March 25, 2011 | 11:48 am

A Pulmonologist Defends Benzonatate

Posted by Albert Fuchs, M.D.

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Last month I posted about benzonatate, a cough suppressant also marketed under the brand Tessalon. (See the link below for the original post.) In that post I detailed an FDA warning about the serious potential side effects of benzonatate, especially in accidental overdoses in children. I also passed along the conclusion of the Medical Letter that safer cough suppressants were available.

My colleague Dr. Roy Artal, a pulmonologist, wrote to me a very thoughtful defense of benzonatate, which he let me share with you.

The thrust of the advisory is that the medication bears a potential resemblance to a candy drop, and that patients need to be cautioned to keep the medication in child resistant containers, etc. In terms of the medication’s safety profile, the FDA article indicates that in the period 1958 through 2010 only 31 cases of benzonatate overdose were reported to the FDA.

As a pulmonologist, chronic cough is one of the most common indications for an office visit with me, and in that setting I’ve found benzonatate to be very well tolerated, effective, and to have an excellent side effect profile. I have had a handful of patients (<2%) come back and tell me it made them slightly woozy, and those patients have simply exercised common sense and discontinued the medication on their own.

I have no qualms about continuing to prescribe benzonatate, although the advisory likely will prompt me to reinforce to my patients who may have small children around the house to exercise appropriate precautions. I would also point out that this is no different from any of thousands of other medications that might be potentially toxic to a small child.

Learn more:

My original post about benzonatate: Benzonatate: A Cough Suppressant So Dangerous, You’d Rather Just Cough

Tangential Miscellany

About a month ago, the Daily Journal had a front page article about the growing popularity of direct primary care practices, practices in which physicians are paid directly by patients – New Direct Primary Care Plans Bypass Insurers and Regulators. The article describes why I and other doctors moved to a direct practice, and features a snazzy photo of yours truly. This practice model has been tagged with several different names: concierge medicine, boutique practice, direct primary care, retainer-based care. I don’t think any of the names have stuck yet, and I suspect that patients will pick the name that persists.

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.

March 17, 2011 | 11:26 pm

News Nincompoops Narrate Nuclear Nonsense

Posted by Albert Fuchs, M.D.

Images from Japan continue to sadden and shock us. Over 12,000 are confirmed dead or missing due to the earthquake and tsunami, and that number will likely rise. Hundreds of thousands have been displaced from their homes. I’m having a hard time finding recent numbers on those without water and electricity, but all the stories state that this continues to be a major problem. The magnitude of what has already been lost, not to mention the serious challenges that remain to get food and water to everyone, seems overwhelming.

As if that wasn’t bad enough, some media outlets, not content with honestly reporting a cataclysmic disaster, have irresponsibly panicked and misled their viewers.

I want to be very clear about this next part. No matter what happens to the reactors in Fukushima, radiation from those reactors cannot harm people on the US West Coast.

The reason for this is simple; the effects of radiation (and of everything else) on the human body depend completely on the dose. Nothing terrible happens to us when we get a chest X-ray. In fact a chest X-ray gives us the same amount of radiation that we get from the normal environment in 10 days. If we were to receive the radiation from 500 chest X-rays at the same time we would be nauseated and fatigued and would lose our hair. The radiation from ten thousand simultaneous chest X-rays would cause bleeding. Forty thousand would cause death.

Chernobyl, the worst nuclear reactor accident ever, caused health problems only to people living in the vicinity of the reactor. Three Mile Island, the worst reactor accident in the US, caused no detectable health problems. The difference was the dose. Much more radiation was released in Chernobyl. (See link below for a fascinating NPR story on the long term effects of radiation around Chernobyl.)

The Fukushima reactors won’t release as much radiation as Chernobyl. The reactor design is much more modern, and we know much more now than they did then about how to prevent and manage meltdowns. Even in the very worst case, radiation would only harm those who are close enough to absorb a significant dose. Tokyo, about 150 miles away, is perfectly safe.

So the US West Coast is really not in any danger. That’s because the Fukushima reactors are on the other side of the Pacific Ocean, and the Pacific Ocean is what scientists call very very big.

Several concerned patients have asked me about potassium iodide tablets. You don’t need them. If you’ve already bought them, don’t take them. The LA Dept. of Health released a very helpful advisory (link below). Please take a few minutes to read it. It details the many reasons that potassium iodide would not be helpful and might be harmful. It also has excellent common-sense advice about what to assemble in your emergency kit.

The fact that California pharmacies have experienced a run on potassium iodide is a shameful testament to our scientific illiteracy and to our sensationalistic broadcast media. If we panic when there is no danger, how will we handle an actual emergency? Will we be able to display the stoic resolve that the Japanese have shown?

The worst aspect of the focus on Fukushima is that it distracts us from two much bigger stories. The first is that hundreds of thousands in Japan need help. See the link below to the American Red Cross and please consider donating. The second story is that we will eventually have a large earthquake here, and we’re not ready.

Learn more:

County of Los Angeles Department of Public Health Advisory: LA County residents cautioned to AVOID ingesting potassium iodide (with thanks to my colleagues Dr. Noam Drazin and Dr. Gene Liu for the link)

NPR story: Chernobyl’s Hot Zone Holds Some Surprises

Donate to assist victims of the Japan earthquake and tsunami through the American Red Cross

Correction:

In last week’s post I wrote “I can’t remember the last time that a natural disaster caused hundreds of deaths in an advanced country.” Of course, that’s boneheaded. My friend Bob C. reminded me that in 2005 Hurricane Katrina killed over 1,800 people in the US. I appreciate the correction.

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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March 11, 2011 | 5:17 pm

Disaster Preparedness

Posted by Albert Fuchs, M.D.

I was I was going to post about a different topic today, but I could not ignore the devastation that befell Japan. The powerful earthquake and subsequent tsunami have caused destruction that is difficult to grasp. (See links below for two news articles.) The magnitude of the disaster is even more sobering when you realize that Japan is a developed modern high-tech country. Japan is extremely aware of earthquake risks and has modern building codes and frequent earthquake drills. Despite these efforts in the last 24 hours hundreds have been killed, 4 million people are without electricity, and mobile phone service and public transportation have been disrupted. I can’t remember the last time that a natural disaster caused hundreds of deaths in an advanced country.

My regular readers know that I’m not one to panic. A flip through the archives will demonstrate that I’m rarely worried about whatever issue is causing the latest hand-wringing. I didn’t think H1N1 flu would hurt a lot of people. I’m not worried about irradiated food, pesticides, or plastic bottles.

But natural disasters deserve our attention. Not because an earthquake of similar magnitude might happen here, but because an earthquake of similar magnitude will happen here. It’s only a matter of time. We, like Japan, live on a fault line. An 8.9 magnitude earthquake in LA is likely to kill more than all the people who have ever died of pesticides in food and chemicals seeping from plastic bottles. Worse than the immediate destruction, such a disaster would completely overtax our emergency response systems. Paramedics, police, fire fighters, and emergency rooms would immediately have too few resources to respond to too many emergencies.

Put simply, you and your family for at least a few days would be on your own. This deserves some panic, but panic after the disaster will not be very helpful. In this case panic before the disaster is essential. Another name for that is preparedness.

The CDC (link below) has a very sensible list of suggestions for preparing for a disaster. It suggests tips for storing non-perishable food and fresh water, assembling a kit of emergency supplies, and making an emergency plan with your family.

So please take a look at the CDC recommendations and schedule a specific time to get prepared. And spare a kind thought for the wounded, the missing, the homeless and the bereaved in Japan.

Learn more:

Wall Street Journal article: Magnitude-8.9 Quake, Tsunami Strike Japan

Los Angeles times article: Japan earthquake, tsunami kill hundreds, cause crippling damage

CDC Emergency Preparedness and Response: Emergency Preparedness and You

Correction added March 17, 2011:

Above I wrote “I can’t remember the last time that a natural disaster caused hundreds of deaths in an advanced country.” Of course, that’s boneheaded. My friend Bob C. reminded me that in 2005 Hurricane Katrina killed over 1,800 people in the US. I appreciate the correction.

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).

0 Comments — Leave your comment

March 4, 2011 | 5:46 pm

News Flash: Diabetes is Not Good

Posted by Albert Fuchs, M.D.

Type 2 diabetes mellitus has long been known to increase the risk of stroke, heart attack, kidney disease, and eye disease. In the US diabetes is the leading cause of kidney failure requiring dialysis and one of the leading causes of blindness. Diabetes is also increasing in prevalence as people become more overweight.

A study in this week’s New England Journal of Medicine attempted to quantify the risk of premature death associated with diabetes. The results were dramatic, and attracted much media coverage. (See links to articles below.)

The study was a compilation of data from 97 previous studies that were done for entirely different reasons. The studies followed over 800,000 people for an average of 13.5 years. At the time of enrollment 6% of the people had diabetes. The study simply compared the death rates of those who had diabetes at the start of the study with the rest of the subjects. The results were adjusted for age, sex, smoking status and body mass index (BMI).

The subjects with diabetes did much worse. As expected, they were more likely to die of strokes, heart attacks and kidney disease, but they were also more likely to die of liver disease, cancer, infectious disease and even suicide. On average, a 50-year old with diabetes at the start of the study died 6 years earlier than a person without diabetes of the same age, sex, smoking status and BMI.

Well, that’s pretty bad, but not as bad as what the media makes of it. This is not a randomized study. All we’ve learned is that one group dies earlier of a lot of diseases and also has diabetes, and another group dies later and doesn’t have diabetes. That doesn’t mean that diabetes causes the earlier deaths, simply that it is associated with earlier deaths. Lots of factors not measured in the study could have both predisposed to diabetes and caused other life-threatening diseases – family history, diet, different levels of exercise, or a tendency to eat ice cream while driving on the freeway. It doesn’t tell us about diabetes as much as it tells us about the people who happen to have it. So the LA Times headline “Diabetes can take six years off your life…” is completely misleading.

Does this help doctors or patients diagnose or treat diabetes? No. Does it mean that the day a patient is diagnosed with diabetes the date of her death advances 6 years sooner? Not at all. This may provide guidance for scientists designing studies to better clarify the harms caused by diabetes, but for doctors and patients there is no actionable information here. It’s just a reminder that if someone comes to your door offering you diabetes, you should decline.

(Thanks to my patient, Jay F. for pointing me to the LA Times article.)

Learn more:

Los Angeles Times article: Diabetes can take six years off your life by increasing risk of cardiovascular disease and cancer, study says

Washington Post article: Study: 50-year-old with diabetes dies 6 yrs sooner

New England Journal of Medicine article: Diabetes Mellitus, Fasting Glucose, and Risk of Cause-Specific Death

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).

0 Comments — Leave your comment