Tag Archives: corticosteroids

Most Medications Don’t Help Knee Osteoarthritis Pain Long Term

If you suffer from knee osteoarthritis (OA) and think drugs can bring you pain relief over the long term, a new meta-analysis is challenging that assumption.

Researchers examined trials that 47 that enrolled more than 22,000 people with knee OA who were given 31 different types of medication as treatment for at least a 12-month period. These including analgesics such as NSAIDs (non-steroidal anti-inflammatory drugs), bisphosphonates, a type of bone-strengthening drug usually used in osteoporosis, injections into the knee such as hyaluronic acid and corticosteroids; and the supplements glucosamine and chondroitin.

Results, published in JAMA, showed that only two medications, Celebrex (celecoxib) and glucosamine, were associated with reduced pain after 12 month. However, researchers noted, 30% of Celebrex trials were determined to have a high risk for bias. When these trials were not considered, Celebrex was determined not to have significant effectiveness. Glucosamine was associated with a small improvement in pain and a significant improvement in physical functioning.

“Larger [trials] are needed to resolve the uncertainty around efficacy of medication for knee” OA, the study’s authors concluded.

MedShadow’s Top 10 Stories of 2018

What were the most popular stories we published in 2018? Our Top 10 includes two stories on drugs that have become popular among opioid abusers, as well as articles dealing with drug interactions, a controversial class of antibiotics and a first-person story on an herbal supplement that has come under attack from the FDA, among others. Here are excerpts of the stories with the highest readership.

1. Gabapentin’s Secret: The Drug Opioid Abuser’s Crave

By Ronni Gordon

For many people who take gabapentin – a drug prescribed to treat seizures and pain caused by shingles – side effects such as sedation can be a challenge, as those who take it off-label for neuropathic pain told MedShadow in the past.

But an increasing number of opioid abusers crave that side effect, reporting a calm feeling when combining gabapentin – developed by Pfizer under the brand name Neurontin – with opioids, muscle relaxants and anxiety medications. Some also get a marijuana-like high and an enhanced euphoria. But when overused or abused, it can cause significant organ or brain damage. Read more →

2. Managing Eczema: Are New Treatments Like Eucrisa Worth It?

By Madeline Vann

Eczema (atopic dermatitis) can feel like a moving target for people who live with it. They get control over one flare, only to have eczema redden and irritate another patch of skin. For some patients, changing their bathing and beauty habits along with a thick moisturizer and topical corticosteroid ointments are enough.

“Steroids are the mainstay of treating atopic dermatitis. They’ve been around for decades. They are generally inexpensive, and for the vast majority of patients, that’s how we start treatment,” explains dermatologist Amy Paller, MD, director of the Northwestern University Skin Disease Research Center in Chicago. American Academy of Dermatology (AAD) guidelines recommend using emollient moisturizers, lifestyle changes to avoid triggers, and corticosteroids at first. Read more →

3. How Imodium Became Appealing to Opioid Addicts

By Padma Nagappan

A sports injury from playing squash in high school lead to a herniated disc for Bob Johnson (name changed to protect his privacy), who was initially given codeine for his pain, and then bumped up to hydrocodone, which is more powerful and used to treat severe pain.

He stopped taking the drugs once he began recovering. All was well until he left for college in Philadelphia and started playing on the squash team — and his back began hurting again. He found it was easy to get access to drugs and began buying OxyContin (oxycodone) from a dealer. Read more → 

4. What is the Best Way to Treat Heat Rash?

By Dave Walker, RPh

Question: It’s summer and I’m going to be spending a lot of times outdoors. I’m susceptible to heat rash. What is the best treatment for it?

I remember anticipating summer vacation as a kid. We were always busy planning and participating in neighborhood sporting activities, biking, hiking, fishing and camping trips. The neighborhood moms always had a ready supply of Band-Aids, Bactine and antiseptic cream to take care of those expected and inevitable scratches, scrapes, cuts and insect bites along the way. Read more →

5. 4 Drugs That Interact with Anxiety Meds

By Christy Huff, MD

If you suffer from anxiety, panic disorder or insomnia, your doctor may have prescribed you a tranquilizer belonging to a class of drugs known as benzodiazepines.

Drugs such as Xanax (alprazolam), Valium (diazepam), Ativan (lorazepam), and Klonopin (clonazepam) are some of the most-prescribed medicines – more than 133.4 million such prescriptions were filled in the US in 2014. As with any medication, drug interactions can occur if you take a benzo with another medication, and in certain cases, may be life-threatening. Read more → 

6. Why Aren’t Seniors Getting the Shingles Vaccine?

By Rita Colorito

Nearly 12 years after the FDA approved Zostavax, the first vaccine to prevent shingles in adults 60 and older, the vast majority of seniors still haven’t received it. Only 30.6% of adults age 60 and older reported getting the shingles vaccine, according to the latest CDC (Centers for Disease Control and Prevention) assessment of vaccine coverage.

Since it became available, Zostavax has faced numerous barriers in terms of getting seniors vaccinated, the assessment found. In October, the FDA approved a new shingles vaccine, Shingrix, for people age 50 and older. Less than a week later, the CDC’s Advisory Committee on Immunization Practices (ACIP) recommended Shingrix as the CDC’s preferred shingles vaccine for adults age 50 plus due to Shingrix’s better efficacy and fewer side effects compared to Zostavax. Read more → 

7. Floxed! The Painful, Life-Lasting Effects of Some Antibiotics

By Suzanne B. Robotti

Last week, we ran a news story on antibiotics causing “rare” damages to people. We had a very passionate response from more than 75 people who all claimed to be harmed by a particular type of antibiotics. More than 60,000 people have complained to the FDA about them. It begs the question, how unusual are these “rare” harms.

The side effects and adverse events associated with Cipro, Levaquin and other fluoroquinolones (FQs) can be significant and life altering. Yet many people who have been damaged by fluoroquinolones complain that there are too few warnings. Many claim that doctors don’t believe that their new illnesses have come from the FQs. Worse, sometimes FQs are prescribed when other, less risky — and just as effective — antibiotics are available. Read more →

8. The FDA Has It Wrong on Kratom: How the Herb is Helping People Like Me

By Andrew Turner

Some may ask who are the consumers of kratom, an herb used to treat pain, depression and anxiety that has been the subject of controversy lately in the news. It’s complicated.

We can be anyone. We are your neighbor, the veteran in the supermarket, your college professor and even your best friend. There’s a lot of misconceptions about kratom, how it’s used to treat certain ailments and its potential for addiction. Read more →

9. Can An Opioid Addiction Drug Treat Autoimmune Disorders

By Deborah Lynn Blumberg

A slew of drugs, both new and old, are used to treat autoimmune disorders like multiple sclerosis (MS), lupus and Crohn’s disease. Most of them come with side effects, some of them serious. But research and experience from patients and doctors are mounting that a drug used to treat substance abuse, when used in lower doses, can effectively treat autoimmune conditions with few side effects.

The drug is naltrexone, which was first approved in the 1980s to treat heroin addiction. In recent years, it has been prescribed more and more at a low dose for patients with autoimmune disorders. But is this off-label use (yet to be approved by the FDA) safe and effective? Read more →

10. Pros and Cons: Prednisone

By Tori Rodriguez

If you visit the doctor from time to time for anything other than a routine checkup, it’s likely that at some point you’ve received a prescription for a type of drug called corticosteroids. These are among the most commonly prescribed medications in the US, and they are used in almost every medical specialty.

In a study published last year, researchers at the University of Michigan found that 1 in 5 American adults with commercial health insurance had been prescribed a corticosteroid at least once over a 3-year period. Read more →

What You Need to Know About Gout Treatments

Gout has a name-recognition problem.

Even though its prevalence is increasing dramatically in the US, many physicians don’t recognize how serious the condition can be, says N. Lawrence Edwards, MD, a rheumatologist with University of Florida Health in Gainesville and chairman of the Gout & Uric Acid Education Society. (Editor’s note: The society receives funding from pharmaceutical companies.)

“We know more about gout’s causes and genetics than any other form of the disease, yet it remains one of the most poorly treated forms of arthritis,” Edwards says.

This very painful form of inflammatory arthritis is caused when uric acid crystals accumulate in the joints. It can manifest through sudden, severe pain, redness, tenderness and swelling in the joints, and often starts with the big toe.

About 4% of American adults have gout, about double what it was 30 years ago, Edwards says. It impacts about 8.3 million Americans.

The rate is soaring because of an aging population, and is also impacted by the obesity epidemic, he notes.

Treating Short-Term Gout Attacks

To treat short-term gout attacks, doctors typically prescribe NSAIDs (non-steroidal anti-inflammatory drugs) such as Advil (ibuprofen) or Aleve (naproxen), the pain reliever Colcrys (colchicine) or corticosteroids, says Rajat Bhatt, MD, a rheumatologist in Kennewick, Washington.

Prescription NSAIDs such as Celebrex (celecoxib) can be taken at a high dose during an acute attack, and then taken at a lower daily dose to try to prevent further attacks. However, they can cause stomach pain, bleeding and ulcers.

Colchicine is used to reduce gout pain. Low daily doses might be prescribed to prevent future attacks. Side effects can include nausea, diarrhea and vomiting.

Corticosteroids, such as prednisone, can be prescribed to reduce pain and inflammation. They can increase blood sugar levels and blood pressure and may induce mood changes.

Long-Term Treatment

For many, however, gout is a chronic condition. Long-term treatment comes from medications that reduce uric acid levels. “Very good approaches have been around for a long time,” Edwards says.

This includes Zyloprim (allopurinol), a xanthine oxidase inhibitor (XOI) that reduces uric acid production. The Mayo Clinic warns that taking allopurinol during a gout attack may make the attack worse or increase the likelihood of an attack right after you’ve started taking it. Edwards says about 10% of patients can’t tolerate the drug because of stomach problems or rashes.

Uloric (febuxostat) is another XOI that can reduce uric acid production, thus reducing the frequency and severity of attacks. But it can cause joint and muscle pain and nausea.

Zurampic (lesinurad) can be prescribed along with an XOI to help reduce uric acid levels if an XOI isn’t effective enough on its own. However, the Mayo Clinic warns it can increase cardiovascular risks. It can also cause other side effects, such as headaches, flu-like symptoms and kidney stones.

If other gout medications haven’t done the trick, Krystexxa (pegloticase) can be given every two weeks as an intravenous infusion. It changes uric acid into a substance called allantoin that is easily eliminated from the body. It can cause gout flare-ups, allergic reactions and chest pain.

Deformed Toes and Relief

Larry Whited, a 78-year-old manufacturing company owner in Cleveland, was diagnosed with gout when he was in his early 50s. He was playing racquetball and initially thought he had broken his ankle. It was a gout flare-up.

He was prescribed allopurinol at the time, but “it never really broke down the uric acid in my body.” As a result of the drug not working for him, his fingers and toes became deformed and he had “pretty severe [gout] attacks on occasion.”

In 2016, Whited was referred to the Cleveland Clinic for a six-month clinical trial of Krystexxa (pegloticase). Initially he received the injection once a week for a month, and it dramatically lowered his uric acid levels. The injection frequency was lowered to once every two weeks, and he now receives it once every three weeks.

He says many others who were enrolled in the clinical trial had to drop out because of side effects, but he has not had any problems with the medication. In fact, with Krystexxa, swelling in his feet and hands decreased dramatically.

For 15 or 20 years, Derrick Mancini, a professor and distillery owner from Riverside, Illinois, would experience occasional minor gout flare-ups in his big toe, which his general practitioner told him to treat with anti-inflammatory medications. His doctor also told him to decrease his red meat consumption and to avoid beer.

Yet the flare-ups continued. “Every time, it was a little bit worse,” and gradually affected multiple toes and then his feet. Eventually “my entire foot blew up,” the 62-year-old says. His general practitioner sent him to a rheumatologist who diagnosed Mancini with chronic gout.

Mancini was prescribed Zyloprim by his rheumatologist about three years ago. He hasn’t experienced any side effects and his uric acid levels have remained relatively constant. “I have not had another bout since.”

Dietary Changes to Minimize Medicines

Although gout may be inevitable for some, dietary and lifestyle changes may reduce gout flare-ups and reduce the needs for drugs. Certain foods, such as red meat, some seafood and alcohol, are known to contain high levels of purines, substances in plant and animal food that your body converts to uric acid. Bhatt recommends a vegetarian, low-purine diet to decrease the likelihood of gout attacks. Low-purine foods include low-fat non-fat dairy products, vegetables, nuts and grains. He also recommends that patients maintain a healthy weight, as obesity is associated with gout.

The Gout & Uric Acid Education Society also recommends limiting intake of fruits that contain a high level of fructose, a naturally occuring sugar, as well as cutting back on soft drinks, which contain high-fructose corn syrup. Fruits high in fructose include apples, grapes, peaches and pears. In addition, you should avoid cereals, ice cream, candy and fast food, as they can be high in sugar and salt.

As part of the long-running Nurses’ Health Study, researchers looked at the relationship between coffee consumption and the risk of gout in nearly 90,000 women over the course of 26 years. It found a reduced risk for women who consumed coffee, according to a 2010 study published in the American Journal of Clinical Nutrition.

Meanwhile, a study published in the journal Arthritis & Rheumatism in 2012 found that consuming cherries can help reduce uric acid and was associated with a 35% lower risk of gout attacks. Eating 20 cherries a day provided the beneficial effect. Less than that number didn’t help. Using a cherry extract also helped to lower gout attacks. And combining cherries and allopurinol was found to reduce the risk of gout attacks by 75%.

Edwards says drinking cherry juice can decrease gout flare-ups, but patients who need “a uric acid medication need to stay with it for life.”

Quick Hits: Decongestant Warning for Children, Prostate Cancer Treatment and Dementia & More

Children under the age of 12 should not be given decongestant medications for a cold as they can have adverse effects and are not effective, according to a new analysis. Researchers examined existing trials that looked at treatments for colds, including decongestants, antihistamines, analgesics, nasal corticosteroids, antimuscarinics and saline nasal irrigation. The analysis showed that short-term use of decongestants can lead to stomach upset, headache, insomnia and drowsiness. Long-term use can lead to chronic nasal congestion. They also reported that there are cases of decongestant use in children under 2 leading to convulsions, rapid heartbeat and death. Part of the problem, researchers say, is that there are relatively few studies examining cold treatment use in children 12 and younger. And while pain relief medications such as Tylenol (acetaminophen) are used during colds, they don’t improve nasal congestion. The researchers say most of the over-the-counter cold remedies either don’t work well or lack evidence that support their benefit. Published October 10, 2018. Via The BMJ.

Androgen deprivation therapy (ADT), used in prostate cancer treatment, is not associated with an increased risk of dementia, according to a new study. The observational study followed 45,000 men diagnosed with prostate cancer for an average of 6.8 years. There was no statistically significant association between those treated with ADT and developing dementia or Alzheimer’s disease. Last year, two studies, published within weeks of each other, came to conflicting conclusions on a link between ADT and dementia. Posted October 11, 2018. Via JAMA Oncology.

The FDA has expanded the use of the HPV (human papillomavirus) vaccine Gardasil 9 to men and women between the ages of 27 and 45. The vaccine was previously approved for men and women ages 9 to 26. Gardasil 9, which is given as either a 2- or 3-shot regimen, can help protect females from cervical, vaginal, vulvar and anal cancer and protect men against anal cancer and genital warts. The most commonly reported adverse events with the vaccine are pain at the injection site, swelling, redness and headaches. Although some have expressed concerns about potential serious side effects associated with the vaccine, a Cochrane Review published this year found those concerns unwarranted. Posted October 5, 2018. Via FDA.

Quick Hits: FDA Raids E-Cig Manufacturer, Asthma Drugs’ Side Effects & More

The FDA conducted a surprise inspection of JUUL Labs as part of the agency’s effort to gain more information on the e-cigarette company’s sales and marketing practices. The FDA reportedly seized more than 1,000 documents. The action comes just weeks after the FDA ordered JUUL and four other manufacturers to come up with plans to curb use of e-cigs by teens. JUUL has the largest share of the e-cig market, and its sales grew more than seven-fold from 2016 to 2017, according to newly released data from the CDC (Centers for Disease Control and Prevention). The CDC also noted that JUUL has among the highest nicotine content of e-cigs available. Posted October 2, 2018. Via CDC.

More than half of people with asthma that take oral steroids such as prednisolone experience significant side effects, according to a new survey. Asthma UK, a charitable organization, interviewed 1,200 patients with severe asthma, most of whom had at least two asthma attacks in the prior year and were on an oral steroid. Of those on a steroid, about 56% experienced weight gain, 55% had trouble falling asleep, 43% were more irritable and more easily upset. And 37% said they were more anxious and had less energy. Asthma UK said that healthcare providers should use newer biologic-based drugs known as monoclonal antibodies to treat asthma, as they have been shown to reduce asthma attacks by up to 50%. Some of these medications include Xolair (omalizumab), Cinqair (reslizumab) and Nucala (mepolizumab). However, they are more expensive than oral steroids. Posted October 2, 2018. Via The Times.

About 20% of people with Alzheimer’s disease use two or more psychotropic drugs that can raise the risk of experiencing adverse events. Researchers in Finland examined the medical records of more than 70,000 people diagnosed with the disease. Antipsychotics were eight times as likely to be prescribed in those with Alzheimer’s compared to those without the disease. The use of at least two psychotropics together was three times more common among people with Alzheimer’s. The most common combination was an antidepressant with either an antipsychotic or benzodiazepine, a class of medications used for anxiety and sleep. Use of acetylcholinesterase inhibitors, a first-line dementia treatment, such as Aricept (donepezil), was associated with less risk for psychotropic polypharmacy, while use of Namenda (memantine), another dementia drug, was associated with a higher risk. Posted October 1, 2018. Via European Neuropsychopharmacology.

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Pros and Cons: Prednisone

If you visit the doctor from time to time for anything other than a routine checkup, it’s likely that at some point you’ve received a prescription for a type of drug called corticosteroids. These are among the most commonly prescribed medications in the US, and they are used in almost every medical specialty.

In a study published last year, researchers at the University of Michigan found that 1 in 5 American adults with commercial health insurance had been prescribed a corticosteroid at least once over a 3-year period.

While its importance is undeniable, you should know corticosteroids such as prednisone come with downsides — a long list of side effects and interactions with numerous other medications. Corticosteroid use is one of the top reasons people are admitted to hospitals due to drug-related adverse events.

Benefits of Prednisone

One of the most widely used corticosteroids is prednisone, a “manufactured hormone similar to the natural hormone, cortisone, produced by humans,” according to Norman P. Tomaka, BSPharm, MS, FAPhA, a media liaison for the American Pharmacists Association and consultant pharmacist and healthcare risk manager based in Melbourne, Fla.

“Prednisone is an anti-inflammatory drug that reduces the body’s immune response in order to manage many different health conditions, including breathing problems, severe allergies, inflamed skin, serious eye swelling, serious arthritis, bowel disorders, blood disorders and certain cancers,” said Tomaka.

Depending on the condition, the drug is used on a short- or long-term basis, and it can be taken in several ways, including pill or liquid form. Along with the extensive number of ailments that it may relieve, there are lots of benefits associated with prednisone treatment when prescribed appropriately. For example, it is a rapid-acting medication, meaning it gets to work quickly once taken. It can also be adapted to a “variety of dosing schedules tapered to the patient’s specific condition and length of treatment,” Tomaka explained.

Risks of Prednisone

More serious side effects, such as an increased risk of infections, psychological effects and weakening of bones/fractures are associated with longer-term use.

Mixing corticosteroids such as prednisone and anticoagulant medicines (e.g., heparin, warfarin, dabigatran, apixaban and rivaroxaban) can make anticoagulants less effective. Also, combining NSAIDs (non-steroidal anti-inflammatory drugs) such as aspirin, ibuprofen, diclofenac and naproxen with corticosteroids increases your risk of developing stomach ulcers and internal bleeding.

When used short-term, prednisone is generally well-tolerated, and when side effects do occur in this scenario, they usually clear up quickly after treatment ends. Even with short-term use, however, some people do experience side effects such as fluid retention, weight gain, fatigue, increased blood sugar, stomach irritation, irritability and increased alertness and hunger.

In the University of Michigan study mentioned above, there was a major increase – by up to 5 times – in rates of several adverse events, particularly sepsis (a bacterial blood infection), venous thromboembolism (a blood clot in a deep vein) and bone fracture, in patients who were on corticosteroids for a short time. These issues occurred even at low doses, and the higher risk of adverse effects lingered even weeks or months after patients stopped taking the drug.

You should also be aware there is the potential for psychological side effects. Prednisone affects areas of the brain that manage the regulation of different neurotransmitters, including serotonin and dopamine — both of which can impact mood.

When fitness instructor Gabriela Correa suddenly developed a red, itchy rash over most of her body, her dermatologist prescribed a one-week course of prednisone. After a few days of taking it, however, Correa felt noticeably more anxious – she was “freaking out for no reason,” as she put it – and had trouble falling and staying asleep. She called her doc, who advised her to stop taking prednisone. Fortunately, most of the rash had already cleared up by then, so no further treatment was needed, and she did not experience any additional problems related to the medication.

When prednisone is used on a long-term basis for the treatment of a serious medical condition, patients should be monitored for negative effects that may include a reduced ability to fight infection, reduced wound healing, softening of bones, skin discoloration, increased sweating, mood swings and behavioral changes, digestion problems, muscle weakening, glaucoma and decreased sex drive.

Staying Safe

If your healthcare provider recommends prednisone, Tomaka offers the following tips about how to avoid side effects:

  • Before starting prednisone, be sure to communicate with your prescriber regarding the details of your past medical history and all medications you are taking or have taken recently
  • Do not take more than the dose prescribed.
  • Take the medication at the time of day directed by the prescriber.
  • Take each dose with food or milk to prevent stomach irritation.
  • Avoid alcohol and other irritating foods and beverages while taking prednisone.
  • Finish your course of treatment as instructed by the prescriber.

There are certain signs that might point to a more serious problem that requires more immediate attention. If you develop any of the following symptoms, you should promptly call your pharmacist or healthcare provider for immediate guidance.

  • Any blood in your stool
  • Nausea and/or vomiting
  • Constipation or diarrhea
  • Chest pain
  • Visual disturbances
  • Serious swelling in your ankles and/or feet
  • New infection or wounds
  • Fever
  • Increased or decreased blood pressure
  • Serious behavioral disturbances, such as hallucinations or delusions

“Most patients benefit from short-term prednisone treatment, while others require low-dose maintenance therapy with medical supervision and routine lab work,” Tomaka said. “Depending on the seriousness of the condition treated, the benefit of using prednisone may outweigh the risks.”

Closely following prescription instructions, clearly communicating with your provider about your health and medication history, and keeping an eye out for signs of a negative reaction can help you reap the intended benefits of this common medication while minimizing its many potential risks.

What Are the Best Treatments for Bug Bites?

Outdoor parties, barbecues, picnics, hiking and camping trips are all great ways to celebrate summer with family and friends. And it’s all well and good until the bugs begin bugging you. Whenever I go on an outing, it seems inevitable: If there are mosquitos out there looking for a meal, they’ll always find me before choosing another victim.

Although mosquitos are the big culprits for me, I’m also allergic to flea bites. Both of these insects are just looking to make an easy meal out of my blood. In contrast, most other insects only sting or bite as a defense mechanism. Bees, wasps, hornets, yellow jackets and even spiders are only trying to protect themselves, their hive or nest.

Treatment of an insect bite or sting depends on the severity. Most insect bites result in a typical itchy, swollen, red blister-like irritation that can be treated by immediately washing with soap and water and applying ice to the area. This is helpful to prevent infection and reduce symptoms by slowing their progression. If the area becomes inflamed or itchy, use over-the-counter hydrocortisone creams, triamcinolone cream or a topical antihistamine (Benadryl).

My favorite is hydrocortisone 2.5% cream, although this requires a prescription. I use this higher-strength cream as soon as I realize I’ve been bitten. It constricts the blood vessels around the area of the bite. This seems to help lessen the spreading of the reaction and provides improved anti-inflammatory effect, often with only 1 or 2 applications.

Some bee stings and spider bites will need medical attention. A sting or bite that results in hives, swelling of the face, wheezing or difficulty in breathing, dizziness or fainting needs to be evaluated by a medical provider. Any individual who has a history of serious reactions to insect bites or stings needs to be examined.

More severe reactions may occur, including unconsciousness or even death in some individuals. I’ve also seen a few brown recluse spider bites that looked innocent enough but later progressed to skin infections with cellulitis requiring oral antibiotics. Watch for increasing pain or symptoms of increased redness, pus or a red streak that spreads toward your body.

You can protect yourself before you go outdoors by using an insect repellent containing DEET. You can also treat your clothing, shoes, bed nets, etc. with permethrin-containing repellents (Permanone) to ward off insects.

Analysis Confirms Combination Inhalers Don’t Increase Asthma-Related Death Risk

Four safety trials have concluded that popular combination inhalers — like Advair (fluticasone/salmeterol) and Symbicort (budesonide/formoterol) — are not associated with an increased risk of asthma-related hospitalizations or deaths, undermining previous findings. LABAs (long-acting beta agonists) such as salmeterol and formoterol, and combination products containing them, received a boxed warning in 2003 because findings at the time suggested that LABAs were associated with serious adverse outcomes, including asthma-related hospitalization, intubation and death.

In 2011, the FDA required the manufacturers of the combination inhalers to perform studies where they compared an inhaled glucocorticoid (corticosteroid) – such as fluticasone or budesonide – plus a LABA (combination therapy) with an inhaled glucocorticoid alone. The analysis included 36,010 patients who participated in the 4 trials. In each trial, patients were randomly assigned to receive a combination therapy (inhaled glucocorticoid plus a LABA) or an inhaled glucocorticoid alone.

The results, details of which were recently published in the New England Journal of Medicine, indicated that there is not a higher risk of severe asthma-related outcomes (endotracheal intubation or death) among patients who receive combination therapy than among those who receive an inhaled glucocorticoid alone.

In December 2017, the results prompted the FDA to remove the “black box” warning from combination products that warned of an increased risk of asthma-related deaths. However, medications that contain just a LABA retain a boxed warning of an increased risk of asthma-related death.

Managing Eczema: Are New Treatments Like Eucrisa Worth It?

Eczema (atopic dermatitis) can feel like a moving target for people who live with it. They get control over one flare, only to have eczema redden and irritate another patch of skin. For some patients, changing their bathing and beauty habits along with a thick moisturizer and topical corticosteroid ointments are enough.

“Steroids are the mainstay of treating atopic dermatitis. They’ve been around for decades. They are generally inexpensive, and for the vast majority of patients, that’s how we start treatment,” explains dermatologist Amy Paller, MD, director of the Northwestern University Skin Disease Research Center in Chicago. American Academy of Dermatology (AAD) guidelines recommend using emollient moisturizers, lifestyle changes to avoid triggers, and corticosteroids at first.

However, some people with eczema find those first steps offer little relief. For these people, new eczema treatments offer renewed hope.

When Corticosteroids Aren’t Enough

Jennifer Merrill, a resident of western Maine, is among those for whom eczema remains a frustrating puzzle. She’s had eczema since childhood. The 40-year-old managed to reduce the eczema on her scalp by washing her hair less frequently and abstaining from hairspray – only to find that eczema moved to the skin around her lips, eyes, wrist and stomach. A dermatologist prescribed a number of different creams, including topical corticosteroids.

“The steroids started to work in the beginning, but quickly things went from bad to worse,” she recalls.

Dr. Paller acknowledges that corticosteroids aren’t good options for everyone.

“Sometimes we have patients who can’t just intermittently put on steroids, clear their skin up, and use moisturizers. They are more chronic,” she says.

A different dermatologist put Merrill on antibiotics and a nonsteroid prescription medication, Elidel (pimecrolimus).

“Things calmed down a bit, but I would get random flares. After about six months on antibiotics I went back, at which time she did a biopsy and the results were eczema,” she says. At that point, Merrill’s dermatologist gave her samples of a medication approved for use on eczema in 2016: Eucrisa (crisaborole).

“It has helped somewhat. Pretty much cleared up the patches on my wrist, has helped but not completely cleared my face, and has done nothing for my stomach. The area I need to use it the most now is around my lips. I’ve used it on my wrists and belly and felt no side effects, but when applied around my lips it burns and itches like crazy! After a few minutes it will go away, but those first few are torture,” she says.

People like Merrill find their eczema requires a menu of strategies, including the relatively new topical Eucrisa (crisaborole).

Eucrisa was approved by the FDA in 2016 for use on eczema in people over the age of 2. A thin layer is applied to the affected areas twice daily.

Eucrisa has been shown to improve eczema symptoms safely, according to a review of the research on the ointment published in the December 2017 issue of the American Journal of Clinical Dermatology. According to the review, a small number of people using Eucrisa experience some pain at the site.

“Topical steroids, while effective, have many side effects, especially when used long term,” says dermatologist Emma Guttman, MD, PhD, vice chair of the department of dermatology at the Icahn School of Medicine at Mount Sinai in New York City. Side effects of corticosteroids include skin irritations and thinning of the skin.

“Many patients prefer to use a nonsteroid cream. Other nonsteroid creams such as Protopic (tacrolimus) and Elidel (pimecrolimus) currently have a black-box warning.”

The FDA requires Protopic and Elidel to carry a black-box warning letting consumers know there might be an increased risk of cancer associated with their use. Eucrisa does not have a black-box warning.

The Benefits of Eucrisa

“Eucrisa is indicated for mild to moderate eczema,” explains dermatologist Holly Gunn, MD, assistant professor in the department of dermatology at the University of Alabama School of Medicine in Birmingham. It is essentially an anti-inflammatory that targets a specific enzyme in the eczema which is causing inflammation. “Some patients love it and others say it didn’t work.”

Gunn says that she particularly likes Eucrisa for delicate skin, such as the skin on the face or close to the eyes, which might be further aggravated by steroid creams. Paller agrees that Eucrisa is promising for areas of delicate skin, and adds that the ointment seems to be effective for hand and foot eczema as well.

But, they say, each person’s skin will respond differently to treatment, so what works for one person might not work for the next. “We put Eucrisa, Elidel and Protopic in the same category,” she says, listing the other nonsteroidal options for eczema treatment.

The Drawbacks of Eucrisa

People who use Eucrisa may find that they feel a burning or stinging at the site, says Paller. Some people can continue to use the ointment and find the unpleasant sensations go away – while others might have to switch to another option, she says. There’s currently no standard recommendation on how to reduce the burning sensations. In some situations, using a corticosteroid ointment to reduce the inflammation and then using another ointment, such as Eucrisa, might help.

The biggest drawback to Eucrisa is its cost. However, says Gunn, it’s possible that you can use Eucrisa sparingly, either to give yourself a break from topical steroids or only on specific parts of your body.

“Typically, insurance companies like us to try less-expensive treatments first,” points out Gunn. So you might have to try other topical treatments before you can try Eucrisa. A 60-gram tube of Eucrisa runs approximately $600, while topical corticosteroids cost half that for a brand-name product, and a quarter as much for a generic. Check with your insurance provider to find out what your copays could be.

Overall, atopic dermatitis is estimated to cost the country $5 billion dollars annually. This annual cost includes the cost of treatment and hospitalization, as well as the cost of lost work and productivity, according to an article published in Advances in Experimental Medicine and Biology in 2017. The most cost-effective strategy for eczema management is the preventative use of moisturizer, according to the February 2017 issue of JAMA Pediatrics.

Paller points out that the arrival of newer eczema treatments such as Eucrisa, Elidel and Protopic is just the tip of the iceberg – she expects researchers in future years to develop more treatments based on increasingly nuanced understanding of how eczema works.

Can the Pain Without the Meds: 8 Non-Pharma Therapies

“When your whole body is a giant toothache, nothing fixes it,” observes Charley Pavlosky, 62, recalling the systemic pain that plagued him 11 years ago. A lifelong athlete, he was familiar with the aches and pains of being active – he’d even had surgery to repair a disc – but this was new to him.

His chronic pain was so severe that he was only getting 2 hours of sleep a night, and during the day he experienced anxiety and panic attacks. The Santa Barbara, Calif., resident found a comprehensive nonpharmaceutical pain management program developed by spine surgeon David Hanscom, MD, author of Back in Control: A Spine Surgeon’s Roadmap Out of Chronic Pain.

With the exception of a temporary prescription for Ativan (lorazepam) to help him sleep, Pavlosky began to create a pain-reducing lifestyle. Pavlosky was mostly pain free within 6 months of working on sleep hygiene along with cognitive behavioral therapy (CBT) and twice-daily expressive writing techniques. Then he gradually weaned himself off the Ativan. He also eats a whole foods diet, stays physically active, drinks plenty of water, and allows himself a massage as needed.

Pavlosky is one of the estimated 100 million adults who live with chronic pain, a condition that costs the United States between $560 and $630 billion annually in healthcare expenses and lost productivity, according to the American Academy of Pain Medicine.

People living with pain may be offered surgery or medications from numerous classes of drugs, including corticosteroids, muscle relaxants, anticonvulsants, antidepressants, opioid pain medications and more.

The landscape of pain management is changing rapidly, as legislatures and federal health agencies seek to more tightly control and monitor opiate pain medication prescription practices. These changes are in response to an increase in prescription pain medications – which quadrupled nationally between 1999 and 2014, according to the Centers for Disease Control and Prevention. Pain remains one of the leading reasons that people seek medical care.

“When we’re treating people with pain, are we treating suffering, or are we treating pain? The expectation of being pain free is an unrealistic expectation for the patient and the doctor,” says osteopath Doug Jorgensen, DO, founder of Patient360, a physician registry firm. Jorgensen observes that for the past 2 decades the trend has been to try to provide medication that would mask pain as much as possible.

“What medicine has done is, we keep throwing simplistic solutions at a complex problem. As the awareness of the complexity of pain grows, we believe in treating every aspect simultaneously,” says Dr. Hanscom, who lived with intense chronic pain for 15 years before developing his multilayered approach to pain management. Dr. Hanscom is in private practice with Swedish Neuroscience Specialists in Seattle.

The complexity of Hanscom’s program reflects the recommendations for non-pharmaceutical pain management outlined by the American College of Physicians clinical practice guidelines and in the Academic Consortium for Integrative Medicine & Health Pain Force White Paper published in 2017.

People with chronic pain might still need medications or surgery. These 8 strategies can be used on their own or with other medical treatments to reduce pain:

  1. Acupuncture. Nurse practitioner Elizabeth Spokoiny, DPNC, RN, on staff at the University of Washington Medical Center in Seattle, found relief from pain with acupuncture after a car accident in 2015, and then was able to tackle 20 years of pain caused by an autoimmune condition. In addition to acupuncture, she uses dietary change, meditation, bodywork and yoga to manage pain. Her experience with acupuncture is mirrored by clinical data. A research review published in a 2017 issue of Programme Grants for Applied Research showed acupuncture to be more effective than a placebo or no treatment.
  2. Massage therapy. At least an hour a week of massage therapy or other soft tissue manipulation could improve your experience of pain. Massage is recommended by the American College of Physicians Clinical Practice Guidelines for acute, subacute and chronic pain.
  3. Meditation, relaxation and biofeedback. These are practices that connect your mind and your body despite pain, and are recommended by the ACP. “My first experience with chronic pain was 40 years ago, when I was 25 years old,” recalls biofeedback practitioner Cindy Perlin, LCSW, author of The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free, in private practice in Albany, N.Y. “I also use exercise, nutrition, homeopathy, energy psychology, occasional massage, self-massage and, most recently, low-level laser therapy to deal with pain challenges that come up.”
  4. Yoga, tai chi and Pilates. Although pain can make you want to be still, movement can also reduce pain. “Movement causes us to produce endorphins, which are naturally occurring opioids,” says integrative medicine pain specialist Heather Tick, MD, associate professor of anesthesiology and pain management at the University of Washington in Seattle.
  5. Nutrition. Make sure your plate offers a rainbow of fruits and vegetables. “Most people don’t know that everything you eat can impact your body chemistry,” says Dr. Tick, lead author of the Consortium’s white paper. She recommends giving up sugary, fatty, processed foods. Instead, aim for the anti-inflammatory eating pattern outlined by the Academy of Nutrition and Dietetics. This approach emphasizes eating produce, whole grains, heart-healthy fats, plant-based proteins or fish, and fresh herbs as seasoning. Dr. Tick also advocates certain supplements, such as magnesium, vitamin D, fish oil and turmeric (curcumin).
  6. Hands-on manipulative therapies. Massage, osteopathic treatment and chiropractic treatments all are evidence-based approaches to pain management.
  7. Challenge your thoughts. CBT is an approach that helps identify harmful thought patterns and provide alternative thoughts, while also identifying and supporting your resilience. CBT has been shown to help with many aspects of pain management, according to a review of research published in the February issue of Physical Therapy.
  8. Sleep better. The relationship between pain and sleep is dynamic: Pain interferes with getting the sleep you need, and sleep deprivation makes pain feel worse. Taking steps to improve the quality of your sleep will be part of your pain management strategy. Pavlosky stresses the value of being more mindful about quality sleep habits. “I don’t look at screens for at least an hour to 2 to 3 hours before sleep. I dim the lights after sundown, so my body can slowly start preparing. I don’t have any coffee or caffeine after noon and no alcohol late at night,” he says.

Finally, whether you opt for any of these approaches, or medication or surgery, make sure your expectations for pain relief match up with the reality of the treatment, advises Sal Raichbach PsyD, LCSW of Ambrosia Treatment Center. Raichbach recommends a substantial conversation so that you and your physician understand both your hopes for pain relief, as well as what you might expect from any given mix of therapies.

Twitter Helps Identify Side Effects of Steroids

When it comes to taking steroid medication, people seem to be more concerned with minor side effects than major ones.

Researchers from the University of Manchester examined more than 20,000 Twitter posts on prednisone or prednisolone, both commonly prescribed steroid. Those posts indicated people are more worried about the minor side effects associated with the drug, according to a study published in the journal Nature Partner Journals (NPJ) – Digital Medicine.

Researchers used advanced computer software that helped them collect 159,297 tweets mentioning the 2 steroids over the course of 3 years. Of those tweets, approximately 20,000 mentioned possible side effects. The study results found that 8.6% mentioned insomnia, 8.2% mentioned weight gain, 7.8% mentioned nonspecific reactions, such as “I hate the way prednisolone makes me feel,” 7.5% mentioned increased appetite and 4.4% mentioned feeling uneasy.

Although insomnia and weight gain were 2 symptoms popularly mentioned, studies have typically focused on the more serious side effects associated with prednisone, such as hyperglycemia and osteoporosis.

The researchers think that social media platforms such as Twitter can serve as a gateway to learning about possible side effects that people may find problematic.

Quick Hits: Imodium Abuse, Polypharmacy and Hospitalization & More

The FDA is requesting that the over-the-counter anti-diarrhea medicine Imodium (loperamide) be packaged differently to prevent abuse. There have been numerous reports indicating that people have intentionally misused and abused high doses of the treatment as a substitute for opioid drugs. In some cases, this has led to serious heart problems and death. In order to rectify this problem, the agency sent a letter to manufacturers asking that they limit the amount of drug per package for short-term use. For instance, a package could contain 8 2-milligram capsules, which would be enough for about 2 days. Posted January 30, 2018. Via FDA.

Taking 5 or more drugs increases hospitalization risk among older adults both with and without HIV. Yale researchers collected data from the Veterans Aging Cohort Study and analyzed adults with and without HIV who received at least 1 medication in 2009. The research team analyzed the patients, who were around 50 years old, over the course of 6 years. The results of the study indicated that older people — both with and without HIV — who took multiple drugs simultaneously had a greater risk of being hospitalized or dying. Posted January 30, 2018. Via AIDS.

The boxed warning on 2 classes of asthma medications has been removed. The warning on long-acting beta-agonists (LABAs) and inhaled corticosteroids (ICS) that cautioned consumers about asthma-related death was removed after the FDA reviewed 4 large clinical trials and found that treating asthma with LABAs in combination with ICS does not cause more serious asthma-related side effects (such as hospitalization, the need for a breathing tube, or asthma-related deaths) than treatment with ICS alone. Posted December 20, 2017. Via FDA.