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What Do You Expect From Your Pharmacy?

What evidence standard should exist for health products sold in pharmacies? That’s today’s bleg, and I’m seeking your input.

In most countries, pharmacy is a registered, self-regulated health profession, with a responsibility to optimize the use of drugs. Pharmacist education consists of several years of university-level education and practical training in real-world health care settings. Pharmacists with advanced degrees and post-graduate residencies are common. Not all pharmacists work in community (retail) pharmacies, but that’s where many pharmacists end up, and it’s the public face of the profession.

In most countries, pharmacies are private businesses, either owned by a pharmacist or by a corporation. They are granted a privileged and exclusive right in the provision of health care: certain health products (both prescription and non-prescription) are only available in pharmacies, because pharmacist consultation and availability has been deemed necessary to maximize the safe use of these products. While it’s a setting for health care (and often the first point of contact into the system), retail pharmacy is a business. Pharmacies count on the retail sale of products for revenue and traffic. And in general, pharmacies have the legal right to stock and sell whatever products they want. Tobacco is one exception, where it is no longer sold in most Canadian pharmacies, but remains prevalent in American pharmacies. And as I discussed in a prior post, when we look internationally there can be considerable differences between which drugs are prescription, and these that can be sold over-the counter.

How Much Evidence?

The evidence standard for products sold in pharmacies is facing increasing scrutiny. Concerns have been raised in several countries that pharmacies may be taking advantage of their privileged status as provers of prescription drugs, and are selling products that aren’t supported by good scientific evidence. Some recent examples:

  • Australian Skeptics awarded pharmacists their Bent Spoon Award in 2006 for selling “quackery and snake oil.” They recently published an open letter to pharmacists criticizing the sale of ear candles, noting, “Pharmacies need to make a profit, but this should not be done through quack products and bad advice. To regain the status a pharmacy should have – a place to get sound advice and effective medicine, supported by scientific and clinical evidence – we implore our pharmacists to stick to worthy products sold by knowledgeable staff.”
  • In New Zealand, some are asking, What are homeopathic remedies doing in New Zealand Pharmacies?
  • In Canada, pharmacists have been advised not to sell natural health products that are not approved for sale by Health Canada. While this sounds promising, it does not establish a rigorous evidence standard, as Health Canada approves and regulates products such as homeopathy.
  • In the United States, the FDA warned consumers in 2009 to stop using Zicam intranasal products, commonly sold in pharmacies, because of serious adverse effects.
  • In the United Kingdom, as part of the Evidence Check into homeopathy, the Professional Standards Director for Boots, a British pharmacy chain, made the following admission: “There is certainly a consumer demand for these products. I have no evidence to suggest they are efficacious. It is about consumer choice for us and a large number of our customers believe they are efficacious.”

Establishing a Standard?

Is it possible to define a minimum evidence standard for products sold in pharmacies? Here are some possible thresholds:

  • Copper bracelets, magnets, homeopathy, and similar implausible products without any persuasive evidence of effect
  • Products with biological plausibility, but without any clinical data (positive or negative) in humans
  • Plausible products, (e.g., some herbal remedies), supported by anecdotal evidence, case reports, or very weak RCT data
  • Products with evidence of benefit and possible harms (e.g.,  some vitamins)
  • Products that may not be helpful, but are generally regarded as safe (e.g., cough and cold products)
  • Products backed with robust evidence, approaching the standard used for prescription drugs (e.g., antibiotics, analgesics)

Other Considerations

In the United Kingdom, the Evidence Check into homeopathy made the following recommendation:

Although the availability of homeopathic products in pharmacies could be interpreted by patients as an endorsement of efficacy, in our view it would be pointless to seek to remove homeopathic products from sale in pharmacies. Many pharmacies sell ranges of non-evidence-based products and homeopathic products are easily available over the internet in any case. We consider that the way to deal with the sale of homeopathic products is to remove any medical claim and any implied endorsement of efficacy by the MHRA—other than where its evidential standards used to assess conventional medicines have been met—and for the labelling to make it explicit that there is no scientific evidence that homeopathic products work beyond the placebo effect.

Is the sale of homeopathy, or any other product acceptable in a pharmacy, if there is full disclosure about the level of evidence supporting efficacy claims?

In Canada, the United States, and some other countries, pharmacies can be part of large retailers like Walmart. Should there be a different threshold in these types of pharmacy settings?

Where do you see the line being drawn between the right of a retailer to sell a product, and the responsibility of a health professional to sell credible products?

Focusing the Question

Let’s keep the discussion focused on products intended or marketed for therapeutic or health use. That is, set aside the sale of chips, tobacco, cosmetics, televisions, donuts, or propane. We’re discussing products intended for therapeutic use, that may be legally sold.

Assume for this exercise that pharmacies that restrict the sale of certain products don’t interfere with market access through other retailers, like vitamin shops.

Pharmacy practice varies by country and even by state. Describe the current standard you observe in pharmacies, and what you think the standard should be.

Let’s leave aside discussion about prescription drug access. Focus only on products available for self-selection (over-the-counter).

Conclusion

Pharmacies play an important role in the health care system by providing access to pharmacists and therapeutic products to support health. If our intent is to support self-selection of science-based products supported by good evidence, what evidence standard should be applied in pharmacies? I look forward to your comments.

Posted in: Pharmaceuticals, Politics and Regulation

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37 thoughts on “What Do You Expect From Your Pharmacy?

  1. Sastra says:

    I recently complained to my local pharmacist. When I went to pick up my prescription, I was handed a special “goody bag” which was evidently being put out by the drug store chain as a sort of promotion. In addition to free hand cream, free poison ivy ointment and the like, a homeopathic sleep-aid was included. I asked the pharmacist if he was aware of what he had handed me, understood the so-called ‘science’ behind homeopathy, and thought he should taint his hard-earned chemistry background by making it seem as if he endorsed the damn thing. In reply, I got a sheepish smile, a shrug, and a vague agreement with a what-can-you-do sigh. It was from the chain. Not his idea.

    Sorry if this isn’t a direct response to your question, but I bring it up because I think it adds a disturbing new category to your list. I don’t think pharmacies ought to sell anything in your “implausible products” category at all — but I’d never felt moved to actually complain directly about the exact same sleep-aid being sold on their counter. Free samples?

    I asked the woman at the register to throw mine out, which she did.

  2. I wouldn’t mind so much if they sold the homeopathic granules in the candy aisle and the copper bracelets along with the kids’ party favours. But they should not be in the area associated with the pharmacy or presented as if they were. Period.

  3. lkregula says:

    Until there’s regulation of herbal remedies (at the very minimum certification that what the company says is in the pill actually is and at the advertised concentration without any unlisted contaminants) herbal remedies should *not* be sold in pharmacies. St. John’s wort, gingko, bilberry and related “herbal supplements” should be in health food stores/groceries/herbaria etc. (if anyplace at all).

  4. mikerattlesnake says:

    My girlfriend is a pharmacy tech at a big chain (three initials, sounds like a major TV network…) and it’s frustrating for her to have to tell people not to buy miracle weight loss cures and miracle foot pads. I don’t think pharmacies should sell anything that has not been tested for efficacy and shown a clear positive benefit in humans (this would cover the first two on your list and probably some of the third; I’d be fine with vitamins with some weak RCT evidence though I wouldn’t buy them myself necessarily). Pharmacies lend a false air of legitimacy to these products, and most employees are neither smart or caring enough to step in like the girlfriend does. Even when they do step in, sometimes people want to believe so badly that these things work that it can be a struggle to get them to understand the implausibility. In another type of store this wouldn’t be a problem, but a pharmacy employee WANTS to help their customers buy the best products for their health and it’s painful to watch struggling people waste money on worthless “cures”.

    Let the supplement shops like GNC and natural food stores sell all the herbs and miracle cures and leave the stuff that works to the pharmacy. I also think they should stop selling cigarettes (though smoking cessation products are good).

    Pharmacies aren’t the only problem, I feel like there are some private institutions in this country that have a public function and a responsibility that has recently been shirked in the name of money. Pharmacies need to deal in proven cures and remedies. The media needs to parse the facts and investigate instead of just making infographics and shouting matches. As non-governmental entitites, there’s not much that can be done, but it would be nice if some folks with a conscience took over and made these businesses stand for something more than profit again. it seems to me like everyone discovered how profitable junk food was and adopted the model to their own business, giving people what they want (and convincing them they want it) instead of giving people what they need and encouraging people to be better than their basest instincts.

  5. Grant Jacobs says:

    To follow up on the link to my article that you gave, you might want to know that in New Zealand the government has recently taken consultation for a revision of the Natural Health Products Bill, e.g.

    http://sciblogs.co.nz/code-for-life/2010/05/13/have-your-say-on-the-development-of-a-natural-health-products-bill/

    (If you click on the ‘natural health remedies’ tag below the article you’ll find other articles I’ve written on this topic.)

    Grant

  6. Harriet Hall says:

    I was recently advised by my physicians to start taking an Omega-3 supplement (for evidence-based reasons). I asked the pharmacist for help in choosing a brand of fish oil.

    I expected her to educate me about the components (EPA, DHA and others) and how to interpret the dosage listed on the label (1000 mg of fish oil is not the same as 1000 mg of omega-3). I expected her to know what dosage was recommended for what medical conditions. I expected she would look up published data on lab testing of different brands for dose standardization, purity, etc. (available from ConsumerLabs and other sources).

    Instead, she told me she was not allowed to recommend one brand over another and she left me to my own devices. I was disillusioned: I expected more from a health professional.

  7. What should the pharmacist’s response be when asked about the various products the pharmacy carries?

    Should the pharmacist tell you there’s no reason to by Airborne? Should they tell you they are not allowed to recommend specific products?

    What is the ethical responsibility of the individual pharmacist, especially when working in a chain pharmacy?

  8. pmoran says:

    ” If our intent is to support self-selection of science-based products supported by good evidence, what evidence standard should be applied in pharmacies?”

    I have been suffering from more foot-in-mouth than usual lately, but this is another area in which I have evolved somewhat atypical opinions, for someone regarding themselves as ruthlessly science-based.

    We should apply here the same risk/benefit approach that applies to any therapeutic decision, but also allowing in this instance for certain limitations to our understanding of all the epiphenomena associated with the use of medical treatments.

    They include various placebo-related responses, the satisfaction of the “treatment compulsion”, and anything else that underpins the truly massive consumption of medical treatments by the general public, the vast majority of which is NOT clearly evidence-based on a “working better than placebo” model of therapeutics.

    The emphasis should thus be on the creation, as far as possible, of a safe environment for public choice which would include firm advice as to where NOT to rely upon dubious remedies. The English “Evidence Check into Homeopathy” has it right, to judge from your quote.

    All decisions logically follow. Paradoxically, authentic homeopathic remedies might survive such vetting even when among the least likely to have intrinsic therapeutic activity. Ear candles wouldn’t because of known dangers.

  9. Harriet Hall says:

    I think I sort of agree with pmoran. I don’t so much mind ineffective remedies being sold. What I object to is lying to customers, misrepresenting ineffective or untested remedies as proven effective, implying they are effective because of where they are sold and who is selling them. I wish there were some way to get accurate information to customers for truly informed consent. I’m not very hopeful that this problem has any practical solution.

  10. antipodean says:

    Pharmacists the world over need to make a decision.

    A. Are you serious science-based health professionals,

    or B. are you quacks with a side business in selling shampoo?

    Until you pick A and actually behave that way it’s very hard for the rest of the reality based community to take you seriously as a profession.

  11. I have always considered the prescription drugs to be the pharmacist’s main domain. I also expect a good pharmacist to be knowledgeable about OTC drugs as well as possible drug interactions between my prescriptions and an OTC or a nutritional supplement, if asked. For first aid, I expect a good pharmacist to be knowledgeable regarding the OTC treatments, antibiotics vs antihistamine vs fungal, but my experience is that they are generally not knowledgeable in the tape, bandage, etc.

    Aside from drug interactions, I don’t expect the pharmacist to be knowledgeable or to make recommends on nutritional supplements, herbals, baby formulas, make-up, candy, beer, wine, liquor or greeting cards. I’ve always believed their training was primarily in prescription and otc drugs, anything else is just them reading the package or being able to point out an aisle.

    For nutritional supplements, I would consult a nutritionist or our doctor.

    Possibly most people don’t make the distinction between the prescription/OTC drugs and the rest of the stuff in a drug store that I do, perhaps doing something to visually delineate the pharmacists domain would be useful. I’m not sure.

    The pharmacist we use, I believe, runs a separate business inside a chain drug store (franchise maybe, not quite sure.) They are friendly and courteous, always call our doctor right away if a prescription hasn’t come through. They called the doctor and settled it right away when the doctor’s office sent in the wrong dosage for one of my medications, they call the insurance company if needed. They do what they can to find the occasional odd drug or track it down at another pharmacy for us. Those services are a good fit for us. Oh, and they have a drive thru, a great thing if you’ve got kids.

  12. I said “OTC treatments, antibiotics vs antihistamine vs fungal,”

    But, I guess I meant anti-fungal, although who knows, there’s probably someone who wants more fungal.

  13. keleton says:

    I see the homeopathic junk, the miracle detox junk, herbal nonsense and the like cleverly positioned so customers waiting in the pharmacy line are forced to look at it. They often even have some stuff right at the register where you pay for prescriptions.

    But to find OTC pain relievers or the iron and magnesium supplements prescribed by my doctor I have to go several aisles away. With so many brands of vitamins to choose from, and so many different forms – citrate, carbonate, et – how is a consumer to know which will be best absorbed and utilized by their body if the doctor hasn’t suggested a particular brand? As mentioned above pharmacists are no help with that.

    I think all the unproven, non-scientifically based stuff belongs in a seperate store clearly labelled “Quackerific Apothecary” or something like that. Doesn’t need to be outlawed or anything, just marginalized so people won’t just assume it’s good because the package says so.

  14. keleton says:

    @antipodean

    I have filled a lot of prescriptions and met a lot of pharmacists and most of them don’t seem to be able to tell me much more than what is on the package insert. A few older, probably soon to retire, pharmacists have been wonderfully knowledgable and helpful. Perhaps this generation has been corrupted by woo in schools?

    Consider this: A friend’s child has celiac disease and recently needed antibiotics. She had to call 8 different pharmacies and check a total of 15 different medications to ensure that the medication was gluten free. Why isn’t this information available? Or am I misplacing the blame here and it really has more to do with the manufacturer/labeling?

  15. Kimbo Jones says:

    I think we have to define some parameters. For example, what is a pharmacy. More and more pharmacies are becoming department/convenience stores, generalizing their offerings to include everything from medicine to chips to birthday cards (and similarly, grocery/department stores are including pharmacies).

    Should we (consumers) advocate for drugs-only stores? Should we advocate for department store type businesses with objective differentiation? If the latter, then what role is a pharmacist within that business? Should they be exempt from promotional stunts? Etc.

    I’d have less of an issue with selling homeopathy if there was clear labeling, but at the same time the mere presence of not-medicine (as opposed to things like chips and cards that don’t have any associated health claims) is confusing to consumers. It’s like “well why are you selling this then?” and I think that there’s a real possibility that consumers could become disillusioned with pharmacies.

  16. kdv says:

    I have little doubt that the aura of legitimate science and qualified training does give pharmacy shoppers a level of confidence in dubious products and/or advice that they may well question in other settings, such as a supermarket. I was rather astounded by a recent experience, though.

    The line at the checkouts of my local pharmacy were becoming progressively longer. There were two checkouts, so the line moved, but slowly, because one of the registers was blocked by a middle-aged woman having a long conversation with the girl operating the machine. [ self preservation alert: I say girl, not because I intend to patronise women, but because she really was a girl. About 17, I'd guess ].

    Anyway, as I got closer, I could hear the woman asking long and detailed questions about how she should take the medication she’d bought, such as whether it could be mixed with food, and how she should space the doses, etc etc. Worse still, rather than referring her to a qualified pharmacist, the girl was attempting to give answers, although it was obvious she didn’t have a clue, and wouldn’t get one even if she smothered herself in clue pheromones and stood in the middle of a roomful of horny clues in the middle of clue mating season.

    The issues, of course, are firstly that the woman would be asking for important advice for a checkout girl, merely because she worked in a pharmacy. Secondly, no matter how professional a pharmacist may be, if they don’t educate their staff about referring appropriate questions to a pharmacist, people may well be given very bad advice indeed.

    Disclaimer: a) Yes, I know, it’s an anecdote. I might be lying (I’m not). Feel free to dismiss it. b) It is a sample size of one. It might have been the only such instance in the history of the world. If so, I suppose I should feel really privileged to have witnessed it.

  17. mxh says:

    Mrs. mxh is a pharmacist at a large chain and she gets customers asking for quack cures all the time (i.e. “which homeopathic remedy will fix my allergies?”. She disappoints them by telling them that there is no evidence that any of them work. They get pissed off at her and avoid her in the future.

    @keleton, in my experience, the older pharmacists tend to be more likely to push the fake cures (and they tend to be dangerously uninformed about newer medicines).

  18. Ken Pidcock says:

    A few months ago, I asked a pharmacist about where I could find homeopathic sleeping pills for a ten twenty-three kind of thing I was doing. The pharmacist was genuinely grateful for the intent.

    I personally believe that most pharmacists (in the US, at least) wish they weren’t carrying this crap. But, the fact is, if they refuse to carry it, they will lose business to competitors. And it isn’t like they’re poisoning people.

    I could never ask a pharmacist to sacrifice their income on pure principle. The only rational solution to this problem is increased public advocacy for science-based medicine. It may seem hopeless, but there’s really no other way.

  19. lkregula says:

    Keleton- Gluten is one of those ingredients that can “hide” as lots of different things. It’s not just a problem with medications, it’s harder to spot in foods than MSG, practically. The manufacturers don’t make it easy to find, and most staff at pharmacies and other stores don’t know what to look for.

  20. keleton says:

    re: hidden ingredients

    because of phenylketonuria, everything containing phenylalanine has to be labeled. I don’t know the stats but surely there have to be a lot of celiacs out there? Is it just because PKU can be more damaging and the symptoms less obvious? Sorry for the derailment.

    @mxh because of your mrs. you have probably been exposed to many more pharmacists than I have, it was just speculation. I’ve just noticed that the younger ones don’t seem to be able to answer questions very well beyond what’s in the package insert. Anecdote, schmanecdote.

  21. lkregula says:

    I don’t know if it’s because of the number of people affected, or severity, or prevalence of gluten (probably a combination), I just know a number of people with gluten problems and know that all of them have difficulty verifying whether or not a new food item has gluten. They’re constantly obsessively reading ingredient labels and asking questions. I may happen to know only slow people with gluten issues. Being around them always makes me glad I don’t have to play find-the-hidden-ingredient. I think the biggest issue is that it’s never labeled just as “gluten” but is usually found in other things (flour, thickeners, etc.)so you have to look for not just one simple word, but a whole list of known ingredients with gluten, and try to decipher whether or not other ingredients have gluten as well.

  22. chaos4zap says:

    In the U.S., Is it actually illegal for a M.D. to prescribe a placebo? (other than in a clinical trial) Or is it just highly frowned upon based on ethics? I think that a distinction between “medicine” and “alternative medicine” is unnecessary and misleading. It works, or it doesn’t. It’s medicine, or it’s not. The only way to find out is through properly controlled trials. When it comes to medicine, saying the demand is there is not enough. I’m not sure how effective it would be in the end, but I think just simply separating the medicine from the alternative stuff might be a good start. The fact that a homeopathic flu remedy is sold right next to the evidence based OTC’s (and the same for just about all ailments) has always bothered me. Why can’t we put the evidence based OTC’s near the pharmacy and the alternative stuff somewhere else? (Maybe somewhere near the AS SEEN ON T.V.” novelty items?). Has anyone heard of any formal protests at large chain pharmacies? I would like to think that if we framed it in the right (and accurate) context or ripping Americans off (especially with homeopathy) and potentially causing harm, maybe we could, at least, get some media attention…perhaps that could help. I fell that the majority of consumers just simply don’t know what they are buying and have no idea that there is any controversy at all. People have a tendency to simply assume that if it’s there, the nit belongs there and there is no real reason to question it. Just a few thoughts.

  23. edgar says:

    What Harriet said,
    I think pharmacists should have have expanded role in our health care system.
    I used to live in Egypt, and i much preferred the system there. You actually consulted with the pharmacist each time.
    You have a cough? What kind? From where? productive or non? Any other symptoms?

    And then a product would be recommended to you.
    Pharmacists should be the ones to decide which drugs you were given.
    Also they should be able to give shots. Need your depo shot? Drop by and get it!
    When I used to get strep as a kid, and got a series of 3(with the accompanied bruised ass), wouldn’t it have been great to just drop by the pharm on the other 2 days? Instead of making an appointment, and driving across town?

  24. barbyrabaker says:

    What would happen if a pharmacy began advertising itself as science based? Would business improve if it claimed “Here at PDF pharmacy, all of our OTC have been tested and shown to be safe AND effective!”
    Or: “PDF pharmacy refuses to sell quack medicine, so you won’t find homeopathic remedies on our shelves!”
    Would enough skeptics switch their prescriptions to PDF to help them defend the lawsuits brought by homeopathic doctors?

    kdv, I know many people who ask for professional advice from mimimum-wage employees, and believe what they are told.

  25. E says:

    Before anyone goes along with the suggestion that the pharmacist should be able to have an expanded role in your healthcare, check out this one:

    http://www.youtube.com/watch?v=VnE-wPm3nPY

    So, are you still okay with that idea? I know I’m certainly. In fact, as a patient, the whole thing frightens the heck out of me.

    While she’s a goof and I couldn’t care less what she thinks about my TSH; I also couldn’t care less what any pharmacist thinks about it either. Imagine going to the doctor and having him/her go along with something because it’s a “Tell him Suzy said so!” idea (?).

    BTW: Did you notice the caption below the video? She lets you know the (incorrect) information she’s about to tell you is “the secret.” Oooooow……that’s scary coast to coast deep!

    I know it’s only one individual, but think about where that idea to go. She has a license.

  26. E says:

    [Oops. Corrected post that fixes typos. Editor: Please delete first copy and post this one. Thanks.]

    Before anyone goes along with the suggestion that the pharmacist should be able to have an expanded role in your healthcare, check out this one:

    http://www.youtube.com/watch?v=VnE-wPm3nPY

    So, are you still okay with that idea? I know I’m certainly not. In fact, as a patient, the whole thing frightens the heck out of me.

    While she’s a goof and I couldn’t care less what she thinks about my TSH; I also couldn’t care less what any pharmacist thinks about it either. Imagine going to the doctor and having him/her go along with something because it’s a “Tell him Suzy said so!” idea (?).

    BTW: Did you notice the caption below the video? She lets you know the (incorrect) information she’s about to tell you is “the secret.” Oooooow……that’s scary coast to coast deep!

    I know it’s only one individual, but think about where that idea could go. She has a license.

  27. edgar says:

    I know a little about the subject. Please point out what she said that was factually incorrect.

  28. ccbowers says:

    “I know it’s only one individual, but think about where that idea could go. She has a license.”

    Your youtube link is really compelling evidence. You should go to Mercola or Dr Oz because they are physicians. Listen, all professions have people that are ‘out there,’ or, at the extremes, quacks. Certain professions have them more than others. Youtube of full of crappy professionals trying to make a name for themselves. Don’t let that sway your opinion of an entire profession.

  29. norrisL says:

    Some years ago I went to the pharmacy across the street from my veterinary surgery. At the counter there was a large display of echinacea products for treating colds. I asked the pharmacist, “Does this stuff actually work?” Her reply was, “Uuuummm, it’s very popular.” “Yeah, but does it do anything at all to help a cold?”
    “I don’t think so.”
    So why are you selling it?
    No reply!
    Pharmacists are supposed to be professional. In Australia they have to pass a 3 year degree (maybe longer now, it’s been a while since I was a university student). They have a governing professional body. They are obliged to be registered with the state government controlled board of pharmacists.
    Professionals severely taint themselves by being associated with snake oil products. In our veterinary surgery we refuse to use any product that does not stand up to the rigors of evidence based medicine.
    Pharmacists are seen as “less professional” and therefore are seen to maybe not be the people to turn to for correct pharmacy advice as a result of their association with herbs, homeopathy etc. Additionally, they are also seen as being chasing after the quick buck. I could very easily chase after the quick buck by pandering to my clients who may wish to use homeopathic etc “remedies”; but I WILL NOT!
    Pharmacists should do likewise OR get out of their profession.

    Someone mentioned to me that in some European countries, the veterinary boards have stated that any vet who practices homeopathy shall be de-registered….not allowed to practice as a vet.
    Does anyone know if this is true?

  30. BillyJoe says:

    Harriet,

    “I don’t so much mind ineffective remedies being sold. What I object to is lying to customers…”

    Selling ineffective remedies (an oxymoron if ever I saw one) is not very much different to lying in my opinion.

  31. BillyJoe says:

    edgar,

    “I know a little about the subject. Please point out what she said that was factually incorrect.”

    She says you can have hypothyroidism in the face of normal TSH levels. Is there evidence for this? Is it true that cells can have reduced uptake of T3 due to deficienies in Zn, Mg, CU, Fe, and Selenium.

    In Australia, T3 and T4 levels are measured only if the TSH level is outside the normal range, suggesting that the TSH level is an accurate measure of throid function. Are we wrong?.

  32. E says:

    Edgar,

    In addition to being incorrect, she’s also misleading. And somehow that seems more treacherous because it is indistinct.

    A physician is probably best qualified to clarify what she says; or, I could suggest going to the websites of the British Thyroid Association or the American Thyroid Association.

    But coming from the perspective of the patient, I know that TSH is one of the first tests a doctor should be ordering. The doctor would then move on from there if necessary, as what BillyJoe has shared. Her implication that it should be skipped completely is incorrect. Also, if a doctor suspected thyroid disease when the TSH level shows to be normal, then ordering imaging would probably also come next. But she fails to mention any of that.

    Another thing, her concrete claim that a deficiency in minerals such as selenium would contribute to thyroid disease is incorrect. As at least based on what I’ve read from reputable sources. I believe the jury is still out on those concrete connections.

    Finally, her instruction to tell your doctor you want your Reverse T3 (RT3) level measured is also incorrect because it implies that kind of testing is a first order of business – and it’s not. My understanding is that a doctor would more likely only be testing RT3 when there is also another serious medical condition involved.

    Her motive, obviously, is to cater to the ‘♣ Let’s manipulate the doctor so we can get a thyroid diagnosis and get on thyroid medication in the hope it turns out to be an easy way to lose weight like all the scummy websites and books we’ve purchased into and have fallen for told us would happen ♣’ club. Demanding a test like the RT3 allows one to more easily get a diagnosis because that test would more likely show as out of range. However, that out of range number can be meaningless if every prior test, starting with the TSH test, shows in range. Aspects like this are why being within the care of a responsible medical doctor is important.

    ~

    It’s hard enough trying to fend off nutty doctors. Let’s not now allow the possibility of nutty pharmacists to jump into that fray.

  33. edgar says:

    Thank you,
    As i said I have very limited experience with this, and only as a patient, and I did a little reading on it (most of which I can’t remember). It is my understanding that there is a realization the reference values are based on a pretty shallow pool, and that docs are moving toward treating based on symtoms, and that T3 is increasing thought to be an important player, regardless of TSH.
    BIt I conceed, I might be remembering wrong.
    I was evaluated post partum. So I was very sleepy!

  34. E says:

    Edgar, the following is not intended to leap at you, really.

    Thyroid disease is one aspect of medicine where there’s a lot of hyped information, mostly for the purpose of selling books. Three aspects among much of the hype include TSH lab ranges, diagnosing and treating mostly according to symptoms, and the often times unnecessary use of T3.

    I have been hearing that some endocrine societies are working on shoring up the TSH ranges for better accuracy in diagnosing. That’s good news for those who have falsely appeared to have thyroid disease, but did not.

    As for diagnosing and treating by symptoms, that’s one poorly behaving doctors like to go by because it allows them to avoid having to order labs. Labs are something they try to steer clear of – particularly the ones who are not adequately licensed. I’d love to see a stricter standard as far as that goes.

    Lastly, T3 gets hyped because it’s still thought of in dieting circles as an easy way to loss weight, even though it’s useless. This is an idea I believe was learned from the bodybuilding community – they use it along with steroids, etc. A lot of the commercial thyroid websites and thyroid books include instructions on convincing a doctor T3 is required. This is an area I’d also love to see a stricter standard on.

    Take care.

    ~

    Speaking of licensing, as an aside to the ABMS: Please make your website accessible without having to register and login. So then everyone can more easily scrutinize the license of any doctor. (That way when a chump like Kent Holtorf goes on The Glenn Beck show and claims he’s board certified in endocrinology, everyone can more easily see he’s lying and point that out to Glenn Beck. Same story for when he claims on Fox News he’s an infectious disease doctor, resulting in Rush Limbaugh describing him that same way. Oh, and then there’s the time he said on RateMD that he was a pathologist, which they changed after being contacted. Then there’s NBC….)

    Thank you.

    ~

    Sorry to dominate.

  35. ccbowers says:

    Keep in mind that pharmacists are often stuck in a position in which they are employed by a large company that sells crap. Not only that, but the bigger problem is living in a country that allows the crap to be sold. Its unreasonable to fault them for the laws of the state they live in, or the desire for the company they work to sell all sorts of things.

    The only thing that I would expect professionally is for them to say what works and what doesn’t when asked, and to properly guide patients towards quality products when appropriate. Not every professional acts professionally, but for countries with high education standards you will have a greater percentage.

  36. upnorth says:

    I don’t think pharmacies should be allowed to sell items with therapeutic intent that don’t have proven efficacy. That means I would accept only the last three items on the list.

    Pharmacists are trained professionals, and I believe that the average consumer trusts that items on sale at pharmacies work. The fact that woo can be sold in locations associated with traditional, regulated medicine is part of the root of the problem. People see these things on sale (with their deceptively “medical” looking packaging) and don’t bother to question. They wouldn’t be selling them at a pharmacy if they didn’t work, right?

    At the very least, there should be a clear physical demarcation between those with and without proven efficacy. I would support regulation that says “If you choose to sell items that do not have proven efficacy, you must put them in a separate area of the store and label them as such” or something like that. You get the idea.

  37. E says:

    ccbowers,

    “You should go to Mercola or Dr Oz because they are physicians.”

    Oh, I’m well aware of these two. All I can say is: “7b6nyhy 678b 76767 hgb hgbyhgb.”

    That’s what types out after I’ve banged my head upon coming across yet another piece of stupidity from Joseph Mercola.

    As for Dr. Oz, he reminds me of a cult-like preacher who constantly uses metaphor as a way to draw someone’s attention away from actually questioning whether or not something is factual. Not long ago, while being interviewed about thyroid disease, the reported broached to him the possibility that thyroid medicine gets overused. He responded by asking her, “What size shoe do you wear?” {Huh? Shoe? What shoe? I thought we were talking about the thyroid?} He then transitioned into bringing up his usual nonsense about how thyroid blood ranges are misleading, etc., etc. (though it is actually he who is misleading). Nice work on doing the ole switcher-roo…just like a cult-like preacher.

    It goes without saying, I despise both of these people and am appalled they both hold a medical license. That is why I feel it’s imperative that we avoid letting any other charlatans into medical practice – charlatans like pharmacist Suzy Cohen and the like.

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