Sunday, August 28, 2011

Say No to EMR

I have discussed the pitfalls of  electronic medical records (EMR) in a previous post
I discussed in that post why, for now, I just say no to EMR. Many doctors have no choice.

One argument advanced for  EMR is to create a national integrated database to improve patient care. And many of those supportive of a national health care system like “Obamacare” look toward England’s National Health Service (NHS) as a success story. 

Not! In many ways, not! By the way, read some of Dr. Scherz's thoughts on Obamacare. 

Now here’s more reason for concern for both EMR and mandatory national health care like Obamacare.

The Lancet, a highly respected British medical journal has called England’s National Programme for IT in the NHS “the world’s most mismanaged national health project”. As stated in the Lancet editorial, “the main aim of the project was to create a fully integrated centralized electronic care records system to improve services and patient care by 2007”. You read that right. By 2007!

It is clear that despite cost overruns and delays, the Department of Health is “unable to deliver a universal system”.

In the U.S. there are huge federal financial incentives for researchers, doctors and hospitals to study and adopt EMRs. These are your tax dollars at work. But there is no good evidence to support the use of EMRs. 

Take heed, all you enthusiasts of electronic medical records (EMR). 

Can we  learn something from this English disaster?                                                    Your Diabetes Endocrine Nutrition Group

Saturday, August 27, 2011

Chronic Kidney Disease:Things to Know. Part 2

In a recent post, I discussed things to know about chronic kidney disease for people with diabetes.

Among the things to know is that too often doctors, including nephrologists, don't prescribe drugs that are proven helpful for the kidneys.

There are several reasons for this inadequate care for people with chronic kidney disease due to diabetes.
A recent study deals with one possible reason. Results of this study are similar to a previous analysis.

Angiotensin converting enzyme inhibitors, abbreviated ACE inhibitors, and angiotensin receptor blockers, abbreviated ARBs, are the drugs with the best evidence for kidney benefit.

When an ACE inhibitor or ARB is started on a person with reduced kidney function, an increase in blood level of creatinine may occur. Blood creatinine, more accurately serum creatinine, is a measure of kidney function. In general, the higher the serum creatinine, the worse the kidney function.

So an increase in creatinine scares the doctor. She might just go ahead and stop the drug. She might be worried that the ACE inhibitor or ARB is making the kidney function worse because the creatinine went up.

It turns out that an increased serum creatinine is common within the first 2 months after an ACE inhibitor or ARB is started . And those people who have the increases in creatinine at the start of therapy actually have the best results over time from the drug. That means they have the most benefit at slowing the rate of loss of kidney function. Their kidney function is more likely to be stable over time as compared to people whose serum creatinine does not change soon after starting the ACE inhibitor or ARB.

An increase of  up to 30% in serum creatinine is okay. The increase in creatinine over the first two months or so actually means the drug is working.

So if you have chronic kidney disease, abbreviated CKD, from diabetes, ask if you are on an ACE inhibitor or ARB. If not, find out why not. If you are not satisfied with the answer you get, consider getting another opinion from another nephrologist.

After all, what can we offer people with CKD to prevent their kidney function from getting worse? Here are four things to know: ACE inhibitor or ARB therapy, good blood pressure control,  good blood sugar control and don't take things that might harm your kidneys. That’s all we have for now.

There is hope for additional therapy. An agent in development called bardoxolone shows promise.

In the meantime, be sure you do all you can and keep in mind these things to know about chronic kidney disease.

Sunday, August 21, 2011

Cinnamon for blood sugars

Does cinnamon improve blood sugars?

I saw a patient with Type 1 Diabetes last week using an insulin pump.
She told me she was taking cinnamon also to help her sugars.

So would cinnamon improve blood sugars in this person?

There are absolutely no data at this time in humans to indicate that cinnamon supplements help Type 1 Diabetes. But the story is quite different for Type 2 Diabetes.

In 2003, a report out of Pakistan suggested that cinnamon might help with blood glucose control in Type 2 Diabetes. Since then other studies have yielded mixed results. Some positive, others negative.

The most recent report of a larger group of persons with Type 2 Diabetes showed a 0.5% reduction in Hemoglobin A1c as compared to placebo. The trial lasted 12 weeks. All patients were also on prescription medication for their diabetes. The cinnamon was given 3 times a day at a total daily dose of 2 grams.

This was a well-designed, randomized, placebo-controlled trial.
Half a teaspoon of cinnamon is about 2.4 grams.
Lower doses of cinnamon appear to be ineffective.

The mechanism of cinnamon effect is probably by way of an improvement in insulin action. Keep in mind that not all cinnamon is the same. Cassia cinnamon is the type used in these trials. Most cinnamon sold as a spice has some cassia cinnamon in it.

The 2 gram dose of cinnamon daily appears to be safe in clinical trials. But these have been for only 3-4 months. Not nearly long enough to be sure about long term safety.

And the effect on glucose is quite small. Fasting glucose dropped only 14 mg/dl.

And the drop in Hemoglobin A1c is even less than what’s typically seen with the least effective prescription medications for Type 2 diabetes.

So if you decide to take cinnamon don't expect any big effect. And don't feel confident about long term safety. Even if it's natural.

Keep monitoring your blood glucose.
Keep up your visits with your endocrinologist.
And let him know if you are taking cinnamon.

Saturday, August 20, 2011

Actos Risks

Many patients have recently seen notices from lawyers about Actos risks.
In fact, if you search “Actos risks”, about all that shows up on the first page are tort lawyer firms looking for business.

So what’s up? Should you stop Actos? What are the risks?

Actos is the brand name in the U.S for pioglitazone. Actos has been available in the U.S. since 1999 for treatment of Type 2 Diabetes. Actos will be available as a generic in about another year. The price should drop by then. Actos is expensive now.

Actos works by making insulin more effective. Another way of stating this is that Actos reduces insulin resistance. Insulin resistance is reduced effectiveness of insulin. Almost all people with Type 2 Diabetes have insulin resistance.

The best treatment for insulin resistance is weight loss. Exercise also helps reduce insulin resistance.

When people with Type 2 Diabetes lose weight and exercise they have much better blood glucose levels and they are healthier overall. The problem is that most neither lose weight nor do they exercise. That’s where drugs come in.

Actos is a very effective drug for blood glucose control.
It does not cause hypoglycemia. And Actos tends to help maintain blood sugar control over years better than pills called sulfonylureas and better than metformin.

Actos can be combined with other medications including insulin. Good glucose control over time means a lower risk of the complications of diabetes.

Improvements in blood lipids often are seen with Actos. The HDL cholesterol and triglycerides improve. And fatty liver improves with Actos treatment.

So those are some of the benefits of Actos. How about Actos risks or side effects?

There were 4 main risks with Actos. Now a 5th has emerged.

There is an increased tendency to weight gain with Actos especially as compared to metformin. Leg edema or fluid with swelling under the skin of the legs is more common with Actos.

There is an increased risk of congestive heart failure with Actos. In one large study of over 5000 patients with Type 2 Diabetes, the risk of heart failure was 5.7 % on Actos and 4.1% with placebo, an inactive pill; that’s almost a 40% higher risk in the Actos users.

Heart failure is impaired pumping action of the heart.
Heart failure is not a heart attack.
Actos is not associated with increased heart attacks.
And no increased risk of death from heart failure has been seen in those on Actos.
Blockage in the arteries appears to be less with Actos than with glimepiride, one of the sulfonylureas.

The cause for the increased heart failure with Actos is not clear. It probably relates in part to the fluid retention or edema that can occur from Actos. For most patients, heart failure is not a problem. In that large study of over 5000 people, about 95% did not develop heart failure. And they were at fairly high risk of developing it for many reasons.
Keep in mind that diabetes itself, regardless of medications, increases the risk of heart failure.

The risk of fractures, broken bones, is higher for post-menopausal women taking Actos. That risk appears to be up to 2 fold higher in women on Actos compared to those not. Measurement of bone density is important in these women taking Actos.
I make sure that vitamin D levels are adequate for all my patients.

That brings us to the most recent Actos risk reported. A recent study conducted in France suggested an increase in bladder cancer. Bladder cancer appeared to be about 10-15% more frequent in Actos users versus non-users. Actos remains on the market in Europe.

Overall the risk of bladder cancer is very low: in one analysis, only 19 people developed urinary bladder cancer out of 12,506 who were taking Actos for years.

Another analysis was recently published  that examined bladder cancer in Actos users versus non-users in northern California. This study included 30,173 Actos users versus 162,926 non users of Actos. They found that those who used Actos more than 2 years were more likely to have bladder cancer.
But how much more likely?

They calculated an incidence rate of 69 cases of  bladder cancer out of 100,000 people treated each year who had Type 2 Diabetes and never used Actos. This number was lower than the 103 cases of bladder cancer in 100,000 people taking Actos for more than 2 years.

95% of the bladder cases in Actos users were at an early stage. The authors of this study could not fully account for factors that are known to increase risk of bladder cancer, like smoking.
So that means, there could have been, for example, more smokers in the patients taking Actos. And that could explain the differences that were seen.
More will be learned as this group of patients is reported on again next year.

For now, it is best to avoid Actos in those with a history of bladder cancer or heart failure.
All drugs for diabetes have their pluses and minuses.

No drug is perfect. I find Actos to be very helpful for many of my patients.

Good glucose control over time means a much lower risk of blindness, nerve damage and kidney failure from diabetes.

Before starting any new medication, I always discuss the risks and benefits with each patient.
How each person feels about the options discussed helps me to decide what might be best for that person. No one drug is good for all patients.

Fortunately, we have a fair number of drugs to choose from.
Our goal is to provide the best care for each person we see.
I hope this update helps you.

Your Diabetes Endocrine Nutrition Group

Saturday, August 13, 2011

Care for Chronic Kidney Disease; Things to Know

 I got mad this week when I saw yet another patient not getting the best care for her kidney disease.
She had been seeing a kidney specialist. The fancy name for kidney specialist is nephrologist.

Nephrologists don't do surgery on the kidney.
Those specialists are urologists.

But nephrologists specialize in kidney disease. So they should be experts on kidney disease. 
That means that they should provide top-notch care for chronic kidney disease called CKD. Right?

Well that’s not what my patient was getting.
She had CKD from diabetes and high blood pressure.

Somehow she got to this nephrologist. I didn't send her.

Not all car shops or car mechanics are the same and that goes for nephrologists too.

There are good guidelines on management of CKD available from the National Kidney Foundation. This nephrologist always seems to ignore those guidelines or not know them. And talking to him has not helped matters.

My patient was not on a drug that has been proven to prevent worsening of her CKD.
Her kidneys were failing.
And medication, that has been proven to help, had not been prescribed.
And this wasn’t because of cost. These helpful drugs are cheap now.

Her CKD is expected to get worse. Then she will need dialysis to take the place of her failed kidneys.

Sure there are many clinical guidelines for doctors to help provide the best care based upon the best evidence. Some guidelines are not too good.

But these guidelines from the National Kidney Foundation are really solid.
They are based upon many well done clinical studies

So it really irked me to see this patient not getting good care. In this case, I went ahead and prescribed the medication. It will also help take care of her high blood pressure.

If you have CKD from diabetes, you should be on a medication that works on the renin angiotensin aldosterone system. The main medications in this category are:
·      angiotensin converting enzyme inhibitors, abbreviated ACE inhibitors
·      angiotensin receptor blockers, abbreviated ARBs.

The ACE inhibitors are generic and cheap. At this point, one ARB, is generic. It’s called losartan. 
It is generally best to use high doses of these medications to get the most benefit for the kidneys. Many doctors prescribe wimpy doses. But a low dose is much better than no dose.

If you are below the age of 80, your blood pressure goal should be below 140 systolic. 
Systolic is the upper number. ACE inhibitors or ARBs are good medicines to use because of their many benefits.

But ACE inhibitors and ARBs are not very powerful at lowering blood pressure.
And many patients will need 3 or more drugs to get their blood pressure to goal. Getting the blood pressure to goal is important to protect your kidneys from further damage.

Get another opinion if you have questions about your kidney disease. 
Just because your doctor has a busy waiting room doesn't mean he’s worth going to. 
For many people it's easier to tell with your car mechanic.

Wednesday, August 10, 2011

What Causes Excessive Sweating?

 I saw a patient earlier this week troubled by excessive sweating.
He came into the office dripping in sweat, unlike his wife who remained dry and cool.
He told me he’d sweat anytime even when he was sitting still in a cool room. He had this sweating problem for about 3 months. 

What caused his excessive sweating?

There are many causes for excessive sweating. One hormonal cause of excessive sweating is an overactive thyroid. Most doctors know about overactive thyroid and check for it. Overactive thyroid is known as hyperthyroidism.

People with hyperthyroidism often feel hot when most other people feel cool or comfortable. People with hyperthyroidism often have other symptoms like weight loss, shakiness or jitteriness and feeling their heart beat fast.

And there are many other symptoms common in people with hyperthyroidism. Excessive sweating is just one of those possible symptoms. Endocrinologists, like those in our practice, are experts on hyperthyroidism.

But there is a far more common cause of excessive sweating. And many doctors, even endocrinologists, overlook this cause or don't know about it.
My patient did not have hyperthyroidism. He had a drug causing his excessive sweating.

Anti-depressant medications that work at least partly on serotonin frequently cause excessive sweating as a side effect. Some, but not all, of those type of anti-depressant medications are listed below with the brand names shown in parentheses:
·      paroxetine (Paxil)
·      sertraline (Zoloft)
·      citalopram (Celexa)
·      escitalopram (Lexapro)
·      fluoxetine (Prozac)
·      milnacipran (Savella)
·      venlafaxine (Effexor)
·      duloxetine (Cymbalta)
·      desvenlafaxine (Pristiq)

In my experience, some of these drugs are more likely to cause excessive sweating than others. And, of course, there are other possible side effects of anti-depressant medications.

In my view, paroxetine is about the worst of the lot (above) when it comes to side effects.

On the whole, many of these anti-depressants are very helpful medications.

But my main point here is this: keep in mind that some anti-depressant drugs can cause excessive sweating.
Often a cautious change to a different drug can be no sweat.

Sunday, August 7, 2011

Does cranberry really help prevent urinary tract infection?

Cranberry juice and drinks and pills with cranberry extract have been promoted to prevent urinary tract infections in women.

But does taking cranberry in one form or another really work?
If so, how much should you take?

First, keep in mind that no studies have shown that cranberry can be used to treat an infection that has already occurred.

But many studies, although not all, show that cranberry can be helpful for prevention of urinary tract infection.

But cranberry for prevention in those with urinary catheters does not seem to work.

In a study published last month, 221 women who had suffered from at least 3 urinary tract infections each year were given either a cranberry pill supplement twice daily or an antibiotic (trimethoprim with sulfamethoxazole abbreviated TMP-SMX) once a day.

This was a randomized study. That means patients were assigned randomly to one treatment or the other. There was no placebo group; that means all the participants had some form of treatment. In this case, cranberry extract or the antibiotic was given.

Over the next 12 months of the study, there were more infections in the cranberry users than those on the antibiotic. Obviously, that's not good news.

But those taking cranberry had less than they had had the year before the study: down from around 7 to 4 infections per year.
And the dose of cranberry given in this study was probably much too low.

Most of the women who took the antibiotic developed bacteria that became resistant to that antibiotic, TMP-SMX. There was more than 3 times the antibiotic resistance in those on the daily antibiotic as compared to those on the cranberry pills.

And resistance to other antibiotics besides the TMP-SMX was also more common in the group on the antibiotic.

Getting resistant bugs is not good. That’s for sure.

So what should you do if you are a woman who tends to gets more than 2 urinary tract infections each year?

Urinating after sexual intercourse can be helpful. 
Many urinary tract infections occur after sex. 
Emptying your bladder after can be a simple effective measure.

And talk to your doctor to get evaluated and consider use of cranberry.

Cranberry appears to be safe and if you take enough it probably helps reduce your chances of another urinary tract infection.

The active chemical substances in the cranberry are probably proanthocyanidins  that reduce the ability of the bacteria to stick to the lining of the urinary tract.

But it is not clear how much cranberry you need to take.

Also not clear: should you use pills with cranberry extract or drink cranberry juice or cranberry cocktail?

I suggest getting pure cranberry juice such as that made by Lakewood or R.W. Knudsen. You can add non-caloric sweetener or dilute it with water or other beverage.

You can’t drink straight cranberry juice! Wow, it’s tart!

If your infections are mostly after sex you might drink the juice around that time.
But if you get infections at any time not related to sex, you could drink juice daily or take daily pills. 
You will note that I am assuming you're not having sex daily.

More studies on cranberry are underway.

In the meantime, I hope this update was of help.

Has cranberry worked for you?

Tuesday, August 2, 2011

What Gives You Energy? That depends.

As shown above, I was hiking with a group in Glacier National Park (in Montana) last month. (See the goat?)
As you might imagine, I had no web access there to submit a blog post.

And I was kind of busy and focused on avoiding an untimely demise from plummeting down the mountain trails.

I returned home to view a reader’s comment on my krill oil post. She said that tuna gave her energy throughout the day. That got me thinking.

In terms of nutrition when nutrition experts say “energy” we mean calories.

Calories are used to describe the energy content of foods, just like inches are a measurement of length. Energy from food is measured in calories. This energy is used by your body for all its functions like heart pumping, muscle action and brain work.

I pulled out a can of tuna. In 7 ounces of chunk light tuna packed in water there are 175 calories and 38 grams of protein. Water packed tuna offers more omega-3 fatty acids for absorption than oil packed tuna: about 500 milligrams in that 7ounce can. You lose some of the omega-3 fatty acids if you drain the oil off from oil packed tuna.

Of course, you can choose to not drain the oil in oil-packed tuna. But if you do that and eat or drink the oil (yuk) you’ll get more calories you don’t need from all that vegetable oil.

I recommend the water packed variety.

And in terms of calories a can of tuna in water does not provide a lot.

But what else is meant when people, other than nutrition experts, speak of energy?

I think many people think of energy as an increased sense of alertness like you might get from a mental stimulant? Caffeine containing foods or drinks will provide this type of “energy” and in some situations caffeine may improve athletic performance.

“Energy drinks” like Red Bull all have caffeine in one form or another. Often the source of the caffeine in energy drinks comes from plants like mate or guarana. These plants naturally contain caffeine.

Many of these energy drinks are loaded with sugar and other additives of questionable benefit.

And caffeine, like most chemicals can cause side effects at high doses. But on the whole caffeine is quite safe.

That these “energy drinks"  have sold so well reflects highly effective marketing campaigns.

When it comes to energy to stay awake and function at your peak, don’t forget adequate sleep and regular exercise.

Exercise will help improve your sleep and better sleep means more energy to exercise.

While in Glacier National Park last month, hiking 6-8 hours a day, I slept well.
I didn’t need too much caffeine to keep me alert: concerns for falling, falling behind, and being eaten by bears did the trick. 

 What gives you energy? What do you do to stay alert?