Internal Medicine Of Southwest Florida Newsletter
Shingles,Vitamin D and Your Pharmacist December, 2009
In This Issue
Shingles Vaccine Available
Vitamin D and Health
The Pharmacist and Healthcare Delivery
In this Article
We periodically update medically newsworthy information on our website. You may view this by clicking the following link.  Dr. Kordonowy has published his personal opinion regarding different concepts to help solve our health care crisis in a more efficienty and fair manner.
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It is now time for our second every-other-month newsletter. We have been trying to optimize the vaccination status of our patients and so we have an article on the shingles vaccine.  There has been a significant trend in health prevention regarding vitamin D and our second article discusses this. Finally, one of our subscribers wanted clarification of the present day role of the pharmacist.  Dr. Kordonowy tries to answer that somewhat difficult question.
New Shingles Vaccine Available to Prevent
Zostavax"Doc is this rash shingles"?  This question/complaint comes up in our practice literally weekly.  We are hopeful that in the future this problem will greatly diminish in frequency, thanks to the relatively new Vaccine called Zostavax made by Merck. 
For those who have had this problem, they know a typical case will often start out initially as pain described as sharp,burning and or tingling but certainly noxious.  Within 1-7 days of the pain, a rash will arise. It will appear red but blisters quickly form on top of the redness. For a picture of a Shingles rash click here.
These blisters are teeming with live chickenpox virus. This virus is also called varicella virus. Persons who have never had chickenpox can actually develop this disease if exposed to these blisters. It is rare not to have had chickenpox/varicella when we are young and thus literally one in 2 adults will get shingles in their lifetime. The odds go down to 1 in 4 with the new vaccine. Pain and discomfort is reduced just under 67% in those persons who go on to a case of shingles after having the vaccine. You should not get ZOSTAVAX if you are allergic to any of its ingredients, including gelatin or neomycin, have a weakened immune system, take high doses of steroids, or are pregnant or plan to become pregnant.

Possible side effects include redness, pain, itching, swelling, warmth, or bruising at the injection site, as well as headache.
We have been vaccinating our children for chickenpox prevention for over a decade and this is basically the same vaccine as Zostavax- the difference is the children get a smaller dose in a series of injections. For adults the recommendation is to get this vaccine once to help decrease the incidence and severity of shingles.  The vaccine is indicated for persons 60 and older as a one time vaccine. We have a handout describing the risks/benefits and cost of this vaccine. 
If you are a current patient and feel you are a candidate for the vaccine and wish to schedule an injection please submit an online Services Request Form.

Please note that you do not need to be a patient of the practice to receive this vaccine. If you have an order from your physician, we will be glad to provide this service for you- this would not require you establish as a patient in our practice.  Also, please feel free to contact us via phone.

Vitamin D Levels Correlate to Cardiovascular Risk.
Vitamin D Picture We normally think of bones when we hear about vitamin D. In 2008, Dr.. Kordonowy attended an excellent lecture reviewing vitamin D's association with cardiovascular disease.  Since that lecture there have been more printed articles discussing recommendations to evaluate patient's vitamin D levels.  If levels are on the low end, supplementation is being recommended by some physicians.  At this point there is no firm evidence that supplementation will decrease disease incidence.  The NIH has recently started a study to look at whether 2000 IU of vitamin D3 and 2 grams of fish oil will benefit the general populations health but this study will take years to report its results. The study is called the Vitamin D and Omega-3 Trial, or VITAL, and is sponsored by the National Institutes of Health.  For more information about this study you may click the following link-

Vitamin D has classical effects on mineral regulation, bone formation (osteoporosis) and parathyroid function. Non-classical effects involve cardiac left ventricle thickness, blood pressure regulation and arterial biology/function. There have been associations with various cancer links as well.
Humans can convert vitamin D from dietary sources (fish. liver and various plants) into its functional form using ultraviolet radiation from the sun.  It appears that as we age our skin's ability to utilize the sun's energy for this purpose doesn't work very well and this likely explains the increasing incidence of vitamin D deficiency in the elderly.  Our kidneys also contribute to functioning vitamin D. As we age our, kidney function decreases and thus so does our ability to convert/process vitamin D.  Data suggest the incidence of below ideal D levels varies from between 40-98% including even medical students and persons living in Miami, Florida!
The relative risk for atherosclerosis was 2.5 times higher for persons at the lowest 1/4 of measured vitamin D levels over those in the highest 1/4. Similar risk was noted for 10 year risk of heart attack as well as peripheral artery disease.  Stroke risk was also significantly raised.
Perusing literature as it relates to osteoporosis indicates that most guidelines are recommending 1000-2000 IU of vitamin D or D3 (the active form of D) in general and specific supplement doses for persons found to be truly low on blood assay testing. Vitamin D is readily available over the counter as a supplement and we offer PureCaps Vitamin D3 as a capsule or a liquid.  The liquid is the best value as one drop has 800 IU of D3 and bottle has 900 drops in it. You can go to our link to see other PureCaps supplements available at our practice.   Theoretically, you can get too much vitamin D as it is stored in body fat when taken excessively.  We have yet to diagnose a significant case of vitamin D toxicity in our practice, however. High calcium levels on routine blood testing would likely be noted before a patient had symptoms of D toxicity.
The Pharmacist and Health Care Delivery.
 PharmacistAs mentioned at least one of our website visitors inquired about the role of the Pharmacist in patient care. Traditionally the pharmacist has been very much involved in patient care. This doesn't seem so obvious in today's busy, highly regulated and business driven environment.
Medical students' curriculum includes an intense course in Pharmacology were drug theory and application is taught at the basic science level.  For most physicians, the clinical application of pharmaceutical treatment started on the hospital wards when treating inpatients. In hospitals, Pharmacists review and manage the medication formularies and in learning centers they often round with (and are very much part of) the medical team.  At the residency level they contributed to case review and educating the resident staff on the various medication classes, indications for treatment of various diseases, dosing, toxicity and side effects. They are also involved in clinical trials involving new as well as established medications and treating medical diseases. They have an advanced degree and are part of the health professional team.
In the outpatient setting, the Pharmacist primary role remains one of filling out prescriptions ordered by licensed treating physicians. Licensed nurse practitioners and dentists may also prescribe certain prescriptions. The Pharmacist duties also include: checking for drug interactions when a new prescription is started, monitoring for allergy potential based upon a patient's prior allergy history, confirming proper dosing of medication being prescribed and avoiding duplication filling of medication.   If there is a medication allergy, use or dose concern, the Pharmacist should assist the patient in clarification preferably by direct communication with the treating physician.  Pharmacists are not diagnosticians and are not licensed to actually diagnose and treat disease.  You may consult them about over the counter medications to alleviate symptoms.  They may provide recommendations regarding your treatment or medication. You or they should bring any recommendations to the treating physician's attention for consideration in managing your case.  A Pharmacists input can only be potentially helpful for your care and thus won't be shunned by your physician.
The following paragraphs relate to perhaps why there is confusion regarding the Pharmacists role in patient management  and also include several suggestions/practical feedback as it relates to patients optimizing their medication program.

In today's busy work environment, I have noticed the professional communication between physicians and pharmacists has become greatly impaired. Part of this is due to sheer customer volume.  Other issues contributing to this include: businesses ownership of pharmacist practices (CVS et al), 3rd party interference with prescription choices and confusion as it relates to patient care and oversight.
Patients often report they didn't fill a prescription because the pharmacist informed them their insurance plan "didn't approve it" or the patient felt the prescription is too expensive.  In my view this is not a proper response. Such clerical issues shouldn't delay treatment (the exception being preventive/long term medication decisions). As a rule, the prescription should be filled, the patient should initially pay for it if it "isn't covered" and then ongoing cost concerns should be settled when the involved parties can sort out the issues.  The physician has no reasonable way of knowing in advance what a particular patient's insurance plan is going to prefer within any medication class especially if a name brand product is necessary.  In the past quarter I have even witnessed patients being denied one generic medication due to a plan preferring a different generic medication.  
The patient  has some responsibility in their treatment as well and following are helpful tips to make your physician office visits more efficient. A formulary is a preferred medication list that your insurance company creates each year based upon prior demand as well as cost issues.  Usually formularies can be mailed to you at the time of insurance enrollment or downloaded from your insurance companies website and printed by computer  You can keep current prescription formularies on hand and bring them to your medical appointments. Bringing your formulary to your visit appointment will help the doctor be successful the first time in picking a "covered"/cost effective medication. Medication decisions are made at the time of an appointment with careful chart review. Such review includes going over present symptoms and the patient's response to recent changes.  Prior side effects from other medications and drug allergies are also routinely checked for.
I am hopeful the preceding paragraphs explain the role of your pharmacist as well as some helpful tips to make your health management safe and efficient. As stated prior attending your appointments with a current active medication formulary will help your doctor review your best options and make medication changes (if appropriate) as your are interviewed and evaluated during your actual appointment.  Often what we prescribe can be life saving but side effects/risk also are incorporated into prescription decisions.  Cost is always a factor but can not be the only factor.  We can not promise to always be able to provide a generic or less expensive medication for your particular illness or set of illnesses but certainly we are happy to do this whenever appropriate. 
As always we value your patronage and consider it a privilege to be involved in your care.  We treat all our patients as if they are our family and daily focus on our mission statement.

On behalf of me, my group and our entire dedicated staff I
sincerely wish you a Happy Holiday Season and a prosperous and healthy 2010!

Raymond Kordonowy MD
Internal Medicine Of Southwest Florida