April 2011: Dr. Will Finneganby John Meadows on April 24, 2011
JOHN: I am pleased to announce that this month’s interview will be with a gentleman named Dr. Will Finnegan. I thought Will would be a perfect interview for our site, and here is why. First of all he is a pharmacist that is educated beyond what is offered in school. He goes above and beyond to understand what he does at a deeper level than most pharmacists out there. Second, I want you to get his perspective on not so healthy drugs that are being commonly prescribed and their effects, and lastly Will actually competed in bodybuilding, and built a great physique in the trenches so he brings that element to the conversation.
Will, it is great to have you. Can you tell us more about yourself, where you went to school, any interesting hobbies, and what you are most passionate about?
WILL: Thank you so much for having me John. I received both my degrees from The Ohio State University. My undergraduate degree is in pharmaceutical sciences. The program prepares you for a health related graduate program while emphasizing several main concepts that apply to pharmacy practice. These include pharmacology, kinetics, biochemistry, anatomy/physiology and several other disciplines. I also participated in the undergraduate research program which opened my eyes to bench work and the actual laboratory side of pharmacy. I then applied to the Doctorate of pharmacy program at OSU and was accepted. This is the degree required to become a licensed pharmacist. My hobbies include drumming (I am in several bands and co-own a studio), computers, and of course bodybuilding. I have taken a great journey from a high school kid lifting weights to a pharmacist self educated in nutrition, supplementation, and homeopathic therapy options.
JOHN: Will, there are many of drugs being prescribed that are actually dangerous when taken as prescribed in my opinion. Do you agree or disagree, and if you agree, what are some of the common drugs that are causing issues. You deal with this on a daily basis, so I am sure you get the real stories, not the pretty pictures we see on TV that certain commercials portray.
WILL: We could write an entire book about this topic. To start, what I really want readers to know is that a pharmacist is the last line of defense between a prescriber and a patient. The way I worded that seems harsh, but I approach every prescription as if something is wrong. I never assume anything is correct. The public in general has grown to think of pharmacy as an almost “fast food” business. They want their medication in 15 minutes and many think our job is to just read the script and blindly do as the prescriber says. If pharmacists did this the results would be disastrous. The law is different from state to state but in Ohio, pharmacists are equally liable for injury to a patient from a prescriber’s mistakes as the prescriber themselves are. In my pharmacy alone we make an average of 12 calls to offices for clarifications a day. Many of those calls result in a change in therapy or directions due to an oversight or flat out improperly written prescriptions. Multiply that out to the thousands of pharmacies in the state and you begin to get an idea of how many problems would arise if we didn’t diligently check every prescription for every patient.
Now to address your main question about drugs, I do agree that many are dangerous when taken as prescribed. That being said, from the viewpoint of a pharmacist, every medication has a useful role in patient care in some way. Weighing the risks verses the benefits is a process that prescribers and patients should be doing before every medication is prescribed. But if you speak with patients, that conversation does not happen. The prescriber writes the prescription and the patient takes that medication. That is why pharmacists exist. We make sure that, based on the knowledge we have of that patient’s health care overall, that medication is going to be safe and effective. Even when we do that, problems can still arise which is what you really address with your question.
Pain medications that include acetaminophen (Tylenol) are some of the most prescribed drugs in the US. And acetaminophen is the number one cause of liver failure in the U.S. The max dose recommended is 4000 mg per day and prescribers often write directions that would allow patients to exceed that dose. It is a very common counsel point for pharmacists.
Insulins and sulfonylurea drugs (glyburide, glipizide) can cause hypoglycemia at prescribed doses, especially in patients that do not diligently monitor their glucose levels.
Statin drugs (zocor, lipitor, pravachol) run the risk of rhabdomyolysis at commonly prescribed doses. Not to mention the fact that though they are great at lowering cholesterol, doing so can affect other hormones and cause imbalances including testosterone.
We are seeing more and more ADHD drugs being used in children and adults (Adderall, Concerta, Focalin). Though these drugs can really help people with their daily focus, they put the cardiac system through a real workout and can cause hypertension, insomnia, and even stroke.
I could continue on and on, but this hits some of the major medication classes that pharmacists across the country are dispensing at greater and greater frequency with each passing year. Again, the risks verse benefits of every medication must be discussed so patients and their health care providers can make the most informed and safe decision every time.
JOHN: What is your take on NSAIDS? Many think of these drugs as a great way to reduce pain and soreness and to help you get ready for your next session, but I am concerned with long term frequent use as you are, mainly due to gastric issues.
WILL: There are many non steroidal anti inflammatory drugs. The main 2 over the counter ones are ibuprofen (Advil, Motrin), and naproxen sodium (Naprosyn, Aleve), and these drugs do have long term negative effects. The main issues deal with gastric problems, and kidney problems. NSAIDS block a pathway in the body that is involved in the creation of the protective coating that lines our stomachs. If you block this pathway enough, you increase your risk for gastritis and ulcers. The more serious problem deals with the renal effects. These drugs also increase blood pressure, specifically within the kidney’s, due to constriction of the blood vessels that exit the kidneys. As a bodybuilder I’m sure you will remember, as I’m sure many of your readers will, the professional bodybuilder Tom Prince. I remember reading that article where he discussed his renal issues. He presented to the ER incredibly ill and the doctor asked for a list of all the drugs he takes. At that he laughed and began listing all the different drugs he was, or had recently taken, along with their dosages. The medical doctor looked at the list and immediately knew what had caused the issue. Tom Prince was taking handfuls of ibuprofen before and after he trained, as well as throughout the day in an effort to control the pain he suffered from due to years of training. This was way above the dose you are supposed to take even under a doctor’s supervision. Imagine his shock when he learned it wasn’t one of the many ‘illegal’ substances he took to be a competitive professional bodybuilder that had caused his issue, but an over the counter medication. I speak with people all the time about this effect of NSAIDs. Many patients are on blood pressure medication, including some that work through renal pathways. Then they bring in a prescription for ibuprofen 800mg, 1 tablet by mouth three times daily, 1 years worth of refills. Makes me slap my head
JOHN: How about medications used to treat GERD such as acid blockers and proton pump inhibitors? I am also concerned that drugs that reduce stomach acid will give us long term digestion issues that can lead to a cascade of subsequent issues if taken continuously for long stretches of time.
WILL: I am one of those people whom take a medication for GERD, or for the readers gastroesophogeal reflux disease. There are several drug classes that can be used for GERD but I believe your question applies mostly to proton pump inhibitors which are the medications that have the greatest impact on acid secretion and the class patients will most likely take long term. I’ve taken generic prilosec, omeprazole, since 2005. I was diagnosed with gastritis and this medication really returned my ability to eat normally and eliminated the nausea I was suffering from. But you bring up a very interesting point. Theoretically, if a person has too much stomach acid, taking a ppi will bring the levels down to normal. But there is the patient population who’s acid level will be brought below normal and result in their acid level being below what their bodies made naturally. In my experience, doctors don’t do any testing of actual levels. They just titrate these meds to effect and once they find the ppi and dose that results in the resolution of the patient’s symptoms prescribers will consider the therapy successful and leave it alone.
To address your concerns about long term use, most of the medical community thinks of these medications as safe and effective with very little negatives to their use. But more and more attention is being brought on long term effects of these medications. Recently researchers have found that on top of the drugs known to require an acidic environment to properly absorb, the metabolism of Plavix can be affected by most PPI’s. This is a fairly recent drug interaction that has caused many patients to be taken off their PPI. A known consequence of stopping a PPI, especially after long term use, is the ‘rebound’ acidity that can occur. I experienced this once when I went a few days without taking omeprazole. It was bad. But rebound acidity is a minor problem compared to other issues now being studied that relate directly to your question. I haven’t read the research directly but I can address the issues that are now being looked at by researchers and in turn raise the awareness of the readers whom can follow up as more research is released, as I will myself.
During my rotations in my 4th year of pharmacy school one of my rotations was at Grady Memorial Hospital up in Deleware Ohio. I spent many days working with the antibiotic stewardship team. The team consisted of Dr. Joseph Gastaldo and Dr. Ian Baird. I spoke with Dr. Baird about how many more cases of C. difficile infections are coming in from the community. This used to be primarily a nosocomial, or hospital aquired infection of the digestive system. It is very hard to treat and is a serious infection. Now they are seeing people come in more and more often with community acquired C. difficile infections. Most people want to immediately relate this to overuse of antibiotics in the outpatient setting but recent studies have shown there may be a connection to PPI use and increased risk of C. difficile infection. This topic needs more research and attention but the data is showing a trend.
Another topic of discussion in the research community is PPI related pneumonia. Everyone aspirates small amounts of stomach acid/contents as we sleep. Even people with absolutely no pulmonary or digestive issues. When you lower the acidity of the stomach you increase the likelihood that bacterial growth can occur, including bacteria that wouldn’t normally be found in the stomach. The lungs of these patients can then be exposed to these bacterial strains and this can result in pneumonia. Again, a topic that needs to be further researched but data is indicating that practitioners should consider this when treating these patients. Including considering the pneumonia being caused by bacteria that you wouldn’t typically expect to see causing pneumonia.
JOHN: Regarding insulin type drugs. I am of the opinion that most cases of type 2 diabetes are brought on by poor eating habits and lack of exercise. Not all certainly, but many. What are your thoughts on the use of all these insulin class drugs? I just never felt it was prudent to mess around with your pancreas unless it is absolutely necessary and you have exhausted all natural alternatives.
WILL: There are 2 types of diabetes. Type 1, or insulin dependent diabetes, usually has an onset at an early age and is not due to eating habits or exercise. What you are referring to, and what has become an epidemic in America, is type 2 diabetes. There are many causes of type 2 diabetes but a major one is poor eating and lack of physical activity. Collectively this issue is being referred to now as metabolic syndrome which your readers can look up and read more about. This results in a development of insulin resistance within the body. The tissues within the body including fat, muscle, and the liver no longer respond to insulin the same way. This reduces the bodies’ ability to clear sugar from the blood stream resulting hyperglycemia. These patients are not put on insulin as a first line therapy. When they first present before diagnosis they may be so hyperglycemic that the use of insulin will be used in the inpatient setting to get the sugar levels down. But after that point they will be put on oral medications, usually beginning with metformin then other therapies are added at the discretion of the practitioner. You don’t see many type 2 diabetics on insulin until their disease has progressed very far. These are usually the patients that have made no lifestyle changes, haven’t changed their eating habits, and usually do not check their blood sugar or take their medications diligently.
To really address your question you are correct, it isn’t prudent to mess with your pancreas with insulin unless all other therapies have been exhausted. But I honestly do not see irresponsible prescribing of insulin in my experience. If you are a type 1 diabetic, your pancreas isn’t making insulin and you will die without it. And if you are a type 2, prescribers really don’t want to put you on insulin until they absolutely have to. In my experience, patients don’t enjoy giving themselves shots so they really don’t want to be put on injections either. Most people reading your interviews are going to be into health and fitness, but I encourage everyone out there who knows someone with or at risk for type 2 diabetes to share their passion for health and fitness with these people. So many cases of type 2 diabetes can be completely reversed with weight loss and changes in eating habits.
JOHN: Can you talk a little bit more about statins and rhabdomyolysis, what is it exactly? How about muscle pain or liver issues, we see that as a warning too? Do you encounter that often?
WILL: Rhabdomyolysis is simply the breakdown of muscle fibers. There are many causes, statins being just one. This breakdown releases the pieces that make up muscle fibers into the system which can then result in kidney damage. The sign we warn patients about is abnormal muscle pain. The average person doesn’t work out, so if they have significant soreness we tell them to get into their doctor as soon as possible. It is harder for a person who trains because soreness is a common occurrence for us. For these patients the problem can progress much farther before it is detected. The easiest way to know something is wrong in this patient population is they will complain of dark urine which is a result of the kidneys filtering those muscle breakdown by-products.
To answer your question about how often I have encountered this, I’m not really sure. Basically, if any patient on a statin begins to complain of muscle pain, we contact their doctor and they are either switched to a different statin or off the drug class all together. How many of those are actual cases of rhabdo is impossible to tell. Most doctors don’t follow up with tests, they just opt to switch the patient off the drug so confirmation is never obtained.
JOHN: How about hormone replacement therapy. I work with a number of folks in their 40’s and 50’s that swear by it. This would seem like a logical medicine to use as our hormone levels decrease with age, yet we hear how dangerous they are from the media and print adds (thank you major league baseball). What has your experience been with HRT? What kind of feedback do you get from patients?
WILL: This is a topic that we both hold a very strong, and I’m sure similar, opinion on. I really could get on a soapbox and go on and on about this topic, and I guess I have done so at work before. It is fully acceptable in our medical community to replace a woman’s hormones as she ages. But if you are a man and want to do so, that means you get steroids, and you are gonna turn into a raging muscular incredible hulk. As you know John, this couldn’t be farther from the truth. Most of the male HRT products are very low dose. The goal is to bring these patients back into the normal physiological range. And I question whether many of my patients even achieve that much of an increase with the most commonly used products (Androgel, Androderm Patch, Testim).I have to believe that these patient’s doctors are following them and ensuring that the therapy is working, but many of the guys really don’t notice much. Whereas I have female patients who’s lives are absolutely changed by HRT and they absolutely can tell a difference. In my opinion, it makes more sense to me to have these guys take weekly or bi-weekly injections of some form of depot testosterone (cypionate, enanthate). But the medical community still hasn’t accepted giving these patients a vial and a needle. There is just too much stigma still which you refer to in the question above which is predominantly caused by the media in relation to pro sports.
The main therapies being used are transdermal gels and patches. These therapies do absorb, but can be affected by so many factors. When these were studied, they were done so under very controlled circumstances. I see many patients not applying the gel to clean, hairless, dry areas. They then put clothes on and some of that gel will get on the clothes. So consider there is always the risk that other people in the household can be exposed, whether it be a wife washing clothes, or a child being held by their father. In fact, there was a HOUSE episode based on this exact occurrence. Compare this to a shot that goes deep into the muscle resulting in 100% delivery of the medication to the intended patient. Now, of course, HRT has risks associated with it. The same risks that steroid use presents, because you ARE using steroids. If you have certain pre-existing conditions, than you are not a candidate for HRT, whether you are male or female. But if you are a male and feel like you are suffering from ‘Low T’, I strongly urge you to speak with your doctor about your concerns. There is no reason why it is fine and acceptable for woman to get relief from decreasing hormones as they age but men are just supposed to suffer through it cause ‘steroids are bad’.
JOHN: I recently heard about a “deodorant” type testosterone application you apply into your armpits. It is called Axiron and is being made by Eli Lilly. Any thoughts on that??
WILL: Axiron is a recently approved testosterone topical solution that is applied to the armpits exclusively. I have not yet dispensed this in my practice nor seen it prescribed but I can see one major benefit. By applying the armpits, you will reduce the likelihood ofperson to person transfer. The armpits are much less exposed than the arm, abdomen, or shoulder. And the biggest question people are going to ask is “Can I still use a deodorant?” The answer is yes, you should just apply it before you apply the Axiron to avoid contamination of the deodorant. Other than the novel application site and delivery system of a metered dose topical solution container, the same issues apply to this as with the other Low-T therapies we already discussed. I still think a shot is going to result in much faster results, will end up being much more convenient for the patient due to less frequent dosing, and completely eliminates the possibility of secondary transfer.
JOHN: What about drugs that are prescribed without sufficient long term evidence of their safety? Do you see any of that in your field?
WILL: As a retail pharmacist I am not dispensing drugs that haven’t gone through the FDA approval process. Nor am I involved in any drug study dispensing, through some retail pharmacies will have patients in those studies and will provide those medications. But that is not a very common situation. Now an argument can be made on what one sees as sufficient long term evidence of safety. And as we have seen in recent years with drugs like Rezulin being removed from the market and the entire drug class of thiazolidinediones being brought under scrutiny for cardiac risk, even when drugs have been approved by the FDA, post market trials and studies can find problems that took much longer to surface. Often times the FDA will mandate “Black Box Warnings” be added to drugs after new studies and evidence show an adverse risk that wasn’t evident or thought as serious when the approval process was underway. This is when they feel that the drug should not be completely removed from the market.
JOHN: I want to touch on thyroid use as well. Specifically, many people in the competitive side of physique display use various thyroid hormones to jack their metabolism up. My primary concern is really around long term use. Year after year of using artificial testosterone will eventually shut down your own production of testosterone. Do we have the same feeback loop for your thyroid? If you take it year after year, will your thyroid gland shrink and lose the ability to produce thyroxin? Here is one example of why I think yes, but feel free to disagree. This isn’t medical science, but I see MANY women use a ton of thyroid to get ready for figure contests year after year. Eventually they rebound, and gain some fat. Then it seems like they can never get in shape again, unless they use ridiculous amounts of it. Your thoughts?
WILL: Okay, I have to admit this one threw me for a loop. I know exactly what you are saying with your anecdotal observations and I would have to agree with you. In my education, the patient population we are studying are those that are either hypothyroid, or have had their thyroid completely removed due to some disease, and we are supplementing their thyroid to bring them into normal levels. You obviously cannot stop therapy in patients that have no thyroid function, but in the patients that are hypo, removal of therapy does not result in a patient with severely decreased thyroid function. There is a negative feedback loop, but it isn’t nearly as severe as you would see with long term testosterone use. I referred to my normal references and there is no warning about long term decrease in thyroid function with exogenous thyroid supplementation. Most state that due to the half life of levothyroxine being between 6-71 days, the return to previous function will happen on average a month or so after stopping therapy. T4 (Levothyroxine), is converted to T3 (Liothyronine) within the body. T3 is the active form and is more potent, but this is rarely used by prescribers in practice. But I, in my bodybuilding experience, have seen the same thing you have seen. So there is much more to this issue involving other processes within the body involving in metabolism. I would love to see you address this question with an endocrine specialist and what their opinion is. I bet if you test those women that you observe, their TSH levels will be normal, but obviously something is going on. And if they require those high doses to take the fat back off next time they diet, some other process has been affected and has not recovered. This is a really fascinating issue that I plan to continue to look into and will update you and the readers if I find more information that sheds some light on this topic.
JOHN: Yes their bloodwork does show normal TSH, and usually decreased t-3. Something else that I think is happening…..overworked adrenals. Think about it, all the cardio, low calories, stress with daily life, freaking out from what you see in the mirror, etc. And we DO know that overworked adrenals means excess cortisol until your adrenals get completely worn out anyway – then you have low blood sugar issues that causes sugar binging! Taking medications for self induced issue like this is not the best route in the world, and hell for that matter most doctors don’t even recognize adrenal fatigue as legitimate unless results are on the extreme low end of cortisol production (Addison’s disease) or high end (Cushing’s Syndrome). I just wrote an article on this that will be out on T-Nation soon. Any thoughts on overworked adrenals???
WILL: I’m glad you brought up the fact that ‘adrenal fatigue’ is not evenly legitimately recognized by health care professionals as a real condition. And you correctly stated, unless you are on the extreme end of either spectrum, you will be considered fine in most circumstances. But as you and I know, adrenal fatigue absolutely exists. I myself have gotten to the point in my life where I can take 2 ephedrine tablets, 2 caffeine tablets and go straight to bed without my heart rate increasing or my blood pressure budging. At that point I would say my adrenals are pretty fatigued. I don’t just chalk that up to tolerance. The adrenals have many functions, but the main 2 we are referring to are the control of cortisol production and the release of catecholemines (epinephrine and norepinephrine). I completely agree with your observation. The better your contest prep, or in other words the harder you are working, the more stress you are going to put on the adrenal glands. Cortisol is considered the enemy by so many bodybuilders/fitness competitors, but it is essential in life. In fact, if you cannot produce enough cortisol in stressful situations, you can be in a life threatening situation very quickly. So to give my thoughts on adrenal fatigue I have to focus in on one area, and that is my recommendation on how to control it as best as possible when prepping for a show. And really, on paper, the best way would be to hold off as long as possible before taking the stimulants that will cause adrenal fatigue. Control stress as best you can while preparing (I have seen doctors prescribe short term benzodiazepines to help control anxiety during these times). And have a good dietitian do your diet for you so your caloric reduction is done in a very controlled and deliberate manner. Be especially careful if using common ADHD medications illicitly to try and speed up weight loss and increase focus during dieting. These drugs are the number one cause, in my practice experience, of adrenal fatigue in patients. I will have patients taking 70mg of Vyvanse and 20mg of amphetamine salts (Adderall), yet they are still tired throughout the day and have trouble staying up at night. Compare this to the roller coaster they were on when first starting the drugs and you quickly see that this isn’t due to just basic tolerance. They don’t go back to normal, they go below normal. Soon, I will see the patient’s doses increased and the process starts over. From a pharmacists standpoint, this is a great reason for drug holidays. These are times when patients stop taking these medications in order to reduce their risk of these negative effects. For kids with ADHD it may be on weekends, and during school breaks. Over the summer when they are not in school and that focus in not needed. Again, for adults the same thing applies. On weekends, holidays, and even days at work where your stress load just isn’t that high. But for competitors getting ready for a show, ‘breaks’ isn’t really a word used. I know, I was there. For the 2004 Mr. Ohio, in order to try and get leaner faster, I ate nothing but fish for over a week. NO salt, nothing else. In a way, this caused adrenal issues as well due to my aldosterone levels getting out of whack and my body pretty much held onto every bit of water. I was eating tons of ephedrine, caffeine, and aspirin combinations, yet still could barely stand up or stay awake. I have never looked so bad in my life. John, you saw me during this period and you knew right away I had messed up bad. The no sodium, combined with the stress that caused on my body resulted in cortisol which must have been through the roof just to try and control my blood pressure. I was in real bad shape, and I have never looked so ‘watery’ in my life. Suffice it to say I didn’t do very well that year and looking back my adrenals must have been fried. So what are my thoughts on adrenal fatigue? I believe it is a much larger problem within society than the medical community recognizes. And I believe it is a massive problem during contest preparation. A competitor’s best bet is to get with someone experienced and follow their advice. Get blood work done by a physician whom will actually run the tests you need to track your adrenals among all the other levels required, and use those substances known to cause adrenal fatigue sparingly and as late in prep as possible.
JOHN: I also would like to get your thoughts on anti-estrogens. Many people who use testosterone might get side effects that include gynocomastia, due to excess estrogen. Do you think there are negative consequences associated with long term use of a) estrogen antagonist like Clomid or Nolvadex or b) aromatase inhibitors like Arimidex? I have some thoughts, but I want to see what you think first!
WILL: So all this is off label use from what I was taught in school and I’m going completely off of what I observed in the sport. It is important to have a balance of testosterone to estrogen for many reasons. When someone takes testosterone, there is the chance that they will aromatize the exogenous testosterone into estrogen which can cause unwanted effects. From all my discussions and readings over the years, there are reasons to use each drug and positive/negatives are found with each option. In cases of simple gynecomastia I have found low doses of Nolvadex will fix that problem in athletes using moderate doses of anabolics due to its breast tissue specific binding. Obviously, as doses increase so will the treatment doses. Nolvadex has also been shown to increase testosterone better than clomiphene,as well as increasing sensitivity to GnRH where Clomid decreases sensitivity. Some argue you can use low doses of clomiphene so it is more economical, but I would still vote for Nolvadex due to less daily dosing. If the person is trying to rebound from steroid use, Clomid has a more common role combined with HCG per the ‘experts out there’.
Aromatase inhibitors (such as Arimidex) block aromatization before it happens instead of blocking estrogen from binding to specific sites. This would make it a more powerful option for patients worried about excess estrogen, whatever the cause may be. Arimidex is very potent and does a great job at blocking aromatization within the body. This is a great tool for someone using excessive testosterone to avoid excess estrogen from aromatization, but again, estrogen is needed within the male body.
So to address the main question, estrogen/testosterone balance is very important in a healthy functioning human body. Estrogen, in its low amounts found in men, is important in maintaining a healthy libido, protecting the cardiovascular system, promoting normal neurological function, and maintaining normal neural function. And of course estrogen helps maintain a normal HPA axis and overall hormone balance. If you suppress estrogen to too low of levels for too long, you will begin to experience negative effects. As an individual whom has decided to administer exogenous testosterone, if you are needing high doses of these anti-estrogens you should re-evaluate the dosage you are doing to try and reduce the chance for these excessive estrogen levels in the first place. It will differ from person to person but if you are one of these ‘aromatizers’, these increased levels of estrogen have been linked to increased risk for diabetes, heart disease, and some cancers. And these high levels of estrogen will trick the brain into thinking that plenty of testosterone is being made making it harder to recover after a cycle has been discontinued. All good reasons to use anti-estrogens if you are going to supplement exogenous male hormones. I am looking forward to hearing your thoughts John. You have worked with many athletes for years and I’m sure you have observed all kinds of issues from people using anti-estrogens long term. I am especially interested in the effect on lipid profiles of these individuals. These off label uses are not covered in pharmacy school so it is up to pharmacists out there to educate themselves. I have seen so many of my colleagues scratch their heads when a male brings in a script for Nolvadex or Clomid. Many think there has been a mistake and call the prescriber’s office to try and confirm. I try to catch them before they do so but often times I don’t see the clarification until the call has been made. In an off topic in general, it is very important for pharmacists to educate themselves on off label uses of drugs because it is part of evidence based medicine and will broaden our understanding of these therapeutic options.
JOHN: What I see is lipid profiles can get crushed by Arimidex and other aromatase inhibitors in many people. Now I know that sounds weird, because there is a bunch of papers out there that claim just the opposite. I am specifically referring to HDL levels. I have seen people go down as low as a 4 with this reading from 1 mg a day of Arimidex for 60 days. I review people’s bloodwork when they come to me, and ask exactly what they are doing, and this is very common. Now Nolvadex on the other hand, seems to help HDL levels. I see that time and time again too, but I don’t know if there is any medical studies to back that up. These kinds of studies on athletes taking antiestrogens to combat aromatization probably aren’t at the top of the medical funding list..LOL..
WILL: Exactly! The problem with delving into these topics is that many of the real questions don’t have evidence in the form of controlled studies done by researchers. No one is going to fund the ‘unethical’ and off label use of these drugs to improve athletic performance or appearance. That is why your working with these individuals on a case by case basis, and having access to their medical data, is truly invaluable to the community of competitors out there. To see someone’s HDL be obliterated like that is really astonishing. I am now going to go read some articles from the approval process of Arimidex and see if these effects were noted. The funny thing is, if the studies were funded by the drug companies, lipid profiles probably didn’t make their way into any final reports. I don’t say that to knock researchers. In fact, without researchers out there doing double blind controlled medication studies we would be in a lot of trouble, but I do believe that it is possible for some of these studies to be influenced and ‘irrelevant’ data, such as lipid profiles, be left out of final analysis. Now if they are there and that dramatic drop in HDL is not noted, then that means that other processes within this specific population of athletes is contributing to the anti-estrogens affecting lipid profiles so dramatically. And herein lays the problem with poly pharmacy, especially in the area of athletic performance boosting. I see people whom are being monitored by a team of physicians and health care providers, and still the use of multiple medications will cause anomalies that cannot be explained. In these situations the practitioners take their best guess and begin changing therapies to hopefully identify the culprit. In the group that you work with, it would be incredibly hard to find trends and try to identify what combination of medications or circumstances are causing the issue. Just from your answer above you seem to have found a solution to one problem. If the person is on Arimidex and their HDL goes into the toilet, change them over to tamoxifen. If you start to see evidence of aromatization, reduce the HRT doseage. One thing is for sure, HDL that low if a very bad thing. And if left that low for too long, you and I both know that there with be cardiovascular problems down the road. Everyone out there reading this, if you are considering using medications for some of these off-label uses, please get blood work done before, during, and after. Without that snapshot of what is going on within the body you are essentially flying blind and will not know when something serious is occurring. And always remember, looking good and being healthy do not always go hand in hand.
JOHN: Will you have been very gracious with your time, so I want to just again say THANK YOU very much for your insight into the many topics we touched on. Best of luck with the band, and keep setting the right example in your field for others to follow!
WILL: Thank you so very much for having me and I hope we can do this again. I went into pharmacy due to my passion for bodybuilding and my amazement with the power of medication therapy. I always have to wear my lab coat and speak from that side of the fence, but hopefully I jumped over to the other side enough to give some unique insight based on my experiences and what I have noted in friends and competitors that I have known over the years. I want to congratulate you on the success of your website and all you have accomplished as a bodybuilder, and a businessman. Hopefully your readers know your entire story, but the situation you have overcome is incredible. And you came out the other side stronger and even more conscience of your health. It really is impressive and inspirational. I am honored that you asked me to be an interviewee and I thank you for taking your time to do this interview.