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| I hope this newsletter finds you and your family well. It's hard to believe we are actually into the "holidays"! I hope everyone had a wonderful Thanksgiving and got a chance to spend time with loved ones.
I have highlighted a couple articles previously looking at potential adverse effects of the commonly used heartburn medications known as proton pump inhibitors (PPI). This month, a new study shows another possible risk of these medications when taken in higher doses, strokes.
In medicine, we often discuss the placebo effect. New medications coming to market have to prove they are more effective than placebos. But what if the placebo is more effective than the medication? This interesting study looked at the use of open label placebos in chronic black pain. The findings may surprise you.
The incidence of myopia (nearsightedness) is increasing rapidly world wide. What is the cause of this and is there a way to prevent this? The third article looks at a Chinese study of schoolchildren to see if there is a method to this.
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Could Your Heartburn Drug Increase Stroke Risk?
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Proton Pump Inhibitors may be culprit
This preliminary study presented at a the American Heart Association Annual Meeting in New Orleans found a significant relationship between taking a type of heartburn medication called proton pump inhibitors and increase risk of strokes. These medications included
omeprazole (Prilosec), pantoprazole (Protonix), lansoprazole (Prevacid) and esomeprazole (Nexium). Many are now available over the counter. These medications increased risk overall by 21% and the risk was dose dependent, meaning that people taking higher doses were more likely to have strokes.
Summary:
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Researchers analyzed the records of 244,679 Danish patients, average age 57, who had an endoscopy - a procedure used to identify the causes of stomach pain and indigestion. During nearly six years of follow up, 9,489 patients had an ischemic stroke for the first time in their lives. Researchers determined if the stroke occurred while patients were using 1 of 4 PPIs: omeprazole (Prilosec), pantoprazole (Protonix), lansoprazole (Prevacid) and esomeprazole (Nexium).
For ischemic stroke, researchers found:
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Overall stroke risk increased by 21 percent when patients were taking a PPI.
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At the lowest doses of the PPIs, there was slight or no increased stroke risk.
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At the highest dose for these 4 PPI's, stroke risk increased from 30 percent for lansoprazole (Prevacid) to 94 percent for pantoprazole (Protonix).
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There was no increased risk of stroke associated with another group of acid-reducing medications known as H2 blockers, which include famotidine (Pepcid) and ranitidine (Zantac).
In comparison with non-users, PPI users were older and had more health conditions, including atrial fibrillation at baseline (3.4 vs. 3.8 percent). The study accounted for age, gender and medical factors, including high blood pressure, atrial fibrillation (irregular heart beat), heart failure and the use of certain pain relievers that have been linked to heart attack and stroke.
Authors believe that their findings, along with previous studies, should encourage more cautious use of PPIs.
This is another study, although preliminary as it hasn't been published yet, that points out the potential dangers to common heartburn remedies. People taking the PPI are at higher risk of strokes. I previously highlighted studies showing possible higher risk of heart disease and dementia as well. At their highest doses, the risk was between 30% for lansoprazole (Prevacid) to 94% for pantoprazole (Protonix). This is a huge increase! The cause seems likely to be some sort of unhealthy vascular function. The good news is that there seems to be no increase or slight increase in risk at the lowest dosages. As with previous studies, there does not seem to be increased risk for stroke with the H2 blockers such as ranitidine (Zantac) or famotidine (Pepcid).
These medications have always been
thought
to be safe, but more studies are showing that this may not be the case. My take home message is if you don't need the PPI medications, don't take them.
They shouldn't be the first choice for heartburn. Instead, take an H2 blocker if you can. If you do need the PPI, take the lowest dose possible for the shortest period of time. Stay away from pantoprazole (Protonix) if you are on the highest dose as this seems to have the highest increased risk. Stopping PPI can be challenging due to rebound heartburn symptoms. A slow taper or switch to alternate medication is the best way to do it.
Popular heartburn medication may increase ischemic stroke risk. American Heart Association Meeting Report- Presentation: 391-Session: EP.AOS.765. Thomas Sehested, M.D., researcher, Danish Heart Foundation, Copenhagen, Denmark; Philip Gorelick, M.D., M.P.H., medical director, Mercy Health Hauenstein Neuroscience Center, and clinical professor, translational science and molecular medicine, Michigan State University College of Human Medicine, Grand Rapids, Mich.; Nov. 15, 2016, American Heart Association, annual meeting, New Orleans.
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Labeled placebo pills effective in chronic low back pain
A placebo is a treatment that seems to be a medical treatment but isn't as there isn't any active ingredient. The typical example is a sugar pill which is often used by researchers in medical studies to help them understand what effect a new drug may have on a particular condition. To be approved, a medication must show that the medication works better than sugar pill.
This study, from the journal
Pain, actually
used open label placebo pills as compared to treatment as usual. This means that the people in the study taking the pills knew they were sugar pills! The findings are pretty surprising. The placebo pills reduced pain more than anti-inflammatory medication. Overall, people had improved pain and disability as compared with normal treatment for chronic back pain. When they had people in the usual treatment group crossed over to take the placebo pill they showed improvement as compared to the usual treatment.
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Abstract: This randomized controlled trial was performed to investigate whether placebo effects in chronic low back pain could be harnessed ethically by adding open-label placebo (OLP) treatment to treatment as usual (TAU) for 3 weeks. Pain severity was assessed on three 0- to 10-point Numeric Rating Scales, scoring maximum pain, minimum pain, and usual pain, and a composite, primary outcome, total pain score. Our other primary outcome was back-related dysfunction, assessed on the Roland-Morris Disability Questionnaire. In an exploratory follow-up, participants on TAU received placebo pills for 3 additional weeks. We randomized 97 adults reporting persistent low back pain for more than 3 months' duration and diagnosed by a board-certified pain specialist. Eighty-three adults completed the trial. Compared to TAU, OLP elicited greater pain reduction on each of the three 0- to 10-point Numeric Rating Scales and on the 0- to 10-point composite pain scale (P < 0.001), with moderate to large effect sizes. Pain reduction on the composite Numeric Rating Scales was 1.5 (95% confidence interval: 1.0-2.0) in the OLP group and 0.2 (−0.3 to 0.8) in the TAU group. Open-label placebo treatment also reduced disability compared to TAU (P < 0.001), with a large effect size. Improvement in disability scores was 2.9 (1.7-4.0) in the OLP group and 0.0 (−1.1 to 1.2) in the TAU group. After being switched to OLP, the TAU group showed significant reductions in both pain (1.5, 0.8-2.3) and disability (3.4, 2.2-4.5). Our findings suggest that OLP pills presented in a positive context may be helpful in chronic low back pain.
I found this study fascinating. When it comes to chronic pain there really isn't anything that has consistently shown to be beneficial. Anti-inflammatory medications such as ibuprofen reduce pain by about 1 on a 10 point scale. Opioids such as oxycodone haven't been shown to improve pain, function or quality of life for myofascial pain long-term and carry strong risk of abuse or dependence. This study showed improvement with placebo pills that far exceeds what our prescription medications have been shown to do.
The researchers randomized 83 people with chronic low back pain to treatment as usual or open label placebo. They created positive expectation of the placebo and were told that the placebo effect can be powerful, the body can respond to placebo, a positive attitude can be helpful, and taking them faithfully three times daily for 21 days was critical. Pain was reduced by 1.5/10 and disability reduced by 2.9/24 as compared to no improvement with usual care. How is this possible? It seems that ritual and expectations can enhance the effects of whatever treatment is offered. The best part is that there are no potential side-effects, drug interactions, or addiction concerns. The most important thing may be actually communicating with people and creating appropriate expectations with the treatments offered.
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Cause of Nearsightedness
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Close work increases myopia
Myopia, or nearsightedness is the most common refractive error of the eye and has become more prevalent in recent years, growing from 25% of the population (ages 12-54) in 1972 to 41.6% by 2004. In this condition you typically have difficulty reading road signs and seeing distant objects clearly but can see well for close up tasks. Although we can't identify an exact cause, it seems to likely be due to eye fatigue from computer use. This study looked at students and evaluated the amount of close work they performed to see if it correlated with development of nearsightedness and if it could be prevented with outdoor activities. They found that the more hours spent by students performing close work, the higher the risk of myopia (nearsightedness). When they looked to see if time spend outdoors, likely performing distance vision activities was preventive, they found that outdoor activities are not preventive.
Abstract:
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Purpose:
To investigate the influence of daily activities on myopic refractive change and myopic onset in Chinese urban students.
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Methods:
The Beijing Myopia Progression Study was a 3-year cohort study. Cycloplegic refraction and a daily activity questionnaire were assessed at baseline and at follow-up examinations. Refractive change was defined as the difference in cycloplegic spherical equivalent (SE) between the final follow-up and baseline. 386 students were initially enrolled in the baseline study.
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Results:
At the final follow-up, 222 students (57.5 %) with completed refractive error and daily activity data were analyzed. These students spent 0.32 +/- 2.33 h/day more on near work, and 0.21+/-1.31 h/day less on outdoor leisure, than they did at baseline. In the multivariate analysis, the younger among the secondary students, and those with more near work hours at baseline, exhibited more myopic refractive change. However, myopic refractive change was not found to be significantly associated with near work hours in the primary students, or with time spent outdoors, in either school level. After stratifying the activity hours into quartile groups, students with a greater near work load at baseline (trend p = 0.03) exhibited a greater myopic refractive change and had a higher risk to develop myopia (hazard ratio, 95 % confidence interval: 5.19, 1.49-18.13), after adjusting for the confounders. However, no significant association was found related to outdoor activity.
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Conclusions:
In this cohort, children with a greater near work load at baseline exhibited more myopic refractive change and were also more likely to develop myopia. The protective effect of outdoor activity on myopic refractive change was not observed.
This study shows us that it is important to take frequent breaks while doing close work. Many of us are engaged in close work much of the day (staring at their phones or computer screens). This leads to myopia or nearsightedness. Taking time to look at distant objects through outdoor activities is not really helpful in preventing the progression. However, taking more frequent breaks while doing close work may be beneficial and would be the strategy that I would recommend. This study was done on school children so it is especially important for them. We should be looking at strategies for children to avoid long periods of strictly close work and give them frequent times of more sustained distance work. During our own work, take the time to frequently look far away to hopefully avoid some of this progression.
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Thank you for taking the time to read through this newsletter. I hope you have found this information useful as we work together to optimize your health.
Proton pump inhibitors are very frequently prescribed medications and I often see people on them for years. It is important to understand that there seems to be potential for vascular dysfunction from them. If you can get off them, it is probably a good idea.
The effects of placebos have been debated for years. This study shows that communication may be a big key in the healing process.
Most of us are involved in close work most of the day. Don't forget to take the time to look away, far away frequently throughout the day.
As always, if you have questions about anything in this newsletter or have topics you would like me to address, please feel free to contact me by email, phone, or just stop by!
To Your Good Health,
Mark Niedfeldt, M.D.
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