Pharmaceutical Adverse Effects Can Sneak Up on You

Recently at my urology appointment I complained to my doctor that the side effects of dry mouth, dry eyes and certain issues pertaining to sexual performance caused by my prescribed medications for prostatism were far worse than the actual urinary frequency and slow stream associated with a normally enlarging prostate gland. In addition to the direct effects of the medication, I was noticing minimal hygiene related issues that annoyed me greatly. I showed him an article from an ancient study done at the Veterans Administration in which seniors who had been on these medications for BPH for years and ultimately had a surgical prostatectomy at 6 months and one year post procedure were ecstatic about their outcomes and didn’t understand why they took the medications and waited so long to have the definitive surgery. He agreed with my assessment and presented surgical options and we set a date for the procedure.

He offered a second drug in advance of the surgery to shrink the prostate and make the procedure easier. He wasn’t sure if I had tried it before and I disliked it but I reviewed the pros and cons and filled the prescription. The medication works by inhibiting testosterone conversion to its active form by inhibiting enzymes called 5-alpha reductases. You do not need to be a pharmacologist or biochemist to understand that anything that inhibits male sex hormones may inhibit your sex drive, inhibit your sexual performance and or decrease your sperm count and volume of ejaculate. I warned my wife and added the medication to my regimen.

Five days later I cancelled my much anticipated trip to the gym for stretching, flexibility and core strength training. I loved these workouts but I just didn’t feel like doing it. The problem is I cancelled the next dozen scheduled workouts. I also packed up my running shoes and put them away deciding that the hip and back pain associated with my three mile trudge wasn’t worth it. I rationalized that I had gotten bored with my workout routine and needed a more senior adult program. I additionally noticed that after getting up early to walk the dog and prepare to make rounds at the hospital I was sitting down in an easy chair and falling back asleep. When I woke up I didn’t want to go out, but I did. My wife noticed the subtle change when I quietly sat in front of the TV watching my beloved Gators make their NCAA tournament run and I didn’t make a peep rather than scream at the screen, when an obvious boneheaded play was made by my team or when an obvious officiating error went against my team. This carried over to the Miami Heat’s late season attempt to make the playoffs as well.

Two weeks ago on a crisp beautiful Saturday, instead of taking the dog for a long walk and doing my run, I sat down in a patio chair and started to go through my accumulated journal articles. Yes those were stacking up too. There it was in the pile, “5 alpha reductase inhibitor use associated with depression and increased risk of suicide in men over 65” The article said that for the first 18 months after starting this medication up to 2/3 of the men became clinically depressed. The suicide rate was far higher than normal in that population. It was like a revelation. This was a new original report so this side effect was not commonly discussed.

I called my internist and discussed my article and my feelings and we decided to stop the medicine. I woke up the next morning and put on my running shoes and took my usual run after taking the dog for a long warm-up walk. It’s taken about two weeks for the cloud to be lifted. I sleep better at night. I am less fatigued during the day. I haven’t missed a workout in two weeks. I look forward to going to work and teaching my students again. I have accessed my office electronic health record and called every patient on this type of medication and we had a meaningful discussion to assess whether they were medically depressed. It snuck up on me so quickly and so insidiously. I still have a procedure coming up but I feel like my usually crazy self again.

The Artificial Sweetener Conundrum

Years ago I attended a Weight Watchers meeting in Brooklyn, NY with the lecturer being their public founder Jean Nidetch. She joked about her sugar free gum, sugar free soda and sugar free snacks contributing to “artificial diabetes.” She drew a big laugh but little did she know her comedy may have a ring of the truth to it.

Researchers have now published reputable data that drinking a diet soda daily greatly increases your chances of having a stroke or developing dementia. In an observational study, researchers using data from the Framingham Heart Study Offspring cohort noticed that individuals who drank diet soda and used artificial sweeteners were at an increased risk of ischemic stroke and all cause dementia when compared to individuals of similar age and risk factor stratification that did not use artificial sweeteners. Their data was published in the neurology journal Stroke. This is an observational study which cannot show cause and effect but uses the analogy and theory “where you see smoke there is fire”.

In an unrelated study, researchers looking at how we metabolize sugars noted that consuming artificial sweeteners may lead to larger food and beverage intake and ultimate weight gain. The data was not much better when they looked at individuals who consumed real sugar in sugary drinks. They noted that sugary drinks accelerated the process of aging in cells. This was somewhat in conflict with the original study referenced in which consumption of sugary beverages did not appear to have an association with stroke or dementia.

Clearly the data is confusing as to what to do. Once again moderation with diets with controlled portion size, limited chemical and antibiotic exposure and; rich in vegetables as well as fruits and nuts with a high quality protein seems to be the direction to go. No matter who studies the Mediterranean type diet the results are favorable.

Once again I lobby for nutritional training in the elementary, middle and high schools with healthy cooking and preparation classes as a sound investment for a healthier population in the future. The classes should go as far as teaching students how to create their own gardens and grow some fruits and vegetables on their own for home consumption. We may not be able to impact the adult population in mass but at least let’s give the children a chance.

Medication Adherence in the Elderly

One of the most challenging and difficult parts of my professional day is trying to determine if my patients are actually taking their medications as prescribed. I ask my patients to bring their medications to each visit in the original pill bottles and we count pills. I ask them to bring their medication lists as well and we go through the time consuming practice of reviewing each medication against the prescribing date and amount and reviewing whether the correct amount of medication has been taken and is left in the pill bottles.

Many of our patients inadvertently make medication mistakes routinely. The toughest groups of patients to treat are elderly couples living independently with no local family member support and possessing a strong will for independence and privacy. Often one patient is moderately to severely cognitively impaired and the other partner is nowhere near as sharp as they think they are. There are frequently out of state children who try to provide support by hiring someone to assist their parents. In most cases mom and dad do not allow that hired person to work full time and terminate any strong willed but well-meaning caregiver who actually does what needs to be done.

Out of town family members usually hire an aide to help their relatives. Aides are not permitted by state law to administer medications. It is not in their job description or permitted by law. Well-meaning relatives usually then hire an agency which sends a nurse to fill up a monthly pillbox with the patient’s medications. All the patient has to do is go to the pillbox, recognize the day and date and remove and take the medications set aside in that section of the pillbox for that particular day.

Unfortunately it doesn’t happen the way it should. Unless a nurse stands there and administers the medication and then documents it, there is a strong possibility that the medication will not be taken correctly.

When bringing this up tactfully to the patient, spouse/partner or family member; they act in disbelief that you would make such an absurd statement despite the pill count in the bottles being off and extra medicine remaining in the pill box. This issue was recently studied by Niteesh K. Choudhry, MD, Ph.D. of the Brigham and Women’s Hospital in Boston, Ma. Working with a younger group of insured patients he showed that even with the use of a pillbox, and a digital timer to remind patients it was time to take their medication, adherence was extremely poor. He concluded that patients need additional support to adhere to their medication schedules and needs. His study was published in the Journal of the American Medical Association (JAMA).

Patients, especially the elderly, need hired professionals to administer and document the administration of their medications or else they don’t get it right. This may be inconvenient and expensive but it works.

Probiotics and Mild Seasonal Allergies

I just completed the 2017 Internal Medicine Review course at Boca Regional Hospital and one of the presenters was Dr Eamon Quigley an expert on the bacteria in the gut or microbiome. He spoke about the future of analyzing the gut bacteria in disease, as well as health, and adjusting it accordingly.

When the question of probiotics came up he was extremely tepid in his views on the benefits they provide. We have routinely added a probiotic to antibiotic regimens for documented infections with the hope that by providing back bacteria for the gut destroyed as collateral damage of treating the infection, we might be preventing antibiotic related colitis and gastrointestinal distress. I left the conference uncertain about the role of probiotics

Upon getting to my desk I found an article in the American Journal of Clinical Nutrition which talked about probiotics filled with Lactobacillus gasseri KS-13, Bibidobacterium bifidum G9-1 and B. longum MM-2 had fewer allergic symptoms than allergic patients given a placebo. It was a controlled double blinded study looking at seasonal allergies. There were 173 participants all with seasonal allergies who filled out weekly MRQLQ questionnaires and had blood samples taken to measure serum immunoglobulin E and regulatory T cell activity.

The results clearly showed an improvement with the probiotics compared to the placebo. The benefit was most noticeable in those with mild symptoms.

Further studies need to be performed but as we head into spring allergy season I will make sure the probiotic I choose contains the cultures mentioned in this study. I will let you know how my allergies feel.