Drug Induced Constipation

Constipation in the general population is quite a common problem. It is even more common for women, older people, African Americans, and those with lower socioeconomic status. In addition, there are many medical conditions and drugs that can cause constipation. The focus here will be constipation caused by medications.

What is Constipation?

Constipation is not a disease, it is a symptom. It is poorly defined but constipation is generally considered to be a decrease in the frequency of bowel movements. Television, radio and now many internet sites will lead people to believe a daily bowel movement is required for a healthy digestive tract. In fact normal bowel movements can range between 3 per day to one every 3 days and still be considered normal. In an attempt to give constipation a better definition the Rome III criteria were developed. These guidelines generally describe increased straining, lumpy and hard stools, sensations of incomplete evacuations, blockage, the need for manual evacuation and three or fewer stools per week. See the above link for more details.

Drugs That May cause Constipation

There is are many medications which list constipation as a side effect. Some of the more common classes (with a couple of examples) include

• Narcotic pain medications: hydrocodone, oxycodone, codeine, morphine, methadone, meperidine, propoxyphene
• Some antacids: calcium carbonate, aluminum hydroxide
• Anticonvulsants: phenytoin, carbamazapine
• Antidepressants: amitriptyline, imipramine
• Blood pressure medications: clonidine, verapamil, diltiazem, nifedipine
• Some chemotherapy medications
• Iron supplements
• Parkinson’s medications
• Non-steroidal anti-inflammatory medications: ibuprofen, naproxen, diclofenac

Treatment of Drug Induced Constipation

There are many ways to treat constipation caused by medications. First you should talk to the doctor who prescribed the medication. A change in drug therapy may be in order if the problem persists or treatment of the constipation is not successful. Also, constipation in combination with nausea, vomiting or abdominal pain could indicate appendicitis and using a laxative could cause it to rupture.

Diet

Increasing fiber in the diet will help for most cases of drug induced constipation. The US Department of Agriculture recommends 14 grams of fiber per 1000 calories consumed. As a result a 2500 calorie diet requires 35 grams of fiber. The primary source of increased fiber should be from food such as grains, fruits and vegetables. Along with an increase in fiber comes an increase in fluids. If there are not enough fluids consumed, the fluid in the bowels are absorbed into the body resulting in hardening of the stool making it more difficult to pass. The standard recommendation for fluids is 6 to 8 eight ounce glasses of non-caffeinated beverages per day. .High fiber diet resources

Exercise

In general, people who walk less than 0.3 miles per day have more constipation while those who are physically active have less problems. Exercise, such as walking, helps the muscles in the intestines move the contents along reducing the chance of constipation. The benefit appears to be proportional to the amount of activity. As a result, moderate exercise should be introduced as tolerated.

Training

Keeping a set toilet routine can help lead to regular bowel patterns. After a meal the bowels undergo an increased in activity known as the gastro-colic reflex. This phenomenon is most pronounced after breakfast. Drinking a hot beverage may help to strengthen this reflex. Also when using the toilet, the knees should be higher than the hips (use a stool if needed), lean forward with elbows on knees, bulge the stomach out and keep the spine straight. This technique can make it easier to have a bowel movement.

Laxatives

Fiber and Bulk laxatives (psyllium, methylcellulose, bran) are usually considered to be safe and effective. They dissolve or swell in the intestines forming gels that promote bowel movements. When the constipation is due to medications, this class of drugs does not work well and may increase the risk of intestinal obstruction. As a result this class of laxative should be avoided for drug induced constipation.

Lubricant laxatives (mineral oil) coat the fecal materials with oil. This retains water in the stool and makes it more easily passed. Mineral oil must be taken while in an upright position and remain upright for 30 to 60 minutes after taking to prevent aspiration into lungs. Avoid use in people with hiatal hernia, difficulty swallowing, or reflux.

Osmotic laxatives (glycerin, magnesium hydroxide, sodium phosphate) draw water into the the bowels causing a loose or watery bowel movement. Some of these ingredients may be absorbed and cause electrolyte problems. Also, they may cause excessive fluid loss and dehydration. Check with your doctor if you have heart problems, kidney problems, or liver problems.

Emollients (softeners) (docusate sodium, docusate calcium) help water in the bowels to mix with the feces to help soften the stool. These should never be mixed with mineral oil. They are a good choice in combination with a stimulant.

Stimulant laxatives (senna, bisacodyl, castor oil) increase the activity of the bowels therefore pushing the contents along. They also help secretion of fluids into the bowels which is an added benefit. This is the preferred class of laxatives to treat drug induced constipation. It is especially useful in combination with one of the docusate products above.

In conclusion, there are numerous medications which may cause constipation. The most notable is the narcotic pain medications. If you are given pain medication, talk to your doctor from the start about using a laxative to prevent constipation.

Treat High Blood Pressure with Lifestyle Modifications

According to the National Institute of Health website (9/16/2008) about 1 in 3 American adults have high blood pressure making it one of the most common health conditions in the country. High blood pressure is considered a silent disease because it usually has no symptoms.

Blood pressure is the force of the blood pushing on the walls of the arteries as it moves through the body. When it remain high it can lead to heart disease , heart failure, stroke and kidney disease and other medical problems. As a result, when blood pressure is high, it is important to lower it back to normal levels. There is a large array of medications available to lower blood pressure. In addition to prescription medications, there are several lifestyle modifications which can use to help control high blood pressure.

Many lifestyle modifications have been studied and shown to significantly reduce blood pressure. It is important enough to incorporate into treatment that the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) includes lifestyle modifications into its treatment guidelines and states “Adoption of healthy lifestyles by all persons is critical for the prevention of high BP and is an indispensable part of the management of those with hypertension”. Unfortunately many people are not educated about the benefits of lifestyle modifications or are reluctant to adopt these changes.

Dietary Modifications

Diet has been shown to both decrease your risk for developing high blood pressure and help to lower a blood pressure that is too high. Dietary changes can reduce blood pressure by as much as 8 to 14 points (systolic blood pressure – the higher of the two numbers). The modifications with the best support is the (Dietary Approaches to Stop Hypertension) DASH plan. This plan includes lots of fruits and vegetables and is low in saturated fats. The plan also includes whole grains, poultry, fish and nuts and is low in fat, saturated fat, cholesterol, red meats, sweets and sugared beverages. When adopting this sort of diet, it may be easier to adopt the changes slowly. There is a book you can use to help you adopt the diet.

Use Less Salt (Decrease Your Intake of Sodium)

The typical American diet consists of approximately 3,300 mg of sodium per day. A moderate reduction to 2,400 mg of sodium as recommended by JNC can decrease blood pressure by up to 2 to 8 points (systolic). Having a goal of 1,500 mg of sodium can result in even more reductions but this goal may be more difficult to maintain. To obtain this reduction in sodium alternative seasonings need to be used. Do not immediately reach for the salt substitutes as these may interact with some blood pressure medications (check with your doctor or pharmacist). Some good alternative seasonings are basil, cinnamon, cloves, dill, ginger, marjoram, nutmeg, oregano, parsley, rosemary, sage and thyme. Also, to reduce sodium intake, read food labels. Many products are very high in sodium and there are often alternatives with much lower sodium content. Foods generally high in sodium include canned vegetables and soups, frozen dinners, lunch meats and many ready to each foods. Learn how to decrease salt in your diet here

Physical Activity

Getting an adequate amount of physical activity is critical for maintaining good health. This is also true in regard to high blood pressure. In fact, following the JNC guidelines of 30 minutes a day of moderate activity most days of the week may result on lowering of blood pressure by up to 4 to 9 points (systolic). The recommendations also state the activity can be broken up into shorter periods of at least 10 minutes each and spread out during the day.

Weight Management

This lifestyle modification can produce the largest results in reducing blood pressure. There is a direct increase in blood pressure as body weight increases. A person who is overweight and has high blood pressure will see the biggest benefit from weight loss. In fact the JNC states even weight loss as little as 10 pound can improve blood pressure. Developing a weight loss plan is beyond the scope of this posting but it is essential to achieve blood pressure control.
Alcohol in Moderation

Moderate alcohol consumption is considered one drink per day, or less, for women and two per day, or less, for men. More than this amount of alcohol can increase blood pressure in addition to many other negative health effects. If you do not consume alcohol, it is not recommended to start due to reported health benefits. If you do consume alcohol, do not exceed to the guidelines for moderate consumption.

The above lifestyle modifications can make a dramatic difference in blood pressure control and overall health in general. Combining several or all of the above items can have an increased effect over any one of them alone. In fact, there is evidence to suggest lifestyle modification can be as effective at controlling blood pressure as a single drug. Also, lifestyle modifications can delay the development of high blood pressure and can improve the effectiveness of blood pressure medications when drug therapy is required.

Here is a great free Guide to Lowering Blood Pressure with more detailed information.

Check out this free Interactive Menu Planner.

The information provided here is not intended to deter you from taking you medicine. It is provided to help encourage changes in diet and activity levels to improve overall health and maintain a health blood pressure.

Get some helpfull books here.

Using Saline Nasal Irrigation to Treat Sinus Problems

What is saline nasal irrigation?

Nasal irrigation is an ancient technique of using a salt solution to bathe or wash the nasal passages. It is also referred to as nasal wash, sinus irrigation, sinus rinse and sinus lavage. The procedure was first introduced hundreds of years ago in India as part of the Ayurvedic medical tradition and called “jala neti”.

There is growing interest in saline nasal irrigation as it has been reported in The New York Times, on NPR radio and on The Oprah Winfrey Show. Also some research suggests a therapeutic benefit for several sinus conditions and more medical professionals are recommending this procedure to their patients.

Which conditions can be treated with saline nasal irrigation?

Healthcare professionals are recommending saline nasal irrigations as adjunctive therapy (added to conventional therapy) for patients with upper respiratory infections (the common cold), sinus infections, chronic runny nose, hay fever and allergies.

How does saline nasal irrigation work?

It is not known for sure how this procedure works to improve nasal symptoms but there is some very good theories. It is believed to work by:

1. As the saline solution passes through the nasal cavity, it cleanses the area of mucus making it easier to breath.
2. Removing inflammatory (causes swelling) chemicals secreted by the body into the mucus which in turn reduces their inflammatory effect.
3. The rinsing improves the movement of tiny hairs in the nasal passages responsible for moving mucus, dust, pollen and germs out of the area. This improved movement allows irritants to be removed more efficiently.

What products are available to perform irrigation?

There are many products on the market available to deliver saline nasal irrigations. The traditional way to perform the rinse involves using a neti pot. This is a small container resembling a tea pot which is used to pour the solution in through one nostril and let it run out the other side. A newer approach is a squeezable bottle which will squirt the solution into one nostril and let it pour out the other side. Both are considered to be equally effective and selection is a matter of personal preference. These can be found at your local pharmacy. If you can’t locate them here is a link for nasal irrigation products.

How do I do these irrigations?

Always use filtered room temperature water. The product you choose should have detailed instructions in the package.. Follow the instructions carefully. There is a video available to watch here. There is also a do-it-yourself instructions here.

Precautions

1. Always check with your doctor before treating yourself.
2. If you have an acute sinus infection avoid this procedure as you could facilitate the spread of bacteria.
3. Make sure there is some airflow through both nostrils before attempting this procedure.
4. Gagging or ear pain may mean you are being to vigorous during the process.
5. Coughing, nasal dripping and draining of fluid in the back of your throat may occur.

Making Sense of Prior Authorization

The Doctor has written a prescription for you and said it would help make you feel better. You go to the pharmacy drop it off and return later to pick it up. The words you hear next make no sense whatsoever. “Sir, your prescription requires prior authorization.” This is the strangest thing you have ever heard and you don’t know what to do….

What is prior authorization?

Prior authorization (also known as prior approval or pre-authorization) is a requirement of the insurance company (third party payer) that a provider (usually a doctor) justify the need for the medication before it will be paid for by the third party.

What does this mean?

The insurance company will not pay for a medication until certain predefined criteria are met. The criteria varies by medication and these criteria are not the same for every company. In fact each company can make its own set of rules and guidelines.

According to the Cigna website (as of 8/31/2008): “Prior-authorization guidelines are determined on a drug-by-drug basis and may be based on FDA and manufacturer guidelines, medical literature, safety, appropriate use and benefit design.”

What is the purpose?

It is primarily a cost containment measure implemented by the insurance company. They could require prior authorizations for a variety of reasons.  Such as:

1. They feel there is a similar medication which could be used but costs less.
2. The drug is being used outside of its approved indications.
3. It is being dosed outside recommended guidelines (usually above the maximum approved dose).
4. Other medications should have been use first according to standard guidelines found in the medical literature.
5. It has serious safety issues for some people.
6. Any reason the insurance company wants to implement.

What happens next?

Anyone involved can contact the insurance company to initiate the prior authorization request but in general, the insurance company wants to hear from the doctor. Often times the insurance company will ask questions only the doctor can answer. Some companies  will accept phone requests for prior authorizations while others prefer a fax form to be filled out by the doctor. As a result you should ask your doctor to initiate the prior authorization request.

Some doctors will not attempt to get a prior authorization from your insurance company as they feel it is too time consuming and will take them away from providing medical care for their patients. In such a case you can initiate a request by contacting the insurance company yourself. Usually the phone number you need to call is on your insurance card.

If authorization is obtained you will then be able to purchase the prescription at your regular copay for this class of medications. If prior authorization is not successful, you have the choice of paying the full cash price for the prescription and possibly getting reimbursed by the insurance company later if it is approved or ask the doctor to change the medication.

How to Avoid the Prior Authorization Process

If the above process does not appeal to you, you are not alone. Many patients, doctors and pharmacists find this to be very frustrating. To avoid dealing with a prior authorization, check with your insurance company before going to the doctor’s office. Obtain a list of “preferred medications” from your company in advance of your appointment. Bring it with you to your visit and ask your doctor to prescribe something from this list. He/She will be happy you have the list with you to make drug selection easier. If you must have a medication that requires prior authorizations then ask your doctor to initiate the request process before you go to the pharmacy. Sometimes the whole process will take several days, other times it takes just a few minutes.

Save Money on Prescriptions Without Changing Pharmacies

Drug prices are an ever increasing concern as the costs of medications continue to rise. Not only are drug costs on the rise but doctors are more commonly using multiple prescriptions to treat a single medical condition. For example, it is not uncommon to see a person with diabetes or high blood pressure being treated with 2, 3 or 4 prescriptions. As this trend continues it is becoming more important for people to find ways to save money without compromising their health.

Here are some tips to save money on medicine without having to switch the pharmacy used. There are some real benefits to maintaining all your medicine in one location, so using mail order, internet pharmacies or shopping around using more than one pharmacy will not be discussed.

The first step to saving money is to evaluate the need for the medicine. When a doctor wants to prescribe a new medicine, ask the doctor if there are alternative ways to treat the condition. For example, high cholesterol can be treated with diet and exercise. This can sometimes work instead of medication therapy. Doctors sometimes feel pressure to prescribe a medication as the patient will feel they have not been treated adequately if the are not given a prescription. Always check for alternative therapy first, if a medication is needed then follow the next suggestions.

Ask the doctor to give you a medication that has a generic version whenever possible. There are many times when a doctor is faced with multiple choices for medications to treat a condition. If you initially indicate you would like a generic, they are more likely to give you one. When they have given you the prescription verify they have signed the line that says “substitution permitted” or any similar statement. When getting the prescription filled, request the pharmacy to fill it generically. Using a generic instead of a brand can save you 80% or more when you don’t have insurance. You generally will have a lower copay with the generic when insurance is involved.

For medicine you will be using long term, ask your doctor to write for a three months supply. If your insurance permits this, they sometimes charge a lower copay for a three months supply as opposed to three 1-month supplies. If you are paying cash you get a bulk discount by getting three months at a time.

Ask your doctor to write within your insurance companies preferred drug list. Your insurance company (not the pharmacy) usually charges a lower copay for drugs on thier preferred list and higher copays for others. You can get a list from your insurance company or from their web site. Bring the list with you when you visit the doctor.

Avoid the “free sample” trap at the doctors office. I call it a trap because doctors do not have an unlimited supply of free samples. These free samples are usually for high priced brand name drugs. Many patients ask for these to save money but when the supply runs out, they are either forced to pay for the expensive medicine or go back to the doctor to get a prescription for a less expensive generic (the one they should have requested initially).

Ask about over the counter drugs. Again, patients may expect the doctor to write a prescription during the office visit. Sometimes an over the counter drug would do the same thing as a prescription. The over the counter version may also be less expensive. A good example is allergy medications, a generic version for over the counter Claritin is available for about $3.00 a month. This may be as effective as any prescription product for some people.

If you cannot avoid an expensive brand name drug look for patient assistance programs. There are many of these around. You can contact the manufacturer by phone or check their website. Every program has different criteria for acceptance but they are worth looking at.

Pill splitting may be an option for some medications. Check with your doctor or pharmacist if it is possible with the one you take. Often a medication’s price is the same regardless of strength. In that case you would request your doctor to write for the higher strength tablet at a half tablet per dose. Verify this is safe with your medication before attempting this.

Combine medications into one pill. Often two separate medications are available in a single tablet with a different name. If you have insurance you would end up with a single copay for the medication as opposed to two copays. If you pay cash, check with your pharmacy on pricing.

Bring your pharmacy receipts with you to the doctor’s office so they can see how much your medications cost. Often, the doctor is not aware of the cost until someone shows them. Once aware, a doctor may be more willing to consider less expensive alternatives.

If you follow the above suggestions, you have the potential to save a substantial amount of money at the pharmacy each year.