Life, Love, and the pursuit of Lemonade

Do you like the tree in the picture above? You too can have this perfect vacation spot in a gated community. It’s tranquil, has friendly quiet neighbors, beautiful trees lining the entryway, and best of all, landscaping is free without homeowner association fees. Downsizing for wifey? We’ll come back to this opportunity later!

For now though, HELLO from the chemo chair, cycle 6, day 1! Today is a treatment milestone because this is the last treatment prior to scheduled imaging on 9/13 which hopefully will bring positive news of no disease progression, and hopefully some disease regression. Also, today could be my last love affair with oxaliplatin for awhile (or forever) to avoid increased or permanent neuropathies as discussed in my previous post. And I have to say, while packing up after chemo today, I had paresthesias which never has happened before heading home. So I expect this cycle will come with more neuropathies – oh well, still no nausea/vomiting and still have my hair.

Meloxicam Update: My anti-inflammatory, meloxicam, continues to work great – no more dexamethasone for over two weeks. I did not take any meloxicam today. Why?
Lesson: Remember, I receive dexamethasone 10mg IV as part of my antiemetic (anti-nausea) regimen prior to chemo. Dexamethasone has a half-life of about 48 hours. The definition of half-life is the amount of time for the blood levels to drop by 50%. So, if the half-life of a drug is 24 hours, and at steady state your blood levels are 100ng/mL, after stopping the drug for 24 hours, your levels would be 50ng/mL, and the next day they would be 25ng/mL. It takes 5 half-lives for the body to eliminate a drug. Ten mg of dexamethasone IV is a pretty big wallop considering that the IV dose is the same as an oral dose (for this drug), and I only needed 3mg orally per day previously for bloating, inflammation, and pain. Dex has a half-life of about 48 hours. Believe me, I don’t need meloxicam today, and will be well covered into tomorrow. Adding meloxicam today just increases bleeding risk since both dexamethasone (a STEROIDAL anti-inflammatory and meloxicam (a NON-STEROIDAL anti-inflammatory) both work for pain. As I explained in the Leisure, Lemon-aid, Lessons, meloxicam favors COX2 and therefore has a lower risk of GI bleed and avoids several other traditional steroid risks. For the record, nobody has ever suggested I skip meloxicam on chemo day-1. These clinics need a pharmacist todo direct patient care, as outcomes would surely improve.

Today, 9/1 started out great. Robin drove me to chemo camp with my backpack and lunch, and blue Converse sneakers (just like a little kid again). I met a new oncologist that was covering for Dr. Onc. We’ll call him Dr. OncCov. What a difference. I never met him. He came into the room and said, “Hi, I’m Dr. OncCov and am covering for Dr. Onc today. I understand you are a doctor. Have you worked at Albany College of Pharmacy? Where have your practiced? What are you doing now? After the introductions he had some general medical questions for me. He proceeded to discuss my bloodwork, tumor markers, and other medical issues around my case, and spoke to me with the assumption that I knew what he was talking about, like a colleague – imagine that! What a breath of fresh air. It’s not like I expect Dr. Onc to address me as Dr. Fudin, but it also isn’t quite right that Dr. Onc goes by “Dr. Onc” and calls me Mr. Fudin regularly. Call me Jeff or call me Dr. Fudin, or expect the same salutation from me. Am I wrong here? See previous blog post (a must for new PharmD students), Is there a [REAL] doctor in the house?
I do have good news about Dr. Onc too though which I’ll discuss later.

I honestly think each week as I’m rounding the weekend after chemo that there isn’t much to write about next time. But, it seems the agenda fills quickly with ideas for my readers. Last week for example, I received a “crazy” gift from my sister – a Smokey the Bear Hat and I thought should I include this as a filler? I’ll address this in a bit.

On 8/19 I received bloodwork and my hemoglobin was up to 9.8g/dL. Still not normal, put I no longer need a drain snake to pluck it out of the toilet – I can actually pick it out, wash it off, and it’s a lot closer to normal. It remained stable today and I’m scheduled for the last of four iron infusions today. It does take several weeks for iron to be incorporated into red blood cells. So, I’ll expect another milestone in 2-weeks; a total iron panel workup (bet on the fact I’ll be on top of that when they draw my blood next time). Not to say I told you so, but I would not have received packed RBCs and 4 sequential iron treatments as soon as I did had I not advocated for myself – quite scary for all you non-medical folks out there.

On 8/20, day-2, cycle -5 with my lemon infuser in tow, I took a trip with my youngest daughter Shirah to, ready for this…
…pick out a cemetery plot for me (and my wife). I think Robin couldn’t bear to think about it, but geeze, she actually let me choose our final home without her. Imagine if I did that with our FL condo – I’d be dead without a gravesite. So no, Robin is not downsizing yet, and neither am I. But, Shirah and I did find a pretty sweet spot near trees, close to an entry road in a gated community with no homeowner association fees. So for friends and family, I’ll be easy to find. Too close to the entry road? Nah – I like noise and people. Maybe I can get a gravestone shaped like a saxophone. Here’s where I’ll be before I start haunting you from the grave, hopefully a very long time from today.
Lesson: It’s never too soon to select a burial site and plan for you, your significant other, and if desirable, the family (you or a family member can always sell portions back to the cemetery if family members decide to rest elsewhere). But, certainly one less thing to place in the laps of your family while they’re grieving – that is in part an advantage of advanced planning with a terminal illness and palliative chemo.

The next day I went to the clinic, got disconnected (ahhh- off the leash for 2-weeks), visited the local Farmers Market with Robin and neighbor Joan S (thanks for the shirt in the main photo here), had a second breakfast there – bacon. The cholesterol probably isn’t too desirable, but the fat (9 Cal per gram) should do me good as an occasional treat. I say occasional because I stopped my simvastatin. Then I powered thru cutting the back lawn and Robin did the front. And the next day, I walked my Siberian Husky pal 3.5 miles which was effortless. I’ve had relatively less neuropathy cycle-5, two weeks ago. But I am getting better at avoiding touch to anything refrigerated or frozen, and also I’m more careful with water temperature out if the faucet. Although if I do grab something in the freezer or wrap my hand around a bottle of refrigerated orange juice, I am getting tingling even 14 days after starting cycle-5, as I’m starting cycle-6 today. That is evidence that the neuropathy is accumulating and its another reason to abandon oxaliplatin after today.

Lesson for your pharmacist and prescribers: I’m not likely going to die of hypercholesterolemia or resultant coronary artery disease. The risk of increased liver toxicity from simvastatin plus chemo and the risk of increased simvastatin blood levels/toxicity from drug interactions by CYP3A4 inhibitors is elevated – figure out from a risk/benefit standpoint if continuing statins in your patient is worth it. My cholesterol, although elevated was never dangerously high.

Rolling Stones (Let’s use As Tears Go By), Milestones, or Set of Stones:
Here I’m going to summarize some upcoming milestones that keep me going. Just to clarify, “set of stones” has to do with precious gems, although I can see where your mind is drifting, as it does take a reasonable amount of chutzpah to write a blog that includes your last address, which will be Congregation Beth Emeth Cemetery; 58 Turner Lane; Albany NY 12211. After I pass, please forward your mail there. Set of stones include a precious gem given to Robin for a milestone birthday. The second gem (a tourmaline) is going into a family ring for my son-in-law (it will become an heirloom); a ring given to me by Robin that previously housed my mother’s diamond. That diamond is now around Robin’s neck – happy birthday. So you see, a set of stones (one for Kris and one for Robin).

Proximal anticipated milestones include hopeful positive news on CT Scan in two weeks, a month long visit from daughter Hannah, followed by a trip to FL condo with her to meet up with her husband for a week and some R&R (assuming the anti-vaxxers in FL grow a set of stones to protect others and get the vaccine, or they wear a quality mask correctly, or stay the hell home), stop off along the way in DC to see our son and “daughter” plus their two beautiful children, new car arrival, trip to Disney (same criteria), 3 new grandchildren by February 2022.
A lot to live for, right? YES!!! Live your life as if tomorrow is your last day.

I had a nice visit with Marge B and Dr. Andrea L. I worked with these two women for over 30 years. Marge was truly my work wife, and intelligent nurse practitioner who was my co-conspirator, colleague, friend, and teacher in the pain clinic. Marge was a champ at mentoring pharmacy students/residents and showing them the importance of a proper medical exam. Her insight was invaluable to guide us in selecting the proper medications. I taught Marge all sorts of complex pharmacotherapeutics as she listened to discussions I had with pharmacy residents and students. Sometimes if we had a difficult patient that was, let’s say doing improper things with their opioids, we’d confront them as good cop/bad cop. Andrea is amazing too. She is a psychiatrist who would often send us consults – without behavior health support, my job would have been impossible. And at times, her job in selecting drug therapy was challenging so we would often order pharmacogenetic testing to select targeted individualized medications – one of my favorite things to do. But early on in our careers, Andrea and I would team up Christmas time and play for Veterans in the VA hospital where we worked; Andrea on flute and me on saxophone. I could kick myself for not getting a pic of these two gems for this post – they’ll be back! I will say this though; a pain management clinic can function quite well with an NP, a psychologist (Andrea is a psychiatrist – called her when we needed her expertise), and a PharmD with the medical doctors doing some more advanced evaluations, interventional procedures, etc. This way the MDs don’t need to deal with the medication therapy at all, have lower liability when prescribing if monitored by a well-trained post-doc PharmD’s specializing in pain therapeutics, and I do believe when medications were indicated, our patients received top notch state-of-the-art science-based care. And in a private setting there may be more of a collegial opportunity for the clinic pharmacist to speak with a community pharmacist if an issue arises with drug interactions, opioid issues, etc.

The Tues after Dr. onc returned from vacation, he/she actually called me in the early evening, first time ever. Dr. Onc was very understanding and a pleasure to speak with, was in agreement with all the med changes discussed in my previous post, Dexterity, Determination, Disbelievers, and Diced Lemons, and the rationale behind all of my choices, was also puzzled by who answered my email messages thru the portal, and was in agreement with oxaliplatin options. Win-win for all!!!

Yesterday I met with Bill B. I have known this man for 30-years. He was a drug salesman for Purdue Pharma. Most of my readers I’m guessing know of all the bad press that Purdue has received over the last several years and the ensuing lawsuits over Purdue’s alleged influence on the opioid crisis. I am happy to report that this man worked for that same company for just shy of 30 years, and at all times was professional, never pushy, always showed concern that MS Contin and OxyContin were used properly and followed all the rules. Sure, there may have been some bad decisions made on the business executive side, but even then, the folks I knew on the medical side were smart and ethical. Not everyone associated with Purdue Pharma are bad people.
Lesson for clinicians (and concerned opioid-requiring chronic pain patients): I have long advocated that all patients in my clinic are treated equally. Whether or not you have a terminal illness, all patients receiving opioids are subject to random urine screens and other chemistries as clinically indicated to safely prescribe long-term opioids and to protect those honest patients that need these drugs.  I outlined that in a previous blog, What’s good for the goose is good for the gander. As a cancer patient, I can pretty much get any pain medications I need from any number of providers (surgeon, primary care, oncology, radiation oncology, etc.). I receive no less than 10-15 notices from my health insurance weekly for copays ranging from $40 to over $200 – how does a person living pay check to pay check pay these bills? It would seem very tempting to sell these drugs for quick cash. I believe that that many, if not most prescription opioids on the street come from cancer patients or families of these patients.  I don’t mean to place blame here, but I’m seeing this unfold in real time and I have had many such patients myself – oh, the stories I could tell!!! THIS IS NOT A REASON NOT TO PRESCRIBE OPIOIDS TO TERMINALLY ILL PATIENTS, BUT IT IS A WAKEUP CALL TO DO IT SAFELY TO PROTECT ALL PATIENTS THAT NEEDS THESE MEDICNE, TERMINALLY ILL OR OTHERWISE.

• Persons abusing opioids have a higher prevalence of cancer
• Substance abuse doesn’t go away with a new cancer diagnosis – it more likely will increase
• No overhead costs except the copays for families selling drugs
• Less scrutiny for cancer patients, often no requirement to check state monitoring platforms

 

On 8/26 I received the COVID-19 booster shot, also agreed upon by Dr. Onc in that telephone conversation. Recall that the day I chose for injection was carefully selected based on anticipated nadir (the lowest blood count predicted post-chemo, in days) and timing of dexamethasone post chemo (and subsequent chemo) because dex is an immunosuppressant. I’m pretty certain that most of the time, decisions for actually when to get that vaccine jab are not as carefully considered by most medical clinicians including pharmacists. I did get a bit wiped out from the booster vaccine, but my buddy joined me to keep me company.

 

 

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The Best News Between Chemo Cycles:
On 8/27, Robin and I had a planned trip to New York City to visit our daughter Sarah, son-in-law Andrew, and sweet little Silbie on Robin’s birthday 8/27. Sarah was due with a baby mid-September. As luck would have it, Sarah and Andrew made their way to the hospital and sweet little Emily was born on 8/28; we missed matching Robin as a birthday twin but BONUS, 8/28 is national bow tie day, #BowTiesThatBind, as pointed out by Sarah.

 

 

Life and Death are Not Predictable!
On 8/23, my dear friend and colleague Dr. Jennifer Lutz Hebner was hit by a truck in our town while out for her routine run. Thankfully she survived with relatively minimal injury to her head. But this could have gone very differently, like a cerebral hemorrhage resulting in stroke or death with a 12-year old daughter and husband at home to deal with such a horrible outcome. But, as I said, Jen is just fine and required 9 staples to her head. More on the hit and run HERE. Bottom Line: Life is not predictable, but enjoying each day and advanced preparation for both are comforting and predictable.

Mike H, thank you for sharing this from America’s Got Talent>>> “You can’t wait until life isn’t hard anymore to be happy”, Nightbirde. I loved this.

What about Smokey the bear – did I forget that? Maybe there is a message here from my sister Debbie. If you’re diagnosed with terminal disease, remember that from the time we are born, we are all terminal. Some people are more terminal than others. If you are served up lemons in the form of cancer, please don’t choose to walk away from the burning forest and cower in a corner sulking about your misfortune as your life is engulfed in flames. Instead, embrace your friends and family (Silbie with newborn Emily on left) who are the firefighting heroes in controlling those flames doused in lemonade. YOU READERS ARE MY HEROES, and for that I am eternally grateful. Please help me keep that fire at bay so I can enjoy new life with two more new grandchildren within 5 months.

Love to all until next post!

As always, comments are welcomed with enthusiasm!