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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
October 22, 2011

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'Natural' Diet Pills Tainted with Sibutramine
Estrogen Might Protect Against Duodenal Ulcers
Cell Phones Not Linked to Tumor Risk in Large Danish Study
Most Americans — Especially Those at Risk — Consume Too Much Dietary Sodium
Prematurity Is an Independent Risk Factor for Death in Young Adults
Spironolactone plus Trimethoprim Induces Hyperkalemia in Elders
Suboccipital Steroid Injections for Cluster Headache

'Natural' Diet Pills Tainted with Sibutramine
     Twenty brands of weight-loss dietary supplements have been found to contain sibutramine, a prescription drug (Meridia) pulled from the market for safety concerns. These products include names like "A-Slim 100% Natural Slimming Capsules," "P57 Hoodia," "PhentaBurn Slimming Capsules," and "Dream Body Slimming Capsules." The drug was removed from the U.S. market last October because it was linked to heart attacks and stroke.
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MM: It’s interesting to note that women statistically have fewer duodenal ulcers than men. Historically this was attributed to women alledgedly having less stress. In today’s society this is a false assumption. More women are responsible as the primary family bread winner than ever before. Additionally, women still fill the traditional roles of caregiver for the entire family. This relatively new development would indicate that women have more stress than ever before. Yet, the propensity for DU’s in women still lags behind that of men. If estrogen is the answer, then a safer form is necessary than the traditional oral route. Compounded, Transdermal, Bio-identical Hormone Replacement Therapy (BHRT). May be an effective alternative to the synthetic estrogen that has typically been given to women. For any woman entering menopause or peri-menopause, and who is concerned about the problems associated with this change in hormones, Mark Drugs is ready to provide information, guidance and if necessary, training for your physician.
Gastroenterology 2011 Sep; 141:854
Estrogen Might Protect Against Duodenal Ulcers
Results of a large population-based study support the hypothesis that estrogen promotes duodenal bicarbonate secretion, which lowers the risk for ulcers.
     Studies have shown that women are less likely than men to develop duodenal ulcers (DUs). Other studies have suggested that estrogen stimulates duodenal bicarbonate secretion, which could be a biological mechanism for the lower incidence of DUs among women. To investigate this possible link, researchers in China conducted an epidemiologic study involving 64,385 patients who underwent endoscopy for dyspepsia.
     The prevalence of DUs was lower in women than men: Women aged 20 to 49 were 4 to 5 times less likely to have DUs than men of the same age; in contrast, women aged 60 to 69 were only 1.3 times less likely to have DUs than men of the same age. Basal and acid-stimulated duodenal bicarbonate secretion levels were higher among women aged 20 to 29 than men of that age group, but this was not true for patients aged 60 to 69.
     Among a cohort of eight volunteers, bicarbonate secretion increased with estrogen levels during the physiologic menstrual cycle. In other subanalyses, exogenous 17-β estradiol stimulated duodenal bicarbonate secretion in both sexes and both age groups, and estrogen receptors were found on the plasma membranes and in the cytosol of duodenal epithelial cells of both sexes.
     The authors conclude that estrogen regulates human duodenal bicarbonate secretion, which might reduce the risk for DUs in women.
     Comment: In this extensive series of analyses, the investigators confirmed a clinical observation in a population and identified a potential physiologic explanation for the finding. However, the results might not be generalizable until they are replicated; the duodenal bicarbonate analyses were performed with only eight individuals in each age- and sex-specific group, and no analyses involved patients with a history of DUs. Nonetheless, these results should stimulate broader investigation of the role of estrogen in the etiology of DUs.
David J. Bjorkman, MD, MSPH (HSA), SM (Epid.) Published in Journal Watch Gastroenterology October 21, 2011
     Citation(s):Tuo B et al. Estrogen regulation of duodenal bicarbonate secretion and sex-specific protection of human duodenum. Gastroenterology 2011 Sep; 141:854.
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Cell Phones Not Linked to Tumor Risk in Large Danish Study
     Use of mobile phones does not increase the risk for brain tumors, a Danish national cohort study finds. The results, reported in BMJ, update an earlier study that reported findings until 2002, to which 5 years of follow-up data (to 2007) have now been added.
     Researchers compared the incidence of brain tumors in nearly 360,000 subscribers to mobile phone services with the incidence in the rest of the population over a 17-year period. They found that tumors of the central nervous system occurred at a similar rate in both groups.
     Editorialists say that continued monitoring of such cohorts is warranted, but new studies "are not needed." Earlier this year, WHO called cell phones "possibly carcinogenic."
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MM: In my opinion the real problem is not the excessive consumption of sodium but the physical condition that so many people are in that predisposes them to the risk of excessive sodium. Much of this risk is secondary to the condition called “metabolis syndrome”. This condition includes the combination of high blood pressure, cholesterol and diabetes. All of which are associated with obesity. The HCG weight loss protocol has demonstrated a way to effectively address aggressive and successful long term weight loss and maintenance and in so doing, cope with and frequently reverse metabolic syndrome.
Most Americans — Especially Those at Risk — Consume Too Much Dietary Sodium
     The vast majority of Americans are not keeping within published dietary guidelines for sodium intake, according to a CDC analysis of NHANES data published in MMWR.
     Government guidelines recommend that people aged 2 years and older should have less than 2300 mg of sodium daily. However, the recommended limit is even lower (1500 mg per day) for certain higher-risk groups: adults over age 50, blacks, and people with hypertension, diabetes, or kidney disease. Nearly half the population falls into these higher-risk groups, the CDC found.
     The analysis showed that 88% of Americans not at risk exceed the 2300-mg limit, and 99% of those in the higher-risk categories exceed the 1500-mg limit.
     The American Heart Association calls the CDC report "too conservative." It quotes a former association president: "We all should be consuming less than 1500 mg a day of sodium, unless your healthcare provider has told you that this doesn't apply to you."
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MM: This is a disturbing statistic but if it opens the eyes of clinicians to look more closely at patient histories, it may save lives. At any rate, we as parents and grandparents should be aware of this possibility as it allows us to take better care of our children and grandchildren even as they become adults. It should also serve as a heads up that we need to focus on a healthy lifestyle and nutritional practices from the cradle through life.
JAMA 2011 Sep 21; 306:1233
Prematurity Is an Independent Risk Factor for Death in Young Adults
. . .even among those born late preterm
     Prematurity is a well-known leading cause of perinatal death. Whether preterm birth increases risk for death during adulthood is unknown. Investigators examined the association between gestational age at birth and mortality through young adulthood in a national cohort of 674,820 singleton infants born in Sweden from 1973 to 1979 who survived past age 1 year. Four percent of infants were born before 37 weeks' gestation, and most of those (80%) were born at 34–36 weeks.
     During 20.8 million person-years of follow-up, 7095 deaths occurred. A significant inverse association was found between gestational age at birth and mortality rates in young adulthood (age range, 18–36). Adjusted hazard ratios for death in young adulthood ranged from 1.31 for those born at 34–36 weeks' gestation to 1.91 for those born at 22–27 weeks' gestation. In young adulthood, gestational age at birth had the strongest inverse association with death from congenital anomalies followed by respiratory (AHR, 0.85) and endocrine disorders (AHR, 0.88), and cardiovascular disease (AHR, 0.93). Gestational age was not associated with death from cancer or injuries in young adults.
     Comment: The association between prematurity and death during early adulthood is important because of the improved survival of premature infants. The association indicates that prematurity has lifelong health effects. A history of extreme prematurity might be elicited during a patient's health history, but preterm birth after 34 weeks' gestation might not. On the basis of these findings, clinicians should consider taking birth histories more carefully and enhancing health surveillance of patients who were born preterm.
F. Bruder Stapleton, MD Published in Journal Watch Pediatrics and Adolescent Medicine October 19, 2011
     Citation(s): Crump C et al. Gestational age at birth and mortality in young adulthood. JAMA 2011 Sep 21; 306:1233
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MM: This is important as these are medications frequently prescribed for urinary tract infections (UTI’s) and the elderly and debilitated are especially prone to UTI’s. A possible alternative treatment for many of these patients could be D-mannose. Given in frequent doses for 3+ days, we have observed many UTI’s to be diminished both clinically and symptomatically. For more information about D-mannose and its potential usefulness for UTI’s call Mark Drugs.
BMJ 2011 Sep 12; 343:d5228
Spironolactone plus Trimethoprim Induces Hyperkalemia in Elders
Treatment with trimethoprim is associated with risk for hospitalization in spironolactone-treated patients.
     Many patients who are treated with spironolactone develop hyperkalemia, especially if spironolactone is co-prescribed with other drugs that also can cause hyperkalemia (e.g., angiotensin-converting–enzyme inhibitors). Trimethoprim, a component of the antibiotic trimethoprim-sulfamethoxazole (TMP-SMX), slows urinary excretion of potassium. In this population-based case-control study, investigators determined risk for hyperkalemia-related hospital admission among older Ontario, Canada, residents (age, >65) who received both spironolactone and TMP-SMX.
     Of 166,000 patients treated with spironolactone during the 18-year study period, 6900 were admitted for hyperkalemia: 306 within 14 days of receiving TMP-SMX, nitrofurantoin, norfloxacin (Noroxin), or amoxicillin (cases). Of these, 248 were matched with 783 spironolactone-treated patients who received one of these antibiotics within 14 days of the index date but were not hospitalized (controls). After adjustment for multiple confounders, patients who were hospitalized with hyperkalemia were >12 times more likely to have received recent prescriptions for TMP-SMX than for amoxicillin (which does not cause hyperkalemia). Nitrofurantoin also was associated with hyperkalemia risk (odds ratio, 2.4), but norfloxacin was not.
     Comment: Treatment with trimethoprim (and, to a lesser degree, nitrofurantoin) was associated with risk for hyperkalemia-related hospitalizations in patients who took spironolactone. The mechanism by which nitrofurantoin raises risk is unclear, although animal research has shown that nitrofurantoin inhibits aldosterone release from adrenocortical cells. Notably, co-prescribing of spironolactone and TMP-SMX is not uncommon. In this study, 18,000 patients taking spironolactone (11%) received at least one prescription for TMP-SMX. Treatment with trimethoprim (and perhaps nitrofurantoin) should be avoided in patients who take spironolactone.
Paul S. Mueller, MD, MPH, FACP Published in Journal Watch General Medicine October 11, 2011
     Citation(s):Antoniou T et al. Trimethoprim-sulfamethoxazole induced hyperkalaemia in elderly patients receiving spironolactone: Nested case-control study. BMJ 2011 Sep 12; 343:d5228. (http://dx.doi.org/10.1136/bmj.d5228)
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MM: Cluster headaches and migraines are more common that we care to think about and the drug based solutions tend to be expensive, limited in effectiveness, demonstrate numerous side effects and frequently exhibit rebound headaches. Use of a compounded trigger point gel has demonstrated remarkable relief for many of our patients. Call Mark Drugs for more information about the prescription and non-prescription alternatives for treating headaches and other types of pain.
Lancet Neurol 2011 Oct; 10:891
Suboccipital Steroid Injections for Cluster Headache
A useful and well-tolerated preventive measure for cluster headache
     Attacks of cluster headache (CH) are, arguably, the worst recurrent pain phenomenon known. The usual mainstay of preventive medication for episodic CH is a diminishing course of oral corticosteroids, together with an escalating dose of verapamil. However, systemic corticosteroid administration is associated with well-known adverse effects, and verapamil often needs to be employed at high doses, necessitating close electrocardiographic monitoring during dose escalation to prevent cardiac arrhythmias (Neurology 2007; 69:668). Therefore, a simple, effective transitional preventive measure is needed to bridge the gap between attack onset and effective attack control by conventional preventive treatments. Manipulation of the greater occipital nerve, both by local injection and by electrical stimulation (Pain 2006; 122:126 and Neurology 2009; 72:341), is therapeutically useful for alleviating pain in several primary headache disorders. Now, researchers have conducted a randomized trial of three local injections (separated by 2–3 days) of the steroid cortivazol in the suboccipital region, ipsilateral to the side of pain, versus placebo injection of saline in 43 patients with episodic or chronic CH.
     Cortivazol was significantly more effective than placebo at reducing the frequency of individual CH attacks to a mean of two or fewer attacks per day immediately after the third injection (achieved in 95% vs. 55% of patients; P=0.012). Cortivazol was also significantly better at reducing the mean number of attacks per person and the mean sumatriptan dose per person between days 1 and 15 of the trial. The authors note that the high placebo response may have resulted in part from some participants coming to the natural conclusion of their bout or benefiting from conventional preventives. Adverse effects were minor and did not cause treatment discontinuation.
     Comment: Despite the potential bias issues raised by the authors, this small, well-designed trial offers further evidence that suboccipital steroid injections have a useful adjunctive role as a well-tolerated preventive approach in cluster headache. This treatment should be considered part of routine transitional management of patients with episodic CH going into a bout, or of patients with chronic CH who need add-on pain relief.
— Alex Nesbitt, BM, BCh, and Peter J. Goadsby, MD, PhD, DSc Dr. Nesbitt is Research Fellow (Neurology), Surrey Sleep Research Centre, University of Surrey, U.K.
Published in Journal Watch Neurology October 18, 2011
     Citation(s):Leroux E et al. Suboccipital steroid injections for transitional treatment of patients with more than two cluster headache attacks per day: A randomised, double-blind, placebo-controlled trial. Lancet Neurol 2011 Oct; 10:891

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