Alan's Health Blog

Simple Ways of Maintaining Health

2009-09-05T09:55:00.003+08:00

At times, we are too obsessed about our health; or we just simply ignore our health.

Either way, it's not going to help us to stay healthy and enjoy our life.

Health is a lifestyle, a process. It's not an end-product.

The key points:

Eat less
Move more (Exercise more)
Sleep more

Eating is a pleasure in life. But it will slowly kill us if we eat too much. Especially, when we are eating sugar.

You might think I am crazy for saying we are eating sugar.

But think about it, each time you eat a full bowl of rice (be it white, brown, red), you are actually eating a full bowl of sugar (after digesting, rice will turn to sugar: starch turns sucrose turns glucose).

What more, the fat we are consuming, plus all those preservatives and coloring agents.

We are killing ourselves by eating more.

How about to move more? Each day, we are very static.

The amount of foods we are eating, are providing us a lot of energy. But by moving less, we are not using the energy, and it will turns into fat, deposited in our body, and slowly clogging around our bodies, causing a variety of chronic diseases.

And talking about sleeping. We are having too many activities going on in our life. We forgot we are made of flesh and bones, not iron.

Our body need rest, so as our brain.

So, instead of being over-productivity, please, sleep more.

If we can live our life according to these 3 principles, we are moving towards healthy lifestyle.

The rest, are just details, and we can pick it up through the process of living healthy.

Enjoy it.

WHO Guideline on Pharmacological Management of Pandemic (H1N1) Influenza

2009-08-22T09:20:00.007+08:00

WHO had just issued (20th August, 2009) the guideline for the use of antivirals in the management of patients infected with H1N1 pandemic virus.

The emphasis of the guideline was on the use of oseltamivir and zanamivir to prevent severe illness and deaths, reduce the need for hospitalization, and reduce the duration of hospital stays.

The H1N1 virus is currently still susceptible to both oseltamivir and zanamivir (neuraminidase inhibitors), but resistant to the M2 inhibitors (rimantadine and amantadine).

So far, worldwide, most patients infected with the virus experienced typical influenza symptoms and fully recover within a week, even without any form of medical treatment. Healthy patients with uncomplicated illness need not be treated with antivirals.

However, this is just a weak recommendation with low quality evidence. It should be based on clinical assessment and how the virus is spreading throughout the community.

In areas where the virus is circulating widely in the community, doctors seeing patients with influenza-like illness (ILI) should assume the H1N1 is the cause. Treatment decisions should not wait for laboratory confirmation.

'At risk' group defined by WHO included:

Infants and children aged less than 5
The elderly (>65 years)
Nursing home residents
Pregnant women
Patients with chronic co‐morbid conditions such as cardiovascular, respiratory or liver disease, diabetes
Those with immunosuppression related to malignancy, HIV infection or other diseases

For 'at risk' population, WHO recommends treatment with either oseltamivir or zanamivir. They should receive treatment as soon as possible after symptom onset, without waiting for laboratory confirmation.

For patients present with severe illness or whose condition begins to deteriorate, WHO recommends treatment with oseltamivir as soon as possible, preferably within 48 hours after symptom onset. However, even after 48 hours, treatment should also be provided.

This recommendation covers all patients groups. The dose of oseltamivir can be given up to 150mg twice daily and longer than 5 days based on clinical response.

Clinical deterioration is characterized by primary viral pneumonia, which destroys the lung tissue and does not respond to antibiotics (sometimes, with the failure of multiple organs, including the heart, kidneys and liver). This type of patients require management in ICU in addition to antiviral (oseltamivir).

How about children?

They are classified as 'at-risk' group, however, they should be treated if presented with severe or deteriorating illness, or if they are at risk of more severe or complicated illness.

For pregnant women, WHO recommends treatment should be started once the symptom onset. (Although the studies on oseltamivir in pregnant women not yet established)

Below is the table to summarize the recommendations:

Healthcare professionals need to be alert to danger signs that signal progression to more severe disease. The progression can be very rapid, medical attention is needed when any of the following signs appear in a patient with confirmed or suspected H1N1 infection:

Shortness of breath
Difficulty in breathing
Turning blue
Bloody or coloured sputum
Chest pain
Altered mental status
High fever that persists beyond 3 days
Low blood pressure

As zanamivir is the only alternative to oseltamivir, it should be used when the patient show signs of resistant to oseltamivir.

Personal remark is:

Oseltamivir is not without adverse effects.

Common ones are:

Diarrhea
Nausea
Stomach pain
Vomiting
And of course, allergic reaction (can be mild like rashes, to severe like anaphylactic shock)

Noted that it has effects on central nervous system as well. So, please observe the patient if they are having such symptoms while taking oseltamivir (it might cause fatal outcome like suicide):

Abnormal behaviour
Confusion
Hallucinations
Mood or mental changes

Source:

WHO Guidelines for Pharmacological Management of Pandemic (H1N1) 2009 Influenza and other Influenza Viruses

Protecting yourself from H1N1

2009-08-20T20:51:00.005+08:00

Now we talk about how to protect yourself from H1N1 virus (and also normal flu virus).

In your everyday life, you should:

Cover your nose and mouth with tissue paper when you cough or sneeze. Immediately throw the tissue into thrash after using it. (Do not keep them!)
Wash your hand often with soaps and water, especially after you cough or sneeze.
Avoid touching your eyes, noses and mouth.
Try to avoid sick people.
If you are sick, please stay at home for at least 24 hours after the fever is gone, except if you are going to seek medical help.
Put on face mask if you are sick and really have to go out (seeking medical help, etc)
Boost your immune system, take foods with high vitamin C. If not possible, then take vitamin C supplement, with zinc. Plus, have enough sleep!
Hydrate youself.

If the government announces about school closures, avoiding crowds, and other social distancing measures, please do follow the instruction!

Doing all these, is not only protecting yourself, but to help spread the flu.

Don't be selfish. Act now!

Oseltamivir

2009-08-20T10:29:00.003+08:00

Oseltamivir is now the blockbuster drug in whole world, including Malaysia.

It is a neuraminidase inhibitor.

The influenze neuraminidase releases newly formed viruses from infected cells, allowing them to spread from cell to cell. This inhibitor mimic the natural substrate of the influenze neuraminidase and bind to the active site, preventing neuraminidase from cleaving host-cell receptors and releasing new virus.

As H1N1 virus attacking Malaysia, out-of-control-ly, nothing preventive can we do now. The last resort is to prescribe (by doctor) and dispense (by pharmacist) oseltamivir (also known as Tamiflu) to those having influenze-like-illness (ILI), especially those having co-morbidities (obesity, diabetes, asthma, etc).

As oseltamivir is being used so extensively, antimicrobial resistance is our concern now.

First, we look at the rational use of oseltamivir.

The sooner the drug is taken after the onset of symptoms (within 48 hours), the better the clinical efficacy (subside of the symptoms in shorter period). If the virus has replicated and infected many cells, the effectiveness of this drug will be severely diminished.

And it should be used in recommended dosage and duration (normally is 75mg twice daily for 5 days; but now the MOH guideline increased the dosing regime up to 150mg twice daily up to 10 days for children more than 12-year-old and more than 40kg).

The over-extensive use of oseltamivir will cause the shortage of supply. That will inspire the sharing of supply, resulting in adequate treatment.

Another problem is the compliance issue. If counselling on this drug is not done appropriately, patients tend to stop taking once the symptoms are gone, regardless the course of treatment already completed, or not (a well-established tendency seen in antibiotic treatment).

The other problem is rather simple: the more you use one antimicrobial on one microorganism, the higher probability the microorganism will develop resistance towards the antimicrobial.

These will lead to the development of oseltamivir-resistance-strain of H1N1 virus.

It's just a matter of when, rather than will it happen or not (there were case of H5N1 virus resistant to oseltamivir already).

We should ensure the proper use of oseltamivir, rather than just providing unlimited supply of it to the public.

Human papillomavirus (HPV) vaccination

2009-08-20T09:31:00.003+08:00

HPV vaccination is getting more and more popular these days.

It is not limited to female, but to male, now, to provide protection against human papillomavirus (HPV). (For male, it's still an unlabelled use, and they claimed that it will help spread the HPV if the vaccination extended to male population)

HPV can cause cervical cancer is discovered by Zur Hansen, the winner of Noble Prize in Physiology or Medicine in 2008.

So, the pharmaceutical companies started to develop vaccines for HPV. The theory is: If you can prevent HPV, you can prevent cervical cancer, too.

So simple? I wish so.

However, there are more than 100 types of HPV (and a study discovered that some of them are linked with development of hypertension too, so, that means vaccination for hypertension in the future?), and at least 15 of them are oncogenic.

Current vaccines only cover some of them:

Gardasil (from Merck & Co) covers type 16, 18, 6 and 11
Cervarix (from GSK) covers type 16, 18

HPV is the most prevalence sexually transmitted disease, however, the virus does not appear to be very harmful as most of them can be cleared by our immune system.

Only for some women, the infection will persist, and eventually develop into cervical cancer. However, till now, we do not have any tool or method to predict what type of woman will have such tendency.

As we cannot predict who will develop cervical cancer, we also cannot predict the effect of vaccine on the young girls and women, 20 or 40 years from now. We can only see the effect using long term clinical trial or follow-up.

Right now, what we have is studies on prevalence of cervical intraepithelial neoplasias grades 2 and 3.

There were adverse events reported on HPV vaccines, mostly on dizziness, headaches, and fever. Not very serious. There were also some serious events such as anaphylaxis, Guillain-Barre syndrome, transverse myelitis, pancreatitis, and venous thromboembolic events. However, we cannot conclude whether these adverse reactions were caused solely by the vaccines, or not.

The situations we are facing now, are:

We do not know the net benefit of the HPV vaccines
We do not know the long term harmful effect of these vaccines either

For medical professional judgement, we tend to weigh between benefits and risks, then to conclude whether a medical decision is sound, or not.

Now, how can we decide?

Economically, we look at the incentives.

If you are a woman/man, plan to live sexually active in the future (having multiple sex partners), taking the vaccine is definitely a good choice. But who will know what kind of life you will have in the future anyway?

And if you are already sexually active, it's already too late to have the vaccines.

And even if you already took the vaccine, it's not a guarantee that you are free from cervical cancer 100% throughout your life. You still need to do regular screening.

So, you should think about the cost (including the potential harmful effects) of the vaccines. before you take it.

How about consulting healthcare professionals?

Well, they are judging whether to take the vaccine, by weighing benefits vs risks as well. And it is important to ask who takes the risk, and who gets the benefits. Indeed.

(Take note that the so-called healthcare professionals' judgement are always clouded by the promotion strategies by pharmaceutical companies)

So, what's the conclusion?

The truth is, I don't have one for you. Sorry.

Diarrhea

2009-08-01T06:57:00.003+08:00

Diarrhea = Increase frequency of bowel movement relative to normal for an individual

I don't have to explain to you what is normal in the definition mentioned above. Everyone has their own normal frequency of passing motion.

Why I am talking about diarrhea here?

Because it may cost your life if you don't manage it properly!

How?

Loss of fluid through diarrhea can cause severe dehydration, and loss of electrolytes (sodium, potassium) and other nutriets.

It's fatal, especially for little children (or we call them infants).

Many factors can cause diarrhea, food poisoning is the most popular one.

Others include: Inflammatory bowel disease, irritable bowel syndrome, malabsorption problems, cancers, and drug-related.

The drugs that commonly cause diarrhea are:

Acarbose
Metformin
Antibiotics
Colchicine
Cytotoxic agents (Chemotherapy)
Sorbitol, mannitol, fructose, and lactose
Laxatives (of course)
Magnesium-containing antacids
NSAIDs

All patients presenting with diarrhea, should be questioned about the relationship between symptoms and changes of drug or initiation of of any drug therapy.

If it's drug-related, management of diarrhea should be focused on the cause (the drug), rather than treating the diarrhea with another drug therapy.

For chronic diarrhea, the management also should be focused on the cause (the underlying disease), rather than keep giving drug therapy.

For acute diarrhea, first thing to do is the fluid replacement: Oral rehydration therapy!

Oral rehydration solution (ORS) is made of water, with salts (potassium, sodium) and glucose.

Commercial-packed is available in most (I should say All) pharmacy stores.

Simple instruction will be:

Everytime after having loose stool (during the period you are having diarrhea), mix a packet of ORS into a cup of warm water, and drink it.
Of course, you need to further rehydrate yourself with your normal daily intake of fluids.

It sounds simple, but it saves lifes.

How about drug therapy?

Well, it's not really recommended, cause diarrhea is a symptom your body to 'detox'. To stop the diarrhea, is to stop the toxins that causing the diarrhea from clearing off your body. It might delay the recovering process.

It is recommended only for social convenience (you need to work, or go to an important meeting, conference, and so on).

The drug therapy is the antimotility. It's not (never) indicated for infants and children.

Loperamide

4mg orally initially, then followed by 2mg for each loose stool. (Maximum: 16mg daily)

Diphenoxylate 5mg + atropine 0.05mg (popularly known as Lomotil despite of the availability of various generic versions)

1 tablet orally 3 to 4 times daily.

The drug therapy should be stop if there is no more loose stool. It should not be taken for long term.

Sometimes, you can supplement the drug therapy with activated charcoal, to help adsorb the toxins and cleared from the GI tract. But it should not be taken with the drug, as it may reduce the absorption of the drugs.

Remember to see the doctor if you get any of these symptoms:

Bloody diarrhea or pus in the stool
Headache, stiff neck and fever
Fever that lasts more than 24 hours
Faintness, rapid heart rate, or dizziness after sitting or standing up suddenly
Diarrhea that not improved (recovering) after 3 days
Weakness, numbness, or tingling, usually in the arms or legs, but sometimes around the mouth

In reality

2009-07-24T20:34:00.002+08:00

In reality, the medications that you are taking, are not only the products of the decisions of the healthcare team. There are many 'commercial' factors.

Let's say in hypertension guidelines, it's listed that ACEI or ARB will be the first line treatment. But which one in these groups are to be used?

Unless you are having other diseases, like kidney failure, or chronic liver disease, which will affect the choice of drug in more precise way, I don't think the healthcare team really have the clear idea of which one to give you.

So in the end, which one to use?

To use those more familiar one.

Well, that's the trick behind it. Those you are familiar with, are either those very established, existed for a long long time, and appeared to be very safe; or, those new drugs that the drug companies keep promoting to the healthcare team.

Normally, the healthcare team will tend to forget about the drugs that are existed very long time with good safety profile. Those, will be only extensively mentioned in text book. It is kind of 'uncool' of the young doctors or pharmacists to deal with them.

So, which left the latter one: Those new drugs that the drug companies keep promoting about.

New drugs mean: New, with lesser safety profile, and slightly (sometimes significantly, but quite rare) more effective than the old drugs; and of course, claimed to be having lesser side effects.

How intensive is the promoting?

Well, you can see the name of the drugs on the pens, the folders, notebooks, reference books, and even guidelines printed by drug companies.

The healthcare team is basically brainwashed by the drug companies every day.

Plus, the obviously biased data provided by the drug companies, with nicely designed charts and figures.

To some lucky ones, they might have incentives if they prescribe more than certain amount of the certain drugs.

How nice. The healthcare team has so so much to gain.

What about the price that the public bear?

More expensive, but just slightly better, with unknown risk ahead.

Who cares?

Simple Advices on Taking Antibiotics

2009-07-17T15:10:00.008+08:00

What are antibiotics? They are the medicines to treat infections.

Well, we all know that. What's the big deal of 'advice' on it?

Surely, the public need advice, from time to time, to remind them that antibiotic is not miracle drug that cure every disease that you got.

You got cold, flu or, sore throat, you go to a pharmacist, or doctor, insisting you need antibiotic. You think you are smart, cause you 'know' antibiotics. And when you pop them in your body, you kind of 'getting well'. And you feel smart again.

Who needs doctor anyway? You think so.

What you don't know, is that you are helping the bacteria to grow stronger. You are brewing 'superbug' in your body. Surely, that is very smart.

What's with 'superbug', anyway?

It's what 'what cannot kill you makes you stronger' really mean. When an antibiotic failed to kill all of the bacteria it targets, the surviver will become resistant to that antibiotic, and frequently, the other antibiotics in the same group as well. Then you asking for 'stronger' antibiotic, then the bacteria quickly learn it, and resistant to them all, one by one.

Because of that, medical researchers need to develop new antibiotics, from time to time, to deal with the 'resistant' issue. But, everytime they come out with new antibiotics, the bacteria will follow the pace, learning fast to adapt to it.

We have to stop this trend.

A simple fact you need to know before I give you advice on taking antibiotics:

Antibiotics do not kill virus.

So, do not expect they can cure your simple cold, flu or sore throat, unless they develop into real bacteria infections.

What to do then? Simple:

Do not take antibiotic, unless you are very sure it will help the condition. Any good (and ethical) could tell you whether you need it or not.
To make sure you really need it, not because you want it: DO NOT INSIST that you need antibiotics when you are seeing doctor. (Because doctors are human too, they might just prescribe it to you, just to get rid of arguing with you)
If you are prescribed one, make sure you finish them all. DO NOT stop taking them just because you already feeling good. (You need to take them for a period of time, to make sure they really clear off all the targetted bacteria)
DO NOT simply purchase antibiotics from pharmacy store, without prescription. (You don't know which antibiotic you need, and how long to take)

And of course, protect yourself from infection in the first place:

Be hygenic. Wash your hand thoroughly with soap and water (you know when you need to wash your hand)
There are plenty of anti-bacterial soaps available in the market. They aren't necessary. Simple soap and water are enough. Overuse of anti-bacterial soaps, is helping the bacteria grow stronger.
Keep foods preparation area clean.
Sleep enough. Lack of sleep will compromise your immune system, and you will get infection easier.

Be responsible! Everytime you are helping the bacteria to grow stronger, you are not only harming yourself. You are harming people around you as well.

Warfarin (Part 2)

2009-07-11T08:59:00.010+08:00

So, How to take warfarin?

The dose, will be decided by your doctor, and might be changed from time to time depending on your INR. My advice on this one: Stick to the dose the doctor prescribed you!

Let's say your dose of warfarin is 2mg, then you should take 2mg of warfarin (one 2mg tablet) everyday at the same time.

What if you missed the dose?

You should take it as soon as you remember. However, do not take the missed dose when it is closed to the next dose (for example, you remember it after 12 hours the time you suppose to take the warfarin). If it's already after 12 hours, just ignore it, and start with the next dose. And remember NOT to double the dose when you are taking the next dose.

Wherever you go, bring your medication, in sufficient supply, to make sure you won't miss any dose.

If you care about your family member, especially the kids, make sure you store the medication in a safe place, where only you can assess to. And to ensure your tablets in good quality, keep them away from moisture and heat (avoid sunlight and water).

Precautions:

If you are pregnant, or might be pregnant, or plan to pregnant; or, you are breastfeeding, please do not take warfarin. Talk to your doctor about it.

If you are having surgery, including dental surgery (extraction of tooth), please tell your doctor or dentist. They might want to ask you to stop taking warfarin before the surgery or procedure few days before.

Plus, if you are taking any other medications or traditional medicines (such as gingko biloba, ginseng, garlic oil, fish oil. St. John's wort, Dong Guai), please inform your doctor or pharmacist about it. There might be drug-drug or drug-food interaction and dosage adjustment might be needed. AND DO NOT start any medications or traditional medicines without first consulting your doctor and pharmacist!

Please tell your doctor if you are having any health problems, even if you think it is minor problem. They might be related to the warfarin therapy.

So, you know about bleeding is the main side effect of warfarin. How to detect it anyway?

Signs of bleeding:

Bruises
Nose and gum bleeding
Cough or phlegm with blood
Bloody stool or urine
Black or dark red stool
Excessive or prolonged period (for female)
Bleeding from vagina
Excessive bleeding from lesion (wound)

If any of these signs appear, please contact your doctor immediately.

If you fall down, you need to inform your doctor also, to check for internal bleeding (you won't feel internal bleeding until it's too late).

Do not ever underestimate any mild signs and symptoms. They might be the tip of the iceberg.

Any advice to minimize the risk of bleeding? Yes:

Avoid using hard toothbrush
Avoid rough use of floss
Avoid risky exercises which can cause injury

How about diet?

Your normal daily diet should not have too much changes. Any changes in diet may affect the INR reading.

Just reduce the intake of vegetables and food which are rich in vitamin K, as it will counter the effect of warfarin.

Foods rich in vitamin K (generally):

Dark green vegetables (spinach, mustard, broccoli, etc)
Cabbage
Soya bean
Peanuts
Alcohol

Of course, you are not advised to stop taking them at all (except for alcohol, you can totally avoid it). You need them to provide you other nutrients.

My advice is to take them in small amount, and in fixed amount, everyday.

OK. That's all for now about warfarin. Thanks

Warfarin (Part 1)

2009-07-10T20:34:00.006+08:00

This post is specially designed for those taking warfarin (well, this is going to be very text book material).

First, why your doctor prescribed you warfarin?

You need to take warfarin when you have a medical condition which need an anticoagulant to reduce clotting, thrombosis and embolism (abnormal formation and migration of blood clots), which are atrial fibrillation (AF), in the presence of artificial heart valve, deep vein thrombosis (DVT), pulmonary embolism, post myocardial infarction (MI - heart attack), etc.

Now the question comes to: Why need to reduce clotting, thrombosis and embolism?

If a blood clot (thrombus) is formed, it might migrate to a spot where it blocks blood supply to vital organs (embolism). Therefore, as high risk patients (which your doctor will evaluate the risk), you need to take warfarin to prevent the future blood clot from forming in your body.

Of couse, your body also need the formation of blood clots. This is how our body response to protect us from excessing bleeding; for example, when we cut ourselves.

As you need blood clot to protect yourself, and you don't want it to kill yourself, you need a balance. That is why the international normalized ratio (INR) comes in.

INR is the measurement of therapeutic effect of warfarin. Normal value for normal people is in between 0.8 t0 1.2. For high risk patients, the INR will be targetted higher, depends on the condition. It tends to be 2 - 3 in most conditions, but it will be up to 2.5 - 3.5 in patients with mechanical heart valve(s). Optimizing INR is important to ensure the achievement of desired therapeutic effects without risking dangerous side effects such as bleeding.

Targeted INR is obtained through the dosing of warfarin. However, it is a complicated process as it will be interacted with many commonly used medications (I'm sure those who need to take warfarin, need to take many other medications as well), and also with the chemicals present in the foods.

So, your INR might change from time to time, even though you are taking the same dose all along. Therefore, you need to follow up with your doctor and pharmacist, to get INR check from time to time, depends on your appointment. If the INR is maintained, the dose will be maintained. If not, your doctor will decide to change dose or not. At the same time, your pharmacist will assess your compliance, and also other factors that might affect the INR, then only decide change dose or just get rid of the factors that affect the INR.

So, constantly follow-up is important when you are taking warfarin!

(Next post will talk about warfarin administration, precautions and advice on lifestyles)

Is there such thing as better antipsychotic?

2009-06-05T16:57:00.003+08:00

The latest results from the European First Episode Schizophrenia Trial (EUFEST) show that when it comes to improving cognition in patients with schizophrenia, there is little difference between antipsychotic agents.

The randomized trial shows that a relatively low dose of haloperidol, a first-generation antipsychotic, is as effective as 4 second-generation antipsychotics, including amisulpride, olanzapine, quetiapine, and ziprasidone in moderately improving cognition among patients experiencing a first episode of schizophrenia.

So, if you are a doctor trying to decide which antipsychotic to use in order to 'restore' the cognition in your patients, 'generation' thingy, is not a point anymore. It will be more to pharmacoeconomic, and side effects.

Talking about side effects, earlier this year, there's a study shows that all second-generation drugs induced fewer extrapyramidal adverse effects than haloperidol (even at low doses), but only clozapine, olanzapine, and risperidone had induced fewer extrapyramidal adverse effects than low-potency, first-generation antipsychotics.

Which means, the classification of first and second generation antipsychotics, is actually confusing and should be abandoned. Actually, the so-called 'second generation antipsychotics' differ in many properties, including efficacy, side effects, cost, and pharmacology, they do not form a homogeneous class, and, basically, neither do first-generation drugs.

So, the glamorous bubbles created by pharmaceutical companies on second generation antipsychotics, is bursting, like the economy in Wall Street.

Time for us to think about the newer drugs in the market, all the so-called more superior drugs than the older one. Are they all as effective as the companies claimed?

References:

Davidson et al. Cognitive effects of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: a randomized, open-label clinical trial (EUFEST). Am J Psychiatry 2009; 166: 675-682
Leucht S, Corves C, Arbter D, Engel RR, Li C, Davis JM. Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet 200810.1016/S0140-6736(08)61764-X.

Triglyceride, Cholesterol, and now Amputation

2009-05-22T21:19:00.002+08:00

Fenofibrate. Ever heard of that? As the name suggest, it's a member in fibrates group, with better safety profile than gemfibrozil.

It has been known as a drug to lower down LDL and most importantly, triglycerides. Now, seems like it has a new role: To lower the risk of amputation in type 2 diabetic patients.

FIELD study showed that amputation risk (first amputation) in type 2 diabetic patients was lower by 36% in patients assigned with long-term fenofibrate, compared with placebo.

For minor amputation events without known large-vessel disease (myocardial infarction, angina, coronary revascularisation, stroke or peripheral vascular disease), fenofibrate reduce the risk by 47%, compared to placebo.

However, for the risk of major amputations, there are no difference between these 2 groups.

The treatment effects of fenofibrate in FIELD study were irrespective of the level of glycaemic control and background use or not of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. In Heart Protection study, it showed no difference in amputation rates between groups, despite substantial reductions in total cholesterol and LDL cholesterol levels, and modest changes in triglyceride and HDL cholesterol levels. These findings suggest that the effect of fenofibrates in reducing amputation risk is non-lipid mediated, and beyond blood pressure and glycaemic measures.

These findings, could lead to a change in the standard for the prevention of diabetes-relate amputations.

References:

Kushwin Rajamani et al. Effect of fenofibrate on amputation events in people with type 2 diabetis mellitus (FIELD study): A prespecified analysis of a randomised controlled trial. The Lancet 2009; 373: 1780 - 1788.
Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetis: a randomised placebo controlled trial. The Lancet 2003; 361: 2005 - 2016

Reflection

2009-05-22T09:54:00.006+08:00

Finally, I am rotated to 'Clinical Pharmacy' after so many months of training.Exciting!

What had I learnt in the ward? Well, it's that I don't know enough, pharmacotherapeutically!

You must be wondering: 'What? 4 years of university education, and this is your feedback?'

Yes. Honestly, yes. And fortunately, I still have the time to catch up (since I'm still under training).

4 years of university training, is really something, but it's not everything, I suppose. It's not the end of education, it's just the beginning everything, to be a pharmacist.

The knowledge we grabbed in university, might be outdated by the time we graduated. And in fact, what knowledge? You might be wondering, what knowledge what've gained from the 4 years? Many of us, surely, will said the so-called 'knowledge' are those unnecesarry junks that we memorised during the exam seasons, and right away after the exams, all the so-called 'knowledge' will be reformatted, and the brain will back to square one.

If really so, why are we wasting our precious 4 years time in university? To get 'emo' (during exam seasons)? To experience more frustrations in life (after exam, when looking at the result slips)? To have sleepless nights (during exam seasons and assignments due dates)?

Looking back those days, it was a bit childish. We tend to blame every 'bad fortunes' in those years to the heavy workloads the course offered us. Complaining it's 'stressful', 'no life', 'inhuman' and so on. We actually did not see how the real world works. We were just a bunch of spoilt kids, complaining about nothing. We said nobody understand us and the pain is just too big for us to bear. Actually, were we even in pain?

Looking at the patients in the ward, they are struggling with real pain (pain caused by myocardial infarction, you can't compare it with our so-called 'pain' during exam season), and yet they do not complaining about life. They just pray that they can recover faster, and carry on with their life.

To help those patients? Well, I'm still a 'noob' in the ward. To communicate effectively with the doctors to provide better pharmacotherapy to the patients? I should. That is what pharmacists do!

We always complaining that in Malaysia, pharmacists have limited role in the ward. Yes, it's true for now. Cause we don't have enough knowledge to empower us to have a significant role in the ward. However, we don't have to give out on ourselves.

We can do better by continuously learning throughout our career:

Humbly learn from doctors about the clinical knowledges, so we can communicate effectively with them.
Dedicated ourselves to learn more about drugs, so we can provide informations that doctors don't know or not aware of.
Learning to communicate with different types of patients, so we can counsel them in more effective ways.
...... (Still in progress of thinking, will update more in following posts)

I think, most powerful skill that I acquired in university, is the skill of learning, means: Learning how to learn.

Knowledge that we are having now, will surely be outdated, but the skill of learning, will not.

While we are complaining that the university did not prepare us enough (which university will, by the way?), why not we use the skill of learning that we learnt during university days, to obtain more knowledge, to empower ourselves, to improve our role as a pharmacist?

I pray, one day, pharmacists in Malaysia will shine and be more constructive, and no longer complaining this and that. What we are now, is the result of what we have done in the past. Since we can't change the past, why not we try to change our future?

Health

2008-11-28T09:43:00.002+08:00

It's been a while I didn't update my health blog.

Today, I just want to simply talk about health.

Health comes free. But, it does not last forever. Like it or not, you won't stay healthy forever, if you don't maintain it. Health is something we need to handle with care. But very often, we just ignore it. We take health for granted all the time, until the day we lost it.

We as modern materialistic human are very strange. Every a few months, we will spend quite some amount of money to service our cars, motocycles, air-conditioners, etc. And we often spend extra for high quality maintainence. But when come to health, we are very very stingy.

Many of us don't really care about the foods we eat. We grab anything cheap to eat, to fill our stomach, so the stomach won't make noise. We never really care about the nutrients that the foods provide us with.

Usually, those foods that we can grab easily and cheaply around us, are made of only starch, oil, flavoring and coloring. Essential nutrients are just hardly existed in those foods. Plus, the foods might contain high amount of trans fat, and the sugar levels are just way too high.

We don't care. We only want to keep moving. We want it fast!

In this way, we actually are losing our health faster (so, be careful with what you wish, hehe)

We may save a lot all these years, but not being choosy in foods. When we found out we lack of certain nutrients in our diet, we don't even bother to take supplements to compensate back. Cause we 'feel' alright. Through that, wow, we actually do save a lot.

Don't forget those diabetes patients, hypertension patients also 'feel' alright with their body most of the time.

So, one day, we finally lost our health, developed some chronic diseases like those I mentioned just now. And yes, that will be the time, we will use the money we saved all those years, trying to get back the health.

But it's too late. Health, once it's gone, it's gone forever.

You can control the chronic disease, but never again, to get back the quality of life.

That will be the time, we start to realise, how important to maintain our own body, instead of our cars and houses.

10 Rules for Safer Drug USe

2008-08-27T11:37:00.005+08:00

I'll continue with the series of rules, to 'educate' the readers on healthcare. This time, 10 rules for safer drug use:

#1: Discuss with your primary doctor, about all the drugs that you are taking
The purpose of the discussion is for you and your doctor to keep an ongoing record of all drugs you are using, the purposes for which they are being used, adverse reactions, whether the drug is working, and other information essential to the safest and most effective use of these products. It will be better if you also tell you doctor the over-the-counter (OTC) products that you are taking.

#2: Make Sure Drug Therapy is really Needed
Whenever possible, lifestyle modification is best to be tried out before carried on to drug therapy. Some psychological problems, are best to be deal with psychotherapy.

#3: If Drug Therapy is Indicated, in most cases, especially in Older Adults, it is Safer to Start with a Dose that is Lower than the Usual Adult Dose
Start low, go slow. A lower dose will cause fewer adverse effects, which are almost always related to dose. Increasing the dose slowly and only if necessary to get the desired effect.

#4: When Adding a New Drug, See if It Is Possible to Discontinue Another Drug
If your doctor is considering adding a new drug, this is an opportunity to re-evaluate existing drugs and eliminate those that are not absolutely essential. The possibility of an adverse drug interaction between the new drug and one of the old ones may lead to discontinuing or changing the use of a drug.

#5: Stopping a Drug is as Important as Starting It
At least every 3 to 6 months, regularly review with your doctor the need to continue each drug being taken. For many mind-affecting drugs, such as sleeping pills, tranquilizers, and antidepressants, and for antibiotics, this re-evaluation should be more frequent and sooner. Many adverse drug reactions have been caused by continuing to use drugs long after they are needed. Many drugs such as antidepressants, sleeping pills, tranquilizers, and others that are prescribed for an acute problem are not needed beyond a short period and cause risks without providing benefits. Slow and careful weaning off these drugs may significantly improve the user’s health.

#6: Find Out if You are Having any Adverse Drug Reactions
If you develop any side effects after beginning to use any drug, contact your doctor, immediately!

#7: Assume that any New Symptom You Develop after Starting a New Drug may be caused by the Drug
Same with rule #6, contact your doctor if you have a new symptom.

#8: Before Leaving Your Doctor’s Office or Pharmacy, Make Sure the Instructions for Taking Your Medicine are Clear to You and a Family Member or Friend
Do not afraid to look stupid. It is important you are understanding about the drugs you are taking.

#9: Discard all Old Drugs Carefully
Do not, ever, give drugs, such as antibiotics, to a friend or relative who you believe may benefit from them. Drug therapy is individualized, and the drugs that are benefit you might harm your friend or relative. Keeping the drugs in safe place, or discard the old drugs carefully can also prevent children from getting them. It is dangerous to let children get access of them, as they might take it like candy.

#10: Ask Your Primary Doctor to Coordinate Your Care and Drug Use
If you see a specialist and he or she wants to start you on new medicines in addition to the ones you are on, check with your primary doctor first. It is equally important to use one pharmacist, if possible.

7 Deadly Sins for Prescribing

2008-08-25T11:25:00.003+08:00

Recently, many prescriptions are wrong, either entirely unnecessary or unnecessarily dangerous. Inappropriate prescribing is causing risks outweigh the benefits, thus conferring a negative health impact on the patient.

This post especially for doctors who prescribe, and pharmacists that should be the prescriptions: The 7 Deadly Sins for Prescribing. It's just a reminder for healthcare professionals to carry on their duty more carefully.

Sin #1: The “disease” for which a drug is prescribed is actually an adverse reaction to another drug.
Sometimes, doctors are unable to identify which 'disease' is caused by side effects of certain drugs, maybe due to lack of experience, or knowledge on drugs. Instead of lowering the dose of the offending drug or replacing it with a safer alternative, the doctor adds a second drug to the regimen to “treat” the adverse drug reaction caused by the first drug. Pharmacists play an important role here to help to doctor in identifying the 'diseases' caused by drugs.

Sin #2: A drug is used to treat a problem that, although in some cases susceptible to a pharmaceutical solution, should first be treated with commonsense lifestyle changes.
Doctors should recommend lifestyle changes as the first approach for some conditions like insomnia, high blood pressure and so on, rather than automatically reach for the prescription.

Sin #3: The medical problem is both self-limited and completely unresponsive to treatments such as antibiotics or does not merit treatment with certain drugs, and yet the doctor still prescribing drugs to 'treat' it.
This is seen most clearly with viral infections such as colds and bronchitis in otherwise healthy children or adults.

Sin #4: A drug is the preferred treatment for the medical problem, but instead of the safest, most effective—and often least expensive—treatment, the doctor recommends the much less preferable alternative (less or equal effective, but much more expensive).
This situation most likely when the doctor can get more incentive from the less preferable alternative.

Sin #5: Two drugs interact. Each on its own may be safe and effective, but together they can cause serious injury or death.
Pharmacists should help doctor to check out the serious drug-drug interaction.

Sin #6: Two or more drugs in the same therapeutic category are used, the additional one(s) not adding to the effectiveness of the first but clearly increasing the risk to the patient.
Again, the role of pharmacists is important for combat this problem.

Sin #7: The right drug is prescribed, but the dose is dangerously high.
This problem is seen most often in older adults, who cannot metabolize or excrete drugs as rapidly as younger people. This problem is also seen in small people who are usually prescribed the same dose as that prescribed to people weighing two to three times as much as they do.

For doctors, to prevent yourselves from sinning, should humbly consult pharmacists concerning drugs issues. Nowadays, healthcare professionals work as a team, no longer the traditional solo act. When necessary, doctors should consult dietitians, nutritionists, physiotherapists, and many other healthcare professionals, too.

Dietary Supplements

2008-08-22T12:18:00.007+08:00

Today, I want to talk about dietary supplements, in general.
First thing is: What are dietary supplements?

Dietary supplements are:

Vitamins and minerals products
'Botanical' or Herbal products
Amino acid products
Enzyme supplements

Why dietary supplements existed? Well, they are designed for those who seek to compensate the essential nutrients that they lack of due to the limitation of their daily diet, caused by diets, medical conditions, or eating habits. Some take dietary supplements to boost energy; or for 'anti-aging' purpose.

Is everyone need dietary supplements? The answer is: If you are having a healthy diet without special medical conditions that limit your various type of foods intake, you don't need one. And, even if you need one, you better consult a healthcare professional, to see which one you need.

Some general advices are:

Dietary supplements are not intended to treat, diagnose, cure, or alleviate the effects of diseases

They cannot completely prevent diseases, as some vaccines can. However, some supplements are useful in reducing the risk of certain diseases, but please note that: REDUCING THE RISK only!

Using supplements improperly can be harmful

Taking a combination of supplements, using these products together with medicine, or substituting them in place of prescribed medicines could lead to harmful, even life-threatening, results.

Some supplements can have unwanted effects before, during, or after surgery

For example, bleeding is a potential side effect risk of garlic, ginkgo biloba, ginseng, and Vitamin E. Therefore, before surgery, you should inform your health care professional about all the supplements you use.

For healthcare professionals:
Do not ignore the use of dietary supplements among the public. Be updated on dietary supplements so that you are able to discuss with your patient about it, and give them proper advice.

For public:

Let your health care professional advise you on sorting reliable information from questionable information.
Be aware that some supplement ingredients, including nutrients and plant components, can be toxic. Also, some ingredients and products can be harmful when consumed in high amounts, when taken for a long time, or when used in combination with certain other drugs, substances, or foods.
Do not self-diagnose any health condition. Work with healthcare professionals to determine how best to achieve optimal health.
Do not substitute a dietary supplement for a prescription medicine or therapy, or for the variety of foods important to a healthful diet.
Do not assume that the term "natural" in relation to a product ensures that the product is wholesome or safe.
Be wary of hype and headlines. A proper health advice is generally based upon research over time, not a single study.
Learn to spot false claims. If something sounds too good to be true, it probably is.

6 Rules: For the Patients

2008-08-20T08:54:00.007+08:00

Previously, I talked about 6 rules for healthcare professionals, by Dr Rob. Now, he came out with another 6 rules, this time is for the patients.

1. The healthcare professional that you consult, he/she can't do it alone
Be it doctor, pharmacist, or dietitian, no matter how good they are, if you ignore the instructions given by them, the problem you are facing, will be quite impossible to be settled. Although sometimes, not following the instruction is due to the unclear explanation given by the healthcare professional. However, it is good that you voice up if you do not understand. Healthcare professional doesn't have ability to read your mind, to know whether you understand or not. And also, if you do not feel like following the instruction, all you have to do is just say it. Then together, you and him/her discuss about other plan.

2. Be honest
Do not be embarrassed about the truth. Your symptoms might be strange, maybe involving your private part. But, there is no any good reason to hide these from the healthcare professional that you are looking for. If you consult them, and don't tell them the whole truth about your health condition, how are they suppose to help you? An ethical, professional doctor/pharmacist/dietitian/etc won't judege you as strange or weird patient. Just give the facts, then you will have best chance to get your desire outcome.

3. They don't play favourites
The professionals one, treat every patient equally, as overly liking or disliking a patient will cloud their judgment. So, do not ask for special treatment. If you get one, well, he/she might have special emotion on you, and very high likely that you won't get the best treatment from him/her, as their judgment already impaired by the special emotion on you. So, if you want to play favourites, you are actually playing with fire.

4. Don’t mess with the staff
Well, maybe in your mind, the hero is the doctor/pharmacist/dietician/etc, and the rest are nothing. So, when you go inside the office, you mess with them, abuse them, showing your prince/princess attitude. What you might not know is: The staff and the healthcare professional are teammates in treating your condition. The staff is the greatest asset the healthcare professional having. They are valuable and the healthcare professional cannot afford to lose them. They are more valuable than you as a single patient. If you mess with the staff, you are actually posing a high risk on getting second class treatment from the whole team.

5. If you don’t trust, leave
People go to the healthcare professionals because they have unique knowledge and experience. They can help to solve your health problems. When you go to a healthcare professional you don’t trust, you will be suspicious about every bad outcome and won’t even trust when things go well. There will be no-win situation for both of you. You are both wasting actually wasting each other's time. Find the one that you trust! However, trusting does not mean you should not ask questions. The one who does not want to be questioned is one you should not trust. Questioning is often the only way to build trust. Unanswered questions tend to undermine trust.

6. No news might be bad news
Never assume that your doctor will call you if there is a problem. They are busy people, and they order hundreds of tests every week. They just cannot keep track of all of them. If you don’t get your test results, call!

You may be fat, but you may be healthy, too

2008-08-15T10:20:00.004+08:00

For all the healthcare professionals, don't assume all your obese patients are unhealthy. Don't judge before you do lab test on their blood.

For those who are obese, don't be hopeless on your health, you may be as fit as the normal weight people!

Based on USA's national health data collected from 5,440 adults, it was shown that weight often is not a reliable indicator for health.

In the study, 6 metabolic components were viewed as indicators of cardiovascular health:

Blood pressure
Triglycerides level
Fasting glucose
High-sensitivity C-reactive protein
Insulin resistance
High-density lipoprotein cholesterol (HDL-C)

For 1 - 5, elevated means abnormal; for 6, lower means abnormal.

For a metabolic healthy adults, they have 0 to 1 metabolic abnormalities; while for a metabolic unhealthy adult, they have 2 or more metabolic abnormalities.

The result, from the 5, 440 adults, 23.5% normal weight adults were metabolically abnormal; while 31.7% of obese adults were metabolically healthy.

Which means: You are not necessary cardiovascularly healthy even if you have normal weight; and you are not necessary cardiovascularly unhealthy even if you are obese.

If you want to know you are metabolically healthy or not, the more proper way will be checking your blood, the 6 metabolic components mentioned above.

So, take away weight issue, behavioral factors play an important role:

Cigarette smoking
Physical activity
Alcohol intake

These factors have more role in altering your metabolic normality in your body.

In addition, role of excessive adipose tissue also still unclear. Adipose tissue is not just a bunch of useless tissue, they are endocrine organ, secreting a variety of hormones and cytokines. Excessive adipose tissues believe to disturb the metabolic pathway in obese people. However, this study showed that this theory may not be completely correct.

One third of the obese people were metabolically healthy, so what is the role of excessive adipose tissue in their body? They are either less responsive to the excessive endocrine secretions; or their adipose tissues do not possess the same endocrine secretory properties of those obese individuals who develop metabolic disorders.

This, lead to a possibility that instead of excessive, the position of the adipose tissue accumulation play a more important role in determining whether a person has higher risk of developing metabolic abnormalities.

Don't get too depressed or happy about your weight, most importantly, you are having a healthy lifestyle:

Be active
No ciggarette
Moderate alcohol intake
Healthy diet
Enough sleep

Reference:

Rachel P. Wildman et al. The Obese Without Cardiometabolic Risk Factor Clustering and the Normal Weight With Cardiometabolic Risk Factor Clustering. Arch Intern Med 2008; 168:1617-1624.

6 Steps that a Diabetic Patient should Take

2008-08-13T10:57:00.009+08:00

Diabetes mellitus is a serious disease. It's not a simple disease; it's a disease with hell a lot of complications, affecting from head to toe of your body.

Nowadays, more and more people are diagnosed with diabetes, especially type 2 diabetes mellitus. We must create more awareness on how to deal with diabetes, from prevention to management. Here, I want to point up 6 steps that a diabetic patient (especially the newly diagnosed) should take:

1. Get a primary-care doctor
Sign up with a primary-care doctor who can work with you on regular basis to keep your blood pressure, blood sugar, and cholesterol levels within recommended guidelines.

2. Get educated
Find a diabetes educator (perhaps, a trustful pharmacist) in your area to help you learn about the disease. The more you know about the disease, the more you are in control.

3. Exercise
Perhaps, this is one of the hardest part. If you do not need to lose weight, 30 minutes per day at most days of the week will be enough. If you need to lose weight, you probably need 1 hour per day at most days of the week. Well, it will be great if you can exercise more than that. Exercise can help in increasing insulin sensitivity, and of course, burn some calories.

4. Take the drugs you need.
Well, I should not discuss about what drugs you should take, as it will be decided by your doctor. Most importantly: Take the drugs as directed; and discuss with the doctor if you have difficulty taking the drugs, or if you are taking other drugs/herbal products.

5. Make a plan for regular specialist checkups.
Besides blood pressure, blood sugar, and cholesterol levels, you shall never forget eyes, feet, and teeth. As I said, diabetes has lots of complications affecting from your head to toe. You can discuss with your primary care doctor on which specialists to refer to.

6. Involve your friends and family
It's quite impossible to make lifestyle modification if everybody that are close to you is doing something else. And also, you need their supports and motivations, to fight with diabetes.

Simvastatin + Amiodarone = Bad Combination

2008-08-11T12:37:00.004+08:00

New warning from USFDA on 080808: When simvastatin is used with amiodarone, the patient will be exposed to higher risk of getting rhabdomyolysis.

Amiodarone is used to control a heart rhythm problem and simvastatin is used to lower cholesterol.

Cordarone (amiodarone) tab 200mg

Rhabdomyolysis:
The breakdown of muscle fibers resulting in the release of muscle fiber contents (myoglobin) into the bloodstream. Some of these are harmful to the kidney and frequently result in kidney damage. (definition from Medlineplus)

This risk is dose-related and increases when a dose of simvastatin greater than 20 mg per day is given with amiodarone.

Before this, the warning on rhabdomyolysis caused by combination of simvastatin and amiodarone was already there. However, following the warning, serious reports of rhabdomyolysis were still keep coming in when amiodarone is used with simvastatin, especially when the doses of simvastatin greater than 20 mg daily.

Compared to other statins, the risk of rhabdomyolysis is more pronounced when simvastatin is administered with amiodarone.

In fact, all statins carry a potential risk of rhabdomyolysis, whether or not they are administered with amiodarone.

It's Statin again!

For healthcare professionals:

When prescribing simvastatin or simvastatin-containing medications, ASK whether the patient is taking amiodarone or not.
If the patient is taking amiodarone, MAKE SURE the doses of simvastatin are NOT more than 20mg daily.
TELL the patients to come back to you when they are experiencing any unexplained muscle pain, tenderness or weakness.

For the public:

TELL the doctors or pharmacists in charge about ALL the medications that you are currently taking (including over-the-counter, or herbal products)
ASK about the medications that the doctors prescribed, or the pharmacist dispensed to you.
BE AWARE of your own body, when you are experiencing any unexplained muscle pain, tenderness or weakness, please go back to the doctor!

6 Rules

2008-08-09T11:53:00.004+08:00

I read a post from Dr. Rob. About 6 rules that doctors need to know.

Well, i think, it's useful for all healthcare professionals.
I use the 6 rules and put my own explanations, to present them to you:

Rule #1: They don’t want to be at your office.

For healthcare professionals, it's normal to be in hospitals, clinics, pharmacy stores and so on. For patient, that will be their rare event, and most of them, don't want to be in. And, they surely prefer not to come back and see you again.

Rule #2: They have a reason to be at your office.
When a person in your office, and he has 'business' with you, most probably, it ain't good for them. Remember, only people who need health advice need to come see you, and most of them, are being sick. And nobody want to get sick (even you). And sick people, definitely, is not in a good mood.

Rule #3: They feel what they feel.
They may not necessary come with 'the right set' of symptoms when coming to see you. The symptoms may not fit the set that you study in the text book, and you may think that they make no sense at all. But, you should trust your patients and help them to analyze deeper in their symptoms. If you do not trust them, it's impossible for them to trust you back. Without trust, the meeting between the healthcare professional and the patient become meaningless.

Rule #4: They don’t want to look stupid.
Or, they don’t want you to treat them like they are stupid. Well, nobody wants to look stupid (including you). So, when you do your explaining to the patient, make sure you use the language that they can understand (probe their education level before explaining will be a nice move). Because, to avoid being stupid, very high likely they will act like they understand your medical terms, even if they don't, at all.

Rule #5: They pay for a plan.
What the patient pay for is a plan of action, a solution. They want to know what is going to be done to help. What medications are given and why? What medications are to be stopped? What tests are ordered and what will the results mean? When is the next appointment? Who should they call for if they have problems? These are not irritating questions. The patient has the right to know all these. The reason why you feel irritated is because you don't know how to answer them. And when that is the reason, you should start to review your own competency.

Rule #6: The visit is about them.
It's not about you and what you think. Your role is to give a plan of action to them, but in the end, it's them who decide whether want to accept your plan or not. If can't, the plan should be review, together with the patient, for a more personalized plan. You cannot force them to do what they don't want to do. It's about them, and you shall not judge (you can only diagnose).

Vitamin C to Shrink Tumour

2008-08-07T09:28:00.006+08:00

Vitamin C, or we call it ascorbic acid is an essential nutrient commonly regarded as an antioxidant, protecting cells from the damaging effects of free radicals.

There's a new study showed that vitamin C can slowed tumour growth by half. Maybe, you want to start relate to the antioxidant effect again, the protecting from free radicals, and so on.

Well, I must tell you: This time, the legendary vitamin C, acts as pro-oxidant!

It's a research from the National Institutes of Health (NIH), USA, showing that vitamin C at pharmacologic concentrations was a pro-oxidant, generating hydrogen-peroxide-dependent cytotoxicity toward a variety of cancer cells in vitro without adversely affecting normal cells.

While in vivo, the researchers injected immune-deficient mice with cells from three aggressive human cancers – ovarian and pancreatic tumours, plus a form of brain cancer called glioblastoma – and found that vitamin C injections slowed tumour growth by up to 53%.

The untreated and ascorbate treated mice showing effects of injected vitamin C

The injections were important, when we take vitamin C supplements or eat foods containing vitamin C, natural physical controls regulate the amount of vitamin C our bodies are able to absorb. Means, we can never achieve pharmacologic plasma concentration of vitamin C through orally.

When you eat foods containing more than 200 milligrams of vitamin C per day day (for examples, lots of oranges), your body will prevent the plasma concentration of vitamin C from exceeding a narrow range.

The dose they use in the study, was up to 4g/kg of bodyweight, which can be achieve only by bypassing the normal controls, through injecting vitamin C into the veins or abdominal cavities of the body.

The researchers discovered that vitamin C's anti-cancer effect is due to the formation of hydrogen peroxide (a common disinfectant) in the fluid surrounding cells in the tumours. However, normal cells were unaffected.

A reminder: The study was done on MICE. So, to apply it on human, it needs more time.

For desperate patients, DO NOT start taking large doses of the vitamin C after reading this article. That may be dangerous, because vitamin C when taken orally, is acting as anti-oxidant, and it could undermine the effectiveness of standard cancer drugs and radiation therapy.

The anti-cancer effect of vitamin C in this study is using pharmacological dose of vitamin C, intravenously!

Reference:

Qi Chen et al. Pharmacologic doses of ascorbate act as a prooxidant and decrease growth of aggressive tumor xenografts in mice. PNAS 2008; doi: 10.1073/pnas.0804226105

Cough and Cold Medication for Children

2008-08-06T11:30:00.002+08:00

Paediatric cough and cold medications are widely available in Malaysia, but the patterns of use among children are unknown.

The lack of these information leads to the underappreciated serious adverse events (maybe even death events) among the children due to cough and cold medications.

Cough and cold medications include those contains antitussive (dextromethorphan), decongestant (pseudoephedrine), expectorant (guaifenesin) and/or antihistamine (diphenhydramine) as active ingredients, be it alone, or in combination.

Some of them are sold as over-the-counter (OTC) products, and some are kept behind pharmacy counters.

In Malaysia, the safety concern on cough and cold medication is not widespread yet.

For your information:

Before consulting doctor, children less than 2-year-old should not be given any cough and cold medication.

In addition, there are no data supporting the efficacy of cough and cold medications in children.

So, children, are at risk of dosing errors in cough and cold medications. Because of the lack of clinical and pharmacological studies of children, most paediatric dosages are extrapolated from adult data.

One thing to keep in mind is: Children's body are physiologically slightly different from adults, as some of the organs are not fully developed yet, such as kidney and liver.

So, for the public:

Before you buy the cough and cold medications for your children, please consult pharmacist or doctors.

Estrogen for Schizophrenia

2008-08-05T10:26:00.009+08:00

Seems like estrogen has more and more roles as time goes by.

Now, we can use it for the treatment of schizophrenia. An Australian study in the Archives of General Psychiatric showed schizophrenic women who get an estrogen patch along with their regular antipsychotic medications have fewer symptoms than women who get inactive placebo patches.

It's a randomized, double-blind study, involving 102 women of childbearing age with schizophrenia. All participants were in an acute or chronic phase of their illness.

Patients were randomized to receive 100 µg of transdermal estradiol {the most important form of estrogen in the body} (n = 56) or transdermal placebo (n = 46) for 28 days.

Psychopathological symptoms were assessed weekly on their positive and negative symptoms. (Schizophrenia is often described in terms of positive and negative symptoms.)

Positive symptoms (Psychosis):
Delusions, auditory hallucinations, and thought disorder

Negative symptoms (Depression):
Poverty of speech, inability to experience pleasure, and lack of motivation

The results?

The addition of 100 µg of transdermal estradiol significantly reduced positive and general psychopathological symptoms during the 28-day trial period compared with women receiving antipsychotic medication alone.

However, the estrogen did not help in improving negative symptoms. In fact, negative symptoms are naturally less responsive to therapy and require longer-term care.

Actually, the link between estrogen and mental illness was recognised through observation for quite some time already:

The female sex hormone estrogen has important effects on chemical signals in the brain, and these signals go haywire in schizophrenia.
Women's first episodes of schizophrenia occur later in life than men's, suggesting a protective role for estrogen.
In women, schizophrenia symptoms often appear just after childbirth and during menopause, when estrogen levels drop.
Women with schizophrenia often relapse during the low-estrogen phase of their menstrual cycles.

Estrogen, besides its actions as a sex hormone, it plays many roles in the brain. As estrogen found abundantly in women, it's not wrong for us for say women are complicated (HeHe).

So, with the result obtained from the study, and the observations throughout the years, some experts said if given over short periods, estrogen therapy may be useful in women with schizophrenia after childbirth or menopause, when women with the disease are more prone to relapse. It may also be useful during low-estrogen phases of a woman's menstrual cycle.

However, we have to bear in mind that this is a small study and it needs to be followed up with further research (more larger-scale, longer term studies) before we can recommend the use of estrogen in schizophrenic women patients.

Reference:

Jayashri Kulkarni et al. Estrogen in Severe Mental Illness: A Potential New Treatment Approach. Arch Gen Psychiatry 2008; 65: 955-960

Introduction to Stress

2008-08-04T10:08:00.007+08:00

Well, today I want to talk about stress, briefly, text-bookly.

We all have stress, sometimes (or all the time).

What we should know that stress is individualized. What causes stress for you may not be stressful for someone else.

Acute stress could be helpful. It can encourage you to meet a deadline or get things done. However, chronic stress can increase the risk of diseases like depression, heart disease and a variety of other problems.

How our body response to stress?

Our body have a stress circuit, that is hypothalamic-pituitary-adrenal (HPA) axis. HPA axis is a feedback loop by which signals from the brain trigger the release of hormones needed to respond to stress.

These compounds include epinephrine , norepinephrine and cortisol. Epinephrine increases blood pressure and heart rate, diverts blood to the muscles, and speeds reaction time. Cortisol, also known as glucocorticoid, releases glucose from the body reserves so that this essential fuel can be used to power the muscles and the brain.

Normally, cortisol also exerts a feedback effect to shut down the stress response after the threat has passed, acting upon the hypothalamus and causing it to stop producing corticotropin-releasing hormone (CRH).

#CRH's role is to trigger more release of cortisol

Therefore, acute stress may cause:

Emotional distress (irritability, anxiety, and depression)
Muscle problems (tension headache, back pain, jaw pain)
Gastrointestinal problems (heartburn, gastritis, flatulence, diarrhea, constipation, and irritable bowel syndrome)
Cardiovascular effects (high blood pressure, palpitations, sweaty palms)

But, it doesn't have enough time to do the extensive damage to the body.

Now we look at the chronic stress. Long term exposure to the cortisol may cause serious damage to our body.

First, your body will be immunosuppressed (means your immune system will be down). When you are immunosuppressed, you are more prone to get various type of infectious diseases, and also, the risk of getting cancer is higher.

Then, cortisol is lowering down your body's insulin sensitivity. Means your body might not respond so well to insulin, causing the glucose level in the blood higher than normal. In long term, you will have higher risk of getting diabetes mellitus.

Next, long term exposure to cortisol also will cause osteoporosis.

In addition, it will also cause hyperlipidemia (high cholesterol level). Together with high glucose level, they are the main risk factors for cardiovascular diseases.

And, chronic exposure to cortisol, may lead you to get depression, chronic insomnia and also mood changes.

For children, the exposure to cortisol in long term, will cause growth retardation. (So, don't give your children so much stress, OK?)

There are many more disorders that stress will bring. So, now, you know that how important is the stress management?

Chikungunya

2008-08-02T10:19:00.008+08:00

According to New Strait Time, by 30th of July, 631 Chikungunya cases were reported in 4 states (Johor, Malacca, Negri Sembilan and Perak ). Of the number, only 15 people (2.4 per cent) had to be admitted to hospitals due to high fever and chronic pain in the joints.

It seems alarming that Malaysia now facing a new threat of disease. So, what is Chikungunya anyway?

In the Makonde (an ethnic group in Africa) language, "chikungunya" means "that which bends up", as joint pains are a major feature of both the acute and the chronic phases of the disease. Why Makonde? Well, the disease first detected there! [1]

First outbreak of chikungunya virus in Malaysia was believed occurred in Klang, between December 1998 and February 1999. The majority of the cases were in adults. Malaysia is heavily dependent on migrant workers from countries where chikungunya is endemic. It is speculated that the virus has been introduced into the country through the movement of these workers. [2]

Chikungunya (Genus: Alphavirus; RNA virus)

Chikungnya involved an African virus (RNA virus) and an Asian mosquito, which reflecting the globalization of vectorborne diseases. The Aisan mosquito involved, is none other than Aedes mosquito. So, if you think Aedes is nothing more than dengue fever, you are wrong! [3]

In fact, Chikungnya's symptoms are similar to dengue fever: fever, joints pain and the tendency of bleeding. Which can be differentiate by further observation of its symptoms, and also performing serology test (in Malaysia, University of Malaya has already developed the serology test).

So what are the symptoms of Chikungunya?

The incubation period of Chikungunya disease is from 2 to 4 days. [4]

Then, patients will have fever up to 39 ℃ (102.2 ℉), red spots or rashes of the trunk and occasionally the limbs, and arthralgia (joint pain) or arthritis (inflammation of the joints) affecting multiple joints. [5, 6] - Acute Phase

Other nonspecific symptoms can include headache, conjunctival injection, and slight photophobia.

Typically, the fever lasts for 2 days and then ends abruptly (dengue fever has longer period of fever).

Patients have complained of joint pains for much longer time periods depending on their age. [5, 6] - Chronic phase (not all patients will have it)

Talking about the treatment, it's kind of... No Specific Treatment!

Well, don't worry much, this disease is self-limiting, means, if the body's immune system is OK, the disease should be gone after a few days or weeks after the symptoms appeared.

The management of the disease includes rest, fluids and medications to relieve symptoms of fever and pain, such as ibuprofen, naproxen and paracetamol. Aspirin should be avoided (may cause refractory arthritis).

Infected patients should be protected from further mosquito exposure during the first few days of the illness so they cannot contribute to the transmission cycle of Chikungunya. [7]

References:

Parola P, de Lamballerie X, Jourdan J, et al. Novel Chikungunya virus variant in travelers returning from Indian Ocean islands. Emerg Infect Dis 2006;12:1493-1499
Lam SK, Chua KB, Hooi PS, Rahimah MA, Kumari S, Tharmaratnam M, Chuah SK, Smith DW and Sampson IA. Chikungunya infection--an emerging disease in Malaysia. Southeast Asian J Trop Med Public Health 2001; 32: 447-451
Rémi N. Charrel, Xavier de Lamballerie, and Didier Raoult. Chikungunya Outbreaks — The Globalization of Vectorborne Diseases. NEJM 2007; 356:769-771
Chhabra M, Mittal V, Bhattacharya D, Rana U, Lal S. "Chikungunya fever: A re-emerging viral infection". Indian J Med Microbiol 2008; 26: 5–12
Simon F, Parola P, Grandadam M, Fourcade S, Oliver M, Brouqui P, Hance P, Kraemer P, Ali Mohamed A, de Lamballerie X, Charrel R, Tolou H. "Chikungunya infection: an emerging rheumatism among travelers returned from Indian Ocean islands. Report of 47 cases". Medicine (Baltimore) 2007; 86: 123–37
Taubitz W, Cramer JP, Kapaun A, Pfeffer M, Drosten C, Dobler G, Burchard GD, Löscher T. "Chikungunya fever in travelers: clinical presentation and course". Clin. Infect. Dis 2007; 45: e1–4
Fact Sheets on Chikungunya. Centers for Disease Control and Prevention, USA

To Pop the Pill, or To Move your Ass?

2008-08-01T09:52:00.011+08:00

It's many people's dream, I know, I know... That you don't have to move, and you will be fit as a tiger (or in this case, a mouse!).

Scientists have found a drug that makes the body fit without the need for exercise (now you can yell: Wow!!!).

Really? But why am I still exercising?

It fools the muscles into thinking they have 'worked out' long and hard, which means they rapidly burn fat and boost fitness.

But well, don't be happy yet, not so fast...

The study was done on mice, only, at least, at this stage. It will be years from now before we can see it on the shelves of 'leading pharmacy stores'.

Yay!

There were two compounds in lab tests in mice. One of those compounds, called GW1516, boosted endurance in mice that exercised, but not in sedentary mice. The other compound, called AICAR, improved endurance in mice that didn't exercise at all.

The research team (included professor Ronald M. Evans, PhD, of the Salk Institute for Biological Studies and the Howard Hughes Medical Institute in La Jolla, California) reported that they boosted endurance (stamina) in mice by tweaking a mouse gene to boost the activity of a protein called PPARδ.

They give GW1516, orally, which boosts PPARδ, into mice's mouths every day for a month. At the end of the month, the mice ran 68% longer and 70% farther than when the experiment began -- but only if they had been running on exercise wheels daily while taking the drug. GW1516 didn't do anything for mice that weren't exercising.

Next compound is the miracle one: AICAR.

The scientists focused on another protein called AMPK (adenosine monophosphate-activated protein kinase). They gave sedentary mice a daily injection of AICAR, which boosts AMPK, for a month.

At the end of the month, those mice ran 23% longer and 44% farther than before starting AICAR treatment. That is, their endurance had improved without working out.

However, the mice tests were all about skeletal muscles and endurance only, not about the drugs' safety or ability to mimic the many other benefits of exercise, such as improving cardiovascular health and making some types of cancer less likely.

Anyway, how GW1516 and AICAR work?

GW1516 increases the production of PPARδ, which boosts the production of muscle fibres which burns fat, instead of sugar, for energy, and increase stamina and endurance.

For AICAR, it boosts the production of AMPK, and AMPK does much more:

AMPK is a metabolic sensor that detects low ATP levels (such as occur during exercise) and in turn increases oxidative metabolism [Mu et al., 2001; Reznick et al., 2006]
Long-term effects of AMPK are in part mediated via regulation of gene expression [Reznick et al., 2006]
Exercise induces activation and nuclear import of AMPK, where it can potentially interact with transcription factors [McGee et al., 2003]
Transgenic mice defective for AMPK activation exhibit reduced voluntary exercise (means it makes you feel like wanna exercise as well!) [Mu et al., 2001; Thomson et al., 2007]

Because of these functions, AMPK can enable your muscle to be fit without exercising. It raises the level of enzyme that gives signal to the muscle cells that the energy is running low and it's time to burn some fat. The enzyme usually produced when we are exercising. But now, you (I mean, mouse, for now) can give the signal by just taking AICAR.

Last but not least, both PPARδ and AMPK can increase the mitochondria (battery of life, which can turn the foods into energy) in the cells.

Wow, really, GW1516 and AICAR really sound miraculous. They are something too good to be true! Next time, you can choose to exercise, or just pop the pill. Life's that simple?

Well, as I mentioned just now, these drugs only beneficial for stamina and endurance of the skeletal muscles. They definitely cannot replace the benefits of real exercise.

And I'm sure that athletes from all around the world are already dripping their saliva over these drugs.

Maybe, these drugs are beneficial for those obesity, diabetes people with medical conditions that keep them from exercising.

After all, these drugs still have long way to go. At least, their adverse effects profile still uknown.

References:

Narkar et al. AMPK and PPARδ Agonists are Exercise Mimetics. Cell 2008; doi:10.1016/
j.cell.2008.06.051 [Original article]
Mu, J, Brozinick, JT, Valladares, O, Bucan, M, and Birnbaum, MJ. A role for AMP-activated protein kinase in contraction- and hypoxia-regulated glucose transport in skeletal muscle. Mol. Cell 2001; 7, 1085-1094
Reznick, RM, and Shulman, GI. The role of AMP-activated protein kinase in mitochondrial biogenesis. J. Physiol 2006. 574, 33-39
McGee, SL, Howlett, KF, Starkie, R.L, Cameron-Smith, D. Kemp, BE and Hargreaves, M. Exercise increases nuclear AMPK alpha2 in human skeletal muscle. Diabetes 2003; 52, 926-928.
Thomson, DM, Porter, BB, Tall, JH, Kim, HJ, Barrow, JR, and Winder, WW. Skeletal muscle and heart LKB1 deficiency causes decreased voluntary running and reduced muscle mitochondrial marker enzyme expression in mice. Am. J. Physiol. Endocrinol. Metab. 2007; 292, E196-E202.

New Warnings for Erythropoiesis-stimulating agents (ESAs)

2008-07-31T10:40:00.008+08:00

USFDA is ordering manufacturers of erythropoiesis-stimulating agents (ESAs) to further restrict their use in treating patients with cancer.

In fact, before this, at 22nd of April, 2008, USFDA already notified these manufacturers to have their additional safety warnings to the labeling of ESAs.

However, Amgen (manufacturer of darbepoetin alfa) did not agree on the statesment of:

ESAs are not intended for use on patients receiving myelosuppressive therapy when the expected outcome is cured. [means ESAs should not be used along with the chemotherapy if the chemotherapy are intended to cure the patients; ESAs should only be used if the chemotherapy is adjunct therapy].
The clear indication of when to initiate and when to discontinue ESAs dosing.

Now, USFDA is ORDERING these manufacturers to put strong Black Box Warning on the products labeling, saying:

The drugs are not indicated for patients undergoing chemotherapy expected to cure their cancer.
The drugs are not suppose to be administered when hemoglobin levels are greater than or equal to 10 g/100ml.
The usage of the drug should stop if the hemoglobin exceeds a level needed to avoid blood transfusion

However, USFDA did not order warnings against giving the drugs to any patient with advanced breast cancer or head and neck cancer, despite a recommendation by an advisory panel in March.

Well, what is ESAs by the way?

They are injectable drugs, genetically engineered forms of a protein, to boost the production of red blood cells.

In Malaysia, ESAs that are available include:

darbepoetin alfa
epoetin alfa (Eprex)
epoetin beta (Recormon)

They are used for anemia in chronic kidney failure (epoietin alfa) and also cancer patients (darbepoetin alfa).

Anemia is a condition where there is a lower than normal number of red blood cells in the blood, usually measured by a decrease in the amount of hemoglobin. Hemoglobin is the oxygen-carrying part of red blood cells. It gives these blood cells their red color.

In fact, ESAs are all the while linked with INCREASED MORTALITY, SERIOUS CARDIOVASCULAR and THROMBOEMBOLIC EVENTS, and TUMOR PROGRESSION.

Full warnings on ESAs (for the use in cancer patients):

ESAs shortened overall survival and/or time-to-tumor progression in clinical studies in patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers when dosed to target a hemoglobin of ≥ 12 g/100 ml
The risks of shortened survival and tumor progression have not been excluded when ESAs are dosed to target a hemoglobin of <>
To minimize these risks, as well as the risk of serious cardio- and thrombovascular events, use the lowest dose needed to avoid red blood cell transfusions
Use only for treatment of anemia due to concomitant myelosuppressive chemotherapy
Discontinue following the completion of a chemotherapy course

I hope MIMS Malaysia can include these warnings in their drug info. I still see the statement of "Treatment may continue for up to a mth after chemotherapy" in the drug info for epoetin beta in their official website.

The usage of ESAs is just to bring back the hemoglobin level to normal level, to avoid blood transfusion. It DOES NOT improve the quality of life of the patient, as it does not improve the symptoms of anemia (such as fatigue, weakness).

So, when your doctor want to start you on ESA, you should discuss with your doctor about:

Why ESA treatment is being prescribed
What are the chances you will get red blood cell transfusions if you do not take ESA
What are the chances you will get red blood cell transfusions even if you take ESA
How taking Epogen may affect the success of your cancer treatment

A competent doctor should be able to effectively discuss with you about these matters.

And during the discussion, you should inform the doctor if you:

Have heart disease
Have high blood pressure
Have had a seizure or stroke
Are pregnant or planning to become pregnant (for woman only)
Are breast-feeding or planning to breast-feed (for woman only)

Plus, you should inform the doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements.

Statins Prevent You from Getting Dementia?

2008-07-30T09:31:00.006+08:00

When you talk about statins, you talk about cholesterol. Well, thing has changed.

A new study suggested that taking statins may help protect against development of dementia in those who are at high risk of dementia.

The study had 1,674 participants and all the participants were free of dementia when entering the study. All participants had cognitive and clinical evaluations performed every 12 to 15 months. 452 participants (27%) took statins at any time during the study.

During this 5-year follow-up, persons who had used statins were about half as likely as those who did not use statins to develop dementia.

However, the result can only establish an association, but not a causal relationship between taking statins and dementia. Even if the preventative effect of statins does exist against dementia, it is not clear if the drugs can be used to treat dementia.

In addition, from the result of the study, we can see that it is possible that cognitive benefits (prevention of dementia) only come with years of statin use.

Some experts suggest that brain permeant (crossing blood-brain-barrier) statins (such as simvastatin) might be far more effective than statins that don't get into the brain (atorvastatin).

In fact, back in 200o, a 6-year-study published in The Lancet already showed such result, that individuals of 50 years and older who were prescribed statins had a substantially lowered risk of developing dementia, no matter they have hyperlipidemia or not; exposed to non-statin lipid-lowering agents or not. The available data do not distinguish between Alzheimer's disease and other forms of dementia.

Difference between these 2 studies: the year 2008 study involved elderly Mexican-Americans; while the year 2000 study involved elderly UK population.

However, as both of the studies are epidemiology studies, the population are not randomized picked, those who taking statins in such studies may be resistant to cognitive decline for reasons other than statin use.

Therefore, for now, it is suggested that people should take statins only for purposes they are originally indicated for, that is: for cholesterol-lowering.

References:

C. Cramer, M. N. Haan, S. Galea, K. M. Langa, and J. D. Kalbfleisch. Use of statins and incidence of dementia and cognitive impairment without dementia in a cohort study. NEUROLOGY 2008; 71: 344-350
H Jick, GL Zornberg, SS Jick, S Seshadri, and DA Drachman. Statins and the risk of dementia. The Lancet 2000; 356:1627-1631

More Exercise. Weight Loss.

2008-07-29T09:52:00.008+08:00

Do we need more studies to tell us that exercise is good? Yes, I think. Especially for those who want to lose weight (women, especially, and men, increasingly).

Weight management, is always a hot topic. I remember one of my previous post mentioned about which type of diet is good for losing weight, and having additional health benefits. Now, there's another study about weight loss, and it's EXERCISING!

The study was led by John M. Jakicic, PhD, of the University of Pittsburgh, and colleagues.

201 overweight and obese women (body mass index: 27 to 40; age range: 21-45 years) with no contraindications to weight loss or physical activity were recruited in this study. At the start, all of the participants were sedentary.

Participants were divided into 4 groups with different behavioral weight loss intervention. They were randomly assigned to groups based on physical activity energy expenditure (1000 vs 2000 kcal/week) and intensity (moderate vs vigorous).

Participants also were told to reduce intake to 1200 to 1500 kcal per day.

Then, surveys of in-person conversations and telephone calls were conducted during the 2 years study period to collect the results.

At the end of the two-year study, women who had lost 10% or more of their initial body weight reported that they had done more physical activity compared with those who did not lose as much weight.

During the first 6 months, women in all four groups had lost an average of 8% to 10% of their initial body weight. But the hard part was keeping that weight off. Most of them regained the weight.

Nearly 25% of the participants managed to maintain 10% or more of the weight loss over the 2 years.

Those women exercised about 275 minutes a week more over their baseline activity levels.

So, what's the conclusion of the study?

The addition of 275 mins/week of physical activity, in combination with a reduction in energy intake, is important in allowing overweight women to sustain a weight loss of more than 10%.

You might need to change the statement now

So, next time, when you want to counsel people (those diabetic, or having cardiovascular diseases and need to lose weight) about lifestyle modification, the previous advice to them, "Exercise 30 minutes per day, 5 days per week", might be outdated.

As 55 minutes per day might sound odd, the duration can be changed to 1 hour per day (well, extra 5 minutes do more good than harm, right?).

Plus, it doesn't matter what type of exercising you are doing, as long as it can burn your calories!

Although this study conducted on women, I think, it's applicable for men, too. Well, exercising, is never a bad thing, for both men and women, right?

And I believe that the benefits of exercising 1 hour per day, 5 days per week, are beyond weight loss.

Reference:

John M. Jakicic, Bess H. Marcus, Wei Lang, and Carol Janney. Effect of Exercise on 24-Month Weight Loss Maintenance in Overweight Women. Arch Intern Med. 2008;168:1550-1559.

Trans Fat

2008-07-28T10:12:00.009+08:00

California Gov. Arnold Schwarzenegger signed a bill that prohibits restaurants from using trans fat in any form of fat including oil, margarine and shortening. Under the new law, the use of trans fat in all California restaurants will be phased out by Jan 1, 2010 in all foods except for baked foods which will be free of trans fat by Jan 1, 2011. Violations of this law lead to fines ranging from $25 to $1,000.

New York City adopted a similar ban in 2006.

Foods that may contain trans fat

What's the big deal? You may ask, why have to ban trans fat?

Well, you may have this concept in your mind, that saturated fat is the culprit of many cardiovascular diseases. The saturated fat increases low-density lipoprotein (LDL) level in the body and may clog your blood vessels and so on. So you are trying your very best to avoid animal source fat (except fish, of course, the omega-3, remember?) as they are the main source of saturated fat.

You even change your butter to margarine, cause you think, they are plant-based, and it's safer. Aha! You are wrong! The margarine actually contains trans fat!

So what is trans fat?

It is actually partial hydrogenation of plant oils.

The goal of partial hydrogenation is to add hydrogen atoms to cis-unsaturated fats, making them more saturated. These saturated fats have a higher melting point, longer shelf-life and desirable palatability including texture and mouth feel (food industry loves them!)

However, the catalyst also catalyses a side reaction that isomerizes some of the cis-unsaturated fats into trans-unsaturated fats instead of hydrogenating them completely.

Trans fats are non-essential for your body!

It is believed that the human lipase enzyme is ineffective with the trans fat, so trans fat remains in the blood stream for a much longer period of time and is more prone to arterial deposition and subsequent plaque formation. (Human lipase enzyme is specific to the cis configuration type of fat)

So, trans fat is worse than saturated fat.

It can raise not only LDL, the bad cholesterol, but also kick out the high density lipoprotein (HDL) , the good cholesterol (Saturated fat only raises bad cholesterol).

Many randomized and controlled dietary trials have already found that consumption of trans-fat can more than raise bad cholesterol. It can promote inflammation that is implicated in many chronic diseases such as cardiovascular diseases, diabetes mellitus and other chronic diseases such as infertility. Recent studies have shown trans fat may also hurt learning ability and memory.

There is no safety threshold for trans fat. Intake of trans fat in any amount may have an adverse effect. Consumers completely avoid intake of trans fat or avoid as much as they can.

OK. Now you want to avoid trans fat, but how?

Note that trans fats are not only 'available' in restaurants (especially fast food restaurants) and bakeries. They are available in processed foods in the shelves of supermarkets (or hypermarkets or whatever you call it) as well.

So, besides trying to eat less at these fast food restaurants and bakeries, you need to learn how to read the food labels also.

Processed foods that contain trans fat including margarines, crackers cookies, snack foods, and other foods made with or fried in partially hydrogenated oils.

Consumers should seek foods that contain 0 g trans fat. However, when a label shows 0 grams trans fat per serving it may contain up to 0.49 grams of trans fat per serving.

0.49 grams of trans fat doesn't seem like a lot, but when you eat more than one serving, this hidden amount can become a problem.

The manufacturers may not list trans fat, but try to add up all types of fat including saturated fat, monounsaturated fat and polyunsaturated fat to see if the total matches the total (serving) size. If both are different, then there is likely some trans fat.

And if any of the ingredients are either hydrogenated or partially hydrogenated, trans fat is there (the manufacturers know how to play trick!).

So, we can't really believe what the manufacturers claim in their products. Zero trans fat as they mention in the product is not really zero. The product label you see on the front of the food is just an advertisement. They are trying to get the consumer to buy it over the competition.

The only way to truly know what the food contains is by reading the nutrition label.

You are responsible for what you put into your body and the more education you have, the better prepared you will be to make those decisions.

NICE: Cut down on Antibiotics Prescribing

2008-07-26T09:45:00.005+08:00

The National Institute for Health and Clinical Excellence (NICE) recently released their latest guideline on antibiotic prescribing in respiratory tract infections, suggest the doctors to cut down their antibiotic prescriptions.

Although the guideline is targeted on doctors in UK, I think, it's applicable for doctors all around the world.

Links:
Respiratory tract infections: full guideline
Respiratory tract infections: quick reference guide

Overuse of antibiotic is a growing concern for healthcare professionals world wide, as there are increasing number of antibiotic resistant bacteria reported, such as methicillin-resistant Staphylococcus aureus (MRSA).

As most of the acute respiratory infections are viral infections, antibiotic has limited role in treating them.

According to the guideline, antibiotic should not be prescribed immediately to patients come in with:

Acute otitis media
Acute sore throat/pharyngitis/tonsillitis
Common cold
Acute rhinosinusitis
Acute cough/acute bronchitis

Otitis Media is an infection of the middle ear

Doctors should reassure the patients that antibiotics are not needed immediately for such diseases as they play no role to these diseases and may cause unnecessary adverse effects, such as diarrhea, vomiting and rash.

If the symptoms worsens or prolongs, then only the patient need another clinical review, to consider whether to prescribe antibiotics or not.

Patients should be educated on the nature of diseases, especially the natural average total illness length:

Acute otitis media - 4 days
Acute sore throat/pharyngitis/tonsillitis - 1 week
Common cold - 1.5 week
Acute rhinosinusitis - 2.5 weeks
Acute cough/acute bronchitis - 3 weeks

However, if the patients are seriously ill, or they are older than 65 years old with certain conditions, especially if they are on steroid drugs, antibiotics should be immediately prescribed.

Warning on the Massive Use of Handphones

2008-07-25T07:51:00.006+08:00

While everybody is so crazy about iPhone, there are some warning signs...

We call it handphone, some call it cellphone. Whatever you call it, it has changed our life.

In a few decades time, the users of handphones are exponentially increased. Somehow, nobody seems to care about handphone do generate electromagnetic field.

Although the biological effect of long term exposure to the electromagnetic field is not established yet, but we need to beware of its potential harmful risk.

Dr. Ronald Herberman, director of the University of Pittsburgh Cancer Institute recently declared that electromagnetic fields emitted by handphone should be considered a potential human health risk.

Children are particularly at risk because their brains are still developing.

Well, surely, there will be people who oppose it, like the American Cancer Society. They said that Herberman's warning was too strong, given the lack of scientific evidence, and that if there is a risk, it is very small.

The warning was based on a few points:

Electromagnetic fields from cell phones are estimated to penetrate the brain especially in children.

Estimation of the penetration of electromagnetic radiation from a cell phone based on age (Frequency GSM 900 Mhz)

Living tissue is vulnerable to electromagnetic fields within the frequency bands used by cell phones (from 800 to 2200 MHz), notably an increase in the permeability of the blood-brain barrier and an increased synthesis of stress proteins.
The most recent studies, which include subjects with a history of handphone usage for a duration of at least 10 years, show a possible association between certain benign tumors and some brain cancers on the side the device is use.

Well, you may say that human epidemiological studies on handphones conducted to date cannot be conclusive. To tell you the truth, even the studies about exposure of tobacco and lung cancer under similar study condition were not established, and it would be difficult to identify an increased risk of cancer, as the risk appears mostly 15 to 35 years later.

And yet, we can say out loud and proud that smoking cause cancers!

But why? When we touch on handphone MAY cause cancers, all suddenly keep quiet, and claim that the warning is too strong?

Is it because our perception towards tobacco and handphones are different?

Everybody use handphones everyday, or perhaps, every hour. But tobacco is only for those people without health conscious, the minority. So, handphone is safe, and tobacco is dangerous.

Please remember that when tobacco first introduced (God knows how long ago), nobody linked it with lung cancers.

So, should we not aware of the potential harmful risk of the usage of handphone?

We do not exactly know how harmful is the handphone, at the same time, we do not how safe the handphone is, too.

We shouldn't wait for a definitive study to come out, but it is better being safe rather than sorry later

There are some practical advice to limit exposure to electromagnetic radiation emitted from handphones:

Do not allow children to use a cell phone, except for emergencies. The developing organs of a fetus or child are the most likely to be sensitive to any possible effects of exposure to electromagnetic fields.
While communicating using your cell phone, try to keep the cell phone away from the body as much as possible. The amplitude of the electromagnetic field is one fourth the strength at a distance of two inches and fifty times lower at three feet. Whenever possible, use the speaker-phone mode or a wireless Bluetooth headset, which has less than 1/100th of the electromagnetic emission of a normal cell phone. Use of a hands-free ear piece attachment may also reduce exposures.
Avoid using your cell phone in places, like a bus, where you can passively expose others to your phone's electromagnetic fields.
Avoid carrying your cell phone on your body at all times. Do not keep it near your body at night such as under the pillow or on a bedside table, particularly if pregnant. You can also put it on “flight” or “off-line” mode, which stops electromagnetic emissions.
If you must carry your cell phone on you, make sure that the keypad is positioned toward your body and the back is positioned toward the outside so that the transmitted electromagnetic fields move away from your rather than through you.
Only use your cell phone to establish contact or for conversations lasting a few minutes, as the biological effects are directly related to the duration of exposure.
For longer conversations, use a land line with a corded phone, not a cordless phone, which uses electromagnetic emitting technology similar to that of cell phones.
Switch sides regularly while communicating on your cell phone to spread out your exposure. Before putting your cell phone to the ear, wait until your correspondent has picked up. This limits the power of the electromagnetic field emitted near your ear and the duration of your exposure.
Avoid using your cell phone when the signal is weak or when moving at high speed, such as in a car or train, as this automatically increases power to a maximum as the phone repeatedly attempts to connect to a new relay antenna.
When possible, communicate via text messaging rather than making a call, limiting the duration of exposure and the proximity to the body.
Choose a device with the lowest SAR possible (SAR = Specific Absorption Rate, which is a measure of the strength of the magnetic field absorbed by the body). SAR ratings of contemporary phones by different manufacturers are available by searching for “sar ratings cell phones” on the internet.

We do not need to ban this technology, but to adapt it, so that it never becomes a major cause of illness.

Kids' Healthy 'Health Foods'?

2008-07-24T10:26:00.006+08:00

There are so many health foods for kids in the market. And it's already becoming a culture to buy these health foods for your kids. If you don't buy it for your kids, your don't love your kids and not concerning about their future.

One question: Are they really healthy?

These cereals, granola bars, fruit drinks, milks and so on, with the 'healthy foods' claims. Are they trustable?

For sure, the parents are anxious concerning everything that helps their kids to grow up healthy (or more healthy than the kids next doors). They want only the best for their kids, and so, they buy these expensive and fancy 'health' foods for their kids.

Junk foods? Nah... These parents already mark them off in their kids' eating list.

But, well, do you think those junk food companies are junks?

You are wrong! They know how to repackage their foods and drinks, add in something, and make it 'healthier'! And so, they emerge in the market again, becoming 'health foods'.

Worse off, those cereals, granola bars, fruit drinks and milk companies, to increase their sales, and to make the kids prefer their products, they make their products sweeter, tastier, and more colourful!

The carbohydrates, fat, sodium and the additives......

Some products, claimed by the manufacturers, are low fat, low sodium, or seldomly, even low carbohydrates! Then high in fibre, calcium, vitamins and sort of.

And the fruit drinks and milk also, well, calcium fortified, DHA fortified, vitamins fortified. Some even with NO CHOLESTEROL claims.

Graphically, some products are showing images of cartoons playing sports, claiming that they are promoting active lifestyle, and their products can provide the kids with more energy (well, more calories) to be active. And of course, the cartoons are so appealing to the kids (everyone wants one!).

In addition, the kids's 'health' foods additives, like colouring and preservatives, are linked with hyperactivity in kids in some scientific studies. And for many products, they are not list what additives they use in their product labels.

YES. For most of the 'health' foods and drinks, their calories, sodium and additives levels are 'within the safety limits'.

But, we shall never forget that the 'within safety limits' is applied to that single product only.

Does your kid only consume a single product in a day?

The real situation is: The kids eat and drink various type of these 'health' foods and drinks per day, and many servings per day.

So... When accumulated, are they still 'within safety limit'? For both short and long term.

Why are there so many obese kids around? Why are the diabetes and hypertension started to attack kids? Why more and more kids associated with attention deficit hyperactivity disorders? If their foods are so 'healthy'.

Viagra, no longer 'For Men Only'

2008-07-23T10:08:00.008+08:00

Apart from increasing suicidal risk, sexual dysfunction is another well-known adverse effect of selective and non selective serotonin reuptake inhibitor (SRI) antidepressant, for both men and women. It's one of the major reason patients stop taking the drugs.

Examples of SRI antidepressant:

Zoloft (sertraline)
Paxil and Paxil CR (paroxetine)
Prozac (fluoxetine)
Celexa (citalopram)
Lexapro (escitalopram)

Good news is: A new study published suggested that Viagra (sildenafil) is able to help the depressed women to cope with the SRI antidepressant related sexual dysfunction.

[H. George Nurnberg, Paula L. Hensley, Julia R. Heiman, et al. Sildenafil Treatment of Women With Antidepressant-Associated Sexual Dysfunction. JAMA 2008; 300: 395 - 404]

DSM-IV criteria for substance-induced sexual dysfunction for women includes impaired desire, arousal (lubrication), and orgasm and sexual pain.

This is a prospective, parallel group, randomized, double-blind, placebo-controlled, 8-week trial to test the efficacy of 50 mg and 100 mg of sildenafil for sexual dysfunction in women.

Women recruited in the study were:

between 18 and 50 year-old
premenopausal
having the diagnosis of major depression
taking SRI antidepressant for at least 8 weeks
experiencing sexual dysfunction for at least 4 weeks
in good health
having regular sexual activity at least twice monthly before the SRI antidepressant treatment
willing to continue the efforts to have sexual activity at least once weekly during the study

In the end, 98 women were recruited.

49 patients were assigned to receive active sildenafil and the other 49 to receive identical placebo. Patients were instructed to take 1 tablet of trial medication approximately 1 to 2 hours before anticipated sexual activity, not more than once daily over the 8-week trial period and were required to make at least 1 attempt but were asked to try to make at least 2 attempts at sexual activity per week. The dose of study drug could be adjusted from 1 (50 mg) to 2 (100 mg) tablets based on investigator judgment of efficacy and tolerability.

Serum blood samples drawn at baseline and at study end. Levels of cortisol, progesterone, estradiol, total testosterone, free testosterone, follicle-stimulating hormone, leutinizing hormone, prolactin, sex hormone–binding globulin, thyroid-stimulating hormone, and total thyroxine were determined.

The results:

73% of women taking placebo compared with 28% of women taking sildenafil reported no improvement in a sexual functioning scale with treatment.

Looking at the individual measures, women treated with Viagra (sildenafil) were significantly more likely to reach orgasm than those in the placebo group.

And also, partner's satisfaction was significantly higher for women treated with Viagra (sildenafil) .

However, for sexual desire, arousal sensation, arousal lubrication and sexual pain, there were no significant different between the Viagra group and the placebo group.

These results showed that Viagra (sildenafil) can only help the women achieving their orgasms, not their sexual desire. Just like it helps the men to erect but not to increase their desire.

In addition, the study also showed that the higher a woman's free testosterone and thyroxine levels, the more likely a positive treatment response occurred, regardless of group assignment. Which means, in order to benefit from the Viagra (sildenafil) to achieve organism, the women have to have at least normal value of free testosterone and thyroxine level. Plus, testosterone is associated with sexual desire, in both men and women.

So, how it works?

In female genital tissue, it seems like the phosphodiesterase type 5 inhibitor enhancement of nitric oxide cyclic guanosine monophosphate in noradrenergic non cholinergic signaling is similar to men.

Which means the Viagra (sildenafil) manage to fill the women's clitoris with blood, and allows them to achieve orgasm.

Pfizer, which sponsored the study, claimed that they have no plans to seek regulatory approval for Viagra as a treatment for female sexual dysfunction. They are looking into other treatment approaches for women.

Antihypertensive Drug Therapy, to Intensify or Not?

2008-07-22T16:27:00.005+08:00

More and more people are having hypertension (high blood pressure) problem nowadays.

Good thing is, there are also more and more people seeking medical help concerning blood pressure problem.

They have their regular blood pressure check-up, at hospitals, clinics or pharmacy stores. And the healthcare professionals give them health advices, about lifestlye modification, and even drug therapy (if they visit doctors).

In doctor's side, sometimes, patients comes regularly, but their blood pressure remain uncontrolled, although the patients already on drug therapy prescribed by the doctors. In such case, doctors will intensify the drug therapy, by either increasing the dose of the drugs, or add on another drugs.

Well, before intensifying the drug therapy, the doctors should have assessed the patients.

The doctors should understand that the patients might be following the appointment dates, but they might not completely follow the treatment as prescribed.

You can cut off the lifestyle modification, as the compliance rate on lifestyle modification pathetically low. Definitely, we need more patient education on this issue, and it takes time.

Now, we look at the compliance of the patient on the drug therapy. The patients might have difficulty taking the drugs as prescribed, due to forgetfulness, or simply too busy to do so.

In addition, the patients might be taking other over-the-counter (OTC) prodcuts (like pseudoephedrine), or herbal products (like ginseng) that can increase their blood pressure, apart from taking the prescribed drugs.

All these, before the doctors decided to intensify the drug therapy, must take into consideration.

If not, the intensification of drug therapy will be ineffective.

Or, if the patient suddenly decided to take all the drugs as prescribed, it will be another health disaster for these patients.

Hepatotoxicity in the Diabetic Population

2008-07-21T09:51:00.007+08:00

Diabetes is associated with clinical complications such as cardiopathy, nephropathy, and retinopathy.

Until now, the link between risk of hepatic failure and diabetic condition was unclear.

However, hepatotoxicity of antidiabetic drugs emerged as a common clinical complication.

Antidiabetic drugs with reported cases of hepatotoxicity include sulfonylureas, alpha-glucosidase inhibitors, biguanides, and thiazolidinediones.

Drug-induced hepatotoxicity has been reported occasionally with second-generation sulfonylureas. Second-generation sulfonylureas include glipizide, glibenclamide and glimepiride.

For alpha-glucosidase inhibitors, the most well-known of this class is acarbose. It is minimally absorbed in unchanged form after oral administration, therefore, this drug is widely believed to be safe. However, there were cases of severe hepatotoxicity reported for acarbose.

Biguanides (metformin) is widely used for the treatment of type 2 diabetes. A serious but rare side effect, lactic acidosis, is caused because of its interference with mitochondrial oxidative processes. For hepatotoxicity, only one or two cases reported so far.

Thiazolidinediones (TZDs, also known as glitazones) are insulin sensitizers now widely used for the treatment of type 2 diabetes. Three TZDs are being used in clinical practice: troglitazone, pioglitazone, and rosiglitazone.

Troglitazone is a peroxisome proliferators–activated receptor gamma agonist that enhances insulin sensitivity. Within one year after its widespread use, individual cases of liver injury and failure were reported. The mounting evidence for the idiosyncratic hepatotoxicity of troglitazone in the following years led to its withdrawal from the market in 2000.

Since then, efforts have been made to make clear the mechanism of troglitazone-induced hepatotoxicity. A number of hypotheses were deduced to explain troglitazone-induced cell injury, including the formation and accumulation of toxic metabolites, mitochondrial dysfunction and oxidant stress, inhibition of the bile salt transporter and bile acid toxicity, and the induction of apoptosis.

After the withdrawal of troglitazone due to hepatotoxicity, only pioglitazone and rosiglitazone can be used for the treatment of patients with type 2 diabetes. Fortunately, these two drugs in the TZD class have a much safety profile for hepatotoxicity.

Well, antidiabetic drugs are to be taken for long term, for life. For this reason, diabetic patients that are taking drug therapies should be monitored regularly. Although till now, antidiabetic drugs are still relatively 'liver-friendly', recent epidemiological studies suggested that patients with diabetes are twice as likely to suffer hepatic failure compared to patients who do not have diabetes. Increased incidences of hepatotoxicity have been observed in patients with diabetes receiving drug therapies.

We are not sure what is the mechanism or the predisposing factors for the hepatotoxicity in diabetic patients with drug therapies.

It is recommended that diabetic patients with drug therapies should have their liver function tests (LFT) regular (perhaps annually, or twice per year).

[Source: U.S. Pharmacist]

Sunburn Boosters

2008-07-19T10:18:00.010+08:00

In America, the melanoma (skin cancer) rate is getting higher. You might be wondering, yes, it's increasing, but it's in America, what to do with Malaysia anyway?

Exposure to the sun's ultraviolet (UV) rays is a known risk factor in skin cancer. And well, I don't know whether you aware of not, Malaysia is exposed to strong sunlight all year long (only dumb won't notice that, by the way). In addition, Malaysia does not have such statistic team to count the rate of melanoma by the way (as I know, maybe there is, but I doubt that). The thing is, we, Malaysians, often living our life without foreseeing. We don't have the sense of risk.

Personally, I think, we are all at risk of the melanoma, ever since the ozone layer started to deplete.

Today, I don't want to talk about sunscreen. Instead, I want to talk about drugs that may increase your sensitivity to the sun, causing drug-induced photosensitivity.

Drug-induced photosensitivity is the development of cutaneous disease as a result of the combined effects of a chemical and light. Exposure to either the chemical or the light alone is not sufficient to induce the disease; however, when photoactivation of the chemical occurs, one or more cutaneous manifestations may arise.

Wavelengths within the UV-A (320-400 nm) range and, for certain compounds, within the visible range, are more likely to cause drug-induced photosensitivity reactions.

Occasionally UV-B (290-320 nm) can also be responsible for such effects.

Note that UV-B wavelengths are most efficient at causing sunburn and nonmelanoma skin cancer.

The drug-induced photosensitivity, can be differentiated into phototoxic and photoallergic reactions.

Phototoxic reactions occur because of the damaging effects of light-activated compounds on cell membranes and, in some instances, DNA.

While photoallergic reactions are cell-mediated immune responses to a light-activated compound.

Here, I want to focus more on phototoxic reactions, as they are the main culprit of increasing the risk of getting melanoma.

Many compounds have the potential to cause phototoxicity. Most have at least one resonating double bond or an aromatic ring that can absorb radiant energy. Most compounds are activated by wavelengths within the UV-A (320-400 nm) range.

Photoactivation of a compound results in the excitation of electrons from the stable singlet state to an excited triplet state. As excited-state electrons return to a more stable configuration, they transfer their energy to oxygen, leading to the formation of reactive oxygen intermediates. Reactive oxygen intermediates such as an oxygen singlet, superoxide anion, and hydrogen peroxide damage cell membranes and DNA.

This drug-induced photosensitivity reactions can occur in persons of any age, as long as you have eaten the 'right' drugs and exposed to enough sunlight to cause the photoactivation.

These are the examples the sunburn boosters:

Diuretics

frusemide and hydrochlorothiazide.

Antibiotics

Tetracyclines drugs (doxycycline, tetracycline), Fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin), Sulfonamides [a.k.a. sulfa drugs] (trimethoprim)

Retinoids

isotretinoin and acitretin {note: they are available in some skin care products as well}

Anti-arrhythmic

amiodarone

Anti-diabetic

Sulfonylureas (glipizide and glibenclamide)

NSAIDs

ibuprofen, ketoprofen

[These are just some examples, for more details, always check your medications with the pharmacists]

Even after you have stopped taking these drugs, their effects may linger, depending on the type of drug (the clearance of the drug from the body) and how long you've been taking it.

And one thing is: You don't even have to go out in the sun to get the drug-induced phototoxicity. You could easily get sunburned in a tanning salon!

Does using sunscreens help protect against photosensitivity?

The answer is unclear.

Sunscreens do lessen the effects of UV radiation, but some contain ingredients that themselves may cause phototoxicity in some people.

Also, most sunscreens protect only from UV-B, whereas most phototoxic compounds are activated by UV-A.

Sunscreens containing bergamot oil, sandalwood oil, benzophenones, PABA, cinnamates, salicylates, anthranilates, PSBA, mexenone, and oxybenzone can all cause phototoxicity.

Titanium dioxide seems to be the least likely sunscreen to cause phototoxicity.

So, to be safe, always ask the pharmacist about the effects of your medications on sun exposure.

Or at least, read the product leaflet (for the skin care products especially).

Menthol cigarettes Manipulate Teens?

2008-07-18T09:36:00.016+08:00

Oh well, there's a research released recently in the American Journal of Public Health found evidence that the tobacco industry has manipulated menthol levels to gain market share among teens.

[Jennifer M. Kreslake, Geoffrey Ferris Wayne, Hillel R. Alpert et al. Tobacco Industry Control of Menthol in Cigarettes and Targeting of Adolescents and Young Adults. AJPH 2008; 0: AJPH.2007.125542v1 (published online ahead of print)]

According to the report, tobacco companies discovered that long-term smokers preferred products with higher menthol levels and stronger perceived menthol sensations; while younger smokers preferred milder menthol products.

The report went on to describe that menthol products tend to mask the harshness of smoke inhalation, allowing for nicotine to enter the systems of these new smokers who subsequently become addicted.

In short, the menthol help to ease the delivery of nicotine into the body, however, strong menthol taste do not appeal to the teens, they prefer milder menthol taste.

In response to this information, these tobacco companies introduced new menthol brands with lower menthol levels to appeal to younger smokers and to gain a larger market share.

In the past decade, brands with lower menthol content have been released, and gained a significant increase of sales among teens.

Brands marketed as menthol cigarettes make up about 27 percent of the U.S. cigarette market. While overall cigarette sales have declined, sales of menthol cigarettes have been stable in recent years.

However, most tobacco companies disagree with the conclusions that menthol levels in their products were manipulated to gain market share among teens. They also denied any research done to design these products.

Yes, I do agree that menthol cigarettes are appealing. Most of my friends start smoking by exposing themselves with menthol cigarettes first, then only progress to normal type of cigarettes. The menthol cigarettes, can be considered as entry cigarettes. And even female friends, can smoke comfortably, 'thanks' to menthol cigarettes.

But, personally, I think, these different types of cigarettes marketed just to cater for different groups of smokers. As we know, different type of people have different taste. Even if the tobacco companies really done the research, it's nothing wrong, as we know, every companies in this world existed to earn profit. And every companies that aim for long term profits are doing researches from time to time to improve their products and to have a more precise market targeting.

Just like coke companies. Every now and then, they come out with new products, to gain market share in new target population. For example, the diet coke: Now, even the diabetic patients can enjoy the taste of coke. But is diet coke really OK for health? Is the aspartame really safe?

Smoking problems, are long existing, and till now, no one seems to have a perfect solution to curb the smoking problems. You can ban open space smoking, ban the sales of cigarettes to underage, put graphic warnings on the cigarettes packing, heavily tax the cigarettes sales...... But the end results, are rather disappointing.

The fact is, everybody knows smoking kills. Everybody knows smoking cause respiratory diseases and cancers. Those who smokes, they know.

Unless you totally ban the cigarettes, categorize them as illicit drugs. Then the problem will be solved. But remember that, till now, people still taking illicit drugs, even it's illegal.

And, total ban on smoking not good for the economic also, right? HeHe...

We can't stop the people from smoking. We can only help them to stop smoking; advise them to stop smoking, through education.

Counseling plays an important role. Even a greater one, is the motivations from friends and family members (provided the friends and family members are not smokers).

Well, counseling and motivations are kind of personal. So, here, I will talk more about the drugs interventions.

First, is the nicotine replacement therapy (NRT).

There are various forms of NRT. The most famous one, of course, is the nicotine gum!

How to use nicotine gum?

The most optimal way of using it is to follow a smoking cessation program and use this gum as directed.

The method of chewing a nicotine gum is not the same as ordinary chewing gum. Nicotine gum is chewed to release nicotine, then rested so that the nicotine can be taken in through the lining of the mouth. Nicotine swallowed in the saliva is not beneficial and in excess may irritate your throat or upset your stomach.

Instruction:

Chew a piece of gum when you feel the urge to smoke.
Chew slowly until the taste becomes strong then stop and rest the chewing gum between gum and cheek.
When the taste fades, chew a few times until the taste gets strong, then rest the chewing gum again.
Keep chewing like this for 30 minutes.
When the chewing gum has lost its strength, dispose it carefully.

Do not chew more than 30 pieces of gum a day. Do not smoke while using this gum.

Because this gum contains nicotine, it has a peppery-like taste. It may cause a tingling sensation when chewed. During the first few days of using this medication, you may experience mouth sores, jaw muscle aches, increased saliva production, indigestion, or headache. These effects should disappear as use of the gum is continued.

Chewing the gum too fast can cause lightheadedness, dizziness, hiccups, nausea, vomiting or insomnia. If these effects occur, chew the gum more slowly. Notify your doctor if you develop symptoms of too much nicotine in your body: cold sweats, fainting, confusion, pounding heart.

Before using this nictotine, tell your doctor or pharmacist your medical history, especially if you are having cardiovascular disease, diabetes mellitus, and jaw or chewing problems.

Of course, allergic reactions rarely happen for nicotine gum, cause, obviously, if you are allergic to nicotine, you won't smoke at the first place. However, there are possibilities that you are allergic to other ingredients in the nicotine gum. So, if you having rashes or other abnormal symptoms, please consult your doctors immediately.

Alternatively, you can use nicotine patch. Especially you are having jaw or chewing problems, or you don't like to chew.

Nicotine patch is a self-adhesive patch, which slowly release nicotine that is absorbed through the skin.

The treatment normally started with stronger strength of nicotine patch.

The treatment period is quite individual. Normally, after 3 months, your body can be managed on a lot less nicotine than it was used to. Therefore, the strength can be cut down gradually.

Note than cutting down the strength does not mean you cut the patches. The patches shall not be cut. There are different strength of patches available.

To apply the patch, select a dry area of skin, free of cuts, redness or irritation, on the upper arm or hip. Avoid using oil, talc and etc, which prevent the patch sticking. Alter the place you stick each day to avoid irritation.

At the end of treatment, you should be able to manage without patches.

If your smoking problem is more of the habit, the habit of picking a cigarette and inhale it. Nicotine inhaler will be more suitable.

Nicotine inhaler should be used when there is an urge to smoke. It can be used in the same way as a cigarette. The dose of nicotine from a puff of the inhaler is much less than a cigarette. Therefore, you might need to use the inhaler for longer period than when smoking to control the craving. Each cartridge can be used for approximately 20 minutes.

For best results, 6 - 12 cartridges should be used per day. One cartridge can replace 4 cigarettes.

Of course, NRT costs more than cigarettes. But think for your future. The high cost is for short term only. After quitting, you can save more than what you spent on the cigarettes. Besides, health is priceless!

And... Those who believe in pills, can try bupropion.

It's a prescription medication designed to help smokers quit more easily than without the drug.

Zyban (bupropion)

Bupropion is atypical antidepressant that acts as a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist.

Consult your doctor if you think you want to quit smoking and NRT is not enough to help you.

Well, healthcare professionals do play an important role in helping those who are willing to quit smoking.

We shall never, never, never, never give up on those who want to quit smoking!

And the Winner is: Low Carb!

2008-07-17T09:41:00.008+08:00

People all around the world keep searching for a effective weight-loss diet. If you believe in scientific studies, instead of the commercialized advertisements, you might be interested in what has been published in New England Journal of Medicine (NEJM) on 17th July, 2008.

[Iris Shai, Dan Schwarzfuchs, Yaakov Henkin et al. Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet. NEJM 2008; 359: 229-241]

The study was conducted by BGU and the Nuclear Research Center in Dimona, Israel, in collaboration with Harvard University, The University of Leipzig, Germany and the University of Western Ontario, Canada.

In this 24 months study (Dietary Intervention Randomized ControlledTrial {DIRECT}) , 322 moderately obese subjects were randomly assigned (mean age: 52 years; mean body-mass index {BMI}: 31; male sex: 86%) to one of three diets:

Low-fat, restricted-calorie (based on American Heart Association guidelines)

(Aimed at an energy intake of 1500 kcal per day for women and 1800 kcal per day for men, with 30% of calories from fat, 10% of calories from saturated fat, and an intake of 300 mg of cholesterol per day.)

Mediterranean, restricted-calorie

(They restricted energy intake to 1500 kcal per day for women and 1800 kcal per day for men, with a goal of no more than 35% of calories from fat.)

Low-carbohydrate, non–restricted-calorie (based on the Atkins diet)

(The intakes of total calories, protein, and fat were not limited. However, the participants were counseled to choose vegetarian sources of fat and protein and to avoid trans fat.)

Low-carbohydrate Diet Pyramid

The results:

For weight changes, 2 phases of weight change observed. The maximum weight reduction was achieved during the first 6 months, followed by maintenace phase of partial rebound and a plateau.

After the 24 months, all groups lost weight, and the reductions were greatest in the low-carbohydrate group: -4.7±6.5kg; followed by Mediterranean group: - 4.4±6.0kg; and the least in the low-fat group: -2.9±4.2kg.

They also measured metabolic markers.

For lipid profiles, increased of high-density lipoprotein (HDL), the good cholesterol was observed in all the 3 groups. The greatest increased was observed in low-carbohydrate group: 0.22 mmol/L; compared to low-fat group: 0.16 mmol/L.

Triglycerides level also significantly decreased in low-carbohydrate group: 0.27 mmol/L; compared to low-fat group: 0.03 mmol/L.

Concerning low-density lipoprotein (LDL), the bad cholesterol, all 3 groups did not show significant decreased in level.

For fasting plasma glucose, for non-diabetes participants, there were no significant changes observed. However, in 36 diabetic participants, Mediterranean group had a decrease in fasting plasma glucose.

How about glycated hemoglobin (HbA1C) level?
In the 36 diabetic participants, only low-carbohydrate group had significant lowering in HbA1C level: -0.9±0.8%.

In liver function tests, changes in bilirubin, alkaline phosphate (ALP) and alanine aminotransferase (ALT) levels were similar among all the diet groups. However, ALT levels were significantly reduced from baseline to 24 months in the Mediterranean group (3.4±11.0 U/L) and the low-carbohydrate groups (2.6±8.6 U/L).

From the study, we can see that low-carbohydrate diet is the more effective diet compared to low-fat diet, which is recommeded by American Heart Association, and also, it is safe.

Apart from the weight, the low-carbohydrate diet has addition benefical metabolic effects as well.

This 24 months study is significant because of the relatively large number of participants coupled with a low drop-out rate: 95 percent were in the study after one year and 85 percent were still participating after the second.

However, there are some details we need to look at:

The NEJM study was funded in part by the Atkins Foundation (the low-carbohydrate diet in this study was based on Atkins diet)
In the "Atkins diet" that was tested, the participants were counseled to choose vegetarian sources of fat and protein and to avoid trans fat. Well, a vegetarian Atkins diet? Most people associate an Atkins diet with MEATS! Not PLANTS!
The investigators reported that those on the low-fat diet consumed 200 fewer calories per day or 10,000 fewer calories per year than those on the Mediterranean diet, yet people lost more weight on the Mediterranean diet. That's just physiologically impossible.
86% of the participants were male.

So?
The conclusion is still the same: The winner is... Low-carbohydrate diet, Atkins VEGETARIAN style! And if you are male, it will be even more practical for you.

Helicobacter pylori actually Protects Us?

2008-07-16T21:35:00.003+08:00

Still remember in 2005, two scientists won a Nobel Prize for discovering that a bacterium called Helicobacter pylori causes most stomach ulcers?

One of them even drank a glassful of Helicobacter pylori to prove the point.

Well, before you judge them as the evil one, and can't wait to kill them all with Triple Therapy, consider this:

A new study from New York University suggests that Helicobacter pylori might be the one that protect you from asthma.

The scientists analyzed data from more than 7,000 participants in a national health and nutrition survey. They found that children between the ages of 3 and 13 are less than half as likely to have asthma if they carry Helicobacter pylori.

Those carry Helicobacter pylori also had half the incidence of hay fever and other allergies.

A hundred years ago, nearly everyone was infected with Helicobacter pylori. It was universal. And it seems that, recently, with the universally widen use of antibiotics, Helicobacter pylori is disappearing.

Ulcer diseases and stomach cancers are going away, but other types of diseases are growing stronger, such as asthma and related disorders (hay fever).

Helicobacter pylori's presence triggers the production of Th17 cells, a type of regulatory cell that determines the body's response to foreign bacteria and pollution.

Till now, nobody has yet weighed the risks of Helicobacter pylori's against its benefits, like..... You prefer to get stomach ulcer, or asthma?

Our immune systems seems like needed to be calibrated.

There must be a reason why Helicobacter pylori being with the human for a very long time. And now, when they start to disappear, there will be consequences.

Warmer World, More Stones

2008-07-16T19:54:00.005+08:00

What will global warming do?
Ice caps melting, arctic species going extinct...?
We talking about health here.
OK. It will increase the incidences of malaria, dengue fever and more tropical infectious diseases?

Well, now, add one more: Kidney stones!

According to research published this week in Proceedings of the National Academy of Sciences USA, as many as 2.3 million more people may develop these mineral deposits in their kidneys by the year 2050 as the result of a warming world.

It's particularly in those areas where heat and humidity lead to dehydration that accelerates stone formation.

In USA, the kidney stones rates are highest in the Southern states, particularly the Southeast. Those areas are referred as 'kidney-stone belt' of USA. Now, the belt will expand north and up the coasts, enveloping 56 percent of the population by 2050.

That's about USA. How about other parts of the world?

Well, kidney stone is not a vector-borne disease, after all. So, now, if it's caused by global warming, and global warming obviously not only affecting USA alone, therefore, kidney stones rate, I believe, will be increased, too!

So how?
Drink more water, as suggested by urologists?

Yes. Perhaps, it's the only thing we can do, to prevent the kidney stones.

Seems like more and more things are associated with global warming now.
There is possibility that there will be more, and maybe even bigger. Kidney stones, will be the tip of the iceberg.

Potentially Inappropriate OTC Medications among the Elderly

2008-07-16T10:07:00.010+08:00

There are a lot of over-the-counter (OTC) medications available in the pharmacy stores. There are also many elderly people purchase these OTC medications each day. Therefore, there are risks of inappropriate use of these OTC medications.

There are some OTC medications commonly used among the elderly people and often pose potentially high risks for adverse outcomes in this population.

First, I want to talk about chlorpheniramine. Chlorpheniramine is a first-generation antihistamine, more well-known as Piriton. It is used to treat flu and allergy symptoms, occasionally, it is used as a sleep aid. It has strong anti-cholinergic (confusion, blurred vision, constipation, dry mouth, light-headedness and so on) and sedative effects. These harmful effects are actually outweigh the benefits of the drug itself, compared to 2nd generation antihistamine, such as loratadine (Clarityne) and cetirizine (Zyrtec).

Clarityne (loratadine) tab 10mg

Zyrtec (cetirizine)

Zyrtec (cetirizine) tab 10mg

For elderly people, due to their age-related changes in cholinergic system, the strong anti-cholinergic effects may lead to decline in cognitive function. As there are other alternatives, like loratadine and cetirizine, it is better to use the alternatives than chlorpheniramine.

Many elderly people have insomnia problem, and some of them use chlorpheniramine as their sleep aid. However, the sedative benefit of chlorpheniramine is short-lived and tolerance may be developed.

It will be a risk to tell these patients not to use chlorpheniramine also. The closest alternative they can turn to, is the OTC dietary supplements. It has to be noted that the regulatory status and the potential for adulteration for these sleep aid dietary supplements remain a major issue. They are not any safer than chlorpheniramine for elderly.

So, for this insomniac problem, the patients have to consult doctors or specialists.

Or, they can just simply review their sleep hygiene, and curb this problem using non-pharmacologic interventions, such as stress management and regular exercise.

Nurofen (ibuprofen) caplet 200mg
[Example of NSAID]

Next, I want to talk about non-steroidal-anti-inflammatory drugs (NSAIDs).

Both acute and chronic pain are common in elderly people. The pains, are normally managed by using OTC analgesics, mostly NSAIDs.

Chronic use of NSAIDs increase the risk of developing chronic renal failure, gastrointestinal (GI) bleeding, hypertension and chronic heart failure.

The most noticable symptom is GI bleeding. While doing drug history taking, one can check out whether the patient has such problem by detecting the increased use of antacids and other GI drugs (like H2-antagonists, proton pump inhibitors) .

To avoid these chronic adverse effects, the pharmacists should counsel the elderly patients, recommend them to use the lowest effective NSAID dose, for the shortest period of time, instead of just sell the medications to them.

The use of proton pump inhibitors could be included in the treatment when necessary.

Even Tesco sells ibuprofen!

Of course, if the pain can be managed using paracetamol, why not?

(There are many OTC medications have the risks of inappropriate use, please update me!)

Pharmacists play a very important role in handling the inappropriate use of these OTC medications. Since the elderly patients normally do not discuss with doctors or pharmacists concerning OTC medications, the pharmacists should initiate the discussion!

Diet and Cardiovascular Diseases

2008-07-15T09:39:00.008+08:00

Increased intake of minerals such as potassium and possibly magnesium and calcium THROUGH A DIET may reduce the risk of high blood pressure and lower blood pressure in people with hypertension, a new study suggests.

In addition, increased intake of these minerals in the diet may reduce the risk of coronary heart disease and stroke.

[Mark C. Houston and Karen J. Harper. Potassium, Magnesium, and Calcium: Their Role in Both the Cause and Treatment of Hypertension. J Clin Hypertens (Greenwich). 2008;10(7 suppl 2):2–11]

This is another latest news concerning the relationship between our daily diet and cardiovascular diseases.

Well, it's not something new that diets affects cardiovascular diseases. In fact, there are new studies published from time to time, to show us which food is good for the heart.

Recent studies focus on flavonoids and antioxidants found in foods, such as fruit, vegetables, herbs, grains and chocolate.

We must not forget the recent study about resveratrol, a compound found in red wine, grapes and nuts, which can prevent aging-related and obesity-related cardiovascular diseases.

Health benefits associated with flavonoids and antioxidants have been reported for decades, but it's still difficult for experts to make specific recommendations about which flavonoids to eat for specific health effects because of a lack of data.

However, as more and more researches on flavonoids and antioxidants becomes vailable, we can almost concluded that no single one will emerge as a miracle food. We just have to combine them to get optimal results.

So, the conclusion is: Take the foods that have flavonoids, vitamins, and minerals, and youwon't get wrong. But there's no specific recommendations.

How about taking dietary supplements? Well, this is the tricky part. How many dietary supplements can you take, daily, to cover all the flavonoids, vitamins, and minerals? Tons of pills?

Note that almost all the studies that showed positive results are related to DIET, not supplements. Why is that so?

The flavonoids, vitamins and minerals levels in the body, can only be interpreted as intake indicators. Which means, taking dietary supplements may increase the flavonoids, vitamins and minerals levels in the body, but they cannot reflect your daily diet.

The flavonoids, vitamins and minerals from the supplements pills may help when your body lack of those. So, check your daily diet, before you decide which flavonoids, vitamins, or minerals to take.

So how does the diet instead of supplements, work the magic?

Well, healthy diets, like lots of fruits and vegetables, contain many vitamins,minerals, and phyochemicals, including those that have beenwidely studied, such as vitamins, minerals and flavonoids, and uncharacterized bioactive substances thatcould be beneficial, either alone or in combination.

Healthy diet serves as marker of a healthy lifestyle, education,or wealth, each of which is associated with beneficial effectson health.

Fruit and vegetables may change gut flora and increasedietary fibre. They may slow carbohydrate absorption,attenuating rapid increases in blood glucose after meals—arisk factor in itself for cardiovascular disease.

Finally,fruit and vegetables are generally low in caloriesand displace energy-dense foods. If you eat lots of carrots,you cannot eat so many sausages, right?

So, what to do?

Eat a good mixture of the foods you like best!

Think variety,go ahead, eat!

Safety of Cervical Cancer Vaccine

2008-07-14T07:26:00.008+08:00

At October of 2006, Drug Control Authority of Malaysia approved a vaccine to prevent cervical cancer and vulvar and vaginal pre-cancers in women, called Gardasil.

In Malaysia, cervical cancer is the second most common cancer after breast cancer.

Gardasil is the first vaccine to prevent cervical cancer, a disease caused almost exclusively by a highly common sexually transmitted virus called the Human Papillomavirus (HPV).

The generic name for Gardasil is Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant.

It helps protect against the following diseases caused by Human Papillomavirus (HPV) Types in the vaccine (6, 11, 16, and 18):

Cervical cancer (cancer of the lower end of the uterus or womb).
Abnormal and precancerous cervical lesions.
Abnormal and precancerous vaginal lesions.
Abnormal and precancerous vulvar lesions.
Genital warts.

3 doses of this vaccine needed to get vaccinated from these HPV.

But, please note that it helps PREVENT these diseases, NOT TO TREAT them.

GARDASIL is for girls and women 9 through 26 years of age, in order to help preventing the cervical cancer at the ages from 30 to 40 years (most prevalence) and reduce the transmission of this highly communicable disease.

And well, to really know whether you at risk of cervical cancer or not, you can have a Pap smear tests, which start at the cost of RM5 or RM10 from government clinics to below RM100 in private hospitals. (Most women in Malaysian have yet to do it)

OK, done with the nice introduction for Merck's & Co.'s Gardasil. Now we look at the ugly sides of it.

Gardasil's long term effect and safety remain unknown after it's marketed. And girls and women all around the world will be the white mice for it.

To date, thousands of adverse reactions to Gardasil, have been reported to the U.S. Centers for Disease Control and Prevention since June 2006. It was linked with 15 reports of death and 10 confirmed deaths, but there is no proof that the deaths were actually caused by Gardasil.

Among the reported adverse reactions are injection site pain, nausea and dangerous blood clots and paralysis due to a neurological disorder.

Of course, there ain't any case reported in Malaysia.

The vaccine was tested in trials of mostly mature women, but often used in teen girls as young as 9 years old.

Well, advices time:

Vaccination does not substitute for routine cervical cancer screening. Females who receive Gardasil should continue cervical cancer screening.
As with all vaccines, Gardasil may not fully protect everyone who gets the vaccine.
Gardasil helps protect against 4 types (6, 11, 16, and 18). These 4 types have been selected for Gardasil because they cause approximately 70% of cervical cancers and 90% of genital warts.
Gardasil will not protect you against HPV types to which you may have already been exposed.
Gardasil also will not protect against other diseases that are not caused by HPV.

So, the conclusion is:
You are not totally immuned from cervical cancer even if you get the shots of Gardasil, and so you still need to get the routine Pap Smears tests.

Plus, any signs of adverse effects occurs after any shot of Gardasil, you should report to the doctors, immediately.

Obesity Updates

2008-07-12T11:56:00.009+08:00

Obesity, is not a new term, but over the years, more and more health problems are found related to it. Well, you name it: cardiovascular diseases, diabetes mellitus, cancers, and the list goes on.

Now, you may add decreased sperm production in the list (that's for male, of course). For female, it has already known that obesity can lower their fertility rate.

This is based on a new study presented at a meeting of the European Society of Human Reproduction and Embryology in Barcelona, Spain.

So if both partners are obesed, it could be a problem for them to have a child.

Link:

Time - Obesity Affects Sperm Production
Food Consumer - Obesity may lower men's fertility

Well, then, obese people needs help, and there are many studies conducted to curb their problems. Unless, maybe certain people stubbornly think that obesity is not a problem. You know, those 'attitude' people'. When you tell them they are having obese problem, their faces will turn green, like a hulk, and confidently tell you: No, no problem at all!

Recently, we have been told that keeping a food diary will help you to lose your weight.

A study conducted by the Kaiser Permanente Center for Health Research and published in the August issue of the American Journal of Preventive Medicine showed those who kept a food diary ended up losing twice as much weight as those who did not.

Well, you don't have to crack your head thinking how it works. It's just because those who wrote a food diary had a stricter control of the calories they ate. They are more aware of what they are eating, and have clearer idea on what foods to be cut, and to be replaced by what.

However, you need to have knowledge on calories counting, and also the advices from healthcare professionals. If not, you will be ended up malnourished and more problems will be risen.

In addition, many experts doubt the possibility of one could keep writing a food diary and stick to a calorie restricted diet for his whole lifetime.

Another study shows that slow eating may be a simplest weight loss method.

The study published in the American Journal of Clinical Nutrition shows chewing each bite 20 to 30 times slowly would reduce intake of calories by 70.

In addition, the results suggest that people should not skip meals. Feeling too hungry would force people to eat his meal as fast as he can, leading to overeating and putting him at risk of weight gain.

And how about drugs to control obesity?

Well, you probably don't need a scientific study to tell you there's no such thing as a magic weight-loss pill.

According to a meta-analysis published at year 2007, compared with placebo, orlistat reducedweight by 2.9 kg (95% confidence interval 2.5 kg to 3.2 kg),sibutramine by 4.2 kg (3.6 kg to 4.7 kg), and rimonabant by4.7 kg (4.1 kg to 5.3 kg). The duration is ranging from 1 to 4 years. Patients receiving active drug treatmentwere significantly more likely to achieve 5% and 10% weightloss thresholds.

These results don't seem promising to those people who seek to lose a lot of weight.

Link:

BMJ - Long term pharmacotherapy for obesity and overweight: updated meta-analysis

However, the drugs' benefits extended beyond cutting weight.

Orlistat is potentially useful in pre-diabetes, diabetes, raised low density lipoprotein cholesterol, hypertension, pre-existing cardiovascular disease;

Xenical (orlistat)

Sibutramine is potentially useful in dyslipidaemia;

Meridia (sibutramine)

While rimonabant is potentially useful in dyslipidaemia, diabetes, mellitus, metabolic syndrome, and hypertension.

Accomplia (rimonabant)

However, the drugs' biggest failure, is that patients don't take them as prescribed.

Why?

They are expensive, and drugs also have side effects.

Orlistat causes weight loss by limiting the body's ability to absorb fat, but that can result in oily feces and sometimes incontinence;

Sibutramine can raise blood pressure and lead to nausea and insomnia;

While rimonabant is associated with an increased risk of psychiatric disorders like depression and anxiety.

Last but not least, as I mentioned earlier, the results don't seem promising to those people who seek to lose a lot of weight.

So much on obesity... But the only golden rule to control it, is:
There's no shortcut.

Drugs that may Increase Risk of Falling for Elderly People

2008-07-11T10:07:00.003+08:00

Researchers at the University of North Carolina at Chapel Hill have created a list of prescription drugs that increase the risk of falling for patients aged 65 and older.

Those taking 4 or more drugs at the same time are having greater risk than those who don’t , and the risk is increased by 2 - 3 folds.

List of the drugs:
Prescription medications that increase the risk of falls for patients 65 and older

The drugs in the list cover a wide range of common prescription anti-depressants, anti-epileptic, analgesics (opioid and non-opioid), anti-psychotic, and more.

The similar property they share is the sedating effect, which makes the patients less alert and slower to react, therefore, having higher risk to fall.

Falls are the major causes of injuries in elderly patients, especially those having osteoporosis.

In addition, some non-prescription drugs have the similar sedating effects as well, such as anti-histamines (cold and flu medications), and anti-tussives (cough medications).

So... The advices are:

For doctors

Doctors should choose the drugs that have been proven safe and effective in elderly patients and choose the drugs that have less sedating effect.

For pharmacists

Pharmacists should be extra-cautious for patients 65 and older who are taking 4 or more drugs and counsel the patients about the additional risk of falling caused by their medications. And they should ask the patients whether they are taking other non-prescription drugs or not.

For patients

Tell your doctors and pharmacists all the medications that you are taking currently, so they can choose the optimal set of medications for you.

No Black Box Warning for Anti-Epileptic Drugs

2008-07-11T09:34:00.003+08:00

In the end, the final decision from the USFDA panels was: No Black Box Warning for Anti-epileptic Drugs.

The advisers to the Food and Drug Administration voted 14-4 against adding a "black box" warning about the risks of suicidal tendencies to all anti-epileptic drugs.

For Pfizer who against it from the beginning, well, it's a relief for them.

Lyrica: Phew...

Personally, I think it's a wise decision. For anti-epileptic drugs, adding such Black Box Warning will cause disasters.

Revision:
A black-box warning is in bold type and is surrounded by a black border to make it stand out on the medication label. In addition, any advertising of products that carry black boxes must also include warning information as part of the advertisement.

The compliance rate for anti-epileptic drugs are low all the while. Well, nobody likes long-term medication right? And also, they do have adverse effects.

The adverse effect profiles of anti-epileptic drugs differ greatly, the common ones are cognitive impairment (especially for patients who work or study), and weight gain.

Plus, these adverse effects are dose dependent and reversible. Therefore, when the patient stop taking the anti-epileptic drugs and started to get rid of the adverse effects, it's hard to get them back to continue their treatment again.

If the Black Box Warning on suicidal risk is added, there will be more patients choose not to take these anti-epileptic drugs.

So, more harms will be actually done than benefits if such Black Box Warning added for the anti-epileptic drugs.

However, the warning should be added in the precaution section in the product insert. And all the healthcare professionals should be aware of such risk.

Cooperation between healthcare professionals, patient's family and the patients is needed to combat the suicidal behaviour, no matter the suicidal tendency is caused by the drugs, or the disease itself.

Anti-Epilectic Drugs Increase Suicidal Risk?

2008-07-10T10:33:00.008+08:00

Another Black Box Warning might be required, urged USFDA. This time, it's the anti-epileptic drugs.

Previously, drugs that required such Black Box Warning are the antidepressants. Now, seems like they want to expand it to anti-epileptic drugs.

FDA analysis of nearly 200 studies showed that patients taking anti-seizure drugs were twice as likely to have suicidal tendencies as those not taking the drugs.

The FDA based its analysis on 11 widely used anti-seizure medicines but has stated it wants to add warnings to all drugs in the class. Panelists will be asked to comment on that recommendation.

Links:

Reuter: FDA urging black box warning for epilepsy drugs
Business Week: FDA panel to weigh suicide risks of epilepsy drugs
The Wallstreet Journal: Drugs' Links To Suicide Risk Draw Concern

FDA's memorandum:
Briefing Document for the July 10, 2008 Advisory Committee Meeting to Discuss Antiepileptic Drugs (AEDs) and Suicidalit y

These are the anti-epileptic drugs involved:

Pfizer Inc., the New York-based company markets the USA's third best-selling epilepsy drug Lyrica with sales of $1.1 billion is disagreed with the FDA analysis, and trying to persuade government regulators not to add stern warnings about suicide risks to its best-selling epilepsy drug. Noted that Pfizer shares closed fell 2 percent to $17.39, on the New York Stock Exchange after the announcement.

Image of Pfizer's Lyrica (pregabalin)

Pfizer claimed that their own analysis showed Lyrica not "associated with an increased risk of suicidal behavior or thinking." They argues that Lyrica works differently than other anti-epileptic drugs and should not be subject to the generalized warning favored by the USFDA.

But how different the Lyrica works?
It binds to alpha₂-delta subunit of voltage-gated calcium channels within the CNS, inhibiting excitatory neurotransmitter release. Although structurally related to GABA, it does not bind to GABA or benzodiazepine receptors.

Mechanism of Action for Pregabalin

On the other hand, GlaxoSmithKline, which makes the drug Lamictal, has said the FDA's analysis of suicidal risks is similar to their own conclusions and should be added to drugs' labeling. Lamictal was the best-selling epilepsy treatment in the US last year, with sales of $2.1 billion. The shares of GlaxoSmithKline also down 2 percent to $45.83 a on the New York Stock Exchange after the announcement.

Image of GSK's Lamictal (lamotrigine)

Well, seems like more and more central nervous system (CNS) drugs are related to suicidal risks. The FDA now is started to ask the drug company to include studies looking for suicidality during the approval process.

Back to anti-epileptic drugs. The problem is: Epilepsy patients are already prone to depression and suicidal behavior, so it's hard to determine the negative impact of the drugs, especially on increased suicidal risk.

In addition, such new Black Box Warning will cause more harm than good if patients stop taking the drugs completely.

For healthcare professionals, if such Black Box Warning is implemented, they should convince the patients to continue taking their anti-epileptic drugs, but provide them closer monitoring, on their behaviour. It may require the cooperation of the healthcare professionals, patients' family, and the patients themselves. If they are feeling depressed and starting to have suicidal thoughts after taking the anti-epileptic drugs, they should quickly talk to their family members and their doctors or pharmacists.

Warning on Ciprofloxacin

2008-07-09T13:40:00.000+08:00

USFDA just issued warning on ciprofloxacin and related antibiotics (fluoroquinolone antibiotics), which include:

Levofloxacin
Gemifloxacin
Moxifloxacin
Norfloxacin
Ofloxacin

Image of Ciprofloxacin

They are notifying the manufacturers of fluoroquinolone antimicrobial drugs for systemic use of the need to add a Black Box Warning to the prescribing information about the increased risk of developing tendinitis and tendon rupture in patients.

Link: USFDA's Information for Healthcare Professionals

What is Black Box Warning?

It is is a type of warning that appears on the package insert for prescription drugs that may cause serious adverse effects. It is so named for the black border that usually surrounds the text of the warning.
A black box warning is required when medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects.
It is the strongest warning that the USFDA requires.

There have been reports of tendon inflammation (commonly Achilles, shoulder, or hand tendons) and/or rupture with fluoroquinolone antibiotics. The risk may be increased with concurrent use of corticosteroids, particularly in the elderly. Patients should discontinue taking this antibiotic at first sign of tendon inflammation or pain; avoid exercise; and immediately consult their doctors to change their treatment regimen.

Tendonitis is the inflammation, irritation, and swelling of a tendon. It can occur as a result of injury, overuse, or with aging as the tendon loses elasticity.

For healthcare professionals, the selection of a fluoroquinolone for the treatment or prevention of an infection should be limited to those conditions that are proven or strongly suspected to be caused by bacteria.

For general public, one should ask their doctors or pharmacists on what antibiotics and other medicines they are prescribed and dispensed. If they are aware of what medicines they are taking, such public warning will serves its purpose.

The Underrated Diabetes

2008-07-09T09:58:00.000+08:00

Very often, you will see a lot people, talking about cancer, and also heart diseases. They even try to take a lot of health supplements, that may help them to reduce their risk of getting these diseases.

Very seldom, you will see people talk about diabetes. To most of us, we thought, getting diabetes is not that bad. You won't really die from diabetes.

Note:

The World Health Organization (WHO) estimates that more than 180 million people worldwide have diabetes. This number is likely to more than double by 2030.

In 2005, an estimated 1.1 million people died from diabetes.

Almost 80% of diabetes deaths occur in low and middle-income countries.

WHO projects that diabetes deaths will increase by more than 50% in the next 10 years without urgent action. Most notably, diabetes deaths are projected to increase by over 80% in upper-middle income countries between 2006 and 2015.

Malaysia, if you wanna classify it as middle-income country, or upper-middle income country (but surely not high income country), is, or will be facing problems arisen from diabetes.

Well, diabetes, in fact, is anything but minor. It taxes on the entire body, affecting everything from hearing and vision to sexual function (erectile dysfunction), mental health (depression) and sleep. It is the leading cause of blindness, amputations and kidney failure, and it can triple the risk for heart attack and stroke.

It's the complications that kill! So it's not true when people said you are not going to die from diabetes.

And also, we have to keep this fact in people's head: Diabetes Mellitus, be it Type 1 or Type 2, is INCURABLE! It can't be cured, it can only be monitored and controlled, CHRONICALLY!!!

It's a disease needed to be kept in check medically, along with lifestyle changes like losing weight, exercising regularly and watching your carbohydrates.

Monitoring Blood Sugar

What I meant by medically? It's taking the drugs, or injecting insulin, as prescribed and directed, following instruction, plus, monitoring of blood sugar level.

Insulin Pens. Ain't that Scary, right?

The lifestyle modification including exercises, enough sleeping time, less carbohydrate (or low glycaemic index) diet and so on.

Patients who are having the regular medical care and proper lifestyle modification have a good chance of living out a normal life span without developing a diabetes-related disability.

Take your Pills as Prescribed!

Patients who say they are too busy to take better care of themselves, are actually trading their health. Too busy to earn money, and the money will eventually be used on medical expenses to deal with the complications.

In Malaysia, it doesn't cost much to manage diabetes mellitus. If you go to Ministry of Health Hospitals (government hospitals), basically, you just have to pay the processing fee, which usually less than RM 10. So the 'no money' is not an valid excuse. If you still have problem paying the processing fee, there are a lot of charity associations available.

So, in Malaysia, the main culprit of making the people resisted of managing their diabetes mellitus properly is: 'Busy-ness'.

Personally, I think, we all have the time, it's more on what you want to use it on. Many people rather spend the free time watching TV at home, than going to the hospital for treatment on their diabetes.

And also, there are some people, claimed that their diabetes mellitus have cured by traditional medicines. Well, the traditional medicine, may be helping to feel better, but definitely, their diabetes mellitus are not cured. There is no short-cut in the management of diabetes mellitus.

Sugar Death!

Diabetes Mellitus is a deadly disease, like heart diseases, and also cancer. It's not to scare you but it's a fact. Diseases that are not killing you instantly doesn't mean they are not deadly.

I'm not bringing hopeless message to those patient having diabetes.

If you can prevent yourself from diabetes, by having healthy lifestyle and healthy diet, that's perfect!

If you do have diabetes, with proper monitoring and controlling, you still can live a normal life, just like any other people. The key words are: Proper MONITORING AND CONTROLLING!

But if you just ignore it, it's deadly and it's not a joke.

Cholesterol Drugs for Kids?

2008-07-08T20:05:00.005+08:00

American Academy of Pediatrics recently was recommending that some children as young as 8 be given cholesterol-fighting drugs to ward off future heart problems.

Link: Cholesterol Drugs for 8-Year-Old?

Cholesterol drugs to Kids?

Wow. That's really a breakthrough recommendation.

The academy also recommends low-fat milk for 1-year-olds and wider cholesterol testing.

Dr. Stephen Daniels, of the academy's nutrition committee, said that the new advice is based on mounting evidence showing that damage leading to heart disease, the nation's leading killer, begins early in life.

One thing to note: Dr. Stephen Daniels has worked as a consultant to Abbott Laboratories and Merck & Co.

Merck & Co's Zocor (simvastatin)!

So... Low fat milk and Abbott Laboratories... Merck & Co. and Cholesterol drugs... Are they just co-incidents?

Abbott Laboratories' Pediasure

Well, I don't deny that childhood obesity is a serious issue. I don't even deny that obesity is often accompanied by cholesterol problems.

But, I do believe that this problem can be combated using other ways, other than drugs and low fat milk.

It's the lifestyle problem. These children, their fat intakes, are not necessary from the milk. If it's so, why were the children last time not having the obesity problem as serious as today?

From milk alone, the children impossible to gain that much of cholesterol, so it must be something else, unless these children are having genetically excessive cholesterol production problem. But, this type of genetic problem, will suddenly becoming epidemic? Is genetic defect contagious? No. It's the lifestyle that is contagious.

If starting the children on the cholesterol drugs, they might have to take it for life. FOR LIFE!!!

There is no safety profile of these cholesterol drugs (statins, fibrates and so on) on children yet; and also, the safety profile for cholesterol drugs, for adult, the longest one also up to 10 years only (Scandinavian Simvastatin Survival Study). So to ask a child to start on cholesterol drugs, you will easily ask them to take it for more than 10 years. Good idea?

Yes, we all know that these obesity and cholesterol problems in childhood can lead to serious health consequences in adulthood. But these problems should not be tackled using drugs. Lifestyle modification should be the priority. It's the healthy lifestyle that we should recommend to the children.