An Apple A Day

Many medications are available only by prescription (unless you own a computer or travel to another country). That is because of the risks that accompany their use. When drugs become available we tend to believe that availability is some sort of certification that they are safe, and weak compared to prescription meds. Not true.

Recent news that daily use of aspirin lowers the risk of a number of cancers (especially esophagus, colon, rectum and lung) is another example of apparently wonderful information that is not, if you know enough. Seems great, doesn’t it? Take a safe drug and prevent some very nasty diseases. Shouldn’t I be taking it anyway, because it prevents heart attacks and strokes?

Here comes the buzz kill. Other studies, larger and more carefully designed, have not found this effect. Also, studies have found that taking aspirin does not prevent a first heart attack or stroke, as we had thought it would. It might be a good idea for that purpose in some middle-aged individuals, and probably is for those who have already had a heart attack or stroke. Finally, recent data shows that daily aspirin doubles the risk of macular degeneration, already one of the most common causes of age-related blindness.

Aspirin used to be routinely given to infants with fever. Then we learned that this could lead to (potentially fatal) Reyes Syndrome. I have never liked using it in this circumstance, because fever is generated by the body in its effort to make itself an unpleasant place for bacteria and viruses to live. Squashing the fever squashes the immune response and, as research shows, prolongs illness.

Ibuprofen, (aka ADVIL, MOTRIN, MUPRIN, RUFEN) seems like a good choice to so many. Inflammation is “bad”, so anti-inflammatory is then good.

Ibuprofen is the leading cause of impaired kidney function in the US. Years ago a kidney specialist told me she would not see a new patient for kidney trouble until the patient had been off ibuprofen entirely for at least a month, because dropping the kidney-imparing ibuprofen fixed 75% of the patients sent to her.

Ibuprofen markedly increases the risk of the most serious problem commonly seen in marathon runners. Their kidneys slow down from the exertion. Taking ibuprofen makes it worse. Their sodium drops and they can die. Not good.

Many athletes take ibuprofen before engaging in their sport. Ironically, ibuprofen increases damage to muscles and soft tissue because “inflammation” is one aspect of the healing process. At the medical meeting of physicians working with endurance athletes before the Marine Corps Marathon last fall, I was delighted to find myself in the company of others who shared my dislike for ibuprofen. We discussed its harms at length, as well as the muscle damaging effects of statin drugs. I loved it.

Is Tylenol, the “safer choice”. Not really. Starting from the very beginning of my medical training I spent a great deal of time working as an Emergency Room Physician. One of my first ER shifts I took care of a teenaged girl who was upset and, crying out for help, took an overdose of Tylenol, believing it was safer than aspirin. By the time she arrived in the ER, she had changed her mind and was feeling fine. She did not realize that, although , in the coming days her life was at risk due to the delayed, liver toxicity of acetaminophen/tylenol.

Following the recognition of the link between aspirin and Reye’s Syndrome, everyone switched to Tylenol. Now many think that the rise in childhood asthma, which began at the same time, is not a coincidence.

Remember, there is no “free lunch” biologically or otherwise. The best medication is no medication. Taking care of yourself, minding the essential health habits, will do far more to help you live well and happily than any medication. There is a place for drugs but they are only pharmacological band aids.

The widely disseminated comments of many organizations and authorities would lead one to believe that any possible linkage between vaccination and autism has been entirely disproven. That is not so. The theory that there might be a connection is biologically plausible. One of the most consistent biological abnormalities among children with autism is their limited ability to detoxify heavy metals. It would be a real possibility then that repeated doses of a heavy metal like the mercury preservative, which had been used in nearly all vaccines, would lead to autism in some individuals. However, a theoretical possibility means just a hair more than nothing. A newly published study supports the view that there may well be a connection between vaccinations and autism.

The authors of this study analyzed nationwide data to investigate the connection between total vaccination exposure, autism and speech or language impairment (SLI). Other studies have typically looked for associations between autism and some specific immunization. When the intent of an investigation is to test the theory that some component, present in many vaccines, might be an autism-causing factor, the design of this study, utilizing the sum of vaccination exposure, makes much more sense.

These researchers took into account the potential confusion created by the timing of vaccine and diagnosis of autism or SLI. Autism begins before age 2 but is typically diagnosed years later. If vaccinations were causative, those first two years are when the child would have received them. So, these researchers used total vaccination exposures up to two years of age. Accounting for the delay in diagnosis, they used the rates of autism and SLI at age 8 for their analysis. Because the effect would become evident in individuals 6 years after their exposure, researchers compared rates of vaccinations in 1999 with autism/SLI rates 6 years later (2005). They then analyzed these data, controlling for known and suspected autism risk factors. They also performed statistical tests for potentially confounding health conditions and access to medical care (which might lead to higher rates of diagnosis), finding that these factors did not influence the rates of autism and SLI.

These researchers identified what we call a linear dose-response. For every 1% increase in vaccination rates there was a 1.7% increase in the number of children having either autism or speech/language impairment. This study does not prove that childhood vaccinations cause autism. It does prove that the issue is unresolved and that caution about all vaccinations is warranted.

Thimerosol, the standard mercury preservative formerly used in childhood immunizations, is the preservative in flu shots. As the institutional authorities of conventional medicine push childhood vaccination for flu, despite little research support of effectiveness, these findings suggest that we might be perpetuating a problem. Dropping thimerosol from vaccines was an excellent idea. Why would it be okay to give it to our children in a different shot?

Most of my patients are concerned about adverse effects of prescription medications. My own skeptical attitude on this and other issues underlies my approach to patient care, and has done so for as long as I have been practicing medicine.

Prescription medications can be life saving, but for many reasons, they can also cause problems. Most of the problems they cause are not so bad, but others are lethal. Some of their most devastating ill effects are quite unpredictable. Too often the medications do not work that well either, despite the incredible sums spent marketing them to all of us (doctors and patients) as simultaneously powerful and harmless. Using these medications is a trade-off between risk and benefit. None of them are “a sure thing”, and it is wise to carefully consider all options before choosing the prescription route.

Generally Americans are not as critical of prescription medications as we should be. Almost on a daily basis I see patients who are suffering the ill effects of some medication, and too often the connection between the medication and the patient’s distress is unrecognized. Sadly, it is not only the patients who are unaware. In fact, numerous patients have complained to me that another physician denied that the bad reaction they had been suffering was caused by the medication. Usually that adverse effect has been well-known, or at least well-documented in the medical literature, and it only takes a minute to look it up. Other times the particular adverse effect is rare and the physician’s adoration of prescription medication keeps him/her blind to the harm it is causing. Regardless of the reasons for this problem, a new study adds to the evidence affirming that those of us with this world view are right to be skeptical.

The study looked for a connection between a variety of medications and violent behavior. Twenty three drugs apparently made those using them more likely to commit acts of violence. Eleven of those 23 were antidepressant medications. Six were sedatives. Three were medications for ADHD.

It would make sense for these findings to be spurious. People with emotional problems are more likely to be violent at some point. We have seen a correlation between ADHD and violent behavior. However, like all reviewers I know of, in my opinion these findings are meaningful because of how the study was designed and the unpredictability of some of the results.

One surprise was that the worst drug was a drug used for smoking cessation varenicline (Chantix). Another surprise was that there was little if any increase in violent behavior linked to anti-seizure medication. Only one antipsychotic medication (ABILIFY - arpiprazole) was associated with increased risk of violence. The lack of a general association betwen antipsychotic medication and violent behavior is striking, as those are the patienst most likely to be violent in the first place. This nonassociation strengthens the contention that the other drugs are in fact causative.

In a side note - although ABILIFY was not strongly linked to violent behavior, I am concerned by how intense the marketing campaign supporting it has become. Magazine ads and TV commercials are pushing people to add ABILIFY to their antidepressant medication. At this point in time antipsychotic drugs like ABILIFY have become the most commonly prescribed drugs in America.

Medicine has an unfortunately well-established pattern of relying on drugs that we think are safe and effective, only to later determine that they are so bad that they are banned. Patients complain of bad reactions. The medical community at first disparages these concerns, especially if the ill effects of the medication are psychological. Early reports of PROZAC and other SSRI drugs leading to suicide, and the anti-malaria drug LARIAM causing anxiety, paranoia and psychosis were pooh-poohed by the medical profession. Those adverse effects are now well-recognized.

The bottom line is that you should be careful about using prescription medications. If you feel a medication is causing you harm, seek expert help, but honor your own sense. You know more about you than anyone. You are the resident expert in your own health care team.