Hope for Traumatic Spinal Injury with stem cell therapy – Dr Mohamad Bydon

Bismillah, alhamdulillah: this was brought to my attention when I was sent a Whatsapp video clip of a man who had a traumatic spinal injury, was unable to walk, had stem cell therapy and now could walk. Is it true, doctor?

gray scale photo of man sitting on wheelchair

Hope for patients with Traumatic Spine Injuries

The clip came from Good Morning America and shows an interview with a patient called Chris Barr who had a traumatic spinal cord injury when surfing. He was operated on immediately after the injury but his quality of life and degree of neurological recovery post-op was not very good. He at times contemplated suicide but his wife helped him through and a phone call from Dr Mohamad Bydon from the Neuro-Informatics Laboratory, at the Mayo Clinic changed all that.

In the case report published by Dr Mohamad and his team they describe the use of mesenchymal stem cells (MSCs) taken from abdominal adipose tissue from the same patient. These were then multiplied in the lab and “the patient received an intrathecal injection of 100 million cells suspended in lactated Ringer solution and infused after a standard lumbar puncture at the L3-4 level”. The degree of improvement is documented very well in the case report and represents an important advance in the field. The Good Morning America clip gives a more headline treatment of the degree of improvement, while the case report shows that the patient had a fair degree of baseline function prior to the stem cell therapy, but nevertheless the degree of response was significant. Below is a snapshot of one of the Tables comparing baseline function to what happened 18 months after treatment:

Table 2.png

 

From health to illness

Bismillah, alhamdulillah, great quotation:

A healthy man is, above all, a man of this earth, and he must, therefore, only live the life of this earth for the sake of order and completeness. But as soon as he falls ill, as soon as the normal earthly order of his organism is disturbed, the possibility of another world begins to become more apparent, and the more ill he is, the more closely does he come into touch with the other world. Dostoevsky Crime & Punishment

How good are the new cancer drugs?

Bismillah, alhamdulillah

LSE researchers call into question the trial standards of newly approved cancer drugs. 25% of all newly approved medications are for cancer, the single largest category of newly approved medication. This was based on 54 key trials but only 3/4 of these were RCTs and of this number almost half of these trials were identified as having a significant risk of bias.

The #BMJ provide a very nice video infographic overview of the study, worth viewing.

https://www.bmj.com/content/366/bmj.l5221

Drug driving – two reminders from the MHRA

Bismillah, alhamdulillah

The Medicines and Healthcare products Regulatory Agency (MHRA), in its August 2019 Drug Safety Update, reminds all doctors that patients taking Naltrexone/bupropion (Mysimba▼) for weight management are at risk of somnolence (common) and loss of consciousness (rare). A risk for driving.

automobile automotive autumn car

It can be illegal for patients on certain medication to drive

It also reminds doctors that it is illegal for patients on certain medication to drive if the blood levels of certain prescription medications are above a threshold amount unless they are doing so as directed by a medical practitioner without impairment of their driving. The law came into effect in 2nd March 2015 and is targeted at drugs which are abused and not at patients. Such patients should always carry a copy of their prescriptions with them. Examples given are as follows:

1. Extreme pain (morphine, diamorphine, ketamine)
2. Anxiety or inability to sleep (diazepam, clonazepam, lorazepam, oxazepam, temazepam)
3. Drug addiction (methadone)
4. Attention deficit hyperactivity disorder, also known as ADHD (amphetamine)
5. Multiple sclerosis (nabiximols)
Reference

 

Can herbs help hypertension? MedRefresh Hypertension Part 4

Bismillah, alhamdulillah

There is a growing interest in the use of herbs or plant based treatments for hypertension. The term herb itself refers to the leafy part of plants while spices are used in contrast referring to all the other parts i.e. fruits, bark, stem, roots etc. The WHO itself has shown an interest in what it calls Traditional Medicine (TM) Strategy (1) which aims to support Member States in developing proactive policies and implementing action plans that will strengthen the role traditional medicine plays in keeping populations healthy.

aroma chili condiments cook

Traditional plant based medicines such as saffron may help with hypertension

Research studies have started to explore the use of different plant based medicines both as an independent therapy and as an adjunct to standard medical therapies. There have been a number of Randomized Controlled Studies (RCTs) looking at the subject with most of the research being coming from China and India which have well established systems of traditional medicine which is now being married with modern scientific techniques and classifications to categorize the usefulness of such treatments. There are sporadic reports of plant based treatments from other parts of the world such as Iran, Korea, Lebanon and other countries.

The issue of standardization of treatments is problematical. Studies have tried to use modern methods such as High Performance Liquid Chromatography to examine the exact constituents of plant based therapies. What they have found is that the same preparation of traditional medicines can vary significantly in their constituent amounts. Plants tend to be grown at a particular time of year differ in the chemical constituents of their leaves, the place where they are grown also makes a difference and so on. This itself is a potential stumbling block in the analysis of such treatments and their efficacy in the treatment of hypertension.

Most studies that have looked at this tend to be small and there are very few head-to-head studies which compare the effects of a particular regime of traditional medicines versus newer pharmaceutical agents. Where these have been done the quantity of traditional medication has been at least three times daily. Most traditional plant based therapies can be prepared through a simple means in a persons kitchen such as boiling whole plant material. This process is known as “infusion”. If the plant material is crushed and then boiled this is known as a “decoction”.

Commercial preparations that can be found in health food stores are formed by a more intricate process with chemical processes to extract plant based components such as extracts formed by alcohol or water based extraction of components which are then purified or dried and then mixed in certain amounts as per ancient formulas. Sometimes these can include other non-plant based components such as coral powder and elements such as Magnesium.

The safety of such traditional based treatments varies, some are very safe such as one TM such as Saffron powder, a spice made from a ground flower, and another using Horse Mint leaves (a herb from the plant commonly used in Arabia in tea). One study on Saffron powder showed that the consumption of 100mg / day reduced blood pressure by about 7/2 mm Hg for the systolic and diastolic readings.(2) Another study on Horse Mint infusions, given once daily, showed a reduction in blood pressure of 12/6 mm Hg.(3) Both saffron powder and Horse Mint are traditionally used herbs and spices in the Middle East and South Asia and their safety has not been called into question over the many hundreds of years they have been used in cooking.

On the other hand some Chinese TMs have been implicated in liver damage and deaths. One such example is a Chinese TM called Tianma Gouteng Yin (TGY). Among the many herbs and ingredients it contains is the dried stem of the Tuber fleeceflower (Polygonum multiflorum Thunb.). This particular ingredient has been associated with 441 case reports of liver damage and also seven deaths and two cases requiring a liver transplant. (4)

Judging from the large interest in the topic, though chiefly fueled by China, there seems to be a significant role for the regular consumption of traditional medicines or plant based therapies in the treatment of hypertension especially as an adjunct to pharmaceutical based medicines in order to reduce the total dose consumed and achieve better control of hypertension through a means that is more palatable to patients.

InshaAllah in the next article I would like to look at one more new treatment for hypertension which is based on biofeedback devices.

 

  1. Qi, Zhang. “WHO Traditional Medicine Strategy. 2014-2023.” Geneva: World Health Organization (2013).
  2. Ebrahimi, Fatemeh, et al. “The effect of saffron (Crocus sativus L.) supplementation on blood pressure, and renal and liver function in patients with type 2 diabetes mellitus: A double-blinded, randomized clinical trial.” Avicenna journal of phytomedicine 9.4 (2019): 322.
  3. Samaha, Ali A., et al. “Antihypertensive Indigenous Lebanese Plants: Ethnopharmacology and a Clinical Trial.” Biomolecules 9.7 (2019): 292.
  4. Lei, Xiang, et al. “Liver damage associated with Polygonum multiflorum Thunb.: a systematic review of case reports and case series.” Evidence-Based Complementary and Alternative Medicine 2015 (2015).

How good are lifestyle changes for my blood pressure? MedRefresh Hypertension Part 3

Bismillah, alhamdulillah

What options are open for patients to reduce the blood pressure that can either be done on their own and / or done in combination with pharmacological medication? How effective are these options? There is a very nice summary table that the UpToDate [1] authors have compiled. I have drawn on this data and represented the data as a radar chart which is given below:

Non-pharmacological treatment of hypertension

Reduction on blood pressure in mm Hg of 6 non-pharmacological interventions

The radar plot gives a rather unique representation of the impact of various interventions.  The table below gives the same data in pecking order with the most effective “interventions”, sounds nicer than treatments, to reduce blood pressure and my comments:

Reduction in BP (mm Hg) Intervention Comments
11 DASH Diet Fruit, veg, nuts, whole grain, low-fat
6 Salt <1.5 g/d Salt Intake <1500 mg / day = 1.5 grams (g) per day. This is a hidden menace that plagues our food, there is a nice online calculator at saltcalculator.co.za [2].  Health warning: it is done by Unilever and sets the recommended amount at 5g per day, not the 1.5g per day i.e. 330% higher than what is needed to reduce blood pressure.
5 Weight loss (5Kg) 5 kg, this is supposed to be 1 mm Hg per 1 Kg loss i.e. every bit counts.
5 Aerobic ~12 min / day Exercise 90 minutes / week i.e. ~13 min/day – probably one of the most difficult things for most people to integrate into their daily lives. Most people enjoyed play times at school, perhaps enlightened employers will bring this back into their offices!
5 Isometrics (11 min/day) 4 x 2 minutes hand grip, 40% of max voluntary contraction, 3 sessions/week. These can be done at your office desk, though your face does show some of the signs of strain as you get to the end of the sets.
4 Potassium >5g/d Potassium aim for 5000 mg/day, this is a very difficult target to meet for most people and does not apply to people who have other chronic disease affecting their ability to regulate their potassium (Cushings, renal disease, aldosteronism etc).
4 Weights (~12min/day) Dynamic Resistance (50% of 1 repetition weight, 6 exercises 3 sets/exercise, 10 reps / set. If you don’t have a handy set of weights, just start this exercise with a 500 ml water bottle held in each hand. This will equal 1/2 Kg per bottle. You can gradually work up to 50% of your maximum weight.
4 Alcohol Reduction Moderation of Alcohol to less than the maximum recommended amounts for men and women. The ideal being none.

 

InshaAllah in the next article I will explore what herbal options are available.

References

[1] Basile, Jan, and Michael J. Bloch. “Overview of hypertension in adults.” UpToDate, Waltham, MA.(Accessed on February 22, 2017) (2015).

[2] “Test to Know Your Salt Take-In.” Salt Calculator, http://www.saltcalculator.co.za/.

Which medication is best for my BP? MedRefresh on Hypertension Part 2

Bismillah, alhamdulillah

There are many options that can reduce blood pressure once hypertension has been diagnosed, this article carries on from the last article: Is your blood pressure going up? MedRefresh on Hypertension Part 1 and looks at what the multi-billion dollar pharma industry offers patients and doctors for patients.

antibiotic blur cocktail glass cocktail tablets

The choice of blood pressure medication is large – but the news is good

Over the years there have been many rules that have tried to guide doctors: which medication for which patients and in which order. The aim: simplify treatment. In reality the opposite tends to be the result: complex rules that change every few years. In practice physicians tend to stick to what they know and are familiar with or have been familiarised with by helpful pharmaceutical sales agents who take every opportunity to reinforce a particular brand in the minds of doctors. But certain ideas have survived through the last many decades of treatment:

  1. Why do we treat hypertension? The point of treating of hypertension is to reduce the future risk of cardiovascular events (heart attacks, strokes, renal failure etc). Sounds a bit obvious but it is worth always bearing this in mind to question the outcome of trials.
  2. Pressure or medication – which is most important? Meta-analyses on both sides of the Atlantic ocean have come to the same conclusion: the reduction in blood pressure is MORE important that the particular medication used, as usual there are exceptions to this observation i.e. beta blockers where rate control is needed as in AF etc.
  3. How effective is treatment? Medication produce an effective response in 30-50% of patients but there is significant variability between patients. If an initial medication does not work by cycling through single medication options 80% of patients will find that they can control their blood pressure with a single first choice agent.
  4. What are the first three choices? First line medication are TZDs thiazide diuretics (hydrochlorothiazide, bendroflumethiazide etc), ACE / ARB (the ‘..prils‘, enalapril and ‘..artans‘ valsartan etc), or a long-acting dihydropyridine calcium channel blocker (the ‘..dipines’, amlodipine etc). TZDs and CCBs are the preferred choice in the elderly and in black patients.
  5. Which dose is best? The largest drop in blood pressure occurs at half-the standard dose as mentioned in pharmacopoeias. If the standard dose is 1 then there are three dosing options: x0.5 / x1 / x2, the corresponding average drop in blood pressures are 7.1 / 9.1 / 10.9 mmHg for all classes of medication. For thiazide diuretics the numbers are 7.4 / 8.8 / 10.3 mmHg.
  6. Which combinations of treatment are best? One such possible exception comes from the ACCOMPLISH [1] trial (11.5K hypertensive patients + 1 risk factor, followed up for 36 months published in 2008), compared an ACE inhibitor (Benazepril) combined either with a CCB (Amlodipine) or TZD (Hydrochlorothiazide). The odd finding was that despite the slightly better blood pressure outcomes in the TZD arm (1.6/0.3 mmHg lower) the cardiovascular primary end point were less in the ACE + CCB arm, 9.6% v 11.8 %. This only applied to non-obese individuals. Makes you wonder what was going on – we are waiting for further confirmatory trials on this topic.

The next post inshaAllah will take a look at non- pharmacological options and lifestyle.

[1] Jamerson, Kenneth, et al. “Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients.” New England Journal of Medicine 359.23 (2008): 2417-2428.

[2] Mann, J. “Choice of drug therapy in primary (essential) hypertension.” UpToDate [Internet]. Philadelphia: Wolters Kluwer Health [updated 2018 Sep, cited 2019 Aug].[about 15p.]. Available from: http://www. uptodate. com/contents/choice-of-drug-therapy-inprimary-essential-hypertensionHTN-recommendations (2019).

How to maximise profits using ‘authorised’ generics

Bismillah, alhamdulillah: Interesting article on how complex pricing strategies by modern pharmaceutical companies are being used to keep overall prices of medication high with ‘authorised’ generics.

person writing on notebook

‘Authorised’ generic medication keeps brand-pharma profits high

Pharmaceutical companies with a brand name coming to the end of its patent period launch their own generic, an ‘authorised’ generic. The overall effect of these authorised generics is to prevent true generic drug manufacturers from getting a foothold in the market. Inadequate market penetration by cheaper true generic manufacturers allows the brand pharma to dictate prices, keep costs relatively higher and profits up. It makes you wonder how widespread this practice is.

Read more at Medscape.