River News Desk

What is a Rotahaler?
Many people that suffer from asthma, COPD (Chronic Obstructive Pulmonary Disease) or cystic fibrosis use dry powder inhalers (DPI’s) to administer their medication. The Rotahaler is just one of many devices that are available. The Rotahaler was designed to make inhaled medication more convenient and effective for asthmatic patients. Improving the success of this treatment, however, is not only a matter of inhaler design but also of optimising and simplifying instructions and the mode of inhalation. It uses special capsules called Rotacaps that contain the medication in a very fine powder form that is effectively delivered into the lungs when you inhale through the Rotahaler.

What is a metered dose inhaler?
A metered dose inhaler (MDI), also known as an aerosol inhaler or puffer, is a device for delivering medicine directly into the lungs. It consists of a pressurised metal canister containing a solution or suspension of medicine, placed within a plastic case with a mouthpiece. When the canister is pushed down, a valve delivers a measured dose of medicine in a fine mist. This is inhaled into the lungs via the mouthpiece. Using an inhaler delivers your medicine directly into the lungs where it is needed.
If you are taking more than one inhaler, it is important to take them in the correct order. The correct order can make a big difference! Be sure to discuss this with your doctor, or pharmacist.

It is very important that one knows the proper way to use their inhaler for safety and for effectiveness.  The wrong technique could mean that the medicine is ending up in your mouth or your throat which can lead to irritation. Always check the expiry date before use.

To use a Rotahaler:
1.    To load the Rotahaler, hold it by the mouthpiece and twist the barrel in one direction until it stops turning.
2.    Holding the Rotahaler vertically, press the clear end of the Rotacap into the capsule insert hole (the top of the Rotahaler should be level with the top of the hole).
3.    Holding the Rotahaler vertically, with the white dot up, twist the barrel in the opposite direction until it stops – the Rotahaler is now loaded.
4.    Breathe out.
5.    Place the mouthpiece in your teeth and close your lips around it.
6.    Tilt your head back slightly.
7.    Breathe in deeply and forcefully through your mouth.
8.    Hold your breath and remove the Rotahaler: from your mouth.
9.    Hold your breath for 10 seconds or as long as you can.
10.    Breathe out slowly.
11.    To ensure you have inhaled the full dose, replace the Rotahaler in your mouth and repeat the above steps.
12.    Discard the empty Rotacap shell.
13.    Sometimes 2 or 3 forceful inhalations are needed to make sure you have inhaled the full dose.
14.    If a second Rotacap is prescribed, repeat the procedure.
15.    If your Diskhaler contains a corticosteroid medicine, rinse you mouth out & gargle with water after you use it, to prevent a local yeast infection (thrush) in your mouth, and hoarseness in your throat.

Source: The Lung Association http://dev.lung.ca

How to Clean your Rotahaler

About once a week, wash each of the two halves of the Rotahaler in warm water, making sure that the empty Rotacap shells have been removed first. Dry the Rotahaler thoroughly before reassembling.

To use an MDI:
1.    Shake the inhaler well before use (3 or 4 shakes)
2.    Remove the cap
3.    Breathe out, away from your inhaler
4.    Bring the inhaler to your mouth. Place it in your mouth between your teeth and close your mouth around it.
5.    Start to breathe in slowly. Press the top of you inhaler once and keep breathing in slowly until you have taken a full breath.
6.    Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out.
7.    If you need a second puff, wait 30 seconds, shake your inhaler again, and repeat steps 3-6. After you’ve used your MDI, rinse out your mouth and record the number of doses taken.
8.    Store all puffers at room temperature

Information for this article was taken from the following sources:  http://www.riverpharmacy.ca, http://www.wvasthma.org, http://www.ncbi.nlm.nih.gov, http://www.netdoctor.co.uk, http://dev.lung.ca/diseases-maladies/help-aide_e.php#rotahaler

Supplies Needed
•    50 mg tabs of naltrexone
•    5  ml syringe or graduated baby medicine dropper
•    4 oz amber glass jar with a tight fitting lid
•    Distilled water

Order your supply of 50mg Naltrexone tablets.  You can convert a 50mg tablet into low dose naltrexone (LDN) simply and easily. To do so, fill a graduated cylinder with 50 ml of distilled water (unlike tap or spring water, distilled water contains no impurities that could potentially react with and thus reduce Naltrexone’s effectiveness). You can also use whatever measuring device you have to measure out 50 ml.  Pour the water from the graduate cylinder into a 4oz glass jar; then drop in one 50mg tablet.  The tablet will mostly dissolve in about 2 hours.  Note that not all of the tablet is soluble in water so instead of yielding a clear solution, the result will be a cloudy suspension.  One ml of the (shaken) suspension will contain one mg of Naltrexone or another way of putting it is that you have created a 1 to 1 ratio of water and tablet. You can use a graduated baby medicine dropper or 5-ml syringe to measure out the dose you need.

Once a drug passes from a solid to a liquid state, its shelf life can decrease dramatically.  Therefore, do not make more than 50 ml of liquid Naltrexone at one time, store it in the refrigerator, and do not keep it for more than 2 months.  Be sure to shake the liquid LDN well before using and keep from direct exposure to sunlight.

The therapeutic dosage range for LDN is from 1.5mg to 4.5mg. Dosages below this range are likely to have no effect at all. Dr. Bahari prescribed doses of 1.5 to 4.5mg taken at bedtime. Bihari theorized that LDN causes a peak endorphin increase during the predawn hours. However, studies show that taking LDN at night is not necessary.

Bahari didn’t prescribe amounts greater than 4.5mg but he didn’t take body weight into consideration. Ian Zagon on the other hand recommends doses ranging from 3 – 10mg daily adjusted to the patient’s weight.
The most common approach in practice is to stop dose increases at 4.5mg.

You may want to gradually introduce the LDN to your system. Many patients start with 1.5 ml dose and continue with this dose for a week or two, then add 0.5 ml and continue for another couple of weeks, then increase again by 0.5ml, steadily increasing the dosage until you reach the maximum dosage which is 4.5 ml.

LDN has virtually no side effects. Occasionally, during the first week’s use of LDN, patients may complain of some difficulty sleeping or may experience vivid dreams. This rarely persists after the first week. Side effects are less likely to occur when a small starting dose is used and gradually increased. If you notice an increase in symptoms you may want to reduce the dose. If sleep disturbance is a problem Zagon recommends taking LDN in the morning.

Most people with high blood pressure have what is known as essential hypertension. It is caused by genetics; bad diet, especially a high salt diet; obesity; lack of exercise; and excessive alcohol intake. A very small proportion of people have hypertension due to another disease. Kidney problems, some endocrine abnormalities and some drugs (such as arthritis medicines and birth control pills) can cause what is known as secondary hypertension. Secondary hypertension is best treated by treating the underlying problem.

The long-term effects of hypertension are cardiovascular diseases such as heart attack, heart beat or rhythm problems, congestive heart failure and stroke. Kidney failure can also be the result of long-term high blood pressure.

Essential hypertension or essential high blood pressure is one of most common problems among adults in the U.S. and Western Europe. In the U.S., about one-third of the population age18 and older, and one-half of the population age 65 and older has hypertension. This translates into more than 60 million American adults having it, today. The number of people with hypertension is growing. This is due to the aging of the population and America’s obesity epidemic. In the U.S., there were 30 million over age 65 in 2000 (13% of the population) and it is estimated that there will be 54 million over age 65 in 2020 (16% of the population). Thirteen percent of American adults were obese in the mid 1960s, compared with 35 percent in 2008.

The systolic blood pressure is the highest pressure reached in the arteries when the heart contracts. The diastolic is the arterial pressure when the heart relaxes. They are measured in a unit known as mmHg (for millimeters of mercury). The definition of normal blood pressure and hypertension that has been agreed upon by a number of medical societies is a number of measurements averaging the following:

• Normal blood pressure: systolic less than 120 mmHg and diastolic less than 80 mmHg

• Prehypertension: systolic 120-139 mmHg or diastolic 80-89 mmHg

• Hypertension:

Stage 1: systolic 140-159 mmHg or diastolic 90-99 mmHg

Stage 2: systolic equal to or greater than 160 or diastolic equal to or greater than 100 mmHg

It is generally recommended that most patients with hypertension be treated such that their blood pressure remains below a systolic of 140 and a diastolic of 90. Most patients likely benefit from even lower numbers closer to the normal range. It is also recommended that diastolic blood pressures be kept above 65 mmHg, because going below this level can increase the risk of some types of stroke, especially among older people.

It is not unusual for people to have blood pressure cuffs at home and take their blood pressure regularly. This is to be encouraged, though proper cuff sizing and proper cuff placement are important. Inaccurate readings, both high and low, can result when the blood pressure is not measured correctly. The patient should be instructed as to what size cuff to use and how to properly place the blood pressure cuff.

A number of drugs are available to treat hypertension. They use various mechanisms of action. Some are good for mild to moderate high blood pressure; others are reserved for more severe disease. Some patients need two or three drugs to control their blood pressure. Interestingly, studies show less than 40% of Americans with hypertension have it under control. This is because hypertension is a disease with almost no symptoms for most of its course. It requires a medical examination to diagnose and is treated with medications that must be taken daily and sometimes impair quality of life. Some patients are significantly inconvenienced by having to urinate frequently due to a diuretic, by constipation due to a calcium channel blocker or by impotence or lightheadedness due to an alpha or beta blocker.

Stress from work and other situations can increase ones blood pressure and your retirement may be helping to lower your blood pressure. Changes in diet, weight loss and exercise have also been known to lower ones blood pressure and decrease the need for hypertensive medication.

It is possible for a person with mild hypertension on a mild to moderate blood pressure medication to reach a healthy blood pressure by changing some factors in his or her life, such that blood pressure medication is no longer needed. This should only be done slowly and under a physician’s supervision. It may be that lowering the dose or switching to a milder medication is ultimately right for you.

Caution: It is not recommended to alter the dosage of your medication without consulting your physician.

This article was derived from CNN Health.

Antidepressants and aspirin don’t mix, a new study suggests.

Researchers found that painkillers such as aspirin and ibuprofen appear to decrease the effectiveness of a popular class of antidepressants that includes Prozac and Celexa.

The finding, published Monday, may help explain why even the most effective antidepressants don’t work for everyone. At best only about two-thirds of patients respond effectively to Celexa and other selective serotonin reuptake inhibitors, or SSRIs.

Non-steroidal anti-inflammatory drugs, or NSAIDs, are a widely used class of pain medicines and include aspirin and ibuprofen but not acetominephen.

“It appears there’s a very strong antagonistic relationship between NSAIDs and SSRIs,” said Jennifer Warner-Schmidt, first author of the study and a researcher at Rockefeller University in New York. “This may be one reason why the response rate [in patients of SSRIs] is so low.”

The finding, which need to be confirmed in further studies, was published in the journal Proceedings of the National Academy of Sciences.

It isn’t clear from the study whether taking ibuprofen for an occasional headache is enough to blunt the effect of an antidepressant or whether it takes long-term use for a condition such as arthritis for there to be an inhibitory effect.

Major depression is estimated to affect 16.5% of U.S. adults over their lifetime, according to the National Institute of Mental Health.

Antidepressants, the bulk of which are SSRIs, were the second most popular drug class prescribed in the U.S. last year, netting $11.6 billion in sales, according to IMS Health, which tracks pharmaceutical sales.

There were 253 million prescriptions for antidepressants in the U.S. in 2010.

The Rockefeller researchers initially looked at changes of a biochemical marker of depression in mice when the animals were consistently given an SSRI, an anti-inflammatory or both medicines.

They figured if there was any effect from combining the two, it would have been to improve depressive symptoms since inflammation, an immune system response to infection, it thought to worsen or even cause depression in some people, Dr. Warner-Schmidt said.

Instead, they found that mice given a combination regimen had a dampened response—and sometimes no response—to the antidepressant compared to the group that got the SSRI alone. Mice who received just the anti-inflammatory didn’t show any change in the protein marker, called p11.

The researchers then looked to see if there was any evidence of this effect in humans. By examining data from an already-completed 4,000-patient large clinical trial of depressed patients known as STAR*D, they found that there was indeed a significant difference. Depressive symptoms—such as feeling down, crying more frequently than usual or having decreased appetite—in patients who took Celexa went away 55% of the time, but that rate dropped to 45% in individuals who reported they also had taken an anti-inflammatory.

The results, though preliminary and in need of replication, suggest that there could be clinical implications for patients who take both types of medications, experts said.

“If it’s substantiated in further studies, it would certainly imply we would have to use a different treatment for patients who are chronically taking NSAIDs,” like those with arthritis, said Steve Wengel, a depression researcher and chair of the University of Nebraska Medical Center psychiatry department who wasn’t involved with the current study.

But Dr. Wengel said that physical pain can make depression worse so patients taking both types of medicines may have harder-to-treat depressions.

The Rockefeller researchers plan to carry out a study that follows human SSRI users over time—some taking NSAIDS and some not—to better investigate the issue.

Madhukar Trivedi, who co-led the STAR*D trial and wasn’t involved in the new study, called the mouse data “clearly compelling” and the STAR*D analysis “very fascinating” but in need of follow-up.

Dr. Trivedi, a psychiatry professor at the University of Texas Southwestern Medical Center, Dallas, said he wouldn’t routinely urge depressed patients to stop taking an NSAID based on the findings, but if they weren’t responding well to the SSRI, he would evaluate whether they needed the painkiller.

Patients who are taking these medicines shouldn’t stop them on their own, experts said, and should talk to their doctor if they have concerns.

It isn’t clear why NSAIDs suppress the effect of SSRIs, but it could be simply an interaction between the drugs where NSAIDs prevent SSRIs from reaching the brain, the researchers said.

“Physicians should consider the advantages and disadvantages of giving an anti-inflammatory with the antidepressant depending on how severe the pain is and how depressed they are,” said Paul Greengard, senior author on the paper and head of the molecular and cellular neuroscience lab at Rockefeller.

This article was originally published in the Wall Street Journal, written by Shirley S. Wang

Although most of us understand this scenario all too well, it’s even scarier to think that we more than likely know someone who experiences this. It’s bad enough that there are many people that can’t afford to visit a doctor so they don’t get the prescriptions they need. But then there are those who get a prescription, but can’t afford to fill them. We hope that River Pharmacy can help offer a solution for those who experience this hardship.

10:54 AM CDT, March 30, 2011

NEW YORK (Reuters Health) – A significant portion of people – perhaps as many as one in five – don’t take drugs a doctor has prescribed because they can’t pay for them, according to a new survey of people visiting an emergency room.

“I think this is a wake-up call,” study author Dr. Karin Rhodes of the University of Pennsylvania told Reuters Health.

Among a group of more than 1500 people who volunteered to complete a questionnaire, more than 20 percent said they had previously not taken a prescribed drug on account of the price tag.

It’s an issue that many doctors aren’t aware of, noted Rhodes, and the system needs to address it. “Patients need to be asked ‘can you afford your medications?’ and they should get help to pay for them.”

A number of studies have shown that people with chronic health problems, including high blood pressure, diabetes and heart disease, commonly fail to take their medications as prescribed.

Other reports have shown similar rates of so-called “nonadherence,” although the actual estimate tends to vary depending on the exact questions researchers ask, according to Dr. Jae Kennedy of Washington State University, who did not participate in the current project.

One recent study found that 22 percent of prescriptions written for 75,000 Massachusetts patients were never filled. And in another, people were less likely to fill “dispense as written” prescriptions (See Reuters Health report, March 25, 2011).

Some people go to the trouble of filling the prescription, but never pick it up. Looking at information collected from 5 million Americans over 6 months, a study late last year showed that just over 3 percent never retrieve their prescriptions from the pharmacy, and were more likely to abandon expensive medications.

During the current study, 21 percent of the 1506 participants said they had previously not taken medications because of money concerns. Another 5 percent said they were worried they might not be able to pay for drugs.

The researchers, who published their results in the journal Academic Emergency Medicine, considered both groups to be “at risk” of nonadherence with future prescriptions.

Looking at the responses to other questions on the survey, Rhodes and her team found that people were more likely to be at risk of nonadherence if they had money issues – for instance, they worried about money, didn’t have enough food, reported housing problems, and had inadequate health insurance. But they were also more likely to be at risk of nonadherence if they smoked, used illegal drugs, or experienced domestic violence, as either the victim or perpetrator.

“I think (nonadherence) goes along with people who have difficult, disorganized lives,” said Rhodes.

Nonadherence has consequences, she added – one problem, if left untreated, will create others, such as when untreated high blood pressure hurts the kidneys. Research shows that people who don’t fill prescriptions or take medications as they’re prescribed are more likely to get sicker, and become hospitalized, said Kennedy in an e-mail.

“Nonadherence is a widespread and serious public health problem.”

There are signs that the people who volunteered to fill out questionnaires may not be entirely representative of the population as a whole, the authors caution. Half of the volunteers were 32 or younger, and the elderly are more likely to have more prescriptions and therefore more trouble paying for them, said Rhodes.

In addition, it’s quite possible that people with money concerns might be less likely to volunteer to answer questions about that problem, she added.

“This is just the tip of the iceberg, and it’s probably just an underestimate of the problem.”

The next logical step, said Kennedy, would be to track how many people actually filled their prescriptions after a doctor’s visit.

“Clinicians need to ask their patients if they can afford to fill their prescriptions, and work with them to make sure they get the medications they are prescribed,” he said.

Copyright © 2011, Reuters