Re: More on H2 blockers (was: Dr. Sy - why cimetidine?)

July 21, 2002

Dr. Lazoff,

You mentioned that turning pale after a workout may be a signal of a

more serious condition. What could that be?

I am a serious long-distance runner, and even after a 14 mile run at

a decent pace, my face will be paler than normal. I never thought

that was a problem. Should I ask my doctor about that?

Nova

> > From: " mschmidt "

> > > Maybe Dr. Sy will see this and explain to the group> her choice

of

> > cimetidine (tagemet) - since this> question has come up before: >

> why Dr Sy

> > chooses > > cimetidine to avoid > > flushing and not any other h2

> >blocker

> >

> > Hi,

> > Thanks for giving me this opportunity to clarify my anti-flushing

> regimen.

> > As I recall, the gist of my regimen was to keep it over-the-

counter.

> > Therefore, the products recommended were examples of OTCs. Other

H2

> blockers

> > such as zantac or pepcid should work. As Marjorie pointed out,

> zantac may be

> > better since it is a BID (twice a day) dose as opposed to QID (4

> times a

> > day).for cimetidine. Although suggesting a QD (once daily) dose

may

> sound

> > like taking a placebo, I have seen patients respond to this

minimum

> dosage.

> > In fact, H2 blockers are given as QHS (once nightly) dose for

> maintenance

> > once the acute condition is under control. Therefore, if once a

day

> dosage

> > works for you, keep it that way. As for drug interaction and side

> effects,

> > most medications have both - you just have to read the drug

inserts

> and be

> > aware of interaction with the medications you may be taking. Or,

> check with

> > your doctor.

> >

> > Another clarification - Other H1 blockers will work as well. I

> suggested

> > chlortrimeton for the same OTC reason. As a matter of fact, H1

> blockers that

> > do not cause drowsiness and are long-lasting, such as zyrtec and

> allegra,

> > may be more practical. However, you need a prescription for both.

> >

> > Re a substitute for aspirin, other NSAIDs which are prostaglandin

> inhbitors

> > such as ibuprofen and indomethacin are alternatives if one is not

> able to

> > take aspirin.

> > However, please be aware that before you take this regimen, you

> should be

> > under the care of a physician. Check the feasibility of these

> medications

> > with your primary care doctor who knows your medical situation

and

> current

> > medications better than I.

> >

> > Sy MD

> > Sy Skin Care

> > http://www.lindasy.com

> > Voice:Toll-free 877-sy (546-3279)

> > Outside U.S.:

> > FAX:

> >

July 21, 2002

Dr. Lazoff,

You mentioned that turning pale after a workout may be a signal of a

more serious condition. What could that be?

I am a serious long-distance runner, and even after a 14 mile run at

a decent pace, my face will be paler than normal. I never thought

that was a problem. Should I ask my doctor about that?

Nova

> > From: " mschmidt "

> > > Maybe Dr. Sy will see this and explain to the group> her choice

of

> > cimetidine (tagemet) - since this> question has come up before: >

> why Dr Sy

> > chooses > > cimetidine to avoid > > flushing and not any other h2

> >blocker

> >

> > Hi,

> > Thanks for giving me this opportunity to clarify my anti-flushing

> regimen.

> > As I recall, the gist of my regimen was to keep it over-the-

counter.

> > Therefore, the products recommended were examples of OTCs. Other

H2

> blockers

> > such as zantac or pepcid should work. As Marjorie pointed out,

> zantac may be

> > better since it is a BID (twice a day) dose as opposed to QID (4

> times a

> > day).for cimetidine. Although suggesting a QD (once daily) dose

may

> sound

> > like taking a placebo, I have seen patients respond to this

minimum

> dosage.

> > In fact, H2 blockers are given as QHS (once nightly) dose for

> maintenance

> > once the acute condition is under control. Therefore, if once a

day

> dosage

> > works for you, keep it that way. As for drug interaction and side

> effects,

> > most medications have both - you just have to read the drug

inserts

> and be

> > aware of interaction with the medications you may be taking. Or,

> check with

> > your doctor.

> >

> > Another clarification - Other H1 blockers will work as well. I

> suggested

> > chlortrimeton for the same OTC reason. As a matter of fact, H1

> blockers that

> > do not cause drowsiness and are long-lasting, such as zyrtec and

> allegra,

> > may be more practical. However, you need a prescription for both.

> >

> > Re a substitute for aspirin, other NSAIDs which are prostaglandin

> inhbitors

> > such as ibuprofen and indomethacin are alternatives if one is not

> able to

> > take aspirin.

> > However, please be aware that before you take this regimen, you

> should be

> > under the care of a physician. Check the feasibility of these

> medications

> > with your primary care doctor who knows your medical situation

and

> current

> > medications better than I.

> >

> > Sy MD

> > Sy Skin Care

> > http://www.lindasy.com

> > Voice:Toll-free 877-sy (546-3279)

> > Outside U.S.:

> > FAX:

> >

July 21, 2002

Dr. Lazoff,

You mentioned that turning pale after a workout may be a signal of a

more serious condition. What could that be?

I am a serious long-distance runner, and even after a 14 mile run at

a decent pace, my face will be paler than normal. I never thought

that was a problem. Should I ask my doctor about that?

Nova

> > From: " mschmidt "

> > > Maybe Dr. Sy will see this and explain to the group> her choice

of

> > cimetidine (tagemet) - since this> question has come up before: >

> why Dr Sy

> > chooses > > cimetidine to avoid > > flushing and not any other h2

> >blocker

> >

> > Hi,

> > Thanks for giving me this opportunity to clarify my anti-flushing

> regimen.

> > As I recall, the gist of my regimen was to keep it over-the-

counter.

> > Therefore, the products recommended were examples of OTCs. Other

H2

> blockers

> > such as zantac or pepcid should work. As Marjorie pointed out,

> zantac may be

> > better since it is a BID (twice a day) dose as opposed to QID (4

> times a

> > day).for cimetidine. Although suggesting a QD (once daily) dose

may

> sound

> > like taking a placebo, I have seen patients respond to this

minimum

> dosage.

> > In fact, H2 blockers are given as QHS (once nightly) dose for

> maintenance

> > once the acute condition is under control. Therefore, if once a

day

> dosage

> > works for you, keep it that way. As for drug interaction and side

> effects,

> > most medications have both - you just have to read the drug

inserts

> and be

> > aware of interaction with the medications you may be taking. Or,

> check with

> > your doctor.

> >

> > Another clarification - Other H1 blockers will work as well. I

> suggested

> > chlortrimeton for the same OTC reason. As a matter of fact, H1

> blockers that

> > do not cause drowsiness and are long-lasting, such as zyrtec and

> allegra,

> > may be more practical. However, you need a prescription for both.

> >

> > Re a substitute for aspirin, other NSAIDs which are prostaglandin

> inhbitors

> > such as ibuprofen and indomethacin are alternatives if one is not

> able to

> > take aspirin.

> > However, please be aware that before you take this regimen, you

> should be

> > under the care of a physician. Check the feasibility of these

> medications

> > with your primary care doctor who knows your medical situation

and

> current

> > medications better than I.

> >

> > Sy MD

> > Sy Skin Care

> > http://www.lindasy.com

> > Voice:Toll-free 877-sy (546-3279)

> > Outside U.S.:

> > FAX:

> >

July 21, 2002

Dr. Lazoff,

You mentioned that turning pale after a workout may be a signal of a

more serious condition. What could that be?

I am a serious long-distance runner, and even after a 14 mile run at

a decent pace, my face will be paler than normal. I never thought

that was a problem. Should I ask my doctor about that?

Nova

> > From: " mschmidt "

> > > Maybe Dr. Sy will see this and explain to the group> her choice

of

> > cimetidine (tagemet) - since this> question has come up before: >

> why Dr Sy

> > chooses > > cimetidine to avoid > > flushing and not any other h2

> >blocker

> >

> > Hi,

> > Thanks for giving me this opportunity to clarify my anti-flushing

> regimen.

> > As I recall, the gist of my regimen was to keep it over-the-

counter.

> > Therefore, the products recommended were examples of OTCs. Other

H2

> blockers

> > such as zantac or pepcid should work. As Marjorie pointed out,

> zantac may be

> > better since it is a BID (twice a day) dose as opposed to QID (4

> times a

> > day).for cimetidine. Although suggesting a QD (once daily) dose

may

> sound

> > like taking a placebo, I have seen patients respond to this

minimum

> dosage.

> > In fact, H2 blockers are given as QHS (once nightly) dose for

> maintenance

> > once the acute condition is under control. Therefore, if once a

day

> dosage

> > works for you, keep it that way. As for drug interaction and side

> effects,

> > most medications have both - you just have to read the drug

inserts

> and be

> > aware of interaction with the medications you may be taking. Or,

> check with

> > your doctor.

> >

> > Another clarification - Other H1 blockers will work as well. I

> suggested

> > chlortrimeton for the same OTC reason. As a matter of fact, H1

> blockers that

> > do not cause drowsiness and are long-lasting, such as zyrtec and

> allegra,

> > may be more practical. However, you need a prescription for both.

> >

> > Re a substitute for aspirin, other NSAIDs which are prostaglandin

> inhbitors

> > such as ibuprofen and indomethacin are alternatives if one is not

> able to

> > take aspirin.

> > However, please be aware that before you take this regimen, you

> should be

> > under the care of a physician. Check the feasibility of these

> medications

> > with your primary care doctor who knows your medical situation

and

> current

> > medications better than I.

> >

> > Sy MD

> > Sy Skin Care

> > http://www.lindasy.com

> > Voice:Toll-free 877-sy (546-3279)

> > Outside U.S.:

> > FAX:

> >

July 22, 2002

Nova, if you have no other symptoms (such as lightheadedness, heart

palpitations, unusual fatigue) yours sounds like healthy vagal tone,

esp in a well-trained athlete and in marathon-type activities.

A rigorous workout normally increases heart rate and blood flow

throughout the body, including the face. Since rosaceans are easy

flushers it's expected their faces might turn even redder. So without

other symptoms (the same as mentioned above) their increased flush

doesn't represent an overstresssed cardiovascular system.

Conversely, a paler-than-normal face during heavy exercise isn't

always a rosacean blessing. It may represent a paradoxical drop in

blood pressure or inability to increase heart rate as the body

demands. In those situations I would expect accompanying symptoms

(such as those mentioned above). It's easy enough to discuss with

one's general practitioner, since individual issues such as age,

general condition, medications or illnesses significantly play into

this.

Marjorie

Marjorie Lazoff, MD

> Dr. Lazoff,

>

> You mentioned that turning pale after a workout may be a signal of

a

> more serious condition. What could that be?

> I am a serious long-distance runner, and even after a 14 mile run

at

> a decent pace, my face will be paler than normal. I never thought

> that was a problem. Should I ask my doctor about that?

>

> Nova

July 22, 2002

Nova, if you have no other symptoms (such as lightheadedness, heart

palpitations, unusual fatigue) yours sounds like healthy vagal tone,

esp in a well-trained athlete and in marathon-type activities.

A rigorous workout normally increases heart rate and blood flow

throughout the body, including the face. Since rosaceans are easy

flushers it's expected their faces might turn even redder. So without

other symptoms (the same as mentioned above) their increased flush

doesn't represent an overstresssed cardiovascular system.

Conversely, a paler-than-normal face during heavy exercise isn't

always a rosacean blessing. It may represent a paradoxical drop in

blood pressure or inability to increase heart rate as the body

demands. In those situations I would expect accompanying symptoms

(such as those mentioned above). It's easy enough to discuss with

one's general practitioner, since individual issues such as age,

general condition, medications or illnesses significantly play into

this.

Marjorie

Marjorie Lazoff, MD

> Dr. Lazoff,

>

> You mentioned that turning pale after a workout may be a signal of

a

> more serious condition. What could that be?

> I am a serious long-distance runner, and even after a 14 mile run

at

> a decent pace, my face will be paler than normal. I never thought

> that was a problem. Should I ask my doctor about that?

>

> Nova

July 22, 2002

Marjorie,

I appreciate your input and expertise as an internist. Please allow me to

answer some of your comments:

> H2 blockers block histamine receptors located primarily in the

> stomach, but also located in vessels. These drugs are often

> prescribed nightly for chronic hyperacidity because that's when acid

> release takes place unopposed, in an empty stomach.

> However, I don't think that's relevent for rosaceans; I wouldn't

> think flushing is a physiologic problem during sleep. For flushing, I

> would intuitively favor use of an H2 blocker such as Zantac first

> thing in the morning (realizing it takes about an hour for Zantac to

> fully enter the bloodstream), with a repeat dose 12 hours later only

> if evening/nighttime control is also needed. (In normal stomachs,

> it's probably not a great idea to inhibit acid release around-the-

> clock indefinitely.)

In my original anti-flushing regimen for rosacea (posted in 1999), I

suggested the H2 blocker be taken in the morning for rosacea flushing. In

the clarification message posted last week, I mentioned that although H2

blockers are regularly taken more than once a day, I have personally

observed once a day dosage to be effective and encouraged those who

responded to qd dose to continue the same way. The once nightly dosage for

H2 was mentioned in support of this, citing that this maintenance dose has

been effectively used once acute condition is under control. It was my

mistake to have neglected mentioning the fact that the acute condition

pertains to gastrointestinal ulcers and not rosacea.

>I think that

> whatever drug(s) work for flushing should be used, I don't understand

> the distinction here between prescription or non-prescription

I suggested non-prescription medication at that time because of my desire to

help members try the regimen in the most accessible and least expensive

manner. In retrospect, I allowed compassion to overtake common sense

regarding professional exposure. Therefore, I reiterate caution to those who

have read my regimen to check with their physicians before undertaking this

regimen.

>Two medications that are effective

> in both lowering blood pressure and decreasing facial flushing are

> beta-blockers such as propanolol (also used for social anxiety), and

> clonidine.

Both clonidine and propanolol were mentioned in the original regimen

message.

>For those

> that can tolerate aspirin, I would think that once daily dosing of

> the lowest amount taken anytime should be more than sufficient.

>

The aspirin suggested in the regimen was minimum dosage and once a day.

BTW, although I am board certified in and practised only dermatology, I have

had two years' training in internal medicine.

Sy MD

More on H2 blockers (was: Dr. Sy - why cimetidine?)

> To add an internists/emergency physicians' perspective (not known

> facts -- please take the below in the casual spirit it is being

> presented, not as medical advice) on H2 blockers to Dr.Sy's

> thoughtful anti-flush regimen:

>

> H2 blockers block histamine receptors located primarily in the

> stomach, but also located in vessels. These drugs are often

> prescribed nightly for chronic hyperacidity because that's when acid

> release takes place unopposed, in an empty stomach.

>

> However, I don't think that's relevent for rosaceans; I wouldn't

> think flushing is a physiologic problem during sleep. For flushing, I

> would intuitively favor use of an H2 blocker such as Zantac first

> thing in the morning (realizing it takes about an hour for Zantac to

> fully enter the bloodstream), with a repeat dose 12 hours later only

> if evening/nighttime control is also needed. (In normal stomachs,

> it's probably not a great idea to inhibit acid release around-the-

> clock indefinitely.)

>

> Be sure to review Zantac's side effects and drug interactions -- they

> are much fewer than Tagamet (no gynecomastia, guys! <g>), but not non-

> existent.

>

> Only H2 blockers impact on histamine-induced flushing. Those on

> proton pump inhibitors such as Propulsid and Nexium will have

> decreased stomach acidity, but they will have no decreased flushing

> since those medications offer no histamine receptor blockade.

>

> As Dr. Sy suggests, consider also an H1 blocker (antihistamine).

> Avoid those that cause fatigue; though safe they tend to provide an

> unnatural sleep so avoid taking them chronically at night. The second

> generation antihistamines are weaker but tend not to cause drowsiness

> at prescribed doses (unless taken with alcohol). For example, Allegra

> is a twice-daily that can be taken with Zantac in the morning,

> repeated taken 12 hours later if needed at night.

>

> Taking both an H1 and an H2 blocker together may help those who don't

> respond to either. Even so, there may not be total cessation of

> flushing -- but an improvement is an improvement. <g>

>

> A dated but seemingly accurate online reference on antihistamines at

> http://www.alphanutrition.com/allergy/antihistamines.htm

> describes the various generic and trade name drugs.

>

> Dr. Sy also suggests treating the release of other peptides that can

> induce vasodilation such as prostaglandins, complement and

> bradykinins. Note that aspirin or NSAIDs can actually cause flushing

> soon after ingestion in some aspirin-sensitive individuals. For those

> that can tolerate aspirin, I would think that once daily dosing of

> the lowest amount taken anytime should be more than sufficient.

>

> For those with high blood pressure, note that a number of medications

> cause flushing as a side effect. Two medications that are effective

> in both lowering blood pressure and decreasing facial flushing are

> beta-blockers such as propanolol (also used for social anxiety), and

> clonidine. As an aside: there was a recent thread discussing how to

> discontinue clonidine. Since rebound symptoms can be dangerous, I

> recommend that be done only under a doctor's supervision. Both drugs

> have a number of side effects that should be reviewed with a

> physician before use; for example, those with asthma should not take

> propanolol since it can induce bronchospasm. Both are generally safe,

> but their side effect provide needs to be reviewed. There are good

> reasons both are only available by prescription only.

>

> There are several reasons why those looking for medical management of

> flushing need to be under a general physician's care. Not only is it

> critical to eliminate other causes of flushing, but despite some of

> these drugs being available OTC for other conditions (acid stomach,

> allergies, pain control, etc), taking them for flushing is different,

> and really does require a physician's monitoring. I think that

> whatever drug(s) work for flushing should be used, I don't understand

> the distinction here between prescription or non-prescription. Also,

> I wouldn't intuitively recommend starting out by taking them all at

> one time. A physician can help individualize a medical management of

> flushing. Finally, there are other drugs available to discuss with

> your doctor, the above is not exhaustive by any means. All rosaceans

> deserve not only good skin and cardiovascular care but to give

> attention to the psychological effects of flushing so many here

> describe.

>

> I'd appreciate not receiving private email with questions on symptoms

> or make a cyberdiagnosis but maybe this can help everyone: a few

> months ago I posted several messages about immunologic disorders;

> it's totally appropriate for a general physician to perform the

> necessary (non-routine) blood work and/or make referral to a

> rheumatologist for a consellation of non-specific symptoms, to rule

> out any treatable or progressive condition that would benefit from

> intervention (although usually none is found).

>

> Also, a few days ago I wrote about the distinction between facial

> redness from inflammation, and facial redness from flushing; it is

> confusing, but I don't see why both can't coexist, where local

> irritative redness at rest appears to develop into a whole face

> affair when superimposed with flushing from exercise.

>

> Conversely, temporarily losing one's red face during exercise (unless

> related to specific medication) may represent a cardiovascular

> problem requiring further investigation -- at a minimum a good

> history and exam, with possibly an ultrasound and/or cardiovascular

> stress test. Let your doctor know what happens to your pulse when you

> exercise.

>

> Marjorie

>

> Marjorie Lazoff, MD

>

> > From: " mschmidt "

> > > Maybe Dr. Sy will see this and explain to the group> her choice of

> > cimetidine (tagemet) - since this> question has come up before: >

> why Dr Sy

> > chooses > > cimetidine to avoid > > flushing and not any other h2

> >blocker

> >

> > Hi,

> > Thanks for giving me this opportunity to clarify my anti-flushing

> regimen.

> > As I recall, the gist of my regimen was to keep it over-the-counter.

> > Therefore, the products recommended were examples of OTCs. Other H2

> blockers

> > such as zantac or pepcid should work. As Marjorie pointed out,

> zantac may be

> > better since it is a BID (twice a day) dose as opposed to QID (4

> times a

> > day).for cimetidine. Although suggesting a QD (once daily) dose may

> sound

> > like taking a placebo, I have seen patients respond to this minimum

> dosage.

> > In fact, H2 blockers are given as QHS (once nightly) dose for

> maintenance

> > once the acute condition is under control. Therefore, if once a day

> dosage

> > works for you, keep it that way. As for drug interaction and side

> effects,

> > most medications have both - you just have to read the drug inserts

> and be

> > aware of interaction with the medications you may be taking. Or,

> check with

> > your doctor.

> >

> > Another clarification - Other H1 blockers will work as well. I

> suggested

> > chlortrimeton for the same OTC reason. As a matter of fact, H1

> blockers that

> > do not cause drowsiness and are long-lasting, such as zyrtec and

> allegra,

> > may be more practical. However, you need a prescription for both.

> >

> > Re a substitute for aspirin, other NSAIDs which are prostaglandin

> inhbitors

> > such as ibuprofen and indomethacin are alternatives if one is not

> able to

> > take aspirin.

> > However, please be aware that before you take this regimen, you

> should be

> > under the care of a physician. Check the feasibility of these

> medications

> > with your primary care doctor who knows your medical situation and

> current

> > medications better than I.

> >

> > Sy MD

> > Sy Skin Care

> > http://www.lindasy.com

> > Voice:Toll-free 877-sy (546-3279)

> > Outside U.S.:

> > FAX:

> >

July 22, 2002