Interesting Reading

• 

• Prejudice is a disadvantage. (Science Daily, h/t The Big Picture)
• Biomechanics are crucial to great running. (Wired)
• If you're going to use pass-phrases instead of passwords, use randomly selected ones. (Boing Boing)
• Requiring employees to work over 40 hours a week is bad for your business. (AlterNet)

Early Warning Signs of Cancer

News since last summer that raise real questions about the usefulness of screening for prostate cancer in men, and breast cancer screening in women under 50 years of age should not seem entirely negative.

It really helps to point out that in many cases it is more important for patients to be aware of some of the early warning signs of cancers. Do realize that in many cases, there may be perfectly benign causes for a particular symptom. However, consideration should be given to cancer as a possible explanation. Certainly, getting this checked out early is better than later.

Here are some common early warning signs of various cancers. Please note that most of the time, cancers do not cause pain early on. Also, enlarged lymph nodes from cancer spread are generally not tender or painful.

Brain Cancer:

• Unusual headaches, especially ones that cause vomiting or wake you up out of a sound sleep. (By unusual, I mean not a bad migraine in someone who has a long history of the same migraine headaches.)
• Personality or behavioral changes.

Throat Cancers:

• Pain, unexplained coughing or hoarseness. (Yes, GERD or "heartburn" is a common cause of cough, but so is cancer.)

Lung Cancer:

• Shortness of breath, coughing up blood.

Breast Cancer:

• Breast lump, blood or discharge from a nipple, reddened skin with the texture of orange peel, lymph node enlargement ("swollen glands") in the armpit.
• Blood from a nipple is never good.

Esophagus or Stomach Cancer:

• Loss of weight and/or appetite
• Things getting stuck during swallowing
• Feeling full easily
• dark black, tarry bowel movements
• throwing up blood

Liver Cancer:

• Nausea, bloating
• Loss of appetite, especially for cigarettes!

Colon Cancer:

• blood in your bowel movements
• sudden changes in your bowel movements
• loss of appetite and weight

Cervical, Uterine, Endometrial Cancers:

• unusually heavy bleeding
• bleeding after menopause

Ovarian Cancer:

• abnormal vaginal bleeding
• nausea, abdominal bloating (note how many benign things can also make you feel nauseous and bloated!)

Prostate Cancer:

• Noticeable development of difficulty getting a stream of urine started
  
• dribbling, interruption or hesitancy in stream
• Feeling like you can't completely empty your bladder
• blood in your urine

Skin Cancer:

• asymmetric border
• border that is wavy or notched
• color that is black, varied or pearly
• diameter larger than 6mm (end of pink pencil eraser)
• enlargement observed

Leukemia/Lymphoma (cancer of bone marrow or lymph nodes):

• easy bleeding or bruising
• weight or appetite loss
• lymph node enlargement
• night sweats

Please do not hesitate to see me about symptoms that may be a warning sign of cancer. You are not "taking up my time"!

What is normal sleep?

As posted on before, it is quite likely that the expectation of 8 hours of uninterrupted sleep was not biologically or historically normal until the industrial revolution imposed it artificially.

This discussion in the BBC's website (h/t Boing Boing) describes further how historical writings, diaries and anthropological study demonstrate that people normally slept in separate four hour blocks often with a few hours of activity in between alone or with others.

I must admit that it makes me wonder about the extent to which industrialization has been all progress!

Misdiagnosis

A contributor to Kevin, M.D. has an interesting post, which also comments on the writings of Dr. Jerome Groopman who has published on the patterns of physician errors in decision-making. I posted on Dr. Groopman's book before, and highly recommend it.

Overall, I agree that correct diagnosis or identification of medical problems is an art as well as a profession. Additionally, I do see that things that can make this more difficult than it already is include inadequate communication and over-reliance on technology.

On the other hand, most of this knowledge should be imparted in medical school and residency training. A great deal of medical education includes learning what lab and imaging studies can do, and what they also cannot do.

I am happy that my teachers imparted several valuable lessons for which I remain grateful and have helped me a great deal:

• "Let the patient talk for at least the first several minutes without interruption." (No one likes to be interrupted, and you'll learn more about what you want to know.)
• "90% of arriving at the correct diagnosis is based on adequate history-taking. Examination and tests rule-out or confirm your impressions." (This is the time-consuming asking of the right questions and paying attention to the answers. This is never wasted time.)
  
• "Ask whether the patient has any questions." (It's polite, and also helps to make sure everyone involved is "on the same page.")
• "Ask the patient what they think is going on: at least half the time they'll be right and save you a lot of trouble." (Yep, pretty much!)
  

For My Military Patients: On Imminent Danger Pay

As one of the very few local docs who sees active duty and military personnel and families, I have gotten some recent concerns or comments about changes in imminent danger pay.

This posting from Kit Up seems to address this nicely, and also provides a useful link and commentary.

(Credit: the graphic is the logo for Danger Close games.)

Interesting Reads

An interesting piece on the evolution of Japanese takes on Western cuisine and apparel. (Wall Street Journal)

The Surgeon General offers a way to create a family medical history; your taxpayer dollars at work! (Health and Human Services, h/t Kevin, M.D.)

Really cool interactive graphic comparing the size and scale of things from quantum foam to the observable universe! Who knew the Grand Canyon is bigger than Rhode Island? 4Chan, h/t Boing Boing. Requires Java)

Just for a hoot, calculate how long it would take for Mitt Romney to make your annual salary. (Slate, scripting required)

Treating Common Warts With Duct Tape

Common skin warts are actually caused by a virus. Your immune system will eventually get rid of the virus and allow your skin to return to normal. The catch is that this can take about a year!

If you don't want to wait that long, there are a number of ways to get rid of them. Freezing them with liquid nitrogen or surgically removing them can be done by me in my office. (Unfortunately, that freezing spray that you can buy over the counter is just not cold enough to get rid of warts, and the acid treatment often fails and is kind of painful.) Aldara (generically known as imiquod) is a prescription cream that can work, and does not sting or burn. However, it is very expensive and not covered by most health insurances.

As an intriguing alternative, duct tape may work (this link is for a technical audience and may require free registration) in getting rid of warts. Yes, duct tape: 101 uses, now 102!

There are only three clinical studies on this, though that's kind of interesting since you could imagine there would be none. The effectiveness is not 100%, but it also doesn't seem to be harmful either. The idea is that covering warts with duct tape causes localized inflammation and irritation, which in turn stimulates an immune system response that helps in getting rid of the warts. This is supposed to be how freezing warts works, too.

The treatment with duct tape in clinical studies is:

1. Cover the wart with a piece of duct tape for seven straight days.
2. Then, remove the tape for 12 hours overnight.
3. Repeat Steps 1 and 2 as needed for up to 6-8 weeks.

Again, there are no wart treatments that are 100% effective. However, this method can be helpful and seems otherwise to have no harmful side-effects unless you are simply allergic to duct tape.

Interesting Reads

Warren Buffet on the risks of bonds assets (ditto from Black Rock): (Bloomberg).

Interesting analysis of the Obama presidency to date,through the lens of the history of modern U.S. Presidents: (Atlantic).

Yves Smith on why the bank bailout sucks: (Naked Capitalism).

Matt Taibbi says "cry me a river" to Wall Street bankers: (Rolling Stone. profanity alert- it's Taibbi)

Could You Pass a U.S. Citizenship Test?

Just for hoots, try passing this 96 question citizenship exam found posted in that hotbed of communist sympathy the Christian Science Monitor.

All applicants for citizenship must pass a Naturalization Test, scoring at least 60% correct. 92% of applicants do so. Have a go at it!

Why Don't You Use a Computer?

I get asked every now and again by patients (usually while I'm writing in their chart) whether I plan to go to a computerized medical record.

I find that to be a really interesting question. Generally, I am a very enthusiastic computer user. I create web content, enjoy computer games, am versed in maintaining and securing wireless networks, and am proficient with several operating systems.

However, I have no plans to adopt "Electronic Medical Records" (EMR) unless they become far more useful than they are at present.

First of all, adopting EMR is shockingly expensive. Start up cost of adding new hardware, licensing software, training staff and doctors in their use and scanning existing paper records to EMR is about $50,000 in itself. This does not include future licensing or upgrades to equipment or software. It also does not include the 10-20% losses in income of the first 1-2 years of adoption due to a decrease in the number of patients that can be seen, as the implementation of EMR slows everything for 1-2 years.

Additionally, there is no widely accepted standard code set or open-source code for EMR. This means it is very easy to sink this kind of time and money into EMR for your office or group or hospital and be absolutely unable to use it to share crucial medical information with neighboring physicians simply because they using one of the other 10-20 most popular EMR platforms being marketed.

It should also be realized that EMR is not new, and has been around for a decade or two. It's intended primary use has never been to enhance the quality or consistency of medical care. Rather, it has been marketed as a way to fully document your visits in such a way as to justify your billing to insurance companies.

Unfortunately, EMR has not been fully re-vamped to optimize patient care and reduction of errors. Instead, features have simply been layered over and added on to the pre-existing systems. As a consequence, studies demonstrate that EMR does not result in improved care and actually results in increased error rates.

All of this may explain why the majority of doctors have not adopted EMR. A regular contributor to Kevin, M.D. nicely sums this up. You might not notice this here in Placerville, since Marshall has implemented an EMR system recently which can make it look like everyone now uses EMR.

I find it interesting that when I answer patient questions by saying that I don't plan to computerize my office the response is usually positive.

Most patients have commented that they find the use of a computer by doctors, nurses and physical therapists to be off-putting insofar as it limits conversation and eye-contact, and seems to take up time that would otherwise be spent examining or communicating with patients. I suspect they have a point here.

I'm sure it's possible to use EMR and not lose this human touch, but the current systems just aren't there yet and aren't likely to be there soon. I myself would rather not risk losing this element of human touch and communication with my patients.

A Reverend and His Calling

The reverend in the picture writes movingly of his experience at the Port of Seattle. The link was forwarded to me by a member of his church. While I've never met the reverend, I have no reason to take his words at anything other than face value. Read his story with an open mind, as his words are very much worth reading.

Choosing a Medicare supplement

The open enrollment period to join or change a Medicare supplement plan is from 10/15 to 12/7 this year. Selecting the right plan for you does not have to be difficult. Seriously.

If you call an insurance broker to help you in this, you do want to sound very assured and informed about what expensive medications you take (if any) and what extent of coverage and monthly premiums you can afford. Otherwise, a broker is going to be unwilling to spend 1-2 hours with you without being able to sell you a plan.

The website for the Open Enrollment Center has gotten easier and easier to use since the start of the Part D (drug coverage) and Part C (Medicare Advantage) programs years ago.

First, click on the blue bar-shaped button called My Medicare Tools. (Sorry, Windows Vista is not easy to use for screenshots.) This goes to the Resource Locator page.

Next, click on the sidebar element called Drug and Health Plans. This will open the Medicare Plan Finder. Jackpot!

From here, you can use your Zip Code to look for available plans in your area. If you want, you can also do a more personalized search based on your Zip Code, and also your existing Medicare Number and demographic information.

Even using the general search just based on Zip Code alone, you still can indicate whether or not you are already on Medicare and whether or not you have any other help with prescription drug costs (such as Social Security, MediCal, SSI and so forth).

Continuing on the general search with regular Medicare alone, you get a chance to create a list of medicines you take by name. You do not have to do this, but it's useful if there are any medicines you get which seem to be unusually expensive. Usual examples of this would be inhalers for asthma or COPD, and pills for rheumatoid arthritis, chronic colitis, chronic pain and cancer. The vast majority of medicines for heart conditions and diabetes are generically available.

If you wish, you can bypass this by clicking "I don't take any drugs", or "I don't want to add drugs now".

The next screen then allows you to check off the pharmacy or pharmacies that you use. You can select as many from how ever many miles from where you live, or just skip ahead.

At this point, you get a Summary of plans in your area. This list will be limited to only ones that fit your selections if you made any specific selections. Here, you can go on to see an entire list of plans. You can also refine how the list is presented to you before you proceed. For example, you may want to show only Part D drug coverage plans because you already have Part A and Part B Medicare. Or, you may want it to show plans listed in order of monthly premium, or in order of annual deductibles, or ratings by consumers.

The last screen is titled Your Plan Results. This is a list of plans where you live, available to any pharmacies you may have chosen and any other specifics you may have made. You can still use the drop-down menu to change the list to show in order of cost, or ratings, or other choices. You can also check the box to the far left of any plans that interest you, and then click on the orange bar "Compare Plans" to show a head-to-head comparison of just the plans that interest you.

For what it's worth, looking for the most highly consumer-rated Part D plans in the Placerville area shows Medco, Blue Shield and AARP to be the best. Certainly, we've had no problems with any of these and patients do not complain about their coverage with them.

Otherwise, please please please DO NOT choose any plan that "takes over for Medicare" or makes Medicare your secondary insurance (this includes Part C Medicare Advantage plans). This will immediately result in a smaller pool of available specialists, more restrictions on medications, and long delays in getting authorization for any tests. If you don't like "the Canadian health care system", then don't pick any plan like this!

Be very suspicious of the nicely dressed, helpful young men and women with the tables set up at the grocery or drugstore. Plans they offer may be cheaper in the short run, but you will definitely be getting what you pay for here. Remember; if it's to good to be true, it is!

Emergency Contraception- the "Morning-After Pill"

"To err is human, to forgive is divine."

Despite best efforts, accidents can happen. In this case, we are talking about unprotected sexual intercourse and the possibility of undesired pregnancy. This could involve teens and young singles, and also married couples who do not yet want to have children or do not want to have more children.

Medication is available that can really lower the likelihood of pregnancy occurring in this event. Higher than normal doses of birth control pills can prevent a fertilized egg from becoming a fetus.

Specifically, these medications can keep an egg (or ovum) which has been fertilized by sperm from being able to implant (stick to) the inside of the uterus, and hence from eventually going on to become a fetus.

Mind you, if you feel or believe that preventing a fertilized egg from sticking to the inside of your uterus (womb) would be something that you feel wrong in doing then by all means do not do so. However, most people who feel strongly about "right to life" issues do not define this as abortion.

Plan B is the brand name of a medication you can buy over-the-counter, and use in case of emergency. It can cost about $45.

It is important to realize that time is of the essence in such a situation as missed birth control pills, condom rupture or unprotected sex. If Plan B is taken within 12 hours, it has a 95% chance of preventing undesired pregnancy. By 2 and 1/2 days later, the chance falls to 72%. Sooner is definitely better! It is probably best to simply buy some and have it ready to use if you ever need it. Twelve hours can go by very quickly when stores are closed on a weekend night.

Plan B was actually based on the known doses of birth control pills needed to prevent undesired pregnancy. It is simply packaged in a form that is easy to use.

This link from Princeton University provides useful guidance in how to use 19 different commonly used birth control pills as emergency contraception.

Life Line ultrasound screening- Meh.

I get asked about this test periodically, whenever Life Line scans come to town.

Do I recommend them? No.

Why doesn't my insurance cover them? Because they are proved not to be helpful.

The tests include ultrasound examinations of the carotid arteries which carry blood supply up to your brain, the abdominal aorta which carries blood supply to the abdomen, and also the circulation in your legs.

These are all standard diagnostic tests which can be ordered by doctors and are covered by insurances. The problem is, they are not useful as screening tests applied to patients who have no concerning symptoms. These tests have only been shown to be useful in preventing strokes, aneurysm rupture or worsening leg circulation in the presence of symptoms or abnormal physical exam findings.

In the absence of such, we find that applying these tests does not prevent these problems and simply exposes healthy people to further and riskier tests in the event of minor abnormalities being found.

Mind you, this is one of the reasons to be seen annually for wellness examinations or physicals. An important part of the exam is checking for findings that would suggest circulatory problems or aneurysms. Happily, the physical exam is quite sensitive in finding these problems and can guide further testing and treatment. When I am listening to your neck and abdomen and feeling pulses in your feet, that is exactly what I am doing!

Effectiveness of Prostate Cancer Screening

If you have been following the news in the last week, you will see that the United States Preventive Services Task Force (USPSTF) has recommended that doctors not routinely screen for prostate cancer in men. A separate and independent review panel agrees with this recommendation.

Mind you, both groups are composed of doctors and analysts who have no ties to government employment or drug companies. Also, their recommendations are based on how well screening and preventive efforts work without regard to their cost. In other words, recommendations are not made on the basis of cost to the system or rationing.

PSA blood testing and rectal examination have to some extent seemed to doctors to be tools that are not the "sharpest tools in the shed", but the only tools available. It was hoped that over time, their use in screening for prostate cancer would have a positive impact on outcomes; that is, keep men from dying of prostate cancer.

The problem here, is that these tests do not seem to end up saving lives. In fact, it may be that they cause more anxiety, suffering and painful and unnecessary tests and surgeries than benefits.

A major difficulty here is that prostate cancer is common, yet dying of it is not.

Cancer cells start to appear in a normal, healthy man's prostate gland as a pure correlate of aging. By the time you are 50 years old, the chance of having cancer cells in your prostate gland is 50%. At 65 years old, the chance is 60% and by 75 years old it is 75%.

Yet, out of 17 men with cancer cells in their prostate, only one will die. The other 16 will go on to die of natural causes or other conditions without any sign of prostate cancer.

The problem is, that we do not have a way of determining who is that 1 guy out of the 17, so we end up treating all of them as if they will go on to die of prostate cancer without treatment.I

In addition to this not very good statistic, the number of men every year who die of prostate cancer is staying the same over time. In other words, we are not saving lives by doing routine annual rectal exams and PSA blood tests.

Faced with this, it seems that it would be better if we simply stopped doing such routine screening until we can develop a way to determine who's prostate cancer should be aggressively treated, and who's can simply be watched.

Mind you, this does not apply where there are symptoms present that raise a concern of prostate cancer- that's not screening, it's diagnosis. It also may not apply to men with a concerning family history of prostate cancer in their fathers or brothers.

This is certainly a discussion that can be had face to face in the office. I just think patients should have all the information at hand to make decisions that they feel are right for them.

For my part, being a man over 50 with no history of prostate cancer in my family, I do not intend to have prostate cancer screening tests done as part of my annual physicals.

Advance Directives- Pre-Hospital DNR, or AND

The idea around decisions or orders to Allow Natural Death (AND), or Do Not Resuscitate (DNR) is to address your preferences or personal wishes in the event of a sudden and immediately life-threatening loss of heartbeat and/or ability to breathe.

In previous posts, we discussed directives you can make which speak to your wishes on matters affecting your medical care.

This post specifically discusses sudden, unexpected and potentially immediately fatal events occurring outside the setting of a hospital or ER, and your wishes in such an event. More particularly, this pertains to a sudden loss of heartbeat and ability to breathe such as might occur in a massive heart attack.

This may be ultimately expected in a terminal illness such as advanced cancer, or may be entirely unexpected.

Doctors generally ask about your preferences since we do not wish to withhold care from you that you want, but we also do not wish to perform heroic or even desperate procedures on you that you actually do not want.

Certainly, you should realize that a decision by you to allow a natural death or not to resuscitate does not affect your care in other matters such as your cancer, pneumonia or hip fracture. As our nursing colleagues rightly point out, "no resuscitation does not mean no care"!

Something to be mindful of in your decision-making is what is occurring during a loss of breathing and pulse and during CPR.

A sudden loss of breathing and pulse can occur for a variety of reasons, but while it is occurring, there is a significant loss of oxygen supply and blood flow to your brain. CPR is an attempt to maintain circulation of blood to the brain while awaiting definitive attempts to restore normal heart rhythm by delivering an electrical shock. This is known as defibrillation (or "shock paddles", as seen on TV). Medicines given if this occurs in a hospital are largely given in order to maximize blood flow to the brain. It is ultimately timely defibrillation that can restore normal heart rhythm with intact brain function.

Note the emphasis on the intact brain function part.

The tricky part here is that your brain can only go for 5 minutes without good blood supply before permanent brain damage starts to occur. Past this limit, the longer the duration of sub-optimal blood flow the more extensive the damage. For a worst-case scenario, think Terri Schiavo.

Even in the best of circumstances where this occurs in a hospital, the odds of going home alive and with an intact brain are about 15%.

If this occurs outside a hospital (such as at home, a friend's house, a movie, a restaurant, etc.) the lack of immediate access to a defibrillator makes an enormous difference.

If you survive long enough to make it to an ER, and survive long enough to actually be admitted to the hospital, your odds of eventually going home alive and with an intact brain are only 2-8%. This is because your valuable 5 minute window of opportunity is already gone by the time paramedics can arrive even if someone has immediately called 911.

Once paramedics arrive, they are legally required to initiate CPR and resuscitative efforts. If, given the aforementioned discussion, you would wish for them to do so, you do not need to take any action at all.

On the other hand, if you would NOT want them to do so, you need a signed order from a doctor instructing them not to start resuscitative efforts.

This handout and sample form can be used if you feel that you would not want paramedics to start resuscitation for such an event in your home. It only requires your signature (or your caregiver's) and your doctor's signature.

(Paramedics will still come to your home and provide the usual help in all other matters! Signing this does not mean that they will not come to your home, or help you if you have fallen down or have a medical problem.)

Advance Directives- POLST

In 2009, a new sort of advance directive became available. It is called Physician Orders for Life-Sustaining Treatment (POLST). It is not meant to replace an Advance Directive for Health Care, but rather to amplify on it in a clear and easily read manner. Also, it can be used even if there is no formal Advance Directive.

Additionally, the POLST form takes the form of a physician order and does not require notarization or witness co-signatures as does the Advance Directive. It addresses your wishes around heroic resuscitation or cardio-pulmonary resuscitation (CPR), as well as your preferences in terms of how intense or aggressive you wish your medical care to be in the event of a serious medical problem.

This is a very helpful list of frequently asked questions from the California Hospice Foundation.

This .pdf document is the actual POLST form itself for your use.

Advance Directives- An Introduction

Advance Directives are important legal documents, but are sometimes misunderstood. Generally speaking, advance directives designate another person or persons to make decisions or take actions on your behalf should you be unable to do so for yourself. They can also be designed to state your own wishes and preferences.

Many people have such directives around legal and/or financial matters. For example, they may have a will or a living trust or they may have a document authorizing their spouse to gain access to financial accounts or pay bills or sell assets if they were to become unable to do so themselves or jointly.

Advance Directives for Medical Care (so-called "Living Wills") make your wishes known about medical care and designate people to make medical decisions for you if you become unable to state them for yourself. For example, you will typically be asked to state a preference around organ donation and around prolonging life in the event that you are in a coma or persistent vegetative state ("brain dead") or some terminally ill condition.

Please be aware that your wishes around artificially prolonging your life only become applicable when you are already brain dead or in a coma or terminal condition. Advance Directives generally do not address your preferences or wishes around scenarios that could lead up to being terminally ill or brain dead.

For example, you may have strong feelings about the roles of interventions or procedures such as dialysis or emergency brain surgery in dire emergencies where you are already so sick that cannot discuss them for yourself. It is okay to add these wishes to your Advance Directive.

Advance Directives allow extra space for the addition of any further statements that you may care to make. In California, they do not require an attorney to draft. They simply require your signature and either a notary public or the signatures of two persons who know who you are.

However, you may wish to enlist the aid of an attorney if such a directive seems complicated or unclear.

This site has state-specific free downloads of Advance Directive forms.

Five Wishes (produced by the non-profit Aging With Dignity) is an advance directive that more fully addresses your feelings around comfort and is a bit more specific around examples of life-sustaining interventions or procedures and allows you to address them as you see fit. The document costs $5, but can be previewed for free as a .pdf document.

This form from the Attorney General's office of the State of California is also freely available.

We also have a handout on this subject and sample forms from the California Hospital Association for your use. Feel free to ask for one next time you are in the office!

Pharmacokinetics: What happens to the medicines I take?

Folks often ask questions about their medicines (whether over-the-counter or prescription) that have to do with how long they last, or how long it will be before they take effect, or how long until side-effects may go away or for the medicine to be out of circulation.

A handy principle or "rule of thumb" has to do with what happens to medicines after you take them; this is known as pharmacokinetics. (On the other hand, what they do after you take them is called pharmacodynamics.) Mind you, this rule of thumb only applies when a medicine is being taken regularly and as directed. This means that it is being taken in the instructed amount and frequency and not "as needed" or "now and again". However, this rule of thumb applies to nearly any medicine by any route (swallowed, injected, i.v., etc.).

How much of a medicine (dosage) and how often it needs to be taken (frequency) has to do with how quickly your body metabolizes or breaks it down, and then how quickly it is excreted out of your body. For the vast majority of medicines, the liver breaks them down, and then they are excreted in your urine.

When taken at the directed dose and frequency, a medicine does not stay at a fairly constant and effective level in your blood stream until after the 4th dose. This is called steady state.

For example, if today you start taking a pill for pain that is supposed to be taken three times every day, then a steady and pain-relieving amount will start to be maintained in your system by later tomorrow. On the other hand, if you start one that is a once a day pain pill, it will not reach a steady level until five days from now.

Similarly, if you are taking a medicine regularly and feel that it is causing troublesome side effects it will not be entirely gone until after the fourth missed dose.

FDA Concerns About Zocor/simvastatin in the 80 mg dose

The Food and Drug Administration (FDA) announced concerns yesterday about the risk of muscle injury specifically around Zocor or generic simvastatin in the 80 mg dose.

Statins have been widely used since the 1980's for reduction of cholesterol and reduction in the occurrence of sudden deaths from cardiac arrest, heart attacks and strokes. Muscle injury is known to be an uncommon side-effect of the statins and is proportional to the potency ("strength") and dosage ("size") of the particular statin.

Simvastatin is the most potent of the generically available statins, and the 80 mg dose is the highest dose made for it.

The FDA is concerned (this link is technically worded) that the risk of muscle injury with 80 mg a day of simvastatin is higher than for comparable doses of other statins. Specifically, they are recommending that doctors not start patients on this dose, or increase patients already on lower doses to this dose.

This concern is based on a recently completed medical study comparing the effects of simvastatin in 20 mg and 80 mg doses with and without supplemental Vitamin B12 and folic acid after heart attack.

One of the findings from this study was that the risk of muscle injury with the 80 mg dose was 0.9%, and 0.02% with the 20 mg dose. Prior to this test, the risk with the 80 mg dose had been reported as 0.53%. Hence, the warning.

Please note that if you already are on simvastatin at 80 mg a day for a year or more and not having side effects (such as persistent muscle or joint pain, or weakness), there is no need of concern.

News announcements suggest switching to other medicines that are as effective as 80 mg of simvastatin. The problem with this is that the only medicines that are equally effective are Lipitor 40 mg and Crestor 20 mg. Neither of these is generic, so they are often much more expensive.

If you would like us to switch you to one of these, let us know. Please check your insurance formulary to see which of these you would prefer so you can let us know which one to switch you to.