Bargains in medication?
How many pharmacies in your street? I
can count five over 500 meters. This must mean we are all very sick and
needing constant medication - or, like beauty salons and massage parlors,
the collective imagination is lacking somewhat.
But back to the pharmacies, with so many of them, the only way they can
compete with each other is on price. A box of Enalapril looks the same as
any other box of Enalapril. So where do they get cheaper drugs in the first
The big money spinners are the drugs which can keep you in a state of
perpetual priapism, a continuing (and painful) male erection and the term
was coined after the Greek god Priapus who is shown in paintings to have a
central member like a third leg.
Cheap pills for Erectile Dysfunction (ED) that seem too good to be true, are
usually just that - too good to be true! The chances are very high that they
One of the patients showed me a box purporting to be genuine brand name
Cialis tablets, which were not having the desired effect. I was immediately
suspicious as the box was not all that well printed. I was quite sure they
were counterfeit when I read the Patient Information slip. The English
grammar was incorrect, and there were spelling mistakes. Eli Lilly, the
‘real’ manufacturer does not send out mis-spelled literature with their
Eli Lilly’s website on Cialis confirms that there is fake Cialis in the
marketplace. The website suggests you ask yourself these questions; any
“yes” answers could mean that the Cialis being sold may be fake:
Is the price so much lower than the price at the hospital pharmacy that it
seems too good to be true?
Does the pharmacy offer “soft tab” or “fast dissolve” Cialis? (Cialis only
comes in tablets. There is no such thing as “soft tab” or “fast dissolve”
Does your local pharmacy offer “generic Cialis” or a drug with a name that
is similar to Cialis? (Such products have not have been evaluated by the FDA
for safety and effectiveness - they could be harmful.)
The World Health Organization puts the annual amount of counterfeit drugs
sales at something like $35-40 billion per year. No wonder I (and you) get
so many offers of drugs through the internet. That’s a very large pie.
The World Health Organization also estimates that one in three drugs on the
worldwide market today is counterfeit. Sometimes the fake drugs contain
toxic substances from which you can die.
Pfizer’s laboratories analyze the fakes and a representative stated, “We’ve
seen boric acid, we’ve seen heavy metals, we’ve seen road paint, we’ve also
seen floor wax to coat the pills and give them a shine. Obviously, they are
detrimental to anyone’s health.”
It is not just Eli Lilly that is targeted. Pharmaceutical giant Pfizer (yes
chaps, the makers of the blue diamonds of happiness) estimates its annual
losses to counterfeit drug sales at $2 billion.
However, this is actually a serious situation. If specific drugs are only
available through pharmacies, on the prescription of a doctor, is it safe to
just buy over the counter (or the internet), without any doctor’s advice?
The American Food and Drug Administration (FDA) says, “Patients who buy
prescription drugs from websites operating outside the law are at increased
risk of suffering life-threatening adverse events, such as side effects from
inappropriately prescribed medications, dangerous drug interactions,
contaminated drugs, and impure or unknown ingredients found in unapproved
According to WHO, drugs commonly counterfeited include antibiotics,
antimalarials, hormones and steroids. Increasingly, anticancer and antiviral
drugs are also fake. And you can add to that, the ‘blue diamonds’. Never
forget the phrase “Caveat emptor” (Let the buyer beware).
If you receive a spam e-mail from someone who you don’t know, offering you
specific pharmaceuticals at a cheap price, that should be enough for you to
go no further. If your local pharmacies will offer you ‘name brand’
medication that is supposedly prescription only at a very cheap price, that
should ring alarm bells in your head too.
Get your medications on a doctor’s prescription from a pharmacy you can
trust. Or suffer the consequences.
Mammograms and BSE. Worthwhile?
The opening of our new Breast Center
the other day made me think once more about breast cancer. Screening for
breast cancer is still a subject that seems to be controversial, though
honestly, I do not know why. The sensationalist press feeds on fear, and by
instilling fear into women about detection of breast cancer will always sell
a few more papers. Despite mammograms and suchlike, there were cases that
escaped detection until it was too late and other such negative predictions.
Was it all then a waste of resources and money?
No it is not, says the American Cancer Society’s director of cancer
screening, Robert Smith, PhD, who says there is plenty of evidence that
mammograms save lives, even for younger women.
“The American Cancer Society and other organizations have endorsed
mammography screening for women in their 40s because direct and inferential
evidence supports its value in reducing morbidity (injuries) and mortality
(deaths) from breast cancer, the second leading cause of cancer death in
women,” he says.
Other groups that recommend mammograms every one or two years for women in
their 40’s include the US Preventive Services Task Force and the American
College of Obstetricians and Gynecologists.
The American College of Physicians guideline says mammograms can reduce
breast cancer deaths by about 15 percent among women in their 40’s, but Dr.
Smith says newer studies indicate the benefit is much greater - 40 percent
Unfortunately, the cancer detection story is one that suffers from a problem
which can be associated with an inexact science. Since we can put men on the
moon, clone sheep (and even rabbits in Chonburi) and other incredible facts,
we should then be able to diagnose human conditions with pin-point accuracy.
Diagnosis and detection are “real time” arts, not sciences. Sure, we use
“science” as a tool, but that is all it is. A tool to help us see the
problem. Just like we can use a telescope to see things at a distance - even
if we can’t see the object, that doesn’t mean to say it wasn’t there. The
telescope was facing the wrong way, the object was behind not in front.
There has been a bit of that thinking with mammograms of late. A lady has
three annual clear mammograms and then finds she has breast cancer during
year number four. Was the testing useless?
Again I ask you to look at the “real time” situation. So today cancer was
found. When did it “start” to grow? This week, this month, this year? The
answer depends upon the type of the cancer. Some fast growing cancers would
be impossible to pick up, even if the person had monthly mammograms. The
slow growing variety can be picked up years ahead. Unfortunately mammography
cannot be a 100 percent indicator - we are not that good - yet. But it is
still one of the best diagnostic procedures we have. And it is better than
Likewise, Breast Self Examination (BSE) has its detractors as well as its
proponents. Sure, a lot depends upon how well the woman carries out this
self testing, but again, surely it is better to look than to carry on in
I do not believe the doomsayers who would tell you that the outcome is just
the same. Breast cancer is like all cancers - the sooner you find it, the
sooner you can deal with it and the earlier treatment is administered, the
better the outcome. In fact, studies from the American National Cancer
Institute show that 96 percent of women whose breast cancer is detected
early live five or more years after treatment. This is called a 96 percent
five year survival rate, one of the ways we measure the severity of life
threatening cancers. If it were a 10 percent figure - in other words, after
five years only 10 percent of the people were still alive, then I would
probably also feel that predictive testing was not all that worthwhile. But
it is not that bleak an outcome - 96 percent are still alive and many go on
for many, many years.
With new 3D screening tests such as digital mammograms with tomosynthesis,
breast cancer can be detected even earlier.
Counting sheep - on the bosses time!
I attended a lecture the other day and
someone asked if falling asleep on the job was enough reason to give an
employee the sack. This was apparently a recurring problem with this
employee, but I did caution that this daytime napping might be a medical
problem, and not a late night karaoke problem.
The medical condition is an interesting one, and it is called Sleep Apnea.
(I actually wrote this article on the World Sleep Day, which is why it
jogged my memory.)
Put very simply, Sleep Apnea is when people stop breathing for some seconds
while asleep. They are usually not aware of this fact, but bed partners are!
People with Sleep Apnea stop breathing repeatedly during the night,
sometimes hundreds of times and often for a minute or longer.
It is a worrisome situation when the person lying next to you just seems to
have stopped breathing. Was that last breath really their last breath?
Should you start CPR?
“Apnea” comes from the Greek and literally means “without breath”, so it is
an apt word for the condition where people stop breathing when asleep.
Like so many conditions in medicine, it is not quite cut and dried simple,
as there are three types of Sleep Apnea. These are called Obstructive,
Central and Mixed, with Obstructive being the most common.
Obstructive Sleep Apnea (OSA) is caused by an obstruction producing a
blockage of the airway, usually caused by the soft tissue in the rear of the
throat collapses and closes during sleep.
In Central Sleep Apnea, the airway is not blocked but the brain fails to
signal the muscles to breathe. Normally as the oxygen level drops, a reflex
in the brain tells the body to breathe, to increase the oxygen saturation.
This reflex is normally very powerful. For example, try holding your breath,
and you will find that you breathe again involuntarily. You cannot over-ride
Mixed Apnea, as the name suggests, is a combination of the two. With each
apnea event, the brain briefly arouses people with sleep apnea in order for
them to resume breathing, but consequently sleep is extremely fragmented and
of poor quality.
Sleep Apnea is much more common than you would have thought, being as common
as adult diabetes, and affects more than twelve million Americans, according
to the National Institutes of Health.
Risk factors include being overweight, and over the age of forty, but sleep
apnea can strike anyone at any age, even children. Males suffer from this
more than females, yet still because of the lack of awareness by the public
and healthcare professionals, the vast majority remain undiagnosed and
therefore untreated, despite the fact that this serious disorder can have
Untreated, Sleep Apnea can cause high blood pressure and other
cardiovascular diseases, memory problems, weight gain, impotency, and
headaches. And I think I don’t want any of them. It is also stated that
untreated sleep apnea may be responsible for job impairment and motor
The symptoms of Sleep Apnea include frequent silences during sleep due to
breaks in breathing, choking or gasping during sleep to get air into the
lungs, loud snoring, sudden awakenings to restart breathing or waking up in
a sweat and feeling un-refreshed by a night’s sleep, including falling
asleep at inappropriate times during the day. While snoring can accompany
Sleep Apnea, snoring is not in itself harmful (other than keeping your bed
Fortunately, these days, Sleep Apnea can be diagnosed and treated in our
Sleep Lab, where the respirations, oxygen saturation and other parameters
can be measured.
Several treatment options exist, and research into additional options
continues. For mild cases, lose weight. Stop using alcohol, tobacco, and
sedatives, or anything that relaxes the muscles of the throat and encourages
snoring. Sleep on your side. Elevate the head of your bed 150 mm. Use a
nasal dilator, ‘breathe right’ strips or saline nasal spray to help open
nasal passages. Surgery may be needed to open the throat.
However, the main route for treatment is the CPAP (Continuous Positive
Airway Pressure) machine which forces air into the lungs through tubes
feeding a face mask. It is cumbersome, but may be necessary, when all else
Should you worry about being a little bit overweight?
Is a little bit overweight dangerous?
In a word - YES!
The western world has an epidemic of obesity, and guess what, the Asian
world is rapidly following. Thirty years ago, it was rare to see an
overweight Thai. Not any longer. What has happened?
Quite simply, our diets are far from healthy, and that includes both food
and drink, especially the kinds of drinks that come in dark green or brown
bottles. I am sure you know the types.
The problem here is the fact that being overweight puts a strain on the
cardiovascular system, which sends the blood pressure up. That in turn
affects all the organs and systems, and everything goes pear-shaped from
there on, as well as your body shape.
You are entering the world of Syndrome X. Unfortunately Syndrome X, which is
otherwise known as the Metabolic Syndrome, is a classic example of what we
medicos call ‘co-morbidity’. This is the situation where one disease process
or ailment affects, or “X”aggerates, another disease process you may have.
In these situations, the combined effects can be life threatening. It is
also a syndrome possessed by around 40 percent of adults over 40.
Now there can be many occasions when you have more than one ailment at one
time. You can have a sore throat and a broken leg all at the same time, and
these conditions have no real bearing on each other. The broken leg will get
better and the sore throat ditto.
However, the combination of diabetes and obesity can be disaster waiting.
The combination of diabetes, smoking, obesity, hypertension and high
triglycerides (blood fats) is cardiac dynamite. Your conclusive heart attack
is a matter of ‘when’ not ‘if’. The risk factors stemming from all those
conditions become not a case of simple addition, but are multiplied.
The problem from your point of view is that most of these factors come on
very slowly, and become part of your daily living. You’ve smoked for years
and never had a smoker’s cough, so why stop now? Every time you get some
trousers made the waistband has to be that little larger. Your belt has been
let out two more holes over the past two years. Your doctor said you had a
“Little bit of blood pressure” three years ago, but you haven’t been back to
check, as you feel quite OK in yourself. Your ‘triglycerides’? “My what?”
Your blood sugar? “It was OK last time it was checked five years ago!”
The big problem is that the “Little bit of blood pressure”, even say
150/100, can produce a very dangerous situation when the person with that BP
has elevated blood sugar as well. Or smokes. It is the multiplication effect
again. Whereas you can (almost) ignore mild elevations like 150/100, if you
have nothing else wrong, ignoring it when there are other conditions
co-existing brings up that co-morbidity problem again. And the likelihood of
a cardiac calamity.
Likewise, a “little bit of extra weight” that we all excuse ourselves for
carrying, may (just ‘may’) be fine for someone with no other medical
conditions, but represents an enormous risk factor for someone with the
For those who like figures with their information, here are some chilling
ones. Between 87-100 percent of people with fatal coronary heart disease, or
a non-fatal heart attack had at least one of the following risk factors -
smoking, diabetes, increased blood fats and high blood pressure. Syndrome X,
or the Metabolic Syndrome, is characterized by having Diabetes, increased
blood pressure, and raised blood fats. Can you now see the importance of
doing something about weight, blood fats and blood pressure? I for one would
not like to be sitting with a condition that gives me between 87-100 percent
chance of a cardiac problem.
So what is this week’s message? Quite simply, if you have diabetes, do
something about the other risk factors. Stop smoking and get your BP and
blood fats checked. If you don’t even know what your blood sugar level is,
then get a check-up and find about all of it!
In the meantime, take 100 mg of aspirin each morning. It is
cardio-protective. I do!