Sunday, May 20, 2012

Hepatitis C Testing- the Fine Print

Yesterday's blog focused on the CDC's new recommendation for ALL BABY BOOMERS to be tested for Hepatitis C, regardless of their other risk factors. The rational is to diagnose this often silent disease early, while treatment can make the most impact saving lives and improving quality of lives. While hepatitis C is largely transmitted via IV drug abuse (which obviously people can identify as a risk factor), there is a significant chunk- usually quoted around 10%- of people who have NO KNOWN risk factors.

So what's the fine print about the testing? First of all, the Hep C test is a blood test (just a heads up for the needle-phobics out there.) Mainly, however, the issues about testing surround the results.

A negative result is wonderful- there is extremely low chance that you have the disease and the test missed it, because this is a very sensitive test.

A positive result, however, leads to a much longer discussion. A positive Hep C Antibody test (the screening test) cannot tell you how long you have been infected. More testing is now required. The next step will be to have a different blood test that measures "viral load"- actually looking for the amount of Hep C virus present in your system. Other blood tests will measure your liver "function" to see if it looks inflamed.  Your doctor may also test to determine the subtype of Hep C in order to better advise you regarding the potential response to therapy. By the way, All positive tests for Hep C will be reported to the health department. This should not to make you paranoid, as your insurance company will obviously know as well, but simply something to note.

If your screening test was positive but your viral load does NOT show any current presence of Hep C, and your liver enzymes are normal- you will be considered to have recovered from a prior Hep C infection, and part of the lucky 15-25% who do not progress to chronic disease.

 If your screening test is positive, your viral load is elevated, but your liver enzymes are normal and you feel fine- you may be a Hep C Carrier, and most people in this category do not require immediate treatment. Carriers are followed closely to be sure they are not having silent worsening of disease (as measured by deteriorating blood tests or symptoms), holding off on treatment until there has been a change.

If your screening test is positive, your viral load is high, and your liver enzymes are abnormal or you have significant symptoms, then you will be heading to a liver specialist to discuss treatments. Though the treatment for Hep C can be challenging, between 50-80% of patients have sustained (successful) responses to treatment, depending on their subtype and how long the disease has been present.

BOTTOM LINE: Baby Boomers should talk with their doctors about getting tested for Hepatitis C, but recognize the results may initially create more additional questions than answers. 

Saturday, May 19, 2012

Baby Boomers & Hepatitis C- Are You at Risk?

Yesterday the Center for Disease Control (CDC) announced that all baby boomers (adults born in 1945-1965) should be tested for Hepatitis C in order to increase earlier detection of this often silent disease. The CDC predicts that one in thirty Baby Boomers is infected with Hep C, and that close to a million people will be newly diagnosed if all in this age category are tested. The hope is that this strategy will save over 100,000 lives.

What is hepatitis C? Hep C is a viral infection that primarily targets the liver, and can potentially lead to severe liver damage, cancer and death. The good news is that 15-25% of people infected will "fight off" the disease and not become chronically ill with this disease.

How does someone catch Hep C? This infection is blood-born, so it is transmitted when there is direct blood-to-blood contact such as when people share needles for drug use. Baby boomers who received blood transfusions before 1992 could have been infected then and harbored silent disease for several decades. (Blood transfusions after that time were able to be screened and are safe.) Hep C can also be spread through sex with an infected person, but the transmission rates are very low (as measured in monogamous couples where one partner has hep C and the other does not.) Tattoos are another potential source of transmission. Unfortunately, most studies show that 10% of people with hepatitis C have no identifiable risk factors,  so that is why everyone should be screened regardless of their behavioral risk factors. 

Isn't there a vaccine for hepatitis? For Hepatitis A and Hepatitis B- YES, but not yet for Hep C.

What is the treatment? Unfortunately, the treatment for hep C is not as simple as taking an antibiotic for a bacterial infection, but it is very effective. Hep C treatment typically lasts a year and requires weekly injections, and the medications can have marked and serious side effects (especially fatigue, flu-like symptoms and depression.) Newer medications may offer shorter treatment courses and will be much better tolerated.

How do I get tested? Schedule an appointment to talk with your doctor about getting a blood test for Hepatitis C. The results are not exactly black and white, so you will want to learn more details before you decide...more on this tomorrow.

BOTTOM LINE: New recommendations suggest ALL BABY BOOMERS should get tested for Hepatitis C.

Wednesday, May 9, 2012

Generic Prescriptions- Worth the Price Break?

Many patients understandably prefer generic medications because of cost. Most physicians are very in tune with this, and will give you their honest opinion about which drugs seem to have clinically equal generics. In my personal clinical experience, I would broadly say that most generics are perfectly fine, but I see I higher rate of patient satisfaction with name brand products in hormones (primarily birth control and thyroid), certain migraine medications, and a few specific antidepressants. That being said, it is VERY patient specific- the only way to know if you tolerate a generic better or worse than a name brand is to try it. For example, while probably 95% of my patients who take sleep aids are happy with the generic, there is a subset that find a dramatic difference between that and name brand, from deriving a morning "hangover" with the generic to simply a decreased effectiveness.

The FDA requires that generic prescriptions have the same intended use, dosing, delivery system, and safety as the original drug. The active ingredients are the same, but there can be different byproducts in the generic which may cause a reaction.

Why do doctors ever write brand names on a prescription if they want you to have the generic? The answer is simpler than you might think- brand names are usually shorter. In fairness, doctors also have their "favorite" drugs, and we think of them often with their trade name. In the old days of drug company-sponsored elaborate trips and gifts, I'm sure physician "favorites" were indeed swayed by the pharmaceutical companies, but I can attest that the vast majority of doctors that I know and work with have "favorites" based on what WORKS for patients- combining effectiveness, side effects (good and bad), ease of dosing (the fewer doses per day or even week, the better), delivery system (shot vs. pill vs. patch or cream), and yes, COST.

BOTTOM LINE: Don't hesitate to ask your doctor what she thinks about the generic alternatives to your prescription medications, and together you will figure out which name brand medications are important for your health. 

Tuesday, May 8, 2012

Dark Circles Under Your Eyes?

Along with sneezing, stuffy nose, cough, and sore throat, seasonal allergies can also affect your eyes. Itchy, red eyes may respond to an oral antihistamine, but often they are better treated with a prescription eye drop that prevents the release of histamine (which is what causes the redness and itch to begin with.) Olopatadine ophthalmic solution, brand name Patanol, is applied twice daily, and is generally well tolerated. There is also a newer preparation, Pataday, by the same pharmaceutical company that is only once daily-newer, more convenient, likely more pricey (depends on your insurance.) Both work well.

I find many of my patients try to use over-the-counter eye drops that "get the red out"...only to find that they need more and more of these drops to accomplish the same results. The only time that I recommend these OTC products (with vasoconstrictors to eliminate red eyes) is for extremely short-term use, such as if you are giving a presentation or taking pictures. If you use these products for more than a couple days, you will develop rebound symptoms of increased redness, and risk getting pulled into the cycle of red eyes, use drops, worse red eyes when drops "wear off", more drops, etc.

What about BELOW the eye-those dark black circles that make you look a hundred years old? Those are called "allergic shiners" in the medical world. Congested sinuses slow down return of blood through the small veins under your eyes, causing them to swell and make the skin above them appear purple or black.
What helps? Oral antihistamines, plus or minus a decongestant, will often do the trick if it is mild. For people who suffer for weeks at a time, I'd recommend talking to your doctor and considering prescription nasal steroid sprays. "Spa" treatments like cucumbers and frozen tea bags work very transiently- I'm not sure it isn't just the coldness of these objects that cause vasoconstriction (shrinking of the veins), but they do seem to have non-scientifically proven positive effects, with few to no negative side effects.

BOTTOM LINE: If you have chronic issues with dark circles or "bags" under your eyes, talk to your doctor about treatment options.

Friday, May 4, 2012

Sneeze, Cough, Stuffy Nose...and LOTS of Medicines

Allergy season is in full swing, and there are so many allergy remedies out there. How do you decide what you need? Do you understand the difference between an antihistamine and a decongestant? And where does an expectorant fit in? It's often tough to figure out when to take which drug might help. Here are the basics:

1. Decongestants simply narrow the blood vessels in the lining of the nose, allowing air to pass more easily. Use these when your nose is "stopped up". Caution: do not use if you have high blood pressure, as they can potentially raise your pressure.

2. Antihistamines block the release of histamine, the chemical in your body that cause cells to swell and leak fluid, resulting in itchy eyes, sneezing, and runny nose. Use these to DRY UP (but not when you are simply "stuffy")

3. Expectorants are all medications that include guaifenesin. This drug breaks up mucus, allowing it to drain down from sinuses or be coughed up from your lungs. It wont work if you are dehydrated, so drink extra water- especially if you are also taking an antihistamine, because they DRY UP mucus and that makes it tougher to break up and clear. Use these when you have sinus and ear pressure, or if you have a cold "go to your chest." There is little evidence-based medicine to support the use of these, but clinically I have seen them help a great deal to relieve head congestion, and often avoid the use of antibiotics.

The AAFP a great website with more detail:

BOTTOM LINE: Don't always grab the "do everything" medicine for your stuffy, sneezy, coughy, itchy symptoms- understand which drug works for which complaint!

Tuesday, May 1, 2012

April Showers Bring May...ALLERGIES!

Greetings from Austin, Texas, where-ACHOO!-those of us with allergies are collecting sneezing our heads off! In our case, the scant April showers still managed to kick up the MOLD pollens enough to wreak havoc on allergy sufferers, so I thought today I'd talk about seasonal allergies.

What are signs and symptoms of allergies?

At the risk of sounding like an antihistamine commercial, it's sneezing (often in fits of sneezes), itchy eyes, itchy throat, scratchy throat, drainage down the back of your throat (which creates early morning sore throats that often fade mid-morning), stuffy eyes, ear pressure and the lovely dark circles under your eyes.

What is recommended for treatment?

We usually start with the non-sedating antihistamines,which used to be prescription but are now available over the counter (OTC). These include Loratadine (Claritin), Fexofenadine (Allegra), and Cetirizine(Zyrtec), to name a few of the most popular. Which is BEST? In my experience, they are clinically equal. What works for you this year may not work as well next year, and there is not great science to explain why. Antihistamines will DRY you up and STOP ITCH. If you are mainly stuffy, you are better off with just a decongestant such as phenylephrine (Sudafed) or if you have both, grab a combination product.

If you are suffering regularly in a particular season, or perhaps year-round from something like molds, your doctor may recommend more preventative therapy such as nasal steroid sprays. These sprays are prescription, and they are not "addictive" like the OTC ones. The OTC sprays that give immediate relief are fine for a day or two, but beyond that, you will get rebound nasal congestion and be chasing your tail with symptoms/spray/more symptoms/more spray. Nasal steroids are minimally absorbed (so no turning into Arnold, gaining weight, or weakening your bones.) They are very safe, and decrease swelling while creating kind of protective barrier against entering irritants, so you don't turn on the histamine system that causes allergy symptoms.

What more prevention can you do?

Well, it's May 1st, so like every first of the month, I recommend changing out your home's air filters! That disgusting air filter pictured above came out of our home this morning- yuck!This "central" or "media filter" type should be changed at least three or four times per year, despite manufacturer recommendations of annual replacement. Yes, that is expensive, but cheaper than many allergy medications, and no other side effects! If you look at your filter (set your calendar to remind you) and you see it looking like this- CHANGE it! HEPA air cleans and vacuum bags are of unclear efficacy, but may help. Limit your outside exposure (get on the exercise bike or treadmill indoors.) If you really suffer, consider getting rid of carpet and drapes in your home, and restricting pets to outside the bedroom.

BOTTOM LINE: If you can't stop sneezing or are having other signs of seasonal allergies, schedule an appointment with your doctor and find out what she can do to help! There are many interventions before considering allergy shots- though for severe sufferers, those shots may be an excellent option.