For the first few days my floater, a tiny black spot in the left eye visual field seemed like a piece of sand on my glasses, or something on my computer screen, but I suspected because it moved it was a floater. Like what many people describe my first inclination was to try to look directly at the opacity to figure out where it is located. This was a weird sensation because the floater would usually immediately disappear when I tried to look at it. Intellectually I understand that this is because with movement of the eye the floater itself moves, and because its location in the eye causing the shadow on my retina is not where it appears to be. Still the first few times I thought I was imagining the speck. Then I closed my right eye and it persisted, closed my left eye and it went away, and I knew I had yet one more sign of my age. Floaters can occur in young people, and can even be congenital, but are more common with aging.

Other people describe floaters as spots, thread or cobweb like shapes, or other descriptions that float slowly through their eyes. These are not an optical illusion, but are real phenomena. Most floaters are caused by gradual shrinking of the vitreous body as some of the molecules in the vitreous dry out and become solid. These degenerate further into fibrils that can be seen as floaters. This vitreous shrinkage that occurs with age can sometimes lead to pulling away of the retina, a.k.a. a retinal detachment. Shrinking of the vitreous can lead to flashing lights across the vision due to mechanical stimulation of the retina, and retinal detachment can cause either a large floater-like area, a type of scotoma, or a sudden appearance of numerous floater-like opacities as blood from the retina disperses in numerous droplets of blood in the vitreous. If you notice a sudden occurrence of multiple floaters you should have a dilated eye exam by an ophthalmologist right away as a retinal detachment is a potentially treatable cause of vision loss.

In general floaters are considered a nuisance, and are not treated. For severe cases treatment may be appropriate, either through a vitrectomy or by use of a YAD Laser. Neither is commonly performed due to the risks of the procedures and controversy over the efficacy treatment. For me I just smile, thank God I can still see well, and try not to let my floaters bother me too much.

Leave a comment below to tell us about your floaters, or any personal experiences you have with this phenomenon.

I think of benign neglect in my office primarily in dealing with patients who are more likely to benefit from not investigating or treating a condition or complaint than by actively managing the condition.  A good example is a woman in her mid 80’s with mild dementia and multiple chronic medical conditions, maybe longstanding diabetes and who has had a coronary bypass surgery 12 years ago who asks if she should have a mammogram. In this case her life expectancy is relatively short, maybe 2-5 years, and the benefit of an early diagnosis of breast cancer is minimal.  In addition the diagnosis is going to force difficult decisions to be made.  Is no treatment, minor treatment, or moderately aggressive treatment best for her situation?  Is she competent to make the choice herself?  The dilemma expands.  Maybe the best approach is to not test for the condition in the first place. In her case most of the time it is an easy consensus to choose not to do the mammogram.

Benign neglect can also apply to situations where leaving relatively harmless conditions alone is better than aggressive treatment.  Examples I see are molluscum contagiosum, where the lesions usually resolve with no therapy in a year or so vs. painful ablative therapy that is far from uniformly successful on the child with the lesions. Another example is with seborrheic keratoses ( the brownish waxy pasted on lesions so common on our skin as we age)  or small lipomas (benign fatty tumors) of the skin.  These generally don’t go away, and often very slowly grow, but usually never bother the patient except cosmetically.  If the y need to be removed later it is not especially more difficult on larger lesions. If patients are comfortable ignoring these, then benign neglect is a great option. Benign neglect is a key to successful parenting too.  It is more widely called ignoring, and involves not rising to the lure of a child’s minor misbehavior.  Often the misbehavior is an attention gaining behavior, and ignoring the behavior will more likely lead to dissipation of it than confrontation or punishment. Examples in early childhood are temper tantrums, and in teens door slamming or a minor cursing. Bringing attention to the behavior may be just the attention the child consciously or subconsciously desired, and the benign neglect of ignoring can be effective at reducing the behavior.

It’s important to understand what you are doing when you choose benign neglect as the best tactic. It is not appropriate when it simply makes your life easier. In order to be truly benign the choice must in it total consequences have a neutral or better impact.  Most of the time when I choose benign neglect I anticipate the likelihood of negative consequences of active intervention to outweigh the likelihood of negative consequences of choosing no active intervention. Benign neglect is an important part of good primary care, yet needs to be used consciously and carefully.

Resolving Subconjunctival Hemorrhage (3 days old)

Today in the office I saw the patient with the subconjunctival hemorrhage, or broken blood vessel in the eye,  in this photo.  It is always fun to see subconjunctival hemorrhage in the office because it is so easy to diagnose and the news is universally good.  Nothing else really looks like a subconjunctival hemorrhage, but it certainly gets your attention if you have one.  If you think of it as just a broken blood vessel in the eye you can imagine how it will look.

The part of the eye that can be seen from the outside consists of the iris and the pupil which are covered by the cornea, and the white part of the eye, the sclera, which is covered by a very thin layer of clear tissue called the bulbar conjunctiva.  The conjunctiva covers the white part of the eyeball and wraps under the eyelids where it is called the palpebral conjunctiva.  The tiny blood vessels that course through the conjunctiva are usually barely visible.  When the conjunctiva is inflamed from allergy, viral or bacterial infection, or other causes of irritation these vessels become engorged and the eye appears pinkish.  This is sometimes called pink eye.

When one of these tiny blood vessels in the bulbar conjunctiva breaks a tiny drop of blood leaks into the space between the conjunctiva and the tough leathery white of the eye.  This blood spreads into a very thin but bright red layer making it look like the whole eye is covered with blood. It looks just like what it is, a broken blood vessel in the eye.  The blood can spread to the whole white area of the eye, or just involve either the inner aspect or the outer aspect of the eye.   This condition is called a subconjunctival hemorrhage.  The “sub” prefix means beneath or under the conjunctiva.

There are several common causes of subconjunctival hemorrhage, but often a person has no idea how the blood vessel was broken.  The most classic of the causes of subconjunctival hemorrhage is labor in pregnant women.  The violent pushing required to expel the fetus commonly causes a broken blood vessel in the eye.   Other fairly common reasons people get a broken blood vessel in the eye are minor trauma, i.e. being poked in the eye, blunt trauma, i.e. being punched in the eye, and sneezing, coughing or rubbing an eye that itches from allergies.

A subconjunctival hemorrhage gradually clears up over a few days to a few weeks time.  The initial bright redness disperses and the blood is reabsorbed.  Usually within 3-5 weeks the redness is completely gone and recovery is complete.  In situations where a person is on an anticoagulant like warfarin or Pradaxa, or an anti-platelet agent like aspirin or Brilinta the bleeding from the broken blood vessel in the eye may be more extensive than usual, but even in these cases the blood usually is reabsorbed fairly quickly.

It is important to differentiate subconjunctival hemorrhage from hyphema.  Hyphema is bleeding into the anterior chamber of the eye behind the cornea, and appears like blood is filling up the space behind the cornea.  Hyphema is an ophthalmologic emergency and needs opthamologic consultation.  Subconjunctival hemorrhage does not affect vision, whereas hyphema usually blocks the visual field.  It is not usually difficult to tell the difference but if there is any question you should definitely see your physician to have your eye examined.

The bright redness of a subconjunctival hemorrhage is not at all like the pinkness of conjunctivitis.  Conjunctivitis on close examination looks like the blood vessels in the conjunctiva are more noticible or injected looking.  With subconjunctival hemorrhage it looks like a pool of blood is covering the eyeball, and looks just like what you would expect from a broken blood vessel in the eye once you understand the anatomy of the conjunctiva and the eye.

Check out this related resource on aspirin side effects.

Hormonal acne has always been among the more difficult types of acne to treat, and in recent years the use of spironolactone for its anti-androgen effects has been found to be helpful for this particular type of acne.  When a woman’s acne is much worse in the week or two prior to her menses or around the time of menopause oftentimes the acne will respond to the anti-androgen effects of spironolactone.  The usual dose is 50-100 mg twice daily.  In adolescents and young women the combination of low-androgenic oral contraceptives is sometimes more effective than spironolactone alone.

The use of spironolactone for suppression of androgenic hair growth by women is also widespread.  Spironolactone can be effective in suppression of facial hair and to a lesser degree body hair.  Again the dose often used is 50-100 mg twice daily.  Polycystic ovarian disease is one of the common medical problems where spironolactone is used for suppression of facial hair growth.

On the other side of hair growth, spironolactone is being used without much evidence to support its efficacy in men with male pattern baldness.   Topical preparations are proported to be helpful for this indication, although I have to say I’m skeptical and the evidence looks pretty sketchy.  Some advocates suggest that adding spironolactone topically to systemic finasteride (Propecia) gives additive anti-androgenic effects at preventing male pattern baldness hair loss.

PMS is a  less well documented and popular use of spironolactone.  Some women find that the drug lessens the severity of the premenstrual dysphoric and fluid retention symptoms.  The primary effect of spironolactone is inhibition of the adrenal hormone aldosterone.  Aldosterone leads to elevation of blood pressure, so inhibition of aldosterone can cause dieresis and so lessen the PMS symptoms of bloating, fluid retention, and premenstrual weight gain.  It is unclear whether the anti-estrogen effects of spironolactone play a role in reducing the emotional symptoms of PMS, or whether any benefit in this regard is related to the diuretic effects.

Traditional uses of spironolactone are more mundane but well documented.  Likely the most common FDA approved uses of spironolactone are to spare potassium loss in combination with a thiazide diuretic, in such fixed dose drugs as Aldactazide and for treatment of congestive heart failure in patients. A commonly noted NEJM article showed that in patients with serious heart failure, LV ejection fraction less than 35%, usually also on and ACE or ARB and loop diuretic like furosemide patients on spironolactone had significantly lower death rates than the control group on placebo.  For more information about furosemide please visit furosemide side effects for a nice resource online.  Other typical diuretic uses of spironolactone are patients with ascites due to cirrhosis of the liver.  The theory behind this is that effects of aldosterone may be harmful to the myocardial cell function.

Spironolactone has potential side effects that can bother patients, and can lead to drug interaction issues.  Common side effects of spironolactone include elevation of serum potassium levels that can be severe at times, Gynecomastia, and diarrhea.  Serious drug interaction side effects can occur with numerous medications, but of special mention are additive potassium elevation effects when used with angiotensin receptor blockers or angiotensin converting enzyme inhibitors, with various other antihypertensive or other cardiac medications.

Spironolactone is pregnancy category D, and carries a black box warning that long term use in rats has been associated with tumor growth and toxicity.

The one antibiotic with a contraindication to use with alcohol is metronidazole, better known by the brand name Flagyl, which has properties in common with Antabuse.  Antabuse is a medication sometimes used in alcoholics because it leads to severe symptoms when used with alcohol.  These symptoms can include flushing, sweating, hypotension, nausea and vomiting.  They can be so severe that Antabuse is only prescribed to alcoholics felt to be dependable enough to successfully abstain from drinking while on the drug.

Another antibiotic with the potential for more common antibiotic and alcohol interaction is trimethoprim-sulfamethoxazole.  This medication is more commonly known by two brand names, Septra and Bactrim, and the side effects nausea, vomiting, and headache may be more common with concomitant use.

Tinidazole is an antimicrobial medication used in the treatment of some of the same infections as metronidazole including amebiasis, giardiasis, and trichomoniasis.  It also shares the Antabuse like side effects when used with alcohol with metronidazole.

Other antibiotics and alcohol have no major drug interactions or problems.  The same issues of antibiotics and alcohol are the same as whti the use of alcohol and any other medication.  These include non-compliance due to inebriation, vomiting and therefore lack of absorption of the antibiotic, and lack of sleep, good nutrition and generally not getting rest and nutrition that can help with recovery from infections.

Severe liver disease can be an issue with some antibiotics, but this is more an issue of use of antibiotics in end-stage liver disease from alcohol than with the use of antibiotics and alcohol together.

My advice regarding antibiotics and alcohol is that your best chance to get well quickly is to get lots of rest, to drink lots of non-alcoholic beverages, remember to take all of your prescribed doses of the antibiotic, and if you choose to drink alcohol and take antibiotics use moderation.

Resource:

Zithromax side effects

When a patient presents with dizziness first I need to assure that they do not have a life-threatening disorder with severe hypotension and shock.  Then the question I need to answer is whether the dizziness is vertigo or lightheadedness.  Vertigo is perceived by patients as a sensation of abnormal motion of some sort, typically as a feeling that they are spinning or that the room is spinning, but sometimes as a feeling of being off balance like they are going to fall to one side or another.  It is often similar to motion sickness for readers who get sea-sick or car-sick.  Other patients describe the feeling of vertigo as being like the feeling of imbalance that they associate with drinking too much and being a bit drunk.  Vertigo is often associated with nausea or vomiting and may sometimes be less severe if they lie or sit perfectly still.  Lightheadedness is the type of feeling you get if you stand up too quickly from lying or sitting, especially if you are mildly dehydrated.

If you feel you have lightheadedness the first thing to decide is whether you are simply a bit dehydrated.  If you suspect dehydration you need to drink more fluids and restore your fluid volume status.  Other causes of lightheadedness include medications, especially anti-hypertension medications, allergic reactions severe enough to cause hypotension, and serious infections.   If it is not clear what is causing your lightheadedness you should consult your doctor and try to find out the cause and get appropriate treatment.

If you have vertigo most of the time you should see your doctor to find out the cause.  Some causes of vertigo are really serious, and it is not a symptom that I can recommend that you try to figure out on your own.  The common causes of vertigo are inner ear viral infections called labyrynthitis or vestibulitis, benign paroxysmal positional vertigo, and Meniere’s disease.  Less common but serious causes can be acoustic neuroma (an auditory nerve tumor), other brain masses including benign and malignant tumors, brain infections like encephalitis, concussions and other head injuries, and other less common disorders.

BPPV is typically worse when turning your head to one side than to the other side, and is common in patients of all ages though more common as you get older.  The Epley Maneuver is a procedure that can be used at the physician’s office or at home to treat BPPV with varying degrees of success.  See the video clip on the prior post for a quick lesson on how to the the Epley maneuver on your own.  Many patients find it more helpful to have the procedure at the doctor’s office because it can make you very vertiginous during the procedure and you may benefit from reassurance and support of your doctor to get through the Epley maneuver.  If you do the Epley maneuver yourself and find no help it is even more important that you see a physician to find out if there may be another cause that needs further evaluation.  Unfortunately the other very common cause of vertigo, acute viral labyrynthitis, may cause vertigo even more severe than BPPV and can be refractory to treatment.  Fortunately acute labyrynthitis usually is self-limited, resolving on its own in a few days to weeks.  We have drugs to help a bit with the symptoms, but none to hurry the cure.

Even though as I implied in my prior post headline the Epley Maueuver Rocks, vertigo definitely does not, and I hope both you and I never have to go through it (again for me).

Let’s take amoxicillin as an example. Amoxicillin is in the penicillin class of antibiotics that is essentially 100% excreted in the urine unchanged. Alcohol on the other hand is largely metabolized in the liver and so there’s no significant metabolic interaction between amoxicillin and alcohol. A potential concern with the use of alcohol and essentially any medication is that when under the influence of alcohol many patients may be less likely to remember to take their medication and compliance could potentially be reduced. Additionally in alcoholics when drinking heavily may not be getting good sleep, eating properly, and generally taking good care of themselves. These behaviors could lead to poor ability to recover from bacterial infections.

Overall the risk of alcohol and amoxicillin or any other antibiotic except metronidazole is relatively insignificant. When patients ask whether they can drink while taking their antibiotic I tell them that they need to focus on taking good care of themselves by getting rest, drinking plenty of non-alcoholic fluids and that one or two drinks is likely to affect their ability to either fight their infection or to interfere with the therapeutic benefits of the amoxicillin.

Another concern about use of some antibiotics and alcohol is that their side effects can be similar. Examples include doxycycline, erythromycin, trimethoprim-sulfamethoxazole, and the tetracycline antibiotics which can cause nausea and upset stomach, also common side effect drinking alcohol.

As mentioned above metronidazole is the major exception to antibiotics and alcohol use together. Metronidazole has an effect similar to Antabuse;  a medication used purposely to lead to sometimes severe illness symptoms when taken with alcohol. The effects with metronidazole are not as consistent or severe is with Antabuse but metronidazole and alcohol need to be avoided in combination.

So unless you have another reason to abstain feel free to have a  glass of a nice cabernet or a mug of porter while on your amoxicillin.  Just remember to take good care of yourself, and maybe add a bowl of chicken soup.

Resource: Amoxicillin side effects

Finally I used Dr. Google to look up home repositioning therapy after one of my younger partners told me about the Epley maneuvers.   These are really pretty simple, and I did them myself with excellent relief.  Within 2 days I was about 95% free of vertigo symptoms.  Yesterday morning I awoke with a recurrence of the vertigo again.  I use my iPhone as my alarm now, and it was lying on the floor charging at the bedside.  On rolling over to turn off the alarm I got so dizzy with the whole room spinning that I had to quickly lie down and let the alarm keep going.  I finally managed to get the alarm off, but felt pretty lousy.  I got to the office and went right to an exam room, and put myself through the Epley maneuvers, with only slight help.  I struggled through a reduced workload day, and last night again did the maneuvers.

I took care last night to avoid rolling to the left, my affected side, and this morning am much better, at least 90% improved, with no true vertigo.  For those readers who say, “What’s vertigo?” first I’m happy for you that you’ve not experienced this miserable symptom.  It is the type of dizziness where there is a sensation of spinning or movement of yourself or the surroundings. It feels like motion sickness, often associated with nausea and severe imbalance.  It can be caused by inflammation or other disorders of the inner ear, particularly the vestibule (semi-circular canals).  BPPV is a type of vertigo where the fluid and tiny granules in the vestibule get out of position, leading to a sensation of motion and vertigo.

I think I managed to practice for 30 years without knowing about the Epley maneuver because John Epley didn’t describe this treatment until 1980, the year I graduated from Med School, and somehow I never heard about it until recently.  The procedure is really simple, though it can produce really miserable vertigo during the procedure for many patients, and can be tough to do without support from a confident helper, like your physician if your vertigo is severe.  It’s also important not to just assume your vertigo is BPPV as there are other more serious causes that may need diagnosis and treatment.  If there is any doubt of the diagnosis see your physician for evaluation.  Here is a You Tube of the maneuver:

As you can see, it’s not really difficult to do, and I now often suggest to my patients to do it at home, or sometimes do it with them at the office. Now I can just send them to this post for details :.) For more  information on the Epley Maneuver and vertigo and dizziness see a later post on the Epley Maneuver.

This patient had presented to our same day clinic three days previously, and had liver function tests as well as testing for hepatitis A,B and C, as well as an abdominal ultrasound ordered.  The LFTs showed significant elevation of the transaminases, a bilirubin of 5.6, and the tests for viral hepatitis were all negative.  The ultrasound added some hope with a gall bladder full of stones, but no common bile duct stone seen on the scan, and the common bile duct was dilated to 16 mm, far larger than normal.

The anatomy of the outflow of bile from the liver and gall bladder is fairly simple to think about, and the pancreatic duct empties into the common bile duct near where the cystic duct from the gall bladder joins the common bile duct.  The head of the pancreas is near this area, and cancer of the head of the pancreas can cause obstructive jaundice of the bile duct.  Cancers of the gall bladder or common bile duct can also cause jaundice as a presenting symptom.  Cancers metastatic to the liver can also cause jaundice by obstruction of intrahepatic bile ducts.

I’m praying that this patient has a common bile duct stone and obstruction that can be cured with removal of the stone and cholecystectomy, but know that it is likely that the stones are not the problem.

Other causes of jaundice include the many types of cellular inflammation of the liver called hepatitis, overly rapid breakdown of red blood cells called hemolysis that can overload the liver with hemoglobin that is metabolized into bilirubin and can lead to jaundice, bile duct disorders like the autoimmune disorder called primary sclerosing cholangitis, and other causes of bile duct obstruction.  Still common things being common I am anxiously awaiting word from my gastroenterology consultant on the results of the ERCP (endoscopic retrograde cholangiopancreatography- a test where a scope passed through the stomach into the duodenum is used to inject dye into the bile and pancreatic ducts) to see what is causing my patient’s jaundice symptoms.

From the Noise to Signal social media cartoon

Starting in January most OTC products, excepting some medical equipment like crutches and diabetic supplies, now cannot be purchased with flexible spending account dollars without a physician prescription.   One of my partners asked last week how I am dealing with this issue.  He has had several patients ask for a long list of prescriptions for OTC products so that they can use their FSP to pay for these things with pre-tax dollars.  This puts us in a no-win situation.  Either we spend the time to write several prescriptions for whatever the patient asks for or spend a similar amount of time explaining why we decline to write the prescriptions.

It is very likely that this is a great example of the law of unintended consequences.  The law was clearly written to increase tax revenue. The unintended consequence is that patients are now asking for a prescription for things like aspirin, Tylenol, body lotion, dandruff shampoo, shoe inserts and nearly anything else you can imagine.  Here are some of the issues I have with this situation:

• Even in the highest tax brackets the savings for some of these items just are not worth my time to write and document a prescription:  Aspirin cost $2.   Tax savings potential  $0.66
• This is one more task added to the primary care physicians to do list after patients are seen to accomplish before we can go home.  It takes at least 30 seconds to open a patient’s chart, write a prescription, and get the Rx to a patient’s pharmacy or to leave at the front desk for them to pick up.   Patients often ask for prescriptions for multiple items, some requiring more time than just writing a prescription.
• These requests use up minutes in a patient visit that can be better used for other care.  Do I want to spend my time gathering enough information to help a patient adjust their insulin and eating to control their blood sugar, or writing prescriptions for their corn pads, aspirin (see aspirin side effects), body lotion and anti-perspirant.
• Once a physician writes a prescription they incur some liability for the product used.  Let’s say a patient uses a product that they ask me to prescribe.  If they then have a problem in any way related to that product you can bet my name will be added to the list of defendants in the product liability lawsuit.
• I really don’t know about much about many of the OTC products patients use.  Some of the herbal and supplement products used have labeling that is nearly indecipherable, and certainly nothing I would ever recommend.  Should I now be writing a prescription for these as a money saving service to patients?  I think I’ll say no to these requests.

Really this new law is a good example of a decision made with one intended consequence that leads to another unintended consequence.  In this case the government is responding to concerns about the cost of health care, so they have tried to save costs to the government by eliminating the pre-tax status of some OTC products. By doing so they have increased primary care physician overhead costs.  This is likely a false savings.  It is certainly poor use of primary care physician’s time and is unlikely to be an incentive for new medical school graduates to choose primary care over higher paying specialty care where few of these prescription requests will be seen.

Let me know what you think about this new law?  Leave a comment.   This health blog loves comments.

Oxycodone is the active ingredient in many prescription pain meds, including Perocet, Tylox as well as the single ingredient generic oxycodone.  It is also the active ingredient in the combination immediate and time release Oxycontin.  The problem with Oxycontin is that a large percentage of the oxycodone is immediately released, while the rest is released over time.  The purpose of this is to give immediate relief of pain, while keeping pain controlled over time with the delayed absorption of part of the medication.  Unfortunately the large percentage released immediately of this particular opioid which has a higher euphoria effect than most opioids makes it a very popular drug of abuse, and even used appropriately it has a high incidence of addiction.

This has resulted in the development of a whole sub-culture of Oxycontin abuse.  It’s become known as Hillbilly Heroin or just oxy on the streets.  Oxycontin is very commonly pulverized into a powder to void the delayed release effect, and ingested, injected, snorted, or inhaled.  Smoking Oxycontin has become a common problem in some areas of the country.  Oxycontin is arguable the most abused opioid in the US.  It is a drug of choice for many prescription opioid addicts and the Oxycontin side effects can be severe.  It has little if any advantage over alternative opioids and is generally best avoided in non-malignant terminal pain patients.

Although physicians have come under a great deal of criticism, sometimes appropriately for excessive prescription of opioids, especially Oxycontin, we have also come under criticism for inadequate treatment of chronic pain.  Recommendations for obtaining expert consultation when prescribing long term opioids sound fine at face value, but at least in the community where I work it is nearly impossible to find such an expert for consultion.

In the last two months I’ve had two young male patients present to the office for help with Oxycontin addiction.  Neither of them had ever received a prescription for Oxycontin from a health care provider.  Both had been given the drug by a friend at their work.  One was trying the med to help with a nagging back ache, another just to see how he liked using the drug.  Both told me they quickly became physically and psychologically addicted within a couple of weeks.

In my community it drug seeking patients have become such a problem that many chronic pain patient can’t find a doctor to prescribe pain meds.  Physicians who become known as willing to take new patients for chronic pain medication management are quickly targeted by both patients with serious medical problems with pain medication requirements and by the drug seeking abusers.  This reputation can quickly make a practice unpleasant and put the physician at risk for sanctions by their state review board.

Look at Oxycodone side effects for another great resource and thanks for reading this medical blog.  Leave a comment and contribute to the discussion about Oxycontin versus Oxycodone below in the proper field.

I was again appalled today at the audacity of the pharmaceutical industry and their pricing.  A drug rep told me about a great new sleeping medication that is not a benzodiazepine, has a low side effect profile, is a non-schedule drug, and is ideal for the typical patient we struggle with, i.e. has trouble falling asleep and staying asleep for more than a few hours.  She then told me that this is a new dosing regimen of an old drug doxepin.  I grew up in medicine with the tricyclic antidepressant meds.  Doxepin was sold as Sinequan, a branded drug when I was a med student, has long been used as a very sedating antidepressant.  It has been used more recently for help with chronic pain, as an add-on med in depression when sleep is needed, and sometimes alone for insomnia.  It is available as a generic in doses of 10,25,50,100 and 150 mg all except the 150 mg doses for $4./ 30 doses at the discount pharmacies.  The drug rep assured me that I did not need to worry about the cost of this medication, because although the med will the in the highest tier copay on essentially all plans, i.e. $ 40-$60./ month for most patients, they would supply coupons to reduce this copay by $25./ month so the “real” cost to the patient will be only $15-35.  As always, I asked her what the real cost is, and after some arm twisting she told me it was about the same as the other “branded” hypnotics.  Asked how much this is she said about $200./ 30 pills.  The new drug is called Silenor, and is simply doxepin packaged in a smaller dose, of 3 and 6 mg.  I presume that this company buys generic doxepin in bulk, that is available as a generic  100 mg dose for  $0.13/ dose and sells 3/50^th   or 3/25^th  the dose for 51x as much as the higher dose.  I was told that they need this pricing to pay for all the research they needed to do to allow them to bring this lower dose to market.  The rep did not mention they also needed to  hire a sales force good enough to somehow convince feeble minded physicians that this somehow is better than a dose of ½ of a 10 mg of the generic. 

Usually I don’t waste my breath, but this was so insane that I gave the rep my usually silent rant about how unethical coupons are, as they essentially remove the disincentive for patients to try to hold down medication costs that the high tier copays are designed to provide.  I added a tirade about their need to pay for the research was not really necessary, because the research only served to allow them to “brand” this low dose of an available generic medication, and to send reps to the field to sell this drug.  She was obviously used to these responses, because when I told her she had a tough sell in front of her, she simply moved on to the next doc and started her sales pitch again.   If any of you are unfortunate enough to have a physician who is convinced that somehow this new dose of doxepin is what you need, just go ahead and ask them to try generic doxepin, save yourself a little money, and take a tiny step toward controlling health care costs.

I enjoy telling my patients who have this condition what is going on because it’s an interesting condition, it’s not serious, it gets better with time and patients can easily understand the cause and course of the problem. This week in the office a very pleasant woman came in with this condition, and although not happy to hear that there was nothing I could do to help, she at least appreciated a diagnosis, and was relieved to hear that her hair would grow back.

Each hair on our body has two major periods in its lifespan. Each hair starts growing and continues to grow for an average of 3 years, the phase called anagen.  Then the growth stops, and the hair follicle enters the phase called telogen.  At any one time 5-10% of a person’s hairs are in telogen.  After about 3 months, and this period of time varies widely from one person to another, the hair in telogen falls out as a club hair.  It’s called this because the root of the hair if looked at microscopically has a rounded, thickened, club-like appearance.  A hair pulled out in anaphase has a ragged, ripped-out looking root microscopically.   On average 1-200 scalp hairs are shed daily. I don’t think I have enough hair left to lose that many.

Certain major stresses and conditions can shock a large percent of the body’s hairs to stop growing and enter telophase simultaneously.  This phenomenon is called telogen effluvium.  When this happens, a few months later a large percentage of an individual’s hair can be shed as club hairs over a few weeks or months period of time.  It can be very disturbing to the person losing their hair.  The classic stress to cause this is childbirth, and in the days when I did maternity care it was not uncommon for me to see women in the office a few months after delivery distraught that they were losing lots of scalp hair.  Other stresses that can cause this are major surgery, high fever, serious illness, major emotional stress, and rapid weight loss.  Medical conditions associated with telogen effluvium are anorexia nervosa, iron deficiency, hypothyroidism, and the sudden conditions mentioned above.

This is a good news/ bad news situation to tell patients about.  The good news is that it is completely reversible, and usually resolves in a few months.  The bad news is that is quite a while before the hair grows back, and that there is nothing to do to speed the process along.  In my experience although many patients come to the office thinking hypothyroidism is the cause of their hair loss this is very rarely the problem.  Emotional of physical stresses are more common causes.

If there is anything good about telogen effluvium, it’s that it has a cool name, and you can impress your friends by telling them a snazzy name for your condition.  You might as well take advantage of the little things.  There’s not much else you can do except wait for your hair to grow back.

All this is good, but I think I really like Unna boots because it is one of the times where as a family physician I get to use a hands-on therapy that really works.  It also just feels good to apply the cool, soothing bandage to the patient’s leg and see them feel better almost immediately.   In addition it’s a treatment where I see the patient weekly, and when it works well we see regular, fairly steady improvement.  Almost always patients are really happy with this treatment, though it usually takes far more visits that they would like.

Dear Dr. B.,

R. was in 08/09/2010.  He is 2-years 9-months-old, and dad says he runs into things.

He appeared to have good central maintained fixation in each eye.  The eyes look straight at distance and near.  They deny any crossing.

After dilation, unlike the last 10 children who are 2 years old and run into things and whom had normal eyes, R. has 7 diopters of farsightedness.  He needs to wear glasses and will be checked in 2-3 months.  I talked to his dad about this.

Sincerely,

Dr. S.

Dr. S has been around for a while, and had the confidence and sense of humor to make his letter not just functional but entertaining.  Many thanks.

Now:  Send me your best stuff.

Here is a link to several photos of Pitiriasis rosea.