General Medication Questions: Part 2

[continued from part 1]

One of the most popular features in Arthritis Today, "On Call" finds answers to your most puzzling arthritis questions by asking a variety of healthcare experts. Just click on the question or title you'd like to see.


The Wait For Generics
Help For Hair Loss
Scared By Side Effects
How Can I Get Butazolidin?
Making Medication More Palatable for Children
Does DMSO Help?
When Your Doctor Tries to Sell You Stuff
Experimenting with Enbrel
Off-Label Drug Use
Taking Methotrexate Safely
Before You Order Drugs Online...
Cancer History and Drug Use
Medical Mistakes: Don't Be a Victim
Fears About Prednisone
Drug-Related Hair Loss
Pain Relievers and Lithium
Side Effects of Inhaled Steroids
Concerns About Drug Safety
Stomach-Safe Drugs
Getting By Without Drugs
Medications' Effects on Teeth

More questions
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The Wait For Generics

Q: I have been reading about all the new drugs (leflunomide, etanercept, celecoxib, etc.) that are coming out for arthritis, but they seem so expensive. When might generic versions of these drugs be available?

A: Generic forms of these medications - or any new medication, for that matter - are not likely to be available for at least five years and possibly as long as 17 years, depending on how long it took their manufacturers to complete research and get FDA approval for them. That is because developers of new drugs are granted protection for a period of time - currently 17 years from the time of discovery or at least five years after it was initially marketed - to help them recoup their research investment, which averages $200 million per successful drug. Without patent protection, drug companies would have less incentive to invest in developing new medications.

It's understandable you're eager for generic versions to hit the market. The competition these no-name brands provide generally lowers the price of drugs by 50 percent or more. But keep in mind the competition may not do much to lower the price of drugs that are inherently difficult and expensive to manufacture, such as the new biologic agents, which are often large, complex molecules that need special handling and manufacturing processes. If you want to find out when generics for specific medications might be available, check out the FDA's list of patent expiration dates, which is available on the Web at www.fda.gov/cder/drug.htm. Look under patent term extensions and new patents. If you don't have Internet access you can obtain this information by calling the FDA at 301/827-4573.

Donald R. Miller, PharmD, Pharmacist


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Help For Hair Loss

Q: Do you know of any treatment that can halt or reverse the hair loss associated with methotrexate use? Having taken methotrexate for 11 years at a dose of 71/2 milligrams per week, I have completely lost my eyebrows and eyelashes, and my hair has become quite thin.

A: Hair loss caused by methotrexate treatment is rare, but when it does occur, it can be difficult to treat. If your hair loss has been present for years and the hair follicles themselves have been affected, nothing may help. However, if hair loss is mild or if new hair continues to grow, it is possible you may benefit from the new prescription drug called leucovorin (Wellcovorin). A dose of 5 to10 milligrams, taken eight to 12 hours after the last dose of methotrexate for the week, has helped some people.

Bernard Rubin, DO, Rheumatologist


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Scared By Side Effects

Q: After reading the pharmacy sheets listing side effects of the medications I take for rheumatoid arthritis (RA), I can't help but wonder if the "cure" is worse than the disease. Is it possible I'd be better off skipping the medications and taking my chances with the RA?

A: I would really hate to see you - or anyone with a potentially disabling disease such as RA - completely give up medications. But I certainly can understand your concerns: No medication is completely safe, and the potential risk of side effects can be frightening. Anytime you interfere with one bodily process you may interfere with others - sometimes in undesirable ways. But the dangers of untreated RA, in most cases, far outweigh the risks of the drugs used to treat it. Each day, medications ease pain, prevent joint destruction and improve the lives of countless people with arthritis and related conditions. In some cases, medications can literally save lives.

The pharmacy sheets are provided as a service to make you aware of side effects that can occur with a certain medication. Keep in mind that the key word here is "can." You shouldn't assume that the listed side effects will necessarily occur in you. Even if you do experience one or more side effects, you may be able to reverse or halt them by stopping or changing medications. In most cases, no action is needed; the side effects resolve on their own.

Many factors can influence how your body reacts to a drug. Some are largely controllable - such as when and how you take your medicine. Factors that can't be changed, such as your age and other health problems, may be compensated for with choice of medication or a dosage adjustment. Life is full of risks. Sometimes we have to risk experiencing a side effect to gain a medication's benefits. The key is weighing risks against potential gain. Your doctor can help you weigh those risks and choose the drugs that provide the most help and do the least possible harm.

There are also several things you can do to reduce your risk of drug side effects. Here are a few:

Let your doctor know about any other medications you are taking - even over-the-counter (OTC) ones- because some can add to the side effects of others. For example, taking aspirin along with a prescription nonsteroidal anti-inflammatory drug (NSAID) can increase your risk of stomach ulcers and other side effects.

Don't underestimate the power of nutritional supplements. Nutritional supplements, too, can affect the way a drug works. In some cases - such as taking folic acid along with methotrexate - vitamin supplements can reduce the risk of certain side effects. In other cases, taking nutritional supplements or herbs in addition to prescribed medications can interfere with the action of the medication or even enhance its potential side effects.

Find out if there are certain foods you should eat or avoid while taking a medication. Most drugs, including NSAIDs, should be taken with food to reduce the risk of stomach upset. For others - such as minocycline, an antibiotic that is being used increasingly to treat RA - taking with food can decrease the drug's absorption.

Forgo alcohol - it can add to the side effects of most drugs, from analgesics to antidepressants. If you can't or don't want to give up alcohol altogether, set a limit of two drinks (including beer) per week.

Ask your doctor to prescribe the lowest beneficial dose of a drug and never take more than the prescribed amount. Many side effects are related to dosage. High doses of glucocorticoids such as prednisone, for example, can cause a wide range of side effects, including fluid retention, fragile bones and increased susceptibility to infections. Low doses, which are often effective in managing inflammatory arthritis, have a low risk of side effects.

Take the drug at the time designated by your doctor. Timing, in some cases, can influence a drug's side effects. For example, taking the osteoporosis drug alendronate when you get up in the morning, rather than before lying down at night, can cut the risk of esophageal ulcers. Timing can also influence some drugs' wanted effects. By taking a drug at the optimum time, you may actually be able to reduce the dose and, thus, the risk of side effects.

Never stop taking any medication without consulting your doctor. A drug can't help you if you don't take it, but abruptly stopping a drug can hurt you. The dosage of drugs such as prednisone, for example, must be tapered to avoid serious adverse effects.

Let your doctor know if you suspect a side effect. He can determine whether the side effect requires treatment or if discontinuing a drug or perhaps educing its dose is in order.

Leonard H. Calabrese, DO, Rheumatologist


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How Can I Get Butazolidin?

Q: Several years ago, my previous physician prescribed a medication called Butazolidin - the only medication that has helped me manage the pain of RA. That physician retired and my new one says Butazolidin is used only for horses. Is this true? Isn't there some way I can get this medication?

A: Butazolidin is the brand name of a NSAID called phenylbutazone. Currently, no U.S. manufacturer produces phenylbutazone for human use. Phenylbutazone, introduced in 1952, was the first NSAID - aside from aspirin - to be marketed and remained popular for many years. As other NSAIDs came out, however, its popularity diminished, due to increased competition as well as the drug's risk of side effects. In addition to having side effects common to NSAIDs, phenylbutazone also causes potentially life-threatening decreases in blood cell counts in some people. Consequently, in 1984 the FDA made its manufacturer add a warning to the drug labeling mandating that phenylbutazone not be used until other NSAIDs were found ineffective in a patient and that caution should be used in prescribing the drug to older people. Eventually, both Butazolidin and its generic versions were discontinued due to low sales. As your physician mentioned, phenylbutazone is still available in veterinary formulations, but severe side effects have been reported in people who ingested veterinary phenylbutazone.

I'm sorry that other drugs have not helped you the way phenylbutazone did, but with the high numbers of NSAIDs on the market - and all the new drugs coming out shortly - I hope you and your doctor will find one that brings you relief.

Donald R. Miller, PharmD, Pharmacist


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Making Medication More Palatable for Children

Q: I have a 7-year-old daughter who takes naproxen twice daily for JRA. Because the medicine tastes so bad, we usually grind it up in applesauce to get her to take it. But she's getting tired of applesauce. Do you know of any other way to disguise the taste? Is there an enteric-coated form of naproxen that might taste better?

A: If you think your daughter would do better with liquid medication, speak to her doctor about switching. Most children don't mind the taste. You might also try disguising the ground-up pill in another food such as chunky peanut butter. Another alternative is to purchase some empty gelatin capsules from your pharmacist. (The capsules come in various sizes to accommodate different pill sizes.) The capsule can be opened and the hard-to-swallow pill inserted. These gelatin capsules go down quite easily.

Carol B. Lindsley, MD, Pediatric Rheumatologist


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Does DMSO Help?

Q: I have heard that DMSO is helpful in reducing arthritis pain. What is DMSO and what are the pros and cons of this treatment?

A: DMSO (dimethyl sulfoxide) is a waste product of paper manufacturing that has been found to be medically useful in some situations. Veterinarians use it for animal treatment and medical doctors use it, with FDA approval, for a bladder condition called interstitial cystitis. Although some claim it relieves pain and reduces swelling in arthritis, studies of its effectiveness and safety are mixed and so it is reserved for experimental use only.

As with any other nontraditional treatment, my first question is: Does the treatment have the potential to cause harm? For DMSO, the answer is yes. Some studies have found it speeds up joint destruction and its adverse effects have included skin reactions, vision damage, and liver and kidney damage. Nerve damage and muscle weakness have occurred in those who have used DMSO at the same time as sulindac, a prescription nonsteroidal anti-inflammatory medication.

On top of that, DMSO is not available in purified form for either oral or topical use. (When used to treat interstitial cystitis, it is administered directly to the bladder through a catheter.) It is absorbed through the skin and stomach very quickly and any contaminants or other ingredients that are in the DMSO -- or on the skin -- are absorbed with it. This can lead to toxic substances being unintentionally introduced into the body.

As a result, I believe that the potential harm far outweighs any potential but unproven benefit it may produce in treating arthritis. I recommend you see a physician to determine the type of arthritis you have and the most appropriate treatment.

C. Tim Lambert, MD, Family Practitioner


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When Your Doctor Tries to Sell You Stuff

Q. During my last visit to my rheumatologist, he suggested I buy a nutritional supplement that only he could sell me. The price seemed a little steep, and it isn't covered by insurance. Do you think I should try it?

A. Probably not -- and for more reasons than one. First, I don't know which supplement your doctor is trying to sell you; naturally, I can't recommend you try a product if I don't know what it is.

However, beyond that, I cannot in good conscience recommend that you go ahead with buying any product from your doctor -- especially if the price seems high to you. The mere fact that he is even attempting to sell you this supplement bothers me.
As a physician, I occasionally receive promotional materials from companies offering me the opportunity to sell products to my patients. The pitch is generally the same: Not only will their product help my patients, it will also help me -- by bringing more money into my practice. In other words, these companies are telling me I can make money on the side by selling supplements to my patients.

Quite often, these products are not available in retail outlets. Some are distributed exclusively through doctors' offices; others are sold through multi-level marketing programs.

No doubt you're familiar with multi-level marketing programs; they've been around for decades as a way to sell products ranging from cosmetics to cleaning supplies. More important, they create "pyramids" of sellers, each making money off friends (and, in turn, those friends' friends) they recruit to sell the products.

What's new is that these multi-level programs are now targeting doctors who could then prey on vulnerable patients desperately seeking relief.

Doctor-exclusive products are not the only ones being sold by doctors involved in multi-level marketing, however. Last year, the American Medical Association (AMA) reprimanded a group of Mississippi doctors who, it was discovered, were engaged in selling commonly available vitamins and supplements for more than three times their retail price.

According to the AMA, the sale of nutritional supplements to patients by doctors is a growing trend. But is it one that's here to stay? Not if the Association has its way

As put forth in a set of guidelines issued recently by its Council on Ethical and Judicial Affairs, the AMA recommends that physicians not participate in exclusive dealerships of health-related products (which would force patients to either buy them from their doctor or to do without) nor sell any product for more than cost.

Unfortunately, the guidelines are just that -- guidelines. They are not mandatory. Some doctors may still be lured by the promise of extra income, particularly as managed care slashes their revenues for doing what they're supposed to be doing -- that is, diagnosing and managing disease.

So for the time being the phrase "buyer beware" holds true even at the doctor's office. I encourage you not to buy expensive products from your doctor just because he says you should.

And if you are truly convinced that you should take a particular vitamin or supplement, see if you can find it at a pharmacy or supermarket after you leave the doctor's office and compare prices.

Doyt L. Conn, MD, Rheumatologist


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Experimenting with Enbrel

Q. I have polymyalgia rheumatica (PMR) and my doctor recently started me on Enbrel twice weekly as an "experiment." However, I haven't noticed any improvement in my condition. Do you think this treatment is appropriate?

A. Enbrel (etanercept) is a new agent recently approved by the FDA for the treatment of RA and juvenile rheumatoid arthritis.
Your doctor refers to your treatment with this new drug as an "experiment," because there are no published data on its use in PMR for him to turn to.

For the same reason, I really can't say whether the treatment is appropriate. In general, Enbrel is safe, although there is some concern in the medical community that Enbrel's ability to influence the immune system could lead to infection or other problems.
There is sufficient reason to believe that Enbrel might be helpful for PMR, however. And rest easy: It is not uncommon for a doctor to prescribe a drug for a type of arthritis other than that for which it was originally tested and approved, if the current treatment is not working.

In this case, your doctor knows the agent works to block tumor necrosis factor (TNF), a powerful mediator of inflammation in RA. And because PMR is an inflammatory disease, he probably considers it to be possible that by blocking TNF, Enbrel may help your PMR as well.

For most people, however, taking low doses of prednisone along with NSAIDs can control your PMR effectively and is a lot less expensive than Enbrel.

Bernard Rubin, DO, Rheumatologist


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Off-Label Drug Use

Q. I have severe rheumatoid arthritis (RA) with vasculitis that hasn't been helped by any of the drugs I have taken. My doctor wants me to take a cancer drug called Cytoxan. Why would he prescribe a cancer drug for RA? Can he do that legally?

A. You’re right that Cytoxan (cyclophosphamide) is a cancer drug. It is approved by the FDA for the treatment of several types of lymphoma, leukemia and other cancers.

Even though it is not approved for RA, studies and clinical practice have shown it to be helpful against RA-associated vasculitis (inflammation of the blood vessels), so rheumatologists prescribe it for that purpose.

Once a drug is approved to treat one condition, a doctor may prescribe it for other diseases as he sees fit. This practice is called off-label prescribing and it is commonly done.

In fact, some of the most successful drugs for arthritis-related diseases were first prescribed off-label, because they were originally developed and/or approved for other diseases. For example, methotrexate, one of the most effective RA treatments, was originally developed and approved as a cancer treatment. Doctors prescribed it off-label for RA for many years before its manufacturer sought and received FDA approval for RA.

But methotrexate is not the only arthritis drug that was first approved for another condition. Here are some of the others:

• Sulfasalazine (Azulfidine), was first approved for inflammatory bowel disease. It wasn't approved for RA until almost 50 years after its development.
• Cyclosporine (Sandimmune, Neoral), which was developed and used to prevent the rejection of transplanted organs, has in recent years been approved for the treatment of rheumatoid arthritis and psoriasis.
• Chloroquine was first used during World War II to treat malaria. Today, the chloroquine derivative hydroxychloroquine (Plaquenil) is approved for both RA and lupus.
• Infliximab (Remicade), was approved for Crohn's disease in 1998. It was approved for RA last November.

Sometimes drugs begin to gain acceptance for off-label use purely by coincidence. For example, in the 1940s while using chloroquine to treat malaria patients, doctors noticed that patients who also had RA experienced improvement in their RA symptoms. In other cases, researchers have seen a similar mechanism between two diseases and decided to try a drug that's already approved for one condition to treat the other.

The FDA does not prohibit the practice of off-label prescribing; however, it does regulate the claims a drug company can make about a drug and the diseases for which the company can market a drug. That is, a drug company cannot market – either through advertisements or one-on-one discussions with doctors – a drug for conditions other than those for which the drug is FDA approved.

Once clinical practice suggests that an off-label use is successful, controlled studies should be – but are not always – done to demonstrate the drug's benefit. If studies confirm that a drug is useful for a condition other than the one(s) for which it is approved, its manufacturer may choose to pursue FDA approval for the other disease as well.

This process helps determine optimal dosages and ensure the effectiveness of drugs for the disease conditions for which they're prescribed. So far the maker of Cytoxan has not submitted it for FDA approval as an RA drug.

No matter which drug your doctor prescribes – off-label or not – it's important that you know how to take the drug properly, recognize potential side effects, and know what to do if you experience side effects.

Doyt L. Conn, MD, Rheumatologist


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Taking Methotrexate Safely

Q. I have been prescribed varying dosages, sometimes up to 20 milligrams of methotrexate per week, for the past two years. What should I be aware of concerning methotrexate use?

A. Methotrexate is an effective and usually well-tolerated medicine for RA. But, like any drug prescribed for any reason, it does have potential side effects.

To get the most benefits from the drug and reduce the likelihood of complications, it's important to heed the following advice:

Take methotrexate exactly as directed by your physician.

• Ask your doctor if you are unclear about the medicine's dosing or possible side effects.
• Don't take other drugs - including over-the-counter ones – without first speaking to your doctor. Certain pain-relievers can act to increase the effects of methotrexate.
• If you notice any unusual bleeding or signs of infection, tell your doctor. Methotrexate can lower the number of blood platelets (which help the blood to clot) and white blood cells (which normally fight infection).
• Don't get any vaccinations without informing the health-care provider that you take methotrexate. Certain vaccinations can be dangerous in people whose immune systems are altered by drugs such as methotrexate.
• Don't drink alcohol while you are taking methotrexate. That's because one of the most serious long-term side effects of methotrexate is liver damage.
• You will decrease the chance of liver problems when you avoid alcohol.
• Call your doctor immediately if you have trouble breathing. In rare cases, methotrexate can cause inflammation of the lungs. Although there is no known way to prevent this side effect, prompt treatment is essential if it occurs.

Don Miller, PharmD, Pharmacist


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Before You Order Drugs Online...

Q. With rheumatoid arthritis, fibromyalgia and several other health problems, I find getting to the drugstore to pick up my medications difficult. I have heard that ordering drugs on the Internet is easy and convenient, so I would like to give it a try. Before I do, is there anything I should know?

A. You can get just about anything over the Internet these days.

Certainly, drugs are no exception. While it is no doubt convenient to get drugs online — essentially all you have to do is point and click — I can think of at least five reasons the Internet isn't necessarily the best place to purchase your medications. Before you decide to place an order, consider these potential problems and consider some words of advice:

1) Questionable products. Online pharmacies may lure you with the opportunity to get drugs, such as narcotic pain relievers, that your own doctor refuses to prescribe. Foreign pharmacies may even offer drugs that aren't approved in this country. Resist the temptation to buy these drugs — there's a reason why they aren't approved in the United States or why your own doctor, who is aware of your medical history, won't prescribe them for you.

Even if you just order the same drugs you have used for years, there is no way to ensure that the products you get from non-U.S. Web sites are genuine, of the right strength and uncontaminated.

2) Faceless doctors and unethical prescribing practices. Although there are a number of reputable online drugstores that require a faxed prescription from your own physician, others ask only that you have a "consultation" with an anonymous online physician, who most likely is not licensed to practice in your state.

The consultation essentially amounts to a brief questionnaire, which can't take the place of a face-to-face meeting with your own doctor and a thorough physical exam. With your multiple health problems, you really need at least one doctor who knows you well and can coordinate your medical care and direct drug prescribing.

3) Excessive costs. When it comes to prescription drugs, online shopping may be convenient, but it isn't cheap. In a study published last December in the Annals of Internal Medicine, researchers at the University of Pennsylvania in Philadelphia searched the Internet extensively to identify sites that provided consultations by a doctor and sold prescription drugs.

Among other things, the researchers found that drugs purchased through those sites were more expensive (even when excluding the shipping costs of $8 to $25) than were the same medications in Philadelphia drugstores. Furthermore, online "consultations" with physicians cost, on average, $10 more than a physician visit in Philadelphia.

4) Inconsistency. If you buy all your medications from one pharmacy, there will be a central location for all your prescription records. It's common for a pharmacist to notice and alert a person to the fact that they are taking, or are about to take, two medications that have the potential to interact with one another. Switching some — but not all — prescriptions to an online pharmacy or ordering new prescriptions online can potentially lead to drug interactions, particularly if you take different medications for your various health problems.

5) Delivery Delays. If you need a medication for an acute problem or if you're down to your last day's supply of the medication you need for a chronic illness, the Internet isn't the place to shop – the soonest an Internet pharmacy can deliver is the next day. In those cases, you should always opt for a local pharmacy where you can get your medications the same day.

I understand your interest in the Internet. But remember that it's not your only option for convenience. Some local pharmacies still deliver. (Check the Yellow Pages for one near you.) If you have health insurance, your plan may have a contract with a mail order pharmacy. Some will deliver three months of medication to your home with a single co-payment. (As with Internet shopping, this isn't appropriate for an acute illness that requires medication immediately.)

Finally, if you do decide to order drugs online, please keep the following in mind: Use only a prescription from your own doctor, choose a U.S. Web site that requires a prescription from your physician, then compare prices — and be prepared to pay more for the convenience.

Doyt Conn, MD, Rheumatologist


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Cancer History and Drug Use

Q. I have heard that malignancies can occur in people taking the drug Arava. Because I have a history of Hodgkin's disease (a cancer of the lymph nodes), as well as RA, do you think I should avoid this drug?

A. Leflunomide (Arava) is a relatively new drug for the treatment of rheumatoid arthritis (RA). The drug reduces joint pain and swelling and, in addition, can slow damage to cartilage and bone, as shown by X-ray. There are no studies showing leflunomide increases cancer risk; however, published studies on leflunomide have involved limited numbers of patients and, because the drug is relatively new, it is really too early to know whether the drug puts people at serious risk of malignancy somewhere down the line.

This potential to cause malignancies has been raised for a number of other RA drugs. Further epidemiological studies are needed to determine if, in fact, drugs do significantly increase cancer risk. Complicating this issue is the fact that RA itself may be associated with an increased occurrence of certain malignancies. In that case treating RA aggressively with medications may actually decrease cancer risk.

I have no easy answer to your question. The best path is to consult both a rheumatologist (arthritis specialist) and oncologist (cancer specialist) and decide which arthritis drugs will likely work best and have the fewest side effects and risks.
Interestingly, some drugs used to treat malignancy, such as methotrexate, are also effective in treating RA.

David S. Pisetsky, MD, PhD, Rheumatologist


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Medical Mistakes: Don't Be a Victim

Q. With all the news today about medical errors, I feel vulnerable. I take several medications and undergo fairly frequent medical procedures for arthritis and a couple of other health problems. Is there anything I can do to protect myself?

A. You are right to be concerned about medical errors that could adversely affect your health care – and your life. Unfortunately, medicine is not an exact science. There is always the potential for human and technical error.

Today's technology enables us to manage and treat disease better than at any time in history – but not without a price. The increasing number of medications and procedures – along with medical staffs that are often rushed and overburdened – also means an increased risk of something going wrong during treatment. Now, more than at any time, it's important that patients take active roles in their own health care.

By being alert to potential problems and knowing what to ask of your doctor and other health-care providers, you can minimize the risk of errors and increase your chances of successful medical treatment.

Here are some specific things you can do to ensure your own safety:

Know what you're taking. When your doctor prescribes a medication, ask him what the drug is, what it's supposed to do and if there are any side effects you should be aware of. When the pharmacist fills your prescriptions, ask the same questions, just to be sure you're getting what the doctor ordered. Some prescription medications – with entirely different uses – can have names with similar spellings and pronunciations (for example, the nonsteroidal anti-inflammatory drug Celebrex and the antidepressant Celexa).

Give a complete answer. If your doctor asks about other medications you're taking – including over-the-counter (OTC) medications and nutritional supplements – be sure to give him a complete list. Some nutritional supplements and OTC medications can interact adversely with prescription medications. Your doctor can't warn you of potential problems if he doesn't know what you're taking.

Bring a friend. If you have difficulty remembering your doctor's instructions or need some moral support at the doctor's office, ask a friend or family member to come along. Your friend may take in more information – or think of important questions – than you can when you're feeling bad. Together, you'll come away with more information than one person could alone. If you have to be hospitalized, having a friend or family member in the hospital room with you can help as well.

Watch him wash up. Make sure your doctor or other health-care provider washes his hands or changes his rubber gloves in your presence before he touches you. Touching a sick patient, and then touching you without first washing his hands, is a good way to spread germs – and harmful illness.

Choose a high-volume hospital. Studies have shown that when you want a successful medical procedure, you should choose a surgeon and a hospital that do a lot of that particular procedure. A study presented at last fall's meeting of the American College of Rheumatology, for example, found that the risk of complications (including dislocation and infection) and death following hip replacement surgery decreases as a hospital's number of surgeries completed increases.

Get the facts. If your doctor recommends a medical procedure, learn as much as you can about the procedure before you have it. Ask your doctor or other health-care provider plenty of questions: How will the procedure likely help? What are its risks? What are the risks of not having it? What should I do to prepare for it? What should I be aware of or watch for afterwards?

Ask if the doctor has any written material you can take home and study. Also, ask if you can take consent forms home to look over or share with a friend or family member. Unless you have an emergency that requires immediate medical care, always do your homework before agreeing to surgery or other medical procedures.

Read the book. Because any medical problem can require hospitalization at some point, I would recommend you buy the book Take This Book to the Hospital with You: A Consumer Guide to Surviving Your Hospital Stay (St. Martin's Press, 1997). Published by the People's Medical Society, the largest medical consumer organization in the country, the book offers suggestions to improve the safety and success of your hospital stay.

While medical errors are far too common, they are still the exception. Safe, successful medical treatment is still the rule. By following these suggestions, you can help ensure that your medical treatment does what it is intended to do – that is to help, not harm, you.

Doyt L. Conn, MD, Rheumatologist


Editor's note: For a free fact sheet, 20 Tips to Help Prevent Medical Errors, contact the Agency for Healthcare Research and Quality at 800/ 358-9295 and ask for AHRQ publication No. 00-P038. Or visit their Web site at www.ahrq.gov/consumer/20tips.htm.


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Fears About Prednisone

Q. Eleven months ago, I was diagnosed with polymyalgia rheumatica and prescribed high doses of prednisone. I have currently tapered down to 1 milligram (mg) and 2 mg (alternating days), but I'm really afraid to continue taking it because I have heard about all its awful side effects. Should I keep taking it at this point?

A: The truth is that all medications, prednisone included, can cause side effects. It's important that patients learn as much as possible about the types of side effects that can occur and how likely they are to happen. (Remember, just because a drug carries a risk of side effects, that doesn't mean that you will necessarily experience those side effects.)

This information concerning side effects, in turn, should be weighed against that of the drug's benefits – the reason you are taking it in the first place. Physicians refer to this as the risk-benefit ratio, and always consider it in making decisions about prescribing a medication.

In most patients with polymyalgia rheumatica, the response to therapy with prednisone is dramatic; they go from feeling sick to well within a matter of days. Generally doctors prescribe a moderate dose of prednisone initially then reduce it slowly, watching for signs of disease recurrence. Because your dose is so low, I assume you are having no problems with your disease. Also, the lower your dose, the lower your risk of side effects. So for you, I'd say, the risk-benefit ratio of prednisone at this dose is very low.

Some people in your situation continue on low doses of prednisone indefinitely; others are able to discontinue it completely. Even if you are seriously bothered by the prospect of side effects, don't stop taking prednisone on your own. Instead, ask your doctor if it would be possible – or wise – to stop taking the drug completely.

John Klippel, MD, Rheumatologist


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Drug-Related Hair Loss

Q. I have been taking Plaquenil for 10 years for my polymyositis. (My current dose is 200 milligrams twice a day.) It has helped me a lot, but during the past few years I have experienced increasingly severe hair loss. Could this medication be responsible?

A: Although certain medications are frequently associated with hair loss, with hydroxychloroquine sulfate (Plaquenil) this problem is extremely rare. Hair loss is listed in the Physicians' Desk Reference as a potential side effect of Plaquenil; however, only six cases of hair loss have been reported to the drug's manufacturer. Furthermore, in individual cases, it is difficult to be sure that hair loss was caused by the drug instead of another cause, such as dietary deficiency, stress or hormonal problems, just to name a few. Even though I know very little about your specific situation, I would suspect that there is probably another cause for your hair loss. And because you seem to be doing well on Plaquenil, I would not recommend stopping the drug. Instead, consult your physician about other possible causes for your hair loss and what might be done to slow or stop it. More information on hair loss, including drugs that promote hair loss, can be found at www.keratin.com. You might find some other useful information there, although I wouldn't recommend purchasing any drugs advertised on the site without first consulting your doctor.

Don Miller, Pharmd, Pharmacist


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Pain Relievers and Lithium

Q. I take 600 milligrams of lithium daily for bipolar disorder, and I also have arthritis in my shoulders. Because many arthritis drugs can’t be taken with lithium, I have suffered a lot. Can you recommend a drug that won’t interact with lithium?

A. It’s true that many arthritis drugs shouldn’t be taken with lithium. Most nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen or naproxen, affect the kidneys’ ability to eliminate lithium from the body. The result: high blood levels of lithium and a risk of adverse effects, such as trembling, muscle weakness, slurred speech and blurred vision.

The magnitude of an NSAID’s effect on lithium levels seems to vary from person to person – and from NSAID to NSAID. It appears that the new COX-2 drugs, celecoxib (Celebrex) and rofecoxib (Vioxx), affect lithium similarly to traditional NSAIDs. However, there is some evidence that two older NSAIDs – sulindac (Clinoril) and aspirin – do not have a significant effect on lithium levels. For that reason, if you want to try using an NSAID, one of those two is probably your safest bet.

For people taking lithium, NSAIDs aren’t absolutely off limits. The combination may be used safely, but only under the close observation of your physician who can check your blood lithium levels and adjust your dose as needed.

If you’d like to try safer alternatives, acetaminophen and topical analgesic medications, such as capsaicin, should have no effect on lithium levels.

Donald R. Miller, PHARMD, Pharmacist


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Side Effects of Inhaled Steroids

Q. Having taken glucocorticoid medications for lupus, I live with the fear of osteoporosis. Now I have learned that my 6-year-old daughter has asthma and will have to take inhaled steroids. Will this put her at risk of osteoporosis as well?

A. Glucocorticoids are powerful and beneficial medicines used for reducing the inflammation of many conditions, including lupus and asthma. For systemic diseases like lupus, glucocorticoids are typically taken orally. For asthma, inhaled glucocorticoids deliver the medication directly to the inflamed airways.

Glucocorticoid medications are associated with a number of possible side effects, including osteoporosis, regardless of how they are administered. But it appears that inhaled glucocorticoids present minimal risks – particularly if used for short periods of time and/or in small doses.

When prescribing inhaled glucocorticoids, doctors start therapy with high doses and then decrease the dose to the lowest one that is effective. The side effects of glucocorticoids administered in this way are usually insignificant when compared to the dangers (including irreversible damage to the airways and even death) of untreated asthma.

Your doctor should work with you and your daughter to assess the need for inhaled glucocorticoids and the lowest dosage that will treat her condition properly.

You can also help by teaching your daughter about the importance of good nutrition and calcium-containing foods, even at her young age. Calcium is especially important for growing bones and to reduce the risk of osteoporosis later in life, whether she’s taking glucocorticoids or not.

C. Tim Lambert, MD, Family Practitioner


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Concerns About Drug Safety

Q: I had been taking Celebrex for about six months, but stopped after Vioxx was taken off the market and started taking Tylenol Arthritis. The results have been about the same, but is there harm in taking this much Tylenol long term?

A: For most people, there is no problem using acetaminophen at doses of up to 4,000 milligrams (mg) per day. At three 1,300-mg daily doses, you are just below that limit. In fact, for many people, acetaminophen may be the safest analgesic, or pain reliever, available.

The main serious side effect seen with acetaminophen is liver damage. This typically occurs only in people who have pre-existing liver problems or who take other substances that affect the liver -- alcohol being the worst culprit. People who consume two or more alcoholic drinks per day are at particular risk of liver side effects if they take acetaminophen.

DANIEL CLAUW, MD, Rheumatologist


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Stomach-Safe Drugs

Q: I was hospitalized with a bleeding ulcer, which my doctor believes was caused by the naproxen I had been taking. Do you know any drugs for rheumatoid arthritis (RA) that are safe for my stomach?

A: Bleeding ulcers are a common and serious side effect of all nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin), ketoprofen (Acton, Orudis) and naproxen (Aleve, Naprosyn). Approximately one to two percent of all patients who use NSAIDs experience bleeding ulcers. Now that you have had a bleeding ulcer, taking a traditional NSAID alone is not a good idea.

Fortunately, there are safer pain-relief options your doctor may want you to try. These include:

• Acetaminophen (Tylenol) to ease pain
• COX-2 inhibitors - celecoxib (Celebrex) -- a class of NSAIDs that are somewhat safer for the stomach, but should be used with caution by those with heart attack risk
• NSAIDs taken with stomach-protective drugs, including acid controllers such as lansoprazole (Prilosec) or misoprostol (Cytotec), a synthetic version of the stomach-protective substances called prostaglandins that traditional NSAIDs wipe out

Foremost, you should keep your RA under control. Treatment for RA should emphasize prompt and aggressive use of disease-modifying drugs (DMARDs) like leflunomide (Arava) and methotrexate (Rheumatrex, Trexall), or biologic drugs, such as adalimumab (Humira), anakinra (Kineret), etanercept (Enbrel) and infliximab (Remicade). None of these drugs cause or aggravate bleeding ulcers and for many people they eliminate the need for NSAIDs.


Keep in mind that many non-drug treatments can help ease pain. These include relaxation techniques, meditation, heat and cold, massage and acupuncture. Speak with your doctor about the best treatments - both the medication and non-medication variety - for you.

DONALD R. MILLER, PharmD, Pharmacist


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Getting By Without Drugs

Q: I have osteoarthritis (OA) in both knees, which makes it very difficult for me to walk. I would like to avoid medications if possible. Is there a diet or something other than drugs that might help?

Yes, there are plenty of options beside medications that can help OA of the knee. Diet, nutritional supplements, exercise and splinting are all important components of a comprehensive treatment plan to ease the symptoms of OA and possibly delay or retard its progression.

Diet. Diet is very important, but it has less to do with what you eat than how much you eat. Being overweight worsens arthritis pain and disability. Rather than going strictly by numbers on a scale, doctors commonly use a measure called body mass index (BMI) to determine obesity. A BMI of 19 to 24 is optimal. If yours is higher, you should lose weight. To calculate your BMI and determine how close you are to your ideal weight range, take your body weight and multiply it by 703, then divide that by your height in inches squared. Let's say, for example, you are 5 foot, 4 inches tall (64 inches) and you weigh 150 pounds. Your BMI would be (150 x 703) ÷ (64 x 64) = 25.74, slightly overwheight.

Supplements. One of the most promising treatments for OA is the dietary supplement glucosamine. Taken in doses of up to 1,500 mg a day, glucosamine has been shown to reduce pain and possibly slow the progression of cartilage loss. Most studies have been performed with pharmacy-grade glucosamine, so it is important to find a high-quality product. If you see "GMP" on the label, you can be assured that the product has been manufactured using "Good Manufacturing Principles."

Exercise. If walking to lose weight is out of the question, there is much more you can do to strengthen the large set of four muscles on the top of the thigh, called the quadriceps. When these muscles are strong, they support the knees, so that less stress is put on the joints themselves. As a result, movement is easier and less painful. Before you embark on an exercise program for your knees, speak to your physician or a physical therapist; either can prescribe helpful exercises. While exercise, in general, is good, you want to steer clear of heavy weights and squatting moves that may cause more damage.

Splints and braces. These devices used to support or stabilize a joint usually aren't a permanent solution by themselves. In cases of knee OA, for example, doctors often prescribe braces for people to use until they have sufficiently strengthened supporting muscles through exercise. Braces and splints may be store bought or custom designed and made by a physical or occupational therapist or orthotist, a person who specializes in making braces and splints.

In addition to these options, there are several other pain-relieving techniques you may try on your own. Apply heat or cold packs, or a combination of the two, to aching joints. Soak in a warm tub or spa, or try practicing relaxation techniques. Surgery, although it is a last resort, can be done using minimally invasive techniques. For more ideas, check out the article "When Knees Go Bad,"

PAUL HOWARD, MD, Rheumatologist


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Medications' Effects on Teeth

Q: I am 37 and my teeth are dull and off-white. I've taken drugs for juvenile rheumatoid arthritis (JRA) for almost as long as I have had my permanent teeth, and I'm wondering if medications are responsible for the discoloration. Do arthritis drugs affect teeth? Would whitening toothpastes or treatments work for me?

A: Your question is a common one. Certain drugs can cause the teeth to be dull and gray. However, without knowing the specific drugs you have taken, I can't say if that is the case for you.

I estimate from your question that you probably started medication for JRA in the 1970s. The most common drugs used for JRA at that time were aspirin, gold and hydroxychloroquine. D-penicillamine came out in the late 1970s and methotrexate emerged as an arthritis treatment in the 1980s. None of those drugs have actually been known to cause tooth discoloration. However, they have been associated with other mouth problems, such as discoloration and ulceration of the gums.

It is possible that drugs you took for other reasons, such as tetracycline for acne or iron preparations for anemia, may have affected your teeth.

The bleaching treatments now used for tooth discoloration may be beneficial in your case. Consult your dentist.

MURRAY PASSO, MD, Pediatric Rheumatologist

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(Arthritis Today, March-April 2002).