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Ask Dr. H

By Dr. Mitchell Hecht, McClatchy-Tribune News Service, Source: MCT News Service

Q: I recently saw a TV story about "therapeutic substitution". It concerns me that the prescriptions my doctor gives me may be switched without my knowledge. How does this happen?

_G.E., Atlanta

A: The practice of "therapeutic substitution" means that a pharmacy can substitute a specific medication of the same class with a similar drug of "comparable" efficacy. This does not typically occur without your physician's knowledge, but it does sometimes happen despite his objections. Hospitals are the most common setting for the practice of therapeutic substitution, done as a cost-saving measure to both the patient, the insurer and the hospital. In the vast majority of cases, the change does not adversely impact the health of the patient. For example, you may be taking Nexium for acid reflux and the hospital/managed care formulary only approves Prevacid. Another example is the substitution of the generic statin cholesterol-lowering drug simvastatin for the branded statin cholesterol drug Lipitor.

For a small percentage of folks, such changes matter a great deal. Substitution of one "SSRI" antidepressant for another could destabilize one's mental health. One statin may cause muscle aches that another does not cause _ or simply not work as well. Substitution of a short acting generic alternative for the longer-acting branded version of a blood pressure medication, seizure medication or antidepressant may seriously affect the health and safety of a patient.

While therapeutic substitution seems a violation of a patient's right and a doctor's right to decide the best treatment, the reality is that this practice is here to stay because the powers that dictate health care believe it saves money. In my office, I always inform patients of a proposed change, and give them the option of trying the alternative drug or paying cash for the original drug. Be aware that nearly all pharmacy plans have a formulary exclusion form that the doctor can submit should a therapeutic alternative cause an adverse reaction or prove to be ineffective.

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Q: From time to time, the skin on the corners of my mouth cracks. I usually just use cortisone cream, and it's gone within a week.

What causes this to happen?

_R.L., Wyncote, Pa.

A: For most folks, "angular cheilitis" ("cheilos" is Greek for "lip") is just due to a case of severe chapped lips. It's very common, especially during the cold winter months. Frequent licking of your lips; poorly fitting dentures; missing teeth that cause moisture to accumulate along the corners of the mouth; and dry lips are common causes for this. Sometimes the cracked corner may become red, tender and crusted due to infection from yeast or bacteria on the surface of your skin. There are also less common causes for angular cheilitis that include iron deficiency; vitamin B2 deficiency; zinc deficiency; malnutrition; untreated celiac disease; and medications which dry the mouth and lips.

The usual treatments for most folks with angular cheilitis are moisturizing lip balm, petroleum jelly or antibiotic ointment, and to avoid licking the lips. Frequent or non-healing angular cheilitis outbreaks should raise the question of an underlying medical condition.

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(Dr. Mitchell Hecht is a physician specializing in internal medicine. Send questions to him at: "Ask Dr. H," P.O. Box 767787, Atlanta, GA 30076. Due to the large volume of mail received, personal replies are not possible.)

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