round 2 advice and other IR stuff

[bandman54]

not really a question,... just wanting some opinions...

I figured when she told me "all of my patients clear" , she meant the ones that last the duration of 12 weeks with svr.... well duh... .. talk about spin.

cw - I am exercising now on a treadmill that they have set up for the teachers where I teach.. even has cable tv!  very cool.

my glucose is still high in the morning, 110-120, even thought the metformin has been doubled and I am exercising... maybe it takes awhile?

HI apache!  yeah, i remember all that.

I am just hoping and praying that IR is the reason I failed.

As far my doctor goes... of course I am getting a new one... and am seriously thinking of trying to talk my pcp into treating me, as he is quite open to all options.  I think he would probably do anything I asked as long as I can back it up with studies , etc.
It is just too hard to run around trying to find a gastro or hepa that is willing to work a little outside of the box... many seem to be content with just following standard protocol.. I guess they reluctant due to lawsuits.

My liver doc does want me to come back in , in april for an ultrasound... probably worthless, although I have had an ultrasound tech that an ultrasound will show a fatty liver as well as liver cancer.

I am going to try an wait on the polymerase/protease inhibitor combos for round 2.
I just don't have much faith in the infergen, or a retreatment with riba/inf.        any opinons?

thanks,
bandman

[bandman54]

tutor... I don't need no stinking tutor!

anyway, one last thing and I will go back under my rock for a few weeks...
the past several mornings my glucose level has been 100.... I know that sounds a little highish... but quite better than the 120s I was getting.
I am exercising on a treadmill and taking 1000mg metforming 2x per day.
This all sounds better, does it not?
I will refigure homa at end of month.

an oh yeah,, here is the good news, I am no longer starving all of the time and I feel much more "normal" phsysically.. if that makes sense.

bandman

[CoWriter]

"ps - I will be back for my test! "
----------------------

If you think CS is going to tutor you, forget it...LOL

Co

[bandman54]

ps - I will be back for my test!

psps - now for the task of finding a good hepatologist willing to personally treat hcv in arkansas!

I will let you know how the search goes....
anyone out there know of one?

bandman

[bandman54]

I knew you would say that!  lol!

bandman

[CoWriter]

"all i have to do is post everything going on and you guys can figure it out!  .... I am telling you, he will do whatever I suggest."
---------------------

That would be irresponsible, unsafe and illegal.  We're not doctors.  And although some people may disagree, we don't have god-like complexes....LOL.


"well yeah, i am thinking of treating under him."
"maybe try something along cs' plan."
---------------------

I'll make you a deal.  When you know as much as CS does, you can treat with whoever you want.  I get to test you and tell you if you pass.  Until then, if you decide to treat, it will be under a good hepatologist.

Remember that CS's treatment plan was approved by his doctor.  So if anything goes wrong, his doctor will be able to handle it.

Co

[CoWriter]

Here's one from June 2007.

"HCV clearance improves insulin resistance"

Conclusion:

In conclusion, the authors wrote, "We showed that clearance of HCV improves insulin resistance, beta-cell function, and hepatic IRS1/2 expression."


http://www.eatg.org/eatg/Global-HIV-News/News-archive/HCV-clearance-improves-insulin-resistance


Co

[bandman54]

well yeah, i am thinking of treating under him....

all i have to do is post everything going on and you guys can figure it out!  .... I am telling you, he will do whatever I suggest... so if I treat soon we basically go with the pegintron or pegasys, riba, alina and metformin along with suggested sups.  We also check viral load as frequently as I can afford and maybe try something along cs' plan.
I have enough interferon stockpiled that I could pump it up even if the doc does not go along (an he will), but I am concerned that insurance will not pay to predose, double dose , etc.  If I get too sick, I just bail or cut back.   I mean it would not take long to tell if my vl was dropping faster than round 1 and if that turns out to be the case, I tough it out for 12 weeks and see what happens.


the lady doc that treated my first round, only went by the book.... but i am going to try and find a local hepatologist first, IF can find one that knows what he/she is doing as far as treatment is concerned....  how?  lots of questions!  Its pretty easy to tell who is full of b.s.  I will start by asking their view of IR and its effect on tx success and see how they react.  I bet few to none will know what I am talking about.

But, if my next biopsy or fibroscan is good, then I am definitely going to wait a couple of years and see what comes out.

I am thrilled to hear that about stevia! made my day.  Stevia good!

bandman

[CoWriter]

So your doc won't know about celexa/SAMe?  

LOL....and you want to treat under him, huh?

bandman....the article Evangelin posted in THIS thread.

Co

[CoWriter]

Stevia was part of the research we did for CS's plan.  We read every single study on Stevia.  It improves insulin signaling.  So it's safe.

Co

[CoWriter]

There are too many variables that can influence whether somebody will become a diabetic or not besides having Hep C. Like....genetics, obesity/diet, yo-yo dieting, amount of exercise, use of meds (like steroids) that can increase the risk of diabetes, smoking (which can cause insulin resistance), previous exposure to toxins (like agent orange), HIV co-infection, lypodystrophy (fat atrophy and re-distribution), having other infections, use of supplements that decrease insulin resistance.... and many more.

A recent study called "Incidence of type 2 diabetes mellitus and glucose abnormalities in patients with chronic hepatitis C infection by response to treatment: results of a cohort study" said that......

Recent studies have shown that in HCV positive patients with an abnormal HOMA IR (insulin resistance test) value who achieve SVR, insulin resistance improves while in Non-responders and Relapsers there were no changes, suggesting that viral eradication may be beneficial in correcting insulin resistance and glucose intolerance.

The study showed that after an 8 year follow-up, the incidence of glucose abnormalities between long-term SVR's and Non-Responders was not significantly different.

HOWEVER.....glucose abnormalities appeared later in long-term SVR's than on Non-Responders. This difference may be explained by the benefit that clearing the virus has on insulin resistance. And interestingly, 6 out of 17 cirrhotic Non-Responders developed glucose abnormalities....while only 1 of the 7 cirrhotics with long term SVR developed glucose abnormalities.

Patients who developed Impaired Fasting Glucose (IFG) and Diabetes had more diabetes risk factors at baseline (family history of diabetes, older age, higher BMI, abnormal HOMA Insulin Resistance values, liver fibrosis and steatosis) which probably played a crucial role in inducing glucose abnormalities despite viral eradication.

Bottom line.....achieving SVR may lower the risk of glucose abnormalities but having a family history of diabetes plays a crucial role in determining which patients are at higher risk of developing diabetes. On HCV patients with long-term SVR, the possibility of developing diabetes is better predicted by the diabetes risk factors they have at baseline rather than by virus eradication.

(I have the whole study in pdf.  If anybody would like a copy, let me know).

Co
P.S.  SVR gets rid of hepatic IR.  To expect SVR to get rid of peripheral IR caused by obesity from a lifetime of poor eating habits is wishful thinking.

[bandman54]

that being said.....
what about stevia, do you think that it to "confuses" the system, resulting in "impared glucose" control??  I hope not.  ME like stevia!

I am starting to fear that perhaps I should not anything that tastes sweet.... honey , fruit, stevia, black strap molasises (not really, I don't even know what that is!).

bandman

[bandman54]

thanks for the posts...... yes, I did miss them the first time around.

I will look for the evangelin post as well.

And I would ask my doctor(s) about SAMe and celexa, but they would have no idea.... I will ask my pharmacist sis instead.

bandman

[CoWriter]

"this book also says that caffeine stimulates the body to produce insulin as well.  possible? "
-------------------------

You must have missed my other post too....

Caffeine worsens insulin resistance in prediabetics.(Metabolic Disorders)
Article from: Family Practice News
Article date: April 15, 2007
Author: Evans, Jeff

WASHINGTON -- Caffeine intake appears to exaggerate post-meal insulin resistance in prediabetic adults who regularly drink several cups of coffee each day, according to preliminary results of a randomized, double-blind, crossover study of 50 individuals.

The results "suggest that caffeine consumption promotes the development of type 2 diabetes in those people who are at greatest risk for this disease," James D. Lane, Ph.D., said at the annual meeting of the Society of Behavioral Medicine.

This is the first time that caffeine's effects on insulin resistance have been measured in habitual coffee drinkers with prediabetes, said Dr. Lane of the department of psychiatry and behavioral medicine at Duke University, Durham, N.C. More than 12 other studies have shown that caffeine administration acutely raises insulin resistance both in healthy, nondiabetic volunteers and in patients with type 2 diabetes.

Other studies have shown that coffee drinking is associated with a significantly reduced risk of type 2 diabetes, but these conclusions have been "based on correlational observations, not controlled, experimental studies," he noted.
In the current study, all participants had prediabetes (average impaired fasting blood glucose level of 111 mg/dL) and drank at least 2 cups of coffee per day, which was confirmed by a 7-day food diary. Each person fasted overnight and did not consume any caffeine, which preserved any tolerance that they had developed from their continued exposure to caffeine.

On the first day of testing, the participants received either 250 mg caffeine or placebo pills and had their fasting blood glucose levels measured. On the second day, they received the opposite of what they had taken on day 1. After 60 minutes, they had their blood glucose levels measured again, and they received a booster dose of 125 mg caffeine or placebo. They also drank a BoostPlus liquid meal replacement shake (75 g carbohydrates, plus fat and protein), which is similar to an oral glucose tolerance test except that it is more like a real meal, Dr. Lane said. Blood samples were drawn during each of the next 3 hours.

The total 375-mg dose of caffeine was equivalent to about 3 cups of brewed coffee, similar to what subjects consumed on average each day (409 mg).

For the first 41 participants with full results available, CAFFEINE INCREASED the 3-hour area under the curve (AUC) for PLASMA GLUCOSE BY 15% more than placebo, though the result was not statistically significant. But the 3-hour AUC for PLASMA INSULIN WAS 18% greater with caffeine than with placebo--a significant difference. AUC is the standard method for measuring responses to oral glucose tolerance tests, said Dr. Lane. "This pattern of results shows that caffeine did increase insulin resistance in these prediabetic subjects."

A normal response to the extra insulin produced with caffeine would have been to reduce the peak glucose level to a point lower than what was seen with placebo. But "'the glucose response was, if anything, a little larger in the caffeine condition," he said. "Given the conditions of our study, we think that this insulin resistance effect occurs every day as these prediabetic individuals and others like them consume caffeinated beverages in the real world."


"also, is SAMe ok with celexa? I have been taking both and do not feel maniacal at all."
-------------------------
Thast's good because I can only deal with one maniacal person at a time and the post is alreadyb taken.

This would be a good thing to check with your doctor.  Also, show him the article Evangelin posted.

Co

[CoWriter]

"co -
I don't know if this is true or not , but the IR diet book I just read said that  artificial sweetners "confuse" your system and cause you to produce too much insulin...  do you think that is possible. "
-------------------------
You miust have missed my post.....


Daily Consumption of Diet Soda Linked to Metabolic Syndrome, Type 2 Diabetes

February 11, 2009. Drinking diet soda at least daily is associated with significantly greater risks for select incident components of the metabolic syndrome (MetSyn) and type 2 diabetes, according to the results of an observational study reported in the January 16 Online First issue of Diabetes Care.

"Two longitudinal cohort studies have shown positive associations between diet soda consumption and incident MetSyn independent of baseline measures of adiposity," write Jennifer A. Nettleton, PhD, from the University of Texas Health Sciences Center in Houston, and colleagues. "Replication of previously observed diet soda-MetSyn associations in a distinct cohort would bolster their credibility and provide further insight into the nature of the relationship. Previous studies have not addressed associations between diet soda and individual MetSyn components or risk of type 2 diabetes nor have they fully addressed potential longitudinal mediators of these relationships, i.e., changes in adiposity status."

The goal of this study was to evaluate associations between diet soda consumption and the risk for incident MetSyn, its components, and type 2 diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA).

Initial evaluation was performed from 2000 to 2002, at which time baseline food frequency questionnaires measured diet soda consumption. Three follow-up evaluations were performed from 2002 to 2003, 2004 to 2005, and 2005 to 2007. Incident type 2 diabetes was defined as fasting glucose levels of more than 126 mg/dL, self-reported type 2 diabetes, or use of diabetes medication. National Cholesterol Education Program Adult Treatment Panel 3 criteria were used to define MetSyn and its components. After adjustment for demographic, lifestyle, and dietary confounders, hazard ratios (HRs) were estimated for type 2 diabetes, MetSyn, and MetSyn components.

Compared with participants who did not drink diet soda, those who drank diet soda at least daily had a 36% greater relative risk for incident MetSyn (HR, 1.36; 95% confidence interval [CI], 1.11 - 1.66) and a 67% greater relative risk for incident type 2 diabetes (HR, 1.67; 95% CI, 1.27 - 2.20).

Of the individual components of MetSyn, only high waist circumference (men: ¡Ý 102 cm; women: ¡Ý 88 cm) and high fasting glucose levels (¡Ý 100 mg/dL) were prospectively associated with consumption of diet soda. Associations between diet soda intake and type 2 diabetes were independent of baseline measures of adiposity or changes in these measures. In contrast, associations between diet soda and MetSyn were not independent of these factors.

"Although these observational data cannot establish causality, consumption of diet soda at least daily was associated with significantly greater risks of select incident MetSyn components and type 2 diabetes," the study authors write.

Limitations of this study include observational design, precluding determination of causality; possible confounding by other dietary and lifestyle/behavioral factors; and difficulties in estimating intake of diet soda or artificial sweetener.

"These results corroborate findings from the ARIC [Atherosclerosis Risk in Communities] and Framingham studies and show stronger adverse associations exist between diet soda and type 2 diabetes," the study authors conclude. "Diet soda consumption, either independently or in conjunction with other dietary and lifestyle behaviors, may lead to weight gain, impaired glucose control, and eventual diabetes."

The National Heart, Lung, and Blood Institute supported this study. The study authors have disclosed no relevant financial relationships.

Co

[jmjm530]

Here's a compromise. Forget committing to the biopsy and expense -- why don't you line up an appointment with Gish (or similar), and have them review you're entire chart. If they think a biopsy is necessary, then you will have their case. If they don't think a biopsy is necessary, then you save the money. In any event, no one can force you to have a biopsy, but the important thing is to have your case evaluated and get someone in place to at least supervise your treatment when you do start. Other than travel, a one-time consult should cost you (guessing here) no more than $500 U.S. and maybe less if you tell them that you don't have insurance coverage. Many people find their "quarterback" right before or after they start treatment. This is the wrong time as you will be under too much stress, especially with the travel involved. Sounds like this might be the right time.

[jmjm530]

Baja,

I understand the limitations you have, but you seem like a resourceful person when motivated -- like your scan in CA and diet, etc -- so I'm thinking you just need more motivation :)

You're in your 60's and may have significant liver damage. In spite of all you're doing by yourself, at some point -- perhaps in the near future -- you are going to need to treat.

Your treatment resources in Mexico, by both admission and what you posted here, are limited and questionable.

Therefore, at a very minimum, you need some sort of let's say "quarterback" in the form of a well-versed hepatologist with a large, clinical practice who can put everything together for you and then at a minimum devise and supervise your treatment when it starts. This you cannot do for yourself, and all of what you are doing is no substitute for this.

So, without sounding like a broken record, I'll try it once again:) You've done everything except probably the most important thing which is to get a liver biopsy and line up someone to supervise your treatment. You can accomplish both things by coming to the States one more time and seeing a hepatologist like Gish in California, or perhaps someone else in his league.

If it were me, I'd see this as a life priority because any money you save by not doing this pales compared to the consequences of not having as ironclad diagnosis as *** soon as possible and not being ready to leave the starting gate with a competent treatment doctor in place should you have to. I just don't see that all your ducks are lined up to start treatment when needed and they really have to be. We've discussed this since October and the clock is still running :)

Be well,

-- Jim

[bajawoman]

thanks for the post Jim  wish my insurance worked in the states to do just that but who knows maybe business will pick up and I can afford to go for the medical help you suggest  Working is a major factor for me now and I work 7 days a week off to work now .  
lived here for almost 25 years so no benefits here or on the other side of the border Just the insurance that covers me here If I can get my GI who is my registered insurance doc to order a test here in Mexico
I can have it and it is 100 percent paid for

tried to talk him into a MRI which was recommened and  which we have here now but he did not go for it insisted on a Cat scan to see my liver and pancreas etc.
will check it with the MRI too maybe with time I can convince him    

( I do not think any of the male dr. or dentists need a vasectomy they are radiated sterile)  
I have had many x-rays here also many scripts for penicillan the all around health cure  remembering the first mamogram I had on an old out dated xray table machine ouch would be hirlarious if it wasn't my body  
took three times to get it done if I live to 80 it will be a miracle  

I was always self employed in the USA  but will look into SS which I paid into so many years ago maybe I can qualify for some help not sure
doin the best I can with what I have to work with  thanks jim I know you care

[jmjm530]

First, I think it's wonderful that you have taken things into your own hands and proceeded beyond what was offered by your original doctor in Mexico. Both the scan and your diet/nutritional program seem very positive and to be working.

That said --  and as I mentioned to you last year after your scan was completed -- you still need a traditional needle biopsy to reconcile things. Call it a "reality check" or simply call it Hep 101 for someone your age with potentially signficant liver damage. But whatever you call it, I would not put it off, especially since you have gone so far. Getting a CatScan at this point IMO serves no purpose other than to give you some unnecessary radiation.

Is it possible you can get an appointment with a top hepatologist in the California area to review your entire case plus your scan results? This would be my strong suggestion and I would not wait any longer. My gues is they will recommend needle biopsy and frankly I don't see any downside only an upside. It will also give you an opportunity to meet and evaluate a hepatologist who could then quarterback your treatment should you start treatment in the future.

All the best,

-- Jim

[bajawoman]

About artificial sweetners  this I heard from my  true years ago from my Brother who besides being a musician wrote medical papers that are in UC at Berkeley
that it is better if you are going to go for a soda drink it with sugar  
however all cabonated drinks are not that healthy at least this is my Dad's opinion  He would not allow them in the house growing up bireley's orange was ok as it was not carbonatet had sugar though  thinking back I think we all ate healthier in the old days

SAMe bothers me with the AD lexapro didn't set well today taking the SAMe in the morning going to take it later in the day as I take lexapro at night before bed  think they need some spacing  for me

In my opinion after having a Fibroscan I do believe they are more acurate over all  but bx has it's place too   I will be following up with a Cat Scan soon if it showed abnormalties I would I guess get a bx will PM you

If you read the labels of the Sups they do tell you what to take with and what not too mine do but mine are from Lef. on line Lef.com Resveratrol I get directly from the company that makes it as they have stronger doses  I am still not up to the 2000mg a day recommendation but working on it

baja

[bandman54]

co -
I don't know if this is true or not , but the IR diet book I just read said that  artificial sweetners "confuse" your system and cause you to produce too much insulin...  do you think that is possible.  I used to drink diet cokes, but quit over a year ago.
this book also says that caffeine stimulates the body to produce insulin as well.  possible?

also, is SAMe ok with celexa? I have been taking both and do not feel maniacal at all.

hmmm.

baja - could you please pm me details on how you went about getting a fibroscan... and anyone, is a fibroscan more accurate than a biopsy??

thanks,
bandman
bandman

[CoWriter]

"Sending you sugarless kisses"
-----------------

This one time, I was teaching a diabetes class and it was close to Valentine's...and some of the people in class, asked me, "What are you giving us for Valentine's?".  So I thought I better look into it.

I went to this very nice candy store.  You know, the ones that have all the fancy, very pretty candy.   I told them I was a Diabetes Educator (you'd be surprised how well we're treated because we can promote their product in our classes) and wanted to look at their sugarless candy.

They took me in the back of the store, showed me how they made it and said I could have free samples for my whole class.

On Valentines day I explained to my class that anything that contains calories will raise your blood sugar.  For example, a sugarless cookie is made with flour, eggs and butter and all those things contain calories.  So even though that cookie has no sugar, it will still raise their your sugar.

Then I told them about my visit to the candy store and gave them a list of the ingredients used to make the sugarless candy...which included mannitol and manilol.... dehadrating agents which can cause diarrhea.  And since I liked them alot, my present was not to give them diarrhea.....LOL

Now....about those sugarless kisses....

LOL

Co

[CoWriter]

You have impecable timing.  Thank you very much for the article.

Co

[portann]

Thanks, Co. That was tons of valuable input you provided last night while I was doing diddly-squat. I wish you would adopt me, too!

Hope CS is feeling okay.

Sending you sugarless kisses,

Port

[evangelin]

I found something about taking Sam e with an anti-depressant.  Joe was taking 800 mg. along with Celexa for quite a while with no apparent problem.  I talked to a pharmacist who thought it would be ok.  From the sound of this article, they have experimented with even higher doses.  Swanson vitamins had their 400 mg box for $12.??(can't remember the cents) but it was the cheapest price I had ever seen.  We had quit taking the Sam e for a while because of the cost.  
After 9 months of pegasys /Riba and Alinia Joe was still detectible so they have switched him to daily Infergen and I bought some more Sam e and will try 1200 mg for a while but I don't think it would be a good idea to stop the Celexa.  This article below gives me some peace about it.
  

SAM-e Offers Hope When Antidepressants Do Not Work
New York NY, 5 May 2004
Source: CO2

Research at Massachusetts General Hospital indicates that antidepressants used in combination with dietary supplement SAM-e were significantly more effective in relieving depression than medication alone.

Study Findings Presented Today at the American Psychiatric Association Annual Meeting in New York City

More than 18 million Americans a year are diagnosed with major depression. Five out of 10 of those people will not respond or will only partially respond to standard antidepressant treatment, or they will discontinue use because of side effects.

The Boston-based Massachusetts General Hospital (MGH) study findings presented today at the American Psychiatric Association Annual meeting indicate that the addition of dietary supplement S-adenosylmethionine, better known as SAM-e (pronounced "sammy"), to a patient's current selective serotonin SSRI (most widely used antidepressants such as Zoloft, Paxil, Prozac) regimen, improves patient response.

"The SAM-e/antidepressant combination was comparable to that of two antidepressants, with faster onset of action and fewer side effects such as weight gain and sexual dysfunction," says Jonathan Alpert, MD, PhD, associate director of the depression clinical and research program at Massachusetts General Hospital and lead investigator of the trial.

"It is common practice for physicians to add a second agent with established or putative antidepressant properties when one alone does not help a patient," adds Alpert. "Recently, interest has increased in adding dietary supplements and other complementary therapies to current treatment options."

"SAM-e is known for having few side effects and being well tolerated," says Maurizio Fava, MD, associate chief of psychiatry for clinical research and the director of the Mass General Hospital Depression Clinical and Research Program. "Based on the trial results, we feel it may be a more acceptable solution for patients who require combination therapy."

Study details

The open trial was designed to evaluate the safety, tolerability and efficacy of oral SAM-e tosylate as an antidepressant adjunct. The trial included thirty patients with current Major Depressive Disorder (MDD) despite an adequate dose of a single Selective Serotonin Reuptake Inhibitor (SSRI), the most common class of antidepressants or venlafaxine (Effexor XR). The patients were given 800 to 1,600 mg of SAM-e over six weeks. The mean patient age was 48.4 +/- 13.0 years.

The primary outcome test was the number of responders and remitters. A responder was defined as someone with a 50 percent reduction in HAM-D-17 score from baseline to endpoint. A remitter was defined as someone who had a final HAM-D-17 score greater than or equal to seven. (Overall, 93% of patients improved. See results, below).

Secondary efficacy measures included the Montgomery Asberg Depression Rating Scale (MADRAS), the Clinical Global Impressions—Severity (CGI-S), Improvement (CGI-I) scales and the 90 item Kellner Symptom Questionnaire (SQ).

When used in combination with prescription antidepressants, SAM-e was associated with a 50 percent intent-to-treat response rate, acceptable tolerability, no weight gain, and statistically significant reductions in reported sexual dysfunction, anxiety symptoms and serum homocysteine levels.

No patient experienced a serious adverse event. Moderate side effects reported in the trial include constipation, GI upset and headaches.

Pharmavite LLC funded the trial and provided the active ingredient. The promising results of this preliminary study provide the basis for a larger, controlled follow-up study that is being funded by the National Institutes of Health.

About SAM-e

S-adenosylmethionine (SAM-e) is a naturally occurring methyl donor in mammals and has been available in the United States in recent years as a dietary supplement.

SAM-e is involved in more than 35 biochemical processes in the human body. SAM-e's broad metabolic role in all tissues, including the brain, suggests that its antidepressant mechanisms may include increasing the availability of neurotransmitters, such as serotonin and dopamine, as well as increasing the number of neurotransmitter receptors.

In December 2002, the Agency for Healthcare Research and Quality (AHRQ) reviewed 39 placebo or active-controlled clinical trials, involving a total of 2,485 patients, on the role SAM-e has in treating depression. AHRQ concluded that SAM-e is more effective than placebo, and is as effective as standard prescription medication for treating patients