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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drug shortages

Monday, January 14, 2013

For the true fan, the injury report is a must read when it comes out before the big game. Whether there is detailed information of an injury or illness like in the NFL reports or the ambiguous lower body injury that populates the NHL releases, knowing who is hurt and if they will play has become big news. A player who is not available affects the coach’s game plan and the duties assigned to other players. Injuries that occur during the game are that much more challenging, requiring adjustments on the fly. It doesn’t make news, but the same thing happens in medicine and the medication shortages are changing the way medicine is being practice in the US.

The Federal Drug Administration lists more than 120 medications that are in short supply or unavailable and that has or will shortly change the game that will affect millions. The potential damage can be mild inconvenience. The shortage of sterile injectable sodium bicarbonate that is mixed in with lidocaine, the local anesthetic that is injected to numb lacerations, means that those injections will burn a little more. Or the consequences of a drug shortage can change the way medicine is practiced. Intravenous nitroglycerin is used to dilate arteries that supply the heart muscle, increasing blood flow should those arteries become narrow and cause chest pain or angina. Nitroglycerin also dilates arteries in the rest of the body, decreasing blood pressure and is one of the front line drugs for malignant hypertension (blood pressure out of control) and aortic dissection (tearing of the main artery that leads from the heart).

The latest shortages can be blamed on Hurricane Sandy and the damage it caused to pharmaceutical manufacturing plants. Doxycycline, a form of tetracycline, is a commonly used antibiotic to treat a variety of infections from pneumonia and bronchitis to Lyme disease and sexually transmitted diseases. That antibiotic is no longer easily found and alternative antibiotics need to be prescribed. At least doctors and patients can have leisurely discussions about different alternatives that may or may not be as effective, and may or may not be prone to side effects and allergies, but a big gun in the physician playbook is on the injured, cannot play list.

The antibiotic shortage is an inconvenience when another pill is available, but what about shortages of intravenous medications that make a difference in people’s care. IV pain medications are in short supply, including Fentanyl, Dilaudid and Ketorolac (Toradol) an injectable anti-inflammatory, all made the FDA list this week. Furosemide (Lasix) injectable, a diuretic that makes a patient urinate, is hard to find and it is one of the mainstays in the treatment of congestive heart failure, along with nitroglycerin. Valium and its cousin Versed, used to sedated patients, are another tough find, as is the sedative/anesthetic Propofol of Michael Jackson fame. Propofol is the go to drug in the ER, OR and ICU but its use is slowly being restricted as supplies dwindle.

Pharmacists have an important role trying to keep their shelves filled with the medications commonly used in their hospital. Should a wholesaler be unable to provide adequate supplies, they need to check their rolodex for alternative sources, often using their connections to call on other hospitals that may have abundance. It’s important for the pharmacist to be proactive and ahead of the game. Once a major shortage occurs, the price for the remaining stockpile can soar. And sometimes, cost is not important. Intravenous fat emulsion is in short supply but is critical in the care of patients whose bowel has stopped working or those who cannot absorb enough nutrients to meet the needs of their body. Total parenteral nutrition (TPN) is used to “feed” these patients though intravenous lines until their intestine starts working again, a situation that can take week, months or longer.

Injury reports are usually in tiny print buried deep in the sports section, but for those who are interested, the information is there. The same is true for drug shortages. The information is there is you know where to look,but for most people, there is blind faith that their hospital or pharmacy has ample supply of the medications that they need. That isn’t always the case and pharmacists and doctors need to be aware that a backup player may need to be ready if their first choice for treatment isn’t ready to play.


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