Proton Pump Inhibitors (PPIs) – Kidney Stones & Other Complications of Use

Medications to reduce acid in the stomach and duodenum are now available as prescription strength or over the counter at half the prescription strength. These are taken for heartburn, indigestion, gastroesophageal reflux disease, gastritis, gastric erosions, ulcers and other gastric inflammatory conditions. They work by inhibiting a parietal cell (stomach cell) hydrogen potassium ATPase (an enzyme) thus reducing the production of acid.

These medications work well and patients who take them regularly at times cannot tolerate the symptoms that return after stopping their PPI. You know the commercial names of these drugs such as Nexium, Prilosec, Protonix, Dexilant. Their use has been hypothesized to improve GI symptoms but put you at risk for a long list of medical illnesses.

In a recent publication in the British Medical Journal online edition, PPIs increased the risk of developing kidney stones in over 27,000 patients followed while taking them. They increased the risk of an initial stone and for each year you continued the therapy they increased the risk by about 4%. PPIs do this by reducing the absorption of the minerals magnesium and citrate. Low citrate levels lead to more acidic urine (lower pH) and this leads to increased calcium crystallization in the urine and stones.  

In the online journal Primary Care editorial is provided by David Rakel MD, FAAFP commenting on the original research of Timothy Overton, MD, MPH. Dr. Rakel notes that when he tries to wean his patients off PPI medications, and they just cannot tolerate the heartburn and gastric distress that returns, he will ask them to collect a 24-hour urine specimen and measure a citrate level. If the citrate level comes back “low” he restarts the PPI but supplements their diet with potassium citrate. The goal is to make the urine pH less acidic and greater than 7.0.

In Dr. Rakel’s review, he discusses all the illnesses that might increase in frequency and intensity by taking PPIs and reducing the acid level of the digestive juices in the stomach. The acidic digestive juices are an infection protector by destroying bacteria, viruses and parasites. Taking PPIs increases your risk of community acquired pneumonias, viral gastroenteritis, clostridia difficult colitis, small bowel intestinal bacterial overgrowth syndrome and the severity of Covid 19.  These same medications can interfere with the absorption of iron, vitamin B12, calcium and magnesium. There is a loose evidence-based association with long term PPI use and chronic kidney disease, stroke and dementia.

It isn’t easy to just stop the PPI medications. If you do, the acid production often rebounds and produces more severe and prolonged symptoms.

Dr. Rakel presents a plan for gradually stopping PPIs.  He gradually reduces the dosage every 10 days initially by 50% and then going to every other day. Prior to beginning the tapering of the drug, he requests that you taper your caffeine intake and consumption of acidic foods.

Instead of PPIs he prescribes sucralafate (carafate) one-gram tablets before meals and at bedtime for two weeks. Another option is substituting licorice (DGL) which coats and soothes the stomach. It is sold over the counter.

For nighttime symptoms he suggests using melatonin 1- 3 mg starting one half hour before going to bed. If that fails, he recommends a trial of acupuncture every 3 – 4 days for 3 weeks. Research has shown that acupuncture works better in symptom relief of heartburn and GERD than doubling the PPI dosage.  His last resort for treating continuing symptoms is to add back an H2 receptor blocker such as Famotidine plus ordering a fiber optic endoscopy to inspect visually what exactly is causing the problem.

Proton Pump Inhibitors work very well in reducing symptomatic acid related GI illnesses. Like all medications, they come with potential side effects. Prior to starting them or stopping them please speak to your doctor about the pros and cons and make the best decision for your individual situation.

Nurse To Patient Staffing Ratios are Important for Safety and Outcomes

There is a battle ongoing between nursing associations and hospital leadership. The main issue is that experienced nurses believe there are only so many patients one nurse can care for in a hospital inpatient location before the health and safety of the patients are put at risk.

When I started practicing medicine in a large public hospital in Dade County, Florida the ratio of nurses to patients on the medical floors was 1:4.  Illness and emergency situations often led to a ratio of 1:5 or even 1:6 patients but the additional patients were usually relatively healthy individuals requiring far less attention.

At that time, the ratio of nurses to patients in the critical care areas such as the intensive care unit, cardiac care unit or surgical intensive care unit was usually 1:1.  Staff illness and emergencies rarely led to a ratio of 1:2 but that second patient usually was well enough to require less attention. Only the more experienced critical care nurses were assigned to that second patient. 

There were times when nursing shortages led to the unit’s charge nurse closing beds in critical care areas rather than bringing in patients who could not receive the attention they required. As a clinician and physician let me make this perfectly clear, the quality of the care was directly proportional to the quality and skill of the nursing staff. Good hospitals with good outcomes had great nurses.  In those days the head nurse or charge nurse on a particular floor or ward was usually experienced and had overseen that area for years.  As a physician you quickly learned that if you wanted your patients well cared for, you followed the rules that the charge nurse on that ward or floor  established. There were other differences such as the same nurse cared for the same patient on the same shift daily until that patient was discharged.

In today’s hospital world there is a post pandemic shortage of experienced nurses. Continuity of nursing care doesn’t exist in most places. The ratio of nurses to patients has dramatically increased.  Hospital administrators cite cost constraints and new technology permitting nurses to care for more patients as the reason ratios are climbing above 1:5 today.

Linda Aiken, PhD, RN of the University of Pennsylvania School of Nursing’s Center for Health Outcomes and Policy Research is a firm believer in keeping the ratios of nurses to patients low.  The best staffed hospitals in her study maintain a 1:4 ratio while some corporate facilities have a 1:11 ratio.  Her research from a 2002 study reveals that there is a 7% patient death rate increase for each additional patient a hospital nurse is assigned.  The State of California is one of the few states that passed legislation limiting the ratio to one licensed nurse per five patients. Other states have tried but they have run into a lobbying roadblock from none other than hospital administrators and corporate owners.

The quality of the care one receives in the hospital is directly related to the quality of the nursing care and the availability of the nurses to assess the patient and respond to their health needs. A ratio of one nurse caring for four patients should be the goal. 

In my community, for the last decade or more, our local community hospital has behaved and billed no different than the for-profit corporate facilities.  The community is affluent and fund-raising campaigns at extraordinarily wealthy country clubs and oceanside and golf course condominiums raise hundreds of thousands of dollars for the local facility. I ask these charitable groups, “Do you know what the money is being used for?”   The answer is always, “No.” When I suggest that they use the charitable funds to sponsor another nurse on each floor to reduce the ratio of patients to nurses they look at me like I am insane. I stand by my suggestion. 

Ask what the ratio of nurses to patients is at your facility. Ask if the same nurse cares for the same patient on the same shift daily.

If you are generous enough to donate and raise funds for your local hospital, sponsor an extra nurse per shift per floor! It could save your life or someone you love!

Walking Leads to Decreased Cardiovascular Events & Mortality Risk

I have often extolled the benefits of continuing to move. The arbitrary goal of 10,000 steps per day seems to resonate throughout the community but peer-reviewed published studies show that with far less walking you receive a strong positive benefit. Timothy Overton, MD MPH and associates published a study in the Journal of the American College of Cardiology that showed as little as 2,600 – 2,800 steps per day reduced your risk of a cardiovascular event and mortality risk. In their study, participants achieved additional benefits when walking up to 8,800 steps per day. Above that level, there was continued improvement in reducing cardiovascular events and reducing the risk of mortality, but the improvement numbers were not considered statistically significant.

Dr. Overton’s study examined the data of 111,309 people from 12 different published studies examining the relationship between step counts and cardiovascular event rates. With 2517 steps per day there was an 8% reduction in all-cause mortality. This increased to an 11% reduction in all-cause mortality with 2,735 steps per day, an addition of just 200-300 steps.  The reduction in mortality and cardiovascular events continued with increasing step counts to 7,126 steps.

Any additional benefit was not considered statistically significant. This did not necessarily mean more steps didn’t help. It may very well have to do with the number of individuals in the study walking that far. That subject needs additional study. 

The study did not define whether there was a benefit to accumulating your steps over the course of the day or all at once in one exercise period. Those studies will need to be done.

What is clear is that you don’t have to hit 10K steps a day to benefit and walking just 2,600 steps per day reduces cardiovascular events and mortality risk. As the weather cools down, find a safe course to walk and get your steps in.  It could save your life and certainly improve its quality.

Cannabis Use and Medical Issues

Marijuana has been legalized in many nations and several states for both recreational casual usage and for medical usage. In the State of Florida, it is available as a medicine. It requires a prescription from a physician who took a short continuing education course for a fee with the script taken to a cannabis dispensary. 

Unlike other prescription drugs, the Food and Drug Administration (FDA) has not been asked to evaluate it as it does for every other prescribed medication. There is no published data on the most effective way to deliver the medication (smoking? vaping? edible?).  There is no data on drug-to-drug interactions and adverse effects. There is no data on which blends of marijuana are best for which situations.

The sale of medical marijuana generates income for the industry and the State of Florida.

Medical research studies have begun to shed light on the pros and cons of legal availability of the product as a medicine and for social recreational usage. A recent study in the British Medical Journal discussed how cannabis usage resulted in fewer seizures in patients suffering from epilepsy with up to a 50% reduction in seizures. Chronic pain patients saw a reduction in pain by 30%. Quality of life was judged to be improved in patients with inflammatory bowel disease (Ulcerative Colitis and Crohn’s Disease). Patients suffering from multiple sclerosis noted less spasticity and pain but increased risk of dizziness, dry mouth and somnolence. The same study pointed out that pregnant women had smaller children earlier. Side effects such as nausea, diarrhea and psychiatric crises were frequently  noted as well.

A study published in JAMA Network Open researched by Owen Hamilton, MD looked at the number of traffic accidents and visits to the emergency department related to the legalization and commercialization of marijuana in Canada. They noted an increase of 475.3% of marijuana-related traffic accidents after legalization. They additionally noted a dramatic increase in visits to emergency rooms for marijuana associated physical and mental issues.

A study in JAMA examined the effects of recreational marijuana usage on adolescents and found that teenagers who use marijuana recreationally are 2  -3 times more likely to have depression and suicidal thoughts than those who do not use it. The study linked recreational marijuana usage by teens with poor performance in school, skipping school and increased run-ins with law enforcement.

As a physician I have no problem with use of cannabis as a medicine under certain circumstances. I want to know how to best deliver it for the different conditions involved. With so many different blends of cannabis available in dispensaries, I want to know which ones work best for which situations. I want to know how marijuana will affect patients with other medications. Should we be avoiding prescribing it in some instances or should we be adjusting dosages of other meds when cannabis is prescribed? It’s clear from the emerging studies that usage by adolescents and pregnant patients is neither harmless nor benign.

Let’s treat medical marijuana as a medicine and provide physicians with the data which is available, and they need, for every other prescribed medication to ensure the most effective and safe usage of this popular product.

Primary Care Physician Visits Before Emergency Surgery Reduce Mortality in Older Adults

In a previous article I discussed the fact that individuals who see their primary care physician three times per year stay healthier compared to patients who see their physician intermittently or only upon developing a problem.  A similar finding was found in older adults who saw their primary care physician prior to emergency surgery. 

Sanford Roberts, MD and associates published their research in a July online edition of JAMA Surgery. His group looked at 102,384 patients composed of 8.4% people of color and 91.6% Caucasians. Patients who had seen a PCP had a mean age of 73.8 years and 54.8 % were females. The mean age of patients who had not seen a primary care physician was 71 years of age and 48.5 % were women. The researchers obtained their data from the Center for Medicare Services Beneficiary Summary Files.

The data revealed that patients who had seen a primary care physician prior to surgery had a lower adjusted odds of death at 30-, 60-, 90- and 180-days post-surgery in both black and Caucasian patients. All together they had a 25% lower mortality after surgery than patients who had not seen a primary care physician. That is a huge difference which the researchers are trying to understand and explain.  Theories abound including one that the patients who did see a primary care doctor might be healthier and more health conscious than those that did not. Further research in this area is required but based on this study the importance of continuity of care and seeing your primary care physician regularly is now supported by emergency surgery survival data.

Find a primary care doctor and establish a professional relationship. See that doctor regularly and keep that physician informed about your health and visits to other physicians and health problems.

Simplifying The Choices of Fall Vaccines in Adults

My wife and I received our COVID-19 booster shots yesterday afternoon. Clearly my injection site is sore today and every ache and pain I normally have when arising is amplified. It’s really nothing that two Tylenol or one Advil won’t relieve. The shot was administered at a chain pharmacy by a very professional technician who asked us if we wanted our flu shots as well as our RSV vaccine. We declined the additional vaccines today and understood clearly that the technician was following the script supplied by her employers, but it gave me an idea for a blog article.

There are three vaccine choices to be made by adults this fall which include influenza vaccination,  COVID-19 monovalent booster and the new RSV vaccine.  Researchers feel that you can safely take the flu shot and COVID-19 booster at the same time. It should be administered in different arms if given on the same day. From my perspective, there is absolutely no reason to take two vaccinations together except for convenience. 

Influenza A generally does not appear in South Florida much before Thanksgiving. We see Influenza B in Emergency Rooms and Urgent Care Centers year-round, especially in children. Influenza seems to peak locally most years the last week in January and first week in February (Super Bowl weekend). 

Adults 65 years of age and older should be receiving the senior high dose quadrivalent vaccine. Younger adults do not need the high dose preparation.  When younger adults receive the vaccine, their immunity lasts for most of the influenza season. Men and women 65 or older see their immunity begin to decrease 90 days after receiving the vaccine. For this reason, I prefer to take the flu shot and administer it after Halloween and before Thanksgiving. For those seniors who took the flu shot in August or September, on the advice of a pharmacist, we can offer them a booster in late December and or January especially if it appears that the flu season will be active into the early spring months. The Flu vaccine is available in my office for patients because it can be stored in a normal refrigerator.

The monovalent COVID-19 booster is available in pharmacies from both Pfizer and Moderna. This vaccine is stored at minus ninety degrees. Therefore, most physicians’ offices do not have freezers capable of storing it for administration. Senior citizens should take it at least two months after their last COVID booster or two months after an active COVID infection. I am a fan of giving this booster to younger adults annually  as well.

Respiratory Synctial Virus (RSV) infection results in the hospitalization of up to 16,000 adults and accounts for about 6,000 – 10,000 deaths annually. Two new adult vaccines have been approved for adults 60 years of age or older. Arexvy by GlaxoSmithKline differs slightly from the Pfizer Abysvo by containing an adjuvant designed to increase the immune response. It’s designed to be administered once year with much longer lasting immunity than the flu shot or COVID booster provide in senior citizens. The major side effects have been soreness at the injection site, but a few cases of Guillan Barre Syndrome have been seen in recipients.

In my practice I am suggesting we observe the response and adverse effects in seniors for a few months after the start of the vaccination program in the USA to better judge what the adverse effect risk profile actually is. The vaccine is covered by Medicare Part D prescription plans which means it must be taken in the pharmacy not in your physician’s office. For those who choose to take it, I suggest separating its administration by about 3 – 4 weeks from the influenza or COVID boosters. This is not based on peer reviewed published research, just common-sense intuition for my patient population of mostly retired senior citizens.

Correlation Between Continuity of Care in Primary Care & Cost Savings

An online version of JAMA printed a synopsis and full text of a research study done at the University of Chicago School of Business and College of Medicine between April 2022 and June 2023. They studied the Medicare billing records of over 500,000 seniors who used traditional Medicare insurance and were either seen regularly by the same primary care physician, irregularly by the same physician or by multiple physicians.  A bit more than half of the study group were women with an average age of 74 year in both sexes.

Patients who saw their physician three or more times during that period were compared to patients who were seen infrequently and waited for an issue to seek medical care. The study results were extremely clear.  Regular visits to the same physician ended up costing the Medicare system far less money. There were fewer trips to the emergency rooms, fewer hospitalizations and fewer trips to medical and surgical specialists. The study excluded patients in Medicare Advantage plans and dialysis patients.

The figures reflect the fact that regular visits to the same primary care doctor keep your chronic issues under control and result in less hospitalizations.  I bring this up because I prefer to see my senior citizens every three to four months. 

My patients ask me why they need to be seen if they are feeling well. I tell them the visits are designed to keep them feeling well. At those visits we review medications, supplements and preventive care such as ophthalmology evaluations, hearing evaluations, skin body checks, colorectal cancer screening tests and a host of gender related tests including mammograms, bone density entry, HPV testing if appropriate plus lab work to examine your sugar metabolism, kidney and liver health, thyroid function, blood counts and tests based on their individual chronic conditions under control. It’s also an opportunity to see how you walk, see how you receive and interpret verbal discussions and how you respond. Just looking at your dress and grooming from visit to visit tells a medical tale to a trained observer. 

Some of my patients actually made me question the wisdom of this practice proclaiming it a waste of their busy day.  It’s nice to have data to back up the suggestions.

Go for your checkups with your medical doctor on a regular basis, stay independent and keep yourself out of the emergency room and hospital.

Shared Decision Making or Covering Your Liability?

Much has been written about patient / physician relationships and sharing decision making responsibility with your patients and their health care surrogates. My concept of shared decision making involves explaining to the patient exactly what the conditions are you are dealing with and trying to remedy.  It involves outlining the choices and options to both evaluate the problem and treat it. That outline should include the physician’s preference for evaluation and treatment and why these suggestions are made. The patient then has the information to ask questions and make their decision.

In reality, that is not occurring especially the part that requires the physician to explain what options they prefer and why. What’s worse is when the patient declines the best option. The physician then documents it on the chart as “ Patient declined suggestion” to lower their medico-legal risk.

This past week’s experiences provide examples.  An 80+ year old patient of mine with dizziness for several days decided to self-refer himself to the emergency department in the middle of the night.  He had no vertigo or loss of consciousness or slurred speech or motor or sensory changes. The patient had not discussed any of these multi day symptoms with me or with his  very responsive cardiologist or neurologist.  He did call me at 3:00 a.m. Saturday morning to let me know he was in the ER. I awoke, logged into the hospital computer electronic health record system and reviewed the very appropriate and complete and thorough evaluation planned by the ER physician and staff.  

Two hours later a physician assistant observed him walking and reviewed the tests and felt he was well enough to go home. An EKG had been read as revealing changes which could be associated with acute poor blood supply to the heart muscle or ischemia.  The Emergency Room physician’s official note says he offered the patient admission to the hospital to stay and evaluate this and the patient declined.

I called the patient at a reasonable hour and, while feeling better but tired, he insisted that no one had ever suggested he stay or that there might be a cardiac problem. I have no idea if the physician actually said, “I think you should stay because your EKG has changed and that may be related to your dizziness.” I suspect that message was never delivered. Instead, the patient received the message, ”Your neurological symptoms have disappeared and the brain CT scan is normal. What do you want to do?”

A similar situation occurred the next evening when at midnight I received a phone call from a family member whose spouse had tripped and fallen in her bathroom putting her head through their dry wall.  There was a cut on her scalp bleeding profusely but she seemed to be neurologically intact.  The patient was 69 years old and had been taking aspirin for aches and pains and occasional ibuprofen. There was no loss of consciousness.

The fall was not related to alcohol ingestion or recreational drug use but probably was related to a foot and ankle orthopedic issue and knee issue that should have been addressed after previous falls. I suggested they go to the local ER and be examined.  They followed my advice and at the ER she was examined and treated. The ER doctor told her she had no neurological abnormal findings and inquired whether she wanted a brain CT scan to look for brain bleeding or injury.  The patient declined. In the official record it is stated that the physician suggested a CT brain scan and the patient declined. At no time did the ER physician say , “I think a CT brain scan without contrast would be a good idea based on your use of aspirin, your age and the trauma involved.”  

The ER physician next asked if the patient wanted her to suture the wound with staples or not. No explanation of the options and reasoning behind choosing one option or the other was advanced. The patient chose no suturing and chart was documented as a suturing offered but declined.

At the very least, patients have to ask “What choice do you think I should make and why?” It would also be acceptable to ask, “If I was your mom, what would you suggest and why?”

Summer – Ramblings and Thoughts

This summer has been unseasonably hot and humid even for south Florida. For weeks now, every day has had temperatures that have felt like they are over 100 degrees Fahrenheit.

South Florida is built for heat and humidity so, except for outdoor workers in construction and landscaping, most of us do our outside work early in the morning or after dark. We have been fortunate in having the least disruptive weather in the country so far. 

Fall athletic preseason training camps opened during the last month for local high schools, colleges and the pros and I believe their coaching staffs have made the necessary adjustments to keep their players safe from heat related illnesses. That means starting early and finishing early, hydrating before, during and after workouts and modifying their practices.

It’s been too hot to take my 12-pound dog on his usual long walks after work. We still walk, using the shady side of the street, but go a considerably shorter distance and take a water break or two where I hydrate him from a special portable dog bowl. Prior to going outside, I put both palms on the sidewalk to make sure the pavement is not too hot for his paws.

While the heat and humidity, violent storms and floods have captured the news headlines, few have discussed the uptick in COVID-19 cases nationally.  Hospitalizations for COVID-19 are up about 10%.

The good news is that between naturally occurring post infection immunity and vaccinations, the number of deaths from this disease has been reduced. Paxlovid, the anti-viral pill, works well especially in the over 65-year age group and the immunosuppressive to prevent hospitalization and death. There are still many out there who have never had COVID.

Dr Robert Wachter, the chairperson of Medicine at the University of California, San Francisco, posted on social media his first experience catching the disease. He is vaccinated, boosted and he is healthy. He ran a high fever with chills and sweat, as well as aches and pains, all night and decided to take a hot shower to clean up and feel better. The warm water caused his blood vessels to vasodilator and that coupled with a bit of dehydration led to a sudden faint and collapse. He woke up on the floor of his bathroom with blood all over the room and a big dent in his garbage pail where his head hit. He was taken to the hospital where imaging revealed a non-displaced cervical fracture, a sub-Duran hematoma and cuts requiring 30 stitches.  He admits that like all of us, masking and distancing had grown tiresome, and he let his guard down. He underestimated the clinical symptoms a first time COVID infection brings even to a healthy fully vaccinated individual. The message from Dr Wachter is clear, in high-risk situations keep up your guard against Covid.

Summer is always a time for relaxation and fun. There is no reason to avoid the things you love. Just be sure to adjust for the weather and evaluate your risks before you engage in hot temperature fun.

Fish Oil Pills & Atrial Fibrillation

The science of fish oils was introduced 40 years ago when researchers noted that individuals who obtained fish oils by eating two fleshy fish meals a week seemed to lower their elevated lipid levels and were less likely to develop cardiovascular diseases. Several years later, these researchers modified their view and suggested that eating two fish meals a month, of canned tuna or salmon, was adequate.

This was the accepted standard for several years until researchers began to detect heavy metals in the very cold-water fleshy types of fish they were encouraging individuals to eat. Lead and arsenic were found in tuna, salmon and other popular fish. The discovery was particularly distressing to women of childbearing age who were advised to avoid fish because the heavy metals produced fetal brain developmental damage.

I am not sure if it was the heavy metal toxicity or just the money-making opportunity but, in short order, over-the-counter fish oils started appearing on the shelves of pharmacies and supermarkets. These supplements were not FDA evaluated and, for all practical purposes, no one knew or cared where these supplements obtained their raw materials from and whether they too were contaminated with lead, arsenic or cadmium. I like fish and have believed that the concentration of heavy metals in fish would not likely affect an older adult, so I chose to get my fish oils from eating a fish meal each week.

When I conduct an office visit with my patients we review their medications plus vitamins, supplements, herbs and minerals in detail. Fish oils are a popular and common part of many senior citizens’ daily medication routine. 

In the August 10th edition of Medscape, cardiologist and electrophysiologist John Mandrola,  MD advances the theory that fish oil supplements increase a patient’s risk of developing the abnormal heart rhythm known as atrial fibrillation (Afib). He evaluated several peer-reviewed cardiology studies and concluded that fish oil supplements do not prevent mortality from heart disease and probably increase your risk of developing atrial fibrillation. He goes on to say ”Omega-3 fatty acids reduce triglyceride levels, but this is not enough to adopt use of these pills.” The lack of consistent reduction in cardiovascular events and the off-target signal of (increased) AF risk argue against routine use of fish oil pills. In an editorial accompanying the article, the reviewer calls for additional research on this subject. For the time being, I will suggest to my patients that omega-3 fish oils can be obtained by eating a fleshy fish meal, or canned tuna or canned salmon, a few times a week. That is what I will be doing, not because of the fish oils, but because I enjoy eating fresh fish in moderation.