Health Column

The questions and answers in this column were taken from past issues of the SVB newsletter. All the information in this section is periodically checked and brought up to date by Dr. Michel Ruel of the Centre hospitalier universitaire de Québec (CHUQ), CHUL Pavilion.

The importance of this column lies in the fact that it provides answers to questions most frequently asked by CF patients to physicians who are specialized in cystic fibrosis. By clicking on a topic, you will access the questions and answers related to the chosen theme.

SYMPTOMS

Acute Sinusitis
Anemia and cystic fibrosis
Arteriosclerosis and heart disease
Arrhythmia and tachycardia
Bad breath
Clubbing
CO2 and Oxygen Flow
Delayed growth
Diabetes and cystic fibrosis
Enlarged heart and cystic fibrosis
Fever
Gastroesophageal reflux
Hemoptysis
Laryngitis
Pancreatic cystic fibrosis
Pneumothorax (respiratory system)
Thirst

TREATMENT

Antibiotics

Antibiotics, intestinal flora and probiotics
Antibiotics and Length of Treatment
Antibiotics: Milk and Alcohol
Antibiotics: Vitamins
Cipro® and Fitness Training
Photosensitivity and Intravenous Antibiotics
Tobi®

Catheters long catheter
Catheters P.A.S. Port and Port-A-Cath
Corticosteroids (cortisone): Action and Side Effects
Cortisol
Cough Syrup
Cyclosporine: Action and Side Effects
Desensitization
Ibuprofen
Ibuprofen and Scarring
Methadone
Monoclonal Antibodies
Omega-3
Oxygen Therapy
Pancreatic enzymes
Super anti-inflammatory drugs (Vioxx^TM, Celebrex^TM and Bextra^TM)
Tamiflu®
Ventolin® Storage
Vitamin E and Cystic Fibrosis
Weight and Force Feeding

TRANSPLANTATION

Blood types
Grapefruit
Pregnancy and Lung Transplantation
Transplantation: Pancreatic Transplantation
Transplantation and Kidney Problems

SEXUALITY

Exercise
Semen
Vaginitis
Viagra^TM

MOTHERHOOD, FATHERHOOD

Male Infertility
Mild Form of CF and Male Fertility

COMMUNITY LIFE

Contamination Risks

GENERAL

Acne and Accutane^TM
Anti-Viral Vaccines
Arterial Blood Gas
Cystic Fibrosis and Blood Donations
Candida albicans
Childhood diseases (smallpox, measles, German measles, mumps, etc.)
Clostridium difficile
Donor Virus
Ecstasy
Flu Vaccine
Hair removal
Indoor Plants
MRSA
Multiresistant Pseudomonas
Pneumococcal Vaccination
Research Phases
Sports to Avoid
Terminology
Vaccines and travel

Antibiotics : Vitamins

Since antibiotics destroy the bacterial flora in the intestines, the vitamins I am given are no longer sufficient when I am taking ciprofloxacin. What should I do?

Antibiotics in general, and not only ciprofloxacin, tend to alter the intestinal flora. For the general population, the main problems related to this are diarrhea and occasionally a bowel infection called pseudomembranous colitis. This complication rarely occurs within the CF population, however. Antibiotics can also destroy certain intestinal bacteria that produce vitamin K. This may cause a deficiency in vitamin K, which is needed for blood clotting, especially in persons whose liver (cirrhosis) and pancreas are both affected. In these cases, a vitamin K supplement must be given. As for the other vitamins, there is no need to increase the amount taken.

HEALTH COLUMN
SVB/ June 1990, No 11, page 31

Antibiotics : milk and alcohol

I am often told not to drink milk or alcohol during antibiotic therapy. Why not?

Milk, like food, decreases the absorption of many antibiotics, making them less effective. This is why we often recommend taking antibiotics on an empty stomach (either one hour before or two hours after a meal) with a glass of water. The effect varies from one antibiotic to another, however, with tetracycline being the most affected.

Drinking alcohol can alter the effects of the antibiotic and exaggerate some of its unpleasant side effects such as dizziness, headaches, hot flushes and digestive problems; this is why moderation is recommended.

HEALTH COLUMN
SVB/ June 1990, No 11, page 31

TOBI^®

I have lately been hearing about a new antibiotic treatment called ”TOBI® ”. Could you explain what it is? What can we expect from this type of antibiotic or treatment?

The ”TOBI®” treatment is a TOBramycin Solution for Inhalation. This kind of treatment is not new; tobramycin and other antibiotics have been administered in aerosol form at our clinics for many years to control chronic bacterial infection of the bronchi, particularly infection related to Pseudomonas aeruginosa. What is new is how the tobramycin is administered. We used to administer smaller doses of tobramycin intravenous solution (160 to 240 mg per day) with a compressor and any brand of nebulizer, in conjunction with Ventolin®. The ”TOBI®” treatment consists of 300-mg phials of tobramycin, specially prepared for nebulization, taken twice daily (600 mg per day) with the help of a ”De Vilbiss Pulmo-Aide” compressor and a ”Pari LC Plus” nebulizer. Tobramycin is given separately because the bronchodilator treatment is given beforehand (metered-dose aerosol, powder, or nebulizer).

A major study on this treatment was recently done in the United States. The results, which were announced last fall at the latest North American congress on cystic fibrosis, showed a 12% improvement in lung function compared with the placebo (inactive substance). On the one hand, hospitalization was less frequent and the number of days on intravenous antibiotic treatment decreased. On the other hand, as far as I know, there was no comparison made between the ”TOBI®” treatment and the traditional aerosol antibiotic treatment given at our clinics.

HEALTH COLUMN
SVB/ Fall 1998, No 23, page 29

Photosensitivity and Intravenous Antibiotics

Are there any contraindications to sunbathing during intravenous antibiotic treatments? If so, what are the risks?

There are in fact a number of medications that make skin photosensitive, resulting in inflammation (swelling, redness and heat) after exposure to the sun. The absorbed medication ends up in the skin and with sufficient exposure to sunlight there is a physicochemical reaction causing inflammation, as in sunburns. Antibiotics are one of these medications. However, it is not the way the antibiotics are administered (orally or intravenously), but rather the type of antibiotic which causes a photosensitive reaction. Antibiotics known as photosensitizers are tetracyclines (including doxycycline and minocycline) and sulfamides (found in Bactrim®). The family of quinolones, which includes ciprofloxacin, may also bring about photosensitive reactions. Intravenous antibiotics used to treat respiratory infections in people with cystic fibrosis are usually not implicated, with the exception of Bactrim® (generic name: trimethoprim-sulfamethoxazole), which is usually taken orally, and sometimes intravenously. Among other drugs that cause photosensitivity are certain diuretics, some oral hypoglycemiants (used in treatment of diabetes) and some anti-inflammatories, to name only medications occasionally used to treat cystic fibrosis. Some drugs used for psychological disorders (depression, psychosis) are also known photosensitizers. To sum up, whenever you take medication that is a potential photosensitizer, protect yourself against the sun (appropriate clothing and sunblock).

HEALTH COLUMN
SVB/ October 1999, No 24, pages 26-27

Antibiotics and Length of Treatment

Have a mild case of cystic fibrosis, so I rarely take oral antibiotics. Recently, a friend of mine was shocked to learn that I stop the treatment as soon as I feel better. I have often stopped taking the antibiotics after six or seven days. Is it true that this makes it more likely for me to develop a resistance to the antibiotics?

The first thing to worry about when cutting an antibiotic treatment short is that you may not completely cure the infection, or that you might become re-infected shortly after an apparent cure.

It is also possible to develop a resistance to the antibiotics. If the treatment is too short, the number of surviving bacteria that have been exposed to the antibiotic can be quite high. There is also an increased risk that one of these bacteria will mutate, enabling it to resist the antibiotic.

HEALTH COLUMN
SVB/ 2001, No 26, page 42

Desensitization

This is the second time I have had to be desensitized to an antibiotic to which I am allergic. I don't understand the medical or biological principle of desensitization. I would like to know why I have to undergo this process every time I need to take the antibiotic. Can you also explain why it has to be done in the intensive care unit?

The principle of desensitization is a phenomenon that is not yet fully understood. What we do know, is that when the immune system is exposed to a substance to which the patient is allergic, it produces an allergic reaction involving, among other things, type E antibodies (IgE). When a person is given very small dose of a substance to which he or she is allergic, and the dose is subsequently increased gradually, the body reacts by developing a different type of immune response that does not involve IgEs. The new immune response will therefore not cause an allergic reaction (irritation of the eyes, runny nose, nasal congestion, itching, urticaria, obstruction of the upper airways, bronchospasm, hypotension and shock).

During the desensitization process, the new harmless immune response will be maintained as long as the drug (including antibiotics) is being administered regularly. But if the drug treatment is interrupted, the patient will have an allergic reaction when exposed to the allergen, i.e., a normal dose of the drug. This is why it is necessary to start the desensitization process over again when a patient starts a new treatment.

Desensitization is not risk free and has to be done under the supervision of an immuno-allergist. Despite all the precautions taken, the process can still provoke allergic reactions with potentially serious consequences, especially in cystic fibrosis patients who have reduced lung function. In most cases, the desensitization process is performed under strict supervision in the intensive care unit so that possible allergic reactions can be detected and treated quickly.

HEALTH COLUMN
SVB/ 2001, No 26, page 43

Long Catheter

In a few weeks, I will be undergoing my third home bronchial cleansing. All in all, I appreciate receiving my antibiotics intravenously at home. My only real problem is the frailty of my veins. Every three or four days I must go to the hospital to have a new short catheter (Jelco) inserted. For my next home treatment, my doctor suggests that I use a peripherally inserted catheter, or percutaneous catheter. Could you explain what a peripherally inserted catheter is, how it is inserted and whether there are any risks involved? Finally, do you think that the prolonged use of a peripherally inserted catheter would add to the deterioration of my veins?

A catheter is a tube that is inserted into a vein. The long peripherally inserted catheter is not very different from the short catheter currently used, like the Jelco. The main difference is its length. There are two kinds of long catheters: the MLC or midline catheter, which measures up to 20 cm and whose tip reaches the shoulder, and the PICC or peripherally inserted central catheter, which is longer and whose tip extends to the superior vena cava, the central vein that enters the heart.

The main advantage of these catheters is their durability. While a short catheter must be replaced every three or four days, a medium- length catheter (MLC) can last eight weeks, and a PICC can be used for as long as six months and sometimes longer.

Insertion is not complicated but requires special training. In Quebec, doctors usually insert this type of catheter, whereas in the United States, specialized nurses are authorized to put them in. The basic principles are similar to those for inserting short catheters. They must be put in under much stricter sterile conditions, however; only the large veins in the arm (basilic or cephalic), above or below the elbow, can be used. When a PICC is inserted, the position of the catheter must be verified by X-ray. Risks include bleeding, tendon or nerve damage, cardiac arrhythmia (when the catheter enters the heart), incorrect positioning of the catheter, and finally, a break in the catheter with part of it migrating to the heart or lungs. After insertion, there is the risk of infection, or of superficial or deep phlebitis. These complications rarely occur, the most frequent being phlebitis (3–4%) and a blocked catheter.

With the long catheter, specific complications related to the insertion of subclavian catheters such as pneumothorax and hemothorax (air or blood in the pleura of the lung) are avoided. Furthermore, subclavian catheters cannot be used for more than two weeks. Repeated use of a long catheter will surely prevent deterioration of the small superficial veins in the arm. There is a slight risk of damaging the large superficial veins as well as the deeper veins, but this seems an acceptable calculated risk.

HEALTH COLUMN
SVB/ Fall 1996, No 21, pages 25-26

Catheter: P.A.S. Port and Port-A-Cath

Two years ago, a CF woman who goes to a different hospital had a P.A.S. PORT inserted. I find the P.A.S. PORT much more aesthetic than the PORT-A-CATH. Could you tell me why doctors seem to prefer the PORT-A-CATH to the P.A.S. PORT?

The PORT-A-CATH and P.A.S. PORT systems are a type of central catheter, such as the subclavian catheter and the PICC, whose access chambers are implanted under the skin, and must be inserted surgically in an operating room. A special needle must be used to pierce the skin and penetrate the chamber of the mechanism. These systems last longer than the subclavian catheter (7–14 days) and can in fact be used for many years. We are familiar with the PORT-A-CATH, but we don’t use the P.A.S. PORT (therefore I cannot speak from personal experience).

The main difference between the two systems is that the chamber of the PORT-A-CATH is inserted in the chest area and the P.A.S. PORT is inserted in the arm. The subcutaneous chamber of the P.A.S. PORT is smaller than that of the PORT-A-CATH. These two features are what make the P.A.S. PORT more aesthetic.

As far as the “automanipulation” of the system is concerned, however, the advantage of the PORT-A-CATH is that it can be handled by both hands. Moreover, because the P.A.S. PORT uses a longer catheter than the PORT-A-CATH, there is a higher risk of catheter blockage, so it may not last as long. This last fact explains why doctors prefer the PORT-A-CATH.

HEALTH COLUMN
SVB/ Fall 1996, No 21, pages 26-27

Corticosteroids (Cortisone) : Action and Side Effects

A few months ago, my doctor decided it was time I should take a cortisone-based medication. On the one hand, I know this medication is supposed to alleviate my asthma. On the other hand, I can’t help wondering about the side effects attributed to corticosteroids. If I understood the side effects, I might more readily accept taking this medication. What is cortisone’s function in the body? Why are there so many side effects?

Cortisone is a molecule that belongs to the large family of corticosteroids. It is a natural hormone that is produced by the adrenals, two glands that are located above the kidneys. This hormone is essential to body function; without it, survival isn’t possible. Cortisone plays many roles: it metabolizes sugars, fats and proteins; it influences the circulation of water, sodium and potassium in the body; it is also a strong anti-inflammatory. This last attribute justifies its use as medication, not only for cystic fibrosis, but many other diseases. Cortisone can be used alone as a medication, but most often synthetic corticosteroids like prednisone are used because they have fewer side effects such as water retention and loss of potassium. All corticosteroids can cause side effects, which are directly related to dosage and length of treatment. The main side effects are weight gain (with the fat distributed around the face and torso), acne, a tendency to bruise easily, a decrease in children’s growth rate, elevated blood sugar, bone loss and substance dependence (when large doses are taken for extended periods, the body stops producing its own cortisone and becomes dependent on the corticosteroids it is given). Since cystic fibrosis causes severe bronchopulmonary inflammation, corticosteroids are part of therapeutic treatment. Clinical studies have shown the efficiency of corticosteroid pills in slowing lung deterioration in a population of CF children, but these studies were carried out despite unacceptable side effects. This medication is used only in very specific situations, the main ones being bronchial hyperactivity (asthma) associated with cystic fibrosis and an allergy to a fungus known as Aspergillus (allergic bronchopulmonary aspergillosis). In these cases, we always try to administer the smallest effective dose for the shortest possible time. Under certain circumstances, such as mild asthma, a corticosteroid spray is used to prevent absorption in the blood stream, thus preventing all the above en comprimés pour ralentir la détérioration de la -mentioned side effects. The throat and mouth must be rinsed out after each use, however, to avoid the proliferation of the benign fungus, Candida albicans. Finally, much research is being done on alternative anti-inflammatory treatments that would have fewer side effects than cortisone and its derivatives.

HEALTH COLUMN
SVB/ Winter 1995, No 19, pages 28-29

Cyclosporine: Action and Side Effects

A CF person told me that the cyclosporine taken after a transplantation makes you impotent. Is this true? The genital organs are already more vulnerable to bacterial infections because of antibiotics; will it be worse with cyclosporine?

A - Impotence is not an acknowledged side effect of cyclosporine.

B - Antibiotics taken orally or intravenously may indeed cause fungal, but not bacterial, vaginal infections.

Cyclosporine is not an antibiotic but a medication that decreases immunity (the body’s defences battling against foreign organisms). On the one hand, this medication prevents the body from rejecting the foreign organ after transplantation; on the other hand, it may encourage the onset of various infections, but not necessarily gynecological ones.

HEALTH COLUMN
SVB/ December 1989, No 10, pages 39-40