Saturday, November 26, 2011

Is CoQ10 worth taking?

Is CoQ10 worth taking? After all, CoQ10 is a fairly expensive supplement.
Is CoQ10 worth the cost?

And what is CoQ10? 

CoQ10 is also called ubiquinone or Coenzyme Q10. Although CoQ10 has been called a vitamin by some promoters,  CoQ10  is not.

Our body makes CoQ10 so that means it is not a vitamin. Vitamins are certain substances required by the body for normal function. Vitamins cannot be made by our body and must be taken in the diet.

CoQ10 has an important role in the function of our mitochondria. Mitochondria are found in most of the cells of our body. Mitochondria are involved in a multitude of cell functions. Mitochondria are the center for energy production in the cell but mitochondria do much more than that. And CoQ10 is important for normal mitochondrial function.

CoQ10 also can serve as an antioxidant. CoQ10 is also found in other parts of our cells besides mitochondria.

So what is the evidence for taking CoQ10? Is CoQ10 worth taking?

The most recent and best evidence come from randomized controlled clinical trials. In these randomized controlled clinical trials, the participating person gets either CoQ10 or placebo. See my post on clinical trials.

Because statin therapy may lower blood levels of CoQ10, studies have looked at whether supplementing with CoQ10 might be beneficial in those people who get muscle problems while on statins. The results are not convincing of benefit. 

There have been two published randomized controlled trials that explore CoQ10 treatment in people with muscle symptoms while taking statins.

The larger study  that lasted longer and used a higher dose of CoQ10 showed no benefit but the patients in that study may not have had such severe muscle symptoms. The other smaller study that lasted only 1 month suggested some benefit, less muscle pain, with 100 milligrams of CoQ10 daily.

Other studies suggest possible benefit for heart failure, muscular dystrophy, high blood pressure , migraine prevention, dry mouth and sperm function.These studies are small and all require confirmation.

If you have muscle aching while on a statin you might try a CoQ10 supplement. 
If you notice no benefit after about a month, stop it. 

We all await the results of more studies on CoQ10
In the meantime, I would suggest that most of us should just save our money. 
CoQ10 is not worth taking.

Saturday, November 19, 2011

Cycloset benefits

Have you heard of Cycloset?
Cycloset was approved by the U.S. Food and Drug Administration (FDA) in May 2009 to treat Type 2 Diabetes.  
That’s over 2 years ago. But I suspect you have not heard of Cycloset.

Yet Cycloset benefits are many. These include lowering blood glucose without causing hypoglycemia (too low blood glucose) and reducing serum triglycerides. And Cycloset does not cause weight gain.
But most important are Cycloset benefits to the heart.

But what is Cycloset? Cycloset is a special quick release formulation of bromocriptine. Bromocriptine has been on the market for over 35 years. Bromocriptine has been used to treat elevated prolactin levels and to treat Parkinson’s disease. So we have a thorough understanding about the safety of bromocriptine. After all, it has been well studied over the past few decades.

Side effects of Cycloset are mostly nausea, dizziness and headache. These tend to be mild and go away over time. And slowly increasing the dose over several weeks and taking the pills with food helps. For most people, these side effects are no big deal.

Cycloset lowers blood glucose modestly.  Fasting glucose drops around 20 mg/dl and after meal glucose drops around 35-50 mg/dl. The Hemoglobin A1c (Hgb A1c) drops around 0.5 to 0.9 %.

These effects on glucose are about as much as you get with the DPP4 inhibitors.
That class of drugs for Type 2 Diabetes includes Januvia, Onglyza and Tradjenta.  
I bet you’ve heard of at least one of those DPP4 inhibitors. They are prescribed fairly often. Especially Januvia; it’s been out the longest.

But I think doctors should be thinking of Cycloset before a DDP4 inhibitor.

Why? Here’s the story.

The FDA requires that all new drugs for diabetes have to be tested for heart safety. That means usually that a clinical trial has to be performed in which the drug is tested versus placebo and the number and type of cardiovascular events is carefully evaluated.

The idea is that any drug used to control the blood sugar for people with Type 2 Diabetes should not increase the risk of heart attack, heart failure or stroke.
Of course, it would be great to reduce those risks but at a minimum the drug should not increase cardiovascular risk. This recent FDA requirement for drugs for Type 2 Diabetes came about after the uncertainty about the heart safety of Avandia.

All new drugs for Type 2 Diabetes are being studied for their cardiovascular safety. 
The study with Cycloset has already been completed.

Cycloset or identically appearing placebo was given to about 3000 adults with Type 2 Diabetes. The average age was 60 years and 31 % already had a history of coronary artery disease and about 5 % had a previous stroke.

Only 12% of the group were using just diet for control of their blood glucose.
The others were on pills or insulin. The study participants were followed closely over 52 weeks. The main result planned was the combined rate of several cardiovascular events. These events included heart attack, need for bypass surgery, hospitalization for heart failure or angina and stroke.

The risk of a cardiovascular event with Cycloset was 42% less! There were 3.2% events in those on placebo but only 1.8% in those on Cycloset.

And many of the patients in the study were already on the usual drugs shown to reduce cardiovascular risk, like aspirin, statins and ACE inhibitors.

How might Cycloset reduce cardiovascular risk? The answer is not known.
There are many possible mechanisms.

 But the clinical results are clear. This is the first medication for Type 2 Diabetes that appears in a randomized placebo controlled clinical trial to reduce the risk of cardiovascular events.

I think Cycloset should be considered more often for people with Type 2 Diabetes. 
And now you know why.

Saturday, November 12, 2011

Prevent Kidney Stones

Did you know that you can prevent kidney stones?

Several weeks ago a patient brought in two kidneys stones she recently passed.

How miserable and painful is passing a kidney stone? Extremely!

Many say it’s the worst pain they have ever had. Women who have experienced both labor and passing a kidney stone say that a kidney stone is far worse than labor.
So wouldn't you think that people who have had a kidney stone would want to do all they could to prevent kidney stones from forming in the first place?    I think so. 

And half the people who have had one stone will have another over the next few years. Some people have many stones in their kidney just waiting to pass at some later date.

Those people who have more than one stone we call recurrent stone formers.
Yet it's amazing that so few stone formers are doing anything to prevent kidney stones from forming.

Maybe that's because they just don't know any better.

Most people have been told that drinking more fluids can help prevent kidney stone formation. That’s true but there is a lot more that can be done.

Sadly, few doctors seem to take an interest in or have knowledge of how to prevent kidney stones. Urologists are surgical sub-specialists.

Urologists usually focus on treating the stone once it’s there causing problems.
I often wonder whether urologists would take more interest in how to prevent kidney stones if they themselves had had a stone.

Two Kidney Stones

But besides knowing what to do, it takes a lot of physician time and energy and working closely with each patient in order to prevent kidney stones.
Just what steps to take to prevent kidney stones depends on the stone composition.

For example, is the stone made up mostly of calcium oxalate or uric acid or something else? The chemical makeup of the stone former’s urine is the other key factor to understand in order to prevent kidney stones.

Detailed analysis of the urine can allow us to design treatment to reduce the chance of another stone. Treatment for each person is often different. No one size fits all.

Sometimes treatment to prevent kidney stones involves modest changes in diet. But that does not mean eating a low calcium diet like avoiding such dairy products as milk, cheese or yogurt.

Did you know that low calcium diets actually may make matters worse for stone formers? Experts do not recommend reducing dietary calcium in those with calcium containing kidney stones.

Often safe, cheap medication is needed to help prevent kidney stones. There is fairly good scientific evidence for kidney stone prevention.

Not everyone’s kidney stones can be prevented but specific treatment can reduce chances of another stone by up to 80%. 
I offer kidney stone prevention to all my patients who have had one or more kidney stones.
I would want that for myself.

Have you suffered from one or more kidney stones?
Maybe we can help prevent your next stone from forming.

Saturday, November 5, 2011

Saving Lives: A Forgotten Study?

It’s almost 12 years since a major clinical trial showed a shockingly simple way to reduce death, strokes, heart attacks and heart failure.
Saving lives: simply and safely.
Saving lives with 1 capsule once a day.

The medication used in that study is often forgotten now because it is off of patent. That means the pharmaceutical companies do not promote it.
And many doctors seem to have forgotten or do not know about this important study.

The study was called HOPE an acronym for Heart Outcomes Prevention Evaluation.

The medication is ramipril. 10 milligrams of ramipril daily was the dose that worked. 
A lower dose has not been shown to provide the same results.
Too often, I see lower doses prescribed.

Ramipril is one of 10 drugs in the U.S. classified as angiotensin converting enzyme inhibitors, or ACE inhibitors, for short. But ramipril is the only one proven to have shown this benefit in saving lives. Perindopril proved beneficial in a large study but all those patients had coronary artery disease.

The HOPE study included over 9200 people aged 55 and older.  80% had cardiovascular disease such as a previous heart attack, coronary artery bypass surgery or other evidence of coronary artery disease. About 11% of the 9200 had suffered a previous stroke. 38% of the whole group had diabetes.

And about 12 percent of the group had diabetes but no previous stroke or known heart disease. These participants with diabetes had other conditions that increased their cardiovascular risk such as high blood cholesterol or protein in their urine or tobacco use.
The people with diabetes in the HOPE trial are like many of the patients with Type 2 Diabetes doctors see in their office.

Half of the 9200 people in the HOPE trial received ramipril and the other half were given an identical appearing placebo. So this was a randomized placebo controlled clinical trial. Patients were followed for an average of 5 years.

Now you should know that ramipril is a blood pressure medication, like the other ACE inhibitors. But blood pressure was fine at the start of the study. It averaged 139/79. That level would be considered normal or acceptable control.

For those who received ramipril, the overall drop in blood pressure was very small at the office measurements: on average 3/2 mm Hg.

Despite this small change in office blood pressure, those participants receiving ramipril had dramatically better outcomes:

22% lower risk of death from cardiovascular causes
20% lower risk of heart attacks
23% less heart failure
32% lower risk of stroke
16% lower chance of dying from any cause

So why this striking reduction in bad outcomes?
How is it that ramipril led to saving of lives when the reduction in office blood pressure was rather trivial?

Well, it turns out that ramipril was given at bedtime. Ambulatory blood pressure monitoring revealed why this might have been important.

A select group of 38 participants in the HOPE trial underwent evaluation with ambulatory blood pressure monitoring. They had on average an office blood pressure of 152/83.

They wore a blood pressure cuff that gave readings over a 24 hour period while doing their usual activities during the day and night; that includes sleeping.
They used this 24 ambulatory blood pressure monitoring before starting on ramipril or placebo and then again 1 year later while in the study.

There was no difference in the office or daytime blood pressures but those on ramipril had 17/8 reduction in nighttime pressure as compared to the group receiving placebo. This meant over the 24-hour period that those on ramipril had 10/4 lower pressure than the placebo group. That’s a lot lower than what was measured in the office.

This significantly lower blood pressure at night could have explained the striking reduction in cardiovascular events in the ramipril group. Lowering blood pressure significantly in those with increased risk means saving lives. 

There may be other mechanisms by which ACE inhibitors may reduce cardiovascular risk in patients such as those in the HOPE trial. This is an area of controversy. Many experts think the results seen were simply due to blood pressure reduction.

Some patients cannot take an ACE inhibitor. The most common side effect is a tickle-in-the-throat type dry cough. This cough occurs in about 5-10 % of people. The cough is more common in women.

Those who cannot take an ACE inhibitor can take a medication called an angiotensin receptor blocker, or ARB for short. An ARB is no more likely to cause cough than is a placebo.

Telmisartan, currently marketed as Micardis, was studied in a very large trial and compared to ramipril. It was as effective as ramipril in reducing cardiovascular events. It is not known if other ARBs are as effective as telmisartan. At the time of this post, there is only one generic ARB, losartan.

The results of ramipril therapy in the HOPE trial again point to the benefit of bedtime dosing of medication for high blood pressure and the potential use of ambulatory blood pressure monitoring to guide therapy as discussed in a previous post

In any case, if you think you are like the people included in the HOPE trial ask your doctor if an ACE inhibitor like ramipril is right for you. Perhaps you're already taking one.