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Hypothyroidism: The facts, the controversies, and the pseudoscience

As glands go, we don’t give the butterfly-shaped thyroid that straddles our trachea too much  thought — until it stops working properly. The thyroid is a bit like your home’s thermostat: turn it high, and you’re hyperthyroid: heat intolerant, a high heart rate, and maybe some diarrhea. Turn it down, and you’re hypothyroid: cold, tired, constipated, and possibly even depressed. Both conditions are associated with a long list of more serious health consequences. Between the two however, hypothyroidism is far more prevalent. The mainstay drug that treats it, levothyroxine (Synthroid), is one of the most prescribed in the world.

One of my more memorable pharmacy experiences involved levothyroxine. The store had recently changed its prescription labelling standards: It switched from listing the brand name, to only including the generic name (with the manufacturer in parentheses). Few patients noticed. But one elderly patient, taking Synthroid, was furious, and accused me of making a dispensing error. I assured her that levothyroxine was the active ingredient in Synthroid, and she was getting the exact same product as her last visit — but she would have none of it. Her symptoms had worsened, she said, because the medication wasn’t the same. “I want Synthroid — this levothyroxine stuff does not work,” she screamed at me across the counter. No amount of reassurance would satisfy her — I think we eventually resorted to custom, typewritten labels.

I mention this anecdote not to dismiss the symptoms of hypothyroidism as sensitive to placebo effects — hypothyroidism is a real condition with objective monitoring criteria. But this episode was one of my earliest lessons in understanding how perceptions  can shape expectations of effectiveness — something that I’ll come back to, when we look at the controversies of this common condition. Any the treatment of hypothyroidism is not without its controversies – most of which occur outside the realm of medicine, and can more accurately be labelled pseudoscience. (more…)

Posted in: Nutrition, Pharmaceuticals, Science and Medicine

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Vitamin B12 – The Energy Panacea?

Having spent many hours working in close proximity to a wall of vitamins, I’ve answered a lot of vitamin questions, and given a lot of recommendations. Before I can make a recommendation, I need to ask some questions of my own. My first is almost always, “Why do you want to take a vitamin?” The most common response I’m given is “insurance” – which usually means supplementation in the absence of any symptom or medical need. Running a close second is “I need more energy.” With some digging, the situation usually boils down to a perceived lack of energy compared to some prior period: last week, last year, or a decade ago. While I may identify possible medical issues as a result of these interviews (these are referred to a physician), I’m often faced with a patient with mild and non-specific descriptions of fatigue. And more often than not, they’ve already decided that they’re going to buy a multivitamin supplement. When it comes to boosting the energy levels, they’re often interested in a specific one: Vitamin B12 (cobalamin). So why does vitamin B12, among all the vitamins, have a halo of benefit for fatigue and energy levels? The answer is part science and a whole lot of marketing. (more…)

Posted in: Herbs & Supplements, Nutrition

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Antioxidants and Exercise: More Harm Than Good?

Multivitamin supplementation has been getting a rough ride in the literature, as evidence emerges that routine supplementation for most is, at best, unnecessary. Some individual vitamins are earning their own unattractive risk/benefit profiles: Products like folic acid, calcium, and beta-carotene all seem inadvisable for routine supplementation in the absence of deficiency or medical indication. Vitamin E, already on the watch list,  looks increasingly problematic, with data recently published confirming the suspected association of supplementation with an elevated risk of prostate cancer.

Reading through the vitamin posts here at SBM, one issue comes through repeatedly: The danger of assuming therapeutic benefits in the absence of confirmatory evidence. Vitamin supplement have the patina of safety and of health, a feature that’s reinforced when you purchase them: You don’t need a prescription, you don’t get counseled on their use, and there isn’t a long list of frightening potential side effects to accompany the product. You can pull a bottle off the shelf, and take any dose you want. After all, how harmful can vitamins be when you can buy 5 pounds of vitamin C at a time, or vitamin E capsules in a 1000-pack?  But the research signals seem to be getting stronger, and most are pointing in the same direction: what we though we knew about antioxidants was based on simplistic hypotheses about nutrition and health. And while we thought we were doing ourselves good with antioxidant supplements, we may have been doing harm. (more…)

Posted in: Herbs & Supplements, Science and Medicine

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Collagen: An implausible supplement for joint pain

I’m one of those odd people that enjoys distance running. I end up spending a lot of time in the company of other runners. And when we’re not running, we’re usually griping about our running injuries. As the cohort that I run with ages, the injuries are getting more prevalent. Besides the acute conditions, the chronic problems are starting to appear. Our osteoarthritis years are here.

As the available pharmacist, I get a lot of questions about joint pain. What’s reassuring, I tell them, is that they shouldn’t blame running. Osteoarthritis is common — the most frequent cause of joint pain. For some, it starts in our twenties, and by our seventies, osteoarthritis is virtually certain. Regardless of your level of exercise, the passage of time means the classic osteoarthritis symptoms — joint pain and morning stiffness, that worsens over time.

Osteoarthritis progresses gradually. Blame biomechanics and biochemistry. It starts with a breakdown of the cartilage matrix. Stage 2 progresses to erosion of the cartilage and a release of collagen fragments. Stage 3 is a chronic inflammatory response. The goals of treatment are to reduce inflammation and pain, and stop progressive disease. There’s no drug therapy that’s been show to actually improve joint function. Reduce pain, or slow inflammation, yes. Analgesics, like Tylenol, and anti-inflammatories are mainstays. But repair damage? Sorry: you lose it, it’s gone. Chondrocytes don’t seem to be able to repair the overall matrix — which is made mainly of collagen. (more…)

Posted in: Herbs & Supplements, Nutrition

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Constipation Myths and Facts

When it comes to health issues, bowels are big business. Bowel movements are part of everyday life, and we notice immediately when our routine changes. Constipation, from the Latin word constipare (“to crowd together”) is something almost everyone has some experience with. In most cases, it’s an occasional annoyance that resolves quickly. For others, particularly the elderly, constipation can be a chronic condition, significantly affecting quality of life.  Depending on the question and the sample surveyed, prevalence seems to vary widely.  It’s estimate that there are 2.5 million physician visits per year in the USA, and the costs of management are estimated at about $7.5 billion annually. It’s not a trivial issue.

One of the biggest challenges in interpreting both individual patient situations, as well as the literature overall, is understanding what’s defined as “constipation”. One person’s regular routine may be another person’s constipation. From my dialogue with patients, personal definitions seem to vary. Some panic after a single missed bowel movement, while others may be unconcerned with daily (or even less frequent) movements. What’s the optimal frequency? It depends. Infants may be 3x/day. Older children may be once daily. Adults may be daily or less frequently.  The literature generally, though not consistently, defines constipation as a delay or difficulty in bowel movements ( usually less than 3 per week) lasting two weeks. Symptoms can include infrequent, painful bowel movements, straining, and lumpy or hard stools.  When these problems last for more than three months, it’s termed chronic constipation. When constipation is accompanied by other symptoms like bloating, diarrhea, and abdominal pain, it may be termed  irritable bowel syndrome (IBS).

There are multiple causes of constipation. It may be a consequence of other illnesses (e.g., high/low thyroid, diabetes, cancer, and neurological diseases like multiple sclerosis). Drugs, both prescription and over-they-counter, can also cause constipation.  Primary or idiopathic constipation is a diagnosis of exclusion, after other causes have been ruled out.  If there are no signs of a more serious underlying condition, treatments can be considered.

Many have firmly-held opinions about their colon and their bowel movements: what’s normal, and what’s not. And there are equally strong opinions about the causes of, and solutions to, constipation. But despite the ubiquity of constipation and the firmly-held opinions on treatments, there’s a sizable chasm between practice and evidence.  This is an area with crappy (sorry) data, and it’s hard to sort out what are true treatment effects. But an absence of evidence isn’t evidence of absence, so we’re challenged to make the best decisions possible, despite a disappointing evidence base. Here are some common statements I’ve encountered, and an evidence check on their veracity. (more…)

Posted in: Science and Medicine

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What’s all that other stuff in my medicine?

If you read enough supplement advertisements, like I do, you’ll often see the purity of  a product often cited as one of its merits. It’s usually some phrase like:

Contains no binders! No fillers! No colours! No excipients! No starch! No gluten! No coatings! No flow agents!

It’s a point of pride for supplement manufacturers to advertise that their product contains nothing but the labelled ingredient. And that’s also seen as an important benefit to many that purchase supplements. The perception from many consumers (based on my personal experience) seems to be that products are inferior if they contain non-drug ingredients. By this measure, drug products are problematic. Pharmaceuticals all contain an array of binders, coatings, supplements and fillers.  Even (gasp) artificial ingredients and sweeteners! And they’re often, though not always, disclosed on the package label.

But rather than being a negative feature, these supplementary, non-medicinal ingredients play a critical role in ensuring that drug products are of consistent and reproducible quality. Without them, we’d have products that are potentially unstable, we’d be unclear if they were actually being absorbed, and we wouldn’t know if they actually delivered any active ingredients into the body. In short, we’d be in the same situation we’re currently in with many herbal remedies and other types of supplements.

(more…)

Posted in: Pharmaceuticals

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Understanding and Treating Colic

Parenting an infant can be totally overwhelming. One of the earliest challenge many face is learning to deal with periods of intractable crying. I often speak with sleep deprived parents when they’re looking for something — anything — to stop their baby from crying. They’ve typically been told by friends of family that their baby must have “colic” and they’ve come to the pharmacy, looking for a treatment. Colic is common, affecting up to 40% of babies in the few months of life.

While distressing, colic is a diagnosis of exclusion — that it, it is given only after other causes have been ruled out (hunger, pain, fatigue, etc.). The most common definition for colic is fussing or crying for more than 3 hours per day, more than 3 days per week, for more than 3 weeks. These criteria, first proposed by Morris Wessel in 1954, continue to be used today. However, scientific evidence to explain the cause is lacking. Ideas proposed include:

  • changes in gastrointestinal bacteria/flora
  • food allergies
  • lactose intolerance
  • excess gas in stomach
  • cramping or indigestion
  • intolerance to substances in the breast milk
  • behavioural issues secondary to parenting factors

Despite its intensity, colic resolves on its own with no interventions. By three months of age, colic has resolved in 60% of infants. By four months, it’s 90%. It sounds harmless and short-lived, but colic’s ability to induce stress in parents cannot be overstated. Parents may be angry, frustrated, depressed, exhausted, or just feel guilty, ascribing their baby’s cries to some parenting fault. (more…)

Posted in: Clinical Trials, Pharmaceuticals, Science and Medicine

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Caffeine for ADHD

“I don’t want to give my child any drugs or chemicals for their ADHD,” says a parent. “Instead, I’m thinking about using caffeine. Sound strategy?”

It may be dispensed by a barista and not a pharmacist, and the unit sizes may be small, medium and large, but caffeine is a chemical and also a drug, just as much as methylphenidate (Ritalin) is. Caffeine is even sold as a drug — alone and in combination with other products. But I regularly speak with consumers who are instinctively resistant to what they perceive as drug therapy — they want “natural” options. Caffeinehas been touted as a viable alternative to prescription drugs for ADHD. But is caffeine a science-based treatment option? This question is a good one to illustrate the process of applying science-based thinking to an individual patient question. (more…)

Posted in: Herbs & Supplements, Science and Medicine

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Who’s to Blame for Drug Shortages?

All the best effort to practice science-based medicine are for naught when the optimal treatment is unavailable. And that’s increasingly the case – even for life-threatening illnesses. Shortages of prescription drugs, including cancer drugs, seem more frequent and more significant than at any time in the past. Just recently manufacturing deficiencies at a large U.S.-based contract drug manufacturer meant that over a dozen drugs stopped being produced. This lead to extensive media coverage, speculating on the causes and implications of what seems like a growing problem. So who’s to blame? (more…)

Posted in: Pharmaceuticals, Politics and Regulation

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Oh yeah? Thalidomide! Where’s your science now?

Online discussions on the merits of alternative medicine can get quite heated. And its proponents, given enough time, will inevitably cite the same drug as “evidence” of the failings of science. Call it Gavura’s Law, with apologies to Mike Godwin:

As an online discussion on the effectiveness of alternative medicine grows longer,  the probability that thalidomide will be cited approaches one.

A recent comment on my own blog, regarding the homeopathic product Traumeel, is typical:

If the scientific method is all that separates an accepted claim, ie Thalidomide, Vioxx, Bextra, Darvon, from mere anecdote, of what benefit is the Science?

As a non-scientist consumer, I’ll take the anecdotes and my own experience. Thank you.

If scientists want to be taken seriously, they must stop selling themselves to the highest bidder becoming corporate whores without a shred of decency. To my mind, that’s how the claims for Thalidomide, Vioxx, Bextra, Darvon were accepted, making the scientific method utterly worthless.

To this commenter, “science has been wrong before.” And that invalidates science, and apparently validates homeopathy. It’s a fallacious argument. But does thalidomide actually represent a failing of science-based medicine? No, not even close. It’s so wrong, it’s not even wrong. Thalidomide is good example of the importance of science-based medicine and why allowing alternative medicine to be sold in the absence of good science is a concern. (more…)

Posted in: History, Pharmaceuticals, Politics and Regulation, Science and Medicine

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