how medication works

Sunday, May 3, 2015

Manny Pacquiao lost the fight of the decade but perhaps not the battle of the excuses. ESPN’s quoted the boxer as saying that “he didn’t want to make alibis or complaints or anything…[but] it’s hard to fight one-handed.” The people in his corner asked that he be injected with an anti-inflammatory in the dressing room just before the bell rung, but were denied permission by the Nevada Athletic Commission because the injury was not previously disclosed. Pacquiao’s trainer said that the requested anti-inflammatory had been previously used in training camp and was on the approved list by the US Anti-Doping Agency.

There are two potential injectable anti-inflammatory medications that are used to treat acute or chronic injuries. The first is hydrocortisone or any of the myriads of corticosteroids that are used to decrease inflammation. They are very effective and by decreasing inflammation, the patient’s pain may also be relieved, but it takes 48-72 hours for the medication to have an effect. The second injectable anti-inflammatory is ketorolac (Toradol), which is a nonsteroidal anti-inflammatory, is an effective medication and is often used as a non-narcotic alternative for acute pain management.

For many medications, the presumption is that the injected medication is “better”, working faster and being more potent. Patients are surprised that isn’t necessarily so. If Mr. Pacquiao was interested, almost 20 years of medical research has shown that ibuprofen (Advil, Motrin] taken by mouth works as well as the injectable Toradol. Testing patient pain levels at 0, 15, 30, 60, 90 and 120 minutes found no difference at any time interval. The only benefit to Toradol is that it is injectable, and therefore helpful when people are vomiting or cannot have anything to eat or drink.

Other medications are similar in that their action works quickly when taken by mouth. An allergic reaction may be a true emergency, especially if there is difficulty breathing, shortness of breath, wheezing or difficulty swallowing. These are all potential disasters that can be associated with anaphylactic shock and calling 911 is a reasonable first step. The second step is taking diphenhydramine (Benadryl) by mouth. Surprisingly, its onset of action is relatively quick when taking orally, starting to work within 15-30 minutes. Hopefully, by the time the patient arrives in the ER, the medication is kicking in. For those patients who develop hives as their allergic reaction, the oral Benadryl may be all that they need.

As much as its important to know how quickly a medication work, it’s just as important to know when the effects begin to fade. For pain medication, that allows the prescribing provider to know how often to recommend taking the drug. Take it too quickly and the accumulation of the drug within the blood stream may lead to an overdose; delay too long and there will be gaps in pain control. The same thought process goes into prescribing long term medications for most medical ailments from seizure control, to heart failure to diabetes. Understanding the pharmacokinetics of a drug, how it’s absorbed, how the body metabolizes it and how it’s excreted, is crucial to know when and how much to take.

For Mr. Pacquiao, the shoulder injury may have put him at a disadvantage in the fight. While the Athletic Commission didn’t allow injectable medications, not considering alternatives might have been a difference maker. But when all was said and done, there would be little opportunity to complain when the judges’ scoring was not in his favor.


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injuries of the head, knee and heart

Monday, December 10, 2012

A sampling of the medical stories in the sports world this weekend.

Manny Pacquiao was knocked out the victim of a big overhead right. Boxing is a sport where inflicting a concussion upon one’s opponent is the key to victory. According to the NY Times: “from Pacquiao’s camp…his CT scan had been negative for neurological damage”. Sadly, this is not necessarily the case. The purpose of the CT scan is to look for bleeding in the brain caused by the blow to the head. The scan itself has no ability to assess how well the brain works. To pretend that a normal CT equals a normal brain is more than a little foolish and not only puts Mr. Pacquiao’s health at risk but also advertises medical quackery. Interestingly, based upon guidelines that exist to help decide who needs a CT scan after a head injury and who doesn’t, being knocked unconscious is not an indication for scanning. Concussion symptoms may be difficult to appreciate and can range from the obvious, for example significant headache or vomiting, to the very subtle like difficulty concentrating or sleeping. There is no great test for brain function that can determine that the brain is completely healed, therefore return to play decisions are usually best guess estimates by doctors.

Robert Griffin (RG III) the Washington Redskin’s rookie quarterback took a nasty hit to his knee over the weekend. The fear of a season ending ACL injury was put to rest when an MRI showed “only” a grade 1 lateral collateral ligament sprain. Ligaments hold joints stable and a sprain equals a ligament injury. Stretched ligament fibers is a grade 1 sprain, a partially torn ligament is grade 2 and completely torn is grade 3. Even grade 1 sprains can cause significant pain and swelling. Treatment will aim at decreasing the inflammation and RICE is the key (rest, ice, compression and elevation), along with anti-inflammatory medications like ibuprofen. The pro football player gets the added benefit of physical therapy for hours a day and may be able to return to play more quickly than a normal human. Some of that is due to better physical conditioning and perhaps also a higher pain tolerance and competitive toughness that can overcome the pain signals from a damaged body part. RG III may be able to play but only if signals from his brain to his leg asking it to run are stronger than the pain signals returning from his knee to his brain asking him to limp.

There is nothing but sadness surrounding the death of Jerry Brown in a car wreck, where the drive, his teammate, was charged with intoxicated manslaughter. Every year in the US, more than 10,000 people die in alcohol impaired traffic crashes (more than one person an hour). The Center for Disease Control and Prevention reports that there are more than 112 million alcohol impaired episodes every year.  It is a testament to the emotional strength of his teammates, that the Dallas Cowboys could play a football game just a few hours later. It’s interesting to work in a trauma center when the ambulance radio goes off reporting a major car wreck with injuries. Everybody has their job to get ready before the victims arrive, but there is a line on everybody’s checklist…”what time is it and where are my kids, husband or wife?” In larger cities, the trauma center gets the badly injured. The fear always exists that the patient being rolled in on the stretcher will be a loved one. Emotional detachment is easy when the patient is a stranger. It’s hard enough caring for somebody you know; it’s impossible caring for somebody you love.

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