PPI Use and Death Risk

In recent weeks we have seen articles linking the long term use of proton pump inhibitors such as Nexium (esomeprazole), Protonix ( Pantoprazole), Aciphex (Rabeprazole), Prilosec ( Omeprazole) with an increased risk of community acquired pneumonia, kidney disease, bone disease, cognitive dysfunction and increased risk of clostridia difficile infection (antibiotic related colitis). These drugs are commonly used short-term for the treatment of ulcers, gastro esophageal reflux disease, Barrett’s Esophagus, upper GI bleeding and H Pylori infections.

Often, after the prescribed treatment period, physicians try to discontinue the use of PPI’s but the patients have a return of their symptoms. With these medications now being sold over the counter, it is very difficult to get a symptomatic individual to curtail therapy even if the long-term risk is daunting.

I often attempt to switch patients to “old fashioned” antacids such as Tums, Rolaids, Mylanta, Gaviscon or even the H2 receptor blockers such as Tagamet and Zantac (Cimetidine and Ranitidine). All too frequently the response is that “my symptoms returned and only get better with the PPI.”

A study published in the British Medical Journal looked at data from the Veterans Administration data base for a period of two years, and selected a representative group of PPI users and non-users. They then followed them for 7-8 years.

Patients taking PPI drugs regularly had a 25% increased risk of death. There was no apparent reason why these medications led to a higher death risk. Further studies will be needed. The conclusion is take them for as short a period of time as possible.

Fish Consumption and Reduction of Risk of Developing Breast Cancer

Fish v2MedPage, the online medical journal of the University of Pennsylvania School Of Medicine reviewed an article published in the British Medical Journal concerning a relationship between consumption of marine fish oil from fish and a reduction in the risk of developing breast cancer. The study was published by Duo Li, MD, a professor of nutrition at Zhejiang University in Hangzhou, China. They reviewed data from 21 “prospective cohort studies involving nearly 900,000 people”. According to their data, eating just one or two portions a week of salmon, sardines, mackerel or other fish rich in marine n-3 polyunsaturated fatty acids is associated with a 1 % reduced risk of breast cancer in later life. Their data came from questionnaires that asked about patients’ intake of fatty acids and from blood levels measured in several studies. When they looked at similar fatty acids which come from plants not fish, such as alpha linoleic acid, they could not see a similar protective effect.

The study was critiqued by Alice H Lichtenstein, DSc, director for the cardiovascular nutrition lab at Tufts University. She had numerous questions and concerns about the methodology and conclusions but did support the need for future prospective studies to examine this question. While I have neither the credentials nor experience of Dr. Lichtenstein in evaluating this type of data I believe strongly in the KISS (keep it simple stupid) principle. Fleshy fish provides fish oils which are felt to be beneficial to our health. The same cannot be said for fish oils which you receive in pills and preparations.

My advice is to eat fish two or three times per week. Prepare it simply in a Mediterranean diet style and obtain the benefits that research seems to consistently show for this eating pattern.

Coffee Consumption May Lead to Safer Driving Trips

CoffeeIt is no secret that for decades men and women have been drinking caffeinated beverages to wake up or stay awake. This is especially pertinent when it comes to driving an auto or a truck and trying to stay alert and awake. Researchers in Australia decided to take a look at the question of whether ingesting caffeine in the form coffee or tea led to fewer accidents. Lisa Sharwood, PhD, of the University of Sydney reported in the British Medical Journal that long haul truckers who reported consuming caffeine to stay awake had a 63% reduced likelihood of crashing than control subjects. Their study looked at 530 long-haul truck drivers who had an accident between December 2008 and May 2011 in Australia. They compared them to 517 controls that had no accidents in the same 12 month period.

Case drivers drove about 1,700 miles in the week before their accident. Controls drove somewhat more, about 2,400 miles, in the week before their interview. 43% of the case drivers admitted to drinking caffeinated beverages specifically to stay awake. Only 3% admitted using illegal substances such as amphetamines or cocaine to stay awake.

The practical side of the study is that if you must operate a motor vehicle and you feel fatigued then stopping for a caffeine containing beverage definitely helps reduce the likelihood of a crash.

Too Much Calcium May Be Harmful For Women

Front view of woman holding seedlingThe Swedish Mammography Cohort, a population based group that includes 61,433 women born between 1914 and 1948 with a median follow-up of 19 years was used to answer the question of whether calcium intake can be harmful? The research team analyzed food intake by questionnaires and estimated the total calcium intake from food and supplements in the study group. Participants were divided into groups based on total daily calcium intake. One group consumed less than 600 mg of calcium per day. A second group consumed between 6000 and 999 mg a day. Group three consumed 1,000 to 1,399 mg per day. The last group consumed more than 1400 mg a day or the equivalent of drinking five 8 ounce glasses of cow’s milk.

The study was led by Karl Michaelsson, MD, of Uppsala University in Sweden and published in the online edition of the British Medical Journal. They found that the group consuming 1400 mg or more per day of calcium had a higher risk of death from cardiovascular disease, ischemic coronary disease and all causes than expected. The high calcium intake did not however increase the risk for strokes. At the other end of the spectrum were those individuals on an extremely low calcium diet with less than 600 mg per day. They were found to have an increased risk of death as well from all the causes mentioned above plus stroke.

Once again this appears to be a call for moderation in one’s diet. Too much or too little of anything is associated with consequences. At the current time postmenopausal women are advised to consume 1600 mg of calcium a day between diet and supplements. It may be time to look at that number and see how it applies to North American women as opposed to Swedish women who participated in this project.

Screening for Cervical Cancer- The Pap Smear

Cervical Cancer is easily prevented and detectable by having regular pap smears performed by your obstetrician-gynecologist or your primary care physician. In many cases the physician will add the HPV (Human Papilloma Virus) test to look for the presence of a virus associated with cervical and oral cancers.

It is recommended that all women begin receiving annual pap smears at age 21 or within three years of having sex, whichever occurs first. These tests should be repeated annually.  If a woman has her cervix surgically removed as part of a hysterectomy it is no longer necessary to have pap smears.  Older women who have had normal pap smears for several years in a row and have the same monogamous sexual partner for many years or are now sexually inactive , may be able to eliminate having pap smears.  Women over 30 years old with several normal pap smears and the same sexual partner may be able to spread out the pap smears from an annual event to one every two – three years.

A recent study in Sweden, published in the British Medical Journal, confirmed that women who had regular pap smears were detected with cervical cancer much earlier than those women who were not tested, and they survived the disease at a much higher rate.  While this type of test is invasive and involves extremely private anatomical areas, the data is clear that this is one screening procedure that saves lives!

What’s New in Dementia, Alzheimer’s

Alzheimer’s Disease is a form of dementia and considered to be a progressive, fatal neurologic disease. Medications to slow it down are successful in about 50 % of patients for a very limited amount of time (6 -12 months).  As Baby Boomers age and move into the retirement sector, we are always looking for positive data regarding the disease to offset the expected epidemic of dementia.  We have a limited amount of good news to report.

Japanese researchers report that they have developed several types of contrast material for imaging studies which will allow doctors to see accumulating plaque in the brain and possibly the tangles of neurons associated with the disease at a much earlier stage.  At the same time researchers now claim to be able to do a spinal tap and, by examining the spinal fluid, make an earlier and more accurate diagnosis. At this point there might not yet be an advantage to early detection of the disease but as research proceeds it may become an important advantage.

The British Medical Journal is reporting that cognitive decline actually starts in midlife. They studied a mix of 7,300 men and women at five years intervals beginning in 1997 and found a decrease in intellectual functions beginning at 45 years old. They concluded that “what is good for our hearts is also good for our heads.”  They stressed the importance of controlling hypertension, obesity and abnormal cholesterol as a way to prevent dementia.

You might ask why I consider the fact that dementia begins in midlife a positive?  It’s a positive because we have the ability to control our weight, blood pressure, cholesterol and exercise level. Anytime a disease is modifiable by how we live our life we are given the chance to prevent it or limits its impact. This fact is supported by a recent study published in the Archives of Neurology looking at individuals with a genetic variant which predisposes them to develop Alzheimer’s Disease.  They found that older adults with the genetic predisposition for Alzheimer’s Disease who exercised regularly, at or above the American Heart Association recommended levels, developed “amyloid deposits” on scans of their brain less than expected and in line with the general public who did not have a genetic predisposition to develop the disease.

These are small but positive steps in facing dementia. We can find it earlier and slow down or turn off genetic predisposition by living a healthy life.

Aspirin Holiday Carries Its Risks

A recent publication in the British Medical Journal looked at the risk of stopping aspirin therapy and taking a drug holiday from it if you are taking aspirin as secondary prevention for heart disease. The study, conducted from 2000 – 2007, looked at almost 40,000 participants aged 50-84 who were taking low dose aspirin (75- 300 mg per day) for secondary prevention of cardiovascular outcomes. They followed the patients for 3.2 years.

Researchers determined that individuals who stopped aspirin for 1-6 months had significantly more myocardial infarctions (heart attacks) and cardiovascular deaths than individuals who continued the aspirin.  Most of the patients who stopped the medication just stopped it on their own for no particular reason.

The study has implications for patients who have known coronary artery disease, have had a heart attack or stent placed or have survived bypass surgery. It says that if you stop the aspirin you increase your risk of having a cardiac event.

As a physician I am always faced with phone calls from patients going for minor dental work and the dentist insists on stopping the aspirin. I have patients going for elective cosmetic procedures who are required to stop their aspirin.  The message must be “is the risk of excessive bleeding from the elective procedure greater than the risk of having a heart attack?”  This is a question you should ask your cardiologist, internist or family physician before stopping the aspirin. You and they will need to ask your dentist or surgeon the same question before you stop the aspirin.

There will be times when you will have no choice but to accept that increased risk to have work done which may be necessary.  By informing your physician of the problem, and discussing it with the surgeon or dentist, we can determine if stopping the aspirin is essential and if there are other measures we can take to prevent a cardiac event.