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Thursday, January 31, 2019

Giving antacids and antibiotics to babies can lead to allergies

There are two main types of cholesterol: high-density lipoprotein (HDL) and low-density lipoprotein (LDL). (Lipoproteins are made of fat and protein, and serve as vehicles for your cholesterol to travel through the blood.) Cardiologists are often asked about low-density lipoprotein (LDL) versus high-density lipoprotein (HDL). The difference is important to understand.
What does HDL cholesterol do?

HDL clears from the body via the liver. HDL may therefore prevent the buildup of plaque, protect your arteries, and protect you from atherosclerotic cardiovascular disease. It is considered the “good” cholesterol, and higher levels are better. A good goal to aim for is higher than 55 mg/dL for women and 45 mg/dL for men. The higher your HDL cholesterol numbers, the lower your risk is for heart disease, vascular disease, and stroke.
How to increase HDL cholesterol

Although HDL levels are driven by family genetics, you can improve HDL levels in three key ways:

    If you are a smoker, research clearly shows that quitting smoking can increase HDL.
    Adopting a heart-healthy diet low in fat and high in fiber can also modestly raise your HDL.
    Aerobic exercise can also have positive effects on HDL. Have trouble exercising? Find a buddy; research shows it helps motivate you. That exercise can be as simple as increasing the amount of walking you do (for the sake of exercise, not a stroll) each week.

Lastly, although primarily used to decrease high LDL, some statin medications may potentially increase HDL levels moderately. Any medical treatment option should be discussed with your doctor. Importantly, high HDL does not protect you from the untoward effects of high LDL.
What does LDL cholesterol do?

LDL is considered the “bad” cholesterol. It carries cholesterol to your arteries, where it may collect in the vessel walls and contribute to plaque formation, known as atherosclerosis. This can lead to decreased blood flow to the heart muscle (coronary artery disease), leg muscles (peripheral artery disease), or abrupt closure of an artery in the heart or brain, leading to a heart attack or stroke. Over a third of the US population has high LDL cholesterol. Diagnosis is made via blood testing, so if you don’t check, you won’t know.

For LDL, the lower the number the better. A good goal to keep in mind is less than 130 mg/dL if you don’t have atherosclerotic disease or diabetes. It should be no more than 100 mg/dL, or even 70mg/dL, if you have any of those conditions or high total cholesterol. It’s very important to set your own target cholesterol levels with your doctor. Obesity, a large waist circumference, a sedentary lifestyle, or a diet rich in red meat, full-fat dairy, saturated fat, trans fats, and processed foods can lead to high LDL cholesterol.
How to lower LDL cholesterol

Lifestyle and diet changes are the main ways to prevent or lower high LDL. A trial of eating a low-fat diet, regular aerobic activity, maintaining a healthy weight, and smaller waist circumference is an appropriate first step. It is best to set a timeline to achieve your goals with your doctor. In some cases, if those lifestyle changes are not enough, your physician may suggest a cholesterol lowering medication, such as a statin. If you are considering over-the-counter herbal or ayurvedic medications for cholesterol, please discuss those with your physician first as well.

Rarely, very high LDL is genetic and passed down in families. This is called familial hypercholesterolemia and is caused by a genetic mutation that decreases the liver’s ability to clear excess cholesterol. This condition can lead to very high LDL levels, and heart attack or stroke at a young age in multiple generations. Those individuals may require special medical treatment for prevention and treatment of atherosclerotic cardiovascular disease.

Remember, knowledge is the first step. If you don’t know your cholesterol levels, get tested. That will give you and your physician a starting point for lifestyle changes and medications if needed. In the meantime, adopt a heart-healthy lifestyle, and do it with friends and family no matter their ages. There’s no time like the present to prevent heart disease. With the opioid epidemic worsening and with no end in sight, as it continues to shorten the life expectancy of our citizens, we must do everything we can to lower the barriers that physicians face to treating addiction. The lowest-hanging fruit is the emergency department. For every fatal overdose, there are roughly 30 non-fatal overdoses, so this is an ideal “captive audience” to embrace, connect with, and engage in treatment.

Buprenorphine (Subutex, Suboxone) is a mainstay of medication-assisted treatment (MAT) for opiate addiction, where a safer opiate is provided for daily consumption in order to supplant the use of illicit opiates, which are all too often deadly. Buprenorphine is often the preferred option as an opioid replacement because it is a partial opioid agonist, meaning that it only partially stimulates the opioid receptors, causing a “ceiling effect” that makes it much more difficult to overdose on compared to other opioid drugs. Buprenorphine has been shown to cut overdose deaths in half, and to allow people to resume productive and fulfilling lives.

I am a practicing primary care doctor who is now 10 years into recovery from opiate addiction. I was recently asked to recount my story to a room full of emergency medicine physicians, as part of a program to inspire them to get “waivered” to prescribe buprenorphine.

To get this waiver, doctors need eight hours of training and a special US Drug Enforcement Administration (DEA) license. (Nurse practitioners and physician assistants can also get a waiver, but they need more training.) The DEA oversees office-based buprenorphine treatment and has the right to inspect physicians’ buprenorphine practices at any time. The DEA conducts unscheduled and random audits, which may intimidate doctors; however, only a minority of practices that prescribe buprenorphine are visited by the DEA annually. The DEA also puts limits on how many patients a doctor can prescribe buprenorphine for. Thus, it requires some additional motivation for doctors to prescribe buprenorphine, another task piled on top of physicians who are often already working past their capacity, at a burnout-level pace, for no extra compensation.

Asking doctors to get waivered must also be considered in the context of the other obstacles that doctors face treating patients who are suffering from substance use disorders. Treating addicted patients is time-consuming and can be frustrating. Relapse is a common, if not an intrinsic, part of the perilous transition from addiction to recovery. Treating the same patient for multiple overdoses can start to feel incredibly futile, and adds to feelings of burnout and discouragement. When a patient is impaired or withdrawing, they are not always on their best behavior. Having been on both sides of this equation, I can vouch for the fact that these interactions aren’t always easy or pleasant.

Sadly, many physicians share the same biases toward addicted patients that the rest of society does, and would rather not interact with them. Stigma inhabits the occupants of white coats who wear stethoscopes around their necks, too. This can lead to substandard care. It needs to change.
MAT treatment in the ER saves lives

At first blush, a busy emergency department may not seem to be the ideal place to start treatment for a chronic, complex disease such as addiction, with the hustle and bustle of the ER, the pressures to move patients along to clear beds for the next emergency, and the fact that there isn’t much, if any, long-term personal connection between patients and ER caregivers.

However, studies have shown that starting buprenorphine in the emergency department significantly increased engagement in addiction treatment, reduced self-reported illicit opioid use, and decreased use of inpatient addiction treatment services. Starting MAT treatment in the ER works. So is it happening? Not much. A 2017 study in JAMA showed that among people who had overdosed on heroin, buprenorphine treatment increased by only 3.6 percent, though a more recent analysis published in Health Affairs shows the use of any medication-assisted treatment to be only as high as 10.8% after overdose and treatment in the ER, which is abysmally low.
How can we support physician training?

The obvious answer is to facilitate the process of emergency room doctors getting waivered — and motivated — to start buprenorphine after overdoses in the emergency department. We need to provide more resources to support these already beleaguered physicians, to encourage them to take on the intimidating prospect of treating opiate addiction.

If, for example, emergency departments were set up with access to fully-equipped addiction consult teams, complete with recovery coaches and navigators, who had the ability to arrange follow up within a week, and make the “bridge” with a primary care doctor or with an addiction clinic, then essentially, all an overworked emergency room doctor would have to do is stabilize the patient, educate, and prescribe buprenorphine. This would make treating addiction feel much more doable. It could create a transformative pipeline from overdose into treatment across the country, which is essential given that the vast majority of people suffering from opiate use disorders are not currently receiving treatment.

Above all else, we need to reduce the stigma of addiction. Anyone can get addicted. Recovery from addiction is about much more than just not taking drugs. It is about humility, mindfulness, and connecting to other people. People who overdose and who come to the emergency department, even repeatedly, deserve a chance at a new lease on life. The emergency department is an ideal point of entry to start a proven, lifesaving treatment, which is just a waiver away. Allergies are on the rise, especially food allergies. While nobody knows for sure why this is happening, a leading theory is that we may be doing things that mess up our natural microbiome.

Our microbiome is the trillions of organisms that live on and in our bodies, such as bacteria, archaea, fungi, and viruses. We generally think of these organisms as “germs” that can cause illness — and while they can, in some situations it turns out that the right organisms in the right balance actually help keep us healthy. Our microbiome affects how we digest foods, stay at a healthy weight, fight infection, and stave off diseases like diabetes. Through its link to our immune system, our microbiome is thought to be linked to our risk of allergic reactions.

Two common types of medications, antacids and antibiotics, can mess up our microbiome. Antibiotics do it by killing not just the bacteria that make us sick, but also the bacteria that help keep us healthy. As for antacids, by making the stomach less acidic they make it more likely that bacteria from the mouth (that are normally killed by the acid in the stomach when swallowed) make it down into the intestine. Those mouth bacteria can crowd out the bacteria that our intestines need to function normally.

In a study published in JAMA Pediatrics, researchers studied almost 800,000 children from birth to about 4 years of age. They looked to see if the children got antacids or antibiotics in the first six months of life, and then tracked to see if they went on to have any allergic conditions. They found that children who got antacids were twice as likely to have food allergies as those who didn’t, and children who got antibiotics were twice as likely to have asthma as those who didn’t. Children who got either antacids or antibiotics showed an increased risk of other kinds of allergic conditions, from hay fever to severe allergic reactions.

This does not mean that infants should never get antacids or antibiotics. Antibiotics can be lifesaving for infants with bacterial infections, and there are situations when antacids can be extremely useful. But both medications are often overused. Antacids are often used in babies with reflux, or fussiness with feeding; while they can be helpful, the symptoms can be managed in other ways and usually resolve with time. Antibiotics are often used for upper respiratory infections, even though most upper respiratory infections are caused by viruses and don’t need antibiotics.

Moving forward, doctors need to be thoughtful and careful about how they prescribe antacids and antibiotics to infants, only doing it when truly necessary. Parents of infants need to be informed consumers. When given a prescription for either antacids or antibiotics, they should ask if it is truly necessary — and whether there are any alternative treatments that might be tried.

It’s about breaking old habits, and thinking about treatments in different ways based on what research is telling us. The more we learn, the more we can keep our children healthy, not just now but for the rest of their lives.

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