Wednesday, November 30, 2011

Aspirin-to take or not to take is the question

Aspirin- to take or not to take is the question.

The value of taking aspirin to help prevent cardiovascular disease has been unclear for many years. Taking aspirin has been about risk. Is the slight reduction in risk of cardiovascular disease greater than the risk of bleeding from our intestine or having a hemorrhagic stroke
Aspirin has been shown to reduce cardiovascular mortality in high risk patients with a previous stroke or myocardial infarct. This is called (secondary prevention). Aspirins benefit for people without know cerebral vascular or heart disease is less clear.( primary prevention )
The American Diabetes Association (ADA) and the American Heart Association (AHA) in the past have recommended low dose aspirin as a PRIMARY PREVENTION strategy for people with diabetes who are at increased cardiovascular risk. This includes some one with diabetes over the age of 40 with additional risk factors such as increased BP,smoking history,albuminuria or dyslipidemia.
Large clinical trials with over 95000 participants found that aspirin reduced vascular events by 12%. interesting caveat were found also; there was minimal effect on reducing death from cardiovascular disease, Aspirin was more effective in reducing coronary events in men than women and women had more benefit in stroke prevention than men

Current 2010 ADA and AHA recommendations
“:low-dose aspirin (75 to 162 mg/day) aspirin use for primary prevention is reasonable for adults with diabetes and no previous history of vascular disease who are at increased risk of cardiovascular disease ( 10 year risk > 10%) and who are not at increased risk of bleeding. This generally includes most men over age 50 and women over age 60 who also have one of the following risk risk factors . 1) smoking 2) hypertension3) dyslipidemia 4) family history of premature vascular disease 5)albuminurea.”
” however ,aspirin is no longer recommened for those at low cardiovascular risk( women under age 60 and men under age 50 with no cardiovascular risk factors) as the benefit is likely out weighed by the risk of significant bleeding “.

My question is ; how do we know who is at low risk. My understanding of silent coronary heart disease is that it is silent and that our know risk factors and most test other than coronary artery ultra sound may miss the underlying disease. See page 48 in Diabetes Office Visit for more details. This type of information has made it difficult for me in making a specific recommendation regarding aspirin. During my 35 years of diabetes practice i have seen many people with myocardial infarcts and I cannot recall any one with a gastrointestinal bleeding from aspirin. My experience taught me to be very liberal with my aspirin recommendations.

How do you feel about aspirin use? more on aspirin tomorrow

Check out my video and see how Diabetes office visit App. could help you reduce your risk of cardiovascular disease .

Dr. Calder

Dr. Calder

Tuesday, November 29, 2011

Diabetes Office Visit: Why is my finger stick often different that the la...

Diabetes Office Visit: Why is my finger stick often different that the la...: Most of my old blogs were lost during the hacking attack and other website changes. I plan to update and repeat some of the previous blogs...

Why is my finger stick often different that the laboratory glucose test?

Most of my old blogs were lost during the hacking attack and other website changes. I plan to update and repeat some of the previous blogs .
We all use home glucose test to manage our diabetes . Home glucose testing has been one of the major improvements in the day to day management of diabetes. It is not perfect but it is still a fantastic improvement when I think about the old urine glucose test that we previously used to make treatment decisions.

We assume that our home glucose test are accurate and we feel comfortable making management decisions based on those results. I believe that our home glucose test meet the requirements needed for very good glucose management. However, have you ever wondered why you finger stick capillary test is often different than the venous glucose test done in a laboratory. Lets take a little closer look at the glucose test processes.

The meter you are using is require to have an error rate of < 20% at glucose levels of 30 to 400mg/dl. so our result could be somewhere between 65 and 95 mg/dl assuming an error rate of 19%. From my own personal experience in the hospital, where I frequently compared finger stick results with hospital lab. results, I believe the error rate on most meters is small and not a major issue.

What else effects the results?

The source of the blood effects the results. Arterial blood is about 5% higher than capillary blood and 10% higher than venous blood. You are not likely to be using arterial blood but you will be comparing capillary blood ( finger stick sample) to venous blood that is usually taken from your arm by a lab. Tech. This means ,that if you did a fingerstick test( capillary blood )at the same time as a laboratory test( venous blood) , your result may be a little higher than the lab result by about 5%
Their is another interesting variable to be aware of. Your glucose meter reads” whole blood ” which is about 10 to 15 % lower than “plasma ” that the lab is using. I believed that this was a good thing when I was following hospital patients on continuous intravenous insulin infusion because the hourly finger stick test were a little higher ( capillary whole blood) and made the lab ( venous plasma )and bedside test have a little better correlation .Then the meter builders decide to convert the whole blood results into a plasma-calibrated result. For the doctor this change resulted in higher bedside result and more concern that we may miss low test results.. I had to adapt to the change.
So this is probable a lot more than you wanted to know but it may help you understand why your home test may not match the lab. results. In general our home meter are wonderful machines that have dramatically improve our lives..

ps —how about watching my App training video and let me know what you think—

David Calder, MD

Monday, November 28, 2011

Avoid Desiccated Thyroid Hormone Replacement

Avoid Desiccated Thyroid Hormone Replacement

Desiccated thyroid hormone , Armour thyroid and Thyroid USP is listed as obsolete by the FDA but continues to be prescribed and used by some people . I recently saw a video promoting the use of desiccated thyroid which prompted me to write this note.

Our thyroid gland produces thyroid hormone in a response to TSH ( thyroid stimulating hormone ) from our pituitary gland. The primary form of thyroid hormone produced and released into our blood is T4 . This T4 is slowly converted to the active hormone T3 in our tissues,primarily the liver . The T3 Hormone in correct amounts helps keep all of the cells of our body running at peak efficiency.

A deficiency of T4 and T3 results in a slow down of all of the machinery in our body and an excess of T4 and T3 can have toxic effects especially for our heart causing arrhythmia , heart failure , angina or even cardiac arrest. The effect of excess T3 is a concern for anyone with heart disease.
( many of us have a little silent coronary heart disease ).

So, why is desiccated thyroid hormone not a recommended treatment for hypothyroidism ?

Desiccated Thyroid Hormone is of animal thyroid tissue origin. This means that it contains a mixture of T4 and T3. The T3 is almost 100% absorbed rapidly producing abnormally high levels of T3 in the blood stream and potentially a toxic effect on that persons heart.

Levothyroxine ( L-thyroxine , levothyroid , synthyroid and others) is T4 and is much safer to use. The T4 is absorbed and converted slowly to the active T3 , similar to the function of a normal thyroid gland. Be safe . If you need thyroid hormone replacement, use T4.
Dr. Calder

Wednesday, November 23, 2011

Glycemic control and congestive heart failure

Lancet 2011; 378 140-146 Glycemic control and the incidence of heart failure
This is an interesting article that brings up another preventable complication of diabetes, congestive heart failure.
Congestive heart failure is basically a failure of a persons heart to pump an adequate volume of blood due to heart muscular damage. The symptoms are generally shortness of breath , swelling of a persons feet and legs and waking up short of breath at night and having to set up in order to breath comfortable. I have treated many patients with congestive heart failure over the years and have generally associated this problem with older age groups . This article followed 20895 patients with type one diabetes , mean age 38.5 years old , and found that 3 % ( 635 patients ) were admitted to the hospital with a primary or secondary diagnosis of heart failure over 9 years.

"Risk of heart

failure increased with age and duration of diabetes. Other modifiable factors associated with increased risk of heart failure were smoking, high systolic blood pressure, and raised body-mass index. In a subgroup of 18281 patients (87%) with data for blood lipids, higher HDL cholesterol was associated with lower risk of heart failure, but there was no association with LDL cholesterol. "

The above picture of a graph does not show well . It genererally shows that higher A1c results are associated with increased risk.

The only risk factors that are not within our power to control is our age and the duration of our diabetes. The others boil down to our own personal choice .

Diabetes is a game of numbers, play hard and win the day .

Dr. Calder

Saturday, November 19, 2011

Who is responsible for your health care ? " Free drugs , Few Takers " )s

There was an editorial in my local news paper yesterday entitled , Free drugs , Few takers . The editorial reported a study done at Harvard -affiliated Brigham and Young Hospital in Boston and funded by Aetna . It involved 6000 patients who had experienced a heart attack . Half were given free medications that would reduce their risk of having another heart attack and the other half paid a copay of 50/month for the same medications. Neither group was good at following the recommendations and only 36 to 46 % of patients making co-payments filled their prescriptions depending on the medication. The people getting free medications were only 4 to 6 % higher.
So basically less than 50 % of people in either group was willing to assume responsibility for their own care.

Each of us as individuals are responsible for our own health care . The reality is that many of us fail to take that responsibility seriously. Studies have shown that less that 11% of people with diabetes achieve 3 target goals for test ( A1c , LDL cholesterol and blood pressure) . Meeting these target goals would reduce their risk of heart disease , stroke ,eye and kidney damage and neuropathy.
I have seen patients with all of the above complications and I can assure you that there are no do overs, no second chances to go back and reverse the reality of a heart attack , stroke , vision loss or amputation .
The other reality is that the complications of diabetes are preventible by correcting know risk factors to recommended targets . Preventive diabetes care is a game of numbers. Correct the numbers to known targets will reduce the risk of complications . I can tell you that preventing diabetes complication is a lot more fun than treating the complications.

The reason for me writing Diabetes Office Visit was to provide as easy to use approach for people with diabetes allowing them to assuming more responsibility for their own care . Most of us with diabetes are adults and we take on the responsibilities of raising children , paying bills and many other things without a second thought , but often fail when it comes to taking care of our own health .
Dr. Calder

Thursday, November 17, 2011

Acarbose , treating hypoglycemia ? Acarbose , cardioprotective effect ?

Answer to yesterdays question .

For People Who Take Acarbose (Precose) or Miglitol (Glyset)

People who take either of these diabetes medications should know that only pure glucose, also called dextrose-available in tablet or gel form-will raise their blood glucose level during a low blood glucose episode. Other quick-fix foods and drinks won't raise the level quickly enough because acarbose and miglitol slow the digestion of other forms of carbohydrate

These two drugs Precose and Glyset inhibit intestinal and pancreatic enzymes that convert carbohydrates into glucose.These medications have not been popular because of side effects , flatulence, diarrhea and abdominal pain.

Acarbose is used to reduce after meal glucose increases and may help lower the risk of heart disease . I have attached comments from the 2011 American Heart Association scientific sessions below. The discussion was about the cardioprotective effect of diabetes medications .

Acarbose re-examined

The older, already FDA-approved drug acarbose may also be a viable option, as it could potentially target postprandial glycemia as a risk factor for CVD, Rury R. Holman, FRCP, of the Oxford Centre for Diabetes, Endocrinology & Metabolism in the United Kingdom, said.

Several trials have associated acarbose with reductions in postprandial glucose and subsequent decreases in CVD risk factors. The Study to Prevent Noninsulin-Dependent Diabetes Mellitus (STOP-NIDDM), for example, revealed a 49% RR reduction for development of CV events in patients with impaired glucose tolerance in a secondary analysis. Similarly, data from a study in Japan linked acarbose with improved postprandial flow-mediated dilation and, thus, improved endothelial function.

To further investigate this association, Holman and colleagues are conducting the Acarbose Cardiovascular Evaluation (ACE) study - a multicenter, double blind, randomized controlled trial designed to assess potential CV benefits of acarbose in 7,500 patients with preexisting CVD and IGT. The study will be at 50% recruitment by the end of 2011 and results are expected in 2017, he said.

"When acarbose first came to the market in the late 1990s, it was seen as a head-to-head HbA1c-lowering drug," Holman said. "If its only impact is on postprandial glucose, it can only ever modestly reduce HbA1c. The drug is really meant to be given in combination, so if it was to be a CV-protecting drug, maybe there is some way to easily roll it out in other doses

Diabetes care is about winning in a game of numbers . Play hard. Dr . Calder

Wednesday, November 16, 2011

A 40 year old man with type 2 diabetes is having symptoms of hypoglycemia and his blood glucose level is 50 mg/dl. His current diabetes medicines include acarbose 50 mg 3 times/day and lantus insulin 40 units each morning. He is a visitor in your home and has none of his diabetes supplies with him. I have attached the current recommendations from the National diabetes clearing house. What is the most appropriate treatment for this man ?

Prompt Treatment for Hypoglycemia

When people think their blood glucose is too low, they should check the blood glucose level of a blood sample using a meter. If the level is below 70 mg/dL, one of these quick-fix foods should be consumed right away to raise blood glucose:

  • 3 or 4 glucose tablets
  • 1 serving of glucose gel-the amount equal to 15 grams of carbohydrate
  • 1/2 cup, or 4 ounces, of any fruit juice
  • 1/2 cup, or 4 ounces, of a regular-not diet-soft drink
  • 1 cup, or 8 ounces, of milk
  • 5 or 6 pieces of hard candy
  • 1 tablespoon of sugar or honey

Recommended amounts may be less for small children. The child's doctor can advise about the right amount to give a child.

The next step is to recheck blood glucose in 15 minutes to make sure it is 70 mg/dL or above. If it's still too low, another serving of a quick-fix food should be eaten. These steps should be repeated until the blood glucose level is 70 mg/dL or above. If the next meal is an hour or more away, a snack should be eaten once the quick-fix foods have raised the blood glucose level to 70 mg/dL or above.

answer tomorrow.

Dr. Calder

Tuesday, November 15, 2011

Traveling with no leg to stand on. Success is a matter of inches

shower boots (picture #1 )
Portable commode chair adapter( picture #2 )

My wife is now about 7 years post bilateral below the knee amputations due to septic shock. Her problem is further complicated by having bilateral knee replacements for over 25 years. Seeding of her damaged joints with bacteria from dental procedures may have been the cause of the bacterial sepsis. I bring this up primarily as a reminder to anyone with joint replacements to take antibiotics before and after any dental procedure regardless of how long the replacement has been in place. My wife had her knee replacements over 20 years before she developed sepsis. I would also discuss the idea of taking the antibiotics for 8 to 10 days after any dental procedure if you have joint replacements . Antibiotic use in this situation is still controversial , so be prepared to argue your case.
Thanks to our wonderful medical community my wife has fully recovered and can now walk without canes in the house. She also walks 1 to 2 miles out side almost daily . We have modified our home so that she can deal with the activities of daily living comfortable. Travel and visiting relatives requires a little more equipment and time. We have stayed in about 15 different hotels and motels in the last few years and have learned a few things that may help you or a friend.

#1 Handicapped rooms does not mean that the room is equipped for someone with bilateral amputations. Many handicap equipped rooms may just have a bar by the commode ( similar to the above picture ) or in the shower and nothing else . I have not been in a room yet that would accommodate a wheelchair and slide board. I have also visited a number of new assisted living and home for older people that would also be of no use to someone in a wheel chair. The solution is simple. There has to be enough room for a wheel chair to pull up beside a commode or bed. See the pictures below.

# 2 commodes, chairs and beds all have different heights . These differing heights create real problems . One to two inches in height can make the difference in getting off of a commode or bed without help. Higher is better . Getting to a bathroom in the middle of the night without a wheel chair and slide board necessitates putting on both legs then being able to stand up in order to lock the legs in place and walking to the bathroom usually with a walker. Low beds make it almost impossible to stand up without help. We have noticed that older hotels and motels have lower beds and commodes.

I now ask to see handicap equipped rooms before renting and avoid rooms with low commodes or low beds .

#3 Taking a bath or shower in hotel rooms is difficult . We have resolved this problem by using thigh high rubber covers for her prothesis and legs. See the pictures #1 above. These covers work but do require two people to put them on .

#4 commode height can be managed with the portable seat seen above in picture # 2

#5 bed height is still a problem. I believe this problem could be overcome with an inflatable cushion similar to the inflatable mattresses .We are still looking for one that works.

The equipment listed above has made automobile travel much easier for my wife and me. We had fun and enjoyed every day of our last trip . I hope this information will be of use to you or a friend with bilateral lower leg amputations. Dr. Calder

Sunday, November 13, 2011

Amazing man story, beautiful women , amputations and inches for function

My wife and I are back home after an unplanned 16 day 4500 mile road trip related to family health problems. It was an enjoyable trip with good visits with our relatives. This trip caused me to fall behind with my " almost daily blog ". I am just getting started again.
I will start with a story of one of my patients. Mr. x is an amazing man who has had type 1 diabetes for many years. He is blind and has had bilateral below the knee amputations. He made regular visits back to his family home in Oklahoma . He traveled by car and always required hospital admission when he returned home to Oregon for treatment of draining ulcers and cellulitis of both legs. After a few admissions to the hospital I made the connection between his road trips and the ulcers and cellulitis. I ask him why this always occurred on these trips. His answer was simple. His only way of getting to the bathroom at night was to crawl on his hands and knees. Another interesting thing about this man was that he always seemed to be surrounded by beautiful women when he was in the hospital. I finally ask him how a blind man with no legs could attract so many women. His reply was powerful, " they are my children ". He raised his own children and about 20 foster children.
I thought of this man frequently as my wife ,who has had bilateral below knee amputations , traveled to Texas. The ability to independently complete daily needs is a matter of inches for beds, bathing and commodes . I will discuss some of the things my wife and I learned on this road trip over the next few days..
Dr. Calder