Elixir of willow bark, cow pancreas, viper venom and moldy plants all sound like the ingredients of an ancient medicine pouch. Actually, they are the beginnings of a list of modern medications founded on lore, luck and hard work.

Carefully stir in explosives and a few Nobel Prize winners and you have an interesting mix of history for today’s commonly used medicines.

Many are old but have been made new by medical advancements. Others exist much as they did when discovered.

Penicillin, unattended mold
Tops on the list of “tried and true” medications is penicillin, the first antibiotic. Discovered quite by accident, the 1928 Nobel Prize-winning discovery came to light when a mold began growing on another experiment, killing it.

Although today’s antibiotics cure common infections that once killed our ancestors, the danger is not necessarily over. Scientists have had to keep pace with virulent strains of bacteria that grow resistant to some antibiotics.

But nature comes full circle.

“Bacteria are constantly evolving resistance to the antibiotics that are used most frequently, so penicillin and other less-utilized antibiotics sometimes become the best method of treatment,” says Lisa Cutrell, Pharm.D., a pharmacist at FirstHealth Richmond Memorial Hospital.

“Oh, my aching joints, head, muscles … ”
While penicillin can actually cure many infections, other tried and true medications make the list for their ability to relieve symptoms of discomfort.

Nitrous oxide: The modern anesthetic also known as “laughing gas” made its way into medicine about 160 years ago. A dentist attending a circus-type sideshow featuring the gas realized its painkilling potential and soon introduced it to the medical community.

It was a welcome option then to highly flammable ether, and today still makes dental patients giggle during otherwise not-so-funny tooth extractions.

NSAIDs: Millions of people, including the 40 percent of North Carolinians over age 50 with arthritis, appreciate the pain relief provided by a very large family of drugs called Non-Steroidal Anti-Inflammatory Drugs (NSAIDs).

Aspirin is the most well-known NSAID, and also the oldest—by centuries. The same pain-reducing ingredients found hundreds of years ago in willow bark produces other amazing benefits that are still being discovered today. (See the accompanying story here)

Dozens of other NSAIDs, including ibuprofen (Motrin), offer an abundance of choices to treat inflammation, fever and moderate pain caused by headaches, injuries and menstrual cramps.

“Each NSAID has its own pros and cons that are often person-specific, so depend on your doctor or pharmacist to sort through the options,” says John Walker, R.Ph., director of Pharmacy at FirstHealth Montgomery Memorial. “And always take the lowest effective dose that controls symptoms.”

Other over-the-counter analgesics
A major problem with all NSAIDs is the risk for bleeding and stomach ulcers. Luckily, other analgesics, or pain-relievers, provide the same pain and fever relief without these side effects.

Acetaminophen is the oldest example of non-NSAID analgesics. Fifty years ago, an American pharmacist was the first to identify and market its benefits widely under the still-familiar name Tylenol.

Acetaminophen works by raising the bar for how much pain we can stand and goes straight to the brain’s “hot spot,” what doctors call the heat-regulating center, to reduce fever.

Don’t depend on them to reduce inflammation or swelling, but they do not usually cause bleeding, ulcers and other side effects more common with NSAIDs.

Narcotic analgesics
First used in medicine by the Greeks before 200 B.C., narcotics such as morphine and other opium-like drugs are now a mainstay in the arsenal of pain medications.

“Morphine remains the gold standard for analgesics,” says Benny Morse, Pharm. D., a pharmacist at FirstHealth Richmond Memorial Hospital. “That’s what you compare everything else to for pain relief.”

When pain is really bad, millions of people depend on narcotics, including morphine, codeine, methadone and Demerol. As a matter of fact, narcotic+acetaminophen combinations (such as Vicodin and others) topped 102 million prescriptions last year alone, making it the most commonly prescribed medication in the United States. Patients should be cautious about acetaminophen that contains analgesics when taking them with other over-the-counter medications containing acetaminophen,
and the potential for overdose should be a consideration.

Old standbys for common diseases
With heart disease being the number one killer nationwide and diabetes a significant concern in North Carolina, medications that tackle these ills get attention.

Diuretics: Used for fluid retention since the 1500s, diuretics, also known as “water pills,” have long been a drug of choice for the treatment of heart disease, high blood pressure, asthma and kidney problems.

New formulations in the 1950s made them safer than ever, and recent studies have proven their worth for lowering blood pressure and preventing heart failure and stroke. They’ve even beaten out newer medications that cost 10 times more. (See information on ACE inhibitors on page 42.)

Not clear is exactly how the drug lowers blood pressure, but, understandably, diuretics are among the most commonly prescribed drugs in the United States today.

Nitroglycerin: “Nitroglycerin is a very old agent that is famous for acting immediately to reduce chest pain, or angina,” says Jason Joyce, Pharm.D., director of Pharmacy at Richmond Memorial Hospital.

Approved by the FDA in 1938, nitroglycerin has medicinal benefits that were actually discovered by accident almost adecade prior when men at a Swedish dynamite factory realized their chest pains subsided at work.

Nitroglycerin—yes, the same basic ingredient of explosives—dilates blood vessels and allows sufficient blood to reach the heart. And don’t worry: Pain relief won’t come at the expense of an explosion. The medication is inert and harmless, although the factory owner later refused to use it for his own heart pains.

In an ironic twist to the nitro story, scientists who helped shed light on the nitro-chest pain connection were awarded the Nobel Prize for medicine just a decade ago. Why is that ironic? It was namesake Alfred Nobel who owned that dynamite factory in Sweden.

Warfarin: The 1.5 million people who take warfarin (Coumadin) every day in the United States might owe their lives to another interesting connection, this one between a booming Wisconsin dairy industry and sweet clover.

In the 1940s, dairy farmers looking for richer feed for their growing herds settled on sweet clover. The problem was that moist clover rotted quickly, forming a blood-thinning mold that actually caused cows to hemorrhage to death.

Warfarin offers two important properties: It prevents blood clots from forming and keeps existing clots from causing damage to the heart, lungs and brain. Today, it’s the most-prescribed blood thinner.

ACE inhibitors: Originally derived from the snake venom of a poisonous Brazilian viper, ACE inhibitors have become a standard for lowering blood pressure and treating heart failure.

The drug works on a naturally occurring enzyme (Angiotensin-Converting Enzyme) that causes blood vessels to contract. By stopping, or inhibiting, the vessels from contracting, ACE inhibitors help keep blood pressure lower.

Insulin & long life: Severe diabetics born before the 1920s were almost surely destined for poor health and early death. From early studies of dogs and then to the first patient’s injection of insulin— made from the pancreas of slaughterhouse cows—scientists have made this life-saving treatment available to the world.

Insulin also became the first human protein to be cloned.

“Insulin has an amazing story, from its beginning to ongoing studies to adapting it for more effective and convenient treatment,” says Joyce.

Although diabetes is still a serious disease that requires vigilance and dedication to good health, today’s availability of insulin means longer life for those who have access to it.

A pound of cure; prevention saves thousands
Calcium is the fifth most abundant element in the human body, found in bones, in teeth and even in the heart, nerves and muscles. Obviously, we need it.

Although the forerunners of calcium supplements appeared as early as 1929, the normal activities of daily living, like lifting, walking and other “weight-bearing” exercises, were enough to maintain strong bones. Decades ago, calcium supplements were essentially unnecessary.

“Today, calcium supplementation is a very important part of preventive therapy due to dietary changes and sedentary lifestyles,” says Cutrell.

Without calcium supplements, the 1.27 million people in North Carolina with low bone mass and osteoporosis might experience greater problems with height loss, stooped posture, back pain and fractures that can be life-threatening.

So eat your rhubarb pie, with molasses and a glass of milk. All are high in calcium. Talk with your doctor, and find a supplement if you need one.

Vaccinations
Is the community swimming hole or the local movie theater a danger zone? They were in the 1950s, when highly contagious polio killed or paralyzed thousands of people each year. Another disease, measles, kept people indoors when it attacked almost half a million people in the Americas during one outbreak. Vaccinations, however, have made it safe to come out to play.

Measles cases, for example, went down to about 40 last year, and polio has all but been eradicated in the United States, where inoculation levels are high.

Global travel makes vaccines especially important today. As a case in point, one un-vaccinated and infected tourist overseas caused a 2003 measles outbreak that affected 700 people and killed three. And there were 1,200 cases of polio in other countries last year.

For public health officials, “community immunity” is the mantra. The more people who are vaccinated, the more protection there is for infants and others who cannot be vaccinated.

Whooping cough (pertussis) is at a 50-year high in the United States. Immunizations for it as well as for measles, smallpox, rubella, tetanus and chickenpox are all part of standard childhood vaccinations in the United States.

Yearly flu and pneumonia vaccines protect all ages, beginning at age 6 months.

Tetanus immunizations work for 10 years to ward off dangers from the often-fatal toxins found in regular dirt. Re-immunize every decade.

The FDA process: From the medical lab to the medicine cabinet “With any medication, you need to understand what it can do, what the risks are, and how much relief it can offer,” says Benny Morse, Pharm.D., a pharmacist at FirstHealth Richmond Memorial Hospital. Ensuring that drugs are safe and effective is precisely the role of the U.S. Food and Drug Administration (FDA), but the agency’s work doesn’t lack controversy. Some critics say drugs are released without thorough research—and with sometimes deadly consequences. Others claim people die when new treatments are held up in the development and approval process, which takes about eight and one-half years in the United States. And yet others say no country offers a better drug approval process.

Benny Morse, Pharm.D.

Other countries face similar criticism. Canada’s review process is less stringent but more lengthy, according to one expert in that country. Europe “has lagged a long way behind the U.S.” in getting life-saving cancer drugs into the marketplace, according to a medical journal there. Pricing and reimbursement issues have also kept drugs in limbo in Canada. In its own balancing act to ensure that drugs are safe and do no harm, the FDA uses an extensive drug approval process. Costly and time-consuming For one drug alone, drug makers in the United States hire hundreds of staff to test 100,000 or more ingredients. And there’s no promise of success. “This is one reason medications cost so much,” says Jason Joyce, Pharm.D., director of Pharmacy at Richmond Memorial. Then comes weeks or years of animal testing, followed by a series of complex clinical trials on thousands of human volunteers. Safety, effectiveness and side effects are evaluated at each level of testing. The final step is New Drug Application review. If a drug checks out for safety and effectiveness for specific uses, the manufacturer begins production. Know your meds No matter how much testing is done, every drug has a risk. And not every drug is good for every patient. “A tried and true drug might be a better—and cheaper—option, or a new one might have additional benefits that actually help the patient in more ways than one,” says Lisa Cutrell, Pharm.D., a pharmacist at Richmond Memorial. The bottom line? “Do research for yourself, and talk to your doctor or pharmacist and know what to expect from your medication regimen,” says Cutrell.