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Lariam

MagazineSeptember 2003 (Vol. 14 Issue 6)Lariam

Summer's here, and with many of you heading to some far-flung corner of the world, the Food and Drug Administration, America's drugs regulator, has conveniently issued a special warning about Lariam, the antimalarial drug

Summer's here, and with many of you heading to some far-flung corner of the world, the Food and Drug Administration, America's drugs regulator, has conveniently issued a special warning about Lariam, the antimalarial drug.

For only the 18th time in its 75-year-long existence, the FDA is ordering doctors to give patients a face-to-face warning before issuing a prescription for the drug. This special treatment is reserved for drugs that 'pose a serious and significant public health concern', says the FDA.

The move follows the tragic events at the American military base Fort Bragg last year, when three soldiers came home from their duties in Afghanistan and killed their wives. All three, who subsequently committed suicide, had been taking Lariam.

American doctors will hand all Lariam patients a medication guide that tells them that the drug has been associated with 'serious psychiatric adverse events' that 'may persist even after stopping the medication'.

The only thing new about this story is the FDA's belated entry into the debate. In May 2002, Roche, Lariam's manufacturer, settled a lawsuit brought by an Ohio woman who claimed her husband had committed suicide after taking the drug.

Hundreds, if not thousands, of soldiers have complained of hallucinations, delusions and suicidal thoughts after taking the drug. In response, Roche has included these adverse events on the product information sheet.

In addition, a Roche spokesman told the American news agency United Press International (UPI) that 'Lariam is not associated with violent, criminal conduct'. It's interesting to note that Roche does not consider the murdering of one's wife as either criminal or violent.

And if you're caught in a moral dilemma between murdering your wife (in a non-criminal way) and catching a deadly disease, a Lancet study has found that arginine, the amino acid found in nuts and rice, is a natural antimalarial agent (Lancet, 2003; 361: 676-8).

PreventionMigraineKeeping headaches at bay without drugsMore than a headache, a migraine is a serious problem affecting millions of people worldwide - women three times more frequently than men. It is estimated that as much as 25-30 per cent of the female population has experienced migraines.

The theory is that migraine occurs when the blood vessels in the brain constrict and then suddenly widen. What causes this pattern is still not known. Conventional medicine uses prescription and over-the-counter drugs to alleviate pain. But these do nothing to help cure the illness. Even worse, some can cause rebound headache (that is, headaches brought on by the medication itself).

In contrast, by addressing and treating the root cause of migraine, sufferers may have a much better chance of long-term relief. Consider the following options.

* Investigate food allergy. Many common food items can act as triggers to migraine, including chocolate, wheat, corn, milk, nuts, shellfish, sugar and oranges.

Some speculate that foods containing amines - which affect the diameter of blood vessels - are a cause. Amines can be found in any fermented, pickled or marinated food as well as in avocados, bananas, caffeinated drinks, chicken liver, monosodium glutamate (MSG), chocolate, citrus fruits, nuts, processed meats, raisins, red wine, ripened cheese, onions and lentils. Removing allergens can dramatically reduce the occurrence of migraine (Lancet, 1983; ii: 865-9; Ann Allergy, 1985; 55: 28-32).

* Is it an infection? Infection with Helicobacter pylori (the organism that causes peptic ulcers) may predispose people to migraine. In one trial, 40 per cent of migraine sufferers were found to have H. pylori infection. Intensity, duration and frequency of attacks of migraine were significantly reduced in all participants in whom the bacteria were eradicated (Hepatogastroen-terology, 1998; 45: 765-70).

* Boost magnesium. Compared with healthy people, migraine sufferers have lower blood and brain levels of magnesium. Taking around 600 mg per day was found to significantly reduce migraine frequency (Cephalalgia, 1996; 16: 257-63). But lower doses of magnesium can also be effective. Just 200 mg per day has been shown to reduce the frequency of migraines in 80 per cent of those treated (Headache, 1990; 30: 168).

* Eliminate excitotoxins. Foods containing aspartame may trigger migraine attacks (Headache, 1988; 28: 10-3; N Engl J Med, 1988; 318: 1200-1). MSG binds to it and transports copper - another possible migraine trigger.

* Stress relief. Reducing and effectively coping with stress may help reduce the frequency of attacks. Yoga, regular massage, meditation or any relaxing hobby should be part of your prevention regime.

* Reduce salt intake. Some sufferers find this helpful (Headache, 1981; 21: 222-6).

* Vitamin B2 (riboflavin). There is reasonable evidence for the benefits of vitamin B2 for migraine sufferers. Supplementing with 400 mg of vitamin B2 reduced the number of migraine attacks by half, although once an attack had occurred, the vitamin had no effect on either the severity or duration (Cephalalgia, 1994; 14: 328-9). Other studies concur (Neurology, 1998; 50: 466-70; Cephalalgia, 1997; 17: 244). Vitamin B2 is generally safe, although some people taking high doses may develop diarrhoea.

* Fish oil. This contains the anti-inflammatory fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which modify the action of prostaglandins, hormone-like substances involved in pain and inflammation. Taking 1 g per 10 lb of body weight has been reported to reduce the frequency and symptoms of migraine (Am J Clin Nutr, 1985; 41: 874; Am J Clin Nutr, 1986; 43: 710).

* Acupuncture. This form of traditional Chinese medicine can prevent a range of different headaches, including migraine. Compared with conventional drug therapy, acupuncture has more than double the cure rate (Am J Acupunct, 1999; 27: 27-30). What's more, improvement is maintained for longer - up to three years in one study (Headache, 1995; 35: 472-4).

* 5-HTP supplements. These may help regulate serotonin function in the blood vessels. In one study, taking 200 mg daily cut migraine attacks by half (Headache, 1973; 13: 19-22). Higher dosages of 400-600 mg daily have proved effective in more than 90 per cent of patients, reducing the frequency, severity and duration of migraine attacks.

* Homoeopathy. Taking homoeopathic remedies such as Belladonna 9C, Lycopodium 1X or 2X, Gelsemium 9C and/or Psorinum 9C may also be useful in alleviating migraines.

* Circadian rhythm disturbances. Specifically, the function of the pineal gland and its cyclical secretion of the brain hormone melatonin may be disrupted in migraine sufferers. Taking 5 mg of melatonin 30 minutes before bedtime may be helpful (Headache, 1998; 38: 303-7).
migraine headaches, alternative treatments, food allergy, Helicobacter pylori, magnesium, excitotoxins, stress, salt, vitamin B2, fish oils, acupuncture, 5-HT, serotonin, homoeopathy, melatonin


PreventionMigraineHerbal helpersA few herbs have been shown to benefit migraine sufferers.

* Feverfew. This herb (Tanacetum parthenium) is probably the most effective plant for preventing migraine. Trials show that remedies standardised to around 250 mcg of parthenolide can reduce the severity, duration and frequency of migraines (Phytother Res, 1997; 11: 508-11). When using feverfew, be patient - it can take four to six weeks before results become evident.

* Cayenne pepper. According to the Natural Health Education Institute (NHEI) at Bastyr University, there is evidence to suggest that this widely grown peppery herb has migraine-preventing potential. Cayenne can make nerve endings less sensitive to painful stimuli by its effect upon substance P (a neurotransmitter for pain, touch and temperature) in the nervous system.

* Ginkgo biloba. This herb can strengthen the vascular system. There is also some evidence to suggest that Ginkgo can inhibit the action of what is known as 'platelet-activating factor', which is believed to contribute to migraine headaches. Unfortunately, there are no trials to confirm this.

* Butterbur. Taking 50 mg of a standardised extract of butterbur (Petasites hybridus) twice daily was shown in a double-blind trial to reduce the incidence of migraine attacks for up to three months (Freie Arzt, 1996; May/ June: 3). The downside is that butterbur contains pyrrolizidine alkaloids (PAs), substances that are potentially harmful to the liver, so its use should be supervised by a qualified practitioner.
migraine headaches, alternative treatments, herbal remedies, feverfew, cayenne pepper, Ginkgo biloba, butterbur, Tanacetum parthenium, Petasites hybridus, pyrrolizidine alkaloids


PreventionMigraineSupporting the spineMigraine sufferers often report neck pain, tender neck joints and limited neck movement. A high percentage of migraine sufferers improve with chiropractic and other forms of spinal manipulation (Australas Chir Osteop, 1997; 6: 85-91). Headache frequency and duration, nausea and sensitivity to light improved for a year after a two-month course of manipulation (Australas Chir Osteop, 1999; 8: 61-5). Indeed, spinal manipulation can be as effective as medication in reducing migraine suffering, with fewer side-effects (J Manip Physiol Ther, 1998; 21: 511-8).
migraine headaches, alternative treatments, spinal manipulation, neck pain, tender joints, light sensitivity, nausea


Medical TestsMegan McAuliffeEndoscopyDangers of the optic 'scope'Endoscopy is the direct visualisation of the digestive tract using an endoscope, a flexible tube with a camera mounted on it that is small enough to pass into cavities in the body such as the stomach, colon, lungs and oesophagus.

For years, this seemingly safe procedure has been fraught with risks, causing problems such as perforation of the wall of the oesophagus, stomach or duodenum (the first section of the small intestine), infections and adverse reactions to anaesthetics. In some cases, the procedure has even led to death.

One study performed across 36 UK hospitals found that 1 in 2000 patients died within 30 days of undergoing endoscopy. One-third of these deaths were due to complications of sedation. In addition, there were 20 perforations in 774 procedures, eight of which were fatal, giving a death rate of nearly 1 in 100 (Gut, 1995; 36: 462-7).

Since this report, there has been no large-scale audit of the procedure. However, reports of deaths continue (Med J Aust, 2002; 176: 147).

As the procedure is invasive, sedation is used to prevent interference from patient restlessness. Anaesthetics such as propofol are commonly used, but patients have been known to become unconscious because of the dosages used, usually by untrained doctors.

Another problem is that the cleaning procedures required for endoscopes are time-consuming and arduous. But without rigorous disinfection and cleaning, the risk of cross-contamination is high. The US Food and Drug Administration (FDA) recently reported that 24 per cent of endoscopes tested produced 100,000 or more different types of bacteria even after cleaning and disinfection.

The report raised concern over the risk of endoscopic cross-contamination. Although there are no known cases of HIV infection due to endoscopy, there is evidence of such transmission of hepatitis B and C, and Creutzfeldt-Jakob disease (Gut, 1983; 24: 171-4; J Clin Gastroenterol, 1999; 28: 290).

Epidemics of mycobacterial infections have also been due to contaminated endoscopic equipment or disinfecting machines (J Infect Dis, 1989; 159: 954-8).

The Society of Gastroenterology Nurses and Associates published recommended guidelines in 1990 for cleaning procedures for endoscopic equipment. However, the report admits that difficulties arise due to the endoscope's "complex and fragile structure".

Another problem surrounding endoscopic procedures concerns the disinfectants required to clean the endoscopic equipment. These agents have been found to be highly toxic, causing side-effects such as swelling of the tongue and bloody diarrhoea in both patients and the medical staff exposed to inadequately rinsed equipment (Endoscopy, 1995; 27: 139-40).
Megan McAuliffe
endoscopy, diagnostic procedures, dangers, sedation, anaesthesia, procedure-related deaths, infections, sterilisation, cross-contamination, toxic chemicals, disinfectants


Condition of the MonthBeware of the TwiddlerDiseases change with the times, it seems. One that is beginning to trouble doctors is twiddler's syndrome, a condition that is affecting an increasing number of people fitted with pacemakers.

It's a situation brought on by the patient himself - he just won't stop twiddling with the pulse generator, which is attached to the internal pacemaker and sits in a surgical pocket. The constant twiddling eventually dislodges the leads, and they start coiling around the generator as the twiddling continues. As a result, the diaphragm starts pacing and the abdomen begins pulsating. In its final stages, the patient's arms start twitching involuntarily - almost in a Hitler-like salute.

Sometimes, admit doctors, the patient is not at fault - or, at least, not directly. They have found that the extra layers of fat in obese patients can accidentally knock the pulse generator, resulting in the same distressing effects as those caused by the Twiddler (N Engl J Med, 2003; 348: 1726-7).
twiddler's syndrome, cardiac pacemakers, twitching, obese patients, involuntary movements


News

* NHS lacks allergy expertiseMore than 80 per cent of respondents to a British survey regard the National Health Service as having "poor" provisions for treating allergies. Furthermore, the report revealed that only a handful of doctors in the UK are trained in allergies, which have reached epidemic proportions (BMJ, 2003; 326: 1415).

*HRT raises cancer risk by 100 per centFurther data are now available confirming earlier WDDTY reports that women who take hormone replacement therapy for five years or more are doubling their risk of developing breast cancer (BMJ, 2003; 327: 9).

* Heart problems following vaccineA significant number of cardiac events [involving ischaemia (blocked blood flow) or inflammation of the tissues surrounding the heart] were reported following a smallpox vaccination programme implemented throughout the USA, raising questions concerning the vaccine's safety (JAMA, 2003; 290: 31-4).

* Chronic back pain in children is mistreatedMany UK children and adolescents with chronic back pain are not being given the appropriate treatment by doctors due to a lack of research in this area as well as the misguided perception among the medical profession that back pain is an adults-only problem (BMJ, 2003; 326: 1409).

* Radiation therapy causes breast cancer in Hodgkin's patientsRadiation therapy, which is commonly used in the treatment of Hodgkin's disease, has been linked to an increase in breast cancer - and the more treatment received, the higher the risk, according to new research (Lancet, 2003; 362: 51).

* Cancer trials not representativeAlthough the majority of cancer cases in the USA are aged over 65, such patients are not being included in trials of cancer therapies, creating a discrepancy between research results, and cancer management and care (JAMA, 2003; 290: 27-8).
allergy treatment, cancer, HRT, hormone replacement, vaccines, heart disorders, back pain, radiation, radiotherapy, Hodgkin's disease, breast cancer, side-effects


Second OpinionHeather WelfordSunlight: a baby's birthrightPicture the scene. Your baby is six months old, and is growing healthily and happily on your breast milk alone.

You're starting to introduce other foods in line with guidance from the World Health Organization and the UK's own Department of Health.

But during a routine visit to your clinic, the health visitor says you aren't doing enough to protect your baby's health. Now that he's six months old, you're told, he needs extra vitamins because your milk is "too low" in vitamin D.

Currently in the UK, breastfed babies aged six months and over are deemed to be at risk of rickets - a serious developmental disorder that results in, among other things, abnormally weakened bones.

The main cause is a lack of vitamin D. Calling this a 'vitamin' is a misnomer - it's a hormone produced in the body after exposure to ultraviolet B (UVB) rays. It's also present in some foods (including breast milk), but most of the vitamin D we use comes from sunlight.

Breastfeeding mothers in the UK are routinely advised to give vitamin D supplements to their infants after six months. In the US, the advice is to start even younger - in the first two months. Formula-feeding mothers are 'exempt'.

This is all rather puzzling. Could Mother Nature have got it so wrong?

The truth is, it's not breast milk that's deficient, but modern-day lifestyles which, at their worst, may mean that babies are deprived of their birthright - sunlight.

As American researcher Cynthia Good Mojab says, "The direct, casual exposure of skin to sunlight is the most common and biologically normal way that human beings attain sufficient levels of vitamin D" (Mothering, 2003; 117: 52-5, 57-63).

We do our babies a major disservice when we wrap them up and bundle them off from house to car to nursery to indoor shopping mall and back home again.

But, in fact, most of us don't do anything like this. Most babies do get sunlight on their skin just by being out and about. In one study carried out in Cincinnati, Ohio, just 20 minutes a day out of doors with exposed hands and face were enough to maintain satisfactory vitamin D levels in older infants.

Time spent outside on most days should be enough to ensure that all babies can make their own vitamin D, including babies whose skins are black or brown and living in Northern European climates. The melanin pigment in their skin protects them against damage from strong sunlight so, compared with light-skinned babies, they may need more time under the weaker, British sun to get what they need.

There is evidence that some toddlers from Asian backgrounds may benefit from supplemental vitamin D; some paediatricians report cases of rickets among unsupplemented, breastfed Asian toddlers, but the numbers are extremely small, and other dietary and lifestyle factors have not been examined (BMJ, 1999; 318: 39-40).

One survey of Asian two-year-olds showed that up to a third had vitamin D blood levels designated as less than adequate, though all were healthy and none had rickets (Eur J Clin Nutr, 1999; 53: 268-72).

Prevention of vitamin D deficiency lies behind the current blanket recommendations in the UK, which don't apply to non-breastfed babies as the vitamin supplements are added to the formula as part of its processing.

So, given that I don't want any baby to suffer from any sort of nutritional deficiency, why would I question the current official recommendations?

Here's why. Any advice given to everyone across the board, regardless of individual circumstances and without providing full background information, is bound to have drawbacks.

The biologically and physiologically normal way to nourish infants is to breastfeed, with the addition of an increasing quantity and variety of solid foods as the baby gets older. It's also normal for infants to spend some time outdoors on most days, except in the coldest weather.

Why not ask mothers how much time they spend outside with their baby? Why not find out if their lives incorporate occasional visits to the shops or the park? Some women - not just Asian mothers - may spend a lot of time isolated indoors; their babies may be left in poor-quality nurseries; there may be other specific circumstances that prevent some children from getting the sunlight they need.

Targeting the judicious use of supplements at families who actually need them makes far more sense than worrying the families who don't. It also avoids any further undermining of breastfeeding, already under pressure in a bottlefeeding culture.

Vitamin D supplements are given in drops which also contain vitamins A and C - and there is no evidence that these additional vitamins are necessary for any breastfed baby but, because they come as a 'package deal' with D, babies end up getting them anyway.

As Good Mojab says, "When rickets occurs in breastfed infants, it indicates that something is very wrong with the context in which breastfeeding is happening, not with breastfeeding itself. Social and environmental problems in that context warrant assessment, further research and amelioration."

Heather Welford
Heather Welford is a freelance journalist and writer as well as the author of several books on infant feeding. She is also a breastfeeding counsellor and tutor with the National Childbirth Trust.
vitamin D, breast milk, breastfeeding, baby formulas, vitamin/mineral supplementation, sunlight, Asian children, rickets, bone disease, developmental disorders, lifestyle, ultraviolet


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