All Posts tagged Dr Smith

Medicine Expiration Dates – What Do They Mean?

As we went through Grandpa’s belongings after his passing one of the things we came upon were some carefully labeled but expired medicines.  And I don’t mean a couple of months expired; generally they had expired a decade or so ago.  Grandpa was always a frugal guy – cutting the mold off the cheese and eating the rest or grabbing and consuming the two-week-old casserole with a questionable odor before we could get it to the disposal.  So what about these expired meds?  Had his frugality in keeping these old prescriptions for later use posed any threat to him?  My bet is that almost all of us keep and take a few meds past their expiration date.  So just how risky is that?

In 1979 a law was passed requiring drug manufacturers to put an expiration date on their meds.  Up to this date the manufacturer guarantees the potency and safety of the medication.  So far so good, but how quickly do medicines lose their safety and efficacy after these expiration dates have passed?  Some years back, the Food and Drug Administration carried out a study to answer that question at the request of the military. The military had a large and expensive stockpile of drugs which they hated to just discard and replace every few years. The study was carried out on over 100 drugs, including both prescription and over-the-counter meds.  They found that more than 90% were both safe and effective even 15 years after their expiration date.

Ok, so for many medicines passing the expiration date doesn’t really mean the medication is no longer effective or is unsafe to use.  But are there exceptions to this?  One important exception is the EpiPen.  They have been in the news recently because of how crazy expensive they can be so there is a temptation to not refill them after the expiration date has passed.  Unfortunately a study done several years back found that the pens do in fact lose potency soon after passing their expiration date.  That means you really do need to keep your EpiPens up to date.  By the way, if somehow you find yourself treating a severe allergic reaction with an EpiPen and notice it’s expired, give it anyways (as long as it isn’t discolored and you can’t see particles in the fluid) since some potency is better than nothing.  But do this as you dial 911 or get immediate emergency care.  Other important exceptions would be nitroglycerin, insulin, liquid antibiotics, and aspirin.  Tetracycline may also be an exception although there is still debate about it.

So you’ll have to decide whether to take Grandpa’s approach and save almost everything or the other extreme of tossing everything the moment it hits its expiration date or some place in between.  For most meds, a little laxity with that stamped on expiration date is pretty reasonable.  Hey, Grandpa lived a healthy 90 years with his approach.

Andrew Smith, MD is board-certified in Family Medicine and manages the Trinity Medical Associates office at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835.  He is accepting new patients with commercial insurance in a typical fee-for-service model and those without insurance or with Medicare in a Direct Primary Care model.


Red Eyes

Recently, just as I thought I was turning the corner on dealing with my own upper respiratory infection, one of the eyes looking back at me from the mirror was red with some thick crusty stuff in and around it (affectionately termed “eye boogers” by many).  I had that common malady which goes by a variety of names such as conjunctivitis, pink eye, or red eye.  This is an inflammation or infection of the conjunctiva which is the thin clear tissue covering the white part of the eye and the inside of the eyelid.  When it gets inflamed it turns pink or reddish.

So what causes conjunctivitis?  The big three are bacterial, viral and allergic.  The first two of these are infectious and are about equal in frequency.  Bacterial conjunctivitis tends to look a bit more angry and red and to have a thicker discharge, sometimes leaving the lids pasted shut in the morning.  Viral conjunctivitis tends to have a more watery discharge, but there is a lot of overlap of signs and symptoms between these two types of conjunctivitis.

The main practical difference is that bacterial responds well to antibiotic drops while viral does not, needing to just run its course.  By the way, with my recent case of bacterial conjunctivitis I was reminded how challenging the simple job of putting drops in your own eyes can be.  My eyelashes and cheeks were more likely to be watered by my eye drops than the actual eye.  At any rate, both of these types of conjunctivitis are quite contagious.  So if you have either one in one eye it is vital to not rub that eye and then the other or wipe a towel or wash cloth from one to the other as it will spread the infection to the unaffected eye.  Even more important is to not share towels or wash cloths with uninfected family members while you have conjunctivitis.  Likewise, rubbing your eyes leaves your hand with infectious material that can then be spread to others.

This is why most daycares and schools encourage children with conjunctivitis to be kept home until symptoms have cleared.  Unfortunately, in the case of viral conjunctivitis, that can be up to 1-2 weeks in some cases.  Bacterial conjunctivitis is usually considered non-contagious after 24 hours of antibiotic drops.

Although these kinds of conjunctivitis are usually not dangerous, there are a couple of special cases that are more worrisome.  In newborns, any conjunctivitis should be checked out quickly and treated aggressively as there are some sight-threatening infections that occur in the newborn period.  That’s why states, including Tennessee, mandate an antibiotic eye ointment for all newborns. Other types of conjunctivitis, which are more serious but also more rare, include herpes, gonorrhea and chlamydia.  All require aggressive, specific treatments to clear them up and prevent eye damage.

Allergic conjunctivitis looks similar to viral, with watery discharge, pink color and itching.  It tends to persist through an allergy season and responds to oral allergy meds and allergy eye drops.  It is, of course, non-contagious but can worry teachers and daycare overseers if they think it is one of the contagious types of pink eye.

Another tricky thing about a pink or red eye is that it is not always conjunctivitis.  Similar symptoms can be caused by getting something in the eye (foreign body, chemical, or other irritant).  This is particularly likely if only one eye is affected.   Other conditions such as glaucoma or inflammations of other structures in the eye (iritis, uveitis) are also causes of a pink or red eye.

So if you wake up to that not-so-pretty color of pink in your eye, or a bunch of eye boogers, given the varied causes and repercussions, it’s a good idea to let your doc have a look.


Labors, Mercies and a Gift of Projection

When someone’s voice would rise above all the rest and be heard across the room, my wife’s family, the Davises, would remark knowingly, “He has the gift of projection.”  A little after nine in the morning a week ago Friday, a man who had, and I would say still has, the gift of projection, died in our home.  That man is my father-in-law, better known to most as “Grandpa”.

He passed into the next life at 91 years and 1 day old, or as he would have said it, 91 years, 9 months, and 1 day old.  When I say he had the gift of projection, I don’t mean that he spoke loudly, though he certainly could make himself heard.  What I mean is that his words projected an uncommon weight and influence.  They did so because, by the grace of God, they emanated from a life so well-lived.

A retired dairy farmer, Grandpa lived with us for some fifteen years. He tended to burst out of his room as if shot out of a cannon, ever on a mission.  At 90 years old he was still delivering meals-on-wheels to “the old folks”, staying active in church, keeping up with politics, quizzing us from the newspaper on where the highest and lowest temperatures in the country were, reading his Bible at length, praying for his 27 grandchildren and their parents, mowing the land on an old Massey Ferguson tractor, and working with the hands made large and strong by decades of working a dairy farm.

But I believe there was even more power in his words than in his hands; In the evenings Grandpa’s voice could be heard as he made daily calls to buoy old friends, encourage grandchildren on their birthdays or any other time he thought they might need it, and reconnect with a host of other people from a life lived stitching together warm human bonds.  He would meet strangers and inform us later that they were joining us for Thanksgiving dinner.  Four months ago he gave the toast at my second oldest daughter’s wedding.  His godly words were a centerpiece of the celebration.

But only a couple weeks later he emerged from his room limping badly with no remembrance of a fall – turned out to be a cracked hip.  That was the start of a steep three-month free fall, from limp, to cane, to walker, to wheelchair, to bed.  The hip would get better, but then other things would go bad.  This vigorous vibrant man suddenly grew weak, shrinking before our eyes until finally, even the booming voice became only a dry whisper. Yet Grandpa’s words, though they became fewer, quieter and more halting, somehow, if anything, grew in impact.

After some initial testing to rule out treatable problems it became clear that there was nothing substantial that we could medically fix.  Grandpa was dying.  In his case, sending him to the hospital would only add misery and isolation to the process. We were able to keep him home as my wife was able to stay with him and many family members and folks from church pitched in to help.  The months carried many labors, many tears, many messes, but also many mercies.  After several days of unresponsiveness, Grandpa would suddenly wake up clear-headed and bless, guide, or express affection for someone in simple words given mass because of the man from whom they came.

There was a certain soul-satisfaction in meeting his basic needs.  And though there were sharp words on rare occasions, Grandpa was mostly humble and appreciative.  I am well aware that for many caring for aging or dying parents it is not that way.  These were great mercies to us.

In Grandpa’s case we were very thankful to be able to keep him home and let him spend his last weeks surrounded by people he loved and who loved him.  His final passing was gentle.  Though death is almost never pretty, his was at least peaceful.  Over his final few days, Grandpa became almost completely silent except for his increasingly labored breathing.  Then one morning he lay in his bed in our home watched by his oldest daughter and finally there was a breath not followed by any more.  He was wholly silent… but not really. It is not just wishful poetry to say that Grandpa’s voice still projects to us.  His life and words resonate in our mind and heart.  God gave this humble, hard-working dairy farmer much mercy and an unusually powerful gift of projection, and I can still hear him loud and clear. And the temporary labors and messes of the past months are more than outweighed by the memorable mercies.


Gout and Pseudogout

I don’t remember doing a thing to my foot; I didn’t stub it, I didn’t drop anything on it, but holy cow it feels like a boil in my big toe.  I woke up and it’s big and red and throbbing.  What do you think is going on with it?”

Indeed the base of Mr. Stoddard’s big toe was swollen, red and very tender to touch or put weight on.  In the end, it turned out to be the age-old malady, gout.  Gout was first identified by the Egyptians over four thousand years ago and then was recognized by Hippocrates in the fifth century BC and referred to as “the unwalkable disease”.

Gout is caused by uric acid crystals which precipitate out in joints.  In up to 90% of individuals with gout, the base of the big toe is involved.  However, other joints such as the wrist, ankle, fingers, knees and elbows may be involved.  Also, another similar condition, often called pseudogout and caused by calcium phosphate crystals, can cause very similar symptoms.

Besides a red, painful, warm joint, gout can sometimes produce a low-grade fever and occasionally involves tophi which are deposits of uric acid crystals in the soft tissues of the ears, fingers, toes, or other joints.  Over time, especially if untreated, gout can ravage joints and can damage other organs such as the kidneys.

Why does someone get gout?  Like with most illnesses, it starts with a built-in genetic tendency.  Add to that certain foods and drink.  Gout used to be called the rich man’s disease because it was mostly the rich who could afford the food and drink which triggered a gout attack.  Traditionally, large meals of meat and beer are considered a common trigger for gout.  The reason is that these kinds of meals cause a spike in uric acid levels which then precipitate out in a joint causing the pain, redness and swelling.  But other foods such as high fructose corn syrup, seafood such as shrimp and scallops, sugary drinks, and organ meats such as liver are also potential triggers for gout.  Also, certain medicines, such as diuretics, and certain conditions such as obesity and cancer will also increase the likelihood of gout attacks.

Gout is not uncommon, affecting about 4% of the adult population.  Pseudogout, officially named calcium pyrophosphate disease (CPPD), affects a higher and higher percentage of individuals the older they get.

So, if you ever awaken with a painful, red base of your big toe, or perhaps some other joint, with no recollection of an injury, what should you do?  The pain is usually enough to motivate you to head to your doctor.  The diagnosis can generally be made by the clinical appearance, usually with a little help from blood work.  Less commonly x-rays may be obtained. The definitive test is aspirating fluid from the painful joint and sending it for analysis to see if crystals can be identified.  Because this is often very painful and difficult, especially if the joint is a toe joint, it is done somewhat infrequently.

Once the diagnosis has been established, anti-inflammitant medicines such as steroids, colchicine, or non-steroidal anti-inflammitants are prescribed.  If a person has repeated episodes of gout, preventive medicines such as allopurinol or probenecid may be used to ward off future painful attacks.

Reading some of the accounts of individuals struggling with painful gout over decades in the days prior to effective medicines makes you thankful for the many available treatments today.  So if gout or pseudogout looks like it has attacked you, get it checked out and fight back.