Listerine Lauded as Fungus Fighter

Q. I have a PhD in mycology [study of fungi] and probably picked up my toenail fungus on a research visit to the tropics. I heard a physician on one of your radio shows note that Listerine was used to eliminate the fungus.

Since I understand fungi pretty well, that made sense. I used a less expensive Listerine equivalent and soaked my infected toe for 10 minutes once a day. I did this for only three weeks but within a month my toenail gradually started to grow out healthy.

I have begun this procedure again for a different toenail that is more severely affected. I will probably try to do this daily for six weeks. I can't believe my doctor wanted me to take a pill with dangerous side effects! I know he doesn't understand fungi and I do.

A. Old-fashioned amber Listerine contains alcohol and herbal oils that appear to have antifungal activity. Others have reported success with this and other foot treatments (cornmeal, vinegar, peroxide, Vicks VapoRub and oregano oil) for fighting nail fungus. We are sending you our Guide to Hair and Nail Care with details about these and other fungus fighters.

Another reader wrote: "My doctor will not prescribe any pills for fungus. He says they're too expensive, take too long and have bad side effects. Plus the fungus frequently comes back even with such medicine.

"The treatment that blew me away (and I don't have a clue why it works, but it does) is the one using cornmeal in tepid water

OTC Painrelievers Work for Migraine

Migraine sufferers often rely on prescription medicines for relief, but a couple of new studies suggest that some of the 28 million Americans who get migraines might be able to use over-the-counter pills. Thai researchers analyzed data from four previous studies using the nonprescription NSAID naproxen. The drug reduced headache intensity and other symptoms within two hours, which counts as a desirable outcome. It was as effective as the prescription migraine medicine frovatriptan.

In other research, almost 400 migraineurs took either 1000 milligrams of Tylenol or an inactive placebo. 52 percent of those taking acetaminophen reported relief after two hours, compared to 32 percent of those on the dummy pill. With prescription drug prices rising, many people welcome OTC medicines to cut short a nasty migraine headache.

[Headache, March, 2010]

Vitamin D and the Brain

Does vitamin D protect the aging brain? Researchers from both France and the U.S. presented data suggesting that there may be a link between vitamin D deficiency and an increased risk of cognitive decline. One study tested 150 Americans with an average age of 85. They were given tests of mental function and their blood was analyzed for its level of vitamin D. People with lower blood levels of vitamin D were more likely to score low on the cognitive tests.

A different study of 129 elderly French women found that those who were deficient in vitamin D were about twice as likely to fail the cognitive test and be classified with cognitive impairment. Vitamin D continues to capture headlines for its crucial role in a wide range of biological systems, including bones, cancer, muscles, blood vessels and possibly the brain.

[American Academy of Neurology annual meeting, Toronto, April, 2010]

Categories:

• Health News

When Will Doctors Pay Attention to an ACE Cough?

We are dumbfounded! No one gets out of medical school without learning about a class of blood pressure medications called ACEi (angiotensin converting enzyme inhibitors). These are among the most commonly prescribed drugs in the pharmacy. We estimate that roughly 100 million prescriptions are filled each ear for drugs like:

Captopril (Capoten)
Benazepril (Lotensin)
Enalapril (Vasotec)
Fosinopril (Monopril)
Lisinopril (Prinivil, Zestril)
Moexipril (Univasc)
Perindopril (Aceon)
Quinapril (Accupril)
Ramipril (Altace)
Trandolapril (Mavik)

Lisinopril, for some reason, has captured physicians' fancy. It dominates all other ACE inhibitors by a wide margin, grabbing 70,000,000 prescription annually. To give you some sense of comparison, the best selling brand name drug in America is Lipitor. At last count, it was "only" dispensed about 50 million times. That is probably why we get so many comments about lisinopril and its major complication.

One of the most common side effects of all these medications is a cough (Annals of Internal Medicine, Jan. 1, 2008; Chest [suppl], Jan, 2006). The medical literature confirms that from 5 to 35 percent of patients will develop a nasty cough while taking an ACEi. And that may be a low estimate. And after stopping an ACEi it may take anywhere from 4 weeks to 3 months for the cough to finally disappear. No amount of cough medicine can quell this kind of cough. The only solution is usually to change to a completely different kind of blood pressure medication. Going from lisinopril to ramipril won't solve the problem!

This is not rocket science, folks. This is as basic as it gets. We continue to be astonished that so many people have posted to this Web site that their physicians have not acknowledged that their cough is caused by an ACE inhibitor like lisinopril. That is like banging your thumb with a hammer and not realizing why it hurts and why the nail turns black.

The most recent comment comes from Ann. We share her story with you just so you will understand that we couldn't make this stuff up if we tried. What really worries us, though, is that if some physicians can't seem to connect the dots when it comes to lisinopril and cough, what other drug-induced side effects are they missing? To read other comments on this ACEi cough, click here.

Paranoia over Eggs Was Misplaced

Q. I gave up eating eggs years ago due to high cholesterol. I have only been eating egg substitutes. I recently heard that eating eggs doesn't really raise cholesterol. If this is true, I would love to go back to eating real eggs again.

A. For decades dietary dogma has kept many people from eating eggs. Because egg yolks are rich in cholesterol, some scientists assumed that eating whole eggs would raise blood cholesterol and increase the risk for heart disease. This assumption was accepted without evidence.

When investigators looked at the data, they found that eating up to one egg daily had little impact on stroke or heart disease risk (Journal of the American Medical Association, Apr. 21, 1999). There is even an experiment showing that egg consumption is linked to higher levels of good HDL cholesterol and markers of improved retinal health in the eye (American Journal of Clinical Nutrition, Nov. 2009).
You can learn more about eggs, cholesterol and dietary approaches to reducing heart disease and high blood pressure in our book Favorite Foods: Mother Nature's Medicine.

People vary in their response to eggs, so it is important to monitor blood lipid levels. Those with diabetes should exercise particular caution, since studies suggest eggs do raise their risk for heart disease

Sugar as Cholesterol Culprit

Eating sugar raises heart disease risk factors such as cholesterol and triglycerides. For years, Americans were admonished to avoid cholesterol and saturated fat to control blood lipids. Sugary snacks didn't seem to be a threat. Now, research published in the Journal of the American Medical Association shows that caloric sweeteners such as sugar and high fructose corn syrup can have a significant negative impact on LDL cholesterol, HDL cholesterol and triglycerides. Over 6,000 adults filled out dietary questionnaires and had blood drawn. Those who consumed the greatest percentage of calories from added sugars were most likely to have low levels of good HDL cholesterol. They also had higher triglyceride levels, which is an independent risk factor for heart disease. Perhaps it's time for Americans to start paying more attention to refined carbohydrates as a heart health risk.

[JAMA, April 21, 2010]

Understanding Radiation Risks

Q. I have seen some reports linking CT scans and cancer. This news has really bothered me since I've had a couple that I really didn't think I needed.

What is your perspective on it? What can be done to avoid unnecessary radiation?

A. CT scans are useful for diagnosing hidden problems, but they can entail a lot of radiation (about equivalent to as many as 400 x-rays). That is why overuse may increase the risk of cancer.

The best approach is for each patient to ask questions when a CT scan is recommended. People need to understand if it is necessary and how it will change the treatment pl

Asthma

It seems that asthma is both more common and more dangerous in the 21st century than at the turn of the 20th century. Asthma is now the most common chronic ailment among children in the United States, and the prevalence of the disease has been increasing rapidly.

Scientists know a great deal more about airway inflammation and doctors have many more drugs than can ease the symptoms. Why are people still dying of this disease?

Learn about the risks of one type of asthma drugs, long-acting beta-agonists (LABAs) and why one expert suggests they should be avoided. Find out the best options for treating asthma in both children and adults.

Guests: David Peden, MD, MS, is Director of the Center for Environmental Medicine, Asthma and Lung Biology. He is also chief of the Division of Allergy, Immunology and Environmental Medicine and Professor of Pediatrics in the School of Medicine of the University of North Carolina at Chapel Hill. The photo is of Dr. Peden.

Shelley Salpeter, MD, FACP, is Clinical Professor of Medicine at Stanford University School of Medicine and Director of Medical Consultation at Santa Clara Valley Medical Center in San Jose, CA. Her article appears in the April 2010 issue of The American Journal of Medicine.

Sally Seymour, MD, is Deputy Director of the Division of Pulmonary, Allergy and Rheumatology Products in the FDA's Center for Drug Evaluation and Research

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Should They Put Crestor in your Water?

Nobody's neutral when it comes to the cholesterol-lowering drugs known as statins.
Some doctors are so enthusiastic about these powerful medications that they would almost consider putting them in salt shakers or tap water.

Some patients who have experienced severe side effects believe they should be banned.
This controversy is likely to heat up with FDA's recent approval of Crestor for healthy people who don't have high cholesterol.

The idea that millions of people should be swallowing a pill every day even if they have normal cholesterol stems from a clinical trial called JUPITER sponsored by AstraZeneca, the manufacturer of Crestor. This very large experiment was done with 17,802 healthy men and women. They had levels of bad LDL cholesterol less than 130, which would be considered acceptable by many physicians. To qualify for the clinical trial, however, the subjects had high blood levels of C-reactive protein (CRP), a marker for inflammation in the body.

The trial was stopped early, after just two years of follow-up on average, because the results seemed so impressive: the relative risk of heart attack and stroke was reduced roughly in half (New England Journal of Medicine, Nov. 20, 2008).

That certainly sounds great. And it is easy to understand why many cardiologists have become such enthusiasts of statin-type drugs. The problem with such statistics is that they are easily misinterpreted. Many people assume that a relative risk reduction of 50 percent means that 50 people out of 100 treated would be spared a heart attack. That is far from true.

Over the course of almost two years, 31 people out of 8,901 on Crestor had a heart attack. Of the 8,901 people on placebo, 68 suffered a heart attack. That means thousands of people had to take Crestor so that 37 would be spared a heart attack.

Think of it this way. People taking Crestor suffered blood clots at a rate of 1.8 per 1000 people per year (New England Journal of Medicine, online March 29, 2009). Those on placebo had blood clots at a rate of 3.2 per thousand people per year. This works out to a relative risk reduction of 43 percent, but in real life healthy people have a low likelihood of suffering a blood clot, a heart attack or a stroke.

Is it really worthwhile for so many people to take a pricey pill that could cause side effects to make a low risk even lower? The FDA approved Crestor to lessen the possibility of heart attack and stroke among men at least 50 and women at least 60 years old with high CRP and at least one other classic risk factor: smoking, high blood pressure, low levels of good HDL cholesterol or a family history of heart disease.

Before you accept a prescription for prevention, make sure you actually fit those criteria. Crestor, like all statins, has risks. Muscle pain and weakness, joint pain and constipation affect quality of life. The manufacturer has also warned that Crestor may raise the chance of developing type 2 diabetes. For more information about the pros and cons of statins see our Guide to Heart Health and Cholesterol at www.peoplespharmacy.com.

Once you know both the benefits and risks of such medicine you will be better prepared to discuss them with your physician.

The Great Prostate Mistake

By RICHARD J. ABLIN

Published: March 9, 2010

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Times Topics: Prostate Gland

EACH year some 30 million American men undergo testing for prostate-specific antigen, an enzyme made by the prostate. Approved by the Food and Drug Administration in 1994, the P.S.A. test is the most commonly used tool for detecting prostate cancer.

The test’s popularity has led to a hugely expensive public health disaster. It’s an issue I am painfully familiar with — I discovered P.S.A. in 1970. As Congress searches for ways to cut costs in our health care system, a significant savings could come from changing the way the antigen is used to screen for prostate cancer.

Americans spend an enormous amount testing for prostate cancer. The annual bill for P.S.A. screening is at least $3 billion, with much of it paid for by Medicare and the Veterans Administration.

Prostate cancer may get a lot of press, but consider the numbers: American men have a 16 percent lifetime chance of receiving a diagnosis of prostate cancer, but only a 3 percent chance of dying from it. That’s because the majority of prostate cancers grow slowly. In other words, men lucky enough to reach old age are much more likely to die with prostate cancer than to die of it.

Even then, the test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t.

Instead, the test simply reveals how much of the prostate antigen a man has in his blood. Infections, over-the-counter drugs like ibuprofen, and benign swelling of the prostate can all elevate a man’s P.S.A. levels, but none of these factors signals cancer. Men with low readings might still harbor dangerous cancers, while those with high readings might be completely healthy.

In approving the procedure, the Food and Drug Administration relied heavily on a study that showed testing could detect 3.8 percent of prostate cancers, which was a better rate than the standard method, a digital rectal exam.

Still, 3.8 percent is a small number. Nevertheless, especially in the early days of screening, men with a reading over four nanograms per milliliter were sent for painful prostate biopsies. If the biopsy showed any signs of cancer, the patient was almost always pushed into surgery, intensive radiation or other damaging treatments.

The medical community is slowly turning against P.S.A. screening. Last year, The New England Journal of Medicine published results from the two largest studies of the screening procedure, one in Europe and one in the United States. The results from the American study show that over a period of 7 to 10 years, screening did not reduce the death rate in men 55 and over.

The European study showed a small decline in death rates, but also found that 48 men would need to be treated to save one life. That’s 47 men who, in all likelihood, can no longer function sexually or stay out of the bathroom for long.

Numerous early screening proponents, including Thomas Stamey, a well-known Stanford University urologist, have come out against routine testing; last month, the American Cancer Society urged more caution in using the test. The American College of Preventive Medicine also concluded that there was insufficient evidence to recommend routine screening.

So why is it still used? Because drug companies continue peddling the tests and advocacy groups push “prostate cancer awareness” by encouraging men to get screened. Shamefully, the American Urological Association still recommends screening, while the National Cancer Institute is vague on the issue, stating that the evidence is unclear.

The federal panel empowered to evaluate cancer screening tests, the Preventive Services Task Force, recently recommended against P.S.A. screening for men aged 75 or older. But the group has still not made a recommendation either way for younger men.

Prostate-specific antigen testing does have a place. After treatment for prostate cancer, for instance, a rapidly rising score indicates a return of the disease. And men with a family history of prostate cancer should probably get tested regularly. If their score starts skyrocketing, it could mean cancer.

But these uses are limited. Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit.

I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.

Richard J. Ablin is a research professor of immunobiology and pathology at the University of Arizona College of Medicine and the president of the Robert Benjamin Ablin Foundation for Cancer Research.

Surviving Prostate Cancer

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Bonus Interview: listen to an additional interview with our guesthere if you cannot view audio player: AbilinPSAMp3.mp3

Prostate cancer poses a particular puzzle for men and their physicians. It is an extremely common malignancy, with most men having some cancerous cells in their prostate glands by the time they reach old age. But there is no single "right" way to treat prostate cancer.

Victoria Hallerman and her husband Dean share the story of how they faced his prostate cancer diagnosis. They drew lessons from their experience about how a couple could approach this situation differently. A urologist shares his insight on the variety of treatments available for prostate cancer and how a couple might choose the most appropriate one.

Guests: Victoria Hallerman is the author of How We Survived Prostate Cancer: What We Did and What We Should Have Done. It's the story of how she and her husband Dean faced his cancer diagnosis and treatment. They are both active in Man to Man, the national prostate cancer support network. Victoria helped found a support group for partners of prostate cancer patients and survivors called What About Me? The photo is of Victoria Hallerman. Her Web site is www.victoriahallerman.com/

Mark McClure, MD, is a urologist in Raleigh, NC. He is interested in both conventional and complementary medicine. His Web site is landmarkurologycare.com/

Richard J. Ablin, PhD, is President of the Robert Benjamin Ablin Foundation for Cancer Research and Research Professor in the Departments of Immunobiology and Pathology at the University of Arizona College of Medicine. Listen to him explain the use and misuse of PSA in the bonus interview. His article appeared in The New York Times

New Use for Thalidomide

One of the most reviled drugs in history continues to find new uses. Thalidomide was initially prescribed as a sedative to pregnant women. In the 1950s thousands of European children were born with deformed limbs because of exposure to this drug in utero. Late in the 1990s the FDA approved thalidomide to treat a complication of leprosy, but it soon gained extraordinary success in treating the blood cancer multiple myeloma.

Now researchers report that thalidomide may also be beneficial in treating hereditary hemorrhagic telangiectasia or HHT. In this condition, there are small malformations in the little blood vessels that supply the skin and lining of body cavities. People with HHT often suffer recurrent nosebleeds that are extremely difficult to control. They may also suffer internal bleeding that can be very serious. If thalidomide proves as effective in humans as it has in a mouse model, it will be a real boon to people with this inherited condition. Other conditions for which thalidomide is being studied include macular degeneration, inflammatory bowel disease, rheumatoid arthritis and lupus.

[Nature Medicine, online April 4, 2010]

Are Your Pills Legit?

When you think about big heists, what comes to mind? Diamonds? Cash stolen from an armored car? Perhaps a priceless painting from a museum?

Prescription drugs turn out to be a growing target for thieves. It's hard to imagine that a case of pills could be worth more than a wide screen TV, but some medications cost more than gold, ounce for ounce.

Because of the way medicines are distributed in this country, it is surprisingly easy to get stolen goods back into the supply chain. Consider a recent break-in at an Eli Lilly warehouse in Enfield, CT.

Thieves drove off with $75 million worth of prescription pills for depression and schizophrenia. The medications included Cymbalta, Prozac and Zyprexa.
This isn't the first time crooks have snatched pharmaceuticals. Last year a parked truck containing insulin was left unattended briefly. Over 100,000 vials were stolen and very few were recovered.

No one gets high on insulin. This is not the sort of drug you sell on the streets. But because of lax supervision by state and federal agencies, such drugs can be sold back into the legitimate drug pipeline.

Some of the stolen insulin was dispensed to diabetics. Because the stolen vials had not been stored under refrigeration, some patients experienced problems with blood sugar control.
Pharmaceuticals can pass through many hands before reaching the drugstore or hospital. A medical center might buy a large lot of antibiotics or heartburn medicine at a great price. They may use some but sell what they don't need to a wholesaler.

That wholesaler may in turn sell portions to various other hospitals, nursing homes, pharmacies or repackagers. With so many people involved and minimal regulation, it becomes possible for stolen or even counterfeit drugs to get back into the market where patients might receive them. Katherine Eban documented this boondoggle in detail in her book, Dangerous Doses.

An article in The Scientist (Feb., 2010) revealed that a Chinese businessman was prepared to sell counterfeit Zyprexa (one of the drugs stolen from the Lilly warehouse), Plavix, Aricept and Cialis to the U.S. market.

He told his contact that he would ship pills from China through South Africa and Brazil so that they would seem less suspicious. In this case, the counterfeiter was caught, but no one knows how many others are operating undetected.

Neither the FDA nor state regulators have the resources to monitor the pharmaceutical supply chain adequately. The FDA advises consumers not to buy prescriptions online but rather to purchase only from state-licensed pharmacies. Unfortunately, this advice, while good, is not quite a guarantee. Even licensed pharmacies might inadvertently purchase counterfeits or poorly stored stolen products from a wholesaler.

What is needed is much stronger documentation of the entire supply chain from factory to pharmacy. The FDA has issued regulations that would require Radio-Frequency Identification (RFID) tracking. This allows for quick authentication that products are what they claim.

We would like to see track-and-trace technology implemented for generic drugs as well as brand name products. This would add a bit to the cost, but should make our medicines much more secure.

Three Strikes Against Antidepressants

At the turn of the 20th century, buying medicine was a risky business. Medicine shows traveled the country, entertaining crowds and hawking pills and potions of dubious origins, known as "patent medicines." Even the medicines sold in apothecary shops had not been shown to work well or be safe.

The establishment of the Food and Drug Administration and the development of its standards in the course of the 20th century were supposed to put an end to that kind of uncertainty. Now, Americans justifiably believe that their medicines should be safe and effective. In fact, the law calls for the FDA to determine that before it approves any new drug.

How well does this work? A new analysis suggests that modern antidepressants are no better than inactive placebo pills for alleviating mild to moderate depression (Journal of the American Medical Association, Jan. 6, 2010). Yet over 100 million prescriptions are written each year for drugs to ease the blues.

According to the meta-analysis published in JAMA, people with severe depression clearly benefit more from antidepressants than from placebo. The authors conclude, "...efforts should be made to clarify to clinicians and prospective patients that whereas ADM [antidepressant medication] can have a substantial effect with more severe depressions, there is little evidence to suggest that they produce specific pharmacological benefit for the majority of patients with less severe acute depressions."

Popular antidepressants like Effexor, Lexapro, Paxil or Prozac can cause side effects, however, even in people who may not be getting significant benefit. Moreover, some of these medicines can be difficult to stop, producing withdrawal symptoms such as dizziness, nausea, sweating, chills, loss of appetite or sensations like an electrical shock.

This is not the first study to throw doubt on the value of antidepressants for mild or moderate depression. In 2008, Irving Kirsch, MD, and his colleagues reported that highly successful antidepressants such as Celexa, Effexor, Paxil, Prozac, Serzone and Zoloft hardly worked better than placebos in clinical trials (PLoS Medicine, Feb., 2008). The authors concluded, "the overall effect of new-generation antidepressant medications is below recommended criteria for clinical significance."

Even before that, a huge government-funded study (STAR*D) revealed that the effectiveness of antidepressant medications was disappointing (New England Journal of Medicine, March 23, 2006). Only one in four patients responded favorably to the first medication prescribed.

Some people really get great benefit from antidepressants. Those who are especially depressed seem to benefit the most.

For the vast majority of people with mild to moderate depression, non-drug approaches such as exercise, talking therapy or controlled light exposure may be helpful. You can learn more about a variety of approaches in our new Guide to Dealing with Depression.

Heart Breakthroughs Break Down

The history of treating blocked heart arteries is tale of two steps forward and one step back. People who suffer severe blockage in a coronary artery often experience chest pain or angina.

The original solution was coronary artery bypass graft or CABG. The trouble with bypass surgery, though, is that it involves opening the chest. This exposes the patient to all sorts of risks from the surgery itself as well as infection. Recovery can be arduous.

Enter balloon angioplasty in the late 1970s. Doctors threaded a long thin tube into the blocked artery and inflated a little balloon attached to its tip. This opened the artery, at least temporarily.

The problem with angioplasty was that frequently the benefit didn't last. Occasionally, the artery collapsed after the balloon was removed. Almost a third of the time the opened artery would clog up again.

A decade later cardiologists came up with an apparently elegant solution. Along with the balloon, they inserted a tiny metal mesh tube (stent) that acted as a scaffold to hold the artery open.

Stents seemed like a great idea until studies revealed that they too had a serious drawback. About a quarter of the patients getting stents still had trouble with the arteries closing up again. This restenosis was due to an immune reaction from the body trying to heal the injury caused by the bare metal. Smooth muscle tissue grew over the stent just as a scar grows over a wound.

Drug-coated stents were introduced in the U.S. in 2003. The metal mesh was coated with an immune-suppressing drug formulated to release the medicine gradually and prevent growth of tissue. It did the job beautifully, and many cardiologists heralded medicated stents as a breakthrough.

There was another unpredicted step backward, however. Since the immune-suppressing medicine was so effective at preventing tissue from growing over the stent, the metal mesh became a trigger for blood clot formation. Platelets (the sticky part of blood) clumped together to form a clot that could block the artery and cause a fatal heart attack.

The solution appeared to be long-term treatment with the anti-clotting drug Plavix, often with low-dose aspirin. Plavix has become the second most prescribed brand name drug in the country. Roughly three million people swallow a pink Plavix pill every day.

How well does Plavix work? In another step backwards, new research suggests that some people have a genetic quirk that makes them less likely to benefit from this anti-clotting medicine. An estimated two to four percent of Americans have two less-active copies of this gene. An additional 25 to 30 percent have a single copy, along with a copy that is more active.

That means that as many as a third of those taking Plavix might not be getting the full benefit of their pricey pink pill. In one study, these patients were at 50 percent greater risk of a heart attack or stroke (New England Journal of Medicine, Jan. 22, 2009).

Genetic tests are expensive and insurance companies are reluctant to pay for them. Consequently, doctors and patients often don't know if Plavix is working as intended.
Stents seemed like an ideal solution to severe heart disease. Now it looks like the story is far more complicated

Diagnostic Puzzles

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How do doctors figure out what is wrong with a patient? While some diagnoses are straightforward, others can be positively puzzling. Small details matter when the doctor has to act like Sherlock Holmes. Both the patient's story for the doctor and the doctor's story for the patient about what's wrong make a difference for diagnosis, treatment and healing.

Guest: Lisa Sanders, MD, is Clinical Instructor in Internal Medicine at Yale University School of Medicine. She writes the Diagnosis column for The New York Times Magazine. Her book is: Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis. Her Web site is www.LisaSandersMD.com

The podcast of this program will be available the Monday after the broadcast date. Podcasts can be downloaded for free for six weeks after the date of broadcast. After that time has passed, digital downloads are available for $2.99. CDs may be purchased at any time after broadcast for $9.99

A matter of mind sets? Religion and Science Part-2

In an Easter special with a difference, renowned philosopher AC Grayling asks: Do science and religion represent fundamentally different mind-sets—different ways of thinking about the world? From the stage of the recent Global Atheist Convention, he makes the provocative case that popular efforts to reconcile the two are misguided. Please follow the link and listen to the program and let me know what do you think.

http://mpegmedia.abc.net.au/rn/podcast/2010/04/aim_20100403.mp3

A matter of mind sets? Religion and Science Part-1

Do science and religion represent fundamentally different mind-sets? Physicist Richard Feynman said, 'Science is what we do to keep us from lying to ourselves'. From the Global Atheist Convention held in Australia this month, philosopher Peter Singer, biologist and popular science blogger PZ Myers, and evolutionary biologist Richard Dawkins weigh in on matters of minds and faith. Next week, renowned philosopher AC Grayling. Please follow the link and listen to the program and let me know what do you think.

http://mpegmedia.abc.net.au/rn/podcast/2010/03/aim_20100327.mp3

Allergic Reactions May Require Extra Epinephrine

Serious allergic reactions, called anaphylaxis, can be life-threatening and may require immediate emergency treatment with epinephrine. Children with food allergies are often given an EpiPen to carry with them at all times, so that a sudden attack can be treated.

Now research shows that effective treatment frequently requires two shots. A review of cases treated in two Boston hospitals show that 12 percent of the youngsters with severe food-induced anaphylactic reactions required more than a single dose. The foods most likely to trigger such a serious response included peanuts, tree nuts, milk, shellfish, fish, and eggs. The children's reactions often started with a rash and itching and proceeded quickly to swelling, nausea and vomiting and trouble swallowing and breathing. The investigators recommend that children with severe food allergies keep two EpiPens with them wherever they go.

[Pediatrics, April 2010]

Turmeric for Liver Health

The yellow spice in curry may someday help heal liver damage. The research was carried out in mice, so it is far too early to apply it to people. The results in mice were promising, though. Animals with chronic liver inflammation were fed diets with added curcumin, a compound in turmeric. After both four and eight weeks, the rodents had less bile duct blockage and less liver scarring. Although curcumin may not offer humans the same protection, adding a little turmeric to the diet is reasonable for most people. Those who are allergic to it and those taking the anticoagulant Coumadin should avoid turmeric, however.

[Gut, March 24, 2010]

Dark Chocolate to Help the Heart

Chocolate has once again been shown to be part of a healthy diet. More than 19,000 subjects were included in a 10-year-long study called EPIC, which stands for European Prospective Investigation into Cancer. German researchers found that the people who consumed more dark chocolate had lower risks of stroke or heart attack. Their blood pressure was also lower than that of those consuming the least chocolate.

Investigators think that these positive effects can be attributed to flavonoids in foods like cocoa, wine and many vegetables. These compounds help the body make more nitric oxide in the lining of blood vessels (through endothelial NO synthase, or eNOS) and this helps improve flexibility and lower blood pressure. The difference between the high chocolate and low chocolate consumers was small overall, only 6 grams a day. That means a piece of dark chocolate just a bit bigger than a postage stamp--enough to tickle the taste buds but not so much that it adds a lot of calories.

[European Heart Journal, March 30, 2010]

Words Help Babies Learn

How soon should parents begin talking to their babies? A new study suggests that speaking to infants as young as three months old helps them conceptualize categories, even though they cannot speak themselves. The research compared the effects of abstract sounds to spoken words in terms of 46 young babies' ability to recognize a related picture. Words were much more effective, suggesting that it is never too soon to start talking to and even reading to the baby.

[Child Development, online March 24, 2010]

Interactions May Have Deadly Results

Ask any sixth grader what 1+1 equals and you will be told the answer is 2. Ask a pharmacist, though, and you might get a different answer.

In the Alice-in-Wonderland world of pharmaceuticals, sometimes 1+1 equals 0 or even 3. That's because certain drugs may cancel out the benefits of other medicine or exaggerate their effects and cause toxicity.

Plavix offers a recent example. When people develop serious blockage in a coronary artery surgeons frequently insert a balloon catheter to widen the passageway. To keep it from closing later, they almost always insert a stent.

Although these little metal mesh tubes help keep heart arteries open, they too may sometimes get clogged. That is why there has been great interest in a newer generation of devices called drug-eluting stents. These tiny tubes are coated with an immune-suppressing medication that keeps tissue from growing around the metal.

While that seems like an improvement, it creates problems of its own. Bare metal is more likely to trigger a blood clot. And that's where Plavix comes in.

This medicine prevents life-threatening blood clots from forming in coronary arteries. There's not much room for error. Too much drug can lead to bleeding; too little can allow deadly clots to form.

One fairly common side effect of Plavix is digestive distress. Not surprisingly, doctors frequently prescribe the most popular heartburn medicines on the market. That includes Nexium (the "purple pill") and similar proton pump inhibitors (PPIs) such as Prevacid, Prilosec and Protonix.

There is a huge problem, however. When PPIs are combined with Plavix we may enter the zone where 1+1 don't always equal 2. More than 16,600 stent recipients were studied by Indiana University School of Medicine and Medco Health Solutions. The data show that patients given a PPI along with Plavix are 50 percent more likely to suffer a heart attack or a stroke than those taking Plavix alone.

This study is consistent with findings reported from the VA earlier this year (Journal of the American Medical Association, March 4, 2009). That study also found that people taking both Plavix and a PPI were more likely to die or suffer cardiovascular complications.

The scientists suspect that the heartburn drugs interfere with the effectiveness of Plavix. This is not the only drug combination that may result in reduced effectiveness.

People who take thyroid hormone (levothyroxine, Levoxyl, Synthroid) are warned not to take calcium supplements at the same time. Calcium can interfere with absorption of the hormone. Some antibiotics may also be less effective when taken with calcium in antacids, supplements or foods.

Other drug interactions may result in unexpected toxicity. This is especially true for medicines like digoxin (Lanoxin) or warfarin (Coumadin), which interact with dozens of other drugs. To learn more about the crazy and confusing mine field of drug interactions, readers may be interested in our book, Dangerous Drug Interactions. It is available in libraries, bookstores and online at www.peoplespharmacy.com.

Thousands of drug interactions pose potential hazards. When physicians and pharmacists are too busy to look up potential conflicts, patients will need to watch out for themselves

Asthma Drug (Xolair) Under Safety Review at FDA

The FDA has been scrutinizing the safety of a relatively new asthma medicine called Xolair (omalizumab). We would not normally issue a People's Pharmacy Alert at this early stage of the investigation, but a recent guest on The People's Pharmacy radio show was so enthusiastic about Xolair that we feel it necessary to temper her enthusiasm with some words of caution.

Xolair is a high-tech treatment that involves a shot every two to four weeks. It targets an antibody called IgE and according to our guest, really helps control moderate to severe asthma.

The trouble with some of these biotechnology treatments, though, is that you are meddling with Mother Nature. The new FDA "Communication on Safety of Xolair" warns about "adverse events involving the blood vessels of the heart or brain (cardiovascular or cerebrovascular events)." That sounds suspiciously like heart attacks and strokes.

Several weeks prior to this new communication the FDA warned about an increased risk of irregular heart rhythms, heart failure, blood clots and pulmonary hypertension in patients taking Xolair. These are all very serious, if not life-threatening, adverse reactions.

Other serious side effects associated with Xolair include upper respiratory tract infections (20%), sinusitis (16%), sore throat (11%) and headache (15%). There has also been a concern raised about a risk of cancer (breast, prostate and skin). Messing with Mother Nature sometimes has unexpected consequences. The powerful biotech TNF blocker arthritis drugs (Cimzia, Enbrel, Humira, Remicade and Simponi) now come with cancer warnings (lymphomas) in children and adolescents: http://tinyurl.com/lfhfds

The FDA is careful to recommend that patients "not stop taking Xolair without the advice of your health care professional." The People's Pharmacy would strongly suggest that anyone receiving Xolair injections have a heart-to-heart talk with the prescribing physician and make sure he or she has carefully considered the new FDA safety review about Xolair!

To see the FDA's latest MedWatch Safety Alerts for August, 2009 including "Male-Enhancement Products Marketed as Dietary Supplements, Stealth Chocolate Powdered Dietary Supplement and Early Communication on Safety of Xolair" go to:
http://tinyurl.com/lyjfqb

Should We Trust Tylenol?

When Tylenol was first introduced in 1955 it was a liquid prescription pain reliever and fever reducer for children. It wasn't until 1961 that Tylenol tablets were launched as over-the-counter pain pills for adults.

Tylenol and its active ingredient acetaminophen (APAP) was promoted as a safer alternative to aspirin. A prominent gastroenterologist, Dr. James Roth, had been traveling the country speaking about the dangers of aspirin for a number of years before McNeil introduced Tylenol. With an alternative analgesic that was less likely to cause stomach upset and bleeding, the company engaged Dr. Roth's services as a consultant.

From the beginning, then, Tylenol (and by implication acetaminophen) has been presented to the public as super safe. During the 1980s the company ran commercials emphasizing the phrase "trust Tylenol." One familiar refrain went, "Tylenol is the pain reliever hospitals use most. I can't think of a better reason to trust Tylenol."

In one commercial, the spokesperson was pictured as an aerobics instructor who took good care of herself by jogging and watching what she ate. She asserted that she was just as careful about her pain reliever, and implied that is why she chose Tylenol.

The ad campaign was extremely effective. More than twenty years later health professionals and patients alike often assume that acetaminophen is much safer than other pain relievers. That's primarily because it is less likely to irritate the digestive tract. To this day, most people don't think twice about possible hazards of nonprescription acetaminophen.

The FDA thinks that should change. This spring the agency determined that labeling for nonsteroidal anti-inflammatory drugs such as aspirin, ibuprofen or naproxen should be changed to highlight the risk of stomach bleeding from these pain relievers.

But acetaminophen won't get off without its own beefed-up warning. The FDA will require the labels of acetaminophen products to caution users about the risk of severe liver damage.

Although liver toxicity from high doses of acetaminophen has been recognized for decades, most Americans don't appreciate the severity of the problem. When drugs damage the liver, health is compromised. Once the injury begins, stopping the medication may not be enough to reverse the process. From 1998 through 2003, acetaminophen was implicated as the leading cause of acute liver failure in the U.S. (Hepatology, Dec. 2005).

The FDA is talking about reducing the maximum daily dose from 4,000 mg to 3,250 mg. People who regularly consume alcohol should probably take even less.

Unintentional overdose is not uncommon because acetaminophen is found in so many different kinds of products, from cough and cold remedies to nighttime sleep aids.

Readers who are feeling apprehensive about daily use of over-the-counter pain relievers for aching joints may find our Guide to Alternatives for Arthritis a welcome option. It contains a number of non-drug approaches as well as a discussion of the pros and cons of medications.

With more than 20 million Americans swallowing pain pills every day, it's high time we paid more attention to their potential hazard

Pfizer Punished for Very Bad Behavior

This is a breathtaking settlement! It is easy to zone out when seeing big numbers, but this is a truly mind-boggling amount of money. Pfizer (and its subsidiaries Pharmacia & Upjohn) have agreed to cough up $2.3 billion to the government because of very bad behavior. It is the largest such settlement in history, bar none!

Pfizer has been one of the biggest and most successful drug companies in the world. Think drugs like Lipitor to lower cholesterol, Norvasc to contol hypertension and Viagra for you know what.

Sales of Lipitor top $14,000,000,000 each year. Throw in other blockbusters such as Aricept for Alzheimer's disease, Zyrtec for allergies and Zoloft for depression and you begin to get an idea of how important Pfizer is in the world of pharmaceuticals.

That is why this settlement is so stunning. To have a company of this size get caught doing so many illegal and unethical things is a black mark on the entire industry. Actually, many other huge drug companies have also been fined enormous amounts of money for illegal marketing practices. Companies like Eli Lilly, GSK (GlaxoSmithKline), Schering-Plough, Merck, AstraZeneca, and Bristol Myers Squibb have all gotten into trouble and paid huge fines and government settlements. It has been described as the cost of doing business. But none of the past fines have reached the magnitude of Pfizer's penalties.

So, what did Pfizer do wrong? Let's start with illegal drug promotion:
• Doctors received free junkets to classy resorts
• Doctors got free golf, massages and goodness knows what else
• Doctors were paid to promote and prescribe certain drugs in violation of kickback laws
• Many drugs were promoted for off label uses (a BIG no-no!)
The list of promotion problems includes drugs like Bextra, Lyrica, Geodon and Zyvox.
• Repeat offenses. Off-label promotion continued even after past transgressions were detected and the company was fined.
• Pfizer paid kickbacks to market drugs like Lipitor, Celebrex, Viagra and Zithromax.
• The company overcharged Medicare and Medicaid and was fined nearly $1 billion

Enough said. The behavior was atrocious. It is time for the American public to react with indignation and outrage when pharmaceutical companies behave so badly. We spend an unbelievable amount of money on medicines to relieve symptoms, improve our health and in some cases, just survive. It is high time we demanded ethical conduct from this hugely profitable industr

Outrage Over Mammogram Mix-Up

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click here if you cannot view audio player: HadlerScreeningFull.mp3

For over 50 years the idea of early cancer detection has been a cornerstone of American medical advice. The American Cancer Society promoted this concept with its slogan, "Fight cancer with a checkup and a check." The idea was that if every tumor were found early enough, there could be an effective treatment, and possibly a cure.

After hearing the message for so many years, it is hardly any wonder that millions of women were mystified and outraged by the announcement of the new mammogram guidelines. When the U.S. Preventive Services Task Force declared that routine mammograms should begin, not at 40, but at 50 years of age, many women felt they were being cheated out of something that could save their lives. And the additional recommendation to have a mammogram every other year instead of annually also stirred up strong emotions.

Susan Love, MD, one of the world's foremost breast cancer specialists, welcomed the new guidelines. But she was one of the few public figures who seemed to understand the limitations of mammograms. Most people have come to believe that they are the Holy Grail of early detection. What has not been appreciated in the discussion is the inadequacy of this test and the amount of radiation a woman receives every time she gets a mammogram.

Even more confusing is the idea that not all cancer requires aggressive treatment. We have seen this in the realm of prostate cancer. Many men are uncomfortable with the concept of "watch and wait." We have been so convinced that a diagnosis of cancer requires instant and often aggressive treatment that delay seems tantamount to malpractice.

Experts are beginning to realize that breast cancer may be somewhat comparable to prostate cancer in that some tumors will never become life threatening. Treatment of such cancer may be counterproductive. The difficulty lies in determining which tumors are dangerous and which are not. Unfortunately, mammograms do not always help with this determination. Just as the PSA test is inadequate for many prostate cancers, so too the mammogram leaves a lot to be desired.

If you want to hear more about this controversial topic we encourage you to take a few minutes to listen to Nortin Hadler, MD. This brilliant physician describes the appropriate uses and shortcomings of screening tests

The People's Pharmacy in The New England Journal of Medicine

Generic drugs dominate the pharmaceutical marketplace. More than two-thirds of all prescriptions dispensed in the U.S. each year are now generics.

It's hardly any wonder that everyone loves generic drugs. They cost a tiny fraction of their brand-name counterparts. Valium, for example, is an anti-anxiety medicine that was once the most prescribed drug in America. To fill a prescription for 100 brand-name pills, you would have to pay about $275. But you could get 100 pills of generic diazepam for less than $15 at a big-box discount drugstore.

The question is: how reliable are generic drugs? We have been asking that question for the last ten years, and the answers we have gotten from the FDA have not been very satisfying. Although the agency says all generics are identical to their brand-name counterparts, we have received thousands of complaints over the last few years.

Until now, the medical community has more or less ignored our pleas for better FDA oversight of these medications. But a Perspective article in The New England Journal of Medicine by Susan Okie, MD, (Aug. 20, 2009) provides a balanced overview of this complicated issue. Sadly, the article is not free...but there is a way you can read it for no charge. It will take you a few minutes, however.

To access this article without paying the $10 "purchase access" fee, you can sign up for a 21-day free trial subscription to the New England Journal of Medicine (NEJM). If you go to "This article requires a subscription" and click on the "Start my FREE trial now" button, it will take you to an electronic subscriber page. Fill out the personal information and click the bill me later button. That way you do not have to provide credit card information but you will have a three-week free sub to the NEJM