Dextromethorphan, an ingredient in most over-the-counter cough medicines, is highly controversial. Studies have shown it is no more effective than placebo in young children. The FDA is also concerned about reports that adolescents may be abusing it. The agency has called for a public meeting in September to review the safety and effectiveness of this medication.
One of the most commonly prescribed drugs for type 2 diabetes may lead to the development of vitamin B12 deficiency over time. Symptoms of the deficiency include fatigue, tingling or numbness in the feet or hands, mental confusion or forgetfulness and anemia. Some of these may be difficult to distinguish from possible consequences of the diabetes itself. The study was conducted in the Netherlands with nearly 400 patients. Half were given metformin three times daily for four years; the other half were treated with a placebo. Those taking metformin had vitamin B12 levels drop by about one-fifth. The patients on placebo had no significant change in levels of the vitamin. There is no medical consensus about regular screening for vitamin B12 levels in patients on metformin, so these patients may need to be pro-active and ask their doctors for a blood test. This might especially important for people also taking acid suppressing drugs like Aciphex, Nexium, Prevacid or Prilosec. Such medications may also make it harder to absorb vitamin B12. The combination could be a double whammy.
[British Medical Journal, May 19, 2010]
Back pain is common and there is no agreement about the best way to treat this common condition. A new study in the journal Academic Emergency Medicine attempted to determine whether heat or cold is more effective. People with acute backaches who went to the emergency department were randomly assigned an ice pack or a heating pad. They were also given 400 mg of ibuprofen. After half an hour they were asked to rate their pain again. All of the patients felt better, but only by a little bit. The authors concluded that using heat or cold was not clinically significant but that just the act of doing something may help people feel better.
[Academic Emergency Medicine, May 2010]
Click the arrow to play audio file:Depression is a debilitating disease that affects as many as 20 million Americans in a year. It can take a terrible toll on health as well as on family and work relationships. Many drugs are prescribed to treat depression, but the evidence is not impressive that they offer most patients great benefit.
Our guest, Dr. Stephen Ilardi, has come up with a number of non-drug approaches that may work at least as well as antidepressants for mild to moderate depression. These lifestyle modifications require effort, but they are inexpensive and don't have dangerous side effects. Could the cure to depression be within your grasp?
Guest: Stephen S. Ilardi, PhD, is associate professor of clinical psychology at the University of Kansas. His book is The Depression Cure: The 6-Step Program to Beat Depression without Drugs
Getting blood pressure under control is a key step to good health. Many people only discover that they have hypertension when their blood pressure is measured in a doctor's office. But is this the best way to monitor this important risk factor for heart disease? According to a new study from Finland, measuring blood pressure at home may be far superior to having it done in the doctor's office. The investigators studied over 2,000 Finnish volunteers between the ages of 45 and 75. They were enrolled between 2000 and 2001 and followed for approximately seven years.
Home blood pressure readings were found to be a more accurate predictor of heart attacks, strokes and cardiovascular deaths than office measurements. The investigators pointed out that more readings provided a better assessment and helped eliminate the so-called white-coat effect that many individuals experience when in the doctor's office. This may falsely elevate blood pressure and lead to unnecessary treatment.
There was a time when people treated heartburn symptoms with simple remedies. A half-teaspoon of baking soda in a glass of water was one standby. If you wanted to get a little fancier you could chew a few Tums or Rolaids or pour yourself a spoonful of Maalox or Mylanta.
In the 1980s, acid-suppressing drugs like Tagamet (cimetidine), Zantac (ranitidine) and Pepcid (famotidine) became popular. Once they lost their patent protection, however, they went over the counter and lost their glamour.
Now, even more powerful acid-suppressing drugs called proton pump inhibitors (PPIs) are among the most prescribed pills in the pharmacy. More than 100 million prescriptions are filled each year for drugs like Aciphex (rabeprazole), Nexium (esomeprazole) and Protonix (pantoprazole). Prilosec (omeprazole) and Prevacid (lansoprazole) are available over the counter as well as by prescription.
Proton pump inhibitors are a pricey way to relieve heartburn symptoms. According to an editorial in the Archives of Internal Medicine (May 10, 2010), more than half the prescriptions for PPIs are inappropriate. Although these drugs are useful for complicated conditions such as ulcers, Zollinger-Ellison syndrome and Barrett's esophagus, they are overkill for indigestion.
New research suggests that the risks are higher than most people realize. A study published in the same journal show that PPIs increase the risk for fracture, perhaps by changing bone metabolism.
Two other studies in the same issue show that acid-suppressors increase the risk of a serious gastrointestinal infection known as Clostridium difficile. This infection causes severe diarrhea that is sometimes lethal.
Pneumonia is another unexpected complication of the routine use of PPIs (Journal of the American Medical Association, Oct. 27, 2004). Because such infections aren't an obvious consequence of drugs for reflux, it took a long time for researchers to uncover these adverse effects.
It also took time to realize that stopping such medicines suddenly can trigger rebound hyperacidity (Gastroenterology, July 2009). This makes withdrawal a challenge.
People who wonder if they will ever be able to get off their Nexium or Protonix may be interested in our Guide to Digestive Disorders, in which we offer tips for stopping these drugs and non-drug ways to deal with heartburn.
While there certainly is a role for strong drugs to treat serious digestive disease, one of the recent studies shows that even people with bleeding peptic ulcers don't need high-dose PPI treatment. Regular doses work just as well (Archives of Internal Medicine, May 10, 2010).
Perhaps it is time for doctors to become less aggressive with these therapies. Patients might ask whether the prescription is really necessary, or whether they could manage their heartburn with common-sense old-fashioned measures such as consuming fewer carbohydrates (and maybe less junk food in general) or raising the head of the bed. An occasional antacid, when necessary, might be less risky than a steady regimen of PPIs.
Bonus Interview:Back pain is extremely common, but there is not great consensus about how it should be treated. Billions are spent on surgery without much evidence that it makes a significant difference. Our guest, Dr. Nortin Hadler, has examined the evidence and finds it lacking when it comes to regional back pain.
Our other guest, Dr. John Sarno, agrees that surgery, drugs or manipulation are not generally helpful. He has a unique approach to back pain. What do his patients think?
Guests: Nortin Hadler, MD, MACP, FACR, FACOEM, is author of Stabbed in the Back: Confronting Back Pain in an Overtreated Society. He is professor of medicine, microbiology and immunology at the University of North Carolina at Chapel Hill and attending rheumatologist at UNC Hospitals. His previous books includeWorried Sick: A Prescription for Health in an Overtreated America and The Last Well Person: How to Stay Well Despite the Health Care System. The photo is of Dr. Hadler.
John Sarno, MD, is attending physician at the Howard A. Rusk Institute of rehabilitation medicine at New York University Medical Center and professor of clinical rehabilitation medicine at NYU School of Medicine. His books include: Mind Over Back Pain, Healing Back Pain: the Mind-Body Connection,The Mindbody Prescription: Healing the Body, Healing the Pain and The Divided Mind: The Epidemic of Mindbody Disorders.
Madeline Guven heads Guven Design, a graphic design firm that produces Memopause notepads. She has experience as a patient of Dr. Sarn
Click the arrow to play audio file:Strong acid-suppressing drugs are widely prescribed for digestive problems, but perhaps they are too popular. Five studies in the current issue of Archives of Internal Medicine point out problems with drugs like Nexium and Prilosec. We talk with Mitchell Katz, MD, who wrote an editorial on why they are failing the acid test.
For years, people were warned to stay away from nuts for fear that their high fat content would raise dangerous blood fats. But lately we have been hearing a different story. A new meta-analysis shows why you might want to put nuts on the menu.
Explore the stories behind the health headlines.
Older people who had suffered a hip fracture were randomly assigned to receive extended or standard physical therapy. They were also given either high-dose or medium-dose vitamin D supplementation. The high dose was 2,000 International Units while the medium dose was 800 IU daily.
The 173 subjects were followed for a year to see if they fell or had to be re-admitted to the hospital. Extended physical therapy reduced the likelihood of falls, but not of hospitalization. The higher-dose vitamin D reduced hospital admission but not falls. In this study, about half the subjects had levels of vitamin D indicating deficiency, and almost all had levels lower than desirable at the outset. The investigators conclude that it might make most sense to use vitamin D supplementation and extended physical therapy together after hip fracture to improve the likelihood for a healthy recovery.
Eating nuts can help lower bad LDL cholesterol and triglycerides. Investigators pooled data from 25 experimental studies carried out in seven countries. They found that almonds, hazelnuts, pecans, pistachios, walnuts and even peanuts help improve blood lipids. Consuming about two and a half ounces daily helped reduce total cholesterol by almost 11 points. Bad LDL cholesterol dropped by about 10 points and triglycerides, a measure of fat in the blood, went down by 21 points or nearly 10 percent.
The benefits were most apparent in people who started with elevated levels of triglycerides or cholesterol. The more nuts people ate, the stronger the effect. Of course, nuts have calories, so over indulging is likely to be counterproductive by leading to weight gain. Perhaps people should eat nuts instead of snacks or dessert.
Doctors should study golf more seriously, especially putting. If you are trying to sink a putt, you have to hit the ball just right. Too hard and the ball goes sailing past the hole. Too soft and you fall short.
The same thing seems to hold true in medicine. A large, long trial of diabetes treatments has brought this lesson home loud and clear.
The ACCORD trial stands for Action to Control Cardiovascular Risk in Diabetes. Patients with type 2 diabetes are at particularly high risk for heart attack, stroke and other cardiovascular complications. More than 10,000 people with this condition were recruited and randomly assigned to different treatments.
The investigators were trying to find out whether aggressive treatment of blood sugar, blood pressure and blood lipids (cholesterol and triglycerides) over many years would lead to fewer complications and deaths. Many physicians expected that intensive treatment of these risk factors would yield big benefits.
The results stunned almost everyone. Instead of improving survival, taking extra measures to get blood sugar down to nearly normal resulted in more heart attacks and deaths (New England Journal of Medicine, June 12, 2008).
Intensive treatment of blood pressure to get systolic pressure down to 120 or less did not reduce the rate of heart attack or death significantly (New England Journal of Medicine, April 29, 2010).
In addition, adding fenofibrate to simvastatin to control blood fats lowered lipids but not the risk of heart attack, stroke or death (New England Journal of Medicine, April 29, 2010).
The ACCORD trial results are no fluke. The earliest large study to explore the treatment of type 2 diabetes was the British University Group Diabetes Program in 1970. Patients who took the oral diabetes medicine tolbutamide, which was relatively new at the time, did worse than patients taking placebo or insulin to control their diabetes.
Not long after that, British researchers recruited thousands of diabetic subjects to a ten-year study. Those who received intensive drug therapy to lower blood sugar did not have fewer heart attacks, strokes or deaths (The Lancet, Sept. 12, 1998).
But hope springs eternal, so British investigators tried again. They employed insulin in addition to oral diabetes drugs to get blood sugar close to normal (The Lancet, Feb. 6, 2010). This turned out to be counterproductive. The patients who used insulin in addition to oral drugs had a 49 percent higher risk of dying during the study than those who just used oral medications to manage their diabetes.
Although American doctors like to address risk factors aggressively, these excellent studies of people who are especially vulnerable to cardiovascular problems suggest that hitting hard might not always be the best approach.
Small steps, especially lifestyle changes, can yield big dividends for general health. A British study found that people who exercised regularly, didn't smoke or drink to excess and ate fruits and vegetables were much less likely to die over the next 20 years (Archives of Internal Medicine, April 26, 2010).
If doctors could coach their patients to adopt healthier behaviors, they might not need as much aggressive drug treatment.
According to the FDA, "Medication errors cause at least one death every day and injure approximately 1.3 million people annually in the United States."
Such statistics are too overwhelming to comprehend, so we tend to ignore, reject and deny them. Patients aren't the only ones having a hard time wrapping their heads around these numbers. Healthcare providers are, too.
Why are medication mistakes so easy to make--and so hard to catch? Part of the problem has to do with the economy. Hospitals struggling to break even in a bad time may cut staff and reduce hours. Pharmacies worried about making ends meet hire more pharmacy techs and have fewer pharmacists supervising them. But all of this means everyone, from the doctor to the pharmacy tech, is in hurry-up mode and may not be double-checking the patient's medicine as carefully as necessary.
Pharmacy technicians do essential work both in the hospital and in the community drugstore. But the training for this position varies widely. Some people may have degrees from a community college, while others may receive most of their training on the job. Yet these are the people who prepare that little bottle of pills you pick up from your neighborhood pharmacy. They may also be preparing medicines for administration by nurses in the community hospital.
A tragedy in Ohio has brought the responsibilities of pharmacy technicians to public attention. A little girl named Emily Jerry was being treated for cancer in Cleveland. She was almost ready for discharge, and her parents were planning to take her to Disney World to celebrate. Then she was given an injection that the pharmacy tech had prepared incorrectly, with 26 times more sodium in the saline solution than it should have had. The supervising pharmacist, feeling rushed, didn't notice the mistake and the toddler died as a result.
Pharmacy technicians are not the only ones who can make deadly blunders, though. Pharmacists make mistakes too. According to one study, the average pharmacy incorrectly fills four prescriptions each day. This adds up to about 51.5 million errors annually (Journal of the American Pharmaceutical Association, March/April, 2003).
Doctors and nurses are not immune. Actor Dennis Quaid's newborn twins were administered a whopping overdose of the blood thinning drug heparin and nearly died. Now he is a vocal advocate for reducing healthcare harm.
Everyone needs to recognize that errors are common, but many can be prevented. Patients play a crucial role in this process.
Next time you pick up a prescription at your local pharmacy, don't just grab your bag of pills and rush out the door. Stop right there at the counter and check to make sure the pills you received are the ones your doctor prescribed. To do that, it helps to keep a photocopy of your original prescription. Check the name, the dose and the instructions.
Before you leave the drugstore ask to speak with the pharmacist. Find out exactly how to swallow your pills (with meals or on an empty stomach), what the most common side effects are and what the most dangerous complications could be. To help you with this conversation we offer our free Drug Safety Questionnaire at www.peoplespharmacy.com.
Click the arrow to play audio file:More than 100,000 people die each year from infections they catch while receiving health care for another problem. The germs that spread in hospitals are often resistant to the antibiotics usually used to treat them. MRSA, for example, is methicillin-resistant Staphylococcus aureus, ordinary bacteria that have become extremely hard to treat.
Meet a survivor of MRSA who caught the infection working in a hospital emergency room. We also speak with Dr. Robert Muder, an infection control specialist who has developed ways to prevent the spread of MRSA at the Pittsburgh VA. Veterans Affairs Hospitals around the country are implementing some of the lessons learned in Pittsburgh.
Guests: Mike is an electrical contractor and MRSA survivor.
Robert Muder, MD, is Professor of Medicine at the University of Pittsburgh in the Division of Infectious Diseases. He is also Chief of the Infectious Disease Section at the Veterans Affairs Pittsburgh Healthcare System. The photo is of Dr. Muder.
Walking briskly has been recommended as an excellent exercise for the heart. Now researchers have evidence that it also benefits the brain. Investigators have followed almost 40,000 female health professionals in the Women's Health Study for over a decade. They found that women who walked regularly were less likely to suffer a stroke.
Walking fast, about four miles an hour, lowered the risk of a stroke caused by a blood clot by 25 percent. It also reduced the likelihood of a bleeding stroke by 68 percent. Women who walked at least two hours a week reduced their risk of any stroke by 30 percent. The conclusion is that vigorous, regular walking can have important health benefits.
[Stroke, April 26, 2010]
Anger is bad for the heart. A new study shows why. More than 600 heart patients in the Netherlands were followed for roughly six years. During the study about 10 percent died or had a heart attack. People who suppressed anger were much more likely to have such a fate. The researchers believe that anger restricts blood flow to the heart and leads to abnormal heart rhythms.
Vitamin E came out first in a test of treatments for fatty liver not due to alcohol abuse. Nearly 250 patients with fatty liver were randomly assigned to one of three treatments: the diabetes drug Actos, 800 UI of vitamin E, or a placebo.
The clinical trial lasted almost two years. At the end of that time, the people taking daily vitamin E were significantly more likely to show improvement than those on placebo. Actos was not significantly better than placebo. Fatty liver is a serious condition that can progress to cirrhosis, a potentially life-threatening disease. There is no currently accepted treatment for nonalcoholic fatty liver but this study suggests that vitamin E might be beneficial.
[New England Journal of Medicine, April 29, 2010]
The Food and Drug Administration has found serious deficiencies in the plant that made Tylenol products for babies and children. The manufacturer, McNeil, has voluntarily recalled 1,500 lots of liquid medication for children and infants. Products range from Benadryl and Motrin to Tylenol and Zyrtec.
What is so disturbing about this particular recall is that McNeil allegedly knew that the raw materials were contaminated with bacteria and used them anyway. The plant in Fort Washington, PA was also cited by the FDA for dust, dirt and duct tape covering pipes in violation of good manufacturing practices.
This isn't the first time that the parent company, Johnson and Johnson, has been cited for manufacturing problems. In January the company had to recall adult medications made in Puerto Rico. Consumers complained of Tylenol and other over-the-counter products that had a bad odor and were linked to digestive tract upset. The FDA does not yet have any reports of children suffering adverse effects from liquid Tylenol, but it is shocking that a leader in the industry would allow a plant to operate with substandard conditions.
Getting blood pressure under control is a key step to good health. Many people only discover that they have hypertension when their blood pressure is measured in a doctor's office. But is this the best way to monitor this important risk factor for heart disease? According to a new study from Finland, measuring blood pressure at home may be far superior to having it done in the doctor's office. The investigators studied over 2,000 Finnish volunteers between the ages of 45 and 75. They were enrolled between 2000 and 2001 and followed for approximately seven years.
Home blood pressure readings were found to be a more accurate predictor of heart attacks, strokes and cardiovascular deaths than office measurements. The investigators pointed out that more readings provided a better assessment and helped eliminate the so-called white-coat effect that many individuals experience when in the doctor's office. This may falsely elevate blood pressure and lead to unnecessary treatment.
