Posted tagged ‘medication’

Teaching your kids to swallow pills (with free bonus math section)

September 17, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Holly (a regular! thanks!) wrote in: “Dr. Roy, are the any tips/tricks on teaching kids how to swallow a pill?  I tried to get my 9-year-olds to take the tiniest of probiotics recently, and it was an epic fail!”

I’ve got no guarantees, here—it turns out that at least some adults never learn to swallow pills whole, which I guess is why Viagra is available as a chewable. But I think a 9 year old might be willing to try to learn. Some tricks can maybe help!

Start with mini-M&Ms. They’re little and cute and small and smooth, and (as you well know) they don’t melt in your hands. If Junior can handle an M&M mini, graduate to full-sized M&Ms, and then even to those monster peanut ones if you’re feeling lucky.

Try a pill-swallowing cup, like one of these. These sort of hide the pill on a little shelf, so it just travels down the gullet along with a gulp of water. Clever!

There are also sprays to make a pill more “slippery” – and, bonus, to make them taste like strawberry. I suppose butter-flavored Pam would also work. Here, try this oily pill that tastes vaguely like popcorn. OK, maybe that’s a bad idea.

Then there’s the tried-and-true, just huck it down your throat and drink some water. After it works once or twice, kids usually get over the mental block, and don’t need any help getting pills down. Though I’d still hide the Viagra.


Bonus Math Section

In case you hadn’t noticed, liquid medications are a complete rip-off. An average 12 year old weighs about 90 pounds, and the correct dose of ibuprofen for that weight is 400 mg—that’s either two adult pills, or 4 tsp (20 mL) of the liquid. Using the brand name Advil and the prices on Amazon, a single dose using pills (300 pills for $16) would be about 10 cents. Using Advil tasty grape flavor, 4.29 per 4 oz,, I get 70 cents a dose. Besides, pills are easy to carry, and the generics are even cheaper. Let’s get those kids swallowing!

Avoiding medication dose errors in children

August 21, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

The thing about medicines: they’re real bio-active substances. They do stuff. Some good stuff, and some bad stuff too. Every medicine (or, really, anything you put in your body that has any biologic effect at all) is also potentially going to have side-effects or adverse drug effects, too. To maximize the good, and minimize the bad, you’ve got to dose medications correctly.

So it’s chilling and discouraging to learn that in a recent study of 300 parents prescribed children’s liquid medications out of Emergency Departments in Philadelphia and New York, about 40% of the time the dose was misunderstood or given incorrectly. That’s a huge number of incorrect doses, and probably contributes to the 10,000 poison center calls made about children’s medicine doses to poison centers each year. Doses were twice as likely to be incorrect if the instructions were given in teaspoons or tablespoons, because those units aren’t necessarily understood correctly by everyone.

The authors suggest that children’s liquid medicines always be dosed in milliliters, and that parents be given a correct-unit-dosing device (like a syringe) marked with the exact dose. Those are good ideas. Parents should not be ladling medicine into their kids from a kitchen spoon—that’s just too inexact, and depends too much on what kind of spoon and how high you fill it. Dosing syringes can be standardized to measure the right amount, and don’t spill medicine all over the place when you’re trying to get them into Junior’s mouth.

When your child is prescribed a medication, make sure you know the correct dose, and the correct way to give the dose. Any questions? Ask your doctor or pharmacist. If you’re going to give your child medicine, you ought to do it right.

Pediatricians can’t always follow FDA medication labels

March 27, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

You know those little packets of paper, folded over eight times, written in type that can’t possibly be seen? You’ve seen them glommed onto the side of stock bottles of medications, or shoved into the paper box alongside a tube of prescription ointment. That unreadable thing is the official “product information”, often called the “label”, required for every FDA-approved medication. It contains all sorts of information, including lists of side effects (Nausea! Anal leakage! Growing a tail!) and what a medicine is “supposed” to be used for.

But often, that information isn’t the best information. It’s just what the FDA approved. Science marches on, and new published information is not routinely included in the product insert. Doctors who pay attention know that there’s usually a whole lot of more-reliable, more-specific, and more-accurate information about here than what’s on the label.

The discrepancy is especially stark with babies and children. According to a new AAP report, “Off Label Use of Drugs in Children,” less than 50% of medications have information about pediatric usage in the FDA-approved product labeling. If you have a child who has been prescribed medication, it’s almost certain that at least some of them have been used “off-label,” in a way that is not specifically approved by the FDA.

As the AAP report outlines, using drugs in this way is not incorrect, unethical, or inappropriate:

The absence of labeling for a specific age group or for a specific disorder does not necessarily mean that the drug’s use is improper for that age or disorder. Rather, it only means that the evidence required by law to allow inclusion in the label has not been approved by the FDA.

Those sound like weasel legal words, I know—but it worth understanding what the FDA’s role here is. The FDA is empowered to regulate the manufacturing, labeling, advertisement, and safety of medications. For a drug to be “FDA approved” for sale in the US, a sponsor has to provide information usually including two large, randomized trials to prove that medicine is safe and effective. Safe in the population studied, and effective for the disease studied. The FDA “approves” the drug for sale using specific parameters from these studies, and does not allow the sponsoring company to promote the use of the medication for any other purpose.

But once a drug is approved, a licensed physician can legally prescribe it for any use. The FDA does not regulate the practice of medicine or how doctors use medication (that can be regulated by state medical boards, if a doctor does stupid or unethical things with a prescription pad.) It is up to licensed prescribers to use their own judgment, based on the totality of the evidence, to make prescribing recommendations. Limiting our knowledge to what’s in the product information sheet—which is seldom modified or updated after a drug is approved—would be unethical and foolish.

In most circumstances, using a drug off-label (for an indication or age not explicitly approved in the FDA label) is not “experimental” or “research.” As long as it’s in a patient’s best interests, using a medication this way does not require any specific information be shared with the patient, beyond what we should be talking about with any medication (risks, benefits, side effects, etc.) However, it’s usually best for doctors to talk about the off-label use in cases where off-label prescribing is unusual or cutting-edge. In pediatrics, that’s seldom the case. We write off-label meds every day, in ways that have sometimes been used for decades, and I would bet that most pediatricians don’t even know when they’re doing it.

That’s because the best therapeutic decision making is not based on the label. It’s based on all of the evidence out there: published studies, experience, judgment, and the best interests of the patient.

Pharma weasel games: Tales of Concerta and Auralgan

June 25, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

I’ve been pretty hard on big pharma in the past—drugs account for a huge part of the cost of health care, and drug companies haven’t always been transparent and fair in the way they’ve priced and marketed new medications. They’re businesses, I understand that, and they exist to make a profit. But the way they game the system to take advantage of gullible docs and patients is sometimes sickening. Two recent stories illustrate their weasel games.

Auralgan is an old medication, an ear drop used to treat the pain that comes with ear infections. For decades it was made with two ingredients, and was sold inexpensively alongside several generic versions. The original product was formulated before current FDA standards for marketing prescriptions, so it was “grandfathered in,” basically allowing it to be sold and marketed “as-is” without proof of safety and effectiveness. It seemed to work well enough, and I suppose no one complained.

A few years ago, the manufacturer of Auralgan “reformulated” the product, adding two more ingredients without changing the name. Naturally, they also reformulated the price—now, cheap Auralgan was priced at over $100. Furthermore, because the ingredients had changed, docs who prescribed “Auralgan” found that pharmacies could no longer substitute inexpensive generics, even though the generics had the ingredients that Auralgan originally contained. In one swoop, the manufacturer dramatically increased the price while eluding generic substitution. Clever, huh?

Maybe too clever. This year, US Marshalls swooped into a warehouse in Kentucky, confiscating 16.5 million dollar’s worth of Auralgan. All new drugs must be FDA approved, and “new Auralgan” had never received FDA approval. It was illegal to sell, and it’s now completely off the market.

A bigger company sells a much bigger drug, Concerta. It’s one of the most popular treatments for ADHD, and one of the biggest selling brand-name medications in the USA. But its patent has expired, ostensibly allowing generic manufacturers to sell their own version of the product (presumably at a lower price.) Johnson and Johnson, maker of Concerta, has fought the expiration of their patents for years in the courts, finally losing an appeal in 2010. But get this: after losing their patent-infringement suit against generic company Watson Pharmaceuticals, J&J turned around and cut a deal with its adversary in court. J&J will now be manufacturing, in their own facilities, an “authorized generic” of Concerta to be sold by Watson. Watson, of course, will pay J&J to make their generic Concerta for them. So J&J will in effect be making the profits off of their own, off-patent Concerta, plus the profits off of the “generic”, which will actually be sold by another company pretending to be their competitor. No wholesale prices have been released, but I’m guessing that this generic Concerta will be priced quite similarly to the brand name. J&J wins. You lose.

Tired of the weasel tricks? Would you like to hear about some real ways to save on prescription drugs? Start here.

Expensive placebos are more effective

August 10, 2010

The Pediatric Insider

© 2010 Roy Benaroch, MD

A simple study from the March, 2008 issue of the Journal of the American Medical Association illustrates something important about the way we perceive the effectiveness of medication.

82 adult volunteers were recruited. They were told they were taking part in a trial of a new pain medication, testing its effectiveness using a standardized, well-established protocol using low-voltage shocks as a painful stimulus.

All of the pills were placebos.

Nevertheless, most of the study participants were able to tolerate higher intensity electrical shocks after taking the pill. And the ones who were told that the pill cost $2.50 found their placebo more effective than the volunteers who were told that their medication costs 10 cents.

Details: 85% of the participants taking the “expensive” placebo found it effective, versus 60% for the cheapo pill.

The authors conclude that one way for clinicians to help patients enjoy the benefits of their generic medication is to de-emphasize the price. By not dwelling on the inexpensive price of certain drugs, they might seem more effective. Of course, the converse is also true: why not deliberately prescribe the most-expensive, newest medication because it’s somewhat more likely to be perceived as effective, even if it’s no better at all?

The costs of a medication have no bearing whatsoever on how effective it might be. Don’t let Jedi Mind Tricks fool you into wasting money on the fanciest New Kid on the Block without real evidence that it really is better than a well-established, safe generic.