Balancing risks and benefits of using heartburn and peptic ulcer disease pills in seniors.

Esophagitis and peptic ulcer disease. (Dr. Noorali Bharwani)
Esophagitis and peptic ulcer disease. (Dr. Noorali Bharwani)

About 25 per cent of Canadian seniors suffer from three or more chronic illnesses and are on six or more medications per day.

One of the medications is Pantoloc. Pantoloc (pantoprazole) belongs to the family of medications called proton pump inhibitors (PPIs).

First introduced in 1989, PPIs are among the most widely utilized medications worldwide, both in the ambulatory and inpatient clinical settings. These medications are central in the management of reflux disease and are unchallenged with regards to their efficacy.

Pantoloc is the fifth most commonly prescribed drug. It is used for patients who have heartburn (GERD or gastro oesophageal reflux disease) or inflamed oesophagus (esophagitis). It is also used for peptic ulcer disease (duodenal or gastric ulcers).

The prevalence of heartburn and reflux disease increases with age and elderly are more likely to develop severe disease.

Treating inflamed oesophagus (esophagitis) due to reflux:

PPIs are indicated for short-term treatment of mild esophagitis. Treatment is usually for four to eight weeks duration. But if you have moderate esophagitis with endoscopic evidence of Barrett’s oesophagus (a premalignant inflammation of the oesophagus) and severe esophagitis grade C or D, then you need long-term to lifelong treatment with PPI.

Peptic ulcer disease

Peptic ulcer disease usually occurs in the stomach and proximal duodenum. It is caused by infection with Helicobacter pylori bacteria and use of nonsteroidal anti-inflammatory drugs (NSAID).

Short-term PPI use for treatment of peptic ulcer disease is recommended for two to 12 weeks, unless maintenance therapy is clearly indicated, such as ongoing NSAID use.

If PPI is so effective then what is the problem. The problem is, and the studies have shown, once a patient is started on PPI, the symptoms are not reviewed and patients stay on them for years with no valid indication.

Long-term use of PPIs is not without risks, including vitamin B12 deficiency, osteoporosis, pneumonia and C. difficile associated diarrhea (colitis). A recent study suggests that the heartburn drugs may be associated with an increased risk of dementia and kidney disease.

What should patients and health care providers do?

There is an interesting website (deprescribing.org) that helps patients understand the rationale for deprescribing certain medications.

If the decision is made to deprescribe, the key to success is monitoring for rebound hyperacidity. Regular follow-up over the following four to 12 weeks is critical to assess for and manage adverse symptoms to deprescribing PPIs.

An article on the Mayo Clinic website by Avinash K. Nehra, MD et al titled “Proton Pump Inhibitors: Review of Emerging Concerns,” says that based on current recommendations, the American Gastroenterological Association does not recommend routine laboratory monitoring or use of supplemental calcium, vitamin B12, and magnesium in patients taking PPIs daily.

Nehra’s current practice is to check creatinine levels yearly, complete blood cell counts every other year, and vitamin B12 levels every five years in patients receiving long-term PPI therapy.

In summary, the best strategy is to prescribe PPIs at the lowest dose on a short-term basis when appropriately indicated so that the potential benefits outweigh any adverse effects associated with the use of PPIs, says Nehra.

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There are many health benefits to eating bananas.

A bowl of mixed fruit. (Dr. Noorali Bharwani)
A bowl of mixed fruit. (Dr. Noorali Bharwani)

More than 100 billion bananas are eaten each year worldwide.

North Americans eat an average of 27 pounds of bananas per person per year – making it the most heavily consumed fruit in America.

“A medium-sized banana provides about 105 calories with virtually no fat, cholesterol or sodium,” says Joanne Hutson, a Mayo Clinic Health System registered dietitian and certified diabetes educator. Her article appears on the Mayo Clinic website.

“Nobody gets fat or develops diabetes from eating too many bananas,” says Jessica D. Bihuniak, Ph.D., R.D., an assistant professor of clinical nutrition at New York University Steinhardt School of Culture, Education, and Human Development. Bihuniak is quoted in a Consumer Magazine article on bananas (April 18, 2018).

But some carb- and calorie-conscious consumers have relegated bananas to the “do not eat” list because of the fruit’s high sugar and calorie count relative to some other fruits.

That rationale is misguided, Bihuniak says. Virtually, there is no harm from eating too much of any fruit. And as with all fruits, bananas are loaded with a bevy of nutrients, some of which promote a healthy heart, gut, and waistline.

I love eating bananas. I was born and raised in Musoma, Tanzania on the shores of Lake Victoria. We used to get our bananas from the neighbouring country of Uganda. The weekly boat from Uganda would arrive at the port of Musoma. The port was about five kilometers from our house. We did not own a car but I was a keen biker. Every Sunday morning when the boat would arrive from Uganda carrying bananas, I would go on my bike to the port and buy one or two large hanging clusters of bananas and take them home on my bike. I was about 13-years-old. Those were the days!

I still love eating bananas. Individual banana fruit is 75 per cent water and 25 per cent dry matter. Cooking bananas represent a major food source and a major income source for many farmers.

The highest consumption of bananas is in countries such as Uganda, Burundi, and Rwanda. The majority of bananas North Americans eat come from Latin and South America. However, they are grown in more than 100 countries with tropical climates.

Bananas are perhaps best known for their potassium count, that governs heart rate, blood pressure, and nerve and muscle function. The body carefully maintains levels of potassium and sodium to keep fluid levels in balance.

A banana can help prevent muscle cramps after exercise, says Hutson. They also provide a good source of vitamins C and B6, as well as magnesium.

An average banana also contains about three grams of fiber, which can help provide a feeling of fullness plus aid the digestion process. These insoluble fiber components help maintain healthy gut bacteria and enzymes needed to digest foods and benefit the immune system.

Bananas are very convenient and portable – in their own sealed package. Simply grab and go for a quick mini breakfast or snack.

Banana is a portable fruit like an apple. It can be carried with you when you go to work, go for a walk or go biking and jogging. Enjoy!

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Heavy Snoring Can Be A Danger Sign

Mount Kidd, Kananaskis Golf Course (Dr. Noorali Bharwani)
Mount Kidd, Kananaskis Golf Course (Dr. Noorali Bharwani)

Do you have sleep problem that leaves you chronically fatigued, sleepy and irritable?

If yes then you may have disorders like narcolepsy, snoring or sleep apnea.

Narcolepsy is a neurological disorder that affects the control of sleep and wakefulness. People with narcolepsy experience excessive daytime sleepiness and intermittent, uncontrollable episodes of falling asleep during the daytime. These sudden sleep attacks may occur during any type of activity at any time of the day.

Snoring is rough rattling noise made on breathing in during sleep by vibration of the soft palate and the uvula.

Snoring is believed to occur in 30 per cent of women and over 40 per cent of men. It can be potentially serious health hazard. Many people may not think of snoring as a sign of something potentially serious, and not everyone who snores has obstructive sleep apnea.

Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. You may have sleep apnea if you snore loudly, and you feel tired even after a full night’s sleep.

Obstructive sleep apnea is more common form that occurs when throat muscles relax and block your airway during sleep and cause snoring. The other two are central sleep apnea and complex sleep apnea syndrome.

Obstructive sleep apnea can seriously affect your health. High blood pressure, heart attack, heart failure and stroke top the list. It can affect your heart rhythms. It can lower your blood pressure, lower your oxygen level and lead to heart attack and death.

If you are a chronic snorer and your partner observes that you make a snorting, choking or gasping sound then you have a problem.

It is time to discuss your symptoms with your doctor and get a referral to a sleep specialist. You will undergo tests to confirm the diagnosis. The tests involve overnight monitoring of your breathing and other body functions during sleep. The test is called nocturnal polysomnography.

If you have obstructive sleep apnea, your doctor may refer you to an ear, nose and throat specialist to rule out any blockage in your nose or throat. An evaluation by a cardiologist may be necessary.

How to manage obstructive sleep apnea?

Guidelines (2014) from the American College of Physicians (ACP) emphasize lifestyle modifications – especially weight loss. Though the guidelines do not offer any radical treatment updates, they do reinforce the effectiveness of tried and true therapies.

Breathing devices are still best for treating obstructive sleep apnea. Continuous positive airway pressure (CPAP) works well. It is the first line of treatment. It has to be used during sleep. It relieves symptoms but does not cure the problem.

Oral appliances are useful. They are worn only during sleep. Research shows that oral appliance therapy is an effective treatment option. But does not cure the problem.

Surgery is the last option to be used if all else fails. There are many different types of surgery for sleep apnea and snoring. Surgery will not fix everything. You may need to continue using CPAP even when surgery successfully reduces the severity of sleep apnea.

Remember, surgery can have side effects and surgery alone will not fix all your problems. Discuss your options, long-term outcome and side effects of treatment with your specialist before going for surgery.

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Good Samaritan: Is there a doctor on board?

Sand art on a beach in Albufeira, Algarve, Portugal. (Dr. Noorali Bharwani)
Sand art on a beach in Albufeira, Algarve, Portugal. (Dr. Noorali Bharwani)

“The parable of the Good Samaritan is a parable told by Jesus and is mentioned in only one of the gospels of the New Testament”, says an article in Wikipedia.

Good Samaritan acts are defined as when doctors and other healthcare professionals who aren’t on duty offer help in an emergency.

The concept of a Good Samaritan is not new. But in the present era of litigation some people are reluctant to help a stranger in an emergency situation.

“When an individual suddenly becomes ill or injured, doctors instinctively stop in the midst of their vacation, their business trip, or their work and offer assistance as good Samaritans, often under trying conditions”, says an article in the Canadian Medical Protective Association Bulletin (CMPA eBulletin MARCH 2018). CMPA provides legal assistance to doctors.

What are the physician’s ethical obligations and legal risks?

The article says legal obligations and risks can be more difficult to determine because emergencies can occur anywhere at any time. Besides physicians may find themselves being asked to provide emergency care in a variety of legal jurisdictions.

In Canada, most jurisdictions do not impose a legal duty or obligation on physicians to provide emergency medical services. Quebec is the only province in Canada that imposes a legal duty on physicians to come to the aid of a person in a life-threatening emergency. Quebec’s Civil Code protects physicians from liability for that care.

All jurisdictions, however, have legislation that protects physicians who voluntarily provide emergency assistance at the scene of an accident or in any emergency.

CMPA does not think courts anywhere would criticize the conduct of a physician who in good faith treated a person in need of urgent medical care.

CMPA says when its members provide care in an emergency as Good Samaritans they are generally eligible for CMPA assistance regardless of where the emergency care was delivered – anywhere in the world. Former CMPA members who act as Good Samaritans are also eligible for CMPA assistance.

With that in mind, the CMPA encourages its members to consider assisting when confronted with urgent or emergent circumstances.

As soon as possible after the emergency, physicians should document the encounter in their own records. The documentation provides a record of the medical reasoning and the steps taken, may facilitate any further investigations and treatments, and provides a valuable resource if afterwards there are questions about the care. One survey showed in spite of the risks involved most doctors are willing Samaritans.

Helping people and saving lives is what doctors do.

In a British study of doctors who acted as Good Samaritans, in the majority of cases doctors received no recognition for the help they provided, although many pointed out they did not want or expect anything. Others received thank you cards, and in a few cases the doctor was rewarded with a gift ranging from a free meal to an airline upgrade.

Most of the time you don’t need to be a doctor to provide basic life saving support. Remember what you learnt in your first aid course on CPR (cardio pulmonary resuscitation). The most popular acronym you learn for CPR is “ABC”. The “A” stands for airway, “B” stands for breathing, and “C” stands either for circulation or compression of a bleeder. If you can do this until further help arrives then you are doing well. You are a Good Samaritan.

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