Solving the puzzle of pharmaceuticals

A unique new Hebrew book explains how to avoid the pitfalls of taking medications.

Pills (photo credit: INGIMAGE / ASAP)
(photo credit: INGIMAGE / ASAP)
If you regularly take more than one medication for chronic conditions and can read Hebrew, this impressive volume is for you.
Some 85 percent of Israelis of all ages take medications at least once or twice a week. While swallowing a pill seems as simple as downing it with a glass of water, there are many medical implications to medications with which even many doctors are not conversant.
La’asot Seder Bitrufot Be’idan Shebo Hameida Ein-Sofi (Managing My Medications In an Era of Information Overload) was written with great care and concern for patients by Sima Livny, a senior pharmacist who previously ran the hospital pharmacies at Rambam Medical Center in Haifa and Hillel Yaffe Medical Center in Hadera. The softcover, 186-page, NIS 85 book was just released by Mendele Publishing.
The book does not seek to replace the physician or the pharmacist, but to help individuals who come to them to cooperate, know what to ask and be aware of possible problems if they are not.
PEOPLE WITH chronic illnesses – and not just the elderly – take multiple prescription medications, food supplements and other pills that may conflict with each other, causing one or more to be less effective or even dangerous. Drinking grapefruit juice, for example, may interfere with medications, as it blocks special enzymes in the wall of the small intestine, thus destroying pills’ active ingredients and preventing their absorption in the body. Thus, smaller amounts of the drugs get into the body than are ingested.
When the action of this enzyme is blocked, more of the drugs get into the body and the blood levels of these medications increase. This can lead to toxic side effects from the medications.
There are some drugs that should be taken in the morning, the evening or before going to bed at night, and any change in schedule can disrupt their absorption.
Many patients may take a pill for years without realizing that it can cause pains, hair loss and other undesirable side effects that they had blamed on aging or another phenomenon.
In explicit detail and using “true stories” about patient’s cases that she has encountered in her professional life, Livny, who now works as a pharmacist in the private medical data base company Zi’ur, does a great service to Israelis. She also replies to queries at the non-profit and at It is meant for people who seek reliable information about the drugs they take or are prescribed for the first time, but when Googling, feel inundated and overwhelmed by inscrutable or unreliable information from commercial and vested interests.
How many times have people with chronic conditions said: “How can I know what effect pills have on me? I am not a doctor or a pharmacist.” But Livny notes that people should take more responsibility for their health, consult with experts and ensure that their health is not harmed by their medications.
Polypharmacy, defined as the use of four or more medications by a patient, usually adults aged 65 years and over, affects about two-fifths of individuals in this age group, but is too infrequently understood by the health system.
The book asks four major questions: Are all my drugs necessary? Are all of my drugs safe? Are all of my drugs effective? Are all of my drugs taken properly? These questions and more are answered in the volume, which also supplies forms to be filled out that help readers consult with their physicians or pharmacists to find out whether harmful or annoying side effects result from their medications.
PROF. RONI Kohen, dean of the Hebrew University School of Pharmacy, says on the inside cover that the author generously gives knowledge in clear language from her extensive experience on the subject. Each of the six chapters, he continues, is challenging and asks questions that have not been dealt with before, offering responsible answers for each.
The Health Ministry in Jerusalem has a website with a drug database, at pharmacy/trufot/index.asp?safa+h, through which one can search drugs by their generic or commercial names. From there, one can download the latest information on drugs. However, writes Livny, there are additional sites such as www.mypharmacist. and even for-payment sites such as Martindale, Micromedex and Lexicomp that provide additional information needed by the patient.
The family physician, who is the patient’s “gatekeeper,” usually knows what prescription drug the individual is taking, but doctors frequently are not fully informed about the over-the-counter medications, aromatherapy preparations, food supplements, homoeopathic mixtures and other pills or liquids that their patients put into their mouths.
Livny notes that problems really begin when one specialist one visits, such as a gastroenterologist prescribes a drug, and on a visit to another specialist such as a neurologist, another medication is prescribed.
To know about all the drugs that the patient is prescribed, the physician has to press F4 or F5 on the computer screen, but pressed for time, not all specialists bother to do so.
In addition, patients who consult with private doctors obtain prescriptions that are not registered on their health fund’s medical records, so public physicians could remain in the dark about them.
Livny explains that pills considered on the Internet as being “beneficial,” such as Omega 3 fish oil capsules, have not been incontrovertibly proven to be good for you. Some researchers maintain they are good for preventing cardiovascular disease, milk depression, hyperactivity and stroke, while other researchers disagree.
Another danger is that drugs legitimately prescribed by a physician may no longer be necessary once the original condition, such as hypertension due to being overweight, are no longer needed.
She advises people who are admitted to hospital always to bring at least three days’ worth of their medications with them, not only to continue taking them in the wards, but also so the medical center doctors are aware of them. Also, when making a regular visit to one’s personal physician, have him or her reassess at least once annually all the medications and preparations taken to make sure all are needed and not causing any harm.
Too often, a patient takes both a generic medication and one with the same active ingredient but with a commercial name, unaware that they are getting a double dose that is not picked up by the physician or pharmacist.
THE AUTHOR explains that unknown side effects can result from taking drugs or a combination of them.
Searching Google for possible side effects may have misleading results, because results one chooses may be outdated. One has to learn to look for the most recent and comprehensive lists of possible side effects.
“If at the end of this book you remember to search for every bit of pharmaceutical information over time, who wrote it and who published it, I have won! This book has achieved its target.”
Some medications have undergone changes in their contents without them being made public. She mentions the infamous case of Eltroxin, a drug for thyroid conditions that in 2011 was “improved” by its manufacturer.
However, the new version was a somewhat different molecule that caused severe itching in some users who were not aware of the change. Even the Health Ministry was in the dark about it, but finally, the original version was made available for those with the unpleasant side effects of the new one.
“Every bit of pharmaceutical information given to a patient is part of a whole tapestry of information that patients must collect to make smart decisions” with their medical caregivers, Livny declares.
Some patients who get some relief from a medication may decide on their own to take a higher dose to make them feel “even better,” but overdosing can be toxic or ineffective. Some drugs taken by men can have a beneficial effect when the dose is cut in half and taken by women, she added. Hormones, body size and other factors cause these differences. There are pills and capsules that should never be cut in two for half a dose, as this mechanical change does not divide all ingredients equally.
Drug dosages for children have to be calculated specially by the doctor or pharmacist. Non-prescription drugs, especially for children, should be regarded like prescription drugs that can be harmful if the dose is too big. Paracetamol, for example, can cause irreversible liver damage and even kill children or adults if given too frequently or the dose is too large.
Even a patient’s individual genetic make can make a specific drug effective or useless, because it is removed from some bodies at a different pace than it is from others.
Women who are pregnant, undergoing fertility treatments, or are breastfeeding must be especially careful not to use a drug without explicit permission from an expert.
Too few available medications have been tested on pregnant and lactating women for doctors to know whether drugs listed as being unsafe for them really are so.
The posture of the body when taking drugs can sometimes be critical. For example, Alendronate (the osteoporosis drug) must be taken while standing up or sitting; if taken when lying down, it could cause a hole to form in the esophagus. Generally, drugs should be downed with plenty of water and not with a dry throat that could keep it stuck in one place without quickly entering the stomach. Some drugs are “thirstier” than others, requiring several glasses to get it down or dilute them.
While numerous patients have heard of the interaction of grapefruit juice and certain prescription medications such as Coumadin for blood thinning, few have heard that one should not eat a large amount of green-leaf vegetables such as broccoli or Brussels sprouts, or even chicken or calf liver if taking Coumadin, as the vitamin K they supply can reduce the drug’s effectiveness.
Despite minor shortcomings, such as a couple of misspellings in the English that appears in the book, such as “Cochran” instead of Cochrane Review and “prednison” instead of prednisone), Livny has done an outstanding job in covering her topic. The volume, which is reportedly the first of its kind in Hebrew, should undoubtedly be translated into English and adapted to world audiences as well.