Questions for Dr. Hibberd
Headlines (Scroll down for complete
stories):
1. Fluid Retention and Lupus
2. Which
Supplements Encourage Fluid Retention
3. Elderly Male Has Pain
in Breasts
4. Numbness in Leg After Back Surgery
5. Gaining
Weight With Celiac Disease
1. I am 50 years old and have problems with water
retention mostly in my ankles and stomach area. I am 5'7'', weigh
329 and I have lupus, which runs in my family. I take a 25 mg HTZ
fluid pill and Lotrel for high blood pressure. Fluid builds up when
my lupus flares and no one is able to help me. Can you help me
understand Lupus?
— Mary C.
Fluid retention (edema) can have many causes. Often flares of
lupus (correctly called SLE or systemic lupus erythematosis) are
treated with prednisone-like medications and immune suppressants
which have fluid retention as a prominent side effect. In addition,
some patients have poor circulation as a result of poor lung or
heart function, while others have physical factors such as obesity
that are major risks for clots and sluggish venous return.
Intermittent swelling of your stomach and legs suggests you
should have a cardiology (heart) and pulmonary (lung) evaluation
promptly. Simple, non-invasive studies such as a 2D cardiac
ultrasound, EKG, Chest x-ray and pulmonary function studies will
help your doctors evaluate these systems, and hopefully help you
avoid worsening problems during lupus flares.
You are very young and extremely overweight. Ask your doctors for
help in reducing your weight, and be sure your lupus is being
aggressively controlled. Laparoscopic gastric banding and other
procedures designed to reduce gastric (stomach) capacity, although
not free of side effects, have become very popular for patients with
extreme obesity who have failed other more conservative measures.
Unfortunately, your lupus may disqualify you from this procedure.
Even if well-controlled, lupus places you at increased risk of
post-procedure complications. Steroid and immune suppressant therapy
will also place you at increased risk during and following the
surgical procedure, making the potential benefits of this procedure
potentially pale against the possible complications of surgery.
Lupus is a serious multi-system autoimmune (antibodies directed
against your own tissues) inflammatory condition. It is more common
among young women of child- bearing age, and is believed to be
caused by unknown environmental triggers. 70-90% of lupus victims
are women. It is more common in black women, but lupus can occur at
any age, even in newborns, infants and children. Lupus often affects
the renal (kidney) system as well as joints, skin and blood cell
production. Nervous system (brain, spinal cord and nerves), heart,
and lung complications are seen often associated with inflammation
of tissue and blood vessels and an increased tendency to thrombosis
(clots), especially in those with anti-phospholipid antibodies.
Lupus and its autoimmune reactions usually run in families. Some
drugs (such as procainamide and hydralazine) may produce a
lupus-like condition that is reversed upon drug discontinuance.
There are many patients with lupus who live very productive lives
with reduced flares thanks to newer medications. The American
College of Rheumatology defines criteria for the classification of
SLE intended to help guide physician treatment interventions. The
Lupus Foundation of America is an excellent source of education and
support for patients and can be contacted at lupus.org. Most
patients with lupus consult rheumatologists who work in conjunction
with the primary physician (family physician or internist) to guide
treatment recommendations.
Editor's Note:
2. Which supplements exacerbate fluid retention? I have
swelling in the ankles frequently and have seen my internist, but so
far we have found no answers. I take vitamin, herb and mineral
supplements.
— Jane S.
Which supplements do you take? The list of supplements that cause
edema is exhaustive. Even the most seemingly innocuous
non-prescription medications have reports of edema associated with
them, and there is no well-organized resource listing side-effects,
because they are largely unregulated by FDA. One brand can be very
different from another. Also, quality, randomized trials (not
provided by biased manufacturers) are hard to find.
Many supplements cause toxicity by interfering with prescription
drugs. Kidney and liver failure due to mixing supplements with
prescription drugs is not uncommon.
You need to talk with your doctor, or perhaps simply give
yourself a break from all but physician-prescribed supplements for
4-8 weeks and watch for effects. Be sure to bring all your pills and
supplements to your doctor for review. This is especially important
if you have self-prescribed this additional drug load without
involving your physician.
There are many interactions between prescription drugs and
so-called "supplements", not to mention side-effects of some
supplements alone. Some supplements, such as DHEA and
androstenedione extracts, have direct steroid-like hormone effects,
and should generally be avoided. They are potentially dangerous, and
will disqualify you from competitive sports. Yohimbe is a
prescription agent, but the supplement yohimbe is actually yohimbe
bark and is regarded as dangerous and potentially deadly. The
supplement may affect renal function and present as edema. Others,
such as kava, can be toxic to your liver and is probably not a safe
agent to use. Supplements such as SAM-e and St. John's Wort may
increase the toxicity of your prescription drugs that rely on
metabolism by the liver.
If you are concerned about side effects related to
supplementation, stop them now. These agents are not
life-sustaining, and many patients in America are over-supplementing
without a clue of the potential problems to expect.
For those of you who are using supplements to improve your
cardiovascular risk, recent evidence shows this claim is unsupported
by current evidence. At the recent European Society of Cardiology
International Symposium in Vienna this September, evidence was
presented showing that B vitamin supplementation is not justified
for secondary prevention of coronary artery disease, whether or not
associated with elevated homocysteine levels. While elevated
homocysteine levels have long been associated with elevated risk of
coronary artery disease, decreasing levels by folate and B12
supplemetation provided no decrease in coronary risk. The most
important take home here is that clinical trials have NOT found
vitamins effective in decreasing the incidence of cardiovasular
events, such as heart attack and heart failure, or death.
I wish to emphasize that supplements are to correct deficiencies
in our diet due to underlying medical conditions, therapies, or
medications, or to the over-processing of food. Avoid being duped by
the snake-oil salesman of the 21st century promising you improved
and longer life by supplementing with all their ‘special’
supplements. If it is too good to be true, it probably is a false
claim.
Go back to the basics in your diet — fresh vegetables, fresh
fruit, fresh fish, etc. Avoid over-processed and chemically treated
foods. Foods with added coloring and preservatives — added to
improve shelf life, not nutrition — are common and are to be
avoided when possible. It’s recently been confirmed that
hyperactivity and attention deficit disorders are triggered by food
dyes and additives. Growth hormone and antibiotic laced products are
also common in our food supply and are to be condemned.
Invest in your diet instead of relying on supplements, and avoid
overcooking your food.
Editor's Note:
3. My husband is 85 years old and occasionally complains
of pain in both breasts, which seem enlarged. What could be the
reason?
— Violet O.
Breast enlargement (gynecomastia) in a male should not be
ignored. Some drugs are known to cause this, including Tagamet,
digitalis, calcium channel blockers, theophylline, reserpine,
spironolactone, estrogens, antifungal meds, anti-tumor medications,
anti-TB medications, anabolic steroids — even marijuana! While
breast enlargement is common and usually normal in younger males
during puberty, it may also occur in old age, and may even be one
sided. This is rarely confused with cancer which is asymmetric, firm
and usually not tender. Various disorders especially liver (hepatic)
and kidney (renal) disease or failure, as well as endocrine
(hormonal imbalance) conditions are associated with gynecomastia and
deserve to be evaluated for by your doctor.
Editor's Note:
4. I had lower back surgery about five years ago. I don’t
have any pain in the back now, but still have numbness in my left
lower leg. Lately I've noticed the strength in the leg is getting
weaker, and the calf muscle looks to be shrinking. Please tell me
there is something that may help reverse this. I am a 49 year old
male in good health and not too overweight.
— Chris B.
The surgery was done to relieve pressure on the L5 nerve root
which supplies several thigh muscles, as well as muscles for knee
flexion and for movement in the ankle, foot and toes. The shrinking
of your calf muscle represents lack of nerve impulses to muscles and
is seen with damage to this nerve root. The numbness to your foot
and the wasting of your leg justifies further evaluation to see if
the problem can be corrected. It also needs to be determined if
additional problems have developed since your surgery or whether
this is a reflection of the prior injury to this nerve root.
Thankfully, most of our lower limb muscles have nerve supply from
more than one level which reduces disability seen from single level
nerve damage. Often an MRI will supply the necessary structural and
nerve information, and EMG studies are sometimes helpful in
assessing local nerve residual function.
Editor's Note:
5. Can you address the problem of being underweight? I'm
75 years old and have celiac disease, so I can't eat wheat, barley
or rye. I eat extremely well - lots of fresh fruits and veggies,
some protein, and only organic canned items. I weight 95 pounds
soaking wet, and nothing I do seems to put on an ounce.
— Doreen M.
Celiac disease, otherwise known as celiac sprue, non-tropical
sprue or gluten enteropathy, is a hereditary disorder where the
bowel is inflamed causing malabsorption, abdominal cramps and
diarrhea. Celiac is caused by sensitivity to the gliadin protein in
gluten (a component of wheat; similar proteins are found in rye and
barley), and it creates intolerance to gluten. Inflammation of the
mucosal lining of the bowel is the result of the body’s immune
reaction to gluten.
Celiac improves with a strict gluten-free diet. Symptoms usually
abate in one to two weeks. Continuing symptoms suggest an incorrect
diagnosis or persistent disease which often responds to
corticosteroid treatment. Residual symptoms demand further
investigation that includes surveillance for intestinal lymphoma (a
malignant condition of lymphoid tissue) which develops in as many as
6-8% of patients with celiac sprue. There is also an increased
incidence of other gastrointestinal malignancies such as small bowel
adenocarcinoma, esophageal and pharyngeal carcinoma etc, which makes
periodic surveillance of disease of great importance.
Remember, being "organic" does not assure product purity, and
gluten is so widely used in processing commercial soups, sauces, hot
dogs, fillers and even ice cream, that you really need a detailed
list of foods to avoid. See your dietician for this, and join your
local celiac disease support group. Be sure to see your private
physician and your gastroenterologist for further evaluation,
endoscopy, biopsy and surveillance since your disease is obviously
not in remission. You need re-evaluation.
Editor's Note:
Editor's Notes:
Dr. Peter Hibberd is a doctor of medicine whose
advice is based on over 25 years of outpatient and
hospital-inpatient experience. He is a fellow and active member of
the American Academy of Family Physicians, a career emergency
medicine consultant, and an active member of the American College of
Emergency Physicians. The previous are questions from our readers
and answers from Dr. Hibberd. If you have a question, e-mail the
doctor at askdrhibberd@newsmax.com.
Dr. Hibberd will not reply directly, but look for your questions and
his answers in future e-mails.
IMPORTANT: These
responses are for informational purposes only. Please consult your
primary care physician for a specific diagnosis and treatment
options.
