December 30, 2010 | 5:14 pm

Echinacea Still Unproven for the Common Cold

Posted by Albert Fuchs, M.D.

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Many of my patients have come down with a nasty cold in the last two weeks – runny nose, cough, hoarseness, sore throat and the kind of fatigue that makes lifting your head off the pillow seem unnecessarily ambitious.  And just in time the Annals of Internal Medicine published a study to give them valuable advice.

The effects of echinacea on the common cold have been studied many times previously, though never as rigorously as in this study.  A definitive benefit has never been proven.

This study enrolled over 700 people who had just developed a cold.  They were randomized into four groups.  One group took no pill.  A second group took echinacea daily and was told that they were taking echinacea.  The last two groups took either a placebo pill or echinacea but were not told which they were taking.  They recorded the severity of their symptoms twice a day.

The results were positively meh.  The average duration of symptoms in the group knowingly taking echinacea was 6.8 days.  In those unknowingly taking echinacea it was 6.3 days.  Those taking placebo felt sick for an average of 6.9 days, and those taking nothing for 7.0 days.  Note that this shows a slight decrease in duration of symptoms between the two echinacea groups and the other two groups.  This difference was so small it was likely to have been due to chance (that is to say, the difference was not statistically significant).  But even if the difference is real it would amount to decreasing the misery of a cold that lasts a week by only several hours.

So this trial suggests that echinacea either doesn’t help in treating the common cold or it has a very small benefit.

Remember, nothing has been proven to decrease the duration of the common cold yet.  The best that you (and your doctor) can do is to make the symptoms less miserable until you recover.

I wish all of us a healthy, joyous and prosperous 2011.

Learn more:

Annals of Internal Medicine Summaries for Patients:  Echinacea for the Common Cold

LA Times Booster Shots:  Echinacea for a cold? Eh, don’t bother, study concludes

NPR Health News Blog:  If Echinacea Does Anything For Colds, It Isn’t Much

And lest echinacea have hurt feelings, Vitamin C doesn’t help in treating colds either.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

December 23, 2010 | 10:12 pm

Flu Incidence on the Rise

Posted by Albert Fuchs, M.D.

(Please excuse this short post during this short week.  If you feel deprived of health education, I’ve listed some educational links for you below.)

You better watch out.  The flu is coming to town, and it doesn’t care if you’ve been naughty or nice.  It looks like flu season is starting later this year than usual, but both the CDC data and Google Flu Trends suggest that illnesses due to the flu are increasing nationwide.

The best way to protect yourself is with a flu shot.  And if you do get sick, call your doctor right away.  Antiviral medicines can help shorten the duration of the flu but only if they are started in the first 48 hours of symptoms.

Learn more:

Google Flu Trends is the coolest way to track flu activity.  You can look at individual states, and now also major cities.  Check it out in time to warn Grandma in Milwaukee!

My post about who should and should not receive a flu shot.

Is it a cold or the flu?  Here’s my post about identifying and treating the common cold.

The Centers for Disease Control and Prevention Flu Activity and Surveillance (written for doctors more than for patients)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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December 17, 2010 | 1:38 pm

NDM-1:  No Drug Matters

Posted by Albert Fuchs, M.D.

My longtime readers know that I’m not one to panic when the media does.  I wasn’t very worried about anthrax in the mail.  I didn’t think swine flu was going to be a big deal.  (See link below.)  And I’m not concerned about the health effects of airport X-ray back-scatter machines.

But there’s plenty of stuff that worries me.  Most of it is scary on time scales longer than the typical media attention span.  What scares me is stuff that will hurt us decades from now.  For example, I’m very worried about stuff like the inevitable but not imminent collapse of Medicare, the fact that world population will peak on about 2075 and then decline, and the unavoidable zombie apocalypse.  OK, I’m just kidding about that last one.

This week’s New England Journal of Medicine published a perspective article about a topic that is sure to become an increasingly dangerous problem.  As far as I can tell it received no media attention.  The article described a new bacterial gene for antibiotic resistance.

The gene is called NDM-1, which stands for New Delhi metallo-beta-lactamase 1.  It deserves our concern for two reasons.  The first reason is that this gene codes for an enzyme that gives a bacterium resistance to almost all current antibiotics.  That’s bad.

To explain the second reason for concern, I first need to explain how genes normally get around.  Say you have a really nice gene, the gene for brown eyes as an example.  Say that you’d like to give that gene to someone else.  The only way for humans to do that naturally is to make another human.  You have to find a mate, procreate, and voila!  Nine months later you have an offspring with your brown eyes.  Genetic engineers have figured out ways to take genes from one living thing and put it into another, but nature typically works by having genes move only from parents to progeny.  You can’t give your tall stature to your neighbor or your natural red hair to your friend.  You can only transmit your genes to your kids.

Well, bacteria long ago have circumvented this limitation, essentially inventing their own genetic engineers.  They have most of their genes on a chromosome that is passed just to the descendents of each bacterium.  But some genes are on a tiny loop of DNA called a plasmid that can leave one bacterium and enter another.  If a chromosome is like a hard drive of genetic information, a plasmid is like a flash drive – tiny and portable.  NDM-1 is coded on a plasmid and has already been identified in several different kinds of disease-causing bacteria.  That means it can spread itself to different bacteria species.  (The equivalent genetic trick would be giving your brown eyes to your dog.)

To put it all in perspective, these bacteria carrying NDM-1 aren’t more infectious and don’t cause worse diseases than their non-NDM-1 cousins.  An E. coli with NDM-1 will cause a bladder or kidney infection that is no worse than a standard E. coli infection.  The disaster is that virtually no antibiotics will work for it.

NDM-1 was first discovered in 2008 and for now seems to be concentrated in the Indian subcontinent, though recent travelers to India have been found to be infected with NDM-1 in many other countries.

Is there anything for us to do?  Doctors should be constantly reminded about the danger of emerging antibiotic resistance and should be urged to use antibiotics rationally.  We should all keep an eye on the story of antibiotic resistance as it unfolds over the next years.  It is entirely possible that antibiotics, after serving us for about a century, will become ineffective.

Learn more:

New England Journal Medicine article:  NDM-1 — A Cause for Worldwide Concern

My post in 2007 about increasing antibiotic resistance:  Serious MRSA Infections More Common

My post from April 2007 when H1N1 flu first made news:  Swine Flu: Unlikely to End the World

It’s never too late to prepare for the zombie apocalypse, until it is.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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December 10, 2010 | 6:45 pm

Animated about Aspirin

Posted by Albert Fuchs, M.D.

Aspirin was hailed as a wonder-drug in the 1800s when it was first purified – the first anti-inflammatory medication that did not have the severe side effects of steroids.  More recently aspirin’s benefits in stroke and heart attack prevention have been proven.  This week another possible benefit of aspirin has been uncovered.

An important study published in The Lancet attempted to find any effect of aspirin on cancer prevention.  I’ve written frequently about the myriad substances that are falsely claimed to prevent cancer after an observational trial shows that people who take X get cancer less frequently then people who don’t take X.  These studies are all meaningless since the only way to test the effects of X is to randomize some patients to take X and others to take placebo.  That’s what’s so tantalizing about this week’s study – it’s a review of randomized trials.

The investigators reviewed all randomized trials which randomized patients to aspirin versus placebo for at least four years.  These studies happened back in the 1970s and 80s and were designed to test aspirin’s ability to prevent strokes and heart attacks.  The investigators looked at individual patient data from this handful of studies and extracted information about cancer deaths.  They counted the number of patients who died of various cancers in the aspirin group and the control group.  The results were impressive.

During the trials themselves, the patients in the aspirin group had significantly fewer deaths due to cancer than the placebo group.  For every about 150 patients who took aspirin rather than placebo for several years, one cancer death was prevented.  This effect was large enough that the mortality from all causes was smaller in the aspirin group.  For every approximately 110 patients who took aspirin, one death from any cause was prevented.  Interestingly the benefit only became apparent 5 years after randomization.  This time delay suggests that that the effect of aspirin is not on cancers that are already present but that aspirin either prevents cells from becoming cancerous or kills very small numbers of malignant cells.

The investigators then followed up on cancer deaths in these patients in the subsequent decades since the end of the trials.  These results were even more striking.  The benefit of aspirin in preventing death from cancer persisted over time even though many of the patients discontinued aspirin back in the 80s when the trials stopped.  There were some consistent patterns across the data.  The benefit of aspirin for cancer mortality prevention was present in each of the trials and was greater with the trial duration.  That is, the longer that people took aspirin rather than placebo, the greater reduction in cancer death risk.  Death from esophageal, stomach and colorectal cancer were most affected.  Deaths from other cancers however, such as leukemias, were not decreased.  Also, interestingly, the benefit was independent of the dose of aspirin, suggesting that a “baby” dose of 81 mg daily is sufficient.

So should we all start taking daily aspirin?  Should we just put it in the water supply?

Not yet.

First of all, children should not take aspirin because of the risk of Reye’s syndrome.  Second, the trials reviewed in this study involved almost exclusively men, so we have no idea if the results can be generalized to women.  (And, importantly, we don’t know the effects of aspirin on cancers that affect women exclusively – breast, ovarian, and uterine cancer.)

Aspirin also has some risks, the most serious being intestinal bleeding and hemorrhagic stroke (bleeding in the brain).  But numerically, these risks seem to be much smaller in magnitude than the benefit of cancer mortality prevention.  Prior to this study these risks had to be balanced against the benefits of aspirin in preventing strokes and heart attacks.  In people with no risk factors for stroke or heart attack the risks outweighed the benefits.

But now, at least for adult men, the idea of daily low dose aspirin for cancer prevention seems compelling.  Lots of experts in the media are cautioning that more information is needed, but what better information could we hope for?  This study is using 20 years of follow up.  Better information will take decades more.

I’m not making any recommendations as of now, and obviously each of you should discuss this with your doctor.  I’m going to discuss this paper with trusted colleagues over the next weeks.  My initial hunch is that we may have reached the tipping point in favor of daily aspirin in adult men.

Learn more:

New York Times article:  Aspirin Helps in Reducing Cancer Deaths, a Study Finds

Los Angeles Times article:  Baby aspirin linked to reduced cancer deaths

The Lancet article:  Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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December 3, 2010 | 5:15 pm

The Most Recent Celebrity Vitamin: D

Posted by Albert Fuchs, M.D.

Every now and then some vitamin or dietary supplement becomes all the rage.  A couple of generations ago vitamin C was the miracle drug that could prevent all diseases, despite lots of evidence to the contrary.  Lots of my patients still take it for colds, demonstrating its persistent mythology.  Vitamin B12 became the wonder-drug a few decades ago, leading to a whole generation of patients getting monthly injections for reasons that remain scientifically mysterious.  And many lesser stars can be added to this grab bag, including glucosamine, folic acid, zinc and selenium, all of whom were taken for all sorts of putative benefits which were later debunked.

Now it’s vitamin D’s turn in the spotlight.  Vitamin D has been receiving increasing attention in the last few years as its role in bone health has been better understood and as more people are found who are deficient in vitamin D.  Unfortunately, with more understanding comes more hoopla, and there are now shaky claims that vitamin D helps prevent myriad diseases.  This week, the Institute of Medicine (IOM), the government body that decides how much of each nutrient we need, revisited their recommendations for vitamin D.  (See the link below for their report.)  This received much (frequently confusing) media attention and a whole bunch of my patients (thanks!) emailed me links to various articles about this story.

Let’s parse this issue and separate what is known from what is speculated.

Benefits of vitamin D

Vitamin D has only two proven benefits.  The first is that vitamin D is essential to maintain strong bones.  Another way to say this is that vitamin D deficiency eventually predisposes to osteoporosis.  The only other benefit of vitamin D which has been proven in randomized trials is that vitamin D supplementation in men and women over 60 helps decrease the frequency of falls.  How does it do that?  Does it help balance?  Does it help muscle strength?  Does it turn off gravity?  No one knows, but I’m pretty sure it doesn’t affect gravity.

Many other supossed benefits of vitamin D are frequently mentioned, from prevention of heart disease to prevention of cancer.  None of these claims are supported by a shred of evidence from randomized trials, so for now we should assume that they are false.  Anecdotally, many patients (including my patients) report a dramatic reduction in aches and pains and improvement in energy after starting vitamin D supplements.

How much vitamin D is enough?

This is where the IOM made waves.  They increased the daily recommended amount of vitamin D from 200 IU to 600 IU.  But many doctors (including me) have already been recommending daily supplementation of 1,000 or 2,000 IU.  So why is the IOM taking such baby steps?  Or, conversely, why are doctors prescribing so much more than the IOM?  The heart of the dispute is a disagreement about what vitamin D levels are normal.  The IOM defines a vitamin D blood level of over 20 nanograms per milliliter (ng/ml) as normal.  By that definition most North Americans have normal levels and 600 IU daily is all that most people need to achieve those levels.

But the Endocrine Society and the International Osteoporosis Foundation have concluded that a level of 30 ng/ml is necessary for optimum bone health.  They call levels above 30 ng/ml normal, levels between 20 and 30 as “vitamin D insufficiency”, and levels below 20 “vitamin D deficiency”.  They have some data that supports their conclusion involving hormonal markers of osteoporosis improving until vitamin D levels climb to 30 ng/ml.  By this more strict definition, many more people have low vitamin D levels (as many of my patients know) and to reach this higher level of 30 ng/ml 600 IU is frequently inadequate.

Risks of vitamin D

What happens if you take too much vitamin D?  Again, many of the reported risks are as unfounded as the reported benefits.  There are loose associations with all sorts of possible diseases, but none of these are from randomized trials, so they should be ignored.  The known risks of vitamin D toxicity all relate to causing abnormally high calcium levels and include kidney stones and decreased kidney function.

How much vitamin D is too much?

The simplest way to answer that question is to have your vitamin D level checked.  The risks listed above occur with vitamin D levels above 80 ng/ml.  Levels that high are very hard to reach with 2,000 IU of vitamin D daily.

So the take-home message is that there is no reason to believe that vitamin D will prevent cancer, make you famous, or lower interest rates.  It will keep your bones healthy and decrease your likelihood of falling when you’re older than 60.  The most accurate way to assess whether you are deficient and how much vitamin D you should take is to have your doctor check your vitamin D level.  Daily supplementation with 1,000 to 2,000 IU daily is unlikely to be harmful.

Learn more:

Institute of Medicine report:  Dietary Reference Intakes for Calcium and Vitamin D

Wall Street Journal article:  Triple That Vitamin D Intake, Panel Prescribes

MSNBC article:  How much vitamin D is enough? Report sets new levels

New York Times article:  Report Questions Need for 2 Diet Supplements

The best recent review I’ve seen in the medical literature about vitamin D deficiency is a New England Journal of Medicine article from 2007:  Vitamin D Deficiency

Tangential miscellany: Happy Hanukkah!

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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