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Anti-inflammatory Agents (NSAID)

Wayne Gretzky seems to be suffering from arthritis. He is not alone. This disease afflicts 4 million Canadians. To stay comfortable, most arthritic patients are on anti-inflammatory agents.

These agents are steroids and/or nonsteroidal anti-inflammatory drugs (NSAID). Neither of them is completely safe.

Inflammation is body’s response to infection or injury. It is characterized by heat, redness, pain, swelling and, occasionally, loss of function.

If the inflammation is due to infection then antibiotic is required. To that one can add an anti-inflammatory agent to help reduce swelling and pain. If the inflammation is due to injury then an anti-inflammatory is enough. No antibiotic is required.

“Dr. B, I have arthritis and my doctor wants me to take an anti-inflammatory agent. I am scarred. My husband was on an anti-inflammatory and he almost bled to death. What are my chances of getting such a complication?”

This lady’s fears are shared by millions of people who are aware of the likely complications of anti-inflammatory agents. But there are millions more who are not aware of the risks.

It is estimated that 5 to 10 percent of patients will die from a bleeding ulcer as a result of NSAID use. The bleeding may start with no prior warning signs of an ulcer. This is true in 81 percent of cases, says a review article in the New England Journal of Medicine (NEJM).

Felix Hoffman, working at Bayer Industries, discovered the first NSAID (aspirin) 100 years ago. It was and is used for rheumatic diseases, menstrual pain, and fever. Since then numerous NSAIDs have been developed. These are one of the most widely used drugs – by prescription and off the counter.

It is estimated that 5 to 50 percent of patients will develop dyspepsia (upset stomach) due to NSAID use. But not necessarily develop an ulcer.

But the risk of developing an ulcer is high in patients who are advanced in age, have a previous history of ulcer, are on steroid (prednisone), are on blood thinner, have other medical problems, use more than one type of NSAID at a time, have bacterial infection of the stomach (H. Pylori), smoke, and use alcohol.

Most patients with osteoarthritis or rheumatoid arthritis have no choice but to take NSAID to stay comfortable. There are millions of people who take NSAID for other aches and pains. Therefore, it is important to make these medications safe.

Two strategies have been used to improve their safety, says the NEJM article. One is to prescribe concomitant medication to protect the lining of the stomach and duodenum and second is to develop safer anti-inflammatory agents.

Studies have shown that omeprazole (20 mg once a day), or misoprostol (200 mg three times a day) appear to be effective in preventing the recurrence of ulcers during continued use of NSAIDs.

Several newer NSAID agents are being studied (nabumetone, etodolac, meloxicam, celecoxib and rofecoxib). The authors of the review article say that the newer agents offer considerable promise in the treatment of inflammatory arthritis, but careful surveillance will be important to determine their ultimate benefit and safety profile.

In the meantime, vigilance on the part of physician and patient is required. Careful prescribing is important. Patients should follow directions properly. Especially, the individuals who consume regular off the counter anti-inflammatory agents.

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Recruiting doctors should always be ongoing.

The Medicine Hat News Friday, September 10, 1999

Letter to Editor

Recruiting doctors should always be ongoing

Recent media report on physician shortage has created considerable anxiety amongst the people of this Region. This naturally begs the question – what are we doing about it?

In the last two years, due to various reasons, we lost 12 physicians (7 family doctors and 5 specialists) but were able to gain 20 ( 8 family doctors and 12 specialists). A net gain of 8.

Current population to physician ratio in Canada is 550:1. In 1997, Prince Edward Island had a ratio of 830:1 compared to Alberta’s 640:1. In 1998, Alberta had a ratio of 620:1.

There are 100 physicians in our Region with a population of 85,000 ( ratio of 850:1). If my calculations are correct, then for our Region to achieve the national ratio of 550:1, we have to recruit about 75 doctors, or 50 doctors to achieve our provincial ratio of 620:1!

We know our Region does not need that many doctors. The national and provincial ratios do not take into consideration mal-distribution of physicians (rural vs. urban vs. metropolis). Two-thirds of Canada’s 56,000 physicians practice in Ontario!

Average age of our Region’s family physician is 44 and specialist is 45 (national average age 47 for all physicians).

Twenty seven percent of our doctors are under 40 (nationally 29 percent), 46 percent between 41-50, 22 percent between 51-60, and 5 percent are over the age of 60 (nationally 16 percent). In the next 5 to 10 years, we should expect 30 percent of our physicians slowing down or retiring.

Where are we going to find new doctors? At what price? Where is the funding going to come from? As we all know, there are no easy answers to these questions. Recruitment should be an ongoing process and our efforts will continue. Hopefully, we will be able to serve the people of our Region satisfactorily.

What are our current recruitment efforts? For Brooks, we are looking for 3 family physicians with special skills – anesthesia, obstetrics or other special interest. For Medicine Hat: 3 family physicians (hopefully with obstetrics), 1 internist, 1 anesthetist and a part-time pathologist.

Noorali Bharwani, FRCSC; FACS
Regional Chief of Staff
Palliser Health Authority

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Esophageal Cancer

Cancer of the esophagus (gullet) is relatively uncommon condition. But because of its poor prognosis, it ranks among the 10 leading causes of cancer death in Canadian men 45 years of age and older

Dave’s uncle Bill finds out about it when he has difficulty swallowing food.

Bill starts to lose weight. He tries bland and pureed (liquid) diet. But he continues to lose weight. Except for saliva, nothing goes down.

Bill lives alone. He does not like to complain or bother other people.

One day, Dave runs into Bill at a shopping mall. Dave is surprised to see how much weight Bill has lost. Dave invites Bill to come over for a good home cooked meal.

Dave’s wife Susan cooks roast beef. Bill is hungry and takes the first bite. He chokes. The food is stuck in the esophagus. He is unable to swallow saliva. He is rushed to the Emergency Department.

Bill undergoes emergency gastroscopy (a flexible long instrument with light and camera at the tip) to check and remove the food bolus from the esophagus. The physician also finds the cause of the blockage – a tumour. He takes biopsies and within few days the result shows cancer.

Bill undergoes more tests to see if the cancer has spread. These tests are chest x-ray, blood tests, ultrasound of the liver, and CAT scan of the chest. Unfortunately, the results show that the cancer has advanced.

Bill is shocked. So is Dave. Naturally, their first question is – now what? They want to know everything about the cancer.

In an adult, esophagus is a long straight tube, 40 cm. long. It starts in the throat, travels through the chest cavity, behind the heart and the big vessels (aorta), passes through the diaphragm and joins the stomach. About 4 cm. of the esophagus is below the diaphragm.

Esophagus connects the mouth to the stomach. What a journey our food has to take before it gets to the stomach!

The esophagus is kept lubricated by saliva we swallow and the mucous secreted by the esophageal glands.

Esophageal cancer is slightly more common in males than females. Some of the possible causes of this cancer are alcohol, tobacco, chronic inflammation of the esophagus, and previous lye-induced injury.

Esophageal cancer occurs either in the upper, middle, or lower part of the gullet. Since the gullet is fairly small in diameter, the symptoms of blockage occur early. But it does not help improve prognosis. In approximately 95 per cent of cases, surgical cure is impossible by the time diagnoses is made.

Hence treatment options are very limited. Besides surgery, radiotherapy has shown promising results in some cases. But 5 year survival rate for surgery, radiotherapy or the combination of the two is poor (5 to 15 percent).

In most cases, the only treatment option is palliative in nature. This may include chemotherapy to treat the systemic disease (cancer spread), dilatation, stent or laser therapy to keep the esophageal lumen open.

Unfortunately, Bill’s tumor has already spread to lungs and liver. Therefore, he has very limited treatment options. And the prognosis remains poor.

Bill and his family need emotional support in this trying time. Pain control is very important for comfort and to keep the moral up. Therefore, he is referred to Cancer Clinic, Pain Clinic and Palliative Care Program.

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

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Euthanasia

Euthanasia – is it murder or mercy?

Recent editorials in this newspaper have examined the Dutch government’s proposed legislation to legalize euthanasia under tight guidelines.

Euthanasia is a Greek word meaning “good death”. Webster’s encyclopedic dictionary of the English language describes euthanasia as the deliberate, painless killing of persons who suffer from a painful and incurable disease or condition, or who are aged and helpless.

Canadian Medical Association’s Code of Ethics for physicians says that passive euthanasia (allowing patient to die by witholding treatment) is morally permissible in certain circumstances. But active euthanasia (taking measures that directly cause a patient’s death) is wrong.

The issue of euthanasia is not new. Part of the Oath of Hippocrates says: I will follow that method of treatment which, according to my ability and judgement, I consider for the benefit of my patients, abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked nor suggest any such counsel.

Gradually, people’s opinions have changed. In the last 10 years, North American surveys have shown that public consistently show strong acceptance of mercy killing and regulated physician-assisted suicide, says Dr. Douglas Kinsella, MD, in a study published in the June 1999 issue of the Annals of the Royal College of Physicians and Surgeons of Canada.

Significant proportions (49 percent) of Canadian Physicians accept its morality and future legalization, and would wish it for themselves and close relatives, if legalized.

Two recent Canadian court cases of euthanasia are well known to the public. Cases against Dr. Nancy Morrison and Mr. Latimar.

In US, Dr. Jack Kevorkian, otherwise known as Dr. Death, took this issue to a new level when physician assisted death of Mr. Thomas Yourk was shown on television. Dr. Kevorkian is seen to inject the lethal drug. On previous occasions, Dr. Kevorkian has let the patients inject themselves so the doctor does not get legally implicated in the process.

It has been 10 years since Dr. Kevorkian, a retired pathologist, started his “mission” to help terminally ill patients die with dignity. He has assisted in more than 100 deaths. He has been charged and acquitted by juries atleast three times. In Mr. Yourk’s case, he was convicted. Mr. Yourk lived in Michigan, which bans assisted suicide.

Oregon has legalized euthanasia (The Oregon Death with Dignity Act). But the controversy continues. There is continuous process to monitor the use and abuse of the Act.

Netherlands established guidelines on euthanasia in 1984. One of the requirements is that the patient should make a voluntary request to die. A study shows that in 1990, there were 900 cases of non-voluntary euthanasia recorded. Now the Dutch government is going to legalize euthanasia. Is that going to change anything?

Whether anything is legal or not, certain individuals in society will continue to abuse the system either for selfish reasons or because they feel they are morally justified. How can you change that?

Besides, who decides if euthanasia is morally and legally right? Why do we accept that it is all right to watch people suffer and die slowly but it is wrong to practice active euthanasia?

Reasonable thing should be to offer euthanasia to the right people, at the right time, for the right reason, at the right place, by the right individuals and in the most dignified and humane way! Is that possible?

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