An important part of every case history, and even ongoing case notes, should be knowledge of the patient’s prescription and over-the-counter drug use. This has always been important, because drugs mask symptoms and physical findings that are important in making an accurate assessment of the need for chiropractic care.
One of the tenets of basic science is the need to maintain homeostasis within the extracellular fluid of the body. This fluid comprises 33% of total body water, and must be maintained within narrow limits of temperature, pH, volume, and concentration of dissolved substances. When one or more of the body’s organ systems is unable to perform its responsibilities for maintaining normal function, we develop symptoms. Hopefully, reduction of stress, a change in diet and exercise, as well as good chiropractic care will be enough to restore normal function. When these efforts are not enough, prescription drugs are used to allay symptoms and to prevent further damage to the tissues.
In that regard, it is important to remember that any visceral dysfunction produces contraction(s) in the muscles that share spinal innervations with the stressed organ(s). This occurs not only in the periphery but at the spine as well. Thus, we have the occurrence of spinal subluxation concomitant with visceral dysfunction.
When prescription drugs are used to alter visceral function, muscle contractions and subluxation patterns change. Thus, it is imperative that a patient’s use of prescription medications and any changes that are made in their medications be carefully noted by the clinician. It is imperative that we remember that prescription drugs are used for the treatment of disease and they do not restore normal function, nor can they maintain health. All prescribed drugs work by either blocking receptor sites or interfering with a human enzyme system. Hence, they all cause side effects that can be recognized very early by changes in muscle contraction and subluxation patterns. An extreme example of this phenomenon is seen with the use of statin drugs for controlling LDL (low-density lipoprotein) cholesterol levels. There is the persistent occurrence of myositis which begins slowly and can gradually progress to loss of joint range of motion and severe pain. But, make no mistake, it occurs to some extent with all medications.
One of the prescription drugs being advertised very heavily now is TriLipix®, so you can expect to see its use quite often in your patients.
TriLipix® is one of a class of fibrate drugs. Fibrates are amphipathic carboxylic acids. That is, they are chemical compounds that are both water-soluble and lipid-soluble. Common amphiphilic substances are soaps and detergents. They are used for a range of metabolic disorders, including high cholesterol and high lipid levels in the blood. Commonly prescribed fibrates your patients may be taking are TriLipix®, TriCor®, Bezalip®, Modalim®, and Lopid®.
Indications for Use
Fibrates are used in combination with statins. Although less effective in lowering LDL, fibrates increase HDL (high-density lipoprotein) levels and decrease triglyceride levels, and seem to improve insulin resistance and other features of the metabolic syndrome (hypertension and diabetes mellitus type 2).
Mechanism of Action
Fibrates are able to penetrate cell membranes and block fatty acid receptors within the cell. They stimulate a class of intracellular receptors that modulate carbohydrate and fat metabolism. Activation induces the transcription of a number of genes that facilitate lipid metabolism.
Free fatty acids can penetrate the plasma membrane due to their poor water solubility and high fat solubility. Once inside the cell, a fatty acid reacts with ATP (adenosine-5- triphosphate) in a number of steps to form the entry molecule for the Krebs Cycle.
Thus, fibrates are agonists, that is they replace fatty acids as well as prostaglandins and leukotrienes at the receptor sites with the cells of muscle, liver, and other tissues. This results in the following:
• Decreased hepatic triglyceride secretion
• Increased lipoprotein lipase activity, and increased VLDL (very low-density lipoproteins) clearance
• Increased HDL
• Increased clearance of remnant particles
• Unfortunately, there are side effects to all this.
Side Effects
When considering the following side effects of fibrate prescriptions, consider, as well, new muscle contractions and subluxation patterns in your patients. The most obvious is myopathy, muscle pain with CPK (creatine phosphokinase) elevations.
• Most fibrates can cause mild stomach upset and, since they increase the cholesterol content of bile, they increase the risk for gallstones.
• T5 to T9—stomach and biliary dysfunctions with concomitant loss of the normal dorsal kyphosis (so-called anterior dorsals).
In combination with statin drugs, fibrates cause an increased risk of rhabdomyolysis (idiosyncratic destruction of muscle tissue) leading to renal failure. Lipobay® was withdrawn because of this complication. The less lipophilic statins are considered to be somewhat safer when combined with fibrates.
• T10 to T11—kidney dysfunction and increased low back pain before the side effects are diagnosed.
My objective in writing this article is not to disparage the use of prescription drugs for the treatment of disease but, rather, to encourage the chiropractor to be aware of the drugs their patients are using and to be aware when there are changes of those prescriptions.
Dr. Loomis can be reached by mail at 6421 Enterprise Lane, Madison, WI 53719 or by phone at 1-800-662-2630. Visit his website at http://www.loomisenzymes.com.