Clinician's Corner

Poison ivy (click for photo example) are all members of the Anacardiaceae family of plants. The Toxicodendron (“means poisonous tree”) genus of plants causes more contact dermatitis than all other causes combined. Ten to fifty million Americans develop allergic contact dermatitis to a Toxicodendron annually. In one study 10% of all occupational injuries among seasonal farm, workers in PA and NY were due to poison ivy contact. The genus/species names are as follows:

• common or northern poison ivy (Toxicodendron radicans)

•...

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Iron is a necessary part of hemoglobin, a protein which carries oxygen from our lungs throughout our bodies. Iron is also part of many other proteins and enzymes. Iron deficiency anemia is the most common type of anemia, and it occurs when your body does not have enough of the mineral iron. Iron deficiency anemia will appear as weakness and even shortness of breath.

If your physician recommends iron therapy, your Nickman’s pharmacist can help you get the most out of iron therapy.

INITIATE THERAPY WITH: ORAL IRON

  • Ferrous sulfate 325mg (5grain) yields 65mg elemental iron ( 20%)
  • Ferrous gluconate 300mg yields 35mg iron (12%)
  • Ferrous fumarate 300mg...
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Vitamin B-12 (cyanocobalamin)—the pharmacist's favorite supplement.

Source of B12: muscle meats, liver & dairy products. Not found in vegetables. Vegetarians are at risk.

Function: involved in cell division and rapidly growing cells in the body. This includes the blood forming system, gastrointestinal tract, and nervous system.

Deficiency:

    • Large blood cell anemia.
    • Untreated Vitamin B12 deficiency may cause neuropathy. Remember that large doses of folic acid will correct the anemia but will allow nervous system damage to progress.

Vitamin B12 is bound to protein in meats and dairy products and is released by the activity of stomach acid. When...

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Mechanism: Folic acid is important for formation of red blood cells, create new proteins as well as DNA synthesis.

Dietary sources: Folate is found naturally in a wide variety of foods, such dark green leafy vegetables, fruits and fruit juices, nuts, beans, peas, dairy products, poultry and meat, eggs, seafood, and grains. Spinach, liver, yeast, asparagus, and Brussels sprouts are among the foods with the highest levels of folate. By FDA requirement, manufacturers add folic acid to enriched breads, cereals, flours, corn meals, pastas, rice, and other grain products, since 1998. This accounts for 100-180mcg per day.

Pregnancy: decreased incidence of Spina bifida (opening of the spine) and...

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Pyridoxine (B6)

Sources: meat, fish, legumes (beans), dry yeast, potatoes and other starchy vegetables and non-citrus fruits.

Function: as an enzyme for a variety of essential reactions in the metabolism of certain amino & fatty acids. Vitamin B6 in coenzyme forms performs a wide variety of functions in the body and is extremely versatile, with involvement in more than 100 enzyme reactions, mostly concerned with protein metabolism.

Deficiency States: may lead to anemia, convulsions in infants, cheilosis (cracked lips), seborrhea like skin reactions and neuropathy. As with riboflavin, the deficiency state consists of rather diffuse symptoms. Dialysis patients, and those deficient in other B-vitamins are more likely to express symptoms of...

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Niacin deficiency was common in the southern United States in the early 1900’s due to diets being heavy in corn-based products. United States Surgeon General Joseph Goldberger observed the link in pellagra and orphanages and mental hospitals. In 1926 he established a diet that supplemented Brewer’s yeast to correct this deficiency. Pellagra can also occur in populations that are homeless, alcoholic, or psychiatric patients who refuse food.

Dietary sources: meat, fish, legumes, whole grains. Grains are supplemented with micronutrients such as thiamin, riboflavin, niacin, iron and folic acid.

Function: converts carbohydrates into glucose, metabolizing fats and proteins, and keeping the nervous system working properly

Deficiency states...

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Function of riboflavin: Function: central component in a number of enzyme systems, especially in the lungs.

Dietary sources: milk and eggs, meats, fish, green vegetables, yeast, and enriched foods such as fortified cereals and breads. Grains have been fortified with B vitamins since the 1950’s. Because riboflavin is light sensitive, milk is usually commercially sold in an opaque container.

Deficiency States: Riboflavin deficiency is extremely rare in the United States. In addition to inadequate intake, causes of riboflavin deficiency can include endocrine abnormalities (such as thyroid hormone insufficiency) and some diseases.

· Inflamed lips cracks and sores at corners of the mouth

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Vitamin B-1 (Thiamine) (also spelled “thiamin”)

Function of Thiamine: works to help break down carbohydrates and plays a role in nerve conduction.

Deficiency States: Also associated with malabsorption, dialysis, and protein-calorie under nutrition. In addition to insufficient intakes of thiamin from the diet, the causes of thiamin deficiency include lower absorption or higher excretion rates than normal due, for example, to certain conditions (such as alcohol dependence or HIV/AIDS) or use of some medications.

  • Dry beriberi: affects the nervous system and may cause psychiatric disturbances.
  • Wet beriberi: may cause heart problems and leads to overall...
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The last fat-soluble vitamin we need to mention is Vitamin-K. We get plenty from the food we eat, and what we make in our bowels. All though Vitamin-K is fat soluble, we accumulate very little. We have at most 7 days of storage.

Sources for Vitamin K: leafy vegetables, vegetable oils, liver, & synthesis by what we make in our intestines. Phylloquinone (Vitamin K-1) is present primarily in green leafy vegetables and is the main dietary form of vitamin K. Menaquinones (Vitamin K-2), especially long-chain menaquinones, are produced by bacteria in the human gut.

Vitamin-K is necessary for activation of clotting factors.

Deficiency States: Can be due to:

• Excessive antibiotic use. Newborns & preemies...

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Vitamin-E: more useful for women than men!

Vitamin E (tocopherol) is a fat-soluble vitamin with antioxidant properties; it protects cell membranes from oxidation and destruction. A few decades ago, it was widely touted for everything, however lately its use has fallen out of favor. As an antioxidant, it protects cells from the damage caused by free radicals. Free radicals are produced from the conversion of food to energy. People are also exposed to free radicals in the environment from cigarette smoke, air pollution, and ultraviolet light from the sun.

• Source: there are 8 naturally tocopherols. The most active is d-alpha-tocopherol.

• Dietary sources: Vegetable oils, wheat germ, leafy vegetables, egg yolk, margarine,...

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Melatonin is classified as a “dietary supplement” by the FDA, even though most of us look at melatonin as drug product.

Our body makes melatonin and is secreted by the pineal gland in the brain to regulate sleep-wake cycles or circadian rhythms. Melatonin is synthesized from the amino acid tryptophan. Melatonin secretion begins around the third or fourth month of life, peaks in pediatric years, and lessens as we age. A 70-year-old has about ¼ of the melatonin secretion as young adults do. Supplementation of melatonin seems to be a reasonable option for sleep induction.

  • USE: May be useful may help to regulate sleep disturbances that occur with insomnia, jet lag, rotating shiftwork, depression, chronic kidney disease.
  • Jet lag: Melatonin can improve...
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What it does: Vitamin A is the name of a group of fat-soluble retinoids, which are involved in immune function, vision, reproduction, and cellular communication. Vitamin A is critical for function in the retinal receptors, as well as for the outer surface of the eye. Vitamin A also supports cell growth playing a critical role in the normal formation and maintenance of the heart, lungs, kidneys, and other organs.

• Dietary sources: fish liver oils, egg yolks, green leafy, orange & yellow vegetables.

Deficiency States:

Night blindness: early sign of Vitamin-A deficiency. May progress to xerophthalmia, which is dryness & ulceration of the cornea. May progress to blindness.

• See decrease...

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Which Calcium is best?

In the last Clinicians Corner, we discussed Vitamin-D supplementation. Although Vitamin-D is helpful in immune system functioning, its primary role is in maintaining calcium regulation in the body. Vitamin-D is necessary for calcium absorption to occur out of our gastrointestinal tract.

Many of our patients, because they are elderly or take acid suppressing drugs, have limited stomach acid. Calcium carbonate, which is made from oyster shells, requires acid for dissolution and absorption. With many of our patients taking acid suppressing therapy, Calcium citrate which does not require acid for dissolution, is a better option for this group.

Calcium carbonate: (Os-Cal-500)

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With 41% of the population being vitamin D deficient, especially in these latitudes, we need to be recommending this Vitamin a whole lot more. In a study done in 2011, the overall prevalence rate of vitamin D deficiency was 41.6%, with the highest rate seen in blacks (82.1%), followed by Hispanics (69.2%). Drinking milk and sun exposure is not the answer to correcting this wide scale deficiency. People low in vitamin D who take a supplement may be less likely to fall. That makes sense, given that vitamin D plays a key role in keeping bones and muscles strong.

Do I have to swallow a capsule, what about drinking milk, or exposure to sunshine?

Dairy Products: It takes about 5 quarts (3000kcal) of milk, to equal...

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Lots of our patients take Metformin, which is the first line therapy for Type-2 diabetes. Metformin is a safe drug for initial treatment of Type-2 diabetes, as it helps the body use its own insulin more efficiently without causing hypoglycemia (low blood sugar). Untreated high blood sugars can lead to diabetic peripheral neuropathy, which begins as tingling and burning in the hands and feet. Vitamin B-12 levels that are too low can also cause tingling and burning in the hands and feet. Sometimes these two conditions (diabetic peripheral neuropathy and Vitamin B-12 deficiency) can have the same symptoms and can be confused.

WATCH for Metformin induced Vitamin B12 deficiency

· Up to 30% of patients on metformin have reduced B12 absorption which...

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A lot of patients have unrealistic expectation with regards to vitamin supplementation. Vitamins do not undergo the same scrutiny as drugs do by the FDA, and many times are promoted as cures. At Nickman’s Drug we only recommend vitamin therapy based on science and medical literature. Thanks to the abundant food availability in the United States, deficiency is rare.

However, in the pharmacy and in the front of the store are drug therapies that deplete certain vitamins. Here are the most common drugs that cause depletion of vitamins. Always feel free to ask your Nickman’s pharmacist.

ARE YOU TAKING: Aspirin, Ibuprofen, Naproxen?

YOU MIGHT BE LOSING: iron

WHAT HAPPENS: May damage stomach lining, causing...

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Everyone is excited that the Pfizer COVID-19 vaccine was approved by the FDA and is now being distributed. Patients have lots of questions and your Nickman’s pharmacist wants to provide you with the most updated information.

SAFETY

Pfizer said that no serious safety concerns related to the vaccine were reported in its study, which included 43,661 volunteers. This would fill Heinz Field to 63% capacity.

Keep in mind that GSK studied Shingrix (shingles vaccine) in 30,000 people! And this vaccine is given ONLY to patients over 50 years of age.

Side effects do occur with any vaccine injections, here is what to expect:

  • Injection site reaction (redness, swelling, some pain)
  • Some fatigue...
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There has been a 40% decrease in Emergency Department visits due to the COVID-19 pandemic. Patients are concerned about going to the Emergency Department due to the potential of being around all those “sick people.”

There are times however that patients MUST go to the emergency department for serious illness. If you are exhibiting any of the following signs, SEEK EMERGENCY CARE IMMEDIATELY.

Signs and Symptoms of Pulmonary Embolism (PE)

A pulmonary embolism is a blood clot in the lung. If left untreated 30% of the patients will die. If you experience the following symptoms seek emergency care immediately.

  • Dyspnea: Difficulty breathing or shortness of breath. Usually sudden and...
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There has been a 40% decrease in Emergency Department visits due to the COVID-19 pandemic. Patients are concerned about going to the Emergency Department due to the potential of being around all those “sick people.”

There are times however that patients MUST go to the emergency department for serious illness. If you are exhibiting any of the following signs, SEEK EMERGENCY CARE IMMEDIATELY.

The best way to describe a stroke is a “brain attack”, where the brain gets deprived of blood supply. If a patient exhibits the signs and symptoms listed below, call immediately for emergency care. Once a patient gets to the hospital, one hour is needed to determine whether the interruption in blood supply is due to a blood clot (occlusive) or a ruptured blood vessel (hemorrhagic)....

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Let’s assume that you bought your hygrometer (humidity monitor) and your child is congested and you want to run a humidifier in your kid’s bedroom. Your Nickman’s Pharmacist can help make the best and safest selection and provide tips to care for your humidifier.

TYPES of HUMIDIFIERS

“Cool Mist” These two types of humidifiers generally appear to produce the greatest dispersions of both bacteria and minerals.

  • Ultrasonic, which create a cool mist by means of ultrasonic sound vibrations.
  • Impeller, or "cool mist," which produces a cool mist by means of a high-speed rotating disk.

Two additional types of humidifiers can allow for growth of bacteria and fungus if they...

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HUMIDIFIERS, what you need to know!

We pharmacists frequently get questions about choosing a humidifier. Your Nickman’s Pharmacist can help you make that decision but here is some pertinent information.

· Every homeowner should own a hygrometer that measures temperature and relative humidity. The ideal relative humidity for health and comfort is about 40-50%. Most allergists recommend, “before you recommend a humidifier, recommend a hygrometer first!”

· In the winter months, it may have to be lower than 40% relative humidity to avoid condensation on the windows

· If a parent wants a cool mist humidifier for a child who is congested or has a runny nose, keep in mind that it may make...

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October 29, 2020

Pete Kreckel

DRUG THERAPY for the FLU

OSELTAMIVIR (Tamiflu®)

Mechanism: keeps the virus from multiplying.

Indications for use: Influenza type A and B. Begin within 48 hours of symptoms. May reduce symptoms by 1 day.

Warnings/Precautions/ Adverse effects: Nausea, vomiting, dizziness, and insomnia. May cause behavior changes in children.

Patient Education

Start as soon as possible. Take two doses the first day.

Not a substitute for the vaccine

Representative Products:

Tamiflu® 75mg capsules and powder for suspension 12mg/ml (available generically)

Adults: 75mg twice daily for 5 days. Get two doses in...

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Pete Kreckel

Who should get the flu vaccine?

That’s easy… virtually everyone from age six months and up, regardless of pregnancy status. Patients with laboratory confirmed COVID 19 infection, symptomatic or not, should not get the influenza vaccination until they are no longer acutely and do not require isolation. On average about 45% of the United States citizens get their annual flu shot.

Efficacy of last year’s vaccine: was estimated to be 45% with 50% accuracy for the Influenza-B and 37% for Influenza-A

Flu vaccines for our patients over age 65:

  • Fluzone High-Dose Quadrivalent® contains four times the amount of antigen as the standard-dose inactivated flu vaccine, producing better protection in the...
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If Fayette county with the changing seasons we think of the holidays of Thanksgiving, Christmas, and New Year’s. At Nickman’s we see these three holidays as family gatherings where germs are exchanged from near and far! Flu season starts in October and November and greatly increases in December and January with the highest peak occurring in February in the Northern Hemisphere. Here are some flu basics that we need our patients to become familiar with.

§ Flu is caused by an RNA virus of the orthomyxovirus family. Viruses are truly not alive, but “take over” a cells machinery to reproduce

§ Antigenic drift: Frequent minor changes in antigenic structure of the virus. This can reach epidemic proportions, but not every year. This is what requires minor adjustments in...

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Let’s assume you didn’t adequately follow our prevention tips. We can cover two scenarios. The first we will discuss when you find a tick on your skin, and remove it. Then we can discuss treatment when the characteristic rash appears.

Pharmacological Prevention of Lyme disease:

The Infectious Disease Society of America recommends antibiotics for prevention of a tick bite only when:

· Attached tick identified as an adult or nymphal deer tick (Ixodes scapularis)

· Tick is estimated to have been attached for 36 + hours

· The antibiotic can be given within 72 hours of tick removal

· The local rate of tick infection with B. burgdorferi is...

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LYME DISEASE #1

Pennsylvania, for many years has led the nation in number cases of Lyme disease. Now that hunting season is underway on our state, everyone is headed to the great outdoors either a day of hunting or staying home and doing yeardwork! Many of our patients are coming to Nickman’s Drug with questions about Lyme disease. Your Nickman’s pharmacist should be consulted with your questions about Lyme disease.

CAUSE: by the bacterium Borrelia burgdorferi and is transmitted to humans by the bite of infected blacklegged ticks (Ixodes scapularis) more commonly referred to as the “deer tick”. SYMPTOMS: include fever, headache, fatigue, and a characteristic skin rash called erythema migrans, which occurs 3-30 days...

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LYME DISEASE #2

As we discussed last week, Lyme disease, caused by a bacteria Borrelia burgdorferi, remains the most common vector-borne disease in the United States. Lyme disease was first described in 1977 as "Lyme arthritis" in studies of a cluster in Connecticut of children who were thought to have juvenile rheumatoid arthritis. When some of these kids got ear infections, and were treated with amoxicillin the “arthritis” went away. Of course, amoxicillin doesn’t treat arthritis, so the researchers looked for an infectious agent.

The problem with Lyme disease isn’t so much with the tick we remove, but the one that is never discovered, and the patient gets infected with the bacteria Borrelia burgdorferi . Only about 25 percent of patients with “bullseye rash”...

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