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What’s New, What’s Gone,What’s Off-label that’s Useful….
Show of hands, please…Who has prescriptive authority?Who uses that prescriptive authority?Who likes be<strong>in</strong>g the first to write for a new drug on themarket?Who knows what a “Black Box” warn<strong>in</strong>g is?Where is that “Black Box”—who sees it?Who has a trusted relationship with a localpharmacist?Who knows if the compound<strong>in</strong>g pharmacy be<strong>in</strong>g usedis accredited?
• How does prescriptive authority apply tonaturopathic doctors?• If NDs are “known” for us<strong>in</strong>g nature to cure, iswrit<strong>in</strong>g prescriptions someth<strong>in</strong>g we shouldhabitually be do<strong>in</strong>g?• Are we los<strong>in</strong>g our medic<strong>in</strong>e and becom<strong>in</strong>g“green allopaths”?
Pharmacist (RPh) s<strong>in</strong>ce 1988Naturopathic Doctor s<strong>in</strong>ce 2004Practiced <strong>in</strong> unlicensed Virg<strong>in</strong>ia from 2005-2012Taught pharmacology at Bastyr this yearCurrently <strong>in</strong> private practice <strong>in</strong> SeattleGave talk (with Tish Dick-Kronenberg, ND) atAANP 2011; will offer similar class at Bastyr thisfall—”Hey, Doc—how do I get off these drugs?”NOTE: I am not anti-pharmaceutical! I am all forpractic<strong>in</strong>g the pr<strong>in</strong>ciples of naturopathic medic<strong>in</strong>eand follow<strong>in</strong>g the Therapeutic Order.
Chloramphenicol• On the market s<strong>in</strong>ce 1949• Antibacterial agent• Pulled 2012 due to bone marrow toxicity(aplastic anemia)
Propoxyphene (Darvon/Darvocet)• On the market s<strong>in</strong>ce 1957• Pa<strong>in</strong> medication• Pulled 2010 because of <strong>in</strong>creased risk ofmyocardial <strong>in</strong>farction & stroke
Rosiglitazone (Avandia)• On the market s<strong>in</strong>ce 1999• Oral hypoglycemic• Pulled 2010 <strong>in</strong> Europe and <strong>in</strong> 2011 <strong>in</strong> NewZealand because of <strong>in</strong>creased risk ofmyocardial <strong>in</strong>farction & death• Still on US market despite estimated 83000heart attacks attributed to product and over13000 lawsuits• In comb<strong>in</strong>ation with metform<strong>in</strong> (Avandamet)and glimepiride (Avandaryl)
Phosphosoda (Fleet’s Phosphosoda)• Over the counter laxative & bowel prep• Pulled 2008 due to acute phosphatenephropathy• Other oral phosphosoda agents rema<strong>in</strong> onthe market by prescription only
Sibutram<strong>in</strong>e (Meridia)• On the market s<strong>in</strong>ce 1997• Appetite suppressant• Pulled 2010 due to <strong>in</strong>creased risk of heartattack & stroke
Gemtuzumab ozogamic<strong>in</strong> (Mylotarg)• On the market s<strong>in</strong>ce 2000 (acceleratedapproval from FDA)• Treatment for acute myeloid leukemia• Pulled 2010 due to <strong>in</strong>creased risk of venoocclusiveliver disease & lack of cl<strong>in</strong>icalbenefit
Efalizumab (Raptiva)• On the market s<strong>in</strong>ce 2003• Treatment for psoriasis• Pulled 2009 due to <strong>in</strong>creased risk ofprogressive focal leukoencephalopathy(rapidly progressive CNS <strong>in</strong>fectionlead<strong>in</strong>g to death or severe disability; nocure known)
Peg<strong>in</strong>esatide (Omontys)• On the market s<strong>in</strong>ce March 2012• Pulled February 2013 due tocardiovascular events, anaphylaxis, death• Treatment for anemia due to chronickidney disease
Ivermect<strong>in</strong> lotion (Sklice)• For the treatment of head lice• Approved February 2012• Anti-helm<strong>in</strong>thic use s<strong>in</strong>ce 1981 (Stromectol)• Now labeled for the s<strong>in</strong>gle use (1 treatmentonly) on dry hair for head lice <strong>in</strong> patientsgreater than 6 months of age
Ingenol mebutate gel (Picato)• For the treatment of act<strong>in</strong>ic keratosis• Approved January 2012• 3-day treatment at the cost of about $600• Euphorbia peplus sap conta<strong>in</strong>s the substance onwhich this is based
Cysteam<strong>in</strong>e hydrochloride drops (Cystaran)• For the treatment of corneal cyst<strong>in</strong>e crystalaccumulation due to cyst<strong>in</strong>osis• Approved October 2012• In cosmetics, a hair wav<strong>in</strong>g/straighten<strong>in</strong>gagent• To be used every hour while awake• [Cysteam<strong>in</strong>e bitartrate (Proscybi) approvedApril 2013 for nephropathic cyst<strong>in</strong>osis]
Ocriplasm<strong>in</strong> <strong>in</strong>jection (Jetrea)• For the treatment of symptomaticvitreomacular adhesion• Approved October 2012• Dissolves prote<strong>in</strong>s lam<strong>in</strong><strong>in</strong> & fibronect<strong>in</strong>,detach<strong>in</strong>g vitreous from macula
Ranibizumab <strong>in</strong>jection (Lucentis)• For the treatment of diabetic macular “wet” edema• Approved August 2012• Monoclonal antibody fragment from same parentmouse antibody as bevacizumab (Avast<strong>in</strong>)• Orig<strong>in</strong>ally approved 2006 for treatment of macularedema follow<strong>in</strong>g ret<strong>in</strong>al ve<strong>in</strong> occlusion; new<strong>in</strong>dication• Cost is $1600 per monthly <strong>in</strong>travitreal <strong>in</strong>jection vs$42 for bevacizumab which is used for certa<strong>in</strong>cancers
Tafluprost ophthalmic solution (Zioptan)• For the treatment of elevated <strong>in</strong>traocularpressure• Approved February 2012• Another prostagland<strong>in</strong> analogue likelatanoprost (Xalatan)
Beclomethasone dipropionate nasal spray (Qnasl)• For the treatment of seasonal and perennialallergic rh<strong>in</strong>itis• Approved March 2012• Prodrug of beclomethasone, on market s<strong>in</strong>ce1972• “Dry” nasal spray
Aclid<strong>in</strong>ium bromide powder for <strong>in</strong>halation(Tudorza Pressair)• For the ma<strong>in</strong>tenance treatment ofbronchospasm associated with chronicobstructive pulmonary disease• Approved July 2012• Antichol<strong>in</strong>ergic; long-act<strong>in</strong>g muscar<strong>in</strong>ic blockersimilar to tiotropium (Spiriva)
Ivacaftor (Kalydeco)• For the treatment of cystic fibrosis with theG551D mutation <strong>in</strong> the CFTR gene• Approved January of 2012• This genetic mutation accounts for 4-5% of CF• Currently be<strong>in</strong>g evaluated <strong>in</strong> genetic mutationF508del, which accounts for 70% CF cases• Vertex (manufacturer, along with CFF) is tomake drug available at no cost to US familieswith no <strong>in</strong>surance and household <strong>in</strong>come lessthan $150000 per year
Luc<strong>in</strong>actan (Surfax<strong>in</strong>)• For the treatment of respiratory distresssyndrome <strong>in</strong> premature <strong>in</strong>fants• Approved March 2012• Designed to decrease duration and risk ofmechanical ventilation <strong>in</strong> children under 2years of age diagnosed with acute respiratoryfailure
Prednisone delayed release tablets (Rayos)• For the treatment of certa<strong>in</strong> <strong>in</strong>flammatorydiseases, <strong>in</strong>clud<strong>in</strong>g arthritis, COPD, asthmaand psoriatic conditions• Approved July of 2012• Delayed release version of 1940s “miracledrug”
Icosapent ethyl (Vascepa)• For the treatment of hypertriglyceridemia• Approved July 2012• Ethyl ester of eicosapentanoic acid• Dose is 4g daily
Taliglucerase alfa (Elelyso)• For the treatment of Gaucher disease• Approved May 2012• Plant-derived enzyme; recomb<strong>in</strong>antglucocerebrosidase from transgenic carrot cells• First plant-made pharmaceutical to ga<strong>in</strong>approval by FDA
L<strong>in</strong>aclotide (L<strong>in</strong>zess)• For the treatment of irritable bowel syndromewith constipation and chronic idiopathicconstipation• Approved August 2012• Forecasted to be blockbuster <strong>in</strong> sales by 2021• Lubiprostone (Amitiza) only otherIBS/constipation drug on the market• Tegaserod (Zelnorm) pulled from market <strong>in</strong>2002 due to <strong>in</strong>creased risk of heart attack &stroke
Pancrelipase tablets (Viokace)• For the treatment of exocr<strong>in</strong>e pancreatic<strong>in</strong>sufficiency due to chronic pancreatitis orpancreatectomy• Approved March 2012• Other pancrelipase products <strong>in</strong>clude brandsCreon, Zenpep, Pancreaze, Pertzye, Ultresa
Pancrelipase delayed release capsules (Ultresa)• For the treatment of exocr<strong>in</strong>e pancreatic<strong>in</strong>sufficiency due to cystic fibrosis or otherconditions• Approved March 2012• Delayed release option
L<strong>in</strong>aglipt<strong>in</strong> + metform<strong>in</strong> (Jentadueto)• For the treatment of type II diabetes• Approved February 2012• Tradjenta (2011) + Glucophage (1994) <strong>in</strong> 1 pill
Mifepristone (Korlym)• For the control of hyperglycemia <strong>in</strong> adults withendogenous Cush<strong>in</strong>g’s syndrome• Approved February 2012• Abortion agent (RU486) with new <strong>in</strong>dication(Mifeprex approved <strong>in</strong> US <strong>in</strong> 2000)
Lorcaser<strong>in</strong> HCl (Belviq)• For the chronic management of weight loss• Approved June 2012• Schedule IV controlled drug withhalluc<strong>in</strong>ogenic activity• Seroton<strong>in</strong> receptor agonist• First weight loss drug approved s<strong>in</strong>ce 1999• Only two rema<strong>in</strong> on market—orlistat (Xenicalby prescription, Alli over-the-counter) &phenterm<strong>in</strong>e (Fast<strong>in</strong>)
Phenterm<strong>in</strong>e + topiramate extended release capsules(Qsymia)• For the treatment of chronic weight management• Approved July 2012• Topamax (anticonvulsant approved 1996) + Fast<strong>in</strong>(appetite suppressant approved 1959) together <strong>in</strong> 1pill• Remember phen-fen (phenterm<strong>in</strong>e +fenfluram<strong>in</strong>e)? Numerous deaths due topulmonary hypertension & heart valve problems.Fenfluram<strong>in</strong>e pulled from market after $13 billionpaid out <strong>in</strong> legal damages. Topiramate’s patentexpired 2009.
Testosterone gel (Bio-T-Gel)• For the treatment of hypogonadism• Approved February 2012• Other topical forms of testosterone on markets<strong>in</strong>ce 2000 or earlier
Estradio valerate; estradiol valerate + dienogest(Natazia)• For the treatment of heavy menstrual bleed<strong>in</strong>g• Approved March 2012• Oral contraceptive 2010• Pharma’s version of bHRT: esterified form ofnatural 17-beta-estradiol + progesterone and 19-nortestosterone derivatives marketed to postmenopausalwomen for treatment of climactericsymptoms. Adverse effects <strong>in</strong>clude breakthroughbleed<strong>in</strong>g, mastalgia, headache, abdom<strong>in</strong>al pa<strong>in</strong>,hypertension, thrush, migra<strong>in</strong>e, weight ga<strong>in</strong>,<strong>in</strong>crease <strong>in</strong> endometrial thickness andmetrorrhagia
Mirabegron (Myrbetriq)• For the treatment of overactive bladder• Approved June 2012• First of its k<strong>in</strong>d—activates β3 adrenergicreceptors <strong>in</strong> detrusor muscle, lead<strong>in</strong>g to<strong>in</strong>creased capacity of bladder through musclerelaxation
Avanafil (Stendra)• For the treatment of erectile dysfunction• Approved April 2012• Cous<strong>in</strong> to sildenafil (Viagra), tadalafil (Cialis),vardenafil (Levitra)
Rotigot<strong>in</strong>e transdermal system (Neupro)• For the treatment of Restless Legs Syndrome• Approved April 2012• Dopam<strong>in</strong>e agonist for use <strong>in</strong> Park<strong>in</strong>son’s (2007)• New <strong>in</strong>dication for RLS
Gabapent<strong>in</strong> enacarbil (Horizant)• For the treatment of postherpetic neuralgia• Approved June 2012• Prodrug of gabapent<strong>in</strong> (Neuront<strong>in</strong> 1994), greaterbioavailability• Approval denied 2010 for the use <strong>in</strong> restless legsyndrome due to concerns about <strong>in</strong>creased cancerrisk <strong>in</strong> some animal studies—gabapent<strong>in</strong> ofconcern, too, but benefit <strong>in</strong> seizure control (notrestless leg syndrome) determ<strong>in</strong>ed to outweighrisk of cancer• Approved for RLS <strong>in</strong> 2011 and PHN <strong>in</strong> 2012.
Pregabal<strong>in</strong> (Lyrica)• For the treatment of neuropathic pa<strong>in</strong>associated with sp<strong>in</strong>al cord <strong>in</strong>jury• Approved June 2012 for this <strong>in</strong>dication• Approved 2004 for neuropathic pa<strong>in</strong>; 2007 forfibromyalgia
Teriflunomide (Aubagio)• For the treatment of multiple sclerosis• Approved September 2012• Active metabolite of leflunomide, a pyrimid<strong>in</strong>esynthesis <strong>in</strong>hibitor used as a DMARD for RA• Teriflunomide is for relaps<strong>in</strong>g/remitt<strong>in</strong>g MS
Perampanel (Fycompa)• For the treatment of partial-onset seizures withor without secondarily generalized seizures• Approved October 2012• Non-competitive AMPA glutamate receptorantagonist
Oxcarbazep<strong>in</strong>e extended release tablets (OxtellarXR)• For the adjunctive therapy of partial seizures <strong>in</strong>adults and <strong>in</strong> children 6 years to 17 years of age• Approved October 2012 <strong>in</strong> this form• Extended release form of Trileptal, which has<strong>in</strong>dications for epilepsy (2000) andbipolar/mood disorder (2009)• Structurally similar to carbamazep<strong>in</strong>e(Tegretol); watch for suicidal ideation
Methylphenidate HCl (Quillivant XR)• For the treatment of Attention DeficitHyperactivity Disorder• Approved September 2012• The extended release version of Rital<strong>in</strong> (1955;Rital<strong>in</strong> LA 2002; Concerta 2008; Covidien 2013)• Once daily dos<strong>in</strong>g <strong>in</strong> liquid form
Elvitegravir, cobicistat, emtricitab<strong>in</strong>e, tenofovirdisoproxil fumarate (Stribild)• For the treatment of HIV-1 <strong>in</strong>fection• Approved August 2012• “The Quad”• For <strong>in</strong>itial treatment of newly diagnosed HIV• S<strong>in</strong>gle pill taken once daily
Vismodegib (Eviredge)• For the treatment of basal cell carc<strong>in</strong>oma• Approved January 2012• Hedgehog pathway <strong>in</strong>hibitor
Regorafenib (Stivarga)• For the treatment of previously treated patientswith metastatic colorectal cancer• Approved September 2012• Expanded use February 2013 to treat patientswith advanced gastro<strong>in</strong>test<strong>in</strong>al stromal tumorsthat cannot be surgically removed and are nolonger responsive to imat<strong>in</strong>ib and sunit<strong>in</strong>ib
Enzalutamide (Xtandi)• For the treatment of metastatic castrationresistantprostate cancer• Approved August 2012• For patients who previously received docetaxel• Androgen receptor antagonist with 5-foldhigher aff<strong>in</strong>ity than bicalutamide (Casodex)
Abiraterone (Zytiga)• For the treatment of metastatic castrationresistantprostate cancer• Approved December 2012• To be used <strong>in</strong> conjunction with prednisone <strong>in</strong>men who have/have not been treated withchemotherapy previously
Ziv-aflibercept (Zaltrap)• For the treatment of metastatic colorectalcancer• Approved August 2012• To be used <strong>in</strong> conjunction with 5-fluorouracil,leucovor<strong>in</strong>, and ir<strong>in</strong>otecan <strong>in</strong> patients resistantto or experienc<strong>in</strong>g progression of disease postoxaliplat<strong>in</strong> therapy
Pazopanib (Votrient)• For the treatment of soft tissue sarcoma• Approved April 2012• Tyros<strong>in</strong>e k<strong>in</strong>ase <strong>in</strong>hibitor for use <strong>in</strong> renal cellcarc<strong>in</strong>oma (2009); new <strong>in</strong>dication for soft tissuesarcoma• May cause severe or life-threaten<strong>in</strong>g liverdamage
Glucarpidase (Voraxaze)• For the treatment of toxic plasma methotrexateconcentrations <strong>in</strong> patients with impaired renalfunction• Approved January 2012• S<strong>in</strong>gle <strong>in</strong>jection; $22,500 per 1ml vial• Derived from genetically modified E. coli
Pertuzumab (Perjeta)• For the first-l<strong>in</strong>e treatment of HER2+ metastaticbreast cancer• Approved June 2012• First of its k<strong>in</strong>d: HER dimerization <strong>in</strong>hibitor—b<strong>in</strong>d<strong>in</strong>g to HER2 <strong>in</strong>hibits dimerization of HER2to other HER receptors, slow<strong>in</strong>g tumor growth
Paclitaxel prote<strong>in</strong>-bound particles for <strong>in</strong>jectablesuspension (Abraxane)• For the treatment of non-small cell lung cancer• Approved October 2012• Taxol was the orig<strong>in</strong>al, approved 1992 forovarian cancer & 1994 for breast cancer; thisversion is album<strong>in</strong>-bound, orig<strong>in</strong>ally approved2005 for metastatic breast cancer• New <strong>in</strong>dication
Bosut<strong>in</strong>ib (Bosulif)• For the treatment of Ph+ chronic myelogenousleukemia• Approved September 2012• Tyros<strong>in</strong>e k<strong>in</strong>ase <strong>in</strong>hibitor
V<strong>in</strong>crist<strong>in</strong>e sulfate liposome <strong>in</strong>jection (Marqibo)• For the treatment of Ph- acute lymphoblasticleukemia• Approved August 2012• Lipid-encapsulated v<strong>in</strong>crist<strong>in</strong>e designed tocirculate <strong>in</strong> blood longer, accumulate <strong>in</strong> tumor,be released over longer period of time at tumorsite• Orig<strong>in</strong>al, Oncov<strong>in</strong>, approved 1963
Omacetax<strong>in</strong>e mepesucc<strong>in</strong>ate (Synribo)• For the treatment of chronic or acceleratedphase chronic myeloid leukemia• Approved October 2012• For use <strong>in</strong> CML resistant/<strong>in</strong>tolerant to two ormore tyros<strong>in</strong>e k<strong>in</strong>ase <strong>in</strong>hibitors
Carfilzomib (Kyprolis)• For the treatment of multiple myeloma• Approved July 2012• Selective proteasome <strong>in</strong>hibitor• Cost is $10,000 for 28-day cycle• Fast-tracked out of Phase 2b trials
Tbo-filgrastim (Neutroval)• For the reduction <strong>in</strong> the duration of severechemotherapy-<strong>in</strong>duced neutropenia• Approved August 2012• Filgrastim (Neupogen 2009); same <strong>in</strong>dicationsand adverse effects
Fentanyl subl<strong>in</strong>gual spray (Subsys)• For the treatment of breakthrough cancer pa<strong>in</strong>• Approved January of 2012• IV anesthetic Sublimaze (1960s), patchDuragesic (1990s), buccal soluble film Onsolis(2009), lollipop Actiq & buccal tablet Fentora(2011)
• Ibuprofen with itraconazole or terb<strong>in</strong>af<strong>in</strong>e <strong>in</strong>DMSO topically for nail fungus• Cimetid<strong>in</strong>e topically for warts• Ketam<strong>in</strong>e, gabapent<strong>in</strong>, clonid<strong>in</strong>e oramitriptyl<strong>in</strong>e with NSAID and guaifenes<strong>in</strong>topically for neuropathic pa<strong>in</strong> (guaifenes<strong>in</strong> ismuscle relaxant when used topically)• Phenyto<strong>in</strong> topically to enhance wound heal<strong>in</strong>g
• Atrop<strong>in</strong>e, ketoconazole, biot<strong>in</strong> <strong>in</strong> vag<strong>in</strong>alsuppository form for vulvodynia• Carbidopa/chromium/5-HTP <strong>in</strong> a lollipop forweight loss• Betahist<strong>in</strong>e 8mg bid for t<strong>in</strong>nitus & vertigo• Dextromethorphan mixed with opioid orally toreduce tolerance
• Low dose naltrexone (1.5-4.5mg) orally forneuropathy, autoimmune diseases,fibromyalgia, autism, PTSD, PCOS• Clonid<strong>in</strong>e for use <strong>in</strong> hot flashes, migra<strong>in</strong>eheadaches, restless legs syndrome (RLS),attention-deficit/hyperactivity disorder(ADHD), sleep apnea, smok<strong>in</strong>g cessation,Tourette's syndrome, withdrawal from alcoholand narcotics
• <strong>Pharmacy</strong> Compound<strong>in</strong>g Centers of America(PCCA)• <strong>Pharmacy</strong> Compound<strong>in</strong>g Accreditation Board(PCAB)• Sett<strong>in</strong>g uniform standards of “sound practices,processes, facilities, equipment and personnel”• Not absolutely necessary, but nice
• SSRIs for generalized anxiety disorder,premature ejaculation, migra<strong>in</strong>e headaches,diabetic neuropathy, fibromyalgia,neurocardiogenic syncope• Any SSRI or SNRI (other than Prozac orLexapro) to adolescents• Wellbutr<strong>in</strong> (bupropion) for weight loss, adultADD/ADHD, RLS/PLMD, sexual dysfunction,bipolar depression, depression of Park<strong>in</strong>son’s;Zyban (bupropion) for depression!
• Lamictal (lamotrig<strong>in</strong>e) as monotherapy, or forbipolar II, treatment-resistant bipolar disorder,treatment-resistant depression• Topamax (topiramate) or Trileptal(oxcarbazep<strong>in</strong>e) for bipolar disorder• Neuront<strong>in</strong> (gabapent<strong>in</strong>) for bipolar disorder,diabetic neuropathy, complex regional pa<strong>in</strong>syndrome, ADD, RLS, trigem<strong>in</strong>al neuralgia,periodic limb movement disorder of sleep(PLMD), migra<strong>in</strong>e headaches, alcoholwithdrawal
• Glucophage (metform<strong>in</strong>) for use <strong>in</strong> gestationaldiabetes, PCOS, HIV lipodystrophy• Keppra XR (levetiracetam) for migra<strong>in</strong>es,neuropathic pa<strong>in</strong>, bipolar disorder, anxietydisorders, and substance abuse/addictions,seizures associated with traumatic bra<strong>in</strong> <strong>in</strong>juryand/or tumor• Adderall (dextroamphetam<strong>in</strong>e + amphetam<strong>in</strong>e)for use <strong>in</strong> depression, “study drug”, appetitesuppressant
1. Re-establish the basis for health2. Stimulate the heal<strong>in</strong>g power of nature3. Tonify weakened systems4. Correct structural <strong>in</strong>tegrity5. Prescribe specific natural substances for pathology6. Prescribe pharmacological substances for pathologyPharmaceutical <strong>in</strong>tervention to halt or palliate disease process7. Prescribe surgery, suppressive measures, radiation, and chemo
1. Re-establish the basis for health2. Stimulate the heal<strong>in</strong>g power of nature3. Tonify weakened systems4. Correct structural <strong>in</strong>tegrity5. Prescribe specific natural substances for pathology6. Prescribe pharmacological substances for pathologyPharmaceutical <strong>in</strong>tervention to halt or palliate disease process7. Prescribe surgery, suppressive measures, radiation, and chemo
1. First Do No Harm primum non nocere2. Identify and Treat the Cause tolle causam3. The Heal<strong>in</strong>g Power of Nature vis medicatrixnaturae4. Doctor as Teacher docere5. Treat the Whole Person tolle totum6. Prevention/Wellness7. “Don’t tell me what to th<strong>in</strong>k!”
• http://www.centerwatch.com/drug-<strong>in</strong>formation/fda-approvals/• www.Rxlist.com• http://en.wikipedia.org/wiki/List_of_withdrawn_drugs• http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm319905.htm• http://en.wikipedia.org/wiki/Chloramphenicol• http://www.medic<strong>in</strong>enet.com/propoxyphene/article.htm• http://www.gibbonslaw.com/UserFiles/Image/1193175381.pdf• http://www.latimes.com/news/nationworld/nation/la-122001fda,0,4840718,full.story• http://www.citizen.org/Page.aspx?pid=2366#rr6• http://articles.mercola.com/sites/articles/archive/2012/02/11/lead<strong>in</strong>g-causes-of-death-cost-for-useconomy.aspx• Introduction to Compounded Medication Alternatives, Natalie Gustafson, PharmD; presentation toOANP, June 15, 2010• http://diabetes.emedtv.com/metform<strong>in</strong>/metform<strong>in</strong>-uses.html• http://www.crazymeds.us/pmwiki/pmwiki.php/Meds/Keppra-XR• http://www.crazymeds.us/pmwiki/pmwiki.php/Meds/LamictalApprovedAndOffLabelUses• http://consumerreports.org/cro/2012/05/off-label-use-of-clonid<strong>in</strong>e/<strong>in</strong>dex.htm• http://www.aafp.org/afp/2003/0801/p498.html• http://www.amcp.org/data/jmcp/contemporary%20subject-559-568.pdf• http://adderall.legalview.com/articles/off-label-use-of-adderall-poses-<strong>in</strong>creas<strong>in</strong>g-threat/173925/• http://www.crazymeds.us/pmwiki/pmwiki.php/Meds/Wellbutr<strong>in</strong>ApprovedAndOffLabelUses• http://www.cancer.gov/cancertopics/drug<strong>in</strong>fo/fda-regorafenib• http://www.ncbi.nlm.nih.gov/pubmed/11827562• Manufacturers websites of <strong>in</strong>dividual agents• Wikipedia.com• http://www.ahrp.org/cms/content/view/861/56/
Thank YOU!In health,Christie Fleetwood, ND, RPh