Dr. Keith Roach

DEAR DR. ROACH: What can you tell me about a prescription of 145 mcg of Linzess, and why a doctor would prescribe a pill over $500? What are the advantages to taking this? Surely, there must be something less expensive that will provide the same results. — J.P.
ANSWER: Linaclotide (Linzess or Constella) is a medicine used for constipation, either in people with irritable bowel syndrome or in people with constipation for no particular reason. It works by activating a protein to allow chloride and bicarbonate (along with fluid) into the intestine. Since it is not absorbed into the body, it has few side effects. The major side effect is that it can work too well and cause diarrhea. This is enough of a concern that the medicine is not used in children under the age of 2. There are three different strengths: 72, 145 and 290 mcg.
If you are asking me to defend pharmaceutical pricing, I can’t do that. I very seldom use this medicine because there are so many other options for constipation — starting with a different diet without using any medicine at all. But in people with occasional constipation despite having a good diet, I will usually start with fiber supplements. If those don’t work, I recommend a surfactant such as docusate (Colace), which allows more water to enter the stool. Yet another option would be nonabsorbable substances like polyethylene glycol (MiraLAX and others), lactulose, sorbitol and magnesium. All of these are much less expensive.
However, there are still people who don’t do well with any of these less-expensive (and also tried-and-true) alternatives. Linzess has made a real difference in the lives of several of my patients. It is usually prescribed by an expert — a gastroenterologist — at least in the case of my patients.
Finally, Linzess is roughly $20 a pill, or about $500 for a month’s supply, in the U.S. without insurance. Some people only need it occasionally and are very willing to pay, even if insurance doesn’t cover it.
DEAR DR. ROACH: The other day when we were changing our bedsheets, my husband asked me if I knew why the sheets and pillowcases on his side of the bed were stained yellow and the ones on my side weren’t. My only thought was that he has a very strong body odor. My high school biology classes came back to me, and I remembered that our sense of smell is a lock-and-key mechanism where odor comes from a tiny particle that locks into the sensors within our olfactory system. So, I thought that the particles might be staining the bedding. Could this be so? — J.M.
ANSWER: Chromhidrosis is the name for colored sweat, and it isn’t uncommon. Both men and women can have chromhidrosis. There are several possible causes. One is that the sweat glands themselves can excrete a colored substance, such as lipofuscin, which often causes a yellow discoloration. I admire your using high school biology, but I don’t think you are right in this case. The odor in sweat comes from bacteria that live in and around the sweat glands. The bacteria themselves rarely cause discoloration, but yellow isn’t typical for bacteria.
Occasionally, medicines can cause sweat to turn a different color. The laxative bisacodyl (Dulcolax and others) can cause people to have yellow sweat. Some antiperspirants will cause sweat to have a yellow color.
Since it’s both the sheets and pillowcases, I suspect that it’s lipofuscin in this case. Treatment may not be necessary, but capsaicin cream (0.025%) has proven effective, although the mechanism behind how it works is unknown.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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