MAYO CLINIC HEALTH LETTER To o l s f o r H e a l t h i e r L i v e s VOLUME 27 NUMBER 11 NOVEMBER 2009

Inside this issue HEALTH TIPS . . . . . . . . . . . . . 3 Avoiding falls. NEWS AND OUR VIEWS . . . . . 4 Acupuncture or acupressure reduces nausea after surgery. Why exercise matters after age 50. HEMORRHOIDS . . . . . . . . . . 4 Blood vessels gone astray. HEART FAILURE . . . . . . . . . . 6 Proven treatments to extend life. THE WAY WE PLAY . . . . . . . . 7 Games for better health.

Neck pain

Off the mark Neck pain can manifest itself in different ways. You may experience stiffness in your neck that interferes with your daily tasks, or a sharp or dull pain in the neck. Sometimes, the neck pain is accompanied by shoulder, back or arm pain. Common causes for ordinary neck pain include: ■ Muscle strains — These are typically triggered by overuse, such as too many hours hunched over a desk or computer, or leaning over a steering wheel. Neck muscles — especially those in the back of the neck — fatigue and become strained (tension myalgia). If the overuse occurs repeatedly, the result can be chronic neck pain. ➧

Some causes can be serious When a necessary task is considered to be less than fun, it’s sometimes described as being a “pain in the neck.” Actual neck pain can be much more troubling. Neck pain is a common problem with many possible causes. Sometimes, simple self-help techniques can ease the pain. But neck pain can at times be related to a more serious condition. Recognizing the difference can be a critical factor in getting the right medical care.

SECOND OPINION . . . . . . . . 8

Neck pain

Coming in December MAGNETIC STIMULATION Therapy for depression, chronic pain and more. SERVICE DOGS Greater independence and safety. EXERCISE TO BURN CALORIES What does it take? DYSTONIA Muscles, nerves and misfires.

Spine

Pain from neckmuscle strains Narrowed disk space Pinched nerve Herniated disk A variety of factors can cause neck pain, including muscle strains, narrowed disk spaces, herniated disks and pinched nerves.

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■ Worn joints — Over time, wear and tear occurs in the neck joints. Neck (cervical) osteoarthritis can result and cause pain and stiffness. ■ Disk degeneration — With age, the spongy disks that provide cushion between the vertebrae of your spine become stiff and provide less shock absorption. This normal aging process may cause neck and upper back pain. Occasionally, the nerves exiting the spine are affected by a herniated disk or outgrowths of bone spurs from around neck joints that are worn. If the nerves are irritated by the disk or bony outgrowth, it may cause pain in the shoulder or arm. Sometimes, pain is related to an injury such as whiplash. Rear-end vehicle collisions can stretch neck muscles and ligaments beyond their limits. Whiplash injuries often affect both the neck joints and the disks.

Home care In most instances, neck pain related to muscle overuse and strain responds well to home care — usually within a few days — and doesn’t require medical treatment. Selfcare measures include: ■ Nonprescription pain relievers — Creams and gels with camphor and menthol, such as Flexall and Bengay, help relieve muscle and joint pain and may offer temporary relief. Acetaminophen (Tylenol, others) may relieve pain as well as other oral medications — but with less risk of gastrointestinal irritation and with lower risk to the kidneys. Other oral options include naproxen (Aleve), ibuprofen (Advil, Motrin IB, others) and aspirin. ■ Using either heat or cold — To reduce inflammation, use an ice pack or ice wrapped in a towel for up to 20 minutes several times a day.

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Beyond home care When simple home care methods alone don’t work, there are other approaches your doctor might recommend to address neck pain and provide relief. The addition of specific neck stretches and exercises may be helpful. A physical therapist can teach you stretching techniques and specific exercises. Generally, you can perform these on your own at home. Doing so helps restore muscle function and reduce tightness experienced as muscle spasm. Increasing neck-muscle strength and endurance is particularly important once you feel ready to participate in these exercises, as they may decrease chances of future neck pain flare ups. However, flare-ups are common, and a large percentage of the population has recurrent neck pain problems. For some, oral medications — particularly prescription pain medications, muscle relaxants or tricyclic antidepressants — may be helpful. Another option may be to inject corticosteroid or numbing medication near nerve roots, small neck joints or muscles. Traction done under the supervision of a medical professional may provide relief, especially if neck pain is related to nerve irritation. Relief may last hours or even days. If traction helps your pain, you may want to talk with your doctor about home-traction devices. Although surgery isn’t a common treatment for neck pain, it may be an option if the problem stems from nerve compression or causes serious complications — such as arm weakness — or if other treatment options have had little impact on your pain. Surgery to relieve nerve compression is successful most of the time.

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Alternate cold with heat by taking a warm shower or using a microwaveable heat pack. However, use heat with caution for the first 48 to 72 hours after injury, as it can sometimes aggravate inflammation. ■ Resting your neck — During the day, lie down for short periods — 10 to 30 minutes — to take a load off your neck from holding up your head. Relaxation and stressreduction techniques, such as progressive muscle relaxation, can help, as can massaging neck muscles. ■ Gentle stretching — Certain stretches done slowly and held for at least 30 seconds can be helpful. However, be aware that there’s a balance between aggravating arthritis and losing your range of motion, so start slowly with any stretches. You might try slowly rotating your head from side to side, keeping your chin level as you turn your

November 2009

Managing Editor Aleta Capelle

Medical Editor Robert Sheeler, M.D.

Associate Editors Carol Gunderson Joey Keillor

Associate Medical Editor Amindra Arora, M.D.

Medical Illustration Michael King Customer Service Manager Ann Allen

Editorial Research Deirdre Herman Proofreading Miranda Attlesey Donna Hanson Administrative Assistant Deborah Adler

EDITORIAL BOARD Shreyasee Amin, M.D., Rheumatology; Amindra Arora, M.D., Gastroenterology and Hepatology; Brent Bauer, M.D., Internal Medicine; Julie Bjoraker, M.D., Internal Medicine; Lisa Buss, Pharm.D., Pharmacy; Bart Clarke, M.D., Endocrinology and Metabolism; William Cliby, M.D., Gynecologic Surgery; Diane Dahm, M.D., Orthopedics; Mark Davis, M.D., Dermatology; Timothy Hobday, M.D., Oncology; Lois Krahn, M.D., Psychiatry; Amy Krambeck, M.D., Urology; Suzanne Norby, M.D., Nephrology; Robert Sheeler, M.D., Family Medicine; Phillip Sheridan, D.D.S., Periodontics; Peter Southorn, M.D., Anesthesiology; Ronald Swee, M.D., Radiology; Farris Timimi, M.D., Cardiology; Aleta Capelle, Health Information. Ex-officio: Carol Gunderson, Joey Keillor. Mayo Clinic Health Letter (ISSN 0741-6245) is published monthly by Mayo Foundation for Medical Education and Research, a subsidiary of Mayo Foundation, 200 First St. SW, Rochester, MN 55905. Subscription price is $29.55 a year, which includes a cumulative index published in December. Periodicals postage paid at Rochester, Minn., and at additional mailing offices. POSTMASTER: Send address changes to Mayo Clinic Health Letter, Subscription Services, P.O. Box 9302, Big Sandy, TX 75755-9302.

Neck alignment in a forward-facing world In a perfect world, your head would rest on the top of your neck, much like a golf ball placed atop a tee. But the reality is your head is much heavier than a golf ball. With our orientation being forward — picture yourself sitting in front of your computer — it’s much more likely your head is tilted forward and perhaps downward as well. Or, if you wear glasses, you may find yourself tipping your head back to better see the computer screen. Either way, this can put a real strain on your neck and upper back muscles. To find your head and neck neutral spine position, start by standing up. A

B

C

Tuck your chin down slightly and pull your head back and up as if to flatten your neck against a wall (A). Next, look straight ahead and jut your chin forward as if you were moving your neck away from the wall (B). Now repeat these movements slowly five times to find your neck’s range of comfortable movement. After the last repetition, allow your head to find a comfortable position between the two movements (C). That’s it — you’ve found the neutral position for your head and neck.

head from one shoulder to the other. Another option is to flex your neck forward, as if to touch your chin to your chest. Then slowly raise your head to a level position. From there, tilt your head slowly to one side until you feel a gentle stretching of muscles on the opposite side of your neck, and then do the same motion for the other side of the neck. Another exercise involves slowly circling your head. Imagine your face to be the hands of a clock as you tip your chin to the 6 o’clock position, then slowly circle upward and stretch your chin up to the 12 o’clock position, continuing in a circle back down to 6 o’clock. See your doctor if self-care doesn’t result in neck pain letting up within a week or two.

When to seek medical care If your neck pain is due to muscle overuse, the cause is usually apparent and it typically gets better

with self-care at home. The majority of neck pain problems are not serious. But in certain rare circumstances, neck pain warrants immediate medical care, including: ■ Severe pain or pain related to a head or neck injury may indicate a fracture or other structural damage. ■ Pain that radiates to your shoulder, shoulder blade or down your arm with or without numbness, tingling or weakness — or leg weakness and walking (gait) difficulties — may indicate that you have a herniated disk or nerve injury. ■ Pain that gets worse at night or is present along with a fever or weight loss may indicate infection or a possible tumor. ■ Throbbing neck pain may be related to a cardiovascular or heart problem. ■ Neck pain before or with a headache can be due to problems in arteries in the neck, which can lead to stroke. ❒ November 2009

Health tips Avoiding falls Falls are by far the leading cause of hip fractures among older adults. Steps that you can take to minimize your risk of falling include: ■ Fall-proof your home — Keep your home well lit. Avoid area rugs and exposed electrical cords or wires. Arrange furniture pieces so that bumping into them is unlikely. Use handrails and stair treads. Put nonslip mats on bathtub and shower floors, and consider installing grab bars in the bathroom. Plug night lights into bedroom, hall and bathroom outlets. Avoid using ladders. ■ Stay active — Exercise improves strength, muscle tone, balance and coordination. Efforts to improve balance are particularly important, as poor balance is a major cause of falls. Simply walking can help improve your balance. In fact, regularly walking is a package deal — you get aerobic exercise, strengthen your leg muscles and reinforce your balance skills. Practicing the ancient Chinese tradition of tai chi (TIE-chee) also has been shown to prevent falls. Standing on one foot and walking heel-toe, heel-toe as if walking on a line also can help improve balance. Do these near something you can steady yourself on if need be. ■ Dress for your own good — Avoid wearing high heels, sandals with light straps or shoes that are either too slippery or too sticky. ❒

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News and our views Acupuncture or acupressure reduces nausea after surgery If you’ve had general anesthesia, you may have also experienced nausea or vomiting after surgery. A recent review of medical studies finds that relief from this common problem may be as simple as stimulating the pericardium 6 (P6) acupuncture point located about two inches — three finger widths — above the crease of the wrist. Stimulating this point is already known to reduce nausea from other causes. The review, published in the April 15, 2009, issue of The Cochrane Library, analyzed 40 studies of P6 stimulation involving a total of nearly 4,900 participants. The studies analyzed used many different methods of acupoint therapy, including traditional needle acupuncture, electric or laser stimulation, and different forms of acupressure, P6 including using elastic wristbands. Overall, P6 stimulation was just as effective as anti-nausea drugs, reducing nausea and vomiting by about 30 percent. In addition, P6 stimulation may have fewer side effects than do anti-nausea drugs. Still, acupuncture can sometimes result in bleeding, bruising and discomfort at the needle site. Mayo Clinic experts say that P6 stimulation appears to be another option for preventing postoperative nausea that could be used instead of — or in addition to — anti-nausea drugs. Acupuncture is becoming more widely available, especially in larger centers. P6 stimulation won’t work for everyone, but neither do anti-nausea drugs. The difficulty of using acupuncture around the time of surgery is that the P6 area may not be accessible because of your position, identification wristbands, blankets or intravenous tubes. ❒

Why exercise matters after age 50 If you’re over 50 and assume it’s too late to benefit from starting a regular exercise program, think again. A recent study published in the British medical journal BMJ found that late starters to regular exercise can actually enjoy some of the same benefits of exercise — in particular, a longer life expectancy — enjoyed by those who had regularly exercised since their younger years. The most active men, who did at least three hours a week of active sports or heavy gardening prior to and at the start of the study, had the lowest death rates during the first five years of the study. Sedentary men who in their 50s shifted to a high level of activity for 10 years, had comparable death rates to those of men who’d been highly active all along. Although it took a decade to catch up, these formerly sedentary men experienced benefits in extended life. Researchers estimated the net gain in life expectancy for men who exercised at the highest level to be about 2.3 years. Mayo Clinic doctors say the study backs the notion that it’s never too late to get more physically active to promote a healthier life. ❒

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Hemorrhoids Blood vessels gone astray Hemorrhoids can be an embarrassing problem. If there’s any comfort in numbers, you’re hardly alone — by age 50, about half of adults have encountered hemorrhoids. Treatment is dependent upon their location and how severe they are. In many instances, lifestyle changes and home treatments can relieve symptoms, but sometimes the best route for relief is surgery.

Anatomy of a problem Hemorrhoids are blood-engorged veins in the lower rectum (anal canal) that form tiny sacs (anal cushions) when too much pressure is exerted on veins serving the pelvic and rectal areas. Factors that may increase pressure on these veins and thereby promote the increase in size of hemorrhoids include straining during bowel movements, sitting on the toilet for an extended time, chronic diarrhea or constipation, obesity, lifting heavy objects, sitting or standing for long periods, and pregnancy. Age also can be a factor. As you get older, tissues supporting the veins in your rectum and anus tend to weaken and stretch. Signs and symptoms related to hemorrhoids depend on whether they’re located internally or externally. Internal hemorrhoids occur inside the anal canal and typically don’t cause discomfort. You can’t normally see or feel them, although they may bleed if the surface is irritated due to straining or passing stool. Sometimes, straining will push an internal hemorrhoid outward through the anal opening. This is called a prolapsed hemorrhoid. It may be felt as a lump or mass and possibly cause pain, irritation and rarely, more-serious complications.

External hemorrhoids are located under the skin around the anus and can itch or bleed if irritated. If blood pools in an external hemorrhoid and forms a clot (thrombosed hemorrhoid), you may have severe pain, swelling and inflammation. Additional signs and symptoms may include: ■ Painless bleeding during bowel movements, noticed either as small amounts of bright red blood on toilet tissue or in the toilet bowl ■ Leakage of feces and mucus Hemorrhoids generally don’t cause serious problems, but rarely, chronic blood loss can occur that might result in anemia. Another more serious complication can occur if an internal hemorrhoid becomes prolapsed and the blood supply is cut off (strangulated). This can cause extreme anal pain and lead to tissue death (gangrene). This is a surgical emergency that requires immediate care. Embarrassment aside, it’s important to talk with your doctor if you experience rectal bleeding. A doctor can determine whether you’re dealing with hemorrhoids or if the bleeding is due to a more serious problem, such as polyps, cancer or inflammatory bowel disease. A colonoscopy may be needed to further evaluate bleeding.

Steps you can take Flare-ups of mild pain, swelling and inflammation due to hemorrhoids often can be managed with self-care measures. Nonprescription hemorrhoid creams, suppositories containing hydrocortisone, or pads containing witch hazel or a topical numbing agent may provide relief. Generally, these readily available products aren’t designed for use longer than a week, unless your doctor directs otherwise. Other steps include keeping the anal area clean. Taking baths in which only the hips and buttocks

Beyond self-care

Internal hemorrhoid

Prolapsed hemorrhoid Internal hemorrhoids occur inside the anal canal. If an internal hemorrhoid is pushed outward through the anal opening, this is called a prolapsed hemorrhoid.

are immersed (sitz baths) in warm water several times a day can offer relief. This can be done in a bath tub or using a plastic tub that fits over the toilet. These are available from medical supply stores and pharmacies. Use moist towelettes or wet toilet tissue that doesn’t contain perfume or alcohol to cleanse the anal area after a bowel movement. To help relieve swelling, use ice packs or cold compresses on the anus. Nonprescription pain relievers such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) also may provide relief. To help soften and bulk up stool for easier passage, drink plenty of water — aim for six to eight glasses of water or other nonalcoholic liquids every day — and increase your intake of high-fiber foods. You can also help boost fiber intake by using fiber supplements such as Metamucil and Citrucel. Exercise and physical activity also can be helpful if your hemorrhoids are mild, but during a flare-up, avoid heavy lifting and strenuous exercise. Finally, don’t delay visiting the bathroom when you feel the need to go. And, when you do go, avoid straining or holding your breath when passing stool, as this strains veins in the lower rectum. November 2009

See your doctor if self-care measures aren’t successful after a month or if you encounter severe pain or persistent bleeding. Several minimally invasive procedures may be considered. Generally, these procedures can be done in your doctor’s office or as an outpatient: ■ Rubber band ligation — This involves placing a rubber band around the base of a hemorrhoid that’s inside the rectum. Blood circulation to the hemorrhoid is cut off, and it withers and falls off in a few days. Ligation success rates are high, but more than one visit to your doctor may be needed, and rare, serious complications do occur. ■ Sclerotherapy — This involves injecting a chemical solution into the hemorrhoid tissue in order to shrink it. It’s more often used for smaller hemorrhoids. There may be some drainage from the injected site after the procedure. Generally, sclerotherapy is much less effective than is rubber band ligation. If you have large hemorrhoids or other treatments haven’t been successful, surgical procedures may be considered. Typically done on an outpatient basis, they include: ■ Hemorrhoidectomy — Excessive tissue that’s causing bleeding is removed. It’s generally the most effective surgical approach. However, hemorrhoidectomy can result in more complications than other procedures. Urinary retention may be a problem in the first 12 to 24 hours after surgery. In addition, it can be quite painful for as long as two weeks afterward. ■ Stapling or hemorrhoidopexy — This surgical technique is designed to block blood flow to the hemorrhoidal tissue. There’s generally less postoperative pain after this procedure than after a hemorrhoidectomy, but recurrence rate for hemorrhoids is slightly higher. ❒ www.HealthLetter.MayoClinic.com

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Heart failure Proven treatments to extend life Heart failure is an ominous sounding disease. However, what many people don’t realize is that three key classes of drugs — and sometimes a pacemaker or defibrillator device — can make a big difference in how you feel and how long you live. Despite this knowledge, studies have shown that fewer than onethird of those with heart failure are taking the three main types of drugs that are most effective in prolonging life and improving quality of life.

Stop the process The process of heart failure generally begins when heart muscle becomes damaged — such as from a heart attack — or otherwise weakened by some factor. Factors may include high blood pressure, heavy alcohol use, diabetes, heart infections, faulty heart valves, obesity, thyroid problems, heart rhythm problems and sleep apnea. The sooner you and your doctor recognize heart failure, the sooner you can take steps to reduce the burden on your heart, possibly slowing or stopping its progression.

Keeping it simple There are many heart failure treatments. However, national guidelines recommend the following drugs as the foundation of care in the vast majority of treatment plans: ■ A n g i o t e n s i n - c o nve r t i n g enzyme (ACE) inhibitors — Drugs in this class — enalapril, lisinopril, others — reduce production of angiotensin, a substance that causes blood vessels to narrow and blood pressure to rise. This lowers blood pressure and reduces workload on the heart. The main side effect is an irritating dry cough for some.

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As an alternative, angiotensin II receptor blockers (ARBs) may offer many of the same benefits of ACE inhibitors, but these drugs are less likely to cause a persistent cough. ■ Beta blockers — Drugs in this class — metoprolol, bisoprolol, others — slow the heart rate and lower blood pressure. They may also help widen (dilate) blood vessels and lessen the risk of developing certain abnormal heart rhythms. Beta blockers are the single most effective drug at improving heart function and symptoms and prolonging life in those with heart failure. ■ Aldosterone antagonists — Drugs in this class — spironolactone and eplerenone — have some diuretic effects, which cause the kidneys to remove more sodium and water from the bloodstream than usual. Aldosterone antagonists also block aldosterone, a hormone that can stress the heart of those with chronic heart failure. Aldosterone contributes to formation of scar tissue in the heart, and blocking it may improve longevity and quality of life November 2009

in those with heart failure. Monitoring potassium levels in the blood is recommended, as aldosterone antagonists can raise potassium to dangerous levels, especially if the kidneys aren’t working properly. As many as half of those with heart failure have abnormalities in their hearts’ electrical systems that cause their already-weak heart muscles to beat in an uncoordinated, inefficient fashion. Implanting a type of pacemaker that coordinates heartbeats (cardiac resynchronization therapy) can improve the heart’s efficiency. Implantable cardioverter-defibrillators also may be recommended — alone or as part of a combined pacing device — to detect and stop dangerous heart rhythms.

Added improvements A healthy lifestyle also is important and includes reducing sodium intake, beginning a doctor-supervised exercise program, not smoking, avoiding or limiting alcohol, and managing stress. ❒

The way we play Games for better health Recreational games can be a rich source for challenge and fun throughout life. However, with age and physical limitations, how you play may be altered. Fortunately, technology and virtual game systems are providing new options. Advanced interactive game systems and their growing popularity are changing the dynamics of play. For example, it’s now possible to compete actively in video gamebased bowling competitions even if your ability to stand or hold a bowling ball is limited. Interactive gaming has also found its way into rehabilitation. It’s creating new incentives, social opportunities and exercise motivation for people who might otherwise settle for less activity due to barriers such as limited range of motion or mobility restrictions.

Activity-based video games are making their mark When Nintendo’s Wii video game system came out in 2006, health professionals working in rehabilitation and retirement living centers recognized the potential for it being another way to help get people active while having fun. The Wii combines virtual environments and wireless motion-sensitive remote controllers that allow you to play a variety of virtual games. For instance, you might choose to bowl while sitting down, or you could stand and get into the actual movements while sighting the pins and taking careful aim on the virtual bowling alley. There are also Wii games that simulate daily living skills, such as driving and cooking. The Wii games encourage physical activity while drawing on cognitive and perceptual skills. Therapists can create a virtual environment with the Wii that’s suited to an individual’s therapy needs and abilities. The Wii Fit was released in 2008 with an added base unit to stand on. The base unit tracks progress as you use the fitness game package for aerobics and yoga to strengthen and improve balance. The base unit is also adaptable for A woman practices her golf swing using people who require use of a the Nintendo Wii. Photo Courtesy of Nintendo of America. walker, cane or wheelchair.

Playing to your strengths These interactive and deeply engaging game worlds are not only fun, but they’re also ripe settings for learning, skill rehearsal and development. With that in mind, therapists specializing in interactive media see many opportunities for potential uses that can result in significant health improvement and behavior modification. Numerous research efforts are under way related to games that can increase physical activity and improve the ability to care for yourself. Study participants range in age from children to older adults, and there’s a wide variety of subjects being examined — from people dealing with chronic health conditions to those who deal with chemical or substance abuse.

One pilot study demonstrated that people with Parkinson’s disease who played the Nintendo Wii a few times a week for a month experienced improvement of their symptoms. Rigidity, movement, fine motor skills and energy levels all improved, and most saw depression levels decrease to zero. In Scotland, a study is under way with people over 70 to determine if their balance and risk of falling might be improved with regular use of the Nintendo Wii (pronounced WEE) and its activities package called Wii Fit. Another study is using physical activity games — such as the Wii and Dance Dance Revolution, which is a video game that gets players up and dancing to musical and visual November 2009

cues — as therapy for people who have had a stroke. Researchers want to see if study participants find the games to be a fun means of ongoing therapy beyond the actual carecenter setting. Increasingly, video game technology is finding its way into physical, occupational and recreational therapy settings. Mayo Clinic therapists say interactive game systems are useful in improving balance, eye-to-hand coordination, problemsolving skills and social interactions. They find that game systems make it easier and more fun for their those they work with to progress. People who have led active lives are enjoying the opportunity to get back into leisure activities that allow them to overcome limitations. ❒ www.HealthLetter.MayoClinic.com

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Second opinion Questions and our answers Q: In recent months, I’ve started taking several new medications. I was shocked at the cost difference between a generic drug that’s been prescribed and one of the brand name drugs, which cost over $100. How can I get generic drugs prescribed instead of the expensive brand-name drugs? A: Awareness of the value of generics is key, so you’ve already taken an important step in recognizing that. You might start by telling your doctor that you’re willing to work together on an ongoing basis to identify medications that meet your needs but aren’t necessarily the latest heavily marketed prescription brand-name drugs on the market. After all, just because something is new doesn’t always mean it’s better, but it’s often more expensive. If your doctor recommends a prescribed brand-name drug, ask whether a generic drug in the same drug family or in a related one might work just as well for your needs. If a drug prescription is needed, consideration may be given to the product that has the lowest risk of side effects or the most convenient dosage form. For instance, if you have high blood pressure, your doctor may be inclined to prescribe an angiotensin II receptor blocker (ARB) because side effects are uncommon — but these brand-name medications can be costly. As an alternative, a generic angiotensin-converting enzyme (ACE)

inhibitor might be prescribed at a much-reduced cost. ACE inhibitors cause few side effects, although a small percentage of people who take them develop a dry cough. You may be able to experience significant savings if you’re willing to try a generic drug first to see if you have a problem with the slightly higher chance of side effects or the less friendly dosing options. Ask your doctor if there are comparable generic drugs that might work for you. ❒

Q: What’s the difference between corticosteroid and hyaluronic acid injections for arthritis?

A: A corticosteroid injection into a joint can dramatically reduce pain and inflammation for weeks to several months. However, it’s best to limit injections into the same joint to two or three a year due to potential side effects with frequent use. A hyaluronic acid injection (Hyalgan, Synvisc, others) — also called visco-supplementation — is thought to restore more normal joint lubrication. This may improve mobility and reduce pain. Relief may last for six months or longer. One key difference is that corticosteroid injections can be performed in those with osteoarthritis or rheumatoid arthritis, and can be done at multiple joint sites, including the elbows, shoulders, knees, hips ankles and wrists. In contrast, the Food and Drug Administration

has approved the use of hyaluronic acid injections only for the knee joint in people with osteoarthritis. Even with knees, corticosteroid injections are typically chosen over hyaluronic acid as the first line injection therapy. Corticosteroid treatment involves only one injection and is much less expensive. A round of the more costly hyaluronic acid injections requires a series of three to five injections over several weeks. With hyaluronic acid, it’s also important that your doctor can confidently get the medication into the knee joint, as an injection that misses the mark can result in a painful red knee. Either type of injection may be recommended when pain-relieving drugs, physical therapy, exercise, bracing or other treatment techniques have failed. If the injection doesn’t work the first time, subsequent injections of the same drug probably won’t work, either. ❒ Have a question or comment? We appreciate every letter sent to Second Opinion but cannot publish an answer to each question or respond to requests for consultation on individual medical conditions. Editorial comments can be directed to: Managing Editor, Mayo Clinic Health Letter, 200 First St. SW, Rochester, MN 55905, or send email to [email protected] For information about Mayo Clinic services, you may telephone any of our three facilities: Rochester, Minn., 507-284-2511; Jacksonville, Fla., 904-953-2000; Scottsdale, Ariz., 480-301-8000 or visit www.MayoClinic.org

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