I find it amusing when I’m watching the evening news on TV and a dozen ads appear for medications with smiling happy people and at the end an announcer rattles off the side effects, ranging from rashes to gastrointestinal issues and sometimes death.  Obviously everyone who takes these medication will hopefully not get all of these side effects.  This brings to mind a situation that I’m finding more common in my practice:  there needs to be shared decision making between doctor and patient when selecting therapeutic medications.

Here are some helpful points to help you and your medical provider to customize your medication regimen.

• There are often MANY medications in each drug class.  If one medication does not work or you experience unpleasant side effects, don’t be afraid to tell your provider you want to try another.  I call this the “Goldie Locks and the Three Bears” process.  As I mentioned earlier, not everyone will have the same side effects from the same medication.
• Find out what has worked for others in your family.  At a recent conference, a psychiatrist mentioned that she treats families where they “swear” by certain anti-depressants and shun others because they don’t work or have unpleasant side effects.  It may not be too far from the truth that people who share some of the same genes would respond better to some medications than others.  I frequently ask my patients with high blood pressure if they have a close relative who also has high blood pressure and what they are taking and whether their regimen is effective.  Over the years, we are learning that high blood pressure has many different causes with a root in genetics.  It makes perfect sense to consider treatments that have worked for blood relatives.
• Do you process medications quickly or slowly?  People who process medications quickly through their bodies usually have to take higher doses, and vice versa.  In general, people who have smaller body sizes and women would be more likely to be slow metabolizers.  To get a better understanding, I like to propose the analogy of people who drink alcohol.  Some people can have one glass of wine and get very tipsy (slow metabolizer), whereas others can have a bottle and remain sharp (fast metabolizer).  Ask yourself, when you take Tylenol or Motrin for pain, do you usually need to take a lot for the pain to go away or can you get by with just one pill?  If you are the latter, you are a slow metabolizer which means you may want to tell your medical provider that you should start on a low dose and increase slowly.
• Find out what the main side effects are and discuss them in the office with your healthcare provider.  Are these compatible with your life and your other health issues?  For example, one type of weight loss medication called Orlistat has a major side effect of diarrhea.  This may not be the best choice if you have hemorrhoids which get worse and can be quite painful with frequent bowel movements!  In the treatment of hypertension, one of the first line drugs is a diuretic (makes you urinate) called hydrochlorthiazide (HCTZ).  For many people who have a long commute in the morning, having to find a bathroom on a subway or bus can be yet another hassle in your day.  Fortunately, there are over 200 other medications to treat blood pressure now!  If the diuretic doesn’t fit into your life, why not try another medication which fits better into your lifestyle.
• Maybe there are side effects which you actually want!  No, I didn’t mistype that last sentence!  Interestingly enough, some side effects can be positive.  A few examples: Metformin taken by diabetics for lowering blood sugar has the side effect of weight loss, Finasteride taken for enlarged prostate can regrow men’s balding areas on their head, Topamax is an antiseizure medication that can also reduce migraines and causes weight loss, Spironolactone is a diuretic (water pill) used for treating high blood pressure that can also reduce body hair (requiring less shaving of the body) and induce breast growth.  Talk with your doctor and ask if there may be a medication which can “kill two birds with one stone”.
• Find a dosing regimen that works for you.  Some medications have “extended release” versions so instead of having to take a medications twice or three times a day, you only have to take it once.  This can also give you a cost savings since you would only need half the number of pills.
• Is there a similar drug with a generic version.  In general, generic versions are cheaper than their brand name counterparts and can be just as effective.  If you healthcare provider prescribes a medication and you realize at the pharmacy that the co-pay is way too expensive, don’t leave the pharmacy with the medication.  Once you do, you will not be able to bring it back for a refund!  I advised that you inform the pharmacist and your provider that the cost is too expensive.  The pharmacist can work with your provider to prescribe a less expensive and likely generic version.
• Healthcare providers often do not know what the cost of the medication will be for your particular insurance.  In the US, each insurance creates a formulary of preferred drugs.  If you are prescribed a non-formulary medication, it will likely cost you more.  I recommend that patients obtain this formulary from their insurance each year (since it can change yearly), and bring it to each provider visit and encourage him/her to prescribe medications on that list.  Some EMR (electronic medical records) can identify the formulary medications, but may not always update with your particular insurance.  As a rough guide, if you have seen a commercial on TV for the medication, it is not likely to be on the formulary as it is a newer medication.

Happy Healthy Heart Health Month!  To mark the occasion, we should all take some time to consider one of the most important organs, the heart.  Diseases affecting the cardiovascular system including myocardial ischemia (“heart attack”), strokes, and aortic aneurysms (ballooning of the large artery in the chest) account for the leading cause of death in the US.  Sadly, these deaths are largely avoidable through lifestyle changes and proper screening.  Are you at risk?  The American Heart Association has put together a wonderful self-assessment tool called Life’s Simple 7, that you can complete to find out.

In addition, here is my checklist of things you need to consider and discuss with your primary care provider:

• Know your numbers.  Blood pressure, cholesterol (including breakdown of LDL “bad” and HDL “good” types), blood sugar, heart rate, weight, height, and BMI are essential to an assessment of your fitness.  If you have any abnormalities in any of these, you should ask your primary care provider how you can improve them.
• If you have a blood pressure monitor at home (I believe everyone should have one of these, even if you don’t have high blood pressure.  They are inexpensive and can detect blood pressure issues early), check your blood pressure a few times a week and record these numbers.  Bring these readings with you when you see your provider.  Having multiple readings at different times can help your provider find out if you have a blood pressure issue.
• Do you have a family history of cardiovascular disease.  Ask your blood-relatives for their history.  It is important to find out about high cholesterol, diabetes and hypertension (high blood pressure) history since these are the main contributors to heart disease.  If you have any family members who have had a heart attack or stroke before the age of 50, this is a VERY significant piece of information as cardiovascular disease affecting younger people usually means there is a genetic component.
• What is your exercise capacity?  Has it changed recently?  The heart helps pump blood to muscles so that you can move around.  If you used to be able to climb three flights of stairs without getting short of breath, but now you climb just one and feel winded, something may be going wrong with your heart.
• Are you still smoking?  Smoking is the most significant risk factor for heart disease.  Quitting will reduce your heart disease risk significantly.
• Is your diet too high in saturated fats and sugars?  In general, most saturated fats are derived from meat.  However, there are also plant-based fats that are bad for you such as the “tropical oils” such as coconut oil or palm oil.  Reduce these in your diet as much as possible.  Sadly, many manufacturers of packaged goods will add these to make cookies and cakes taste better.  Be sure to read the labels of all the food you buy and if you see these oils, avoid buying those foods.  Sugar comes in many forms, some which are worse than others.  I would reduce intake of any corn-based sugars such as corn syrup as these have been shown to worsen blood sugar.  Honey or cane sugar, in moderation of course, would be better options.  Stevia, which is technically a spice that makes things taste sweet but doesn’t contain sugar and has no calories, would be the best option.
• What is your stress level?  More and more studies show that stress has a very negative impact on our health.  Stress induces our body to secrete hormones such as cortisol and epinephrine.  In small doses, these are great for helping us ‘weather the storm’ when we face challenges.  However, over time these can have deleterious effects on our body such as increasing blood sugar, weight gain, and raising blood pressure.  We all need to manage stress as much as possible.  Try meditation to help with stress, or start seeing a therapist to talk through your issues.

Be sure to get your annual physical exam, including bloodwork and possibly and EKG!

This year is proving to be one of the worst flu seasons I have seen in my career.  I think many factors are to blame.  Terrible weather and natural disasters late last summer, such as Hurricane Maria, decimated access to health care and forced people to congregate in crowded shelters.  The weather was also unseasonably cold in most parts of the US this winter.  Australia had a particularly severe flu season (peaking in July, during the Southern hemisphere’s winter season)  which usually translates to a worse season for the Northern Hemisphere.  The flu shot efficacy has been called into question, but I believe the strains in the flu shot as it was originally formulated was effective, unfortunately it is likely that one of the strains, the H3N2, likely mutated.  H3N2 is thought to be a nasty strain of the flu which causes more prolonged illness and is easily transmitted.  Historically, years where H3N2 predominates are more severe flu seasons.

Unfortunately, we are not seeing an end to this flu season anytime soon.  In New York, the rates of flu have not come down, indicating we haven’t even reached the peak of the flu epidemic.  Some experts have even proposed that the flu season may not end till May this year (usually ends around late March or April).

Here are some steps to protect yourself and your family:

• Get your flu shots!  It’s never too late.  While no flu shot is 100% effective (in typical years, 60% is about the maximum efficacy), it can lessen the severity and duration of your symptoms.  Even if you got sick from the flu, you should get the flu shot after you feel better.  There are at least 5 strains of the flu going around, getting sick from one strain doesn’t protect you from the others.  Getting a flu shot with multiple strains (3 or 4, depending on the type of flu shot) lowers your chances of getting the others.
• If you have the flu, stay away from others.  Isolate yourself as much as possible.  Stay home from work, avoid gatherings of large people until 24 hours after your last fever (100 degrees Fahrenheit).  Be especially careful about tissues or items such as clothing you may have coughed or sneezed into, these usually contain large amounts viruses.  Do not let anyone clean these up for you, as that can transmit the flu easily.  In fact, you can even designate a separate trash bag for these, or keep a separate trash can near your bed or seat on the sofa.
• Avoid unnecessary contact with others.  People who are infected with the flu are infectious 24 hours even before showing any symptoms of the flu.  A simple handshake or hug could mean an easy transmission of flu virus.
• Use antibacterial wipes liberally.  I use them to wipe down the armrests, seatbelt buckles, and tray tables on planes before I sit down.  You should also use them after touching restaurant menus or riding on public transportation.
• Avoid going to the hospital or doctor’s office for any unnecessary visits.  Postpone any non-urgent surgeries such as vasectomies or plastic surgery.  The last thing you want to do is to go to where there are large numbers of people with the flu.  Surgery is a stressful time for the body and makes you very succeptible for getting the flu.  Instead of visiting someone in the hospital, consider using video chat, or Skype to send them your well wishes.  If you must go into the hospital to visit someone, wear a mask the entire time.  Most hospitals will gladly provide you with one if you request it.
• Wash your hands often.  Be sure to use soap and water.  How long is considered adequate?  You should be able to sing the “Happy Birthday” song twice.
• Cover your mouth when you cough or sneeze and advise others to do the same.  Each cough or sneeze generates a large plume of droplets containing billions of flu viruses.  The best way to cough or sneeze is into the bent elbow.  If you cough into your hands, you’re more likely to spread the flu viruses when you use that hand to open doors.
• Boost your immune system.  A weakened immune system makes you vulnerable to colds and flus.  Get adequate sleep at night, drink plenty of fluids, avoid excessive amounts of alcohol (no more than one drink for women, two drinks for men in 24 hours), reduce stress, and exercise regularly.
• If you have a compromised immune system from diabetes, HIV, cancer, or other chronic diseases, or have respiratory illnesses such as asthma or COPD, you should contact your healthcare provider if you suspect you may have the flu.  The first signs of the flu are the sudden appearance of body aches, fever, and sore throat.  Common colds are usually different because the symptoms develop over days as opposed to 1-3 hours for the flu.
• Teach your family good hand hygeine.  Keep hand sanitizers handy near the front door.  Encourage all your family members to use it upon returning home.
• Based on new research, the flu virus can even be spread just by being in the same room with someone who has the flu.  Having fresh air circulating can be helpful.  If the temperature outside is mild, open the windows to bring air into your home.  Alternatively, if someone has the flu, try to limit them to one or two rooms so they are not spreading the virus throughout the home.
• GET YOUR FLU SHOTS!  No, this not a mistake, I am putting this tip again to emphasize that this is the BEST thing you can do for yourself and your family.  The flu shot will protect you and your loved ones!

This winter has been brutally cold in many parts of the US.  The cold can have a very negative impact on our health.  It can weaken our immune systems and dry out our nasal passages, making us more vulnerable to colds and flus.  The cold weather also limits our ability to do exercise outdoors and get much needed Vitamin D from sunlight.  Here are some ways to beat the cold.

• Make sure to cover up all exposed skin when outdoors.  Scarves, gloves, and a thick coat are a must when the temperature drops.  Put them on at least 5 minutes before heading outdoors.  The heat you trap in the clothing will keep you much warmer.
• Exercise indoors.  When you exercise, your body temperature will rise.  The sweat you generate will also moisturize the skin.  Avoid exercising outdoors, as very cold air can cause our bronchi (tubes that deliver air to our lungs) to spasm and make it difficult to breathe.  Asthmatics often notice worsening of their asthma during colder months.
• Humidify the air.  Hot, dry air leads to dry nasal passages and eyes which are the main reason we get upper respiratory infections in the winter.  Add humidity to the air in your home by using a humidifier and avoid making the home temperature too warm.  Sure 80 degrees feels great, but it will dry you out too much.  70 degrees would be a reasonable home temperature in the wintertime.  If you have a green thumb, purchase some indoor plants.  They release moisture into the air.  If not, you can place bowls or baking sheets with water around the home.
• Moisturize your skin liberally.  The best time to slather on lotion is after your shower to lock in moisture.  Dry skin can result in bothersome itching and irritation.
• Get your flu shot.  We are in the midst of a potentially deadly flu season.  If you haven’t gotten your flu shot, it’s not too late.
• Use hand warmers when outdoors for long periods of time.  These small packets generate heat and can be placed into your shoes or gloves to keep these areas warm.  If you are shoveling snow or doing necessary outdoor activities in the cold, make sure you warm up indoors every 15 minutes or so.
• Drink plenty of fluids, preferably warm or room temperature.  Teas and soups are perfect for raising our body temperature before or after being outdoors.
• Avoid alcohol or excessive amounts of caffeine.  Both of these are diuretics (cause you to release water) and can worsen dehydration.  Alcohol also dulls the pain of frostbite, so you may not realize you are being injured by the cold.
• Take a Vitamin D supplement.  Vitamin D is a necessary vitamin that we get from certain foods, such as fortified dairy, eggs, and sardines.  Some scientists believe that low levels of this vitamin can contribute to anxiety and depression that many of us experience in the winter months.  Ever wonder why we feel more energetic in the summertime?  We need approximately 15 minutes of exposure to the sun to activate this vitamin.  If you aren’t exposed to the sun for this amount of time during the wintertime, your levels will surely be low.  I recommend taking a supplement with 1000 IU of Vitamin D3 per day during this time.  Be sure to take it with food as it is a fat soluble vitamin and preferably in the morning.  If you are really feeling the winter “blahs”, schedule a trip to a sunny getaway further south.  You will be able to replenish your Vitamin D within hours on the beach, it’s just what the doctor ordered!

As we start the holiday season, we should all consider that the average American gains 2 pounds every year around this time!  While it may not seem like much, it can really add up over the years and make it more difficult to reach your ideal body mass index.

Here are some tips to navigate the festivities wisely and stay healthy:

• Indulge, but within reason.  Depriving yourself of your favorite food may not be an option, but limiting the portion can be.  Budget your calories.  If you know you will be having a large dinner, eat a more reasonable lunch with plenty of vegetables.
• Avoid excessive amounts of alcohol.  Alcohol can be very high in calories.  For example, some beers such as IPA’s (India Pale Ales) can have upwards of 200 calories per bottle!  (that’s more calories than soda!) Here are some tips on moderation.  Alcohol can also worsen depression and anxiety.
• Exercise as a family.  Encourage your kids to get off the couch and get active.  Go for a hike if the weather isn’t too cold.  Even walking in a museum or shopping mall can be exercise.
• Drink plenty of water.  Many of the salty foods and alcohol cause us to be dehydrated.
• Get enough rest and quality sleep.
• Get your flu shot if you haven’t.  I am already seeing signs that this is going to be a terrible flu season.  The flu shot may not be 100% effective this year, but it will still provide some protection, which is better than nothing.
• Spend quality time with your loved ones, check in on elderly relatives.  Holidays can trigger depression, sometimes related to seasonal affective disorder, lack of Vitamin D, or social isolation.  Put away the phones, tablets, computers, and video games and have conversations.  Play fun board games, go hiking, or bake cookies together.

Happy Holidays to you and your families!!!