Hepatitis C; New WEIGHT LOSS drug approved by FDA; Gout

On Friday February 24, 2012, Skip & I discussed several interesting topics.  We started with the helpful hint that you should prepare for all doctor's visits by writing down what you want the doctor to know.  This should include your symptoms & concerns, how long you've been ill, what refills you need (& whether you need 1 month vs. 3 months at a time), & any new medications or tests ordered recently by other physicians.  In fact, it is very helpful to briefly tell all of this to the staff which gets you ready for the doctor... as they can sometimes get the refills or test results in advance of his arrival, thus making the visit much more effective.  By having everything written down, you can expedite things, & it is more likely that the doctor will address all of your issues, or at least he will help prioritize the concerns into a gameplan of future visits & tests.

There was an e-mail question regarding screening for Hepatitis C.  Hepatitis C is a viral infection which attacks the liver, & can lead to liver failure & thus death.  It is spread like HIV infection... by blood.  Thus you are at risk if you use IV drugs & share needles, if you receive a blood transfusion or an organ transplant from someone who is Hep. C positive (though the Blood Bank screens blood & organs for this... at least since 1992!), & if you are a healthcare worker who is exposed to a Hep. C positive patient's blood via a needle stick.  Unprotected sex is another option for spread, & although this is not the most common way, the risk increases if you have multiple sex partners.  Since it is passed to others via blood, note that it can even spread via a shared toothbrush or razor!  Two weeks to six months after exposure a person might have acute flu-like symptoms which can be benign enough to go unnoticed, while others never have symptoms from the acute infection.  Once you have the Hepatitis C virus, you likely ALWAYS have the virus, though it is sneaky in that it usually causes no symptoms for years, though you can certainly spread it to others during this time!  It is most often diagnosed when a person has routine blood work & is found to have elevated liver enzymes, as this is a reflection of liver inflamation.  If your liver tests are elevated, your doctor will do more tests to try to find out why... usually to include a hepatitis profile which includes Hepatitis A, B, & C tests.  It might also be found when a person tries to donate blood as the Blood Bank screens every unit for this...  & they will politely call to request you NEVER donate again if you are found to be positive!  Once a person is diagnosed with Hepatitis C, further tests can determine how sick his liver is, & this will dictate treatment.  Some people who are not very ill might opt for watchful waiting while at the same time being kind to their livers by avoiding liver-toxic agents such as alcohol, Tylenol, & certain other medications.  Others might need medication, such as Interferon & Ribovarin, though these are harsh agents which often make the patient feel ill & all too often do not lead to a cure.  Just recently the FDA approved a new drug Incivek (=Telaprevir) which is to be used with Interferon & Ribovarin, & which is reported to have a 90% CURE rate... exceptional news as we have not had anything like this before!  Lastly, patients who are very ill with liver failure due to Hepatitis C may need a liver transplant.  Though this buys valuable time, it is not a cure, as the person still has the virus in his body & it obviously will infect his new liver!  Thus you can see the excitement over this new drug Incivek, as it offers a good chance of a cure.  Another interesting point is that there is NO vaccination fo prevention of Hepatitis C, but anyone with Hepatitis C infection should get Hepatitis A & Hepatitis B vaccinations as obviously you would not want a sick liver to get a 2nd or 3rd infection!  And finally to answer the question, "yes" screening would likely decrease the spread of Hepatitis C, but it must be done as early as possible in the disease process & this is difficult to pinpoint as it will likely vary person to person.  So if you have never been tested, do so, especially if you have risk factors.  This can be done either via a Hepatitis C antibody test (which is the most specific test), or with a Comprehensive Metabolic Profile (=CMP) which measures liver enzymes as well as multiple other common tests, or even via a blood donation.  And if you are found to be positive for Hepatitis C, see a Gastroenterologist to get further studies & treatment options, & be careful not to expose friends, family, sex partners, or healthcare workers to your blood!

And on to a timely topic... obesity!  With so many of us being overweight, God knows we need help!  Now, I agree with everyone that there are no easy answers, & that proper diet & exercise are an absolute necessity, but it looks like we just got some much needed assistance in the form of a newly approved medication named Q-Nexa!  I was involved with one of the studies of this drug, so I have some experience with it.  I also worked years ago in an obesity clinic where we prescribed PhenFen, & I myself had a suction lipectomy in 1984, so obesity is a topic of special interest to me!  Q-Nexa is not really a new drug.  It is simply a combination of 2 old drugs... a bit like PhenFen which was never ONE drug, but rather 2 drugs made by 2 different Pharmaceutical companies, used in combination by doctors.  However, unlike PhenFen, Q-Nexa has actually had clinical trials done which evaluated the safety & efficacy (how well it works) of the drug combination, thus leading to its approval as ONE drug.  It is an interesting combination of Phentermine (an amphetamine which causes increased metabolism & decreased appetite) and Topamax (which is an anti-seizure medication which causes weight loss as a side-effect).  Each drug can be used in low dose as they both cause weight loss, & their side-effects are minimized not only by the low-doses, but also because they offset one another.  Whereas Topamax causes drowsiness & sedation, the Phentermine acts like "speed" to awaken the person.  Where Phentermine can increase blood pressure & heart rate, Topamax does not.  So keep your eyes open for this new option to help with weight loss, but remember diet & exercise will speed the process if done in addition to just swallowing the pill.  Also, since Q-Nexa is just 2 old drugs in a combination, consider asking your doctor to get you the 2 generic drugs instead of buying the expensive name-brand.  And for the record, Phentermine which is a component of Q-Nexa is in fact the same Phentermine which was part of PhenFen, as only the Fenfluramine component of PhenFen was taken off the market.

Another listener asked for information about gout as he has had some recurrent pain in his feet.  Gout is a disease in which the person has a high level of uric acid in his body.  This can occur due to a genetic predisposition or due to one's diet.  Foods that increase your uric acid level include:  alcohol (especially beer), fructose-sweetened sodas, rich cream sauces, certain seafood, & organ meats... as well as many other foods, so you might want to search for a list if you have concerns yourself.  It has long been known as a "rich man's" disease as in the past only wealthy men could afford to indulge in the rich foods & alcohol that lead to its development.  Gout is often diagnosed by the history:  a red, hot, swollen, terribly painful joint, especially the joint of the big toe where you get bunions, athough it can affect the ankle, knee, wrist, or elbow.  Usually the pain is so bad that even your bedsheets touching the joint or the wind blowing over the joint can be excruciating!  This history along with a blood test showing a high uric acid level usually leads to the diagnosis of gout, & typically your primary care doctor or a podiatrist will make the diagnosis.  If there is a question regarding the diagnosis, the doctor can stick a needle into the affected joint to aspirate fluid, which in turn should show uric acid crystals.  Uric acid in the blood is not a problem, but if the blood level gets high enough, the uric acid can form crystals in the joints causing gout or in the kidneys causing kidney stones.  These crystals look like a pin with 2 sharp points, so you can imagine how painful it is when these poke around in the joint, resulting in inflamation of the joint bursa!  Treatment of gout requires us to realize that there are 2 aspects with which we must deal:  the high uric acid level itself, & the painful flare-up when the crystals are actively irritating the joint.  If you have the painful flare-up, you need an anti-inflamatory medication such as Colcrys, Indocin, Ibuprofen, or even Prednisone.  Do NOT start treatment to lower your uric acid level DURING an acute flare!  Instead, wait until 1-2 weeks later, then start one of these anti-inflamatory medications to decrease the risk of a flare-up being so painfully debilitating.  After you are stable on this "prophylactic" (=preventive) medication for 1 week, you then begin a medication to help remove the uric acid from your body... such as Allopurinol, Febuxostat, or Probenicid.  These drugs must be monitored for safety as well as to see how well they lower the uric acid level, as the goal is to find the dose that gets the uric acid level below 6.0.  Once that level is achieved & maintained for 6 months, it is unlikely that an acute flare-up will occur, so at this point the anti-inflamatory can be discontinued... but the uric acid lowering medication is continued indefinitely in order to maintain the uric acid below 6.0!  Though gout is an old disease, it is often mistreated, so understanding the above will help you to get the best treatment with the least amount of pain!

Again, I hope you find this interesting & helpful... if not for yourself, hopefully for someone for whom you care!  Here's to our health!

Doctor Gigi

PS  As you know by now, this blog reflects the topics discussed during the radio broadcast of Let's Talk Medical with Doctor Gigi, which can be heard live on WTAN 1340-AM in the St. Petersburg/Tampa/Clearwater area at 1:00 on Fridays.  You can also listen live or to the recorded podcasts via:  www.SkipShow.com.  I welcome phone calls during the live show, & can be reached locally at (727)-441-3000 or toll-free at (866)-TAN-1340.  If you prefer, you can always e-mail me via:  DoctorGigi@SkipShow.com.