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To Your Good Health

Health Advice From Dr. Roach

Jun 17, 2019 | 9:59 AM

Severe exertion intolerance may be chronic fatigue syndrome

DEAR DR. ROACH: My husband is tired all the time. He functions but frequently has to sit to recoup his energy, even after a shower.

He is diabetic and has been for over 10 years. He does not take insulin and manages to keep his A1C within 7.1 to 6.9. He weighs 207 pounds, and he’s 6 feet, 1 inch tall and 75 years old.

His bloodwork always comes back normal, and a nuclear stress test came back negative. We have discussed this chronic fatigue with our family doctor. His only explanation is possibly low testosterone (the low end of normal).

We know that some if not all of his medications list fatigue as a side effect, but we cannot persuade our doctor to do further tests. My husband does have an appointment with a cardiologist in May for a consultation and any suggestions, and also a checkup in six months with our family doctor.

My concern is his medications and the fact that they are generic. I have read many stories about generic drugs and problems with their effectiveness. — J.C.

ANSWER: Fatigue, which is the sensation of feeling tired, is a nonspecific symptom and a complaint that’s commonly heard by general doctors. It can be related to many diseases, as disparate as multiple sclerosis to heart failure, anemia to depression, and chronic infection to sleep disturbances. However, your husband notes a severe intolerance to exertion, which makes me suspect systemic exertion intolerance disorder, also called myalgic encephalomyelitis or chronic fatigue syndrome. Poor sleep, difficulty thinking or concentrating, and having worse symptoms with standing also go along with this diagnosis. There is yet no lab test for confirmation. The diagnosis is made after considering other causes, and testing for those that make sense after a careful history and exam.

Diabetes, when not well controlled, may lead to chronic fatigue. I’m not so concerned with generic medications as I am about too many or the wrong ones, so a careful review of medications is appropriate. I have previously recommended a graded exercise program for this condition; however, the study that led to this recommendation had several significant issues; many people will actually have worsening of their post-exercise fatigue, so exercise must be used very cautiously and on an individualized basis. Cognitive behavioral therapy has had some benefit, but we desperately need better treatments.

DEAR DR. ROACH: Is it possible to suffer and maybe die from a broken heart? We all have many life events that change our lives dramatically. — M.A.K.

ANSWER: Absolutely.

The first condition is rare, and it’s called takotsubo cardiomyopathy (the condition was first described in Japan: “takotsubo” means “octopus trap” in Japanese, reflecting the characteristic appearance of the heart on echocardiogram; “cardiomyopathy” is a nonspecific term for something that’s gone wrong with the heart muscle). This condition accounts for 1% to 2% of all suspected cases of heart attack based on EKG and blood tests. It is much more common in women (80%) and is most often diagnosed in a person’s 60s or 70s.

About 28% of people with takotsubo cardiomyopathy have emotional stress as the precipitating factor, while 36% had a physical trigger (such as infection or surgery), 8% had both physical and emotional triggers, and 28% had no identifiable trigger.

However, even people without this catastrophic condition have increased risk of heart disease and death after one (or especially more than one) stressful life event. It’s important for ourselves, and for our loved ones, to be especially vigilant of our own physical and emotional health after stressful life events, such as death or serious illness of a spouse, loss of a job or major violence.

DEAR DR. ROACH: I read your recent column on pulmonary fibrosis. I especially appreciate knowing that there are medications known to slow progression of lung disease, reduce exacerbations and reduce mortality. With a 20-year-old diagnosis of COPD and having been prescribed medications to reduce exacerbations, you might imagine my interest in your article.

I’m wondering how pulmonary fibrosis differs from COPD and if the two medications that you mention (pirfenidone and nintedanib) might be helpful in slowing the progression of lung disease in patients such as myself. Have any studies been completed using these medications on patients with COPD? — S.A. ANSWER: Chronic obstructive pulmonary disease — its two main forms are emphysema and chronic bronchitis — usually, but not invariably, is a result of long-term exposure to lung toxins, especially smoke. In the most common case of COPD, due to cigarette smoking (at least, that’s the most common in North America and Europe: cooking fires are still a common cause in less developed countries), stopping the exposure will dramatically slow down further damage. Unfortunately, there are no established treatments that can restore lung function in people with moderate to advanced COPD.

Pulmonary fibrosis is, by contrast, a rare disease; about 30,000 people in the U.S. are diagnosed each year (compare that with the 9 million people in the U.S. diagnosed with chronic bronchitis last year). The exact mechanism of action of pirfenidone and nintedanib is not known, but they are not thought to be effective in COPD. Surprisingly, I did not find a published trial looking at whether these drugs might be effective. The need for new therapies to treat COPD is so great that I would have thought some researcher might have tried it, despite the long odds.

DEAR DR. ROACH: I have a friend who recently found out that she’s prediabetic. She’s also very obese. She has started juicing her fruits and vegetables in order to lose weight and get healthier. Isn’t it just healthier to eat produce whole as opposed to making juice out of it? — N.F.E.

ANSWER: Eating more vegetables and fewer simple sugars and processed starches is a good idea for nearly all people who want to eat healthier, and it may help people lose weight. Fruits are also an important part of diet, but for people with or at high risk for diabetes, I recommend no more than one or two fruits with meals, and that the fruits be whole. Fruit juice is absorbed much more rapidly into the blood, so excess fruit juice can actually precipitate diabetes or worsen diabetes control.

Juicing makes it easy to consume vegetables and fruits, but in addition to the problem with faster sugar absorption, taking food in liquid form usually isn’t as satisfying. That’s not true for everyone, but since reducing calories is essential for weight loss in nearly everybody, juicing may have the opposite effect, unfortunately, and I don’t recommend it in general.

Of course, what doesn’t work for one person may work great for someone else. If she is able to change her diet, reduce unhealthy choices and lose some weight, then juicing may be just right for her. I would still recommend against too much fruit juice, and to have fruits mixed in with vegetables, preferably taken with some protein and healthy fat.

DEAR DR. ROACH: My nephew has foot odor. Even after showering, his feet have a bad odor. His shoes smell bad and have to be replaced often. What is the remedy for this problem? — B.C.

ANSWER: Foot odor is caused mostly by bacteria living on your feet. Bacteria thrive in warm and moist environments, so people who sweat a lot from their feet are at high risk. Some people are also colonized with particularly bad bacteria, such as Kytococcus (formerly Micrococcus), Corynebacterium or Dermatophilus. These bacteria do not cause disease, but they break down dead skin cells into unpleasantly smelly chemicals. A careful look at the skin on his feet may reveal small pits in the skin, especially around the heel, after a long day in socks and shoes.

Treatment may include disinfecting skin solutions (such as chlorhexidine), antibiotics (topical erythromycin or clindamycin), and keeping the feet as dry as possible. This may require application of antiperspirants to the feet, either regular over-the-counter or prescription varieties. He also should wear lighter, more breathable footwear. Washing (and then drying) the feet several times daily and putting on new socks each time may also help during the treatment phase.

Although ultraviolet-light shoe sanitizers exist, I’d recommend getting new footwear while trying to get rid of as much of the bacteria as possible.

DEAR DR. ROACH: At 75, I had my first ever kidney stone in December. The urologist told me to stop drinking so much milk. But he never asked if my diet had changed. I had been eating almonds by the handful every day. I felt certain this was the cause of the stone. I drink skim milk, which is practically tasteless. I started adding a slight bit of almond milk to the skim to give it a more pleasant taste. Should I not be doing this? — P.T.

ANSWER: I am not certain why the urologist told you to stop drinking cow’s milk. We used to believe that the calcium in milk increased risk for kidney stones, especially calcium oxalate stones, which are the most common type; however, dietary calcium paradoxically decreases risk of kidney stones, whereas calcium supplements increase risk of stones. What makes the biggest difference in diet is the oxalate content. Almonds, as well as almond milk, are very high in oxalate; cow’s milk is not. I don’t know what you mean by a “slight bit” of almond milk, but I would try to avoid taking too much (more than a few teaspoons a day), and find another way to flavor the milk if you really don’t like it. I know a few people who add a drop of vanilla. Coconut milk — which I don’t recommend consuming in large quantities due to the saturated fat content — does not have oxalate.

Essentially, everybody with kidney stones should drink plenty of water, and nearly everyone should be very careful not to have too much sodium.

DEAR DR. ROACH: Short of sounding like a conspiracy theorist, why hasn’t the Food and Drug Administration approved sildenafil in a set dosage for blood pressure medication? I saw a decrease from 150/90 to 115/70 in a reading about an hour after taking a 20-mg tablet. That’s a far superior result compared with the medications I am on. — J.I.C.

ANSWER: Sildenafil (Viagra) does have a blood-pressure-lowering effect in many men. However, the average effect is only about 8 points systolic and 6 points diastolic, far less than the 35 and 15 point drop you saw. Further, the blood pressure effect is gone in less than 8 hours. The goal for blood pressure medicine is continuous lowering without big ups and downs.

I’m not a big believer in conspiracy theories. If the medication were truly safe and effective for blood pressure control, you can be sure it would be marketed as a blood pressure pill with additional benefits for some people, just as tadalafil (Cialis) is marketed as a treatment for benign prostate enlargement, in addition to its proven role in treating erectile dysfunction. Tadalafil is also being studied as a potential benefit in heart failure treatment.

DEAR DR. ROACH: I happened to be using a topical steroid for a bug bite when I got a sunburn on the area. To my surprise, the area that had the steroid on it had no redness or pain. Are topical steroids effective sunblocks? If so, why don’t we use them? — W.R.R.

ANSWER: High-potency steroids are powerful anti-inflammatory drugs. Although they do not prevent the damage done to the skin by the sun, they do prevent the inflammatory reaction that shows up as redness and warmth on the skin. That reaction appears for hours or days after sun damage, depending on the degree of the sun exposure and the individual’s protective skin pigment.

Broad-spectrum sunscreens do partially protect a person’s DNA against the sun. In addition to avoiding excess sun by staying out of it, especially during the most dangerous time of the day, other strategies to reduce risk of sun damage and skin cancer include wearing sun-protective clothing and the regular, repeated and liberal use of UVA and UVB sunscreens.

High-potency topical steroids are not proven to and probably don’t reduce the risk of skin cancer. More importantly, they have far too many side effects to use on a large area of the body. I don’t recommend steroids in prevention nor treatment of sunburn.

DEAR DR. ROACH: What are your views on the safety and effectiveness of glucocorticoid nasal sprays, instead of, and in addition to, oral antihistamines and decongestants, for managing allergic rhinitis? — P.L.V.

ANSWER: My experience, backed up by the research, is that more people will get relief with regular use of nasal corticosteroids, such as fluticasone (Flonase) or triamcinolone (Nasacort), than with oral antihistamines or decongestants. All three classes are generally safe. However, nasal steroids cause nosebleeds in some people; decongestants can raise blood pressure, occasionally strikingly; and some antihistamines are sedating. Older men can have prostate problems with either decongestants or antihistamines. Some people may prefer one or the other just for convenience. Some of my patients just cannot stand nasal sprays, even newer ones that have much less sensation upon spraying. Other people don’t like pills. The combination of the two has more potent effects than either by itself.

Before taking medications, it may certainly be wise to consider how to reduce contact with substances that trigger one’s symptoms. It may be impossible to avoid triggers entirely.

DEAR DR. ROACH: My wife has been diagnosed with atrial fibrillation. Doctors tried an electrical cardioversion, but it came back after a few days. She is taking metoprolol and Eliquis. We have read about the supplements red clover, turmeric, omega-3 and hawthorn. Should she discontinue the pharmaceuticals and take supplements instead? — J.C.

ANSWER: Please don’t do that, and let me explain why.

Atrial fibrillation is an abnormal heart rhythm. The goal of treating it is first to relieve symptoms, such as fast heart rate and dizziness, and second, to reduce the risk of stroke. Blood clots can form inside the heart when the atria are fibrillating (a chaotic, non-coordinated muscle movement). Those clots can break off and go into the blood vessels of the brain, causing cell death and loss of function in that part of the brain. That’s a stroke.

Your wife is taking metoprolol to slow the heart rate. Atrial fibrillation causes the ventricles to go too fast, causing a sensation of fast heart rate and palpitations. Metoprolol, a beta blocker, protects the heart from damage from a too-fast heart rate, in addition to relieving symptoms. Apixaban (Eliquis) is a powerful anticoagulant, reducing the risk of clot formation.

Red clover is usually used in herbal medicine for its estrogen-like activities. Unfortunately, estrogens INCREASE clot risk, so this herbal medicine absolutely should not be used by someone at risk for clots. Sweet clover hay is the source of warfarin (Coumadin), another often-used anticoagulant in people with atrial fibrillation: This may be the source of confusion. However, warfarin needs to be dosed precisely, with frequent blood level checks.

Turmeric is an antioxidant that does have some mild anticoagulant properties. However, it is not remotely powerful enough to do the job of protecting your wife adequately from stroke.

Omega-3 fish oils were once thought to reduce risk of atrial fibrillation; unfortunately, a 2013 study showed no benefit.

Hawthorn has two potential benefits: To a slight extent, it acts as a beta blocker (like metoprolol) as well as an anticoagulant. However, no trials have proven its effectiveness. It may interfere with both her medicines. The metoprolol and Eliquis have much more safety data.

DR. ROACH WRITES: In a recent column, a reader noted she had a history of irritable bowel syndrome and described intermittent sharp rectal pain. My answer discussed control of her IBS. When I saw the column printed in the newspaper, weeks after I wrote it, I realized instantly that the diagnosis was probably proctalgia fugax, which is a spasm of the muscles of the anus. It is thought to be related to nerve compression. I learned from my predecessor of this column, Dr. Paul Donohue, that sitting on a baseball or tennis ball can sometimes stop the pain instantly, and that creams and sometimes oral or inhaled medications can be effective in harder-to-treat cases.

I also want to point out that I fell victim to something called an anchoring heuristic error.

I read about my reader’s irritable bowel and became “anchored” to that diagnosis. Admitting an error and trying to understand why it happened are critical to reducing the likelihood of making the same error again. Anyone can make a mistake; it’s important to learn from them.

* * * Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803. (c) 2019 North America Syndicate Inc. All Rights Reserved

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