Saturday, December 17, 2011

Since this past Monday I have had occasional sharp pain on my left side below the rib cage near my waist.

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What does it mean if i star to not be able to hold in urine, i don't pee all over my self but do have some urine leak out

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What would happen if I stop my hypothyroidism medicine for 15 weeks?

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Does Green Tea and Crestor contraindicate?

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Thursday, December 15, 2011

Big Pharma has struggled of late to demonstrate the availability & safety of a product that can raise HDL & prevent cardiovascular events. Initial efforts to raise HDL via cholesterylester transferase protein (CETP) inhibitors have not been very successful, eg torcetrapib in 2006. More recently, witness the debacles that were fenofibrate and niacin.

So why the push to raise HDL? Well, we've gotten pretty good a lowering LDL w/statins. But more importantly, for any given LDL, cardiovascular events still occur, demonstrating residual risk. From a different perspective, the higher the HDL, the lower the risk of events.

For instance, in a prospective cohort study published last week in the Annals of Internal Medicine, the authors followed for 11yrs 26,861 healthy women participating in the Women's Health Study and concluded that HDL is inversely related to cardiovascular events, even in those with low LDL. And just how much HDL does one need to appreciate benefit? More than 61.6mg/dL even in women w/median LDL <89mg/dL!

So if we don't have any drugs in our armamenterium, what do we do? Fall back upon our old standby and exercise!

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Wednesday, December 14, 2011

Nutrition vs Stroke Risk

We learned yesterday about a meta-analysis demonstrating that active treating pre-hypertension, repeated blood pressure readings higher than normal but not high enough to diagnose as hypertension, lowers stroke risk. And we learned earlier this month that dietary antioxidants lower stroke risk in women. Back in September, we learned that lifestyle, including vegetable consumption, affects stroke risk.

So it shouldn't be too much of a surprise that a review article to be published in next month's issue of Lancet Neurology found both the Mediterranean diet and the DASH (Dietary Approaches to Stop Hypertension) diet associated w/lower risk of stroke. Furthermore, less salt & sugar consumption along w/greater potassium intake was also associated w/lower risk of stroke.

On the other hand, supplementation w/antioxidant vitamins, B vitamins & calcium did not appear to materially affect & lower stroke risk. In other words, attempts to isolate the benefit of healthy nutrition and narrow risk mitigation down to a few vitamins & minerals don't appear to have major benefit. It would appear that from a healthcare perspective, there are no shortcuts. Healthy aging is a product of consistent & persistent healthy nutrition & regular physical activity. Healthy aging is not the product of consistent daily consumption of a handful of pills.

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Tuesday, December 13, 2011

Hypertension: When Is Blood Pressure Too High? Part 2

Two months ago, I pointed a new study that demonstrated at pre-hypertension, that no man's land between normal blood pressure & hypertension, was associated with an increase risk of stroke. Well, in a meta-analysis published online this week prior to print in February 2012, the authors proved that treating patients w/pre-hypertension lowered their risk of stroke.

Specifically, in 16 studies involving 70,664 participants, those w/pre-hypertension (systolic blood pressure 120-139mm Hg and/or diastolic blood pressure 80-89mm Hg) randomized to treatment had a statistically significant 22% reduction in stroke risk compared to those randomized to placebo. In fact, only 169 patients had to be treated for 4+ years in order to prevent 1 stroke (which compares favorably to the 118 w/hypertension who need to be treated in order to prevent 1 stroke).

As with any other therapy, there was a downside to these double-edged medications. High potassium, kidney failure, excessively low blood pressure, and water retention were all identified as complications & side effects of the medications. When you consider that over 53 million adults in America alone have pre-hypertension, even the small risk of side effect implies affecting a not inconsequential number of patients.

I don't know about you, but aside from kidney failure, I'd rather deal w/hyperkalemia, hypotension, and edema than the residual effects of a stroke.

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Monday, December 12, 2011

Antidepressants: Which One Is Best?

Let's cut to the chase: no single antidepressant is head & shoulders better than the rest. Of course, this statement isn't going to make me welcomed by Big Pharma. This isn't just my opinion but rather the conclusion of a systematic review & meta-analysis of 234 studies of 2nd generation antidepressants published this month in Annals of Internal Medicine. In other words, the clinical effectiveness of this class of drugs is the same across the board - they all work in the treatment of major depression.

However, as noted in USA Today, due to differences in onset of action, adverse effects, and of course, out-of-pocket costs, one antidepressant may be better for a given individual but not his/her twin sibling. The authors pointed out that it's reasonable to tailor antidepressant choice based upon (desired) side effect(s). For someone complaining of insomnia, we should consider a more sedating medication. For someone complaining of weight loss, we should consider an appetite stimulating medication. For someone complaining of sexual dysfunction, we should consider one w/less adverse sexual effects. And so on & so forth.

In fact, these conclusions are quite similar (at least to this simple family physician) to those derived from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D), at least at first glance. But as I dug into this large publicly funded study a bit further, it turns out that a reanalysis of STAR*D turned up some issues w/bias & statistics such that antidepressants are only "marginally efficacious" when compared to placebo in treating major depression.

If this is indeed the case, it would certainly explain the difficulty we have in finding the right medication for each individual. More importantly, it raises the question of just how do we treat major depression?

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