photo: Ortho-McNeil Pharmaceutical, Inc.
 

Special Delivery
Should You Wear Your Medicine?

The use of a prescription patch that is worn on the skin to deliver medicine directly into the bloodstream was first introduced in 1980 with the development of a motion-sickness patch. It was closely followed by the Transderm-Nitro patch, used to treat heart disease. But the idea didn't really catch on until 1996, when the Food and Drug Administration approved the over-the-counter use of the nicotine patch to help people quit smoking. Today there are patches for a variety of medical concerns including contraception, pain relief, hormone replacement therapy and overactive bladder disorder. And expected on the market within the next six months are patches that will treat depression and children with attention deficit disorder, as well as one that will painlessly deliver insulin to diabetics.

The transdermal patch works by allowing medicine easy access to the bloodstream through thousands of capillaries close to the surface of the skin. This increases drug effectiveness and offers a host of other advantages over traditionally administered oral medications.

For example, patches are useful for patients who have difficulty swallowing. Patches don't have the problem of inconsistent absorption via the gastrointestinal lining, and they can help people avoid many side effects that some pills can cause including bloating and heartburn. Patch medication also avoids the delay and side effects of having to pass through the stomach and the liver before reaching the target tissues. And less medicine may be needed to get a similar effect because of the patch's proximity to the bloodstream. Plus, busy patients don't have to worry about forgetting to take their medicine. They just slap on the patch and go.

But patches are newer inventions in the pharmaceutical marketplace, and they haven't been fully tested yet, so we don't know all the differences between them and conventional pills. Sometimes patches don't compare exactly to the pill versions of medications either in possible side effects or effectiveness. Since the standard oral form has been around a lot longer, doctors don't always know precisely how patients will react to a particular patch medication. Also, the adhesive used to hold the patch in place can be irritating for patients with sensitive skin. Even though the patch is waterproof, it may still slip off during bathing or from sweating, or become less effective from immersion in water or dirt. Wearing the patch can also have the downside of being too convenient: The user may forget to remove the patch or change it at the prescribed interval.

Long-Acting Pills
There is a third option in the drug arsenal: long-acting pills, which don't have to be taken as frequently as the conventional tablet. The downside is that if a patient experiences side effects, she will have to wait to get relief until the drug's effects wear off. Still, for some patients, long-acting pills have distinct advantages over the short-acting versions. For example, Fosamax, a drug used to treat and prevent osteoporosis, has to be taken with a glass of water, on an empty stomach, while standing up for 30 minutes to prevent possible gastrointestinal problems. Now there's a long-acting form of the drug called Once Weekly Fosamax, which reduces the arduous procedure of taking the medication from every day to just once a week. Actonel, another osteoporosis drug, also comes in a long-acting version, and preliminary studies have shown no significant gastrointestinal side effects.

The good news is that patients now can choose among several drug delivery systems. Below are some examples of patch medication options and their pros and cons. If you decide to switch to a patch version of a drug you're currently taking, check with your doctor to make sure that the medication delivered through the patch is the same medication you're used to in pill form. Sometimes the drugmaker has to chemically alter a medication to make it skin absorbable instead of stomach absorbable. If you do want to change to a patch version, review carefully with your doctor some of the possible side effects noted here.

Is a Patch Right for You?
Contraception
Ortho Evra: supplies estrogen/progesterone

PROS: Has to be changed just once a week, eliminating the need to remember to take a daily pill.

CONS: May cause skin irritation and more breast tenderness than the Pill. Plus, its long-term effectiveness and side-effect profile versus the standard pill versions haven't been determined.

Depression
EmSam: an MAO inhibitor (FDA approval of the patch is expected in spring 2004.)

PROS: Avoids common side effects of antidepressant MAO inhibitor pills such as a spike in blood pressure. The patch gets into the bloodstream more quickly than oral medications, achieving effectiveness in just a week instead of the usual two to four weeks with pill versions.

CONS: Has the same drug interaction problems as other MAO inhibitors. Use caution if also taking prescription blood-thinning medication or certain migraine drugs. The combination may result in abnormal bleeding, a rise in blood pressure, and coordination problems.

Hormone Replacement Therapy
1. Alora, Climara, Esclim, Estraderm, Vivelle, Vivelle-Dot: contain estrogen only.

PROS:
Because the medication bypasses the liver and goes directly into the bloodstream, using the patch may help women avoid some of the problems associated with the pill version such as an increased risk of heart attack, stroke and blood clots.

CONS:
Like the pill version, the patch may increase the risk of breast cancer. Women who haven't had a hysterectomy must use the patch with progestin to protect against uterine cancer.

2. Climara Pro, CombiPatch: contain estrogen and progestin. For women who haven't had a hysterectomy.

PROS:
May cause fewer gastrointestinal problems than the pill version.

CONS:
The combination patch may have the same risks as the pill version for increases in breast cancer and heart disease.

Overactive Bladder
Oxytrol: relieves bladder and urinary spasms

PROS: Is effective for up to four days per patch; doesn't cause dry mouth or constipation, side effects that are common with the oral medications.

CONS: Can't be exposed to the sunlight, must be worn under clothing; as with the pill medications, Oxytrol may cause bloating and intestinal discomfort.

Pain Relief
Duragesic (narcotic), Lidoderm (non-narcotic): provide constant medication for the symptoms of both long- and short-term pain

PROS: The Duragesic patch is an alternative to Percocet or morphine preparations and provides long-acting relief for unremitting pain. The Lidoderm patch is applied to local areas of inflammation and provides longer-lasting relief than either the gel or ointment.

CONS: The Duragesic patch is not useful for patients with episodic pain; may cause skin irritation, lower blood pressure, or affect breathing. Lidoderm is a local anesthetic and relieves pain only in the area where it's applied.

Smoking Cessation
Nicotrol, Nicoderm CQ: provide nicotine in the bloodstream, curbing the physical cravings for cigarettes

PROS: Prolonged use replaces the nicotine found in cigarettes, reducing nicotine dependency from smoking. Highly effective when used alone or with Zyban, an antidepressant pill that treats the psychological craving of nicotine withdrawal.

CONS: May cause nightmares; may be removed at bedtime to minimize the side effect.