Best Medication for Dizziness

So how would one go about figuring out the best medication for dizziness due to motion-sickness leading to nausea and even vomiting?

Well, step 1... Put a bunch of people in a machine and figure out the necessary motions that will cause dizziness.

Step 2... Do the same thing, but this time, put people on different medications and figure out what works the best.

Sound crazy?

Well it has been done by the friendly folks at NASA. Why would they perform such unpleasant experiments? It's for the fighter pilots and astronauts who may encounter motion sickness where dizziness may mean the difference between life and death and have no alternative other than medications.

So what medication did they find works the best?

Through trial and error, they have found that a combination of oral scopolamine (not the patch), to suppress vomiting, and dextroamphetamine, to counteract scopolamine's potential to induce drowsiness, reduced the incidence of motion sickness from 70 percent to about 12 percent among passengers in the "Vomit Comet"—a DC-9 aircraft used to achieve brief periods of zero gravity as part of NASA's Reduced Gravity Program.

They have also found that conditioning (repeating movements that induce dizziness) over and over again does result in the development of tolerance to a motion environment in 95% of individuals.

Read more about this here.

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Possible Cure for Common Cold And Other Viral Infections

For real... at least in mice, but has potential for human application if the promise holds out!

MIT researchers have developed a radical new approach to eradicating viral infections no matter what the virus may be... common cold, HIV, Ebola, polio, dengue fever, etc.

The usual anti-viral antibiotics in use today target the viral replication process which unfortunately often fails with time as the virus adapts and develops resistance to the medication.

The new medication dubbed "DRACO" (Double-stranded RNA Activated Caspase Oligomerizers) approaches viral infections using a totally different approach. It is able to IDENTIFY cells infected with the virus and KILLS the cell itself before the virus has a chance to take over the cell and create more virus copies. As such, the virus itself is not targeted, but rather the infected cells themselves instead.

To use an analogy, let's use an ant colony as the "viral infection". Current antivirals work by trying to pick off the Queen Ant or the ants themselves. DRACO works by destroying the entire colony. It doesn't care about individual ants or where they came from. All it cares about is the colony itself and initiates it's entire destruction.

For those more intellectually curious, DRACO is able to identify "double-stranded RNA" (ds-RNA) which is ONLY found in cells infected with a virus. One part of DRACO is able to identify and bind to this unique viral marker. The other part of DRACO is a protein that signals the cell to undergo suicide (apoptosis) thereby preventing the virus from hijacking the cell to make more virus particles. If a virus can't make copies of itself, no infection can occur.

Given ds-RNA is unique to viral infections, DRACO does not care what kind of virus it is (remember, it is not targeting individual "ants" to use the analogy). As such, whether it be the common cold or the dreaded Ebola virus, DRACO kills virus-infected cells indiscriminately. If no ds-RNA is present, DRACO remains inactive and healthy cells remain unharmed.

The tests reported in this study were primarily accomplished in cultured human and animal cells, but researchers also tested DRACO in mice infected with the H1N1 influenza virus. When mice were treated with DRACO, they were COMPLETELY cured of the infection. The tests also showed that DRACO itself is not toxic to mice.

More animal tests are underway and if all goes well... human trials may hopefully occur in the future!

Very promising!

Read a media report on DRACO here.

Reference:
Broad-Spectrum Antiviral Therapeutics. PLoS ONE 6(7): e22572. doi:10.1371/journal.pone.0022572

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Reflux (Acid, Non-Acid, Mixed Types) in Neonates & How It May Also Apply to Adults

A study was published this month in the journal Pediatric Research which described reflux characteristics in neonates, but the findings can certainly be applied to adults as well.

What I found gratifying about this study was not so much that reflux was evaluated, but what measurements obtained by 24 hour pH-impedance were taken which apply just as much to adults as neonates. Just exactly what was measured and what did the study find (at least in neonates suspected of having reflux)?

• Only 54% of reflux events was associated with symptoms

• Defined by physical characteristics of reflux events:

• 51.3% were liquid
• 29.1% were gas
• 19.6% were mixed

• Defined by chemical characteristics of the reflux events:

• 48.5% were acidic
• 51.5% were non-acidic

• Defined by how high the reflux traveled away from the stomach:

• 79.2% reached the throat/mouth level
• 20.8% stayed in the chest level

Although these findings are specific for neonates, adults experience similar problems, though precise numbers are probably different and need more study.

Laryngopharyngeal reflux is when reflux reaches the throat level. Depending on the chemical characteristics of the reflux (acid vs non-acid as well as how high it goes), the symptoms may be quite variable. NON-acid reflux is considered "silent" and patients may not experience any symptoms of heartburn. Rather, common symptoms include:

• Phlegmy throat
• Chronic cough
• Swollen sensation in the throat (globus)
• Chronic throat-clearing

These results point out another issue... Common medications used to treat reflux (zantac, pepcid, nexium, prilosec, prevacid, etc) only treats ACID reflux. Not NON-acid reflux.

As such, other modalities must be pursued to address symptomatic non-acid reflux beyond medications involving lifestyle changes including diet as well as surgery.

Whether it be babies or adults, characterization of the spatial-temporal-physical-chemical nature of reflux events as defined by pH-impedance methods offers the best chance of evaluating and treating symptoms due to reflux.

Or in more simplistic terms...

NOT ALL REFLUX IS ACID!!!

NOT ALL REFLUX CAUSES HEARTBURN!!!

Reference:
Significance of gastroesophageal refluxate in relation to physical, chemical, and spatiotemporal characteristics in symptomatic intensive care unit neonates. Pediatr Res. 2011 Aug;70(2):192-8.

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Major League Baseball Bans Under the Tongue Deer Antler Spray Use

On Aug 6, 2011, ESPN reported that MLB players have been issued a warning regarding use of Deer Antler spray administered under the tongue.

Deer-Antler spray contains "potentially contaminated nutritional supplements" along with IGF-1 (Insulin Growth Factor) which players have used in the past as an alternative to steroids, especially given it can't be detected in urine samples (only blood testing).

What's with Deer-Antler spray specifically? Scientists discovered IGF-1 in the velvet of immature deer antlers and IGF-1 is considered a performance-enhancer that mediates the level of human growth hormone in the body.

Why under the tongue (sublingual administration)? Because the mucus membrane is quite thin under the tongue richly underlaid with capillary blood vessels allowing for direct diffusion of the substance directly into the body's bloodstream with little or no alteration. This process takes less than a minute to occur. This is in contrast to swallowing a pill which gets digested in the stomach with acid, further digested in the intestines with enzymes, absorbed into the hepatic circulation where further degradation occurs in the liver before getting into general body circulation for effect. A 30-60 minute process.

That's why sublingual nitrogen is such a potent medication to treat chest pain due to an impending heart attack. It works FAST!

It's another reason why sublingual immunotherapy otherwise known as allergy drops is a growing acceptable alternative to allergy shots to try and cure allergies.

Read the ESPN story here.

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"Sneeze Whisperer" Target Pharmacy Commercial

Take a look at this commercial promoting Target Pharmacists as a "sneeze-whisperer"...



Though pharmacists are very important healthcare professionals who are essential to the management and distribution of prescription drugs, patients need to be aware that pharmacists may be financially rewarded to encourage patients to use certain drugs and not others without regard to whether a given medication may be better or not health-wise.

In fact, in some cases, pharmacists may automatically switch certain prescriptions to an alternative without patient or physician knowledge. In other situations, pharmacists may call physician offices asking if it is OK to switch a prescribed medication to an alternative for one reason or another (again, possibly due to unclear financial incentives).

To be fair, in an effort to cut costs, pharmacy benefit managers (PBM) who oversee pharmacies including Target Pharmacy as well as pharmaceutical companies, offer various incentives to encourage (or persuade) not only pharmacists to choose certain drugs over another, but also patients and physicians.

Such persuasion include:
- Higher copays for the patient who may ASK a drug to be changed to a cheaper alternative.
- Prior authorizations which in essence is paperwork harassment for the physician who may be influenced to prescribe alternative medications just to avoid the paperwork.
- TV Commercials (yup... just like the commercial mentioned above) informing patients that THEIR drug is the best
- Rebate coupons
etc etc

So... before you start thinking a Target Pharmacist is a true "sneeze-whisperer", consider all the other competing whispers a pharmacist hears... Copays, incentives, rebate coupons, patients, doctors, drug reps, PBMs, etc.

It should be obvious, but did want to point out that pharmacists do not receive any advanced medical training in allergy unlike an allergist who has dedicated literally YEARS to the subject.

References:
The effect of pharmaceutical benefits managers: is it being evaluated? Ann Intern Med. 1996 May 15;124(10):906-13.

Economic impact of pharmacist-reimbursed drug therapy modification. J Am Pharm Assoc (2003). 2011 Jan-Feb;51(1):58-64.

Drug Maker's Efforts to Compete in Lucrative Insulin Market Are Under Scrutiny. New York Times 1/28/2006

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Steroid and Anti-Histamine All-In-One Nasal Spray!

Meda Pharmaceuticals has announced a new nasal spray "Dymista" that contains both a steroid and an anti-histamine active ingredient. Why is this significant? It's because it's the first and only one to do so. Of course, it's not available yet until the FDA approves it, but at least it has shown effectiveness in Phase 3 clinical trials.

At this time, nasal sprays as it relates to nasal allergies come in two separate flavors:

1) Steroid Nasal Spray (flonase, nasonex, nasacort, rhinocort, veramyst, omnaris, etc, etc)
2) Anti-Histamine Nasal Spray (patanase, astepro, astelin)

This new combo nasal spray "Dymista" contains fluticasone and azelastine. Fluticasone is a steroid that is also found in flonase nasal spray whereas azelastine is an anti-histamine also found in astepro and astelin nasal sprays.

Clinical trials in the past have shown that using a steroid nasal spray and an anti-histamine nasal spray was more effective than using one or the other individually.

Similarly, Dymista has also been found to be better than either nasal spray alone, but with the convenience of using a single nasal spray.

Look for it in the near future! Let's just hope insurance will cover it however.

Read the press release here.

Reference:
Onset of Action of MP29-02 in the Treatment of Seasonal Allergic Rhinitis. J Allergy Clin Immunol 2011; 127; 2; Abstracts 199

MP29-02 in the Treatment of Nasal Symptoms of Seasonal Allergic Rhinitis. J Allergy Clin Immunol 2011; 127; 2; Abstracts 199

Combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal spray in the treatment of patients with seasonal allergic rhinitis. Annals of Allergy, Asthma and Immunology, 2008, vol. 100, no. 1, pp. 74 - 81.

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What Exactly Does a Generic Drug Mean (Opposed to Brand Name)?

Some patients are very confused by what the difference between a generic drug versus brand name drug is.

From the patient perspective, they are thinking, how in the world can the same drug be called different things?

Doctors answer by talking about active ingredients, patents, and copays which sometimes confuses patients even more. Well, here's to set the record straight using an analogy.

So let's talk about orange juice.

I consider Tropicana Orange Juice a brand name "drug".

The "active ingredient" in Tropicana Orange Juice is the fruit "orange".

A generic drug equivalent to Tropicana Orange Juice is Target (or other supermarket name) Orange Juice.

They both contain the same active ingredient of oranges, but the name is different.

The generic orange juice is also always cheaper.

Now, some people do not feel there is any difference between the brand name Tropicana and the supermarket branded generic orange juice, but some people insist that Tropicana tastes better and is healthier as it is not made from concentrate.

Others say that in the end, it really is the same because the active ingredient of oranges is the same.

Same controversy and arguments for orange juices also apply to drugs.

Hopefully, people understand the difference between brand name and generic equivalent drugs a little better now.

Personally, I feel if generic drugs work for you, save your money and stick with it rather than a brand name drug.

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Generic Singulair Expected in August 2012

Why August 2012? That's when the patent for singulair, an allergy and asthma medication, goes off-patent. Generic versions of singulair should be expected soon after the patent expires.

For those who don't know... generic versions of medications are much cheaper than brand name medications, but contain the same active ingredient. Here's a list of a few brand name medications relevant in the ENT world with generic names in parentheses.

Flonase (fluticasone)
Prilosec (omeprazole)
Prevacid (lansoprazole)
Claritin (loratidine)
Zyrtec (cetirizine)
Benadryl (diphenhydramine)

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Xyzal and Clarinex Generics Now Available

Xyzal and Clarinex are both anti-histamines used to treat allergies. Both medications are now available as generics by prescription since December 2010. The active ingredient for both xyzal and clarinex are the active stereoisomer of the over-the-counter zyrtec and claritin respectively.

In other words, zyrtec and claritin available over-the-counter contain the same active ingredient found in xyzal and clarinex, but in an "un-purified" state. Still confused? Read this article which probably contains more information than you ever wanted on this subject.

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Allegra Going Over-The-Counter March 2011!

For allergy sufferers, the prescription anti-histamine, Allegra, will be going over-the-counter on March 4, 2011.

And not just Allegra, but the full family of Allegra including those formulations for kids as well as Allegra-D which contains sudafed.

Click here for more info.

Allegra joins claritin and zyrtec which also used to be prescriptions but went over-the-counter in 2003 and 2007 respectively.

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Vaginal Premarin Cream for Recurrent Nosebleeds?

It is an old trick of the trade where a physician may prescribe vaginal premarin cream to treat recurrent nosebleeds.

The premarin cream (just as it does when placed vaginally) causes the nasal mucosa lining to thicken thereby "burying" the superficial blood vessels that are often the culprits for recurrent nosebleeds. Application is by rubbing the cream 2-3X per day to the anterior wall of the nasal septum (Kiesselbach's plexus) where 90% of nosebleed sources are located.

Understandably, males may be reluctant to be prescribed this medication due to the small (but temporary) risk of breast enlargement given the very small amount that can be systemically absorbed (based on vaginal studies, less than 20 pg/ml).

Furthermore, given there are other good options for treating nosebleeds including nasal emollients, cauterization, and packing, this option is mainly for females who are scared to death of nasal cauterization/packing when other more conservative treatment fails.

Though I wish I can provide a few good references... there aren't any. It is considered general knowledge. The only one I was able to find is:

Mehriz A, Weber DR. Estrogen therapy for recurrent epistaxis: case histories and literature review. Hosp Pharm. 1999;34:1057-1064.

The vast majority of research on use of premarin cream for recurrent nosebleeds is actually for treating individuals suffering from Hereditary Haemorrhagic Telangiectasia (HHT), also known as Osler-Weber-Rendu Syndrome.

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Taking Tylenol and Ibuprofen Also Has A Potential Risk of DEATH!

The New York Times in July 6, 2009 published an interesting article regarding the potentially fatal risk of taking tylenol and ibuprofen. The story titled "Reasons Not to Panic Over a Painkiller" states that tylenol (due to liver damage) kills about 400 people and hospitalizes about 42,000 every year in the United States. Ibuprofen is even worse. More than 100,000 Americans are hospitalized each year with complications associated with ibuprofen and an additional 15,000 to 20,000 die from ulcers and internal bleeding linked to their use.

Tylenol and ibuprofen is also linked to hearing loss with regular use. [more info]

The reason I am mentioning these facts with such a ubiquitous medication like tylenol and ibuprofen is because many patients have a distorted sense of what is risky and what is not. I had one parent who refused to give her child zyrtec or benadryl for severe allergies as she did not want to "add poison to her child's body." Though such sentiment is usually laudable (and in some cases, even encouraged by me), in these particular cases, it's odd to say the least, mainly because she was giving her child repeated doses of motrin and tylenol for symptom relief. As far as I know, zyrtec and benadryl has not killed anyone. Tylenol and motrin have... many times.

Or get this... the average woman puts on herself 515 chemicals on her body everyday through self-inflicted use of body and facial moisturizers, perfumes, deodorants and various other make-up products. Click here to read more on this.

There are many other such examples, but it is always nice to have in perspective that even supposedly "safe" medications really aren't safe if taken improperly.

Read the NYT story here to read more about the risks of tylenol and ibuprofen.

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