Voltaren Gel: Does It Work?
The science of the topical pain-killers, which can be effective without dosing your entire system
Think of Voltaren® Gel as “ibuprofen in a gel.” It’s actually the drug diclofenac, but ibuprofen is a much more familiar drug name in North America, where the product is still relatively new. It’s a topical anti-inflammatory medication,NSAID and FDA-approved to treat osteoarthritis in “joints amenable to topical treatment, such as the knees and those of the hands.”1 The evidence shows that it “provides clinically meaningful analgesia,” and quite safely, a claim that has been repeatedly validated by extensive testing over many years now.234
This is an appealing treatment idea that actually works reasonably well: what a pleasure to be able to say that!5 It is undoubtedly one the best of the OTC pain-killers.
Other topical pain-killers like topical salicylates, Tiger balm, and arnica
Voltaren is the most famous topical pain-killer, but it’s hardly the only one. Topical salicylates (cousins to aspirin) have been around for ages, and may even work better than Voltaren for some people and purposes. Other popular pain-relief ointments have never shown much potential, like the “spicy” ointments like tiger balm or Arnica creams (Traumeel, T-Relief). More on all of these below.
Why is Voltaren mainly for joints, and only some joints?
When the FDA refers to joints that are “amenable to topical treatment,” what do they mean? Is an amenable joint friendly and easy-going? No, just accessible: a pain-killing gel is useful only for joints that are not covered by a thick layer of muscle (like the shoulder). The medication gets diluted as it penetrates deeper into tissue, and a meaningful amount can only get into joints if they are just under the surface of the skin. The shoulder, hip, and spinal joints are notably quite deep.6
For more superficial joints, though, Voltaren® Gel delivers a good dose of medication, while sparing the gastrointestinal tract from the harshness of NSAIDs — which are known as “gut burners,” because many people just can’t stomach ibuprofen. A topical drug mostly eliminates the risks associated with digesting the stuff.7
More conditions Voltaren might be good for (unofficially)
There are probably some good uses for Voltaren® Gel above and beyond what it’s already been specifically approved for (“off-label” uses). Here are some of the common conditions that, in my opinion, are also likely to be good targets for this drug.8
But I am not a doctor, and safety first: please check with your doctor before you start spreading topical diclofenac on painful problems it isn’t made for! (Especially if you already take several other drugs, or have complex medical issues.)
- iliotibial band syndrome
- patellofemoral syndrome
- plantar fasciitis
- shin splints (particularly medial tibial stress syndrome)
- most common tendinitises,9 especially where the tendon is just under the skin, such as …
- tennis elbow (lateral epicondylitis)
- Achilles tendinitis
- patellar tendinitis
- carpal tunnel syndrome
- ligament sprains
- acute muscle strains
- bursitis
- some neck pain and headaches10
- sacroiliac joint pain, and possibly low back pain in general (more on this below, because it’s not obvious why Voltaren might be useful for back pain)
Availability and related drugs: different forms and cheaper generic versions)
Topical diclofenac is now widely available without a prescription in most places around the world. It was first available over-the-counter in the United States in early 2020, after being a prescription drug since 2007. Most other countries made it available without a prescription long before the US did (the FDA has a laudable history of being cautious with drug approval).
Topical diclofenac is now sold with several other major brand names and forms in addition to Voltaren Gel: Flector, Pennsaid, Rexaphenac, and Solaraze. There are also diclofenac patches, creams, and sprays.
Oral dicofenac has been around decades, and has been widely used globally since the 90s, and it continues to be prescribed frequently despite major safety concerns in recent history. More on this below.
Generic topical diclofenac has arrived! The first generic (cheaper) equivalent of Voltaren® Gel entered the marketplace in 2016, produced by Amneal Pharmaceutical, and that should be for sale most places now. There’s a rack of tubes of Voltaren by the till at my neighbhourhood drugstore, and I suspect pretty much every drugstore everywhere by now.
Voltaren for back pain too? Maybe! Surprisingly
I’ve emphasized that Voltaren is mainly appropriate for shallow inflammation, but there is some evidence that Voltaren might be able to “reach deeper.” This is hardly the stuff of medical certainty yet, but researchers Huang et al found that Voltaren treated pain coming from deep inside the spine, right in the centre.11
Surprisingly, Voltaren may even help some kinds of deep back pain.
They concluded that it could be a “convenient and safe clinical intervention” for a few types of back pain. An anti-inflammatory gel will likely fail with many kinds of back pain, but there’s also virtually no down-side to trying. See my low back pain tutorial for extremely detailed information about medications for back pain.
However, it probably does not work well for deeper tissues in most cases.
For instance, there’s evidence that it doesn’t work at all for the muscle soreness that follows unfamiliar exercise intensity,12 probably because it can’t be absorbed far enough into thick muscle tissue — but oral NSAIDs do have a modest effect on that kind of pain1314 (one of the only things that does).
Voltaren Gel is probably better than ice
Ice is nice. I have some extremely thorough icing advice on this website.15 But Voltaren® Gel strikes me as being, well, better — definitely more evidence based.16 Or at least more convenient.
Obviously icing for pain relief has some advantages. It’s free, other than the cost of running your freezer. It’s extremely safe. And “natural.”17 But Vitamin I (for “ibuprofen”) in a gel? C’mon! That’s just awesome! Medication delivered straight to the inflamed tissues, and only the inflamed tissues … it’s kind of futuristic.
There’s no reason not to use both, of course. But Voltaren® Gel has the potential to make ice obsolete as a treatment choice, except for situations where you don’t have any Voltaren® Gel handy.
On the other hand, no medication is completely risk-free.
What do the skeptics say?
Many readers assume that “skeptics” will always favour mainstream and pharmaceutical treatments like Voltaren, but nothing could be further from the truth. Indeed, some skeptics are leading the charge against bad pharmaceutical industry science and practices (and a great example is Ben Goldacre’s new book, Bad Pharma: How drug companies mislead doctors and harm patients).
Pharmacist Scott Gavura of Science-Based Pharmacy was certainly skeptical about topical NSAIDs like Voltaren when he first tackled the topic early in 2011.18 “When I recently noticed a topical NSAID appear for sale as an over-the-counter treatment for muscle aches and pains … I was confident it would make a good case study in bad science.”
He was surprised, however, and he changed his mind when he read the evidence. Having worked with Scott as an editor, I know he can’t be persuaded by anything less than robust evidence. On a few occasions, Scott has proven himself to be even harder to impress than I am (which is really saying something). He concludes:
Over the past two decades, evidence has emerged to demonstrate that topical versions of NSAIDs are well absorbed through the skin and reach therapeutic levels in synovial fluid, muscle, and fascia. …
For chronic conditions like osteoarthritis, the data are of fair quality and are persuasive. On balance, there’s good evidence to show that topical NSAIDs are clinically- and cost-effective for short term (< 4 weeks) use, especially when pain is localized.
Nothing’s perfect, however, and some concerns about Voltaren are covered below.
Where’s the fire? Treating “inflammation” may be a bad premise in many cases
Are you sure that you’re actually inflamed? Don’t answer too quickly.
One concern about the use of products like Voltaren is that several conditions may be less inflammatory in nature than they seem like. Patients usually assume that the “burning” pain of repetitive strain injuries like tendinitis is caused by inflammation. Seems reasonable.
But classic, acute inflammation is almost entirely absent, especially after initial flare-ups have died down (but pain is still carrying on).
While it is extremely likely that tendinitis is still inflamed in some sense,19 it’s somewhat doubtful that they are inflamed in a way that NSAIDs are actually good for. The biochemistry of cranky tendons is very “here be dragons” on the map of biology — large and unexplored. There’s probably some overlap between the biology of acute, classic inflammation and the subtler biology of chronic tendinitis, but no one really knows.
So the value of Voltaren for tendinitis is simply unclear. You can read about this in much greater detail in my RSI article: Repetitive Strain Injuries Tutorial: Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome
Don’t forget that exercise is also an anti-inflammatory medication
Note that moderate exercise is almost certainly anti-inflammatory as well.20 Which is cool.
Never just use Voltaren (or any pain-killer). Ideally, even the safest pain-killer should only be used sparingly, and to make it easier to exercise — whatever exercise you can do without excessive discomfort.21 Even if you’re really hurting, you may still be able to do easy pain-free range of motion exercises. Just beware of overdoing it while medicated!
How diclofenac works
Diclofenac suppresses inflammation, fever, and pain mainly by blocking production of prostaglandins, a signalling molecule involved in a huge array of biological processes — which is how all the NSAIDs work, broadly speaking.
What seems to be different about diclofenac is that it’s better at doing NSAID-ish things than other NSAIDs. For instance, it may inhibit prostaglandin-making in both of the two common ways, whereas all the other NSAIDs are either one or the other. But the biochemistry is dazzlingly complex, and there are several other possible mechanisms (and mysteries) for making it more potent (and dangerous).
The drug is active biologically for just an hour or two as traditionally measured, but when absorbed into the synovial fluid of joints, it sticks around for least ten hours, which may account for why it particularly makes a difference for arthritis pain.
More about safety, and the trouble with oral diclofenac
Long term and/or large oral doses of any of the NSAIDs can be extremely dangerous, even lethal. They “nuke” your entire system with much more active ingredient than you really need, all of it absorbed through the digestive tract and distributed through your entire circulatory system.
These drugs can and do cause complications at any dose, and are linked to heart attacks and strokes and ulcerations of the GI tract. What a bunch of jerks!
But oral diclofenac is a special kind of awful.
Diclofenac is an extremely popular drug and it is also associated with serious cardiovascular risks. McGettigan et al:22
There is increasing regulatory concern about diclofenac. … Diclofenac has no advantage in terms of gastrointestinal safety and it has a clear cardiovascular disadvantage.
This has been in the news quite a bit, and NPR had a hit in 2013 with this headline: “World’s Most Popular Painkiller Raises Heart Attack Risk.” And it’s not wrong, that headline. It’s not hype and alarmism — there is a real problem.
Topical diclofenac is a completely different animal than oral
The difference between oral and topical is extremely important. Spreading a medication on your skin is not the same thing as swallowing it.
Because Voltaren Gel is applied to the skin, dramatically less medication reaches the bloodstream — only a tiny fraction of what you would get from oral usage.2324 It is safe to assume that cardiovascular risks of moderate topical use are negligible compared to oral diclofenac, because so much less medication is actually getting into general circulation, and that is what the evidence now shows.25 Multiple studies have concluded that topical NSAIDs are both effective and safe.262728
At correct dosages for limited time periods, I think Voltaren Gel is probably almost completely safe: the worst side effect is probably the chance of irritated skin. ScienceBasedMedicine.org agrees:29
The main advantage of topical NSAIDs is the reduced exposure of the rest of the body to the product, which reduces the side effect profile. Given the toxicity of NSAIDs is related in part to the dose, it follows that topical treatments should have a better toxicity profile. Consequently, the cardiovascular risks of topical diclofenac, even in those with a high baseline risk of disease, should be negligible with the topical forms.
Some skin side effects for some people
I am definitely not saying Voltaren is completely safe or risk free. No drug is. The drug is still being absorbed, but instead of being a “gut burner” it can be a “skin burner.” From the Voltaren® Gel website …
The most common adverse reactions reported in Voltaren Gel clinical trials were application site reactions in 7% of treated patients. With all NSAIDs there may be an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal.
Sounds bad, doesn’t it? But those warnings are primarily there in an abundance of legal and medical caution provoked by the problems with oral NSAIDs. For short-term, moderate topical use, I believe the benefits clearly outweigh the minor risks.
What about long-term use?
This drug was basically invented as an arthritis treatment. Those patients may be interested in using topical diclofenac regularly and indefinitely. Is that kind of long term usage safe? Is regular use of any medication a good idea?
There is no good data on long term safety that I’m aware of. It probably doesn’t exist yet.
In principle, long-term use of any medication should be minimized as much as possible. The benefits of topical diclofenac aren’t so great that they justify the risks of frequent use indefinitely.
If I wished I could use it that way, I’d probably plan to take usage breaks: just stop using it for a while, a few times a year.
On the other hand, it’s probably about as safe for regular use as any medication gets. But that’s just an educated guess, extrapolating from the short term safety data.
Tramadol vs. Everything: 744 Drug Interactions and Counting
A 43-year-old woman presented to our emergency department with complaints of anxiety, intermittent “cramping” in her left hand, and jerking movements of her body that had been going on for five days. She had depression following the death of her son 14 months earlier, for which she was started on Effexor 37.5 mg once daily two weeks earlier.
One week before this visit, the patient had back pain and headache, for which she was evaluated at a local emergency department. She had lumbar x-rays showing mild degenerative changes in her spine and a normal head CT scan. The emergency physician who saw her prescribed tramadol 50 mg for every eight hours as needed for pain and cyclobenzaprine 10 mg for every eight hours as needed for spasm.
The patient subsequently developed uncontrollable anxiety and clenching of her left hand. The patient called her psychiatrist to inquire if it might be related to her taking Effexor, but her psychiatrist said the patient’s symptoms were unlikely to be side effects of the drug.
The patient then followed up with her primary care physician, who observed an episode of uncontrollable clenching of the patient’s left hand and was concerned about hypocalcemia or a central neurologic issue such as focal motor seizure. Her primary care provider then ordered laboratory tests, including calcium levels, ionized calcium levels, PTH, vitamin D levels, TSH, C-reactive protein, complete blood counts, electrolytes including magnesium and phosphorus levels, and liver function tests, all of which returned normal results. The primary provider scheduled an outpatient MRI of the brain and wrote prescription refills for tramadol and cyclobenzaprine.
The patient subsequently developed jerking movements involving her entire body, which seemed worse on the left side. The patient had not yet had her MRI brain scan, which was scheduled for later that afternoon, but presented to our emergency department with uncontrollable flinging and jerking movements of her body along with worsening anxiety.
Her physical exam was remarkable for frequent myoclonic jerking, tremor, hyperreflexia, and some incoordination with finger-to-nose and heel-to-shin testing. The patient was able to ambulate, but she intermittently had truncal ataxia while sitting. Otherwise, neurologic examination found her motor, sensory, and cranial nerve functions to be normal. Routine labs were normal, and the myoclonus was considerably improved with lorazepam 1 mg via IV.
We suspected that the patient had serotonin syndrome and recommended discontinuation of her meds, except for Ativan, to control the myoclonus. MRI of the brain was normal. Symptoms rapidly improved after discontinuing the medications, and the patient completely recovered within a few days.
Serotonin Syndrome
Signs and symptoms of serotonin syndrome include agitation or restlessness, diarrhea, rapid heart rate, elevated blood pressure, increased body temperature, loss of coordination, hyperreflexia, ataxia, myoclonus, agitation, nausea and vomiting, and hallucinations. (Ochsner J 2013;13[4]:533; Pain Med 2014;15[8]:1429.) Diagnosis of serotonin syndrome is typically made by identifying the clinical signs and symptoms when the patient is exposed to drugs known to elevate serotonin. The simple-to-follow Hunter Serotonin Toxicity Criteria offer simple if-then-else rules to diagnose the condition. (Am Fam Physician 2010;81[9]:1139; QJM 2003;96[9]:635.)
Offending drugs increase serotonin levels by inhibiting serotonin reuptake, inhibiting degradation of serotonin, or increasing serotonin release. (Am J Case Rep 2014;15:562.) A few drugs are also direct or indirect serotonin receptor agonists. (See table.)
The Rise of Tramadol
Tramadol is a blockbuster drug, and it became the 20th most prescribed drug in the United States by 2015. (IMS Health, Dec 2015; http://bit.ly/2h3QPMO.) A total of 424 tons of tramadol was consumed worldwide in 2012 alone. (WHO, 2014; http://bit.ly/2h3PTrw.)
The Drug Enforcement Agency re-categorized hydrocodone from a schedule III to a schedule II drug on Oct. 6, 2014, requiring it to be prescribed using triplicate prescription pads. This move was a response to the growing problem of prescription opioid abuse and diversion. Consequently, the burden of having to write triplicates may prompt physicians to seek alternatives such as tramadol. Tramadol had previously been placed into the schedule IV category on July 7, 2014.
Beware Cyclobenzaprine
Antidepressant medications are the most prescribed class of drugs in the United States, and one in 10 Americans is on antidepressants, according to the CDC. SSRIs are widely used as antidepressants, but frequent prescribing of tramadol and a lack of knowledge about the major drug interaction between tramadol and SSRIs can result in a growing number of patients experiencing the negative effects of these interactions.
Emergency physicians often prescribe a muscle relaxant in cases of muscle strain, spasm, or blunt trauma. Cyclobenzaprine should also be given with caution (if at all) to patients on other drugs that increase serotonin levels. The FDA instituted a safety labeling change to cyclobenzaprine in April 2013: “The development of a potentially life-threatening serotonin syndrome has been reported with Flexeril when used in combination with other drugs, such as selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), tramadol, bupropion, meperidine, verapamil, or MAO inhibitors.” (http://bit.ly/2h3D9kX.)
Physicians should be aware that cyclobenzaprine potentially poses some risk in combination therapies.
Toxic Combinations
Our patient on Effexor was prescribed a potentially toxic cocktail of tramadol and cyclobenzaprine by an emergency physician. This combination can result in a major reaction, potentially increasing serotonin levels and lowering the seizure threshold. (Psychiatry [Edgmont] 2009;6[4]:17.) Pairing any two of the three drugs prescribed to our patient — Effexor, tramadol, and cyclobenzaprine — will have major interactions.
Studies show only 15 to 20 percent of physicians are aware of the potentially serious interaction between tramadol and SSRIs. (Clinical Therapeutics 2015;37[8]:e43.) Symptoms of serotonin syndrome can range from mild to severe. It is likely that many patients with mild symptoms are simply overlooked by their physicians. Many patients who receive concomitant tramadol and SSRIs will likely have no symptoms, but it is difficult to anticipate which patients will have problems. A physician who prescribes tramadol monotherapy cannot predict whether a second physician may add other medications that can cause severe drug interactions. The use of electronic medical record systems that include drug interaction checking is encouraged.
The patient in this case either did not disclose these new medications or the psychiatrist failed to recognize the combination as dangerous. The patient then saw her own primary care provider who issued a new prescription for the same medications, apparently also not recognizing the risk of the combination. It is unfortunately common for physicians to fail to recognize the risk of serotonin syndrome from commonly prescribed drugs. (Eur J Hosp Pharm 23 March 2016 [ePub Ahead of Print].) Physicians who prescribe tramadol as part of their practice should take note of the myriad problems associated with tramadol in polypharmacy, and hospital pharmacies may play an important role in signaling the interactions and advising prescribers.
Partial List of Drugs Known to Increase Serotonin Levels
* Amphetamines and derivatives
* Ecstasy
* Dextroamphetamine
* Methamphetamine
* Sibutramine
* Analgesics
* Cyclobenzaprine
* Fentanyl
* Meperidine
* Tramadol
* Antidepressants/mood stabilizers
* Buspirone
* Lithium
* Monoamine oxidase inhibitors (selegiline, phenelzine, tranylcypromine)
* Selective serotonin reuptake inhibitors (SSRIs) (fluoxetine, sertraline, paroxetine, citalopram, escitalopram, dapoxetine, seproxetine, zimelidine, mesembrine)
* Serotonin-norepinephrine reuptake inhibitors (venlafaxine, duloxetine, desvenlafaxine, milnacipran)
* Serotonin 2A receptor blockers (trazodone)
* Tricyclic antidepressants (amitriptyline, imipramine, nortriptyline)
* Antiemetics (metoclopramide, ondansetron)
* Antimigraine drugs
* Carbamazepine
* Ergot Alkaloids
* Triptans
* Valproic acid
* Miscellaneous
* Cocaine
* Dextromethorphan
* Linezolid
* L-tryptophan
Dr. Barrows is a physician with Code 3 Emergency Physicians in Dallas. He trained at Baylor College of Medicine and the University of Texas, Southwestern, in Houston and Dallas, respectively.
Beauty 411: Retin-A vs. Retinol
What’s the difference between Retin-A and retinol?
Both are retinoids. They’re both made from vitamin A and promote faster skin cell turnover. And they’re some of the most proven, effective, and powerful options for treating skin issues ranging from acne to signs of aging.
Retinoids come in prescription form and in a range of over-the-counter products. Prescription-level retinoids fall into these groups:
- Tretinoin, including the brands Atralin, Retin-A, Retin-A Micro, and Renova
- Tazarotene, such as the brand Tazorac
- Adapalene, such as the brand Differin
All three groups prevent the buildup of dead cells in the skin’s pores and follicles, and all three promote the growth of healthy cells. Common side effects include dryness, redness, irritation, and skin peeling as well as making skin more sensitive to the sun.
Retinol is found in many products that don’t require a prescription. Retinols are much weaker than prescription retinoids. Unless vitamin A is listed as one of the top five ingredients and the product is packaged in an airtight opaque bottle, what you’re getting might not be all that effective. Neither retinoids nor retinols should be used by breastfeeding or pregnant women.
Coronavirus, Covid-19
COVID-19
Reported illnesses have ranged from people with mild symptoms to people being severely ill and dying. Symptoms can include: Fever, Cough, Shortness of breathTypical Symptoms
COVID-19 typically causes flu-like symptoms including a fever and cough. In some patients – particularly the elderly and others with other chronic health conditions – these symptoms can develop into pneumonia, with chest tightness, chest pain, and shortness of breath. It seems to start with a fever, followed by a dry cough. After a week, it can lead to shortness of breath, with about 20% of patients requiring hospital treatment. Notably, the COVID-19 infection rarely seems to cause a runny nose, sneezing, or sore throat (these symptoms have been observed in only about 5% of patients). Sore throat, sneezing, and stuffy nose are most often signs of a cold.Typical Symptoms
COVID-19 typically causes flu-like symptoms including a fever and cough. In some patients – particularly the elderly and others with other chronic health conditions – these symptoms can develop into pneumonia, with chest tightness, chest pain, and shortness of breath. It seems to start with a fever, followed by a dry cough. After a week, it can lead to shortness of breath, with about 20% of patients requiring hospital treatment. Notably, the COVID-19 infection rarely seems to cause a runny nose, sneezing, or sore throat (these symptoms have been observed in only about 5% of patients). Sore throat, sneezing, and stuffy nose are most often signs of a cold.80% of cases are mild
Based on all 72,314 cases of COVID-19 confirmed, suspected, and asymptomatic cases in China as of February 11, a paper by the Chinese CCDC released on February 17 and published in the Chinese Journal of Epidemiology has found that:- 80.9% of infections are mild (with flu-like symptoms) and can recover at home.
- 13.8% are severe, developing severe diseases including pneumonia and shortness of breath.
- 4.7% as critical and can include: respiratory failure, septic shock, and multi-organ failure.
- in about 2% of reported cases the virus is fatal.
- Risk of death increases the older you are.
- Relatively few cases are seen among children.
Pre-existing conditions
See also: Death Rates by Existing Conditions Pre-existing illnesses that put patients at higher risk:- cardiovascular disease
- diabetes
- chronic respiratory disease
- hypertension
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Addison’s Disease
What is Addison’s disease?
Addison’s disease is a condition that affects your body’s adrenal glands. These glands are located on top of your kidneys. They make hormones that affect your mood, growth, metabolism, tissue function, and how your body responds to stress.
Addison’s disease damages those glands. It causes your body to shut down production of the hormones. The disease commonly affects people 30 to 50 years of age. However, it can occur at any age and affects both men and women.
Symptoms of Addison’s disease
Symptoms appear over a period of several months. They are difficult to diagnose because they are vague. Symptoms include:
fatigue
muscle weakness
joint or muscle pain
fever
weight loss
nausea, vomiting, and or diarrhea (leading to dehydration)
headache
sweating
changes in mood or personality, such as irritability, anxiety, or depression
loss of appetite
darkening of the skin (called hyperpigmentation)
lightheadedness or fainting when standing up, due to low blood pressure
cravings for salty food
sudden, severe pain in the abdomen (lower stomach), lower back, or legs
confusion or slurred speech
sluggish movements
seizures
high fever.
When symptoms appear suddenly, or quickly get worse, it is called acute adrenal failure. Sometimes it’s called Addisonian crisis. This can lead to death if not treated. If you have any of the following symptoms, contact your doctor or go to an emergency room immediately.
sudden, intense pain in your lower back, abdomen, or legs
severe vomiting and diarrhea (which will lead to dehydration)
lower than normal blood pressure
unconsciousness
high levels of potassium and low levels of sodium.
What causes Addison’s disease?
Addison’s disease is caused by injury to your adrenal glands or when your glands are affected by another medical condition. This is called adrenal insufficiency. There are 2 types of adrenal insufficiency:
Primary adrenal insufficiency: This occurs through damage to your adrenal glands by an autoimmune disease (when your body attacks its own immune system). Other causes of primary adrenal insufficiency include:
Tuberculosis (or other infections) of the adrenal glands
Cancer of the adrenal glands
Bleeding of the adrenal glands
Secondary adrenal insufficiency: This occurs when another condition causes the adrenal glands to stop producing hormones. For example, a problem with your pituitary gland can cause secondary Addison’s disease. Or, you may develop Addison’s disease if you suddenly stop taking a corticosteroid medicine (such as prednisone). Corticosteroids are sometimes prescribed to treat conditions such as asthma, allergies, arthritis, cancer, and immune system problems.
How is Addison’s disease diagnosed?
Your doctor will ask you about your medical history and your symptoms. He or she may also perform laboratory tests to determine whether you have Addison’s disease. Those lab tests include:
Blood tests to measure your body’s hormone and mineral levels. Your doctor may check your blood before and after an injection to see if your body is responding normally to increased levels of certain hormones.
Computerized tomography (CT) scan or magnetic resonance imaging (MRI) to look at the size of your adrenal glands or pituitary gland. These scans are similar to an X-ray.
Can Addison’s disease be prevented or avoided?
Addison’s disease cannot be prevented or avoided.
Addison’s disease treatment
Treating Addison’s disease usually involves taking prescription hormones. This can include hydrocortisone, prednisone, or cortisone acetate. If your body is not making enough of the hormone aldosterone, your doctor may prescribe fludrocortisone. These medicines are taken every day by mouth (in pill form).
Your doctor may also recommend that you take a medicine called dehydroepiandrosterone. Some women who have Addison’s disease find that taking this medicine improves their mood and sex drive.
If you are experiencing an Addisonian crisis, you need immediate medical care. The treatment typically consists of intravenous (IV) injections of hydrocortisone, saline (salt water), and dextrose (sugar). These injections help restore blood pressure, blood sugar, and potassium levels to normal.
Living with Addison’s disease
Living with Addison’s disease involves learning to live with the unpleasant symptoms. In addition, you need to prepare for the possibility of Addisonian crisis. This is a medical emergency that requires you to:
Carry a medical alert card and bracelet at all times. This gives emergency medical workers information about your condition.
Keep extra medicine with you in case you forget to take your medicine. Ask your doctor for an injectable form of corticosteroids for use in an emergency.
Tell your doctor if your symptoms change or if your medicines stop working the way they used to.
Questions to ask your doctor
Is Addison’s disease hereditary?
Can the severity of my symptoms get worse over time?
Is Addison’s disease rare?
Can Addison’s disease cause long-term kidney failure?
Resources
National Institute of Diabetes and Digestive and Kidney Diseases, Adrenal Insufficiency & Addison’s Disease
U.S. National Library of Medicine, Addison’s Disease
Acute Bronchitis
What is acute bronchitis?
Acute bronchitis is inflammation of your bronchial tree. The bronchial tree consists of tubes that carry air into your lungs. When these tubes get infected, they swell and mucus (thick fluid) forms inside them. This makes it hard for you to breathe.
Acute bronchitis only lasts a short time (several weeks or less). Chronic bronchitis is long lasting and can reoccur. It usually is caused by constant irritation, such as from smoking.
Symptoms of acute bronchitis
The symptoms of acute bronchitis can include:
sore throat
fever
cough that brings up clear, yellow, or green mucus
chest congestion
shortness of breath
wheezing
chills
body aches.
Your cough can last for several weeks or months. This happens because the bronchial tree takes a while to heal. A lasting cough may signal another problem, such as asthma or pneumonia.
What causes acute bronchitis?
Viruses most often cause acute bronchitis. They attack the lining of the bronchial tree and cause inflammation. The same viruses that cause colds can cause acute bronchitis. You can catch a virus from breathing it in or skin contact. As your body fights these viruses, swelling occurs and mucus is produced. It takes time for your body to kill the viruses and heal damage to your bronchial tubes.
Lesser-known causes are bacteria or fungal infections. Exposure to irritants, such as smoke, dust, or fumes, also can cause acute bronchitis. You are at greater risk if your bronchial tree already has damage. If you have GERD (gastroesophageal reflux disease), also known as heartburn, you can get acute bronchitis when stomach acid gets into the bronchial tree.
How is acute bronchitis diagnosed?
Your doctor can confirm acute bronchitis. They will do a physical exam and review your symptoms. They might order an X-ray to rule out pneumonia.
Can acute bronchitis be prevented or avoided?
You can help prevent acute bronchitis by staying healthy and avoiding germs. Wash your hands often to kill any viruses. If you smoke, the best defense against acute bronchitis is to quit. Smoking damages your bronchial tree and puts you at risk for infection. Smoking also slows down the healing process.
Acute bronchitis treatment
Most cases of acute bronchitis can be treated at home.
Drink fluids, but avoid caffeine and alcohol.
Get plenty of rest.
Take over-the-counter pain relievers to reduce inflammation, ease pain, and lower your fever. Acetaminophen (Tylenol) also helps ease pain and lower your fever.
Use cough medicine, if your child is age 6 or older.
Increase the humidity in your home or use a humidifier.
Do not hold in a cough that brings up mucus. This type of cough helps clear mucus from your bronchial tree. If you smoke, you should quit. It will help your bronchial tree heal faster.
Antibiotics do not help treat viruses. They can help treat cases caused by bacterial infections. Some people who have acute bronchitis need medicine that treats asthma. You might need this if you are wheezing. It can help open your bronchial tubes and clear out mucus. You usually take it with an inhaler. An inhaler sprays medicine right into your bronchial tree. Your doctor will decide if this treatment is right for you.
Living with acute bronchitis
Most cases of acute bronchitis go away on their own. You should call your doctor if:
You continue to wheeze and cough for more than 2 weeks, especially at night when you lie down or when you are active.
You continue to cough for more than 2 weeks and have a bad-tasting fluid come up into your mouth. This may mean you have GERD. This is a condition in which stomach acid gets into your esophagus.
Your cough produces blood, you feel weak, you have an ongoing high fever, and you are short of breath. These symptoms may mean you have pneumonia.
Questions to ask your doctor
What is causing my acute bronchitis?
Are there over-the-counter medicines or prescriptions that can help relieve my symptoms?
Am I contagious?
Am I at risk for getting pneumonia or other lung infections?
What should I do if my couth doesn’t respond to treatment or gets worse?
Resources
American Lung Association, Acute Bronchitis
Depression in Children and Teens
What is depression?
Depression is a medical illness. It affects your mental and physical health. Anyone can have depression. It is important to know that it is not your fault. Children and teens who are depressed may have different symptoms than adults.
Younger children who are depressed may:
have a poor appetite and/or weight loss
feel sad or hopeless
not enjoy playing as much as usual
worry more.
Older children who are depressed may:
be anxious or have trouble focusing
be angry and act out or lose their temper more
have changes in appetite (eating more or less than usual)
not want to go to school or other social activities
complain of feeling sick often
seem less confident or feel like they can’t do anything right.
Things to consider
Young people can be depressed for many reasons. Genetics, health conditions, and life events can be factors. Below are other possible reasons for depression in children and teens.
Your family moves to a new place to live.
Your child has to change to a new school.
A pet, friend, or family member dies.
Someone in your family is very sick.
Your child experiences bullying or a form of abuse.
Your child suffers from behavioral problems, such as attention-deficit hyperactivity disorder (ADHD).
Currently, the American Academy of Family Physicians (AAFP) recommends depression screening for teens, ages 12 to 18, who have symptoms. The AAFP does not have enough evidence to assess the benefits and risks of screening children younger than 11 years of age for depression.
When to see the doctor
If you notice symptoms for 2 or more weeks, it might mean that your child is depressed. Your doctor can do an exam and refer your child to a specialist. This may include a counselor, therapist, psychologist, or psychiatrist. Your child can talk to them about what and how they feel. Family counseling can help everyone in your family. A combination of counseling and medicine can help treat depression in most young people.
Contact the National Suicide Prevention Lifeline if you think your child or teen is having thoughts of suicide. Call 911 if your child attempts suicide.
Questions to ask your doctor
How can I tell if my child or teen is depressed?
What can I do to help prevent depression?
What types of medicine help treat depression in children and teens? What are the side effects?
Can you recommend a support group for my child or teen who is depressed?
Resources
American Academy of Family Physicians, Clinical Recommendation for Depression
National Suicide Prevention Lifeline, 1-800-273-TALK (8255)
National Institute of Mental Health, Depression Studies for Children
National Institute of Mental Health, Teen Depression
This content has been supported by Forest Laboratories Inc.
ACL Injuries
What is an ACL injury?
ACL refers to the anterior cruciate ligament. It is 1 of 4 ligaments in your knee. The other knee ligaments are PCL (posterior cruciate ligament), MCL (medial collateral ligament), and LCL (lateral collateral ligament). The ACL is located behind the kneecap (patella). It stabilizes the knee when it rotates. The ACL and PCL connect your thigh bone (femur) to your shin bone (tibia).
A torn ACL is a common knee injury. On average, women are 2 to 8 times more at risk of ACL injuries than men. Teenagers also are getting ACL injuries at an increased rate. More kids are involved in organized sports. The increase in ACL injuries is also due to awareness and advanced testing.
Symptoms of an ACL injury
The primary sign of an ACL injury is a popping noise. This is often combined with pain and swelling. You could experience grinding feelings of your bones or kneecap. Another sign is not being able to put weight on your leg.
What causes an ACL injury?
ACL injuries often occur in sports or active environments. They usually occur without contact rather than with direct contact. Several things can cause the injury, such as:
If you are moving and quickly stop or change directions.
If you are still and make a sudden movement, like a jump or turn.
If you overstretch your knee joint.
If someone hits you in the knee, causing it to move away from the rest of your leg.
This can happen while doing things like skiing, playing soccer or football, and jumping on a trampoline.
When you injure your ACL, it can be a partial or full tear. Other injuries can occur at the same time. These include other torn knee ligaments (primarily the MCL, the ligament that gives your knee stability), a torn meniscus (knee cushion), or bone bruises.
How is an ACL injury diagnosed?
If you think you’ve injured your ACL, seek medical attention. Your doctor will perform a knee exam to check range of motion and extent of injury. An MRI (magnetic resonance imaging) could confirm the injury.
Can ACL injuries be prevented or avoided?
The leading way to prevent injuries such as an ACL tear is to follow a certain training routine. Prevent Injury, Enhance Performance (PEP) programs have become more common for this purpose. They combine stretching, strengthening, and agility exercises that focus on knee stabilization. Organizations like U.S. Soccer have seen positive results and fewer injuries with PEP. The Santa Monica Sports Medicine Foundation (SMSMF) created this program.
There is no clear evidence that use of a knee brace prevents ACL injuries. There also is no proof that a knee brace helps more in treatment or physical therapy.
ACL injury treatment
Your doctor will weigh several factors to decide on a treatment plan. These include severity of the injury, age, physical condition, medical history, and other injuries or illnesses.
People who are young, active, and healthy typically get surgery. Your primary care doctor will refer you to an orthopedic surgeon. In surgery, they will repair, or reconstruct, the ACL with tissue. This can come from your hamstring or a minor patellar (knee) tendon. They also can get it from a donor. Surgery should be performed shortly after the injury, within 5 months, for best results. After surgery, you will need intense physical therapy to rebuild strength in your knee and leg.
Another treatment option for people who are aren’t as active or healthy is therapy. This is less intense and invasive. Therapy programs can range anywhere from 10-32 weeks. The goal is to increase movement and strength, and allow the ligament to heal naturally.
Living with an ACL injury
Recovering from an ACL injury can be difficult. This is especially true if the injury happened during a daily or regular activity. Keep in mind, your doctor’s goal is to restore your ACL, so treatment is important.
There is some evidence that people who have ACL injuries will develop osteoarthritis or degenerative arthritis over time. This outcome is similar regardless of how the injury is treated.
Questions to ask your doctor
Why are women and girls more at risk of ACL injuries?
How long after surgery or therapy until I can play sports or be active again?
Can I re-injure my ACL? If so, how can I prevent re-injury?
Resources
American Academy of Orthopaedic Surgeons, Management of ACL Injuries: Clinical Practice Guideline
Santa Monica Sports Medicine Foundation, PEP Program