Blood Clots Can Kill You by Dr. Chris Prakash, MD

Dr. Chris Prakash, eParisExtra columnist

Dr. Chris Prakash, eParisExtra columnist

Deep vein thrombus (DVT) is a blood clot that forms in the deep veins, usually in the legs. DVT affects an estimated 300,000-600,000 individuals in the U.S. each year, causing considerable morbidity and mortality. It is an equal opportunity disorder affecting all races and age groups. It is an important and growing public health problem. The blood clot can travel to the lung resulting in pulmonary embolism (PE). Up to 100,000 people die each year of DVT and PE (according to the CDC). Not many people are aware of its dangers.

Why do people get DVT?

Several factors can put people at risk of developing blood clots, such as:

  • Recent surgery or broken bone
  • Immobility for a long period
  • Pregnancy
  • Taking birth control pills or hormone replacement
  • Cancer
  • Genetic predisposition (Approximately 5 to 8% of the U.S. population has one of several genetic risk factors, also known as inherited thrombophilias in which a genetic defect can be identified that increases the risk for thrombosis.)
  • Risk rises with age, as well as smoking and obesity.

What are the symptoms?

Symptoms are not always obvious. These may include:

  • Swelling, pain and redness in a leg.
  • Unexplained shortness of breath*
  • Coughing up blood*
  • Chest pain*

*    If any of these symptoms arise, seek immediate medical attention, since this may be indicative of pulmonary embolism (PE). PE can be fatal.

How is the diagnosis made?

The doctor will diagnose DVT based on history, physical examination, and results of tests. An ultrasound (venous Doppler) is the most common test done to diagnose DVT. A CT Angiogram is done to diagnose PE.

Testing may be necessary to check for inherited clotting disorder that can cause DVT. This may be the case if you have repeated blood clots, or if you develop blood clots in an unusual location, such as a vein in the liver, brain or kidney.

How is a DVT treated?

Patients are started on anticoagulants (blood thinners). These may be a combination of injections (heparin in different forms) and pills (warfarin). Most of the times, treatment can be done without needing to be hospitalized, but in some situations, hospital stay may be necessary. The blood thinners may be needed for 3-6 months, or longer (depending upon risk factors). A blood test called Prothrombin time (PT or INR) is done periodically to ensure that the dose of warfarin is correct. Since warfarin works by inhibiting Vitamin K dependent clotting factors, you will be advised to avoid diet containing Vitamin K (such as salads and green leafy vegetables).

New Anticoagulants

Several new drugs have become available for the treatment of DVT over the past couple of years. These drugs are oral and do not require concurrent administration of heparin. Most prominent among these are Rivaroxaban (Xarelto) which is a factor 10 inhibitor, and Dabigatran (Pradaxa), a direct thrombin inhibitor. Your doctor will decide if you are a candidate for either of these new treatments.

What is Inferior Vena Cava filter?

Some patients are unable to take blood thinners due to the risk of internal bleeding. These patients may require an inferior vena cava filter (IVC filter). This is placed in the inferior vena cave (large vein that carries blood from the legs to the heart). It works by potentially trapping any clots that may break off, and prevent them from traveling to the lungs.

Prevention is the key!

There are several simple measures you can take to prevent DVT:

  • During long trips: move your legs to encourage blood flow; drink plenty of fluids and avoid alcohol; if traveling by car, stop about every hour and walk; if traveling by plane, walk the aisles.
  • Moving around as soon as possible after surgery or illness
  • Regular checkups with your doctor
  • Know your family history and risk factors

This information is strictly an opinion of Dr Prakash, and is not intended to replace the advice of your doctor. Dr Chris Prakash is a contributing columnist, and author of eParisExtra’s “The Doctor is In” column. He is a medical oncologist at Texas Oncology Paris. He is board certified in Internal Medicine, Oncology and Hematology. He lives in Paris, TX with his wife and two children, and can be reached at 9037850031, or Sucharu.prakash@usoncology.com

 

 

I Have Osteoporosis, Now What? By Dr. Chris Prakash, MD

 

Dr. Chris Prakash, eParisExtra columnist

Dr. Chris Prakash, eParisExtra columnist

Q: I am a 65 year old woman. My bone density test showed that I have osteoporosis. My doctor prescribed Fosamax but I could not tolerate it. What should I do?

A: Osteoporosis (or bone loss) is a very common disease. According to The World Health Organization, almost 1 in 4 women ages 60 to 70 have osteoporosis. The incidence goes up to 70% in women more than 80 years old. Weakening of bones is a normal aging phenomenon. However, if untreated, it can have drastic physical and emotional consequences. So, treating osteoporosis can have enormous benefits.

Who is at risk?

You may be at risk if:

  • You are a woman (especially thin, or of advanced age).
  • You are white or Asian, especially with a family member with osteoporosis.
  • Postmenopausal (including if you had early or surgically induced menopause).
  • If you have any of the following: Cigarette smoking, low amounts of calcium in the diet, heavy alcohol consumption, inactive lifestyle, and use of certain medications, such as corticosteroids and anticonvulsants.

How is the diagnosis made?

A bone mineral density test or a DXA scan is done (dual energy X-ray absorptiometry). This measures the bone density of the spine and hip. The result is compared to others your age (to calculate the Z-score) and to young adults (to calculate the T- score). Normal T score is -1 or higher. Osteopenia is defined as a score between -1 and -2.5. You have osteoporosis if the T score is -2.5 or lower.

How is Osteoporosis treated?

Even though medications form the backbone of management of osteoporosis, ancillary measures are important to enhance the efficacy of treatment. This will include a combination of dietary, exercise, and lifestyle modification approaches.

  • Exercise - Weight-bearing physical activity strengthens bones.
  • Calcium and Vitamin D – According to National Institutes of Health (NIH), adults should get 1200 mg of calcium daily (8oz of milk has 300 mg). Calcium supplementation may be necessary to make up the difference. Vitamin D is essential for calcium absorption and bone health. 800 – 1000 units a day are recommended but the recommendations vary widely.
  • Quit smoking as smoking cigarettes speeds up bone loss.
  • Limit alcohol – If you drink alcohol, consider limiting it to one drink a day or less.

Which medications are used?

Bisphosphonates are a class of medications that are the first choice to treat osteoporosis. These include:

  • Alendronate (Fosamax) – orally weekly
  • Risedronate (Actonel) – orally monthly
  • Ibandronate (Boniva) – intravenous infusion every 3 months
  • Zoledronic acid (Reclast) – intravenous infusion once a year

Hormones, such as estrogen, and some hormone-like medications, such as raloxifene (Evista), can also be used, but are prescribed less often now, due to their side-effects, and because bisphosphonates are so effective.

A new medication called Prolia has been approved for use in osteoporosis. This is a RANK ligand inhibitor with a unique mechanism of action. It is given as a subcutaneous injection every 6 months at the doctor’s office. It is more expensive than other treatments, and is indicated for use only after failure of other treatments.

What side effects can I expect?

  • The most common side effect with bisphosphonates is stomach upset and heartburn (can be avoided by taking the medication on an empty stomach)
  • Some people experience pain or aching in their bones.
  • Bisphosphonates also have the potential to cause Osteonecrosis of the jaw. This is a rare condition in which a section of jawbone dies and deteriorates. This may occur after a dental extraction, after trauma to the jaw or sometimes even just spontaneously. It happens primarily in patients with cancer in the bones, who receive high doses of bisphosphonates.
  • Note of Caution: Before starting a bisphosphonate, make sure your teeth are healthy, and practice good oral hygiene.

How do I decide which drug to take?

The decision to take one drug over another is often personal, and is based on your preference, convenience, and dosing schedule. Your doctor might recommend a monthly dose of medication if it’s going to be better tolerated or better accepted. But if you’re the type of person who might forget to take your medicine every month, you might do better taking it once a week. Some women prefer an injection given yearly, which ensures that they are fully protected until their next treatment.

This information is strictly an opinion of Dr Prakash, and is not intended to replace the advice of your doctor. Dr Chris Prakash is a contributing columnist, and author of eParisExtra’s “The Doctor is In” column. He is a medical oncologist at Texas Oncology Paris. He is board certified in Internal Medicine, Oncology and Hematology. He lives in Paris, TX with his wife and two children, and can be reached at 9037850031, or Sucharu.prakash@usoncology.com

 

IS TYLENOL SAFE? By Sucharu Chris Prakash, MD

Dr. Chris Prakash, eParisExtra columnist

Dr. Chris Prakash, eParisExtra columnist

Tylenol is one of the most commonly used medicines. We reach for it when we are sick, be it for fever, pain, or even the flu. It is easy to buy; it is over the counter, cheap, and available without a prescription. It comes in all shapes and varieties, and easy to consume formulations such as a solution, chewable, and even a suppository. The whole world takes Tylenol. It’s got to be safe, right? Maybe not!

Most of us are aware that acetaminophen (active ingredient in Tylenol) has the potential to cause liver damage. But exactly how much Tylenol can you safely take before you start worrying about it? There is no clear answer to this question. However, the data from NIH (National Institute of Health) is very clear: Tylenol is the leading cause of acute liver failure in our country. The daily recommended dose of Tylenol is 3 gm (recently dropped from 4 gm by the manufacturer). Taking more than that dose, even for a few days can result in major illness. How easy is it to get to the maximum recommended dose? One extra strength Tylenol contains 500 mg of acetaminophen. Taking 2 tabs at a time three times a day gets you to the allowed dose. If you are taking other over the counter products at the same time, such as cough and cold medicines (they often contain Tylenol), you can easily surpass the safe dose of acetaminophen, and could land in serious trouble.

How common is Tylenol overdose?

According to the CDC, acetaminophen overdose is responsible for 7800 emergency room visits a year, 3300 hospitalizations, and almost 450 deaths. It is important to recognize Tylenol poisoning, because prompt medical care can save your life. A person may not show signs of overdose for up to 12 hours. After that, the following symptoms may appear:  nausea, vomiting, poor appetite, abdominal pain and jaundice. You should know that there is an antidote available to acetaminophen overdose (N- acetylcysteine), but it is most effective when given within 8 hours of ingesting acetaminophen. It can prevent liver failure if given early enough. For this reason, it is absolutely necessary that acetaminophen poisoning be recognized, diagnosed, and treated as early as possible.

Other dangers from Tylenol:

It is not just liver failure that you worry about, with Tylenol.

  • Long term use of Tylenol can cause kidney damage.
  • Tylenol can cause gastrointestinal side effects.
  • It has even been shown to have cardiovascular toxicities.
  • A study in UK showed that with Tylenol, there was a 36% increase in risk of gastric ulcers, a 14% increase in risk of heart attack and a 20% increase in renal failure risk.

Lessons to learn:

  • Don’t assume that OTC medicines are safe.
  • Look at labels: Acetaminophens is often combined with cold and cough remedies, and even sleep aids. Know what you are taking.
  • Do not drink alcohol while taking Tylenol. It increases risk of liver damage.
  • Fasting, or being unable to eat, increases toxicity of Tylenol.
  • Remember that Tylenol is an ingredient in several strong pain killers such as: vicodin, lortab, norco, Percocet and darvocet.

It is important to realize that most people can take Tylenol without any problem! Tylenol remains a very effective and important medication available to us over the counter. Tylenol is safe if you follow the precautions and guidelines outlined above.

This information is strictly an opinion of Dr Prakash, and is not intended to replace the advice of your doctor. Dr Chris Prakash is a contributing columnist, and author of eParisExtra’s “The Doctor is In” column. He is a medical oncologist at Texas Oncology Paris. He is board certified in Internal Medicine, Oncology and Hematology. He lives in Paris, TX with his wife and two children, and can be reached at 9037850031, or Sucharu.prakash@usoncology.com

 

IS ORGANIC FOOD BETTER? By Sucharu Chris Prakash, MD

Dr. Chris Prakash, eParisExtra columnist

Dr. Chris Prakash, eParisExtra columnist

Common perception dictates that organic produce is healthier. If our products are grown without using pesticides, or injecting antibiotics and hormones, it’s got to be better, right. Maybe not!

Organic products continue to get more popular. Organic food industry is a multibillion dollar enterprise ($24.4 billion to be exact). This popularity has spawned the growth of grocery store chains such as Whole Foods and Trader Joes, all over the country. Most of us are willing to pay a premium for these products. After all, organic foods are often twice as expensive as conventional, and may not be readily available at the local grocery store.

What is organic?

“Organic” is a pretty simple concept. Farmers who grow organic produce don’t use chemical fertilizers, do not use pesticides, and do not give animals growth hormones and antibiotics. Organic produce can be fruits, vegetables, grains, dairy products or meat. Organic farming practices are designed to be “greener” and reduce pollution. Organic products can sometimes be mislabeled and thereby misleading. In order to be certified as organic by the USDA, all foods have to meet strict standards. These standards are based on how these foods are grown and processed. If a product is certified as at least 95% organic, they will display the official USDA “Organic” seal. Some produce may be labeled as “natural”, which is different from organic. The word “natural” on food packaging can mean any number of different things, such as free range or hormone free, but the term “organic” is strictly defined by uniform, federal regulations.

Is organic better?

This question was researched by a team of scientists at Stanford, and their findings were published in the Annals of Internal Medicine. They concluded that “there is no difference between organic and conventional foods as far as the nutritional value is concerned”. This was the most comprehensive meta-analysis to date of existing studies comparing organic and conventional foods, and included 237 of the most relevant studies to date. The review showed no evidence that conventional foods posed greater health risks than organic products. Organic produce however, had a 30 percent lower risk of pesticide contamination in their study, which would be expected. This analysis stresses the point that organic foods are produced with fewer pesticides and more natural-growing practices, but that doesn’t always translate into a more nutritious or healthier product.

The Dirty Dozen

Some foods are considered high risk due to a higher concentration of pesticides that may be on the surface or even inside the produce. The Environmental Working Group calls these the dirty dozen. It may make sense to buy these organic if possible. The dirty dozen includes: Apples, Celery, Strawberries, Peaches, Spinach, Nectarines, Grapes, Sweet bell peppers, Potatoes, Domestic blueberries, Lettuce, Kale and other collard greens.

Should you buy organic?

Now that you know the scientific data, you can make an educated decision whether you should choose “organic”. Some of the reasons for buying organic foods are:

  • Concerns about the effects of conventional farming practices on the environment and animal welfare.
  • Taste preference.
  • Limit exposure to pesticide residues.
  • Limit intake of food additives such as preservatives, artificial sweeteners, colorings and MSG.
  • NOTE: People should aim for healthier diets overall, and eat fruits and vegetables, however they are grown.

 

This information is strictly an opinion of Dr Prakash, and is not intended to replace the advice of your doctor. Dr Chris Prakash is a contributing columnist, and author of eParisExtra’s “The Doctor is In” column. He is a medical oncologist at Texas Oncology Paris. He is board certified in Internal Medicine, Oncology and Hematology. He lives in Paris, TX with his wife and two children, and can be reached at 9037850031, or Sucharu.prakash@usoncology.com

Aspirin a day keeps the doctor away? By Sucharu Chris Prakash, MD

Dr. Chris Prakash, eParisExtra columnist

Dr. Chris Prakash, eParisExtra columnist

Q: I have heard that aspirin can prevent heart attack and stroke. Should I take it every day even if I am healthy?

 A: Aspirin (or acetylsalicylic acid) was developed in 1897 by the German chemist Felix Hoffmann, and since that time, has been invaluable as an analgesic. Aspirin has been a mainstay on pharmacy shelves, for relief of pain and fever. We have also known for some time now, that aspirin can help prevent heart attacks and strokes. There is new evidence that indicates that aspirin can also reduce the risk of some cancers, and may even help protect against Alzheimer’s disease.

So, is it safe to say that aspirin is a wonder drug?

Maybe!

Multiple studies and meta-analyses have confirmed that the use of aspirin substantially reduces the risk of cardiovascular disease, and prevents heart attack and stroke in otherwise healthy individuals. This evidence prompted the United States Preventive Services Task Force to strongly recommend that men ages 45 to 79, and women ages 55 to 79, take a low-dose aspirin pill daily, with the exception of those at risk for gastrointestinal bleeding.

Over the past couple of years, there have been several reports about aspirin’s benefits in cancer prevention. In 2011, British researchers, analyzing data from some 25,000 patients in eight long-term studies, found that a small, 75-milligram dose of aspirin taken daily for at least five years reduced the risk of dying from common cancers by 21 percent.

In 2012, The Lancet published a research paper which reviewed five long-term studies involving more than 17,000 patients. It found that a daily low-dose aspirin lowered the risk of getting adenocarcinoma – a common malignant cancer that develops in the lungs, colon and prostate, by an average of 46 percent (for some folks with a particular genetic mutation, it slashes the risk of colon cancer by 82 percent).

How does Aspirin do it?

Aspirin helps prevent cardiovascular disease through a variety of mechanisms, including being a natural anticoagulant (prevent blood clots). It is a powerful anti-inflammatory agent, and many experts believe it helps prevent cancer, in part, by dampening a person’s immune response to damaging insults in the body.

Is Aspirin safe?

Aspirin can cause irritation of the stomach lining and loss of stomach protection. This may make people more likely to bleed. Taking aspirin in coated or buffered form may help lower this risk but does not eliminate it. People, who take aspirin regularly, will have roughly double the likelihood of having a perforated ulcer or bleeding in the GI tract.

So how do you decide whether aspirin is right for you?

As with all medications, individuals should first speak with their health care provider to discuss using aspirin. The doctor will then discuss the potential benefits and harm of aspirin therapy.

The following individuals may clearly benefit from low dose daily aspirin:

  • Those who have a documented personal or family history of heart disease, including heart attacks, stokes, or angina.
  • Those with diabetes.
  • Those who have high blood pressure or high cholesterol.
  • If you are a smoker, or have obesity.
  • All males 45-79 and all females 55-79 years old, if benefits outweigh the risks.

The recommended dose for prevention is 75 or 81 mg daily.

This information is strictly an opinion of Dr Prakash, and is not intended to replace the advice of your doctor. Dr Chris Prakash is a contributing columnist, and author of eParisExtra’s “The Doctor is In” column. He is a medical oncologist at Texas Oncology Paris. He is board certified in Internal Medicine, Oncology and Hematology. He lives in Paris, TX with his wife and two children, and can be reached at 9037850031, or Sucharu.prakash@usoncology.com