Heart Burn: Are we treating for too long?

Heart burn is a common phenomenon that can be characterized by a burning sensation in the throat, and chest. Heartburn is relatively easy to treat with a variety of OTC and prescription products. Proton Pump inhibitors (PPIs) are the premier drug class for treating heart burn, and have had a reputation for being benign drugs, until recently.

New evidence is emerging about long term use of PPIs showing correlations between opportunistic infections, pneumonia, and malabsorption of nutrients.^1,2 The current recommendation for PPIs for heartburn is 8 weeks, but the reality is many patients surpass this time-frame.

Health care providers should be striving to limit PPI therapy duration in patients to avoid these complications until more information is available.

Difficulty Ceasing?

In patients that have surpassed the recommended 8-week therapy duration, there are two main barriers that make it difficult to terminate therapy.

One of the barriers stopping PPIs therapy cessation is patient preference. Most patients are not optimistic about stopping their PPI therapy, because of how well they work.

The second barrier that causes issues with cessation of PPI therapies is the perceptions of health care providers.  PPIs have been available since 1988, and many healthcare professionals view them as safe drugs. Since most health care professionals view them as harmless, they are less likely to intervene with patients using PPIs long term.

Who does this affect the most?

Although long durations of PPI therapy should be a concern for all patients, it is especially troublesome in older adults. Older adults are more prone to infection, and are more likely to suffer from nutritional deficiencies. Long term PPI use in older adults also adds an extra layer of issues due to drug interactions. To limit this potential harm, it is important to always address any PPI use in older adults.

What can we do?

The best way to decrease complications of long term PPI use in heartburn patients is to play a more active role in product selection, and therapy duration discussions.

Tips:

1) Recommend lifestyle interventions such as exercise, weight loss, and limiting meals before bed.³

2) Consider other drug classes first before PPIs when dealing with mild & moderate cases of heartburn.

3) Discuss with patient and prescribers expected duration of therapy prior to PPI initiation.

4) Investigate any patient prescribed PPIs for longer than 8 weeks and discuss possible taper options.

5) Attempt to taper patients on long term PPIs at least once a year using a combination of life style modifications and other drugs to help.

Quick Tip: Never stop a PPI abruptly due to risk of rebound hyperacidity.

Although PPIs are used mostly to treat minor ailments, it is important to remember the associated risk with long term use. 

Hopefully these tips will be helpful for everyone, because I am signing off.

I hope you have enjoyed my posts & are excited for the next student blogger.

Sincerely,

Derick Oduro

References:

1) Trifan, Anca, et al. “Proton Pump Inhibitors Therapy and Risk of Clostridium Difficile Infection: Systematic Review and Meta-Analysis.” Advances in Pediatrics., U.S. National Library of Medicine, 21 Sept. 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5643276/. 

2) Heidelbaugh, Joel J. “Proton Pump Inhibitors and Risk of Vitamin and Mineral Deficiency: Evidence and Clinical Implications.” Advances in Pediatrics., U.S. National Library of Medicine, June 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC4110863/. 

3) Ness-Jensen E, Lindam A, Lagergren J et al. Weight loss and reduction in gastroesophageal reflux. A prospective population-based cohort study: the HUNT study. Am J Gastroenterol 2013;108(3):376-82.

Recalls and Shortages: Knowledge is Power

In today's digital age information is readily available quickly, which can be both positive and negative.  

Health Canada recently recalled Valsartan, a drug for hypertension due to carcinogenic contaminants. As one would expect, this caused a lot of panic among the public. Working in a community pharmacy at the time, I remember getting several frantic calls from frightened patients about this recall. Several patients were displeased that we did not contact them first. The most common calls however, were patients trying to confirm if any of their other medications were being recalled. This panic could have easily been avoided if patients were aware of the resources available to them. 

Health Canada provides updates on its website and app, both of which are underutilized by health care professionals and patients. The website and app provide updates on Health Canada’s decisions for recalls and shortages pertaining to food, consumer goods, vehicles, and drugs.  

Importance of Accuracy? 

Since information spreads quickly in the digital age, it is important to get accurate updates, especially in regards to drugs. 

A game of broken telephone often occurs when news breaks, causing misinformation to spread. A great example would be the Valsartan recall. Health Canada had the entire list of Valsartan products being recalled along with their strengths, and manufacturers. Many news outlets simplified this to the drug name, Valsartan and its primary indication, blood pressure. Many patients simplified this to a medication for blood pressure when contacting their family and friends. This led several people down an emotional roller coaster only to find out their drug was not affected. 

Why does this matter? 

Providing patients with these resources provides a reputable source for information on drug recalls and shortages. Well-informed patients are less likely to make rash decisions or panic. The goal is not to stop patients from contacting their health care providers, but to provide better tools for self-care. Self-care is an integral part of health maintenance. Drug recalls and shortages are a common occurrence, and it is difficult to relay this information to patients. Arming patients with these tools for recalls and shortages promotes self-care and limits the harm that misinformation causes. Hopefully this is something that you will strongly consider for yourself and your patients. 

Thanks for your time & catch you next week, 

Derick Oduro 

Website Link: 

https://healthycanadians.gc.ca/recall-alert-rappel-avis/index-eng.php?cat=3 

App Links: 

Google Products & Android Mobile Devices

Apple Mobile Devices & Products

Amazon App

Toenail Fungus: Wow, that's a lot on your plate

The issue?

Toenail fungus is not the most fun topic, but it is something we must talk about, especially when nail infections  currently effects 6.4% of Canadians.¹ This is approximately 2.3 million cases of nail fungus in Canada, most of which are toenail infections. Toenail fungus is usually preceded by athlete's foot, but it can occur independently. Toenail infections can cause several complications and should be treated promptly. A common issue with toenail infections is the aftermath after a successful treatment.

There are two terms used to define a successful treatment for toenail fungal infections. A mycological cure refers to the eradication of the fungi at the nail. A complete cure is defined by the eradication of fungi at the nail and the appearance of a healthy-looking nail. Most successful treatments of toenail fungus end with mycological cure, leaving patients with discolored and thickened nails. 

The hard part?

Unfortunately, the medications available for treating toenail fungus are not great at achieving complete cures. Topical antifungals and oral antifungals are the preferred therapy for treating toenail infections.

Efinaconazole and Ciclopirox are the two available topical therapies for the treatment of toenail fungus and have a respective 17% and 8.5 % complete cure rate.² Achieving these cure rates are difficult because it requires patient's to be compliant with once daily usage for 48 weeks. 

The oral therapies Itraconazole and Terbinafine have the advantage of a lower duration of therapy (12 weeks) but come with unwanted drug interactions. Oral antifungals are notorious for their plethora of drug interactions, which can effect people taking medications for:

• Depression
• Pain
• Migraines
• Blood Pressure
• Heart rate
• Cholesterol
• Psychosis
• Anxiety
• Sleep Deprivation
• Urinary Incontinence
• Heart Burn

Since several drug interactions exist it is difficult to treat most patients without risk of interactions. All this extra risk coincides with a higher cure rate, but not much. Terbinafine has the highest complete cure rate for oral antifungals commonly used. When used optimally, it’s complete cure rate is 38%.2

Good hygiene:

Low complete cure rates are a reason for concern for fungal toenail infections. Good hygiene practices can decrease the risk of contracting a fungal infection.

Hygiene Practices:

• Wearing shoes that minimize humidity. Preferable shoes made of canvas or leather.
• Avoid sharing toe nail clippers, towels, and other foot care devices with individuals
• Keep nails clean and short
• Avoid being bare footed in publicly shared spaces such as swimming pools, nail salons, gym locker rooms.
• Dry feet immediately after washing
• Wash feet with soap and water every day
• Change socks worn each day, and even more frequently for physically activity individuals or those with a propensity to sweat
• Wear socks preferably made of acrylic, cotton, polypropylene or wool.

Quick Tip: All these hygiene practices are valid for preventing both nail and foot fungal infections.

Although the mycological cure rate is respectable for most antifungals, the complete cure rate is usually low. Hopefully this will keep you on your toes, and get you to make the appropriate changes to your daily routine to decrease your risk.

Thank you for your time, and have a nice long weekend!

Derick Oduro 

References:

1) Gupta AK, Gupta G, Jain HC et al. The prevalence of unsuspected onychomycosis and its causative organisms in a multicentre Canadian sample of 30,000 patients visiting physicians' offices. J Eur Acad Dermatol Venereol 2016;30(9):1567-72.

2) Gupta AK et al. J Cutan Med Surg. 2015 Sep-Oct;19(5):440-9. doi: 10.1177/1203475415581310. Epub 2015 Apr