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This is a wordy page. Sorry about that. It is written as a result of my trying to find out about my own condition: which task was not as easy as I could have hoped! Maybe others have similar questions and some of the answers I have found may be helpful. There are a variety of conditions mentioned here but all are probably interconnected and as I cannot tell what may be relevant to whom, I will leave little out. It is written to try and make sense to others, so essentially in the order things happened to me.
I am updating is gradually and paragraphs that have a date after them {e.g. (20090615).} have been changed on that date.
In October 1980 I visited the doctor with heartburn. I had, all my life, had a tendency towards excess acidity and used to take sodium bicarbonate to quell the symptoms. I was born in 1943. I had what I later realised was GORD (or GERD if you are American!): Gastro Oesophageal Reflux Disease. However the doctor in 1980 diagnosed stress as being the present problem and prescribed me a course of Libraxin. My son had been born about a year ago in 1979. It was at the end of 1983 that my marriage of 11 years broke up! Stress was apparently the correct diagnosis!
This drug has become obsolete now (2009) but it was clidinium bromide (2.5mg) plus chlordiazepoxide (5mg), otherwise known as librium. I found it quite effective, used on demand. I took one when I felt the symptoms. There is a pdf document available at gut.bmj.com/cgi/issue_pdf/advertising_pdf/25/9.pdf
It was some time in 1984 that I was out walking with my young son when I took a short-cut through a hedge. I was aged 40 and was not yet wearing glasses, but my vision was not that of a young man. I managed to poke a twig in my right eye. No real damage, but I got an eye infection. This gradually descended my nasal passages, transmuting into a cold, then a cough. The cough refused to go away. I went to the doctor, who referred me for a barrage of tests.
The texts all proved negative. Unfortunately I simply has an unexplainable, chronic, productive cough with no infection to account for it. Something I had to live with!
In retrospect it would appear that it was at that exact point that I developed bronchiectasis: a condition with which I was diagnosed in 2007. Clearly I do not know for certain that that was the case, but it seems to make a lot of sense. I was post-divorced, in a dusty, dirty job and in an altogether depressed state - in fact it was during this time that I evaluated the quality of my life and the only thing that kept me from suicide was the certain knowledge that things would get better.
At that time I was working for a welding company and the office I had was above a very dusty machine which made cored wire for alloy injection into steel. My office was dirty and if I blew my nose, the result was very dirt-laden. Also at this time the wire being produced was cored with calcium silicate. Calcium Silicate at that time contained arsenic and phosphorus as impurities and when opened to damp air gave off significant quantities of Arsine gas. Arsine is not known to be connected with bronchiectasis. However I think it unlikely that my apparent development of the condition at that time was entirely unconnected to the dust and general poor environment.
In 2007, my habitual cough had become significantly worse. I also had a dry tickly cough, so was not only coughing up mucus, but had this dry cough. I decided enough was enough and went to the doctor. I was referred to Addenbrokes chest clinic, where I was diagnosed with mild bronchiectasis. I was put on regular visits and saw a consultant who specialised in the condition. During these visits I mentioned the fact that I had a tendency to heartburn which was significantly worse these days - a fact that I put down to my being above my comfortable weight (At that time I weighed approximately 73kg - not enough to be medically concerning, but I knew I was uncomfortable!)
The consultant referred me to Addenbrooke's new endoscopy department for examination. There I was diagnosed with a hiatus hernia, Barrett's oesophagus (a long section - 9cm) and a couple of oespophageal ulcers to boot. I was immediately put on a course of omeprazole and another endoscopy booked for 4 weeks time.
Suddenly my life-long symptoms were explained: it seems that I must have been born with a hiatus hernia. When young, the reflux symptoms were relatively mild and easily controlled. But when I was worried, maybe the wrong muscles tensed up and held my internal organs in such a way that acid refluxed. Or so I theorised. When I am over my comfort weight, the excess fat in my abdomen also evidently displaces my stomach, causing bad reflux symptoms.
I have also been told that with a life-long hiatus hernia and reflux disease, aspiration of stomach acid into my lungs could have occurred without my being aware of it and this could have caused the bronchiectasis. Possible, but I cannot help but be suspicious that this condition is connected with the dust-laden atmosphere at Welding Alloys Ltd in Fowlmere where I was working when the first symptoms of bronchiectasis occurred.
In February 2009 I had decided to be more diligent in reporting problems to the doctor. At 65, one's urogenital system is aging. My bladder pressure was lower than it once was, and a bit erratic. At age 60 I had had a medical examination, including a prostate exam. "Your prostate's a bit soft, but that's normal for your age." The doctor had said.
Was I developing prostate trouble? I had a blood test for prostate cancer indicators. That was clear - but my HDL/LDL (cholesterol) ratio was unfavourable. Also my kidney function was reduced, as indicated by creatinine clearance results. But that's another story (which I may write)!
The creatinine clearance result made me seriously wonder about my omeprazole dosage and kidney function. There is no general warning to be found on the internet, but there are tests where people with reduced kidney function have had problems while on a high dosage omeprazole. However medical advice is that Omeprazole is not cleared by the kidneys but is metabolised by the liver.
Nevertheless I don't like taking unnecessary drugs and the endoscopy department had been less than lucid in discussing symptoms and prescribing medication. I had initially been prescribed one 40mg dose of omeprazole daily. After 4 weeks, when the ulcers had not healed at the next endoscopic examination, this had been doubled to 40mg every 12 hours. The doctor at that time had said that the 40mg dose would last about 20 hours, so I needed the extra to effect a proper cure.
In practise I found that 40mg would indeed keep me symptom-free for about 20 hours. However, there appear to be two factors here: when on a regular course of medication, each tablet may keep one asymptomatic for, perhaps, 22 hours, but if the regular regime is reduced or erratic, each single dose lasts less time. As a result I has settled on a 40mg dose repeated at about 16 hour intervals as being the best compromise for me. I found this cycle worked well, giving a regular 48 hour cycle. I'd take one at 8:00 in the morning on getting up, one at around midnight before going to sleep, and one around 4pm the next day.
However I knew that this was a slight overdose: it was a compromise between the 40mg capsules I had been prescribed and a regime I could adhere to. Could I reduce the dosage? Not easily using the 40mg capsules. So off to the doctor who prescribed me 20mg capsules to allow me to experiment.
Here is the real oddity.... Taking 20mg doses at 16 hour intervals had almost exactly the same result as taking 40mg doses at the same intervals! Clearly I don't need the 40mG overdose, which must have been creating high initial blood levels which were relatively quickly metabolised, rather than used for their intended purpose. The 20mg must more like a correct background level as it gets eliminated in not much less time than the double dose. But it indicates that more frequent small doses are a better solution? Watch this page!
More notes (Thursday the 11th of June, 2009)
The 20mG doses lasted a bit less that 16 hours. Probably around 14 hours, but as no stomach pH tests were done, it's rather subjective.
So I anticipated that 10mG would last about 12 hours. My initial findings seem to confirm this.
The moral here is, if you are on a PPI, experiment to find the best dosage for you. Rather than, for instance, 20mg once a day, 10mg twice a day may be better.
Bile reflux and tickly cough
Thursday the 7th of October, 2010
Omeprazole is claimed to be generally without side effects. I find this untrue. I have now proven to by own complete satisfaction that the bile reflux I suffered was promoted to Omeprazole, as was the tickly cough.
I have proven this by reducing even further my dosage. I find that 1/2 of a 10mG capsule, 3 times daily (7:00, 15:00 and 23:00) keeps stomach acid low and since going on this regime I have suffered no bile reflux whatsoever, and the tickly cough has also vanished.
During my experimentation I have found that the Omeprazole dosage and time are as below
| Dosage (mG) | Time (Hrs) |
|---|---|
| 40 | 20 |
| 20 | 18 |
| 10 | 15 |
| 5 | 10 |
The times are of course only approximate but it is certain that the significant effect of taking any high dosage is that it gets metabolised: it is a well known fact that it is metabolised in the liver. It is metabolised in the liver and discharged into the bile, which is also produced by the liver. a high blood serum level of PPI will get metabolised at a greater rate sot it is not too surprising that excess Omeprazole can disturb bile production, but it's not clear whether it does so by increasing the volume of bile or by making it be produced at the wrong time or by some other mechanism.
In particular, I found that I was subject to attacks of bile reflux at night, when my stomach was empty. Now bile release is normally triggered by fats in food. In the small hours of the night the stomach is essentially empty so nothing should be triggering bile release. Clearly - Omeprozole was doing just that!
I cannot explain the tickly cough so easily: cough receptors are widespread and can be triggered by many things. Bile is one of them. However I am now satisfied that the cough was not triggered only by the bile (which was erratic - the cough is not, it is (on the 5mG dose) a gentle reminder that I am late taking the dose!
The dosage findings are complex: Omeprazole certainly works best as a steady regime. When changing dosage it takes several days for a pattern to stabilise. Twice I tried reducing from 2 x 10mG per day to 3 x 5 mG and twice I had terrible nocturnal bile attacks. Third time I was lucky. I have now been on this regime for over 3 weeks with zero bile reflux!
A word of warning
5mg doses result in a blood drug concentration below that required for complete acid supression. This is a tricky area - stomach acid varies sharply with plasma concentration and is therefore difficult to control. I eventually had to go back to 10mg doses.The half-life of omeprazole is short, 0.5-1 hour. There is also a slow pharmacodynamic onset, with acid inhibition only 50% of maximum at 24 hours, and a long-acting pharmacodynamic effect of acid secretion reduction to baseline over 3-5 days. It is these effects that make Prilosec ineffective in acute relief and make it beneficial for 24-hour prevention.
Other pages say similar things: one says half-life is highly pH dependant. My my own measurements, above, five a half-life of about 2 1/3 hours - but then the granules are coated to be 'slow release' (not slow enough im my opinion). So a 20mg dose lasts 2 1/3 hours less than a 40mG dose. 10mG lasts 2 1/3 hours less than 20mg.
This is all quite consistent and anyone giving the matter the least thought can see that little and often has to be the only way to go.
As well as acid reflux, I suffered from bile reflux - something far more unpleasant. Now most evenings I used to have a drink and I had found cream liqueur to be quite palatable - wine and many other drinks, I found aggravated my reflux symptoms. In retrospect, I think the cream may have lined my oesophagus, partly relieving the symptoms. But it may be that this contributed to the bad LDL/HDL ratios in my blood test!
Once that the stomach acid level was under control, I discovered that the cream drink was causing bile reflux. I also discovered that, some time before I got bile reflux, dry tickly throat would return, causing the cough.
It seems there are cough receptors in the oesophagus: these are evidently sensitive to bile and cause the cough some time before I notice the actual taste of bile. There appears to be little known about the mechanism of cough production but it is known that there are sensitive receptors in the oesophagus. Maybe it's a referred response!
My evening drink of cream liqueur was more habit than anything else so it's now on my black list! However - because of the cholesterol blood test results, I had done some www browsing and I discovered the claimed benefits of coconut oil, which seemed quite convincing. I refer you to Ray Peat's essays on diet. For a short while I deliberately took coconut oil, for instance instead of butter substitute on a slice bread. But I discovered that the coconut oil triggered my bile reflux. Sure enough, bile production is indeed triggered by fats in the diet. However my diet has never been high in fats, but clearly for my own comfort I need fewer calories generally. The few days of trying coconut oil did nothing obvious except cause bile reflux! So now we just use coconut oil in cooking instead of the small amount of vegetable oil we used to use.
Cutting out the cream liqueur and reducing my meal size very slightly has reduced my weight by about 6kg (from 73kg in Feb 2009 to 67kg in June 2009). Since my waist measurement also decreased by about 2 inches this was mostly visceral fat I was loosing. (20090615).
As I lost went, gradually the bile reflux diminished and the tickly cough went. But then, some time after I thought it had completely disappeared, the tickly cough started to reoccur, erratically and apparently acausally. I do not know if there is some change in sensitivity or whether body fat is being re-deposited as visceral at. (20090615).
In early June 2009 my doctor prescribed Lisnoprisil. Two weeks after that, the dry, tickly cough had returned with a vengeance. This was confusing and it wasn't until I did a www search that I found this is a common side effect of Lisnoprisil.
I am interested in free wild food, so it was natural to look for alternative hypotension (blood pressure lowering) remedies. I must get a pressure monitor and a supply of Kudzu vine - the other good herbal remedy is Fenugreek. (20090615).
I hope my experiences above have helped you. If so, why not use the contact button and let me know. If you have any related points you think we could usefully discuss, by all means contact me.
Document URI: www.torrens.org.uk/Med/HHetc.html
Page first published: 13th March 2009
Last modified: Thu, 26 Jan 2012 08:47:00 GMT