Emerging Cannabis Drug Interactions

One of the great things about legalizing marijuana is the amount of clinical data we are now able to garner about the plant.

Before legalization, while marijuana was commonly used to self medicate, it was rarely talked about. It was certainly not studied to the degree that we see now. Even with its wide spread use, we knew relatively little about its effects and particularly, how it would interact with other medications.

We now know that cannabis is an inhibitor of CYP 2C19 (27), an enzyme responsible for metabolizing many drugs, including two of the most widely used antidepressants: citalopram and escitalopram.

What does this mean for people using cannabis and also taking one of these medications?

Well, if cannabis inhibits the enzyme responsible for breaking down these drugs, that means that the drug will be broken down more slowly. With regular dosing, this could lead to a build up of the medication in the body. So the general plan with these interactions is to reduce the dose of the drug affected. Citalopram is usually dosed between 10 and 40mg per day, whereas escitalopram is usually dosed between 5 and 20mg per day. Indeed we see that the guidance from B.C.’s Provincial Academic Detailing is to reduce the maximum dose of citalopram and escitalopram by 50% (max dose of 20mg for citalopram and 10mg for escitalopram). This is a SIGNIFICANT dose decrease we are now suggesting to our patients that prior to legalization we never even knew to consider.

Key takeaway: tell your doctor and pharmacist if you are using cannabis products. It could affect the way you take your other medications. ***It is not advised to change doses of any medications without discussing with your prescriber first!***

Have you asked your pharmacist about those supplements?

The popularity of complementary and alternative medicine has increased dramatically in recent years sending supplement sales skyrocketing worldwide. With the COVID19 pandemic this trend has only increased. People have more time than ever to research their health conditions and the supplement industry is ready to offer quick solutions.  Like many industries, supplement brands have pivoted during this time and are now targeting people worried about their immune health, touting vitamin C, D and zinc combinations as the saviour for immune systems everywhere.

But before you spend your hard earned money on a new supplement, might I suggest you check in with your pharmacist?

Why you ask? Because supplements can be dangerous if not properly evaluated properly prior to use.

Common safety issues with supplements

It once was the case that supplements beyond your classic vitamins and minerals were provided in a naturopathic physician’s office and patients could only access what had been prescribed to them.  Now, there is a distinct lack of clinician oversight with high potency supplements found in the naturals section of many grocery stores and online through retailers like amazon and well.ca.  When I ask my clients what prompted them to start taking these products they will often cite a Youtube video, or a blog post with no mention of a discussion with a clinician.

When new clients come to me the first thing I do is analyze their supplement regimen. Invariably there will be a list of drug therapy problems to contend with. Here are the top issues I will commonly find:

Lack of evidence for effectiveness and safety

Due to the unregulated nature of supplement manufacturing, we only have small scale, short term studies to draw from. There is often a lack of evidence for using the supplement for reason the patient is reporting. Lack of evidence does not necessarily mean lack of effectiveness, but it means that we cannot prove it is effective, and the patient has to accept that reality. Often the patient has been misled and expects more from the supplement than the data suggests we should.

The short term studies means that we also cannot prove safety beyond a certain point. If we’ve only ever studied a supplement for one month, I cannot tell you it is safe to take daily for years. This again, is not something made clear on the bottles or marketing materials of supplement brands.

Doses above safety limits

With the number of different sources of information available to patients it can be hard to know what dose to take. The bottle might say one thing, but an internet blog will tell you another. I have often come across doses that are well above the tolerable upper limit for a vitamin or mineral. The tolerable upper limit is the intake level where we can say the ingredient likely doesn’t pose any health risks to almost all individuals. It’s important to note that the level reflects nutrients from all sources, not just supplementation. Furthermore, it is not a recommended daily intake, but rather a level to remain under (26).

Interactions with conditions, drugs, supplements and food

Any supplement is bound to interact with other aspects of your life, but you would never know from the packaging. Interactions can be with other supplements, prescription medications, food and medical conditions.

Condition-Supplement Interactions:

Supplements can interact with other conditions you may have. For example, many ingredients can act like estrogen and are not recommended for people with hormone sensitive conditions like breast cancer and uterine fibroids.

Drug-Supplement Interactions:

Supplements can additive effects with the drugs you take making it more likely that you experience side effects. They can also work opposite to your prescription medications making them less effective. Then there are the metabolism interactions where the supplement may make a drug metabolized faster or slower by your body leading to either ineffective dosing or higher chances of side effects.

Food-Supplement Interactions

Food can increase or decrease the absorption of various ingredients and in severe cases can change the way your body metabolizes them.

Supplement-Supplement Interactions

Just as supplements can interact with prescription drugs, they can interact with each other too!

Check with your pharmacist first

The above list may seem like a landmine of potential issues to avoid. And it is. But your pharmacist has been specially trained to sift through complex information and give you the facts in a way that can help you make an informed decision. Having a relationship with your pharmacist and checking with them before starting a new supplement is key to keeping you safe.

REFERENCES

As always, references can be found here.

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Why "green pharmacy" is not the answer

A couple of weeks ago I had a woman approach me at the pharmacy counter asking about chromium supplementation for blood sugar control.

She told me that her blood sugar levels were higher than they should be and that she would really like to get off of metformin because she “doesn’t like taking drugs”.

My first step was to ask her about her diet and lifestyle. Turns out she infrequently exercises, has high stress levels, gets poor sleep, and her diet is high in processed foods and carbohydrates with low fiber and minimal vegetables. I suggested we optimize these things as a way to possibly get off of metformin rather than immediately adding chromium.

Not sold on lifestyle changes and seeking a quick fix, she still wanted more information on chromium, so I obliged and informed her of the evidence for effectiveness and safety as well as the warnings and precautions, side effects and drug interactions. It was this piece that got her attention. She was surprised to hear that a natural health product could have just as many side effects as a doctor prescribed pharmaceutical.

Now that I had her attention, we discussed some lifestyle changes and the possibility of seeing a health coach to help her with implementing them. She left educated and ready to make a change.

A common scenario

Working in community pharmacy, this is a scenario that plays out often for me.

Patient doesn’t want to take drug >>> Patient also doesn’t want to change lifestyle >>>Patient seeks alternative. >>> Shiny natural alternative to drug presented by natural health company promises results >>> Patient asks me about said product.

This phenomenon of swapping pharmaceuticals for natural alternatives is called “Green Pharmacy” and it is becoming increasingly common as the wellness economy booms globally. Worth 3.7 Trillion in 2015, the wellness economy saw growth of 800 Billion in just 3 years to a value of 4.5 Trillion in 2018 (21).

But you’re a functional medicine pharmacist. Shouldn’t you be happy about this?

While i am pleased to see health and wellness is becoming more top of mind globally, I still have some criticisms of green pharmacy.

Reasons I try to avoid green pharmacy:

wellness companies are still for profit companies

Just because wellness companies are selling natural products, doesn’t mean they aren’t out here to make money. Companies that make natural health products have massive marketing departments just like any other for profit company. Furthermore, while pharmaceutical prices are set by strict standards and there are limits to the profit a pharmacy can make off of them, natural health products are not subject to the same standards. The price of a supplement is based on whatever profit the seller can get away with.

They are still a bandaid solution

Natural health products are limited in the same way as pharmaceuticals in that they do not address the root cause of dysfunction. I go easier on vitamins because they are at times needed to address nutritional deficiencies, but if they are needed for more than just a short time, you have not addressed the cause of the deficiency.

Just because they are natural doesn’t mean they are without side effects

People are often surprised to hear the laundry list of side effects I rattle off for a natural health product, expecting this to only be the case for pharmaceuticals. But natural health products can have just as many, if not more side effects than pharmaceuticals. Take chromium for example which can cause cognitive and motor disruptions at common over the counter doses (22).

The world of natural health product data is murky with respect to:

• What the product actually contains

  Since 2004, HealthCanada has instituted the Natural and Non-prescription Health Products Directorate, aimed at ensuring that the natural health products available to Canadians meet safety, efficacy and quality standards (23) . Prior to this directorate it was much more difficult to be sure that products were labelled properly. But even since this directorate came to be, Health Canada continues to find products laced with bona fide pharmaceuticals. Take Rhino 7 Platinum 5000 for example which was marketed as a natural erectile dysfunction option but found to contain sildenafil, the active ingredient in viagra, as recently as September 2019 (24). For this reason it is important to vet natural health products carefully yourself or purchase them from someone you trust has vetted them.

• Safety and efficacy data

  Though the financial incentives of the wellness economy have led to a great deal more research in recent years, historically good quality research on natural health products has been lacking. As a result we often see conflicting efficacy data with a multitude of small studies of varying quality. With respect to safety, we do not have the same post marketing surveillance of natural health products that we do with pharmaceuticals so in the absence of individual practitioner clinical experience it is hard to be sure of long term safety. When we look at the data available for chromium we see that the FDA suggests 200mcg daily is safe for up to 6 months. Beyond that we do not have good quality data showing it is safe (22).

• Drug interactions

  Again, compared to pharmaceuticals which are dispensed through pharmacy software and subject to interaction checks each time, natural health products often fly under the radar. Patients either will not report using them to their health care providers, or they will have an interaction check done once with their pharmacist and then forget about it, not bothering to check upon subsequent medication changes.

How do i use natural health products in my practise

The world of natural health products is far from perfect, but they can still be used safely and effectively to help achieve health outcomes. As a pharmacist, I simply apply the same framework that I use to evaluate pharmaceuticals. I’ve discussed this framework at length in a previous blog, but I will now apply it to natural health products.

Necessary:

First thing is first: do we really need this product? Can we address the problem with lifestyle interventions instead? Or maybe it isn’t even a lifestyle issue. I had one patient ask me about a liver support product because her liver enzymes were up. A quick look at her medications list revealed that she was taking an antibiotic called minocycline for acne, which can increase liver enzymes (25). Instead of starting her on this new product, I faxed her doctor to inform them of the issue.

Effective:

Is this product going to be effective for the patient? What data do we have showing efficacy? Are the studies of sufficient quality? How many studies do we have?

Safe:

What sort of safety data do we have overall? Are there any interactions with other medications the patient is taking? How long have these things been studied? How long can we anticipate the patient will take this for?

Adherence:

Is the patient going to be able to take the product as it was studied? What if the studies used massive doses multiple times a day? Are they going to be able to afford that?

proceed with caution and always ask your pharmacist

I hope that this article has provided you with a more balanced perspective on natural health products. As with a great deal of functional medicine topics, the truth lies somewhere in the middle of two opposing views. Natural health products are not all quackery, and they are not a panacea either. When in doubt, always ask your pharmacist!

References

As always, references can be found here.

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Remission: A new frontier in Type II Diabetes management

To be told you have type II diabetes is to be told you have a new life sentence with the medical system.  Practitioners are taught, and patients are told that it is a chronic, progressive condition.  In other words: it only gets worse from here.

And for many many years, this trend has been the reality.  A patient gets a diagnosis for diabetes and is asked to try lifestyle changes.  When that fails they are put on oral blood sugar lowering medications. As time goes on, more and more oral medications are added until the patient is finally given insulin via subcutaneous injection.  Approximately 50% of those with type II diabetes need insulin within 10 years of diagnosis. (18).

The medication centric approach to diabetes is both costly and ineffective.  Diabetes Canada reports that diabetes treatments in Canada in 2019 came in just shy of $30 billion dollars, up from $14 billion in 2008 (19).  

What’s more, it is getting worse: It is predicted that by 2030, 439 Million adults will have diabetes (20). 

But it’s not all doom and gloom for those living with Diabetes, at least not for much longer. 100 years after the discovery of insulin, we have another breakthrough to report, one which promises to radically shift the way we view diabetes:

Remission: A new frontier

Diabetes Remission is technically not new, but with our standard approach it is incredibly uncommon.  Kaiser Permanente reports that the remission rate in the usual care model of diabetes is 0.23% (18).

With a success rate like that it’s no wonder no-one brings it up as an option!  But in just the last few years, a critical mass seems to have been reached, where talk of lifestyle interventions has become trendy, and patients, seeing that the status quo is not working, are taking to the internet to find alternatives.

That’s what prompted Sean McKelvey, rockstar Canadian Pharmacist to create the Institute for Personalized Therapeutic Nutrition (IPTN), and why the folks at the IPTN work tirelessly to educate practitioners and the public about this new possibility of diabetes remission through therapeutic nutrition.  

What is Remission?

Diabetes remission does not have a standard definition, but generally the goal is to get a patient’s hemoglobin A1C, a marker of glucose control to below 6.5% for a period of time in the setting of no glucose lowering medications (metformin is often kept on board due to its myriad other benefits)(18). 

Normal blood sugar and insulin levels!? Without medication!? When I first heard that I nearly fell out of my chair. 

How do we achieve remission?

As it stands three methods have the most evidence available on achievement of remission: bariatric surgery, low calorie diets and low carb diets. As a pharmacist interested in helping patients achieve their greatest vitality, bariatric surgery does not concern me.  I’m all about those therapeutic nutrition interventions though! Let’s talk about them:

Low calorie diets

There are a variety of diets out there that restrict calories for weight loss. In the setting of type II diabetes remission research, generally the diets restrict calories to somewhere below 1200 calories per day using a mix of prepackaged foods and the patient’s own food (18).

There have been many short term studies using low calorie diets in the setting of type II diabetes, but the DIRECT trial was special in that it looked directly at achieving remission (A1C<6.5% with no diabetes medications for 2 months), and it was a long term study (18).  

In this study, patients were placed on a low calorie total dietary replacement diet for 3-5 months and then slowly reintroduced to normal food thereafter.  At 1 year follow up the results were impressive with a whopping 46% of the intervention group achieving remission compared to 4% of the control group. At two years the percentage still in remission was 36% with the study ongoing to test for longer term results (18). 

As a pharmacist who dispenses so-called blockbuster drugs all day I can tell you that success rates like this are RARE.

Low Carbohydrate and Ketogenic Diets

Low carbohydrate diets which generally restrict carbohydrates below 130g/day have shown some beneficial effects on metabolic health, but the real magic lies in the ketogenic diet.  In a ketogenic diet, carbohydrates are restricted to achieve a state of ketosis with carbohydrates going as low as 20-30g per day (18).

As with low calorie, there have been many short term, small studies showing benefit in the space of type II diabetes.  The Virta Health Trial stands out for itss large size and long term follow up.  Additionally, as opposed to the strict inclusion criteria of many other trials, this one included patients with long standing diabetes and those taking insulin, thus it represents a more real world scenario (18).

Virta Health is a company based out of the United States delivering individualized ketogenic diets to patients via a remote care platform.  They are in year 3 of their 5 year study.  Patients on this program are provided with equipment for remote tracking of biomarkers, access to an online community, a health coach and physician/nurse practitioner support via telehealth.  As compared to the DIRECT trial where the diet was pre-packaged, Virta’s patients choose a diet that works specifically for them with the help of their health coach (18).  

Results from one year show that 60% of those who completed the diet achieved an A1C below 6.5% in the setting of no glucose lowering medications except metformin, with insulin removed in 94% of the intervention group.  The two year results, similar to those in the DIRECT trial, show a lower, but still impressive 54% achieving an A1C below 6.5% with either no glucose medications or with metformin still on board (18).  

This intervention was shown to be so successful compared to standard care, that after 2 years it was deemed unethical to continue studying the usual care arm.  As such, those people were offered entry into the Virta world.

There is another exciting study that should be published soon that utilized community pharmacists to provide ketogenic diets to patients in British Columbia with Type II diabetes.  The results are unpublished so I cannot speak to them now, but trust me when I tell you they are exciting!

Honourable mentions:

There are many other dietary approaches that are dynamite as a therapeutic nutrition tool, but for which there is currently inadequate data on diabetes remission. Examples are plant based diets, intermittent fasting and mediterranean diets.  A full review of their wide reaching health benefits is beyond the scope of this article, but they are all useful in their own way.  Hopefully with time we will see data come out which sheds more light on their use towards diabetes remission. 

How do I start!?

After reading this article you’re likely wondering what to do to get started.  If remission is a possibility, let’s do this now!

Please please please, WHATEVER YOU DO, talk to your health professional first.  What was not covered ad nauseum in this article is the path from multiple medications to no medications.  Low calorie and low carbohydrate diets are very effective and they are effective quickly.  If you are starting out on a variety of medications, many will need to be removed to prevent adverse events, some even on the first day of the diet.  Additionally, as with all effective treatments, there are contraindications to the use of these diets.  It is important to talk to a healthcare professional first, before taking on any new diet.

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As always, references can be found here, or by clicking on the number in the text.

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Healthy Habits

In functional medicine we deal with something called the functional medicine matrix. It’s a really neat way to lay out a patient’s relevant medical information so that it becomes obvious where you ought to begin.

The bottom of the matrix has 6 spaces for the patient’s modifiable lifestyle factors. These are parts of the patient’s lifestyle that can either add to the risk of disease or mitigate it. A patient with genetics for a disease can substantially lower their risk by keeping these factors in check. On the other hand, a person with no genetic predisposition can drastically increase their risk for disease by having poor diet and lifestyle factors.

The matrix takes the plethora of lifestyle factors and organizes them into five major categories:

Sleep and relaxation- sleep helps the body repair damage from the days activities and build up resiliency for the coming days. Relaxation helps to keep a person’s nervous system balanced between sympathetic (fight or flight) and parasympathetic (rest and digest).

Exercise and movement - An appropriate amount of movement in one’s life can help with everything from mood regulation to risk for cardiovascular disease and diabetes.

Nutrition - What we eat can play a major role in our risk for cardiometabolic diseases like diabetes and high blood pressure. It can also add to or mitigate inflammation in our bodies which plays into risks for autoimmune conditions like rheumatoid arthritis and psoriasis.

Stress - Short term stress, like the stress brought on by brief exposure to cold water, or regular moderate exercise, can be an excellent trigger for our bodies to become more resilient. But chronic stress can wreak havoc on our bodies and increase risk for a number of diseases.

Relationships - A healthy, loving relationship can help to soften the blow of life’s ups and downs. But a toxic relationship can really make it difficult to focus on leading a healthy lifestyle, often being the driver for escapism in the form of drugs and alcohol.

Many patients present with poor lifestyle factors across the board. In these individuals they are often not surprised to be feeling ill. But many patients have excellent nutrition, exercise, sleep and relationships, but high job stress. They are often left feeling perplexed, thinking that if they’re doing everything right, they shouldn’t be feeling poorly. It’s important to remember that while each lifestyle factor is important, it’s the total picture that makes the difference to a patient’s health. A tonne of exercise can only compensate for poor diet for so long before we see the negative effects begin to appear.

With the bottom of the matrix in mind, I’ve developed a “healthy habits quiz”. It’s written in the style of a trashy magazine quiz. It is not diagnostic in the slightest, but meant to get you thinking about what areas of your life you could improve in order to feel better.

Before taking the quiz, please remember that health is a journey! You’re not going to score perfectly in all areas of this quiz overnight. If it were that easy, chronic disease wouldn’t exist and I’d be out of a job!

Is your urban garden toxic!?

Up until this year, my relationship with vegetables has begun at the grocery store. I want kale. I buy kale. I eat kale. We had a flower garden growing up, and a rhubarb patch in the back, but that’s about it.

Then I met a Kootenay man, born and raised. We moved in together and low and behold…I garden now. And by golly: I love it! Who knew something so simple could bring you such joy! It was a busy spring, but we managed to sow seeds for a big garden in the same plot that the previous owners had used. We planted potatoes, cabbage, beets, kale, peas, carrots, and all sorts of squash. I’ve really enjoyed watching the veggies grow and learning about all the plants. Plus, spending time weeding lets me sit in the dirt and acts as a sort of meditative practise.

The squash sprouting up from amidst the weeds, with a backdrop of peas and carrots.

Then, I got my garden soil tested.

While getting our septic system inspected it was pointed out to us that our garden sat directly overtop of the septic field. D’oh! How could I be so stupid! I had been shown where our septic field was located while inspecting the house a mere 6 months ago. I was so excited about having a garden that I didn’t even consider where it was located. We made the common and critical error of acting first before critically thinking about our actions.

I got thinking: if it were just human waste going down our pipes that would probably be fine…but what about all the soaps and detergents!? Sure, I use the greenest products I can find, but what about the previous owners. This septic has been in place since 1992, before natural alternatives were common place on the shelves. How many loads of tide have been pumped into the ground!? How many CLR treatments of the bathroom!? Panic set in.

I decided to test my garden soil.

It was pretty easy to get the test done thanks to my friend Andres who runs a fertilizer company. He included my sample with his regular shipment to A & L labs and two weeks later the results were in.

The heavy metals test results for our garden, affectionately named “flushing meadows”.

The Verdict

When you get lab tests back from the doctor, they come with reference ranges and an indication of whether the result is high, low or normal. Unfortunately for me, soil tests do not come in this easy to interpret format. The best I could find from the lab was a range of common concentrations in “natural soil” as well as an average value. On the same reference, they say that if your result is “significantly” higher than the average, you ought to investigate further. There is of course, no indication of what value would be considered “significantly higher”, though.

Of all the metals tested in my garden, three of them are higher than the average values provided by the laboratory:

Lead:

Average value: 10 mcg/g

My result: 53 mcg/g (5 times higher than the average)

Cadmium:

Average value: 0.06 mcg/g

My result: 1.38 mcg/g (23 times higher than the average)

Zinc:

Average value: 50 mcg/g

My result: 168.75 mcg/g (3 times higher than the average)

Of the three metals tested, zinc is the least concerning to me. Zinc is an important micronutrient, so it is nice to see that there is likely lots of it in my veggies. As far as I can tell, toxic levels of zinc cause the plants to produce a poor yield and that’s about it.

A beautiful big beet basking in my lead contaminated soil. :(

Lead however, is toxic to humans, both with long term low level exposure and acute high levels. It can damage many body systems including the kidneys, nervous, reproductive and endocrine systems. According to a publication from the University of California Agriculture and Natural Resources, lead concentrations in soil are often directly related to their distance from highly travelled roads (leaded gasoline wasn’t banned in Canada until 1990!), especially those in industrial areas, and older buildings painted with lead-based paints. Other sources of lead are the disposal of scrap metals containing lead and lead-acid batteries.

Hmmm. I live very near a busy industrially trafficked road in an area that used to have a thriving jam production industry, downstream from a pulp mill.

Okay, so there is lead in my soil, and it’s not dramatically high, but still unsettling. How do I get exposed to it through gardening?

According to this same resource, the most likely exposure to lead in soil comes from soil dust. This can either be consumed as dust clinging to unwashed vegetables, or inhaled as dirt is turned up outside, or inside after being tracked in on shoes. **Thinks in horror back to the days spent weeding the garden and shaking dirt everywhere. Secondary to the leaded soil dust, is the consumption of plant tissue containing lead. According to this same resource, lead is taken up into plants in different levels depending on a variety of factors of the soil like presence of organic matter, temperature and acidity. Of the lead that DOES get into the plant, most of it is concentrated in the roots, then the leaves. They advise against eating leafy vegetables (something I read while scarfing down a giant salad bowl filled with kale and beet greens!!) or root/tuber crops like carrots, beets and potatoes (drat! The beets are just now getting big and plump looking!).

Cadmium is not a metal I am particularly familiar with. Luckily, this document from Cornell University gives an overview of Cadmium, as well as some other metals that are commonly found in gardens. Cadmium is a known carcinogen, and can pose a threat if a person is exposed to low levels over time, similar to the case with lead. It is a common impurity in the zinc plating found on galvanized steel. It’s also commonly found in coal burning emissions and some fertilizers. Compared to lead, it appears to be much more soluble and available to plants in the soil, which is bad news for a gardener! And you guessed it: preferentially taken up by leafy greens! Dang it!

What now!?

It’s hard not to look at my veggies in this way now.

So finding high levels of heavy metals in my garden is not awesome. But I can still enjoy the garden this year with some modifications. We will no longer be harvesting the green leafy veggies or the root crops. My heart breaks for all the delicious carrots and beets I will be missing out on! Next year we will either move our garden to another area in the yard (if the soil samples come back clean), or move entirely to a raised bed system with imported top soil.

There are some silver linings from all of this though:

• no more weeding the garden this year (yay!!)

• we found the problem early in our gardening journey. We’ll be here enjoying the beautiful growing conditions of the West Kootenays for years to come and aside from this first few months, it will be a healthy addition to our lifestyle.

• According to my research, it seems most fruits and fruits masquerading as veggies (I see you tomatoes and cucumbers!) are safe even in lead contaminated soil as long as they are washed well before eating. And conveniently they are just ripening now!

• If we move to a raised bed system, my back will be saved!

A handful of raspberries straight from the garden! Yummmmm.

Today I learned that squashes grow little spikes all over them! They must all be rubbed off by the time they get to the grocery store. Cool!

Takeaways:

Even activities that seem wholesome and safe, like letting your kids play in the dirt and growing a home garden, can be dangerous if we fail to consider the unfortunate contamination of our environment. Environmental standards have come a long way, but sadly our past mistakes can haunt us for a long time.

If you plan to have a garden, get your soil tested, BEFORE planting to avoid any unnecessary heartache. If heavy metals are a concern, make sure you plant non-edibles as a coverage crop to avoid tracking them into the house, and use a raised bed garden system with non-contaminated soil, especially for your greens and roots. If you’re tight on money, look out for programs like this one in Trail, BC that promote healthy environments and may provide soil testing and replacement at no cost to you.

Stay safe out there friends!

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Covid-19 Plea from your pharmacist: Spring Cleaning is NOT an essential errand!

I have just returned home from the COVID-19 testing facility in Trail, BC: A single room blocked off from the rest of the clinic by a plastic drop sheet.

In one corner of the room sits a single chair blocked off with tape on the ground. In the other corner, a single healthcare worker and a table of COVID-19 pamphlets and testing supplies.

After being prescreened via 811, I’m given an appointment time and directions to the clinic. The locked door is opened by a staff member who instructs me to put on a mask and sanitize my hands.

The efficiency stands in stark contrast to the normal day to day operation of our healthcare system. In a system that usually sees routine wait times of up to an hour, I was in and out of that clinic in two and a half minutes, including a customary pre-swab nose blowing and a debrief on self isolation and where to get results.

Unfortunately, the sense of urgency and care being taken by the healthcare system seems overshadowed by a certain return to normalcy in the community at large.

In the first few days of this week, my drive to work felt eerie; like travelling through an abandoned ghost town. Recently though, there seems a new visitor has arrived: complacency.

I see it at the parking lot to the home renovation stores the most. Every day when I drive past Canadian Tire there seem to be more and more people in the parking lot. People who appear to be taking advantage of all this time off to get their projects done around the house.

I know it is tempting. We in modern society with our 40 hour work weeks and packed social schedules often have a laundry list of tasks we’ve been putting off. With our mentality that any time not spent “doing” is wasted time, we so badly want to spend this time checking things off that list.

But I am here to plead with you to leave the list alone for just a few weeks longer.

We know there is community transmission of this virus. At the pharmacy we been doing what we can to protect ourselves and our ability to continue to serve our community. We’ve asked people not to come into the pharmacy to request refills: To go home and call in their requests.

Our pleas are met with eye rolling, anger, frustration and blatant disregard for our safety and the safety of our most vulnerable.

Beginning last week we lost two pharmacy assistants.

Today we lose a pharmacist. The relief pharmacist to be precise. I was already filling a temporary role covering the pharmacy while they rehired. Now they need to find relief for the relief.

For how long? I’ve been told I’ll get results in 2-4 days as a healthcare worker and that I’ll need to self isolate for 10 days if positive and until asymptomatic if negative.

So please: do your part to stop the transmission of this virus. I hope to hear reports of my town returning to deserted status. I won’t see for myself, because I’ll be following orders to STAY HOME!

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Why does it take so long to put some pills in a bottle and slap a label on it!?

In my article, “What do pharmacists do?” I outlined the process that pharmacists go through to prescriptions for a given patient. In this blog post I’ll take you behind the counter and inside the mind of your community pharmacist. You’ll see all the questions we ask ourselves before clearing your medication to be prepared and dispensed. Hopefully by the end of this article you’ll have more confidence in your pharmacist and a little less frustration the next time you visit the pharmacy.

Here are the 18 key questions we ask ourselves when evaluating a new prescription for a patient. You’ll note that the answers are PATIENT SPECIFIC, which means your pharmacist may need to ask you some personal questions to do their job effectively and keep you safe. The questions fall under 5 headings, Necessary, Effective, Safe, Adherence, and Unmet Needs. So strap on your reading glasses and follow me.

Necessary:

1) What is the medical condition we are trying to treat?

There’s no point taking a medication with no medical condition to treat. Full stop. You may be confused when your pharmacist asks you what condition this prescription is for. Shouldn’t the pharmacist KNOW what the antibiotic is for!? Not necessarily: Many drugs are used in a variety of conditions, just at different doses, for different lengths of time. It’s important for us to know what condition we’re evaluating the drug for.

2) Does the patient have this medical condition?

Usually we don’t do much here. Your physician should have gone through this part and diagnosed you with a condition before selecting a drug. He/she will have looked at your signs/symptoms/lab values to come to this conclusion. However, technically it is our job to confirm that the diagnosis is appropriate.

3) Consider the patient’s other medical conditions as contributing factors to this one.

Just because you present with a certain set of symptoms doesn’t mean we need to treat with another drug. These symptoms could be your other conditions getting worse due to suboptimal treatment. Or it could be the result of a side effect from another medication you take. If this is the case, we should take a step back and consider your other conditions and medications first before adding another drug on top.

4) What are the goals of therapy for this condition?

Okay, now that we know there is a definite medical condition that we ought to treat, what is the end goal for treatment? Is it a condition that can be completely cleared up, like strep throat? Or is a progressive disease like multiple sclerosis. This questions helps to give some context to the treatment plan.

5) What options for treatment do we have at our disposal?

It’s important to know ALL the options available and the evidence for each of them. Without knowing this piece your pharmacist would be a fish out of water when assessing your new prescription. This is where the four years of pathophysiology, pharmacology and therapeutics comes in.

6) Is the patient already taking anything for their condition?

Perhaps they’re already taking a self selection product from the pharmacy, or they are on one of the options for treatment and now presenting with a prescription for an alternative. Knowing this helps us to determine if this medication is an add on therapy, or if it will replace what you already take.

7) Knowing the answers from 1-6, is there even a reason to take another drug?

The answers from 1-6 culminate in a stop or go question. Do we continue to evaluate this drug for our patient or do we contact the doctor and advise of another route that might be more appropriate.

Effectiveness:

Now that we know it is necessary to treat this condition of yours, is the drug in question going to be the best one for you?

8) Is this drug indicated for the condition we are trying to treat?

Sometimes this means it is an official Health Canada indication. Sometimes the medication is used commonly, but is not official per Health Canada. This is called an “off label use”. Sometimes it is abundantly clear that the medication the doctor meant to choose got replaced by something that sounds and looks a lot like it. We’ve unfortunately replaced poor doctor handwriting with drop down lists on computer software that have their own sources of error.

9) Is this the MOST EFFECTIVE drug for the condition?

Assuming the drug is indicated, is it the best one? Are there better options with higher efficacy?

10) Is the rest of the prescription (dose, frequency, duration of therapy etc) appropriate?

Even if it’s the most effective drug, the dose selected may not be appropriate. Ex: For antibiotics, the same drug can be used across a spectrum of different infections, but at different doses and durations. Sometimes the duration may seem really long for the infection, but then we talk to the patient and it’s their second infection of that kind in a month. Treating for longer may bring about the cure we desire.

11) Onset of action

Okay, so the drug will work, and work well at this dose, but how quickly is it going to work? Is the onset of action going to be appropriate for this condition? For example, there are antidepressants out there that work for anxiety, but they take about a month to have an effect. This would not be an appropriate choice for a person in a full blown panic attack. For that we need something that will act quickly to provide some relief to our patient.

12) Are there any interactions we need to look out for that would make this medication less effective.

Is the patient already on another drug that will cause this one to work less well. If yes, we may still be able to proceed, but with some changes.

Hang in there! We’ll get through this blog post together!

Safety:

Sweet! We’ve gotten this far. We know the medication is necessary and effective. But is it safe? This is by far the most important step to get right when considering a new medication. This step has four questions:

13) Contraindications!

Every drug comes with a list of them, and every patient ought to be screened to see if they have them. The classic case: pregnancy. This is why as a female you will very often be asked if there is any chance you could be pregnant.

14) What are the side effects?

Are any of them going to be unbearable for the patient? Or might those side effects contribute to a worsening of their other conditions? For example, some blood pressure lowering drugs work by dilating blood vessels. If a person already suffers from migraines, they could experience a worsening of that condition, so we might fax the doctor and ask for something with a different mechanism of action.

15) Is this a duplication of therapy?

If we’re already using this class of drugs, it can be dangerous to add another one on. However, in some cases, duplication can be okay and even necessary. Take pain management for example: the best control comes from using a long acting formulation in combination with a short acting one to be taken if there is any breakthrough pain.

16) Interactions

Are there any interactions with this drug that would make it unsafe to take? Interactions can be between the drug and a patient’s condition, other drugs or supplements. Some drugs even modify certain lab tests, which is important to know if that value is being monitored by your doctor for your other conditions.

Adherence:

17) After all of that, does our patient even WANT the drug?

This is another one that will stop you dead in your tracks. In fact, I often skip straight to this one before considering anything else. We consider whether the drug is available (Oh Canada, the land of drug shortages!), affordable, and whether the patient will have any other troubles taking the drug. We often see patients with trouble swallowing pills. In that case we’d need to switch them to a liquid formulation. Some drugs are highly effective, but need to be taken every 4 hours. That’s no good for someone who leads a busy life and is likely to forget half of the doses. To add insult to injury, often the most effective drugs are also the most costly. If a patient doesn’t have coverage, they will have to pay out of pocket for that expense. There is a lot to consider ON TOP of safety and efficacy, that we spend time considering behind that giant counter of ours.

Unmet Needs:

Often after evaluating a medication for a particular patient, it becomes clear that they have some other issue that need taking care of. Sometimes this means a referral to a specialist, education about non-drug measures they can take to reduce their symptoms or need for medication. Or perhaps a vaccination they are eligible for that will reduce the incidence of an infection in the future. Most often, we discover through our consult that the patient needs further evaluation of their other conditions to optimize treatment.

Still with me? You’re sleeping aren’t you? Well if you HAVE read this far, here’s a picture of my cat.

WAKE UP! The blog’s over!

So there you have it folks. The reason it SHOULD take your pharmacist at least 20 minutes to fill a new prescription. So the next time you get your medication within 5, perhaps you should ask a few questions of the white coat.

Now go get some fresh air. That was a lot.

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Therapeutic Nutrition: The most powerful weapon against superbugs?

We’ve all heard by now that the post antibiotic apocalypse is coming if we don’t do something to preserve our antibiotic supply. Whether you’re a medical professional or a member of the public, you’ve been impacted by the concept of antibiotic stewardship (a fancy term for ensuring we have effective antibiotics to treat our grandkids with).

A classic headline warning us all of the post antibiotic apocalypse. Source: https://www.cbc.ca/news/health/superbug-deaths-1.4429406

Antimicrobial stewardship promotes the judicious use of antimicrobials to limit the development of antimicrobial resistant organisms. Antimicrobial stewardship programs support coordinated interventions designed to improve and measure the appropriate use of antimicrobials including selection, dosing, duration of therapy and route of administration. source: https://www.publichealthontario.ca/en/health-topics/antimicrobial-stewardship

As a pharmacist, I’ve spent many hours learning about the spectrum of action of antibiotics such that given a particular infection, we choose an antimicrobial with the narrowest spectrum of action first, preserving the hard hitters for more severe and dangerous bugs. As the last person to see a potential prescription before it gets to a patient, it’s important for me to know how to spot inappropriate antibiotic use.

The logo for the professional resource and educational group Do Bugs Need Drugs Source: http://www.dobugsneeddrugs.org/

As a member of the public you’ve likely been impacted as well. Popular educational campaigns by the website http://www.dobugsneeddrugs.org/ can be found on the back of buses in cities and plastered all over the walls of doctor’s clinics and hospitals. Or perhaps you’ve been to the doctor in awful condition assuming you’d get an antibiotic only to be told that the infection is viral and you’d have to wait out the symptoms?

Every year the Canadian government spends a staggering amount trying to tackle the problem of antimicrobial resistance. The current figure is $1.4 Billion per year, spent funding projects to study resistance patterns, educate members of the public, lawmakers and healthcare professionals alike. That cost is expected to increase if we don’t change the way we approach this problem substantially.

“The Canadian report’s findings on the economic and social toll of antimicrobial resistance are stark. Currently, the problem costs the national health-care system $1.4 billion a year, and by 2050, that figure is projected to grow to $7.6 billion, the report says. The cost to GDP is expected to jump from $2 billion to up to $21 billion annually.”

— https://www.cbc.ca/news/health/superbug-deaths-1.4429406

As an engineer, taught to rigorously study systems problems and find effective solutions, here’s what I see:

The current antimicrobial stewardship program is Odie, I am Garfield.

The current antimicrobial stewardship program is producing some results, no doubt. But given the predicted increase in cost referenced above, it’s not doing enough. In my humble opinion, we’re focusing too much on the wrong part of the system-the prescription of drugs. We’re just blindly accepting that our population will get a certain amount of infections per year, and then spending our time educating prescribers about recognizing viral infections, and prescribing the most narrow spectrum agent when appropriate. But what if we looked a bit more upstream for a solution?

we should be focusing more on reducing the need for antibiotics, rather than solely focusing on the downstream process of prescribing those antibiotics.

The relationship between an unhealthy population and increased antibiotic use, which begs the question: Shouldn’t we take a look at those burgers?

In the image above, I point out the relationship between an unhealthy population and antibiotic use, employing the image of a tasty burger to represent the myriad of factors that are contributing to lowered immune status in our population. Other important factors are the impact of stress and sleep to name a few, but in the interest of time, I’m going to focus on food choices.

The western diet and the immune system:

The paper referenced below does a great job of explaining the effect of food choices on the immune system. The author even breaks the evidence down between human studies and animal studies. The image taken from the same paper shows how poor food choices lead to the down regulation of our immune system through gut inflammation and dysbiosis leading to leaky gut.

A particularly powerful statement from the study explains that obese individuals actually have fewer, and less effective white blood cells available to fight infection:

Obese individuals have fewer white blood cells to fight infection and those cells they do possess have reduced phagocytosis capability [11,12]. While a complex interplay of hormonal, metabolic, and immunologic processes contribute to the biologic responses in the obese the resultant immune dysfunction increases the risk of infections of the gums, respiratory system, and of surgical sites after an operation

What does the data say about our antibiotic use?

Now that we’ve reviewed the mechanisms through which poor food choices contribute to lowered immune status, we can look to the data to see if those mechanisms show up in our population. To do that, I looked to the following paper from the Journal of Antimicrobial Chemotherapy:

This paper, published in 2017 sheds some unnerving light on the use of antibiotics in our western culture. The study, performed by the UCL Institute of Health Informatics looked at the frequency of antibiotic prescribing amongst different patient groups in the UK. They surveyed the data from ~1.9 million people across more than 300 medical clinics and found that over half of the antibiotics prescribed in primary care were for only 9 percent of patients!

“Individuals with heart failure, asthma or peripheral arterial disease were prescribed 53%–69% more antibiotics than individuals without these conditions. Compared with the general population, diabetics and individuals with coronary artery disease were prescribed 47% more antibiotics. Obesity, stroke and chronic kidney disease were all associated with more than a one-third increase in rates of antibiotic prescribing compared with individuals without these conditions.”

— https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5437523/pdf/dkx048.pdf

What patients, made up those 9%? Patients with comorbidities including asthma, coronary artery disease, chronic kidney disease (CKD), COPD, diabetes, heart failure, obesity, stroke, peripheral arterial disease (PAD), and smokers. The paper cites that individuals with diabetes and coronary artery disease ALONE, were prescribed 47% more antibiotics than the general public.

Note that obesity, while represented as it’s own medical condition in the paper, contributes greatly to most of the other 10 conditions listed. The only two conditions not directly related to obesity are are smoking and asthma. But wait! Asthma is an autoimmune condition! Refer back to the image from the Western Diet article and you will see autoimmunity being driven by poor food choices leading to dysbiosis!

conclusion: the most effective antibiotic stewardship begins with the diet.

The bad news: The burden of obesity far outstretches our waistlines, leading to increased antibiotic prescribing and threatening the longevity of our antimicrobial supply.

The good news: We have a clear upstream target to focus on: nutrition!

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Health Professionals: it’s time to pay attention to therapeutic nutrition!

It’s nothing new that patients are searching the internet for answers to their health questions. This has been a phenomenon for as long as I have been in the world of pharmacy. What is new, is the quality of information available via the internet for anyone with an interest to access. There was a time when accessing niche information on particular protocols was difficult. One only found out about alternative treatments through a friend or a naturopath if funds permitted. Now, with content creation becoming a major source of business development for health care practitioners, it’s not hard to find high quality information that pertains to your condition online. Unfortunately, the majority of health care workers, myself included, find it hard to keep up with the rate of information, and often lag behind our patients, playing catch up when they see us at the pharmacy counter.

What I wish to present to you is the case of a man with an acute case of gout precipitated, I believe , by a 72 hour fast.

The scenario:

A middle aged man came into the pharmacy to fill his usual medications; rosuvastatin, ramipril and amlodipine, and asked if there was anything over the counter he could use for an acute gout attack. Upon further consult, the man told me that he knows poor diet is a factor for gout and that he’d been trying to clean up his act. In fact, he had been fasting for the past three days to try and kick start his transformation.

How I handled it in the pharmacy:

Without time to go and look up the connection between fasting and acute gout I suggested to the man that the timing of this attack was not a coincidence and I felt that the fast had brought on this attack. I suggested that instead of doing a 72 hour fast, he could switch to intermittent fasting which should have lower consequences. My theory was that the fasting had caused a breakdown of amino acids which would result in a higher level of uric acid in the blood, hence an attack of acute gout.

A more likely scenario.

Upon review, gout can indeed be precipitated by a fast, but the mechanism is actually related to the kidneys. It’s not a greater production of uric acid that is to blame, but rather a reduction in excretion. Fasting causes both a reduction in glomerular filtration rate, and a competition for excretion between uric acid and ketone bodies, produced when the body switches into ketosis to fuel itself in the absence of glucose. Indeed, in an article from 1969, the author reports that a history of gout has historically been considered a contraindication to fasting in obese patients. (source: https://pmj.bmj.com/content/postgradmedj/45/522/251.full.pdf).

The take-away

As the most accessible component of the healthcare team, pharmacists need to understand the complex connection between diet and different disease states. At the very least we need to be able to counsel patients on the effect of diet on the medications they take and the diseases they live with. In the case of gout, this man had a sore toe to deal with. In other patients there are more severe consequences like over medication with anti-hypertensives and a risk of falling. Ideally, pharmacists have an opportunity to recognize the power of diet in managing disease and helping to get patients off of unnecessary medications, spending less time at the pharmacy counter and more time living their lives.

A pharmacist's sacred text: the drug monograph

Ever wonder where your pharmacist gets all that information? Wouldn’t it be nice to have access to it as well? Fret no more, because in this post I will show you how to get the information you want about any medication in Canada without needing to sift through the google of things to find it!

Pharmacist’s are strange people. It’s no secret. Even Hollywood has caught on (ever seen a normal pharmacist in any form of media ever?). Part of our collective strange is our compulsive need for standardization and organization. It permeates our entire culture; from the way prescriptions are filled and labeled, to the resources we use to answer your questions. Why are we so particular?

Because pharmacists are the goalies of the healthcare team.

We’re the last line of defence before a medication reaches a patient, and it’s our responsibility to ensure that whatever we sign off on is safe and effective for our patients. Being a goalie is high pressure! There are countless ways that things can go wrong with medications, and the threat is even greater with the aging population and increased pressure on our healthcare system. With that in mind, what we need from a drug information resource is a standard format of unbiased data that we can interpret and make a decision with quickly. Enter the product monograph:

What is a drug monograph?

A screenshot of the first page of the monograph for ramipril.

A drug monograph is a set medication data compiled by the manufacturer and meant to guide its safe prescribing and use. Monographs have a standard format beginning with the indications for use, and ending with packaging and storage particulars.

In a drug monograph you will find the following:

• Summary of the product-full list of ingredients for each dosage form and strength available

• Indications and clinical use-lists the Health Canada approved uses

• Contraindications-who should absolutely not use this drug

• Warnings and Precautions-gives an overview of some things that can go wrong with the medication

• Adverse Reactions-a list of the reactions people have had to the medication including the frequency at which these things were reported.

• Drug Interactions-does this medication play nice with others?

• Dosage and Administration-what dose and regimen should be prescribed? Dosing strategies are provided for the general population as well as for special cases like the very young, or people with impaired kidney function.

• Overdosage-signs and symptoms of overdose and how to manage it

• Action and clinical pharmacology-how does it work and how does it interact with the body’s systems.

• Storage and stability

• Dosage forms, composition and packaging

How to find a drug monograph:

The best place tofind a monograph for any drug product licensed for sale in Canada is the Drug Products Database hosted by the Government of Canada. Here’s what the page will look like:

You can browse the database alphabetically or search it based on the information you have available. Usually the easiest way to search is using the Drug Information Number (DIN), which you can find on your medication label from the pharmacy. The image below shows my search for ramipril, a very common medication for hypertension:

Eventually, you will get to a page with a link to a pdf of the monograph. Voila! You’ve now got everything you could possibly hope to know about the medication in question. Beware though: the information contained therein is not for the faint of heart. Read on and you might just understand why your pharmacist is so nutty all the time!

Happy learning!

xo Kimberley

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Functional Pharmacy In Action-Paroxetine and Cholesterol

Yesterday I had a gentleman come into the pharmacy with a new prescription for rosuvastatin 40mg to treat high cholesterol. Knowing that he has been taking paroxetine for some time I quickly had a look at the paroxetine monograph in the interactions section. Low and behold, paroxetine has been shown to increase cholesterol levels in patients.

From the product monograph:

“ Serum Cholesterol Elevation

Several public domain studies have shown increased LDL-cholesterol levels of ~10% in volunteers and patients taking paroxetine for 8 to 12 weeks, which generally normalized after paroxetine discontinuation. In addition, of the patients in placebo-controlled clinical trials for whom baseline and on-treatment measurements were taken, total serum levels of cholesterol showed a mean increase of ~1.5 mg/dL in paroxetine-treated patients (n=653), compared to a mean decrease of ~5.0 mg/dL in placebo-treated patients (n=379). Increases from baseline of 45 mg/dL or greater were recorded in 6.6% of paroxetine-treated patients compared to 2.6% of placebo-treated patients (see Monitoring and Laboratory Tests, Serum Cholesterol Elevation).”

I informed the patient about the interaction and let him decide if he wanted to start the statin or discuss alternatives to paroxetine with his doctor before adding this medication to his regimen. The patient explained that since it had been a long road to finding an effective antidepressant, he would start the statin. I faxed the physician and let him know of the interaction. Now the patient, myself and the physician are all aware that while he is at an age where high cholesterol begins to be a problem, his other medication may be contributing to his levels as well. We will all be in a position to help counsel him on his cholesterol management from a more understanding and informed perspective.

This case study highlights the importance of a functional medicine approach to new prescriptions. One of the worst features of our current medical system is the treatment of medication side effects with additional medication. As drug experts, pharmacists are the ideal professional to identify and rectify this problem saving patients and the healthcare system time and money.

Also highlighted here is the importance of a true community pharmacist able to take care of patients with care and attention. With the recent cutbacks to pharmacy, we’re seeing more and more pharmacists being asked to do more with less. As a pharmacist in an independent pharmacy I had the time to catch this and take the appropriate actions, but for the majority of the pharmacists out there this is unfortunately not the case.

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Probiotics for Women's Health: Ultra Flora Women's

Ever since beginning to work in a pharmacy beside a maternity clinic I see a lot of women for prescriptions each day. The plight of vagina ownership is REAL y’all. I see many a woman with an initial antibiotic prescription for a urinary tract infection, followed by another antibiotic for bacterial vaginosis or by an anti-fungal for yeast infection. If she’s really lucky I’ll see her again and again for a never ending cycle of unhappy vagina.

HOWEVER. I have had great success recently with my new favourite probiotic: UltraFlora Women’s by Metagenics.

Why is it my favourite new probiotic?

This little combo packs a mean punch against vaginal flora imbalance. It’s been Health Canada approved for both bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC), aka yeast infections. Each capsule contains two diferent strains of lactobacilli: lactobacillus rhamnosus GR-1, and lactobacillus reuteri RC-14. This specific combination has shown some impressive results in treating BV and VVC.

Use in the treatment of Bacterial Vaginosis

First of all: Did you know that the treatment success for bacterial vaginosis is very rarely as high as 40%!? How many women have I sent away from the pharmacy counter with high hopes of BV abolishment, only to be sadly disappointed?! To those ladies, I apologize. From now on, I will also provide you with information on this probiotic.

I had a look at 3 BV studies for this probiotic. On it’s own it was able to restore the normal microbiota over 60% of the time with 6 weeks of use. When combined with other antibiotic therapies, there was a significant increase in the effectiveness of the regimen over placebo. When we look at the metronidazole study, the probiotic addition more than doubled the cure rate! The details on each study can be found in the infographic below:

Use in the treatment of Vulvovaginal Candidiasis (yeast infections).

So you get a prescription for metronidazole to treat your bacterial vaginosis and the pharmacist tells you “this medication may cause diarrhea or a vaginal yeast infection”. HOW LOVELY! JUST WHAT I NEED!

Fret no longer. Not only is this probiotic effective for bacterial vaginosis, but it also improves the effectiveness of yeast infection therapies like fluconazole as shown in the following figure:

The results in vulvovaginal candidiasis (VVC) are less impressive, possibly due to a higher cure rate of the standard therapy making the probiotic addition look less impressive. I’d still prefer an ~90% cure rate vs. 65% any day though!

How do I use it?

The second image on this page gives the regimens used in the trials reviewed, but generally the dosage is 2 capsules for 30 days.

Disclaimer:

Before adding this probiotic to your therapy, speak to your pharmacist. There are details of the studies that have not been presented here. For example, none of the studies included pregnant women, so the safety in this population is unknown.

Where can I get more information?

1) The citations at the bottom of the infographics point to the studies I read when formulating this blog post, so you can always read those.

2) I am working on a monograph of sorts with more detailed information aimed at healthcare providers. It will detail the populations studied including exclusion criteria, adverse effects and much more. Sign up for my e-mail list to be notified as soon as it’s ready!

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Where is your data coming from?

While researching intermittent fasting for my talk a few weeks ago, I was able to find quite a bit of data, but only a fraction of that data was from human studies. It’s not surprising that this should be the case when you consider that fasting was a fringe health topic until recently. With fasting of all sorts becoming better known, the body of scientific research on the topic is increasing. This review, conducted in 2014 outlines the mechanisms involved in fasting and the evidence available in everything from single celled organisms to humans.  I’ll be providing more information on the contents of this article and other cool studies in my fasting series, but first: let’s talk about human vs. animal data.

Humans vs. Animals

Photo stolen from this website

It’s not that the only good data is human data. All research has a place in the scientific process. However, the key difference between animal and human data is the applicability of that data. Animal data gives us a hint of what the results might look like in humans, and allows us to justify performing similar work in humans. This is necessary because in modern medical research we have these things called ethics committees. They are responsible for approving studies before they’re done and are quite helpful in avoiding the sorts of things one might see in sci-fi movies. The ethics board would really prefer that before you start mucking about with humans, you muck about with animals first (sorry PETA). If the animal data appears promising, and doesn’t show anything terribly dangerous, we move on to designing similar trials in humans.

So testing things with animals is good, and necessary. But how does that data stack up against human data? Well, the whole reason that we test in specific animals, like rats, is that they have a lot of similarities to humans. But of course, a rat is not a human, and the differences are greater than just whisker size and tail length! This has implications in both the kinds of data we can obtain, and the way we can apply this data to humans.

Humans vs. Animals; Designing trials

As mentioned above, human trials need to clear an ethics evaluation before being approved. People tend not to care all that much if we propose to genetically modify a group of mice to determine how that gene plays out in disease development. Not so much the case if the same were proposed with humans. By studying animals we can really speed up our drug discovery and testing process. The other difference between humans and lab animals is the number of confounding factors present. In the lab, you can take a group of animals and control for just about everything. When you look at the results of your study, they’re pretty clean. Humans on the other hand, have many confounding factors (ex: socioeconomic status, diet, lifestyle etc). Hence trials are more complex and thus, more expensive. It’s best to try the intervention in animals first, before spending all your R&D money on a failed human trial.

Humans vs. Animals; Hierarchy of evidence

The evidence based medicine pyramid, pictured below, shows how different evidence is ranked for weighting in clinical decisions. Before studying pharmacy I thought that randomized control trials (RCTs) were the be end of the end all. Turns out there’s a lot of really poorly done RCTs out there! That’s why we weigh reviews of many RCTs, and meta analyses more heavily than a single RCT (more heavily weighted=at the top of the pyramid). Where does animal data fit in there? Well, if we’re making clinical decisions about that animal, it would go right in the spot corresponding to the type of study done. But if we’re making clinical decisions about humans, the animal data should probably go in the background information section. We can use it to inform further research, but not to inform clinical decisions in humans.

https://guides.library.utoronto.ca/evidencebasedmedicine

How can you tell the origin of a statement or piece of evidence?

Ideally the information will be clearly referenced. Use caution when consuming health information that isn’t sourced. (An exception to the rule: Sometimes an expert in a topic might feel that a piece of information is obvious because they deal with this stuff so regularly. While it may be novel information to you, they may not feel the need to source it.) But even if the information has not been explicitly referenced, there are some clues that can point to the origin of the data:

Clue 1: The data is from a study that would not have been ethical in humans

Photo stolen from this website

Again with those pesky ethics boards!

Clue 2: The data pertains to prevention of disease vs treatment of a disease

A classic case of confounding factors. Photo stolen from this website.

As mentioned above, the number of confounding factors in a population of humans is enormous. It is difficult to isolate the effects of a single intervention since so many of them are linked together in behavioural patterns. For example: smoking and drinking go hand in hand, but it’s clearly the smoking that causes lung cancer, not the drinking. Similarly, there are different diets that show promise in preventing chronic disease. But is it the diet itself, or is that diet a proxy for a more health conscious lifestyle?

What can you expect from me?

What you can expect from me in my blogging is evidence based health information that is clearly referenced and described with enough detail such that you don’t need to go to that article and waste your time fact checking me. I won’t shy away from animal studies because sometimes that’s all we have (ex: drug use in pregnancy and lactation), and often animal studies pertain to cutting edge concepts which is pretty cool! However, in the case that I cite an animal study, I will clearly indicate that fact. But for the purposes of providing health information tailored to individual humans, the best studies are indeed human studies and I’ll always choose the unfavourable results of a human study over the favourable results of an animal one.

Happy learning!

xo Kimberley

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