Browsed by
Author: Stephen J. Klemawesch, MD

Dear Dr. K –

Dear Dr. K –

Last year my gynecologist started me on Flomax because I feel the need to urinate frequently.  She first gave me Detrol, but that caused severe dry mouth.  The Flomax has worked great and I don’t have to “locate the bathroom first” whenever I go out.  However, since starting it I’ve had sinus congestion that won’t go away.  Are they related?

The short answer is “yes”.  Flomax is one of a number of drugs called an alpha blocker.  Other drugs in the same category are Uroxatral, Doxazosin, Rapaflo and Terazosin.

Alpha refers to one side of the Yin/Yang dynamic of the autonomic(sympathetic) nervous system.  The complimentary component is Beta.  Most parts of our bodies are under control of the alpha/beta system including smooth muscles.

Many women with urinary frequency and many men with the same problem due to enlargement of the prostate benefit by relaxing the smooth muscles in the bladder/prostate area.  Alpha stimulation constricts smooth muscles, thus an “alpha blocker” allows them to relax.

Unfortunately for you, smooth muscles are also formed in blood vessels. When Flomax relaxes the smooth muscle in the blood vessels in your nose/sinus area, the blood vessels dilate.  This “tumescence” is what causes the sinus congestion.  In some people it can also cause a runny nose, post nasal drip, cough, headache and even a tendency to sinusitis.

Alpha blockers have also been used to treat high blood pressure.  They accomplish this by the vessel-dilating mechanism, thus lowering hydraulic pressure.

Since you didn’t tolerate the other family of bladder medicines (Detrol family), you might ask your gynecologist about either Botox or DDAVP (works via a pituitary hormone).

Bacterial Baptism – All the Rage – or Not so Sage?

Bacterial Baptism – All the Rage – or Not so Sage?

By: Sasha Klemawesch, MD

 

If you haven’t heard of Bacterial Baptisms, you are not alone.  However, in some communities, the trend of vaginal seeding or “baptism by bacteria” has started to really catch on.

The idea behind the movement started due to the theory that when babies are born via C-section, it is a very sterile procedure, and they end up lacking the immediate exposure to the normal bacterial flora that infants for centuries experienced as they made their way through the birth canal into the world for their first breath. Some researchers postulated that with the ever-increasing number of cesareans performed in western medicine and therefore, growing number of children who lacked that initial exposure to bacterial flora, could that in some way be related to or partly responsible for the also ever-increasing prevalence of various autoimmune disorders, atopy, obesity, and other illnesses that continue to rise in prevalence of the same populations?

It seems like a sound idea, especially since the Hygiene Hypotheses is so widely known and accepted, which is why there have been a growing number of mothers who choose to practice Vaginal Seeding; a process in which an infant born via C-section will immediately be swabbed with gauzes that have been instilled inside the mothers’ vagina for a period of time prior to delivery in order to transfer the normal vaginal microbiome onto the infant.  A small study in 2016 found that this practice was safe and possibly beneficial, however now there are more voices on the other side raising concerns; for instance, some argue that babies already are exposed to normal healthy bacteria via contact with mom’s skin and breast milk and that they don’t need the extra load.  Some say that there are too many other confounding factors, and it is unlikely that the lack of that initial exposure to vaginal bacteria is really the biggest issue.  Both sides agree that larger and more long-term research studies are needed before making the ultimate decision.  So, for now, if you are expecting in the near future, talk to your OB about what her thoughts are on the topic to make the best decision for you and for your little one.

New Flu Drug

New Flu Drug

Xofluza (baloxavir marboxil) is the first new antiflu medication to be developed in 20 years.  It works by inhibiting Cap-dependent endonuclease, an enzyme essential for influenza virus to multiply itself.  It is very effective and only requires a single oral dose to work.  It is effective against both influenza A and B viruses.  It does need to be taken within the first 48 hours of the flu to be effective.

The only other drugs that are currently available to treat influenza are Tamiflu (taken orally for 5 days), Relenza (used trans nasally) and Rapivab (only available by IV for hospitalized patients).  These drugs work on a different viral enzyme called neuraminidase.  Because they have “been around for a while” some viral resistance is developing.

An aspirin a day keeps the doctor away?

An aspirin a day keeps the doctor away?

By:  Sasha Klemawesch, MD

 

Maybe not.  For a long time, people have taken a baby aspirin regularly (with and/or without their physician’s input), because it seemed like conventional wisdom was that it would help with heart health, and after all, it was “just a baby dose”.  However, a recent landmark study has turned the notion of ASA for primary prevention on its head.  Primary prevention means that you are trying to prevent something from every happening in the first place, in this case, a heart attack, stroke, or other serious cardiovascular event.  Compare this to secondary prevention which is when someone has a heart attack and then they take steps to prevent getting another one in the future.  This study is NOT dealing with adults who already have known coronary or significant vascular disease burden (so if you have already had an MI or TIA, you can stop reading).

What the study found was that taking Aspirin did not provide any additional benefit for primary prevention in non-diabetic adults, even those who may have some risk factors such as high blood pressure.  In fact, they found a slightly increased risk for bleeding complications in them which outweighed any perceived benefit of the drug.

This idea really flies in the face of what many doctors and cardiologists in particular thought and practiced for a long time, but it is quickly being accepted into standard practice now.

Another caveat though is that the study addressed those adults who were not already on an aspirin regimen, so there is a large cohort of people out there who are already on an Aspirin whether or not it was recommended, an there is somewhat of a question as to if they should be taken off it or not.  So far, many doctors err on the side of not recommending curtailing someone’s long-standing regimen, but the jury is still out on how to address this.

The bottom line?  If you are not on ASA, have never had an MI or stroke, and no doctor has ever told you to be on ASA, don’t start it willy-nilly “to help your heart”.

And just an aside on ASA from an Emergency perspective, many people do not realize that ASA is one of the most feared overdoses of EM docs.  It is more dangerous a drug than many people realize; in adults it can cause both chronic and acute toxicities which are quite nasty, leading to terrible acidosis and other difficult to manage metabolic anomality’s.  In children, Oil of Wintergreen which contains the active ingredient in ASA is one of the few “deadly in a dose” drugs; even a lick (<1 tsp) of the concentrated oil can be fatal in pediatric population, so if you have any balms or ointments in the house be SURE to keep them away from children.

Q – Tips: Inhaler use

Q – Tips: Inhaler use

A recent study found that fewer than 50% of asthmatics were compliant with their inhaler use if they didn’t like the device.  Since asthma inhalers come in a variety of formats, be sure to discuss your preference with the prescribing doctor.

Beware the Nocturnal Predator

Beware the Nocturnal Predator

For many years now, asthma has been referred to as “The Nocturnal Predator” because of its tendency to exacerbate at night.  The traditional explanation given was due to our normal circadian variation in adrenal gland output.  Our adrenal glands produce two hormones that are an innate treatment for asthma: adrenalin and cortisone.  In fact, many of the pharmaceutical therapies for asthma mimic the body in that they contain forms of adrenalin and cortisone.

Our adrenal glands “wake up” about an hour before we do and release surges of adrenalin and cortisone until about 4 or 5 pm.  Then they “shut down” so we can be prepared for our sleep quietude.  It is this dramatic drop in adrenal output at night that can allow asthma and other allergies to exacerbate. For many years this physiology was felt to be the total story.  But science always moves forward and new research is showing that adrenal variation is just part of the equation.

One very new understanding is that in addition to our brains circadian clock, individual cells including the immune cells also have circadian clocks.  When these clocks are disrupted the immune cells do not function optimally and therefore are less able to respond to allergic threats or microbial (virus & bacteria) invasion.  As small a clock disruption as that which impacts many students: their school/work schedule versus their weekend schedule can lead to greater difficulty with allergies and infection.

For years, the phenomenon of “everyone getting sick” at the beginning of fall semester has been blamed on the gathering effect of the “herd” that had been separated during the summer.  Certainly, this still plays a role, but the clock paradigm is equally important.

This clock effect also helps explain why shift workers and people who travel one or more time zones distant tend to have more allergies and more infections.   When bed time versus wake-up times have been studied it turns out that wake-up time is the critical factor.  You didn’t hear it from me but tell your teenage children not to sleep in until noon on Saturdays.

Food Allergy/Undeclared Ingredients

Food Allergy/Undeclared Ingredients

Researchers at Utrecht University in the Netherlands recently published a study on food allergy reactions due to undeclared ingredients.

They studied 73 patients with food allergy who had a reaction even though they thought they were avoiding their known food allergies.  In 22 patients the scientists could find no explanation for the allergic attack.   But in 51 cases analysis of the offending food revealed one to four culprit allergens not listed under “ingredients”.

The most common “undeclared food” was milk followed closely by peanut and sesame.  The less common offenders were:  tree nuts, egg and celery.

The foods most commonly guilty of containing unlabeled ingredients were cookies and cakes, bread and rolls, chocolates, sauces and dried fruits.

Hearing Protein Discovered

Hearing Protein Discovered

The key sensory proteins for pain, touch, taste, smell and sight have all been identified.  In fact, their discoveries have been so important to health wellness that they have led to a number of Nobel Prize awards.  However, for forty years the protein for hearing has eluded scientific research.  But not any longer, neuroscientists have discovered it.  It is named TMC-1 (trans-membrane channel-like protein) and it works via a calcium channel in the inner ear.  It stimulates the inner ear hair cells thus playing a crucial role in both hearing and balance.

Its’ discovery should lead to new developments to help the ½ billion humans on the planet who have hearing loss and/or balance problems.

Novel Nasal Polyp Treatment

Novel Nasal Polyp Treatment

The FDA has recently approved “Sinuva”, a sinus implant to treat nasal polyps.  Up to 25% of patients with allergic rhino-sinusitis develop nasal polyps.  The polyps can cause nasal discharge, chronic congestion, snoring, tendency to sinus infection and loss of sense of smell.  Often the polyps can be treated with nasal steroid sprays and with leukotriene modifier pills such as Singular or Accolate.

But, for some patient’s surgery is the only option.  Unfortunately, in many surgical patients the polyps often regrow.

Enter Sinuva, a mometasone-eluting sinus implant.  Mometasone is a topical steroid found in skin creams, nasal sprays and asthma sprays.  The implant is placed, often following nasal polypectomy and left in place to slowly release the mometasone.  Research has shown a dramatic reduction in polyp regrowth.  The main side effect was bloody nasal discharge.  The cost is $1,275 per nostril.