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  • Patient information: Asthma treatment in adolescents and adults (Beyond the Basics)









    ASTHMA TREATMENT OVERVIEW



    Asthma is a common lung disease affecting millions of people worldwide. It is caused by narrowing of the airways (breathing tubes) in the lungs. This narrowing is partially or completely reversible. Symptoms of asthma include wheezing, coughing, chest tightness, and shortness of breath. These symptoms tend to come and go, and are related to the degree of airway narrowing in the lungs. The airways are sensitive to a variety of stimuli, which may include viral illnesses (eg, the common cold), allergens, exercise, medicines, or environmental conditions.



    Asthma can usually be treated successfully. This requires being well informed about the disease and being an active player in managing it.



    This topic will review asthma treatment in adolescents and adults (adolescents defined as children 12 years and older). Other topics about asthma are also available. (See "Patient information: How to use a peak flow meter (Beyond the Basics)" and "Patient information: Asthma inhaler techniques in adults (Beyond the Basics)" and "Patient information: Asthma and pregnancy (Beyond the Basics)" and "Patient information: Exercise-induced asthma (Beyond the Basics)".)



    Topics about asthma in children are also available. (See "Patient information: Asthma symptoms and diagnosis in children (Beyond the Basics)" and "Patient information: Asthma treatment in children (Beyond the Basics)" and "Patient information: Asthma inhaler techniques in children (Beyond the Basics)" and "Patient information: Trigger avoidance in asthma (Beyond the Basics)".)



    CONTROLLING ASTHMA TRIGGERS



    The factors that set off and worsen asthma symptoms are called "triggers." Identifying and avoiding asthma triggers are essential steps in preventing asthma flare-ups. Common asthma triggers generally fall into several categories:



     




    • Allergens (including dust, pollen, and furred animals)


    • Respiratory infections


    • Irritants (such as tobacco smoke or chemicals)


    • Physical activity


    • Certain medicines, known as beta blockers


    • Emotional stress


    • Menstrual cycle in some women



     



    A small number of patients will develop asthmatic symptoms after exposure to aspirin or other nonsteroidal antiinflammatory medications, like ibuprofen or naproxen. (See "Patient information: Trigger avoidance in asthma (Beyond the Basics)" and "Allergen avoidance in the treatment of asthma and allergic rhinitis".)



    After identifying potential asthma triggers, you and your clinician should develop a plan to deal with the triggers. There are three main options:



     




    • Avoid the trigger entirely (eg, if allergic to animals, do not own pets, if sensitive to aspirin or related medications, avoid all forms of these medications).


    • Limit exposure to the asthma trigger if it cannot be completely avoided (eg, move to another seat if someone with strong perfume is seated nearby, have someone else do house cleaning if allergic to dust mites).


    • Take an extra dose of bronchodilator medication before exposure to an asthma trigger. Talk with a healthcare provider before using this approach; it should only be used if the first two options are not possible. Be careful not to use more than twice the amount of medication normally used.



     



    Special approaches to unavoidable allergic triggers include allergy desensitization injections (“allergy shots”) and an injected medication targeting allergy proteins in the blood (anti-immunoglobulin E antibody, called omalizumab).



    MONITORING SYMPTOMS AND LUNG FUNCTION



    Successful asthma treatment relies on your ability to monitor your condition over time. This is done by recording the frequency and severity of symptoms (such as wheezing, coughing, and shortness of breath) and by measuring lung function with a peak flow meter



    Asthma diary — A healthcare provider may recommend keeping a daily asthma diary when symptoms are not well controlled or when starting a new treatment. In the diary, your peak flow readings, asthma symptoms (eg, coughing, wheezing), and medications are recorded (figure 1).



    A periodic diary may be recommended if you have stable symptoms and your medications have not changed recently. This type of diary can be completed before visiting the healthcare provider and helps you and your healthcare provider to determine whether the asthma treatment plan needs to be adjusted (form 1).



    Peak expiratory flow (PEF) — PEF measures the rate at which you can exhale. This rate is dependent on the degree of airway narrowing. PEF monitoring can be used to monitor your lung function and response to treatment, assess the severity of asthma attacks, and guide decisions regarding treatment.



    Peak flow meters are inexpensive and easy to use. Adults with persistent asthma may, at times, use a peak flow meter once or twice daily to monitor their lung function. (See "Patient information: How to use a peak flow meter (Beyond the Basics)".)



    Review of treatment — Adolescents and adults with asthma are usually seen by their healthcare provider once or twice a year if their asthma is well-controlled or more often if their asthma is not well-controlled. At these visits, the healthcare provider will evaluate the severity and frequency of your asthma symptoms and response to treatment. If your asthma control has been adequate for at least three months, your medication dose may be decreased. If control is not adequate, your medication schedule, delivery technique, and trigger avoidance will be reviewed, and your medication dose may be increased.



    CATEGORIES OF ASTHMA SYMPTOMS



    The medications used for asthma treatment vary according to your age, the severity of asthma, and the level of symptom control. The asthma treatment plan must be reviewed and adjusted on a regular basis. If symptoms are well controlled, medication can often be reduced. As symptoms worsen, medication should be increased.



    Intermittent asthma — People with intermittent asthma are defined as those who have the following characteristics (see "Treatment of intermittent and mild persistent asthma in adolescents and adults"):



     




    • Symptoms of asthma occur two or fewer days per week


    • Asthma does not interfere with daily activities


    • Nighttime symptoms awaken you two or fewer nights per month


    • Oral steroid treatment (eg, prednisone) is needed no more than once per year to treat increased asthma symptoms



     



    If your asthma is triggered only by vigorous exercise (exercise-induced bronchoconstriction), you might fit into this category, even if you have episodes of asthma with exercise more than twice per week. (See "Patient information: Exercise-induced asthma (Beyond the Basics)".)



    Persistent asthma — People with persistent asthma have symptoms regularly. There may be days when your activities are limited due to symptoms, and you may be awakened from sleep.



    Based on how frequently you have symptoms and the severity of your asthma flares, the clinician will determine whether your persistent asthma is mild, moderate, or severe. Treatment plans will vary based upon the severity of your asthma, as well as your level of symptom control. (See "Treatment of moderate persistent asthma in adolescents and adults".)



    The symptoms that are used to determine your asthma severity include the number of days per week that you have one or more of the following:



     




    • Symptoms such as cough, wheeze, and shortness of breath


    • Nighttime symptoms that awaken you from sleep


    • Symptoms that need treatment with a bronchodilator (reliever medication)


    • Symptoms that affect your ability to participate in normal activities



     



    ASTHMA RELIEVER MEDICATIONS



    Bronchodilators — Short-acting bronchodilators (usually beta-2 agonists) relieve asthma symptoms rapidly, by temporarily relaxing the muscles around narrowed airways. In the United States, albuterol (Ventolin®, Proventil®, and ProAir® plus generic albuterol) is the most commonly used short-acting bronchodilator. These medications are sometimes referred to as "quick-acting relievers." People with intermittent asthma, the mildest form of asthma, will require these symptom-relieving medications only occasionally.



    The preferred way of taking medication for mild intermittent asthma is by inhalation with a metered dose inhaler. This method allows the medication to take effect rapidly with maximum strength and minimal side effects. (See "Patient information: Asthma inhaler techniques in adults (Beyond the Basics)".)



    There is no benefit to using short-acting bronchodilators on a regular basis. If your asthma symptoms are consistently occurring more than two days per week, you should review your treatment plan with a healthcare provider. Other medications are more effective for persistent symptoms in this situation.



    Side effects of bronchodilators — Some people feel shaky, have a rapid heart rate, and/or feel anxious after using an inhaled short-acting bronchodilator. Using a single puff rather than the usual two puffs may limit these side effects and only minimally decrease their benefit. In addition, these side effects usually become less noticeable over time.



    ASTHMA CONTROLLER MEDICATIONS



    People with persistent asthma need to take medication on a daily basis to keep their asthma under control, even if there are no symptoms of active asthma on a given day. Medications taken daily for asthma are called "long-term controller" medicines.



    Some controller medicines are delivered by inhaler, while others are taken as a tablet. The doses and types of controller medications prescribed depend upon your asthma severity and level of symptom control.



    Inhaled steroids — Inhaled steroids (also known as glucocorticoids) act to decrease inflammation (swelling) of the airways over time. The steroids used to treat asthma are different from the ones athletes take to build muscle. Regular treatment with an inhaled steroid reduces the frequency of symptoms (and the need for inhaled bronchodilators for symptom relief), improves quality of life, and decreases the risk of serious attacks.



    A number of inhaled steroid medications are available, most of which are taken once or twice a day. An inhaled bronchodilator is still used as needed for relief of symptoms and before exposure to asthma triggers. There is no need to take the inhaled bronchodilator before each daily dose of inhaled steroid.



    Side effects of inhaled steroids — Unlike steroids that are taken as tablet or liquid by mouth, very little of the inhaled steroid is absorbed into the bloodstream, and there are few side effects. However, as the dose of inhaled steroid is increased, more of the medication is absorbed into the bloodstream, and the risk of side effects increases.



    The most common side effect of low-dose inhaled steroid is oral candidiasis (thrush). This can usually be prevented by taking inhaled steroids from a metered dose inhaler with a spacer (which helps to deliver medication to the lungs, rather than the mouth) (picture 1). You should rinse your mouth or brush your teeth and tongue immediately after inhalation. A hoarse voice and sore throat (without thrush) are less common side effects that are usually managed by changing to a different inhaled steroid preparation.



    Rare but possible side effects of long-term high-dose inhaled steroid treatments, besides oral candidiasis, include cataracts, increased pressure in the eye (glaucoma), easy bruising of the skin, and increased bone loss (osteoporosis).



    The risk of these complications is far less with inhaled glucocorticoids compared with oral glucocorticoids (eg, prednisone). Nevertheless, every effort should be made to use the lowest possible dose that controls asthma and minimizes the risk of an asthma attack.



    Long-acting bronchodilators — A long-acting inhaled bronchodilator is often recommended, in combination with an inhaled steroid, for adults with persistent asthma. Long-acting bronchodilators (salmeterol, formoterol) are recommended because they work for a longer period than short-acting bronchodilators (for 12 or more hours). A device that contains both an inhaled steroid and a long-acting bronchodilator is usually preferred (Advair®, Symbicort®, Seretide® in Europe, and Dulera®). A short-acting bronchodilator is still used as needed for immediate relief of asthma symptoms.



    Cromolyn and nedocromil — Cromolyn (Intal®) and nedocromil may be recommended as an alternative to low-dose inhaled glucocorticoids; however, only the cromolyn nebulizer solution is available in the United States. These medicines work by decreasing the activity of allergy cells. They are generally less effective than inhaled glucocorticoids. They are also less convenient because they must be used three or four times daily.



    Cromolyn can be used to prevent symptoms before exposure to an asthma trigger or before exercising. (See "Patient information: Exercise-induced asthma (Beyond the Basics)".)



    Leukotriene modifiers — Leukotriene modifiers, such as montelukast (Singulair®), zafirlukast (Accolate®), or zileuton (Zyflo®) are an alternative to inhaled glucocorticoids. Leukotriene modifiers work by opening narrowed airways, decreasing inflammation, and decreasing mucus production. They are taken by mouth as a pill once or twice daily and have very few side effects. Mood alteration and depression are rare side effects. However, compared with inhaled glucocorticoids, leukotriene modifiers are generally somewhat less effective in controlling asthma.



    Leukotriene modifiers can be used to prevent symptoms before exposure to a trigger or before exercising. (See "Patient information: Exercise-induced asthma (Beyond the Basics)".)



    Oral steroids — If symptoms are not controlled with the above medications, an oral steroid (eg, prednisone) may be added to the treatment regimen. Steroids used to treat asthma are in a class called glucocorticoids and are different from the ones athletes take to build muscle. Most healthcare providers recommend a 5 to 10 day course of oral glucocorticoids for flares of asthma.



    EXERCISE-INDUCED ASTHMA



    If exercise is a trigger for asthma, an extra dose of bronchodilator medication, leukotriene modifier, or cromolyn taken before exercise can be used to prevent asthma symptoms. A topic review that discusses exercise-induced asthma is available separately. (See "Patient information: Exercise-induced asthma (Beyond the Basics)".)



    ASTHMA IN PREGNANCY



    Asthma is the most common chronic medical condition that affects the lungs during pregnancy. About 4 percent of pregnant women have asthma. With good asthma treatment during pregnancy, most women can breathe easily, have a normal pregnancy, and give birth to a healthy baby. It is essential to keep asthma well controlled during pregnancy to ensure that optimal levels of oxygen reach the baby.



    Before becoming pregnant, women with asthma should learn as much as they can about the condition and talk with their healthcare providers about asthma treatment during pregnancy. More information about asthma during pregnancy is presented separately. (See "Patient information: Asthma and pregnancy (Beyond the Basics)".)



    ASTHMA ATTACK TREATMENT



    The term "asthma attack" is somewhat confusing because it does not distinguish between a mild increase in symptoms and a life-threatening episode. Symptoms may be aggravated by changes in air quality, the common cold, exercise, exposure to allergens, or changes in the weather. These triggers can cause mild, moderate, or severe symptoms to develop. Any of these changes could be considered an asthma "attack."



    Some people have periodic, mild asthma attacks that never require emergency care, while others have severe and sudden asthma attacks that require a call for emergency medical services.



    Asthma action plan — You should work with your healthcare provider to develop personalized directions (also called an asthma action plan) to follow when symptoms increase or your peak flow begins to decrease. Asthma action plans for adolescents and adults and school asthma action plans are available (form 2 and form 3A-C).



    Peak expiratory flow rates can be divided into three zones, which are assigned colors similar to those of a traffic light. These zones can be used to make decisions about the need for treatment:



    Green — Green signals that the lungs are functioning well. When symptoms are not present or are well controlled, you should continue your regular medicines and activities.



    Yellow — Yellow is a sign that the airways in the lungs are somewhat narrowed, making it difficult to move air in and out; asthma symptoms may be more frequent or more severe. A short-term change or increase in medication is generally required. You should change or increase your medication according to the plan that was discussed with your provider.



    Red — Red is a sign that the airways are severely narrowed and require immediate treatment. Symptoms are usually more severe and frequent. In addition to using 2 to 4 puffs of the quick-acting reliever inhaler (eg, albuterol), steroid tablets are often required to bring relief, according to the plan discussed with your provider.



    Emergency care plan — You should work with your healthcare provider to formulate an emergency care plan that explains exactly what to do if symptoms worsen. This may include more frequent use of a reliever medication (eg, albuterol) and starting or increasing the dose of a long-term controller medication (eg, prednisone).



    However, if symptoms are severe and worsen or do not improve after use of a quick-acting reliever medication, someone should immediately call for emergency medical assistance. Severe asthma attacks can be fatal if not treated promptly. In most areas of the United States, emergency medical assistance is available by calling 911. You should not attempt to drive yourself to the hospital, and you should not ask someone else to drive. Calling 911 is safer than driving for two reasons:



     




    • From the moment EMS personnel arrive, they can begin evaluating and treating your asthma. When driving in a car, treatment cannot begin until you arrive in the emergency department.


    • If a dangerous complication of asthma occurs on the way to the hospital, EMS personnel may be able to treat the problem immediately.



     



    Following an asthma attack, most people are given a 5 to 10 day course of an oral steroid medication (eg, prednisone). This treatment helps to reduce the risk of a second asthma attack.



    Wear medical identification — Many people with medical conditions wear a bracelet, necklace, or similar alert tag at all times. If an accident occurs and you cannot explain your condition, the identification will help responders provide appropriate care.



    The alert tag should include a list of major medical conditions and allergies, as well as the name and phone number of an emergency contact. One device, Medic Alert® (www.medicalert.com), provides a toll-free number that emergency medical workers can call to find out a person's medical history, list of medications, family emergency contact numbers, and healthcare provider names and numbers.



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Asthma in adults (The Basics)

    Patient information: Avoiding asthma triggers (The Basics)

    Patient information: How to use your metered dose inhaler (adults) (The Basics)

    Patient information: How to use your dry powder inhaler (adults) (The Basics)

    Patient information: Medicines for asthma (The Basics)

    Patient information: Asthma and pregnancy (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: How to use a peak flow meter (Beyond the Basics)

    Patient information: Asthma inhaler techniques in adults (Beyond the Basics)

    Patient information: Asthma and pregnancy (Beyond the Basics)

    Patient information: Exercise-induced asthma (Beyond the Basics)

    Patient information: Asthma symptoms and diagnosis in children (Beyond the Basics)

    Patient information: Asthma treatment in children (Beyond the Basics)

    Patient information: Asthma inhaler techniques in children (Beyond the Basics)

    Patient information: Trigger avoidance in asthma (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Agents affecting the 5-lipoxygenase pathway in the treatment of asthma

    Allergen avoidance in the treatment of asthma and allergic rhinitis

    An overview of asthma management

    Diagnosis of asthma in adolescents and adults

    Evaluation of severe asthma in adolescents and adults

    Identifying patients at risk for fatal asthma

    Natural history of asthma

    Severe asthma: Evidence for heterogeneity of the disease

    Treatment of acute exacerbations of asthma in adults

    Treatment of intermittent and mild persistent asthma in adolescents and adults

    Treatment of moderate persistent asthma in adolescents and adults

    Treatment of severe asthma in adolescents and adults



    The following organizations also provide reliable health information.



     




    • The National Library of Medicine



     



    (www.nlm.nih.gov/medlineplus/healthtopics.html)



     




    • National Heart, Lung, and Blood Institute



     



    (www.nhlbi.nih.gov/)



     




    • American Lung Association



     



    (www.lungusa.org)



     




    • American Academy of Allergy, Asthma, and Immunology



     



    (www.aaaai.org/patients.stm)



     




    • American College of Allergy, Asthma, and Immunology



     



    (www.acaai.org/allergist)



    [1-3]



    ACKNOWLEDGMENT



    The editorial staff at UpToDate, Inc. would like to acknowledge Dr. Suzanne Fletcher, who contributed to an earlier version of this topic review.





    Literature review current through: Jul 2013. |This topic last updated: Sep 6, 2012.



    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.




    References





    1. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Lancet 1998; 351:1225.


    2. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-4051). www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on September 01, 2007).


    3. Fanta CH, Haver KH, Cristiano LM. Harvard Medical School guide to taking control of asthma, Free Press (Simon & Schuster), New York 2004.









    GRAPHICS





    Asthma diary


    Image


    Use the symptom severity key to give a numerical value to the severity of your asthma. In the notes section, note any triggers that seem to affect your asthma on the day it occurs. Triggers can include colds or infections, exercise, irritants, allergens, and cold air.

     


     







    Self-assessment form*


    Image



    * These questions are examples and do not represent a standardized assessment instrument. Other examples of asthma control questions: Asthma Control Questionnaire (Juniper); Asthma Therapy Assessment Questionnaire (Vollmer); Asthma Control Test (Nathan); Asthma Control Score (Boulet).


    Reproduced from: National Heart, Blood,and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.







    Accessory devices used with metered dose inhalers


    Image


    These pictures show different types of spacers, with and without a face mask. A spacer makes it easier to use an inhaler and helps more of the medicine reach the lungs. Picture A shows an AeroChamber spacer. Picture B shows an AeroChamber spacer with a face mask. Picture C shows an InspirEase spacer.

     


     







    Asthma action plan


    Image



    %: percent.


    Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.







    School asthma action plan


    Image



     


    Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.







    School asthma action plan (continued)


    Image



     


    Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.







    School asthma action plan (continued)


    Image



     


    Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines
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  • Patient information: Barrett's esophagus (Beyond the Basics)









    BARRETT'S ESOPHAGUS OVERVIEW



    The esophagus is the tube that connects the mouth with the stomach (figure 1). Barrett's esophagus occurs when the normal cells that line the lower part of the esophagus (called squamous cells) are replaced by a different cell type (called intestinal cells). This process usually occurs as a result of repetitive damage to the inside of the esophagus caused by longstanding acid reflux disease, called gastroesophageal reflux disease (GERD). In people with GERD, the esophagus is repeatedly exposed to excessive amounts of stomach acid. Interestingly, the intestinal cells of Barrett's esophagus are more resistant to acid than squamous cells, suggesting that these cells may develop to protect the esophagus from acid exposure. The problem is that the intestinal cells have a risk of transforming into cancer cells.



    More detailed information about Barrett's esophagus is available separately. (See "Epidemiology, clinical manifestations, and diagnosis of Barrett's esophagus" and "Management of Barrett's esophagus".)



    BARRETT'S ESOPHAGUS RISK FACTORS



    There are a number of factors that increase the risk of developing Barrett's esophagus:



    Age — Barrett's esophagus is most commonly diagnosed in middle-aged and older adults; the average age at diagnosis is approximately 55 years. Children can develop Barrett's esophagus, but rarely before the age of five years.



    Gender — Men are more commonly diagnosed with Barrett's esophagus than women.



    Ethnic background — Barrett's esophagus is most common in white populations, less common in Hispanic populations, and uncommon in Asian and black populations.



    Lifestyle — Smokers are more commonly diagnosed with Barrett's esophagus than nonsmokers.



    BARRETT'S ESOPHAGUS SYMPTOMS



    Barrett's esophagus itself produces no symptoms. Instead, most people seek help because of symptoms of GERD, including heartburn, regurgitation of stomach contents, and, less commonly, difficulty swallowing.



    BARRETT'S ESOPHAGUS DIAGNOSIS



    A healthcare provider may suspect Barrett's esophagus based upon a person's symptoms and the risk factors described above. An endoscopy is needed to confirm the abnormal esophageal lining.



    Upper endoscopy — Upper endoscopy is a test that allows your doctor to see the inside of the esophagus and stomach. Before the test, you are sedated to prevent discomfort. The doctor will insert a thin lighted tube into the esophagus. The tube has a camera, which allows the doctor to see the lining of the esophagus.



    Normally, the lining should appear pale and glossy; in a person with Barrett's esophagus, the lining appears pink or red and velvety. The doctor will remove a small sample of the lining (a biopsy) during the endoscopy so that it can be examined with a microscope for signs of Barrett's. (See "Patient information: Upper endoscopy (Beyond the Basics)".)



    Endoscopy detects most (80 percent) but not all cases of Barrett's esophagus. Individual variations in the anatomy of the esophagus and the area where it meets the stomach can make the diagnosis of Barrett's esophagus difficult in some people.



    BARRETT'S ESOPHAGUS TREATMENT



    The goal of treatment in patients with Barrett's esophagus is to control reflux symptoms. Aggressive reflux treatment may be more effective in preventing cancer than treating only when there are reflux symptoms. (See "Management of Barrett's esophagus".)



    Behavior and diet changes — The first priority in treating Barrett's esophagus is to stop the damage to the esophageal lining, which usually means eliminating acid reflux. Most patients are advised to avoid certain foods and behaviors that increase the risk of reflux. Foods that can worsen reflux include:



     




    • Chocolate


    • Coffee and tea


    • Peppermint


    • Alcohol


    • Fatty foods



     



    Acidic juices such as orange or tomato juice may also worsen symptoms. Carbonated beverages can be a problem for some people. (See "Patient information: Acid reflux (gastroesophageal reflux disease) in adults (Beyond the Basics)".)



    Behaviors that can worsen reflux include eating meals just before going to bed, lying down soon after eating meals, and eating very large meals. Placing bricks or blocks under the head of the bed (to raise it by about six inches) help to keep acid in the stomach while sleeping. It is not helpful to use additional pillows under the head.



    Medications — A clinician may prescribe medications that reduce the amount of acid produced by the stomach. A class of medications called proton pump inhibitors is commonly recommended. Five different formulations (some of which are available as a generic) are currently available: omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Aciphex) and pantoprazole (Protonix); any of these is an acceptable option.



    Surgery — People who have severe reflux may benefit from surgical procedures to reduce reflux. Surgery is not the best treatment in all situations, so you should discuss this option with your doctor. More information about surgical treatments for reflux is available in a separate topic review. (See "Patient information: Acid reflux (gastroesophageal reflux disease) in adults (Beyond the Basics)".)



    BARRETT'S ESOPHAGUS COMPLICATIONS



    One potential complication of Barrett's esophagus is that, over time, the abnormal esophageal lining can develop early precancerous changes. The early changes may progress to advanced precancerous changes, and finally to frank esophageal cancer. If undetected, this cancer can spread and invade surrounding tissues.



    However, progression to cancer is uncommon for any individual patient; studies that follow patients with Barrett's esophagus reveal that fewer than 0.5 percent of patients develop esophageal cancer per year. Furthermore, patients with Barrett's esophagus appear to live approximately as long as people who are free of this condition. Patients often die of other causes before Barrett's esophagus progresses to cancer.



    BARRETT'S ESOPHAGUS MONITORING



    Monitoring for precancerous changes is recommended for most patients with Barrett's esophagus. At this time, monitoring includes periodic endoscopy with tissue biopsy. (See "Patient information: Upper endoscopy (Beyond the Basics)".)



    Although new technologies for monitoring are on the horizon, most are still considered to be experimental. Experts do not agree about the usefulness of monitoring. The benefits of monitoring depend upon each person's chance of developing esophageal cancer, which may be difficult to determine.



    Benefits — Reasons to perform endoscopic monitoring include:



     




    • Monitoring can detect precancerous changes (dysplasia) in the esophageal lining. These changes may indicate that the person has an increased risk of cancer. Early detection may be especially important for younger patients.


    • Monitoring may detect cancer at an earlier stage, when it can be more effectively treated.



     



    Limitations — However, not all patients will benefit from endoscopic monitoring.



     




    • Progression of Barrett's esophagus to cancer is uncommon.


    • Endoscopy carries certain risks and often causes anxiety.


    • Endoscopy may miss areas with premalignant changes or cancer.


    • Even if endoscopy detects cancer, the available treatment options may have unacceptably high risks.



     



    PRECANCEROUS CHANGES AND BARRETT'S ESOPHAGUS



    Confirmation and staging — If precancerous changes are discovered, they should be confirmed by a second pathologist, an expert in examining tissue samples. It is sometimes difficult to correctly identify precancerous changes, especially when there is inflammation (usually caused by the ongoing reflux of acid). Many clinicians increase the dose of acid-suppressing medications in this situation.



    The precancerous changes must then be graded as "low-grade dysplasia" or "high-grade dysplasia," depending upon their severity.



    Treatment options — People with low-grade dysplasia are often told to increase their dose of acid suppressing medication and undergo a repeat endoscopy within 6 to 12 months. The management of low-grade dysplasia is especially controversial. Some physicians recommend frequent endoscopic surveillance for patients with low-grade dysplasia, while others recommend destroying the abnormal tissue with radiofrequency ablation (see below).



    A person with high-grade dysplasia has more limited options. The management of this condition is controversial. The optimal treatment depends upon the person's age and health and the patient and physician's preference. The options include removal of the esophagus (esophagectomy) and removing (eg, endoscopic mucosal resection) or destroying (eg, radiofrequency ablation, photodynamic or other ablation therapies) the abnormal tissue using endoscopic techniques.



    Esophagectomy — In removing the esophagus, esophagectomy removes all of the precancerous tissue and some of the lymph nodes near the esophagus. However, this treatment has higher rates of procedure-related death and long-term complications than the endoscopic treatments for dysplasia.



    Esophagectomy is not necessary in most patients who have dysplasia in Barrett’s esophagus. In some patients, however, it may not be possible to destroy all of the abnormal tissue by endoscopic treatments, and esophagectomy may be recommended for those patients. Esophagectomy should be performed by an experienced physician in a hospital where the procedure is performed frequently. In one study of 340 esophagectomies performed at 25 different hospitals, the mortality rate was 3 percent for patients who had the operation at institutions that did five or more esophagectomies per year, compared to 12 percent for patients treated at institutions where the operation was performed less frequently [1].



    Endoscopic treatments — Endoscopic treatments are usually recommended for patients with high-grade dysplasia.



    Endoscopic mucosal resection — Endoscopic mucosal resection (EMR) involves the removal of a large but thin area of esophageal tissue through an endoscope. EMR provides large tissue specimens that can be examined by the pathologist to determine the character and extent of the abnormality and determine if an adequate amount of tissue was removed. Therefore, it can help to confirm the person's diagnosis and completely treat the abnormality (if the abnormal tissue is removed completely). However, this technique is generally performed only in specialized centers. Generally, EMR is performed if the endoscopist sees an area of nodularity in the Barrett’s esophagus. EMR is commonly followed by ablation of the remaining Barrett’s esophagus, usually with radiofrequency ablation (see below).



    Radiofrequency ablation — Radiofrequency ablation (RFA) is an endoscopic procedure that uses radiofrequency energy (microwaves) to destroy the Barrett’s cells. In short-term studies, RFA has been shown to prevent high-grade dysplasia from progressing to cancer and to prevent low-grade dysplasia from developing more advanced features. However, there is limited information on the long-term outcome of this approach. In up to 5 percent of patients, the procedure causes a complication, such as narrowing of the esophagus, which may require repeated treatments to open the esophagus.



    Another concern with RFA is that, in a small minority of patients with high-grade dysplasia (less than 2 percent), there may be cancer in the lymph nodes adjacent to the esophagus. RFA cannot cure cancer in the lymph nodes. In all cases, the patient and family should discuss the risks and benefits of possible treatments with a healthcare provider.



    Photodynamic therapy — Photodynamic therapy is a treatment that uses chemical agents, known as photosensitizers, to kill certain types of cells (such as Barrett's cells) when the cells are exposed to laser light. Patients are given the photosensitizer medication into a vein and then undergo endoscopy. During the endoscopy, a laser light is used to activate the photosensitizer and destroy the Barrett's tissue.



    However, there is limited information on the long-term outcome of this approach. Furthermore, photodynamic therapy is expensive and available in only a small number of academic medical centers. In up to 40 percent of patients, the procedure causes a complication, such as narrowing of the esophagus, which may require repeated treatments to open the esophagus.



    Another concern with photodynamic therapy is that patients with high-grade dysplasia may have areas of invasive cancer that are not treated adequately. Photodynamic therapy has largely been replaced by RFA, which appears to be safer and at least as effective. In all cases, the patient and family should discuss the risks and benefits of possible treatments with a healthcare provider.



    SUMMARY



    Despite the uncertainties surrounding the monitoring and treatment of Barrett's esophagus, there is consensus on one matter: The available options should be tailored to the individual patient. The following are general guidelines:



     




    • People with Barrett's esophagus should be treated to decrease reflux symptoms. This may improve or eliminate symptoms of heartburn, reduce inflammation, help prevent complications, and improve the accuracy of endoscopy results.


    • People without evidence of precancerous changes (ie, no dysplasia) or esophageal cancer should have endoscopy performed every three to five years to look for the development of precancerous changes, unless there are other medical conditions that increase the small risks usually associated with endoscopy.


    • If endoscopy reveals a precancerous change (dysplasia), this finding should be confirmed by at least one expert; if necessary, additional tissue samples should be collected to resolve any doubt.


    • People with early precancerous changes (low-grade dysplasia) often are advised to have repeat endoscopy at 6 and 12 months, followed by annual endoscopy if the lesion does not appear to progress. In some cases, RFA may be considered to treat low-grade dysplasia.


    • People with advanced precancerous changes (high-grade dysplasia) should have their diagnosis confirmed by an expert. If the diagnosis is confirmed, treatment usually involves a combination of EMR and RFA.



     



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Acid reflux (gastroesophageal reflux disease) in adults (The Basics)

    Patient information: Barrett's esophagus (The Basics)

    Patient information: Esophageal cancer (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: Upper endoscopy (Beyond the Basics)

    Patient information: Acid reflux (gastroesophageal reflux disease) in adults (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Autofluorescence endoscopy for Barrett's esophagus

    Endoscopic resection for treatment of high-grade dysplasia and early cancer in Barrett's esophagus

    Epidemiology, clinical manifestations, and diagnosis of Barrett's esophagus

    Management of Barrett's esophagus

    Narrow band imaging in Barrett's esophagus

    Pathogenesis of Barrett's esophagus and its malignant transformation

    Photodynamic therapy for ablation of Barrett's esophagus

    Radiofrequency ablation for Barrett's esophagus



    The following organizations also provide reliable health information.



     




    • National Library of Medicine



     



    (www.nlm.nih.gov/medlineplus/healthtopics.html)



     




    • The American Gastroenterological Society



     



    (www.gastro.org)



     




    • The American College of Gastroenterology



     



    (www.acg.gi.org)



     




    • The American Society for Gastrointestinal Endoscopy



     



    (www.askasge.org)



    [1-9]





    Literature review current through: Jul 2013. |This topic last updated: Jul 18, 2013.



    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.




    References





    1. Swisher SG, Deford L, Merriman KW, et al. Effect of operative volume on morbidity, mortality, and hospital use after esophagectomy for cancer. J Thorac Cardiovasc Surg 2000; 119:1126.


    2. Sharma P, McQuaid K, Dent J, et al. A critical review of the diagnosis and management of Barrett's esophagus: the AGA Chicago Workshop. Gastroenterology 2004; 127:310.


    3. Eckardt VF, Kanzler G, Bernhard G. Life expectancy and cancer risk in patients with Barrett's esophagus: a prospective controlled investigation. Am J Med 2001; 111:33.


    4. Conio M, Blanchi S, Lapertosa G, et al. Long-term endoscopic surveillance of patients with Barrett's esophagus. Incidence of dysplasia and adenocarcinoma: a prospective study. Am J Gastroenterol 2003; 98:1931.


    5. Shaheen NJ, Inadomi JM, Overholt BF, Sharma P. What is the best management strategy for high grade dysplasia in Barrett's oesophagus? A cost effectiveness analysis. Gut 2004; 53:1736.


    6. Hirota WK, Zuckerman MJ, Adler DG, et al. ASGE guideline: the role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc 2006; 63:570.


    7. Wang KK, Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's esophagus. Am J Gastroenterol 2008; 103:788.


    8. American Gastroenterological Association, Spechler SJ, Sharma P, et al. American Gastroenterological Association medical position statement on the management of Barrett's esophagus. Gastroenterology 2011; 140:1084.


    9. Spechler SJ, Sharma P, Souza RF, et al. American Gastroenterological Association technical review on the management of Barrett's esophagus. Gastroenterology 2011; 140:e18.









    GRAPHICS





    Gastroesophageal reflux disease (GERD)


    Image


    When we eat, food is carried from the mouth through the esophagus, a tube-like structure that is approximately 10 inches long and 1 inch wide in adults. At the lower end of the esophagus, where it joins the stomach, there is a circular ring of muscle that relaxes and opens when food reaches that point, called the lower esophageal sphincter (LES). This allows food to enter the stomach and then closes to prevent the back-up of food and acid into the esophagus. Reflux can occur if the LES is weak or stays relaxed too long.

     


     








     



     



     


     




     


     




     


     




     



     



     




     


     


     


     


     


     


     


     


     


     






    -->



  • Patient information: Acute bronchitis in adults (Beyond the Basics)












    BRONCHITIS OVERVIEW



    Bronchitis develops when there is swelling and irritation of the bronchi, the large tubes that carry air to the lungs (figure 1). There are two types of bronchitis: acute (sudden onset) and chronic (long-standing).



    Acute bronchitis often occurs with a viral infection, such as the common cold, and is sometimes called a "chest cold”. The most common symptom of acute bronchitis is a nagging cough. Treatment of acute bronchitis usually involves treating the symptoms, such as sore throat and congestion. Antibiotics do not help to eliminate acute bronchitis caused by a virus. Antiviral agents are useful in some cases of acute bronchitis due to influenza, but there are no antiviral agents for other forms of viral bronchitis.



    This article will review the causes, symptoms, diagnosis, and treatment of acute bronchitis. Articles that discuss the common cold and sore throat are also available. (See "Patient information: The common cold in adults (Beyond the Basics)" and "Patient information: Sore throat in adults (Beyond the Basics)".)



    Chronic bronchitis is discussed separately. (See "Patient information: Chronic obstructive pulmonary disease (COPD), including emphysema (Beyond the Basics)".) More detailed information about acute bronchitis is available by subscription. (See "Acute bronchitis in adults".)



    BRONCHITIS CAUSES



    Most cases of bronchitis are caused by a viral infection of the upper airways, such as the common cold or the flu. Less commonly, a bacterium called Bordetella pertussis, which causes pertussis (whooping cough), is the cause. (See 'Whooping cough' below.)



    BRONCHITIS SYMPTOMS



    The most common symptoms of acute bronchitis include:



     




    • A persistent cough; this may last 10 to 20 days

    • Some people cough up mucus, which may be clear, yellow, or green in color



     



    Fever is not common in people with acute bronchitis. However, having a fever can be a sign of another condition, such as the flu or pneumonia. (See "Patient information: Influenza symptoms and treatment (Beyond the Basics)" and "Patient information: Pneumonia in adults (Beyond the Basics)".)



    Conditions with similar features — There are other conditions that have symptoms similar to those of acute bronchitis.



     





     



    BRONCHITIS DIAGNOSIS



    Most people who have a persistent cough after an upper respiratory infection (cold) do not need to see a healthcare provider. Diagnostic testing, such as x-rays, cultures, and blood tests, are not usually needed for people with acute bronchitis. However, testing may be recommended if your diagnosis is not clear based upon your examination or if another condition, such as pneumonia, is suspected.



    When to seek help — You should call your healthcare provider if you have any of the following:



     




    • Fever (temperature greater than 100.4º F or 38º C)

    • A cough that lasts longer than 10 days

    • Chest pain with coughing, difficulty breathing, or coughing up blood

    • A barking cough that makes it hard to speak, especially if it persists

    • Cough accompanied by unexplained weight loss



     



    People who are older than 75 do not always have a fever or other concerning symptoms. If you are over 75 years and you have a persistent cough, you should call your clinician to determine if and when an office visit is recommended.



    BRONCHITIS TREATMENT



    Relief of symptoms — There is no specific treatment for bronchitis. There are a few treatments available for the common cold. (See "Patient information: The common cold in adults (Beyond the Basics)".)



     




    • A nonsteroidal antiinflammatory drug (ibuprofen, naproxen), aspirin, or acetaminophen (Tylenol®) can help to relieve the pain of a sore throat or headache.

    • Heated, humidified, air can improve symptoms of nasal congestion and runny nose, and has few to no side effects.

    • Cough suppressant medications have not been shown to be helpful for most patients.

    • Inhaler medications, commonly used for patients with asthma, are only helpful for those patients whose symptoms include wheezing or airflow obstruction and would require prescription.



     



    Antibiotics — Antibiotics are NOT helpful for most people with bronchitis since the illness is typically caused by a virus. Antibiotics treat bacterial, not viral infections.



    Many people request antibiotics in the hopes that it will get rid of the cough, and some people even think that antibiotics have helped on previous occasions. However, there is no benefit of antibiotics for most cases of bronchitis.



    Whooping cough — Whooping cough is caused by a bacterium, Bordetella pertussis. A vaccine is routinely given during childhood, and again during adolescence or adulthood, to reduce the risk of becoming infected with pertussis. However, the illness can still develop in those who were vaccinated. (See "Clinical manifestations and diagnosis of Bordetella pertussis infections in adolescents and adults".)



    Signs of whooping cough in adults include repeated "spasms" of severe coughing, sometimes followed by vomiting. Whooping cough often occurs as outbreaks, usually involving people who are incompletely immunized. If whooping cough is suspected, your healthcare provider may prescribe an antibiotic. Antibiotics will not help the cough, but can reduce the risk of spreading the infection to others. (See "Treatment and prevention of Bordetella pertussis infection in adolescents and adults".)



    PREVENTING THE SPREAD OF ILLNESS



    Hand washing is an essential and highly effective way to prevent the spread of infection. Wet your hands with water and plain soap and rub them together for 15 to 30 seconds. Pay special attention to the fingernails, between the fingers, and the wrists. Rinse your hands thoroughly, and dry with a single use towel.



    Alcohol-based hand rubs are a good alternative for disinfecting hands if a sink is not available. Spread the hand rub over the entire surface of your hands, fingers, and wrists until dry. You can use hand rubs repeatedly without irritating the skin or losing effectiveness. Hand rubs are available as a liquid or wipe in small, portable sizes that are easy to carry in a pocket or handbag. When a sink is available, you should wash visibly soiled hands with soap and water.



    Wash your hands before preparing food and eating; after going to the bathroom; and after coughing, blowing the nose, or sneezing. While it is not always possible to limit contact with people who are ill, avoid touching your eyes, nose, or mouth after direct contact, when possible.



    In addition, use a tissue to cover your mouth when sneezing or coughing. Throw away used tissues promptly and then wash your hands. Sneezing/coughing into the sleeve of your clothing (at the inner elbow) is another way of containing sprays of saliva and secretions and does not contaminate your hands. Sneezing and coughing without covering your mouth can spread infection to anyone within six feet.



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Acute bronchitis (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: The common cold in adults (Beyond the Basics)

    Patient information: Sore throat in adults (Beyond the Basics)

    Patient information: Chronic obstructive pulmonary disease (COPD), including emphysema (Beyond the Basics)

    Patient information: Influenza symptoms and treatment (Beyond the Basics)

    Patient information: Pneumonia in adults (Beyond the Basics)

    Patient information: Chronic cough in adults (Beyond the Basics)

    Patient information: Allergic rhinitis (seasonal allergies) (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Acute bronchitis in adults

    Clinical manifestations and diagnosis of Bordetella pertussis infections in adolescents and adults

    Management of infection in acute exacerbations of chronic obstructive pulmonary disease

    Etiology and evaluation of hemoptysis in adults

    Fluoroquinolones

    Respiratory syncytial virus infection: Clinical features and diagnosis

    The common cold in adults: Treatment and prevention

    Treatment and prevention of Bordetella pertussis infection in adolescents and adults

     



    The following organizations also provide reliable health information.



     





     



    [1-3]





    Literature review current through: Jul 2013. |This topic last updated: Sep 9, 2011.




    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.









    GRAPHICS





    Normal lungs


    Image


    The lungs sit in the chest, inside the ribcage. They are covered with a thin membrane called the "pleura." The windpipe (or trachea) branches into two smaller airways called the left and right "bronchus." The space between the lungs is called the "mediastinum." Lymph nodes are located within and around the lungs and mediastinum.
     


     








     



     



     


     




     


     




     


     




     



     



     




     


     


     


     


     


     


     


     


     


     







    -->



  • Patient information: Recovery after coronary artery bypass graft surgery (CABG) (Beyond the Basics)





     





     




    FindPrint ShareThis





     




    Contents of this article





     







    BYPASS SURGERY OVERVIEW



    Coronary artery bypass graft surgery, also known as CABG or bypass surgery, can help to restore blood flow to an area of the heart. However, surgery does not stop the progression of atherosclerosis (coronary heart disease), which deposits fatty material into artery walls, narrowing them and eventually limiting blood flow.



    Patients and healthcare providers must work together after surgery to treat the underlying atherosclerosis and the factors that can cause progression of heart disease. (See 'Reduce cardiac risk factors' below.)



    This topic review discusses treatments that are recommended after coronary artery bypass graft surgery. These treatments can help to:



     




    • Reduce the risk of developing complications of coronary heart disease, including having a subsequent heart attack or dying


    • Help a person to feel better and have more energy.



     



    An overview of coronary artery bypass graft surgery is discussed in detail separately. (See "Patient information: Coronary artery bypass graft surgery (Beyond the Basics)".)



    CARE AT HOME AFTER BYPASS SURGERY



    Care after bypass surgery aims to reduce the risk factors for heart disease and includes strategies to help patients and family members to stop smoking, control high blood pressure, improve cholesterol levels, begin exercising regularly, and reduce stress. Some of these changes can be made by adjusting lifestyle habits through diet and exercise. However, lifestyle changes alone may not be adequate and medications are often needed.



    Discharge from the hospital — Patients with an uncomplicated heart attack usually go home after about five days in the hospital. In some cases, the hospital stay is longer. If complications have occurred, discharge is delayed until the person's condition is stable.



    Before leaving the hospital, it is important for the patient and family to participate in and understand the discharge plan. Make sure all questions are answered and obtain written directions for how to take all medications (new and old). After bypass surgery, it is common to start new medications and stop or adjust the doses of previous medications.



    Medications — Most people who have had bypass surgery are sent home with prescriptions for several medications, most of which are taken every day. Some of these drugs improve survival and some help to prevent or treat recurrent chest pain.



     




    • Antiplatelet therapy — Clopidogrel (brand name: Plavix®) and aspirin are antiplatelet medications that are given to help prevent the formation of blood clots that can block either the graft or your own arteries. Clopidogrel is continued for at least one year after surgery while aspirin is usually recommended indefinitely. (See "Patient information: Aspirin and cardiovascular disease (Beyond the Basics)".)


    • Beta blockers — Beta blockers slow the heart rate, lower blood pressure, and decrease the heart's demand for oxygen. They are given to some patients with high blood pressure, heart failure, or a heart attack, and to some patients in whom CABG is not expected to relieve all symptoms of angina. If a person cannot tolerate a beta blocker, a calcium channel blocker may be substituted.


    • Nitrates — A nitrate, either as short-acting nitroglycerin, or as a long-acting preparation (isosorbide mononitrate or dinitrate). These drugs dilate coronary blood vessels, bringing more blood to the heart muscle. Nitrates also reduce the amount of blood returning to the heart, which decreases the heart's demand for oxygen. Nitrates are often given to treat or prevent further episodes of chest pain. Nitrates may be given to patients after CABG if some of the coronary blood vessels could not be bypassed. (See "Patient information: Angina treatment — medical therapy (Beyond the Basics)".)


    • ACE inhibitor — Angiotensin converting enzyme (ACE) inhibitors are often used to treat high blood pressure.

      Examples of ACE inhibitors include captopril (brand name: Capoten®), enalapril (brand name: Vasotec®), lisinopril (sample brand names: Zestril® or Prinivil®), and ramipril (brand name: Altace®).



      Some patients who cannot tolerate an ACE inhibitor (often because of a chronic cough) may be prescribed an angiotensin II receptor blocker (ARB). These related drugs are satisfactory replacements.



      Examples of ARBs include losartan (brand name: Cozaar®), valsartan (brand name: Diovan®), and irbesartan (brand name: Avapro®).



     



     




    • Lipid lowering therapy — Almost all patients are given a medication to lower lipids after CABG. Cholesterol lowering can be beneficial both before and after CABG because it can halt the progression of atherosclerosis in both native and graft vessels.


    • Other medications „Ÿ Other medications may be given on a short term basis to prevent the development of an irregular heart, to manage discomfort associated with healing incisions, or to allow for regular bowel movements.



     



    Lipid therapies are recommended even for patients who have values that are in the "normal" range. The goal level for "bad" cholesterol (called LDL or low density lipoprotein) is less than 70 mg/dL (1.8 mmol/L). (See "Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)".)



    Statins are the most common medications used to lower cholesterol levels. Other drugs may be used as well (table 1).



    Wound care — After discharge from the hospital, the patient is usually given instructions about how to care for their chest and/or leg wounds. It is important to follow these instructions closely and to notify a healthcare provider immediately if there are questions or concerns.



     




    • Avoid heavy lifting and extremes of shoulder movement (eg, as in tennis, baseball, and golf) for six to eight weeks after surgery to allow for complete healing of the breast bone (sternum)



     



    When to seek help — If the patient develops any of the following signs or symptoms of wound infection, a healthcare provider should be contacted immediately. Most wound infections develop within 14 days of the surgery.



     




    • Fever greater than 100.4º F (38º C)


    • New or worsened pain in the chest or around the incision


    • A rapid heart rate


    • Reddened skin, bleeding or pus-like drainage from the incision



     



    CARDIAC REHABILITATION



    Most people who have undergone bypass surgery benefit from participating in a structured, comprehensive cardiac rehabilitation program. People who participate in cardiac rehabilitation usually have appointments several times per week in a hospital or clinic, allowing the person to live and sleep at home. The potential benefits of rehabilitation include an improvement in heart function, a lowering of the heart rate at rest and during exercise, and a reduced risk of dying or developing complications from heart disease.



    There are several components to cardiac rehabilitation, including exercise, reducing risk factors, and dealing with stress, anxiety, and depression. The benefits of cardiac rehabilitation are seen only when this multifactorial approach is used. In other words, one component alone is not enough.



    Exercise — Exercise has consistently been shown to improve cardiovascular health. Importantly, the first step in starting to exercise is to determine the potential risk of heart and/or blood vessel complications from exercise. This is usually done by undergoing a monitored exercise test on a treadmill. Although nearly everyone can exercise safely after discharge, the intensity and duration of exercise should be adjusted according to the severity of a person's heart disease.



    Risk categories for exercise — Risk categories are a way of describing a person's risk of cardiovascular (heart-related) complications related to activity. Each category has a unique requirement for supervision and exercise restrictions. People in risk category A are generally healthy, do not require medical supervision during exercise, and have no limitations on the duration or intensity of exercise. Conversely, people in exercise category D have strict limits on activity and should not exercise, even with close medical supervision. Most people who have had bypass surgery are in category B or C.



     




    • Class A — Individuals who are apparently healthy and in whom there is no evidence of increased heart-related risk with exercise.


    • Class B — Individuals with established coronary heart disease that is stable. These individuals are at low risk of heart-related complications with vigorous exercise.


    • Class C — Individuals who are at moderate or high risk of heart-related complications during exercise. Examples of people who would be in this category are those who have had several heart attacks and those who have chest pain at a relatively low level of exercise. Patients with certain positive findings on an exercise test may also be in this group.


    • Class D — Individuals with unstable disease who should not participate in an exercise program.



     



    Exercise — During cardiac rehabilitation, a trained clinician will work with the patient and physician to develop an exercise program that is safe and beneficial. The program will consider the patient's fitness level, heart health, any physical limitations, the amount, intensity and duration of exercise needed to improve heart health, and the need for supervision.



     




    • Type of exercise — The exercise should use large muscle groups and include aerobic exercise. Walking, jogging, cycling, rowing, and stair climbing are some examples.


    • Frequency — The recommended frequency of exercise is three to five times a week.


    • Content and duration — It is important that each session consist of a 5- to 10-minute warm-up phase, a conditioning phase of at least 20 minutes, and a 5- to 10-minute cool-down phase. Eliminating the cool-down phase can increase the risk of heart-related complications.


    • Intensity — One of the most important components of the exercise prescription is the intensity of exercise. This is based upon the patient's heart rate or the level of exertion. A number of formulas exist to calculate the appropriate maximum heart rate for each patient.



      The patient gauges the level of exertion during an activity by rating it on a standardized scale called the rating of perceived exertion (RPE) (table 2). Moderate-intensity exercise (an RPE of 12 to 13) is needed to achieve cardiovascular health benefits. The benefits of very high intensity exercise are small; intense exercise is not recommended because it leads to muscle fatigue and increases the risk of physical injury and cardiovascular complications.


    • Exercise progression — Over time, most people can gradually increase the level of exercise in the workout. Beneficial exercise can also be built in to the daily routine by taking a brisk walk or enjoying active play with children or grandchildren.


    • Supervision — Patients who are in Class C should be in a medically supervised program where the electrocardiogram (ECG) is monitored during exercise. Advanced life support equipment (eg, a defibrillator, medications, personnel trained to use this equipment) should be on hand. This level of supervision should continue for at least 8 to 12 weeks.



      Lower-risk patients (Class B) benefit from a medically supervised, ECG monitored program for the first 6 to 12 sessions. Following this, a home-based exercise program is safe and effective.



     



    REDUCE CARDIAC RISK FACTORS



    A number of factors increase the risk of developing or speeding the progression of heart disease. Reducing or eliminating these risk factors can be helpful, even if a person already has heart disease or has had a heart attack. Strategies to reduce risks are discussed below.



    Follow a heart healthy diet — Diet counseling is helpful for people who need to lose weight or reduce cholesterol levels. A registered dietitian is the best person to consult about foods that are helpful and harmful, appropriate portion sizes, total calorie recommendations, and realistic ways to change bad eating habits.



    Most cardiac rehabilitation programs have a dietitian who is knowledgeable and experienced in advising people who are recovering from a heart attack. (See "Patient information: Diet and health (Beyond the Basics)".)



    Stop smoking — Cigarette smoking significantly increases the risk coronary heart disease and heart attack, and stopping smoking can rapidly reduce these risks. One year after stopping smoking, the risk of dying from coronary heart disease is reduced by about one-half and the risk continues to decline with time. In some studies, the risk of heart attack was reduced to the rate of nonsmokers within two years of quitting smoking.



    Cardiac rehabilitation programs can recommend a treatment to help stop smoking, such as group programs, nicotine patches, gum, or nasal spray, or a prescription medication . (See "Patient information: Quitting smoking (Beyond the Basics)".)



    Treat high blood pressure and high cholesterol — Medicines to control high blood pressure and high cholesterol are usually recommended after bypass surgery (see 'Medications' above). It is important to take these medications exactly as prescribed. (See "Patient information: High blood pressure treatment in adults (Beyond the Basics)" and "Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)".)



    Manage diabetes — People with diabetes are at an increased risk of developing complications after bypass surgery. Tight control of blood glucose levels can help to reduce the risk of these and other types of complications. Tight control can be achieved by losing weight, managing the diet, exercising, monitoring blood glucose levels regularly, and taking oral hypoglycemic medications (for people with type 2 diabetes) or insulin (for people with type 1 and sometimes type 2 diabetes). (See "Patient information: Preventing complications in diabetes mellitus (Beyond the Basics)".)



    Psychosocial treatment — Feelings of depression, anxiety, and denial are common after bypass surgery, occurring in up to 40 percent of people. Depression can reduce a person's ability to exercise, decrease energy levels, cause more fatigue, or reduce a person's quality of life and sense of well-being. Women, and in particular younger women, are at an especially high risk for depression.



    These symptoms can cause problems within the family, marriage, and the workplace. Individual or group therapy, and sometimes treatment with an antidepressant medication, can be helpful. Many cardiac rehabilitation programs have trained personnel, including psychologists, psychiatrists, or social workers, to help manage these issues. Treating depression and anxiety can improve a person's long-term outlook and general sense of well-being. (See "Patient information: Depression in adults (Beyond the Basics)".)



    Reduce stress — Long-term stress in the home, at work, or with finances can increase the risk of heart attack, stroke, and chest pain. Many cardiac rehabilitation programs teach patients how to reduce stress in an attempt to lower these risks.



    Stress reduction techniques may include one or more of the following:



     




    • Psychotherapy involves meeting with a psychologist, psychiatrist, or social worker to discuss emotional responses to living with stress, treatment successes or failures, and/or personal relationships.


    • Group psychotherapy allows patients to compare their experiences with stress and heart disease, overcome their tendency to withdraw and become isolated, and support one another's attempts at more effective management.


    • Relaxation techniques can relieve musculoskeletal tension, and may include meditation, progressive muscle relaxation, self-hypnosis, and biofeedback. Biofeedback may be especially helpful for people with chronic stress.


    • Group skill-building exercises help patients to learn about living with stress and heart disease, including ways to improve relationships and build strength, ways to avoid negative thinking, and learning to deal with stress.



     



    WHEN IS SEX SAFE?



    An important issue for many patients who have had bypass surgery is when sexual activity can be safely resumed. In the first two weeks after an uncomplicated heart attack, most people are at high risk of heart-related problems during sex as a result of a rise in the heart rate and blood pressure. However, this risk becomes much smaller by six weeks after the MI.



    Patients with complications of a heart attack, such as recurrent chest pain, abnormal heart rhythms (arrhythmias), or heart failure are at intermediate or high risk of heart-related problems during sex. People in these risk groups need further evaluation and/or treatment before attempting to have sex. A cardiologist or internal medicine specialist can help a person to know when sex is safe.



    Sexual problems — Sexual problems after a bypass surgery are common, occurring in one-half to three-quarters of patients. Both men and women may have less sex or feel less satisfied with sexual activity. A variety of factors may contribute, including side effects of drugs (such as beta blockers), depression, and fears about triggering a new heart attack or dying. Since sexual activity is a type of physical activity, exercise testing can be used to determine if a person is at any risk of heart problems related to sex.



    Use of Viagra®, Cialis® or Levitra® — For many men with erectile dysfunction, medications such sildenafil (brand name: Viagra®), tadalafil (brand name: Cialis®) or vardenafil (brand name: Levitra®) are highly effective. There have been concerns that these agents might cause side effects or increase the risk of heart attack in people with CHD. However, if used appropriately, these drugs appear to be well tolerated and safe. (See "Patient information: Sexual problems in men (Beyond the Basics)".)



    Unfortunately, these medications are not usually helpful for women with sexual problems after a heart attack or bypass surgery. Other treatments are available for women. (See "Patient information: Sexual problems in women (Beyond the Basics)".)



    Nitrates and medications for erectile dysfunction — None of the medications for erectile dysfunction (eg, Viagra, Cialis, Levitra) should be used if a person regularly or intermittently requires nitrates (such as nitroglycerin or isosorbide) for recurrent chest pain. This combination of medications can cause a life-threatening drop in blood pressure.



    Thus, if a man develops chest pain after taking Viagra, Cialis or Levitra, he should not take nitrates for 24 hours (or longer in some cases). Instead, the man should rest and wait 10 minutes to see if the pain resolves. If the pain does not resolve or if the chest pain is severe, he should immediately call for emergency medical services (in the United States by calling 911).



    FOLLOW-UP CARE



    Following the discharge plan and participating in a cardiac rehabilitation program are the best ways to recover from bypass surgery. In addition, it is important to schedule and attend periodic visits with an internal medicine provider and/or cardiac specialist (cardiologist).



    Follow-up care is of great importance since people who have had bypass surgery have a significantly increased risk of more cardiac events, including recurrent chest pain, heart attack, heart failure, and an increased risk of dying. The risk of these problems is greatly reduced by closely following a clinician's recommendations for rehabilitation, follow-up visits, and treatments. Over time, the treatment plan may change as heart health improves or other medical problems develop.



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

     



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Coronary heart disease (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: Coronary artery bypass graft surgery (Beyond the Basics)

    Patient information: Aspirin and cardiovascular disease (Beyond the Basics)

    Patient information: Angina treatment — medical therapy (Beyond the Basics)

    Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)

    Patient information: Diet and health (Beyond the Basics)

    Patient information: Quitting smoking (Beyond the Basics)

    Patient information: High blood pressure treatment in adults (Beyond the Basics)

    Patient information: Preventing complications in diabetes mellitus (Beyond the Basics)

    Patient information: Depression in adults (Beyond the Basics)

    Patient information: Sexual problems in men (Beyond the Basics)

    Patient information: Sexual problems in women (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Cardiac rehabilitation in patients with heart failure

    Cardiac rehabilitation: Exercise training and secondary prevention of coronary heart disease in older adults

    Components of cardiac rehabilitation and exercise prescription

    Efficacy of cardiac rehabilitation in patients with coronary heart disease

    Exercise assessment and measurement of exercise capacity in patients with coronary heart disease

    Overview of the therapy of heart failure due to systolic dysfunction

    Rehabilitation after cardiac transplantation

    Sexual activity in patients with cardiovascular disease



    The following organizations also provide reliable health information.



     




    • National Library of Medicine



     



    (www.nlm.nih.gov/medlineplus/healthtopics.html)



     




    • National Heart, Lung, and Blood Institute



     



    (www.nhlbi.nih.gov/)



     




    • American Heart Association



     



    (www.americanheart.org)



     




    • Society of Thoracic Surgeons



     



    (www.sts.org)



    [1-4]





    Literature review current through: Jul 2013. |This topic last updated: Sep 9, 2011.



    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.








    GRAPHICS





    Lipid lowering medications











































































    Statins

    Lovastatin

    Mevacor®, Altoprev®

    Pravastatin

    Pravachol®

    Simvastatin

    Zocor®

    Fluvastatin

    Lescol®, Lescol XL®

    Atorvastatin

    Lipitor®

    Rosuvastatin

    Crestor®

    Cholesterol absorption inhibitors

    Ezetimibe

    Zetia®

    Bile acid sequestrants

    Cholestyramine

    Questran®, Questran Light®

    Colestipol

    Colestid®

    Colesevelam

    WelChol®

    Nicotinic acid

    Niacin (immediate, sustained, and extended release)

     

    Fibrates

    Gemfibrozil

    Lopid®

    Fenofibrate

    Tricor®, Triglide®




     


     







    Rating of perceived exertion





























































    Original scale

    6

    very, very light

    7

    8

    9

    very light

    10

    11

    fairly light

    12

    13

    somewhat hard

    14

    15

    hard

    16

    17

    very hard

    18

    19

    very, very hard

    20




     


     








     



     



     


     




     


     




     


     




     



     



     




     


     


     


     


     


     


     


     


     


     






    -->



  • Patient information: High blood pressure, diet, and weight (Beyond the Basics)





     





     




    FindPrint ShareThis





     




    Contents of this article





     







    HIGH BLOOD PRESSURE OVERVIEW



    Hypertension (high blood pressure) is a common condition that can lead to serious complications if untreated. Making dietary changes and losing weight are effective treatments for reducing blood pressure.



    Other lifestyle changes that can help to reduce blood pressure include stopping smoking, reducing stress, reducing alcohol consumption, and exercising regularly. These changes are effective when used alone, but often have the greatest benefit when used together.



    An overview of hypertension and a discussion of treatments can be found elsewhere. (See "Patient information: High blood pressure in adults (Beyond the Basics)" and "Patient information: High blood pressure treatment in adults (Beyond the Basics)".) More detailed information is available by subscription. (See "Salt intake, salt restriction, and primary (essential) hypertension" and "Diet in the treatment and prevention of hypertension".)



    DIETARY CHANGES AND BLOOD PRESSURE



    Making changes in what you eat can help to control high blood pressure.



    Reduce sodium — The main source of sodium in the diet is the salt contained in packaged and processed foods and in foods from restaurants. Reducing the amount of sodium you consume can lower blood pressure if you have high or borderline high blood pressure. (See "Salt intake, salt restriction, and primary (essential) hypertension".)



    The body requires a small amount of sodium in the diet. However, most people consume more sodium than they need. A low sodium diet contains fewer than 2 grams (2,000 milligrams) of sodium each day.



    A detailed discussion of low sodium diets is available separately. (See "Patient information: Low sodium diet (Beyond the Basics)".)



    Reduce alcohol — Drinking an excessive amount of alcohol increases your risk of developing high blood pressure. People who have more than two drinks per day have an increased risk of high blood pressure compared to nondrinkers; the risk is greatest when you drink more than five drinks per day.



    On the other hand, drinking one (for women) or two (for men) alcoholic beverages per day appears to benefit the heart in people greater than 40 years old. This protective effect applies to people with preexisting high blood pressure. (See "Patient information: Risks and benefits of alcohol (Beyond the Basics)".)



    Eat more fruits and vegetables — Eating a vegetarian diet may reduce high blood pressure and protect against developing high blood pressure. A strict vegetarian diet may not be necessary; eating more fruits and vegetables and low-fat dairy products may also lower blood pressure. (See "Diet in the treatment and prevention of hypertension".)



    Eat more fiber — Eating an increased amount of fiber may decrease blood pressure. The recommended amount of dietary fiber is 20 to 35 grams of fiber per day. Many breakfast cereals are excellent sources of dietary fiber. More information about increasing fiber is available separately. (See "Patient information: High-fiber diet (Beyond the Basics)".)



    Eat more fish — Eating more fish may help to lower blood pressure, especially when combined with weight loss [1].



    Caffeine — Caffeine may cause a small rise in blood pressure, although this effect is usually temporary. Drinking a moderate amount of caffeine (less than 2 cups of coffee per day) does not increase the risk of high blood pressure in most people (table 1).



    EXERCISE



    Regular aerobic exercise (walking, running) for 20 to 30 minutes most days of the week can lower your blood pressure, although the effect is not as pronounced among older adults. To maintain this benefit, you must continue to exercise; stopping exercise will allow your blood pressure to become high again. (See "Patient information: Exercise (Beyond the Basics)".)



    WEIGHT LOSS AND BLOOD PRESSURE



    Being overweight or obese increases your risk of having high blood pressure, diabetes, and cardiovascular disease. The definition of overweight and obese are based upon a calculation called body mass index (BMI) (calculator 1 and calculator 2). You are said to be overweight if your BMI is greater than 25, while a person with a BMI of 30 or greater is said to be obese. People who are overweight or obese can benefit from losing weight.



    To lose weight you must eat less and exercise more. (See "Patient information: Weight loss treatments (Beyond the Basics)".)



    WHAT IF I STILL HAVE HIGH BLOOD PRESSURE?



    If you continue to have high blood pressure despite making changes in your diet, exercising more, and losing weight, you may need a medication to reduce your blood pressure. Medications for high blood pressure are discussed separately. (See "Patient information: High blood pressure treatment in adults (Beyond the Basics)" and "Choice of therapy in primary (essential) hypertension: Recommendations".)



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: High blood pressure in adults (The Basics)

    Patient information: Controlling your blood pressure through lifestyle (The Basics)

    Patient information: Diabetes and diet (The Basics)

    Patient information: Renovascular hypertension (The Basics)

    Patient information: High blood pressure emergencies (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: High blood pressure in adults (Beyond the Basics)

    Patient information: High blood pressure treatment in adults (Beyond the Basics)

    Patient information: Low sodium diet (Beyond the Basics)

    Patient information: Risks and benefits of alcohol (Beyond the Basics)

    Patient information: High-fiber diet (Beyond the Basics)

    Patient information: Exercise (Beyond the Basics)

    Patient information: Weight loss treatments (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Ambulatory blood pressure monitoring and white coat hypertension in adults

    Can therapy be discontinued in well-controlled hypertension?

    Cardiovascular risks of hypertension

    Choice of therapy in primary (essential) hypertension: Recommendations

    Definition, risk factors, and evaluation of resistant hypertension

    Diet in the treatment and prevention of hypertension

    Hypertension: Who should be treated?

    Initial evaluation of the hypertensive adult

    Overview of hypertension in adults

    Patient adherence and the treatment of hypertension

    Prehypertension

    Renin-angiotensin system inhibition in the treatment of hypertension

    Salt intake, salt restriction, and primary (essential) hypertension

    Blood pressure measurement in the diagnosis and management of hypertension in adults

    Treatment of hypertension in blacks

    Antihypertensive therapy to prevent recurrent stroke or transient ischemic attack

    Treatment of hypertension in patients with diabetes mellitus

    Treatment of hypertension in patients with heart failure

    Treatment of hypertension in the elderly patient, particularly isolated systolic hypertension

    Treatment of resistant hypertension

    What is goal blood pressure in the treatment of hypertension?

    Who should be evaluated for renovascular or other causes of secondary hypertension?



    The following organizations also provide reliable health information:



     




    • National Library of Medicine



     



    (www.nlm.nih.gov/medlineplus/healthtopics.html)



     




    • National Heart, Lung & Blood Institute (NHLBI)



     



    (www.nhlbi.nih.gov)



     




    • American Heart Association



     



    (www.americanheart.org)



    [1-6]





    Literature review current through: Jul 2013. |This topic last updated: Oct 31, 2012.



    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.








    GRAPHICS





    Caffeine source and amount*






















































































    Source

    Caffeine (mg)

    Coffee

    Drip (8 ounces)

    234

    Percolated (8 ounces)

    176

    Regular instant (8 ounces)

    85

    Decaffeinated instant (8 ounces)

    3

    Expresso (1 -2 oz)

    45-100

    Starbucks grande (16 oz)

    330

    Cocoa and chocolate

    Cocoa from mix (6 ounces)

    10

    Milk chocolate (1 ounce)

    6

    Baking chocolate (1 ounce)

    35

    Soft drinks (12 ounces)

    Dr. Pepper

    39.6

    Regular cola

    46

    Diet cola

    46

    Tea

    1 minute brew

    9-33

    3 minute brew

    20-46

    Instant

    12-28

    Canned iced tea (12 ounces)

    22-36




    * It is important to remember that these figures are approximate and vary among products. In addition, different types of beans and teas have different caffeine contents, and the way the beverage is brewed also affects the caffeine content.


     








     



     



     


     




     


     




     


     




     



     



     




     


     


     


     


     


     


     


     


     


     






    -->



  • Patient information: Chronic obstructive pulmonary disease (COPD) treatments (Beyond the Basics)





     






     




    FindPrint ShareThis





     




    Contents of this article





     








    CHRONIC OBSTRUCTIVE PULMONARY DISEASE OVERVIEW



    COPD, or chronic obstructive pulmonary disease, is a condition in which the airways in the lungs become damaged, making it increasingly difficult for air to pass in and out.



    There are two major kinds of damage that can cause COPD:



     




    • The airways in the lungs can become scarred and narrowed.

    • The air sacs in the lung, where oxygen is absorbed into the blood and carbon dioxide is excreted, can become damaged.



     



    When the damage is severe, it may become difficult to get enough oxygen into the blood and to get rid of excess carbon dioxide. These changes lead to shortness of breath and other symptoms.



    Unfortunately, the symptoms of chronic obstructive pulmonary disease cannot be completely eliminated with treatment and the condition usually worsens over time. However, treatment can control symptoms and can sometimes slow the progression of the disease.



    This article discusses treatment options for people with chronic obstructive pulmonary disease. Treatment of suddenly worsening symptoms, which often requires hospital treatment, is not discussed here. A review of the risk factors and diagnosis of COPD is also available. (See "Patient information: Chronic obstructive pulmonary disease (COPD), including emphysema (Beyond the Basics)".)



    CHRONIC OBSTRUCTIVE PULMONARY DISEASE MEDICATIONS



    Bronchodilators — Medications that help open the airways, called bronchodilators, are a mainstay of treatment for chronic obstructive pulmonary disease. Bronchodilators help to keep airways open and possibly decrease secretions.



    Bronchodilators are most commonly given in an inhaled form using a metered dose inhaler (MDI), dry powder inhaler (DPI), or nebulizer. It is important to use the inhaler properly to deliver the correct dose of medication to the lungs. If you do not use the inhaler correctly, little or no medicine reaches the lungs. (See "Patient information: Asthma inhaler techniques in adults (Beyond the Basics)".)



    There are several types of bronchodilators that can be used alone or in combination. (See "Management of stable chronic obstructive pulmonary disease".)



     




    • Short-acting beta agonists – Short-acting beta agonists, sometimes called rescue inhalers, can quickly relieve shortness of breath and can be used when needed. Examples of short-acting beta agonists include albuterol, levalbuterol, and pirbuterol.

    • Short-acting anticholinergics – Short-acting anticholinergic medication (ipratropium, Atrovent) improves lung function and symptoms. If symptoms are mild and infrequent, short-acting anticholinergic medication may be recommended only when you need it. Or, if symptoms are more severe or more frequent, it may be recommended on a regular basis.

    • Short-acting combination inhaler – A combination inhaler that contains albuterol and ipratropium (Combivent) is also available. Combination inhalers may be used just when needed or regularly, depending on the frequency and severity of your symptoms.



     



    Long-acting treatments are often recommended for people who must use medication on a regular basis to control COPD symptoms.



     




    • Long-acting beta agonists – Long-acting beta agonists may be recommended if your symptoms are not adequately controlled with other treatments. Examples of long-acting beta agonists include salmeterol, formoterol, and arformoterol.

    • Long-acting anticholinergics – The long-acting anticholinergic medication, tiotropium (Spiriva), which is taken once daily, improves lung function while decreasing shortness of breath and flares of COPD symptoms. Aclidinium (Tudorza), a long-acting anticholinergic that is taken twice daily, also improves lung function. This type of medication may be recommended if your symptoms are not adequately controlled with other treatments, such as the short-acting bronchodilators.

    • Theophylline – Theophylline in slow release form (eg, Theo-Dur, Slo-bid) is a long-acting bronchodilator that is taken in pill form. Theophylline is not commonly used, but may be beneficial to some people with more severe, but stable chronic obstructive pulmonary disease. The dose of theophylline must be monitored carefully by blood tests because of its potentially toxic effects.



     



    Glucocorticoids — Glucocorticoids (also called steroids, although they are very different from muscle building steroids) are a class of medication that has anti-inflammatory properties. Glucocorticoids can be taken with an inhaler, as a pill, or as an injection. Inhaled glucocorticoids may be recommended if your symptoms are not completely controlled with bronchodilators and/or if you have frequent flares of chronic obstructive pulmonary disease.



    Glucocorticoids taken in pill form are sometimes used for short term treatment (eg, for flares of COPD), but are not generally used long-term because of the risk of side effects.



    Combination treatments — Combinations of short and long-acting bronchodilators, anticholinergics, and/or glucocorticoids are often used in people whose symptoms are not completely controlled with one medication.



    Cough medicines — Cough medicines are not generally recommended for people with COPD because they have not been shown to improve COPD symptoms. Although cough can be a bothersome symptom, cough suppressants should be avoided since suppressing cough may increase the risk of developing an infection.



    SUPPLEMENTAL THERAPIES FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE



    Stop smoking — One of the MOST important treatments for chronic obstructive pulmonary disease is for current smokers to stop smoking. Studies of people with COPD show that the disease progresses more slowly after stopping smoking. Most people who stop smoking will cough less and produce less sputum, although this may take several months. A detailed discussion of ways to quit smoking is available separately. (See "Patient information: Quitting smoking (Beyond the Basics)".)



    Oxygen — People with advanced chronic obstructive pulmonary disease can have low oxygen levels in the blood. This condition, known as hypoxemia, can occur even if the person does not feel short of breath or have other symptoms. The oxygen level can be measured with a device placed on the finger (pulse oximeter) or with a blood test (arterial blood gas). People with hypoxemia may be placed on oxygen therapy, which can improve survival and quality of life. (See "Use of oxygen in patients with hypercapnia".)



    Some people with COPD who travel by air may be prone to hypoxemia during travel because of the changes in air pressure inside the plane. If a clinician determines that you are at risk for hypoxemia during a flight, in-flight oxygen can be prescribed. (See "Patient information: Supplemental oxygen on commercial airlines (Beyond the Basics)".)



    Supplemental oxygen must never be used while smoking. Oxygen is explosive, and smoking while using oxygen can lead to severe burns. Fatal fires have occurred in people attempting to smoke while using oxygen.



    Nutrition — More than 30 percent of people with severe COPD are not able to eat enough because of their symptoms (shortness of breath, fatigue). Unintended weight loss caused by shortness of breath usually occurs in people with more advanced lung disease. Not eating enough can lead to malnutrition, which can make symptoms worse and increase the likelihood of infection. (See "Nutritional support in advanced lung disease".)



    To increase the number of calories you eat:



     




    • Eat small, frequent meals with nutrient-dense foods (eg, eggs)

    • Eat meals that require little preparation (eg, microwaveable)

    • Rest before meals

    • Take a daily multivitamin

    • Nutritional supplements (liquids or bars) are also good sources of extra calories because they are easy to eat and require no preparation

    • If you continue to lose weight, a prescription medication may be recommended to stimulate your appetite



     



    Pulmonary rehabilitation — Pulmonary rehabilitation programs may include education, exercise training, social support, and instruction on breathing techniques that can ease symptoms of breathlessness. Pulmonary rehabilitation programs have been shown to improve a person's ability to exercise, enhance quality of life, and decrease the frequency of exacerbations of COPD. Even people with severe shortness of breath can benefit from a rehabilitation program. (See "Pulmonary rehabilitation in COPD".)



    Surgery — Surgery, such as lung volume reduction surgery or lung transplantation, may be helpful in reducing symptoms in some patients with emphysema.



    Lung volume reduction surgery — Lung volume reduction surgery involves removing the areas of lung that are most abnormal, which allows the remaining lung to expand and function more normally. (See "Lung volume reduction surgery in COPD".)



    This procedure may be an option for people who have severe symptoms after trying all other routine therapies, including pulmonary rehabilitation. Not all patients will benefit from this surgery, and some may actually become worse. An imaging test, such as a CT scan, may be recommended to help determine if surgery is likely to be of benefit.



    Lung transplantation — Lung transplantation may be considered in cases of severe chronic obstructive pulmonary disease. If successful, transplantation is likely to improve symptoms. However, lung transplantation has not yet been shown to prolong the life of people with COPD. (See "Lung transplantation: General guidelines for recipient selection".)



    Other therapies — Other treatments for COPD are occasionally recommended, including: noninvasive ventilatory support (the use of a special mask and breathing machine to improve symptoms), anti-anxiety or anti-depressant medications, or morphine-like medications to reduce shortness of breath.



    PREVENTION AND TREATMENT OF INFECTION IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE



    People with chronic obstructive pulmonary disease are at risk for worsening symptoms as a result of respiratory infections. Avoiding these infections and treating them quickly if they occur are important parts of COPD therapy.



    Vaccines — Everyone with chronic obstructive pulmonary disease should have a pneumococcal vaccination, which helps prevent a type of pneumonia. (See "Patient information: Pneumonia prevention (Beyond the Basics)".)



    People with COPD should also get an annual flu shot before flu season, generally in the late fall or early winter. For patients who get the flu, antiviral medications may be prescribed. (See "Patient information: Influenza prevention (Beyond the Basics)".)



    Antibiotics — Antibiotics are of some benefit in people with a bacterial respiratory infection who have worsening COPD symptoms. However, most respiratory infections are caused by viruses, which will not improve with antibiotic treatment. (See "Management of acute exacerbations of chronic obstructive pulmonary disease".)



    Continuous use of antibiotics to prevent infection is not currently recommended.



    PROGNOSIS



    Although chronic obstructive pulmonary disease usually worsens over time, it is difficult to predict how quickly this will occur. A number of factors play a role in the severity of COPD symptoms, including whether you continue to smoke, are underweight, have underlying medical problems, and how your lungs function during exercise. People with COPD who have less severe symptoms, are a healthy weight, and do not smoke tend to live longer.



    The BODE index is an example of an index that clinicians use to predict survival and to guide the timing of lung transplantation. It uses a combination of body mass index (BMI), severity of airflow obstruction on spirometry, degree of shortness of breath with exertion, and distance walked in six minutes. (See "Chronic obstructive pulmonary disease: Prognostic factors and comorbid conditions".)



    END OF LIFE DECISIONS IN COPD



    Although discussions about death and dying can be uncomfortable for patients, family members, and healthcare providers, the subject is important, especially for people with severe chronic illnesses. Not everyone with COPD will die as a result of their disease. However, discussions about what you want at the end of your life should occur well before you become seriously ill. This is particularly important for people with COPD, who are at risk for being placed on a ventilator (breathing machine) when they are very ill.



    Important questions to consider include:



     




    • Who do I want to make medical decisions for me if I cannot communicate?

    • Are there specific treatments that I do or do not want at the end of my life?



     



    Certain legal documents, called a healthcare proxy and living will, are used to communicate your preferences. The document you need depends upon where you live. In the United States, state-specific documents can be downloaded from the internet (such as www.caringinfo.org) and do not require a lawyer.



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Chronic obstructive pulmonary disease (COPD), including emphysema (The Basics)

    Patient information: Medicines for chronic obstructive pulmonary disease (COPD) (The Basics)

    Patient information: Chronic bronchitis (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: Chronic obstructive pulmonary disease (COPD), including emphysema (Beyond the Basics)

    Patient information: Asthma inhaler techniques in adults (Beyond the Basics)

    Patient information: Quitting smoking (Beyond the Basics)

    Patient information: Supplemental oxygen on commercial airlines (Beyond the Basics)

    Patient information: Pneumonia prevention (Beyond the Basics)

    Patient information: Influenza prevention (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Bullectomy for giant bullae in COPD

    Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging

    Chronic obstructive pulmonary disease: Risk factors and risk reduction

    Management of infection in acute exacerbations of chronic obstructive pulmonary disease

    Dynamic hyperinflation in patients with COPD

    Lung volume reduction surgery in COPD

    Management of acute exacerbations of chronic obstructive pulmonary disease

    Management of stable chronic obstructive pulmonary disease

    Mechanical ventilation in acute respiratory failure complicating COPD

    Chronic obstructive pulmonary disease: Prognostic factors and comorbid conditions

    Pulmonary rehabilitation in COPD

    Use of oxygen in patients with hypercapnia

    Nutritional support in advanced lung disease

    Lung transplantation: General guidelines for recipient selection



    The following organizations also provide reliable health information.



     




    • National Library of Medicine



     



    (www.nlm.nih.gov/medlineplus/copdchronicobstructivepulmonarydisease.html, available in Spanish)



     




    • National Heart, Lung, and Blood Institute



     



    (www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd_WhatIs.html)



     




    • American Lung Association



     



    (www.lungusa.org)



     




    • Alpha-1 Foundation



     



    (www.alphaone.org)



    Patient Support — There are a number of online forums where patients can find information and support from other people with similar conditions.



     





     



    (http://copd.about.com/forum)



    [1-4]





    Literature review current through: Jul 2013. |This topic last updated: Dec 7, 2012.




    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.









     



     



     




     



     



     




     


     


     


     


     


     


     


     


     


     







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  • Patient information: Preventing complications in diabetes mellitus (Beyond the Basics)





     






     




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    Contents of this article





     







    DIABETES OVERVIEW



    Diabetes mellitus is a chronic condition that can lead to complications over time. These complications can include:



     




    • Coronary heart disease, which can lead to a heart attack


    • Cerebrovascular disease, which can lead to stroke


    • Retinopathy (disease of the eye), which can lead to blindness


    • Nephropathy (disease of the kidney), which can lead to kidney failure and the need for dialysis


    • Neuropathy (disease of the nerves), which can lead to, among other things, ulceration of the foot requiring amputation (see "Patient information: Diabetic neuropathy (Beyond the Basics)")



     



    Many of these complications produce no symptoms in the early stages, and most can be prevented or minimized with a combination of regular medical care and blood sugar monitoring.



    CONTROLLING BLOOD SUGAR IN DIABETES



    The long-term complications of diabetes are caused by the effect of high blood sugar levels on blood vessels. Two important studies, the Diabetes Control and Complications Trial (DCCT) in patients with type 1 diabetes and the United Kingdom Prospective Diabetes Study (UKPDS) in patients with type 2 diabetes, found that people with lower blood sugar levels had fewer complications than those with higher values.



    Thus, keeping blood sugars close to normal can help prevent the long-term complications of diabetes mellitus. However, there are some risks associated with tight control, particularly an increased risk of hypoglycemia (low blood sugar).



    Monitoring blood sugar levels — Monitoring blood sugar with finger sticks at home can indicate how well diabetes is controlled and serves as a guide to adjusting therapy. (See "Patient information: Self-blood glucose monitoring in diabetes mellitus (Beyond the Basics)".) For most people, a target for fasting blood sugar and for blood sugar levels before each meal is 80 to120 mg/dL (4.4 to 6.6 mmol/L); however, these targets may need to be individualized.



    A blood test called A1C is also used to monitor blood sugar control; the result provides an average of blood sugar levels during the previous one to three months. An A1C of 7 percent or less is recommended; this corresponds to an average blood sugar of 150 mg/dL (8.3 mmol/L) (table 1).



    The A1C target may be somewhat higher in people who are older or who have conditions that increase the risks associated with hypoglycemia. Even small decreases in the A1C lowers the risk of diabetes-related complications to some degree.



    The combination of A1C and fingerstick blood sugars provides information about the average and daily blood sugar levels.



    Type 1 diabetes — Blood sugar control in type 1 diabetes requires some form of insulin, which can be given with insulin injections or an insulin pump. Most healthcare providers recommend intensive insulin therapy, which requires frequent blood sugar monitoring in addition to frequent injections or use of an insulin pump. (See "Patient information: Diabetes mellitus type 1: Insulin treatment (Beyond the Basics)".)



    Intensive insulin therapy increases the risk of low blood sugar, is more expensive than traditional insulin therapy, and requires that the person monitor their blood sugar levels, diet, and activities. Some people who use intensive insulin therapy gain weight, although regular exercise and controlling the amount eaten can prevent weight gain. (See "Patient information: Hypoglycemia (low blood sugar) in diabetes mellitus (Beyond the Basics)".)



    Type 2 diabetes — With type 2 diabetes, it is sometimes possible to control blood sugar levels with lifestyle changes, often in combination with oral medications. Insulin injections may be needed when a person is first diagnosed or later in the course of treatment. Most people with type 2 diabetes who take insulin require only one or two injections per day. (See "Patient information: Diabetes mellitus type 2: Insulin treatment (Beyond the Basics)".)



    EYE COMPLICATIONS IN DIABETES



    Regular eye examinations are essential for detecting eye complications (called retinopathy) at an early stage, when the condition can be monitored and treated to preserve vision.



    An eye exam should include dilating the pupils (with medicated eye drops) to completely examine the retina. Unless the pupils are medicated, they contract in response to light, making it impossible to view the entire retina. In some people with retinopathy, photographs of the retina will be taken to monitor the changes. This examination should be performed by a doctor who specializes in the eyes (called an ophthalmologist or optometrist).



    The risk of diabetic retinopathy varies with the type and duration of diabetes and with other life events. Thus, the screening guidelines differ from one person to another.



    Type 1 diabetes — People with type 1 diabetes should have an eye examination by an ophthalmologist or optometrist beginning five years after they are diagnosed with diabetes, although screening is usually not necessary before puberty. People who have difficulty with their vision or who require glasses or contacts may need to be seen sooner. The frequency of subsequent examinations will depend upon the results of the initial exam. An eye exam is usually recommended every one to two years after the initial examination.



    Type 2 diabetes — People with type 2 diabetes should have an eye examination by an ophthalmologist or optometrist when they are first diagnosed with diabetes. The reason for this is that blood sugar levels often increase over a period of several years before the person is diagnosed. Eye complications can develop during this time and often have no symptoms. Having an eye examination soon after diagnosis can help to determine if there are eye complications, the extent or severity of the complications, and if treatment is needed.



    The frequency of subsequent exams will depend upon the results of the initial examination. An eye exam is usually recommended every one to two years after the initial examination.



    FOOT CARE WITH DIABETES



    Diabetes can decrease the blood supply to the feet and damage the nerves that carry sensation. These changes put the feet at risk for developing potentially serious complications such as ulcers. Foot complications are very common among people with diabetes, and may go unnoticed until the condition is severe. (See "Patient information: Diabetic neuropathy (Beyond the Basics)".)



    Self exam — People with diabetes should examine their feet every day. It is important to examine all parts of the feet, especially the area between the toes. Look for broken skin, ulcers, blisters, areas of increased warmth or redness, or changes in callus formation; a healthcare provider should be notified if any of these changes are found. (See "Patient information: Foot care in diabetes mellitus (Beyond the Basics)".)



    This examination can be a part of the daily bathing or dressing routine. It may be necessary to use a mirror to see the bottoms of the feet clearly. Anyone who is unable to reach their feet or see them completely, even with the help of a mirror, should have someone else (such as a spouse or other family member) assist with the examination.



    Clinical exam — During a routine medical visit, the clinician will check the blood flow and sensation in the feet. In people with type 1 diabetes, annual foot examinations should begin five years after diagnosis. In people with type 2 diabetes, annual foot exams should begin at the time of diagnosis.



    During a foot examination, the clinician will look for changes such as ulcers, cold feet, thin skin, bluish skin color, and skin breaks associated with athlete's foot. The clinician will also test the sensation in the feet to determine if it is normal or diminished. People with decreased sensation are at risk for foot injuries that can go unnoticed due to lack of pain.



    KIDNEY COMPLICATIONS IN DIABETES



    Diabetes can alter the normal function of the kidneys. A urine test that measures the amount of protein (albumin) in the urine can determine if diabetes is affecting the kidney's filtering action. Microscopic amounts of albumin in the urine (microalbuminuria) can be an early indicator of diabetes-related kidney complications (called nephropathy). The amount of albumin in the urine can also help the provider determine if nephropathy is worsening. (See "Patient information: Protein in the urine (proteinuria) (Beyond the Basics)".)



    Urine screening tests should begin in people with type 1 diabetes about five years after diagnosis, and in people with type 2 diabetes at the time of diagnosis. If the test shows that there is protein in the urine, tight blood sugar and lipid (cholesterol and triglyceride) control are recommended.



    A blood pressure medication (an ACE inhibitor or angiotensin receptor blocker [ARB]) is generally recommended if albuminuria does not improve, even if the blood pressure is normal. People with elevated blood pressure and albuminuria are also treated with an ACE inhibitor or ARB. These medications decrease the amount of protein in the urine and can prevent or slow the progression of diabetes-related kidney disease.



    HYPERTENSION AND RELATED COMPLICATIONS IN DIABETES



    Many people with diabetes have hypertension (high blood pressure). Although high blood pressure causes few symptoms, it has two negative effects: it stresses the cardiovascular system and speeds the development of diabetic complications of the kidney and eye. A healthcare provider can diagnose high blood pressure by measuring blood pressure on a regular basis. (See "Patient information: High blood pressure in adults (Beyond the Basics)".)



    A blood pressure reading below 140/90 and perhaps below 130/80 is recommended for most people with diabetes who do not have kidney complications; a lower blood pressure goal (less than 130/80) is recommended for people with diabetes who have kidney disease.



    If a person is diagnosed with prehypertension (>120/80), the healthcare provider may recommend weight loss, exercise, decreasing the amount of salt in the diet, quitting smoking, and decreasing alcohol intake. These measures can sometimes reduce blood pressure to normal. (See "Patient information: High blood pressure, diet, and weight (Beyond the Basics)".)



    If these measures are not effective or the blood pressure must be lowered quickly, the provider will likely recommend one of several high blood pressure medications. The provider can discuss the pros and cons of each medication and the goals of treatment (see "Patient information: High blood pressure treatment in adults (Beyond the Basics)").



    CARDIOVASCULAR COMPLICATIONS IN DIABETES



    In addition to lowering blood glucose levels, a number of other measures are important to reduce the risk of cardiovascular (heart and blood vessel) disease.



     




    • Quit smoking.


    • Manage high blood pressure with lifestyle modifications and/or medication(s).


    • Have a blood test to measure cholesterol and triglyceride levels, and modify the diets if needed. Some people will also need a medication to lower their LDL ("bad cholesterol") or triglycerides.



      If medication is needed, a statin drug should be included whenever possible. The statin drugs have been shown to decrease the future risk of heart attacks, strokes, and death in people with diabetes who are over age 40, even when cholesterol levels are normal.



      The American Diabetes Association recommends that people with diabetes have a low density lipoprotein (LDL) cholesterol level less than 100 mg/dL (2.59 mmol/L). Some studies suggest lowering LDL even further, to 70 to 80 mg/dL (1.81 to 2.07 mmol/L). (See "Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)".)


    • Aspirin (81 to 100 mg per day) is recommended for anyone with diabetes who already has or is at increased risk of cardiovascular disease. (See "Patient information: Aspirin and cardiovascular disease (Beyond the Basics)".)



     



    PREGNANCY AND DIABETES



    Control of diabetes and its potential complications is especially important for women who are planning to become pregnant, as well as in those who already are pregnant. Controlling blood sugar levels before and during pregnancy decreases the risk of many complications in both the mother and the baby. A separate topic review is available on this subject. (See "Patient information: Care during pregnancy for women with type 1 or 2 diabetes mellitus (Beyond the Basics)".)



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Type 2 diabetes (The Basics)

    Patient information: The ABCs of diabetes (The Basics)

    Patient information: Recovery after coronary artery bypass graft surgery (CABG) (The Basics)

    Patient information: Diabetic ketoacidosis (The Basics)

    Patient information: Hyperosmolar nonketotic coma (The Basics)

    Patient information: Gangrene (The Basics)

    Patient information: Detached retina (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: Care during pregnancy for women with type 1 or 2 diabetes mellitus (Beyond the Basics)

    Patient information: Foot care in diabetes mellitus (Beyond the Basics)

    Patient information: High blood pressure in adults (Beyond the Basics)

    Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)

    Patient information: High cholesterol treatment options (Beyond the Basics)

    Patient information: Self-blood glucose monitoring in diabetes mellitus (Beyond the Basics)

    Patient information: Diabetic neuropathy (Beyond the Basics)

    Patient information: Diabetes mellitus type 1: Insulin treatment (Beyond the Basics)

    Patient information: Hypoglycemia (low blood sugar) in diabetes mellitus (Beyond the Basics)

    Patient information: Diabetes mellitus type 2: Insulin treatment (Beyond the Basics)

    Patient information: Protein in the urine (proteinuria) (Beyond the Basics)

    Patient information: High blood pressure, diet, and weight (Beyond the Basics)

    Patient information: High blood pressure treatment in adults (Beyond the Basics)

    Patient information: Aspirin and cardiovascular disease (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Clinical presentation and diagnosis of diabetes mellitus in adults

    Estimation of blood glucose control in diabetes mellitus

    Glycemic control and vascular complications in type 1 diabetes mellitus

    Glycemic control and vascular complications in type 2 diabetes mellitus

    Medical management of type 1 and type 2 diabetes mellitus in pregnant women

    Insulin therapy in adults with type 1 diabetes mellitus

    Insulin therapy in type 2 diabetes mellitus

    Management of diabetes mellitus in hospitalized patients

    Management of persistent hyperglycemia in type 2 diabetes mellitus

    Overview of medical care in adults with diabetes mellitus

    Screening for diabetes mellitus

    Treatment of hypertension in patients with diabetes mellitus

    Treatment of type 2 diabetes mellitus in the elderly patient



    The following organizations also provide reliable health information.



     




    • National Library of Medicine



     



    (www.nlm.nih.gov/medlineplus/healthtopics.html)



     




    • National Institute of Diabetes and Digestive and Kidney Diseases



     



    (www.niddk.nih.gov/)



     




    • American Diabetes Association (ADA)



     



    (800)-DIABETES (800-342-2383)

    (www.diabetes.org)



     




    • The Hormone Foundation



     



    (www.hormone.org/public/diabetes.cfm, available in English and Spanish)



    [1-6]





    Literature review current through: Jul 2013. |This topic last updated: Jun 12, 2012.



    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.












    GRAPHICS





     





    A1C level and average blood sugar
































































    If your A1C level is (percent)

    That means your average blood sugar level during the past 2 to 3 months was

    If you live within the US, use these values. Your blood sugar is measured in milligrams/deciliter (mg/dL).

    If you live outside the US, use these values. Your blood sugar is measured in millimoles/liter (mmol/L).

    5

    97

    5.4

    6

    126

    7

    7

    154

    8.6

    8

    183

    10.2

    9

    212

    11.8

    10

    240

    13.3

    11

    269

    15

    12

    298

    16.5

    13

    326

    18.1

    14

    355

    19.7



    The A1C blood test tells you what your average blood sugar level has been for the past 2 to 3 months. This table lists which A1C levels go with which average blood sugar levels. Blood sugar is measured differently within the United States than it is in most other countries. The column in the middle is for people in the United States. The column on the right is for people who live outside the United States.

     


     








     



     



     




     



     



     




     


     


     


     


     


     


     


     


     


     






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  • Patient information: Acute diarrhea in adults (Beyond the Basics)





     






     




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    Contents of this article





     








    DIARRHEA OVERVIEW



    Diarrhea is defined as three or more loose or watery stools per day. Nearly everyone will have an episode of diarrhea at some point during their life, with the average adult experiencing it four times per year. Although most cases of diarrhea resolve within a few days without treatment, it's important to know when to seek help.



    This topic review discusses the causes and treatments of sudden onset (acute) diarrhea in adults in developed countries. A discussion of acute diarrhea in developing countries and returning travelers is not included here. Diarrhea that lasts for more than 14 days (called chronic diarrhea) and acute diarrhea in children are discussed in separate topic reviews. (See "Patient information: Chronic diarrhea in adults (Beyond the Basics)" and "Patient information: Acute diarrhea in children (Beyond the Basics)".)



    A topic review that discusses antibiotic-associated diarrhea is also available. (See "Patient information: Antibiotic-associated diarrhea caused by Clostridium difficile (Beyond the Basics)".)



    DIARRHEA CAUSES



    Diarrhea can be caused by infections or a variety of other factors. The cause of diarrhea is not identified in most people, especially those who improve without treatment.



    Diarrhea caused by infections usually results from eating or drinking contaminated food or water. Signs and symptoms of infection usually begin 12 hours to four days after exposure and resolve within three to seven days. (See "Patient information: Food poisoning (food-borne illness) (Beyond the Basics)".)



    Diarrhea not related to an infection can occur as a side effect of antibiotics or other drugs, food allergies, gastrointestinal diseases such as inflammatory bowel disease, and other diseases. In addition, there are many less common causes of diarrhea. A summary of the various common causes of diarrhea is available in the table (table 1).



    DIARRHEA SYMPTOMS



    A person with diarrhea may be mildly to severely ill. A person who has mild illness may have a few loose bowel movements but otherwise feels well. By contrast, a person with severe diarrhea may have 20 or more bowel movements per day, happening up to every 20 or 30 minutes. In this situation, a significant amount of water and salts can be lost, seriously increasing the risk of dehydration. Diarrhea may be accompanied by fever (temperature greater than 100.4ºF or 38ºC), abdominal pain, or cramping.



    DIARRHEA HOME CARE



    Drink adequate fluids — If you have mild to moderate diarrhea, you can usually be treated at home by drinking extra fluids. The fluids should contain water, salt, and sugar. The fluids used for sweat replacement (eg, Gatorade) are not optimal, although they may be sufficient for a person with diarrhea who is not dehydrated and is otherwise healthy. Diluted fruit juices and flavored soft drinks along with salted crackers and broths or soups may also be acceptable.



    One way to judge hydration is by looking at the color of your urine and monitoring how frequently you urinate. If you urinate infrequently or have urine that is dark yellow, you should drink more fluids. Normally, urine should be light yellow to nearly colorless. If you are well hydrated, you normally pass urine every three to five hours.



    If you become dehydrated and are unable to take fluids by mouth, a rehydration solution can be given into a vein (intravenous fluids) in a healthcare provider's office or in the emergency department.



    Diet — There is no particular food or group of foods that is best while you have diarrhea. However, adequate nutrition is important during an episode of acute diarrhea. If you do not have an appetite, you can drink only liquids for a short period of time. Boiled starches and cereals (eg, potatoes, noodles, rice, wheat, and oats) with salt are recommended if you have watery diarrhea; crackers, bananas, soup, and boiled vegetables may also be eaten.



    Antidiarrheal medications — Medications to reduce diarrhea are available, and are safe if there is no fever (temperature greater than 100.4ºF or 38ºC) and the stools are not bloody. These medications do not cure the cause of the diarrhea, but help to reduce the frequency of bowel movements.



     




    • Loperamide (Imodium®) is available without a prescription; the dose is two tablets (4 mg) initially, then 1 tablet (2 mg) after each unformed stool. No more than 16 mg is recommended per day.

    • Diphenoxylate (Lomotil®) is a prescription medication used to treat diarrhea; its benefit is similar to loperamide, although it can be associated with more bothersome side effects.

    • Bismuth subsalicylate (Pepto-Bismol®, Kaopectate®) has also been used for treatment of acute diarrhea, although it is not as effective as loperamide. Bismuth subsalicylate may be recommended in certain situations, such as if you have fever and bloody diarrhea. However, women who are pregnant should not take bismuth subsalicylate. The dose of bismuth subsalicylate is 30 mL or two tablets every 30 minutes for up to eight doses.



     



    Antibiotics — Antibiotics are not needed in most cases of acute diarrhea, and they can actually worsen diarrhea or cause further complications if used inappropriately. Antibiotics may be recommended in certain situations, such as if you have the following signs or symptoms:



     




    • Moderate to severe traveler's diarrhea

    • More than eight loose stools per day, dehydration, symptoms that continue for more than one week, a weakened immune system, and in those who require hospitalization



     



    However, the decision to use antibiotics must be made carefully after discussing the potential risks and benefits with a healthcare provider who is familiar with the situation.



    Preventing spread — Adults with diarrhea should be cautious to avoid spreading infection to family, friends, and co-workers. You are considered infectious for as long as diarrhea continues. Microorganisms causing diarrhea are spread from hand to mouth; hand washing, care with diapering, and staying out of work or school are a few ways to prevent infecting family and other contacts.



    Hand washing — Hand washing is an effective way to prevent the spread of infection. Hands should ideally be wet with water and plain or antibacterial soap and rubbed together for 15 to 30 seconds. Pay special attention to the fingernails, between the fingers, and the wrists. Rinse the hands thoroughly and dry with a single use towel.



    If a sink is not available, alcohol-based hand rubs are a good alternative for disinfecting hands. Spread the hand rub over the entire surface of hands, fingers, and wrists until dry. Hand rubs may be used several times. Hand rubs are available as a liquid or wipe in small, portable sizes that are easy to carry in a pocket or handbag. When a sink is available and the hands are dirty, wash them with soap and water.



    Clean the hands after changing a diaper, before and after preparing food and eating, after going to the bathroom, after handling garbage or dirty laundry, after touching animals or pets, and after blowing the nose or sneezing.



    DIARRHEA PREVENTION



    Food safety — The following precautions have been recommended for all consumers by the Food Safety and Inspection Services (www.fsis.usda.gov) and the Centers for Disease Control and Prevention.



     




    • Do not drink raw (unpasteurized) milk or foods that contain unpasteurized milk.

    • Wash raw fruits and vegetables thoroughly before eating.

    • Keep the refrigerator temperature at 40ºF (4.4ºC) or lower; the freezer at 0ºF (-17.8ºC) or lower.

    • Use precooked, perishable, or ready-to-eat food as soon as possible.

    • Keep raw meat, fish, and poultry separate from other food.

    • Wash hands, knives, and cutting boards after handling uncooked food, including produce and raw meat, fish, or poultry.

    • Thoroughly cook raw food from animal sources to a safe internal temperature: ground beef 160ºF (71ºC); chicken 170ºF (77ºC); turkey 180ºF (82ºC); pork 145ºF (63ºC) with a three minute rest time.

    • Seafood should be cooked thoroughly to minimize the risk of food poisoning. Eating raw fish (eg, sushi) poses a risk for a variety of parasitic worms (in addition to the risks associated with organisms carried by food handlers). Freezing kills some, although not all, harmful microorganisms. Raw fish that is labeled "sushi-grade" or "sashimi-grade" has been frozen.

    • Cook chicken eggs thoroughly, until the yolk is firm.

    • Refrigerate foods promptly. Never leave cooked foods at room temperature for more than two hours (one hour if the room temperature is above 90ºF/32ºC).



     



    Food safety for pregnant women or those with a weakened immune system — The following additional recommendations apply to pregnant women and those who have a weakened immune system:



     




    • Do not eat hot dogs, pâtés, luncheon meats, bologna, or other delicatessen meats unless they are reheated until steaming hot; avoid the use of microwave ovens since uneven cooking may occur.

    • Avoid spilling fluids from raw meat and hot dog packages on other foods, utensils, and food preparation surfaces. In addition, wash hands after handling hot dogs, luncheon meats, delicatessen meats, and raw meat, chicken, turkey, or seafood or their juices.

    • Do not eat pre-prepared salads, such as ham salad, chicken salad, egg salad, tuna salad, or seafood salad.

    • Do not eat soft cheeses such as feta, Brie, and Camembert, blue-veined cheeses, or Mexican-style cheeses such as queso blanco, queso fresco, or Panela, unless they have a label that clearly states that the cheese is made from pasteurized milk.

    • Do not eat refrigerated pates or meat spreads. Canned or shelf-stable products may be eaten.

    • Do not eat refrigerated smoked seafood unless it has been cooked. Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna or mackerel, is most often labeled as "nova-style," "lox," "kippered," "smoked," or "jerky." The fish is found in the refrigerator section or sold at deli counters of grocery stores and delicatessens. Canned or shelf-stable smoked seafood may be eaten.



     



    Travelers' diarrhea prevention — Recommendations to prevent travelers' diarrhea are available separately. (See "Patient information: General travel advice (Beyond the Basics)".)



    WHEN TO SEEK HELP FOR DIARRHEA



    If your diarrhea is not severe, you do not always need to be seen by a doctor, especially if the diarrhea begins to improve within 48 hours. Self-care measures for this situation are discussed above (see 'Diarrhea home care' above).



    However, if you have one or more of the following signs or symptoms, you should be evaluated by a healthcare provider:



     




    • Profuse watery diarrhea with signs of dehydration. Early features of dehydration include sluggishness, becoming tired easily, dry mouth and tongue, thirst, muscle cramps, dark-colored urine, urinating infrequently, and dizziness or lightheadedness after standing or sitting up. More severe features include abdominal pain, chest pain, confusion, or difficulty remaining alert.

    • Many small stools containing blood and mucus

    • Bloody or black diarrhea

    • Temperature ≥38.5ºC (101.3ºF)

    • Passage of ≥6 unformed stools per 24 hours or illness that lasts more than 48 hours

    • Severe abdominal pain/painful passage of stool



     



    In addition, if you have persistent diarrhea following antibiotics, are older than 69 years, have other medical illness or a weakened immune system, you should also consult your healthcare provider.



    SUMMARY



     




    • Acute diarrhea is defined as three or more loose or watery stools per day.

    • Diarrhea can be caused by infections or other factors. Sometimes, the cause of diarrhea is not known. Diarrhea caused by an infection usually begins 12 hours to four days after exposure and resolves within three to seven days.

    • A person may have mild to severe diarrhea. Some people with diarrhea also have fever (temperature greater than 100.4ºF or 38ºC), abdominal pain, or cramping.

    • People with mild diarrhea do not usually need to go to the doctor, especially if the diarrhea begins to improve within 48 hours. If you develop any of the following, you should call your doctor or nurse immediately:



     



     




    • Profuse watery diarrhea with sluggishness, becoming tired easily, dry mouth and tongue, thirst, muscle cramps, dark-colored urine, urinating infrequently, and dizziness or lightheadedness after standing or sitting up. More severe features include abdominal pain, chest pain, confusion, or difficulty remaining alert.

    • Passage of many small stools containing blood and mucus

    • Bloody or black diarrhea

    • Temperature ≥38.5ºC (101.3ºF)

    • Passing 6 or more watery stools per 24 hours or illness that lasts more than 48 hours

    • Severe abdominal pain



     



     




    • In addition, if you have persistent diarrhea after finishing antibiotics, are older than 69, or have other medical illness or a weakened immune system, you should also consult your doctor or nurse.

    • The most important treatment for diarrhea is to drink fluids that contain water, salt, and sugar. Sports drinks (eg, Gatorade) may be acceptable if you are not dehydrated and are otherwise healthy. Diluted fruit juices and flavored soft drinks along with saltine crackers and broths or soups may also be acceptable.

    • If you have dark yellow colored urine or do not pass urine frequently, you should drink more fluids. The urine should normally be light yellow to clear colored.

    • Medications to reduce diarrhea are available without a prescription, and are safe if there is no fever (temperature greater than 100.4ºF or 38ºC) and the stools are not bloody. These medications do not cure the cause of the diarrhea, but help to reduce the frequency of bowel movements. Common medications include loperamide (Imodium®), diphenoxylate (Lomotil®), and bismuth subsalicylate (Pepto-Bismol® or Kaopectate®).

    • If you do not have an appetite, you can drink only liquids for a short period of time. Boiled starches and cereals (eg, potatoes, noodles, rice, wheat, and oat) with salt are recommended if you have watery diarrhea; crackers, bananas, soup, and boiled vegetables may also be eaten.

    • Antibiotics are not needed for most people with diarrhea.

    • If you have diarrhea, be careful to avoid spreading the infection to family, friends, and co-workers. You are contagious for as long as diarrhea continues. Infections are usually spread from hand to mouth; hand washing, care with diapering, and staying out of work or school are a few ways to prevent infecting family and other contacts.



     



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Diarrhea in adults (The Basics)

    Patient information: Diarrhea in children (The Basics)

    Patient information: Food poisoning (The Basics)

    Patient information: Lactose intolerance (The Basics)

    Patient information: Antibiotic-associated diarrhea (C. difficile infection) (The Basics)

    Patient information: Managing loss of appetite and weight loss with cancer (The Basics)

    Patient information: Dehydration (The Basics)

    Patient information: Ischemic bowel disease (The Basics)

    Patient information: Cryptosporidiosis (The Basics)

    Patient information: Salmonellosis (Salmonella) (The Basics)

    Patient information: Travelers’ diarrhea (The Basics)

    Patient information: E. coli (The Basics)

    Patient information: Listeria (The Basics)

    Patient information: Campylobacter infection (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: Chronic diarrhea in adults (Beyond the Basics)

    Patient information: Acute diarrhea in children (Beyond the Basics)

    Patient information: Antibiotic-associated diarrhea caused by Clostridium difficile (Beyond the Basics)

    Patient information: Food poisoning (food-borne illness) (Beyond the Basics)

    Patient information: General travel advice (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Approach to the adult with acute diarrhea in developed countries

    Clinical manifestations, diagnosis, and treatment of Campylobacter infection

    Clostridium difficile in adults: Clinical manifestations and diagnosis

    Clinical manifestations and diagnosis of Shigella infection

    Clinical manifestations, diagnosis and treatment of enterohemorrhagic Escherichia coli (EHEC) infection

    Clinical presentation and diagnosis of rotavirus infection

    Epidemiology, clinical manifestations, and diagnosis of cryptosporidiosis

    Pathogenic Escherichia coli

    Differential diagnosis of microbial foodborne disease

    Epidemiology and causes of acute diarrhea in developed countries

    Epidemiology of viral gastroenteritis in adults

    Epidemiology, clinical manifestations and diagnosis of norovirus and related viruses

    Overview of Vibrio cholerae infection

    Management of acute viral gastroenteritis in adults

     



    The following organizations also provide reliable health information.



     





     



    [1-4]





    Literature review current through: Jul 2013. |This topic last updated: Aug 6, 2013.




    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.









    GRAPHICS





    Possible causes of sudden onset (acute) diarrhea

























































    Cause Features Treatment
    Infectious diarrhea
    Viral infection Loose stool, low-grade fever, feel ill None, usually resolves within 48 hours
    Bacterial infection Fever (temperature >101°F or 38.4°C), bloody stools Usually none, antibiotics in selected situations
    Parasite Not common in developed countries, may be seen in returning traveler or camper Antibiotics in most cases
    Non-infectious diarrhea
    Antibiotics Loose stool begins after antibiotic started, usually resolves with a few days after stopped Usually none
    Food intolerance (eg, lactose intolerance) Diarrhea, abdominal pain, and/or gas after consuming food Determine if food intolerance is the cause
    Inflammatory bowel disease (eg, Crohn's disease, ulcerative colitis) Mouth sores, diarrhea, abdominal pain, weight loss, and fever See a healthcare provider for full evaluation and treatment
    Irritable bowel syndrome Chronic lower abdominal pain, diarrhea and/or constipation Symptomatic treatment
    Celiac disease (gluten sensitivity) None to diarrhea, weight loss, abdominal pain, gas Complete avoidance of wheat, rye, barley




     


     








     



     



     


     




     


     




     


     




     



     



     




     


     


     


     


     


     


     


     


     


     







    -->



  • Patient information: Edema (swelling) (Beyond the Basics)





     





     




    FindPrint ShareThis





     




    Contents of this article





     







    EDEMA OVERVIEW



    Edema is the medical term for swelling caused by a collection of fluid in the small spaces that surround the body's tissues and organs. Edema can occur nearly anywhere in the body. Some of the most common sites are:



     




    • The lower legs or hands (also called peripheral edema)


    • Abdomen (also called ascites)


    • Chest (called pulmonary edema if in the lungs and pleural effusion if in the space surrounding the lungs)



     



    Ascites and peripheral edema can be uncomfortable and can be a sign of a more serious condition. Pulmonary edema, which can be life-threatening, is a symptom of heart failure and is discussed in more detail separately. (See "Patient information: Heart failure (Beyond the Basics)".)



    EDEMA SYMPTOMS



    Symptoms of edema depend upon the cause but may include:



     




    • Swelling or puffiness of the skin, causing it to appear stretched and shiny. This typically is worse in the areas of the body that are closest to the ground (because of gravity). Therefore, edema is generally the worst in the lower legs (called peripheral edema) after walking about, standing, sitting in a chair for a period of time, or at the end of the day. It accumulates in the lower back (called sacral edema) after being in bed for a long period. Pushing on the swollen area for a few seconds will leave a dimple in the skin (picture 1).


    • Increased size of the abdomen (with ascites).


    • Shortness of breath (with edema in the chest).



     



    CONDITIONS ASSOCIATED WITH EDEMA



    A number of different problems can cause edema.



    Chronic venous disease — A common cause of edema in the lower legs is chronic venous disease, a condition in which the veins in the legs cannot pump enough blood back up to the heart because the valves in the veins are damaged. This can lead to fluid collecting in the lower legs, thinning of the skin, and, in some cases, development of skin sores (ulcers) (figure 1). (See "Patient information: Chronic venous disease (Beyond the Basics)".)



    Edema can also develop as a result of a blood clot in the deep veins of the lower leg (called deep vein thrombosis [DVT]). In this case, the edema is mostly limited to the feet or ankles and usually affects only one side (the left or right); other conditions that cause edema usually cause swelling of both legs. (See "Patient information: Deep vein thrombosis (DVT) (Beyond the Basics)".)



    Pregnancy — Pregnant women retain extra fluid. Swelling commonly develops in the hands, feet, and face, especially near the end of a normal pregnancy. Swelling without other symptoms and findings is not usually a sign that a complication, such as preeclampsia (sometimes called toxemia), has developed. (See "Patient information: Preeclampsia (Beyond the Basics)".)



    Monthly menstrual periods — Edema in women that occurs in a cyclic pattern (usually once per month) can be the result of hormonal changes related to the menstrual cycle. This type of edema is common but does not require treatment because it resolves on its own.



    Drugs — Edema can be a side effect of a variety of medications, including some oral diabetes medications, high blood pressure medications, non-prescription pain relievers (such as ibuprofen), and estrogens.



    Kidney disease — The edema of kidney disease can cause swelling in the lower legs and around the eyes. (See "Patient information: Chronic kidney disease (Beyond the Basics)".)



    Heart failure — Heart failure, also called congestive heart failure, is due to a weakened heart, which impairs its pumping action. Heart failure can cause swelling in the legs and abdomen, as well as other symptoms. Heart failure can also cause fluid to accumulate in the lungs (pulmonary edema), causing shortness of breath. This can be a very dangerous condition requiring emergency treatment. (See "Patient information: Heart failure (Beyond the Basics)".)



    Cirrhosis — Cirrhosis is scarring of the liver from various causes, which can obstruct blood flow through the liver. People with cirrhosis can develop pronounced swelling in the abdomen (ascites) or in the lower legs (peripheral edema). (See "Patient information: Cirrhosis (Beyond the Basics)".)



    Travel — Sitting for prolonged periods, such as during air travel, can cause swelling in the lower legs. This is common and is not usually a sign of a problem. Table 1 provides tips to minimize leg swelling during travel (table 1).



    If your leg(s) remain swollen or you develop leg pain hours or days after the flight, contact your healthcare provider. Continued swelling and pain can be signs of a blood clot (DVT). (See "Patient information: Deep vein thrombosis (DVT) (Beyond the Basics)".)



    DIAGNOSING THE CAUSE OF EDEMA



    If you develop new swelling in one or both of your legs, hands, in your abdomen, or around your eyes, you should call your healthcare provider to determine if you need to be evaluated. (See "Clinical manifestations and diagnosis of edema in adults".)



    EDEMA TREATMENT



    Treatment of edema includes several components: treatment of the underlying cause (if possible), reducing the amount of salt (sodium) in your diet, and, in many cases, use of a medication called a diuretic to eliminate excess fluid. Using compression stockings and elevating the legs may also be recommended. (See "General principles of the treatment of edema in adults".)



    Not all types of edema require treatment. Edema related to pregnancy or menstrual cycles is not usually treated. Peripheral edema and ascites are usually treated slowly to minimize the side effects of rapid fluid loss (such as low blood pressure).



    Reduce salt (sodium) in your diet — Sodium, which is found in table salt and processed foods, can worsen edema. Reducing the amount of salt you consume can help to reduce edema, especially if you also take a diuretic. Guidelines on how to reduce sodium are available separately. (See "Patient information: Low sodium diet (Beyond the Basics)".)



    Diuretics — Diuretics are a type of medication that causes the kidneys to excrete more water and sodium, which can reduce edema. Diuretics must be used with care because removing too much fluid too quickly can lower the blood pressure, cause lightheadedness or fainting, and impair kidney function.



    You may have to empty your bladder more frequently after taking a diuretic. However, other side effects are uncommon when diuretics are taken at the recommended dose.



    Compression stockings — Leg edema can be prevented and treated with the use of compression stockings. Stockings are available in several heights, including knee-high, thigh-high, and pantyhose. Knee-high stockings are sufficient for most patients. Some stockings can cause skin irritation or pain, although proper measurement and fitting of the stockings can reduce the risk of discomfort. More detailed compression stocking tips are available in table 2 (table 2 and figure 2A-C).



    Effective compression stockings apply the greatest amount of pressure at the ankle and gradually decrease the pressure up the leg. These stockings are available with varying degrees of compression.



     




    • Stockings with small amounts of compression can be purchased at pharmacies and surgical supply stores without a prescription.


    • People with moderate to severe edema, those on their feet a lot, and those with ulcers usually require prescription stockings. A healthcare provider may take measurements for stockings or may write a prescription for stockings and then have a surgical supply or specialty store take the necessary measurements.


    • The white "antiembolism" stockings commonly given in the hospital do not apply enough pressure at the ankle and are not adequate treatment for edema.



     



    Body positioning — Leg, ankle, and foot edema can be improved by elevating the legs above heart level for 30 minutes three or four times per day. Elevating the legs may be sufficient to reduce or eliminate edema for people with mild venous disease but does not usually suffice in more severe cases. In addition, it may not be practical for those who work to elevate their legs several times per day.



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Chronic kidney disease (The Basics)

    Patient information: Swelling (The Basics)

    Patient information: Preeclampsia (The Basics)

    Patient information: Glomerular disease (The Basics)

    Patient information: Growth hormone treatment (The Basics)

    Patient information: Tricuspid regurgitation (The Basics)

    Patient information: Tricuspid stenosis (The Basics)

    Patient information: Diastolic heart failure (The Basics)

    Patient information: Systolic heart failure (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: Cirrhosis (Beyond the Basics)

    Patient information: Heart failure (Beyond the Basics)

    Patient information: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) (Beyond the Basics)

    Patient information: Chronic venous disease (Beyond the Basics)

    Patient information: Deep vein thrombosis (DVT) (Beyond the Basics)

    Patient information: Preeclampsia (Beyond the Basics)

    Patient information: Chronic kidney disease (Beyond the Basics)

    Patient information: Low sodium diet (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Clinical manifestations and diagnosis of edema in adults

    Idiopathic edema

    Clinical manifestations and diagnosis of lymphedema

    Prevention and treatment of lymphedema

    Pathophysiology and treatment of edema in patients with the nephrotic syndrome

    Mechanism of action of diuretics

    Neurogenic pulmonary edema

    Overview of heavy proteinuria and the nephrotic syndrome

    Pathophysiology and etiology of edema in adults

    Treatment of refractory edema in adults

    General principles of the treatment of edema in adults

     



    The following organizations also provide reliable health information.



     




    • National Library of Medicine



     



    (www.nlm.nih.gov/medlineplus/edema.html, available in Spanish)



     




    • National Institute of Diabetes and Digestive and Kidney Diseases



     



    (www.niddk.nih.gov)



     




    • National Kidney Foundation



     



    (www.kidney.org)





    Literature review current through: Jul 2013. |This topic last updated: Nov 20, 2012.



    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.







    GRAPHICS





    Pitting edema


    Image


    This picture shows how a doctor or nurse can check for swelling in a person's foot. To check for swelling, a doctor or nurse presses down on the skin near the ankle (as shown in Picture A) and then lifts his or her finger up. If the skin stays indented (as shown in Picture B), the person has swelling.

     


    Reproduced with permission from: Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking, 9th ed, Lippincott Williams & Wilkins, Philadelphia 2005. Copyright © 2005 Lippincott Williams & Wilkins.







    Chronic venous insufficiency


    Image



     


    Reproduced with permission from: Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking, 8th ed, Lippincott Williams & Wilkins, Philadelphia 2003. Copyright © 2003 Lippincott Williams & Wilkins.







    Tips to avoid lower leg swelling and deep vein thrombosis during prolonged travel
























    All travelers should consider the following recommendations for flights longer than six to eight hours:



    • Stand up and walk around every hour or two





    • Wear loose-fitting, comfortable clothing





    • Flex and extend the ankles and knees periodically, avoid crossing the legs, and change positions frequently while seated





    • Consider wearing knee-high compression stockings





    • Avoid medications (eg, sedatives, sleeping pills) or alcohol, which could impair your ability to get up and move around






     


     







    Tips for using compression stockings













































    Here are tips for using compression stockings:

    • Wash new compression stockings before wearing them to reduce their stiffness and to make them easier to put on.

    • Put on stockings as early as possible in the morning after you bandage any sores you have because swelling is less in the morning. If you do not put the stockings on early, raise your legs for 20 to 30 minutes before putting the stockings on.

    • When putting on stockings, sit on a chair with firm back support (not on the bed).

    • Knee-high stockings can be put on using the "heel-pocket-out method." The heel-pocket-out method to put on compression stockings is as follows:

    1. Turn the leg part of the stocking inside-out down to the heel.

    2. Put your foot into the stocking, hold onto the folded edge, and pull the stocking onto your foot and over the heel.

    3. Gently work the stocking up your leg by turning it right-side out.

    Some people find it helpful to wear rubber gloves to put their stockings on. This can make it easier to slide the stockings up the legs.

    • Heavy compression stockings may go on more easily if light silk pantyhose are worn under the compression stockings, or if you first put powder on your legs.

    • Skin moisturizers and treatments that are used to treat open sores can make the stockings dirty and wear them out. Wash the stockings each day after wearing them if possible. Stockings can be washed in cold water by hand. You can also wash them with cold water and a small amount of mild detergent in a washing machine. Hang the stockings up to dry, and do not dry them in a machine. Buying at least two pairs of stockings at a time will let you wear one pair while the other pair is drying.

    If you have an allergy to rubber (latex), you can buy compression stockings without elastic.

    If you are not able to pull on your stockings, talk with your doctor or nurse. There are different stockings you can use or devices that can help you put on stockings.




     


     







    Putting on compression stockings


    Image



     


     







    Heel-pocket-out method to put on compression stockings


    Image


    The heel-pocket-out method to put on compression stockings is as follows:



    1. Turn the leg part of the stocking inside-out down to the heel (as shown in A).


    2. Put your foot into the stocking, hold onto the folded edge, and pull the stocking onto your foot and over the heel (as shown in B).


    3. Gently work the stocking up your leg by turning it right-side out (as shown in C).



     


     







    Using a stocking donner to put on compression stockings


    Image



     


     








     



     



     


     




     


     




     



     



     




     


     


     


     


     


     


     


     


     


     






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  • Patient information: Acid reflux (gastroesophageal reflux disease) in adults (Beyond the Basics)





     





     




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    GASTROESOPHAGEAL REFLUX OVERVIEW



    Gastroesophageal reflux, also known as acid reflux, occurs when the stomach contents reflux or back up into the esophagus and/or mouth. Reflux is a normal process that occurs in healthy infants, children, and adults. Most episodes are brief and do not cause bothersome symptoms or complications.



    In contrast, people with gastroesophageal reflux disease (GERD) experience bothersome symptoms as a result of the reflux. Symptoms can include heartburn, regurgitation, vomiting, and difficulty or pain with swallowing. The reflux of stomach acid can adversely affect the vocal cords causing hoarseness or even be inhaled into the lungs (called aspiration).



    This topic review discusses the symptoms, causes, diagnosis, and treatment of adults with gastroesophageal reflux disease. A discussion of gastroesophageal reflux in infants, children, and adolescents is available separately. (See "Patient information: Acid reflux (gastroesophageal reflux disease) in children and adolescents (Beyond the Basics)" and "Patient information: Acid reflux (gastroesophageal reflux) in infants (Beyond the Basics)".)



    WHAT IS GASTROESOPHAGEAL REFLUX?



    When we eat, food is carried from the mouth to the stomach through the esophagus, a tube-like structure that is approximately 10 inches long and 1 inch wide in adults (figure 1). The esophagus is made of tissue and muscle layers that expand and contract to propel food to the stomach through a series of wave-like movements called peristalsis.



    At the lower end of the esophagus, where it joins the stomach, there is a circular ring of muscle called the lower esophageal sphincter (LES). After swallowing, the LES relaxes to allow food to enter the stomach and then contracts to prevent the back-up of food and acid into the esophagus.



    However, sometimes the LES is weak or becomes relaxed because the stomach is distended, allowing liquids in the stomach to wash back into the esophagus. This happens occasionally in all individuals. Most of these episodes occur shortly after meals, are brief, and do not cause symptoms. Normally, acid reflux should occur only rarely during sleep.



    Acid reflux — Acid reflux becomes gastroesophageal reflux disease (GERD) when it causes bothersome symptoms or injury to the esophagus. The amount of acid reflux required to cause GERD varies.



    In general, damage to the esophagus is more likely to occur when acid refluxes frequently, the reflux is very acidic, or the esophagus is unable to clear away the acid quickly. The most common symptoms associated with acid reflux are heartburn, regurgitation, chest pain, and trouble swallowing. The treatments of GERD are designed to prevent one or all of these symptoms from occurring.



    Hiatus hernia — The diaphragm is a large flat muscle at the base of the lungs that contracts and relaxes as a person breathes in and out. The esophagus passes through an opening in the diaphragm called the diaphragmatic hiatus before it joins with the stomach.



    Normally, the diaphragm contracts, which improves the strength of the LES, especially during bending, coughing, or straining. If there is a weakening in the diaphragm muscle at the hiatus, the stomach may be able to partially slip through the diaphragm into the chest, forming a sliding hiatus hernia.



    The presence of a hiatus hernia makes acid reflux more likely. A hiatus hernia is more common in people over age 50. Obesity and pregnancy are also contributing factors. The exact cause is unknown but may be related to the loosening of the tissues around the diaphragm that occurs with advancing age. There is no way to prevent a hiatus hernia.



    ACID REFLUX SYMPTOMS



    People who experience heartburn at least two to three times a week may have gastroesophageal reflux disease, or GERD. The most common symptom of GERD, heartburn, is estimated to affect 10 million adults in the United States on a daily basis. Heartburn is experienced as a burning sensation in the center of the chest, which sometimes spreads to the throat; there also may be an acid taste in the throat. Less common symptoms include:



     




    • Stomach pain (pain in the upper abdomen)


    • Non-burning chest pain


    • Difficulty swallowing (called dysphagia), or food getting stuck


    • Painful swallowing (called odynophagia)


    • Persistent laryngitis/hoarseness


    • Persistent sore throat


    • Chronic cough, new onset asthma, or asthma only at night


    • Regurgitation of foods/fluids; taste of acid in the throat


    • Sense of a lump in the throat


    • Worsening dental disease


    • Recurrent lung infections (called pneumonia)


    • Chronic sinusitis


    • Waking up with a choking sensation



     



    When to seek help — The following signs and symptoms may indicate a more serious problem, and should be reported to a healthcare provider immediately:



     




    • Difficulty or pain with swallowing (feeling that food gets "stuck")


    • Unexplained weight loss


    • Chest pain


    • Choking


    • Bleeding (vomiting blood or dark-colored stools)



     



    ACID REFLUX DIAGNOSIS



    Acid reflux is usually diagnosed based upon symptoms and the response to treatment. In people who have symptoms of acid reflux but no evidence of complications, a trial of treatment with lifestyle changes and in some cases, a medication, are often recommended, without testing. Specific testing is required when the diagnosis is unclear or if there are more serious signs or symptoms as described above.



    It is important to rule out potentially life threatening problems that can cause symptoms similar to those of gastroesophageal reflux disease. This is particularly true with chest pain, since chest pain can also be a symptom of heart disease (see "Patient information: Chest pain (Beyond the Basics)"). When the symptoms are not life threatening and the diagnosis of gastroesophageal reflux disease is not clear, one or more of the following tests may be recommended.



    Endoscopy — An upper endoscopy is commonly used to evaluate the esophagus. A small, flexible tube is passed into the esophagus, stomach, and small intestine. The tube has a light source and a camera that displays magnified images. Damage to the lining of these structures can be evaluated and a small sample of tissue (biopsy) can be taken to determine the extent of tissue damage. (See "Patient information: Upper endoscopy (Beyond the Basics)".)



    24-hour esophageal pH study — A 24-hour esophageal pH study is the most direct way to measure the frequency of acid reflux, although the study is not always helpful in diagnosing gastroesophageal reflux disease or reflux-associated problems. It is usually reserved for people whose diagnosis is unclear after endoscopy or a trial of treatment. It is also useful for people who continue to have symptoms despite treatment.



    The test involves inserting a thin tube through the nose and into the esophagus. The tube is left in the esophagus for 24 hours. During this time the patient keeps a diary of symptoms. The tube is attached to a small device that measures how often stomach acid is reaching the esophagus. The data are then analyzed to determine the frequency of reflux and the relationship of reflux to symptoms.



    An alternate method for measuring pH uses a device that is attached to the esophagus and broadcasts pH information to a monitor worn outside of the body. This avoids the need for a tube in the esophagus and nose. The main disadvantage is that an endoscopy procedure is required to place the device (it does not require removal, but simply passes on its own in the stool).



    Esophageal manometry — Esophageal manometry involves swallowing a tube that measures the muscle contractions of the esophagus. This can help to determine if the lower esophageal sphincter is functioning properly. This test is usually reserved for people in whom the diagnosis is unclear after other testing or in whom surgery for reflux disease is being considered.



    ACID REFLUX COMPLICATIONS



    The vast majority of patients with gastroesophageal reflux disease will not develop serious complications, particularly when reflux is adequately treated. However, a number of serious complications can arise in patients with severe gastroesophageal reflux disease.



    Ulcers — Ulcers can form in the esophagus as a result of burning from stomach acid. In some cases, bleeding occurs. You may not be aware of bleeding, but it may be detected in a stool sample to test for traces of blood that may not be visible. This test is performed by putting a small amount of stool on a chemically coated card.



    Stricture — Damage from acid can cause the esophagus to scar and narrow, causing a blockage (stricture) that can cause food or pills to get stuck in the esophagus. The narrowing is caused by scar tissue that develops as a result of ulcers that repeatedly damage and then heal in the esophagus.



    Lung and throat problems — Some people reflux acid into the throat, causing inflammation of the vocal cords, a sore throat, or a hoarse voice. The acid can be inhaled into the lungs and cause a type of pneumonia (aspiration pneumonia) or asthma symptoms. Chronic acid reflux into the lungs may eventually cause permanent lung damage, called pulmonary fibrosis or bronchiectasis.



    Barrett's esophagus — Barrett's esophagus occurs when the normal cells that line the lower esophagus (squamous cells) are replaced by a different cell type (intestinal cells). This process usually results from repeated damage to the esophageal lining, and the most common cause is longstanding gastroesophageal reflux disease. The intestinal cells have a small risk of transforming into cancer cells.



    As a result, people with Barrett's esophagus are advised to have a periodic endoscopy to monitor for early warning signs of cancer. (See "Patient information: Barrett's esophagus (Beyond the Basics)".)



    Esophageal cancer — There are two main types of esophageal cancer: adenocarcinoma and squamous cell carcinoma. A major risk factor for adenocarcinoma is Barrett's esophagus, discussed above. Squamous cell carcinoma does not appear to be related to GERD. Unfortunately, adenocarcinoma of the esophagus is on the rise in the United States and in many other countries. However, only a small percentage of people with GERD will develop Barrett's esophagus and an even smaller percentage will develop adenocarcinoma. (See "Patient information: Barrett's esophagus (Beyond the Basics)".)



    REFLUX TREATMENT



    Gastroesophageal reflux disease is treated according to its severity.



    Mild symptoms — Initial treatments for mild acid reflux include dietary changes and using non-prescription medications, including antacids or histamine antagonists.



    Lifestyle changes — Changes to the diet or lifestyle have been recommended for many years, although their effectiveness has not been extensively evaluated in well-designed clinical trials. A review of the literature concluded that weight loss and elevating the head of your bed may be helpful, but other dietary changes were not found helpful in all patients [1]. Thus, these recommendations may be helpful in some, but not all people with mild symptoms of acid reflux.



    For people with mild acid reflux, these treatments can be tried before seeking medical attention. However, anyone with more serious symptoms should speak to their healthcare provider before using any treatment (see 'Acid reflux symptoms' above).



     




    • Weight loss – Losing weight may help people who are overweight to reduce acid reflux. In addition, weight loss has a number of other health benefits, including a decreased risk of type 2 diabetes and heart disease. (See "Patient information: Weight loss treatments (Beyond the Basics)".)


    • Raise the head of the bed six to eight inches – Although most people only have heartburn for the two- to three-hour period after meals, some wake up at night with heartburn. People with nighttime heartburn can elevate the head of their bed, which raises the head and shoulders higher than the stomach, allowing gravity to prevent acid from refluxing.



      Raising the head of the bed can be done with blocks of wood under the legs of the bed or a foam wedge under the mattress. Several manufacturers have developed commercial products for this purpose. However, it is not helpful to use additional pillows; this can cause an unnatural bend in the body that increases pressure on the stomach, worsening acid reflux.


    • Avoid acid reflux inducing foods – Some foods also cause relaxation of the lower esophageal sphincter, promoting acid reflux. Excessive caffeine, chocolate, alcohol, peppermint, and fatty foods may cause bothersome acid reflux in some people.


    • Quit smoking – Saliva helps to neutralize refluxed acid, and smoking reduces the amount of saliva in the mouth and throat. Smoking also lowers the pressure in the lower esophageal sphincter and provokes coughing, causing frequent episodes of acid reflux in the esophagus. Quitting smoking can reduce or eliminate symptoms of mild reflux. (See "Patient information: Quitting smoking (Beyond the Basics)".)


    • Avoid large and late meals – Lying down with a full stomach may increase the risk of acid reflux. By eating three or more hours before bedtime, reflux may be reduced. In addition, eating smaller meals may prevent the stomach from becoming overdistended, which can cause acid reflux.


    • Avoid tight fitting clothing – At a minimum, tight fitting clothing can increase discomfort, but it may also increase pressure in the abdomen, forcing stomach contents into the esophagus.


    • Chew gum or use oral lozenges – Chewing gum or using lozenges can increase saliva production, which may help to clear stomach acid that has entered the esophagus.



     



    Antacids — Antacids are commonly used for short-term relief of acid reflux. However, the stomach acid is only neutralized very briefly after each dose, so they are not very effective. Examples of antacids include Tums®, Maalox®, and Mylanta®.



    Histamine antagonists — The histamine antagonists reduce production of acid in the stomach. However, they are somewhat less effective than proton pump inhibitors (see 'Proton pump inhibitors' below).



    Examples of histamine antagonists available in the United States include ranitidine (Zantac®), famotidine (Pepcid®), cimetidine (Tagamet®), and nizatidine (Axid®). These medications are usually taken by mouth once or twice per day. Cimetidine, ranitidine, and famotidine are available in prescription and non-prescription strengths.



    Moderate to severe symptoms — Patients with moderate to severe symptoms of acid reflux, complications of gastroesophageal reflux disease, or mild acid reflux symptoms that have not responded to the lifestyle modifications and the medications described above usually require treatment with prescription medications. Most patients are treated with a proton pump inhibitor.



    Proton pump inhibitors — PPIs include omeprazole (Prilosec®), esomeprazole (Nexium®), lansoprazole (Prevacid®), dexlansoprazole (Kapidex™), pantoprazole (Protonix®), and rabeprazole (AcipHex®), which are stronger and more effective than the H2 antagonists.



    Once the optimal dose and type of PPI is found, you will probably be kept on the PPI for approximately eight weeks. Depending upon your symptoms after eight weeks, the medication dose may be decreased or discontinued. If symptoms return within three months, long-term treatment is usually recommended. If symptoms do not return within three months, treatment may be needed only intermittently. The goal of treatment for GERD is to take the lowest possible dose of medication that controls symptoms and prevents complications.



    Proton pump inhibitors are safe, although they may be expensive, especially if taken for a long period of time. Long-term risks of PPIs may include an increased risk of gut infections, such as Clostridium (C. diff), or reduced absorption of minerals and nutrients. In general, these risks are small. However, even a small risk emphasizes the need to take the lowest possible dose for the shortest possible time. (See "Patient information: Antibiotic-associated diarrhea caused by Clostridium difficile (Beyond the Basics)".)



    If symptoms are not controlled — If your symptoms of gastroesophageal reflux disease are not adequately controlled with one PPI, one or more of the following may be recommended:



     




    • An alternate PPI may be prescribed or the dose of the PPI may be increased


    • The PPI may be given twice per day instead of once


    • Further testing may be recommended to confirm the diagnosis and/or determine if another problem is causing symptoms


    • Surgical treatment may be considered



     



    Surgical treatment — Prior to the development of the potent acid-reducing medications described above, surgery was used for severe cases of GERD that did not resolve with medical treatment. Because of the effectiveness of medical therapy, the role of surgery has become more complex. In general, anti-reflux surgery involves repairing the hiatus hernia and strengthening the lower esophageal sphincter.



    The most common surgical treatment is the laparoscopic Nissen fundoplication. This procedure involves wrapping the upper part of the stomach around the lower end of the esophagus (figure 2).



    Although the outcome of surgery is usually good, complications can occur. Examples include persistent difficulty swallowing (occurring in about 5 percent of patients), a sense of bloating and gas (known as "gas-bloat syndrome"), breakdown of the repair (1 to 2 percent of patients per year), or diarrhea due to inadvertent injury to the nerves leading to the stomach and intestines.



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Acid reflux (gastroesophageal reflux disease) in adults (The Basics)

    Patient information: Acid reflux (gastroesophageal reflux disease) in children and adolescents (The Basics)

    Patient information: Acid reflux (gastroesophageal reflux disease) during pregnancy (The Basics)

    Patient information: Acid reflux (gastroesophageal reflux) in babies (The Basics)

    Patient information: Upper endoscopy (The Basics)

    Patient information: Peptic ulcers (The Basics)

    Patient information: Hiatal hernia (The Basics)

    Patient information: Barrett's esophagus (The Basics)

    Patient information: Achalasia (The Basics)

    Patient information: Hiccups (The Basics)

    Patient information: Cough in adults (The Basics)

    Patient information: Esophageal stricture (The Basics)

    Patient information: Eosinophilic esophagitis (The Basics)

    Patient information: Bronchiectasis in adults (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: Acid reflux (gastroesophageal reflux disease) in children and adolescents (Beyond the Basics)

    Patient information: Acid reflux (gastroesophageal reflux) in infants (Beyond the Basics)

    Patient information: Chest pain (Beyond the Basics)

    Patient information: Upper endoscopy (Beyond the Basics)

    Patient information: Barrett's esophagus (Beyond the Basics)

    Patient information: Weight loss treatments (Beyond the Basics)

    Patient information: Quitting smoking (Beyond the Basics)

    Patient information: Antibiotic-associated diarrhea caused by Clostridium difficile (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Approach to refractory gastroesophageal reflux disease in adults

    Clinical manifestations, diagnosis, and treatment of non-acid reflux

    Clinical manifestations and diagnosis of gastroesophageal reflux in adults

    Complications of gastroesophageal reflux in adults

    Endoscopic therapy for gastroesophageal reflux disease: Sewing and full-thickness plication techniques

    Gastroesophageal reflux and asthma

    Helicobacter pylori and gastroesophageal reflux disease

    Laryngopharyngeal reflux

    Medical management of gastroesophageal reflux disease in adults

    Overview and comparison of the proton pump inhibitors for the treatment of acid-related disorders

    Pathophysiology of reflux esophagitis

    Surgical management of gastroesophageal reflux in adults



    The following organizations also provide reliable health information.



     




     



    [1-5]





    Literature review current through: Jul 2013. |This topic last updated: Nov 26, 2012.



    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.








    GRAPHICS





    Gastroesophageal reflux disease (GERD)


    Image


    When we eat, food is carried from the mouth through the esophagus, a tube-like structure that is approximately 10 inches long and 1 inch wide in adults. At the lower end of the esophagus, where it joins the stomach, there is a circular ring of muscle that relaxes and opens when food reaches that point, called the lower esophageal sphincter (LES). This allows food to enter the stomach and then closes to prevent the back-up of food and acid into the esophagus. Reflux can occur if the LES is weak or stays relaxed too long.

     


     







    Nissen fundoplication


    Image



     


    Original artwork by JP Gray, 2007.








     



     



     


     




     


     




     


     




     



     



     




     


     


     


     


     


     


     


     


     


     






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    Patient information: Hypothyroidism (underactive thyroid) (Beyond the Basics)





     





     




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    HYPOTHYROIDISM OVERVIEW



    Hypothyroidism is a condition in which the thyroid gland does not produce enough thyroid hormone. It is the most common thyroid disorder.



    This topic discusses HYPOthyroidism. HYPERthyroidism is discussed separately. (See "Patient information: Hyperthyroidism (overactive thyroid) (Beyond the Basics)".)



    WHAT IS THE THYROID?



    The thyroid is a butterfly-shaped gland in the middle of the neck, located below the larynx (voice box) and above the clavicles (collarbones) (figure 1). The thyroid produce two hormones, triiodothyronine (T3) and thyroxine (T4), which regulate how the body uses and stores energy (also known as the body's metabolism).



    Thyroid function is controlled by a gland in the brain, known as the pituitary (figure 2). The pituitary produces thyroid stimulating hormone (TSH), which stimulates the thyroid to produce T3 and T4.



    HYPOTHYROIDISM CAUSES



    In about 95 percent of cases, hypothyroidism is due to a problem in the thyroid gland itself and is called primary hypothyroidism. However, certain medications and diseases can also decrease thyroid function. As an example, HYPOthyroidism can also develop after medical treatments for HYPERthyroidism, such as thyroidectomy (surgical removal of the thyroid) or radioactive iodine treatment (to destroy thyroid tissue). In some cases, hypothyroidism is a result of decreased production of thyroid-stimulating hormone (TSH) by the pituitary gland. (See "Patient information: Hyperthyroidism (overactive thyroid) (Beyond the Basics)".)



    Thyroid problems are more common in women, increase with age, and are more common in whites and Mexican Americans than in blacks.



    HYPOTHYROIDISM SYMPTOMS



    The symptoms of hypothyroidism vary widely; some people have no symptoms while others have dramatic symptoms or, rarely, life-threatening symptoms. The symptoms of hypothyroidism are notorious for being nonspecific and for mimicking many of the normal changes of aging. Usually, symptoms are milder when hypothyroidism develops gradually.



    General symptoms — Thyroid hormone normally stimulates the metabolism, and most of the symptoms of hypothyroidism reflect slowing of metabolic processes. General symptoms may include fatigue, sluggishness, weight gain, and intolerance of cold temperatures.



    Skin — Hypothyroidism can decrease sweating. The skin may become dry and thick. The hair may become coarse or thin, eyebrows may disappear, and nails may become brittle.



    Eyes — Hypothyroidism can lead to mild swelling around the eyes. People who develop hypothyroidism after treatment for Graves' disease may retain some of the eye symptoms of Graves' disease, including protrusion of the eyes, the appearance of staring, and impaired movement of the eyes. (See "Patient information: Hyperthyroidism (overactive thyroid) (Beyond the Basics)".)



    Cardiovascular system — Hypothyroidism slows the heart rate and weakens the heart's contractions, decreasing its overall function. Related symptoms may include fatigue and shortness of breath with exercise. These symptoms may be more severe in people who also have heart disease. In addition, hypothyroidism can cause mild high blood pressure and raise blood levels of cholesterol.



    Respiratory system — Hypothyroidism weakens the respiratory muscles and decreases lung function. Symptoms can include fatigue, shortness of breath with exercise, and decreased ability to exercise. Hypothyroidism can also lead to swelling of the tongue, hoarse voice, and sleep apnea. Sleep apnea is a condition in which there is intermittent blockage of the airway while sleeping, causing fitful sleep and daytime sleepiness. (See "Patient information: Sleep apnea in adults (Beyond the Basics)".)



    Gastrointestinal system — Hypothyroidism slows the actions of the digestive tract, causing constipation. Rarely, the digestive tract may stop moving entirely. (See "Patient information: Constipation in adults (Beyond the Basics)".)



    Reproductive system — Women with hypothyroidism often have menstrual cycle irregularities, ranging from absent or infrequent periods to very frequent and heavy periods. The menstrual irregularities can make it difficult to become pregnant, and pregnant women with hypothyroidism have an increased risk for miscarriage during early pregnancy. Treatment of hypothyroidism can decrease these risks. (See "Patient information: Absent or irregular periods (Beyond the Basics)" and "Patient information: Menorrhagia (excessive menstrual bleeding) (Beyond the Basics)".)



    Myxedema coma — In people with severe hypothyroidism, trauma, infection, exposure to the cold, and certain medications can rarely trigger a life-threatening condition called myxedema coma, which causes a loss of consciousness and hypothermia (low body temperature).



    HYPOTHYROIDISM DIAGNOSIS



    In the past, hypothyroidism was not diagnosed until symptoms had been present for a long time. However, simple blood tests can now detect hypothyroidism at an early stage. A person may be tested for hypothyroidism if there are signs and symptoms, such as those discussed above, or as a screening test.



    Blood tests — Blood tests can confirm the diagnosis and pinpoint the underlying cause of the thyroid hormone deficiency. The most common blood test for hypothyroidism is TSH (thyroid stimulating hormone). TSH is the most sensitive test because it can be elevated even with small decreases in thyroid function. Thyroxine (T4), the main product of the thyroid gland, may also be measured to confirm and assess the degree of hypothyroidism.



    Routine screening — All newborn babies in the United States are routinely screened for thyroid hormone deficiency. It is not clear if all adults should be tested for thyroid disease [1].



    HYPOTHYROIDISM TREATMENT



    The goal of treatment for hypothyroidism is to return blood levels of TSH and T4 to the normal range and to alleviate symptoms.



    Medication — The treatment for hypothyroidism is thyroid hormone replacement therapy. This is usually given as an oral form of T4. T4 should be taken once per day on an empty stomach (one hour before eating or two hours after). Generic (levothyroxine) and brand-name (Synthroid®, Levoxyl®, Levothroid®, Unithyroid®) formulations are equally effective. However, it is preferable to stay on the same type of T4 rather than switching between brand name and/or generic formulations.



    If a switch is necessary, a blood test is usually done six weeks later to determine if the dose needs to be adjusted. Color-coded tablets can help with dose adjustments.



    Some clinicians prescribe another form of thyroid hormone, triiodothyronine (T3) in combination with T4. However, since T4 is converted into T3 in other organs, the majority of studies have not shown an advantage of combination T3 and T4 therapy over T4 alone.



    In most cases, symptoms of hypothyroidism begin to improve within two weeks of starting thyroid replacement therapy. However, people with more severe symptoms may require several months of treatment before they fully recover.



    Duration and dose — A healthcare provider will prescribe an initial dose of T4 and then retest the blood level of TSH after six weeks. The T4 dose can be adjusted at that time, depending upon these results. This process may be repeated several times before hormone levels become normal. After the optimal dose is identified, a provider may recommend monitoring blood tests once yearly, or more often as needed. Most people with hypothyroidism require lifelong treatment, although the dose of T4 may need to be adjusted over time.



    Never increase or decrease the T4 dose without first consulting a healthcare provider. Overreplacement of T4 can cause mild hyperthyroidism, with the associated dangers of atrial fibrillation (irregular heart beat) and, possibly, accelerated bone loss (osteoporosis).



    Dose changes — Changes in the T4 dose are based upon the person's TSH and T4 level. The dose may need to be increased if thyroid disease worsens, during pregnancy, if gastrointestinal conditions impair T4 absorption, or if the person gains weight. A high fiber diet, calcium- or aluminum-containing antacids, and iron tablets can interfere with the absorption of T4 and should be taken at a different time of day.



    The dose may need to be decreased as the person gets older, after childbirth, or if the person loses weight.



    Monitoring — Individual T4 doses can vary widely and depend upon a variety of factors, including the underlying cause of hypothyroidism. People with certain conditions require more frequent monitoring.



    Advanced age and heart disease — Thyroid hormone makes the heart work a bit harder. Therefore, a clinician may opt for more conservative T4 treatment in older adults and in people with coronary artery disease.



    Pregnancy — Women often need higher doses of T4 during pregnancy. Testing is usually recommended every four weeks, beginning after conception. Once the optimal T4 dose is established, testing is usually repeated at least once per trimester. After delivery, the woman's dose of T4 will need to be adjusted again.



    Surgery — Hypothyroidism can increase the risk of certain surgery-related complications; bowel function may be slow to recover and infection may be overlooked if there is no fever. If pre-operative blood tests reveal low thyroid hormone levels, non-emergency surgery is usually postponed until treatment has returned T4 levels to normal.



    Hypothyroidism without symptoms — In some cases, hypothyroidism is extremely mild or causes no obvious symptoms (called subclinical hypothyroidism). The decision to treat subclinical hypothyroidism with T4 is controversial. Many experts treat patients with subclinical hypothyroidism if their TSH is >10 mU/L to prevent the development of hypothyroidism and associated symptoms. Treatment is also recommended for people who have a goiter or nonspecific symptoms of hypothyroidism, such as fatigue, constipation, or depression.



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Hypothyroidism (underactive thyroid) (The Basics)

    Patient information: Hemochromatosis (The Basics)

    Patient information: Thyroid nodules (The Basics)

    Patient information: Congenital hypothyroidism (The Basics)

    Patient information: Hypoparathyroidism (The Basics)

    Patient information: Panhypopituitarism (The Basics)

    Patient information: Thyroiditis after pregnancy (The Basics)

    Patient information: Thyroiditis (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: Hyperthyroidism (overactive thyroid) (Beyond the Basics)

    Patient information: Sleep apnea in adults (Beyond the Basics)

    Patient information: Constipation in adults (Beyond the Basics)

    Patient information: Absent or irregular periods (Beyond the Basics)

    Patient information: Menorrhagia (excessive menstrual bleeding) (Beyond the Basics)



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Acquired hypothyroidism in childhood and adolescence

    Cardiovascular effects of hypothyroidism

    Central hypothyroidism

    Clinical features and detection of congenital hypothyroidism

    Clinical manifestations of hypothyroidism

    Diagnosis of and screening for hypothyroidism

    Disorders that cause hypothyroidism

    Growth failure after childhood cancer: Role of hypothyroidism

    Laboratory assessment of thyroid function

    Myxedema coma

    Neurologic manifestations of hypothyroidism

    Overview of thyroid disease in pregnancy

    Subclinical hypothyroidism

    Treatment and prognosis of congenital hypothyroidism

    Treatment of hypothyroidism



    The following organizations also provide reliable health information.



     




    • National Library of Medicine



     



    (www.nlm.nih.gov/medlineplus/healthtopics.html)



     




    • The American Thyroid Association



     



    (www.thyroid.org)



     




    • The Hormone Foundation



     



    (www.hormone.org/public/thyroid.cfm, available in English and Spanish)



    Patient support — There are a number of online forums where patients can find information and support from other people with similar conditions.



     




     



    (http://thyroid.about.com/forum)



    [1,2]





    Literature review current through: May 2013. |This topic last updated: Jun 18, 2012.



    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.








    GRAPHICS





    Thyroid and parathyroid glands


    Image


    The thyroid is a butterfly-shaped gland in the middle of the neck. It sits just below the larynx (voice box). The thyroid makes two hormones, called triiodothyronine (T3) and thyroxine (T4), which control how the body uses and stores energy. The parathyroid glands are four small glands behind the thyroid. They make a hormone called parathyroid hormone, which helps control the amount of calcium in the blood.

     


     







    Endocrine glands


    Image


    This figure shows the location of the adrenal glands, hypothalamus, and pituitary.

     


     








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  • Patient information: Migraine headaches in adults (Beyond the Basics)





     





     




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    MIGRAINE HEADACHE OVERVIEW



    Headaches can be quite debilitating, although the vast majority are not due to life-threatening disorders. Approximately 90 percent of headaches are caused by one of three syndromes (table 1):



     




    • Migraine headache


    • Tension-type headaches


    • Cluster headaches



     



    This article discusses migraine headaches in adults. Other types of headaches are discussed separately. (See "Patient information: Headache causes and diagnosis in adults (Beyond the Basics)" and "Patient information: Headache treatment in adults (Beyond the Basics)".)



    MIGRAINE HEADACHE SYMPTOMS



    Between 12 and 16 percent of people in the United States experience migraine headaches, making it the second most common type of headache.



    Pain — The pain of a migraine headache usually begins gradually, intensifies over minutes to one or more hours, and resolves gradually at the end of the attack. The headache is typically dull, deep, and steady when mild to moderate in severity; it becomes throbbing or pulsatile when severe.



    Migraine headaches are worsened by light, sneezing, straining, constant motion, moving the head rapidly, or physical activity. Many migraine sufferers try to get relief by lying down in a darkened, quiet room. In 60 to 70 percent of people, the pain occurs on only one side of the head. In adults, a migraine headache usually lasts a few hours, although it can last from four to 72 hours.



    Other symptoms — Migraine headaches are often accompanied by nausea and vomiting, as well as sensitivity to light and noise. Between 10 and 20 percent of people with migraines also experience nasal stuffiness and runny nose, or teary eyes.



    The symptoms of a migraine attack may be severe and alarming, but in most cases there are no lasting health effects when the attack ends.



    Aura — About 20 percent of people with migraines experience symptoms before the headache; this is called an aura. The aura may include flashing lights or bright spots, zigzag lines, changes in vision, or numbness or tingling in the fingers of one hand, lips, tongue, or lower face. You may have one or more of these aura symptoms.



    Auras may also involve other senses and can occasionally cause temporary muscle weakness or changes in speech; these symptoms can be frightening.



    Aura symptoms typically last five to 20 minutes and rarely last more than 60 minutes. The headache occurs soon after the aura stops. Muscle-related auras may last longer.



    MIGRAINE HEADACHE TRIGGERS



    Migraines can be triggered by stress, worry, menstrual periods, birth control pills, physical exertion, fatigue, lack of sleep, hunger, head trauma, and certain foods or drinks that contain chemicals such as nitrites, glutamate, aspartate, tyramine. A partial list of potential triggers appears in the table (table 2).



    Certain medications and chemicals can also trigger a migraine, including nitroglycerin (used to treat chest pain), estrogens, hydralazine (used to treat high blood pressure), perfumes, smoke, and organic solvents with a strong odor.



    Headache diary — People who have frequent or severe headaches may benefit from keeping a headache diary over the course of one month. This can be used to determine what triggers the migraines and what makes them better. A sample diary is included here (figure 1).



    MIGRAINE HEADACHE TREATMENT TYPES



    Migraine headache treatment depends upon the frequency, severity, and symptoms of your headache.



     




    • Acute treatment refers to medicines you can take when you have a headache to relieve the pain immediately.


    • Preventive treatment refers to medicines you can take on a regular (usually daily) basis to prevent headaches in the future.



     



    Acute treatment — The pain of migraines can be tough to get rid of. Treatment is most likely to work if you take it at the first sign of an attack (eg, at the first sign of aura if one occurs, or when pain begins).



    In some people, an aura occurs before the migraine (see 'Aura' above). Therefore, an aura can serve as a reliable warning that a migraine headache is on the way, and should be the signal to take migraine medication. (See "Acute treatment of migraine in adults".)



    Pain relievers — Mild migraine attacks may respond to pain relievers, some of which are available without a prescription. These drugs include:



     




    • Aspirin


    • Acetaminophen (sold as Tylenol®)


    • Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (sold as Motrin® or Advil®), indomethacin, or naproxen (sold as Naprosyn® or Aleve®).


    • Indomethacin is a prescription medicine that comes in a rectal suppository, which may be useful for people who have nausea during their headaches.



     



    Pain relievers are also available in combination with caffeine, which enhances their antimigraine effect. As an example, some pain relievers contain a combination of acetaminophen, aspirin, and caffeine.



    Pain relievers are often recommended first for mild to moderate migraine attacks. However, they should not be used too often because overuse can lead to medication-overuse headaches or chronic daily headaches. If you respond to a pain reliever, continue taking it with each attack, as long as you do not take it more than once or twice per week.



    People with gastritis (inflammation of the stomach), ulcers, kidney disease, and bleeding conditions should not take products containing aspirin or NSAIDs.



    Anti-nausea medications — If you have nausea and vomiting with a migraine, you can take an anti-nausea medicine by injection or rectal suppository. In some cases, antimigraine drugs can be taken in combination with drugs that alleviate nausea and vomiting, such as metoclopramide or prochlorperazine. Anti-nausea medications given by mouth are usually used in combination with other medications to treat acute migraine. However, anti-nausea medications can be given alone in the hospital by intravenous and intramuscular administration to treat acute migraine headache.



    Triptans — If a pain reliever does not control your migraine pain, most healthcare providers will recommend a treatment that is migraine-specific. This includes a class of medications called triptans. Examples of triptans are sumatriptan (also sold as Imitrex®), zolmitriptan (sold as Zomig®), naratriptan (sold as Amerge®), rizatriptan (sold as Maxalt®), almotriptan (sold as Axert®), eletriptan (sold as Relpax®) and frovatriptan (sold as Frova®).



    Triptans can be used at home or work/school, and are all available in an oral (pill) form. Sumatriptan and zolmitriptan are available as nasal sprays, and sumatriptan is available as an injection.



    People with familial hemiplegic migraine, basilar migraine, uncontrolled high blood pressure, vascular disease (including ischemic stroke and coronary artery disease), Prinzmetal's angina, pregnancy, and severe kidney or liver disease should not take triptans in most cases.



     




    • Sumatriptan — Sumatriptan is available in many different formulas, including a tablet, nasal spray, and injection. Over 70 percent of people get pain relief within one hour of injecting sumatriptan; by two hours, 90 percent of people notice improvement. Your healthcare provider can help to decide which formula (pill, nasal spray, or shot) is best for you.



     



    Common side effects of injectable sumatriptan include pain at the injection site, dizziness, a feeling of warmth, and tingling in the arms or legs. Most of these reactions occur soon after the injection and resolve within 30 minutes. These drugs are safe for most patients.



    Sumatriptan nasal spray begins to work faster than the pill form and has fewer side effects than the injection. The most common side effect of the nasal spray is an unpleasant taste.



    A tablet that contains a combination of sumatriptan-naproxen (sold as Treximet®) appears to be more effective than each medication taken alone. It is not known if taking the two medications separately would be as effective as the combination tablet.



    Ergots — Ergotamine is an older, migraine-specific drug. It is often combined with caffeine. Ergots are not usually as effective as triptans and are more likely to cause side effects. Ergots are sometimes recommended for people with migraines of a long duration (greater than 48 hours) or that frequently recur. People with high blood pressure, coronary artery disease, or kidney or liver disease should not use ergotamines.



    Dihydroergotamine is related to ergotamine, and can be taken by nasal spray for mild or moderate migraine attacks. It can also be given by injection for severe attacks.



    Other medications — Other medications for migraine are not as well studied or are less effective. A small percentage of people with migraine headaches do not respond to routine acute treatments and may require additional treatment for pain.



    Dexamethasone is a glucocorticoid (steroid) medication that can be given by injection, along with another acute migraine treatment, to reduce the risk of a migraine coming back. Dexamethasone injections may be given in an emergency department or clinic.



    Preventive treatment — Preventive treatment effectively controls migraine headaches in most people, although the benefits of this treatment may not be evident for three to four weeks. In some cases, both acute treatment and preventive treatment are necessary to adequately control migraines. (See "Preventive treatment of migraine in adults".)



    Beta blockers — Beta blockers were originally developed to treat high blood pressure. In addition, beta blockers reduce the frequency of migraine attacks in 60 to 80 percent of people. Commonly used beta blockers include propranolol, nadolol, atenolol, and metoprolol. Beta blockers may cause depression in some people or impotence in some men.



    Antidepressant medications — Tricyclic antidepressants (TCAs) and certain other antidepressant medications are often recommended for migraine prevention. These include amitriptyline, nortriptyline, and doxepin. Of these, amitriptyline has proven benefit for migraine prevention, while there is less data for the other tricyclics.



    Side effects are common with tricyclic antidepressants. Most of these drugs cause drowsiness, particularly amitriptyline and doxepin. Therefore, these drugs are usually taken at bedtime and started at a low dose. Additional side effects of tricyclics can include dry mouth, constipation, palpitations, weight gain, blurred vision, and urinary retention. Confusion can occur, particularly in older adults.



    Anti-seizure medications — The anti-seizure medications valproate (also called divalproex or Depakote®), gabapentin, and topiramate (sold as Topamax®) are sometimes used to prevent migraines.



     




    • Valproate is an anti-seizure drug that seems to work as well as beta blockers for preventing migraine, and may be better tolerated. However, valproate can cause weight gain and hair loss. Women who are pregnant or sexually active and not using birth control (pills, condoms, etc) should not take valproate.


    • Gabapentin was effective for reducing migraine headache frequency in a small clinical trial. Potential side effects include lightheadedness, drowsiness, dizziness, and balance problems.


    • Topiramate is an anti-seizure drug that can help to prevent migraine. It can cause mild to moderate side effects that may include abnormal sensations (often tingling), fatigue, nausea, changes in taste, loss of appetite, diarrhea, and weight loss. More severe side effects can occur, including difficulty with thinking and concentration.



     



    Calcium channel blockers — Calcium channel blockers were developed to treat high blood pressure. Calcium channel blockers are widely used for migraine prevention. Examples of calcium channel blockers include verapamil and nifedipine extended-release. Verapamil is frequently used as a first choice for preventive migraine therapy because it is easy to use and has few side effects.



    Calcium channel blockers may lose their effectiveness over time, but this can sometimes be remedied by taking a higher dose of the drug or switching to a similar drug.



    Herbal therapies — Herbal therapies have been evaluated for the treatment of migraine headache, including feverfew and butterbur. Of these, feverfew has been the most widely studied. Some studies have found it to be effective for migraine prevention, although most experts agree that the benefits are still unproven. Neither treatment is recommended.



    Avoiding medication overuse — It is essential to use antimigraine medications according to the prescription and clinician's instructions. Overuse of certain medications for migraine, including over-the-counter drugs such as acetaminophen and nonsteroidal antiinflammatory drugs, or prescription drugs such as triptans, can lead to medication-overuse headaches (also called rebound headaches) and to a pattern of daily headaches that require increasing quantities of drugs for relief.



    A vicious cycle occurs when frequent headaches cause you to take medications, which then cause rebound headaches as the medications wear off, causing you to take more medication, and so on. (See "Patient information: Headache treatment in adults (Beyond the Basics)".)



    Speak with a healthcare provider if your migraine treatment does not relieve your headaches or if you are having unpleasant medication side effects. Switching to another drug or switching from acute treatment to preventive treatment may be helpful.



    MENSTRUAL MIGRAINES



    Migraines occur about three times more commonly in women than in men. Estrogen has a variable effect on the frequency and severity of a woman's migraines; some women who take birth control pills (which contain estrogen) or hormone replacement therapy experience worsening headaches, while others improve. Similarly, some women have more frequent or severe headaches during pregnancy while others have improvement. (See "Estrogen-associated migraine".)



    Menstrual migraines are migraine headaches that occur around the beginning of a woman's menstrual period (usually two days before to three days after the period begins). Women with menstrual migraine may also have migraines at other times during the month. Most often, there is no migraine aura associated with menstrual migraines, even if the woman usually has aura at other times.



    Menstrual migraines are thought to be triggered by the normal decrease in estrogen levels that occurs before the menstrual period begins. Menstrual migraines tend to be longer lasting, more severe, and more resistant to treatment than other types of migraine.



    Treatment — Initial treatment of acute menstrual migraine is the same as treatment for migraine occurring at any other time. (See 'Acute treatment' above.)



    Preventive therapies for menstrual migraine can be either nonspecific (those that do not address the hormonal trigger) or specific (hormone-based treatments). (See "Estrogen-associated migraine", section on 'Preventive therapies'.)



    With nonspecific strategies, success requires accurate anticipation of menses for scheduling interventions; therefore, women with irregular cycles are not good candidates for these options. Coexisting problems, such as dysmenorrhea, menorrhagia, endometriosis, as well as contraception needs may influence choice of preventive therapy.



    A preventive treatment may be useful for women who have menstrual migraines on a predictable schedule. This treatment strategy is called "mini-prophylaxis".



     




    • Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen or naproxen are one option for mini-prophylaxis of menstrual migraine.


    • Triptans such as frovatriptan, sumatriptan, or naratriptan are another option. Typically, long-acting triptans are dosed twice daily beginning two days before anticipated menses and continued for five days.



     



    Hormonal treatments may be recommended to prevent menstrual migraines. One approach is to use estrogen-progestin contraceptive pills in an extended cycle; another choice is menstrually-targeted supplemental estrogen. These treatments work by preventing a rapid decline in the level of estrogen in the body before the menstrual period, which is believed to trigger the migraine. However, some experts avoid treatment with estrogen-progestin contraceptives for women who have a menstrual migraine with aura. Others consider the use of such treatment only for healthy women younger than age 35 who do not have focal neurologic signs and who do not smoke.



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Headache (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: Headache causes and diagnosis in adults (Beyond the Basics)

    Patient information: Headache treatment in adults (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Acute treatment of migraine in adults

    Basilar-type migraine

    Chronic migraine

    Estrogen-associated migraine

    Evaluation of headache in adults

    Headache syndromes other than migraine

    Headache, migraine, and stroke

    Preventive treatment of migraine in adults



    The following organizations also provide reliable health information.



     




    • National Library of Medicine



     



    (www.nlm.nih.gov/medlineplus/migraine.html, available in Spanish)



     




    • National Institute of Neurological Disorders and Stroke



     



    (www.ninds.nih.gov/disorders/migraine/migraine.htm)



     




    • American Headache Society



     



    (www.achenet.org/resources/information_for_patients/)



    [1-4]





    Literature review current through: Jul 2013. |This topic last updated: Dec 16, 2011.



    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.








    GRAPHICS





    Characteristics of common headache syndromes












































    Symptom

    Migraine headache

    Tension headache

    Cluster headache

    Location

    Unilateral (one sided) in 60 to 70 percent; occurs on both sides of the forehead or all over the head in 30 percent of cases

    Bilateral (involves both sides of the head)

    Always unilateral, usually begins around the eye or temple

    Characteristics

    Gradual in onset, builds up over time; pulsating; moderate or severe intensity; aggravated by routine physical activity

    Pressure or tightness which waxes and wanes

    Pain begins quickly, reaches a crescendo within minutes; pain is deep, continuous, excruciating, and explosive in quality

    Activity

    Prefers to rest in a dark, quiet room

    May remain active or may need to rest

    Remains active

    Duration

    4 to 72 hours

    Variable

    30 minutes to 3 hours

    Associated symptoms

    Nausea, vomiting, photophobia (bothered by light), phonophobia (bothered by sound); may have aura (usually visual, but can involve other senses or cause speech or motor problems)

    None

    Tearing and redness of the eye on the same side as the headache; stuffy, runny nose; pallor; sweating; eye drooping; rarely neurologic deficits; sensitivity to alcohol




     


     







    Headache triggers




































































    Diet

    Alcohol

    Chocolate

    Aged cheeses

    Monosodium glutamate (MSG)

    Aspartame (Nutrasweet)

    Caffeine

    Nuts

    Nitrites, Nitrates

    Hormones

    Menses

    Ovulation

    Hormone replacement (progesterone)

    Sensory stimuli

    Strong light

    Flickering lights

    Odors

    Sounds, noise






















































    Stress

    Let-down periods

    Times of intense activity

    Loss or change (death, separation, divorce, job change)

    Moving

    Crisis

    Changes of environment or habits

    Weather

    Travel (crossing time zones)

    Seasons

    Altitude

    Schedule changes

    Sleeping patterns

    Dieting

    Skipping meals

    Irregular physical activity





     


     







    Headache diary


    Image



     


    Reproduced with permission from: Bristol-Myers Squibb Company. Copyright 2001 Bristol-Myers Squibb Company.








     



     


     




     



     




     


     


     


     


     


     


     


     


     


     






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  • Patient information: Diet and health (Beyond the Basics)





     





     




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    Contents of this article





     







    HEALTHY DIET OVERVIEW



    The food choices we make can have an important impact on our health. However, expert opinions continue to change about which and how much of these foods is optimal.



    This topic summarizes the relationships between various foods or supplements and specific health conditions, and concludes with general recommendations for following a healthy diet. A separate topic review is available about diets for weight loss. (See "Patient information: Weight loss treatments (Beyond the Basics)", section on 'Choosing a diet or new eating plan'.)



    FRUITS AND VEGETABLES



    A number of studies have demonstrated important health benefits of eating fruits and vegetables.



     




    • Increased intake of fruits and vegetables is linked to a lower risk of premature death.


    • Fruits and vegetables decrease the risk of cardiovascular diseases including coronary heart disease (CHD) and stroke, including death from CHD [1].


    • High intake of fruits and vegetables also reduces the risk of developing certain kinds of cancer (including lung cancer and cancer of the gastrointestinal system). Tomato and tomato-based foods may be beneficial at lowering the risk of prostate cancer.


    • At least five servings of fruits and/or vegetables should be eaten daily.



     



    FIBER



    Eating a diet that is high in fiber can decrease the risk of coronary heart disease, stroke, colon cancer, and death [2,3]. Eating fiber also protects against type 2 diabetes, and eating soluble fiber (such as that found in vegetables, fruits, and especially legumes) may help control blood sugar in people who already have diabetes. (See "Patient information: High-fiber diet (Beyond the Basics)".)



    The recommended amount of dietary fiber is 25 grams per day for women and 38 grams per day for men. Many breakfast cereals, fruits, and vegetables are excellent sources of dietary fiber. By reading the product information panel on the side of the package, it is possible to determine the number of grams of fiber per serving (figure 1). A list of the fiber content of a number of foods can be found in the table (table 1).



    FAT



    Eating foods higher in healthy fats and lower in unhealthy fats can reduce the risk of coronary heart disease.



    The type of fat consumed appears to be more important than the amount of total fat. Saturated fats and trans fats should be avoided in favor of monounsaturated and polyunsaturated fats (eg, in fish, olive oil, peanut oil, nuts).



     




    • Trans fats are those that are solid at room temperature, and are found in many margarines and in other fats labeled "partially hydrogenated." Another major source is oils that are maintained at high temperature for a long period, such as in fast food restaurants.


    • Saturated fats come mainly from animal products, such as cheese, butter, and red meat.



     



    It is important not to replace fat with refined carbohydrates (eg, white bread, white rice, most sweets). Increases in refined carbohydrate intake may lower levels of high density lipoprotein (HDL) cholesterol (good cholesterol), which actually increases the risk of coronary heart disease.



    FOLATE



    Folate is a type of B vitamin that is important in the production of red blood cells. Low levels of folate in pregnant women have been linked to a group of birth defects called neural tube defects, which includes spina bifida and anencephaly. Vitamins containing folate and breakfast cereal fortified with folate are recommended as the best ways to ensure adequate folate intake.



    However, supplements containing folate (called folic acid) are no longer recommended to reduce the risk of heart disease.



    ANTIOXIDANTS



    The antioxidant vitamins include vitamins A, C, E, and beta-carotene. Many other foods, especially fruits and vegetables, also have antioxidant properties. Studies have not clearly shown that antioxidant vitamins prevent cancer, and some studies show they may actually cause harm. There is no evidence to support antioxidant vitamin supplementation for individuals who do not have specific vitamin deficiencies.



    CALCIUM AND VITAMIN D



    Adequate calcium and vitamin D intake are important, particularly in women, to reduce the risk of osteoporosis. A healthcare provider can help to decide if supplements are needed, depending upon a person's dietary intake of calcium and vitamin D (table 2). Although the optimal level has not been clearly established, experts recommend that premenopausal women and men consume at least 1000 mg per day and postmenopausal women should consume 1200 mg per day. No more than 2000 mg of calcium should be consumed per day. (See "Patient information: Calcium and vitamin D for bone health (Beyond the Basics)".)



    The current recommendation is that postmenopausal women with or at risk for osteoporosis consume at least 800 International Units of vitamin D per day. Lower levels of vitamin D are not as effective while high doses can be toxic, especially if taken for long periods of time. Although the optimal intake has not been clearly established in premenopausal women or in men with osteoporosis, 400 to 600 International units of vitamin D daily is generally suggested.



    ALCOHOL



    Moderate alcohol intake may reduce the risk of heart disease. However, it is not clear what amount of alcohol is best. There are some risks associated with alcohol use, including breast cancer in women; cancers of the mouth, esophagus, throat, larynx, and liver; other illnesses such as cirrhosis and alcoholism; and injuries and other trauma-related problems, particularly in men. (See "Patient information: Risks and benefits of alcohol (Beyond the Basics)".)



    Based on the trade-off between these risks and benefits, the United States Dietary Guidelines recommend alcohol intake in moderation, if at all. This means no more than one drink per day for women, and up to 2 drinks per day for men. Those who do not drink alcohol do not need to start.



    Drinking is discouraged for those under 40 years who are at low risk of cardiovascular disease because the risks are likely to outweigh the benefits in this group.



    CALORIC INTAKE



    Calories count. Too many calories lead to weight gain and obesity. It is linked with premature death as well as an increased risk of cardiovascular disease, diabetes, hypertension, cancer, and other important diseases [4-8].



    The total number of calories a person needs depends upon the following factors:



     




    • Weight


    • Age


    • Gender


    • Height


    • Activity level



     



    GENERAL RECOMMENDATIONS FOR A HEALTHY DIET



    Eat lots of vegetables, fruits, and whole grains and a limited amount of red meat. Get at least five servings of fruits and vegetables every day. Tips for achieving this goal include:



     




    • Make fruits and vegetables part of every meal. Eat a variety of fruits and vegetables. Frozen or canned can be used when fresh isn't convenient.


    • Eat vegetables as snacks.


    • Have a bowl of fruit out all the time for kids to take snacks from.


    • Put fruit on your cereal.


    • Consume at least half of all grains as whole grains (like whole wheat bread, brown rice, whole grain cereal), replacing refined grains (like white bread, white rice, refined or sweetened cereals).



     



    Cut down on unhealthy fats (trans fats and saturated fats) and consume healthy fats (polyunsaturated and monounsaturated fat). Tips for achieving this goal include:



     




    • Choose chicken, fish, and beans instead of red meat and cheese.


    • Cook with oils that contain polyunsaturated and monounsaturated fats, like olive and peanut oil.


    • Choose margarines that do not have partially hydrogenated oils. Soft margarines (especially squeeze margarines) have less trans fatty acids than stick margarines.


    • Eat fewer baked goods that are store-made and contain partially hydrogenated fats (like many types of crackers, cookies, and cupcakes).


    • When eating at fast food restaurants, choose healthy items for yourself as well as your family, like broiled chicken or salad.



     



    Avoid sugar-sweetened beverages and excessive alcohol intake. Tips for achieving this goal include:



     




    • Choose non-sweetened and non-alcoholic beverages, like water, at meals and parties.


    • Avoid occasions centered around alcohol.


    • Avoid making sugar-sweetened beverages and alcohol an essential part of family gatherings.



     



    Keep calorie intake balanced with needs and activity level.



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Diet and health (The Basics)

    Patient information: High-fiber diet (The Basics)

    Patient information: Coronary artery bypass graft surgery (The Basics)

    Patient information: Vitamin B12 deficiency and folate (folic acid) deficiency (The Basics)

    Patient information: Coronary heart disease in women (The Basics)

    Patient information: Vitamin supplements (The Basics)

    Patient information: Can foods or supplements lower cholesterol? (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: Weight loss treatments (Beyond the Basics)

    Patient information: High-fiber diet (Beyond the Basics)

    Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)

    Patient information: Calcium and vitamin D for bone health (Beyond the Basics)

    Patient information: Starting solid foods during infancy (Beyond the Basics)

    Patient information: Risks and benefits of alcohol (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    Diet in the treatment and prevention of hypertension

    Dietary and nutritional assessment in adults

    Dietary carbohydrates

    Dietary fat

    Fish oil and marine omega-3 fatty acids

    Lipid lowering with diet or dietary supplements

    Nutrition in pregnancy

    Healthy diet in adults



    The following organizations also provide reliable health information.



     




     





    Literature review current through: Jul 2013. |This topic last updated: Jan 4, 2013.



    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.








    GRAPHICS





    Nutrition label


    Image


    This is an example of a nutrition label. To know how much fiber is in a food, look at the line that reads "dietary fiber." This product has 3 grams of fiber in each serving.

    %: percent.


     







    Amount of fiber in different foods




























































































































































































    Food

    Serving

    Grams of fiber

    Fruits

    Apple (with skin)

    1 medium apple

    4.4

    Banana

    1 medium banana

    3.1

    Oranges

    1 orange

    3.1

    Prunes

    1 cup, pitted

    12.4

    Juices

    Apple, unsweetened, w/ added ascorbic acid

    1 cup

    0.5

    Grapefruit, white, canned, sweetened

    1 cup

    0.2

    Grape, unsweetened, w/added ascorbic acid

    1 cup

    0.5

    Orange

    1 cup

    0.7

    Vegetables

    Cooked

    Green beans

    1 cup

    4.0

    Carrots

    1/2 cup sliced

    2.3

    Peas

    1 cup

    8.8

    Potato (baked, with skin)

    1 medium potato

    3.8

    Raw

    Cucumber (with peel)

    1 cucumber

    1.5

    Lettuce

    1 cup shredded

    0.5

    Tomato

    1 medium tomato

    1.5

    Spinach

    1 cup

    0.7

    Legumes

    Baked beans, canned, no salt added

    1 cup

    13.9

    Kidney beans, canned

    1 cup

    13.6

    Lima beans, canned

    1 cup

    11.6

    Lentils, boiled

    1 cup

    15.6

    Breads, pastas, flours

    Bran muffins

    1 medium muffin

    5.2

    Oatmeal, cooked

    1 cup

    4.0

    White bread

    1 slice

    0.6

    Whole-wheat bread

    1 slice

    1.9

    Pasta and rice, cooked

    Macaroni

    1 cup

    2.5

    Rice, brown

    1 cup

    3.5

    Rice, white

    1 cup

    0.6

    Spaghetti (regular)

    1 cup

    2.5

    Nuts

    Almonds

    1/2 cup

    8.7

    Peanuts

    1/2 cup

    7.9



    To learn how much fiber and other nutrients are in different foods, visit the United States Department of Agriculture (USDA) National Nutrient Database at: http://www.nal.usda.gov/fnic/foodcomp/search/.

     


    Created using data from the USDA National Nutrient Database for Standard Reference. Available at http://www.nal.usda.gov/fnic/foodcomp/search/.







    Foods and drinks with calcium




























































    Food

    Calcium, milligrams

    Milk (skim, 2 percent, or whole, 8 oz [236 mL])

    300

    Yogurt (6 oz [168 g])

    250

    Orange juice (with calcium, 8 oz [236 mL])

    300

    Tofu with calcium (1/2 cup [113 g])

    435

    Cheese (1 oz [28 g])

    195 to 335 (hard cheese = higher calcium)

    Cottage cheese (1/2 cup [113 g])

    130

    Ice cream or frozen yogurt (1/2 cup [113 g])

    100

    Soy milk (8 oz [236 mL])

    300

    Beans (1/2 cup cooked [113 g])

    60 to 80

    Dark, leafy green vegetables (1/2 cup cooked [113 g])

    50 to 135

    Almonds (24 whole)

    70

    Orange (1 medium)

    60




     


     








     



     



     




     



     



     




     


     


     


     


     


     


     


     


     


     






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  • Patient information: Osteoporosis prevention and treatment (Beyond the Basics)





     





     




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    Contents of this article





     







    OSTEOPOROSIS OVERVIEW



    Osteoporosis is a common problem that causes bones to become abnormally thin, weakened, and easily broken (fractured). Women are at a higher risk for osteoporosis after menopause due to lower levels of estrogen, a female hormone that helps to maintain bone mass.



    Fortunately, preventive treatments are available that can help to maintain or increase bone density. For those already affected by osteoporosis, prompt diagnosis of bone loss and assessment of fracture risk are essential because therapies are available that can slow further loss of bone or increase bone density.



    This topic review discusses the therapies available for the prevention and treatment of osteoporosis. A separate topic discusses bone density testing. (See "Patient information: Bone density testing (Beyond the Basics)".)



    OSTEOPOROSIS PREVENTION



    Some of the most important treatments for preventing osteoporosis include diet, exercise, and not smoking. These recommendations apply to men and women. (See "Overview of the management of osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men".)



    Diet — An optimal diet for preventing or treating osteoporosis includes consuming an adequate number of protein and calories as well as optimal amounts of calcium and vitamin D, which are essential in helping to maintain proper bone formation and density.



    Calcium intake — Experts recommend that premenopausal women and men consume at least 1000 mg of calcium per day; this includes calcium in foods and beverages plus calcium supplements. Postmenopausal women should consume 1200 mg of calcium per day (total of diet plus supplements). However, you should not take more than 2000 mg calcium per day due to the possibility of side effects. (See "Patient information: Calcium and vitamin D for bone health (Beyond the Basics)".)



    The main dietary sources of calcium include milk and other dairy products, such as cottage cheese, yogurt, or hard cheese, and green vegetables, such as kale and broccoli (table 1). A rough method of estimating dietary calcium intake is to multiply the number of dairy servings consumed each day by 300 mg. One serving is 8 oz of milk (236 mL) or yogurt (224 g), 1 oz (28 g) of hard cheese, or 16 oz (448 g) of cottage cheese.



    Calcium supplements (calcium carbonate or calcium citrate) may be suggested for women who cannot get enough calcium in their diet (table 2). Calcium doses greater than 500 mg/day should be taken in divided doses (eg, once in morning and evening).



    Vitamin D intake — Experts recommend that men over 70 years and postmenopausal women consume 800 international units of vitamin D each day. This dose appears to reduce bone loss and fracture rate in older women and men who have adequate calcium intake (described above). Although the optimal intake has not been clearly established in premenopausal women or in younger men with osteoporosis, 600 international units of vitamin D daily is generally suggested. (See "Calcium and vitamin D supplementation in osteoporosis".)



    Milk supplemented with vitamin D is a primary dietary source of dietary vitamin D; it contains approximately 100 int. units per 8 oz (236 mL). Another good source is salmon, with approximately 600 int. units per 3.5 oz (98 g) serving. Experts recommend vitamin D supplementation for all patients with osteoporosis whose intake of vitamin D is below 400 int. units per day.



    Protein supplements — Protein supplements may be recommended in some people to ensure sufficient protein intake. This may be particularly important for those who have already had an osteoporotic fracture.



    Alcohol, caffeine, and salt intake — Drinking alcohol excessively (more than two drinks a day) can increase the risk of fracture due to an increased risk of falling, poor nutrition, etc., so it should be avoided.



    Restricting caffeine or salt has not been proven to prevent bone loss in people who consume an adequate amount of calcium.



    Exercise — Exercise may decrease fracture risk by improving bone mass in premenopausal women and helping to maintain bone density for women after menopause. Furthermore, exercise may decrease the tendency to fall due to weakness. Physical activity reduces the risk of hip fracture in older women as a result of increased muscle strength. Most experts recommend exercising for at least 30 minutes three times per week.



    The benefits of exercise are quickly lost when a person stops exercising. A regular, weight-bearing exercise regimen that a person enjoys improves the chances that the person will continue it over the long term. (See "Patient information: Exercise (Beyond the Basics)".)



    Smoking — Stopping smoking is strongly recommended for bone health because smoking cigarettes is known to speed bone loss. One study suggested that women who smoke one pack per day throughout adulthood have a 5 to 10 percent reduction in bone density by menopause, resulting in an increased risk of fracture. (See "Patient information: Quitting smoking (Beyond the Basics)".)



    Falls — Falling significantly increases the risk of osteoporotic fractures in older adults. Taking measures to prevent falls can decrease the risk of fractures. Such measures may include the following:



     




    • Removing loose rugs and electrical cords or any other loose items in the home that could lead to tripping, slipping, and falling.


    • Providing adequate lighting in all areas inside and around the home, including stairwells and entrance ways.


    • Avoiding walking on slippery surfaces, such as ice or wet or polished floors.


    • Avoiding walking in unfamiliar areas outside.


    • Reviewing drug regimens to replace medications that may increase the risk of falls with those that are less likely to do so.


    • Visiting an ophthalmologist or optometrist regularly to get the optimal eye glasses.



     



    Medications — Prolonged therapy with and/or high doses of certain medications can increase bone loss. The use of these medications should be monitored by a healthcare provider and decreased or discontinued when possible. Such medications include the following:



     




    • Glucocorticoid medications (eg, prednisone)


    • Heparin, a medication used to prevent and treat abnormal blood clotting (ie, anticoagulant)


    • Certain antiepileptic drugs (eg, phenytoin, carbamazepine, primidone, phenobarbital, and valproate)



     



    OSTEOPOROSIS MEDICATIONS



    The non-drug measures discussed above can help to reduce bone loss. A medication or hormonal therapy may also be recommended for certain men and women who have or who are at risk for osteoporosis.



    Who needs treatment with a medication? — People with the highest risk of fracture are the ones most likely to benefit from drug therapy. In the United States, the National Osteoporosis Foundation (NOF) recommends use of a medication to treat postmenopausal women (and men ≥50 years) with a history of hip or vertebral fracture or with osteoporosis (T-score ≤-2.5). An explanation of T-scores is provided in the table (table 3).



    In addition, the NOF recommends drug therapy for people who have osteopenia (T-score between -1.0 and -2.5) and an estimated 10-year risk of hip or osteoporosis-related fracture ≥3 or ≥20 percent, respectively. The absolute risk of fracture can be calculated using the World Health Organization FRAX calculator (www.shef.ac.uk/FRAX/), click on Calculation Tool, and select country.



    However, some people who do not meet these criteria will benefit from a medication to treat osteoporosis or osteopenia. The final decision about use of a medication should be shared between the patient and healthcare provider.



    Treatment in premenopausal women — The relationship between bone density and fracture risk in premenopausal women is not well defined. A premenopausal woman with low bone density may have little increased risk of fracture. Thus, bone density alone should not be used to diagnose osteoporosis in a premenopausal woman; further evaluation is generally recommended. (See "Evaluation and treatment of premenopausal osteoporosis".)



    Bisphosphonates — Bisphosphonates are medications that slow the breakdown and removal of bone (ie, resorption). They are widely used for the prevention and treatment of osteoporosis in postmenopausal women. (See "The use of bisphosphonates in postmenopausal women with osteoporosis".)



    These drugs need to be taken first thing in the morning on an empty stomach with a full 8 oz glass of plain (not sparkling) water. The person must then wait:



     




    • At least half an hour (with alendronate [Fosamax®] and risedronate [Actonel®]) before eating or taking any other medications.


    • At least one hour (with ibandronate [Boniva®]) before eating or taking any other medications.



     



    These dosing instructions help ensure that the drugs will be absorbed, and also reduce the risk of side effects and potential complications.



    An enteric coated delayed-release formulation of risedronate is also available. Unlike immediate-release risedronate and other oral bisphosphonates, delayed-release risedronate is taken immediately after breakfast and with at least four ounces of water.



    Patients should remain upright (sitting or standing) for at least 30 minutes after taking any oral bisphosphonate to minimize the risk of reflux.



    Side effects of bisphosphonates — Most people who take bisphosphonates do not have any serious side effects related to the medication. However, it is important to closely follow the instructions for taking the medication; lying down or eating sooner than the recommended time after a dose increases the risk of stomach upset.



    There has been concern about use of bisphosphonates in people who require invasive dental work. A problem known as avascular necrosis or osteonecrosis of the jaw has developed in people who used bisphosphonates. The risk of this problem is very small in people who take bisphosphonates for osteoporosis prevention and treatment. However, there is a slightly higher risk of this problem when higher doses of bisphosphonates are given into a vein during cancer treatment.



    Experts do not think that it is necessary for most people to stop bisphosphonates before invasive dental work (eg, tooth extraction or implant). However, people who take a bisphosphonate as part of a treatment for cancer should consult their doctor before having invasive dental work.



    Alendronate — Alendronate (Fosamax®) reduces vertebral and nonvertebral fractures, and decreases the loss of height associated with vertebral fractures. It is available as a pill that is taken once per day or once per week.



    Risedronate — Risedronate (Actonel®) is approved for both prevention and treatment of osteoporosis. It can be taken once per day, once per week, or once per month. Risedronate reduces the risk of both vertebral and hip fractures.



    Ibandronate — Ibandronate (Boniva®) can be used for prevention and treatment of osteoporosis. It is available as a pill that is taken once per day or once per month. It is also available as an injection that is given into a vein once every three months. Although ibandronate reduces the risk of bone loss and spine fractures, there is no proof that it reduces the risk of hip fractures.



    Zoledronic acid — A once yearly intravenous dose of zoledronic acid (Reclast®) is also available for the treatment of osteoporosis. This medication is given into a vein over 15 minutes and is usually well tolerated. Yearly intravenous zoledronic acid can improve bone density, decrease the risk of spine and hip fractures, and decrease the risk of recurrent fractures in high-risk patients with recent hip fracture [1].



    Side effects of zoledronic acid can include flu-like symptoms within 24 to 72 hours of the first dose. This may include a low grade fever, muscle and joint pain. Treatment with a fever-reducing medication (acetaminophen) generally improves the symptoms. Subsequent doses typically cause milder symptoms.



    Intravenous zoledronic acid is an appealing alternative for people who cannot tolerate oral bisphosphonates or who prefer a once yearly to a monthly, weekly, or daily regimen. However, the ideal duration of therapy and long-term safety (>3 years) have not been established.



    "Estrogen-like" medications — Certain medications, known as selective estrogen receptor modulators (SERMs), produce some estrogen-like effects in the bone. These medications provide protection against postmenopausal bone loss. In addition, SERMs decrease the risk of breast cancer in women who are at high risk. Currently available SERMs include raloxifene (Evista®) and tamoxifen. Raloxifene can be used for the prevention and treatment of osteoporosis in postmenopausal women, although it may be less effective in preventing bone loss than bisphosphonates or estrogen. (See "Patient information: Medications for the prevention of breast cancer (Beyond the Basics)".)



    SERMs are not recommended for premenopausal women.



    Estrogen/progestin therapy — In the past, estrogen or estrogen-progestin therapy was considered the best way to prevent postmenopausal osteoporosis and was often used for treatment. Data from the Women's Health Initiative (WHI), a large clinical trial, found that combined estrogen-progestin treatment reduced hip and vertebral fracture risk by 34 percent. A similar reduction in fracture risk was seen in women who took estrogen alone.



    Estrogen had the additional advantage of controlling menopausal symptoms. However, the WHI found that estrogen plus progestin does not reduce the risk of coronary artery disease, and slightly increases the risk of breast cancer, stroke, and blood clots. The details of the WHI are discussed elsewhere. (See "Patient information: Postmenopausal hormone therapy (Beyond the Basics)".)



    Thus, estrogen is not recommended for the treatment or prevention of osteoporosis in postmenopausal women. However, some postmenopausal women continue to use estrogen, including women with persistent menopausal symptoms and those who cannot tolerate other types of osteoporosis treatment, and those women are usually protected against bone loss and so do not need to consider additional drugs to prevent bone loss.



    Estrogen may be an appropriate treatment for prevention of osteoporosis in young women whose ovaries do not make estrogen. This treatment may be given as a skin patch or orally, such as a birth control pill. (See "Patient information: Absent or irregular periods (Beyond the Basics)".)



    Calcitonin — Calcitonin is a hormone produced by the thyroid gland that, together with parathyroid hormone, helps to regulate calcium concentrations in the body. Synthetic calcitonin is sometimes recommended as a treatment for osteoporosis. Calcitonin may be administered via nasal spray or injection (subcutaneous salmon calcitonin). Nasal administration is typically preferred due to ease of use and because the injections tend to cause more nausea and flushing. (See "Calcitonin in the prevention and treatment of osteoporosis".)



    Other drugs are usually recommended in preference to calcitonin because it is not clear if calcitonin improves bone other than the spine. However, due to its pain-relieving (analgesic) effects, calcitonin may be suggested as a first-line therapy for those who have a sudden, intense (acute) onset of pain due to vertebral fractures. The treatment regimen is typically changed once the acute pain subsides or if the pain fails to subside over a prolonged period (eg, four weeks).



    Parathyroid hormone (PTH) — PTH is produced by the parathyroid glands and stimulates both bone resorption and new bone formation. Intermittent administration stimulates formation more than resorption. Clinical trials suggest that PTH therapy is effective in both the prevention and treatment of osteoporosis in postmenopausal women and in men.



    A PTH preparation called Forteo®, given by daily injection, is approved for the treatment of severe osteoporosis for two years. It is more effective at building spine bone density and reducing spine fracture risk than any other treatment. Because it requires a daily injection and is expensive, it is usually reserved for patients with severe hip or spine osteoporosis (T score <-2.5 and an osteoporosis-related fracture). It is not recommended for premenopausal women.



    Denosumab — Denosumab (Prolia®) is an antibody directed against a factor (RANKL) involved in the formation of cells that break down bone. Denosumab improves bone mineral density and reduces fracture in postmenopausal women with osteoporosis. It is administered as an injection under the skin once every six months. Although denosumab is generally well tolerated, side effects can include skin infections (cellulitis) and eczema. A mild transient lowering of blood calcium levels has also been reported, but this is not usually a problem in patients with good kidney function, who are taking enough calcium and vitamin D.



    Because it is a new drug and there are no long-term safety data, denosumab is usually reserved for patients who are intolerant of or unresponsive to oral and/or intravenous bisphosphonates. Denosumab should not be given to patients with low blood calcium until it is corrected.



    MONITORING RESPONSE TO TREATMENT



    Testing may be recommended to monitor a person's response to osteoporosis therapy. This may include measurement of bone mineral density (DXA scan) or laboratory tests that indicate bone turnover (ie, rate of new bone formation and breakdown). (See "Patient information: Bone density testing (Beyond the Basics)".)



    SUMMARY



     




    • Osteoporosis causes bones to become abnormally thin, weakened, and easily broken. This condition can be treated and prevented with diet, exercise, and not smoking.


    • Calcium and vitamin D can prevent and treat thinning bones. The main dietary sources of calcium include milk and other dairy products, such as cottage cheese, yogurt, or hard cheese, and green vegetables, such as kale and broccoli (table 1). Milk is a primary source of dietary vitamin D, containing approximately 100 international units per 8 oz (236 mL).


    • Calcium and vitamin D can also be taken as a supplement (eg, in a pill) (table 2). A total of at least 1000 mg of calcium per day (total diet plus supplement) is recommended for premenopausal women and men. Women after menopause should consume 1200 mg calcium per day (total diet plus supplement). Experts also recommend 800 international units (IU) of vitamin D each day for men over 70 years and postmenopausal women, and 600 international units daily for younger men and premenopausal women.


    • Exercise can help to prevent and treat thinning bones. Exercise should be done for at least 30 minutes three times per week. Any weight-bearing exercise regimen is appropriate (eg, walking).


    • Smoking cigarettes can cause bones to become thinner and weaker. Stopping smoking can reduce this risk.


    • Falling can cause fractures in the elderly. Preventing falls can lower the risk of fractures.


    • Some medications can cause bone thinning. Such medications include glucocorticoid medications (eg, prednisone), heparin, and certain antiepileptic drugs (eg, phenytoin, carbamazepine, primidone, phenobarbital, and valproate). Patients should ask their healthcare provider about the possibility that these medications should be replaced or the dose lowered. (See 'Medications' above.)


    • There are several medications that help prevent osteoporosis in women after menopause. We think alendronate (Fosamax®), risedronate (Actonel®), or raloxifene (Evista®) are the best medications for prevention. (See 'Bisphosphonates' above.)


    • Alendronate (Fosamax®) or risedronate (Actonel®) are recommended to treat women after menopause who have osteoporosis. (See 'Bisphosphonates' above.) Zoledronic acid (Reclast®) or raloxifene (Evista®) may be suggested for patients who cannot tolerate oral bisphosphonates, or who have difficulty taking the medication, including an inability to sit upright for 30 to 60 minutes.


    • Denosumab (Prolia®) improves bone density and reduces fracture in postmenopausal women with osteoporosis. It is another option for patients who are intolerant of or unresponsive to oral and/or intravenous bisphosphonates. (See 'Denosumab' above.)


    • Parathyroid hormone (Forteo®) is another medication that can be used to treat osteoporosis. We recommend this medication for men or postmenopausal women with severe hip or spine osteoporosis. (See 'Parathyroid hormone (PTH)' above.)


    • Hormone replacement (eg, estrogen, progesterone) is not usually recommended to prevent osteoporosis in women after menopause. Hormone therapy is recommended for young women whose ovaries do not make estrogen normally. (See 'Estrogen/progestin therapy' above.)


    • Testing may be recommended to monitor how the bones respond to osteoporosis treatment. This may include a bone density scan (DXA) or laboratory tests. (See "Patient information: Bone density testing (Beyond the Basics)".)



     



    WHERE TO GET MORE INFORMATION



    Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



    This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

     



    Patient level information — UpToDate offers two types of patient education materials.



    The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



    Patient information: Osteoporosis (The Basics)

    Patient information: Menopause (The Basics)

    Patient information: Calcium and vitamin D for bone health (The Basics)

    Patient information: Vitamin D deficiency (The Basics)

    Patient information: Bone density testing (The Basics)

    Patient information: Exercise (The Basics)

    Patient information: Primary hyperparathyroidism (The Basics)

    Patient information: Paraplegia and quadriplegia (The Basics)

    Patient information: Aseptic necrosis of the hip (The Basics)

    Patient information: Hip fracture (The Basics)

    Patient information: Vertebral compression fracture (The Basics)

    Patient information: Medicines for osteoporosis (The Basics)

    Patient information: Monoclonal gammopathy of undetermined significance (The Basics)



    Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



    Patient information: Bone density testing (Beyond the Basics)

    Patient information: Calcium and vitamin D for bone health (Beyond the Basics)

    Patient information: Postmenopausal hormone therapy (Beyond the Basics)

    Patient information: Nonhormonal treatments for menopausal symptoms (Beyond the Basics)

    Patient information: Exercise (Beyond the Basics)

    Patient information: Quitting smoking (Beyond the Basics)

    Patient information: Medications for the prevention of breast cancer (Beyond the Basics)

    Patient information: Absent or irregular periods (Beyond the Basics)

     



    Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



    The use of bisphosphonates in postmenopausal women with osteoporosis

    Calcitonin in the prevention and treatment of osteoporosis

    Calcium and vitamin D supplementation in osteoporosis

    Clinical manifestations, diagnosis, and evaluation of osteoporosis in men

    Diagnosis and evaluation of osteoporosis in postmenopausal women

    Evaluation and treatment of premenopausal osteoporosis

    Metabolic bone disease in inflammatory bowel disease

    Metabolic bone disease in primary biliary cirrhosis

    Overview of the management of osteoporosis in postmenopausal women

    Pathogenesis of osteoporosis

    Postmenopausal hormone therapy in the prevention and treatment of osteoporosis

    Screening for osteoporosis

    Treatment of osteoporosis in men

    Use of biochemical markers of bone turnover in osteoporosis



    The following organizations also provide reliable health information.



     




    • National Library of Medicine



     



    (www.nlm.nih.gov/medlineplus/healthtopics.html)



     




    • Osteoporosis and Related Bone Diseases National Resource Center



     



    Toll-free: (800) 624-BONE (2663)

    TTY: (202) 466-4315

    (www.osteo.org)



     




    • National Osteoporosis Foundation



     



    Phone: (202) 223-2226

    (www.nof.org)



     




    • National Women's Health Resource Center (NWHRC)



     



    Toll-free: (877) 986-9472

    (www.healthywomen.org)



     




    • Osteoporosis Society of Canada



     



    Phone: (416) 696-2663 x 294

    (www.osteoporosis.ca/)



     




    • The Hormone Foundation



     



    (www.hormone.org/public/osteoporosis.cfm, available in English, Spanish, French, Italian, German, and Portuguese)



    [1-6]





    Literature review current through: Jul 2013. |This topic last updated: Dec 17, 2012.



    The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.




    References





    1. Lyles KW, Colón-Emeric CS, Magaziner JS, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med 2007; 357:1799.


    2. Delmas PD, Bjarnason NH, Mitlak BH, et al. Effects of raloxifene on bone mineral density, serum cholesterol concentrations, and uterine endometrium in postmenopausal women. N Engl J Med 1997; 337:1641.





    3. Patient information: Peptic ulcer disease (Beyond the Basics)









      PEPTIC ULCER OVERVIEW



      Peptic ulcers are sores or eroded areas that form in the lining of the digestive (gastrointestinal) tract. They usually occur in the stomach (gastric ulcer) or in the duodenum (duodenal ulcer), which is the upper region of the small intestine (figure 1). The two primary causes of peptic ulcers are infection with specific bacteria (Helicobacter pylori) and use of nonsteroidal antiinflammatory medications.



      Peptic ulcers affect more than 4 million people each year in the United States. Most ulcers heal while others worsen over time. Complications of peptic ulcers can be serious or even life-threatening. Fortunately, most people who develop peptic ulcers can be treated successfully and avoid long-term problems.



      HOW ULCERS DEVELOP



      The stomach and duodenal lining have several mechanisms that help prevent ulcers from developing, including the following:



       




      • A coating of mucus (mucous layer) protects the stomach lining from the effects of acidic digestive juices.


      • Food and other substances in the stomach neutralize acid. Certain chemicals produced by the stomach protect the cells lining the stomach.



       



      If the mucous layer is damaged or if acid neutralizing substances are not present in normal amounts, digestive juices can cause irritation and breakdown of the stomach or duodenal lining, allowing an ulcer to form.



      PEPTIC ULCER SYMPTOMS



      People with peptic ulcers may have a wide variety of symptoms, have no symptoms, or, rarely, develop potentially life-threatening complications such as bleeding. Symptoms of ulcers may include:



       




      • Pain or discomfort (usually in the upper abdomen)


      • Bloating


      • An early sense of fullness with eating


      • Lack of appetite


      • Nausea


      • Vomiting


      • Blood in the stools



       



      Moderate to severe bleeding can cause foul-smelling black or tarry stools. Bleeding can also cause a low red blood cell count (anemia).



      Many of these symptoms can occur in people who do not have an ulcer. For this reason, anyone who has one or more of these symptoms should discuss their concerns with a healthcare provider to determine if further testing or treatment is needed.



      Gastric versus duodenal ulcer — Although there is much overlap, symptoms of a gastric ulcer may be different than those of a duodenal ulcer.



      Duodenal ulcer — "Classic" symptoms of a duodenal ulcer include burning, gnawing, aching, or hunger-like pain, primarily in the upper middle region of the abdomen below the breastbone (the epigastric region). Pain may occur or worsen when the stomach is empty, usually two to five hours after a meal. Symptoms may occur at night between 11 PM and 2 AM, when acid secretion tends to be greatest.



      Gastric ulcer — Symptoms of a gastric ulcer typically include pain soon after eating. Symptoms are sometimes not relieved by eating or taking antacids.



      PEPTIC ULCER CAUSES



      The two most common causes of peptic ulcers are:



       




       



      In addition, smoking and certain other genetic and environmental factors (such as medications) may influence the course of peptic ulcer disease. Psychological stress and dietary factors were once thought to be the cause of ulcers, although these factors are no longer thought have a major role.



      Helicobacter pylori infection — Helicobacter pylori, also known as H. pylori, is the most common chronic bacterial infection in humans. Conservative estimates indicate that the bacteria are present in the stomach in approximately one-half of the world's population. Surprisingly, the importance of H. pylori was not appreciated until 1982. A researcher demonstrated that the bacteria were able to cause stomach problems after he voluntarily swallowed them. H. pylori is now recognized to be an important cause of gastric and duodenal ulcers.



      The presence of H. pylori causes a number of changes in the normal environment of the stomach and duodenum. In particular, it disrupts the mucous layer and causes the release of certain enzymes and toxins that may directly or indirectly injure the cells of the stomach or duodenum.



      The effect of these changes is that underlying tissues become more vulnerable to damage from digestive juices, such as stomach acid. This results in chronic inflammation in the walls of the stomach (gastritis) or duodenum (duodenitis). Most individuals with chronic gastritis or duodenitis have no symptoms. However, some people develop more serious problems, most commonly a stomach or duodenal ulcer. (See "Patient information: Helicobacter pylori infection and treatment (Beyond the Basics)".)



      Nonsteroidal anti-inflammatory drugs — Nonsteroidal anti-inflammatory drugs (NSAIDs) are responsible for the majority of peptic ulcers not caused by H. pylori. A number of NSAIDs are available in both prescription and over-the-counter medications, including aspirin, ibuprofen (Advil®, Motrin®), naproxen (Aleve®, Anaprox®), and others. The risk of developing an ulcer depends upon the specific type of NSAID, the dose and duration of use, and individual factors. A few other drugs increase the risk of developing an ulcer, although these cause far fewer ulcers than NSAIDs.



      Other contributing factors — H. pylori infection or NSAID use alone may not be sufficient to cause peptic ulcer disease. Genetic and environmental factors may also contribute. For example, people with duodenal ulcers are more likely to have family members with duodenal ulcers compared to the general population. Another risk factor for developing an ulcer is use of tobacco (cigarette smoking); smoking increases the risk of developing ulcers and impairs their healing. Alcohol abuse also appears to interfere with ulcer healing.



      PEPTIC ULCER DIAGNOSIS



      Not everyone with ulcer symptoms has an ulcer. Similar symptoms can be caused by a wide variety of conditions such as functional dyspepsia (ie, the presence of ulcer-symptoms without a specific cause), abnormal emptying of the stomach, acid reflux, gallbladder problems, and, much less commonly, stomach cancer. Thus, the process needed to diagnose an ulcer depends upon the person's medical history and sometimes, use of specific tests. (See "Patient information: Upset stomach (functional dyspepsia) in adults (Beyond the Basics)" and "Patient information: Acid reflux (gastroesophageal reflux disease) in adults (Beyond the Basics)" and "Patient information: Gallstones (Beyond the Basics)".)



      H. pylori testing — Many people with ulcer symptoms are tested for H. pylori with a blood, breath, or stool test. Those who test positive for H. pylori are treated for the infection and ideally re-tested after treatment to ensure that the infection has been cured. However, some providers recommend further testing only if symptoms recur.



      Upper endoscopy — People who have certain "alarm" features such as weight loss, difficulty swallowing, or anemia, and particularly if the person is older, typically undergo more specific tests to better define the cause. The most common test is an upper endoscopy, in which a small flexible tube with a camera is passed through the mouth to examine the lining of the stomach and the duodenum. (See "Patient information: Upper endoscopy (Beyond the Basics)".)



      PEPTIC ULCER COMPLICATIONS



      Peptic ulcers can heal spontaneously and may come and go. They can also be associated with serious, potentially life-threatening complications, sometimes without warning signs. This is most common in elderly patients and those who take NSAIDs. The most common complications of ulcers are bleeding and perforation.



      Bleeding — Bleeding can be gradual or abrupt; abrupt bleeding often causes black, tarry, loose stools, and a drop in blood pressure. Most ulcer bleeding can be controlled with endoscopy, which allows a physician to cauterize the ulcer or inject it with epinephrine to stop the bleeding. Only about 2 to 5 percent of people with a peptic ulcer require surgery.



      Perforation — Perforation is the medical term for a puncture of the stomach lining or duodenum caused by the ulcer. Perforation usually causes sudden severe abdominal pain and usually requires surgery.



      PEPTIC ULCER TREATMENT



      Most ulcers can be healed with medications. Surgery is rarely needed, except when complications have developed.



      Identify cause of ulcer — The initial step in treating an ulcer is to identify the cause. NSAIDs should be stopped, regardless of the cause. People who have H. pylori are treated with antibiotics and a medication that reduces acid production.



      Treating H. pylori — No single drug effectively cures H. pylori infection. Treatment involves taking several medications for 7 to 14 days.



       




      • Most of the treatment regimens include a medication called a proton pump inhibitor. This medication decreases the stomach's production of acid, which allows the tissues damaged by the infection to heal. Examples of proton pump inhibitors include lansoprazole (Prevacid®), omeprazole (Prilosec®), pantoprazole (Protonix®), dexlansoprazole (Dexilant®), rabeprazole (AcipHex®), and esomeprazole (Nexium®).


      • Two antibiotics are also generally recommended; this reduces the risk of treatment failure and antibiotic resistance.



       



      Although the optimal treatment regimen continues to be investigated, the American College of Gastroenterology has recommended four regimens that use a combination of at least three medications. These regimens successfully cure infection in up to 90 percent of people. For the treatment to be effective, the entire course of all medications must be taken.



      Side effects — Up to 50 percent of people have side effects of H. pylori treatment. Side effects are usually mild, with fewer than 10 percent of patients stopping treatment because of side effects. For those who do experience side effects, it may be possible to make adjustments in the dose or timing of medication. Some of the most common side effects are described below.



       




      • Some of the treatment regimens use a medication called metronidazole (Flagyl®) or clarithromycin (Biaxin®). These medications can cause a metallic taste in the mouth.


      • Alcoholic beverages (eg, beer, wine) should be avoided while taking metronidazole; the combination can cause skin flushing, headache, nausea, vomiting, sweating and a rapid heart rate.


      • Bismuth, which is contained in some of the regimens, causes the stool to become black and may cause constipation.


      • Many of the regimens cause diarrhea and stomach cramps.



       



      Ways to help ulcers heal — A number of other measures help to ensure ulcer healing and prevent ulcer recurrence.



       




      • Stop smoking. (See "Patient information: Quitting smoking (Beyond the Basics)".)


      • Avoid NSAIDs if possible. All medications should be reviewed with a healthcare provider to make sure that they do not contain NSAIDs. If it is necessary to continue NSAIDs, one or more medications may be added to aid in ulcer healing and prevent recurrence.


      • If you had complications from your ulcer (such as bleeding or perforation), you should be retested for H. pylori to make sure that antibiotic therapy was successful. Although controversial, most experts recommend that a medication to reduce acid secretion is continued, even after a complicated ulcer has healed.


      • Antacids are permissible during ulcer treatment if needed, although antacids should not be used within one hour before or two hours after taking ulcer medications since they can interfere with their absorption.


      • Efforts to reduce stress can benefit your overall health and may have a small benefit in healing ulcers. However, most ulcers heal with medications, even in people who continue to live a stressful life.


      • Herbal medications and supplements (such as licorice, marshmallow, and glutamine) probably have no role in the treatment of peptic ulcers. In addition, the manufacture of these treatments is not regulated and their safety and efficacy are not known.



       



      PEPTIC ULCER FOLLOW-UP



      Duodenal ulcers — People with uncomplicated duodenal ulcers should have follow-up testing after treatment, especially if symptoms recur or do not improve. Follow up testing is also recommended for people who have had complications (such as bleeding or perforation) to ensure that H. pylori has been successfully cured.



      Gastric ulcers — People with gastric ulcers usually undergo a repeat endoscopy to ensure that the ulcer has healed and to ensure that the ulcer does not contain cancer cells. Long-term treatment to suppress stomach acid is usually recommended if a person has a high risk of ulcer recurrence (eg, a history of ulcer complications or frequent recurrences).



      People with ulcers due to H. pylori who have been cured of the infection are unlikely to develop another ulcer if NSAIDs are avoided.



      WHERE TO GET MORE INFORMATION



      Your healthcare provider is the best source of information for questions and concerns related to your medical problem.



      This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

       



      Patient level information — UpToDate offers two types of patient education materials.



      The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.



      Patient information: Peptic ulcers (The Basics)

      Patient information: H. pylori infection (The Basics)

      Patient information: GI bleed (The Basics)

      Patient information: Gastritis (The Basics)



      Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.



      Patient information: Helicobacter pylori infection and treatment (Beyond the Basics)

      Patient information: Upset stomach (functional dyspepsia) in adults (Beyond the Basics)

      Patient information: Acid reflux (gastroesophageal reflux disease) in adults (Beyond the Basics)

      Patient information: Gallstones (Beyond the Basics)

      Patient information: Upper endoscopy (Beyond the Basics)

      Patient information: Quitting smoking (Beyond the Basics)

       



      Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.



      Association between Helicobacter pylori infection and duodenal ulcer

      Clinical manifestations of peptic ulcer disease

      Overview of the complications of peptic ulcer disease

      Diagnosis of peptic ulcer disease

      Management of duodenal ulcers in patients infected with Helicobacter pylori

      Overview of the natural history and treatment of peptic ulcer disease

      Peptic ulcer disease: Genetic, environmental, and psychological risk factors and pathogenesis

      Refractory or recurrent peptic ulcer disease

      Role of surgery in the management of peptic ulcer disease

      Surgical management of complications of peptic ulcer disease

      Overview of the treatment of bleeding peptic ulcers

      Unusual causes of peptic ulcer disease



      The following organizations also provide reliable health information.



       




      • National Library of Medicine



       



      (www.nlm.nih.gov/medlineplus/healthtopics.html)



       




      • Centers for Disease Control and Prevention (CDC)



       



      Phone: (404) 639-3534

      Toll-free: (800) 311-3435

      (www.cdc.gov)



       




      • National Institute of Diabetes and Digestive and Kidney Diseases



       



      Phone: (301) 654-3810

      (www.niddk.nih.gov)



       




      • The American Gastroenterological Association



       



      (www.gastro.org)



       




      • The American College of Gastroenterology (ACG)



       



      (www.acg.gi.org)



      [1-4]



      ACKNOWLEDGMENT



      The editorial staff at UpToDate, Inc. would like to acknowledge Dr. David A. Peura, who contributed to earlier versions of this topic review.





      Literature review current through: Jul 2013. |This topic last updated: Oct 4, 2011.



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  • Patient information: Pneumonia in adults (Beyond the Basics)





     






     




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    PNEUMONIA OVERVIEW



    Pneumonia is an infection of the lungs. It is a serious illness that can affect people of any age, although it is most serious in the very young, people over the age of 65, and those with underlying medical problems such as congestive heart disease, diabetes, and chronic lung disease. It is most common during the winter months, and occurs more often in smokers and men.



    This article will focus on community-acquired pneumonia (CAP), which refers to pneumonia that develops in people in the community, rather than in a hospital, nursing home, or assisted-living facility. About four million cases of CAP occur each year in the United States, and approximately 20 percent of people require hospitalization.



    LUNG FUNCTION



    As we breathe, air is inhaled through the nose and mouth, and travels through the trachea and the bronchi to the bronchioles. At the end of the bronchioles, there are tiny air sacs, called alveoli. Alveoli have thin, porous walls that contain capillaries (figure 1).



    The mouth and respiratory tract are constantly exposed to microorganisms as air is inhaled through the nose and mouth. However, the body's defenses are usually able prevent microorganisms from entering and infecting the lungs. These defenses include the immune system, the specialized shape of the nose and pharynx, the ability to cough, and fine hair-like structures called cilia located on the bronchi. Pneumonia can develop if your defenses are not adequate or the microorganism is particularly strong.



    As microorganisms multiply, the alveoli become inflamed and accumulate fluid. These changes lead to the symptoms of pneumonia. (See 'Pneumonia symptoms' below.)



    HIGH-RISK GROUPS



    Some groups of adults are at a greater risk of developing pneumonia. These include people who:



     




    • Are greater than 65 years old

    • Are cigarette smokers

    • Are malnourished due to health conditions or lack of access to food

    • Have underlying lung disease, including cystic fibrosis, asthma, or chronic obstructive pulmonary disease (emphysema)

    • Have other underlying medical problems, including diabetes or heart disease

    • Have a weakened immune system due to HIV, organ transplant, chemotherapy, or chronic steroid use

    • Have difficulty coughing due to stroke, sedating drugs or alcohol, or limited mobility

    • Have had a recent viral upper respiratory tract infection including influenza



     



    PNEUMONIA CAUSES



    Pneumonia can be caused by a variety of microorganisms, including viruses, bacteria, and less commonly, fungi. The most common cause of pneumonia in the United States is the bacterium Streptococcus pneumoniae, or pneumococcus.



    Viruses are estimated to be the cause of adult CAP in at least 20 percent of cases. Fungi rarely cause pneumonia in people who are generally healthy; people with a weakened immune system (those with HIV, organ transplant patients, or those on chemotherapy) are at higher risk of fungal infection. Other organisms, such as Mycoplasma, are a common cause of mild pneumonia but can occasionally cause serious disease.



    PNEUMONIA SYMPTOMS



    Common symptoms of pneumonia include shortness of breath, pain with breathing, a rapid heart and breathing rate, nausea, vomiting, diarrhea, and a cough that often produces green or yellow sputum; occasionally the sputum is rust colored. Most people have a fever (temperature greater than 100.5ºF or 38ºC), although elderly people have fever less often. Shaking chills (called rigors) and a change in mental status (confusion, unclear thinking) can occur.



    The characteristics of pneumonia are different than those of a more common infection, acute viral bronchitis, which does not usually cause fever and does not require treatment with an antibiotic. (See "Patient information: Acute bronchitis in adults (Beyond the Basics)".)



    PNEUMONIA DIAGNOSIS



    Pneumonia is usually diagnosed with a medical history and physical examination, as well as a chest x-ray. The need for further testing depends upon the severity of the illness and the person's risk of complications.



    Chest x-ray — Chest x-ray and sometimes other imaging studies, such as CT scan, are used for diagnosing pneumonia when the history and physical examination also support the diagnosis.



    Sputum testing — Sputum testing requires a sample of sputum, collected from a deep cough. Culture of sputum is used to identify the bacteria that caused the pneumonia and can help determine which antibiotic is best.



    Urine antigen testing — Urine tests can be helpful for diagnosing pneumonia caused by two bacteria, Streptococcus pneumoniae and Legionella pneumophila. These tests are easy to perform, and provide rapid results.



    Blood testing — Patients who are hospitalized require blood testing, including a complete blood cell count (CBC) and sometimes a blood culture. A CBC measures the number of many types of blood cells, including white blood cells (WBC); these cells multiply when there is a bacterial infection. An increased number of WBCs is one indicator that a bacterial infection, including pneumonia, may be present.



    A blood culture is used to determine whether the infection has spread from the lungs into the blood stream. It involves taking a sample of blood from a vein and testing it for bacteria. Normally, there should be no bacteria in the bloodstream. Blood cultures are used to identify the bacteria that caused the pneumonia and to guide the choice of antibiotic. A patient's antibiotics may be changed when results of the blood or sputum cultures are completed (usually after 48 to 72 hours).



    Blood oxygen measurement — Pneumonia can decrease the amount of oxygen available in the blood. As a result, a blood oxygen level is often measured by attaching a small clip to the finger or ear that uses infrared light. In those who are sicker, the oxygen level may be measured by withdrawing a sample of blood from an artery.



    Bronchoscopy — Patients who present initially with severe pneumonia or who fail to improve or worsen during their hospitalization despite treatment with antibiotics may require further testing with bronchoscopy. In this procedure, a physician uses a thin, flexible tube with a camera to view the trachea and bronchi (the tube between the trachea and lungs). This allows them to look directly at the lungs, collect fluid samples or a biopsy (a small tissue sample), and determine whether there is an underlying cause of infection, such as a growth or inhaled foreign body. (See "Patient information: Flexible bronchoscopy (Beyond the Basics)".)



    PNEUMONIA TREATMENT



    The goal of treatment for patients with CAP is to treat the infection and prevent complications. Initial treatment of CAP is based upon the organism that is likely to be causing pneumonia (called empiric treatment). Most patients improve with empiric treatment.



    Hospital versus home care — Most patients are treated for CAP at home with oral antibiotics. People who are seriously ill or are at increased risk for complications may be hospitalized. Hospital monitoring usually includes measurement of heart and breathing rate, temperature, and oxygen levels. Hospitalized patients are usually given intravenous (IV) antibiotics initially. The number of days spent in the hospital is variable, and depends upon how a person responds to treatment and if there are underlying medical problems.



    Some patients, including people with previous lung damage or disease, a weakened immune system, or infection in more than one lobe of the lungs (called multilobar pneumonia), may be slow to recover and require a longer hospitalization.



    Antibiotic choice — A number of antibiotic treatment regimens exist for treatment of CAP. The choice of which antibiotic to use is based upon several factors, including the person's underlying medical problems and the likelihood of being infected with a bacteria that is resistant to specific drugs.



    People with certain underlying medical problems and those who have used antibiotics in the past three months have a higher risk of infection with drug resistant bacteria. For all antibiotic regimens, it is important to finish the entire course of medication and take it exactly as directed.



    EXPECTED RECOVERY FROM PNEUMONIA



    A person with pneumonia usually begins to improve after three to five days of antibiotic treatment. Improvement may be defined as feeling better or having fewer symptoms, such as cough and fever. Fatigue and a persistent, but milder, cough can last for up to one month, although most people are able to resume their usual activities within seven days. Patients treated in the hospital may require three weeks or more to resume normal activities.



    All patients, whether treated at home or in the hospital, should take special care of themselves during the recovery period. This includes getting adequate rest at night and taking naps during the day if needed. Patients should drink fluids to avoid becoming dehydrated; there is no specific amount of fluid recommended, but thirst is a good indicator of the need to drink more fluids. Patients should be sure to finish all of their antibiotic medication, even if they feel better after a few days.



    All patients should see a healthcare provider four to six weeks after being diagnosed with pneumonia. This visit allows the provider to be sure that the patient is feeling better and has no new problems.



    PNEUMONIA COMPLICATIONS



    Pneumonia can usually be treated successfully without leading to complications. However, complications can develop in some patients, especially those in high-risk groups.



     




    • Fluid accumulation — Fluid can develop between the covering of the lungs (pleura) and the inner lining of the chest wall; this is called a pleural effusion. If the fluid becomes infected as a result of pneumonia (called empyema), a chest tube (or less commonly, surgery) may be needed to drain the fluid.

    • Abscess — A collection of pus in the area infected with pneumonia is known as an abscess. They can usually be treated with antibiotics; rarely, surgical removal is needed.

    • Bacteremia — Bacteremia occurs when the pneumonia infection spreads from the lungs to the bloodstream. This is a serious complication since infection can spread quickly from the bloodstream to other organs. Bacteremia can also cause the blood pressure to be dangerously low.

    • Death — Although most people recover from pneumonia, it can be fatal in some cases. The mortality rate is approximately 5 to 10 percent among patients admitted to a general medical ward, but is as high as 30 percent in patients with severe infection requiring admission to an intensive care unit.

       



     



    WHEN TO SEEK HELP



    Anyone who suspects that they have pneumonia should seek medical care as soon as possible. Pneumonia is a serious illness that can be life-threatening if not treated, especially for people who are older than 65 years, alcoholic, have underlying medical problems, or a weakened immune system.



    People with the following symptoms should see their healthcare provider promptly:



     




    • Fever and cough with phlegm that does not improve or worsens

    • New shortness of breath with normal daily activities

    • Chest pain with breathing

    • Feeling suddenly worse after a cold or the flu



     



    PREVENTION



    The pneumococcal vaccine is one of the most effective ways to prevent pneumonia. The influenza (or "flu") vaccine is important not only for preventing influenza but also for preventing its complications, including pneumonia. These vaccines are discussed separately. (See "Patient information: Pneumonia prevention (Beyond the Basics)" and "Patient information: Influenza prevention (Beyond the Basics)".)



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