Low back pain is a part of life—common across sexes, age groups, and countries, it’s something that almost all people experience at some point. Treatment for low back pain often includes a combination of medication and non-medication options. What should you start with? What treatments have the best evidence? And more importantly . . . what’s coming our way for low back pain treatment?
To start #OldSchool—the best evidence exists for these three treatments:
- Non-steroidal anti-inflammatory drugs (NSAIDS). Which NSAID? Ibuprofen (Motrin, Advil), naproxen (Aleve), and celecoxib (Celebrex) are common examples. There does not appear to be a “best” NSAID for low back pain from the evidence. Start with low doses and go higher if needed, aiming for short term use. If you can’t take NSAIDS (stomach issues, kidney problems) take acetaminophen (Tylenol) instead.
- Muscle relaxants. Adding a muscle relaxant to an NSAID improves low back pain. Start with one that doesn’t make you tired like methocarbamol (Robaxin) or metaxalone (Skelaxin). See my previous blog here for full discussion on muscle relaxants for low back pain.
- Heat. Superficial heat for low back pain has been shown to help. There is moderate evidence from a small number of studies that heat wrap therapy provides short-term reduction in pain and disability in those with acute or sub-acute low-back pain (less than 12 weeks). When using heat wraps, use them only for 15-20 minutes at a time. Don’t fall asleep with them on.
Ok, then what’s next for back pain?
- Physical therapist or chiropractor. To sum up the evidence here: for low back pain, physical therapy and chiropractic manipulation have similar effects on symptoms, function, satisfaction with care, disability, recurrences of back pain, and subsequent visits for back pain. So think of them as being equally effective. I’d pick whichever one is more convenient and covered more by your insurance.
- Other exercise therapy. For example,yoga, tai chi or qigong. There is fair evidence that yoga and movement therapies will help for your back pain. Pursue them on your own and stick with one that interests you the most and is the most convenient.
- Other alternative therapies. Mindfulness stress reduction (meditation + yoga) and cognitive behavioral therapy outperformed NSAIDS in a recent study. Both are worth a try for sure if you are struggling with low back pain. Acupuncture, though—not so much. In the last two years a review of scientific evidence found the practice of acupuncture was no better than placebo in treating those living with low back pain and sciatica. Gua sha is another alternative therapy that may exhibit a more long-lasting anti-inflammatory effect relative to hot pack for pain relief and improved mobility in elderly patients with chronic low back pain.
What’s next for those with chronic, neuropathic (nerve-like) low back pain?
- Gabapentin (Neurontin) or duloxetine (Cymbalta) have the best evidence in addition to the above listed options for nerve-like pain in your low back that may radiate down your buttock or leg. Tramadol (Ultram) may also be added to your regimen at this point.
- The hot-button issue: Opioids for low back pain. Opioids are no more effective than NSAIDS for low back pain and have a high rate of adverse effects (the understatement of the year). Avoid opioids at all costs for low back pain.
Moving on—invasive procedures:
- Epidural steroid injections. Steroid injections in the lumbar spine are performed by pain management or interventional radiologists, and they do work. Epidural injections done with several approaches (interlaminar, caudal, or transforaminal) have been shown to reduce pain and disability short term (usually at 2 weeks) and help delay the need for surgical intervention. Epidural steroid injections may provide relief for a period of time and additional repeat injections are an option if pain recurs.
The future—and beyond:
- Radiofrequency denervation aka radiofrequency ablation (RFA) was the rising star, but a recent large study revealed disappointing results. RFA is a medical procedure where the nerve is ablated (the nerve endings are deadened) using high frequency alternating current. But does it work for chronic low back pain? Not so well. A recent study (JAMA July 4; 318(1):68-81) found radiofrequency denervation added to a standardized exercise program for chronic low back pain resulted in either no improvement or no clinically important improvement compared with a standardized exercise program alone. To sum it up: the findings do not support the use of radiofrequency denervation to treat chronic low back pain originating in the facet joints, sacroiliac joints, or intervertebral disks. Disappointing.
- Platelet rich plasma. Platelet rich plasma (PRP) has shown promising results when injected into the intervertebral disc and is currently being studied. PRP is high in growth factors, which is why it’s being studied, yet there are no active studies for low back pain being done. Will PRP help for low back pain? We don’t know yet, and won’t for a while.
- Stem cell therapy to regenerate cells and increase disc matrix production (the gel- like central part of the disc) is also currently being researched. This may be coming our way for low back pain, but no results yet.
- Cannabis. Studies on cannabis/medical marijuana are limited because it is still illegal under federal law, but several trials have evaluated the effectiveness of cannabis for patients with neuropathic pain. Patients with nerve pain from spinal stenosis or degenerative disc disease show a 30% improvement in chronic pain score following cannabis therapy. Pain relief provided by cannabis is dose-dependent, with higher THC content producing more pronounced pain relief. Know this: the strains of cannabis containing high levels of CBD (cannabidiol) generally make patients feel less high, since CBD acts as an antagonist to the psychoactive effect of THC. Consider starting with high-CBD, low-THC strains if you are concerned about feeling high.
What has helped for you?
Female Pattern Hair Loss (FPHL) is the most common cause of hair loss in women. While the cause is unknown, FPHL is more common in women with obesity, high blood pressure, and insulin resistance (pre-diabetes).
FPHL mainly affects the mid and frontal regions of the scalp, while preserving the frontal hairline. Your part gets wider, and hair near your temples may recede, but you will not lose all of your hair. Noticing that your part is widening, or your ponytail is thinning, may bring you to your doctor. Help! What works?
Common myths about hair loss in women
- Genetics do not appear to play a role in female pattern hair loss. No definitive familial inheritance has been identified in women, unlike in men with androgenic alopecia (“male pattern baldness”) where genetics play an important role from both mom and dad’s side.
- The majority of female hair loss is NOT tied to high levels of androgens (male hormones). Only 39% of women with FPHL have high androgen levels whereas male balding is a genetically determined androgen-dependent trait.
- Taking oral estrogen (hormone replacement therapy) has no clear effect on hair growth and in some studies showed an inhibitory effect.
Medical causes for hair loss in women
Before you make the diagnosis of Female Pattern Hair Loss (FPHL) which has no known causes, look for these:
- An under or overactive thyroid. Hypo or hyperthyroidism may cause hair loss, and is easy to rule out with a blood test called TSH (thyroid stimulating hormone).
- Iron deficiency anemia. A common complaint in iron-deficient women is hair loss, with increased loss reported in women with ferritins less than 100ng/dL. That’s an easy blood test.
- Psychological and emotional stress. A major illness, severe psychological trauma, significant weight loss and childbirth may precipitate an episode of hair loss that begins a few months after the episode. This is called telogen effluvium, and hair loss occurs in all areas of the scalp.
- Polycystic Ovarian Syndrome (PCOS). Sometimes this condition causes your body to produce too many androgens, which can decrease the growth of hair on your scalp.
- Medications. Some common culprits include beta blockers, antidepressants, anticoagulants, and chemotherapy drugs. Read more about this in our blog here.
Options for treating hair loss
Once your hair loss has been determined to be FPHL, and not related to one of the above-listed conditions, here are your options:
- Topical solutions of 2% minoxidil (Rogaine). Minoxidil, applied as 1 ml twice daily, is the only drug approved by the FDA for the treatment of female pattern hair loss. What is interesting is that minoxidil 2% and 5% have basically the same result.
- Oral finasteride (Propecia). While finasteride 1 mg tablets have not been shown to be helpful, a few studies have shown improvement with finasteride 5 mg daily.
- Zinc sulfate + calcium pantothenate. These are over the counter supplements. For those using daily topical minoxidil adding zinc sulfate capsules 220 mg + calcium pantothenate tablets 100 mg twice a week was better than with minoxidil alone. Worth a try!
- Spironolactone (Aldactone). There is some evidence that using Aldactone (spironolactone) at a dose of 100-200 mg a day benefits women who haven’t responded to the use of topical Minoxidil.
- Platlet rich plasma (PRP) scalp injections. Very recent studies have shown that PRP injected into the scalp can improve both hair density and thickness. The basic idea behind PRP injection is to deliver high concentrations of growth factors to the scalp, which the hope of stimulating hair regrowth.
Hope this helps!
Most sore throats in adults are caused by a viral illness and will resolve on their own without antibiotics. Signs your sore throat is likely a viral pharyngitis (sore throat) are cough, stuffy or runny nose, and diarrhea. This means many of you will be managing your throat pain at home—so what should you take for pain relief?
Here are 10 things to know:
- NSAIDS (ibuprofen, Motrin, Advil, naproxen, Aleve), Tylenol (acetaminophen) and aspirin will all help to relieve throat pain within 1 – 2 hours, and will provide relief for several hours. In general, start with one of these three choices. Using these along with sprays or lozenges may provide the most effective symptom relief—but read on.
- What works the best? Data from randomized trials suggest that NSAIDs are more effective than acetaminophen (Tylenol) for relief of throat pain.
- Pill vs. lozenge/spray to start? Remember that the pill options listed above will also help for the fever and headache you may have with your sore throat, while lozenges and sprays will not. That’s a plus.
- Ok, so which NSAID and how much? Ibuprofen 200 – 400 mg every 6 – 8 hours is the place to start. Ibuprofen decreases acute sore throat pain by 32 to 80 percent in two to four hours. To sum it up, ibuprofen produces a significantly greater reduction in sore throat pain compared with acetaminophen. Winner.
- When should I use Tylenol over ibuprofen? Though ibuprofen works slightly better, acetaminophen should be your first choice if you have a history of gastroesophageal reflux disease (GERD), ulcers, or kidney disease. Acetaminophen 1000 mg decreases acute sore throat pain by approximately 50 percent after three hours. Remember, try not to go above 4000 mg a day of acetaminophen.
- If you choose aspirin, start with 325 mg for throat pain. Aspirin is effective sore throat relief from one through six hours after taking it. Upside is that studies show headaches and muscle aches/pains are also significantly reduced if you take aspirin for sore throat. Mind the gut here though.
- Topical treatments. There is no evidence that one particular lozenge or spray is better than another. While sprays or lozenges are quicker-acting than the oral meds listed above, they have a shorter duration of pain relief. Studies show that lozenges that need to be sucked achieve higher initial concentration in the mouth and throat—and have slower rates of clearance compared with throat sprays and gargles (they last longer). That’s a win for lozenges over sprays.
- What kind of lozenge should I try? Active ingredients to look for in lozenges include menthol (Halls, Cepacol), dyclonine (Sucrets) or benzocaine (Chloraseptic lozenges).
- Throat sprays. Over the counter throat sprays can provide rapid relief of sore throat pain. Chloraseptic is a common example which contains phenol. Ultra Chloraseptic anesthetic throat sprays available over the counter contain benzocaine. Data on the effectiveness of throat sprays are limited, but they are worth a try if you don’t like lozenges.
- Throat Coat tea. Available through Amazon and some pharmacies, Throat Coat tea was shown in a small study to significantly diminish sore throat pain compared with placebo 30 minutes after drinking it. Throat Coat is an herbal tea containing licorice root, elm inner bark, marshmallow root, and licorice root aqueous dry extract. Worth a try for sure.
When should I worry about strep throat and see a doctor?
You should go see your doc If you have a sore throat AND:
- Fever over 100.4°F
- Exudate (whitish or yellowish discharge) on tonsils
- Swollen lymph nodes in your neck
Combination inhalers prescribed for asthma, smoking lung disease (COPD), or persistent cough after an upper respiratory infection are some of the top selling drugs in the United States. Several steroid + long acting bronchodilator combinations are currently available: the older Advair and Symbicort and the newer Dulera and Breo Ellipta.
While Advair and Symbicort are recommended for treatment of both moderate persistent asthma and COPD, Breo has been introduced with the indication for COPD treatment only. Which combo inhaler you are prescribed is often based on your insurance coverage because while they differ in delivery mechanism, they generally work just as well.
- Voice changes. Hoarseness or huskiness are common symptoms, related to the steroid component of the inhaler. Voice changes occur in 5 to 10% of people and are more common with frequent use and with fluticasone (in the Advair) compared to other steroids. Rinsing your mouth by gargling with water will help remove the locally deposited steroid in the mouth (not where you want it, you want it in the lungs). It has been shown that 56% of the dose from your inhaler is deposited in the mouth/throat and a mouth rinse promptly can remove 60% of this residue.
- Yeast infections of the mouth/thrush. The steroid in your combo inhaler may cause candidiasis (yeast) infection in the mouth as a potential side effect. This will look like white, soft plaques that leave a painful red, eroded, or ulcerated surface. The sides of the tongue, back of throat and inside the cheek are common sites where you may notice tenderness, burning, and pain with swallowing. The antifungal mouthwash Nystatin can be used to treat this.
- Cavities (dental caries) from dry mouth. Dry mouth and increased thirst is reported with the combination inhalers. The bronchodilator part of the inhaler (beta-2 agonist) is associated with the increased frequency of cavities. Long term use of beta-2 agonists is associated with diminished saliva production and secretion.
- Pneumonia. This may be the case only with the steroid in Advair (fluticasone) and not with Symbicort (budesonide). The use of Advair has been associated with a higher prevalence of pneumonia in the major long-term studies, but no similar increased risk of pneumonia has been reported in patients with COPD treated with Symbicort. This difference may be explained by the longer retention of fluticasone in the airways.
- Headache. 7% to 11% of folks using these combination inhalers report headaches.
- Cough. While we don’t know exactly why this occurs, cough may be a result of throat irritation from the inhaler.
- Throat pain. Even without thrush, pain and soreness in the throat is reported in 6 to 9% of folks using these combination inhalers.
- Adrenocortical suppression. Side effects like this are unlikely to occur at prescribed doses of the newer inhalers unless you are using them long term. With long term use of inhaled steroids at high doses you can suppress your own production of certain hormones (cortisol). Abruptly discontinuing your inhaler may lead to serious symptoms like extreme fatigue and low blood pressure.
- Osteoporosis and bone fractures. Steroids stimulate the process of bone turnover but at doses lower than 800 mcg a day this is unlikely to occur. Long term use of inhaled steroids (half of the contents of your combination inhaler) may lead to brittle bones and increased risk of spine and hip fractures. For reassurance you can look at your inhaler for the dose of steroid it contains: for example Advair 250 mcg/50 mcg contains 250 mcg of the steroid fluticasone.
- Skin thinning and purpura (purple spots on the skin, most commonly arms). Long term use of the steroid in your combo inhaler leads to loss of subcutaneous fat. Skin bruising and purple spots may happen with long term combination inhaler use.
An interesting fact—inhaled corticosteroids, particularly fluticasone, are absorbed more (meaning more chance for unwanted systemic side effects) in folks with normal lung function. This is a reminder that you should step down the inhaled steroid dose/combo inhaler once your breathing from asthma or COPD is adequately controlled.
Tinnitus, or ringing in the ears, is a perception of sound in one or both ears in the absence of an external source. It’s often described by patients as buzzing, ringing, or whooshing.
Tinnitus can be a continuous sound or occur intermittently and while there is often no known cause, there are a handful of medications that can contribute. “Ototoxic medications” are those that may damage the inner ear. Toxic damage to the ear from medications can result in symptoms like tinnitus, vertigo, and even deafness. Discontinuing these medications can prevent progression to hearing loss and/or vertigo, though the ringing may not always go away. Here are eleven commonly prescribed medications known to cause tinnitus:
- Gentamicin and tobramycin are aminoglycoside antibiotics used for the treatment of severe bacterial infections. Gentamicin, used intravenously, is a well known cause of tinnitus and vertigo along with hearing loss.
- Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen (Aleve) and ibuprofen (Motrin, Advil) are well known causes of ringing in the ears. Those taking daily aspirin for stroke and heart disease protection should be given a heads up about this possibility—though tinnitus from aspirin usually occurs only at high doses.
- Loop diuretics including furosemide (Lasix) and bumetanide (Bumex) are commonly prescribed for swelling in the legs, heart failure, and to lower blood pressure. They are known to cause ringing in the ears.
- Tricyclic antidepressants like amitriptyline and nortriptyline are used for the treatment of depression, chronic pain, and migraine prevention and they may also cause ringing in the ears.
- Azithromycin (Zithromax or the “Z-pack”) and clarithromycin are antibiotics in a class called macrolides, and they’re prescribed for bacterial infections like community-acquired pneumonia, sinusitis, bronchitis, etc. Both are reported causes of ringing in the ears.
- ACE inhibitors are medications used to lower blood pressure that may cause ringing in the ears. These end in -il (common examples are lisinopril, enalapril, and ramipril).
- Amlodipine (Norvasc) and nicardipine (rarely prescribed) are calcium channel blockers. Amlodipine is commonly prescribed for high blood pressure, and reports of tinnitus follow its use.
- Alprazolam (Xanax), diazepam (Valium) and lorazepam (Ativan) are benzodiazepines used for the treatment of anxiety, which may cause tinnitus.
- Isotretinoin (Accutane, Claravis, Absorica, and others) is a pill used for severe acne that may lead to tinnitus.
- The fluoroquinolone antibiotic ciprofloxacin (Cipro) has been reported to cause tinnitus, but, some good news—those reports have not carried over to a similar antibiotic levofloxacin (Levaquin). Cipro is prescribed for bacterial infections like urinary tract infections, acute sinusitis and pneumonia and may lead to tinnitus.
- Atorvastatin (Lipitor), but not other statins, has been reported to cause tinnitus. Atorvastatin is used to lower cholesterol.