Are ADHD Medications Safe for Kids?

I see a troubling trend in the pharmacy that has been going on since I started working with a license. And it’s probably no surprise since if you clicked on the link, you already know what I’m going to be discussing today.

ADHD? No problem. There's a pill for that.

ADHD? No problem. There’s a pill for that.

I see kids as young as 3-4, yes that’s right, 36-48 months of life, on ADHD medications. That’s quite interesting to me. I’m not going to be discussing the idea that ADHD might not be real. I will discuss the drugs and implications.

The story usually goes something like this:

A child has a lot of energy and can’t focus in school. Parents of said child get a note or call from a teacher about the disruptions, lack of attention, not working on assignments etc. Mom takes a child to doctor and, after performing some routine tests (at least we hope so), mom receives a prescription for some Ritalin, Adderall or other stimulant, goes to the pharmacy and gets to talk to the pharmacist.

This is where more truth comes out because we pharmacist have to disclose more information than a doctor typically would, or would want to. Side effects include; dizziness, sleepiness, decreased appetite, weight loss (that’s why meth addicts are so skinny), high blood pressure, arrhythmias, seizures, priapism, growth suppression, nervousness, insomnia, tachycardia, nausea, headache, palpitations, and visual disturbances.

Truth be told, many people like the effects of stimulants because they get you going, help you feel good, and can hit the pleasure centers of the brain to cause euphoria and if used long enough, or if the effect is strong enough, addiction.

I’ve talked with moms who’ve seen some of these effects in their children. The most common is weight loss and lack of appetite, which go hand in hand. Many also have nausea, compounding the weight loss problem.

What’s worse is that many are getting antipsychotic medications and/or anti-anxiety medications. We’re talking the big guns like benzodiazepines (Xanax, Ativan, Klonopin) and dopamine blockers (Risperdal, Seroquel, Geodon). According to a report from Columbia University, rates of antipsychotics have doubled in children ages 2-5 from 2000-2007. [1]

What’s worse is that less than half of these children actually had any kind of mental health evaluation, visit with a psychiatrist or have a psychotherapy visit.

One story of an 18 month old, yes 18 months, can be read at the New York Times [2] about how he was prescribed medications for temper tantrums. His condition got worse until his parents and some good doctors were able to wean him off everything other than some Vyvanse (a stimulant for ADHD).  He was overweight and his mother described him as having “blankness” in his eyes by the time he was three.

Part of the problem may be that our public school system is a one size fits all approach to students. We try to fit some square students into a round hole approach. For some children, the public school system works well, especially with good parent involvement. For others, it fails them horribly. I have no data to support the idea that a change in paradigm with public schools’ approach to education might actually curb the rate of prescribing of these medications, but I think it would.

That’s for another post though.

This type of problem solving is analogous to a report I heard on NPR recently about nursing homes and long-term care facilities. A team went to discover if the residents in these types of facilities were really demented and had other mental health problems. Many residents of these types of facilities will yell out and make other types of disturbances during the day and night.

The tea tasked itself with discovering if their really was mental illness or something else going on. In one instance, a woman would yell out at night. Many times in this type of situation, nurses will administer depakote (an anti-seizure medication) or benzodiazepines to calm a patient down.

This team tried to communicate with her. What they found was, after some time and effort, was that she was cold at night. They got her a blanket and she calmed down and slept, all without medications.

Communication: what an amazing concept!

Rather than not listening to yelling and grunting and crying, we should listen and see if we can discover the real problem

Rather than not listening to yelling and grunting and crying, we should listen and see if we can discover the real problem

Now I know some people do legitimately have mental illness, there is no doubt about it. Getting a proper diagnoses from the proper channels is important though. Immediately throwing a drug at a problem is a mentality that unfortunately, too many doctors and patients and patient’s moms have. Working through a problem rather than throwing a tablet at it is harder, but can be worth it. Avoiding problems like the story in the New York Times is advisable.

Proper nutrition and activity is generally a good idea, especially for very active kids. Some kids are content to live in their brains more so than others. Others just can’t sit still. They need to move.

A child’s brain is also continuously developing. To address problems like ADHD at 2 or 3, or a temper tantrum at the same age is probably very premature.

My little 3 year old gets frustrated sometimes because she desperately wants to say something. Even when my wife or I is listening intently she’ll get mad or begin to cry. When asked the problem her reply is usually, “I just don’t know how to say it.” Her vocab isn’t quite up to par so her mode of expression goes from words to crying. I certainly don’t fault her for being unable to adequately express in words what’s she’s feeling at the age of 3.

If you think your child may have problems with ADHD and want to take them to a doctor, that’s fine. I don’t disagree with that. But a psychological evaluation by a professional recommended by the doctor is a good place to start. In some cases, if medication is needed on top of a healthy diet and activities, there are alternatives like clonidine which can be prescribed that don’t carry some of the risks of stimulants, or the potential abuse among children or their friends.

CIAO

 

1.Olfson, Mark, et al. “Trends in antipsychotic drug use by very young, privately insured children.” Journal of the American Academy of Child & Adolescent Psychiatry 49.1 (2010): 13-23.

2.http://query.nytimes.com/gst/fullpage.html?res=9D02E0DE1E3CF931A3575AC0A9669D8B63

 

Is Low Dose Naltrexone Helpful?

I always try to present the facts to anyone who reads this blog. I try not to stretch the truth. Maybe I haven’t been super successful in that regard, but I try to present accurate information without blowing it out of proportion. That’s what I want to do today, present some information and put it into context. For the record, I personally think naltrexone has promise for certain disease states.

Naltrexone is a drug that is specifically for narcotic overdose. It blocks receptors that normallyendongenous endorphins (and narcotics) will bind to create a sense of well being, euphoria, or analgesia (pain relief). Runners will often talk about the runner’s high they get after a good run. That’s endorphins. Mmm, endorphins (think Homer Simpson).

Homer trying to get that endorphin high

Homer trying to get that endorphin high

Naltrexone is wicked awesome, I used awesome not only as a superlative, but as in it’s crazy amazing to watch someone who should probably be dead because of no breathing from narcotic overdose, at reversing it completely. It’s bad to give the full dose all at once too because a person can go from not breathing to full withdrawal within a few seconds. It’s almost like watching someone raise the dead. ER docs will usually give it bits at a time and wait for response to avoid withdrawal.

So why use a revival agent for narcotics in something like rheumatoid arthritis or multiple sclerosis?

It has to do with what naltrexone actually does. You can think of it as an immune modulator. In autoimmune disorders like rheumatoid arthritis, the immune system is literally attacking the host body. Your immune cells are targeting you. No bueno. The only cases where we want this happening is when a cancer cell forms or a virus has infiltrated a cell.

For those that don’t want more nitty-gritty on the mechanism, you can skip this next part, but you should read it anyway and learn something new.

Naltrexone is known to bind the opiate receptors on cells. [1] This of course is how it helps prevent narcotics from doing their job, because they can’t do anything but float around aimlessly in the blood.

At a standard dose of 50mg, naltrexone causes blockade of opiates and if you were to take your Vicodin or Percocet, they wouldn’t do anything, other than the acetaminophen of course. What scientist have found is that when the dose is cut down to about 1/10 or so, blockade still occurs, but because there is little drug in the system, the body is able to clear it quickly and more endorphins are created to overcome the blockade.[2,3] In a normal dose or even a slightly higher dose, the naltrexone is present in enough quantities to stop the transient rise.

In the low dose, this rise creates the possibility of greater analgesia (pain relief) as well as immune modulation. These factors MAY increase quality of life, mood, and/or disease resilience. [4] It’s important to remember that word “may” because large trials haven’t been conducted in a placebo controlled, double-blind manner, which means we only have preliminary data to draw from.

It has been shown that naloxone can reduce inflammation cytokines (chemical messengers that incite inflammation from immune cells) in macrophages in the periphery.[5] This may help explain some of the immune modulation thought to produce effects in things like arthritis or Crohn’s disease. It should be noted that this was done with naloxone and not naltrexone. While similar, you can’t always transfer effects of one drug to another, even though while in the same class.

In the nervous system, naltrexone has been shown to affect microglia, which are immune cells. By reducing inflammatory cytokines, they may help in neurodegenerative disease brought on by inflammation. Indeed, both naloxone and naltrexone, seem to have a neuroprotective effect, at least in mice. [6]

So what about actual studies looking at disease?

Fibormylagia have you feeling fatigued? Maybe naltrexone could help.

Fibormylagia have you feeling fatigued? Maybe naltrexone could help.

In one looking at fibromyalgia, one study looked at 10 women with the disease and found that 6 out of 10 received relief to some degree over placebo, and showed that mechanical and heat thresholds were improved. [7]

In another of fibromyalgia, 30 women were treated with placebo or naltrexone and there was a significant reduction in pain for the naltrexone group over the placebo group. [8]

Another fibromyalgia study with a 50mg dose showed no difference in groups. [9] As discussed above, this could be do the dose, rather than the drug. Remember that at higher doses, the blockade of opiate receptors happens for a longer period and the increased endorphins can’t do their job.

In another study with 60 participants with multiple sclerosis, naltrexone was found to improve mental health quality over placebo. [10] The authors did point out this study did not assess the drug as a disease modifying agent, such as Copaxone. They did state there did seem to be no interactions with typical MS drugs.

In patients with Crohn’s Disease, 18 naltrexone patients had significantly more reduction in severity score associated with the disease over 16 placebo patients. [11]

A trial with children found that it also may be very effective. [12]

Because of its mechanism, it’s not improbable that it could help with other autoimmune conditions like rheumatoid arthritis because of the inflammatory effects of the disease. Others like lupus might also benefit.

Naltrexone seems to be tolerated well, especially since it is being used at a lower dose. Some nausea has been reported as well as abnormal dreams. People that have liver disease might be cautious, as it has been shown to cause liver problems, but those are in the 50-100mg/day dose range. 4.5, the common dose used in many studies, doesn’t seem to have that effect.

Naltrexone also must be compounded by a compounding pharmacy. The lowest commercial dose available to pharmacies is 50mg/tab, so they have to make it into caps or suspensions, depending on the dose. You can call a compounding pharmacy and ask how much it would be for 30 caps of 4.5mg naltrexone. Most will probably already know or be able to get you a number relatively quick.

It also must be an immediate release formulation, no extended release. One note of caution: if you do choose to use naltrexone and you take narcotics, you’ll want to wean off of them. Naltrexone, even at a small dose, will block the effect of your pain med and cause problems. Talk to your doc about that if that’s a concern.

Because no large studies have been done, it’s hard to gauge just how effective it is. I’ve read several personal anecdotes of people claiming it has done great things for their lives. I have hope for it as I think it has much promise. Hopefully someone will be able to do larger scale trials to give us a better idea of how well it actually works at a more general population level with a given disease.

I’ve read about some people seroconverting with HIV, while others have claimed that their viral load decreased. Again, I haven’t seen clinical data to back that up, but if true, would be a great thing for people battling that horrible virus.

In short, if you’re willing to give naltrexone a try, their probably shouldn’t be much problem, other than maybe convincing your doctor of writing a script.

CIAO

 

 

 

1.Wang D, Sun X, Sadee W. Different effects of opioid antagonists on mu-, delta-, and kappa-opioid receptors with and without agonist pretreatment. J Pharmacol Exp Ther. 2007;321:544–552

2.Tempel A, Gardner EL, Zukin RS. Neurochemical and functional correlates of naltrexone-induced opiate receptor up-regulation. J Pharmacol Exp Ther. 1985;232(2):439–444

3.Zagon IS, McLaughlin PJ. Gene-peptide relationships in the developing rat brain: the response of preproenkephalin mRNA and [Met5]-enkephalin to acute opioid antagonist (naltrexone) exposure. Brain Res Mol Brain Res. 1995;33(1):111–120

4.Brown N, Panksepp J. Low-dose naltrexone for disease prevention and quality of life. Med Hypotheses. 2009;72(3):333–337.

5.Liu SL, Li YH, Shi GY, Chen YH, Huang CW, Hong JS, Wu HL. A novel inhibitory effect of naloxone on macrophage activation and atherosclerosis formation in mice. J Am Coll Cardiol. 2006;48(9):1871–1879

6.Hutchinson MR, et al. Non-stereoselective reversal of neuropathic pain by naloxone and naltrexone: involvement of toll-like receptor 4 (TLR4) Eur J Neurosci. 2008;28(1):20–29.

7.Younger J, Mackey S. Fibromyalgia symptoms are reduced by low-dose naltrexone: a pilot study. Pain Med. 2009;10(4):663–672

8.Younger, Jarred, et al. “Low‐dose naltrexone for the treatment of fibromyalgia: Findings of a small, randomized, double‐blind, placebo‐controlled, counterbalanced, crossover trial assessing daily pain levels.” Arthritis & Rheumatism 65.2 (2013): 529-538.

9.Younger, Jarred W., Alex J. Zautra, and Eric T. Cummins. “Effects of naltrexone on pain sensitivity and mood in fibromyalgia: no evidence for endogenous opioid pathophysiology.” PloS one 4.4 (2009): e5180.

10.Cree, Bruce AC, Elena Kornyeyeva, and Douglas S. Goodin. “Pilot trial of low‐dose naltrexone and quality of life in multiple sclerosis.” Annals of neurology 68.2 (2010): 145-150.

11.Smith, Jill P., et al. “Low-dose naltrexone therapy improves active Crohn’s disease.” The American journal of gastroenterology 102.4 (2007): 820-828.

12.Smith, Jill P., et al. “Safety and tolerability of low dose naltrexone therapy in children with moderate to severe crohn’s disease: a pilot study.” Journal of clinical gastroenterology 47.4 (2013): 339.

 

 

What is Your Health Worth?

The answer to the above question really is priceless. Your health is one of the few things that truly affects you directly every single day. No one escapes it. Whether you feel like a million bucks or feel like someone just stomped a hole in you, you get to deal with your health and only you have the power to change it.

That’s right, only you have the power to change it. No one else can.

Sure you can visit a doctor to seek out treatment or advice, but it is you that made the decision to go, not the doctor. It is you that made the decision to take the prescribed medication. It’s you that decided to eat or not to eat something. It’s you that has control.

I thought it’d be fun to put some numbers up to look at this question. They won’t be exact, especially since everybody’s situation is different, but it will give an idea of money attached to healthcare.

Without any major hospitalizations here are a few things to consider:

If you have been diagnosed with hypertension at the age of 35 (something that isn’t uncommon) you can expect to be taking something for that, usually lisinopril is one of the first choices. You can get a 90 day supply at your local WalMart for $10. That’s $40/year. At first you’ll have a couple visits to the doc from the time you’re diagnosed as follow up to make sure you’re doing well on the medication. If you have a $35 copay that’s between $70-$105 total visits for the year, at least for the first year and assuming you go to the doctor for nothing else that year.

3 visits = $105

1 year of meds = $40

Total = $145

Subsequent years would look like this:

1-2 follow up visits/year = $35-$70

1 year of meds = $40

Total = $75-$110

Over 20 years ~ $1500-$2300

Now this is assuming a few things. First you don’t ever have problems keeping your blood pressure from going up after the initial diagnoses and treatment, which is rarely the case for most. This also assumes you have no problems with the initial medication and have to get it changed, although this wouldn’t add a whole lot.

If you’re on two blood pressure medications, this jumps to $2300-$3000 over 20 years. This of course is no mortgage but still it adds up. If you happen to be taking a beta blocker like metoprolol as one of those blood pressure medications your cholesterol might go up just enough to trigger a prescription for something like simvastatin. Add another 10 dollars a month for that one.

Simvastatin $120/year

Metoprolol (assuming the cheap immediate release) $40/year

Lisinopril $40/year

2 visits/year $70

Over 20 years ~ $5400/20 years or $270/year

If you become borderline diabetic because of the simvastatin and the metoprolol in combination or were already there and these push you over you might add some metformin into the mix for blood glucose control. Three months of twice daily metformin will run you another $40/year.

Total ~ $6200/20 years or $310/year

We’re still not even close to a mortgage, but we’re increasing.

Now we’ve only discussed the financial part of all of this. Metoprolol is also going to sap some of your energy because it prevents chemicals like epinephrine and norepinephrine from having their full phsyiological effect. What does this mean? Well as I said it will probably sap some of your energy depending on the dose. It won’t necessarily make you drowsy, but it will make you tired easily.

Simvstatin as well as others have the tendency to cause muscle pain and weakness. I’ve had members of my family experience this, and I’ve experienced it myself. Many older folks attribute this to older age. I call nonsense. Yes we do degenerate as time goes on but my own grandmother was able to walk again in her 80’s after stopping simvastatin. It really can be that bad for some.

I’ve talked to others who’ve told me about lisinopril or losartan (angiotensin converting enzyme inhibitor and angiotensin receptor blocker respectively) who describe feeling like people who are on metoprolol do, with a lack of energy. Not enough to keep them from being out and about, but enough to make a few dread having to do anything because they have no energy to do it with.

Instead of medications doing some physical activity 2-3 times per week and backing off on total calories every day will likely achieve what most medications are seeking to achieve. Going on a brisk walk and having only one plate at dinner are two things that go a long way in improving health.

Think about it for just a moment; if you have only 1 plate, or maybe a smaller portion, you save on food and caloric intake. Eating till you have to undo your pants button is ok on Thanksgiving, Christmas and your birthday,…ok and maybe 1-2 other times/year but that’s it. If having to loosen your belt regularly after eating is a habit I can tell you that the belt is only going to get tighter and tighter.

Taking a brisk walk or going on a hike or riding the bike or whatever it is you might find joy in will get your heart pumping and muscles working. Blood pressure will go down as some of the fat comes off and you will feel more energized and not get out of breath while doing things you love.

I personally wish I could go back to Tahiti now that my heart is conditioned better to be able to stay underneath the surface while snorkeling with the fish longer.

Having a plan and sticking to it will pay off dividens in the long run. It’s sad to see people who take their medications exactly as the doctor directs and have been doing so for a long time only to see them deteriorate. Don’t be a statistic. Change now! Plan for the future, however long that may be, and make a difference in your life.

I know the amount of money that we went over above isn’t a lot in the grand scheme of things, but that’s assuming you take the meds and nothing ever happens and you never deteriorate any further than where you are. Not having to deal with the side effects and not having to visit the doctor is worth going biking and feeling awesome at the same time.

CIAO

Should I Give My Child Cough Syrup?

untitledWith the cold and flu season upon us many people come into the clinic with their children because, well, kids cough. No surprises there. I tell parents at least 20 times a day (no joke) about cough syrup. I understand that many parents are what we call “well worry” parents and they want their children to be healthy and happy. Nothing wrong with that. What kills me though is that so many people think drugs are going to be the answer. Some parents will come back and see another doctor to get something if the first one doesn’t prescribe.

*Facepalm*

PIccard

The feeling I get when someone is convinced that the only way to get better is to get medication that has been proven not to be better than placebo.

I think we should probably go over the obvious. Antibiotics don’t do anything to take care of a cough…unless that cough is due to a BACTERIAL infection. Some common signs of bacterial infection include, but aren’t limited to; fever, congestion, thick colored mucus, cough, earache, headache and generally feeling like crap. And these are just for upper respiratory infections.

VIRAL upper respiratory infections can include but aren’t limited to; congestion, thick mucus, cough, headache, earache and generally feeling like crap. Notice how viral infections like a common cold and bacterial infections look similar? That’s because they are, at least in their presentation.

Kids have a hard time and it is no fun for any parent to see their little tykes go through a cold. Draining down the back of the throat at night can cause the throat to become red and irritated and sore. Coughing usually ensues. No bueno.

This is where cough syrups supposedly come into help save the day. Guaifenesin is common and so is dextromethorphan. The two are often combined. You’ll see this as Robitussin DM or Q-Tussin DM. Guaifenesin basically hydrates mucus more so that people can expell it easier and dextromethorphan works in the brain to slow down and stop the coughing reflex.

For people that have this draining issue neither medication works particularly well. The mucus is already thin and the coughing comes from trying to expel it.

I’m not saying these two meds don’t have a place in therapy, but it’s probably not nearly as often as you might think. Heck the FDA doesn’t even recommend them in kids under 2 because they really don’t do anything and there’s the potential for problems.

One study looked at honey vs placebo and found that honey actually relieves cough better than placebo. [1] The funny thing was that placebo actually helped cough too.

A study just came out that looked at the efficacy of agave nectar vs placebo in children with cough. Agave nectar also gave relief to children. [2]

If you’re planning on giving you’re child honey for cough and they aren’t 12 months old, please don’t. Although the risk is low, there is a chance of botulism poisoining with infants ingesting honey and that is far worse than any cough they will have.

If you’re not sure and still want to give your kids diphenhydramine or dextromethorphan, a study from Duke showed that those faired no better than placebo. [3] In fact dextromethorphan actually caused more insomnia so less sleeping and still the chance of coughing.

For anyone interested in the agave nectar the doses were as follows:

3 mL for ages 2 to 5 months

4 mL for ages 6 to 23 months

5 mL for ages 24 to 47 months

The honey dose was about 7.4ml or 10gm.

If you’re kids are having some cough or you yourself are experiencing issues give some agave nectar or honey a try. I prefer honey in some ginger tea. It works great to fight off the beginnings of a cold. Just staying hydrated will also help.

CIAO

 

1.Cohen, Herman Avner, et al. “Effect of honey on nocturnal cough and sleep quality: a double-blind, randomized, placebo-controlled study.” Pediatrics 130.3 (2012): 465-471.

2. Placebo effect in the treatment of acute cough in infants and toddlers, Ian M. Paul, et al., JAMA Pediatr, doi:10.1001/jamapediatrics.2014.1609, published online 27 October 2014.

3.Paul, Ian M., et al. “Effect of dextromethorphan, diphenhydramine, and placebo on nocturnal cough and sleep quality for coughing children and their parents.” Pediatrics 114.1 (2004): e85-e90.

Acetaminophen and Back Pain

I guess since I’m a pharmacist I should talk about drug related topics once in a while.

There is a study that was recently published about the use of acetaminophen (Tylenol) and its use in lower back pain. I don’t have access to the study other than the summary so I can’t make any conclusive remarks about what actually took place but wanted to comment on what was printed.

In this study conducted down under, 1643 people were analyzed for lower back pain and relief with acetaminophen (APAP for the rest of this post). The subjects were randomized into 3 groups; an around the clock dosing, an as needed dosing and placebo. [1]

The amounts of APAP in the first group were around 3990mg/day, the second group was 4000mg/day and then placebo which had none. They were followed for 3 months but only received 4 weeks of medication. Researchers were looking to see when patients reported relief on a pain scale of 0-1 (on a 1-10 pain scale) for 7 consecutive days.

The results were there was no difference between the 3 groups. The authors concluded that regular use of APAP,

does not affect recovery time compared with placebo in low-back pain, and question the universal endorsement of paracetamol in this patient group”

Again I don’t have access to the study itself so I can’t delve into specifics, but we can ask a few questions.

Was their a decrease in pain at all and if so how quickly did pain decrease and by how much? What kind of injury caused the back pain in the first place? Was it acute pain or chronic?

To answer the last question it does sound like it was probably more acute pain. Had it been chronic I doubt there’d been any difference in the pain levels over 4 weeks or 4 months, at least not to 0-1.

I can’t answer the first question but I suspect that the answer is the treatment probably did decrease pain, just not to a 0-1 level. I do admit that personally I don’t really respond to APAP for pain, but it does wonders if I have a fever and the opposite is true for Ibuprofen. Some people I’ve talked to respond well to APAP and others don’t.

Since I can only speculate I assume some of the patients did get pain relief while others may not have. The other question though, what caused the pain in the first place, would be relevant as well because if there is an inflammation component that is clinically significant, then APAP might not do so well as it doesn’t help inflammation.

Does that mean that APAP is worthless and shouldn’t be used for lower back pain? Not necessarily. It may be very helpful for some and the only real way to know is to try some. Be aware though that doses much higher than 625mg aren’t more effective than 1000mg.

Taking lots of APAP has the effect of decreasing glutathione in the liver which is one of the body’s main antioxidants. For a short period of time this is likely not a problem, but over weeks and months this could leave you vulnerable to oxidative damage assuming the body isn’t getting enough nutrients in the diet to replenish stores. Fresh meats, veggies like asparagus and spinach, and other foods like garlic contain sulphur compounds which are what the body uses to replenish stores. N-acetyl-cysteine is also used because it’s rapidly converted in the body to glutathione.

This is one of the major problems in the United States as far as drug overdoses are concerned. Around 150 people die every year from APAP overdose. [2] Those who survive usually end up with sever liver damage and many require transplants. That number of 150 is an average over 10 years from 2001-2010 and they are all accidental.

Yup, accidental!

From 1998-2003 The leading cause of liver failure was APAP overdose.[3]

From 1998-2007 there was an estimated 57,000 ER visits and 26,000 hospitalizations per year due to overdose.

This is pretty serious.

The max recommended dose per day is 3000mg for a healthy adult. Please be aware of medications that may have APAP in them. In other words READ THE LABEL!

Be very careful with children’s doses as well. Sometimes the bottles you get at the pharmacy for an infant will be a different strength that for a bottle you buy at the store that also says infant.

I didn’t mean to turn this into a scare post but it’s important to remember that no medications is benign. We make a big deal about things like weight loss drugs and steroids, and rightly so, but we need not forget the dangers of simple things like APAP.

If you need to use some APAP please don’t feel like I’m discouraging its use. It may be helpful. Just please remember that for something like back pain it’s probably not going to make you feel 100% and that taking more will do nothing for the pain and potentially make it worse if you keep at it for long due to liver problems. NSAIDs like naproxen or ibuprofen may be better suited to the task but talk to your doc or handy pharmacist if you have questions.

CIAO

1.Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial Christopher M Williams, Christopher G Maher, Jane Latimer, Andrew J McLachlan, Mark J Hancock, Richard O Day, Chung-Wei Christine Lin
The Lancet  24 July 2014

2.http://www.propublica.org/article/tylenol-mcneil-fda-use-only-as-directed

3. http://www.fda.gov/downloads/AdvisoryCommittees/…/UCM164897.pdf

 

B12: Are You Getting Enough?

B12Many people in the United States suffer from what very well could be a vitamin deficiency. In fact it wouldn’t surprise me at all. With the food supply seriously lacking in essential nutrients and minerals it isn’t a surprise at all that people are having issues with things like lethargy, anxiety and depression, and even disorders such as Alzheimer’s. These are just a few problems associated with B12 (cobalamin) deficiency. So lets talk about it shall we?

B12 is a vitamin responsible for healthy nerves, blood cells, DNA production….essentially stuff to keep you alive. B12 is available in many foods including but not limited to; shellfish, liver, fish, meat, eggs, and dairy. It is very noteworthy that plant products don’t have significant amounts of B12. Don’t be fooled by claims that state otherwise. Many of these foods are fortified with B12, but don’t have it naturally occurring or at very small amounts. And the foods that do, like seaweed, have pseudovitamin B12, which competes for absorption with regular B12. [1] One exception may be green and purple lavers, a type of algae. [2]

This is corroborated by studies that show that vegetarians and vegans are 50% and 80% deficient respectively. [3,4]

If you choose to not eat any animal products whatsoever, you need to supplement. More about that in a minute.

As mentioned above, B12 is really important for certain functions in the body. One problem associated with low B12 is many people don’t even know they are deficient. Working in a clinic I do see lab tests a lot, mostly for CBC’s and Cholesterol or A1c’s for diabetics. I don’t see B12 tests unless the doctor suspects something like anemia. But if there is neurological dysfunction, I don’t see it. The point is that since it isn’t something routinely checked for, it gets missed.

As Chris Kresser pointed out in an article:

In Japan and Europe, the lower limit for B12 is between 500-550 pg/mL, the level associated with psychological and behavioral manifestations such as cognitive decline, dementia and memory loss. Some experts have speculated that the acceptance of higher levels as normal in Japan and the willingness to treat levels considered “normal” in the U.S. explain the low rates of Alzheimer’s and dementia in that country.” [5]

The normal reference range in the USA by comparison is 247-911 pg/mL. That’s like the Rockies, one big mother range.

On top of that, a good deal of the population may have deficiency. [6] According to this study as many as 2/5 of America may have a problem. That’s around 125,000,000 people. While not everyone with deficiency show signs, it is still disconcerting. The article which I linked said that there was nothing to worry about though because we can get adequate B12 from more dairy and fortified cereals…..

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Modern dietary advice giving us the only reasonable response.

Modern dietary advice giving us the only reasonable response.

Yeah because hey, fortified cereals are where it’s at nutritionally.   ……NOT!

Make no mistake, the addition of niacin to the US flour supply was probably one of the very few smart things the federal government was able to do to actually influence in a POSITIVE manner the population’s health. By helping people get enough niacin they were able to eliminate pellagra, a very serious condition that resembles schizophrenia. The problem with fortified cereals are the only nutrition you get from them are the spray on vitamins. That might be helpful for some, but meat or liver or fish is probably the much better option.

Another issue is that people experience symptoms even when their levels on are on the lower end of “normal”. It’s entirely possible that our range, like many other medical ranges may be off and probably needs to be increased.

Lets Talk About Absorption Baby, Lets Talk about You and Me!

If you don’t remember back or are new to the blog, a few weeks ago I discussed the adverse effects of taking acid reducers chronically. Here’s the link:

https://pharmacybrute.wordpress.com/2013/12/10/acid-supressing-drugs-lower-nutrients/

Acid in the stomach is an important part of the process to get B12 absorbed in the body. Acid cleaves B12 from the carrier it resides on so that it can be attached to intrinsic factor, allowing for absorption. No acid, no cleavage, no absorption. Other drugs can cause problems too. If you’re diabetic, metformin is known to reduce not only B12 but the other B vitamins as well.

People that have leaky gut or other inflammatory processes going on in the gut may have impaired absorption as well. Don’t assume just because you are a meat eater you’re getting all the B12 you need. Fixing your gut is important for many reasons and B12 is definitely one of those reasons.

Pernicious Problems

If you have problems with energy and have been able to rule out blood sugar dysregulation and sleep as potential problems, B12 might be a great place to look. People with anemia can have B12 or iron deficiencies. Since B12 is also required for myelin sheaths (the insulation on the nerves) it is thought that it is important for prevention of neurodegenerative disorders such as Alzheimer’s and Multiple Sclerosis. It may also play a part in anxiety and depression as well as autism and learning disabilities in children.

Maternal breast milk has a content of B12 that is linked with intake from mom. So if a mom is a vegetarian or a vegan, it is extremely important that she supplement to get adequate supplies for the baby.

Supplementation

You can find B12 in just about any B-Complex. It typically comes in the form of cyanocobalamin. I want to point out that this form of cobalamin is linked with cyanide, hence cyanocobalamin. This form is usually injected at a doctor’s visit. Methylcobalamin on the other hand seems to be the form that is most useful, especially in neurological problems. [7] This is the form most used by the Japanese. In fact they don’t use cyanocobalamin anymore because it doesn’t work very well if at all.

The British also don’t use cyanocobalamin. They use hydroxocobalamin. In a paper addressing some concerns about cyanocobalamin, researchers point out that hydroxocobalamin is preferrable to cyanocobalamin and that it’s use should be discontinued. [8]

Cyanocobalamin, methylcobalamin and hydroxocobalamin are the most common forms.

So if you need it, what do you use? I would recommend methylcobalamin in the oral form. There are sub-lingual tabs which absorb and bypass the gut altogether:

http://www.amazon.com/Source-Naturals-MethylCobalamin-Flavored-Sublingual/dp/B001G7R8J2/ref=sr_1_2?ie=UTF8&qid=1334825392&sr=8-2

This would be a good option to start with if you use acid reducers or have gut problems. The one I listed is 1mg which is likely enough. For those fighting off peripheral neuropathies or trying for nerve regeneration much higher doses are likely required, as in doses used in injections.

I would stay away from cyanocobalamin if possible. I know it’s cheap and for a simple anemia where a low dose is effective then it might be ok. But to really maintain good health it’s better to use the other forms. Much like folic acid is synthetic and not naturally occurring folate, cyanocobalamin is cheap (yes I said cheap) and not as effective.

Get the best forms from your food. Fish, shellfish, meat, liver and dairy are good sources. If your gut is in need of help, get it the help it needs so you can get the B12 you need from food. If you are a vegetarian or vegan please make sure to get enough through supplements. I recommend food first of course.

CIAO

1.Watanabe, Fumio, et al. “Pseudovitamin B12 is the predominant cobamide of an algal health food, spirulina tablets.” Journal of agricultural and food chemistry 47.11 (1999): 4736-4741.

2.Watanabe, Fumio, et al. “Characterization and bioavailability of vitamin B12-compounds from edible algae.” Journal of nutritional science and vitaminology 48.5 (2002): 325-331.

3.Antony, Aśok C. “Vegetarianism and vitamin B-12 (cobalamin) deficiency.” The American journal of clinical nutrition 78.1 (2003): 3-6.

4.Bissoli, L., et al. “Effect of vegetarian diet on homocysteine levels.” Annals of nutrition and metabolism 46.2 (2002): 73-79.

5.http://chriskresser.com/b12-deficiency-a-silent-epidemic-with-serious-consequences

6.http://www.ars.usda.gov/is/pr/2000/000802.htm

7.http://www.nutritionaltest.com/methyl.html

8.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697096/

Disclaimer: All info on this website is for education purposes only. Any dietary or lifestyle changes that readers want to make should be done with the guidance of a competent medical practitioner. The author assumes no responsibility nor liability  for the use or dissemination of this information. Anyone who chooses to apply this information for their own personal use does so at their own risk.