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Over-the-counter pain relievers and your heart

Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen are and have been the go-to “benign” pain medication for doctors and patients alike. Why? They aren’t addictive, and it’s not easy to overdose. Serious side effects like gastrointestinal ulcers and bleeding seemed to be limited to high doses taken for longer periods or time, or to people with significant medical problems.

Even before the era of the opioid epidemic, it was raining NSAIDs, across the country.

In 2004, the manufacturer of the NSAID Vioxx pulled it from the market because the drug was associated with serious cardiovascular problems like heart attacks and strokes. Soon thereafter, a related medication (Bextra) was also discontinued due to cardiovascular risks and potentially fatal skin reactions.

Not all NSAIDs were caught up in that furor. Some prescription NSAIDs (including celecoxib (Celebrex) and some over-the-counter ones (ibuprofen, naproxen) were thought to be relatively safe.

But multiple studies suggest a clear link between all NSAIDs and heart attacks, strokes, and heart failure.

In 2015, the FDA strengthened the recommended warning on all NSAIDs:

NSAIDs can increase the risk of heart attack or stroke in patients with or without heart disease or risk factors for heart disease. A large number of studies support this finding, with varying estimates of how much the risk is increased, depending on the drugs and the doses studied.

The latest on NSAIDs and risk of cardiovascular disease

In 2016, European researchers published a study linking NSAIDs to an increased risk of heart failure. They looked at almost seven million people who had been given prescriptions for 27 types of NSAIDs. They found that people taking NSAIDs had a 20% higher risk of heart failure compared to people who were not using them; the higher the dose of NSAIDs, the greater the risk.

A recent Danish study showed an increased risk of cardiac arrest among people who took NSAIDs within the previous month. They identified 29,000 cases of cardiac arrest deaths, and linked these to prior diagnoses and prescription data using population level databases. Careful analysis found that just over 3,300 patients had taken NSAIDs with the month prior to death, and any NSAID use was associated with a 31% increased risk of cardiac arrest. The NSAIDs diclofenac and ibuprofen were associated with a 50% and 31% increased risk, respectively. The risk was even higher for patients with known heart problems (prior heart attack, coronary artery disease, chronic heart failure, arrhythmias) or stroke.

“The findings are a stark reminder that NSAIDs are not harmless,” warned study author Professor Gunnar Gislason in a press conference. “NSAIDs should be used with caution and for a valid indication. They should probably be avoided in patients with cardiovascular disease or many cardiovascular risk factors.”

So, now what?

While some doctors recommend caution for patients at risk for heart attack, stroke, and heart failure, NSAIDs are still widely prescribed, even to patients with significant risk factors. This is partly because they are good at relieving many types of pain. And they are easily available, from pharmacies to airports to gas stations to big-box discount warehouses. Right now, anyone can pick up a two-pack of 200-mg ibuprofen tablets with 500 per bottle — that’s 1,000 tablets!

So, does everyone need to stop using all NSAIDs? No. But, some things have to change:

  • Patients need to know about these risks, because bad things have happened even to patients without known risk factors for heart disease or stroke.
  • People at particularly high risk need to be aware that these drugs (either prescribed or over the counter) may not be safe for them.
  • These medications probably should not be available for purchase in massive quantities, as that makes most average consumers think that they’re safe to take in large quantities and for longer periods of time.

Personally, I will continue to take the occasional NSAID, but after writing this piece, I may think twice and wait longer before I do.

Sources

Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis. New England Journal of Medicine, December 2016.

Use of nonsteroidal anti-inflammatory drugs in patients with cardiovascular disease: a cautionary tale. Cardiology in Review, July-August 2010.

Cardiovascular events associated with rofecoxib in a colorectal adenoma chemoprevention trial. New England Journal of Medicine, March 2005.

Cardiovascular risk associated with celecoxib in a clinical trial for colorectal adenoma prevention. New England Journal of Medicine, March 2005.

Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials. BMJ, June 2006.

Role of dose potency in the prediction of risk of myocardial infarction associated with nonsteroidal anti-inflammatory drugs in the general population. Journal of the American College of Cardiology, November 2008.

Cardiovascular risk with non-steroidal anti-inflammatory drugs: systematic review of population-based controlled observational studies. PLoS Medicine, November 2011.

Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ, January 2011.

Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet, August 2013.

Comparative evaluation of cardiovascular outcomes in patients with osteoarthritis and rheumatoid arthritis on recommended doses of nonsteroidal anti-inflammatory drugs. Therapeutic Advances in Musculoskeletal Disease, August 2014.

Non-steroidal anti-inflammatory drugs and cardiac failure: meta-analyses of observational studies and randomised controlled trials. European Journal of Heart Failure, November 2008.

Nonsteroidal anti-inflammatory drugs as a trigger of clinical heart failure. Epidemiology, March 2003.

ESC Committee for Practice Guidelines. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESCE. European Heart Journal, July 2012.

Non-steroidal anti-inflammatory drugs and risk of heart failure in four European countries: nested case-control study. BMJ, September 2016.

Non-steroidal anti-inflammatory drug use is associated with increased risk of out-of-hospital cardiac arrest: a nationwide case-time-control study. European Heart Journal. Cardiovascular Pharmacotherapy, December 2016.

Rates of Nonsteroidal Anti-Inflammatory Drug Use in Patients with Established Cardiovascular Disease: A Retrospective, Cross-Sectional Study from NHANES 2009-2010. American Journal of Cardiovascular Drugs, January 2017.

January 23rd, 2017 Posted by | health, health care, new, Uncategorized | No Comments

Taking medicines like you’re supposed to: Why is it so hard?

It’s so hard to remember to take your medicine, let alone take it correctly (with food, on an empty stomach, not at the same time as other things you’re taking, at night, without grapefruit juice… the list seems endless). There are so many barriers and distractions that can get in the way. Many people aren’t thrilled about having to take medications because they worry about side effects, or they’re having side effects, or they just don’t like the idea of needing to take medicine. If it’s for prevention, like aspirin to prevent strokes, or to treat an “invisible” condition like high blood pressure, they may not think they need it at all.

Even when a person is highly motivated, there are still missed doses. Even when that person is a doctor! I had strep throat last year, and for the life of me I couldn’t consistently remember to take my amoxicillin three times a day. (Which is probably why I got strep again.)

As a primary care doctor, I try to prescribe only the drugs needed, be mindful of side effects, and find the simplest regimen possible. But many people require a lot of medications, and their regimens may be necessarily complex.

The cost of not taking medicine correctly

Doctors, pharmacies, and insurance companies are all acutely aware of the poor outcomes and massive costs incurred by “medication noncompliance.”* Research articles on medication noncompliance show that when people don’t take their medication, they are likely to get sicker (even die) and incur higher healthcare costs. This is especially true for people with chronic illnesses like diabetes, high blood pressure, high cholesterol, and heart disease.

So let’s instead talk about medication adherence. Medication adherence sounds so much better. Because it is. Almost all research examining medication adherence demonstrates a link between improved medication adherence and better health outcomes, longer life, and lower health care costs.

*Medication noncompliance. I hate this term, because it sounds like patients are being willfully disobedient. Hey, when I missed all those amoxicillin doses, it was because I frequently work through lunch or am out and about in the mid-afternoon. Either the pills were not on me, or fluids were not on me, or I simply didn’t have the opportunity to take them. I wasn’t noncompliant, buster!

What helps people take medicines correctly? Here’s what the research says

A recent study tested three really inexpensive gadgets designed to improve medication adherence. These included: a pill bottle strip with toggles with day numbers that could be slid closed; a digital timer cap that recorded the time and date of the last time the cap was opened; and a standard pillbox like the one my grandmother uses. Adherence was measured using pharmacy claims data.

Would you believe there was no difference between any of the gadget groups? In fact, the only group who had improved adherence was the control group, who had received absolutely no help in remembering to take their medicine. Researchers did note that previous studies have shown adherence changes according to what’s going on in a person’s life, which makes sense.

A recent analysis of over 700 studies on this topic looked at a broad range of strategies including special packaging, individualized instructions, consequences/rewards systems, and reminder devices. The only somewhat consistently effective approach was habit analysis, and linking medication adherence with existing habits. What does that mean? It means that if I’m prescribing a pill that’s to be taken twice a day, I ask the patient, “Can you think of anything that you always do twice a day?” and if the patient says “Yeah, I brush my teeth,” then I say, “Okay, then take this pill every time you brush your teeth. Put the bottle with the toothpaste.”

Obviously, this simple approach isn’t going to work for everyone. Will anything really help people take their medications? A recent analysis of 65 studies of medication adherence in the elderly provides a clue. Researchers identified eighty obstacles to adherence, including impaired memory or cognition, poor dexterity, depression, anxiety, or other mental health issues, language barriers, alcohol or drug use, low education level, sleep problems, cost and insurance issues, resistance to care or skepticism about treatment, inadequate medication labeling, vision problems, pills needing to be cut, dissatisfaction with the physician… on and on.

Eighty.

How best to help people take their medications? As those conducting this analysis concluded: it’s complicated.

Sources

Adherence to long-term therapies: evidence for action. Geneva, Switzerland, World Health Organization, 2003, pp. 1-198.

Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost. Medical Care, 2005.

Adherence to Statins, Subsequent Healthcare Costs, and Cardiovascular Hospitalizations. American Journal of Cardiology, 2011.

Association between number of doses per day, number of medications and patients non-compliance, and frequency of readmissions in a multi-ethnic Asian population. Preventive Medicine Reports, 2014.

Medication Adherence Leads to Lower Health Care Use and Costs Despite Increased Drug Spending. Health Affairs, 2011.

Medication adherence among geriatric outpatients prescribed multiple medications. American Journal of Geriatric Pharmacotherapy, 2012.

The Role of Medication Adherence in the U.S. Healthcare System, June 2013.

Effect of Reminder Devices on Medication Adherence: The REMIND Randomized Clinical Trial. JAMA Internal Medicine, published online February 27, 2017.

Medication adherence outcomes of 771 intervention trials: Systematic review and meta-analysis. Preventive Medicine, 2017, e-pub ahead of print.

Systematic review of the barriers affecting medication adherence in older adults. Geriatrics and Gerontology International, 2016.

January 5th, 2017 Posted by | health care, new, Uncategorized | No Comments

Cheap taxi taxis in hanoi

Coming to our Phi Long truck rental service you will find the difference. At affordable prices have been used by Hanoi people.

Now moving goods has become very popular and familiar. For everyone in the capital city and all over the country, as society grows. Households, or businesses, are increasingly demanding to improve conditions. And high demand for life, living environment and work better. In order to save precious time and effort of his family.

Choose the truck service to deliver the goods for you to quickly and efficiently. Move things within short distances. Or go to the provinces, then you should choose the most reputable and cheapest taxi company. Is a reasonable solution. When you choose for yourself a taxi service loaded cargo. I still do not know where to find, so please quickly contact the taxi company download Phi Long. ( Cho thuê xe tải )

Phi Long Company specializes in transporting goods to distant provinces. Or inner city in Hanoi, and Ho Chi Minh City. Also we also have service with our strengths tendencies. Help customers quickly move your home away. Do not worry about broken furniture, or packaging as you have. Full-service transfer or full-service office transfer service. Included already have the highest level of cargo insurance. For customers who have a number of valuable assets.

Phi Long taxi company we have many different vehicles to help customers choose.

Diverse types of vehicles such as:

➔ 7-ton trucks covered with canvas roofing can be moved to the tunnel. Apartment buildings with a maximum height of 1.9m. And in addition you need our 7 th truck, run to the provinces. Or in Hanoi, we have a 24-hour license. Now you no longer have to worry about loading bans.

➔ One-ton truck with 24-hour license runs in Hanoi. Without stopping the car, make sure your cargo stays smoothly.

➔ Truck type 1.25 tons dedicated closed box, you can rest assured with our car. For a whole new life and a 24-hour license, you can be assured.

➔ Truck type 1.4 tons running license 24 customers completely mind. And take the initiative to choose when using the service Phi Long.

With the size of the trunk you can call about the taxi station download Phi Long. To be advised you the fastest, best. And there is always a discount during the holiday month.

With our truck operation running 24h / 24h. Meet all transportation needs of customers, from A to Z. Fast, convenient, professional in the packaging. Loading and unloading when moving house, office, warehouse. With long experience and professionalism of Phi Long company. Served millions of large domestic corporate clients. And businesses, households, special incentives. For customers signing regular transport contract, taxi loading Phi Long. We will give you a discount when you sign up for a permanent contract. Trucking services for truck hire on a monthly, quarterly basis, depending on the requirements of the customer.

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January 5th, 2017 Posted by | new, Uncategorized | No Comments

Best time to visit Mai Chau

Isolated Mai Chau and the nearby villages are in a valley around 139km from Hanoi and only 150 metres above sea level. Nestled between two towering cliffs and surrounded by emerald green paddies, it is an enchanting sight as you approach down the windy cliff side road and the villages and surrounding countryside present an idyllic rural scene that could easily charm you into staying longer than intended.

The climate of Mai Chau, Hoa Binh is tropical monsoon. The average annual temperature is 18°C with a maximum of 29°C in July and a minimum of 16°C in January. In spring Mai Chau is a bright, almost parrot-green and by autumn this green transforms into golden hues as the rice approaches harvest. Taking the time to watch these transitions of colour seems like a perfectly useful way to spend your time while there.

Mai Chau valley landscapes

In general, Mai Chau’s climate is quite good around the year. It rains less and the humidity is lower than other Northern Vietnam cites. The best weather extends from September to May with temperatures ranging from 15°C to 30°C. With sunny day, you can join Mai Chau cycling tours or Mai Chau motorbike tour to explore this beautiful valley.

Mai Chau biking tour

Explore Mai Chau by bike

It can be quite cold during winter from November to the end of February. From June to September, it has the monsoon with stronger breezes and higher humidity. The temperatures are warmer in this time, varying between 25°C and 35°C.

For hot (but not too hot), sunny weather, October-November and February-May are the best time to go. In December, January and sometimes February too, the weather can get pretty chilly. However, the stilt houses have no shortage of fluffy blankets to keep you warm at night; staying cool in the summer, however, is more of an issue. The stilt houses usually have fans but even then so they can get uncomfortably hot between June and September. In addition, these months are the rainiest, which makes outdoor exploring more problematic.

There is a market on Sundays which brings together different minority groups from the surrounding area, but given the higher numbers of weekend tourists (see ‘Stay away from’) this is not necessarily a reason to time your visit for a Sunday.

From above information, it hopes that you will have the most comfortable Mai Chau valley tours.

December 2nd, 2016 Posted by | new, travel, Uncategorized | No Comments