“I have a dream today. I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin, but by the content of their character. I have a dream today.” Dr. Martin Luther King’s speech on Aug 28, 1963 feels like it could have been given yesterday and it would speak to so many of today’s problems. Dr. King’s speech is also full of hope and hope is an essential ingredient for any monumental societal change. I am definitely not in Dr. King’s league, but I had a dream too. I dreamt the handle on my Lazy Boy recliner was 4 feet long. That 4-foot handle made it difficult for me to raise my foot rest. I assume I was dreaming about my Lazy Boy handle, because the real one broke off. I now have to raise my foot rest with a broken handle nub. My daughter Emily felt sorry for me. She ordered me a replacement handle off the internet. True to the words
“Lazy Boy”, I haven’t gotten around to attaching the new handle yet.

Something else that can be hard to handle is mouth pain. A common cause of pain in the mouth are canker sores. Canker sores are little ulcers or erosions in the mouth. Their medical name is aphthous stomatitis or aphthous ulcers. A person usually gets their first canker sore between the ages of 10 and 20. Somewhere between 5-25% of the population gets them. Canker sores happen less often as we age. Women, people under 40, people with a family history of canker sores, people who have recently quit smoking and people with upper-middle socioeconomic status tend to get canker sores more often.

We don't know what causes canker sores. There are probably lots of factors involved. We think the most common predisposing factors are trauma to the mouth (like biting your cheek, or the sharp corners of dental appliances rubbing) and stress. Certain foods may play a role including chocolate, coffee, peanuts, almonds, strawberries, cheese, and tomatoes. A poor diet may cause a nutrient deficiency which can make canker sores more common. Pain killing drugs like NSAID's may also make canker sores happen more often.

One interesting theory of canker sores has to do with Vitamin B12. There is at least one case study of giving a patient with recurring canker sores a Vitamin B12 supplement. This patient’s blood levels were checked and the supplement brought their B12 level back to normal. The patient then had no recurrences of canker sores for at least 6 months. Another study gave people with recurrent canker sores either Vitamin B12 1000 mcg under the tongue or a placebo. 74% of the B12 patients had no canker sores for 6 months while only 32% of the placebo group were canker sore free at 6 months. In another twist, when they checked the participants B12 levels with a blood test, it didn’t seem to matter if the participants B12 blood level was normal after treatment or not. I guess that means Vitamin B12 and canker sore is an interesting link, but needs more study.

Canker sores can be more than just annoying. Patients with more severe canker sores may have a lot of pain which can cause difficulty eating, speaking and swallowing. There are 3 types of canker sores: minor, major and herpetiform. Far and away the most common canker sores are the minor aphthae which account for 70-90% of the cases. Minor aphthae or minor canker sores are painful, small, round or oval ulcers which have clear raised edges with a red halo around them. They are smaller than 1 cm and usually have a whitish grey pseudomembrane over them. Minor canker sores occur singly or in groups up to 5 on the inside of the lips, cheek, floor of the mouth, underside of the tongue and the soft palate. Minor canker sores heal by themselves in 7-10 days, which is good, but that is more slowly than other oral wounds heal. Some people might feel some discomfort a few days before the actual canker sore occurs. Major aphthae or major canker sores are not very uncommon. They are larger than 1 cm in size and can be in groups of more than 5. Herpetiform aphthous ulcers are the least common canker sore. They are multiple clusters of small pin-point ulcers than can number in the 100’s.

To prevent canker sores, first try to minimize trauma to the inside of your mouth. Chew slowly and carefully to try to avoid accidental self-biting. Avoid sharp-edged food like hard candies, hard toast, crackers and potato chips. If it feels like your teeth or dental appliances have sharp spots that are hurting the inside of your mouth, see your dentist.

We have several non-prescription options to treat canker sores. The dentists all seem to love salt water rinses several times per day. Dissolve a teaspoon of salt in 250 mL of warm water, rinse, spit and repeat. Do a salt water rinse several times a day. This helps to keep the canker sore clean which promotes healing. Local anesthetics like benzocaine and lidocaine, like in the product Orajel, will numb the pain of a canker sore for 20-45 minutes. For gels, ointments and pastes to work the best, dry the canker sore with a Kleenex before applying. Then apply with a Q-tip and avoid eating, drinking and speaking for 30 minutes. These analgesic gels can be used up to 4 times a day. In addition to local anesthetics, you could use acetaminophen or tylenol pills. Don't use ibuprofen, naproxen or
ASA. It is possible these NSAID's will make canker sores worse. Protecting pastes like orabase can also do a nice job of covering up the canker sore to make it more comfortable.

If your canker sores don't go away in less than 2 weeks or if they are very painful, you should see your dentist. They may prescribe an oral paste with the steroid triamcinolone in it to decrease the pain and inflammation. They could prescribe a numbing mouth wash called tantum or benzydamine to reduce mouth pain. They could also ask the pharmacist to compound a tetracycline mouth wash. Tetracycline is an antibiotic. As a mouth wash it can reduce canker sore pain and size of the sore. However, like other antibiotics, it has potential side effects like oral thrush, skin rash, sore throat and stained teeth.

“I have a dream that one day this nation will rise up and live out the true meaning of its creed: We hold these truths to be self-evident, that all men are created equal.” Great men dream of making the world better a better place. Lazy boys dream of handles on chairs. I told Emily about my Lazy Boy handle dream. She said, “Wow, you really are an exciting guy, aren’t you?” That’s me. The lazy boy of anemic and small dreams. I should get that on a business card! Ah, maybe later. I’m kinda comfy in my chair.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have this and most other articles published in the Parkland Shopper on our Website. Please visit us at www.dcp.ca

"Far better is it to dare mighty things, to win glorious triumphs, even though checkered by failure ... than to rank with those poor spirits who neither enjoy nor suffer much, because they live in a gray twilight that knows not victory nor defeat."  In 1899, Teddy Roosevelt said that in a speech called “The Strenuous Life” just before becoming US President.  That sentiment, to “Dare Mighty Things” is plastered on the walls of the Jet Propulsion Lab in California.  JPL has made many advancements for NASA over the decades, including to help build the Mars Rover Perseverance that just landed on the Red Planet. Another group that was involved in the Perseverance Rover is a little closer to Dauphin.  Canadian Photonic Labs from Minnedosa, developed a high-speed camera for Perseverance that you could run over with your truck and not damage it.  I think that qualifies it as a Mighty Thing.

It turns out that one of the decongestants in the pharmacy cough and cold aisle might not be a Mighty Thing. In January 2016, Meltzer et. al. published a paper in the Journal of Allergy and Clinical Immunology saying phenylepherine doesn't work any better than placebo.  I knew it!  But maybe I should back up a little.

If you get a cold, your nose will probably get plugged up.  My favorite decongestant pills used to have just pseudoephedrine in them.  Then about 15 years ago, companies stopped making decongestants with just pseudophedrine in them.  Do you remember the Series Breaking Bad?  In the show, high school chemistry teacher Walter White, starts making crystal meth to pay for his cancer treatments.  Well, in real life, bad guys were using pseudoepherine tablets to make crystal meth.  That's when the decongestant aisle of the pharmacy became full of phenylepherine containing products.

Decongestants work by constricting the blood vessels inside the nose.  That means there is less blood in the nasal mucosa, which leads to less snot production.  That makes decongestants very useful to treat the nasal symptoms of a cold.  Oral decongestants have some potential side effects though.  They can stimulate the heart which can cause high blood pressure, and fast heart rate.  They can stimulate the nervous system and cause anxiety and sleeplessness.  They can also cause urinary retention.

I've tried both phenylepherine and pseudoephedrine on my stuffy nose.  I've had patients talk to me after I switched them from pseudoephedrine to phenylepherine.  Almost to a person, we all agreed the pseudoepherine products worked better than the phenylepherine products.  So, we were all annoyed with the people who made crystal meth out of pseudoephedrine.  The amateur chemists were making it harder to treat a head cold.

Eventually, decongestants with pseudoephedrine combos with things like ibuprofen came back.  My favourite is Advil Cold and Sinus.  This meant I could treat my stuffy nose and the amateur chemists still couldn't easily make crystal meth.

If you want to try non-drug measures for nasal congestion, start with drinking lots of fluids and getting lots of rest.  Then you can try nasal saline sprays to help loosen the snot build up.  The ones that put lots of salt water up the nose like neti-pots and Hydrasense work, but using them can feel like you are drowning the first time you try them.  Breathe Right strips open up your nostrils and some people find that helps them breathe better.  Humidifiers might work, but use the cool mist ones.  The warm or hot ones can cause burns if a child pulls them onto themselves.

It isn't completely clear why phenylepherine doesn't work any better than placebo for nasal congestion.  It might be that phenylepherine isn't absorbed into the body very well.  Whatever the reason, some experts are even calling on the FDA in the US to review whether phenylepherine should be approved to treat nasal congestion.

When the parachute opened above the Perseverance rover, it unfurled a secret message to all the people back on Earth.  Strings of 1’s and 0’s coded for some particular letters and numbers.  They spelled out “Dare Mighty Things” on the canopy.  This is a fantastic message to any science types in the Parkland who might want be involved in space exploration.  Maybe a future space flight will have Dauphin technology on it as well as cameras from Canadian Photonic Labs in Minnedosa.  The Perseverance parachute had one more message: “34o 11’ 58” N, 118o 10’ 31” W”.  That’s the GPS location of JPL Labs in California.  Just in case any of our Dauphin space explorers need directions. 

As always if you have any questions or concerns about these or other products, ask your pharmacist

Meltzer article on Phenylepherine - http://www.sciencedirect.com/science/article/pii/S1081120615007073

Mars Rover’s giant parachute carried a secret message – Washington Post - https://www.washingtonpost.com/lifestyle/kidspost/mars-rovers-giant-parachute-carried-secret-message/2021/02/24/0103b276-6765-11eb-8468-21bc48f07fe5_story.html

Manitoba Company Helps land Perseverance rover on Mars with high-speed camera - https://www.cbc.ca/news/canada/manitoba/mars-rover-perseverance-landing-minnedosa-manitoba-company-1.5930798

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca

My sister suggested we try to technologically get together over Christmas.  My sister and her husband are in Langley, BC.  My parents are in Pinawa, MB and my immediate family is in Dauphin.  We asked if my parents, who are in their mid-seventies, thought they could handle Zoom.  They said that they’d be fine.  My parents have been playing a lot of cards with their friends over the internet during the pandemic.  They play a lot of Bridge, I game I have never understood, but for the sake of the kids and grandkids they suggested we play some easy card games together.  While my sister and I tried to agree on a time that everyone was available to Zoom, it occurred to me I didn’t know if I have a deck of cards in my house.  The last time I played cards was probably at my parent’s house.  That was a year and a half ago.  Do cards count as essential items that I can buy at the store?

The Drug Program Information Network or DPIN is essential.  DPIN is a computer network that links all the community pharmacies in Manitoba.  This way if you fill one prescription in Winnipeg, one in Grandview and one Ste. Rose all these prescriptions are stored in one place at Manitoba Health.  This helps your pharmacist catch interactions and duplications with prescriptions you filled at another pharmacy.  It doesn’t mean I can automatically fill a prescription you last had filled in Winnipeg, though.  In fact, from your DPIN profile, I can’t even see where you filled that other prescription.  You still have to tell me where you filled it and the phone number of that pharmacy and then I can call them and get the prescription transferred.  

DPIN is very useful to doctors in their offices and to nurses in the ER as well.  If you, the patient, are unable to tell them what medications you are taking, they can look them up electronically.  There are a few holes in the DPIN system, though.  DPIN can’t show compounds.  Compounds are when the pharmacist mixes two or more ingredients together.  All DPIN shows is “compound”, not what is in it.  DPIN can’t show when you take your medications.   DPIN can show you take 5 pills a day, but it can’t show that you take 2 pills at breakfast, 1 pill at lunch and 2 pills at supper.  And DPIN can’t show if a medication was stopped.  If your doctor gave you a blood pressure pills on Tuesday and on Thursday you and your doc decided it wasn’t working, stopped it and started a different pill, on DPIN it would look like you were still on both blood pressure pills.  As good as DPIN is, it is important to have a written list of your medications with you to show doctors and other health care professionals.

There are ways patients can unintentionally fool DPIN.  Let’s say a husband and wife, Bill and Mary, both take the same blood pressure medication.  Whether for convenience, or to save money they decide to just fill Bill’s prescription and both use meds from the same bottle.  What harm could that do?  Let’s send Mary to the ER with chest pain.  Mary is confused and unable to tell the ER doc what meds she is on.  The ER doc has no idea the Bill and Mary are both using the same bottle of pills.  The ER doc looks at DPIN thinks Mary is on no blood pressure meds.  The ER doc might give Mary a medication that interacts badly with the prescription the doc doesn’t know Mary is taking.  

Like many things in healthcare, DPIN stops at the provincial border.  Our new patient, Sam, has an eye condition.  His family doc gives him an eye drop, but the condition doesn’t get better.  Sam is referred to an eye specialist in Yorkton, SK.  The eye specialist decides to change the eye drops and writes Sam a prescription.  Sam fills the prescription in Yorkton.  A couple weeks later, Sam’s eye is really sore and he goes to Walk-In.  The Walk-In doc asks Sam what eye medication he is on.  Sam says he can’t remember.  No problem, the Walk-In doc looks on DPIN.  However, the Walk-In doc can only see the eye drop originally prescribed by the family doc that was filled in Manitoba.  The Walk-In doc can’t see the eye drop filled in Saskatchewan.  Now the Walk-In doc has the wrong information on which to try to decide what is going on with Sam’s eye.

The DPIN system is really helpful for keeping Manitobans safe and healthy.  As a pharmacist, DPIN can help me catch when a specialist from Winnipeg prescribes a medication that will interfere with another prescription that a patient’s family doctor has written.  It helps an ER doc see what blood thinners an unresponsive patient is on.  But as good as DPIN is, it is important to know it has limitations, so we don’t unintentionally make our DPIN chart work against us.  All members of your family should have their own prescriptions even if several family members use the  same medication.  Prescription medications filled out of province don’t show up on the Manitoba DPIN system.  And whether you write it out, or have your pharmacist help you, having a physical list of your medications on you is a really important safeguard for your health.

I found a deck of Dauphin Clinic Pharmacy playing cards in the basement.  I thought I was set for the Zoom card game.  Then the hamster wheel in my brain started spinning again.  How do we play cards with three different decks?  One in Langley, one in Pinawa, and one in Dauphin.  Do we each divide the deck into 3 parts?  Since 3 doesn’t divide evenly into 52, do we throw out cards?  And really, there are 4 people in Dauphin, 2 in Langley and 2 in Pinawa.  Should we divide our decks into 8 equal chunks, one chunk per person?  And what if the Ace of Diamonds ends up in the Langley chunk?  Do I never get to see the Ace of Diamonds in Dauphin?  My mind was twirling about how this freakishly complicated game was going to work.  I called my parents, the online card experts, about all the intricacies of this upcoming game. I could hear the smiles on their faces over the phone.  “No dear.  We aren’t going to use physical cards.  We are all going to sign into a website.  The cards are virtual.  It’s like we are all sitting in the same room using one deck of cards.”  And that is how my parents, in their mid-seventies, taught us all how to play virtual cards at Christmas.

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us 

at www.dcp.ca

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional

As always if you have any questions or concerns about these or other products, ask your pharmacist.

Where is the fracking file!  Keep your knickers on. I said fracking.  I wrote it on my laptop in Winnipegosis.  It was supposed to sync to DropBox and now be here on my home computer.  It isn’t.  So, it also isn’t on my phone.  So, I can’t record it at CKDM.  What am I supposed to do, just ad lib a pharmacy feature about insulin?  That’ll so great!  I’m sure I won’t sound stupid at all.  Wait a minute.  Maybe I just saved it to the wrong folder.  Okay.  There it is.  Now open.  Just open.  I said OPEN.  Okay.  Crisis averted.  Blood pressure falling.  Calming down.  Deep breath.  Focus.  Okay, let’s talk about insulin.  

I was in the dispensary and a patient started asking about a slow acting insulin that I’d never heard of.  Then I went to the fridge and found several slow acting insulins I’d never heard of.  Time to do some reading.

Insulin is used to treat diabetes mellitus.   The Latin translation of diabetes mellitus  is “sweet tasting urine”.  It was diagnosed by “water tasters” who drank the urine of those suspected of having diabetes.  The urine of people with diabetes mellitus was thought to be sweet-tasting. The Latin word for honey (referring to its sweetness), 'mellitus', is added to the term diabetes as a result.  Doctors today should be very happy they have lab tests.

Fast forward to the 1920’s and Canadians made a huge advance in the treatment of diabetes.  Fredrick Banting and Charles Best found a substance called insulin inside the pancreas of dogs.  It turned out that if you injected this “insulin” into people with the strange wasting disease called diabetes, it stopped them from dying.  

We now think diabetes is when your body has trouble storing and using glucose.  Glucose is a simple sugar that fuels many processes in the body.  There are 3 types of diabetes: type 1, type 2, and gestational diabetes.  Type 1 diabetes is when your pancreas doesn’t produce insulin.  You must inject insulin or you will die.  In Type 2 diabetes, your body may produce normal, or even above normal amounts of insulin.  However, other parts of the body like your muscle and fat cells aren’t listening to the insulin signal.  That means tissues like muscle and fat don’t suck the glucose out of the blood and use it.  Type 2 diabetes can be treated with diet, exercise, pills or insulin, or often a combination of these.  Gestational diabetes only occurs in pregnancy.  

There are many types of insulin.  The simplest is called R or Toronto insulin (Did I mention Banting and Best worked out of the University of Toronto?).  It is produced by microbes that have a tiny bit of human DNA implanted in them and is identical to the insulin that the human body produces (and you thought genetic engineering was in the future).  It is a short acting insulin.  Insulin has to be injected into the body because if it is taken orally, the stomach acid will destroy it.

Slow acting insulin start with Toronto or R insulin and get tweaked a little.  But first, why would you want to use a slow acting insulin?  When the pancreas is working properly it releases a small amount of insulin continuously all day.  We call this the basal insulin level.  The pancreas then releases a spike of insulin when you eat something with sugar in it.  We call this bolus insulin.  To mimic the basal or background insulin level we could hook a patient up to an insulin pump all day.  Or if we had really long acting insulin we could inject the patient once or twice a day and it would slowly disperse insulin all day and mimic the basal insulin level.

The first long acting insulin I started dispensing was insulin glargine or Lantus.  Lantus lasts for 24 hours in many patients, but it can vary from 11 to over 24 hours.  Basaglar is another insulin glargine made by another company.  It is essentially the same as Lantus.  Toujeo is also insulin glargine.  However, it is more concentrated that Lantus so people who need many units of insulin glargine can get them with having to inject less volume.  Levemir is different than Lantus.  Levemir is insulin detemir and it lasts from 6 to 24 hours.  The way they are long acting is different.  

Lantus is made by genetically engineered E.coli, a bacterium.  Levemir is made by genetically engineered brewer’s yeast.  Lantus is made such that it stays in solution in the acidic environment of the Lantus pen, but precipitates out when it is injected into the neutral pH of the fatty tissue under the skin.  The precipitated insulin glargine or Lantus then slowly leaks into the blood stream over the next day.  Levemir is a neutral solution of insulin.  It is designed to stick to itself when injected.  It slowly leaks into the blood stream from its injection site.  Then it binds to a protein in the blood called albumin.  This is interesting since the insulin detemir or Levemir now has to detach slowly from the albumin to become active.

Which is better Lantus or Levemir?  Hard to say.  They both can be injected once or twice a day.  Lantus might sting more at the injection site.  Some studies have found Levemir to be more consistent than Lantus, but not all studies found that.

Tresiba is different again.  It is insulin degludec and it is really long acting.  It lasts 42 hours.  It may cause less low blood sugars than Lantus.  It works by a substance called hexadecanedioic acid, which allows the insulin to form soluble multi-hexamers once injected.  These multi-hexamers result in a slower release of insulin than is possible with other insulin such as Levemir and Lantus.

I’ve got a million-dollar idea for a tech start up.  But you’ve got to keep it very hush, hush okay?  Tech that works better when I’m frustrated and angry.  Hear me out.  Maybe it’s a phone that resets to its last working state when I throw it.    Maybe it’s a desktop that actually finds what I want when I kick it.  Maybe it’s a voice assistant like Siri or Alexa that knows when I curse at it, it is time to stop fracking around.  Way easier to sell frustration tech than learning to control and manage my emotions in a crisis, right?

As always if you have any questions or concerns about these or other products, ask your pharmacist. 

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca