When you (or loved ones) are taking prescription or over the counter medications…there is a lot you should be worried about, and a lot that your pharmacist may not be telling you.

Most people are aware, for example, that several medications taken together can sometimes cause harmful interactions. Most also know that drug allergies can pose significant hazards. (These are topics of other articles in this series). And, many people know that young children, elderly adults, pregnant women, nursing women, and severely debilitated people may all be at higher risk for adverse drug events.

But what most people don’t know is that a simple blood test can be one of the most important pieces of information in determining the correct dose of many medications…and the results of that test are almost never available to your pharmacist, especially if your pharmacist fills your prescription in a retail drugstore. (And, that’s a bummer.)

The test I’m talking about, of course, is the ’serum creatinine test’ (’SEAR-’em cree-AT-tuh-neen tehst’. It’s a difficult name to pronounce and a difficult test to understand…but one that you NEED to know about if you or loved ones are taking over-the-counter or prescription medications.)

A serum creatinine test gives a physician or pharmacist an estimate of kidney function.

Serum creatinine is the ‘bean counter’ of modern medicine… letting folks know if the beans (the kidneys) are working as well as they should.

Why is that important?

Well, kidney function is extremely important in determining the correct doses of many medications since the kidneys (along with the liver) assist in the removal of medications from the body.

Almost all medications (and/or their chemical by-products) are either removed by the liver, by the kidneys, or, in many cases, by both the kidneys and liver working together.

So, simply put, when the beans are not working well, many medications will accumulate in the body and increase the risk of drug side effects. And that’s an even bigger bummer. (The same is true for liver problems, and we will talk about that in another article in this series.)

As a result, patients with reduced kidney function often need LOWER doses of many medications.

So how does this all work?

Well, creatinine is a chemical that occurs and circulates naturally in the human body. It is the result of normal protein break-down. And, like many medications, creatinine is normally removed from the blood by the beans. So, when the kidneys are not working well, the level of creatinine circulating in the bloodstream will start to go up…just like the blood level of many medications.

Physicians and pharmacists are routinely and easily able to determine how much creatinine is in the blood with the results of a serum creatinine test. (This test is part of a very common panel of blood tests. And, if the serum creatinine is high, many drugs need to have a lower dose.) The normal value for serum creatinine is about 0.4 to 1.5 mg/dl…but that can vary a bit from lab to lab.

So remember: ‘kidneys no work…serum creatinine go UP’.

Now, serum creatinine is not the best measure of kidney function (there are other tests that are much more accurate), but results of the serum creatinine test are usually the most readily available…and cheapest…and are generally accurate enough for most purposes…so serum creatinine is the de facto standard for estimating kidney function…most of the time.

The gold standard test that doctors use for measuring kidney function is called ‘creatinine clearance’ (cree-AT-tuh-neeeen CLEAR-uhhh-nce) However, not many patients get this particular test because it is pretty darn inconvenient…and smelly. You have to collect all of your urine for 24 hours and keep it in the fridge. Not a lot of volunteers for this test…

Creatinine clearance is the volume of blood that the kidneys clear of creatinine in a given amount of time (and it is usually reported as milliliters per minute).

So, when kidney function decreases, creatinine clearance (the amount of blood that the kidneys are successfully ‘cleaning’) also decreases.

So remember: ‘kidneys no work…creatinine clearance go DOWN’. (Note: this is easy to remember because it is the exact opposite of what you were initially thinking, and the opposite of what happens with serum creatinine. Most of medicine is like this.)

Now for the super tricky part just for those gunning for an A. There is a way to ‘guestimate’ creatinine clearance using serum creatinine…isn’t that neat. And, that’s probably the best way to determine renal function if a measured creatinine clearance is not available.

What you do is run the serum creatinine value through a fancy equation that will give you an estimated creatinine clearance, which is itself an estimate of kidney function. (Estimates of estimates of estimates…that’s the kind of exacting science I live for.)

For adults, that equation is the famous ‘Cockcroft-Gault equation corrected for ideal body weight and gender’…the equation everyone loves to hate. The Cockcroft-Gault equation (presumably named after Drs. Cockcroft and Gault…or maybe just Dr. Cockroft-Gault, or maybe Lara Croft), is generally considered very reliable since it has never been well validated in young patients, old patients, thin patients, fat patients…basically all the patients it gets used on. So go figure. Double bonus points if you can remember this:

For men, creatinine clearance =

((140- Age) ‘ IBW) / (72 ‘ SCr)

For women, creatinine clearance =

((140- Age) ‘ IBW ‘ 0.85) / (72 ‘ SCr)

Where Age is in years, IBW is ideal body weight in kilograms, and SCr is serum creatinine in mg/dl.

Now once you run this a few times, you’ll find that creatinine clearance for young healthy people is about 100 ml/min (we’ll just leave off the ‘ml/min’ part from now on).

And, dead people have a creatinine clearance of about 0, depending on how healthy they are.

Everyone else falls somewhere in between.

(Now someone in the back of the room is saying, ‘I just ran this on myself and I have a creatinine clearance of 150′. Well aren’t you special? In fact, young good-looking people can have creatinine clearances of 130, 140, or more…but it doesn’t do a whole lot of good since 100 is perfectly acceptable. In fact, it’s just another case of overachiever overkill.)

Now, if someone has a creatinine clearance of 80, that means that they have about…80% kidney function.

And, if someone has a creatinine clearance of 50, that means that they have about…50% kidney function. (Are you following all of this?)

Many drugs that are eliminated by the kidney will require moderate dosage reductions once a patient’s renal function is in the 40-60 range.

Patients in the 20-40 range will typically require very large reductions in dose.

And, patients who are in the ‘less than 20′ range will often need HUGE dosage reductions for medications eliminated by the kidney (or better yet, they’ll need to take medications that are removed by some other organ altogether…if such an alternative is available).

One last tidbit to consider. Renal function declines as people age. No getting around that. But, the rate of decline is different for different people. By the time you’re 50 years old, there is a reasonable chance you’ll have moderate renal function (or worse)…by the time you’re 80, you’ll almost certainly have some important degree of renal impairment… and you probably won’t even know it or feel it.

Now that you know more renal physiology than you ever, EVER wanted to know…let’s get back to the main thread of this article…medication safety.

If you (or a loved one) are at risk for having decreased kidney function (and I’ll tell you who such folks are in just a second), you need to step up to the plate and get a handle on this issue (because there is a very good chance that your physician and pharmacist either didn’t have renal function data or didn’t consider it when coming up with a dosage for you).

Here are the steps I recommend for everyone taking prescription or over-the-counter medications:

1) For everyone: If you have access to the results of a recent serum creatinine test (it is probably part of your annual physical and you may have gotten a copy), memorize it or write it down and then say to your physician or pharmacist when you get a medication, ‘Say, I think my serum creatinine is about X. So, does this medication need any dosage adjustment in order to be safe for me?

2) If you are in one of the following categories, you should expect your physician and pharmacist to have considered your renal function before dosing a medication:

• known kidney disease;
• age greater than 50;
• history or heart attack, angina, stroke, or other artery blockages;
• history of diabetes (any type);
• history of high blood pressure;
• prior exposure to chemotherapy drugs;
• prior prolonged exposure to IV antibiotics;
• frequent use of pain medications (especially non-steroidal anti-inflammatory drugs, but others as well).

So you might say to your physician or pharmacist, ‘Is this drug removed by the kidney, because I have condition X that could decrease kidney function and I just want to be safe.’ If the drug is removed by the kidney, you might also ask the physician or pharmacist to tell you what your serum creatinine is…and if he or she does not have this information, a big red flag should be going up in your head.

3) If you are not in one of the categories in question 2 and you don’t have a serum creatinine available, don’t worry. You’re probably safe. But you may want to ask your physician if there is a serum creatinine in your chart and if so, what it is.

4) If you are on dialysis of any sort, serum creatinine is not all that useful for dosing medications. Just make sure your physician and pharmacist are aware that you are on dialysis and perhaps ask, ‘Now is this the usual dose for someone on dialysis?’

These are some of the steps I hope you will consider the next time you get a prescription or over-the-counter medication so you can be sure that that you (or your loved one) are getting the right dose.

When Aspirin Isn’t Enough

It’s surprising how clearly we can recall getting hurt. Years later, we can recount our first fall from a too-tempting tree, a bee-sting, the birth of a child. We can even tell humorous stories about those events because the pain was transient ? it passed.

But many illnesses and conditions can make pain a daily visitor, interfering with our jobs, family lives, even sleep. Even ancient people tried to relieve the devastation of chronic pain using surgeries and medicinal herbs. By the 1800s, people started using narcotics (drugs like opium) to reduce pain. Even the narcotic heroin was originally developed as a pain medication! But many narcotics were found to be addictive, to interfere with digestion and mood, and even to slow or stop breathing!

Fortunately for us, modern research has uncovered safer pain-relief drugs for chronic conditions. One of these drugs is Ultram (the generic drug Ultram contains is called tramadol). Ultram’s effect on your body is similar to the effect of narcotics and is as effective in relieving pain. But since it isn’t a narcotic, it doesn’t have as many of the side-effects which have made medical narcotic use so dangerous.

The Wonder Woman of Pain Control?

Ultram can help manage pain from many sources, just like comic-book superheroes can foil thieves, kidnappers, and polluters! Ultram can reduce pain from cancer, spinal problems (kyphosis, scoliosis), arthritis ?even surgery !. Some physicians report using it to help people with severe, chronic headaches and endometriosis.

The Dark Side of Ultram

While Ultram is not a narcotic, both physicians and patients have reported cases of dependence on it. Signs of dependence (addiction) include getting tolerant to the dose (not getting the effect you used to from one pill), a continuing feeling that the dose needs to be increased, and withdrawal symptoms (sleeplessness, jitteriness, mood disorders) if you stop taking the drug. Checking in with your physician regularly while on this medication helps both of you notice any symptoms of addiction so you can stop any problems before they start!

The other effects of Ultram tend to be mild and transient. You might notice dizziness, drowsiness, stomach or intestinal distress (usually constipation). People taking Ultram are discouraged from driving ? driving under it’s influence is a bit like driving after having a few drinks. Ultram requires a prescription, so while you’re talking with your doctor about using it, schedule a regular time to discuss any side-effects or difficulties you experience while on this medication.

Control the Medication - Don’t Let It Control You

How can you benefit from this drug while minimizing its risks? First, when deciding whether to start on Ultram, be candid with your physician about any dependence issues with alcohol or other drugs you’ve had. People who have struggled with other addictions may be more susceptible to Ultram dependence. Remember - your physician is on your side and telling her about your history will help her tailor pain medications to your needs!

Second, be aware that Ultram is pretty powerful stuff and treat it with respect! Any change in dose should be discussed with your doctor; mild drowsiness at one dose can become a deadly blackout in another. Never “lend” this drug to a friend, even if he’s in great pain ? what works for you could be fatal for him.

Thirdly, make sure that you tell your physician about other drugs you’re taking: many drugs (including alcohol and over-the-counter medications) can enhance the effect of Ultram, making it act like you’re taking a much bigger dose.

These sound like dire warnings, but remember: by working with your physician, this drug can be a powerful tool to help you reach the active, pain-free life you were meant to have.

According to ongoing research about the needs of patients with emotional problems misinformation or shame to speak about the problem with the doctor or psychotherapist is a major limitation to treatment success. However, transparency, good information and participation in the course of the therapy is the most important factor for a lasting positive result. Maybe the following list of the most relevant questions might help you to get good information about your personal somatic or psychological problems, diagnosis and treatment options.

This list, however, might help you to be prepared for the right questions :

1. Is there a name (clinical diagnosis) for my problem?

2. What are typical symptoms (somatic and psychological)?

3. What are the causes of the problem or the disorder?

4. What is the typical experience of other patients with this kind of problem or disorder?

5. What could I do myself to achieve a solution?

6. What kind of further technical diagnosis is necessary to exclude other organic disorders?

7. What is the aim of these diagnosis? Are there any possible risks?

8. What kind of treatment options (drugs, psycho-social help, different psychotherapy-methods, biological treatment options) exist for my problem?

9. What kind of advantage can be achieved with the treatment (and how long does it take)?

10. What is the goal of suggested clinical diagnostic process

11. What kind of different treatment options are available?

12. What will be realistic advantages of a positive therapy outcome?

13. Can the treatment offer me a reduction of my complaints?

14. How long will it take to achieve first positive results?

15. What might be the influence on my feelings or personality?

16. Are there any negative consequences for my sexuality?

17. Are there risks or possible side effects of the treatment?

18. Do you think my problems will reoccur? Is it a chronic disorder?

19. What kind of information is relevant for people, who care for me?

20. Is there anything I could do myself to accelerate my rehabilitation?

21. How do I get additional information?

22. Are there self-help groups for my problem?

This is a rather comprehensive list of questions and you must not expect to get a quick answer within a short time. But it might be a start to get the answers you need. Reading books and using the internet to find reliable information related to your personal problems is a great support for you and your doctor.

This is a true story.

Yesterday, I picked up a new antibiotic prescription for my daughter from my local pharmacy.

(We recently adopted my daughter from India where she had recurrent ear infections resulting in severe hearing loss. And, she is about to undergo the second of several planned surgeries in order to try to repair the damage.)

Before putting her to sleep, I got the new medication out of the bag, glanced at the instructions, and prepared to give her the drug according to the instructions on the label.

Just before doing so, I had a quick double-take.

Something seemed to be wrong. I looked at the instructions again, and thought to myself slowly, *What*s going on…this doesn*t seem right.* Then, it hit me that the dose seemed awfully high for her.

It took me a minute or two to put the pieces together (it had been an unusually tough fight getting her ready for bed, I was tired, I was confident in my daughter*s physician, and I was thinking perhaps less critically that I should have). And then I noticed it. The label had a stranger*s name on it.

After another moment or two, I saw what had really happened.

The medication came in a box. Each side of the box had a different label…one label was for my daughter and one label was for a stranger. And, the stranger*s dose was more than double what my daughter*s surgeon had recommended.

(This error didn*t happen in a mom-and-pop pharmacy. It happened in a modern new chain pharmacy whose name you would recognize from advertisements on TV.)

I*m not a surgeon…and I*m not a pediatrician…but I am a physician trained in internal medicine and I have spent most of the last twelve years writing about, speaking about, and developing systems to reduce the frequency of medication error and improve the safety of pharmacy practice.

This pharmacy error brought the topic of drug safety home to me…literally.

What I can tell you is that this sort of error occurs all too often in the United States (and around the world). And, that it can have devastating consequences for the people involved.

A recent study in the New England Journal of Medicine indicated that 25% of patients who take one or more prescription medications will experience an adverse drug event within three months-and 39% of these are preventable or avoidable.

The Harvard Medical Practice Study found reported in JAMA in 2001 that 30% of patients with drug-related injuries died or were disabled for more than 6 months.

And, what almost everyone who studies this problem agrees is that current systems for selecting drugs, dosing them, communicating a prescription to a pharmacy, dispensing drugs, and instructing patients on their safe use are woefully inadequate.

In this series, we are going to take a close look at the processes that cause medication errors (some things that your physician and pharmacist may not even want you to know) and what steps you can specifically take to make sure that you and your love ones are protected from this hazard.

Ten years ago, your ability to get current, objective, reliable information on your medications in a quick and easy way was practically non-existent. It probably would have involved a trip to the library and required considerable knowledge about pharmacology to get the answers.

Today, that*s not the case. There is a host of on-line tools, databases, and resources that allow you to learn information about medications that even your physician and pharmacist may not know.

We*re going to talk about them, show you were to go, tell you the key things you need to know about medications, expose some myths, and let you know the questions you should be asking. It*s not as hard as it may seem.

In fact, you need to become the final line of defense in the battle against medication errors.

Throughout, we are going to give you some key rules that should guide your defense.

So, Rule Number 1. Trust, but verify. Never assume that the medication you have received is the right medication for you or that it is dosed correctly for you. Specifically, you should check:

• the name of the patient on the bottle;
• the name of the doctor on the bottle;
• the name of the medication (and cross check it to be sure that it treats a disease or problem you actually have… there are lots of look-alike/sound-alike drug names out there);
• the dose (from an independent source…to make sure that it is a plausible dose for you);
• the *route* (to make sure, for example, that eye drops are being prescribed for the eye, and not the mouth, or the ear…amazingly injuries from drug misplacement occur all the time);
• the expiration date.

We*ll talk about some specific resources that will help with each of these throughout this series.

The result, we hope, will be the piece of mind to know that you and your family are getting your 7 rights:

• right drug;
• right patient;
• right dose;
• right time;
• right route;
• right reason;
• right documentation.

Right on!

When a patient has a serious illness and there is no approved drug available, the physician may want to try one which has not been authorized for marketing by national health authorities but has shown promise in clinical trials. European Named Patient Programs, like US compassionate use programs, offer physicians access to pharmaceuticals which have not yet been licensed. However, there is one important difference: in Europe an unlicensed drug can be reimbursed. This presents drug-makers with an opportunity to generate revenues while development is still in-progress.

Significant Revenues Are Possible

The additional revenues can be considerable. For example, Pharmion, a US based company focusing on Oncology and Hematology reported dramatic increases in its Thalidomide sales from $1.9 million in 2Q ‘03 to $15.3 million in 2Q ‘04, primarily due to named patient sales in Europe for Multiple Myeloma. Thalidomide sales accounted for approximately 75% of Pharmion’s total revenues for the first half of 2004, according to company sources, and were generated while the product awaits marketing approval for this indication.

Myth #1: “Nothing can be done about arthritis…”

You don’t have to put up with arthritis. Now motre than ever, there are excellent medicines that can not only treat the symptoms but also, in many cases, get the disease into remission. Arthritis when diagnosed and treated properly can be controlled.

Myth #2: “It’s all due to getting old…”

Arthritis affects all age groups. Arthritis can even affect children. Three out of every 5 people with arthritis are younger than 65 years!

Myth #3: “If I wait, it’ll go away…”

Six million Americans believe they have arthritis but have never seen a physician! A proper diagnosis and treatment are important! Who doesn’t want to see their children graduate or play with their grandchildren? It’s a choice many Americans make every day.

Myth #4: “Arthritis medicines have too many side-effects…”

Yes… Many of these medicines do have potential side-effects! Witness the latest flap over the COX 2 drugs. But…When properly monitored by an arthritis specialist, the chances for severe side-effects are much much lower! Let’s face it… any medicine you take has potential side-effects. What you and your physician have to determine is this: Are the potential side-effects- which by the way are relatively uncommon despite what the media would have you believe- worth my quality of life?

Myth # 5: “I’ll never get arthritis…”

Seventy million people in the United States (25% of the population) suffer from arthritis!” Also, arthritis strikes 750,000 new people a year. More than 97% of people over 50 will get arthritis. Just because you don’t have symptoms now doesn’t mean you won’t get symptoms soon.

Myth # 6: It’s just aches and pains… Nothing I can’t live with… Arthritis is the #1 cause of loss of personal freedom. More than 100,000 Americans can’t walk independently from their bed to the bathroom because of arthritis. Ten million Americans are limited in their daily activities because of arthritis. Arthritis is the:

* leading cause of physician visits in adults over 65

* most common chronic disease

* most common cause of crippling

* most common cause of impairment and functional limitation in adults

Myth # 7: “My doctor can take care of arthritis…”

Unless your physician is a rheumatologist is remains active on the cutting edge of new research, there is no way he or she can “take care” of this condition. There has been a literal explosion of new treatments in the last three years. These treatments can make the difference between a life filled with joy and a life filled with dread.

Dr. Wei (pronounced “way”) is a board-certified rheumatologist and Clinical Director of the nationally respected Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine and has served as a consultant to the Arthritis Branch of the National Institutes of Health. He is a Fellow of the American College of Rheumatology and the American College of Physicians.

Being afflicted by hemorrhoids is no laughing matter. The pain and itching associated with the condition can be embarrassing as well as distracting. There are a variety of solutions to help you overcome hemorrhoids and we’ll discuss some of your options here.

Exactly what are hemorrhoids? In short, hemorrhoids refers to a condition in which the veins around the lower rectum or anus are swollen and inflamed. Hemorrhoids can be found internally within the anus or externally around the anus.

The condition is often worsened as sufferers attempt to make a bowel movement. Other causes include: diarrhea, anal intercourse, pregnancy, constipation, and aging.

Signs of hemorrhoids are observed through blood on toilet tissue, as well as blood found in and around the toilet bowl. A lump or painful swelling around the anus can be a physical sign as well as extreme itching in the same area.

There are two methods you can try to actively reduce or eliminate the condition:

1. Apply a hemorroidal cream or suppository to the area affected.

2. Warm tub baths, several times a day, in plain water.

To prevent future attacks you can take the following steps:

1. If constipation is a problem for you, increase your fiber intake to bring on smoother bowel movements.

2. Cut back on caffiene as coffee and similar products may exacerbate the problem.

3. Exercise regularly.

In severe cases you may require a physician’s intervention. Your doctor may suggest that affected tissue be burned or the hemmorhoid removed altogether. Other options include rubber band ligation or the injection of a chemical solution to alleviate the condition.

Some cases of hemorrhoids simply go away on their own. In all cases you can control and even eliminate the condition by following the steps outlined for you.

In an age of managed care, rationing of care, and technological care, there is The Art of Care. We live in a society that has been given various choices to “self-determine” one’s destiny in dying as one has been able to “self-determine” one’s destiny in life itself. We have medicines and technological capabilities, and areas of the country allowing us to hasten or postpone one’s dying. The purpose of this position paper is to outline the legal, ethical, religious, and philosophical ramifications involved in Physician Assisted Suicide (PAS) and how affects of such decisions effect those connected to this issue.

The pros for PAS are:

• People should have the right to die with dignity

• People should have the right to die with their senses intact

• People should have the right to die free of pain

• People should have the right to take charge of futile care

The cons for PAS are:

• Slippery-slope effect, or acceptable and unacceptable euthanasia

• No policy is able to effectively govern the scope of the right to die

• True wishes are hard to discern due to communication challenges

• Playing God

I am simply giving an overview, and not, a detailed analysis on this issue. My intent is to surface the issues in PAS and move toward a philosophy of care that can minimize people’s fear of death by the utilization of a type of care = The Art of Care. The Art of Care will help people gain inner strength that can enable him or her to cope with the external losses happening to their body. At the end of this paper, I hope to outline practical ways people can help terminal patients cope with a dying body from a place inside them that remains steadfast &ndash their soul.

It was Karl Barth who said that “it is for God and God alone to make an end to human life” and that God gives life to us “as an inalienable loan.” It is my belief that we are given meaning and hope in all life situations. This instinct to survive and find value in all of our existence leads me to trust that there is much to learn in all phases of our life. Our ability to trust our Creator’s divine guidance and plan to make us more soul than body at the end of life is just as important as other aspects of living as well. We may do well to trust more and control less. It appears that maturity teaches us all to let go and follow a path inside us that does not always make sense to us externally. As we do, we begin to follow insight. To see from within what cannot be seen from without is our soul’s longing to be known and to surface in our lives.

In On Liberty, John Stuart Mill cautions, “A person should be free to do as he likes in his own concerns, but ought NOT to be free to do as he likes in acting for another, under the pretext that the affairs of the other are his own affairs. Autonomy is so important to us that science, as well as religious communities strive to honor and respect it. For within autonomy is the ability for one to discern for him or herself one’s needs, values, and destiny. This is a movement into the art of care (science and religion) can work together in forging a healing response on the level of soul when physical cure is no longer possible.

On the other side of this issue, it is evident that the Oregon ’s Death with Dignity Act has had its impact on America . Some people want this service available even if it is not chosen by a great number of people. The Oregon ’s Death with Dignity Act has been used very sparingly and a slippery slope does not appear to be in the present forefront. “In 2001, twenty-one Oregonians chose to end their lives by ingesting a lethal dose of medication prescribed by a physician, accounting for 0.33% of the 6,365 Oregon deaths from similar diseases. The number of Oregonians opting for physician-assisted suicide has remained fairly stable, ranging from sixteen in both 1998, the first year the law was in effect, to twenty-seven in both 1999 and 2000. Clearly, there is no landslide in the making.”

It seems then, that people still want to have some sort of control in their dying and autonomy remains prevalent throughout the issue with PAS. This strong need to determine one’s path in the face of suffering offers us hope, faith, and love in a sense of the self not easily defined without losing the grandeur of a trust within oneself to be led by the same power that brought our lives into being. It is here that we turn to the art of care to help us when curative care no longer has any answers. Here, we begin where we end, in that we trust in the very wisdom that has created us.

Samuel Oliver, author of, “What the Dying Teach Us: Lessons on Living”

For more on this author; .soulandspirit.org