Drug Holidays – what are they and when to consider

A drug holiday is a conscious decision to stop a medication.  The reasons to do so usually revolve around “seeing if I still need it” and side effects.

I was interviewed by Sara Klein in Prevention Magazine on this topic.

Click here for the story!

http://www.prevention.com/health/drug-holiday-facts

The path to wellness begins with a proper diagnosis

Tell Me What You Want

I am asking readers to tell me what you want.  Not in general, but at a health or wellness talk.  A few weeks ago I was asked to speak at a wellness seminar given at a company for its employees about heart health.  The talk was well received, and we had a good discussion after my presentation.

What struck me was how willing people were, in a room full of co-workers, to ask questions about their personal health.  In the office, we have safeguards to protect privacy at check-in, in the waiting room and at check out.  Yet in this conference room, with people they know listening, I was told about cholesterol results and other tests, treatments they were given, etc.  Granted, we were talking about heart disease, which may not seem as socially or professionally awkward as some other topics, but it still surprised me.

It also made me wonder – what did they want?  My professional interpretation and opinion of their situation, or validation that the choices they had made in their own care were “good choices”?

I did my best based on the information people gave me to address their concerns, while encouraging them to speak to their doctors.  Some had questions understanding what they were treating or how to interpret their results.  Others had decided to try a different therapy (often homeopathic) than what their doctor recommended and wanted my approval – so the answer to my initial question is “both”.

I found it to be a little uncomfortable being asked to approve someone’s decisions with limited information, especially if I didn’t “approve.”  However, the talk and Q&A are for the attendees, not me, so I did my best to give a recommendation and encourage discussion between the person and their doctor.

This is a copy of the talk I gave – I want to thank TheVisualMD for the image support in the talk.

My question to you – if you went to a talk like this what would you prefer?  A general Q&A or time at the end to make a mini-appointment to discuss your questions one on one with the speaker?  Tell me what you want!

The path to wellness begins with a proper diagnosis

Addiction and Substance Abuse

Of all the illnesses I treat, conditions I diagnose and problems I am presented with, one of the most difficult is addiction. Addiction can be to many things – alcohol, illegal drugs, prescription drugs, smoking, food, exercise, gambling and other behaviors. Addiction affects not only the person involved, but their entire network of friends and family.

One of the biggest challenges in diagnosing addiction is that the person may not admit there is a problem. A family member may speak to me, but the conversation usually ends with – “don’t tell them I spoke to you, I just wanted you to know what is happening…” I can not force a patient to come speak to me, nor can I tell that family member anything about what I may have discussed with the patient (without their permission). After awhile, their addiction becomes a palpable element in the room that no one can speak about. I will ask about it, but if the patient will not acknowledge an issue, there is little to be done.

What causes addiction?

Addiction is defined as a chronic, relapsing disease characterized by compulsive drug seeking and use despite harmful consequences as well as neuro-chemical and molecular changes in the brain.    Addiction crosses lines of race, economics and education.  In 2010 it was the 15th leading cause of death in the United States.

When exposed to a potentially addicting substance, the brain produces a substance called dopamine.  This activates the brain’s “reward circuitry” which will begin to create cravings.  Some people are genetically predisposed to be more susceptible to this, so addiction can run in families.

In addiction to the reward center, cognition and understanding are affected.  The prefrontal cortex of the brain – the higher brain involved in thinking and reasoning becomes affected as well.  A phenomenon called Restricted Awareness occurs – the addicted person becomes unable to fully grasp the deficits their behavior has created – so there is a neuro-chemical issue and not just denial at work.  Similar changes are triggered by high fat/high sugar foods as are by drugs.

Drugs of abuse - from the National Institute of Drug Abuse
Drugs of abuse – from the National Institute of Drug Abuse

Physical effects of addiction

The changes in the brain are consistent across substances.  Different substances can have different effects on other parts of the body.  While this is not a comprehensive list, some commonly abused substances and their physical consequences are:

  • Marijuana can damage the lungs just as cigarettes do
  • Cocaine increases plaque building in the arteries, increasing the risk of heart attacks
  • Heroin suppresses breathing
  • Prescription pain killers slow down the digestive system, as well as potentially cause liver and kidney damage
  • Alcohol damages the liver
  • Any drug that is injected, especially when needles are shared, increases the risk of Hepatitis B and C (which can cause liver failure and liver cancer) as well as HIV

How is addiction treated?

Treatment for addiction begins with a patient recognizing that their behavior is affecting their life in a negative way, and that they are unable to control it without help.  Treatment programs can be inpatient – meaning admission to a facility for detoxification and treatment with 24/7 monitoring or outpatient – meaning going to appointments with physicians and counselors while remaining in the community.

Regardless of the setting, treatment involves

  • Detoxification – stopping the substance of abuse and treating physical withdrawal
  • Counseling to help the addicted person process what they have been through and develop coping strategies for the stresses that led to the addiction
  • Medications may be used either short or long-term to block the effects of drugs of abuse, prevent activation of the rewards center in the brain or treat other issues related to substance abuse

Successful treatment can reverse the brain changes that occur with addiction, just as smoking cessation reduces the risk of heart attack, stroke and lung cancer.

Brain scan showing near normal activity after14 months of sobriety
Brain scan showing near normal activity after 14 months of sobriety. Source: National Institute of Drug Abuse

 

How does this affect us?

Substance abuse takes many forms, and I need to be alert to signs that there may be issues – clues from behavior as well as physical findings.  Direct questions from a physician are usually answered with some truth.  That can begin a conversation about starting a treatment program.

In the case of prescription drug abuse, physicians have some additional tools.  Several states have databases that physicians can register for to see if prescriptions are being filled by multiple doctors and from which pharmacies and on what dates.  When you can show a person what their behavior has been, it again can be the beginnings of help.  A physician also needs to have a plan about stopping addictive prescriptions to prevent or end the cycle of abuse a person is in.  As a friend of mine who once became addicted to prescription pain killers told me that he hoped that a doctor would “catch” him so that he could get the help he knew he needed but did not know how to ask for.

If you or someone you know needs help:

National Institute of Health information of drugs of abuse – http://www.drugabuse.gov/publications/term/160/InfoFacts

Narcotics Anonymous – https://www.na.org

Or see your physician and ask for help!

The path to wellness begins with a proper diagnosis

Testosterone Therapy – MANopause or Marketing?

Fatigue, weight gain, decreased sex drive and depression are very common complaints, especially as men age.  There are many diagnoses associated with such symptoms – obesity, diabetes and hypothyroidism are some examples.  They can also be associated with hypogonadism – which in men – is low testosterone or LowT.

What is Testosterone?

Testosterone is a hormone made in the testicles.  It’s production is controlled by other hormones in the pituitary gland, which senses the testosterone level in the body and directs production.  Testosterone is involved in genital development and other sex characteristics such as deepening of the voice, body hair, and sex drive.

How is Testosterone measured?

Testosterone is measured with a blood test.  There are two values that can be checked – total testosterone and free testosterone.  Free testosterone is the amount of hormone circulating that is directly and instantly available to the body, and not tied to another molecule in the system.

Normal levels of total testosterone range from 300-800 mg/dl.  One of the difficulties in measuring testosterone is that the value varies throughout the day and can be affected by a recent meal, exercise or the amount sleep you had prior to the test!

How is Testosterone supplemented?

Testosterone is not digestible, so it must be administered topically as a patch, cream, or gel, or injected into a muscle.  Each method has its pluses and minuses.

Topical medications are convenient, but may cause skin irritation.  There may be irregular absorption of the testosterone through the skin.  Also, if the testosterone is not completely absorbed it can be transferred to someone else’s skin – an important consideration if there are children or women (especially if pregnant).

Injections deliver a more precise dose and there is no risk of transferring the medication to someone else, but an injection every 2-4 weeks may be painful and less convenient – whether done at home or in a physician’s office.

How does Low Testosterone develop?

Damage or dysfunction of the testicles or pituitary gland either from medications, tumors or other problems can cause low testosterone.    Anabolic steroids – those used as performance enhancing drugs in sports – can lower testosterone levels among other side effects.  It was for severe deficiency around early development or testicular damage that synthetic testosterone was initially prescribed and FDA approved for – not for helping aging men feel 30 again.

Testosterone levels normally begin to decline by about 1% per year after age 30 – but this is very variable.  This decline, especially when blood tests became routinely available to check testosterone levels, gave rise to terms like andropause, male menopause or manopause.  In the past 10 years, testosterone use in men over 40 has quadrupled, and has become a multibillion dollar industry.

Similar to hormone replacement therapy (HRT) for women, restoring hormone levels to an earlier age has been marketed as a way of turning back the clock, restoring youth and vigor – and treating some very common, non-specific symptoms.  It wasn’t until after decades of HRT that a large study was done demonstrating that rather than helping improve women’s health, HRT increased rates of heart attacks, stroke, breast cancer and endometrial cancer!

Recently, several studies have been published linking testosterone therapy with an increased risk of heart disease.  These studies have called into question the wisdom of testosterone supplementation in the absence of true hypogonadism.  One study found that in men 65 and older the risk of a heart attack doubles in the first 90 days after starting treatment and goes up by 2-3 times in men under 65 with a history of heart disease.  This and other studies have prompted the FDA to review the safety of testosterone therapy and a large study similar to the one done for HRT is now underway to determine the benefits and harms of testosterone therapy.

How does this affect MY practice?

As with most diagnoses, a good history of symptoms is essential to determine their cause.  How long symptoms have been present, what seems to improve them, what else is going on in one’s life all contribute to weight gain, sex drive, energy and mood.  Diet and exercise habits need to be explored as changes  can have a huge impact on well-being, including raising testosterone levels without supplementation.

After discussing symptoms and a physical exam is performed, lab tests can be ordered.  I usually check a total testosterone first – it is much less expensive and the results come back faster.  If it is low or borderline, adding the free testosterone can be helpful to confirm or rule out the diagnosis.

Once all the data is back, we can review both symptoms and data together to decide if testosterone supplementation is likely to improve how one feels or if there is a different, more likely diagnosis.    Prior to starting supplementation I always check a blood count, cholesterol level, liver, kidney  and sugar tests as well as a PSA.  Supplementation can effect all these things which in turn can have health consequences.  For example, testosterone can cause the prostate to grow and may unmask an undiagnosed cancer – which is why supplementation therapy needs to be monitored.

At follow-up visits we assess the effect of treatment on both testosterone levels and most importantly, symptoms.  If the levels normalize and there is no change in how you feel, then as I wrote in an earlier post (What is a Diagnosis), treatment should be stopped and the diagnosis reconsidered.

The new evidence about the increased risk of heart attack will increase the conversations I have with my patients, especially those over 65 or with a history of heart disease, and likely increase how closely they are monitored.

Numbers from a lab without the context of symptoms don’t make a diagnosis.  Symptoms without the correlation of lab results often can not make a diagnosis.  Treating either in isolation does not improve health.  When used together, solutions can be found.

The path to wellness begins with a proper diagnosis

Thyroid Disease – a little gland – big effects

January was Thyroid Disease Awareness month and thyroid disorders are very common.  Unfortunately, it’s usually not the answer to the 10 pounds you are trying to lose.

What is the Thyroid?

The thyroid is a gland located in the neck near the “Adam’s Apple”.  It’s job is to produce Thyroid Hormone (T4, T3) – which helps set your metabolism and plays a role in almost all of your bodies’ functions.
Your thyroid gland is regulated by another gland called the Pituitary Gland, located in the brain. The pituitary acts as a thermostat to control the thyroid – the technical term for this is a “negative feedback loop.”  The pituitary measures the amount of thyroid hormone in the body.  Based on this measurement, it secretes either more or less Thyroid Stimulating Hormone (TSH) telling the thyroid gland to increase or decrease thyroid hormone production.  So TSH goes up when the pituitary senses low levels of thyroid hormone and goes down for high levels.  That is why when your thyroid is tested, the doctor looks at both the level of thyroid hormone in you blood as well as the TSH level.  This allows assessment not only of how your thyroid gland is working, but also how hard it is working to maintain a level.
Based on the values of the TSH and T4 we can begin to tell if the problem is in the thyroid gland itself or in the pituitary gland regulating your levels.  Testing T3 levels can be helpful when the TSH/T4 levels are borderline or someone’s symptoms and the test results don’t make sense – but most people can be diagnosed and managed without it.

Thyroid Disorders

There can be structural issues of the thyroid – nodules, cysts and tumors (both cancerous and benign).  These may or may not affect the overall functioning of the thyroid, but may be felt on physical exam or found when evaluating other neck issues.  I can write more about those issues in a future post if people are interested.  The remainder of this article will focus on the two major functional thryoid disorders – hypothyroid (underactive) and hyperthyroid (overactive).  There can be many causes of of hypo- and hyper- thyroidism, which is part of the challenge – determining your diagnosis – specifically what is your thyroid issue?

Hypothyroidism

This is the most common of the functional thyroid disorders.  Hypothyroidism means an underactive thyroid gland.  Symptoms include fatigue, constipation, dry skin and hair, weight gain, swelling, depression or change in concentration.  The symptoms can also be variable.  Many people are diagnosed with minor hypothyroidism (called subclinical) when their tests are abnormal during a routine exam.  There are many causes of hypothyroidism.
If the pituitary gland is not working properly and cannot produce TSH, then the thyroid gland, although normal, will not produce thyroid hormone.  This is usually due to an abnormal growth in the pituitary such as an adenoma (a benign tumor). This type of hypothyroidism occurs in about 1% of cases.
Autoimmune thyroiditis – also known as lymphocytic or Hashimoto’s Thyroiditis is the common cause of hypothyroidism.  The body’s immune system recognizes the thyroid gland as foreign and starts to attack it by making antibodies against it.  As the structure of the gland gets damaged, it is unable it produce thyroid hormone and you develop hypothyroidism.  Your blood tests will show a high TSH and a low T4.  There is also a blood test to detect the anti-thyroid antibodies, which, if present, confirm the diagnosis.
Other forms of hypothyroidism are more difficult to find a direct cause for, but they are all diagnosed by a high TSH and a low T4.

Hyperthyroidism

When the thyroid gland is overactive – making too much thyroid hormone – a person is Hyperthyroid.  The most common cause for hyperthyroidism is Grave’s Disease – another autoimmune disease of the thyroid gland.  In Grave’s Disease, the body makes antibodies against the thryoid gland like in Hashimoto’s Thryroiditis, but instead of destroying the gland, these antibodies stimulate the thyroid gland to continue producing thyroid hormone regardless of what the pituitary gland tells it to do.  These antibodies are called Thyroid Stimulating Immunoglobulins (TSI) and can be tested for in the blood.
The symptoms of hyperthyroidism are feeling keyed up (over caffinated), diarrhea, weight loss, rapid heart rate and hair loss.  Grave’s Disease can also cause the eyes to bulge due to antibodies building up in the muscles behind the eyes.

Treatment

Hypothyroidism is treated mostly with levothyroxine, which is synthetic T4.  It is an exact match for what the body naturally produces, as opposed to earlier treatments which used animal thyroid glands.  There are many dosages available, allowing us to match the dosage given to what your body needs.  We measure success by following the TSH.  Based on your TSH level and how you feel, we can be sure to get the dosage specific to your needs.  There are a small percentage of patients who do not tolerate levothyroxine, and may use  different medications.

 

Hyperthyroidism is treated in a few ways.  Firstly, if a person’s heart rate is very rapid, medication to block the effect of excess thryoid hormone (called beta blockers) can be used to treat the symptoms while treatment to regulate the thyroid gland takes effect.  There are medications called methimazole and propylthiouracil (PTU) which can be used to reduce the production of thyroid hormone.  Radioactive iodine can be given to destroy a portion of the thyroid, reducing its ability to produce hormone.  The thyroid gland can be surgically removed as well.  Surgery and radioactive iodine have a high rate of making someone hypothyroid, which would then require lifelong levothyroxine.

How does this affect MY practice

Thyroid tests are something I order as part of general physical exam.  Because the symptoms can be subtle, we can diagnose and begin treating a problem before it gets too severe if we screen for thyroid disorders.  Thyroid tests are also ordered when someone complains of the symptoms of either hyper or hypothyroidism.  When the tests come back abnormal, I order the antibody test – if the cause of thyroid disease is autoimmune it is important to know – as people with one autoimmune disease are at higher risk of developing another.
If a person is hypothyroid, they are usually given levothyroxine, and a TSH level is repeated in about 6 weeks, then, based on those results the dosage is adjusted until symptoms are controlled and the TSH is in the proper range.
Many people ask me about over the counter thyroid supplements instead of prescription levothyroxine.  I generally advise against this for a few reasons:
  • They are not FDA regulated
  • The dosages can not be as finely tuned as levothyroxine can.  They are usually made up from animal thyroid glands and can contain impurities
  • A recent NY Times article quoted a study that showed 9 out of 10 thyroid supplements tested at random contained 2-3 times the starting dosage of thyroid hormone – which should only be dispensed with a prescription
When hyperthyroidism is diagnosed, we immediately focus on controlling the symptoms such as anxiety, heart palpitations and tremor.  Then a discussion as to the best means to control their thyroid gland’s production – medication, radioactive iodine or surgery.
Thyroid problems are very common and can have a large impact on  a person’s sense of well being.  By using a person’s own control systems to dose their medication, we can come very close to restoring their thyroid levels to what their body needs.  Together, doctor and patient can review symptoms, get tests and most importantly, get a diagnosis.  Then a treatment plan and healing begins.

 

The path to wellness begins with a proper diagnosis

Exercise – The Power to Heal Yourself

 

exercise - the power to heal yourself
Visualizations are provided by www.theVisualMD.com

New Year’s is a time of resolution, renewal and rejuvenation.  People resolve to stop smoking, lose weight and exercise.  More gym memberships are sold in January than any other time of the year, and many go unused.  We all have this sense that we should exercise more – but have you ever wondered why that is such a universal sentiment?  What is it about exercise that makes it hard to maintain but remain so high on our wish lists?  What does exercise do for us?

Exercise impacts not only our muscles but almost every body function we have – it changes multiple hormone levels, insulin sensitivity, pain perception, hunger, sex drive and mood.  Exercise gives you the power to heal yourself.  Regular exercise promotes the following changes in the body:
  • increases the development of new blood vessels (can help in heart disease)
  • improves the functioning of multiple immune system aspects
  • decreases anxiety and depression
  • decreases inflammation
  • decreases pain in osteoarthritis
  • improves blood pressure
  • improves cholesterol
  • improves diabetes beyond weight loss
  • decreases the cravings for cigarettes
  • strengthens muscle fibers as well as promotes the development of more muscle tissue
  • improves digestion
  • stimulates the reward centers in the brain with substances called endorphins
  • and many other functions
These effects are separate from and in addition to the usual weight loss that accompanies exercise.

So what is exercise?

Exercise is any activity that maintains or improves physical fitness, health and wellness.  Studies have shown moderate activity will begin to show the benefits of exercise.  Moderate exercise is defined as 150 minutes per week (30 minutes/5 days per week) of brisk walking or similar activity.  The more intense your activity, the less total time you need – 75 minutes per week of intense activity will give similar benefits to the 150 minutes of moderate activity.
recent study in the journal Lancet  showed that in people with a high risk of heart disease and pre-diabetes decreased their risk of a heart attack by 10% just by increasing their walking by 2000 steps per day.   Another study in the British Medical Journal demonstrated that regular exercise was as effective as medication in preventing death from second heart attacks, rehabilitation from a stroke, improving heart failure and preventing diabetes.
The trick is maintaining the activity to continue reaping the benefits – if you don’t use it, you lose it.  Another way of looking at it is stated very well by Jim Rohn, an author and self development coach.  “Motivation is what gets you started, habit is what keeps you going.”

What do I recommend in my practice?

So, should everyone stop their medications if they exercise?  No, and certainly not without discussing your plans with your doctor.  Not every condition can be controlled with exercise, and not every medication can be safely stopped abruptly.  What I try to emphasize with my patients is that medication begins to correct a problem immediately – for example – lowering cardiovascular risk with a statin; adding an exercise program helps manage the long term risk.  We can then decide if immediate action is necessary, and set a goal – say losing a certain amount of weight.  When the goal is reached, stop the medication and reassess the condition.
By re-evaluating your diagnosis the effect of medication and the effect of your actions on your diagnosis can be measured, and your treatment plan revised.  You become an equal partner on your journey to wellness by revising your diagnosis!
Personally, I reconnected with running about 3 years ago. While there have been some ups and downs, I’ve managed to keep about 20 pounds off, and will be running my 7th half marathon next weekend. If you’d like to read about my own story on how I started maintaining a program, see this post – Exercise for a Cause, originally posted on TheVisualMD.com in 2011.

The path to wellness begins with a proper diagnosis