A personal story about a medication

In May and June of 2022, I had both knees replaced. I was given a prescription for diclofenac, a non-steroidal-anti-inflammatory (NSAID) and instructed to take one each morning and evening. I took only two or three, so had a lot left over. Lately, I’ve discovered that they are a great pain reliever for my sciatica, so I started taking them several times a week.

When researching the side effects of that drug, I came across research conducted by Washington State University College of Pharmaceutical Sciences that investigated the fact that, for some people, diclofenac causes heart damage. In the U.S., diclofenac could be purchased over the counter until 2013, at which time the FDA restricted it to prescription-only because of the heart damage reports. Nevertheless, more than 10 million prescriptions for diclofenac are written every year in the U.S., and it is one of the most widely used NSAID drugs worldwide, including countries in Asia, Africa, and the Middle East where it can be purchased without prescription.

I wrote to Bhagwat Prasad, one of the lead researchers. He wrote back. Here are excerpts from our several email exchanges. I began by introducing myself and explaining my history of taking diclofenac, after which I add the following sentences:

Me: Is there a way I can find out if I am one of those for whom diclofenac can cause heart problems? Diclofenac is the only medication I take.

Bhagwat: Our study suggests that individuals who don’t carry UGT2B17 gene are prone to higher levels of diclofenac in blood and risk to greater toxicity after oral administration. However, there are many factors that affect safety of diclofenac in different people.

Me: Since last writing to you, I had an MRI and learned that I have “severe spinal stenosis” (L4-L5). Painful sometimes. I do lots of stretching and exercising. Diclofenac is a big help.

I signed up with 23 and Me when the company first got started. I’ve contacted them and was able to search my raw data. I got the following response: “No genes or markers found matching UGT2B17.” I guess that’s bad news, but good to know. I’ll keep taking diclofenac on golf days anyway. It works.

Bhagwat: Thank you so much for these updates. First, I should thank you for taking care of yourself and prioritizing your health. You have become my role model! This is all very impressive that you have 23andMe data available for you to consider when taking medicine. [He goes on to recommend sharing this information with my physician and reducing the dose, etc.]

Me: I want to share a bit of alarming information from a book I read recently, called From Here to Eternity, by Caitlin Doughty. The book describes various ways in which different peoples from around the world deal with death. In Mumbai, the Parsis build platforms on which they place their dead bodies for vultures to devour. Doughty writes, “The vulture population has dropped 99 percent. In the early 1990s, India allowed the use of diclofenac (a mild painkiller similar to ibuprofen) for ailing cattle. Hoof and udder pain were eased, but when the animal perished and the faithful vultures soared down for the meal, the diclofenac caused their kidneys to fail.”

Are you familiar with this? As you can imagine, that paragraph caught my attention!

Bhagwat: Yes, I am aware of the vulture being vulnerable to extinction with diclofenac use. It’s a huge man-made disaster as we are killing the scavengers. The problem has recently been noticed in Spain and UK as well. Diclofenac causes vasoconstriction and damages kidneys of vultures. There are multiple reports of kidney related problems of diclofenac in humans with chronic use. [So far, email exchanges end here.]

Maybe I shouldn't even take diclofenac on golf days.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Nighttime mouth breathers: try taping your lips closed

 This is the second blog I’ve posted on forcing yourself to breathe through your nose by taping your mouth closed at night. I’m revisiting it because of readers’ comments following an article published by The New York Times (summarized briefly in the next paragraph). Many readers said that the practice was “life changing.” So, while I have no experience with the practice, maybe some of you would find it to be valuable.

The benefits of nasal breathing are many: it humidifies and filters the air; activates your lower lungs; lets you take deeper, fuller breaths; helps your body relax; helps filter out allergens, pathogens, and dust; helps lower blood pressure; improves blood flow; improves air flow; and reduces snoring. Sleeping with your mouth open can cause you to wake up with dry mouth, which can contribute to cavities, bad breath, a hoarse voice, and dry, cracked lips. 

If you normally struggle to breathe through your nose, taping your mouth closed is probably not a good idea. If you want to try it, choose a tape, such as surgical tape, that comes off easily. Some people recommend SomniFix sleep strips, also 3M Durapore. (One person recommended using an adult pacifier!) You can ease into the practice by starting during the day, taping your mouth for about ten minutes a day, then working up to 20 or so minutes.

For more information about mouth vs. nasal breathing, see my earlier blog on the subject.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Diet and cognitive decline

Scientists from the Harvard School of Public Health and Rush University Medical Center performed a landmark study to determine if a Mediterranean-style diet could protect people against cognitive decline. (Short answer: No.) The study, called the MIND Diet Trial, was considered “landmark” because the researchers used the “gold standard” of research: the randomized controlled trial. Because such trials are expensive and take a lot of time, they’re rarely undertaken for nutrition studies. (Most nutrition studies are “observational” and thus not trustworthy.)

After screening 1,929 people, researchers selected 604 older adults who were either overweight or obese, whose diets were “suboptimal,” and who had a family history of dementia, putting them at a high risk for the disease. The participants—none of whom had dementia—were divided into two groups: one who ate a MIND diet with “mild caloric restriction,” and one who ate their normal diets, but also with caloric restriction. At the beginning of the trial, all participants were given cognitive assessment tests and brain scans.

As you’d probably guess, the MIND diet consists of whole grains, leafy green vegetables, nuts, beans, berries, occasional poultry and fish, and olive oil. Specifically, it calls for at least six servings of leafy greens and two servings of berries each week. It restricts pastries, sweets, red meat, cheese, and fried foods to less than one serving a week, and limits butter to less than a tablespoon a day.

The trial lasted for three years, at the end of which participants were again given cognitive assessment tests and brain scans. As reported in The New England Journal of Medicine, outcomes “did not differ significantly between those who followed the MIND diet and those who followed the control diet….”

Perversely, this outcome pleases me. I get so tired of the sanctimonious advice-givers touting the Mediterranean diet. Bring on the cheese and butter! 

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Urinary tract infections

A recent article in The New York Times covered many of the basics about urinary tract infections (UTIs, aka bacterial cystitis). Here’s a summary:

• Over half of us women will get a UTI at some point in our lives. Fourteen percent of men will get UTIs. (Their number is smaller because of their longer urethras, which makes it more difficult for bacteria to reach the urinary tract.)

•  UTIs are mostly caused by E. coli bacteria, which live in the gut and sometimes hang out in the area between the anus and vulva (or scrotum).  How and in what circumstances the bacteria migrate into the urethra and urinary tract is “not 100 percent worked out” (an understatement).

•  A UTI can occur anywhere along the urinary tract (urethra, bladder, kidneys and, in men, the prostate). Symptoms vary, but common ones include burning and the constant sensation of needing to pee.

•  Whether or not sexual practices cause UTIs is debatable. Studies have not been conclusive. Hygiene practices—wiping front to back, avoiding tightfitting underwear, how well you bathe, etc.—are “not rooted in scientific evidence.”

•  Antibiotics are not always needed: “Young, healthy patients find that the body can eventually flush out bacteria on its own.” (See comments below about this one.)

•  Cranberry products—juice, tablets, or capsules—reduce the risk for women with recurrent infections. For older women with decreasing levels of hormones, vaginal estrogen can prevent infections.

Over 700 people—many of whom were physicians—wrote comments in response to the article. Here are some worth noting:

Important:

• Antibiotics: One physician wrote, “Delaying treatment of urinary infection can cause serious damage before it can be stopped. Before the introduction of antibiotics one of the most common causes of death among women was ‘Brights disease’—kidney failure from recurrent and chronic UTIs.” Other physicians made similar comments. For example, “A UTI affecting the kidney (pyelonephritis) can lead to sepsis…it’s very, very common!” A lay person added, “My mother developed a UTI in her assisted living facility which became sepsis and she died from it.”

• Delirium in the elderly:  Many people, including physicians, made comments such as, “UTIs in elderly patients are likely to be manifest as confusion or delirium, increased lethargy, blunted fever response, new-onset incontinence, changes in personality, and anorexia.” These symptoms go away after the infection has cleared up.

Worth considering: Many commenters swore by a product called D-Mannose powder to prevent infections. There’s some truth to this. The powder is a type of sugar that might stop bacteria from latching on to cells in the urinary tract.

Sex: Lots of people mentioned sex as a culprit, for example: “I had UTIs constantly, until I divorced and came out as a lesbian.” “A friend’s recurrent UTIs cleared up after her husband became too ill to have intercourse.”

Interesting symptom: Three people mentioned that, when urinating, they experience tingling in their hands, and/or pain and discomfort in their hands and arms.

Eyebrow-raising:  Many commenters contributed their remedies for UTIs, including boric acid suppositories, a gallon of water every 24 hours, 100% cotton underwear, oil of oregano, forgoing toilet paper, avoiding consumption of chicken, and, my favorite, washing “down there” with tequila spritzer.

As for myself, I had a UTI once in my 20s, and have had a couple more recently. Even though I resist taking antibiotics, the minute I felt the symptoms I grabbed the first antibiotic I saw in the medicine chest, which happened to be my husband’s amoxicillin. I took it for two days and the symptoms went away. (I also saw a doctor and got a different antibiotic for future infections.)  As a preventive measure, I use a vaginal estrogen cream once a week. So far, so good.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

No shame in taking meds

 I’m a big fan of Dr. Aaron Carroll. He writes sensible op ed pieces about medicine in The New York Times. I was surprised by his latest article in which he discusses his struggles with depression, anxiety, and obesity. He’s resisted taking medications for these conditions, partly because he viewed them as a “crutch” that would make him feel like a failure and partly because “the medical understanding of them seemed vague.”

 After a panic attack, he gave in. His doctor prescribed a selective serotonin reuptake inhibitor (S.S.R.I.) called sertraline. It worked. “It had a remarkable effect on my mood…I was more optimistic, friendlier and more engaging.” Neither he, nor other medical people, can explain why the medication works for him or for anyone else.

 

Dr. Carroll also began taking one of the new obesity drugs, such as Ozempic and Wegovy. (At the moment, these drugs are approved only for diabetes, so are not covered by insurance. As with S.S.R.I.s, doctors don’t fully understand why the treatments work.) He’s had a lifelong struggle with his weight. Even though he exercises and eats healthfully, he recently slipped into obesity, according to his body mass index. “Though I’ve tried every diet, nothing has really helped. I’d lose up to 10 pounds and then plateau until my weight crept back up. …I felt like a failure, which led to self-hatred and anger.” After starting the new drug regimen, he lost 15 pounds in five weeks, and “I’ve done it with ease. I’m not hungry all the time. I’m not thinking about food incessantly.”

 

As with his need for anti-depressant drugs, he feels shame about needing meds to control his weight. “We make assumptions that people with depression aren’t trying hard enough, that people with obesity lack willpower.” Neither of these assumptions is true. Like other maladies, something in his body and brain is off balance. The drugs are correcting the imbalance. No shame in that.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.