After practicing medicine for 20 years, I’ve become adept at “clarifying” to insurance companies why patients are taking certain medications. The same medications appear to trigger red flags for both long-term care and life insurance companies.
Their “concern” makes sense for some medications because they are used for serious chronic illnesses, but for others, the insurance companies are worried about your lifestyle. Most on this list are important medications so do not stop taking them because you’re concerned about rejection and do not omit them from your forms. Instead, along with your physician, you can clarify and appeal their decision.
Here are the ten worst medications to be taking that will trigger a “no” or a further review if applying for life insurance or long-term care insurance.
- Namenda (memantine) or Aricept (donepezil). One of the more obvious red flags, dementia is expensive for Long-term care insurance plans because folks with dementia are often physically healthy and their care is expensive. Pro tip: be careful here because Namenda is also prescribed for migraine prevention and may trigger an unnecessary alarm.
- Hydrocodone, oxycodone, morphine aka “Opioids.” Long-term use of pain medication raises red flags for insurance companies and almost always results in a closer review. Why? Because costs associated with chronic pain patients taking opioids are substantial and range from 560 to 635 billion per year in the U.S. in 2010. Insurance companies run for the hills because of that.
- Xanax (alprazolam), Ativan (lorazepam) and Valium (diazepam) are benzodiazepines that will lead to a closer review of your application. Why? Several studies have shown an association between benzodiazepines and risk of death. In folks 65 years or older benzodiazepines increase the risk of falls and fracture-related mortality. Some studies have found a threefold or higher increase in the risk of all-cause mortality among adult populations using benzodiazepines even for durations shorter than one month.
- Lithium and Divalproex. Life insurance companies love to hate bipolar medications because suicide rates in bipolar patients average approximately 1% annually, or 60 times higher than the international population rate. Pro tip: If you take Valproic acid for migraine prevention or trigeminal neuralgia you will want to clarify if turned away.
- Paxil (paroxetine), Lexapro (escitalopram), Celexa (citalopram), Zoloft (sertraline) aka the “SSRI” antidepressant medications. This is one of the common reasons my patients are turned away, and yes you can appeal and clarify this. Why are life insurance and long-term care insurance plans worried? Because of the risk of suicide and increased use of healthcare resources in folks with depression and anxiety.
- Plavix (clopidogrel). This is another common medication that will often lead to a “no”. Clopidogrel is used for the treatment of coronary artery disease and atherosclerosis – often given to patients who have had stent placement for coronary artery disease. This puts you in a high-risk category and insurance companies don’t like that.
- Arimidex (anastrozole) or tamoxifen. These are medications taken long term to prevent the recurrence of breast cancer. Even though cancer outcomes have been improving dramatically in recent years, life insurance companies continue to see cancer as a high-risk situation. Breast cancer receives quite a bit of scrutiny from insurance companies.
- Naltrexone, Campral or Antabuse (disulfiram) are medications used for the treatment of alcohol abuse and that sends insurance companies running for the hills. Insurance companies don’t like alcohol overuse or abuse to be part of your history and this medication is used to help with alcohol cravings and will trigger a red flag.
- Harvoni, Sovaldi, and Viekira Pak. Medications used for the treatment of Hepatitis C will cause insurance companies to balk at your application. Pro Tip: Here is a perfect example of where you can file an appeal and have your doctor help with clarification especially if you have achieved cure (sustained virologic response) of your Hepatitis C.
- Atripla and Genvoya are commonly prescribed combination HIV medications and will often trigger a “no” for long-term care and life insurance policies.
Has this happened to you?
If you’re like everyone I’m seeing in the clinic these days, your cough may be keeping you up at night, and driving you and your coworkers crazy. Do any of the over-the-counter (OTC) or prescription medications really work for a cough? Let’s walk through it.
First, let’s go through the OTC cough suppressants
- Acute cough due to viral upper respiratory tract infection (URI) is the most common form of cough, and a ton of money is spent on prescription and non-prescription cough medications. You may be surprised to hear that studies show OTC cough suppressants like Robitussin aren’t any more effective than a placebo.
- A review of over-the-counter (OTC) medications for acute cough found fairly disappointing results for the effectiveness of Mucinex and antihistamine-decongestants (Dimetapp, Delsym), and concluded that there is no evidence for or against the effectiveness of those preparations for an acute cough.
- Here’s a cool fact. Honey (specifically Buckwheat honey) can suppress a cough better than over the counter meds in children – and possibly adults – by forming a soothing film over irritated mucous membranes.
Still coughing? Moving on to prescriptions…
- Benzonatate capsules are generic for Tessalon and they do work. How does it work? Benzonatate is a prescription non-narcotic cough capsule that acts by numbing the stretch receptors of nerves located in the alveoli (air sacs) of the lungs, the airways, and the pleura (lining of the lung). You can take it every 8 hours. Studies have also shown that Benzonatate in combination with Mucinex 600mg works even better. Benzonatate and Mucinex suppress a cough to a greater degree than one alone.
- What about adding inhalers when I have a cough? If your doctor hears wheezing with your cough, an Albuterol inhaler (Proventil, Proair) may be prescribed. Routine use of inhalers like Proventil and Proair, however, has not been shown to improve a cough or shorten the duration of a cough.
- The big guns – codeine cough suppressants. If your cough is keeping you up at night, these will help. There are many opiate prescription cough syrups like promethazine/codeine that work well. Their daytime use is limited because you can’t afford to feel dopey during the day, and the codeine may make some folks nauseated. Oh, and it’s habit-forming. Codeine cough syrups are an option for short-term use in desperate times.
Hope this helps.
You’ve likely heard there is a new shingles vaccine, Shingrix that is more effective than our existing vaccine Zostavax. The painful blisters of shingles are bad enough, but the complication known to occur in 20% of folks after their singles outbreak, called “postherpetic neuralgia” is even worse, and can be a chronic painful condition. With a new Vaccine always comes new questions and concerns: cost, side effects, and when or if you should get it.
A word about cost: Medicare Part D will likely be covering the new vaccine, Shingrix, as should Anthem, Blue Cross, and other plans. Whether you’ve been previously vaccinated with Zostavax or not, I’m hearing the same questions from my patients about Shingrix so let’s talk about it.
Is Shingrix THAT much better than Zostavax?
Yes. Shingrix is 97% effective at preventing herpes zoster (shingles) in folks over 50 whereas the Zostavax shot is 50-64% effective in preventing shingles in those 50-70 and even lower for those over 70.
When should I get the shingles vaccine?
For Shingrix, people 50 and over should receive the series of two vaccines. For Zostavax those 50 and over with a medical condition or 60 and over for all-comers.
What if I’m not sure if I’ve had chicken pox?
First, know that almost everyone born before 1980 tests positive for exposure to varicella –the virus that causes chickenpox, and reactivates to cause shingles. All published recommendations suggest that whether you remember having chicken pox or not, you should receive the Shingles vaccine (Zostavax or Shingrix). The shingles vaccine Zostavax is 19 times stronger than the chickenpox (varicella) vaccine.
Are the side effects for Shingrix different than Zostavax?
There is where the issue arises… yes, the side effects are quite a bit different, and I’ve been seeing this in my patients who get Shingrix.
Adverse Reactions of Zostavax (given as a single vaccine)
- Pain at injection site (≤34 to 54%)
- Redness at injection site (36% to 48%)
- Swelling at injection site (26% to 40%), localized tenderness (≤34%), itching at injection site (7% to 11%)
- Any other side effects are very uncommon (< 1%)
Adverse reactions for Shingrix (a series of two vaccines)
- Fatigue (37% to 57%
- Headache (29% to 51%)
- Shivering (20% to 36%)
- Gastrointestinal adverse effects (14% to 24%)
- Pain at injection site (69% to 88%)
- Swelling at injection site (23% to 31%)
- Muscle aches/Myalgia (35% to 57%)
- Fever (14% to 28%)
- Other side effects are uncommon (< 1%)
To sum it up, Shingrix is a much better vaccine, but with a twist. That twist? Shingrix has many more adverse reactions than Zostavax. This means we need to keep an eye on this vaccine because it is so new. If you get Shingrix be sure to be aware of what adverse effects you may feel and a 500 mg Tylenol (Acetaminophen) after the shot has helped for some of my patients.
“Doc, I’m leaving on my trip, what prescriptions do I need to get?”
First, a few general tips. Of course, bring your routine prescription medications, as well as over-the-counter medications like ibuprofen, Tylenol, Benadryl, and maybe Immodium. Then, check the CDC Travelers’ Health website to ensure you don’t need any immunizations.
Next, here are ten prescription medications commonly used by fellow travelers…
- Ambien (zolpidem). The traveler who asks about this is going on a long flight, longer than 5 hours, and wants to ensure they get enough sleep to wake up somewhat rested when they land. For folks who have a meeting or presentation after they land this is key. Does taking Zolpidem the first few nights “delay” your jet lag symptoms? It appears not, and in fact, it may be the other way around – taking Zolpidem the first few nights may still help you acclimate to the new time zone.
- Bactrim (sulfamethoxazole/trimethoprim). Bactrim, the jack of all trades, is a good antibiotic to travel with (unless you have a sulfa allergy). Acceptable uses for Bactrim are staph aureus, skin and soft-tissue infections, and urinary tract infections. If on vacation your cut or scratch starts to look infected, red, hot or tender you can rely on your Bactrim prescription. It’s also a good choice for urinary tract infections.
- Cipro (ciprofloxacin). Cipro is an antibiotic that may help out for the traveler who picks up “traveler’s diarrhea.” Cipro taken twice a day for 1-3 days is indicated for the treatment of traveler’s diarrhea. Additionally, Cipro may help for treatment of urinary tract infections (UTI).
- Diflucan (fluconazole). A single 150 mg tablet of Diflucan is a good first line treatment for vaginal candidiasis aka “vaginal yeast infection”. Yeast infections may occur more frequently on vacations because of wet bathing suits, increased sexual activity or a change in diet, and a single dose pill is an easy treatment.
- Zofran (ondansetron). Ondansetron orally dissolvable tablets work well for nausea. If you have horrible luck and pick up a foodborne illness in another country this will help get you through the 24-48 hours of nausea and vomiting.
- A Steroid cream more potent than over-the-counter hydrocortisone 1%. A good medium potency steroid like triamcinolone 0.1% or 0.5% requires a prescription and may be a good choice to travel with for itchy, red rashes or bug bites.
- Transderm Scop (scopolamine) seasick patches. The traveler heading out on a cruise or boat trip will be smart to get a prescription from their doc to bring these along. Like, really smart.
- Muscle relaxants. Robaxin (methocarbamol) or Skelaxin (metaxalone) muscle relaxants help the traveler who is struggling with neck or back pain after a long plane ride or sleeping on a different bed/pillows.
- Xanax (alprazolam) or Ativan (lorazepam). For acute anxiety symptoms, most commonly fear of flying, a very low dose short-acting benzodiazepine will help. This is not a long-term fix and your doctor would prefer a non-medication option like cognitive behavioral therapy to really resolve the issue, but alprazolam or lorazepam can help get you on that plane for now.
- Bactroban (mupirocin). The traveler who would use Bactroban antibiotic ointment has a skin or soft tissue infection from Staph or Strep that’s only mildly red or sore. As mentioned above, the oral antibiotic Bactrim would be used for more serious skin infections. Why would this happen on vacation? For my patients it’s because vacation means more flip-flops, walking the beaches barefoot, stepping on coral, etc. with limited access to properly clean wounds.
Zolpidem reduces the sleep disturbance of jet lag. Jamieson AO1, Zammit GK, Rosenberg RS, Davis JR, Walsh JK.Sleep Med. 2001 Sep;2(5):423-30. https://www.ncbi.nlm.nih.gov/pubmed/14592392
Antibiotic Guidelines Treatment Recommendations for Adult Inpatients. https://www.hopkinsmedicine.org/amp/guidelines/Antibiotic_guidelines.pdf
Snoring is extremely common and 70% of folks with obstructive sleep apnea (OSA) snore. On the other hand, those who suffer from snoring do not necessarily have OSA. Snoring is caused by the vibration of soft tissues obstructing the throat during sleep.
Patients and their partners often seek help from their doctor with the primary complaint of snoring. Remember, if you have significant obstructive sleep apnea (OSA) wearing a nighttime CPAP device is the solution. However, if snoring in the absence of significant sleep apnea is your problem, treatment may be much easier.
It’s impossible to discuss effective snoring treatment without looking at the role of the nose in snoring. The nose is the first anatomical boundary of the upper airway and stuff congest nasal passages may contribute to snoring.
So, let’s look at the evidence. How do you stop snoring?
…But only in pre-obese or obese snorers. What does that mean? Losing weight does help improve snoring, but only to a certain point. In obese and pre-obese folks, lowering boxy mass index (BMI) to 25 is all it takes, and there is no improvement with extra weight reduction after that. Interestingly, weight reduction is not helpful in adult snorers with a normal BMI. What is your body mass index? Use this to find out.
Nasal dilators aka “breathe right strips”
Yes, they work and you can buy them over the counter. Both internal (NoZovent, Mute) and external (Breathe Right Strips) nasal dilators improve snoring. When studied, the internal (inside the nose) dilators improved snoring more significantly than the external dilators like Breathe Right, but both do help. Worth a try for sure.
Limiting alcohol and hypnotics at night
Nasal steroid sprays
Nasal steroid sprays have been shown to decrease mouth breathing and increase nasal breathing at night which improves snoring. Using a daily nasal budesonide spray (Rhinocort), fluticasone (Flonase) or triamcinolone (Nasacort), can decrease snoring frequency and increase rapid eye movement sleep (deep sleep).
Avoiding the supine position
Sleeping on your back (supine) shrinks the airway by a third and I’m always impressed when reviewing the sleep studies of my patients to see the difference in snoring and apnea when folks are sleeping on their backs. Train yourself not to do this.
These take a bit more work to get as you will need to find a specialist who can fit you for these. “Mandibular advancement devices” are effective in reducing snoring and sleep apnea. These oral appliances are made individually by a dental technician and are usually upper and lower devices that work to move the lower jaw forward.
Oropharyngeal (mouth and throat) exercises
This is the current hot topic in snoring treatment, yet it will take getting a referral to someone who knows what they are doing. Studies show that patients attending weekly visits where they were trained to do eight minutes of oropharyngeal exercises three times a day had significant improvement in snoring. Tongue and mouth/throat exercises have been shown to decrease snoring by 50%. It’s worth asking your primary care doc for a referral for this is you’ve failed other interventions.
Hope this helps.