Saturday, December 31, 2011

Enjoy Grapefruit with Your Statin


Do you worry about grapefruit? This is not a strange question if you take a statin. 
I say: enjoy grapefruit with your statin.

Do you take a statin? Do you like grapefruit or grapefruit juice? Then read on.

There are 7 statins on the market. They all lower the LDL cholesterol and are prescribed to reduce the risk of cardiovascular disease. These statins are listed below with the brand name in the U.S. given in parentheses:
·      atorvastatin (Lipitor)
·      fluvastatin (Lescol),
·      lovastatin (Mevacor)
·      pitavastatin (Livalo)
·      pravastatin (Pravachol)
·      rosuvastatin (Crestor)
·      simvastatin (Zocor)

If you take a statin, you may have seen warnings or alerts about eating grapefruit or drinking grapefruit juice. Those warnings imply that drinking grapefruit juice anytime during the day even hours apart from when you take your statin may be deadly.

These alerts are almost everywhere. And I believe they are way overblown and not based upon sufficient scientific or clinical evidence.

Only three of the above statins have warnings regarding eating grapefruit or drinking grapefruit juice while taking the statin. Those 3 statins are: atorvastatin (Lipitor), lovastatin, and simvastatin.

The official prescribing information for these 3 statins cautions about drinking more than a quart a day of the grapefruit juice. 
Wow that’s  a lot! There are not going to be too many people doing that.

But what if you’re a little weird and do drink more than a quart a day of grapefruit juice and  also take atorvastatin which is now available as a generic? Or, what if you love grapefruit and eat 3 a day and also take simvastatin?

How risky is this?

Well it turns out that this whole issue might be important but it is probably very much exaggerated.
Or to put it another way it is likely clinically insignificant.

The chemical components in many foods affect how our body handles or processes the chemical molecules in drugs. Grapefruit is one of those foods that contain substances that affect how are body processes some of the statins.

The liver and kidneys are the main organs that metabolize, breakdown, process or eliminate the chemicals in drugs and the many chemicals that make up our foods. Remember food is composed of chemical molecules too.

Food is digested in our small intestines. And substances that make up our food get into the bloodstream from our intestines.

Well, it turns out that besides the kidneys and liver, our intestines also change and process chemical substances from our medications. The intestines are not just for digestion. They also process chemical molecules.

Grapefruit juice has substances that affect how the intestines process many drugs. 
Those effects vary between people.
And these effects of grapefruit are also difficult to predict and very complicated.

It appears that some substances, called furanocoumarins, in grapefruit juice may reduce intestinal CYP3A4 an enzyme that breaks down many drugs.
Grapefruit may also reduce uptake into the bloodstream of substances by acting on OATP1A2, a transporter protein.

And last, grapefruit may affect blood levels of drugs by affecting a substance called P-glycoprotein. P-glycoprotein helps the body eliminate drugs from cells.

Most of the scary alerts about grapefruit and statins arose because of a study done out of one center in Finland. That study used a 60 milligram dose of simvastatin which is now above the recommended maximal dose of 40 milligrams. In addition, that study had the 10 volunteers drink 200 milliliters of double strength grapefruit juice three times a day. That amount of grapefruit juice is equivalent to about 40 ounces or 1 and ¼ quarts of single strength grapefruit juice daily!

In this study there was an increase in the blood level of simvastatin. The study was conducted over only 2 days.

Another, more recent study conducted by these same researchers also showed an increase in blood levels of simvastatin but the volunteers in this 3 day study drank only only 200 milliliter (about 7 ounces). The amount (expressed as area under the curve and peak concentration) of the simvastatin was increased on average about 3-4 times above the usual.

And when the simvastatin is taken24 hours after high dose grapefruit juice, no meaningful increase in simvastatin levels were seen.

The concern is that there may be an increased risk of muscle damage with the high blood levels of the statin. Muscle damage or myopathy is the only real risk of statin use.

Rhabdomyolysis is a severe form of muscle damage. Rhabdomyolysis is rare.
Rhabdomyolysis occurs in less than 2 persons out of 100,000 who take statins for a year.
Doctors can reduce the chances of a patient getting rhabdomyolysis by understanding  factors that increase risk.

 No clinical reports of problems have been described in humans when grapefruit juice is taken with statins.

And remember, this is primarily a possible issue with simvastatin and lovastatin
In a recent study, daily drinking of grapefruit juice did not have a significant effect on drug levels of atorvastatin despite the official prescribing information

Grapefruit juice should be an important concern in those people on immuno-suppressants, those on chemotherapy and those on drugs for HIV infection.

There are also certain medications that you might be taking that could increase your risk of statin myopathy whether you drink grapefruit juice or not.
Your doctor should know about those and take one of three steps:
reduce your statin dose or change you to a safer statin or change the other medication.

For most people,  you can enjoy grapefruit with your statin.
Check with your doctor if you have questions. And direct him to this post if he is not sure.






Sunday, December 18, 2011

No Flush Niacin is No Good

No Flush Niacin is no good
No good for improving your cholesterol or triglycerides. 
And no flush niacin is no good for raising your HDL cholesterol. 
The HDL cholesterol is the so-called “good” cholesterol.

You may know that niacin is one of the B vitamins. The Recommended Daily Intake for niacin is 20 milligrams. You may see this as Daily Value on the label of the vitamin supplement you may be taking. 
Niacin can be taken as nicotinic acid or nicotinamide.

By the way, nicotinic acid has nothing to do with nicotine.
Nicotine is a very different chemical.
Nicotine is the addictive substance found in tobacco. Niacin is not nicotine.

High doses of niacin as nicotinic acid but not nicotinamide can lower cholesterol and triglycerides. Those fats in the blood are called lipids.

But, in general, you need at least 500 milligrams of niacin to see an effect on lipids. This benefit of niacin on lipids has been known since 1955. 
It is nicotinic acid that is the active substance that lowers the lipids. If there is not enough nicotinic acid produced from the pill, the lipids don't improve.

The problem is that niacin in a dose as low as 100 milligrams can cause unpleasant skin redness, itching, and burning. These symptoms are the niacin flush. The niacin flush may last about an hour or more and starts shortly after you take the pill.

And there are other possible side effects of niacin. But the flush is the main challenge.

Most people get flushing from niacin when they take immediate release niacin to lower their lipids. Prescription niacin that is extended release and marketed as Niaspan is safe and less likely to cause this flushing.

The good news is that the flushing goes away over time and there are several tips that we give our patients to keep the flushing to a minimum. Most patients who stick it out and continue on niacin therapy are not troubled by the niacin flush.

But there are two things we do not advise. 
First don't use the non-prescription slow release niacin. These supplements might work for the lipids but slow release niacin supplements appear more likely to cause liver damage.

Number two. No flush niacin is no good. The usual no flush niacin that is sold is inositol hexanicotinate. This stuff appears to deliver very little nicotinic acid. Remember nicotinic acid is the chemical that lowers the lipids.

Based upon the best evidence, inositol hexanicotinate sold as no flush niacin simply does not work. Save your money!

And check your labels. I do not recommend non-prescription niacin. Before Niaspan was available, I advised my patients to use immediate release niacin. Now, if I  tell people to take niacin I prescribe Niaspan.

But keep in mind, in terms of reducing heart attacks and strokes, niacin has far less evidence of benefit that do the statins. An old study before statins were available that was done in men who had had a heart attack showed a slightly lower chance of having a second heart attack. 
A more recent trial  in people already on statin therapy showed no benefit of Niaspan in reducing cardiovascular events.

Still niacin can still be very helpful in selected people like those with high triglycerides.
But the niacin flush must be worked through.


Sunday, December 11, 2011

How Not to Treat Obese Children

You may have heard of the obese 8 year old in Cleveland Ohio who was taken from his home because the governmental Child and Family Services agency felt the mother was neglectful. After all, he was failing to lose weight as the doctor was advising.

Sure she was not beating him. But he stayed fat.  In the government's view this constituted neglect.

Wow! Does that ever happen to adults that physicians advise to lose weight? And adults have more coping skills and understanding than an 8 year old. Maybe we should we take obese adults out of their homes too?

After all if they get Medicare or Medicaid this costs the taxpayers money. Maybe we should we arrest anyone who is getting government healthcare who is seen leaving McDonalds with a large fries.

And do you think it is easier for obese children to slim down than it is adults?

This child was doing well in school. He was likely getting food from someone other than his mother. That's why her efforts were not successful in getting him to lose weight. But the state agency took him out of his home and put him into a foster home.

There is no evidence that this intervention would help a child lose weight. 

And don't you think he might do a little more eating now in response to stress?

I could not restrain my outrage. I wrote a letter to the Cleveland Plain Dealer.

This incident made the national news.

You can  read the news release on November 30 2011 from the Obesity Action Coalition here.
They were equally incensed.

The American Society of Bariatric Physicians was also extremely critical of this crass government intrusion. 

We have a lot more to learn about treating obesity.
We don't need government bullies to help us.

Your Diabetes Endocrine Nutrition Group


Sunday, December 4, 2011

Does good sugar control help healing?


If you have diabetes, there are many good reasons to control your blood sugar.   
And what about healing?

Does good sugar control help healing?
How about vice versa?
If you heal well, does that mean your sugar is under good control?

Let’s tackle the first question, first. Does good sugar control help healing?
Is there good evidence that better blood glucose control means a better chance of healing of wounds, skin sores or infections?

Many doctors believe that skin wounds or soft tissue ulcers on the arms, legs or feet might heal better with better blood sugar control. But it may surprise you to learn that there is no solid evidence that better sugar control translates into a better chance of healing. Getting blood glucose close to normal might help healing and certainly shouldn’t hurt healing but there just are no high quality studies that I could find to prove the benefits of blood sugar control on healing.

It is clear that certain infections are much more likely to occur when blood sugars are uncontrolled. For example, vaginal yeast infections, called vaginal candidiasis are much more likely when blood sugars are high. In fact, some women discover they have diabetes when they just can’t seem to get rid of their vaginal yeast infection and their doctor thinks to check the urine for sugar or to check the blood sugar level.

And men can get yeast infections on their penis when their sugars are running especially high.

But when it comes to skin cuts, wounds or ulcers on the feet, legs and arms, blood sugar control has not yet been proven to be important for healing.  
On the other hand, some doctors who run wound care centers think blood sugar control really makes a difference. They see non-healing foot ulcers suddenly heal when the blood sugar is controlled. 
Despite these doctor's stories, that we call anecdotes, the proof is not there that good sugar control helps healing.

So now I bet you can answer the other question I asked.
If my cuts and sores heal quickly, does that mean my sugar is well controlled?

The answer is absolutely not!

You can have poor control of your diabetes and still heal okay.
I have certainly seen this among my patients.

You need to test your sugar and have testing of Hemoglobin A1c (abbreviated HgbA1c) in order to tell if your diabetes is under good control.

Remember, there are many reasons to keep those sugars controlled. Like protecting your eyes, kidneys and nerves from damage. And when there’s nerve damage, over time, there’s an increased risk of foot problems, even amputations.

Until further studies are done, prevention is key. 
Keep your glucose well controlled and take good care of your feet.