September 18, 2009 | 5:37 pm

A New Blood Thinner May Outperform Coumadin

Posted by Albert Fuchs, M.D.

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Atrial fibrillation is a very common abnormal heart rhythm affecting 3 million Americans.  The most dangerous complication of atrial fibrillation is stoke, which can happen when a blood clot forms in the fibrillating heart chambers and travels to the brain.

Blood thinners have been the mainstay of treatment for atrial fibrillation.  They reduce the risk of stroke by preventing blood clots.  Warfarin (marketed under the brand name Coumadin) is the most effective available oral blood thinner, but taking it is fraught with difficulty.  The appropriate dose varies widely between individuals because of genetic differences, and even in the same individual the correct dose varies from one time to another.  The only way to dose warfarin correctly is to check blood tests periodically and adjust the dose based on the results.  Too much warfarin and the risk of dangerous bleeding increases; too little and the risk of stroke from atrial fibrillation is undiminished.  This need for frequent lab monitoring and the many interactions that warfarin has with foods and with other medications make it one of the least convenient and potentially most dangerous medicines in common use.  But for atrial fibrillation warfarin is the best we have.

An important study in this week’s New England Journal of Medicine compares a new blood thinner, dabigatran, with warfarin.  Over 18,000 patients with atrial fibrillation were randomized to either warfarin or to two different doses of dabigatran.  The lower dose of dabigatran was as effective at preventing strokes as warfarin, but was safer, causing fewer incidents of major bleeding.  The higher dose of dabigatran was as safe as warfarin (i.e. equal numbers of major bleeding) but prevented more strokes.

That by itself would be encouraging enough, but the major advantage for many patients will be that dabigatran does not require laboratory monitoring and has much fewer interactions with other medications.  It is taken twice a day at a fixed dose, making it dramatically simpler than taking warfarin.

Dabigatran should be available in the US in 2010.

Learn more:

Wall Street Journal article:  New Blood Thinner Matches Warfarin

New England Journal of Medicine article:  Dabigatran versus Warfarin in Patients with Atrial Fibrillation

New England Journal of Medicine editorial:  Can We Rely on RE-LY?

Tangential miscellany:

To my Jewish readers I extend wishes for a sweet and healthy year.  To my readers who, like me, are astronomy geeks: happy fall equinox!

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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September 11, 2009 | 4:41 pm

The Facts on Red Yeast Rice

Posted by Albert Fuchs, M.D.

Many of my patients ask me whether they should take red yeast rice to lower their cholesterol.  This week’s issue of The Medical Letter has a very handy review of red yeast rice which I summarize below.

Red yeast rice is a food that is produced by fermenting rice with a specific species of yeast.  It has been used in Chinese cooking and medicine for centuries.  It contains many molecules that are similar to statins, the family of medicines including Liptor, Zocor and Crestor.  In fact one of its ingredients is lovastatin, the medication in Mevacor, the first statin approved in the US.

Statins have been repeatedly proven to prevent strokes and heart attacks, but statins also sometimes cause muscle or liver inflammation, a side effect also present in red yeast rice.

Because it is sold as a food supplement, not as a medication, the quantity of active ingredients in red yeast rice formulations is not standardized and varies widely.

The article concludes that red yeast rice has many of the benefits and side effects of statins but unlike statins, its ingredients are not standardized.  The bottom line is that “generic lovastatin would be safer and cost less”.

Learn more:

The Medical Letter review of Red Yeast Rice (by subscription only)

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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September 4, 2009 | 12:09 pm

National Cholesterol Education Month

Posted by Albert Fuchs, M.D.

The CDC says that September is National Cholesterol Education Month, and who am I to argue?  So here is a dollop of education about cholesterol.

• High cholesterol is a major risk factor for strokes and heart attacks.  Other risk factors include
  • smoking,
  • age,
  • high blood pressure,
  • diabetes and
  • having a first-degree relative who had a heart attack in middle age or younger.
• High cholesterol doesn’t feel like anything.  The only way to know if your cholesterol is high is to have it checked.
• High cholesterol can be safely and effectively lowered with dietary changes, exercise and medications.
• Lowering high cholesterol with a family of cholesterol medicines called statins has been proven to prevent strokes and heart attacks.

So if you haven’t had your cholesterol checked in years, or if you know your cholesterol is high and you’ve been desperately ignoring it, get back to your doctor and get her advice.

Learn more:

The CDC webpage for National Cholesterol Education Month

Tangential miscellany:

My last post, Rational Rationing, generated lots of email responses and led to very stimulating discussions.

This month The Atlantic published a terrific article on the problems of our current healthcare system written by media and technology executive David Goldhill.  (Thanks to Timo K. for pointing me to it.)  It’s a very well researched and very personal analysis of what’s wrong and how to fix it.  I urge you to read it.  How American Health Care Killed My Father

Have a happy and safe Labor Day.

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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August 28, 2009 | 8:01 pm

Rational Rationing

Posted by Albert Fuchs, M.D.

The healthcare reform debate has generated much heat but very little light.  (And it’s also getting a lot of coverage, so there’s very little else to report about this week.)

I wrote a couple of months ago my opinion of two simple (but unpopular) steps that would make high-quality healthcare affordable to virtually everyone: abolishing the employer tax deduction for health insurance, and slowly phasing out Medicare.  The entire national debate is going in the opposite direction, with one party offering Medicare (or something like it) to everyone, and the other party opposing this because it would threaten Medicare.

In this hullabaloo, there is one word being shouted that I think deserves more explanation: rationing.

Classical economics is founded on a rule called the principle of scarcity which states that the sum of everything that everyone wants exceeds everything that exists.  People want more stuff than all the stuff in the world.  That means that some desires go unmet.  Every economic system is essentially a system to address scarcity by establishing rules that determine who gets what – which needs are met and which are not.  That is the definition of rationing: a method of distributing stuff in a world of finite resources and infinite demands.

That means that every economic system that has ever existed has used rationing in one way or another.  In a feudal system, the local lord distributed land to his vassals.  In centrally planned economies the government allocates all goods and sets prices.

Free economies have rationing too.  In free economies virtually all transactions are voluntary.  No one is forced to buy or sell a good or service, and the price depends only on the consent of the involved parties.  No one is forced to sell me apples, I don’t have to buy apples, and the price of apples can be whatever I and the grocer both agree to.  This is also a kind of rationing; it is rationing by price.

Rationing by price has lots of advantages.  The first is that I ultimately decide which of my desires are met and which are not by choosing what I will buy in exchange for my finite dollars.  Since everyone has different values, preferences and goals, there is no better way of getting the most for your dollars than in making these decisions yourself.

Rationing by price also results in the best products and services at the cheapest prices.  Suppliers, forced to compete with each other for customers, can only survive by continually making better stuff cheaper.

Now, there are some goods and services that, by their nature, just can’t be distributed through free markets because they are delivered to entire groups, not to individuals.  For example clean air, local law enforcement and national defense couldn’t be pragmatically purchased by each individual citizen in whatever quantity she chooses.  But for the vast majority of other goods and services, rationing by price has led to better products at cheaper prices than any other method.  Moreover, in a history marked almost entirely by grinding poverty, free markets and rationing by price is the only method that has produced societies with any degree of comfort and affluence for its average citizens.

If healthcare is important, maybe we should consider distributing it the way that works best – by each of us spending what we can afford to get what we believe we need.  There would still be a role for government programs and private charities in the care of the indigent, but the rest of us would have access to terrific inexpensive care.

Instead we spend our (and our employers’) money on an insurance policy and wait for them to tell us what’s covered, while our elected officials debate whether government should control more of the healthcare marketplace or all of it.

Learn more:

For someone (like me) with virtually no formal background in economics, I know of no better introduction than ”Basic Economics” by Thomas Sowell.

My post in June:  The Healthcare Meltdown – Part IV, A Recipe for Reform

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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August 21, 2009 | 12:39 pm

Important Influenza Inoculation Information

Posted by Albert Fuchs, M.D.

Our office just received our first batch of influenza vaccines, so it’s time for the annual flu shot post.

The seasonal flu vaccine does not protect against novel H1N1 (swine) flu.  Availability of the swine flu vaccine is still at least a couple of months away, and I’ll write about it in more detail when it becomes available.

This year the CDC is recommending flu vaccination for the following people:

• Children aged 6 months up to their 19th birthday,
• Women who will be pregnant during this flu season,
• People 50 years of age and older,
• People of any age with certain chronic health conditions (such as asthma, diabetes, or heart disease),
• People who live in nursing homes and other long-term care facilities,
• Household contacts of person at high risk for complications from influenza,
• Household contacts and out of home caregivers of children less than 6 months of age,
• Health care workers, and
• Anyone else who wants to reduce the likelihood of becoming ill with flu or infecting others with flu.

The following people should not receive the vaccine:

• People who have a severe allergy to chicken eggs,
• People who have had a severe reaction to an influenza vaccination,
• People who have developed Guillian-Barré syndrome within 6 weeks of getting an influenza vaccine,
• Children less than 6 months of age (influenza vaccine is not approved for this age group), and
• People who have a moderate to severe illness with a fever (they should wait until they recover to get vaccinated).

So if you should receive the vaccine call your doctor’s office (or your local pharmacy or your workplace vaccination program) and get your flu shot.

Learn more:

CDC patient information for the flu shot

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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August 14, 2009 | 5:47 pm

Weight Lifting Helps Breast Cancer Survivors with Lymphedema

Posted by Albert Fuchs, M.D.

One of my goals for these posts is to use individual studies to point out the broader trends they suggest.  This week I want to focus on our increasing understanding of the value of exercise after illness or injury.  A generation ago a heart attack meant weeks of bed rest in the hospital followed by strict instructions from the doctor to take it easy.  The weakened heart couldn’t take much exertion, we thought.  Now after a heart attack patients are told to start exercising as soon as they’re out of the hospital.  Similarly, patients with acute back pain were prescribed bed rest for days; now we encourage staying active and gradually increasing activity to decrease the pain.

This week the New England Journal of Medicine continues that trend for breast cancer patients.  One of the most uncomfortable consequences of breast cancer surgery is lymphedema in the arm.  Lymphedema is the accumulation of fluid that can happen after lymph nodes are removed during breast cancer surgery.  The affected arm can become swollen, painful and prone to skin infections.

The typical advice for women with lymphedema has been to avoid weight lifting or vigorous exercise with the affected arm, fearing that this would worsen the swelling or injure the susceptible limb.  This week’s study tested that assumption, randomizing women with arm lymphedema after breast cancer surgery to a group that engaged in closely supervised weight lifting and another group that did not.

Surprisingly, the women who were lifting weights had fewer exacerbations of their lymphedema, and had milder lymphedema symptoms than those who were not lifting weights.  Not surprisingly, the women who were lifting weights also developed better upper body strength.

So there are increasingly fewer medical reasons to be sedentary, and we can add breast-cancer-related lymphedema to the many conditions that are improved by exercise.

Learn more:

New England Journal of Medicine Article:  Weight Lifting in Women with Breast-Cancer–Related Lymphedema

CNN article:  Weight lifting benefits breast cancer survivors

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).

1 Comments — Leave your comment

August 7, 2009 | 12:57 pm

Vertebroplasties:  Not Very Valuable

Posted by Albert Fuchs, M.D.

Osteoporosis, the demineralization and weakening of bones, is common in older patients.  A potentially incapacitating consequence of osteoporosis is a vertebral fracture, in which one of the vertebrae in the spine collapses and breaks under the weight it’s carrying.  Like other broken bones, this is frequently very painful.  Sometimes the fractured vertebra heals and the pain resolves after some time, but other times the pain can be incapacitating and prolonged.

A few years ago a procedure called vertebroplasty was developed to stabilize fractured vertebrae and provide some pain relief.  In it, a radiologist numbs the skin over the broken vertebra with a local anesthetic, then inserts a needle into the broken vertebra and injects some surgical cement.  The thought is that as the cement hardens it fuses the broken fragments of the vertebra and thereby gets rid of the pain.  Last year this minor surgery was done about 100,000 times in the U.S.  It is occasionally spectacularly successful.  Some patients who are initially bed-bound in pain are walking comfortably a day later.

We physicians want to help patients and need to believe we are helping patients.  So it’s perhaps not surprising that this new procedure which was generally assumed to be helpful was never rigorously tested, until now.  Two studies in this week’s New England Journal of Medicine tested the effectiveness of vertebroplasty for vertebral fractures.

The designs of the studies were ingenious.  Patients with vertebral fractures were randomized to vertebroplasty or sham surgery.  The patients agreed at enrolment that they would not know which procedure they received.  The sham surgery consisted of the application of the local anesthetic, and in one study even the insertion of the needle into the broken vertebra, but without the infusion of the cement.  Because the cement has a strong scent, the radiologist even opened a container of cement during the sham surgeries to let the odor fill the room.

Both studies showed the same surprising result: patients receiving the sham surgery had as much pain relief as patients receiving vertebroplasty.  Both the sham and vertebroplasty groups improved, both immediately and months later.  But there was no benefit of vertebroplasty over sham surgery.

How can this be?  How can we have done hundreds of thousands of procedures which are no better than placebo?  Asked another way: how can the placebo be so good?

One explanation is that the natural history of vertebral fractures is very favorable.  Fractures tend to heal naturally.  So just as with colds, anything you do for a vertebral fracture will appear effective since you’re intervening in a problem that is likely to improve anyway.

Another explanation is what statisticians call regression to the mean.  Illnesses tend come to medical attention when symptoms are at their worst, so on average symptoms for stable illnesses will improve after medical attention no matter what is done.

The final explanation is the power of the placebo effect.  Patients want to get better, and they know that the physician expects them to improve.  For subjective outcomes such as pain, expectations are a powerful treatment.  Many studies have shown the surprising efficacy of placebos, and some have shown that an invasive procedure has an even stronger placebo effect than a sugar pill.

The lesson for doctors is that we need to keep reminding ourselves to test our assumptions.  Just because we mean well doesn’t mean we’re helping.  The lesson for patients is that just because you’re better doesn’t mean we helped.

Learn more:

New England Journal of Medicine articles and editorial:

A Randomized Trial of Vertebroplasty for Painful Osteoporotic Vertebral Fractures A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures Balancing Science and Informed Choice in Decisions about Vertebroplasty

Wall Street Journal article:  Spine Surgery Found No Better Than Placebo

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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July 31, 2009 | 11:21 am

H1N1 Flu:  Potential Pregnancy Problem

Posted by Albert Fuchs, M.D.

H1N1, the flu previously known as swine, is still in the news, but this week for a good reason.

Most of us still have little to worry about.  The CDC estimates that over a million Americans have been sick with H1N1 flu as of July 24.  The vast majority of illnesses were mild and resolved without incident, many without any treatment.  As of that same date there have been 5,011 hospitalizations and 302 deaths.  That means that getting sick with H1N1 flu caries half a percent chance of hospitalization and a probability of death that is 3 percent of 1 percent.

But there is a special population that may be at increased risk:  pregnant women.  This week Lancet published a paper studying the statistics from the U.S. on pregnant women with H1N1 flu.  The numbers were much more worrisome than those for the general population.  Of 34 confirmed or probable H1N1 flu cases in pregnant women, 11 (32%) were hospitalized and six (about 18%) died.  All the pregnant women who died were healthy prior to developing the flu.

Pregnant women should therefore seek medical attention immediately if they develop flu symptoms. They should receive treatment with antiviral medicines (Tamiflu or Relenza) as early as possible.

Pregnant women will also be a high-priority target group for the H1N1 vaccine, but vaccine availability is at least 3 months away.  I’ll have more to say about the H1N1 vaccine before then.

Learn more:

Lancet article:  H1N1 2009 influenza virus infection during pregnancy in the USA

Wall Street Journal article:  CDC: Pregnant Women With Flu Symptoms Should Receive Anti-Viral Drugs

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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