Weird Medicine Healthcare for the Rest of Us

June 24, 2018

Interesting Article Regarding Prescription Opioids

Filed under: Steve's Blog — dr steve @ 2:02 pm

The common narrative these days is that prescription opioids are driving the opioid “crisis” and doctors must be restricted from writing “so many pills.”   While the initial wave of self-imposed and statutory restrictions on using opioids for the treatment of chronic, nonmalignant pain were successful in decreasing the total volume of pharmaceutical grade opioids being dispensed, deaths from overdose and other adverse events continue to rise:

CDC and IQVIA

Note the peak of prescription opioid prescribing hit in 2011 and has been falling steadily since (as of 2016, to 2006 numbers), while the deaths from opioid related misadventures began to rise dramatically.  This is likely due to the fact that limiting prescription opioid prescriptions does nothing to deal with the DEMAND for these drugs;  when one avenue is closed, people will switch to more available drugs (heroin, street fentanyl, krokodil, etc) which, due to erratic dosing, are inherently more dangerous.  Until we deal with the demand for opioids for abuse, through treatment, early intervention, etc., this problem will just shift from one arena to another, but will not “go away.”  All health care providers (with vanishingly small exceptions) want to make sure they are not part of the problem.  Many are concerned, however, that their patients with legitimate pain are being called to pay for the shenanigans of others.

There is a beautiful editorial in the Journal of Pain Research that every clear-thinking policy maker should read.  It presents a very balanced analysis of the current situation and ultimately states:

It is easy to demonize and point fingers at industry, prescribers, or anyone who calls into question the newest battle in the never-ending war on drugs. While we would agree that anyone involved in the distribution of illicit drugs such as heroin and illicitly manufactured fentanyl derivatives should be stopped from harming others, and the misuse and abuse of prescription opioids have played a role in the problems we see today, in the right hands prescription opioids can help eliminate human suffering.

…we need to find ways to work together, instead of against each other, emphasizing civil discourse instead of finger pointing. We are concerned that some people who are intent on blaming prescribers, patients, and the pharmaceutical industry for the problem without offering solutions (other than perhaps eliminating prescription opioids) are making it more about them than the people they are actually trying to help. We have many problems, but there are also many solutions.

This article from the journal Pain Medicine  paints a somewhat different picture than that you may have read before.  It’s important that we don’t “throw the baby out with the bathwater,” when it comes to legitimate patients with chronic pain, and opinions like this need to be considered as policy (corporate, governmental, personal) is being written.

 

We’ll stay on this story!

 

 

yr obt svt,

 

 

Steve

June 20, 2018

Ketogenic Diets

Filed under: NSNG — dr steve @ 7:19 am

A recent study published in Circulation got headlines recently, screaming “HIGH PROTEIN DIETS ARE LINKED TO HEIGHTENED RISK FOR HEART DISEASE..” This prompted a lot of questions to the show about ketogenic diets and whether they were “dangerous” and should be abandoned.

As usual, the hype isn’t warranted;  even the original study states clearly “In middle-aged men, higher protein intake was marginally associated with increased risk of HF.”

It’s also a myth that ketogenic (and NSNG) diets are necessarily “high protein.” “Low carbohydrate”doesn’t necessarily mean high protein; a classic low carb meal would be a salad with lots of green, leafy vegetables, cucumbers, peppers, etc., and grilled chicken or salmon. It boggles the mind to think that anyone would consider this an unhealthy meal, and it’s certainly not “high protein” in the sense that this was used in the Circulation study.

Let’s look at some of the research on ketogenic diets:

 2013 Aug;67(8):789-96. doi: 10.1038/ejcn.2013.116. Epub 2013 Jun 26.

Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets.

Paoli A1, Rubini A, Volek JS, Grimaldi KA.

Abstract

Very-low-carbohydrate diets or ketogenic diets have been in use since the 1920s as a therapy for epilepsy and can, in some cases, completely remove the need for medication. From the 1960s onwards they have become widely known as one of the most common methods for obesity treatment. Recent work over the last decade or so has provided evidence of the therapeutic potential of ketogenic diets in many pathological conditions, such as diabetes, polycystic ovary syndrome, acne, neurological diseases, cancer and the amelioration of respiratory and cardiovascular disease risk factors. The possibility that modifying food intake can be useful for reducing or eliminating pharmaceutical methods of treatment, which are often lifelong with significant side effects, calls for serious investigation. This review revisits the meaning of physiological ketosis in the light of this evidence and considers possible mechanisms for the therapeutic actions of the ketogenic diet on different diseases. The present review also questions whether there are still some preconceived ideas about ketogenic diets, which may be presenting unnecessary barriers to their use as therapeutic tools in the physician’s hand.

Another review article discusses positive effects of ketogenic diets:

 2014 Feb 19;11(2):2092-107. doi: 10.3390/ijerph110202092.

Ketogenic diet for obesity: friend or foe?

Paoli A1.
Abstract

Obesity is reaching epidemic proportions and is a strong risk factor for a number of cardiovascular and metabolic disorders such as hypertension, type 2 diabetes, dyslipidemia, atherosclerosis, and also certain types of cancers. Despite the constant recommendations of health care organizations regarding the importance of weight control, this goal often fails. Genetic predisposition in combination with inactive lifestyles and high caloric intake leads to excessive weight gain. Even though there may be agreement about the concept that lifestyle changes affecting dietary habits and physical activity are essential to promote weight loss and weight control, the ideal amount and type of exercise and also the ideal diet are still under debate. For many years, nutritional intervention studies have been focused on reducing dietary fat with little positive results over the long-term. One of the most studied strategies in the recent years for weight loss is the ketogenic diet. Many studies have shown that this kind of nutritional approach has a solid physiological and biochemical basis and is able to induce effective weight loss along with improvement in several cardiovascular risk parameters. This review discusses the physiological basis of ketogenicdiets and the rationale for their use in obesity, discussing the strengths and the weaknesses of these diets together with cautions that should be used in obese patients.

I have to get to work;  I’ll continue to post to this thread as time goes on.  There is an overwhelming amount of data on ketogenic diets (not all positive, of course, as is true in most science) and we’ll continue to update you on this fascinating topic.

 

your obt svt,

 

 

Steve

 

Please visit stuff.doctorsteve.com

June 5, 2018

Another Step Closer to a True Generalizable “Cure for Cancer”

Filed under: Non-pseudoscience Cancer Cures — dr steve @ 8:20 am

Immune recognition of somatic mutations leading to complete durable regression in metastatic breast cancer

From “Nature: Medicine”
https://www.nature.com/articles/s41591-018-0040-8

Immunotherapy using either checkpoint blockade or the adoptive transfer of antitumor lymphocytes has shown effectiveness in treating cancers with high levels of somatic mutations—such as melanoma, smoking-induced lung cancers and bladder cancer—with little effect in other common epithelial cancers that have lower mutation rates, such as those arising in the gastrointestinal tract, breast and ovary1,2,3,4,5,6,7. Adoptive transfer of autologous lymphocytes that specifically target proteins encoded by somatically mutated genes has mediated substantial objective clinical regressions in patients with metastatic bile duct, colon and cervical cancers8,9,10,11. We present a patient with chemorefractory hormone receptor (HR)-positive metastatic breast cancer who was treated with tumor-infiltrating lymphocytes (TILs) reactive against mutant versions of four proteins—SLC3A2, KIAA0368, CADPS2 and CTSB. Adoptive transfer of these mutant-protein-specific TILs in conjunction with interleukin (IL)-2 and checkpoint blockade mediated the complete durable regression of metastatic breast cancer, which is now ongoing for >22 months, and it represents a new immunotherapy approach for the treatment of these patients.

Analysis:

This is a patient with metastatic breast cancer who did not respond to chemotherapy (“chemorefractory”).   This is a disease that is generally considered treatable but not curable, and patients with chemorefractory disease are often considered terminally ill.

This patient was treated with immune cells (tumor-infiltrating lymphocytes) that were specifically “trained” against mutated proteins only found in the cancer cells (SLC3A2, etc).   The researchers tossed in some other “helper” meds, including the immune cell controller interleukin 2 and a “Checkpoint Blockade” (another facet that essentially takes the gloves off of parts of the immune system) medication.

The result was a “complete, durable regression” (i.e., “cure”) which has held for greater than 22 months.  They won’t call it a true “cure” until 5 years out.  We’re so used to cancers like this being incurable that the term complete regression seems more palatable to oncologists.  Hopefully in the future, the language will change as we see real “cures” for this kind of disease.

This is “only” one patient, but if it’s reproducible, this will add another large chunk of ammunition in the war against cancer.

yr obt svt,

 

 

Steve

 

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