GERM
00:00:09.200 – 00:00:11.360
Allillanchu! My name is Germ.

WORM
00:00:11.520 – 00:00:12.400
I’m Worm.

GERM
00:00:12.800 – 00:00:27.440
Welcome to the Germ and Worm Travel Health Podcast, episode 97: Blue Light and jet Lag. Is there a connection? It’s a big planet. See it in good health. I’m Dr. Paul Pottinger, also called Germ. I’m a professor of Infectious diseases at the University of Washington in Seattle.

WORM
00:00:27.670 – 00:00:35.430
Hi, I’m Dr. Chris Sanford, also known as Worm, Associate professor in the Departments of Family Medicine and Global Health, also at the University of Washington.

GERM
00:00:35.590 – 00:01:43.100
This is what we do here on this podcast, Chris: Field great questions from our listeners across the country and around the world on travel health. Today.

We’re going to get a bunch of them taken care of. They include, Who really needs an MPOX vaccine before they travel? What is the right Diamox dose when I climb a mountain? Why are airline tickets more and more expensive recently? And are guides deliberately poisoning tourists on Mount Everest? These questions and many more.

A reminder to all of our listeners. Please contact us with your travel health questions, your stories, and your tips for success. Or if you hear something on a previous episode you’d like us to clarify or correct, we’d love to hear from you. Just Visit our website, germandworm.com or send us an email germanworm@gmail.com Before we jump in, as always, our medical disclaimer.

This podcast is designed to inform, inspire, and entertain both, but you should not use this podcast as clinical care before you travel. Please see a qualified healthcare professional for recommendations specific to you and your itinerary.

So, Chris, here’s a question. This one comes to you and this is our title for the episode. What is the deal, if any, between blue light and jet lag?

WORM
00:01:43.660 – 00:02:55.510
Yeah, blue light basically is put out by artificial lights, LED lights, and also by your computer screen and your cell phone screen. The there’s this German word, zeitgeber, and what a zeitgeber is. It’s a cue from your environment that you should be awake.

So it would be like the sun or another bright light. And essentially blue light suppresses melatonin, which is a hormone in your brain that tells you it’s time to go to bed.

So the bottom line is that current recommendation is to avoid blue light for two to three hours before you want to go to bed. So how you can exacerbate jet lag is get to wherever you’re going.

And for the three hours before you want to go to bed, just stay adherent to something electronic like your laptop or your cell phone. Things that are better would be to Be in a darkened room before you want to go to sleep or be lit by an old fashioned incandescent light.

Heck, use a candle, get into it wherever you’re going.

But bottom line, and this is true even for good sleep when you’re at home, is to hold off on blue light exposure, laptop and cel for at least three hours before you want to be sleepy.

GERM
00:02:56.070 – 00:03:55.730
Okay, so I buy it. You had me at blue light. Like that resonates with me, I gotta say. How do I actually do this?

I mean, everything you said is totally common sense and I believe it, and yet I’m joined at the hip to my cell phone.

So I think one of the things I’d love to hear from our listeners honestly is for people like me who are, maybe you’re a doom scroller or maybe like me, you’re on YouTube or something.

If that’s a way to try to help yourself fall asleep, I think it’s to switch it up and can tell you for me it’s been this return to the romance of the, of the book. Like just a published, you know this, it’s made of paper, You’ve seen them, you can touch them, smell them.

An actual book, because then the light can be a warmer color light. You know, actually incandescent light.

I have one of those by my bedstand and read the book and you touch it, man, I find that I fall asleep much better honestly than I do if I’m on my phone now. Do as Dr. Pottinger says, not as he does. But I’ve tried to do this. That’s one thing that’s helped me. What do you think?

WORM
00:03:55.810 – 00:04:32.730
No, I think that’s a great idea.

I still am resistant to traveling with a Kindle, although in terms of word per weight ratio, a Kindle is phenomenally better than these antiquated physical books that I still travel with. One thing you can do if you are addicted to your electronics, as are we all, there tends to be a night mode available on both laptop and cell phone.

And if you click on the night mode or it’s called other things, dark mode, better for sleep mode that actually is halfway there.

So definitely at night, don’t get the full bright screen, but put it in that it changes the col pattern, it decreases the blue light and that’s a big step in the right direction.

GERM
00:04:33.450 – 00:06:15.610
Okay, so let’s hear from our listeners other things that they have found to be helpful in this context. I like that a lot. I’m going to give you a quick preview on something else you mentioned jet lag and light, and this really caught my attention.

I had no idea this was happening here at my own university. It’s very strange, very exciting, and to me, totally unexpected. And that is the question. It’s just a question.

Is it possible that liver cancer could be related to our circadian rhythm?

I’d never thought about this before, and this is not at all established, but I was fascinated to learn that some of our colleagues here in Seattle at the Fred Hutch Cancer Research center are looking into this question of whether hepatocellular carcinoma, a bad form of liver cancer, could somehow be related to a disruption of our circadian rhythm. If we don’t sleep and wake in a reasonable time, does that put us at higher risk of cancer? And, you know, jet lag is one way that that happens.

So mad respect and fascination with our colleagues, including Professor Trang Vo Pham, who are looking at this. This is a grant that’s now been awarded to our colleagues at Fred Hutch to look at this.

I think the award’s close to a million bucks from the American Cancer Society to try to understand whether this may be. Stay tuned. I think that study is going to take at least a year, if not longer. So as we learn more, we’ll share it with you.

Meantime, if you read about this study and you start getting scared about kitchen liver canc from jet lag, it’s a little bit too soon. And I would not say that you should avoid international travel to avoid liver cancer.

I would say yet another reason for us to really be organized, thoughtful about trying to keep our circadian rhythm, you know, in a good situation. And try not to get too much jet lag.

WORM
00:06:15.850 – 00:06:43.770
Yeah. This research hypothesis is not yet actionable, so I’m glad they’re looking at this, but don’t change anything. There’s no proven link yet.

We’ll keep you up to date should something interesting be published on this. All right, Paul, next question for you. This is about mpox. Is it still a thing? Do I need to get the vaccine?

And if not, everybody who needs to be vaccinated for mpox?

GERM
00:06:44.489 – 00:10:42.740
Yeah. Thanks. So is MPOX still a thing? I think yes. This is a viral infection that’s closely related to other pox viruses, including smallpox.

As we’ve talked about here on germ and worm. Many times, the MPOX infection can be very severe and debilitating. In fact, in some cases, it can actually be life threatening.

But for people who acquire Mpoke, it’s a miserable state of affairs. People feel very sick. They have a Vesicular or blistering type of rash on their body.

And this can often be spread through very intimate contact, including sexual contact. And that means that parts of the body that get heavily involved are often where the infection gets into the body.

So this could be the genital area, this could be the rectum, could be the throat. And I’ve worked with patients who have battled this and recovered, and it’s just a miserable thing.

So we really do want people to feel empowered to protect themselves against mpox. But to this listener’s question, does everybody need to have this vaccine? No.

It’s only those who are epidemiologically at greatest risk of acquiring mpox.

So current guidance from our own federal health sources, which I happen to agree with, and also colleagues internationally, say, you know, mpox vaccination is recommended for people who anticipate having high risk second activity, whether domestically or overseas. Okay.

And high risk sexual activity is defined as having sex with a new partner or paying for sex or exchanging some other goods or service for sex, like drugs, for example, or social status.

Or if you anticipate going to a large social event where there might be sex afterwards, then you should very much talk with your physician about getting immunized against mpox. This is agnostic. Doesn’t matter your sexual orientation, doesn’t matter your gender identity. It’s about that high risk experience.

Now, it’s true that in the United States, most of our people who have battled mpox have been men who have sex with men, but that’s not exclusively the case.

So if someone is thinking of traveling internationally, getting a new sex partner, regardless of that traveler’s gender orientation or the gender orientation of the person they might have sex with, it is usually in your best interest to get that MPOX vaccine. And again, if you’re unsure, talk with your physician. Why are we raising this? Mpox has been around for a while.

I think people are somewhat familiar with the concept. But the virus is changing, right, Chris? It’s not going away.

In fact, as we’ve mentioned before, there are two broad families, probably different genetic lineages of Mpox, Clade1 and Clade2. Most of our experience with people battling MPOX here in the United States has been clade 2.

Therefore, it’s very concerning that we actually see more Clade 1, especially Clade 1B, a different lineage in people who are acquiring this through sexual contact, including in Europe. Clade1B has been around in West Africa, for example, for quite some time.

No surprise, I suppose, that it’s now getting away from West Africa, including to Europe. So if you are planning to visit any place internationally, the risk of clade1b seems to be on the rise. Case in point.

We have reports from colleagues in Germany, especially in Berlin, that they have more than 30 cases of people who are infected and diagnosed confirmed with Clade 1B. The difference between Clade 1B and Clade 2, they’re both bad, but Clade 1B is often worse.

More severe syndrome and potential and risk even for more life threatening infection. You don’t want either of these infections.

The good news is that the vaccine that we’re talking about, trade name is Jyneos It is a safe and good vaccine and it is best studied for its protection against Clade 2 because that’s what we’ve seen most here in the U.S. but it should also have very high levels of protection, we hope probably around the level of 80 to 90% or maybe higher against clade 1B. So regardless of whether you think you might be exposed to clade 2 or clade 1, get your Jyneos on.

And again, if you have questions, I hope that our listeners would talk with their physician about this.

WORM
00:10:43.380 – 00:11:38.360
Yeah, and just to stress again, the people I’ve seen with this are miserable, it’s painful, it takes you out of circulation for a long duration. If you are in an at risk group, definitely the vaccine is the lesser of two evils. Paul, next question also for you.

And I was kind of saddened to read about this, this whole thing that came out of out of Nepal. There was some recent press that apparently some immoral tourist businesses in Nepal are deliberately poisoning tourists.

And this is in conjunct corrupt insurance people. And basically it’s a big scam to get money from insurance companies. Is this a real thing? Are guides really poisoning tourists on Mount Everest?

GERM
00:11:39.080 – 00:16:15.010
So the quick answer is no, that’s not happening. So the question is where do these headlines even come from? So it’s super fascinating that there’s something about Everest right now.

As you know, we’re recording this conversation in mid April 2026. This is the climbing season. I have friends and colleagues up on Everest doing their best to come up and down safely.

So there’s a fascination with Everest because it’s the world’s tallest mountain, it’s difficult to climb and there are a lot of people who do this.

And so it gets a lot of media scrutiny and that means that there’s also the possibility for media malfeasance and some fake stories getting out there. So sensationalistic headlines, are they real? Probably not.

But there’s as usual with any kind of Conspiracy or fake news, there’s going to be some grain of truth. So the grain of truth seems to be this.

And I’m basing first of all, as somebody who climbed Everest in, well, was on an Expedition 15 and got to the summit on 16, I’ve never heard of such a thing. If this is actually happening, it’s got to be rare as hen’s teeth. And so stay tuned. We’ll get more information about this as the proceedings go.

But yes, it looks like the government of Nepal, the Tourism Ministry, is looking into reports that there are a handful of out of many thousands of wonderful outfitters, there may be a handful of people who have tried to game the system. And what do I mean by game the system?

The biggest opportunity seems to be people who are faking medical illnesses or medical records on behalf of the people who they are guiding into the Khumbu Valley on the way to Mount Everest, pretending that they got sick and needed to be evacuated.

There’s reports that some of these guides are encouraging people who are feeling unwell to take a helicopter ride down either back to Lukla or straight back to Kathmandu. All the way. That helicopter ride, you know, it can be thousands of dollars per patient who is medevaced.

And so the allegations that we’re preliminarily reading about is that a handful of these folks may, in certain cases have been in cahoots and collaborated with each other, doctors, guides, X ray technicians, that there’s been some sort of scam going against the insurance companies, the evacuation companies, so that there’s been an increase. And this, I think is very true. We’re seeing a lot more helicopter traffic in the Khumbu.

And in some cases this is done in order for the people who are guiding those people getting evacuated to get a kickback, to get some kind of slice of the pie so that the travel insurance companies will receive claims for illness or injury. And those claims may or may not be true. That usually I think they are.

But that’s the allegation here coming from official channels in the Tourism Ministry in Nepal. Exactly how it works is not clear to me.

We have reports that some people used another person’s chest X ray to make it look like somebody really couldn’t breathe. Right. They’re having pulmonary edema. It wasn’t even that person’s chest X ray.

But exactly how the money has flown, the corruption that is alleged to have happened, I don’t have the details. And again, you mentioned somebody actually getting poisoned to be sick. They had a GI illness, so they had to be evacuated.

That is really hard to believe. Honestly, I just can’t quite wrap my head around it. I’d be surprised if that actually became true.

I think this is more about people who are generally feeling like crap because they’re climbing up to above 17,000ft in a very challenging environment. Beautiful. Incredible. You should do it. It’s hard.

And so I think this is about people getting sick anyway who are then being encouraged to avail themselves of the evacuation insurance that they already have. That apparently has happened. I’ve never heard of such a thing. And again, I’ve been to Nepal three times.

It seems to me inconceivable, but I guess, you know, like any society, there might be a handful of bad apples. Don’t let them spoil the barrel.

If you’re thinking of going to Nepal, the chance of you getting poisoned by your guide is approximately zero, I promise you. So this should not turn people off from it. It is a reminder, having said so, that I think evacuation insurance is actually a good thing to have.

I benefited from that. When there was a big earthquake in 2015, I had to fly down from Camp 1 to Base Camp.

Look, I was going to fly anyway, but it saved me a little money to do it. And then number two, it is a warm, welcoming ethos of the people, especially those who are indigenous to the Khumbu Valley.

That’s the Sherpa people and they love having outsiders come in. And I have just never ever heard of a Sherpa person or guide abusing their clients. There’s no financial incentive for them to really do this.

It would get a get a bad name for the entire valley. It’s just. I think this is largely fake news, but stay tuned, let’s find out.

And I actually was very grateful to read a very nice report in Outside Online. It’s a great magazine. If you want to read more about this good perspective on Outside Online, I would encourage our listeners to do so.

Chris, what’s your take on this?

WORM
00:16:15.010 – 00:16:34.980
Well, first, I’m glad to hear you are generally skeptical of this alarming report. I’ve never heard of such a thing personally, you know, from any of the many people I’ve taken care of. I do have a follow up question.

Suppose I’m thinking about climbing Everest. What is the best way to make sure I end up with a reputable climbing service? A guide service?

GERM
00:16:35.380 – 00:17:58.310
Yeah, that’s a really important topic. And we talked about this a little bit with respect to. Yeah, you and I had a recent conversation about my own experience on Everest.

So Chris, thanks for asking about that. You and I had a conversation on this in episode 95 and I’m hoping that people can go back and listen to that.

That’s a little bit of my reflection on my own experience climbing Everest. And I give some tips on how people can potentially select a high quality guide. But the bottom line is it can be word of mouth, that’s okay.

But if you’re going to actually climb versus Trek, that’s a huge difference. But either way, I just want to say, you know, you want to have somebody who you have direct experience with when possible. Most people will not.

And so don’t let price alone be the only thing that guides your decision. If you have a friend who’s used a particular guide, that is all word of mouth is always a great way to go. And then do your due diligence.

It does not have to be a Western guiding company. You can use a Nepalese guiding company. There are many that are excellent. In my own experience.

If you’re unsure, and you have been, you’re relatively new to the adventuring trekking world, it would be totally reasonable to start with an American outfitter or if you’re listening to us in Europe, to start with a European outfitter.

If you’re starting in Australia, start with an Aus group, somebody who you know and can actually do a little bit of homework with directly before you go. The bottom line is, please do not just show up ready to make that trip.

You want to have conversation with them and communicate ahead of time so you get a sense of whether you trust this group.

WORM
00:17:58.710 – 00:18:02.070
So not with Steve’s tour guides on his first expedition?

GERM
00:18:02.070 – 00:18:38.160
Depends who Steve is. If it’s Steve House, that’d be great. But most Steve’s, I would say probably.

Okay, Chris, here’s a question for you.

This is part of our ongoing series. I’m going to brand it RFK Watch. Remember baywatch from the 80s or the 90s? This is RFK Watch.

By the way, there may be a Venn diagram where people who love Baywatch also love RFK Watch. I’m not sure, but we’re going to call it RFK Watch. So what’s the latest? Would you please give us an update on RFK junior?

And I should say junior for sure, not rfk, but RFK Junior. What is RFK junior doing lately that we should be concerned about?

WORM
00:18:38.880 – 00:20:42.060
He’s a drunk bull in a china shop.

So there’s this thing, this very constructive, high level, intelligent group of people called the uspstf and that stands for United States Preventative Services Task Force, Bright Docs World and US Experts, they get together regularly, they work with the CDC and they come up basically with recommendations for preventative care.

So they, after consultation with researchers and literature, they decide how often they’re going to recommend your screen for breast cancer or colon cancer or cervical cancer and what about screening for diabetes and cholesterol and a bunch of other preventative things. And they actually come out with important recommendations that I, as a family practice doc, adhered to.

So if they say check for colon cancer every so and so years, I would do that because I have faith in the quality of this group. They meet several times a year, or they did meet several times a year. They actually haven’t met now, I think for over a year, which is terrible.

This is very important that these things, these recommendations are updated on a regular basis. And also insurance companies tend to pay for these recommendations and not pay if they don’t recommend it.

So stopping this is catastrophic on a national level, I think it’s going to lead to a deterioration in health metrics by which I mean it’s going to cause more people to get sick and to die. So it’s just one more thing that this non medical professional weirdo is doing to all our health care system.

And it’s not just germ and worm who have a dim view of RFKG Jr. And what he’s doing. If you look at Lancet, which is the primary medical journal in the UK, they had a recent cover and it just said RFK Jr. One year of failure.

And there was a very vehement and appropriate description of all the harm he’s inflicted on Americans. And this isn’t going to go away soon.

I hope he’s out of this position as Secretary of HHS soon, but it’s going to take years to decades to undo all of the damage he’s doing and all of the doubts he’s instilling about vaccines and other health care issues.

GERM
00:20:43.510 – 00:21:45.850
Yeah, I’m with you.

And I think for our public servants who take an oath of office and swear their allegiance to the people and the government of the United States, not to whoever sit in the White House, but to the people, that’s the oath that those people take for us as physicians.

When we graduate from medical school and become doctors, we swear that we will first do no harm and that we’ll do what we think is best for the people. And in this case, I suspect if we could actually sit him here, which would be a desecration of our recording studio, we could actually Talk to him.

He would say the same. He actually thinks he’s doing the right thing. It’s just that it’s so obvious to everyone with any qualification that he’s not. This is the problem.

And I think cancer is on the rise in the United States. Our life expectancy is going down. I’m an infection person, right. An ID doctor. But I gotta say, this goes well beyond infectious diseases.

We’re talking about other preventative things that are not being appropriately looked at. And so I’m just really. Anyway, the United States Preventative Services Task Force is important and I really wish that they could get back to work.

WORM
00:21:52.410 – 00:22:05.930
All right, Paul, this is coming to you. I’ve bought a few jet tickets recently and they’re more expensive. What’s going on?

Why are jet tickets in the US and in fact worldwide more expensive of late?

GERM
00:22:07.090 – 00:24:59.710
Yeah, I mean, no surprise. Turns out that when you go to war with a country that controls one fifth of the oil on the planet, that everything’s going to get more expensive.

People go to the gas pumps, they’re finding these record highs when they try to fill up their car. And the same is true, right, as a knock on effect with filling up your jet.

So it turns out that the price of jet fuel is a fifth to a third of the cost of that operation of that flight. And so it’s true, these commercial airlines, it’s not a charity.

They are, at least here in the United States, they’re definitely businesses, they definitely have shareholders and they’re there to make a profit. So as their operating costs go up, they pass that on to the consumer. That’s not the whole story. I think it’s actually more complex.

Right, but that’s an obvious thing to say, hey, as jet fuel prices go up, the price of your ticket is going to go up. But it’s more than that. Right. What are we talking about?

As of last month, mid March, you know, at the beginning of the war in Iran, we have this, you know, cost that’s gone up substantially even during that month or so. There’s about a 20% increase in the ticket price of most average costs of most domestic United States flights.

And so that’s pretty much straightforward that. That’s exactly the proportion of operating costs that comes from that. But it’s more than that too.

It’s also the fact that people don’t know what the hell’s going to happen next. Right. You look at the stock market, how volatile that is. You know, these are people who are looking at commodities trends, supply chain.

It’s that uncertainty. And frankly, it’s more than that. I think. I think it’s because they can do whatever the hell they want. There is. I mean, competition takes you so far.

But I’m not saying that these companies are all in cahoots with each other, but any excuse that they have to charge more, they’re going to do that. That could be the charge of checking your bag, could be the charge of reserving your seat. If you see this.

So some airlines are now saying, oh, you want to have a seat, you got to pay us more to reserve that seat. I’m looking at you, Southwest. So it’s just. It’s very aggravating, and I think it’s annoying and unfair and.

But it’s also an economic experiment, isn’t it, Chris? If people are willing to pay these higher prices, regardless of the excuse they come up with, real or imagined, they’re going to keep doing this.

So do we, as the American people, like I live and work in America like Chris does, I think it’s true globally as well. Do the consumers say, we’ve had enough and we’re not going to do it anymore, and so we’re not going to pay, you know, we’re going to travel less?

I think that could be coming with an overall generalized global and certainly domestic U.S. economic downturn that really seems to be happening. I think the only thing that’s propping up our economy is AI, which I don’t even understand is a real thing.

We’re going to have an economic downturn, travel will reduce, and in that context, I strongly suspect that these prices will go down. The X factor is the oil, because I do not see the Strait of Hormuz opening up anytime soon to let oil barrels come through.

So I think this is complicated. I think it’s aggravating. I think it’s very real.

WORM
00:25:00.270 – 00:26:00.490
Yeah.

And something I see along with this is not only are airlines charging additional money for tickets and ancillary services like seat selection, but they are putting increasing pressure on the traveler to have to choose the ancillary services.

And what I mean by that is, if you don’t pay the extra money for seat selection, not only, of course, are you in the middle seat, but I just flew a few days ago and I chose not to pay for seats selection, and I wasn’t assigned a seat. So I got to the gate, you know, 15 minutes before my flight, and they say, you don’t have a seat yet. We’ll give you one in a few minutes.

And they sent out a thing it’s like, oh, we’ll give you money if you don’t fly today. So I wondered if I was going to be bumped, and I sort of felt like I was in group Zeta Zeta.

You know, everybody in the airport got on the jet before me and my wife did. And I sort of felt like it was yet more pressure to spend money to fly as we used to fly with no additional fees.

So the trend, unfortunately, I’ll just say that flying is not as much fun, especially US Carriers, as it used to be.

GERM
00:26:01.210 – 00:26:15.530
And ain’t that sad? Okay, Chris, here’s a question about travel insurance. Can you get it for any destination in the world where you plan to go?

WORM
00:26:16.090 – 00:27:43.630
No. First, travel insurance often is a good idea, especially if there’s some uncertainty in your life.

Basically, you pay a little bit of money up front, and that way if you have to change your plans or cancel flight or accommodations or car rentals, you get the money back. If you’re super sure that everything’s going to unfold as you think it will, which is never the case, then, it’s less important now.

I tried to buy it recently. I did buy it recently, and I went to a site I really like called squaremouth.

Squaremouth.com and squaremouth is essentially a clearinghouse for, I don’t know, 20 or so different insurance companies selling travel insurance and health insurance and evacuation insurance. And I read in the fine print, though, when I selected a company and bought it, that square mouth. None of the companies cover about 20 countries.

And this would include Afghanistan, Belarus, Democratic Republic of Congo. And this list of about 20 countries is almost identical to the U.S. state Department Category 4, Level 4 advisory travel advisories.

So it’s very unstable places. North Korea, Russia, Somalia. So I don’t think you should go to one of those 20 countries as a general rule anyway.

Most of them, there’s wars, there’s civil unrest, there’s a high level of crime or some other threat. And the US Embassy cannot help you if something bad happens to you there.

But this is yet another reason to avoid those very tumultuous places in the world, is if you go there financially, you’re on your own. You can’t get off an evacuation insurance or trip insurance.

GERM
00:27:44.530 – 00:28:05.090
Well, I agree. And as a friendly reminder, we’re not monetized here and we are not sponsored by square math.

Actually, I need to check out that you’ve been recommending that website to me for years. I will check it out next time I need travel insurance, which will certainly come up, but that’s One that we are not sponsored by.

It’s just the thing that you found in your own experience that your patients like and that you personally have used and had a good experience.

WORM
00:28:05.810 – 00:28:12.490
However, square mouth, if you’re listening, it’s journeymanwormmail.com large denominations accepted.

GERM
00:28:12.490 – 00:28:16.550
All right, so if they actually give us a call and we get monetized by them, we’ll have that in our discord.

WORM
00:28:16.550 – 00:28:17.230
We’ll let you know.

GERM
00:28:17.310 – 00:28:18.190
We’ll let you know.

WORM
00:28:25.150 – 00:28:52.770
All right, Paul, this is for you. And this comes from Evelyn in Seattle. Hey, German worm.

I’m hearing some varying views about Diamox, AKA acetazolamide, and was hoping you could help me.

When I took Diamox in the past for mountain climbing, I started at one to two days before the hike, but then I stopped it at my maximum altitude while still on the mountain. Some other folks, not medical, said, no, no, no, I was doing it all wrong. One needs to stay on it if you choose to take it at all.

What is your opinion? Sincerely, Evelyn.

GERM
00:28:52.850 – 00:32:32.980
Evelyn, you are correct. You did great.

At least that’s the best state of the art that we currently have from the Wilderness Medicine Society, which has a beautiful set of guidelines on this. It’s limited by the fact that the studies in this area are not as sufficient as we want them to be.

But yes, you have followed the rules and that’s what I personally have done. I’m a mountaineer also, so that’s what I have found to be helpful as well. What is acetazolamide? This is a carbonic anhydrase inhibitor.

What that does, in a nutshell, is it will very slightly drop the ph, very slightly acidify the PH of your blood. As our blood holds onto more carbon dioxide, in other words, as we get a little bit more acidic, we will breathe more deeply.

So that’s basically what happens here. Our body is driven to breathe more deeply in order to exhale carbon dioxide. Carbon dioxide, that’s the oxygen we breathe in plus the carbon.

That is a waste product of our metabolism. And that happens as we get a slightly lower ph. So as your PH of the blood drops, you are driven to breathe more deeply.

That’s important because as we go higher and higher, of course, there’s less oxygen. Now, the proportion of oxygen we breathe never changes. It’s still 20%. Just there’s less 20% because there’s less pressure up there.

So especially at nighttime, I’m not too worried, honestly, about the day. But it’s mostly at night when we sleep, people tend to Breathe less deeply during sleep anyway. Right, Chris?

This is something that happens to most anybody, but especially folks with obstructive sleep apnea, people who may be a little bit heavier, etc. If you don’t breathe deeply at nighttime, you’re going to wake up with a terrible headache.

You’re going to be at higher risk of getting into a number of complications, what we call acute mountain sickness. So I like that idea a lot that this forces us to breathe deeply when we sleep and to sleep well. Sleep is such an important restorative process.

It may also have benefits during the day.

But typically when people are breathing in the day, they’re working hard, they’re breathing deeply because they’re hiking, they’re moving up higher and higher. The duration is what you said, Evelyn.

I like to have people start this the day before I actually start it personally, the day that I depart or start going up, and that we should do it as 125 milligrams twice a day. When I started back more than 10 years ago, close to 20 years ago, it was closer to 250 milligrams. That’s way too much. So 125 is fine.

I personally take that as half a dose at 62.5 milligrams. But that’s not official. That’s just what I do.

I have found that that’s enough for me and that we do that for, well, the official guidelines say two to four days. The average is three of your new sleeping altitude. Not your climbing altitude, but your sleeping altitude.

If you had a new sleeping altitude, let’s say it’s 14,000ft. Every night you spend at 14,000ft, you should take that dose twice a day. But if you’re going to stay there beyond three days, you can stop.

The benefit to side effect ratio is impaired. At that point, you may have side effects. What are the side effects of acetazolamide? Number one, you’re going to be up all night peeing.

This is a diuretic, so that can interrupt sleep architecture. Number two, you actually make less cerebrospinal fluid. The CSF is the watery juice that bathes our spine and our brain.

And so you may get weird headaches, you may feel woozy and dizzy just for that reason. Number three, your mouth, your fingertips, toe tips, pins and needles, feeling. Because you’re breathing so darn hard, you get that sense.

It’s almost like you’re hyperventilating. And finally, if you try to drink a beer, it’s going to taste terrible. Any carbonated beverage tastes rotten, too.

So there are side effects with this medicine. On balance, I think it’s helpful.

But I would not go beyond three days at a new sleeping altitude, and I would not continue it after I begin my descent. Once you start going down, whether it’s a trek or a climb, I usually stop. And there are some people who do it differently. That’s how I roll.

Chris, what’s been your experience, please?

WORM
00:32:33.060 – 00:33:42.950
Well, there are some drugs that you need to take an exact amount of. So for example, there’s a blood thinner called Coumadin, and you need to take exactly a certain amount.

So we say medically that that drug has a narrow therapeutic index. However, Diamox, also called acetazolamide, has a wide therapeutic index. So everything Paul said is true.

But you could not take it at all and climb a mountain and see if you could get symptoms and start it at a higher dose. If you do get symptoms, you could take it for three days.

You could take it for three days, stop at altitude, see if you get symptoms, and if you do, take a few more days. So there’s a wide variety of protocols and there’s not just one.

So I agree, in answer to your question, it’s okay to stop after you’ve been at altitude for a couple of days. But there’s no one fixed protocol. Taking the drug is not mandatory.

Frustratingly, you might think, well, I’ll only take it if I’ve had mountain sickness in the past, and I haven’t, so I don’t need it.

But concerning all forms of mountain sickness, whether it’s mild acute mountain sickness or serious haste or pace, having it or not having had it in the past is a very poor predictor of getting it in the future. So you may get it even if you’ve been to altitude in the past and never had any trouble with altitude.

GERM
00:33:43.190 – 00:35:00.410
Yeah, I agree. And, Evelyn, to your question, we’re talking about the prevention of acute mountain sickness. You may get acute mountain sickness regardless.

In that case, this can still again, be a helpful drug. We’ve talked about this before. If you have acute mountain sickness, go down number two if you’re going to use this medicine as treatment.

Actually, we double the dose up to 250 milligrams per dose. That’s different from the preventative dose. We appreciate you asking about this. I hope you have a great experience in the high mountains.

Send us a postcard, a picture or whatever form of media you want to share. We’d love to hear from you and let us know your experiences good, bad and otherwise with Acetazolamo. Everybody.

That’s a wrap for episode 96 of Germ and Worm. As always, we welcome your questions on Travel Health. Please send them to us along with your tips for success or suggestions. Corrections.

Find us online germandworm.com or shoot us an email germandworm@gmail.com If you have enjoyed this episode, please subscribe to us, rate us favorably on your device and spread the word with friends, family and we’d love to see you on the socials. Those are free ways to support this podcast. I’m Germ.

WORM
00:35:00.410 – 00:35:02.970
I’m Worm. It’s a big planet. See it in good health.

GERM
00:35:03.050 – 00:35:23.270
We look forward to seeing you next time.

This podcast is designed to inform, inspire and entertain, but it does not establish a doctor patient relationship and therefore it should be not replace your conversation with a qualified healthcare professional. Please see one before your next adventure.

The opinions in this podcast are Dr. Sanford’s and Dr. Pottinger’s alone and do not necessarily represent the opinions of the University of Washington or UW Medicine.