Chase that metronidazole with a beer! Pop some 30 year old pills! Retrain your brain as our esteemed guest Dr. Douglas Paauw goes over his popular annual ACP presentation on Medical Myths. Learn about how some common medical myths originate and continue in our practice. We discuss why it’s okay to drink on metronidazole, take expired medications, inject epinephrine into extremities and why recurrent sinusitis may not really exist.
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Written and Produced by: Justin Berk, MD MPH MBA
Infographic and Cover Art: Beth Garbitelli
Hosts: Justin Berk, MD, MPH, MBA; Matthew Watto MD, FACP; Paul Williams MD, FACP
Editor: Emi Okamoto MD (written materials); Clair Morgan of nodderly.com
Guest: Douglas Paauw, MD
We are excited to announce that the Curbsiders are now partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Check out curbsiders.vcuhealth.org/ for more information.
Dr. Pauuw’s best advice: Don’t try to look good. Be good.
“Medical myths” are practices that are accepted as dogma but lack evidence. They occur:
Paul also suggests perhaps they just align with a good mnemonic.
While there is a warning label on metronidazole, there is no strong evidence to avoid alcohol.
In 1950, there was a thought that metronidazole had a disulfiram-like reaction. Studies disproved this but were mostly ignored. A review of case reports documented emesis from people that had been drinking and taking metronidazole (Williams, 2000). But there was no evidence for the reaction.
In rat models, there is no inhibition of aldehyde dehydrogenase. But acetaldehyde levels did increase in the GI tract which perhaps could make prone persons more likely to have diarrhea or side effects.
In 2000, a randomized controlled trial of 12 healthy volunteers (medical students) received metronidazole or placebo for five days then ethanol, and there was no difference in symptoms or acetaldehyde levels between groups (Visapaa, 2002)
Dr. Paauw Expert Opinion: “And that is all of the world’s literature on the interaction between metronidazole and alcohol.” Rumors suggest the next CDC STI guidelines will remove the metronidazole warning.
Research from the US military suggests that many medications can be around for a very long time (Lyon, 2006). In one study of 122 different medications, almost all had >90% potency (the FDA requirement) at 1 year beyond expiration (with an average extension to 66 months). This included many antibiotics and painkillers.
One study of 14 sealed medications that were 28-40 years expired showed 12/ 14 had >90% potency with the exception of aspirin (Cantrell, 2012). Aspirin did break down to <1% potency. There are no significant toxic side effects either. The classic teaching of expired tetracycline causing Fanconi syndrome was a formulation that was taken off market in the early 1980s.
The studies mentioned related to unopened medications. One study looked at 12-week-expired and opened travoprost eye drops and found them to be equally clinically efficacious as unopened medications (Reis, 2004).
Dr. Paauw fun fact: travoprost eye drops are more valuable than gold by weight
Epinephrine auto-injection devices may also last longer than the expiration date, often labeled 18 months or less from manufacture. A study in Annals of 40 expired pens highlights that most all have a good level of potency at 1 – 2.5 years after expiration (Cantrell, 2017).
Dr. Paauw Expert Opinion: Don’t toss the expired epinephrine pens but, for now, have them as a back-up only. Other important medications may also need fresh refills; (we cannot confidently or safely say that all medications never expire), more data is needed for necessary and important medications.
Recurrent sinus headaches are less likely bacterial sinusitis but actually a variant of migraine headaches. One study of nearly 3000 patients who had self diagnosed or physician-diagnosed “sinus headaches (sinus pressure, sinus pain, nasal congestion), showed 88% met criteria for IHS migraine (80%) or migrainous criteria (8%) (Schreiber, 2004).
These studies were in 2004-2006, but this has not made mainstream primary care information. One study suggested an 8 year delay in diagnosis of migraine for those with recurrent sinus symptoms (Hashel et al, 2013).
The pain can affect the trigeminal nerve (i.e. nerves around the sinus) and include bilateral pain (in contrast to typical migraine pain that is thought to be unilateral) (Eross, 2007).
A study on “sinus headaches” showed many of these patients had normal sinus endoscopies and CT scans. Ultimately, migraine-directed therapy like triptans had a 92% effectiveness in treating “sinus headaches.” (Of note, there was an enormous drop out after the diagnosis phase of the study, because individuals did not feel that a migraine cocktail could possibly help.) (Kari, 2009).
Watto opinion: Be gentle when telling people they don’t have sinusitis.
Existing dogma states epinephrine in the extremities can cause ischemic necrosis in end-arterial areas. Instead, it may actually help with bleeding.
In a randomized control trial with 60 procedures (20 years ago), lidocaine with epinephrine was associated with less bleeding and had no more adverse complications (Wilhelmi, 2001).
In 2005, a study of 9 hand surgeons (3,110 consecutive cases) showed that epinephrine injection was associated with zero finger infarctions. (Lalonde, 2005). Recall in the anaphylaxis episode (Curbsiders #151), even accidental epinephrine pens in fingers have not been associated with necrosis!
A study in the 1970’s showed a podiatrist with over 65,000 surgical procedures using lidocaine with epinephrine and found no complications due to epinephrine. This has been confirmed with a more recent literature review (Ilicki, 2015).
Paul contribution: Check out the first article describing Heyde Syndrome (a 1958 NEJM Correspondence). An excerpt: “I have not found any reference to this association in the literature, and thought that a letter to a prominent journal might elicit some response about the matter.”
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Listeners will challenge the dogma of specific medical practices that have been spread without evidence basis.
After listening to this episode listeners will…
Dr Paauw reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Pauuw D, Berk J, Williams PN, Watto MF. “#215 Medical Myths: Challenge Dogma with Dr. Douglas Paauw”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list May 25, 2020.
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
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