But medications can be expensive!  Your insurance plan’s drug benefit should help cover the cost, but sometimes there’s a problem.

If you arrive at your pharmacy and discover that your prescription is much more expensive that you expected, please have the pharmacy call us right away.  Perhaps we’ve prescribed a brand that your insurance company doesn’t cover.  Or perhaps there’s an equivalent medicine that works the same but costs less.   Or maybe the drug manufacturer has a “trial program” that would get you started at minimal cost.

We are quite happy to make a switch if we think it will work as well.  But we don’t know about the cost problem unless you tell us.   Don’t be shy!  Unfortunately, we can’t keep track of all the insurance formularies, because they’re all different.   And we don’t keep drug samples in our office.  But with the help of your pharmacist, we can find out which effective treatment will result in the lowest out-of-pocket expense for your family.

I’m always sad to hear that a family has decided not to purchase medication that I’ve prescribed because they can’t afford the cost, or that the family spent more than necessary.

Whether the medication is for eczema, asthma, ADHD or an infection, there’s almost always a way to make sure that you can afford your medication.   PLEASE call us before deciding that you can’t afford a medication that we’ve prescribed!

–  David Epstein MD

Of course, to be certain about a drug reaction, the child should be examined.  However, if the child seems otherwise well (no fever, acting ok etc.), you can wait until regular office hours.

The most common reaction to amoxicillin is a red bumpy rash.  We call it an “amoxicillin reaction” or an “Amoxil reaction” (named for the original “brand” of amoxicillin).  Do you see little red raised bumps, like mosquito bites, all over the trunk or limbs?  It may look very dramatic, but it probably doesn’t itch or bother the child.  It usually starts about 5-7 days after the amoxicillin was begun; it fades after a few days with no treatment, even if the amoxicillin is continued.

This “Amoxil reaction” is not dangerous, and is not an allergy.  It is also not a reason to avoid amoxicillin in the future.  We think that it may be an interaction between the amoxicillin and another virus temporarily in the child’s immune system.

Of course, any child might develop a true allergy to amoxicillin (or any drug) that might require stopping the drug or giving further treatment.  If you see coin-sized (or bigger) blotches, especially if they’re itchy, this is of more concern.  If there is any question, give us a call or schedule an appointment.  And of course, if there is wheezing or other symptoms of concern, call right away!

–  David M. Epstein, MD

There is no doubt that physicians should prescribe steroid medications carefully.  However, I am not convinced that these studies should alter our standard treatment for wheezing and allergy in children.

One study enrolled 687 children younger than 6 years old, admitted to hospitals in England for wheezing.  Those who received prednisolone (Orapred and other brands) stayed in the hospital 11 hours on average; those who received placebo stayed 14 hours on average.  There was no difference in side effects.  The authors concluded, despite the 20% reduction in hospital stay, that the prednisolone was unnecessary.

These results are puzzling.  Typically, young children might wheeze from asthma, or from a viral infection.  Many previous studies have found a big benefit from using prednisolone to treat wheezing children with known asthma, often quickly relieving their breathing difficulty.   However, the benefit is less clear for children wheezing due to a viral infection.  In my practice, I have found that prednisolone in short courses is effective in reducing wheezing in some, but not all children.  Side effects have been minimal.  I will prescribe it sometimes, if there is a family history of asthma, to try to keep a child out of the hospital.

I am concerned that this study lumped these two groups of wheezing children together, diluting the apparent benefit of the short course of prednisolone.  Steroids have been used for decades as a safe and effective treatment for asthma-related wheezing, when carefully used along with albuterol and other treatments.  Further research might show a diminished role for steroids in the future, or find better rescue treatments for children with asthma attacks, but the weight of evidence still leads me to feel comfortable treating asthmatic children with prednisolone for wheezing and difficulty breathing when necessary.

The second study, performed in Canada, enrolled 129 healthy toddlers and preschool children to receive 10 months of either high-dose inhaled fluticasone, or placebo, hoping that the fluticasone would prevent wheezing.  It did; wheezing severe enough to require oral steroids was reduced from 18% to 8% of children.  However, children receiving fluticasone gained less weight (1 pound) and less height (1/4 cm).  The authors concluded that the benefits of preventative high-dose fluticasone might not outweigh the risks.

I agree with their conclusions, as far as they go.  High dose fluticasone appears to carry potential risks of slowed growth.  However, the study used doses of fluticasone that are 4 to 8 times higher than the standard doses of Flovent, Flonase and Veramyst that we use in children.  Previous studies, with larger numbers of children over longer periods of time, have shown minimal or no measurable effect on height growth from daily use of the usual doses of steroids.  This study does not persuade me to avoid using standard doses of fluticasone and other steroids for children who need them.

No medication should be prescribed without weighing the potential benefits against possible side effects, and discussing them with the family.  And further research may change expert opinion.  But as things stand now, I remain reassured that our usual, standard treatment of asthma and hay fever remains safe and effective, when used properly.

–  Copyright 2009,  David M. Epstein MD