Sunscreen Works!

Sunscreen - FDA v2For decades, dermatologists and health care professionals have been urging patients to use sunscreen to protect against sun damage and skin cancer. What has been lacking is excellent research to prove the point.

The June 4th edition of the Annals of Internal Medicine Volume 158 #11 contains the results of just such a study. The study originated in Australia in a collaborative study of the University of Queensland and the Manchester Academic Health Sciences Centre in the United Kingdom under the authorship of Maria Hughes, Gail Williams, Peter Baker and Dele Green – all PhD’s. Nine hundred and three adults, younger than 55 years old, were randomized into one of four groups. One group used a broad spectrum sunscreen daily and 30 mg of Beta Carotene. The second group used sunscreen and a placebo, the third group had a choice of using sunscreen and beta carotene when they felt they needed to and; the fourth group had a choice of using sunscreen and a placebo.  All four groups were then followed between 1992 and 1997 for changes in their skin.

The findings:

·         ~ At 4 ½ years, the daily sunscreen group showed no detectable increase in skin aging.

·         ~ Skin aging was 24% less in the daily sunscreen group compared to the discretionary sunscreen group.

·         ~ Beta Carotene had absolutely no effect on retarding skin aging.

Despite some questions about the methodology, the study clearly showed that, in middle aged men and women, daily use of sun screen prevented skin aging.

As we head into summer it’s important to take this research to heart and use sunscreen of SPF applied to sun exposed areas before you go out.  Depending on how long you are exposed to the sun, you will need to reapply the sunscreen to continue receiving the protection you require.

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Lipid Levels Similar Regardless of Whether Patients Are Fasting Before The Test

Blood SampleAn article in the Archives of Internal Medicine, November 12th, 2012 edition, reviewed the lipid profiles of more than 200,000 patients who had different fasting times recorded before their blood was drawn. Many did not fast at all. The results showed that mean levels of total and HDL cholesterol didn’t differ much at all if the patients fasted or did not fast. Triglyceride levels were the most sensitive to eating or fasting. The data indicated that for the most part, unless your fasting triglyceride levels are 400 or greater there is no need to fast before checking your blood lipid levels.

Diabetics or patients with abnormal blood sugars are required to fast to accurately measure their fasting blood sugar levels. Since science and fact should govern our medical decision making, I changed my office lab testing policy beginning January 1, 2013. We will no longer ask patients to fast before blood drawing unless they are diabetics or have high triglycerides. This will make it far easier for patients who are wondering “what can I eat and drink the morning of my blood drawing for tests?” When we schedule appointments for patients being treated for elevated cholesterol we will no longer ask them to fast or not eat. We will reserve fasting appointments for patients who are suffering from diabetes mellitus or who have a history of elevated triglycerides.

If you are not diabetic and if you do not have extremely elevated triglyceride levels, please take your medications and eat before your scheduled appointment.

I will draw a fasting glucose blood test on all non-diabetic patients annually. Fasting is permitted if your visit is for your annual physical exam.

How Long Do Prescription Drugs Last?

In a letter to the Archives of Internal Medicine, Lee Cantrell, PharmD of the California Poison Control System in San Diego, discussed his research that showed that many prescription medications and their main ingredients retain their effectiveness and potency 40 years after the expiration date. He and his group specifically looked at aspirin, butalbital, phenacetin, caffeine, phenobarbital, homatropine, chlorpheniramine and acetaminophen. Of the 14 compounds analyzed, 12 retained the generally recognized minimal acceptable potency of 90% of the labeled amount almost 40 years after they had reached the expiration date. Out of the 14 compounds, Aspirin and amphetamine were the only 2 that didn’t retain their effectiveness some 336 months beyond the expiration date.

The authors did not advocate relying on outdated and expired pharmaceuticals. They did see a cost savings in re-defining how long a product will last and remain effective when stored appropriately. This could save consumers thousands of dollars each year if they store their prescription drugs in the correct environment.

I will certainly not advise my patients to use significantly outdated and expired prescriptions. The study shows that, under emergency conditions, these specific outdated compounds still maintain their efficacy.

Their research did not answer questions about the multitude of newer drugs that have been developed over the last 40 years and how long they will last.  Nor did not address the question of whether over time any new chemicals developed within the 40 year old products that may be harmful. The research certainly did raise the question of why we need to look at the traditional expiration dates and reassess the length of time a product still is safe and of value to the consumer.

Infectious Disease Society of America Updates Guidelines for Strep Throat

The Infectious Disease Society of America updated its 2002 guidelines for the diagnosis and treatment of Group A streptococcal sore throat.  In adults with a sore throat, only 5 – 15% actually have Group A streptococcal sore throat and require an antibiotic to treat the illness. Adults in that group usually have been in the proximity of young children or adolescents who have strep throat.  In 85 – 95% of the cases, the adults have a viral illness that is causing their sore throat and viruses do not respond to the use of antibiotics.    For patients at risk for Group A streptococcal sore throat, usually presenting with fever, swollen neck lymph glands and an exudative pharyngitis; it is recommended that a rapid antigen detection test be performed to confirm the diagnosis and appropriately start the patient on antibiotics.

According to Stanford Shulman, MD of Northwestern University’s Feinberg School of Medicine in Chicago, once the rapid antigen detection test is positive no confirmatory formal throat culture is necessary.  If the test is negative in a child or adolescent only, they recommend performing a formal throat culture to rule out the bacterial infection. This is not necessary for adults because there is a low risk of them having this type of infection and very low risk of complications like rheumatic fever.

Once strep throat is diagnosed, the treatment of choice remains penicillin or amoxicillin taken for 10 full days. If the patient is penicillin allergic, alternative choices of antibiotics including cephalosporins, clindamycin or clarithromycin are warranted.  Acetaminophen and non steroidal anti-inflammatory medications are acceptable to reduce discomfort and symptoms.

Distinguishing between a viral sore throat and bacterial Group A streptococcal sore throat is very difficult using symptoms alone since the bacteria have changed their presentation as an adaptive survival mechanism. Most clinicians however feel confident that if the patient has a runny nose (rhinorrhea), hoarseness, mouth ulcers and cough it is probably viral and does not require antibiotics.

This guideline change comes on the heels of a report in the Archives of Internal Medicine pointing out that antibiotic use by senior citizens in the southern United States is more frequent in January through March than in other parts of the country. The study talks about the inappropriate use of oral antibiotics during the cold and flu season leading to bacteria becoming resistant to simple and inexpensive antibiotics.  In addition to a resistance to antibiotics, we are observing an increased number of complications of antibiotic use such as antibiotic related colitis (clostridium difficile).

This information is presented as an educational effort especially for patients who demand an antibiotic inappropriately when they catch a cold (viral illness) or who demand an antibiotic when they travel “just in case I catch a cold”.

Narcotic Painkiller Use Increased in the Elderly

An investigative newspaper article published in the May 30, 2012 issue of the Milwaukee Journal Sentinel, in cooperation with online periodical MedPage Today, chronicles the increased use of narcotics for chronic pain relief in the elderly. The article highlights how in 2009 the American Geriatrics Society put together a panel of geriatric pain specialists who published geriatric narcotic pain relief guidelines that have led to the dramatic increase in use of narcotics in the elderly. There is apparently no outstanding or solid evidence that Opioids or narcotics actually work better than non-narcotic pain medications in relieving the chronic pain of senior citizens.  It is the Milwaukee Journal’s opinion that the members of the blue ribbon panel who made this decision received financial benefits from the pharmaceutical manufacturers who produce narcotic pain pills and were biased in their recommendations.  Individual members of the panel received financial rewards from the companies making the narcotic pain pills and the sponsoring organization, the American Geriatric Society, reportedly received $344,000 from Opioid manufacturers.

A study in the 2010 Annals of Internal Medicine looked at over 10,000 people who had received 3 or more Opioid prescriptions over a 90 day period. The researchers found that 51 had suffered an overdose including six deaths.  Of the 40 most serious overdoses, 15 occurred in those aged 65 or older.  A 2010 research paper in the Archives of Internal Medicine looked at 12,840 Medicare patients with an average age of 80 who had used Opioids, traditional anti-inflammatory drugs, or a class of non narcotic   prescription painkillers like Celebrex. Their findings included:

  • Opioid users were more than four times more likely to suffer a fall with a fracture than non-Opioid users
  • Deaths from any cause were 87% more likely in Opioid users.
  • Cardiovascular complications including heart attacks, strokes, and cardiac death were 77% higher in Opioid users than in users of NSAIDS.

In part, as a result of the American Geriatrics Society guidelines, Opioid use for pain relief has increased by over 32% since 2007.   Locally, we have seen the proliferation of pain clinics. These clinics, often owned by non-physicians, bear some responsibility for the proliferation of narcotic pain pills on the streets of America being used illegally.   Poorly conceived state legislation and the lack of surveillance and monitoring led out-of-state drug pushers to drive into Florida, hire individuals to doctor shop from pain clinic to pain clinic where they accumulate thousands of pills that are sold out of state on the streets illegally.  Ultimately this led to a law enforcement and statewide crackdown which drove illegal and legitimate pain specialists out of the state of Florida. It is almost impossible to find a certified pain physician in Palm Beach or Broward County who will take on a new patient under the age of 65 years old due to the legal hurdles recently imposed on them to crack down on the illegal dispensing of drugs.

George Lundberg, MD and Maria Sullivan, MD of Columbia University presented a sane and reasonable approach to pain pill management in MedPage Today in the June 11th issue.  They suggested that non narcotic pain products be tried initially. They encouraged doctors and nurses to discuss the side effects of narcotics with patients including constipation, sedation, addiction, and overdose and with long term use the risk of hyperalgesia and sexual dysfunction.

They noted the high abuse potential of short acting Opioids such as Dilaudid (hydromorphone) and Vicodin (Hydrocodone/acetaminophen) and pointed out that these drugs may be good for short term initial pain relief but not chronic use.  They reviewed the pharmacology of methadone and pointed out that it is responsible for far too many overdoses due to its basic metabolism and mechanism of action. They suggested never using it in patients who have not taken Opioid narcotics regularly.

They discussed the need for patients to keep controlled substances in a secure and locked place to prevent theft of the medication.

For those practitioners who prescribe Opioids for chronic pain they suggested having a chronic pain narcotic protocol including a medication contract with the patient that outlines its correct use. Psychological evaluation for abuse potential should be considered in all chronic pain patients prescribed narcotics. Urine toxicology screening periodically should be performed to look for abuse.  There are clinical interview screening materials such as the SOAPP (Screening and Opioid Assessment for Patients with Pain) form which helps identify individuals with a high risk of abuse.  Stratifying your pain patients into low, medium, and high risk individuals may help distinguish the level of surveillance necessary to safely treat the patients.

It would make great sense for the state of Florida and the Florida Medical Association to develop a common sense pain management course for practicing providers to take prior to renewing their state medical licenses.  The course would cover the newer pain protocols and medicines and review the safe and monitored use of Opioid narcotics.  We must treat and eliminate or reduce pain. We just need to do this in a safer manner.

Statins May Reduce Your Energy Level

Beatrice A. Golomb, MD, PhD. of the University of California San Diego and colleagues discussed the results of their ongoing studies in the Archives of Internal Medicine online edition regarding cholesterol lowering drugs Simvastatin and Pravastatin and recipients’ perception of their energy level. Their research suggested that Simvastatin might leave its users, especially women, feeling tired and drained after exertion.  The scores hinted that almost 40% of women felt more tired and fatigued during physical activity on Simvastatin than without the lipid-lowering drug.

The trial included 1,016 men and women with low-density lipoprotein (LDL) cholesterol screened at 115- 19- mg/dL who were randomized to receive 20 mg Simvastatin, 40 mg Pravastatin, or placebo each day for 6 months. These patients did not have documented heart disease, cardiovascular disease or diabetes.

There was a worsening of perceived energy level and exertion related fatigue in 4 of 10 women on Simvastatin. The effect was much less, and not significant, with Pravastatin or placebo.   In a recent review of statins and adverse effects in the Cleveland Clinic Journal of Medicine, the authors pointed out that muscles performing work required  fats and lipids as a source of fuel and energy to work successfully. They hypothesized the possibility that the goals of cardiology to reduce lipid levels to prevent cardiovascular disease to extremely low levels may create an environment in working muscles where the lipid levels are too low to generate the fuel or energy needed to perform the exercise and work needed to be done.

Clearly, further research needs to be done.  We must remember all these participants DID NOT have vascular disease and this is a primary prevention study to prevent them from developing cardiovascular disease.  Might there be other methods to achieve this?  Is Simvastatin the only statin to cause this type of problem or will the other statins do the same?  Is this a problem of the particular generic brand of Simvastatin used or is it an across the board effect of Simvastatin?  All these questions require additional research to obtain the answers that we need.

Statin Use and Diabetes in Older Women

Older women who take statins may be at an increased risk of developing Type 2 Diabetes Mellitus (adult onset). In a study published in the Archives of Internal Medicine, Dr Ma, of the University of Massachusetts School of Medicine, looked at the 154,000 women in the Women’s Health Initiative who did not have Diabetes when the study began in 1993.  Seven percent (7%) of them were on statins at the time through follow-up, 12 years later.  At that point, 10,242 cases of new cases of diabetes were reported. They theorize that this computes to an almost 50% increase in becoming a Diabetic if you are on a statin as compared to women who are not. Surprisingly, this occurred far more frequently in thin women taking a statin than in heavy or obese women.

The salient points taken out of this research are that women on statins need their liver enzymes monitored frequently they need their blood sugars monitored as well. The overriding message is that as physicians and patients we need to make a monumental effort to control elevated lipids by diet , exercise and weight loss without statins if humanly possible.

This also raises the question of whether we should be measuring HDL and LDL subtypes an Lpa levels on all patients before instituting statin therapy?  While this raises doubt about a popular class of drugs that are a crucial part of the prevention of cardiovascular disease, it does not yet make it clear what the clinical implications are for postmenopausal women on statins.

I will reevaluate all my female patients on statins as I see them for follow-up visits.