Analgesics – “Feeling no pain” in Greek. These are some of the most common medications taken. Many are available OTC (over the counter-without prescription). Most all of these drugs work on three things: pain, inflammation, and fever. Each varies in its potency for one of these three complaints. Aspirin and Tylenol are taken for colds, headaches, sinus pain, muscular aches. Aspirin has a strong anti-inflammatory action and is often taken for many problems involving inflammatory reactions: infections, bruising, broken bones and arthritis.

A newer drug, Celebrex, interrupts a different point in the inflammatory process and is called a COX-2 inhibitor. Although the latter avoids the side effects of aspirin, recent research has raised concerns about side effects associated with Celebrex which call for consultation with your physician as to which medication is best for you.

Severe pain, such as after surgery, may require stronger analgesics, narcotics, such as codeine, Darvon or Percodan.

Antacids – Who hasn’t had “heartburn” after a big, fatty or spicy meal? So called “heartburn” has nothing to do with the heart, but refers to the burning pain felt behind the breast bone related to meals. The cause is gastric acid backing up into the esophagus.

There are three levels of treatment for mild to moderate to severe symptoms. Popping a Tums or Rolaids, which contains an alkaline chemical, directly neutralizes acid. If heartburn occurs frequently, several times a week, your physician may recommend Zantac or Pepcid which are OTC available histamine blockers. Histamine in the stomach is one of the signals that stimulates acid production. For severe heartburn your physician may prescribe a medication that directly blocks acid production, a proton-pump inhibitor, such as Prevacid (sounds like someone combined “prevent” and “acid”). Each is progressively more effective, but more expensive and with more side effects. However, Prilosec is now available OTC at lower cost than prescription versions.

Rheumatoid arthritis is an autoimmune disease, that is, the immune system attacks joint tissue as if it were foreign tissue leading to joint pain, swelling, redness, warmth (the four criteria of inflammation). Ultimately, joint tissues are damaged. The cause is unknown, but something triggers the inflammatory reaction which becomes chronic and results in destruction of joint structures.

All antiarthritic medications have a common goal, to avoid, suppress or interrupt the inflammatory process. Keep in mind that inflammation is a normal and desirable process when we have an infection. Normally, the inflammatory process, involving bringing in leucocytes (white blood cells) and antibodies does it job and then resolves with the healing process. It is when inflammation develops as a result of an abnormal trigger and/or becomes chronic that normal tissues can be damaged with joint destruction and immobility as a result.

Aspirin and Aleve belong to a category of drugs called NSAIDS (nonsteroidal antiinflammatory drugs). These medications inhibit synthesis of an intermediary chemical in the inflammatory process called prostaglandins. A newer drug, Celebrex, interrupts a different point in the inflammatory process and is called a COX-2 inhibitor. Although the latter avoids the side effects of aspirin, recent research has raised concerns about side effects associated with Celebrex which call for consultation with your physician as to which medication is best for you.

Humira represents a new category of drug recently developed, called slow-acting anti-inflammatory agents, which targets another trigger for inflammation, TNF-alpha. TNF (tumor necrosis factor) is a normal trigger for inflammation, but when produced in abnormally high levels, triggers a chronic, destructive inflammation in joints. This medication has a unique action. It is an genetically engineered antibody which binds and “hides” TNF from the immune system thereby avoiding destructive activity. Since TNF is a normal part of the inflammatory process, patients who already have an ongoing infection must consult with their physician about its use or continued use.

Remicade is heavily advertised for Crohn’s Disease, a chronic inflammatory disease primarily involving the bowel. However, it is approved for rheumatoid arthritis also. It has a similar mechanism of action as Humira.

Antibiotics – There are many of these drugs so only a brief overview can be offered. Two major categories are called broad spectrum meaning many types of microorganisms are affected, and narrow spectrum meaning one or a few microorganisms are affected. First, how do antibiotics work? How can they kill “bugs” but not us? Two examples follow: Humans need folic acid but can’t make it, so we have to get it in our diet as a vitamin. Bacteria can’t take in folic acid, so they must make it. Sulfa drugs block synthesis of folic acid. Voila! Okay for us. Bad for bacteria. Another example is bacteria have an extra layer around themselves called a cell wall. Penicillins block cell wall synthesis. Humans lack a cell wall outside our cell membranes. Okay for us. Bad for bacteria.

Sulfonamides, also called sulfa drugs (not “sulfur” as in brimstone!), were the earliest antibiotics. In those old WWII movies when you see them sprinkling a powder on wounds, that may be a sulfa drug. Over time many organisms have developed resistance to sulfa drugs, so newer antibiotics have to be used. Or, patients develop allergic reactions to sulfa drugs and they must be replaced with other antibiotics. However, they are still used for urinary tract infections and in burn units among other specific uses. Why do you suppose SULFAcetamide, SULFAmethoxazole, and SULFAsalazine are called “sulfa” drugs?

Penicillin is effective against a wide variety of microorganisms including pneumococcal pneumonia, staphylococcal infections, meningitis, syphilis and gonorrhea. How would you know that nafcillin, oxacillin, ampicillin and amoxicillin are all forms of peniCILLIN? Unfortunately, some individuals develop an allergic reaction to penicillins and many microorganisms have become resistant. In this category are newer antibiotics called cephalosporins. Resistant strains have developed against these antibiotics also. What is the nature of antibiotic resistance (more difficult to kill)? In the case of penicillins some microorganisms have developed an enzyme, penicillinase, that inactivates the antibiotic. Microorganisms may also change the chemical structure of their cell walls, the target of penicillins and cephalosporins. Those wily bacteria!

Tetracyclines interfere with bacterial protein synthesis. They effectively stop bacterial growth so our immune system can finish them off. This works because of subtle differences in the protein making machinery of microorganisms and human cells. Tetracyclines (I have doxycycline in my cabinet) are used in chlamydial infections, Lyme disease, Rocky Mountain spotted fever, mycoplasma pneumonia, cholera, syphilis, among others. Another inhibitor of protein synthesis is Erythromycin which is the drug of choice for Legionnaires Disease and one of the few antibiotics that can penetrate the prostate gland. Since it covers a similar spectrum of microorganisms as penicillins, it can be used to treat syphilis in patients who are allergic to penicillin.

Why won’t my doctor prescribe an antibiotic when I have a really bad cold? Common colds are caused by viruses. Viruses have neither cell walls nor their own metabolic machinery (they use yours). Consequently, antibiotics don’t work against viruses.

Anticoagulants – Well, they really don’t make your blood thinner. What they do is make your blood less likely to clot (coagulate) when it is undesirable for clotting to take place like inside your coronary arteries (remember thrombus and embolus?). Since anticoagulants interfere with the clotting mechanism, their use must be carefully monitored to make sure clotting does take place normally with a finger cut, but prevent clots forming after your hip surgery.

Anticonvulsants – Although head trauma or a brain tumor can cause seizures, many times there is no specific cause and it may be inherited. The function of anticonvulsant drugs is to suppress the source of abnormal electrical activity in the brain. Dilantin is a first choice drug in controlling many forms of seizures. Dilantin along with Valium (a tranquilizer) are first line drugs for “status epilepticus”, continuous seizure activity which must be stopped quickly. However, there are various anticonvulsants for specific forms of epilepsy, all with differing effectiveness, side effects and potential drug interactions with other medications. Many famous people have had epilepsy: Socrates, Julius Caesar, Napoleon, Handel, Charles Dickens, Alfred Nobel and Elton John among many others.

Antidepressants – All of us have days when we feel “blue” and for some good reason, disappointment or bad news. But, persistent sadness, preoccupation with negative thoughts, insomnia, prolonged loss of concentration at work and loss of interest in personal affairs may signal a need for medical intervention. All these medications elevate mood from feeling “down”. Two major categories of drugs in use for depression are called tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors (SSRI’s). Put simply, both medications modify the chemicals (neurotransmitters) that carry signals in our brain. They target brain areas that are associated with emotional feelings and our reactions to them. Feel better? Act better!

Antihistamines – Histamine is a natural substance produced by many tissues of the body. Histamine release in nasal passages in response to bacteria or virus infection, sensitivity to various pollens results in a runny nose and nasal congestion. Histamine release in lung tissue causes constriction of air passages. Histamine release in the skin produces redness and itchiness. So, the wide distribution of histamine and its unique actions in those tissues account for the variety of reactions that can occur with its release. Antihistamines block the action of histamine at its target organ.

Antihyperlipidemic drugs – As if we didn’t have enough cholesterol in our diet, our liver actually makes the stuff! Our body uses cholesterol for building cellular structures and making steroid hormones. But, with high fat diets, we get way more then we need. The extra cholesterol gets stuck to the walls of our blood vessels and clogs them with disastrous effects to the heart and brain (heart attack and stroke). If you can’t bring down your cholesterol with diet and exercise, you may need a prescription for one of these medications. The most frequently prescribed drugs are generically called “statins”, because their chemical names all end with…..statin! They reduce the manufacture of cholesterol in our liver. There are also other drugs used to lower cholesterol that work by different mechanisms. Niacin works indirectly to reduce total cholesterol by reducing the production of building blocks for low density lipoprotein, “bad” cholesterol, and increasing production of high density lipoprotein, “good” cholesterol.

Cholestyramine works in a very indirect way. It binds a substance made by the liver, bile acids, in the digestive tract and removes them in the feces. In response, Cholesterol in the blood is converted into bile acids replacing what was bound and removed in the feces thereby lowering blood cholesterol.

Antihypertensives – High blood pressure is a common problem, that can result in heart attack, kidney failure or stroke. However, there are many of us walking around with elevated blood pressure with no obvious symptoms. Getting frequent blood pressure checks is part of a healthy lifestyle. There are three main mechanisms the body uses to control blood pressure: the pumping force of the heart, the contraction of arteries (sympathetic stimulation-vasoconstriction) and a kidney enzyme system that causes vasoconstriction and retention of salt and water increasing blood volume, indirectly blood pressure. There are four commonly used drug mechanisms that reduce high blood pressure: reduce fluid volume in the body indirectly reducing the pressure, reduce cardiac pumping force, interfere with the kidney enzyme system, or reduce vasoconstriction of arteries.

A simple and often effective means to reduce blood pressure is to reduce the volume of body fluid with a diuretic (see category in this list). Getting rid of more fluid by excreting more sodium chloride (salt) into the urine carries off more water, reducing fluid volume in the blood vessels, reducing blood pressure. Another group of drugs are called beta blockers (Inderal and Tenormin samples in cabinet) which act on the heart to reduce its pumping force, reducing blood pressure. ACE inhibitors (drugs ending in “pril”) interfere with the kidney enzyme system that results in both reduced salt and water retention and indirectly dilates arteries. Calcium channel blockers (Norvasc sample in cabinet) cause relaxation of the muscle layers of both coronary and other arteries lowering blood pressure. Alpha blockers directly relax the muscles of arteries lowering resistance to blood flow and reducing blood pressure. An individual patient may require more than one of these drugs to adequately control blood pressure.

Cardiac drugs – There are three major uses for heart medications: regulate an abnormal rhythm (pattern of contractions), strengthen the contractions of a failing heart, respond to cardiac pain.

An irregular heart rhythm can lead to a fatal arrhythmia, sudden cardiac death, that is, the heart pumping action failing and stopping. In the normal heart there is one special area of tissue, the pacemaker, that sets “the beat”, the heart rhythm. If an area of the heart becomes irritable or damaged, it can become an abnormal pacemaker. Antiarrhythmic drugs suppress abnormal, irritable tissue from taking over from the normal pacemaker. A myocardial infarct, “heart attack”, may cause abnormal pacemakers to appear or may disrupt the normal signal conduction pathway through the myocardium. Antiarrhythmic drugs also suppress abnormal conduction pathways. In an oversimplified way, many antiarrhythmic drugs act like a local anesthetic on the myocardium.

The heart may begin to lose efficiency as a pump due to long term hypertension causing back pressure in the heart, a damaged heart valve allowing leakage can cause back pressure or damaged myocardium can result in reduced pumping efficiency following a heart attack. The back pressure in the heart causes fluid to back up in the lungs, hence the name, congestive heart failure (CHF). The failing heart needs a boost, a drug that will strengthen the force of contractions. Digitalis (Lanoxin in cabinet) is a standard drug used in CHF. Diuretics (see that category) and drugs that dilate blood vessels to lower pressure may also be used to reduce the work load on the heart.

Cardiac ischemia produces a unique pain called angina pectoris (remember that term from the cardiovascular module?). It is the heart’s cry for more oxygen due to inadequate coronary artery blood flow. One patient described it “like an elephant sitting on my chest”. A commonly used medication for angina is nitroglycerine. It is not an analgesic (see that category), but relieves the cause of the pain, insufficient blood flow to the myocardium. This medication causes the coronary arteries to dilate allowing more blood flow to heart muscle and the anginal pain subsides.

Diuretics – “Promoting urine” in Greek. These medications may be used alone or in combination with blood pressure medication. Their purpose is to rid the body of excess fluid which can help lower blood pressure and work demand on the heart. Easing the heart’s work load indirectly prevents fluid accumulation in the air sacs of the lungs which can cause difficulty breathing, especially when lying down. The commonest mechanism is to reduce reabsorption of sodium chloride (salt) in the kidneys. More sodium chloride in the urine pulls more water into the urine reducing the body’s fluid volume.

Erectile dysfunction, what used to be called “impotency”, is the inability to achieve or sustain an erection sufficient to complete intercourse. The three current oral medications for this complaint work by a similar mechanism. Achieving an erection depends upon an hydraulic function of increasing blood flow into the penis at a rate faster than the penile veins can drain it away. Sexual stimulation causes a chemical, nitric oxide, to be released by the lining of the penile arteries which causes relaxation of the muscles of the arterial walls resulting in dilating (widening) of the arteries and increased blood flow. Each of these drugs contain a chemical that slows down the destruction of nitrous oxide so the latter prolongs the dilation of the penile arteries. Note that the medication must act on existing nitric oxide released by sexual stimulation. Popping a pill is not enough. No sexual stimulation. No erection.

Although these drugs work by a similar mechanism, they may differ in their effectiveness in individual patients, side effects and drug interactions.

Chronic insomnia, not being able to get to sleep, frequent waking up, not getting enough sleep, can ruin your day! People with sleeping problems may feel drowsy, even nod off, during the work day. Chronic fatigue from lack of sufficient rest is physically and emotionally draining. Hypnotics are sleep-inducing drugs. Their activity is similar to anti-anxiety medications (see “downers” in the list), tamping down brain activity so you can more easily fall asleep and stay asleep. Hypnotics differ in emphasis. Some are most effective in helping you fall asleep, but are very short acting, and may not be very effective for staying asleep. Others are more effective in minimizing number of awakenings for up to eight hours. All hypnotics have a sedation effect. So, you still may be drowsy during the day, but from medication effects. Your physician can best determine the choice of drug and dosage that will balance a good night’s rest with minimal or no daytime sedation.

Hypoglycemic agents – People with diabetes can not properly control their body’s blood sugar. Chronically high blood sugar leads to serious complications such as eye and kidney damage. There are two major types of diabetes: insulin-dependent (formerly called juvenile diabetes) and non insulin-dependent. The former must have insulin injections. The latter may control their blood sugar with a combination of diet, drugs that lower blood sugar and insulin injections. The majority of diabetics are non insulin-dependent.

There are different types of insulin that combine speed of action with duration of action. Regular insulin has the fastest effect (within minutes), but shortest duration requiring more frequent injections. Semilente insulin is intermediate in action onset and duration of effects. Lente insulin is a mixture of Semilente and Ultralente (longest acting). Specific formulations can be chosen by the physician to meet individual patient needs.

Oral hypoglycemic agents (Diabeta and Glucotrol in the cabinet) act primarily by stimulating the pancreas to produce more insulin and facilitate uptake of insulin by body cells. Patients may need to supplement with additional insulin injections. Glucophage has a different mechanism of action. It does not stimulate the pancreas to produce more insulin, but inhibits the liver from releasing stored sugar into the blood.

Osteoporosis Therapy: Bones develop and stay strong and healthy by a constant cycle of bone growth and breakdown involving uptake of calcium from the blood and calcium release into the blood. Among other activities, proper levels of blood calcium are necessary for normal muscle contraction and nerve function. Formation and thickening of bone during early development, in response to stresses (exercising muscles) and fracture repair is the job of osteoblasts, bone building cells. Reabsorbing bone with release of calcium into the blood is the job of osteoclasts, bone breakdown cells. In postmenopausal women hormonal changes result in accelerated calcium release from bones leaving them brittle and at increased risk of fracture. Fosamax, Actonel and Boniva share a common mechanism of action, they all inhibit the activity of osteoclasts, thereby, slowing the release of calcium. The result is stronger bones and fewer fractures.

Tranquilizers – From time to time we all feel stressed about our job or what our teenagers are up to, but we manage to get on with our lives. Sometimes, however, we feel constantly on edge and overwhelmed with worry to the point that it interferes with tasks of daily living. The normal “fear” response takes over inappropriately, and we become immobilized with anxiety. These medications may supplement the support from loved ones and professional counseling. The most commonly used tranquilizers (anxiolytics, antianxiety drugs) have two major actions: to reduce anxiety and to sedate (sleep-inducing). The basic mechanism is to inhibit activity in the area of the brain associated with “fear”. The challenge for your physician is to choose a medication that will reduce anxiety without your falling asleep at your work during the day!