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ARE PPI MEDICATIONS (NEXIUM, PRILOSEC, ETC) ASSOCIATED WITH HEART ATTACKS?

BMJ 2015;350:h3220

A study in London showed a 16% increase in heart attacks in people using these types of stomach acid blockers. There were no connections to heart disease with other acid blockers (Zantac, Pepcid, etc.) It is not known why although it is suspected that PPI medications interfere with vascular function. It should also be noted that this study did not prove that there was a direct causation with these drugs and heart disease, just an association. More testing needs to be done.

Until more information becomes available, long term PPI use should only be used with the consent of your physician. If you can switch to other types of acid medications and it works just as well, it might be worth trying. There are, however, many patients who only get relief with PPI’s. As with all treatment options, benefits versus risk should always be weighed.

 

NEW CHOLESTEROL MEDICINE

The FDA has given preliminary approval to a new class of cholesterol medication called PCSK9 inhibitors. These drugs, which work differently than statins, are indicated for lowering LDL cholesterol in patients with hypercholesterolemia, especially for patients with heterozygous familial hypercholesterolemia (HeFH). Other groups predicted to get special benefit include those at high cardiovascular risk or who don’t tolerate statins. This looks like it will be an injectable medication and  will have a good side effect profile.

There are a few problems:

1.       Many people do not want to inject a medicine as opposed to taking a pill.

2.       The are NO OUTCOME studies that show that this drug will actually prevent heart attacks.

3.       Most insurance companies will most likely NOT pay for this. (My guess is that it will initially cost at least $25,000/year!!)

The FDA is supposed to give final approval in July and there is already a second PCSK9 drug in the wings.

 

SUPPLEMENTS AND NEUROPATHY (NERVE PAIN)

There are NO medications that work great for nerve pain. The most common ones, like CYMBALTA, NEURONTIN and LYRICA offer some relief to some people but results are very variable. Narcotics are commonly used but normally just cause addiction and constipation. Physical therapy and exercise can also be beneficial but once again there are many patients that do not get relief.

Because of the relative ineffectiveness of conventional therapy, many people look into supplements. The ones that have been studied the most include FISH OIL (anti-inflammatory benefits), CURCUMIN (also anti-inflammatory properties). ALA (alpha lipoic acid) and GLA (gamma-linolenic acid ) are 2 supplements that have been studied that has shown mild success when compared to placebo.

Be aware that supplements are often no better than prescriptions, and because they are not FDA approved, you may not be aware exactly what you are getting.

ARE TESTOSTERONE GELS SAFER THAN INJECTIBLE VERSIONS?

JAMA Internal Medicine

 

 

Researchers have evaluated 500,000 men in 3 different studies to see if there was a difference in topical gels versus injectable testosterone replacement. They found that some men get a large spike in testosterone levels right after an injection which caused a slightly higher risk of heart disease. There are risks in taking any medication, which is why I only prescribe testosterone in patients who are clearly symptomatic from “LOW T”. Testosterone DOES NOT cause prostate cancer and for every study that shows a relationship between testosterone and heart disease there a ten times as many that show a DECREASED risk.

The advantages of injectable testosterone is that it only has to be taken every 2 weeks and the patient is assured of absorbing it. It also costs about $4/injection and can be self-injected.

Topical testosterone gels are messy and absorption is variable. Once applied, you cannot come in contact with any women or children until you shower it off.

If you are lucky enough to have commercial insurance, there are coupon vouchers that cut the cost to $10/month. Medicare patients(and some commercial) are out of luck and if not covered could cost as much as $240/month.

STEROID INJECTIONS FOR LUMBAR STENOSIS ARE NOT EFFECTIVE

There have been many studies questioning the effectiveness of injectable steroids for spinal stenosis. I have written several blogs about this in the past. This current study showed that pain relief, if obtained lasted only 3 weeks. On the other hand, those injected with lidocaine (a local anesthetic) provided a longer lasting relief of pain. Researchers do not have an answer for this.

Their recommendations in treating spinal stenosis remains unchanged: oral pain killers, physical therapy and time. The lack of long term benefit with steroids should be considered when seeing a pain specialist.

 

MEDICATIONS AND WEIGHT GAIN

New obesity guidelines are now going to increase consumer awareness about medications that can cause weight gain. Most physicians are aware of this and like myself, try to avoid these medications if possible.

Antipsychotic medications like Zyprexa and clozapine are almost guaranteed to cause a large gain in weight. Others, like Abilify (the number 1 grossing medication in America) claims to have limited weight gain, but that is not necessarily true. Antidepressants, like Paxil or Remeron are also associated with weight gain but not as much as the antipsychotics.

Some anti-seizure medications like gabapentin,  Depakote or Lyrica can be associated with a lot of weight gain. Others, which I use in my practice, like Topamax or Zonagran are so weight negative that I often prescribe them as part of a weight loss program

Even diabetes medications can cause weight gain! I try to avoid glipizide or glyburide (sulfonylureas) if I can. The majority of my patients taking these are “forced” to by their cheap money saving insurance companies. Actos or Avandia, which can also be effective in the treatment of diabetes, also cause weight gain. The biggest offender?  INSULIN. It’s not unusual to gain over 15 pounds after you start taking insulin products. (Luckily, there are many great new diabetes product that not only control sugar but also cause weight loss.

 

 

LEVOTHYROXINE (THYRIOD) MEDICATION

Many patients are concerned about the right “way” to take their thyroid medication. The pharmacist will usually instruct you to take it 30 minutes prior to eating breakfast. This is not necessarily true. It’s more important to take it the same time every day. Yes, it’s true that food may decrease absorption of the medicine, but your dose can be titrated so that it does not become a factor. It is also OK to take the medicine at nighttime-once again be consistent and take it the same time at least 4 hours after eating. There are some medications that can interfere with levothyroxine, and these should not be taken at the same time. Calcium, Iron, phosphate binders and even acid reducers, like Omeprazole, will decrease absorption. For those of you taking osteoporosis medications, it’s best to take thyroid pills 30 minutes after the osteoporosis meds.

Some patients ask about branded Synthroid versus generic levothyroxine. Basically there is no difference in the majority of patients. All generics must be BIOEQUIVALENT and is regulated by the FDA. The only thing I would advise is to recheck the TSH (thyroid test) 4-8 weeks after changing brands if you don’t feel “right”.

 

 

UPDATE ON GENERIC MEDICATIONS USED IN MY PRACTICE

WELCHOL (cholesterol)             MARCH 2015

ABILIFY (major depression)     APRIL 2015

AGGRENOX (anti-platelet)      JULY 2015

GLEEVEC (anti-cancer)               JULY 2015

AVODART (prostate)                 NOVEMBER 2015

AXERT (migraines)                      NOVEMBER 2015

FROVA (migraine)                       NOVEMBER 2015

JALYN (prostate)                         NOVEMBER 2015

GLUMETZA (diabetes)              FEBRUARY 2016

ENABLEX (bladder)                     MARCH 2016

CRESTOR (cholesterol)              MAY 2016

BENICAR (blood pressure)      OCTOBER 2016

PRO AIR (asthma)                       DECEMBER 2016

ZETIA (cholesterol)                     DECEMBER 2016

VYTORIN (cholesterol)              APRIL 2017

STRATTERA (ADD)                       MAY 2017

NASONEX (allergy)                     OCTOBER 2017

VIAGRA   (ED)                                DECEMBER 2017

LEVITRA (ED)                                  OCTOBER 2018

VESICARE (bladder)                    NOVEMBER 2018

LYRICA (nerve pain)                    DECEMBER 2018

CHANTIX (smoking)                    MAY 2020

ANDROGEL (LOW T)                    AUGUST 2020

BYSTOLIC (blood pressure)      SEPTEMBER 2021

VYVANSE (ADD)                            JUNE 2023

JANUVIA (diabetes)                    APRIL 2026

DEXILANT (acid reflux)               FEBRUARY 2027

AXIRON (LOW T)                           JULY 2027

PRISTIQ (anti-depressant)        JULY 2027

JANUMET (diabetes)                  JULY 2028

ONGLYZA (diabetes)                   NOVEMBER 2028

QSYMIA (obesity)                         JUNE 2029

ULORIC (gout)                                SEPTEMBER 2031

VIMOVA (NSAID)                          MAY 2033

 

 

DRUGS AND DEMENTIA

Researchers have found a connection between common anticholinergic drugs and dementia. Examples of anticholinergic medications include common anti-histamines like Benadryl which are used to aid in sleep (Tylenol PM) as well as chlorpheniramine, a common sedating OTC medication for allergies. Medications used for overactive bladders like oxybutynin and tricyclic antidepressants like Elavil, which are often used for migraines and chronic pain have been linked to memory problems even at low doses.

There are many annoying side effects of these type of drugs, like dry mouth, constipation and urinary retention but when these medications are used long term-it doesn’t matter how low the dose is-the risk of dementia rose.

It should be noted that the newer non-sedating allergy medications (Allegra) do not affect memory. All tricyclic medications should be used with caution in older patients, especially with heart disease and one bladder medicine, Myrbetriq probably does not affect memory. It should also be noted that it is considered a DUI if you have an accident while under the influence of Benadryl-even if you took it the night before!

 

MORE CONTROVERSY WITH NSAIDS (Advil, Aleve, etc.)

Journal of Neurology 2014 Nov 25.

In the ever changing world of medicine, there are few medications that as many concerns than the non-steroidal anti-inflammatories (NSAIDs). Yes, they are great for pain and inflammation but they do not alter the course of arthritis. It is well known that this class of medications can cause ulcers and intestinal bleeding but we also know that they are not heart healthy and can increase the risks of heart attacks and strokes. Anyone remember Vioxx? NSAIDs are also becoming a leading cause of chronic kidney disease.

In this study, neurologists looked at the connection between NSAIDs, aspirin and strokes. Their finding are not surprising since we have known for years that NSAIDs can interfere with the benefits of taking aspirin. (By the way, it wasn’t that long ago that I reported about the controversy of even taking aspirin to prevent heart disease.) On the other hand it is known that NSAIDs can decrease certain cancers including colon and skin cancers by up to 35%.

This is one of the reasons that I like to prescribe topical compounded analgesics for many of my patients so the medicine only works where it is needed and very little is absorbed systemically.

So, what should you do?

If you must use NSAIDs, ALEVE is less likely to cause problems compared to the rest, and if, used with aspirin, it should be taken several hours after the aspirin to help maintain aspirin’s benefits.

Discuss this (and all non-prescription medications and supplements) with your physician!

 

 

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