ArcaMax

DEAR DR. ROACH: I recently read in your column that you test your patient's magnesium levels when they have been on long-term proton-pump inhibitors (PPIs). When I asked my doctor to include this in his order for blood tests, I was told that the test isn't accurate, and he wouldn't order it. Is there a special magnesium test that I can request?

When I looked it up on the internet, this is what I found: "Standard magnesium blood tests (serum) are generally not considered an accurate indicator of total body magnesium. While they can detect severe deficiency, they are unreliable for diagnosing mild-to-moderate deficiencies because less than 1% of the body's magnesium resides in the blood, with levels tightly controlled by borrowing from bones." -- J.B.

ANSWER: Although many clinicians do test their patients for low magnesium when they are on long-term PPIs like omeprazole, this isn't a standard guideline. The expert societies don't recommend testing magnesium levels, although the Food and Drug Administration recommends that clinicians "consider" checking magnesium levels prior to starting therapy, as well as periodically during treatment.

People who are on PPIs and most diuretics are at a high risk for low magnesium. It's true that most magnesium is in the cells; however, like potassium and calcium, a low blood level does indicate that the body level is also low, and steps should be taken to keep the body from losing more magnesium.

Although there are people who need long-term PPIs, such as those with Barrett's esophagus or those in whom tapering off PPIs has failed, my experience is that there are many people who are taking these medicines who may not need them. I am sure that they were started on them for a good reason, but most people can be tapered off the medicine after six weeks or so.

DEAR DR. ROACH: I'm 80 years old. I stopped using aspirin about six months ago after years of use. I understand that it isn't needed when a patient doesn't have a history of heart disease, pain upon exercising, heart attacks, etc. However, I saw a cardiologist after a coronary calcium score (that I asked for) suggested a problem; it showed arterial calcification of the left anterior descending artery (98). I had a normal stress test, and there wasn't any evidence of inducible myocardial ischemia or a "high physical work capacity."

In light of all of this, the cardiologist recommended 81 mg of aspirin nightly. Why is he recommending aspirin? It causes bruises even from soft contact with a hard object. My arms are covered with bruises. -- H.G.

ANSWER: For many years, aspirin was given to all men (and some women) who were at a high risk for heart disease, and it's still given to nearly everyone with proven blockages in the arteries. However, recent studies have shown that aspirin's potential to cause major bleeding (not just bruises -- internal bleeding that is serious enough to cause hospitalization) outweighs the benefits in preventing heart attacks.

In people over 80 without known blockages, the balance of the risks and benefits usually lands on the side of not giving aspirin. The fact that you have a calcium score of 98 (on the low side but definitely not zero) still doesn't outweigh the bleeding risk in a person over 80. In my opinion, aspirin is more likely to cause more harm than good in your situation.

A statin drug is likely to cause more benefit and less harm, and if you aren't taking one, I would discuss this with your cardiologist when you discuss stopping aspirin. (I don't recommend that you stop without discussing this with your doctor. He may know something about you that I don't.)

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

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