Rating Physicians; Generic Plavix; Vicodin Reformulated; Stop Smoking; Headaches; Blood Clots & Travel.

Welcome back to my blog, which puts into writing the topics discussed during the June 15, 2012 episode of Let's Talk Medical with Doctor Gigi

Rating Physicians:

Many websites are available to rate physicians, & you can use them to rate your doctor or even to learn about a doctor before you establish a relationship with him.  Keep in mind however that like all statistics, these rating scales do not always tell the truth.  Often times, the most dissatisfied patient is the one most likely to cast an opinion.  Also, anybody is allowed to vote, so I could encourage friends & even relatives to give glowing reports.  I generally get good scores, but I lose a few points when judged on timeliness.  At first you might think that I don't respect my patient's time, or perhaps I overload my schedule, or perhaps I have too many distractions, but in fact I run late because I spend so much time with patients... they get the time they need, not just the time for which they were scheduled.  So, the fact that I do not get a perfect score, does not truly reflect a defect or problem with my medical care.  Keep in mind that a perfect doctor for you might not be the perfect doctor for someone else.  If your doctor has good basic medical knowledge & judgement, if he listens to youeducates yousincerely tries to understand & know you, & in general treats you as a friend or family memberyou have a fabulous doctor... for yourself... & you should not worry about the rating he might get from other patients.

Generic Plavix:

Plavix (= Clopidogrel) is a medicine used to thin blood, thus it is used to decrease the risk of strokes & heart attacks.  It is pretty expensive, so many people have been awaiting the release of the generic version.  Happily, the generic Plavix hit the market in May 2012.  If you have insurance coverage for your medications, you likely have seen the price drop.  However, if you pay for your own medications, you might not see the price drop until after the first year that the generic is available.  Thus you will get a cheaper Plavix around May 2013.  Again, this illustrates the fact that although a generic medication is approved, the price often does not drop significantly for cash-pay patients until 1 whole year after the initial approval.  This is due to the fact that usually only 1 company gets the right to produce the generic version the first year.  Many companies can begin to produce their generic versions once that first year has passed, & this results in a significant cost savings for all patients (insured & non-insured).

Vicodin Reformulated:

With the use of narcotics on the rise... an epidemic you might say... there has been much concern about the fact that most narcotics are combined with Tylenol.  Many doctors & most patients forget this, & frequently patients end up taking an overdose of Tylenol which can be lethal.  In fact, we used to recommend a maximum daily dose of 4,000 mg of Tylenol, but now we have lowered that maximum dose to 3,000 mg of Tylenol per day

Vicodin is a commonly used narcotic pain medication which combines Hydrocodone (the narcotic) with Tylenol.  It used to be available with 5, 7.5, or 10 mg of Hydrocodone, combined with 325-500 mg of Tylenol.  Physicians used to frequently prescribe the Vicodin 5/500 at a dose of "1 to 2 pills every 4 to 6 hours as needed for pain."  Therefore a patient was allowed a maximum dose of 2 pills every 4 hours (6 times per day), resulting in a total daily dose of:
     5 mg of Hydrocodone per pill X 2 pills = 10 mg of Hydrocodone per dose
     10 mg Hydrocodone per dose X 6 doses per day = 60 mg Hydrocodone per day.
Unfortunately, if you figure out the dose of Tylenol, you will find that this dosing provides an OVERDOSE of Tylenol:
     500 mg of Tylenol per pill X 2 pills =  1,000 mg of Tylenol per dose
     1,000 mg of Tylenol per dose X 6 doses per day = 6,000 mg Tylenol per day!

Thank God for Pharmacists who have worked diligently to educate physicians about the dangers of these combination drugs, & have often suggested other doses which will not overdose our patients on Tylenol.  This was not lost on the Pharmaceutical industry, who is now reformulating narcotic-Tylenol combination products

Vicodin will soon be released in its newly reformulated version... which will use 300 mg of Tylenol regardless of the amount of Hydrocodone in the pill.  Thus if a patient takes 2 pills 6 times per day, they will only get a max of:  2 pills X 300 mg Tylenol X 6 doses = 3,600 mg of Tylenol per day.  Though this is higher than the new overdose level of 3,000 mg of Tylenol per day, it is at least below the 4,000 mg dose which is the known toxic dose.  Expect to see this change occur during September or October 2012, & expect other narcotic medications to follow with similar reformulations.

By the way, Tylenol overdose is a nasty way to die.  The Tylenol injures your liver, but it takes up to 5 days for your liver to show the full extent of that damage.  Thus, a person who intentionally overdoses on Tylenol will often wake up in the hospital after having had his stomach pumped.  Most times he is happy to be alive & thankful that the suicide attempt was not successful.  Unfortunately, about 5 days later his liver will begin to die, & without a liver transplant, so might he.  Physicians can check a Tylenol level when the person first shows up in the Emergency Room, & they can use this level to predict whether the liver will actually die or not.  Of course, slow daily unintentional overdose is different as the damage to the liver occurs slowly over time, but the outcome is the same.

Stop Smoking:

If you or someone you love is trying to stop smoking, here are some helpful hints.

If you live in Florida, you should check out "Tobacco Free Florida" as I think they can provide you with free nicotine patches.  If you have never tried these patches, you should, as they often work well for people truly committed to stopping smoking.  Be sure to follow the directions, as the strenghth you will need varies depending upon the amount of cigarettes you smoke.  The 21 mg patch is the correct strength for someone who smokes about 1 pack per day, whereas a 1/2 pack per day smoker should use the 14 mg patch.  Of course you start with a high dose, then wean down over time.

Though the nicotine patches help many people stop smoking, I prefer the Nicotrol Inhaler device.  It is a small plastic device that looks like the plastic tip on a cigar.  It unscrews, & inside it holds a small sponge that is impregnated with nicotine.  As you "smoke" the device, air comes in through the sponge & picks up the nicotine, thus carrying it into your lungs.  Thus you get the nicotine... which is  truly what you are addicted to... but you do not get the tar & smoke!  Your hands & mouth feel as though you are smoking, so they are happy too!  Over time you are supposed to use less & less of these inhalers, but even if you never stop using them, you will at least be doing less damage to your body than if you continue to smoke cigarettes.  Also, because you only get nicotine when you "smoke" the Nicotrol inhaler, you can choose to smoke a real cigarette interspersed with the inhaler, thus you do not have to worry if you have an occassional "slip" with the tobacco cigarette.

Though Nicotrol inhalers are expensive, I recently saw where you can get a month's supply for a maximum of $50.  To cash in on that deal, you should go to the website www.Nicotrol.com where you can get a coupon which will limit your cost to $50.  You will still need a prescription, but I don't think there is a physician among us who would not be happy to provide you with that!


If a 50 year old lady starts to develop headaches which are associated with nausea, is this likely to be migraines?  It is certainly true that migraine heasdaches can develop when ladies go through hormonal changes such as menopause, but at 50 years old you must also give consideration to neurologic abnormalities such as masses, tumors, strokes, or pre-strokes (called TIA's, which stands for transient ischemic attacks).  Thus it is likely that this lady should have a neurologic examination & perhaps an MRI of her brain, just to be certain there is not a more ominous cause for her headaches.

Also, tension headaches, which are caused by muscle tension or spasm, can be associated with nausea as well.  And don't forget, stress can cause both migraine & tension headaches.

Though you can certainly awaken with a tension headache or a migraine headache, you should also give consideration to the fact that morning headaches can be a sign of sleep apnea.  So if you awaken with headahces, snore loudly, have daytime exhaustion, & awaken feeling as tired as you were when you went to bed, you just might have sleep apnea.  Talk to your physician & he can order a sleep study to evaluate this further.  As a cost-effective measure, ask if you can get a "home" sleep study, as these can now be conducted at your own home, which is less expensive than going to a sleep lab.

Blood Clots & Travel:

If blood sits still too long it tends to clot.  Thus it should come as no surprise that travel increases the risk of getting blood clots in your legs which are called "deep vein thromboses" or DVT's.  These unfortunately can break free & go to the lungs where we call them "pulmonary emboli" (= PE).  Pulmonary emboli can kill you as they block up the blood vessels of the lungs, thus liquid blood cannot pass through the lungs to pick up oxygen, resulting in a deadly lack of oxygen to all the body's organs.  So if you travel 2 hours or more, you should pump your feet up & down to push the blood through your leg veins.  You should also stand up or at least try to stretch out straight so you remove the bend at your hips, thus re-establishing a straight course for the blood to flow from your feet to your heart.  If you develop red, hot, swollen legs or shortness of breath after travel, do not delay in contacting your doctor & be sure to give him this history so he will evaluate you urgently.  The best study to evaluate for DVT's is a Doppler ultrasound of the legs, & the usual test for a PE is either a ventillation-perfusion scan or a spiral CT of the chest.  Again, these clots can be life-threatening, so if you think you have one, get your studies done urgently, even if that means going to the Emergency Room!

Thanks for visiting my blog, & I hope you learned something useful.  Remember you can hear me live on WTAN 1340-AM on Fridays from 1-2PM Eastern time.  Or if you prefer, check it out on www.SkipShow.com where you can listen live or to the podcasts.  I would love to hear from you... comments of questions.  You can reach me live during the show via (727)-441-3000 or on our toll-free number:  (866)-TAN-1340.  If you prefer, you can reach me any time via:  DoctorGigi@SkipShow.com.

Here's to our health!

Doctor Gigi

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