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Should you stop your heartburn medication?

Proton pump inhibitors (PPIs) are medications used to control frequent heartburn, gastroesophageal reflux disease, and inflammation of the food pipe (esophagitis). The common PPIs are omeprazole (Losec ® ), esomeprazole (Nexium® ), lansoprazole (Prevacid®), dexlansoprazole (Dexilant® ), pantoprazole (Tecta® , Pantoloc ® ), and rabeprazole (Pariet® ).

Gastroesophageal reflux disease needs 4 to 8 weeks of treatment and peptic ulcers 2 to 12 weeks.

Adults 18 years of age and older who have continuously used a PPI for longer than 4 weeks should ask their doctor about deprescribing.

Deprescribing involves decreasing the dose, stopping the medication, or using it “on-demand” (as needed only).

It is best to discuss this decision with a doctor

Certain conditions such as Barrett’s esophagus, severe esophagitis, or bleeding gastrointestinal ulcers may require ongoing use. Patients who use regular daily doses of nonsteroidal anti-inflammatory drugs (NSAIDs) may also need to use a daily PPI to protect the gut.

Reflux symptoms are sometimes caused by other medications (e.g., acarbose, anticholinergics, beta-agonists, benzodiazepines, caffeine, digoxin, calcium channel blockers, erythromycin, estrogen, alcohol, narcotics, nicotine, nitroglycerin, orlistat, progesterone, theophylline).

How to stop

Stopping your PPI suddenly may worsen acid reflux symptoms due to a “rebound hypersecretion” effect. The withdrawal effect lasts for 2-4 weeks and can be blunted by decreasing the PPI dose by 50% for a few weeks or increasing the interval between doses to every 2 or more days. Sometimes an alternative medication like ranitidine can be substituted in.

Why would you want to stop your PPI?

Although PPIs are generally very well-tolerated, they can lead to uncommon side-effects such as diarrhea, vitamin B12 deficiency, magnesium deficiency, gut infections (Clostridium difficile, Salmonella and Campylobacter), hip fractures, and pneumonia.

 

Link:

http://www.open-pharmacy-research.ca/wordpress/wp-content/uploads/ppi-deprescribing-algorithm-cc.pdf

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Chronic idiopathic urticaria/chronic spontaneous urticaria

Acute urticaria (hives) is often caused by viruses or allergy. Chronic urticaria (hives) lasts longer than  6 weeks and is thought to be autoimmune. Urticaria is itchy, comes and goes, and can move around. The eruptions are spontaneous or inducible by exercise (exercise-induced anaphylaxis and cholinergic urticaria), water (aquagenic urticaria), coldness (cold urticaria), or sunlight (solar urticaria). One-third to two-thirds of cases are associated with angioedema (swelling beneath the skin). If a patient is on an ACEI drug, this must be stopped. Urticaria usually resolves in 24 hours and angioedema in 72 hours. Severity is measured by the weekly urticaria activity score (UAS7). If individual lesions last over 24 hours, a skin biopsy may be required.

The treatment algorithm starts with a second generation antihistamine like cetirizine (10-40mg/day), desloratadine (5-20mg/day), fexofenadine (120-480mg/day), or loratadine (10-40mg/day). These drugs can be increased up to four times the standard dose. Montelukast can be added and exacerbations may be treated with an oral steroid.

Omalizumab and cyclosporine are third-line therapies initiated at the specialist level.

Resources:

www.itchingforanswers.ca

www.skintolivein.com

www.optionsinciu.ca

CIU Tracker App on App store and Google play

Over-The-Counter

A recent survey among physicians and pharmacists have identified the top over-the-counter brands recommended by Canadian professionals.

Adult allergies: Reactine

Children’s allergies: Benadryl

Nausea: Gravol

Children’s painkiller: Tylenol

Painkilling cream: Voltaren

Scar/stretch mark therapy: Bio-Oil

Sunscreen: Ombrelle

Wart treatment: Compound W

Cold sore cream: Abreva

Vaginal lubrication: Replens

Antibiotic cream: Polysporin

Antibiotic eye and ear drops: Polysporin eye and ear drops

Dry eye drops: Systane

Vaginal yeast infection cream: Canestan

Vaginal yeast infection pill: CanesOral

Iron supplement: Feramax

Laxative: Lax-A-Day

Lice treatment: Nix

Natural cold remedy: Cold-FX

Pregnancy test kit: First Response

Blood Glucose Monitor: OneTouch

Blood Pressure Monitor: Omron

Hand Dermatitis (eczema)

Hand dermatitis (eczema) is associated with irritants or allergies and can be triggered or aggravated at work (occupational dermatitis). Many patients are employed as healthcare workers/nurses, hair stylists, restaurant servers/staff, bakers, or printers.

There are 3 types of hand dermatitis: irritant, allergic, and atopic.

Chronic hand dermatitis lasts at least three months or incurs two relapses in a calendar year. Alitretinoin, cyclosporine, high potency topical corticosteroids, and phototherapy are indicated in Canada for the treatment of chronic hand dermatitis. (Acitretin, azathioprine, methotrexate even soriatane are sometimes used.)

Itchiness is a symptom of both allergic and atopic hand dermatitis. Irritant hand dermatitis often has little or no itchiness.

Common irritants include friction, dryness, moisture, and chemicals (e.g., hand disinfectants, germicides, detergents, ink, dyes, solvents, etc.). When these offending exposures are in the working environment, symptoms develop gradually, show little improvement on weekends, but marked recovery with extended periods away from work.

Allergens like latex, animal fur/dander, perfumes, and food are also be implicated. This is often characterized by redness, blistering, and severe itchiness. Work exposure usually improves on weekends, symptoms disappear on vacation, but recur soon after returning to work. A patch test can confirm the diagnosis.

Atopic dermatitis is frequently unrelated to occupation and a family history of allergy is common. It can involve the flexor surfaces of the wrists, the nails, and the “snuff box”. Blisters are often seen and the skin can turn thick and leathery (lichenification).

The mainstay of hand dermatitis treatment is topical corticosteroids.

Moderate potency corticosteroids are sometimes used for 4-8 weeks (2 weeks if dorsal location) to manage mild-to-moderate chronic hand dermatitis. Severe chronic hand dermatitis uses a potent topical corticosteroid for 4 to 8 weeks (2 weeks if dorsal location) or super-potent topical corticosteroid for 2 weeks.

When moderate chronic hand dermatitis is not improved by prevention strategies, emollient therapy, and a high potency topical corticosteroid of 2-week duration, it is treated as severe and phototherapy/oral treatment is considered. An oral treatment is alitretinoin but pregnancy must be avoided (pregnancy prevention program).

Treatment should be combined with moisturizing therapy and hand protection (eg, gloves), which should continue after discontinuation of corticosteroids.

In hyperkeratotic dermatitis, salicylic acid 20% or urea 5–10% is sometimes prescribed to smooth the skin and help with treatment penetration.

Topical steroids— Potency

Low

  • Desonide 0.05%
  • Hydrocortisone 0.5%, 1%, 2.5%
  • Hydrocortisone acetate 0.5%, 1%, 2%

Medium

  • Betamethasone valerate 0.05%, 0.1%
  • Clobetasone butyrate 0.05%
  • Diflucortolone valerate 0.1%
  • Fluocinolone acetonide 0.01%, 0.025%
  • Hydrocortisone valerate 0.2%
  • Mometasone furoate 0.1%
  • Triamcinolone acetonide 0.025%, 0.1%, 0.5%
  • Prednicarbate 0.1%

High

  • Amcinonide 0.1%
  • Betamethasone dipropionate 0.05%
  • Fluocinonide 0.05%
  • Halcinonide 0.1%
  • Desoximetasone 0.05%, 0.25% •

Ultra-high

  • Beclomethasone dipropionate 0.05% in base containing propylene glycol
  • Clobetasol propionate 0.05%
  • Halobetasol propionate 0.05%

RESOURCES

Diabetes

Patient task list:

  • Have HbA1C tested every 3 months
  • Annual eye examination
  • Annual foot examination
  • Intermittent cholesterol levels, ECG, kidney function
  • DASH diet if no kidney disease
  • Quit smoking
  • Exercise at least 150 minutes per week (moderate-intensity exercise) and resistance training (three times per week)
  • Prioritize at least 7 hours of sleep per night

Intervention Targets

  • The traditional HbA1C target is <7%
  • An HbA1C target ≤6.5% will decrease the risk of eye disease (retinopathy), kidney disease (nephropathy), and nervous system disease (neuropathy).
  • The blood pressure target is <130/80 mmHg
  • LDL-Cholesterol target is <2 mmol/L
  • Patients with a BMI ≥25 should aim for reduction of body weight by 5 to 10%

Patient resources: http://www.diabetes.ca


Doctors secrets …

Pre-diabetes is associated with a 5-fold increased risk for future type 2 diabetes. Metformin reduces the risk of future diabetes in pre-diabetic patients by 25 to 30%

Step 1 Rx = start metformin (if GFR >45 and monitor B12 in chronic use), stop if GFR <30

If the A1C is >7.5%, the patient will likely need dual treatment. If HBA1C >9%, start dual treatment. If the A1C is >8% despite dual treatment, the patient likely needs basal insulin. Consider insulin when HBA1C >10% and symptomatic.

Add additional agent if not in target >3/12 e.g SU, TZD, (edema, HF, bone fracture, weight gain risks), DPP-4-i (avoid if Hx of pancreatitis), SGLT-2-i, thiazolidinedione, GLP-1-RA( avoid if FH of medullary thyroid carcinoma, MEN2, pancreatitis, gastroparesis), basal insulin. CVS outcomes reduced with Liraglutide (GLP-1), empagliflozin (SGLT-2). Watch for euglycemic DKA in SGLT-2 inhibitors. Watch for CCF with saxagliptin, alogliptin (DPP-4); (if pre-existing CCF or CKD). Avoid dpp4-i + GLP-1-RA.

 

– Insulin

Start 10U (or 0.1 to 0.2U/kg) of basal and increase dose by 10-15% (or 2-4U) once or twice weekly until FBG in target. NPH is cheapest. If HBA1C <8% or hypoglycaemia- decrease dose by 4U (or 10-20%). If insulin does >0.5U/kg and not at target, need to start adding basal

– Rapid insulin

Start 4U per meal (0.1U/kg, or 10% of basal dose)- consider decreasing basal dose by same amount of starting mealtime dose. Increase 1-2U (10-15%) once or twice weekly. Hypoglycemia- decrease 2-4U (10-20%)

– Premixed insulin

divide basal dose into 2/3am and 1/3 pm. Increase 1-2U (10-15%) once or twice weekly to target. Hypoglycemia- decrease 2-4U or 10-20%. Can increase to TID dosing if failure to control.

Intrauterine contraception (IUC)

Are you interested in intrauterine contraception? There are a few questions you need to ask yourself.

Are you currently sexually active and do you need birth control? Do you have any plans to get pregnant and, if yes, how soon? How important is it for you not to be pregnant right now? How would your relationship/job/education be affected by becoming pregnant? What do you want to achieve before you fall pregnant?What contraception have you used in the past and what are you using now? What is the most important factor in your choice of birth control?

IUC is highly effective.

No contraception method is foolproof, but for women who are serious about not falling pregnant anytime soon, IUC is their best bet. Contraceptive failure rates (i.e. pregnancy rates per 1000 women during the first year of use) are as follows:

1) Condoms: 180/1000 women
2) Pill/patch/ring: 90/1000 women
3) Injection: 60/1000 women
4) Copper IUD: 8/1000 women
5) Levonorgestrel-releasing intrauterine system (e.g. Mirena, Jaydess, Kyleena): 2/1000 women

IUC can be left in place for 3, 5, or 10 years depending on the device. When removed, fertility rapidly returns to normal.

To view an excellent resource for patients, go to http://www.sexandu.ca

Dispelling a few intrauterine contraception myths …

Women and adolescents can use IUC whether they have given birth in the past or not. When discontinuing IUC use, women can rapidly conceive and fertility rates are the same as those of women who have never used an IUC. Women using IUC have less than half the risk of ectopic pregnancy compared to women who are not using contraception (remember IUC is highly effective in preventing pregnancy). IUC can be placed at any time during the menstrual cycle provided there is certainty that the woman is not pregnant. IUC does not cause infections (e.g. pelvic inflammatory disease or PID). PID is caused by sexually transmitted infections. However, there is a small risk of PID related to the insertion procedure in the first 20 days after IUC placement. Some women may stop menstruating while the IUC is in place. This is not unhealthy. Placement may cause a little pain in some women but every woman experiences pain differently.

Primary Headache Treatment

Behavioural management

•Keep a headache diary

•Reduce caffeine intake

•Regular exercise

•Adequate sleep

• Stress reduction

Medications

Medications can be used as acute treatment (when needed) or prevention treatment (daily prophylaxis). In chronic migraines (occurring on more than 15 days a month, for over 3 months), prevention medications are used daily for at least 3 months. If effective (50% improvement), the drug may be continued for 6 to 12 months.

Chronic tension-type headache 

Acute treatment: non-steroidal anti-inflammatory drugs (NSAIDS)

Prophylaxis: amitriptyline or topiramate.

Menstrual migraines

Perimenstrual prophylaxis (starting 2 days before the period and continuing during the period), e.g. frovatriptan 2.5 mg twice daily, zolmitriptan 2.5mg three times a day, naproxen 500 mg twice daily or mefenamic acid 500 mg three times a day. Continuous use of the combined contraceptive pill or estrogen patch can also help.

Cluster headache

Acute treatment: subcutaneous sumatriptan 6 mg (maximum two per day) or intranasal zolmitriptan 5 mg or 20mg intranasal sumatriptan (or 10mg zolmitriptan orally); 100% oxygen 12 L/min for 15 min through non-rebreathing mask.

Prophylaxis: verapamil 240-480 mg/day in three divided doses (bridge with 60 mg of prednisone for 5 days, then reduced by 10 mg every 2 days until discontinued)

Acute migraine

Combination therapy: triptan+non-steroidal anti-inflammatory drug (NSAID) or actaminophen+antiemetic

  • Acetaminophen 1000 mg
  • Domperidone 10 mg or metoclopramide 10 mg for nausea

NSAID options:

  • Ibuprofen 400 mg
  • Aspirin 600–900 mg (ideally effervescent)
  • naproxen sodium 500-550 mg
  • Diclofenac 50mg

Triptan options:

  • Oral: eletriptan 40 mg (Relpax), rizatriptan 10 mg (Maxalt), zolmitriptan 2.5 mg, oral sumatriptan 100 mg, , almotriptan 12.5 mg (Axert),  , frovatriptan 2.5 mg, naratriptan 2.5 mg
  • Oral wafer (if fluid ingestion worsens nausea): rizatriptan 10 mg or zolmitriptan 2.5 mg
  • Nasal spray (if nausea): zolmitriptan 5 mg or sumatriptan 20 mg
  • Subcutaneous sumatriptan 6 mg

Triptans should be used, on average, on no more than 2 days per week (10 days per month) to reduce the risk of a triptan-overuse headache. Nasal preparations have a faster onset of action than oral preparations and the subcutaneous injection has the fastest onset.

Medication overuse headaches happen when patients use combination analgesics, opioids, or triptans on ≥ 10 days per month or acetaminophen or NSAIDs on ≥15 days per month.

Migraine prophylaxis

Over the counter options

• butterbur 75 mg twice daily

• riboflavin 400 mg/d

• melatonin 3mg daily

• magnesium citrate 300 mg twice daily

• coenzyme Q10 100 mg 3 times daily

Prescription options

Usually topiramate or a beta blocker.

• topiramate 25mg to 50mg twice daily (useful if the patient is overweight, avoid in depression, can reduce the efficacy of the contraceptive pill)

• propranolol 20-80mg twice daily (avoid in asthma, diabetes, depression, smokers and >60 years of age)

• metoprolol 25-100mg twice daily (avoid in asthma, diabetes, depression, smokers and >60 years of age)

• amitriptyline 10-50mg at bedtime (useful if depression, anxiety, insomnia, or tension-type headache)

• venlafaxine 37.5-150mg/d (consider for migraine in patients with depression)

• gabapentin 300-1800 mg/d

• divalproex 250-500mg twice daily (avoid in pregnancy or when pregnancy is possible)

• candesartan 8-16mg/d

• onabotulinumtoxinA 155-195 units every 3 months for chronic migraines only (headaches on ≥15 days per month)


Doctors secrets …

Headache Impact Test (HIT 6)

Migraine Disabilities Assessment Test (MIDAS)

Hospital Anxiety and Depression Scale (HADS)

Strictly unilateral headache: consider hemicrania continua and conduct a 9-day indomethacin challenge. Headaches should respond to indomethacin 75 mg to 100 mg daily (given in three divided doses) for three days; the dose can then be increased if necessary to a total daily dose of 150 mg for three days, followed if necessary by a total daily dose of 200 mg to 225 mg daily (given in at least three divided doses per day) for three days. Arrange for neuroimaging.

Guideline: http://www.cfp.ca/content/cfp/61/8/670.full.pdf