Smarter Medical Care

Sustained significant weight loss requires medical, exercise, behavioral, and nutritional care. For best results, chronic commitment is essential. Obesity means there is too much fat when too many calories are eaten compared to the calories used. Obesity requires confronting the issues that have led to excess weight. Chronic commitment is essential to change foods consumed, increase exercise and understand how obesity occurred in you. Changing to foods with low calories such as more vegetables and fruits that contain water and fill the stomach are very effective foods to promote weight loss. You need protein found in the higher calorie foods, but not as much as many people eat. Three meals a day, even with snacks is fine, if it keeps caloric intake low. You need to plan what you eat, even if you’re eating out. In addition, several 10 minute walks contribute to weight loss. A small pedometer in your pocket counts the steps each day. Building to 10,000 steps/day is a good weight maintenance goal. People need to know why they want to lose weight because commitment is essential to maintain weight loss. One set of goals can be to maintain better health. Regular feedback about high blood pressure, cholesterol levels, Diabetes and sleep apnea help maintain motivation. Follow up visits are most often necessary to first take off weight and then keep it off.

Anorexia is the loss of appetite. There are several causes of anorexia in all people, but the most common cause in cancer patients, is the chemotherapy. Cancer appears to not only change your desire to eat but also how you perceive taste. Tastes change in many people with cancer. You can also get sores in your mouth referred to as ulcers from chemotherapy. When you lose your appetite, caloric intake is diminished, and that in itself can make people feel poorly. There are a number of medicines that can stimulate the appetite but each has risks as well as benefits. The drugs include steroids like decadron, amphetamines, Marinol, a derivative made from marijuana, and Megace. These drugs do have the potential to put you back into positive caloric balance. Don’t forget the dieticians; they often understand how to modify the diet to be tolerated better by cancer patients.

Nausea in people with cancer occurs but not in everyone, even when they get chemotherapy. The commonest cause is chemotherapy and therefore it is predictable for any chemotherapy when it might occur. Treatments are usually very effective. Cancers in the liver, cancers of the stomach or brain, or pain in a person with any cancer can be nauseating. Great progress has been made with drugs that prevent or treat nausea. The chemotherapy and expectation for when the nausea may occur determines which drugs may be best for you. Nausea or short periods of vomiting are not helpful. You should call your physician for persistent nausea. Prior discussions with your physician can determine for you when to call. If something unexpected occurs--- fever with the nausea, a bad headache, you feel badly all over and its 3 to 5 days after you had chemotherapy ---you should call your physician.

Dr. Rodvien discusses what cancer is and what the causes of cancer are. Cancer is made up of cells that grow in an uncontrolled manner or that do not die on time. Usually although we may look like all of ourselves are living with us as we move from day to day, week to week, and month to month, all of our cells are being born, then living for a relatively short time, and then undergoing death to be replaced by other cells. It is only when cells accumulate within an area of our body, and then develop the capacity to spread to other organs such as our liver lung, brain or bone, that we are either living with cancer or being threatened by that cancer. Cancers then, are a group of diseases that we name by the organ where they begin. When they spread elsewhere we still name them by the initial organ where they began but we now say that the cancer is metastatic to another area. An example would be: cancer that has spread or is metastatic to the liver. Pathologists also describe cancers by what they look like under the microscope and these words are added to the others to give a more complete description of the cancer.

Multiple, loose bowel movements that are watery define of diarrhea. In the setting of cancer may not be self-limited and can be dangerous to the patient. Beyond the usual causes, there can be an overgrowth of bacteria or other infectious organisms in the bowel. The cause of diarrhea in the setting of cancer needs to be identified, especially those caused by these unusual infections. Calling the physician should occur if it’s a first episode, if the diarrhea was not expected, if a symptom beyond diarrhea is making you sicker than expected, or if the cancer physician had suggested that if diarrhea occurs then a call is necessary. Fever or weight loss also will often make it necessary to call. Diarrhea can be persistent and be dangerous. Over-the-counter treatments can be used early on but sometimes detailed evaluation and other treatments are needed.

Anemia is a diminished number of red cells in the blood. Red cell count, hemoglobin and hematocrit also measure anemia. Lowered blood levels means you can’t deliver oxygen as well to the tissues of your body. Anemia is quite common; the common causes are iron deficiency, thalassemia, infections and/or inflammation, blood loss, poor functioning of the bone marrow (myelodysplasia), sickle cell anemia and pregnancy. Blood loss can cause chronic or very acute anemia. Some of these problems --- thalassemia and sickle cell disease which inherited forms of anemia. There are numerous other causes. The degree to which you feel poorly depends upon the rapidity that the anemia occurs and the extent of the anemia. People who are are sick from the anemia may have a high pulse rate, a lowered blood pressure, shortness of breath and anxiety among other problems. Each of the causes of anemia may also have special symptoms specific to that cause of anemia. If you lose blood fast, you can get sick quickly. If blood loss occurs slowly, symptoms can be quite subtle for a long period of time. Therapy depends upon what’s causing the anemia. For example, people can be iron deficient or folate or B12 deficient. Replacement with the specific vitamin is a first step, but each of these problems then need to be addressed at a second level: why are you lacking the vitamin? Erythropoietin is used when the marrow is not working as well as it should. The FDA is limiting the use of this drug for good reason. It should be used in an individual, understanding its potential benefits and what the risks are in you. Transfusion of red cells also has its proper uses and can be quite helpful if blood loss is significant. The reason to transfuse blood should be understood by you, including its risks and benefits, before it is given. For both blood transfusion and erythropoietin use, your physician or another appointed health care professional should give that explanation since it needs to address the issues in you.

Leaving the hospital when taking Coumadin is a transition from one environment to another so Coumadin doses can change, sometimes markedly. Get a blood test, an INR (or PT), very soon after you leave. Knowing the INR within 36 hours of leaving the hospital may save you a trip to the emergency room if the INR is shifting away from the desired level for you. Your diet, your activity and other medicines can easily change your sensitivity to the Coumadin. The list of potentially interacting drugs is very long, but for most of the drugs, you may not be sensitive to a change in Coumadin on or off other drugs. Some drugs however are often modifiers of your need to change Coumadin doses; these drugs include antibiotics 9such as Septra for a UTI) and amiodarone, a heart medicine. Get your tests in one laboratory; the INR does vary between labs. If your physician uses a laboratory that does INR tests on blood taken from the elbow area, that test may take hours to get back. In that case, I would prefer to have early hour appointments with the doctor or at least an early visit to the laboratory, and I would avoid Fridays to decrease the chances of not being called with the INR and Coumadin adjustments over the weekend. Whenever you leave the hospital, have the contact information for your physicians. Also, be responsible for yourself. Know what the next steps are in your care, and when your next visit to the doctor or doctors are. Get a discharge summary (which will include your hospital identification number and the hospital’s medical record number assigned to you as well as your diagnoses at discharge), have a list of all your medicines, know which ones may be interacting with the Coumadin, and what happens to the INR and Coumadin if one of the medicines is modified or stopped after discharge.

Clots, forming in the veins of the legs or pelvis, can migrate to the lungs and cause problems that range from no symptoms through mild problems to quite severe problems with pain, shortness of breath, changes in the heart's capacity to support your blood pressure, coughing up blood, and in fact death. High risk times for anyone to get these pulmonary emboli exist when there have been prior clots in the legs, active cancer, prior surgeries or hospitalization in general. Often pulmonary emboli can be prevented using medications, cuffs on the thighs and calves, or filters. Beginning the medicines before surgery allows less drug to be used and creates some protection from having emboli. Treatment of established pulmonary emboli are variable; frequently physicians use heparin for 5-10 days followed by coumadin for months. Even then the clot may not break down but it is adherent to the inside of the vein wall that they will rarely embolize (migrate to the lungs) after that period of time. New clots may form however and they will need active therapy. Pulmonary emboli are one of the major causes of worsening medical problems that appear to occur more frequently once in the hospital.

Coumadin is usually completely absorbed when taken by mouth. Differences in doses from one to another person occur because Coumadin in the liver is altered by at least two different proteins that determine how long the Coumadin will remain as an active drug. VKOR and CYP2C9 are these proteins and they are genetically determined for each of us. Research is ongoing right now, funded by Medicare, to see If we can determine early Coumadin doses by measuring these proteins, and if this information gives us a safer dose range that translates into less bleeding, and less rethrombosis.

Vitamin K is a series of different chemicals, all of which allow your body to change four inactive proteins made in the liver into proteins that can protect you from bleeding excessively. (There are a few other proteins made in a similar fashion in the presence or absence of Vitamin K that affect other tissue such as the bone, but their clinical effects are minor in comparison. ) These same four proteins, when changed by Vitamin K, may create clots --- thromboses – in places that can harm you. Of the different Vitamin Ks, One type is in the food you eat. Although there are foods with lots of this Vitamin K, it is not clear how much gets absorbed since the Vitamin K is contained within little microscopic capsules within the food. To absorb this Vitamin K, the capsule needs to be digested. Another type of Vitamin K is made in your colon; it is affected by some antibiotics which decrease the production of this Vitamin K. Then, less is absorbed to go to your liver. The third type of Vitamin K is stored in your liver. All the Vitamin Ks can make the same change in the four proteins made by the liver. Without Vitamin K, or in the presence of Coumadin, the change to a potentially active set of proteins cannot be made. It is NOT an all or none effect by the different Vitamin Ks on these proteins; the proteins that don’t get changed are a small per cent of the total made by your liver so that correct doses of Coumadin can slow down clotting but not eliminate it. Off Coumadin, a healthy American diet gives you enough Vitamin K. On Coumadin, you still don’t need to measure total Vitamin K stores. You just monitor the blood level with an INR; but that implies you try to eat about the same amount of Vitamin K. Don’t take a Multivitamin with Vitamin K if you’re on Coumadin unless you’re specifically told to do that. (That shouldn’t be done unless you’re part of a clinical study.) The relationship of INR to Coumadin and Vitamin K is not an easy one to understand. The INR measures one of the four proteins, Factor VII, in the blood. Factor VII has a very short half-life compared to the other three proteins that are the main participants in clotting or allow bleeding. But the INR usually measures only that protein and physicians have learned how to use the INR to get your other Vitamin K-sensitive proteins made in the correct proportions. Because of the difference in how long these proteins stay in your blood (about 6 hours for Factor VII and more than 30 hours for the other three proteins), the INR is suggesting what may be happening in the next few days as you get a changing dose of Coumadin.

Coumadin can be stopped electively or temporarily because of bleeding. There are many variables for your physician to consider, but if Coumadin is stopped but Vitamin K is not given, complete reversal may not occur for 3-7 days. It depends upon the dose of Coumadin you’re taking and the other medicines you are prescribed. Many people don’t need Coumadin indefinitely; for example, if you have developed a thrombus or clot in the leg. After many months, the drug may be stopped simply by letting the drug be broken down by your body. In other circumstances, you may need life-long Coumadin; the best example is a person with specific types of artificial heart valves. People with atrial fibrillation may need indefinite Coumadin. There are some patients in whom urgent reversal of Coumadin is needed. A physician then will stop the drug, often give Vitamin K and may even use plasma from the Blood Bank. This latter material is called FFP --- fresh frozen plasma. Other plasma materials are being tested now for those who need urgent removal of the Coumadin effect. Mild elevations in INR do occur, often without bleeding, and one can lower the INR by different techniques --- skipping one or more doses with or without taking some oral Vitamin K. These are judgments your physician will make should the INR be high with or without bleeding. Find out in advance how your physician wants you to act should your INR be high at some point. Also know what to do if bruising or other bleeding occurs. There are some steps you can take to try to prevent bruising, other bleeding or a high INR. One important step is to let anybody who prescribes or stops any medicine for you know then and there that you take Coumadin. Try to eat about the same type of diet, especially with regard to green, leafy vegetables. Also, remember that, although aspirin and Coumadin put you at greater risk to bleed than Coumadin alone, the INR will usually not reflect that increased risk.

Home monitoring of the INR can be done measured on a drop of blood from a finger stick. Then, people have more freedom to travel on Coumadin and to get tests immediately should they be bleeding or hurt themselves. The machines have several other advantages including the fact that there is not variability in the INR result because of machine variation. Often people on Coumadin can call the result to their physician or clinic so that professionals can guide changes in Coumadin dose if the INR is outside desired limits. Insurance companies often defray the costs of these machines; the manufacturer’s can help you in this process.

Coumadin is given to people who have an established thrombus or clot or who at risk to have a clot. An INR and history to include other medicines you take (including Chinese herbs and over-the-counter medicines), other illnesses and diet will determine how much Coumadin you get. Within each of these groups, there are factors that can affect your risk to bleed. In addition, certain genes control how Coumadin is broken down by the body and how Vitamin K is recycled. These two genes can vary from person to person. They can make us differently sensitive to Coumadin, a difference that may explain why some people have bleeding issues with Coumadin within the first month of receiving the drug. Many medicines interact with Coumadin and will alter what dose to start at. Usually, it is common to take 5 mg a day. The commonest response to Coumadin is nothing although there are rare people who will inappropriately have clots. You may feel a painful bruise over your breast or hip. Call your doctor. You need to be very systematically given Coumadin and get frequent blood tests --- an INR --- every other day to increase the safe use of this drug. The INR blood test result early on may reflect a higher risk to bleed a few days later; the INR in the beginning reflects “Coumadin” effects days later more than at the time you had the drug. Coumadin Clinics give you that systematic care with software that searches out the right dose very methodically. Still, it can often take 5 to 7 days to get you to the point where you are adequately anticoagulated.

For patients who have experienced blood clots, there's much to know about lifestyle changes, the proper use of Coumadin, and interactions of Coumadin with other medications. In this episode of Smarter Medical Care, Hematologist/Oncologist Dr. Robert Rodvien, founder of the Coumadin Clinic at the California Pacific Medical Center in San Francisco, discusses the relative merits of anti-coagulation clinics. Test results are immediately available when finger sticks to do INRs are done, and education of the patient discussing questions emerging from present circumstances are the best way to learn about this drug so that it works best for you as the patient.

An increasing number of patients are being prescribed Coumadin, yet far too many are unclear about what the drug does, how it works, and why it's critically important that dosing be properly monitored. For example, warfarin and Coumadin are equivalent. There are many potential ways that your dose of Coumadin may varyu, depending upon other medicines we take and the foods we ingest.  Vitamin K is in many foods to different degrees but not everyone absorbs all the Vitamin we eat.  In this episode of Smarter Medical Care, Hematologist/Oncologist Dr. Robert Rodvien, founder of the Coumadin Clinic at the California Pacific Medical Center in San Francisco, explains how Coumadin works, how blood tests can help you avoid episodes of bleeding or clotting and what else to anticipate when taking this medication.