Author: noorali

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Indigestion

Individuals, health care institutions and Alberta Blue Cross spend millions of dollars for the use and “abuse” of pills for indigestion, heartburn and the treatment of peptic ulcer disease. Is there a sensible way of using these pills?

Recently, this subject was discussed in the DUE (drug use in the elderly) Quarterly.

Dyspepsia (indigestion) affects 29 percent of the adult population and accounts for seven percent of visits to family physicians.

Most widely prescribed and used acid suppressing agents are:

-Proton pump inhibitors (PPI)- accounts for 90 percent of Alberta Blue Cross Group (ABCG) 66’s cost of acid suppression agents (examples-Losec, Prevacid, Pantaloc)

-H2 antagonists –accounts for 10 percent of the ABCG 66’s cost of acid suppression agents (examples-Zantac, Pepcid, Axid and their generic versions)

Why would one need these pills?

-For eradication of Helicobacter pylori organism from the stomach. A protocol requires that any patient with H. pylori infection, in the presence of an ulcer, should receive one week of “triple therapy” – two antibiotics and PPI. In the absence of an ulcer, the use of “triple therapy” is controversial.

-For gastroesophageal reflux disease (heart burn) – four to eight weeks of treatment with PPI or H2 antagonist is indicated with life-style changes.

-For functional dyspepsia, also known as non-ulcer dyspepsia or indigestion. In this condition, an individual has all the symptoms of an ulcer but no ulcer is found on investigations. A difficult condition to treat satisfactorily. A person may end up using the pills for prolonged period of time for symptomatic relief.

-For NSAID-related dyspepsia – individuals who are on non-steroid anti-inflammatory drugs (NSAID) are prone to peptic ulcer disease or indigestion. These individuals are on long-term use of stomach pills.

Losec should be taken half an hour before any meal, while Pantaloc and Prevacid should be taken before breakfast. These pills should be taken whole, not broken or chewed.
The Quarterly says that PPI have been recognized to be efficient and safe in what they do. And there is not much difference in the clinical use of the three PPIs except for the cost.

The cost comparison of PPIs in Alberta shows that Losec 20mg once daily costs $66.00 per month, Pantaloc 40mg once daily costs $61.26 per month and Prevacid 30mg once daily is the cheapest at $60.00 per month.

The largest group of patients on PPI are the ones with heartburn and gastroesophageal reflux disease. Many of these patients can be treated with life style changes and over the counter medications and/or cheaper H2 receptor antagonists like Zantac, Pepcid, or Axid. Those who do not respond to these measures can be stepped up to a PPI. These patients also require investigations to assess the degree of damage to the lining of the oesophagus by gastric and biliary juices.

The next large group on PPI is one with indigestion due to NSAID use. Patients who have peptic ulcer due NSAID therapy are best treated with PPI. NSAID patients are usually on another drug called misoprostal, which offers protection against development of ulcers.

Patients with non-ulcer dyspepsia should not be on long term PPI therapy without trial of other therapies, which are cheaper, and with minimal side effects. Prolonged acid suppression in the stomach without good reason may lead to atrophy of stomach glands and deficiency of vitamin B12. Plus the cost to the patient and other institutions that pay for the prescriptions.

So, if you are on any of the pills mentioned here on long term basis then ask your doctor: Do I really need it? Is there anything cheaper? Is there anything else you can do to relieve your symptoms?

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Tamoxifen and Cancer Prevention

Dear Dr. B: Is there a pill to prevent breast cancer? Yours: Ms. Worried.

Dear Ms. Worried: There is no straight answer to this question. Studies have shown that, in some women, tamoxifen can prevent breast cancer.

Recently, an article was published on this subject in the Canadian Medical Association Journal. It is a joint guideline from the Canadian Task Force on Preventive Health Care and the Canadian Breast Cancer Initiative’s Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer.

The objective of the guideline is to assist women and their physicians in making decisions regarding the prevention of breast cancer with tamoxifen and raloxifene.

Raloxifene is a drug used for prevention and treatment of osteoporosis in
post-menopausal women. Current evidence does not support the use of raloxifene for prevention of breast cancer.

Tamoxifen is a drug used for certain categories of women who have had breast cancer. It has shown to reduce the recurrence of cancer in the same breast, reduce the occurrence of new breast cancer in the other breast, and reduce the risk breast cancer spreading to other parts of the body (metastasis).

Tamoxifen has been found to be effective in preventing breast cancer. On that basis the Task Force has made recommendation in the use of Tamoxifen for prevention of breast cancer.

How do I know tamoxifen will help me prevent breast cancer?

First, you need to determine your risk. This is not easy. You have to go on the internet and check the Gail risk assessment index. This is a model used to estimate an individual woman’s risk of breast cancer.

The index uses a series of risk factors (age, age at first period, age at first live birth, number of breast biopsies, family history and ethnic origin) to calculate a “baseline risk.” The article says that the Breast Cancer Risk Assessment Tool, which is based on the Gail index, is available online: http://bcra.nci.nih.gov/brc. This will calculate percentage risk for you.

Once you have done that, then check the following recommendations to see if they apply to you:

1. Women at low or normal risk of breast cancer (Gail risk assessment index less than 1.66 percent at 5 years): There is fair amount of evidence to recommend against the use of tamoxifen in this group.

2. Women at higher risk of breast cancer (Gail index equal to or more than 1.66 percent at 5 years): Evidence supports counselling women in this group on the potential benefits and harms of breast cancer prevention with tamoxifen.

Examples of women in the second group would be – two first-degree relatives with breast cancer, a history of breast biopsy showing lobular carcinoma-in-situ, or atypical hyperplasia. Tamoxifen reduces the risk of breast cancer by 50 percent or in atypical hyperplasia by 86 percent.

Use of tamoxifen is not without side effects like stroke, blood clots in the lung or leg veins, cancer of the uterus, hot flashes and vaginal dryness. The article says that the side effects increase with a woman’s age.

So, Ms Worried, tamoxifen will do the trick for you if you are the right candidate. And remember, the benefits are not without side effects. “The benefit of protection against breast cancer is more likely to outweigh the risks on women aged 35 to 50 years”, says the Canadian Task Forces’ guideline.

Good luck, Ms. Worried.

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Screening Can Save Your Life

Dear Dr. B: Are there any recommendations for colorectal cancer screening from the Canadian Task Force on Preventive Health Care? Yours, Mr.C.

Dear Mr. C: Yes. A statement from the Task Force on colorectal screening was published recently in the Canadian Medical Association Journal. These recommendations are for asymptomatic people with no personal history of ulcerative colitis, polyps or colorectal cancer. I will summarise the recommendations here:

Recommendations for people over the age of 50 who are at normal risk:

1. There is good evidence to suggest that these people should have annual or biennial (every two years) test to check for non-visible blood in the stool (fecal occult blood tests).

2. There is fair evidence to include flexible sigmoidoscopy (an office procedure). Some recommend this every five years.

3. There is insufficient evidence to recommend whether only one or both (1 and 2) should be performed.

4. There is insufficient evidence to include or exclude colonoscopy as an initial screening test in this age group. Some recommend colonoscopy every 10 years.

Recommendation for people at above-average risk:

1. There is fair evidence to include either genetic testing or flexible sigmoidoscopy of people in families with familial adenomatous polyposis – a condition in which multiple adenomatous polyps progressively develop throughout the colon. The polyps first appear after puberty. Other benign and malignant lesions may appear on the body.

2. There is fair evidence to include colonoscopy screening in the periodic health examination of people in families with hereditary non-polyposis colon cancer – a condition in which three family members are affected with colorectal cancer, two of whom are in successive generations and at least one is under the age of 45 years. It is unclear at what age the screening should start and how often colonoscopy should be done.

3. There is insufficient evidence to recommend colonoscopy for people who have a family history (people who have two or more first degree relatives) of colorectal polyps or cancer but who do not meet the criteria for hereditary non-polyposis colon cancer. Some experts recommend colonoscopy for this group as it is accepted that people with family history of colon and rectal cancer may be at increased risk but that this risk is not well defined.

What are the advantages of screening? To reduce the number of deaths from colorectal cancer.

What are the disadvantages? The incidence of false positive and false negative tests especially with fecal occult blood testing. There is incidence of perforation from flexible sigmoidoscopy (1.4 per 10,000 procedures) and colonoscopy (10 per 10,000 procedures).

Colorectal cancer is the third most common cancer in Canada. It accounts for more than 12 percent of cases of cancer in both sexes.

It was estimated that there would be 17,000 new cases and 6,500 deaths from colorectal cancer in Canada in 2000. These rates, especially among men, are among the highest in the world.

But how many of us are ready to submit ourselves to screening for colorectal cancer? Not many. The embarrassment and discomfort of a rectal examination, unpleasant bowel cleansing before flexible sigmoidoscopy and colonoscopy, risk of bowel perforation, and anxiety dissuade people from coming forward for screening. Even symptomatic patients take a long time before they see their doctors.

Well, Mr. C, if any of the recommendations apply to you then see your doctor and have yourself checked out. Prevention is better than…….?

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Breast Self Examination

Dear Dr. B: I have been doing breast self-examination (BSE) for many years. But recent recommendation by the Canadian Task Force on Preventive Health Care has confused me. Can you please tell me whether I should continue to do BSE? And what is the Task Force’s exact recommendation? Yours, Ms. Confused.

Dear Ms. Confused: My recommendation would be to continue to do breast self-examination. If we are going to ask women to discontinue with BSE then we should ask the public to stop having rectal examination for detection of rectal and prostate cancer, we should stop doing PSA tests, we should stop checking moles, we should ask men not to examining their testicles for tumour – well I can go on and on.

Unfortunately, medicine is not a perfect science. That is why evidence based medicine is not popular with physicians who have to deal with sick and anxious patients face to face. Common sense and sense of responsibility dictates that we should continue to examine and check our bodies for any obvious abnormalities.

Of course, conducting unnecessary invasive tests without adequate clinical indication is not acceptable. But BSE is inexpensive and non-invasive test requiring no high tech machinery.

What did the Task Force recommend?

1. Women aged 40-69 years should not do BSE, as there is a fair evidence of harm and no evidence that it saves lives.

2. Women younger than 40 and older than 70 – no recommendation was made as there is lack of sufficient evidence to evaluate the effectiveness of BSE in this age group.

What are the recommendations based on?

The Task Force reviewed several large studies and failed to find any evidence that BSE prevents death from breast cancer. In fact, the studies show that women who do BSE visit doctors more often for evaluation of benign breast disease, and have higher rates of benign breast biopsy results. This inflicts anxiety and pain not only to patients but to their families as well.

Is this a big price to pay to rule out breast cancer?

Breast cancer is the most frequently diagnosed cancer among Canadian women. Breast cancer accounts for 30 percent of all new cancer cases diagnosed each year, says the Task Force article in the Canadian Medical Association Journal. Each year, 25 percent of women with diagnoses of breast cancer die.

Well, you be the judge. Each woman has to decide what is important for her. It is your body and you should have full control over it. If you are going to do regular BSE then make sure that you learn the right technique. Information pamphlets and videos are available at the Canadian Cancer Society office (Phone: 529-8015).

Early detection of breast cancer requires three tests: BSE, clinical examination of the breasts by a physician or a trained nurse, and mammography. None of these tests are hundred percent accurate in detecting early breast cancer. Therefore, many physicians, including myself will follow the dictum that a breast lump is malignant until proven otherwise. I would rather remove a benign lump then miss a breast cancer!

Ms. Concerned, I hope this answers your question. If you are going to continue to do BSE then make sure that your technique is correct.

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