Interesting article
Pain Free Injections
Anesthetic Skin Cream With Time-Release Feature Available
R. Mclean
November 2001
Ferndale Laboratories of Ferndale, Michigan, is now promoting its
time-released, deep penetration topical skin cream for purchase on the Web
and pharmacy shelves.
The non-prescription cream is used to numb the skin before procedures and
injections, and is also effective in treating minor cuts and abrasions. The
cream contains four percent lidocaine, a dental anesthetic typically used to
relieve mouth pain. The anesthetic is absorbed into the skin via the cream’s
liposomal delivery system. The system has the same chemical structure as
natural cell membranes in the body, which allows the cream to absorb more
quickly, penetrate more deeply and last longer. Unlike Emla cream, ELA-Max
is available over-the-counter, requires no occlusion to use and is quicker
acting, according to Stephen King, Ferndale Laboratories’ senior product
manager.
ELA-Max comes in 5-gram or 30-gram tubes. Prices range throughout the
country. For more information, contact Ferndale Laboratories at (877)
352-6294. To order online, log on to www.ferndalelabs.com or
www.dermstore.com.
June 15th, 2003 at 4:26 pm
You can get 5% lidocaine ointment ointment from Canada without a
prescription, a 30 gram tube, for about $13 plus shipping. That is about
10% of the price here.
Been there, done that.
August 5th, 2003 at 10:31 pm
My Experiences with Exenatide
on Tuesday, February 21 @ 11:37:25 EST
Anne Peters, MD, Clinical Professor, Director of Clinical Diabetes,
University of Southern California, has been using Byetta(exenatide)since
it first came out, This week she shares her thoughts and experiences
with us. My Experiences
My Experiences with Exenatide
Anne Peters, MD
In my practice, when starting a new antidiabetes medication, I use the
change in therapy as an opportunity to readdress lifestyle
modifications. I have found this particularly true with exenatide, which
is a drug that enhances a patient’s sense of satiety and makes it easier
for a patient to eat less without the usual struggle against food
craving. However, I have had occasional patients who start on exenatide;
find themselves eating less; and then decide that, because they are
eating smaller portions, they can eat more high-calorie foods, such as
cake, cookies, candy, and potato chips. Unfortunately, fewer
high-calorie foods are largely equivalent to more lower calorie foods,
and these patients have little, if any, weight loss while on the
exenatide. On the other hand, I have patients on exenatide who have
worked hard on eating less overall, with an improvement in the
composition of their diet and a reduction in caloric intake, such as
eating a salad with light dressing for lunch instead of a roast beef
sandwich, who have lost much more than the expected weight loss (20-30
lb in a few months).
An important message for all patients with diabetes, no matter what
treatment is used, is that the therapeutic response is always enhanced
when lifestyle modifications are incorporated into the daily pattern of
behavior.
Since the most common side effect is nausea, which in some participants
was accompanied by vomiting. I always warn patients about the potential
for nausea when starting exenatide. It always helps if patients are
forewarned, so they know what to expect and understand that the nausea
will usually improve over time. I also recommend that the patient
contact me if the nausea and/or vomiting is severe or persistent. There
is no known treatment for the nausea, other than time.
In original studies the nausea and vomiting tended to diminish over time
and were less frequent if patients started on a lower dose of exenatide.
Therefore, to reduce the occurrence of nausea, a lower starting dose (5
mcg twice daily) is recommended for the first month, with an increase to
10 mcg twice daily (if tolerated) thereafter.
If one of my patient is having a lot of difficulty with nausea, I reduce
the dose from twice daily (before breakfast and before dinner) to just
once daily (before dinner for a week or 2) until the drug is tolerated.
This has been helpful in reducing the symptoms.
Another effect of exenatide in the pivotal studies was an increase in
rates of hypoglycemia when used in patients on a sulfonylurea agent.
Exenatide, on its own, will not cause hypoglycemia — and didn’t when
used in combination with metformin alone. However, when added to a
sulfonylurea agent, it will lower blood sugar levels and make the
patient more susceptible to sulfonylurea agent-induced hypoglycemia.
Therefore, if a patient is taking a sulfonylurea agent, the dose should
be reduced by 30% to 50% when exenatide is added.
Clinically, because exenatide has a greater effect on postprandial blood
glucose levels than on fasting levels, sometimes backing off too much on
the sulfonylurea dose will cause an increase in fasting glucose levels
while the exenatide improves postprandial levels. Therefore, it is a
balance between preventing hypoglycemia with an anticipatory reduction
in the sulfonylurea agent dose vs causing an increase in fasting blood
sugar levels by cutting back too rapidly.
Although exenatide is only approved for use with metformin and/or a
sulfonylurea agent, there is no pharmacologic reason to believe that it
can’t be used as monotherapy or in combination with all agents for
treating diabetes, including thiazolidinediones and insulin. Studies
have been completed assessing the combination of exenatide and a
glitazone, and the data have been submitted to the US Food and Drug
Administration.
Anecdotally, I have used (off-label) glitazones in combination with
exenatide essentially since the drug was released, and my patients have
done well. The same is true for the combination with insulin, although
there are yet no formal data on this approach to treatment. The rule of
thumb for reducing the dose of any drug that can cause hypoglycemia when
exenatide is added holds true when it is added to insulin. I generally
keep the basal insulin dose the same, but reduce or eliminate the
premeal insulin doses, using the exenatide to enhance endogenous premeal
insulin secretion. Remember, however, that exenatide does not substitute
for insulin in patients with type 1 diabetes; patients need to have
functional beta cells to respond to exenatide. Patients with type 1
diabetes may benefit from the administration of pramlintide with their
premeal insulin; pramlintide is neuroendocrine hormone secretion from
pancreatic beta cells.[8]
Other incretin mimetics that should be useful in combination therapy for
the treatment of type 2 diabetes are under development.[9,10] One is
liraglutide, which is a human long-acting form of glucagon-like peptide
(GLP)-1 that is similar in action to exenatide. A related class of
medication, which increases endogenous GLP-1 levels, is the dipeptidyl
peptidase IV inhibitors, such as vildagliptin. These oral agents
increase GLP-1 levels by slowing its breakdown, which prolongs its
half-life.
In summary, the incretin mimetics are extremely useful agents for the
treatment of type 2 diabetes. The currently available drug exenatide is
approved for use in combination with a sulfonylurea agent, metformin, or
the combination of both. Exenatide is supplied in an easy-to-use
predosed pen, and is generally well tolerated. However, patients should
be warned that they may feel nauseated from the drug, a side effect that
generally diminishes over time. Patients on sulfonylurea agents may need
to have their dose reduced to avoid hypoglycemia. If used appropriately,
exenatide can help improve A1C levels and aid in weight reduction, which
helps both provider and patient achieve goals that were more difficult
to reach in the past.
Anne Peters, MD, Clinical Professor, Director of Clinical Diabetes,
University of Southern California, Keck School of Medicine, Los Angeles,
California; Director of Clinical Diabetes, University of Southern
California, Westside Center for Diabetes, Los Angeles, California
Part of the information for this article was from Medscape Diabetes &
Endocrinology. 2005;7(2)