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Monday, June 27, 2011

Antibiotics for appendicitis, heparin for burns and other stories of wonder

In the recent batch of throw away journals, several articles reported on findings that are at least moderately exciting.

The first was from the annual meeting of the Central Surgical Association in Detroit. An analysis of several studies pointed out that many cases of CT scan proven appendicitis can be effectively treated with intravenous antibiotics.  In the past, when I was trained in medicine and surgery, appendicitis was diagnosed entirely on clinical grounds. Exquisite tenderness in the right lower quadrant, fever, elevated white blood cell count and a story of diffuse abdominal pain gradually focusing on the lower abdomen were sufficient evidence to operate on a suspected acute appendicitis. Cases without all of these findings were also operated on, and removing a normal appendix was considered part of the cost of preventing a catastrophic appendix rupture with the associated spillage of fecal matter into the sterile abdominal space. Now classic cases of appendicitis as described here will usually be corroborated with an abdominal and pelvic CT scan which will show a characteristic swelling of the appendix. When appendicitis is treated with antibiotics, 20% of patients can avoid an appendectomy and will be able to walk home without an incision in their belly and without the risk of surgical and anesthesia complications.

The British Medical Journal online is said to have reported on a New Zealand study showing that  in a randomized controlled trial of nearly 40,000 patients, women who took a somewhat low dose of calcium and vitamin D, 1 gram and 400 IU, had about 1.2 times the risk of women not taking calcium and vitamin D of having heart attacks and strokes.  Other studies show similar findings for calcium alone.  To truly evaluate the risks and benefits of calcium, one would need to know if calcium and vitamin D supplements in normal women actually prevent the condition they are prescribed for, that is osteoporotic fractures.  When last I heard, proof of a positive effect of calcium on bone strength was lacking and vitamin D supplementation was only definitely good for fracture prevention in the frail elderly. I am not entirely sure what to do with this information, other than inform my patients of the depth of our ignorance regarding these supplements.

At the international conference of the American Thoracic Society, researchers reported that daily treatment with the antibiotic azithromycin could postpone exacerbations of chronic lung disease for nearly 100 days compared to patients not treated with the antibiotic.  Azithromycin, because of how well tolerated it is and how it can be given in a very short course due to its persistence in the body, is one of the most overused antibiotics in my experience. It is pretty much good for what ails you: hang nails, mosquito bites, colds and flu. It is even generic. Using it daily on patients with chronic lung disease will undoubtedly cause an increased resistance of community bacteria to the drug, making it useless for others who might need it. Clearly this is an intervention that needs to be chosen after much consideration, and for patients who really have very little lung reserve.

A rheumatological meeting at New York University reported that treatment of gout with medications that reduce uric acid  levels can decrease heart related mortality by nearly 50%.  Patients with gout have elevated levels of uric acid in their blood streams, related to diet, genetics, kidney function and medications they take.  Many patients have elevated uric acid levels without getting gout (a very painful inflammation of joints and soft tissues, especially in the legs.) These patients also will benefit from lowering the uric acid levels.  The medication used most commonly to lower uric acid is allopurinol. It is very inexpensive and sometimes causes an allergic rash or hair loss. In general it is very well tolerated and very affordable.  There are many medications that can control gout symptoms but only the medications that reduce uric acid levels are helpful to the heart.  Allopurinol and it's new cousin Febuxostat work, as do the two ancient gout drugs probenicid and sulfinpyrazone which make a person eliminate uric acid in the urine. This study will help me counsel patients on what medicine to take to prevent gout.

The proceedings of the National Academy of Science apparently reported on a slight reduction of the effectiveness of SSRI antidepressants such as Prozac (fluoxetine) in patients (and mice) treated with certain medications for pain, specifically NSAIDs such as ibuprofen and naproxen.  The effect is small, but certainly worth thinking about if a patient doesn't respond to antidepressant medications.  Of course, if they give up their effective pain medication, which may reduce their exercise, depression may rear its head in another way.

The British Medical Journal reported in May that using beta blocker medications along with asthma inhaler medications for chronic obstructive lung disease actually improves survival. I had always been convinced that use of a beta blocker in a patient who wheezed was a very bad idea and would reduce the effectiveness of a drug that stimulated beta receptors, such as albuterol. In fact I would often scoff at the silliness of doctors who would have their patients on both beta blockers and beta stimulators. I'm thinking now that I was probably wrong.

The last and most fascinating drug story came to me in the form of a high school friend whose father, a family practitioner, I knew from childhood. She visited me unexpectedly last weekend and told me his story and showed me his website. He, Michael Saliba MD, worked in La Jolla and did some research early on at UC San Diego medical school on treatment of burns.  He found that a common and inexpensive medication that we use for treating blood clots, heparin, was a very powerful stimulator of skin healing in burned or otherwise denuded skin.  He was able to try this on humans and over the years has successfully treated people with quite severe burns with heparin.  He applies the solution by dripping it on a wound in the case of small wounds, and intravenously and as a subcutaneous injection of high doses in much more significant burns.  He found that not only did it dramatically speed healing but it also nearly completely relieved pain, and patients often healed without much scarring. Most of the centers which use heparin are overseas, however, and the routine has never caught on in the US. Although there have been more studies reported, some showing dramatic successes and reductions in associated costs, there are none of the large multi-center studies that usually herald a major change in therapeutics.  Some explanations include the fact that heparin has been a generic medication for so long that it doesn't financially benefit anyone to study it, that high doses of heparin worry physicians due to perceived risk of major bleeding (which actually only happens if there are bleeding injuries in the first place) and possibly due the fact that our standard treatments of very large burns is very big business, supporting all kinds of medical industry. Or he could just be making it up. Having known Dr. Saliba for as many years as I have, his overall kindness and trustworthiness are strong enough that I doubt that his claims are exaggerated.  I think I will try it for the next burn wound I see. Besides being a very inexpensive treatment, what excites me most of all is the potential to treat burn pain which is so difficult to manage with oral medications.

1 comment:

Bob Folkerts said...

Thank you for the story of Dr. Saliba and his work on treating burns with heparin. I experience end stage kidney disease this January, and I am currently recovering from a kidney transplant. So I have become well acquainted with heparin. I am investigating the possibility of creating heparin raw material in the midwest (Iowa has 15 million hogs and only 3 million people). I find it exciting that this inexpensive medication could have yet another use.