A colleague of mine recently published a video on Facebook that took me by surprise. Dr. Steve Jensen, the owner Jensen's Community Pharmacies in Dexter and Saline, Michigan, learned about a 'new" nonprescription product for heartburn. But it's not really new - it's been around for a very long time. Read on to find out why it's not well known here in the US, how it works, and its risks and benefits.

A brief review of heartburn and GERD

Heartburn happens when stomach acid finds its way from the stomach back into the esophagus (the tube leading from the throat to the stomach). Digestive juices containing acid were meant to stay in the stomach, so when they get into the esophagus it burns. Usually the muscular valve between the esophagus and stomach prevents acid backflow. But that valve can become less efficient for a number of reasons. Heartburn may occur rarely, but if it happens regularly the lining of the esophagus can be irritated or damaged. Frequent or chronic heartburn is often referred to as GERD (gastroesophageal reflux disease). And it affects nearly a quarter of the population in the US.

Treating heartburn and GERD

Keeping stomach acid out of the esophagus effectively treats heartburn symptoms and prevents damage to the esophagus. The most common remedies are available without a prescription, and easy to find.

Antacids - Antacids (Tums, Maalox, Gaviscon, Mylanta and others) neutralize stomach acid. They quite effective at providing rapid relief of symptoms, are relatively inexpensive and quite safe. The most common side effects are constipation and diarrhea. The biggest drawback is that they can be inconvenient to take regularly if you have frequent symptoms. And watch for drug interactions -- antacids may decrease the absorption of other meds, requiring them to be taken a couple of hours apart.

H2RA's - Famotidine (Pepcid and Zantac) and cimetidine (Tagamet) are histamine-2 receptor antagonists. They block the effect of histamine in the stomach to decrease acid production. Like antacids, these meds are good for relieving symptoms pretty quickly, but unlike antacids they can also be used to prevent acid reflux. Side effects are rare, but H2RAs do carry some important drug interactions, so check with a pharmacist or go to drugs.com if you take other meds.

PPIs - Proton pump inhibitors like Prilosec, Nexium, and Prevacid are available over the counter, too. These meds work by blocking the "pumping" of acid from certain cells in the stomach. They aren't that great at treating existing symptoms, but they're very effective at preventing them. So much so, that oftentimes they're used much longer than necessary. And with regular, long-term use, they can have important side effects like osteoporosis and nutritional deficiencies..

Enter (or re-enter) Alginates!

Alginates are substances that come from brown seaweed. They're actually part of thediet in some cultures, and so here in the US they're considered a dietary supplement. When alginates are taken in a high enough dose, they dissolve in the stomach contents and form a gel that "floats like a raft" on top of the stomach contents. This "raft effect" prevents the acid below from entering the esophagus. And research has shown that alginates can be at least as effective as other heartburn remedies, at least for some folks.

Why haven't we known about this all along? Well, that has to do with FDA regulations. The US version of the antacid Gaviscon, which we mentioned above, does contain alginic acid. But alginic acid was never approved as a medication in the US. So it can't be used in a high enough dose to be considered an active ingredient. If you look at the Gaviscon label, you'll see it listed as an inactive ingredient. At the same time, Gaviscon sold in other countries contains sodium alginate in a high enough dose to be effective for heartburn.

Nearly 25% of people in North America have at least weekly symptoms of GERD. And it's well known that the most effective acid-reducers (PPIs) are often overused, sometimes with long-term side effects. So researchers started looking more closely at the safety and efficacy of alginates in recent years. The research mentioned above looked at sodium alginate or alginic acid doses of 500-1000mg after meals and found that it compared well to other heartburn remedies for many of the study subjects.

If you want to try it

First, and very importantly, if you've been taking a PPI regularly for more than a few weeks, it's best to taper it over the course of a couple of weeks. You can do that while starting an alginate supplement, no need to wait.

Second, it's also important to know that you may not find any alginate supplements with seals of approval from outside organizations. Because the FDA regulates supplements so loosely it's hard to be sure you're getting a product of reliable quality. Do your best to find a product you feel you can trust. The video mentioned in the introduction to this post reviews the product pictured here.

From there, choose a product that can provide 500-1000mg of sodium alginate or alginic acid per dose. The recommendation is to take it after meals, and at bedtime if you tend to have symptoms overnight.

Research indicates that side effects are rare. There is a possibility that the "raft" of gel in the stomach may interfere with the absorption of some medications, though the significance of interactions isn't clear. For now it may be best to make sure you take prescription meds at least an hour before you take alginate.

Alginates appear to be worth trying if you 1) have mild heartburn symptoms, 2) have found yourself using a PPI for an extended period of time or 3) just want to try something new and see how it works. If you've ever taken an alginate supplement please share your experiences in the space below. Questions and other comments are also welcome, or you can contact us directly at Better My Meds. We love hearing from you!

What medications should be tapered rather than abruptly stopped?

If you've stopped a prescription medicine in the past, you may have wondered if it was okay to stop abruptly. It's always a good question to ask. There are many prescription medications that should be tapered slowly to avoid uncomfortable or even life-threatening consequences. With prescription medications, your doctor or pharmacist is in a great position to guide you. Or check out this article to help you decide if tapering is necessary. 

But what about NON-PRESCRIPTION medications?

You may not have known that some non-prescription medications can also cause problems if stopped abruptly. The two most important groups are decongestant nasal sprays and certain heartburn medications. Both can result in "rebound" when stopped abruptly. "Rebound nasal congestion" can result after using decongestant spray routinely for more than a couple of days."Rebound acid production" may result after using certain heartburn medications for more than a few weeks. 

Nasal Decongestant Sprays

Nasal decongestants like Neo-Synephrine, Dristan and Afrin contain the medications phenylephrine and oxymetazoline. By constricting blood vessels inside the nose they widen the nasal passages. allowing more air to flow through the nose. They provide great relief when a virus or allergy keeps you from breathing with your mouth closed. The labels on these medications recommend that they should be used no longer than three days. Why? Because once the effect of the medication is gone, the nasal blood vessels swell back up and block air flow. This can happen even if your virus or allergy is resolved. The rebound symptoms can be uncomfortable for several days.

Rebound congestion makes you feel like you still have cold/allergy symptoms and still need to use the nasal spray. You might even continue to use the nasal spray indefinitely, since the congestion keeps returning.

There's a better way, though. If you've used a decongestant spray for more than a couple of days, be ready to taper it slowly. One way to taper is to start by using only half of a usual spray in one nostril while using the full dose in the other, then stop using it in that nostril altogether. Or use the usual dose with decreasing frequency in one nostril for a couple of days, then stopping. Either way, once that nostril seems back to normal, start tapering the same way in the other nostril. The idea is that by slowly tapering the dose and allowing one nostril to recover at a time, the uncomfortable symptoms of rebound congestion can be minimized.

Heartburn medications

The heartburn medications known as "proton-pump inhibitors" (PPIs) include Nexium, Prevacid, and Prilosec. They work by preventing the production of stomach acid, so they're really good at relieving  heartburn symptoms. So good, in fact, that they are often used for longer than the recommended 14 days. If used regularly for more than a few weeks then stopped abruptly, the rebound acid production may result in severe hearburn symptoms. Ultimately, these meds are sometimes continued indefinitely, even lifelong.

The ideal way to handle the possibility of rebound acid secretion is to prevent it. If you use a PPI only "as needed"  instead of every day you're at a very low risk of rebound. If you must use it daily, the risk is lowest if you stick to the recommended two weeks or less. But if you find yourself wondering if your chronic heartburn is a consequence of rebound acid production, try tapering it. The tablets/capsules must be swallowed whole, so the dose can't be gradually decreased. Instead, use two to four weeks to slowly extend the interval between doses. For example, if you're currently taking the PPI once daily before breakfast, start by extending the interval by an extra six hours or so, taking the next dose at lunchtime on the second day. Then extend it further and take the next dose at bedtime on the third day. Continue tapering in that way for at least two weeks before stopping. There are many ways to slowly decrease the dose, so find one that works for you. Non-prescription heartburn medications such as Zantac, Pepcid, and others can be used for occasional symptoms while you're tapering.  

Know when it's important to taper non-prescription medications.

Knowing ahead of time that your non-prescription medicine may need to be tapered will decrease your risk of rebound side effects. You can use the medication when you need it but not find yourself using it longer than necessary. For other questions about medications that should be tapered, talk with your community pharmacist or contact us at BetterMyMeds!

Have you seen articles or ads about the wonders of creatine supplementation for older adults? Wondering if you should try it? A reader asked me about creatine recently, so I looked into the research. What I learned was quite interesting.

Creatine is a compound that our bodies need to build muscle. We get some of it from animal protein in our diet and some from our body's manufacturing processes. Though it comes from protein (the building block of muscle), its function is different. Instead of building muscle, it supplies energy to muscles. Competitive athletes often use creatine supplements because it helps their muscles adapt to and recover from intense workouts more quickly. But what can it possibly do for older adults?

It turns out that muscle strength can go a long way to keeping us independent as we age. Muscle strength helps us move, lift, and keep our balance. More than that, it helps our brains work better. 

The Muscle-Brain Connection

Research has shown that older adults who stay physically active are at lower risk of developing dementia, but why? Well, it turns out that there's a connection between muscles and the brain. Muscles send chemical messages to the brain, and the brain sends chemical messages back to muscles. The two organs work together to keep the body strong, even as we age.

How Does The Muscle-Brain Connection Affect Older Adults?

In early adulthood, muscles and brains are at their strongest. The signals they send to each other are strong, too, keeping us physically and mentally healthy. But aging bodies gradually get less efficient at building muscle. At the same time the body gets less efficient at making creatine, the energy source for muscles. So as we age, not only do we lose muscle mass, we lose the energy needed to make them work.

This is where the muscle-brain connection comes in. Chemical signals they send one another may be weaker, so they don't support each other as well as they used to. Keeping muscles strong can go a long way to improving both physical and mental health. And those two things are essential for us to maintain independence as we get older.

It makes sense that providing more energy to muscles would help them grow and get stronger. And as they get stronger, the brain will stay healthier, too. Many experts and researchers believe that creatine supplements can serve as that energy source.

But What Does the Research Show?

Much research supports the efficacy and safety of creatine in competitive athletes who want to improve their performance and increase muscle mass. But most older adults aren't trying to be competitive. Instead, most of us want to maintain (or modestly improve) our strength so we can stay healthy and active. Researchers have been looking more closely at this in recent years.

Like research on most dietary supplements, many studies are small or poorly controlled. But researchers have taken close looks at many of them found areas where results are similar. One review of several studies concluded that creatine supplementation improves muscle strength in older adults when used in combination with resistance training. Those who used creatine supplements for several weeks found they could lift more weight than those who didn't. In another study, "sit to stand" time was shown to improve, meaning that lower body muscles became stronger and balance improved. Research does seem to show that it's the combination of creatine supplements and weight/resistance training that does the trick. Creatine supplements or weight/resistance training alone were much less effective.

Creatine supplementation has been studied for its effects on brain function, too. The brain is a muscle, and so requires plenty of energy to do its job. Creatine supplies that energy, and so it makes sense that creatine supplementation would improve cognition and memory. But while some research suggests creatine may be helpful, the evidence is far from conclusive.

What Could All This Mean For Daily Living?

Creatine supplements have the potential to bring positive, noticeable changes to daily life. Stronger muscles may allow us to do more with less fatigue. Maybe carry two bags of groceries from the car instead of just one. Or regain balance more easily and avoid a fall. Even get out of the easy chair with less effort. Some research indicates that mood might improve (whether due to increased activity and engagement or just better brain function isn't clear). 

Overall, the research isn't compelling enough to guarantee that everyone will benefit from creatine supplements. But it's compelling enough to suggest it might be worth considering..

Safety and Dose

Creatine shouldn't be used by those who have kidney or liver disease. But other than that it's pretty safe, with no known drug interactions. It may cause intestinal discomfort in some folks, a bit of water-weight gain in some. This is important -- it can alter the results of a common lab test that checks kidney function so be sure to let your doctor know if you decide to use it.

At the same time, creatine IS a dietary supplement, and is not tightly regulated like medicine. Please read my previous post on the regulation of dietary supplements, and protect yourself.

The most commonly studied dose is 3-5 grams daily. It's pretty easy to take - it comes in a powder that can be dissolved in a drink and has little flavor. It can be taken at any convenient time of day.

Stay Stronger, Longer!

Whether you decide to try creatine supplementation, or just use aerobic, core, and resistance training alone, make physical activity a daily priority!  If you decide to give creatine a try, watch for noticeable changes in strength, balance, and fatigue. And let us know how it goes!

Please add your comments to the space below, or contact us directly at Better My Meds. We love hearing from you!

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Until the early 2000's, hormones were used pretty routinely to treat women with uncomfortable menopausal symptoms. Then a study by the Women's Health Initiative changed everything. It seemed to show that the risks of hormone replacement far outweighed the benefit. So for the past two decades or so, doctors have discouraged the use of hormones. But a reanalysis of the research results found that some conclusions didn't apply to women of all ages. So late last year the caution light on hormone replacement was essentially changed from red to yellow.

Let's start at the beginning

When young girls enter puberty, hormones start changing their bodies. Estrogen, produced by the ovaries, is the major hormone affecting reproduction, but it has other roles, too. It keeps bones strong and improves cardiovascular health. It affects mood, too (for both good and bad). Overall, estrogen is a major factor in the health and well-being of women for much of their adult lives.

Estrogen levels begin to decline as women age, throwing off the balance between estrogen and progesterone (another hormone produced by the ovaries). This is perimenopause, which may last for months or years before actual menopause. Menopause is the point at which menstruation completely stops (on average, around age 52). From then on the ovaries will produce little, if any, estrogen. 

Menopausal symptoms

Even though all of this is natural and expected, it can still be uncomfortable. Many women get through this change without much trouble. But for others, the physical symptoms that go along with the loss of estrogen can be debilitating. Hot flashes, insomnia, night sweats, vaginal discomfort, low sex drive. There are psychological symptoms, too -- mood changes from anger, to depression and anxiety. Over the past two decades, these women have had few options for relief. That's what's changed since last fall -- there's effective treatment now for many women. It's "menopausal hormone therapy", or MHT.

Until recently, you may have heard the term "hormone replacement therapy", or HRT. MHT is the current term, but they mean the same thing. MHT provides estrogen that can significantly ease the severity of menopausal symptoms in most women.

Let's talk about the risks of MHT first

The WHI study was started in 1991. At that time doctors often started MHT for menopausal symptoms and then continued it indefinitely. It was thought that MHT could prevent chronic diseases like cardiovascular disease and osteoporosis. The study recruited thousands of women, and was planned to go on for nine years. But it was stopped early when it was found that women taking MHT had a higher risk of breast cancer, stroke, cardiovascular disease, and pulmonary embolism. So, for what seemed like very good reasons, MHT was "blacklisted" and considered to be way more risk than benefit.

The WHI study clearly showed that lifelong MHT didn't prevent chronic disease. But it didn't look at the risks of MHT given just for menopausal symptoms. Last fall, a different look at the study results revealed that nearly 3/4 of the women enrolled in the MHT trial were between 60 and 79, much older than most women entering menopause. When results were analyzed with respect to age, it was found that women in their 50's had a very low risk of adverse effects and a high likelihood of significant benefit.

That doesn't mean that MHT is without risks. There is a slight increase in risk of stroke or blood clots, though that doesn't seem to be true when estrogen is administered in a skin patch instead of a pill. Breast cancer rates are somewhat higher but only in those who take combination MHT (see below) and are on it long-term. Uterine cancer risk is higher for women who still have a uterus and take only estrogen (see below). These risks can all be assessed ahead of time and plans made to avoid problems. 

Other possible side effects of MHT include nausea, breast tenderness, weight gain, and headache, but are generally mild.

What are the benefits of MHT?

MHT provides significant benefits for most women who take it while in the throes of menopause. It can decrease the frequency and severity of hot flashes and night sweats. Sleep quality may improve, mood swings may soften. Discomfort during sexual intercourse often eases. Even modest improvements in menopausal symptoms can make daily life more livable for women with severe discomfort..

Menopausal symptoms usually start early in the perimenopause/menopause period. And luckily, they typically wane and then fade away over a few years. Typically MHT can be used for a few years, and then tapered gradually to prevent return of symptoms. So most women won't need MHT past their late 50's or early 60's.

But some women have long-lasting symptoms that negatively affect their daily life. And though the risks of MHT increase as women approach 70, the benefits of MHT may still outweigh the risks in some cases. If you're in that situation, talk with your pharmacist and/or doctor about what might be right for you.

Now -- what exactly IS MHT?

The major symptom reliever is estrogen, typically given as estradiol. It's can be used as a daily pill, or transdermally as a skin patch applied once or twice weekly. Research has shown that the skin patch is less likely than the oral pill to increase the risk of stroke and blood clots. (For most healthy women entering menopause in their early 40's to late 50's the difference in risk may not be meaningful.)

Women who have had a hysterectomy can safely use estrogen alone. But for those who still have a uterus, progesterone replacement MUST be combined with estrogen. Combination MHT prevents damage to the uterine lining, which may increase the risk of uterine cancer.

There are also locally-acting estrogen products that can be used for women whose major symptom is vaginal discomfort. Dryness and pain can be relieved with an intravaginal cream, gel, or suppository. In this case using estrogen alone is safe even for those with an intact uterus, as little estrogen reaches the bloodstream.

Making an informed decision

Now you know why MHT was first used lifelong to prevent chronic disease, then frowned upon for 20 years, and now back to being a safe and effective treatment for menopausal symptoms. You may be wondering if it's right for you, or for someone you know. Think about the risks and benefits, talk with your pharmacist and/or doctor, and be confident making a decision that's right for you.

Ask questions or make comments in the space below. Or contact us at Better My Meds -- we love hearing from you!

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Pharmacogenetics (AKA Pharmacogenomics) 

Pharmacogenetics (PGx) -- the study of how genetics affects your response to drugs -- is an exciting field in healthcare. Read our recent post  to learn the basics of PGx and why it's important in predicting your response to certain medications. But who needs testing? How does it work? In this post we'll talk about practical issues of pharmacogenetic testing.

First, WHO should consider pharmacogenetic testing and WHY?         

Most of us have meaningful genetic variations in our drug-metabolizing enzymes. Not only that, but many of us take at least one med that can be affected by those variations. And the more meds we take, the higher the chance those genetic variations will be important. The US Food and Drug Administration (FDA) has recommended genetic testing before starting treatment with several medications and has given guidance about testing for nearly 150 others. And research continues to provide new information about genetic differences in drug responses. Pharmacogenetic testing can help doctors prescribe the right drug at the right dose, the first time. So really, anyone who takes prescription medications, or who might in the future, can benefit from PGx testing.

Next, WHEN is the right time for pharmacogenetic testing?

As mentioned above, FDA recommends PGx testing prior to starting certain medications. At the time your doctor wants to use one of those meds, they can order a PGx test to determine if that med is likely to be safe and effective for you. The drawback with that timing is that they may have to delay treatment while awaiting test results. Another option is to do testing proactively, before it's absolutely necessary. Then results are already available when a new medication is needed. Your doctor can confidently prescribe a safe and effective medicine without having to wait for test results.

The great thing about PGx testing is that results last a lifetime. Since genetic makeup doesn't change, PGx test results can be used years down the road. When a new diagnosis is made, or a new medication is marketed, those results will be able to guide treatment decisions. So having the test done before you need it - proactively - may be the most efficient way to put PGx into action, and make your healthcare more personal.

WHAT type of test?            

Several types of PGx tests are currently available. "Single gene tests" are used when trying to decide if it's safe to use one particular medication. Multi-gene tests, called "panels", test several genes. Some panels test a small number of genes based on a person's current medication regimen or health problems. Other panels are broader, testing most of the genes that affect the metabolism and transport of medications.

A broad-spectrum PGx panel is a good choice for anyone who wants information that'll be useful both now and later. Better My Meds works with OneOme, a lab founded by Mayo Clinic over a decade ago. They offer the RightMed® test, a broad-spectrum PGx panel that currently covers 27 genes. 

Finally, WHERE and HOW is the test done?

Though PGx testing is available without a prescription, there are drawbacks to that approach. One is that while the actual testing process is simple, interpreting the results is likely to be a stumbling block for most consumers. Another is that it puts you in charge of being sure your healthcare providers have access to the results and know how to use them. 

We recommend looking to your healthcare team for Pharmacogenetic testing. You can find it at some clinics, hospitals, community pharmacies and Medication Management Services. But the type of test (single-gene, specific gene panel, or broad-spectrum panel) will vary from place to place.  BetterMyMeds is ready to help with a broad-spectrum PGx test that will provide information you can use now and into the future.  Learn more.        

The testing process is simple. First, ask your doctor to write an order for the test. You'll get a test kit with a cotton swab to rub along the inside of each cheek, collecting cells that contain genetic information. The swab gets sealed inside a protective container and sent to the lab, and results come back in about a week. You can see a sample report here.

Pharmacists are your experts in PGx test interpretation. The best way to get a clear understanding of the results is to meet with a pharmacist who has experience interpreting PGx test results. Pharmacists have extensive training in drug metabolism, so are able to interpret and explain results better than other medical professionals. When you work with Better My Meds you'll get a written report clearly explaining your results. We'll also provide a copy of the results for you to share with your doctor and your medical record.  More information about PGx testing services from BetterMyMeds can be found here.

It's up to you to make your healthcare personal!

We've talked in the past about the the importance of good communication between patients and their healthcare providers. If you feel that pharmacogenetic testing is right for you, or for someone in your family, it's up to you to discuss it with your prescriber. Bring up the issue, explain your concerns, and request a written order to perform the test. It may not be a priority for your prescriber unless they know it's a priority for you!

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We all want our healthcare to fit us as individuals. An important piece is having good communication with our healthcare providers. But let's talk about something even more personal -- something totally unique to each one of us.

The role of genetics in medication effectiveness and safety

Our DNA makes us unique. We differ from one another in eye and hair color, height, gender, physical ability and more. All of these things are determined, at least in part, by our genetic makeup. We look different from each other and respond to our environment in different ways. Why did anyone ever think that medications would work identically in everyone?

With the mapping of the human genome, it became possible to identify genetic differences in our responses to drugs. Some genetic differences may make us more likely to respond well to a particular medication. Others may make put us at higher risk of side effects. This field of study is called pharmacogenetics (AKA pharmacogenomics)  -- "the study of how genetics affects a person's response to drugs".   

 Let's start at the beginning.

Most medications are chemically changed (metabolized) by enzymes your body produces. Some drugs need to be changed in order to be effective. Others are changed so they can be eliminated from the body. Over the years we've learned that there are a handful of enzymes that are responsible for the majority of drug metabolism. And the enzymes we're talking about are encoded by our genes.

There are also enzymes that move (transport) drugs across membranes in the body. Sometimes the drugs are moved to make them effective. Other times they're moved so they can be eliminated. And it turns out these transport enzymes also are encoded by our genes.

Genetic testing can determine ancestry and give us interesting information about where our families came from. That same kind of testing can tell us about the enzymes that metabolize and transport drugs. And it turns out that the efficiency of these enzymes varies widely from one individual to another.

Our DNA may make our drug-metabolizing and drug-transporting enzymes work extra hard. Or our DNA might cause them to be sluggish and work slowly.  Pharmacogenetic testing can help predict how we might respond to certain drugs.

Here are a few examples of the ways genetics can affect drug response.

Plavix (clopidogrel) is a medication that works to keep blood from clotting quickly. It's often used to prevent heart attacks and stroke. The ingredient in the Plavix tablet starts as an inactive chemical - it needs to be activated by an enzyme. A specific genetic variation causes that enzyme to work so slowly that enough of the drug doesn't get activated. The risk of another heart attack or stroke is much higher in folks with that genetic variation. Knowing about that genetic variation ahead of time allows the doctor to prescribe a different medication that's more likely to work.

There's a similar situation with some pain medications, such as codeine and tramadol, both of which are dependent on enzymes to do their job safely and effectively. Those with specific genetic variations in those enzymes can be at risk of severe side effects or of getting no benefit at all from the medications

Mental health disorders are often treated with medications. And sometimes it requires lots of trial and error to get to the right one. Genetics are part of the reason for that. Many of the medications used for mental health treatment are metabolized by the enzymes we've been talking about. Genetic variations can result in some medications being inactivated so fast they're essentially useless. Others might be inactivated so slowly they cause severe side effects. It's clear that the treatment of mental health problems is complex, and success or failure of a treatment plan isn't only about pharmacogenetic variations. But still, medications are a mainstay of treatment for lots of people, and knowing which medication is more likely to work can result in a shorter time to treatment success.

Omeprazole (Prilosec) is commonly-used medication for heartburn and stomach discomfort. It has to be metabolized in order to be eliminated from the body. Genetic variations in enzymes cause some people to metabolize omeprazole so rapidly that it doesn't work well. Knowing that ahead of time would allow a doctor to prescribe a more effective med.

Then there are the "statins" - drugs that reduce cholesterol to help prevent heart attack and stroke. Transporting enzymes help eliminate certain statins from the body. Genetic variations in that enzyme can make it work too slowly, keeping active drug in the body for a longer time and increasing the risk of side effects. If pharmacogenetic information were available, the safest drug could be chosen from the beginning.

These are just a few examples of the many ways pharmacogenetics can improve the way we use medications. And ongoing research continues to give us new information.

So what can you do to make your healthcare more personal?

Just like genetic testing for ancestry, pharmacogenetic testing is widely available. An accompanying post explores where the test can be obtained, how it's done, how results are documented and interpreted, and what your role is in making sure your genetic makeup is taken into account by your healthcare providers. Healthcare can be personal!

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Each of us is unique. We have our own personalities, lifestyles, environments, and genetics. We may enjoy the same things as someone else, or not. Our bodies may respond to a particular medical treatment more efficiently than someone else's, or not. It's important that healthcare providers see each patient as an individual rather than as a disease that needs treatment. But how do we make that happen?

Personalized medicine allows the treatment to fit the person.

In years past, medicine tended to group people into categories based on their health problems. There were diabetics, hypertensives, heart failure patients, cancer patients, and others. A diagnosis would be followed by a plan to treat a disease, rather than a plan to treat a patient. The doctor would explain to the patient what they needed to do, and the patient was expected to comply. In those days, it was more or less thought that the doctor was in charge of the patient's health.  

Personalized medicine puts you, the patient, in charge of your health. Yes, that's a big responsibility. And yes, you'll need help from your doctor as well as others on your healthcare team. But the advantages are immense. Now, instead of just considering a disease, other things that impact your health help determine the treatment plan. Things like lifestyle, environment, and genetics that make you different from others. And while genetics can be tested and documented, things like environment and lifestyle can be ever-changing. And sometimes those issues aren't obvious; they may even be neglected during doctor-patient conversations. Whose job is it to make sure these important issues are discussed and prioritized when making treatment decisions?

It's all about patient-provider communication!

Communication is the key to making medicine personalized. Healthcare providers can't know what people are able (and willing) to do unless it's discussed. Here's an example: Let's say Jane Doe's blood pressure is higher than normal, and has been the last couple of office visits. Maybe her doctor would like to suggest she lose ten pounds and start walking every day, but assumes that like many people Jane wouldn't want to do those thing. So instead a medication is prescribed. But Jane thinks to herself, "I don't want to take medications!" and doesn't fill the prescription. At the follow up visit three months later, her blood pressure is still high and her health hasn't improved.

What if Jane had explained that she wants to avoid medications if at all possible? She and her doctor may have talked about lifestyle options for bringing her blood pressure down. She may have surprised her doctor (and maybe even herself) by realizing that she'd rather make small changes in her lifestyle than take a medication. Then they could have discussed how to start out on those changes, and what short-term and long-term goals she should shoot for. Together, they may have come up with a plan they could both get behind. The likelihood is that if they openly discussed options, Jane would be more likely to follow through with a treatment plan that she had a role in creating.

Let your healthcare provider know who you are and how treatment plans might fit your life (or not).

There are plenty of other examples of things that should be discussed with healthcare providers. What if an injectable medication is prescribed, but you're squeamish and reluctant to use an injection? What if your doctor prescribed a medication that needs to be taken three times a day and you know you just can't fit the middle dose in due to your daily schedule? Or your doctor recommends losing weight, but you've tried and tried and know that won't work for you? Bringing up your concerns will allow for a discussion about alternative treatments. Talking about those alternatives, and their pros and cons can help you and your healthcare provider come to an agreement about where to start.

Always ask what the treatment goal is.

Don't forget to talk about the goals of new (and old) treatments. Whether it's a goal blood pressure, goal blood sugar, goal weight, or anything else, it's important that you and your doctor are on the same page. 

Chronic pain is a good example. Whether it's a knee, hip, or any other body part, what most of us yearn for is for the pain to just go away. Completely. So as patients, our goal may be zero pain. But healthcare providers may be looking at a different measure, like being able to walk farther, play on the floor with grandkids, or participate in more activities. Agreeing on a goal for pain relief can make it easier for both patient and provider to see if a treatment plan is working.

Don't be afraid to ask questions!

Many patients have told me that they're reluctant to ask questions of their doctors. There are common reasons - the doctor is too busy; the doctor may get angry; it might be a stupid question. There are plenty of reasons for not discussing treatment decisions with our providers. But when discussion doesn't happen, personalized medicine won't happen, either. Much of the responsibility for making healthcare personal lies with the person. 

Be the person who makes your healthcare personal!

And remember, Better My Meds can help answer your questions too! Contact us to get the best health outcomes from your medications!

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Originally published May, 2019. Revised April, 2021; March, 2022, March, 2026

There's a good chance you take at least one prescription medication or dietary supplement. Almost three-quarters of us do, and 20% of us take five or more. The older we get, the more likely we are to have health problems. And medications are the mainstay of treatment for chronic health problems like heart disease and diabetes. That's because so much research shows they work well to keep people with chronic diseases healthier and more active.

But the reality of medication use isn't all that rosy. Less than half of us actually take our prescription drugs as prescribed. There are lots of reasons: cost, forgetfulness (all ages!), side effects. And some of us wonder if we really need all of our meds, or if they're safe. Add to that the folks who use devices like inhalers but have never been shown how to use them correctly. Whatever the reason, the majority of people who take prescription drugs take them incorrectly at least some of the time.

And there's more. Many of us don't learn about or don't remember what side effects to watch for. That might cause us to ignore side effects, treat them with another medication, or worse, find ourselves at our doctor's office or the ER. Drug interactions between prescription meds or with dietary supplements can cause trouble. And all these risks increase as the number of medications goes up. Age makes a difference, too. As our bodies age and change, risks of side effects and dose limits of some medications also change.

While the CDC hasn't published recent statistics on medication errors and their cost, we know from previous research that medication errors and side effects result in millions of emergency room visits, hundreds of thousands of hospitalizations and over a hundred thousand deaths in the United States annually. And the price tag for all that is in the billions of dollars annually.

All this to say that most of us don't get the best value or health outcomes from the meds we buy and try to take every day. But there's hope!

Pharmacist-Provided Medication Management to the Rescue!

You can call it medication counseling, medication education, or just getting your questioned answered. But the official name for the education and support you get from your pharmacist is Medication Management. Pharmacist-provided medication management starts with asking questions. First, is every medication necessary? Is each medication doing its job? Are there worrisome side effects? Is it easy enough to take regularly? And is it being taken as prescribed? These questions and others are addressed to make sure that meds are actually providing the best health outcomes. In simpler terms, your pharmacist works with you and your healthcare team to make sure all your medicines are the right ones for you. Pharmacist-provided Medication Management is exactly the right tool to improve health, decrease hospitalizations, and decrease overall healthcare costs.

Medication management is an important and detailed healthcare service, just like your doctor visits. For that reason it's typically appointment-based, allowing your pharmacist enough time to get to all your questions. 

Here are some Frequently Asked Questions about Medication Management.

• • • Who provides medication management?

    • What's the difference between Medication Management and Medication Therapy Management (MTM)?

    • Where are Medication Management Services provided?

    • How does Medication Management work?

    • When should you consider Medication Management?

    • Who will pay for Medication Management?

 

Who provides Medication Management Services?

You may be used to your doctor or their staff updating your med list at every appointment. This is done to make sure your health record contains an accurate med list, but not to evaluate each medication's health benefit for you. Most (not all) doctors simply don't have the time to consider each med carefully. Your pharmacist's insight is a valuable addition to your doctor's care. Pharmacists are the medication experts on every healthcare team, with at least 6-8 years of university-level training centered around medication use, a Doctor of Pharmacy (PharmD) degree, and plenty of experience to boot. Pharmacists are in the best position to help you get the most value from your medicines. Whether you find your pharmacist in a retail pharmacy, clinic, hospital or independent practice, all have the knowledge to help.

If your pharmacist is in a busy community pharmacy, or far away providing mail-order prescriptions, you may find it hard to connect regularly with them. That's where an independent practice like Better My Meds can help. Independent practices allow you to develop a relationship with your own personal pharmacist. A pharmacist who can give you the time you need - to help you understand your treatments, answer your questions, and find confidence talking with your prescriber.

But Medication Management still works best with a team approach. Every member of the healthcare team, including you, your pharmacist, and your doctor(s) should work together to make decisions about your treatment. When a pharmacists helps manage medication use, you'll stay healthier, be at less risk of hospitalization, and likely spend less money on your healthcare.

Back to FAQs

My prescription insurance company sent me information about "Medication Therapy Management". Is that different from "Medication Management"?

The term Medication Therapy Management (MTM) was coined by Medicare. You'll hear this term when Medication Management is offered through a Medicare Part D prescription drug policy. Medicare Part D provides MTM benefits to all members who meet certain criteria. Medicare has strict guidelines for MTM, but it's still done with the same goal in mind -- to optimize the health benefits of medications.

Comprehensive Medication Management (CMM) is another term for services that fall under the Medication Management umbrella. You may hear the term CMM if you receive care in a clinic where pharmacists are a part of the healthcare team. 

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Where are Medication Management Services provided?

Many community pharmacies, both independent and chain, have successful Medication Management programs. Most provide MTM services through Medicare Part D plans (as described above), but some have even broader reach. These services are often provided face-to-face in a private area of the pharmacy.

Unfortunately, not all pharmacies have enough pharmacists on staff to devote the necessary time for in-depth counseling. Some larger chain pharmacies may provide the service to their patients from a central call center. Video calls may make some appointments a little more convenient. Though face-to-face visits have their advantages, a telephone or video appointment still allows you to get the help you need.

Some doctor's offices and clinics employ pharmacists to provide medication management services. Clinics with a team-based approach to healthcare are more likely to have a pharmacist available. Getting care from a pharmacist right there at your doctor's office is efficient for you, your doctor, and your pharmacist. Everyone can join the conversation, view the same records, and make decisions together. If you have access to a pharmacist at your doctor's office, get to know them. Bring medication-related questions to your visit when they come up, and get the most out of your healthcare!

Pharmacists employed by hospitals may also provide medication management services. This may happen behind the scenes when pharmacists consult with doctors about medication choices, doses, or side effects. Or you may talk with a pharmacist to review your medicines before you go home. Some hospitals even employ pharmacists to follow up with patients AFTER they get home. That's the time when changes in medicine can get confusing, and problems can lead to another hospitalization. If you have contact with a hospital pharmacist, be sure to find out who to call if you have questions after you go home!

Nursing homes employ pharmacists to review the medications of all residents every month. Sometimes the pharmacist has a chance to talk to the residents he or she cares for. If you or someone you love is in a nursing home, you can be confident that there is a pharmacist there keeping watch. If you have questions, be sure to ask the nursing home staff how to reach a pharmacist who can help!

And finally, there are pharmacists who can meet you right in the comfort of your own home! An independent pharmacy practice may provide home visits or video/telephone appointments. Better My Meds currently uses both options for medication management appointments. A home visit may be more convenient for you, and it gives our pharmacist more insight into day-to-day medication problems that may not come up in conversation. If there's no option for a face-to-face meeting, a video call is the next best option, and the telephone can always be used if necessary.

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How does Medication Management work?

The multi-colored wheel shown here illustrates the patient-centered care process. Your pharmacist starts by learning about you (collecting information). The information may come directly from you, or from your health record if your pharmacist has access to it. Then, you and your pharmacist evaluate (assess) each medicine to see if it's effective, safe, and personalized to you. This is the time when any problems you're having (cost, side effects, and so forth) can be discussed. Together, you and your pharmacist (with the help of your doctor if needed) will make a plan to resolve any problems that came up during your discussion. This may include setting health-related goals as well as tracking progress toward those goals. Next, you'll put the plan into action (implement). You can continue to work with your pharmacist (follow up) to make sure the plan is working. If needed, you and your team can change the plan to help you meet your goals, and the process continues.

The process works best when you and your pharmacist have an ongoing relationship. That way, you can ask questions or discuss problems whenever they come up, and you can check in with your pharmacist regularly. If you find the plan isn't working, changes can be made and new goals set. This process is a great way to help you use your medicines more effectively and stay healthy!. 

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Who needs Pharmacist-Provided Medication Management?

Studies show that people begin to go off track with medications nearly as soon as they start taking them. Many people stop taking new medicines soon after starting them. Children, young adults, the middle-aged and the elderly all make mistakes with medicine or simply decide not to take it. Developing a relationship with your pharmacist early on allows you to talk openly about medicines. You can learn about risks and benefits of your medicine, changes in lifestyle that may decrease the need for meds, and talk openly about what's important to you. In short, the earlier you get to know your pharmacist and begin talking about your medications, the better!

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Who pays for Medication Management Services?

In the community pharmacy setting, Medicare Prescription Drug Policies cover medication management for those who qualify. That's a start, but it only helps a small number of those who could benefit from it. Some other insurers, seeing the value pharmacists add to healthcare, are covering the service for more of their members. Some clinics have pharmacists on their medical team, and the pharmacist's time generally comes at no added expense to patients in these settings. Nursing homes generally include the cost of the pharmacist's services in the overall cost of medications. 

But if you're not one of those whose insurance covers medication management, paying out of pocket is very likely still a winning strategy for you. Why? Because ongoing help from a pharmacist can add real value to your healthcare. Your health will improve, you'll understand the risks and benefits of your medicine, and you'll spend less money overall on your healthcare. 

Independent Medication Management practices such as Better My Meds employ pharmacists to focus on medication use rather than medication sales, and they are slowly gaining traction as the value of pharmacist input becomes clearer. This type of practice offers a variety of services at different prices. Contact us to make your appointment today!

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Low thyroid (hypothyroidism) is a common problem among adults. It's most often caused by iodine deficiency in other parts of the world, but here in the US it's usually due to an autoimmune disorder (Hashimoto's disease). More often than not, a diagnosis of hypothyroidism will require lifelong treatment with a thyroid hormone replacement. Luckily, thyroid replacement therapy is relatively simple. Safe and effective oral medications are available and doctors are experienced in making sure the dose is just right.

If you have hypothyroidism, it's important for you to know that the FDA is taking a hard look at thyroid replacement meds. They're currently planning to take one of them off the market later this year. If you take a thyroid medication, their actions may affect you.

What is Thyroid Hormone?

The thyroid gland sits at the base of the neck. It secretes two hormones that, together, we think of as "thyroid hormone".  One of the hormones (thyroxine, or T4) is slowly converted to the other (T3) by the liver. The conversion happens at a speed that typically keeps T4 and T3 in just the right balance. Together, these hormones regulate the body's metabolism, including heart rate, weight gain/loss, and heat production to keep your body functioning well.

When the thyroid gland stops producing enough hormone, people experience symptoms like weight gain, feeling cold more frequently, lack of energy, thinning hair and other problems. Diagnosis of hypothyroidism is typically based on the level of thyroid hormones in the blood. And the good news is that treatment is simple and effective.

Thyroid Hormone Replacement 

Levothyroxine is the most widely-prescribed thyroid replacement medication. It's a synthetic form of T4, so is slowly converted in the body to T3. Getting to the right dose may take some time, and it may need occasional adjustment, but usually it resolves all the symptoms of hypothyroidism.

Some people find that levothyroxine alone doesn't resolve their symptoms. That can happen when T4 isn't converted to T3 quickly enough to provide the right balance. Liothyronine, a synthetic form of T3, may be added at that point. It's an active medication right when it hits the bloodstream so can have a more immediate effect on symptoms. When levothyroxine and liothyronine are combined, their doses can be adjusted individually to resolve symptoms without significant side effects.

The other thyroid replacement medication is known by several names --  Dessicated Thyroid Extract (DTE), Armour Thyroid, Porcine Thyroid, or Natural Thyroid. We'll call it DTE for simplicity. It's made from grinding up the thyroid glands of pigs or cows; that makes it a biologic rather than synthetic compound. DTE contains both T3 and T4, but in different amounts than the human thyroid. It was the very first thyroid replacement medication in the late 1800's, and was a huge step forward in treating hypothyroidism.  Its discovery provided welcome relief to people who needed it. And it's still used now..

Why is the FDA concerned about DTE?

DTE was already in use when the FDA was created in the early 1900's so was "grandfathered" in as a prescription drug. The FDA's drug approval process has evolved from evaluating safety only to now evaluating both safety and efficacy. And DTE has never been evaluated for either.

But why, now, is the FDA is suddenly taking action on this matter? It turns out that the action isn't really sudden at all. While it's clear that DTE is effective, FDA has been concerned about its potency, purity and safety for a long time. In recent years they've urged manufacturers of DTE to submit applications for approval. But thus far manufacturers have chosen not to submit those applications. So in August of 2025 FDA gave manufacturers a deadline to gain approval for their products. At the same time, the action gives patients and their healthcare providers time to transition to other treatments.

Though many people who take DTE do well on it, others who take it encounter problems. One is that the content of T4 and T3 can vary from one manufacturer to another, from one batch of the same product to another and even from pill to pill within the same batch. Over he years that has resulted in patients having recurrence of symptoms or adverse effects. Another issue is that because DTE is a biologic product, it may contain impurities when strict manufacturing processes aren't used. And finally, the higher amount of T3 puts patients at a higher risk of heart problems and other side effects.

The FDA is charged with ensuring safety, efficacy, and purity of medications. Apparently they've decided it's time to make manufacturers accountable for providing thyroid products that meet those standards.

What's the alternative to DTE?

The synthetic products we talked about earlier, levothyroxine (T4) and liothyronine (T3), are the safest and most effective thyroid replacement alternatives. They're approved, reliable, and have been used safely for many years.

Most people do well with T4 (levothyroxine) alone. Some may need additional T3 (liothyronine) to get the right balance for their bodies. If you're already taking these synthetic replacements, there'll be no changes for you. But If you're taking DTE, start talking with your pharmacist and doctor to come up with a plan. It's still possible that makers of DTE will submit applications for approval. If so, the FDA may determine that some DTE products are safe and reliable. But if not, rest assured that there are effective alternatives to keep you healthy. .

As always, send us your comments and questions in the space below. Or contact us at Better My Meds -- we love hearing from you!

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I went on a month-long adventure recently. No, didn't go on a vacation abroad, didn't hike the Appalachian Trail or climb a mountain. I used a continuous glucose monitor (CGM) for a month to see how my lifestyle affects my blood sugar. Let me tell you why I did it, what I learned, and why I think you might benefit from doing the same!

What is CGM?

Continuous Glucose Monitoring is a way to learn how your blood sugar (glucose) responds to normal activities. Your diet, level of physical activity, and daily stressors all affect your health in many ways. CGM allows you to see in real time how they affect your blood glucose.

CGM has been around for 25 years or so. But it's become much more user-friendly in the past 5-10 years and is now easy for anyone to use and interpret. The newest models use a tiny needle to insert a small filament (tube) under the skin. The filament attaches to a biosensor which collects and stores the glucose measurements. Those data are then transmitted to a mobile app that gives the user real-time information about their blood glucose.

We'll focus on over-the-counter (OTC) CGM devices in this post, but there are prescription-only devices too. Prescription devices are intended for use by those with diabetes and typically have more features, like alerts for very low or very high readings. Some even have the ability to communicate with wearable insulin pumps. 

There are currently two OTC devices available -- Stelo (made by DexCom) and Lingo (made by Abbott). They can be used by folks who have diabetes but don't use insulin - those who aren't at risk of dangerously high or low blood glucose. They're also great for people with prediabetes, or anyone who wants more information about their health.

My experience with CGM

I've been convinced for some time now that CGM is a valuable tool and have recommended it to patients with diabetes. But without personal experience I couldn't explain how to purchase it, use it, or interpret the results. At the same time, my annual lab results showed me slowly inching my way toward prediabetes. Why? What was I doing wrong? Like many of you. I was doing my best to stay healthy. So I started a journey to learn about CGM for me, my patients and my readers.

Both of the OTC models are compatible with Apple and Android phones. To be sure your phone will support the app, go to your app store and download the Stelo or Lingo app. If your phone lets you download and install, you should be good to go!

I chose to use the Stelo. It was easy to order biosensors (ordering Lingo appears to be simple, too), and they arrived at my doorstep in two days. Two sensors lasted the entire month, which was perfect for my adventure.

Applying the sensor was simple, even for me. The sensor applicator is pictured here. The bottom cover comes off, then the applicator is pressed firmly against the skin on the back of the arm. Pushing the white button you see there forces the sensor onto the skin. A tiny needle pierces the skin, leaves the filament under the skin, then retracts back into the applicator. You don't even see it or feel it. The sensor stays on with adhesive, and an extra (mostly invisible) adhesive cover is used to keep it in place.

The Stelo sensor typically stays on for 15 days. On the 16th day app told me it was time to replace the sensor, and that was quick and easy. After a month both sensors were used up and the app uninstalled. But the information collected by the sensor and app was downloadable, so I have all of it to refer back to. That  information will help me adjust food, activity, and stress to (hopefully) keep my glucose in a healthy range.

What I learned

I learned a lot about my habits during my month-long adventure. About my food choices, my exercise habits, my stress level. Here are some of the tidbits I came away with.

• Even a little physical activity after a meal is better than eating at my desk and staying there.

• It's best to eat pure carbs (even a healthy banana or apple) AFTER eating protein and fiber.

• A little fat in a meal also helps to curb rises in my blood glucose. But there are risks with dietary fat, too, right?

• When I give talks in the community, even though I enjoy it and don't feel nervous, the stress raises my blood glucose!

Who should consider CGM?

CGM is a great way to learn how your body responds to different things. If you're like me, you can read about it and understand it, but when you see results from your own body on a phone screen it gets real. Here are the people who can benefit the most:

People with diabetes. If you're using insulin, a prescription CGM is safest, and insurance might even cover it. An OTC model should be safe for you if you don't use insulin.

People with prediabetes. Prediabetes is typically treated with lifestyle changes rather than meds. What better way to make lifestyle changes than to know exactly what lifestyle changes are needed!

Anyone who wants more information about their health. We can all benefit by knowing how our lifestyle affects our blood sugar..

Cost

The current cost for two biosensors (about a month) is around $90-$100. But the app is free, and if all you want to do is learn some information it can be a one-time expense. For those who want continued information, sometimes subscribing can be a bit less expensive per month.

CGM can be a valuable tool for staying healthy

I'm glad I went on that month-long adventure. I highly recommend it to you, too, if you have questions about how your blood glucose affects your health. You could even consider giving a month-long adventure with CGM to a friend or loved one as a holiday gift!

And please post your comments and questions in the space below. Or contact us directly at Better My Meds -- we love hearing from you!

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