DEAR READER: Plavix is prescribed by physicians to prevent blood clots that could lead to heart attack or stroke in some patients. Prilosec (omeprazole) reduces the incidence of excess stomach acid. In November 2009, the Food and Drug Administration issued a warning to patients not to take one if you are on the other. New research suggests that when Prilosec and Plavix are taken, the ability to block platelet anticlotting may be reduced by almost 50 percent. Plavix alone isn’t capable of producing an anticlotting effect until it is metabolized or converted into an active form with the assistance of the liver enzyme CYP2C19. With the addition of Prilosec, this liver enzyme is blocked, substantially reducing the potential effectiveness of the Plavix.

Once the possible interaction was noted, the FDA requested additional studies from the manufacturer that supported the existence of a significant interaction that could negatively impact a person’s health. As a result, the Plavix label has been updated and now includes warnings regarding the use of Prilosec and other drugs that block the liver enzyme. It is unknown how other proton-pump inhibitors (PPIs) may interfere, but the recommendation is that Nexium, Tagamet and Tagamet HB, Diflucan, Nizoral, VFEND, Intelence, Felbatol, Prozac, Sarafem, Symbyax, Luvox and Ticlid also not be taken with Plavix because of the potential for similar interactions.
Any patient prescribed Plavix who needs medication to control stomach acid should speak with his or her physician for a recommendation of possible substitutes, such as Zantac, Pepcid, Axid and others that do not inhibit the CYP2C19 enzyme. So make a telephone call now or set up an early appointment with your doctor to resolve the issue.

To provide related information, I am sending you a copy of my Health Report “Consumer Tips on Medicine.” Other readers who would like a copy should send a self-addressed stamped No. 10 envelope and a $2 check or money order to Newsletter, P.O. Box 167, Wickliffe, OH 44092, or download an order blank from my Web site, www.AskDrGottMD.com. Be sure to mention the title.

DEAR READER: Gastroesophageal reflux disease (GERD) commonly causes heartburn and a sour taste in the mouth; however, nearly half of all sufferers experience a chronic cough with no other symptoms. If the heartburn medication works, you probably have GERD. You may wish to try using antacids, which are less expensive and have the additional benefit of adding extra calcium to your diet. If they do not work, go back to the Prilosec. My hat is off to your allergist for thinking outside the box of his specialty and doing everything he could to help you.

In February 2007, my husband was found to have high blood pressure and was started on lisinopril, hydrochlorothiazide and metoprolol which he took until October 2007 when he developed an unproductive cough, extreme fatigue and lightheadedness. He could sleep 24/7. He saw his doctor who ordered testing but nothing was found.

He then developed dizziness when turning his head or bending over and saw the doctor again after developing a slight fever. He was given amoxicillin. At that time we asked about the possible side effects of the lisinopril and were told he could stop it.

Now fearing medication my husband stopped them all. He then returned back to the physician because his symptoms persisted and was found to have very high blood pressure and a heart rate of 120. His cough had disappeared shortly after stopping the medications but he continued to be dizzy, lightheaded and tired. He was admitted to hospital that day where he had a chest X-ray and was seen by a cardiologist who prescribed atenolol, lisinopril, a low dose aspirin, and Lipitor. His symptoms continued.

We called his primary physician again when he started trembling. At that time he told us to discontinue the lisinopril. The Lipitor was never started because we felt he had enough problems already without taking more medications. My husband then developed a hiccup spasm which is very loud and happens sporadically. He continued to have the extreme tiredness, lightheadedness, dizziness, and trembling so back to the doctor we went. An ultrasound of the carotid artery was ordered and was found to be clear, despite the fact that he nearly fell over after the exam. We were referred to an ear-nose-and-throat specialist to rule out a middle ear infection. Everything appeared to be fine but recommended to our personal physician that a test be done on the inner ear and an MRI of the ear and brain. We decided to hold off on the testing at that point.

In January 2008, our doctor prescribed an antidepressant, fluoxetine. His symptoms improved slightly but two weeks later, my husband couldn’t urinate and was sent to a urologist. He finally was able to go shortly after we arrived for the appointment. During the exam everything was found to be normal but it was recommend that he have an internal exam of his bladder. That test was never done.

Back when my husband had the cough, he felt something happen in his lower torso but didn’t notice anything. He then developed a bulge in late January 2008 that was diagnosed as a hernia. By the time this arrives to you he will probably have had corrective surgery (scheduled for May 2008). He continues to have symptoms despite stopping most of his medications and now has trouble urinating, constipation and a hernia. We don’t know what to do, his doctors cannot find anything wrong and I am worried.

DEAR READER:
Your husband appears to have a series of seemingly unrelated symptoms. Some are similar to adverse effects of his medications, others of vertigo, infection and his hernia.

Your husband’s doctors appear to have done appropriate testing and exams but thus far have failed to find an explanation. Therefore, I recommend your husband get a second opinion from another internist who specializes in ailments of the whole body rather than just this part or that part. You should bring a copy of your husband’s medical record with you to the appointment which will provide an accurate history of symptoms, medications, testing and more. Perhaps having a fresh set of eyes look over the history and do another general examination will reveal something overlooked.

As for holding off on the testing, I urge you to now have that MRI of the ear and brain. The dizziness, lightheadedness and nausea may all stem from vertigo. Vertigo is caused by an abnormality within the ear that can, often upon waking, looking up, bending down and more can cause motion sickness-like symptoms.

The constipation, inability or difficulty to urinate may be part of the hernia which once repaired should stop symptoms. A hernia occurs when part of the intestine slips through an abnormal hole in the abdomen into various areas. Depending on the area of the hernia, symptoms vary. Constipation is fairly common because the stool within the bowel can become blocked in the area that has been “misplaced”. If the intestine is pushing on the tubes leading from the kidneys or the bladder, urination can be affected.

Get a second opinion and follow-up on the recommended testing. Let me know how this turns out.

When the patent on Prilosec was about to expire the formula was “tweaked” just enough to receive a new patent which was then marketed as Nexium. This “tweaking” caused the Nexium to have some side effects that the Prilosec did not.

I would like to be off the medication but diet, exercise and over-the-counter antacids don’t work. Do you have any suggestions?

DEAR READER:
First, let’s address your concerns about Nexium and Prilosec. I am not a pharmacist and was unaware that Nexium and Prilosec (while it was still a prescription) were even made by the same manufacturer let alone were practically the same drug. After reading your letter, I went to my trusty Physician’s Desk Reference and looked up both medications. It turns out, you are at least partially correct in your assessment. From my limited knowledge of drug chemistry, it appears to me that Nexium and Prilosec are practically the same formula with only minor alterations. However, your statement that because of this “tweaking” one drug has side effects the other doesn’t is incorrect. Both medications have distended stomach, fatigue, back pain, and leg pain listed as known, but rare (occurring in less than one percent of users) side effects.

Why you are affected so severely by one and not the other is a mystery but I must congratulate you on discovering the cause of your symptoms.

Proton pump inhibitors, such as Nexium, Prilosec and others, work to block some of the stomach’s acid producers. They are prescribed for those with gastro-esophageal reflux disease, hiatal hernia and ulcers. Before medication is prescribed, physicians should recommend the patient change his or her diet, lose weight if necessary, get regular exercise and use over-the-counter medications as needed. If symptoms are still a problem, then prescription medications should be used. In some cases of hiatal hernia, symptoms still persist and surgery may be necessary to tighten the opening between the stomach and throat. Unfortunately, this only works about 50% of the time and may not be permanent.

I often recommend that acid reflux sufferers make drastic changes in their diets by avoiding all trigger foods such as fat (fried foods, greasy bacon, etc.), citrus/acidic (tomatoes, oranges, lemons, etc.) and some spices. Spicy foods are not the main culprit as many believe. In fact, I have heard many sufferers say that they don’t have a problem with spices, but rather it is milk and lettuce that are the major sources of discomfort.

If you are continuing to have difficulties, speak with your gastroenterologist about alternatives to prescription medications.

To give you related information, I am sending you a copy of my Health Report “Hiatal Hernia, Acid Reflux and Indigestion”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.