Issue: 76

May: The Snowbirds Have Returned!!
The annual northerly migration of the Snowbirds is largely complete.  Welcome back--we missed you!  I simply ask my snowbirds to schedule two appointments: the first upon your arrival to catch up on everything that has happened over the past six months while you were away, including changes in your medications, care-providers, and insurance plans; the second, before your departure, to make sure you have everything you need to keep you safe during the upcoming winter season.  Please remember to bring all your medication bottles to every visit!  The labels contain valuable information!  Following this simple advice gives you the best chance of staying healthy year-round.

John A. Schmidt, MD 
Summertime Precautions
Insects can transmit a number of diseases, most notoriously, Lyme Disease. Your best protection is to wear an insect repellent, such as DEET , which can be purchased without a prescription.  Apply over your sunscreen, especially around the neck, wrists, and ankles to deter would be attackers.

Remember there is no such thing as a healthy tan.  Tanning results from exposure to solar ultraviolet rays which damage DNA and lead to skin cancers , including melanoma. While skin cells have evolved elegant DNA repair mechanisms, they are not always effective. Prevention is the best policy.  Avoiding mid-day sun, using high potency, waterproof sunscreens, and refreshing your sunblock throughout the day, is best.  Wide brimmed hats and covering up with light colored clothing provides extra protection.  Get your vitamin D from a bottle, not sun-bathing!!
What's In Your Inhaler?
Patients with asthma and COPD have noticed that a large number of new inhalers have appeared over the last two years, making what had been a relatively simple topic far more complex.  So, let's review some basic principles to help you navigate this barrage of new medicines. (Yes, your inhaler is a medicine! Bring it with you each and every visit!  Thank you!)

Principle 1.  Inhalers deliver medicines where they are needed most, your lungs, thereby reducing the dose to the rest of your body and minimizing side-effects.  Having said this, only a fraction of the inhaled medicine reaches the lungs. The rest hits the back of the throat and is swallowed where it does no good. Thus, one of the goals of inhaler technology is to maximize "deposition rate" , i.e., the fraction of the dose that reaches its target in the lungs.  Dry powder inhalers such as the Diskus® and Ellipta® devices, in general, provide the highest deposition rates when good technique is used.  Nebulizers (such as Devilbiss® ), by comparison, have low deposition rates and require much more drug to achieve the same therapeutic effect.  I sometimes prescribe nebulizers for short term use in sick patients because they are less effort/technique dependent and cost much less.

Particles must be within a certain size range to penetrate deep into the lung.  Too large and they get caught in the throat; too small and they are exhaled back into the air.  Inhalers must therefore generate particles of the right diameter, usually 4-10 microns , to be maximally effective.

The FDA requires inhalers to deliver very consistently, actuation after actuation.  Though they look simple, the plastic parts must be made with high precision. Much of the manufacturing technology is protected as trade secrets rather than by patent thus making it more difficult for generic drug companies to make biosimilars .

Principle 2: Know the difference between " relievers " and " controllers. " Relievers are designed to provide quick relief.  The most widely used relievers are albuterol ( Ventolin® , Proventil® ) and levalbuterol ( Xopenex® ).  Two "puffs" of albuterol or levalbuterol often provide near instantaneous relief by dilating the airways and allowing effortless flow of air in and out of the lungs.  Failure to respond to albuterol, or requiring more puffs of albuterol than usual, is termed an " exacerbation " and often leads to ER visits, hospitalization, and worst of all, admission to an ICU for  ventilator therapy .  

The need to prevent costly exacerbations has led to the development of "controllers." Controllers must be used on a daily basis to get the best results.  There are three classes of controllers: the long acting beta agonists (LABAs; e.g., salmeterol , formoterol , and vilanterol ), the long acting muscarinic antagonists (LAMAs; e.g., tiotropium and umeclidinium) , and the inhaled corticosteroids (ICSs; e.g., fluticasone , budesonide , ciclesonide ).  Because controllers must be taken daily, companies have worked hard to achieve once daily dosing.  Thus, whereas the older Diskus® products are twice daily, the newer Elipta® products are once daily.  This is a major advance because once daily products improve compliance and therefore prevent more exacerbations.

The three types of controllers work in different and complementary ways.  LABAs dilate the airways.  Although LAMAs also dilate the airways they also reduce mucus production, especially in patients with chronic bronchitis.  ICSs reduce airway inflammation. 

Principle 3: Controllers are often more effective when used in combination.  Until recently, there were two controller combinations in widespread use.  The first combined LABAs with ICSs (e.g., twice daily Advair Diskus® and once daily Breo Elipta® ) mainly for use in asthma.  The second combined LABAs with LAMAs (once daily Anoro Elipta® and once daily Stiolo Respimat® ) mainly for use in COPD.  Now comes a third combination ( Trelegy Elipta® ) that combines all three controllers into a once daily inhaler for patients with COPD. 
When is a Triple Controller Inhaler Appropriate?
As published in the May 3 issue of the New England Journal of Medicine, a once daily triple inhaler combining all three controller agents (LABA/LAMA/ICS) was compared to the dual controller inhalers (LABA/ICS and LABA/LAMA) in patients with COPD and history of exacerbation. All three use the same Elipta® device.  The triple controller inhaler resulted in a significantly lower rate of exacerbation than either dual controller inhaler and a lower rate of hospitalization than the LABA/LAMA dual controller inhaler, the current standard of care.  The triple controller inhaler also gave better improvement in FEV1 and a higher quality of life. The one disadvantage was a higher incidence of pneumonia in the triple controller group (and the ICS/LABA group) but the number of exacerbations prevented far exceeded the number of excess pneumonias, suggesting that this was an acceptable trade-off.

The  accompanying editorial claimed that the study was biased in favor of the triple controller because many of the patients coming into the trial were already on ICSs.  While this may be true, the positive results obtained with the triple controller suggest that there is a substantial proportion of COPD patients who will do better using a once daily triple controller inhaler than a dual controller inhaler. 
MRI and MRI Guided Biopsy are the New Standard of Care in Prostate Cancer Diagnosis
Men with positive prostate specific antigen (PSA) tests are currently referred to a urologist for multiple ultrasound (US) guided , trans-rectal , needle biopsies of their prostate glands , as many as 18.  If the results show a cancer with a Gleason score of 7 or higher, the patient is referred for radiation or surgical prostatectomy .  The shortcomings of this approach are twofold: first, some elevations in PSA are false positives, i.e., the test is positive but the patient has no cancer or has a low grade cancer that if left alone will never hurt him; second, some patients have false negative biopsies, i.e., they have a focal Gleason 7 high grade cancer that is tucked away in the corner of their prostate and missed by the biopsy needle.

As published in the May 10 issue of the New England Journal of Medicine and in the accompanying editorial , magnetic resonance imaging  (MRI) addresses these shortcomings.  MRI has long been used as a staging tool to see if the cancer has extended beyond the capsule of the gland.  Advances in MRI technology now make it possible to interrogate the interior of the gland to see if there are nodules meeting imaging criteria for cancer.  If no, the patient is spared needle biopsy and can be followed longitudinally for worrisome changes.  If yes, a MRI can then be used to guide the biopsy needle into the area(s) of greatest concern thereby increasing the reliability of the biopsy.  Going forward, one can imagine using MRI to guide precision radiation therapy to sterilize just the tumor rather than the entire gland and thereby avoiding the troublesome side effects that sometimes complicate radiation therapy . MRI therefore stands to significantly improve outcomes for men with a positive PSA. Within the Hackensack Meridian Health Care System , both Hackensack University Medical Center and Bayshore Medical Center offer this technology.
Now Hear This!
I am pleased to announce that Ms. Jenna McDonnell will assist Valerie this summer in our front office. Ms. McDonnell is a rising fourth year nursing student at Ramapo College. I am also pleased to announce that Ms. Donna Sentner will be assisting me in the back office making sure that hospital and nursing home encounters are coded and billed properly. Welcome!

The office will be closed on Saturdays until Labor Day. Please think ahead and try to get your weekend requests in by Thursday, if possible. As always, I can be reached on my cell phone, through the answering service, or via our patient portal in the event of an emergency.

Valerie, Ms. Clark, Ms. Catong, Ms. McDonnell, Ms. Sentner, and I wish you a wonderful beginning to the summer season! 
In This Issue
May: The Snowbirds Have Returned!!
Summertime Precautions
What's In Your Inhaler?
When is a Triple Controller Inhaler Appropriate?
MRI and MRI Guided Biopsy are the New Standard of Care in Prostate Cancer Diagnosis
Now Hear This!
John A. Schmidt Jr., M.D.
Board Certified Internist
Dr. Schmidt is one of the leading internists in Monmouth County offering  Medical Home  services.  
He is an attending physician at Jersey Shore University Medical Center.
Dr. Schmidt is enrolled in the Maintenance of Certification Program of the American Board of Internal Medicine
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"There is nothing like returning to a place that remains unchanged to find the ways in which you yourself have altered."

- Nelson Mandela


John A. Schmidt Jr., MD
Meaningful Medicine in Your Medical Home
2006 Highway 71, Ste. 3, Spring Lake Heights, NJ 07762
Phone:  732-282-8166  
Fax:  732-280-0147 
Disclaimer: The articles in Healthy Living are for general information only and are not medical advice.
Discuss all medical concerns and treatment options with your physician.