What Size?

I needed to replace the lightbulbs in a bathroom fixture. As I stood at the vast lightbulb display, holding the old bulb in my hand, I realized that my choice was limited to two. Nothing else would fit. A couple of years ago I needed to replace the refrigerator in my kitchen. With that purchase I had only one option; I bought the model that fit into the space.

We face much of the same dilemma in clinical medicine. Pharmaceuticals come in defined doses and we need to choose from what is available. Sophisticated delivery systems (sustained release, enteric coating) mean that cutting pills to achieve an in-between dose will affect how a medication is metabolized. Only rarely should capsules be opened.

The good news is that a limited number of dosing options will meet almost every need. Even though patients come in all sizes, healthy kidneys and livers are remarkably uniform in size and function. Lean body mass, which is most often how we determine the amount of medication to use, doesn’t vary too much across the population.

When I bought my lightbulbs, I was confident that the size of the socket was not going to change while I was at the store. Nor is the size likely to change one year from now. It doesn’t matter how often I flip the light switch. Human behavior is not as predictable. Choosing a medication dose for a patient assumes that the medication will be taken the same time every day under the same conditions (with or without food). Additional medications or certain foods can alter drug metabolism. The underlying disease might change. What would appear to be the perfect calculated dose might not work out. This is why lightbulbs are over the counter and most medications need a prescription. 

A Regular Routine

The kids are back to school: time to resume the schedule. While it’s fun to laze about a bit during the summer, we as human beings really do better with a set routine. Just as a two year old is less terrible with a set naptime, adults benefit from eating and sleeping in a predicable pattern.

The time that we awaken sets the biological clock for the day. Getting up at the same time every day allows our hormones to assume a diurnal pattern leading to better mood, digestion and cognition. Since we need at least eight hours of sleep, we should plan on going to bed about eight and a half hours before we plan to start the day. Wind down at the end of the day and turn off all screens.

It is recommended that we don’t eat for at least two hours before going to bed: this will help determine the best time for dinner. Sit down and enjoy the meal. Since the overnight fast will be at least ten hours, chances are that we will be hungry for breakfast. Consider some non-traditional foods to start the day, rather than the carbohydrate heavy regulars. Therefore, awakening the same time every day will help determine what time to eat both breakfast and lunch. Most people will want a meal at midday. Brown-bagging will help make wise choices and save a lot of money.

Exercise should be part of the daily routine. Midday is an excellent time for this since it will help provide energy for the afternoon tasks. Think back to grade school – wasn’t running around after lunch the best part of the school day?

Having a predicable sleep/wake/eating pattern might be mundane, but it really works to maintain health. Try to maintain the pattern on the weekends as well.

Bravo

I was delighted to be a guest at a wedding shower recently. The event was at a local restaurant overlooking a small stream. The bride was lovely and gracious, overwhelmed at the number of beribboned Crate & Barrel boxes. The guests were friends and family happy to see one another with the addition of a few obligatory extras. 

I was assigned to the table with the mother of the bride, who told me how thrilled she was to welcome the groom into her family. The food was delicious and the waitstaff attentive. Despite all this, I couldn’t wait for the shower to end. I had the misfortune to sit next a remarkably self-centered woman.

This woman neglected to read the invitation: the guest of honor and the hostesses were of no interest to her. Nor did she think that anyone at her table could have anything to say that was nearly as interesting as her recent travels, the books that she read or the plays that she has seen. In fairness, she did ask the appropriate leading question but never stopped talking long enough to hear an answer.

This domination of the conversation was tiresome and the other guests soon had their own side conversations. But what was over the top was the way that this woman tortured the waiter about her food allergies. If her diet was so restricted, perhaps she should have had a sandwich before she came. I often told my children that they were not required to eat the dinner that I had prepared, but they did need to sit at the table and make pleasant conversation. (This woman never got that message).

The final straw was when the guest approached the mother of the bride while the gift-opening festivities were to start, asking if the cake was prepared in a nut-free facility. The mother of the bride turned and said, “I suggest that you call Famous Bakery and ask how the cake was prepared” before walking away.

Bravo.

Personal Trainers

In an op-ed column in the New York Times, Frank Bruni wrote about the influence of personal trainers. I too have noticed that people will zealously follow every recommendation of their trainers, convinced that following the personalized advice will lead to better health. I am all in favor of better health, but let’s examine who is doing the recommending. As Mr. Bruni points out, all it takes to become a personal trainer is $400 and a pulse. All it takes to be an internist is 8 years of classroom work and at least 3 years of supervised training (and passing nightmarish exams).

The ascension of personal trainers is a direct challenge to evidence-based medicine, the shown to be effective tenet of the conventional medical establishment. In other words, rather than getting the advice that really works the patient would much prefer to get the advice that he or she really wants to hear.  Why actually sweat in the gym – just work on the “core.” It’s much more fashionable to undertake a colon cleanse than to just cut out overly processed food.

I am always pleased when my patients commit to an activity program. It’s a good idea to get some instruction when using a new piece of equipment. However, it should be buyer beware when purchasing nutritional and health advice. The trainer may have the best of intentions – but doesn’t know what he doesn’t know. 

Aspirin

Aspirin is the cornerstone of the treatment of cardiovascular disease. Since there can be complications associated with the use of aspirin, we should use the lowest dose known to be effective. For the prevention of heart attacks and strokes, the lowest effective dose is 75 mg. In the United States, the lowest widely available dose is 81 mg, which seems to be an odd amount.

Before the rise of the modern pharmaceutical industry, chemists used the old English system of measurement. The smallest unit of weight is the grain, which is 65 mg. The standard dose of two aspirin was 10 grains. Each tablet was 5 grains (325 mg). It was thought that the appropriate dose of aspirin for a baby was one-quarter tablet (81 mg). An enterprising manufacturer spared the parents of yore from turning aspirin tablets into heaps of powder attempting to quarter them by formulating “baby aspirin.” To make the product more appealing, the tablets were colored and flavored orange.

There can be serious gastric irritation from aspirin. In an attempt to protect the GI tract, what is now called “low dose adult aspirin” is available with an enteric coating. The unexpected consequence of this coating is that not enough of the aspirin is absorbed. The actual delivered dose of aspirin is not 81 mg; it’s not even the 75 mg generally recognized as the minimum dose needed to prevent cardiovascular events.

Equivalent doses of enteric-coated aspirin are not as effective as plain aspirin, since there appears to be lower bioavailability from the coated product. The pseudoresistance may be more marked in heavier individuals.

I recommend that the patient who needs to take aspirin for the prevention of cardiovascular disease take 81 mg of the immediate release product. There appears to be less gastric irritation if taken with a meal. 

The Paradox of Disease Prevention

There is no way to prove that a person’s efforts to prevent disease actually worked. One can assume that a healthy diet, regular exercise and not smoking will prevent a heart attack. But not every fat, sedentary smoker will succumb to heart disease. The outcome of prevention is invisible: it creates an absence of events.  

There is no drama in prevention. Wearing a seat belt that prevents the need for dramatic surgery will never be featured on a television show. The benefit of reducing stress won’t have an effect by the end of the week. The difficult part of healthy behavior is adhering to the healthy decisions day after day.

Avoidable health risks need to exposed as avoidable and we need to establish a culture that celebrates everyday healthy choices.

Dr. Harvey Fineberg of the Institute of Medicine has written an easy to understand discussion on the paradox of disease prevention. Much food for thought.

Acetaminophen

The first line medication to treat mild to moderate acute pain is acetaminophen (Tylenol). It is generally well tolerated, has few drug-drug interactions, doesn’t raise blood pressure, can be used during pregnancy and is the drug of choice with impaired kidney function. It is also inexpensive.

The side effect profile for acetaminophen is exceedingly good, but there is a relatively narrow therapeutic window (the difference between a therapeutic dose and a toxic dose). The main toxicity, hepatic injury, is a serious concern. Until recently, the maximum daily dose of acetaminophen was 4000 mg daily (12 regular strength Tylenol). Since acetaminophen is in so many over the counter medications there is increasing concerns about unintentional overdose. Government regulators suggest that the maximum dose should be 2600 mg per day (8 regular strength pills).

Although the drug is remarkably safe when taken at usual therapeutic doses, overdose of acetaminophen   has been recognized since 1966 to cause fatal and nonfatal permanent liver damage. It is suspected that even repeated therapeutic or slightly excessive doses can be hepatotoxic in susceptible individuals, such as alcoholics. Acetaminophen poisoning has become the most common cause of acute liver failure in the United States.  

Patients who are older and malnourished appear to be at increased risk for acetaminophen toxicity. Smoking may also be a risk factor. Acetaminophen should not be taken on an empty stomach. 

The most important advice is to carefully read the label of all over the counter medications. Acetaminophen is a component of hundreds of over-the-counter and prescription medications used worldwide. Many patients ingest excessive amounts of acetaminophen because they misunderstand dosing directions or fail to recognize that acetaminophen is found in more than one medication they are using. 

Acetaminophen is a valuable medication but it must be respected as much as any prescription product.