Howard LeWine, M.D.
Posts by Howard LeWine, M.D.
For the third time in two years, the FDA has approved a drug to help people lose weight. The new drug, Contrave, combines two generic drugs, naltrexone and bupropion. Naltrexone is used to help kick an addiction to alcohol or narcotics. Bupropion is used to treat depression and seasonal affective disorder. Many people also take bupropion to stop smoking. Neither naltrexone nor bupropion by itself has been approved for weight loss. Specifically, Contrave was approved for use by adults who are obese (meaning a body-mass index of 30 or higher) and by overweight adults (body-mass index between 27 and 30) who have at least one other weight-related condition or illness, such as high blood pressure or type 2 diabetes. Across the clinical trials on which the FDA based its approval, some people lost more than 5% of their body weight. But it’s important to note that more than 50% had minimal or no weight loss. Side effects ranging from seizures and high blood pressure to diarrhea and constipation were reported.
The results of a clinical trial reported in yesterday’s Annals of Internal Medicine showed that low-carb diets helped people lose weight better than low fat diets. A report in today’s Journal of the American Medical Association tells a somewhat different story. A review of 48 head-to-head diet trails showed that average weight loss on either a low-carb or low-fat diet for 12 months was the same, about 16 pounds. And when the researchers compared named diets, which ranged from the low-carb Atkins and South Beach diets to moderates like Weight Watchers and Jenny Craig and low-fat approaches like the Ornish diet, all yielded similar weight loss. The main message from careful comparisons of different diets is that there’s no single diet that’s right for everyone. Any healthy diet can help people lose weight. And there’s more to a diet than weight loss. What’s needed for long-term health is an eating plan that can be followed day in and day out that is good for the heart, bones, brain, and every other part of the body. One eating strategy that can provide all that is the so-called Mediterranean diet.
Screening — checking a seemingly healthy person for signs of hidden disease — is an important part of routine medical care. It is done for various types of cancer, heart disease, diabetes, and other chronic conditions. Screening makes sense when finding and treating a hidden condition will prevent premature death or burdensome symptoms. But it doesn’t make sense when it can’t do either. That’s why experts recommend stopping screening in older individuals, especially those who aren’t likely to live another five or 10 years. Yet an article published online in JAMA Internal Medicine shows that many doctors still recommend cancer screening tests for their older patients. Many don’t benefit, and some are even harmed by the practice. Asking people who can’t benefit from a cancer screening test to have one is a waste of their time and money, not to mention a waste of taxpayer money (since these tests are usually covered by Medicare). Screening tests can also cause physical and mental harm. Decisions about cancer screening should be mutually made by an individual and his or her doctor. Equally important, the person should be well informed about the risks of the test and about what will happen if a test suggests there may be cancer that won’t shorten the his or her life.
The handshake is an important way that many people communicate nonverbally. It’s a standard gesture when we say hello, goodbye, and make an agreement. We’ve been doing it for millennia. But hands carry germs that can spread infections to others. And some of these infections can be very serious, including those that can’t be killed by standard antibiotics. Is it time to consider changing the tradition of shaking hands? Two researchers from Aberystwyth University in Wales make the case that handshaking exchanges a lot more germs than a modern alternative, the fist bump. In a nifty experiment, they showed that shaking hands transmitted 2 times more bacteria than high fives, and 10 times more bacteria than bumping fists. Their results are published in the August 2014 issue of the American Journal of Infection Control.
It’s not uncommon for people to blame the weather for making their arthritis or back pain flare up. A team of Australian researchers has one word for that: bunk. They followed nearly 1,000 people who were seen for acute low back pain in several Sydney primary care clinics noted the weather conditions when the back pain started, as well one week and one month earlier. And they found … nothing. No connection between back pain and temperature, rain, humidity, or air pressure. The results were published online in the journal Arthritis Care & Research. This isn’t the first word on the pain-weather connection, and won’t be the last. If animals can sense earthquakes, then it may be possible for people with back pain, arthritis, or other types of pain to sense changes in the weather that the rest of us don’t notice. But we need good proof.
Breaking a smoking habit can be hard. Nicotine is so addictive that smoking, or using tobacco in other forms, may be the toughest unhealthy habit to break. But it’s possible to quit. Nicotine replacement, in the form of nicotine patches, gum, sprays, inhalers, and lozenges, can help overcome the physical addiction. Medications such as varenicline (Chantix) and bupropion (Zyban) can also help. They can help reduce the cravings for a cigarette, and may also make smoking less pleasurable. Two new studies show that adding one or both of these medications to nicotine replacement can help improve quit rates. This research doesn’t suggest that smokers take varenicline and bupropion as a first step in smoking cessation. But when nicotine replacement alone hasn’t helped, adding varenicline with or without bupropion may lead to success.
The annual pelvic exam, an oft-dreaded part of preventive care for women, may become the as-needed pelvic exam, thanks to new guidelines from the American College of Physicians. For decades, doctors have believed this exam may detect problems like ovarian cancer or a bacterial infection even if a woman had no symptoms. But an expert panel appointed by the American College of Physicians now says that healthy, low-risk women do not need to have a pelvic exam every year. The exam isn’t very effective at finding problems like ovarian cancer or a vaginal infection, and it often causes discomfort and distress. Sometimes it also leads to surgery that is not needed. The new guidelines only apply to the pelvic exam, and only in healthy women.
“Replacing” a hormone the body normally makes when it is running low isn’t necessarily the safest thing to do. Women and their doctors learned this with estrogen after menopause. Now the FDA is sounding a warning that testosterone therapy can cause potentially dangerous blood clots in men. Such blood clots, called deep-vein thrombosis (DVT) and pulmonary embolism kill as many as 180,000 Americans each year, more than the number of people who die from breast, prostate, colon, and skin cancers combined. The new warning is not related to the FDA’s evaluation of possible links between testosterone therapy and stroke, heart attack, and death. Experts recommend testosterone therapy for men with a low testosterone level and one or more of the “classic” symptoms. For the rest? They get a talk-with-your-doctor recommendation. The warnings highlight that taking testosterone isn’t risk free. Combined with the lack of evidence about who really benefits, it means that the decision to start testosterone therapy is an individual one. A man must weigh the potential benefits against the potential increased risks of heart attack, stroke, and blood clots. If the balance tips in favor of moving forward, then trying testosterone is reasonable thing to do.
A few years ago, the U.S. Food and Drug Administration issued warnings that children and teens who took a common kind of antidepressant might experience suicidal thoughts. The point of the warning was to make sure that parents and doctors paid closer attention to kids taking these medications. But the plan may have backfired. A national team of researchers tracked antidepressant use among 2.5 million young people between 2000 and 2010. After the FDA’s warnings in 2003 and 2004, use of commonly prescribed antidepressants fell by 30% in teenagers while suicide attempts rose by 22%. The researchers concluded that the decrease in antidepressant use, sparked by worries over suicidal thoughts, may have left many depressed young people without appropriate treatment and that may have boosted the increase in suicide attempts.
Researchers at Boston University and Massachusetts General Hospital have developed a bionic pancreas. In an early test of the device, reported online this week in the New England Journal of Medicine, it helped control blood sugar levels in 20 adults and 32 teenagers with type 1 diabetes who went about their daily lives without the constant monitoring and injecting that’s required with type 1 diabetes. Right now, this artificial pancreas is essentially an app that runs on an iPhone wirelessly connected to a monitor worn on the abdomen that continually checks blood sugar and two pumps, one for insulin and one for glucagon. The team that developed the bionic pancreas have begun a second round of testing, and hope to have a more sophisticated version on the market in five years. While not a cure, the development of a bionic pancreas represents a bridge that would let people with type 1 diabetes control their blood sugar with less hassle, and more safely, than they do now.