Isn't My Blood Thin Enough Already?

"Isn't that the same stuff they put in rat poison?  I don't want to take that, I think my doctor is trying to poison me!" said the customer as he was approaching the counseling area in the pharmacy where I work.

"Well sir, yes, the ingredients in this medication are similar to a rat poison prduct, however, I do not believe your doctor is trying to poison you.  The dose and the intention of treatment are a little different", I said.

We went on to have the conversation about why his doctor was starting him on a blood thinning medication.  We first started with the concept that the medication does not actually thin the blood; rather, it helps slow the time it takes for the blood to clot.   I helped the gentleman understand that his doctor was prescribing him this medication to help him from developing a blood clot that may get stuck in his legs, lungs, heart or brain. 

Specific conditions pose an increased risk for developing a blood clot, such as irregular heart rhythm, a recent heart attack, heart valve replacement, and certain surgeries such as hip or knee replacement.   Blood clots form when there has been damage to the blood vessel, either the artery or the vein, and also when blood stops moving and becomes stagnant.

An artery blood clot may occur when someone has developed plaque along the inside of the blood vessel from increased cholesterol, called atherosclerosis. (read my blog topic discussing cholesterol) The plaque increase and limits the space the blood has to flow.  If the plaque ruptures then a blood clot may form and lead to a stroke or a heart attack.

A blood clot in the vein may occur when a person is immobilized for some reason and their muscles are not contracting to push the blood back to their heart.  Small clots begin to form in the stagnant blood along the walls of the vein.  These clots increase and eventually limit the amount of blood that returns to the heart. 

A blood clot may form in the heart when the heart is not beating in an organized fashion.  When the heart has irregular rhythm, blood tends to pool or stagnate in certain sections.  When the blood stagnates, little clots may form on inside wall of the heart.  These clots may then be pumped out into the circulatory system and lead to a stroke or a heart attack.

Until recently, Warfarin was the mainstay of anticoagulation therapy for most patients that needed this type of treatment.  Over the past year two new medications have been released that are appropriate for use in certain situations, and more options are available on the horizon. 
  • Dabigatran (Pradaxa-tm)
  • Rivaroxaban (Xarelto-tm)
  • Warfarin (Coumadin-tm)
This is a category of medication where becoming educated about your treatment, the side effects, drug interactions and precautions may significantly improve your outcome of therapy.   If you, or someone close to you takes one of these anticoagulation medications, I encourage you to logonto the Medication Counseling section of AudibleRx and listen to the MedicationSpecific Counseling SessionsTM for the anticoagulation medications.


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Is Your Trash Medicated?

These days there is definitely a push towards pharmacy "take-back" programs for expired and unused medications.  I truly appreciate that more and more people want to do the right thing with their left over medications.   

We really do not want to have a drawer or two of old medications piled in on top of one another in our kitchen or dining room.  Situations where this type of a medication hazard has accumulated really need to be cleaned up to help prevent some sort of medication mis-adventure.   That said, the last thing anyone wants is our old medications leaching into the ground and ending up in our water supply. 

This concern or contamination has led to pharmacy take-back programs where you can take your medications into a pharmacy and deposit them into a mail box type container where the meds are picked up on a routine schedule and transported to a distant location where they are then incinerated.  Not all pharmacies participate in take-back programs because the process has yet to be standardized under state and/or federal pharmacy regulation. 

In fact, the trend may be moving back to disposing expired and unused medications in the trash.  A recent study by The University of Michigan Department of Engineering shows that disposing of medications in the trash actually has less of an impact on the environment than taking your old medications to a take-back program.  Take a moment to read this article, it really is quite interesting.

Until further notice, I will describe the current recommendations for disposal of your old, expired and unused medications.

Please, do not give your expired medications to anyone else to take, especially if it is a prescription medication.   It is against federal law to share prescription medication.  An individual needs to be evaluated by a health care practitioner and prescribed a medication before they may legally take a prescription medication.  

Please do not flush your medications down the toilet.   Check with your local pharmacy or your waste management program to see if there is a medication take-back program available.

If there is no medication take-back program available, then you may take the medications and put them in a container such as a zip lock bag. Mix in something unpalatable such as kitty litter or coffee grounds then add a little water to the mixture. Now, take the container and put it in a brown paper bag and put it in the garbage.


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Blood Pressure....What's The Big Deal?

Why is it that within the first 5 minutes of sitting down in a patient room in either a doctors office or urgent care clinic there is someone right there taking your blood pressure?  What's the big deal?  The big deal is that everyone has blood pressure.  If your blood pressure is to low or to high, then the doctor has some serious considerations to make regarding your visit to the office that day.

I like to look at blood pressure with the same view that I look at water pressure in a house.  If the water pressure is to high in the pipes in my house I need to decrease the pressure some how before the pipes break, the faucet mechanism is destroyed, or the water pump burns out.  I can either turn down the pump feeding water to the house, I can put in larger pipes, or I can open up the faucet and let some of the water out of the pipes.  All three will decrease the pressure, however, it takes some evaluation to decide which mechanism will be the most effective in any given situation.

If I don't have a routine for regularly checking the pressure in my pipes, I won't know the pressure is to high until either the faucet blows out, the pipes break, or the pump burns up.  Just the same, if I am not vigilant at checking my own blood pressure, (or having it checked regularly) I won't know that the pressure is getting higher until I have a problem.

Just like our plumbing system, we have a circulatory system comprised of a pump (the heart), pipes (blood vessels), and a faucet (our kidneys).  We also have medications that will decrease how much blood our heart pumps, medications that will relax our blood vessels and medications that will increase the flow of fluid out of our kidneys. All three will decrease our blood pressure, however, the doctor needs to evaluate the entire system to see which mechanism is best in any given situation.

If high blood pressure is left untreated, the blood vessels will begin to harden and this will eventually lead to a heart attack or stroke.  Increased blood pressure will also damage the blood vessels that supply the retina with blood and lead to vision problems.  Furthermore, the filtering cells in the kidneys will become damaged an will lead to kidney failure.  Lastly, the heart will tire from pumping against the increased pressure and eventually lead to heart failure.

Please, if you haven't had your blood pressure checked within the last 6 months check your blood pressure today.  You may either use your own blood pressure machine, stop by a phrmacy where there is an automated machine, or visit your doctors office and have it checked.
If you would like to learn more about any medications used for blood pressure, please visit and register to become a member.  You will then have full access to all of the Medicatioin Specfic Counseling SessionsTM for a full five years.

Beta-Blockers and Blood Pressure
ARB's & ACEI's and Blood Pressure


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Fantastic News for AudibleRx :-)

AudibleRx, medication information you listen to.

Thanks for your continued support!

AudibleRx is a website where you may listen to 6-8 minute Medication Specific Counseling Sessions which discuss all of the important information about each medication. 

To learn more about any of the medications listed in this discussion, please go to , navigate to the Medication Counseling section and click on the medication you would like to learn more about.  It will open and play in your computer media player, no downloading necessary.

This presentation is part of a Pharmacy Topic written discussion series presented by AudibleRx.  To read this discussion on line, or view any of the other discussions, please visit  To listen to this discussion, please visit the Pharmacy Topics section at the AudibleRx website.

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Understanding Nerve Pain

A few years back I was reading a pharmacy journal and came across this picture that totally hit the nail on the head when it comes to nerve pain.  This poor gentleman was lying in bed and from his toes to his thighs were thousands of red ants.  Just thinking about it gives me the creeps.  The pain he was experiencing had come to life; tingling, shooting, sharp, burning and prickling pain.

Nerve pain, as opposed to bone, joint or muscle pain, originates from some sort of nerve damage.  We all have three types of nerves in our body; autonomic nerves which control the involuntary actions In our body such as breathing and stomach propulsion, motor nerves which control how we move by carrying messages from our brain to our muscles, and sensory nerves which send messages from our skin and muscles up our spinal cord to our brain so we can feel things.

Because nerves are everywhere in our body, it really only takes a small amount of nerve damage to cause significant nerve pain.  Those of us who have even experienced a small amount of nerve pain realize how debilitating it can be.  There is an exhaustive list of what can cause nerve damage, including trauma, cancer, disease, medications and genetics.  For the purpose of this discussion, I am more interested in telling you that there are some medications that work quite well at disrupting the pain from nerve damage.

When a nerve is damaged for one reason or another, it gets activated inappropriately and sends messages to the brain that are unsolicited.  This process is similar to when an individual experiences a seizure.  During a seizure, unsolicited nerve impulses are being sent to the brain causing the epileptic reaction.  It is interesting that anti-seizure medications, which have a nerve calming effect, also work well to calm an inappropriate nerve pain impulse.

Nerve pain medications interfere with the signal transmission process.  This works well when the signal the medication is interfering with is a pain signal.  The issue is, many signals are constantly being sent through your nerve pathways, and quite often, some of the signals used  for other body functions may be interfered with also.  This is a complex process that needs to be diagnosed and monitored by a physician. 

This category of medications has the possibility of helping decrease nerve pain, however, it is extremely important that the patient be fully aware of all the counseling information about the specific medication before they begin treatment.  This category of medications requires specific counseling around titrating the medication to the appropriate dose for the each particular patient.  These mediations quite often require a certain level of motivation in a patient, along with encouragement from their pharmacist that when the titration is followed appropriately, your body will most likely acclimate to the side effects.  It sometimes takes 10-14 days of therapy before a reasonable level of pain control is achieved.

I currently have Medication SpecificCounseling SessionsTM  for medications used to treat nerve pain, including Gabapentin (NeurontinTM), Duloxetine (CymbaltaTM), Pregabalin (LyricaTM), and Carbamazepine (TegretolTM) available at  Please visit the registration area of AudibleRx and sign up to become a member and you will then have full access to all of the counseling sessions.



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"Chain of Custody", pharmaceutically speaking

Canadians go to Canadian pharmacies to get their prescriptions; they do not go online to a Canadian Internet Pharmacy.    Canada has specific regulations that put a cap on the price of their prescription medications for Canadian Citizens, which is considered part of the Canadian Health Care System.

I am not here to debate health care systems, rather, I want to discuss for a moment the wide spread practice of ordering prescription medications over the internet from a so-called Canadian Internet Pharmacy.

The Food & Drug Administration (FDA) in the United States assures all medications approved for use in the United States meet specific requirements.  These requirements are numerous and include things like quality, manufacturing, labeling, and storage.  The facility where the medications are manufactured are certified and monitored, as well as the tracking of all of the ingredients to each medication. 

"Chain of Custody", in this situation, refers to the tracking of the ingredients of a medication from their point of origin to the manufacturer, followed by the tracking of the produced medication all the way to the pharmacy where the medication is dispensed.  During this process, there are specific storage and handling requirements that need to followed and documented the entire process.  At every point there is a United States, either federal or state, licensed entity that takes responsibility for this process.

When a medication is manufactured in another country for use in the United States, the FDA provides the same level of monitoring, following the "chain of custody" of the medication from the point that it was manufactured all the way to the pharmacy where the medication is dispensed to the patient. 

When a medication is sold for use in another country, the FDA's "chain of custody" is broken and the other country takes over with whatever laws they have.   If a medication is manufactured by a United States FDA approved drug company, and is then exported to another country, that country then takes over the ownership of the medication.  It is then illegal to import that medication back into the United States.  The "chain of custody" has been broken and there is no guarantee that the medication has been stored and handled 100% appropriately.

The law states that there are certain situations where a patient may take a prescription to Canada and purchase up to a 90 days' supply of medication and bring it back into the United States for personal use.   These particular situations are limited to medications that are not currently available in the United States yet still necessary for specific illness.  They do not include purchasing medications available in the United States just because they are cheaper from another country.  Nowhere does it state that it is legal to order these medications over the internet and have them mailed to you.   That said, it is done all the time by regular people who do not realize that they are "trafficking prescription medications across a federal border".

Joe McCallion, a consumer safety officer in the FDA's Office of Regulatory Affairs, sums it up this way: "If you buy drugs that come from outside the U.S., the FDA doesn't know what you're getting, which means safety can't be assured."

Just do a Google search and see how many Canadian Internet Pharmacies you find.  These folks set up an internet store front in Canada and then market great deals on prescription medications.  The actual warehouse may be in India or Malaysia or anywhere…  There is absolutely zero FDA regulation on the "chain of custody" of these medications. 

Not only may the manufacturing, storage and handling of these medications be inappropriate, the medication themselves may be counterfeit.  Just use common sense, if a medication costs $120 for 30 days' worth at your local pharmacy, and it costs $29.95 over the internet for the same medication, what's the deal.  If they do not need to worry about storage and handling or concern about the manufacturing plant being licensed and monitored, or even if the correct ingredients are being used,  well then, we can cut corners and charge less money. 

There have been multiple documented cases of medications being imported through Canadian Internet Pharmacies where the patient has gotten severe side effects or the medication has not worked.  Upon evaluation, the medication was a counterfeit.  There is no recourse if this happens; only the consumer who purchased it over the internet is to blame.

Please, do not order your medications from Canadian Internet Pharmacies.  You do not know what you will be getting.  If you are having trouble paying for your medications, talk with your pharmacist.  They may have some ideas on a cheaper generic, or perhaps connect you with the manufacturer of the medication so you can use their "Patient Assistance Program".

For more information, take a look at this publication.


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Erectile Dysfunction

I remember back in the late 70' there was this Saturday Night Live sketch where Steve Martin came on stage advertising his product called Steve's Penis Cream.  All you need to do is massage this cream gently into your penis for 30 minutes once daily…..

Well, if that doesn't work, we now have this category of medications called the PDE5 inhibitors which are quite effective at treating erection issues.

These medications do not directly cause a penile erection; rather, they affect the way the body responds to sexual stimulation.  Nitric oxide is one of the main building blocks for a penile erection.  Sexual stimulation causes an increased level of nitric oxide. 

Nitric oxide activates an enzyme system that results in relaxation of the penile smooth muscle, followed by an increased blood flow in the penis which creates an erection.  This category of medications treat erectile dysfunction (sometimes called ED), by blocking the enzyme that breaks down Nitric Oxide. 

It is important to note that in the absence of sexual stimulation, there will be no nitric oxide released and this type of medication will have no effect.  In the presence of sexual stimulation, the nitric oxide that is produced will not be broken down as quickly, thereby significantly increasing the opportunity for erection.

Medication Specific Counseling Sessions are available for three of the oral medications currently available to treat Erectile Dysfunction.

            Sildenafil (ViagraTM)

            Tadalafil (CialisTM)

            Vardenafil (LevitraTM)

To listen to the Medication Specific Counseling Sessions for any these or any other medications, please register to become a member at AudibleRx and then have full access to all of the counseling sessions.


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Estrogen Therapy and Warnings

Estrogen therapy is common practice these days and is prescribed regularly for the treatment of menopausal symptoms such as hot flashes, mood swings and vaginal dryness.  In this particular discussion, I don't necessarily want to discuss all of the specific indications of estrogen therapy, or even the pros and cons of whether someone should use estrogen treatment.  My goal in this specific blog is to bring to light the warnings that are associated with these medications.  I feel that the cautions and warnings accompanied with the estrogen category of medications are sometimes glossed over because the immediate benefit of therapy is so great.

Estrogens are to be taken in the lowest effective dose for the shortest duration of time for your particular situation.  Please contact your doctor at least every 6 months so you may discuss how you are doing at your current dose and to evaluate if the dose needs to be adjusted or if you still need to continue taking your estrogen therapy.  While you are taking your estrogen therapy, please make sure you receive a complete physical exam with your doctor at least once a year.

It is important to note that if you are using estrogen therapy for the treatment of atrophy, burring or dryness in and around the vagina; and these are the only symptoms you are treating, it is recommended to talk with your doctor about a vaginal cream, vaginal tablet or vaginal insert.  Taking a systemic medication that needs to circulate through your blood system, such as a tablet, patch or injection may significantly increase your chance of estrogen related side effects.

Estrogen therapy is also prescribed to help prevent bone loss in women after menopause; however, if bone loss is the only issue, there are other medications that are safer to take and are just as effective at maintaining bone structure. 

In my opinion, the Black Box Warnings written for the estrogen medications are very complicated.  I took some time arranging them so they may be a little easier to understand and digest.  These warnings are divided into two categories and I have listed them below. 

If you take, or may be taking estrogen therapy in the future, please take the time to read these warnings.  It is important that you discuss this issue with your physician before you begin on estrogen therapy.

Black Box Warning

Warning#1 Endometrial Cancer (cancer of the uterus)

-There is an increased risk of cancer in the uterus in women who use estrogen without also taking a progestin.  Adding a progestin to the therapy may reduce the likelihood of the cascade of events that leads to uterine cancer.  If you are postmenopausal and taking estrogen and are having undiagnosed genital bleeding, please seek medical attention.

Warning#2 Cardiovascular and other Risks

-Estrogen therapy given by itself has been associated with an increased risk of stroke and serious blood clots in the legs.
-Estrogen therapy given in conjunction with progestin therapy has been associated with an increased risk of heart attack, stroke, blood clots in the legs or lungs, and increased risk of breast cancer.
-Estrogen therapy, with or without progestin, has been shown to increase the incidence of heart disease and dementia and should not be used for the treatment of either of these two disease states  
-Estrogens, with or without progestin, should be prescribed in the lowest effective dose for the shortest duration of therapy, consistent with the treatment goals for each individual patient.

Thanks for reading and pass this on to someone who may be interested in learning about this information.

To listen to Medication Specific Counseling Sessions on different types of estrogen therapy, please visit  Once you register and become a member, you will have full access to all of the estrogen counseling sessions, as well as all of the other Medication Specific Counseling Sessions.


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