Wednesday, December 29, 2010
Tuesday, December 21, 2010
It is true that testing of platelets in a test tube have show that using PPI's can decrease the potency of Plavix (potentially leading to more MIs), this has not been in many observational studies. Strangely and in a surprise to most Cardiologists, the FDA forced the makers of Plavix to warn their patients about this test tube interaction.
This potential interaction has only been tested in one randomized clinical trial. The COGENT randomized almost 4,000 patients and found NO increased signal for increased cardiovascular events. What it did show was a highly statistically significant decrease in gastrointestinal events (GI bleeding and ulcers) in the patients taking both omeprazole and Plavix.
I have been using Plavix in conjunction with PPI's for years. I have never seen an increase in MI's or other cardiovascular events in these patients. The COGENT trial supports what I have seen clinically -- while there may be an interaction in the test tube, the concomitant use of Plavix and a PPI is not only safe but also possible helpful.
Monday, December 20, 2010
I recently read to editorials on obesity. Both of these were written as thought pieces after the announcement of first new diet pill to be approved by the FDA in over ten years. I thought both were extremely poignant and I could not have written them better myself. I agree completely with their overwhelming sentiment that overcoming our obesity epidemic needs to be a concerted effort to change our eating habits and getting moving and not with a magic diet pill.
The second piece I read this morning on kevinmd.com
By John Mandrola, MD
I need help. In dealing with obesity as a medical problem, that is.
I am pretty solid at arrhythmia management, but as an obesity doctor, not so much. If I was the teacher, and my obese patients were the students, I would surely be fired for poor student test performance. At least, if the core measure was the patient's BMI.
If a student does poorly on an achievement test, is it the student's or the teacher's fault? If the obese patient does not lose weight, is it the doctor's or the patient's fault?
Recently in the NEJM, I read about Arena pharmaceutical's attempt at creating the new "wonder pill" for obesity. Lorcaserin is a novel serotonin re-uptake inhibitor which acts primarily in the brain centers that control hunger and satiety. Theoretically, it provides a patient with the good sense not to eat too often, and as the skinny farmer advises, leave the table before you are stuffed.
Although, Locarserin had no major adverse effects, the weight loss was modest, up to 5-10% of body weight. Thirty pounds is only the prologue for the 300 pound patient.
So, now we may have another pill for fatness. Like we do for tiredness, and the low sex drive of male middle-agedness.
The study conclusion is worded with scientific precision. The researchers say, in conjunction with behavioral modification, the drug was effective in weight loss What people hear, though, and the drug manufacturer are really saying is: take this pill and be thin.
Cynicism is knocking at my door, and I am trying to ignore it.
It is clearly true that obesity is one of the developed world's most important medical problems. Paradoxically, while the fury of modern medicine has lowered death rates from heart disease and cancer, the obesity epidemic continues unabated. The more sophisticated we become as a society, the fatter we get.
As a doctor of the heart, it is crystal clear that lifestyle choices lie at the heart of health. No disease is more preventable by lifestyle choices than heart disease. And these same lifestyle choices work on obesity as well. Call it being on "the program." Not a diet, the program is a simple concept: finding the groove of enough exercise, wise food choices and adequate rest.
I own only one belt. It is thick leather. At times, as I am human, the white-chocolate-chip brownies in the doctor's lounge get the best of me. If this behavior persists with any regularity the belt feels tighter. Thick leather belts do not stretch. The tighter belt says, pedal a little longer and cut smaller pieces of brownie. Doing so restores equilibrium. But if I deny too much the result is grumpiness. The pattern is repetitive.
This simple formula is the problem.
However, the notion that obesity is simply an imbalance of the equation, calories-in, calories-burned, is not in vogue. It seems, by saying to the patient, eat less (really, it is sadly amazing how few calories a sedentary middle-aged human needs) and move more, you are at risk of being perceived as judgmental, incurious and even aloof.
If on the other hand you talk about enhanced receptor sensitivities in hunger centers that may be inhibited by sophisticated chemicals, you are smart, and a sensitive doctor. The obese patient may conclude that poor lifestyle choices are not their fault, rather a chemical imbalance in the brain. (And maybe this will be proven so.)
I don't think we should persecute the obese. Malfeasance is bad for the heart. Nor am I against novel pharmaceuticals or innovative surgery. But taking a pill or having surgery (that someone else pays for) will always be easier than saying no to white-chocolate-chip brownies.
As we advance in medical technology, the simplicity of making a series of good choices should not be overshadowed by the science of receptor inhibition in the brain.
Surely, doctors should emphasize the program more.
John Mandrola is a cardiologist who blogs at Dr John M.
Friday, December 17, 2010
The CT woman, Charla Nash, who was severely mauled by her friend's chimpanzee made an return to Stamford Hospital.
It was a very positive story about the staff and hospital.
I'm proud to be a part of the staff at this hospital.
From the BlackBerry
Thursday, December 16, 2010
Ever since I was a medical student, I've be amazed what patients requiring Coumadin have to go through. Coumadin (warfarin) is a blood thinner, ie it keeps the blood from clotting. It is used for many conditions - atrial fibrillation, after placement of metallic heart valves, blood clots in the legs or lungs and many other conditions.
Its action is very dependent on diet, its very effected by the amount of vitamin K ingested. Therefore, patients must have frequent blood tests to ensure the level of their blood thinnest is safe (level of anti-coagulation). We use the INR to measure this. An INR of 1 is normal. For atrial fibrillation, we aim for an INR 2-3. For other conditions, we aim for an INR of 2.5-3.5. Keeping patients within this narrow therapeutic window can be difficult. Too low, patients blood and clot - in atrial fibrillation this increases the risk of a stroke. Too high, patients can spontaneously bleed. Therefore, patients need to have their blood tested at least one a month. If the levels are off and adjustments in dosage need to be made, patients may need weekly blood tests. This is a big deal for patients who need this medication indefinitely.
For years, I've been looking forward to a new medication for patient with atrial fibrillation to take Coumadin's place. I envisioned that all my patients would be immediately switched to this drug. I thought we would be able to close the Coumadin Clinic which we run in my office (15-25 patients come through this clinic on a daily basis).
Well, that time is here. But, the reality of American medicine is keeping my above dream from becoming a reality. Dabigatran (Pradaxa) has been released. It is a new class of medications called factor Xa inhibitors). Clinical trials have shown that it works better than Coumadin. It reduces strokes and other embolic and reduces significant major bleeding events. Also, its absorption is consistent and not effected by diet. Therefore, as long as it is taken morning and night, NO blood tests are required.
So, why are so few of my patients jumping on the dabagatran bandwagon? $$$$$ Coumadin, specifically generic warfarin, cost pennies. Depending on my patients insurance plan, Pradaxa costs $90-300/month.
So we have a medication that works better and is safer but is not being used because insurance companies will not pay for it.
My hope for 2011 is that more of my patients will be able to be afford this new Rx. As more and more Factor Xa inhibitors come to the market (at least 3-4 are in the works), market forces will push down the price making each Rx cheaper.
If you are interested about leaning more about this new Rx, please talk to your physician.
Wednesday, December 15, 2010
Tuesday, December 14, 2010
This was a fascinating segment contained two stories on the treatment of hypoplastic left heart syndrome, or HLHS for short. "In utero, the left side of the heart does not develop properly. The mitral and aortic valves, the first part of the aorta itself, and the left ventricle of the heart are small, underdeveloped or nonexistent."
After listening to this segment, I totally forgot about being late to work.
Monday, December 13, 2010
- Eat smaller portions of food
- Eat slowly
- Go for a walk after a meal
- Off to bring a low calorie dish to the party
- Go ahead and mingle - get away from the food
- Say "no" to fast food
- Be realistic - now is not the time to diet but to maintain