WHICH ORAL ANTIBIOTICS ARE SAFE DURING PREGNANCY AND BREASTFEEDING?

Many are okay...and LESS risky than an untreated infection. But some have special precautions...and several should be avoided.
Penicillins and cephalosporins are usually safe.
Consider using a higher or more frequent dose during the 2nd and 3rd trimesters...to compensate for the increased volume of distribution and clearance.
Erythromycin and azithromycin are also generally safe in pregnancy. Don't use clarithromycin...due to concerns about birth defects in animal studies.
Nitrofurantoin is usually okay during pregnancy and breastfeeding. Don't use it close to delivery due to a small chance of hemolytic anemia in the newborn.
TMP/SMX should usually be avoided. Trimethoprim may cause birth defects during the 1st trimester...and sulfonamides may cause high bilirubin and jaundice in the baby if given near term.

Metronidazole is sometimes avoided in the 1st trimester due to concerns about possible malformations. But it can be used during pregnancy if there are no good alternatives.
For a single dose while breastfeeding, suggest stopping breastfeeding for 12 to 24 hours to allow the drug to be eliminated.
Clindamycin is an alternative to metronidazole for anaerobic coverage and is considered safe in pregnancy and lactation.
Fluoroquinolones (ciprofloxacin, etc) are associated with cartilage damage in animals. Even though this isn't confirmed in humans, try to avoid fluoroquinolones during pregnancy.
Tetracyclines should be avoided in pregnancy...especially in the 2nd and 3rd trimesters. They're associated with adverse effects on fetal teeth and bones, other defects, and maternal liver toxicity.
Tell moms that tetracycline can be used during breastfeeding...it only shows up in very low concentrations in breast milk.

On-line resources:
Motherisk. http://www.motherisk.org/index.jsp. Offers consumers answers to questions about morning sickness and the risk or safety of medications, disease, chemical exposure, and more. Provides teratogen information for healthcare professionals and updates on Motherisk's continuing reproductive research.
Perinatology.com. http://www.perinatology.com/. Provides teratogen information for healthcare professionals and links to clinical guidelines and more.
Organization of Teratology Information Specialists (OTIS). http://www.otispregnancy.org/. Provides medical consultation on prenatal exposures for consumers and healthcare professionals.
OBfocus. http://www.obfocus.com/. Provides information for healthcare professionals and consumers on pregnancy related issues, including drug exposure. Provides a list of resources on high risk pregnancy



Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for Women Still Drinking During Pregnancy

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

BOOKS TO READ ON THE BEACH

BOOKS TO READ ON THE BEACH SO YOU CAN SMARTLY CONVERSE AT LIBERAL DOCTOR HATING COCKTAIL PARTIES THIS FALL – OR READ THIS AND SAY YOU DID

Guy Clifton, a neurosurgery professor at the University of Texas Health Science Center in Houston, argues in his book Flatlined: Resuscitating American Medicine that there are two ways to control healthcare costs: price controls with rationing (used by most industrialized nations and abhorred in the U.S.) or increased efficiency. Clifton points out that the cost of healthcare is so high that it is affordable only if someone else is paying for it, such as government or employers. The "haves" consume the healthcare of the "have nots," to the detriment of both. An estimated 30,000 patients die each year from overtreatment. He estimates that 50 percent of healthcare is a waste, if you factor in excessive medical care and patient health behavior.

In The Great American Heart Hoax: Lifesaving Advice Your Doctor Should Tell You About Heart Disease Prevention (But Probably Never Will), cardiologist Michael Ozner claims that the annual 1.5 million U.S. angioplasties and coronary bypass surgeries, for which the price tag is $60 billion, neither save lives nor prevent heart attacks. He cites Harvard research that 70 to 90 percent of those procedures are unnecessary.

The U.S. is the only industrialized nation not to guarantee healthcare to its citizens. We spend more than twice as much per capita as any other country, yet if longevity is the criteria comparatively we do not live longer lives. Medical professor Nortin Hadler, author of Worried Sick: A Prescription for Health in an Overtreated America, says healthcare interventions rarely, if ever, improve longevity. He defines two types of medical malpractice. Type I malpractice: Doing something medically necessary unacceptably poorly. Type II malpractice: Doing something unnecessary very well.

Journalist Shannon Brownlee, author of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, gives partial credit of overtreatment to Americans’ blind faith in technology and science. About 34 percent agreed with the statement in a Harvard survey that modern medicine can cure almost any illness with the right technology. However, Brownlee points out that 25 to 40 percent of autopsies show that patients were being treated for the wrong diagnosis, which is virtually unchanged from 1910.

Physician Dennis Gottfried, who wrote Too Much Medicine: A Doctor’s Prescription for Better and More Affordable Health Care, wants to ban direct-to-consumer advertising for medications and aggressive promotion of pharmaceuticals to physicians because both result in prescription of more expensive, less effective drugs. About 31 percent of patients who see these advertisements ask about the drug, and a significant portion of them want it even though they are clueless to its effects. Unfortunately, he says,a significant percentage of doctors comply because they do not want to lose a fully insured patient.

For A Responsible National System Of Balanced, Evidence-Based, And User-Friendly Drug Information

In a health care system that rewards quantity over quality, rushed clinical encounters with physicians and pharmacists leave too little time to review drug risks and benefits says Jerry Avorn [Communicating Drug Benefits and Risks Effectively: There Must Be a Better Way. Jerry Avorn, MD, and William H. Shrank, MD, MSHS 21 April 2009 | Volume 150 Issue 8 | Pages 563-564]

This is not to mention a problematic mix of overpromotion, undercommunication, and inadequate regulation which has left many patients bewildered and mistrustful of prescriptions.

Avorn makes the case that as lay people and physicians increase their demands for coherent, evidence-based, unbiased drug information, we would all be well served by a comprehensive program to replace our current patchwork of bad communication and excessive promotion with a responsible national system of balanced, evidence-based, and user-friendly drug information.

Neither the package inserts nor the container labels offer as much help as they should says Avorn. Much discussion about drug information for lay people has focused on the package inserts; however, these documents are primarily written for physicians, not patients, and they are rarely inserted in the packages patients actually receive. Another source is the label affixed to the medication bottle. These communicate the name of the pharmacy in large type but vary greatly in their reporting of warnings (3) and instructions (4). When communicating essential safety information, container labels often use a font too small for many patients to read, and they often emphasize information more relevant to the pharmacist than the patient.

This reappraisal should not stop with evaluating patient-directed materials. Physicians need to learn about benefit and safety data through sources that are more useful than the tiny-print overkill that now constitutes these official documents (12–14). But as the work of Schwartz and colleagues points out, more than reformatting will be needed to create educational materials that guide physicians and patients in the right direction.

Using a Drug Facts Box to Communicate Drug Benefits and Harms-Two Randomized Trials Lisa M. Schwartz, MD, MS; Steven Woloshin, MD, MS; and H. Gilbert Welch, MD, MPH 21 April 2009 | Volume 150 Issue 8 | Pages 516-527

Two randomized, controlled trials were conducted between October 2006 and April 2007 by Lisa M. Schwartz et al. This was a symptom drug box trial using direct-to-consumer ads for a histamine-2 blocker and a proton-pump inhibitor to treat heartburn, and a prevention drug box trial using direct-to-consumer ads for a statin and clopidogrel to prevent cardiovascular events.

In the symptom drug box trial, 70% of the drug box group and 8% of the control group correctly identified the PPI as being "a lot more effective" than the histamine-2 blocker (P < 0.001), and 80% and 38% correctly recognized that the side effects of the 2 drugs were similar (P < 0.001).

When asked what they would do if they had bothersome heartburn and could have either drug for free, 68% of the drug box group and 31% of the control group chose the proton-pump inhibitor, the superior drug (P < 0.001).

In the prevention drug box trial, the drug box improved consumers' knowledge of the benefits and side effects of a statin and clopidogrel. For example, 72% of the drug box group and 9% of the control group correctly quantified the benefit (absolute risk reduction) of the statin (P < 0.001). Most of the control participants overestimated this benefit, and 65% did so by a factor of 10 or more.

A drug facts box improved U.S. consumers' knowledge of prescription drug benefits and side effects. It resulted in better choices between drugs for current symptoms and corrected the overestimation of benefit in the setting of prevention.

Should End Of Life Patients Smoke?

I’m in complete sympathy with Peter A. Ubell, MD ,director of the Center for Behavioral and Decision Sciences in Medicine at the University of Michigan who writes that “Eighteen years out of training, and I still find myself struggling to understand the moral imperatives of medical practice.”

“Not long ago,” he relates, “as part of my hospital duties, I cared for a man who could no longer swallow. This dysphagia was his only medical complaint, one that had sneaked up on him over the course of a month. He simply couldn’t find the muscular strength to propel food and liquid down to his stomach. After some investigation, the medical team discovered he had metastatic lung cancer. That explained the dysphagia: cancer had stimulated his immune system to attack his swallowing muscles.

While the cancer was incurable, we hoped we could slow its progression and give him a few extra months of life — small solace for a man in his mid-50s with a loving wife and several children ready to start new families, but the best we could offer. On rounds the morning after he received a feeding tube, I stopped by to see how he was doing — checking his abdomen for signs of infection and, more important, assessing his fragile mood. I tried to keep things upbeat, making small talk while examining his belly. But something about his response, and the look he gave his wife, was troubling.

I looked up and asked him how he was feeling, keeping purposely vague about whether I was posing a medical, or a social question. His wife replied— angrily. She lashed out at her husband for having sneaked off that morning for a cigarette. He glared back and told her to mind her own business. She looked toward me for support — I was the physician, after all — and I found myself in a common medical quandary.

According to this new paradigm of preference-sensitive decision-making, doctors like me shouldn’t tell patients what to do (Take your pills! Stop smoking!), but rather should educate our patients about the risks and benefits of their options. So going by the book, I should have informed my patient about the pros and cons of tobacco. But I couldn’t stand by, in the role of a dispassionate educator, and let this man hurt himself. Instead, I felt compelled to give him advice that would promote his best interests.

I advised him to smoke. Then I turned to his wife. “I know that you are trying to keep your husband from smoking because you love him and don’t want him to get sicker, but those cigarettes aren’t going to hurt him now. If anything, they’ll help him relax.”

Medical decisions these days are increasingly recognized as being more than simply medical, with the right choice depending in part on the patient’s preferences. My duty as a physician, says Ubell is to improve my patients’ lives. And if I can do that by sharing my perspective with them, however strange or uncomfortable it may sound, then that is what I must do. Even if it means encouraging them to smoke.

This anecdote brought me back a few decades when my father was also at his end of life. He was in his room at Johns Hopkins Hospital for several weeks suffering from Chronic Obstructive Lung Disease [COPD]-after a lifetime of cigarette smoking-Lucky Strikes, unfiltered to keep the taste strong. Every breath was an effort. But he managed to breathe “better” while smoking, he said.

I was a resident physician at the hospital which made it easier to visit with him 3-4 times per day. Oxygen tanks for his oxygen treatments every 2 hours were in his room- so smoking and matches in his hospital room were out of the question.

My father understood this.

So when no one was looking-or he thought no one was looking-- he wheeled his chair into the visitors lounge. His engaging good nature always managed to get him a cigarette- from either a patient or guest. Today smoking is banned in offices and workplaces and even banned in many bars but those were the days when smoking was not banned even from hospitals.

He smoked in the hospital visitors’ lounge-but quickly put it out and hid it when nurses were close. One nurse whispered to me about his secret violations of the medical regimen and insisted that I stop his smoking or she would tell his pulmonologist who happened to be my boss.

What was I to do? Smoking is contra-indicated in everybody-especially those ravaged by the terrible effects of tobacco in the lungs. But was cessation of smoking now going to help him after 50 years of the habit resulting in death approaching in weeks if not days?

My duty as a physician is to improve patients’ lives. Moreover, like Ubell strange as it may sound, even if it means enabling them to smoke.

I made the same decision. In fact, I aided and abetted him by getting him an occasional cigarette and wheeling him to the outside deck of the Marburg floor where he could privately smoke in peace in the early Baltimore Spring.

He understood and was grateful. His eyes told me even though he would not say it for fear of incriminating me in the crime.

His pulmonologist also understood. He never mentioned anything about it to me.

My father died later that spring.