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Those Dreaded Side Effects

“So, it seems like the prednisone cleared up your allergic rash pretty well.  Did you have any side effects from it?”

My thirtyish female patient looked at me with a little smile and responded, “Does the term, ‘Psycho Chick’ mean anything to you? I stuck with it because it was clearing up my rash and itching so nicely.  But I was moody, couldn’t sleep, and was biting everybody’s head off.  My husband couldn’t wait for me to be done with it.”

On the other hand, in answer to the same question about side effects for the same medicine I’ve gotten the answer, “I love that stuff.  I had tons of energy, all my joints felt better and my mood was great.  My house is spotless.  I just wish I could stay on it.”

It never ceases to amaze me how differently people respond to the same medicine.  There are those who never seem to have a negative reaction to anything.  Then there are some who have reacted to 20 or 30 different med.  These are the patients where we are trying to find one antibiotic they still can tolerate, or the one blood pressure medicine that doesn’t make them feel badly.

And what about the endless list of dire reactions mentioned in television advertisements for certain medicines? The announcer rattles off possible side effects that seem to include everything from liver failure to growing a second head and usually ending with “death”.  You think to yourself, “Why in the world would anyone even think about taking that medicine if it can do all that?”

So how do we take a reasonable approach when sifting possible side effects and deciding whether or not to take a medicine or not?  First of all, realize that the rapidly-listed side effects on t.v., or the long list on the package insert serve more as legal statements than helpful medical information.  They want to mention every possible problem anyone could encounter with this medicine, whether it is at all likely or not.  Most of us are aware that if they ever did the same for something like aspirin and gave it some other name we didn’t recognize, few would take it.

The key is always to compare the likelihood and severity of the possible side effects with the likely benefit of the medicine.  For example, statin cholesterol medicines can bump the liver enzymes in about 1 out of every 100 patients taking them.  Varying quoted frequencies for muscle aches can range up to 10% or more.  However both of these side effects are easy to identify and generally clear quickly when the med is stopped.  On the other side of the coin, for a person at substantial risk for heart attack or stroke, studies show that statins can substantially lower the likelihood of these two devastating events and extend one’s lifespan considerably.

So, for the right person, the benefits far outweigh the possible side effects.  Yet occasionally someone who could clearly benefit from treatment states something to the effect of, “Statins?  Those things blow out your liver don’t they?”  And so a more informed discussion is needed.  Hopefully you can get a fair amount of feedback on these kinds of questions from your doctor as well.

Side effects of medicines can run the gamut from trivial to severe to even desirable (such as anti-depressants that help with sleep or certain diabetes medicines that usually result in weight loss).  It can be pretty complicated sorting through it all.  So, sit down with your doc when needed and weigh the pros and cons – it’s worth some thought before you either reject a very helpful medicine on the one hand, or take one where the cure might be worse than the disease.

Andrew Smith, MD is board-certified in Family Medicine and practices at 2217 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835



Low Testosterone? Separating medical advice from marketing with Dr. Andrew Smith

            “Hey Doc, do you think I have low T?”  It’s a question that comes up quite a lot these days.  Whereas 10 or 15 years ago, testosterone (T) was an occasional level to be checked, it is now a frequent part of a blood workup.  This may be partly due to marketing.  But, at the same time, low T is rather common, affecting perhaps 20% of men or more.  That estimate keeps changing, partly because what is considered a normal T level keeps being changed as well.

Clinical low T is diagnosed when a low blood of testosterone is coupled with some of the signs or symptoms of low T.  So, what are these signs and symptoms?  They can include anemia, muscle wasting, reduced bone density, increased belly fat, sexual dysfunction, reduced sense of vitality, depressed mood, decreased motivation, increased irritability, difficulty concentrating, and/or hot flushes. Of course the problem is that these symptoms can have many other causes as well.  Still, they are troublesome enough that a T level is worth checking if someone has some of them.

It is probably not a good idea to simply screen all men for low T and treat everyone whose number is low.  Why?  If someone isn’t having any of the symptoms of low T, it isn’t generally recommended that they be treated with T replacement.  T replacement can occasionally have side effects.   For example, if you have the beginnings of prostate cancer, T may stimulate it to grow more rapidly, though it doesn’t seem to increase the incidence of prostate cancer.  T can also worsen benign enlargement of the prostate leading to increased difficulty with urination.  Fluid retention and an increase in red blood cell count can also occur and thereby increase blood pressure, heart failure, heart attack and stroke in those who are prone.  The numbers here don’t seem to be large, and there are some definite benefits to T replacement, but the point is that only those who will truly benefit should be treated with T replacement.

Perhaps surprisingly, sperm production can also be reduced by T replacement, thus impairing fertility.  Sometimes the sperm count doesn’t readily return to normal after T replacement is stopped.  So, for young men who may wish to have more children in the future, rather than directly giving T, there are other prescriptions such as clomiphene that can stimulate the body’s own T production without impairing the sperm count.

All those precautions being noted, if you have some of the symptoms of low T which we have listed, it makes sense to check a T level.  If indeed your levels are low, and you have symptoms that correlate, it is certainly reasonable to consider a trial of testosterone replacement.

What are your choices for replacement?  Testosterone is not absorbed well when swallowed.  So, T can be given by injections, patches, gels and dissolvable oral pellets given by prescription.  Levels can then be rechecked to ensure that adequate replacement has been given.  The other key is to see whether the symptoms of low testosterone have actually improved substantially with replacement.  T replacement is only continued if it actually helps your symptoms and doesn’t give troublesome side effects.  Usually a 2-3 month trial is long enough for a man to know how much difference T replacement makes in how he feels.  We have many men in our practice who find that T replacement has greatly improved their sense of well-being and who have no interest in going back to being without it.

This whole issue of when low testosterone is really pathologic, when it should be replaced, and for how long, is still an evolving story but more and more practical answers are being hammered out. So, if you’ve got the symptoms, get it checked, and then think it through with your doctor and decide whether to treat your low T and how.


Andrew Smith, MD is board-certified in Family Medicine and practices at 2217 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835


Keeping Your Medical Care Personal

aerial-aerial-view-application-935869In my last article, I alluded to how medical care is changing at near warp speed, as the volume of new knowledge keeps doubling every few years or less.  There’s a load of good treatment and care, as well as improved outcomes that comes from that.  At the same time, there are some downsides to the changes in medical care that I believe should be resisted when possible.  One downside is that the default drift of our medical care is to become steadily less personalized, less relational.

Consider the family doctor of past decades who would often help deliver the children, see them when they were sick, watch them as they grew up, do home visits when needed, and be present when death came.  They knew the families well and could administer care in very reassuring and intimate ways.  Of course, they often averaged only a few patients a day, had a low overhead, needed only minimal, if any, staff and had an exponentially smaller amount of medical facts to digest.  That is not in the least to diminish them; they were often brilliant, sacrificial, intensely devoted persons administering the most effective treatments of their time in a deeply personal manner.  But going back to that kind of practice with today’s medical realities and costs is probably not practical.

Continuing forward to my three decades of medical care, the depersonalization of medical care has continued apace.  I have watched the trend rather regretfully and most patients have been the poorer for it.  So, what are the driving forces for this depersonalization of care?  In my opinion there are several:  One is the smothering blanket of bureaucratic requirements that sucks more and more time away from the patient-doctor interaction.  Another force is the fragmentation of care.  Patients receive care from so many different doctors, walk-in clinics, specialists and non-physician providers that no one care-provider is likely to really know the patient in the way a physician of bygone decades would have.

Another driver toward depersonalization is the huge financial overhead that pushes a typical practice to see more patients, shrinking down a typical visit to a few pressured minutes.  Add to that the loss of physician/patient control of medical care brought about by the insurance-driven model of medical care.  With insurance typically collecting and then distributing the money in this system, they increasingly assume the power to decide what gets done, what the payment will be, who you can see (and that might change year to year) and what diagnostic and treatment options will be withheld.

In spite of all this, I love what I do.  But, at the same time, these forces, and probably many I haven’t mentioned, have threatened to sap away much of the blessing of providing personal, relational medical care.  My intent isn’t to be negative, but only to point out some of these forces with the hope of battling to preserve personal medical care.

Of course, no one is obligated to follow my suggestions.  But as a participant in medical care over three decades, my hope would be that many would:

  • Promote the right of patients and their physicians to direct medical care, not insurance companies and government agencies.
  • Consider joining one of the cost-sharing ministries to cover your major costs and then budgeting for your own basic primary care, perhaps through a direct primary care arrangement with your doctor, so that the financial power stays in your hands.
  • If possible, consistently see your own physician for your standard medical care so that you stay connected and a level of personal relationship develops that enhances your medical care.
  • Support policies that reduce bureaucratic burdens that suck away the time and attention of your physicians from actual personal care.

This is a topic that is close to my heart, but impossible to cover in the scope of a brief article.  Still, maybe this can stimulate a little of your own thoughts and ideas; maybe in some small ways we can, together, battle to keep the human touch, the focused personal connection of medical care.  Personally, I hope so.

Andrew Smith, MD is board-certified in Family Medicine.  He has recently relocated his practice to 2217 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835


Polymyalgia Rheumatica

Wow he’s really struggling coming up that hill.”  I was watching my eighty-something father-in-law labor up the hill to our house.  In context, you need to realize that, “Grandpa” is normally one of the most vigorous elderly guys you’ll ever see.  He generally comes blasting out of his room in the morning like a man on a mission.  After breakfast he may head down the hill to the barn and chop some wood, spray the poison ivy, or any number of other projects.  Even much younger folks are usually huffing and puffing after making their way back up the hill to our house.  But Grandpa was pretty used to it and usually took it in stride.

That’s why it seemed odd that he actually looked old as he slowly made his way up the hill, pausing a couple times along the way.  When he got in the house he quickly eased into a chair and looked spent.  On asking him if he was alright he responded, “I don’t know; I guess I’m just getting old.  Getting up that hill is really getting tough.  My thighs and shoulders are sore as can be.  I can barely get moving in the morning.”  I’d noticed he certainly wasn’t rocketing out of his room of late.

Given that he was eighty, there were concerns that maybe age had finally caught up with him.  Or maybe he had some hidden cancer, or late-onset rheumatologic disease, or any number of other problems.  With how he felt, it wasn’t hard to get him to come in for a check-up.  Most of the tests came back pretty unremarkable, but an old, simple blood test, the sedimentation rate, was very high.  It’s a non-specific test, but together with his other symptoms and the normalcy of most of the rest of his tests, it pointed to a diagnosis we see a couple times a year: polymyalgia rheumatica (PMR).  The clincher would be how he responded to a low dose course of oral steroids.  They tend to work like magic with PMR and that can help confirm the diagnosis.  Sure enough, a week or so after starting the steroids, we had the old “young” Grandpa back, motoring up the hill like it was nothing.

PMR is an uncommon, but occasional, illness involving the rapid onset of soreness in the large muscles of the thigh and shoulders with a sense of weakness and fatigue.  Sufferers are almost always over age 50 and more than twice as many women as men get it.  The cause is not known and is thought to possibly be autoimmune.  As noted, steroids work wonders for PMR and are slowly tapered over many months.  The entire course of PMR averages about three years.  It’s one of those diagnoses you don’t want to miss since it’s so debilitating to have, but so very treatable.

Interestingly, about 15% of people with PMR also have a condition called giant cell arteritis (GCA), which has also been called temporal arteritis.  GCA involves inflammation of arteries, most commonly the temporal artery up on the head.  GCA causes a substantial temporal headache, and if untreated (with higher dose steroids), can even cause sudden blindness.  Grandpa actually had some temporal pain that came and went.  In the end we had him get a temporal artery biopsy (which happily was normal) so as to not miss this potentially blinding malady.

Unlike almost 50% of individuals with PMR, Grandpa did not experience a relapse.  Several years later, he’s still going strong.  The only minor glitch – I hear him all too enthusiastically recommending prednisone to any of his older friends with aches and pains: “I’m telling you, get your doctor to put you on some prednisone – it fixed me right up in no time.”  But it’s a small price to pay to have him back as a young Grandpa.

Andrew Smith, MD is board-certified in Family Medicine and practices at 2217 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835