Zyrtec and Claritin are more likely to cause drowsiness then Allegra.  I must admit I am slightly biased because I heart me some Allegra  but others claim Zyrtec or Claritin works better for them.  I would think about cost and what works best with the least side effects for you personally.

If you decide OTC Allegra is for you -go visit their website and get a coupon! 

I hope this clears some questions up!  Thank you for all your comments and questions -please keep them coming!

Question: My father in law  takes a lot of medication and we are concerned that no one is keeping an eye on the big picture to make sure the medicines are all compatible.  The list of what he takes is below.  Are you aware of any possible problems associated with this combination of drugs. 
Glyburide 5mg Take 2 tablets twice a day.   Metformin 500mg Take one tablet twice a day   Simvastatin 40mg take one tablet once a day. Cozaar 50 mg take one tablet daily . Doxazosin 4mg   take one & half tablet at bedtime.
Thanks!

Here is my response:

Hi!  Thanks for contacting us!

Glyburide 5mg -2 tablets twice a day–Diabetes
Metformin 500mg -one tablet twice a day–Diabetes
Simvastatin 40mg -one tablet once a day –Cholesterol
Cozaar 50 mg -one tablet daily –Blood Pressure/kidney protectant
Doxazosin 4mg- one & half tablet at bedtime –BPH/ Blood Pressure

There aren’t any major interactions here.  Use of Cozaar, Doxazosin and Glyburide together can increase risk of blood pressure and blood sugar being too LOW.  This is easily monitored with testing blood pressure and sugar.
Also, he can monitor how he feels -low blood pressure: dizzy, fatigue, light-headed especially upon standing up.  Low blood sugar -light-headed, dizzy, sweating, headache.

He may want to consider adding…
1.  OTC CoEnzyme Q10.  This will help replace the CoQ10 that is decreased from the simvastatin.
2.  OTC B12 (or B-complex).  This will replace the B12 that is decreased from metformin
3.  Talk to physician about adding OTC calcium and vitamin D supplements -for general health and to counteract calcium depletion by Cozaar.

Lastly, are these medications working for him?  Are they controlling his
blood pressure, cholesterol and blood sugar/ A1c?

Hope this helps!  Please contact us with any questions/comments.

There you have it!  Of course, this is quite specific for this patient but if you have questions about your or your family member’s medications -please leave us a comment, submit a question or send an email at nova@getpharmacyadvice.com .

Finally, my video on the good and the bad of Provigil.  I’ve been promising this one for a long time, but somehow I let my normally disorganized self get disorganized yet again.  I was on a roll there for a bit, then came the holidays and another side project and off I was, on the road to disarray. 

Reset!  No better time than this very moment to get back on track.  Here’s my video:

As you can tell, it was a long day at work!  No, it’s not the 1st day of the month, as stated in the video, but it was the first Monday of the month and the year…recipe for craziness. 

To go along with this video, I previously posted a clip called “Overview of Provigil.”  Check it out by clicking on the link!

Please comment below, let’s get a conversation started!  You can also e-mail me at Cate@getpharmacyadvice.com.

Good night.

First, some background-what is gout all about?

It is a condition caused by chronically high blood levels of urate/uric acid.  Only 1/3 of patients actually develop symptoms.  Joints are the most commonly affected by the high uric acid -like the big toe!  Gout can also cause kidney stones. 

What kind of symptoms does gout cause?

Gout can cause swelling, redness and tenderness of the joint -which most people describe as “painful!”  The good news is that most gout attacks will eventually clear up (within a few days to a few weeks) even without treatment.

How is gout treated?

There are two ways to treat gout -by decreasing the amount of urate in the system by increasing clearing the urate from the system OR by decreasing the amount of urate produced by the body.

Typical treatments include allopurinol, colchicine and NSAIDs.

What are the new medications available to treat gout?

1.  Uloric (febuxostat) : This medication works like allopurinol -so it helps lower uric acid in the body.  It hasn’t really been proven to be any better then allopurinol with typical dosing.  So, with the price being about 20 times more then allopurinol (!)  go ahead and stick with allopurinol.  Uloric can be used IF allopurinol is not tolerated.

2.  Krystexxa (pegloticase): This medication works by breaking down the uric acid.  This medicine can seriously lower uric acid levels -the bad side is that it is 10 times more expensive then Uloric (which is 20 times more expensive then allopurinol) …pricey!  AND it has some major side effects, including risk of severe allergic reactions, gouty flares and possibly making heart failure worse.  Some major thought weighing positives and negatives should be done before starting on this med.

There you go -some info on the new meds.  Have some questions or input -LOVE to hear from you!  Please leave a comment or email me at nova@getpharmacyadvice.com

Just a note:  One remedy I talk about in the video (little  spoiler alert) is pilocarpine 2% eye drops mixed with water and taken orally.  Ryan took time to leave a comment below -he was concerned that people may mistake pilocarpine 2% eye drops with a typical OTC eye drop (like Visine-which is dangerous when taken orally).    I could totally see this happening so I wanted to make a note that the only eye drops that would work for dry mouth are PILOCARPINE 2% -so talk with your physician or pharmacist about it. 

Note #2: Isn’t Toshi (the shih tzu) too cute?

I would love to hear all about your dry mouth remedies…please leave a comment!

I saw your Youtube page and I am now interested in getting some advice from you.  I have some flushes in my face and they turn a patchy red by my cheeks, towards my nose. My doctor prescribed me Metronidazole, Ovace,
and Doryx. I am fine taking the Metro lotion and ovace but I am a little “iffy” about taking the oral antibiotic, Doryx. My flush isn’t too bad but it is a bit noticeable. Combined with these other medications, would it be best to try to topical lotion first?

 Also, with the metro lotion, will alcohol still effect me if the metro is topical? I know that we shouldn’t mix alcohol with anything, but  I’m wondering if it makes a difference if it is topical or oral.

 To my understanding, antibiotics can kill the ‘good’ bacteria. I don’t like using antibiotics ever even if I have a sinus infection. I believe it is best for my body to build up that defense on its own.

Please let me know your thoughts on this. And thanks for sharing your advice.

Here is my answer: 

I am glad you contacted us!  Your symptoms and medications point toward you having rosacea.  There are a couple of options at this point.  

 1)  Start with topical medications only -which can take over 6 weeks for symptoms to improve.  Oral antibiotics can always be added later if needed.

 2) Start with topical and oral for about 4-6 weeks then slowly (over 4 weeks) taper off the oral antibiotics.   

The benefit of starting with topical and oral is that the symptoms will improve more quickly.  However, it is not a bad choice to just use topicals alone.   Just an FYI here about saving money with Doryx.  Doryx is extended release doxycyline.  To save money, you can take generic doxycyline twice a day instead of Doryx once a day.  It depends -money versus convenience.  

 The topical treatment of metronidazole should be safe with alcohol because it is minimally absorbed into the body.  

You are right -antibiotics do not discriminate -they kill good and bad bacteria.  We have “good” bacteria in our gut that the antibiotics can kill and cause issues such as fungal infections, belly ache and diarrhea.  If you choose to take the oral antibiotics, consider also taking probiotics.  The probiotics replace the good bacteria.  To get these probiotics, you can either eat yogurt daily or if that is not your thing, you can find capsules of acidophilus or lactobacillus OTC at most pharmacies.   

Okay, almost done here!  Just a note about rosacea and lifestyle changes.  There are some triggers that can worsen rosacea -everyone is different so your triggers can be unique to you.  However, general triggers include: spicy food, hot foods, alcohol -red wine, hot temperatures and sunlight.

End of email!

Would you like to discuss rosacea some more?  Please email me at nova@getpharmacyadvice.com or just leave us a comment!

Some time ago (not sure of exact date) I made a video explaining what to do if you vomit after taking your medication (click here to see video).

A couple of days ago I received this question from a reader (a real life scenario on the topic at hand!):

Roughly 30 minutes after taking my bp meds:lisinopril 40mg, methyldopa 250mg, Hctz 25mg, I vomited. Should I redose?

This answer may be confusing, but hopefully you’ll get the jist of my message!

Very interesting situation you’re in…blood pressure medications are certainly important.  In your case, I would consider how well your BP is being controlled.  Are you at your goal blood pressure with your medications on a consistent basis?  Have you had any cardiovascular events (i.e. heart attack, stroke, etc.)?  The less severe your case, the better I’d feel about not re-dosing your meds!

Most likely some of each of the medications got into your bloodstream, but probably not to the full extent they usually do.  If I were you, I’d redose one of them (whatever one you’d like -none of them will be over max dose if you take them again), and then you can see how you feel. 

If you end up with a headache, it’s likely you’re BP is up.  You could take another one of your BP meds at this point.  If you feel dizzy or light-headed, it may be that your BP is low (most you can do here is sit/lay down and wait it out…should be fine in a bit!).

If you don’t feel anything, that’s okay too.  Just resume your regular dosing schedule the next day!  Hope this helps and wasn’t too confusing. Let me know if I need to be more clear!

Thanks for getting in touch,
Cate

If any of you are confused about my answer or have further questions, please get in touch with me at Cate@getpharmacyadvice.com or leave a comment below.

And I highly suggest you check out our video course on how to save money on your prescription meds…it’s free for you and will help you keep that moolah in your wallet or bank account or pocket! 

Peace out.