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INSIDE HEALTH

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Programme 1.

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TX:听 21.01.14听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听 ERIKA WRIGHT

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Porter

Hello. Coming up in today鈥檚 programme:听 Weight loss 鈥� we take a critical look at the latest medical slimming device to hit the market.听 Spasmodic dysphonia 鈥� the voice equivalent of writer鈥檚 cramp - an easily missed condition that can leave you struggling to be heard.听 And antacids - are we over-using the latest generation of treatments for indigestion and heartburn?

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Clip

These drugs can be very hard to stop and one of the very particular axes to grind that I have is this issue around the fact that patients take them because they have 鈥渋ndigestion鈥� (in inverted commas) but once you start taking them four out of 10 people who don鈥檛 have an acid problem will develop one.

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Porter

But first moves to bolster research by including your GP medical records in the NHS database known as care.data. If you live in England and haven鈥檛 already received a leaflet outlining the new plans, then you will soon.

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Entitled Better Information means better health care 听it lists the benefits as including everything from better use of NHS resources, to finding more effective ways of preventing, treating and managing illness.听 If you don鈥檛 want your records to be included then you have to opt out 鈥� if you do nothing it will be assumed that you agree to sharing them.

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Dr Mark Davies is Medical Director of the Health and Social Care Centre which will be responsible for looking after the data.

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Davies

The principle of using this data is that it needs to be used to improve patient care 鈥� and that鈥檚 a really important point.听 So there are no other purposes that we will use this data for.听

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Porter

So who鈥檚 deciding whether the data鈥檚 being used appropriately?听 I鈥檓 thinking if I鈥檓 a private company, a pharmaceutical company, and I want access to that data to help develop a drug or perfect something I鈥檝e already got.

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Davies

So I think this is a really important point and we will only share data for the purposes of improving patient care, we will not share it for any other purposes, such as insurance or otherwise, this is about ensuring that we are doing the best care that we possibly can for individual patients and indeed for communities.听 We are not talking about sharing patient confidential data, identifiable data, outside the NHS, that will not happen.听 And the only data that flows into the system is either anonymised or we take all the identifiers from the data, we remove them and replace them with a code that only has meaning to us and that code is held in a separate place from the data itself.听 This is not about making money, this is about us covering the costs of us providing this data but it鈥檚 not about making a profit.

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Porter

So going back to my example of a private research company 鈥� a pharmaceutical company 鈥� I would pay for that data but you would not be making a big profit out of me is what you鈥檙e saying?

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Davies

Absolutely.

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Porter

The other criticism has been that this is an opt out scheme.听 So if you don鈥檛 happen to read your leaflet or you don鈥檛 object your data will be included in this.听

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Davies

The vast majority of the public actually are very comfortable with that and as long as they can understand how their data is going to be held securely and they understand what鈥檚 going to be done to the data and it鈥檚 used responsibly they鈥檒l feel comfortable with that happening.听 The other reason is that actually there is a matter of some urgency with this.听 We have an NHS that is facing considerable financial challenges currently, it鈥檚 critical that we start to measure outcomes and the quality of care in a systematic way and actually we need this data in order to plan and run the NHS efficiently.

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Porter

There are some mumblings that because it鈥檚 gone for an opt out system that it may contravene some draft EU legislation, make the whole thing illegal.

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Davies

We are confident about the legal basis that we are collecting the data, our legal advice is that we have a robust case for doing this but I think more importantly is it鈥檚 the ethical and the moral case.听 And actually I think most of us as citizens once we start to understand that our individual data can actually start improving the care that we deliver to our population and to others who have similar conditions actually the moral case for us doing this as individuals I think is compelling.

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Porter

Dr Mark Davies.听 And listening to that with me are Liam Smeeth, who鈥檚 Professor of Clinical Epidemiology at the London School of Hygiene and Tropical Medicine and who also works as a GP in North London, and our very own Dr Margaret McCartney who is in our Glasgow studio.

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Margaret, do you welcome this initiative?

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McCartney

It鈥檚 a difficult one.听 I think there鈥檚 no doubt that we need high quality data about what鈥檚 happening in the NHS.听 What I really about is the way that this has been gone about.听 People are being given four weeks to opt out and the leaflet that the NHS is sending round is really quite vague about what鈥檚 happening, in fact they don鈥檛 actually mention the words 鈥渃are data鈥� which is the big computer program that鈥檚 been generated by the technology company ATOS to draw out identifiable information from GP records, which are then going to be passed to this other organisation, called the Health and Social Care Information Centre, and which can then be distributed to researchers who have got a good reason for wanting to look at it.

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Porter

So you鈥檙e worried that no matter how hard they try and anonymise this data that there鈥檚 a chance that somebody鈥檚 individual details may come out?

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McCartney

I think we don鈥檛 know.

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Smeeth

I don鈥檛 think anyone can guarantee there鈥檚 no risk.听 What matters here is that the potential benefits are enormous.听 This will be a unique opportunity internationally for research purposes, as well as greatly helping people trying to run local services and trying to run the NHS more efficiently.

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Porter

Margaret, how do you feel about some of the campaigning that鈥檚 gone on around this 鈥� looking at some of the charities for instance they鈥檙e obviously supporting this initiative?

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McCartney

Yeah, we鈥檝e got very emotive adverts being placed by the Wellcome Trust and supported by several large charities with a picture of a little boy saying:听 鈥淗ello, I鈥檓 Peter, we haven鈥檛 met before but one day you can save my life.鈥澨� And in the leaflet drop, of course, people are complaining that the leaflet has been muddled up with lots of other takeaway menus and charity leaflets for bin bag collections for clothes.听 Really and truly is this the best way to tell the population what鈥檚 happening?

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Smeeth

People want to use the NHS, they want the NHS to be safe and effective and to be run effectively and that does need their data, that鈥檚 part of being a patient in the NHS and part of the deal is that if you get the benefits from the NHS then yes we will need to use your data.听 I just want to pick up on one thing that Margaret said and she said that identifiable data will be made available to researchers 鈥� that is not true.听 Now I can鈥檛 guarantee that insurance companies, for example, will not criminally go through my dustbin contents, find out things about me and criminally increase my insurance premiums and I can鈥檛 guarantee that insurance companies will not undertake criminal acts to hack into this data but that would be a criminal act to do that, as well as being unethical, so that鈥檚 the first point.听 And second, the data that I use for research, for example, from general practice, are already anonymised and scrambled, so we have patients鈥� records, with all the identifiers stripped out and they鈥檝e been given a brand new identification number that鈥檚 only used for research purposes, so it鈥檚 got no link to their real identity.

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McCartney

For me, as a doctor, I really need to know that when my patients come in to see me they have got full confidence that what they tell me will not go any further.听 And as it stands I don鈥檛 feel as though the information that people are getting is enough to enable them to feel that and I feel as though this could have been overcome by anonymising the data as it leaves the GP practice rather than later on.听 And I think that until we do that and until we give people a genuine choice of what鈥檚 happening we鈥檙e missing out on an opportunity for people to feel confident about their data being used in a way that will be to their, their family and their community鈥檚 advantage later on.

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Smeeth

I completely agree and I鈥檓 completely 鈥� I鈥檓 just as concerned about my own data, my family and my loved ones data being made available and of course it needs to be anonymised.听 But what matters is that it鈥檚 done in the best possible way and if the IT specialists and the IT systems and the best up-to-date systems are saying this is the best way to maintain this anonymity, make sure we hold the data securely, then I think this is the way we go.

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Porter

Professor Liam Smeeth we must leave it there, thank you very much.

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It will come as no surprise to Inside Health listeners that the UK has a weight problem but just how much was succinctly highlighted in a report out last week that claims at least two million adults in the UK are now so overweight they would be eligible for surgery on the NHS.

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Well the Inside Health team has come across two novel approaches to tackling our waistbands 鈥� one involves swallowing a balloon, the other kicking one around a pitch.

Obalon is the world鈥檚 first balloon treatment that can be swallowed in a capsule and it鈥檚 currently only available privately at cost of least 拢2,000. But what does it add to existing options?

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Consultant surgeon Sally Norton, from Southmead and Frenchay hospitals in Bristol, is among the first specialists in the UK to be trained in its use.

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Norton

Basically when it goes in it鈥檚 the size of a pretty large pill but nonetheless the size of a pill, which means that you can swallow it.听 And then it stays in for three months and then at the end of the three months you have an endoscopy at that point, just to take the balloon out.听 So it鈥檚 a lot easier to insert than previous balloons.

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Porter

When you say you swallow a pill 鈥� the balloon is inside that pill?

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Norton

Yes it鈥檚 basically a capsule.

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Porter

And so how does it get inflated?

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Norton

So the capsule is attached to a very thin catheter, like a piece of string really, so when the patient swallows the capsule I screen it down under x-ray to make sure that it鈥檚 in the stomach and then at that point it鈥檚 inflated with 250 CCs of nitrogen gas and then the catheter, obviously, is just tugged off.

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Porter

You just pull the catheter off, so that leaves鈥�

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Norton

Yeah it takes two minutes.

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Porter

鈥� the balloon鈥檚 left in there.听 Can you give me some idea of what that does to the volume of the stomach 鈥� what鈥檚 the volume of a normal stomach?

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Norton

Oh gosh, I鈥檝e seen many, many stomachs over the years, a stomach can vary in size hugely but the conventional balloons that we put in are about 750 CCs, so they鈥檙e considerably bigger.听 This balloon is about 250 CCs, which is the size probably of an apple 鈥� a medium, large size apple.听 And because it鈥檚 filled with gas it sits at the top of the stomach, so it floats at the top, which helps people feel full.听 But unlike the fluid filled balloons that we do have it doesn鈥檛 move around quite as much making you feel sick.听 And that鈥檚 really important because if people aren鈥檛 feeling sick, getting stomach cramps and the sort of symptoms that they were getting with balloons in the past, it means that they can actually make some healthy changes to their lifestyle while the balloon鈥檚 in place and that鈥檚 where the key to this whole treatment is I think.

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Porter

And how鈥檚 it working 鈥� literally by making you feel full?

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Norton

Yes and I think that that鈥檚 really quite an interesting ethos because the thing about this balloon is that it makes you feel full with smaller portions.听 So I would like to see this used as an aid to help people retrain how they see their food portions and try and get them to change their eating behaviour over the three month period, so that they can continue that behaviour long term.

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Porter

Who鈥檚 this for?

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Norton

Well as a weight loss surgeon I鈥檝e got surgery that I can offer to people who鈥檝e got a body mass index of 35 and above, who are seriously overweight.听 But I鈥檝e got nothing really to offer people who鈥檝e got less weight to lose but are still concerned about their health.听 So we鈥檙e talking about people who are overweight and obese, as opposed to severely obese.听 So that鈥檚 a body mass index for this balloon of 27 and above, up to about 35.听 So this is the group of people who haven鈥檛 really got any treatment available to them other than conventional dieting, which we know from experience just doesn鈥檛 really work.

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Porter

Because 27鈥檚 not very high, that鈥檚 marginally overweight.

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Norton

Well it鈥檚 more than marginally overweight, it is a reasonable amount overweight and actually you don鈥檛 have to be that much overweight to have a significantly increased risk of diabetes, arthritis, high blood pressure.听 And so I think we do have to start tackling people鈥檚 weight at an earlier stage because I see them then when they鈥檙e a lot heavier and they鈥檙e then coming for surgery, it would be nice to be able to tackle it earlier on.

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Porter

At the moment obese patients have to fulfil lots of criteria before being considered for gastric surgery and that typically includes six 鈥� 12 months on a conventional medically supervised diet and exercise plan even though it won鈥檛 work for most of them.

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Guy Slater is a weight loss surgeon at St Richard鈥檚 Hospital in Chichester.

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Slater

Surgery is the only intervention with a large amount of medical evidence supporting it.听 There鈥檚 still absolutely no evidence for medically supervised programmes in terms of psychological input, medication, exercise programmes or dietetic support.听 At best patients will lose about 5% of their bodyweight and most studies show that they regain that in the years after they finish.

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Porter

Guy, what鈥檚 your impression of this new device?

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Slater

I think it鈥檚 interesting.听 It鈥檚 a novel way of treating obesity.听 Previous balloons have acted really by occupying space within your stomach giving you a sense of fullness.听 This balloon鈥檚 designed to float up into the upper part of your stomach where receptors that control appetite lie and it interferes with those receptors to work primarily by reducing appetite, which is actually similar to some methods of bariatric surgery.

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Porter

And have you been impressed by the data?

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Slater

The data currently is of very small numbers. There鈥檚 three published abstracts with 10 patients in, 15 patients in, one with a hundred in.听 I think the data currently puts this device into that sort of category of lifestyle or slimming aid, all the data to date shows that it doesn鈥檛 seem to be harmful, so I think that鈥檚 positive.听 Whether or not patients get a good outcome is another thing, at least it鈥檚 not harmful.

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Porter

One of the things that strikes me about this is the lower threshold, I mean they鈥檙e talking about BMI of 27 which is only one above where I am and it seems that that would encompass quite a lot of people.

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Slater

In my opinion it鈥檚 not clear yet that this is a health intervention, it may be more of a lifestyle choice in terms of how you lose weight.听 But I think what will be interesting is that presumably in time they鈥檒l run the studies again in much larger patients and then we鈥檒l see whether it has clear health benefits or not.

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Porter

This also seems quite a short term measure, what do you think about leaving something in for just three months?

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Slater

I think that you will lose weight in that three month period but the big question is whether you sustain that weight loss or not after the device is removed.听 In my experience, when we reverse bariatric surgery, patients gain their weight very quickly because I think appetite is hardwired.听 People think of diets as a temporary measure when what you really need is a lifestyle solution that lasts years.

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Porter

Guy Slater.听 And Inside Health鈥檚 Margaret McCartney has been listening to that. Margaret, do you think this new balloon is an advance?

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McCartney

No, no I don鈥檛 think it鈥檚 an advance.听 I think we keep going round and round in circles with another type of gastric balloon, another type of surgery, another medical intervention and basically we don鈥檛 have any medium or long term data to say that they will actually be doing you a favour.听 So I鈥檓 very reluctant to think that this will yet again be a miracle solution we鈥檝e all been waiting for.听 I think if your BMI is a bit above normal we know the kind of things that work but they are difficult to do and it鈥檚 basically just cutting down calories and exercise.

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Porter

But that is one of the depressing things about this area isn鈥檛 it 鈥� that actually the only thing that has that quality long term data is surgical intervention.

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McCartney

Yes.听 Although I have some good news 鈥� there鈥檚 a great study this week in the Lancet, a study that was done in my home town, in Glasgow and across Scotland and it was a study of overweight guys who were going to premier league football clubs.听 And they asked some of these fans if they would like to come on a weight loss and exercise programme and it鈥檚 fantastic 鈥� they had 12 weekly sessions, 90 minutes each, I think that time is probably very significant, where they got basic diet advice and they did fitness training.听 And then they got six e-mails over the next nine months, they had a nine month reunion and then a 12 month reunion.听 And what鈥檚 really staggering 鈥� most weight loss interventions you end up with very small numbers of people actually who participated in all the sessions 鈥� they get 80% of men to participate and those men lost an average of five kilograms on average over the year, which is really quite impressive.听 And that鈥檚 probably one of the best trials I鈥檝e seen because it was a randomised control trial as well, so it was a very high quality trial actually showing that when you get it right, when you pitch it right literally at the right people, you can actually make some really good differences just with those basic lifestyle changes.

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Porter

A glimmer of hope from Glasgow. Thank you Margaret.听 And you will find some useful links on bariatric surgery on the Inside Health page of bbc.co.uk/radio4.

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Now imagine if your voice sounded like this:

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Clip 鈥� staccato

The patient might talk a bit like this and it sounds very 鈥� very sort of staccato and broken up.

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Porter

Around 70,000 people in the UK are thought to have some form of dystonia 鈥� uncontrollable spasms that can affect almost any part of the body, from the muscles around the orbit causing screwing up of the eye, to tightening of the hand and forearm leading to writer鈥檚 cramp.听 But in spasmodic dysphonia it鈥檚 spasm of the muscles in the voice box that causes the problem.

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Palmer

My name is Phil Palmer and I have spasmodic dysphonia.听 Probably about 10 years ago or so I started having quite sporadic periods where my voice would just suddenly either drop out or I鈥檇 have a lot of problem getting words out or getting a sentence out and there was just 鈥� and sometimes my voice would go very high.听 It almost sounded strangulated.

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Costello

My name鈥檚 Declan Costello and I鈥檓 a consultant ear, nose and throat surgeon specialising in voice disorders.

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Interestingly spasmodic dysphonia only happens when speaking, it鈥檚 a task specific dystonia, so if the patient is yawning or laughing or crying the sound that their vocal cords produces is more normal.

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Porter

Do we know what the cause is 鈥� I mean the fact that it only occurs during speech suggests that the problem is higher up than the muscles itself, it鈥檚 the control of the muscles that鈥檚 the issue?

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Costello

Yes, that鈥檚 likely to be the case.听 It鈥檚 really not clear what the underlying cause is.听 It鈥檚 probably a combination of factors.听 What we know is that there are some genetic predispositions that can lead people to be more likely to develop it but there is almost always in patients a single trigger, a single thing that happens that sets it all off.听 And that might be an upper respiratory tract infection, it might be an emotional event, for example, as well.听 And that鈥檚 led some people to think of this in years gone by as being a psychogenic problem, whereas it鈥檚 very genuinely not, it鈥檚 very clearly a neurological problem.

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Porter

Because this was one of the issues with writer鈥檚 cramp, wasn鈥檛 it, in the days when people actually wrote with pen and paper it was seen as some form of psychological writer鈥檚 block almost?

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Costello

Yes that鈥檚 right and although this is very much not a psychological problem stress and tension can make it worse.听 And patients typically will say that their voice is better if they鈥檙e relaxed, worse if they鈥檙e having to speak to a group of people, worse on the phone is one of the particular problems.听 And unless you鈥檝e heard it before you wouldn鈥檛 necessarily have a clear idea of what you鈥檙e listening to.

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Palmer

I was getting to a point where my job which was about talking to people basically evaporated because my clients couldn鈥檛 understand me, let alone the people I was trying to talk to.听 I couldn鈥檛 make phone calls because nobody could understand what I was talking about. 听If I went into anywhere vaguely noisy it would completely fall out on me and completely disappear so I couldn鈥檛 talk to anyone.

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Porter

What did you think was going on?

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Palmer

To be honest I really didn鈥檛 know, I thought there was something wrong with me mentally 鈥� that I was getting worked up or nervous about something for some reason, I didn鈥檛 know why because the trouble was I鈥檇 been through about four years of going and seeing different doctors, different specialists 鈥� everything under the sun 鈥� so ranging from 鈥� I had acupuncture, I had hypnotherapy, I had cognitive behavioural therapy, I had massage, I went to a doctor who told me I had horrific gastro-reflux鈥�

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Porter

Indigestion 鈥� heartburn yes.

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Palmer

鈥� I then had an operation for that.听 And all of it was doing nothing.

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Costello

Part of the issue is in confirming the diagnosis but assuming we do think they have SD then we will usually suggest a treatment of injections of botulinum toxin 鈥� Botox.听 And the purpose of the Botox is to weaken the vocal cords and weaken them to the point where there is no longer spasm but clearly not weaken them to the point where they lose their voice altogether because if we slightly overdo it with the Botox we run the risk of their voice being weak and breathy.

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Porter

And how do you get the Botox to where it鈥檚 needed 鈥� is this done internally?

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Costello

No it鈥檚 done with a needle in through the front of the neck and we use an electrical circuit actually that comes out of the back of the needle in the neck and is attached to a computer circuit that it tells us when we鈥檙e in the right muscle.听 And the process of doing the injection takes about 20 seconds generally speaking, sometimes less.

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Porter

And something you do in outpatients?

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Costello

I do that in outpatients, we have about a hundred patients on our books in Birmingham who are coming back for regular injections because of course Botox wears off after a period of time, it typically lasts about three or four months and patients come back for a repeat injection, sometimes two or three or four times a year.

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Porter

ENT surgeon Declan Costello. 听And thanks to Phil Palmer for coming to see us in between treatments.

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You鈥檒l find some useful links about spasmodic dysphonia, and other dystonias, on the Inside Health page of the Radio 4 website.

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And please do get in touch if there is a medical issue that you would like us to look into 鈥� e-mail us via insidehealth@bbc.co.uk.

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Now if you haven鈥檛 ever experienced acid related indigestion, heartburn or dyspepsia 鈥� call it what you will 鈥� then I bet that someone in your family has. And if it鈥檚 a frequent problem then there is a good chance that you will have been given omeprazole, lansoprazole, or a related member of the proton pump inhibitor family. Around 50 million prescriptions are issued for these PPIs every year but Inside Health has learned that there is growing concern in some quarters that we have become too quick to use them 鈥� a problem compounded by the fact that, once you start the drugs, they can be difficult to stop.

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To discuss the problem I am joined by Inside Health鈥檚 Margaret McCartney and Dr Anton Emmanuel who is a Consultant Gastroenterologist at University College Hospital in London.

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Anton, do you think they are overused?

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Emmanuel

As a gastroenterologist I think the answer is yes.听 It鈥檚 very clear that these drugs completely change the landscape of acid management 30 years ago when they came available to us.听 Apart from being very effective they鈥檙e also incredibly clean drugs seemingly, we thought that they really had no side effects at the time, so we were quite happy about them.听 And whilst initially expensive they鈥檝e become cheaper and now most of them are off patent, so we can even buy them over-the-counter. 听So there is a real issue around their overuse at the moment.听 Patients suffer with dyspeptic, sometimes quite a lot, we all get tummy aches of various sorts at least 鈥� about half of us get it once a year 鈥� and it鈥檚 easier therefore to think oh well I鈥檒l reach for something safe and effective.听 It then leads to the problem where these drugs can be very hard to stop and one of the very particular axes to grind that I have is this issue around the fact that these drugs can sometimes actually induce the symptoms that we use to treat.听 So what I mean by that is that patients take them because they have 鈥渋ndigestion鈥� (in inverted commas) which of course covers a variety of things.听 But once you start taking them four out of 10 people who don鈥檛 have an acid problem will develop one.听 In other words these drugs are so potent, they鈥檙e so effective at suppressing acid, that when you stop them you get this rebound acidity level which then gives people terrible symptoms and they suddenly think oh my goodness I must go back on it because I鈥檝e stopped it and it鈥檚 got bad.

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Porter

And of course the problem with that, Margaret, is that you and I are prescribing for symptoms 鈥� somebody comes back and says I tried to come off the drug, my symptoms have come back 鈥� so what do we do?听 We continue the prescription.

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McCartney

Absolutely, that鈥檚 the obvious thing, they worked so well before why wouldn鈥檛 they work again now and we begin to think that the mistake was taking patients off the tablet in the first place where actually that might still be the most rational thing to do.

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Porter

Do we know what happens to these people 鈥� I mean assuming that whatever they were taking it for has got better and they鈥檙e just getting rebound excess acid levels 鈥� how long is that likely to go on for?

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Emmanuel

It鈥檚 likely to carry on long term because you鈥檙e into that see-saw where the rebound hyperacidity occurs, you take the tablets, you try and stop it again, you rebound again.听 So unless you take a sort of step wise approach and are prepared to accept symptoms for a few days then you will carry on with the medication long term.

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Porter

So what should we be doing when it comes to weaning people off these pills?

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Emmanuel

So there is a reasonably clear sort of evidence base to go from on this, albeit very limited but it鈥檚 very clear what it says which is to initially halve the dose of the medication, take that for about a fortnight, after that then discontinue it but the patient to be offered some over-the-counter type antacid, sort of normal regular antacid that one can buy in the chemists and then use that accepting that there may be breakthrough symptoms for a day or two but if you can get through that fortnight, three weeks, of weaning you鈥檒l be okay the other end of it.

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Porter

Margaret, how often are you doing that in your practice?

听

McCartney

Never to be honest.听 I鈥檝e learned something today.听 And I think it鈥檚 a big problem for us because very much when we鈥檙e reviewing patients鈥� medication our aim is to find out is someone on a medication that they could stop but it鈥檚 very difficult if someone comes back in having stopped it to think that you haven鈥檛 made a mistake as a doctor in advising them to do so.听 So I think that鈥檚 really useful information to know 鈥� to expect a little bit of rebound of symptoms but to try cut down the dose gradually and try and just get through those few days.

听

Porter

So what you鈥檙e saying Anton is if you go through that weaning process and you then find actually the symptoms are still back at four to six weeks afterwards they probably do need to go back on the pills 鈥� they鈥檝e got an ongoing problem with reflux or whatever it might be?

听

Emmanuel

Absolutely you mustn鈥檛 underestimate the fact that about 5% of us get long term reflux symptoms which need long term control and we have a fantastic drug to do that.听 But the other 15% of us who take these drugs don鈥檛 necessarily need them long term.

听

Porter

What about people who do need to take these medicines long term and often for years and years, is there anything we should be worrying about?

听

Emmanuel

I think our perspective on this as specialists has changed, we used to consider these terribly benign drugs, what鈥檚 clear is that for some individuals there are potential risks of taking it long term.听 Again it relates to how potent these drugs are in terms of how strong and how effective they are, which is by suppressing acid so completely it can interfere with our digestive processes, so it can interfere with the way we absorb certain minerals and vitamins and in particular things that have really been focused on have been Vitamin B12, which is important for how we make blood cells and how our nerves function but also things like calcium, which of course is a really big issue in the world, especially in the Western world in terms of osteoporosis and risks of bone fracture.听 There鈥檚 also an evolving issue for some hospitalised patients that maybe use of these drugs may even increase the risk of hospital related and antibiotic related gut infections.听 So there are some fairly prevalent issues out in the community but also some hospital based conditions we worry about.

听

Porter

And that鈥檚 presumably because the acid plays a key role in the absorption process but it鈥檚 also the first line of defence for infections 鈥� is that right?

听

Emmanuel

Yes so we鈥檝e evolved to have acidic stomach to help us digest and to help repel pathogens.

听

Porter

Margaret, in your practice if you鈥檙e looking at somebody who鈥檚 been on omeprazole for instance, the most commonly prescribed version, for four or five years are you doing any routine blood tests to look for deficiencies or anything as a result?

听

McCartney

Yeah, so the medicines and healthcare regulatory authority last year 鈥� the MHRA 鈥� told us that we should consider checking for magnesium levels in patients who are taking long term omeprazole, PPI type drugs.听 But it鈥檚 a big vague, they haven鈥檛 really been explicit about when, how, how often, why we should do this, when it鈥檚 safe not to do it because of course more tests, more lab tests, it鈥檚 more NHS resources, you want to make sure you鈥檙e using resources wisely.

听

Emmanuel

The issue 鈥� it鈥檚 easier in hospital of course, as Margaret eluded to, patients expect to be monitored.听 I think the issue is that the vast majority of patients who use these drugs never see a specialist and how they get monitored is difficult.

听

Porter

Anton Emmanuel and Margaret McCartney, thank you both very much.

听

Just time to tell you about next week鈥檚 programme when we will be looking at antidepressants in pregnancy.听 Around one in 30 women take them at some stage but how safe are they? And prostate cancer 鈥� I will be finding out about a new technique to improve its diagnosis and treatment and it鈥檚 coming to a hospital near you.

听

And before I go, just a reminder, that there鈥檚 still time to enter the All in the Mind Mental Health Awards. You鈥檝e got until the end of January 鈥� details on the Radio 4 website.

听

ENDS