More than one in ten visits to a primary care doctor is for fatigue. Fatigue is composed of three major components: generalized weakness (difficulty in initiating activities), easy fatigability (difficulty in completing activities), and mental fatigue (difficulty with concentration and memory). While certainly not the only answer, medications may cause fatigue. Here are some of the common culprits.
Beta-blockers wear many hats. They are commonly prescribed to improve survivability after a heart attack, lower blood pressure, help prevent a migraine headache, and control heart rate in atrial fibrillation. But, there is a downside. They can make you sleepy.
Carvedilol (Coreg), atenolol and metoprolol are common offenders when it comes to fatigue, occurring in more than 10% of people taking them. In fact, a quarter to half of the folks taking beta blockers discontinue their use during the first year of taking them, often for fatigue.
Pro tip, starting at low doses and titrating up will help with the fatigue so lower doses of beta blocker, increasing over time, is the way to go.
These are medications used for allergies, hives, nasal congestion, and itchy rashes. Benadryl, Atarax and cyproheptadine are all very sedating, and most available over-the-counter. Over the counter meds ending in ‘pm’ like Tylenol PM contain Benadryl and of course will cause drowsiness.
Many folks taking muscle relaxants for back or neck pain have no idea these may make them feel like Gumby for a few days. Commonly prescribed muscle relaxants cyclobenzaprine, Soma (carisoprodol) and Zanaflex (tizanidine) are hugely sedating.
Amitriptyline and Nortriptyline are also used to treat depression, chronic pain, and migraine and cause drowsiness and fatigue. In some studies, up to 40% of folks taking these two reported fatigue. That’s high.
Another good option? Studies have shown that bupropion SR and XL (Wellbutrin XL) are just as effective as SSRIs for the remission of major depressive symptoms. Those taking bupropion are less likely to suffer symptoms of sleepiness and fatigue than those treated with SSRIs.
Topiramate causes drowsiness and fatigue in up to 15% of people using it. Commonly used for prevention of seizures, migraine headache and weight loss (Qsymia contains topiramate), Topamax carried the nickname Dopamax because those taking it may feel ‘dopey.’
And last but not least
- Narcotics like hydrocodone, oxycodone, and acetaminophen/codeine may make you sleepy.
- Benzodiazepines like Ativan (lorazepam), Valium (diazepam) and Xanax (alprazolam) often cause you to feel sleepy.
Pattern of Adverse Drug Reactions Reported with Cardiovascular Drugs in a Tertiary Care Teaching Hospital. J Clin Diagn Res. 2015 Nov;9(11)
Discontinuation of beta-blockers in cardiovascular disease: UK primary care cohort study. International Journal of Cardiology Vol 167 (6) 10 Sept 2012 pages 2695-2699.
Prescription opioids like oxycodone, hydrocodone, codeine, and morphine have long been considered some of the most helpful drugs for managing acute pain, where the body is immediately reacting to trauma or injury. Each year, over 200 million opioid prescriptions are given out in the United States.
Unfortunately, the rates of opioid abuse and overdose deaths have skyrocketed in recent years, leading healthcare providers and patients alike to be cautious about the use of opioids. And now it turns out that there is another reason to avoid opioids: they may not be the most effective treatment for acute pain after all.
Do opioids work better than other drugs?
A recent study in the Journal of the American Medical Association throws into question how well opioid drugs actually treat acute pain.
In the study, researchers assigned 416 emergency room patients with moderate-to-severe pain to one of four treatment groups. Three of the treatment groups received a combination of a common opioid painkiller (either oxycodone, hydrocodone, or codeine) plus 300 mg of acetaminophen, a common non-opioid pain medication often sold over the counter as Tylenol. The fourth group received 400 mg of ibuprofen, a non-opioid painkiller, plus 1,000 mg of acetaminophen.
The result? All four groups experienced the same levels of pain relief. While opioid drugs did help to reduce pain, they were no more effective than a combination of non-opioid painkillers.
What are other options for pain treatment?
While opioids are usually given for acute pain, some of the following options also work well for chronic pain, or pain that lasts longer than six months.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Ibuprofen, naproxen, and aspirin are known as nonsteroidal anti-inflammatory drugs (NSAIDs). They control pain, lower fevers, and reduce inflammation. NSAIDs are often considered to be the first line of defense for acute pain, especially pain that doesn’t respond to non-drug treatments.
NSAIDs are available over-the-counter with brand names including Advil, Motrin, Aleve, Bayer, and Excedrin. NSAIDs are also available in prescription strength, with common brand names like Celebrex, Naprelan, Anaprox, Voltaren, and Feldene.
One word of caution: long-term use of NSAIDs can lead to stomach distress or bleeding in your gastrointestinal tract, and the FDA warns that non-aspirin NSAIDs may increase the risk of heart disease and stroke.
Acetaminophen is used on its own as a painkiller and is also an active ingredient in many combination medicines for pain and colds. It is a popular over-the-counter option, sold under brand names like Tylenol. Acetaminophen is especially helpful in addressing acute pain for conditions like headache, arthritis, and cancer pain.
Acetaminophen does not cause the gastrointestinal or cardiovascular side effects of NSAIDs, but taking amounts in excess of the recommended dosage may lead to liver damage or even liver failure. Because acetaminophen is present in so many medications, check whether other medications you’re taking contain acetaminophen as well.
A category of antidepressants called tricyclic antidepressants have the most evidence for treating pain, especially nerve pain. Imipramine (Tofranil), nortriptyline (Pamelor), desipramine (Norpramin), and amitryptiline (Elavil) are tricyclic antidepressants. While these drugs can be helpful, they aren’t effective for everyone.
Some evidence shows that two other categories of antidepressants–selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), or serotonin and norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (Cymbalta)–are also helpful for chronic pain, but more research is needed.
Anti-epileptics can be taken to address chronic nerve pain and chronic pain from conditions like diabetes, shingles, chemotherapy, herniated disks, and fibromyalgia. Research on how well anti-epileptic medications work for pain is unclear. Some people may receive significant benefits while others may not receive any pain relief at all.
Newer anti-epileptic drugs such as gabapentin (Neurontin), and pregabalin (Lyrica) have more evidence of being effective painkillers than older drugs, and they carry fewer side effects. But, some studies have shown that older antiepileptic drugs such as carbamazepine (Tegretol) and phenytoin (Dilantin) can also help for certain pain conditions. However, these older medications cause more side effects.
Corticosteriods, commonly referred to as just steroids, decrease inflammation and reduce the activity of the immune system. They can reduce swelling and pain for conditions like cancer, back injuries, arthritis, joint pain, and nerve pain. Steroids can be helpful for short-term treatment of acute pain and are also used for the management of some chronic pain conditions., Common steroids used for pain relief are dexamethasone (DexPak), prednisone (Deltasone), and prednisolone (Prelone).
Steroids can be taken orally, applied as a cream, injected, or inhaled. Steroids do come with side effects such as weight gain, high blood pressure, and weakened immune system. Taking low doses of steroids for short periods can minimize those side effects. Injecting steroids directly into an area of pain also reduces side effects and promotes targeted treatment of the affected area.
Non-drug treatments like exercise, physical therapy, yoga, acupuncture, cognitive behavioral therapy, biofeedback, chiropractic, and relaxation training can provide pain relief, especially for chronic pain., In fact, organizations as diverse as the American College of Physicians, the U.S. Department of Veterans Affairs, and the Centers for Disease Control and Prevention recommend non-drug treatments as the first course of action for chronic pain. Although side effects for non-drug treatments tend to be minimal, be sure to consult with a healthcare provider before beginning any new treatment activities.
It’s the beginning of the school year, which means that it is time to prepare for the little bugs that get passed around the classroom, lice!
Head lice are parasitic insects that can be found on the head, eyebrows, and eyelashes. Preschool and elementary school-aged children, as well as their parents and caregivers, are at the greatest risk for lice infestation. The most common way to spread lice is through head-to-head contact, which can easily happen when children are playing.
Here are some tips from the pharmacist to help prevent and treat head lice.
Try over the counter options first
There are over the counter (OTC) options that can be used if your child has lice. OTC items like Nix are available at your local grocery store. Using an OTC option first can save you money, as many of the prescription-only items can be costly, and may not be covered by your insurance.
Prescription treatment is available
If you’re unable to get rid of lice using OTC products, your doctor can write you a prescription for lice treatment. The following are examples of prescription-only lice treatment.
- Sklice is for children 6 months of age and older. It is a 10-minute treatment that doesn’t require any nit combing. The manufacturer offers a savings program that can reduce your co-pay to at least $30. For more information, visit their website here.
- Ovide is a lotion used on children 6 years of age and older. Keep in mind that it is flammable, and a second treatment may be required after seven days if lice are still present.
- Ulesfia is for children 6 months of age and older. Be sure to repeat the treatment after seven days. The manufacturer offers a savings program that can reduce your co-pay to as little as $10. For more information, visit their website here.
- Natroba is a topical solution indicated for children 6 months of age and older. Nit combing is not required, but using a fine-tooth comb may be helpful to remove dead lice and nits.
Don’t share personal items
Teaching your child to share is an important life lesson; however, some personal items should not be shared in order to protect against spreading lice. Make sure your child knows that personal items like brushes, hats, helmets, headbands, and towels should not be shared.
Check with your state department of health
Each state department will have information on symptoms, treatments, and guidance for lice prevention and treatment. Refer to your state’s department of health website for more information.
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!