A lady with advanced secondary cancer in the liver was admitted with breathlessness and swelling in the lower limbs. After investigations, she was found to have a failing liver, abnormal kidney function and a large amount of fluid in one side of her chest. The fluid in the chest was drained and she felt better. Over the next few days, her doctor, Doc A, tried to ‘dry her up’ with diuretics (medicine to make you pass urine) and restricted her fluid intake. As Doc B had treated her for the advanced liver metastases before, the family requested that Doc B be involved in her care.

When Doc B first saw her, she was troubled by generalised aches and a strong desire to go home. She was told by Doc A that because of the fine, in-dwelling catheter in her chest she had to stay until it was removed. After explaining to her that Doc B’s immediate management aim was to make her more comfortable, Doc B prescribed an oral medicine and a tiny dose of morphine dripped over 24 hours. She had her first uninterrupted, comfortable sleep that night. The next day she felt comfortable and better. She asked Doc B if there was any possibility that she could be discharged home. Doc B informed her that it should not be a problem as long as all the ancillary home support for her had been arranged. “Even with the tube in the chest?” she asked. “Yes, even with the tube in the chest.” Doc B replied. The following day, blood tests showed that in addition to her deteriorating liver function, her kidney function had deteriorated dramatically. Doc A asked a kidney physician, Doc C, to advice on her kidney management. Doc C prescribed several medicines for her abnormal kidney results and asked her to drink as little as possible as she still had fluid in her legs. When Doc B saw her, she was feeling miserable and confused by the other doctors’ instructions. She had difficulty speaking and her throat was uncomfortable because she was feeling parched and she dared not drink at all. Doc B tried to clear her confusion and told her that she could drink for comfort. She was told by Doc B that she was unlikely to harm herself by drinking since the amount she could drink spontaneously would not be too much. Later that afternoon, the patient decided to be discharged as soon as all the home support services had been arranged. Doc B promised to visit if and when necessary. The patient went home with the fine tube in her chest. At home she had sips of her favourite drinks. She spent a few days at her home before slipping away peacefully in her own bedroom.

It is likely that some families have had similar experience as the scenario described above. Doc A was concerned and focused with treating the immediate problem her patient was experiencing. Doc C was interested in treating the numbers from the blood tests. However, Doc B was taking a holistic approach to the management of this poor lady with terminal cancer. Doc B was attuned to the patient as a whole. The deteriorating liver and kidney functions were inevitable in the course of her underlying condition. What were of most importance was how she felt and what she wished.

If you ever were in the same situation as the lady above, what would you want your doctor to do? Would you like him to treat the numbers or treat you as a whole?

Recently I was asked to see an adolescent for abdominal pain. After taking a full medical history and examining the patient, I diagnosed acute appendicitis and recommended surgery to the patient and mother. The mother’s first response was “There is no risks right?”. I often hear this response from patients or parents but I don’t hear this response when I prescribed a pill.

Aspirin tablet is freely available and we commonly take it for headaches or toothaches. Low dose aspirin is also used in an attempt to prevent cardiovascular event in at-risk patients. Even without the doctor’s recommendation, some are self medicating with daily aspirin because they have read or heard that it prevents cardiovascular events. However, is taking a pill without risk? The answer is a definite ‘NO’. Low dose aspirin use can cause gastro-intestinal mucosa haemorrhage. The key consideration for the doctor and patient should be - Is it necessary to take the medicine and if so, can the risk be minimized?

A recent study from the University of Glasgow investigated the efficacy of famotidine, a histamine 2 receptor antagonist, in preventing peptic ulcers and erosive oesophagitis in patients receiving low-dose aspirin (75 – 325 mg) for cardiovascular protection (Lancet 2009; 374: 119 – 125). A total of 404 patients were randomized to receive famotidine twice daily or placebo twice daily together with low dose aspirin. At the end of 12 weeks, patients were re-endoscoped to determine how many had developed stomach or duodenal ulcers or erosive oesophagitis. The study showed that mucosal protection with famotidine led to significantly fewer ulcers or oesophagitis. The incidence of gastric ulcers, duodenal ulcers and erosive oesophagitis in famotidine treated patients were 3.4%, 0.5% and 4.4% respectively versus 15%, 8.5% and 19% respectively in the placebo group.

The study is not advocating that all patients on low dose aspirin must take famotidine at the same time. If future large studies confirm the findings of the above study, then patients should be informed of the risks involved and the possible options in mitigating the risks. It is then up to the patient to decide what options suits him best.

Whenever I am asked ‘There is no risks right, doctor?’, I prefer to use the analogy of crossing a road. In crossing the road, we run the risk of being knocked down and possibly killed by a vehicle. The risk is always there but is it a big risk or a small risk. Can the risk be minimized?

In my line of work, everything I prescribed is associated with a finite risk. I can only suggest the best course of action but in the end it is the patient’s choice to take the risk or not.

This week the findings of two scientific articles on improving longevity in mice and monkeys made it to the pages of the lay newspaper. The newspapers were speculating on the possibility that one day we might be able to pop a pill daily and prolong our life.

The researchers in Maine, USA, fed a drug called rapamycin to male and female mice aged 600 days of age to see its effect on survival (Nature 2009, July 8 epub). Compared to control mice, rapamycin extended the survival of female mice by 14% and male mice by 9%. (Rapamycin is a powerful drug used to suppress the body’s immune system and is used to prevent organ rejection in patients who have received an organ transplant. Patients who are taking immunosuppression agents, such as rapamycin, are at increased risk of getting all kinds of infections. They are also at an increased risk of developing cancers.) The researchers discussed about the mTOR signaling pathway as possibly being involved in the regulation of mammalian lifespan.

In a different study from the University of Wisconsin, the researchers examined the effect of calorie restriction on longevity in rhesus monkeys (Science 2009; 325: 201 – 204). This 2 decade long study examined the outcome in 2 groups of monkeys – one group of monkeys were allowed to eat as they like while the other group of monkeys were allowed a diet with 30 percent fewer calories. The study found that 80% of the calorie restricted monkeys are still alive compared to only half of the monkeys allowed to eat normally. The calorie restricted monkeys had fewer cancers, less cardiovascular disease, better preserved brain function and no diabetes. (Diabetes is a common problem in monkeys.)

While many are searching for the longevity pill, perhaps the more interesting questions to ask are – Are we doing something which is shortening our lifespan? Are we doing something which is accelerating our aging process? If you eat more than required, you start to put on weight. It is well established that overweight / obese people have increased risk of developing cardiovascular diseases, respiratory problems, diabetes mellitus and joint problems. If you smoke or drink excessively, you can develop respiratory problems, lung cancer and chronic liver disease. All of these do contribute to a reduced lifespan.

To me, eating more than necessary, smoking and drinking hastens our aging process. Until the day when a safe and effective longevity pill is available, you might consider adopting healthy lifestyle habits. It might just be the right longevity pill for you!