Author: noorali

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Doctors advised to treat elderly carefully with cholesterol-lowering drugs (statins).

Dubai, United Arab Emirates. (Dr. Noorali Bharwani)
Dubai, United Arab Emirates. (Dr. Noorali Bharwani)

The College of Physicians and Surgeons of Alberta in their newsletter, The Messenger (Jan 11 2017) advised doctors to use statins carefully in the elderly.

If your blood cholesterol level is high then you should ask your doctor if treatment with statins is right for you.

High cholesterol level is a risk factor for heart disease. Statins are drugs that can lower cholesterol level in your blood. If your blood cholesterol level is high then plaques build up on the blood vessel walls. This causes partial or complete blockage of the blood vessels and reduces or blocks blood circulation. Why would you want that to happen?

Statin drugs are commonly used to reduce blood cholesterol level. Examples of statins include – atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Altoprev), pitavastatin (Livalo), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin (Zocor).

Statin is effective in lowering the cholesterol level. It may have other health benefits but we do not know everything about it. What is the effect of statin in the elderly is not very well known either. There is a variable quantity of data related to statin use in the elderly, according to the Canadian Cardiovascular Society Guidelines (2016).

The 2016 guidelines continue to recommend treatment for individuals at high risk for cardio-vascular events. This is with the caveat that for adults older than age 75 who are otherwise robust, a discussion should take place regarding the risks and benefits in the context of their individual situation. As I said earlier we do not have much information on the side effects of statin in individuals over the age of 75.

What are the side effects of statin use?

The most common adverse events (1.3 per cent) identified include musculoskeletal events (aches and pains in the muscles) and elevation in liver enzymes. Although not statistically significant, there may be new-onset diabetes and cataract formation. Doctors should monitor their patients for cognitive impairment as well, as it may be associated with statin use.

If you have been on statin prior to age 65, then you can continue to take it after that age if you have had no side effects. Make sure you discuss this with your doctor. You should try to keep total cholesterol level below 6.22 mmol/L. LDL or “bad” cholesterol should be below 3.37 mmol/L.

Taking a statin is one thing but you have to remember lifestyle changes are essential for reducing your risk of heart disease, whether you take a statin or not.

To reduce your risk: 1. Quit smoking and avoid second hand smoke. 2. Eat a healthy diet that’s low in saturated fat, trans fat, refined carbohydrates and salt, and rich in fruits, vegetables, fish, and whole grains. 3. Be physically active, sit less and exercise regularly. 4. Maintain a healthy waist girth: less than 40 inches in men and less than 35 inches in women.

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The significance of expiry dates on medicine and food.

Franklin Delano Roosevelt Memorial in Washington, DC. (Dr. Noorali Bharwani)
Franklin Delano Roosevelt Memorial in Washington, DC. (Dr. Noorali Bharwani)

In the Medical Post (November 25, 2003) Dr. Maria Hugi wrote a column titled, “Drugs still effective long past their expiry dates.” Dr. Hugi is an emergency physician in Vancouver. She was using the information obtained from an article in the Medical Letter (October 28, 2002).

The Medical Letter article says drugs stored without exposure to humidity (stored at a dry room temperature) probably retain 90 per cent efficacy five years after the expiration date if not much longer.

What does U.S. Food and Drug Administration (FDA) web site say?

It says expiration date matters. If your medicine has expired, it may not provide the treatment you need. Expiration dates help determine if medicine is safe to use and will work as intended.

According to Wikipedia, shelf life is defined as the length of time that a commodity may be stored without becoming unfit for use, consumption, or sale. Most expiration dates are used as guidelines based on normal and expected handling and exposure to temperature.

The Canadian Food Inspection Agency produces a Guide to Food Labelling and Advertising that sets out a “Durable Life Date”. The authority for producing the guide comes from the Food and Drugs Act. The guide sets out what items must be labelled and the format of the date.

Harvard Health Publications (HHP) asks, “Drug Expiration Dates – Do They Mean Anything?”

Since a law was passed in the U.S. in 1979, drug manufacturers are required to stamp an expiration date on their products. This is the date at which the manufacturer can still guarantee the full potency and safety of the drug.

Most of what is known about drug expiration dates comes from a study conducted by the Food and Drug Administration at the request of the military.

What they found from the study is 90 per cent of more than 100 drugs, both prescription and over-the-counter, were perfectly good to use even 15 years after the expiration date.

So the expiration date does not really indicate a point at which the medication is no longer effective or has become unsafe to use. Medical authorities state expired drugs are safe to take, even those that expired years ago, says the article in the Harvard Health Publications (HHP).

What are the exceptions to the rule?

Excluding nitroglycerin, insulin, and liquid antibiotics, most medications are as long lasting as the ones tested by the military. Place medication in a cool place, such as a refrigerator, will help a drug remain potent for many years, says HHP.

So the expiration date doesn’t really indicate a point at which the medication is no longer effective or has become unsafe to use. There is relatively little scientific data about out-dated medications. What you see on the drug and food packages is a guideline. Use the guideline smartly. If in doubt talk to your pharmacist or food store.

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The thyroid gland has an enormous impact on your health.

Lake Louise, Alberta. (Dr. Noorali Bharwani)
Lake Louise, Alberta. (Dr. Noorali Bharwani)

In my last column we discussed the management of a thyroid tumour. Today, we will discuss another aspect of thyroid disease: under active (hypo-thyroid) and over active (hyper-thyroid) thyroid gland.

It is estimated thyroid disorders affect one in 20 Canadians and most thyroid disorders are five to seven times more common in women.

Thyroid hormones are produced in the thyroid gland from iodine and an amino acid, tyrosine. The normal function of the thyroid gland is to produce and secrete hormones. There are two hormones which are closely related: T3 (triiodothyronine) and T4 (thyroxine).

These hormones have enormous impact on our health, affecting all aspects of our metabolism. They maintain the rate at which our body uses fats and carbohydrates, help control our body temperature, influence our heart rate, and help regulate the production of protein. These hormones are important for normal growth and development of children.

Hypothyroidism

Hypothyroidism causes many symptoms: weight gain, lethargy, cold intolerance, menstrual irregularities, depression, constipation, and dry skin. Deficiency of thyroid hormones in children leads to dwarfism and mental retardation.

There are many causes of hypothyroidism. Thyroid function can be diminished due to congenital development defect or acquired conditions like radiation therapy or autoimmune disease (Hashimotos’ disease).

Hashimoto’s disease is a condition in which your immune system attacks your thyroid. Inflammation from Hashimoto’s disease, also known as chronic lymphocytic thyroiditis, often leads to hypothyroidism. Hashimoto’s disease is the most common cause of hypothyroidism in North America. It primarily affects middle-aged women but also can occur in men and women of any age and in children.

Thyroid function is tested to help detect Hashimoto’s disease. Treatment of Hashimoto’s disease with thyroid hormone replacement usually is simple and effective.

Good news is accurate thyroid function tests are available to diagnose hypothyroidism. Treatment of hypothyroidism with synthetic thyroid hormone is usually simple, safe and effective. Finding an adequate replacement dosage of thyroid may take a little time.

Hyperthyroidism

On the other hand hyperthyroidism is not that easy to manage.

Clinically, hyperthyroidism presents with palpitations, nervousness, tremor, heat intolerance, weight loss, muscular weakness and quite often there is goitre.

Hyperthyroid gland can cause Graves’ disease that accounts for at least 90 per cent of all patients with hyperthyroidism. But the cause of hyperthyroidism is not very clear.

Graves’ disease is a condition where eyes are affected. It is called exophthalmos – protrusion of the eyeballs. Graves’ disease is an autoimmune disorder in which antibodies produced by your immune system stimulate your thyroid to produce too much thyroid hormone.

It is not clear what causes Graves’ disease, although several factors, including a genetic predisposition, are likely involved.

Unfortunately, there is no satisfactory treatment to prevent Graves’ eye disease. Because hyperthyroidism seems to affect the eyes, it is very important to treat hyperthyroidism quickly and effectively. In most patients, the eyes tend to get somewhat better when the thyroid abnormality has been treated.

Patients who are hyperthyroid are often treated with radioactive iodine or anti-thyroid medications to reduce and normalize thyroid function. However, in some cases, treatment of hyperthyroidism can result in permanent hypothyroidism.

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Thyroid lumps need investigations to rule out cancer.

Sunset in Saint Martin, Caribbean. (Dr. Noorali Bharwani)
Sunset in Saint Martin, Caribbean. (Dr. Noorali Bharwani)

Thyroid is a small gland located at the base of the neck, just above the breastbone. Thyroid nodules are solid or fluid-filled lumps that form within the thyroid gland. Most of them are benign. Thyroid cancer accounts for only a small percentage of thyroid nodules.

Small thyroid lumps are not visible to the naked eye. Some nodules are big enough to be seen. Sometimes your doctor will feel the lump when he examines your neck.

A solitary nodule, within an otherwise apparently normal gland, is of more concern than a thyroid gland with multiple nodules (multi-nodular goiter). Multi-nodular goiters are usually benign.

Thyroid nodules are more common in women. Single nodule is four times more common in women than men.

About 45 to 75 per cent of nodules are simple cysts (colloid nodules); 15 to 40 percent are benign tumours (adenomas); and only eight to 20 per cent are cancerous.

A patient with a history of radiation treatment to the neck, or any radiation exposure near the thyroid gland, has increased risk of developing nodules. These nodules tend to develop long after the radiation exposure. Family history of thyroid cancer increases the likelihood of a thyroid nodule being malignant.

How do we investigate a solitary thyroid nodule?

The most recent guideline from the American Thyroid Association recommends measurement of thyroid stimulating hormone (TSH) level in the blood and ultrasound of the neck in all patients with a thyroid nodule, says an article in the Canadian Medical Association Journal (CMAJ December 6, 2016).

Ultrasound is a good test for thyroid lumps. It can tell us if there is more than one nodule, if the lump is solid, cystic or mixed; and it is the best method to determine the size of the nodule.

Blood test is also useful. A low TSH level (< 0.3 mU/L) suggests an autonomously functioning nodule, and a thyroid scan with iodine-123 should be performed.

Although nodules are present in 20 to 70 per cent of individuals, most do not require biopsy.

If the nodule is hyper-functioning then it requires medical treatment. Surgery is rarely indicated.

If the TSH level is normal or high (> 5 mU/L), then fine-needle aspiration (FNA) biopsy should be considered. All thyroid nodules do not need a needle biopsy. Only non-cystic nodules greater than one to two cm need to be biopsied. FNA biopsy is recommended for nodules with features on ultrasound that indicate higher risk of malignant disease.

If the needle biopsy is negative for cancer in the first instance then the new guidelines recommend a repeat needle biopsy after three months. Repeat needle biopsy yields a more definitive diagnosis in up to 90 per cent of cases based on high-quality studies, says the CMAJ article.

After two benign needle biopsy results, ultrasound surveillance is no longer indicated. However, if the lump gets bigger or causes symptoms then there is an indication for surgical treatment.

So, a solitary thyroid nodule is not always malignant. But it should not be ignored. Appropriate investigations should be done to rule out cancer.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!