Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, June 25, 2009

Inadvertent Therapeutic Trial

The definition of a therapeutic trial is when the diagnosis of a particular condition is established by a trial of specific treatment.

Not that this lets physicians off the hook for making the diagnosis. You still have to do a history and physical. In fact, you basically have to make the diagnosis first, then use the treatment to see if you're right. In everyday practice, the application of a therapeutic trial is quite limited. It is not valid, for example, to give penicillin to everyone with a sore throat and see if they get better. The regimen has to be very specific to the condition; it's the only way to be sure it's really the treatment that's having the observed effect, if any. There are very few conditions that have treatments specific enough to qualify as a true clinical therapeutic trial.

But what happens when you give someone a medication to treat one thing, and something else happens?

A patient with longstanding irritable bowel symptoms and a known allergy to cats (no relationship between those two conditions) broke out in really bad hives from inadvertent exposure to cats, and was treated with steroids. Three months later, she called to tell me that while she was on the steroids and for about two months afterward, her IBS symptoms resolved completely. Now they were coming back.

Oops! Perhaps her GI symptoms weren't due to irritable bowel syndrome -- something you wouldn't expect to be affected by corticosteroids -- after all. Perhaps she really had something completely different, like inflammatory bowel disease (Crohn's disease or ulcerative colitis) or celiac disease. Sure enough, her tissue transglutaminase antibodies came back elevated, indicating celiac. She's off to the gastroenterologist for confirmatory biopsies, followed by lifelong avoidance of gluten. The good news is that her GI symptoms should resolve completely (again). The bad news is that she's at increased lifetime risk of assorted other conditions like diabetes and cancer, although some of these can be lessened with the gluten-free diet.

All because she broke out in hives.

(And noticed the change in her IBS symptoms and called me.)

(And because I knew what to do.)


At Thu Jun 25, 09:39:00 AM, Blogger ShrinkingDoc said...

WTG, Dino.

Sucks for her, though. Avoiding gluten is tough. Have had to help The Husband do it (won't miss not having to worry about it--I did email you, hope you got it).

It takes a lot of trial and error to find good gluten-free recipes and substitutes (and a lot of thrown out baked goods and half-used products).

Couple tips you could give her:

Pamela's Gluten-Free Baking Mix is a good substitute for flour in moist, flavorful baked goods like banana bars, pumpkin bars. Cream cheese frosting on top helps.

Gluten-Free Baking Classics by Annalise Roberts is the only of many gluten-free cookbooks that I bought that I actually use. The bread actually tastes good. The cookies, etc. are yummy even for people who can eat wheat. And you can get by with just a couple funky flour mixtures to make basically everything in the book, one of which you can buy premixed online at Authentic Foods.

Trader Joes has several good gluten-free products. Their gluten-free brownie mix is the bomb, especially when covered in fudge frosting. Their GF pancake mix is very good. Their GF cereals are cheap.

Once she finds products she likes, it's often cheaper to buy them in bulk on Amazon than to buy at local healthfood stores.

A couple chain restaurants with GF menus (ask) are Chili's and Outback.

I'd be willing to pass her a couple recipes I used the Pamela's in, etc. if she has it and she's interested:
HugeMD (at) comcast (dot) net

At Thu Jun 25, 11:37:00 AM, Anonymous Anonymous said...

A gluten-free recipe that everyone should know (assuming that peanut allergies aren't an issue):

Peanut Butter "Brownies"

1 cup peanut butter (salted, unsweetened, crunchy or smooth)
1/2 cup honey
2 eggs
1 tsp baking soda

Mix everything together. Bake in a 9x9 pan at 350 for 30 min (or until firm enough for your liking).

(optional additions: 1 very ripe banana, 1 tsp baking spice such as cinnamon, 1/2 cup cocoa + 1/2 cup honey, less baking soda=less cakey, more egg=more cakey. This recipe happily accepts many adaptations so be adventurous---for example, you can use a different nut butter. You can use sugar instead of honey to make peanut butter cookies)


At Thu Jun 25, 11:40:00 AM, Anonymous Celeste said...

She might be interested in this really great magazine called Living Without. It's for people who have to be on a restricted diet due to health issues such as hers, and it has really great ideas on working around the problems that naturally come up. It's a nice resource especially for people who are not really up for joining a support group or online forum for whatever reason.

At Thu Jun 25, 12:14:00 PM, Anonymous ndenunz said...

Had a patient who was having difficuly conceiving get pregnant while on a course of prednisone for an asthma flare.

Her OB thought she may have had some antibodies to her husband's sperm that got suppressed while on the steroids.

At Thu Jun 25, 12:56:00 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

Good pick up, Doc!

Send her to gluten free girl blog. Nice resource for recipes.


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