Tuesday, January 31, 2012

Women and Heart Disease- The Evening News Again

  hint - save 46 seconds just read the high lighted area

It is the evening news again. Last night one of the major  news stations reported on a new study , the first proof ,  that "women can  reduce their risk of having cardiovascular disease by taking taking a Statin ".

I think it is great that they helping every one become more aware of the value of " Statin " drugs .  But maybe they should have said it confirmed previous studies.

The Heart Protection Study  published in Lancet vol.360 -july 6, 2002 included women. This study of high risk individuals , found that taking Simvastatin  40 mg /day for 5 years would prevent about 70 to 100 people per 1000 from suffering a major vascular event  irrespective of age, sex and presenting cholesterol concentrations. 

The CARDS study  also published in Lancet vol. 364 Aug.21, 2004 was done on people with Diabetes and with no previous history of heart disease but including people with known risk factors. Women were included in this study also.
 The treatment group receive atorvastatin 10 mg /day . The results of the CARDS study shows that atorvastatin 10 mg /day leads to a 37% reduction in major vascular events and a 48 % reduction in strokes.

 The last sentence in the CARDS study report is one of my favorite lines.

 " The debate about whether all patients with Type 2 Diabetes  warrant statin treatment should now focus on whether any patients can be reliably be identified as sufficiently low risk for this safe and efficacious treatment to be with held, "

I believe that we  can add "all men and women "and can remove " with Type 2 Diabetes " from the above statement because we are all at risk of having vascular disease.

Remember , you are responsible for your for your health care.  Don't let yourself down.  Know and correct any risk factors you may have for heart disease..

Have fun , Be Smart and Defeat Heart Disease
David Calder,MD

Click on the tag below for more ideas for preventing heart disease

Diabetes Office Visit- Helps you prevent Heart Disease

Monday, January 30, 2012

Omega -3 - fatty acids and Heart Disease

            Hint ; save 39.2 seconds of your time by just reading the highlighted area

We know that Omega 3 fatty Acids , EPA and DHA, in Fish Oil  reduce triglyceride levels but do they reduce the risk of having heart disease.

There is one study done in Japan, Jelis Study (Japan EPA Lipid intervention Study) reported in Lancet 2007;369: 1090-8

 This study was included 18,000 patients with and without heart disease with total cholesterol of 251 mg/dl (6.5 mmol/L ) and LDL of 171 ( 4.4 mmol/L ) and randomized to a low dose statin alone or a statin plus 1.8 grams of EPA purified from omega - 3- fatty acids in fish oil and followed for an average of 4.6 years.
 Results ;
       Statin only group  --- ------------     3.5%  had a major coronary event
       Statin  plus 1.8 grams of EPA --   2.8%  had a major coronary event

A 19% relative risk reduction in the group receiving 1.8 gms of EPA

 There was a followup analysis of this study reported in Artherosclerosis 2009 may:204(1):233.
 This analysis looked at people in the Jelis study with elevated Triglycerides > 150 mg/dl and
  HDL < 40 mg/dl. In this higher risk group, EPA treatment resulted in a 53% relative risk reduction.

There is another planned study - REDUCE IT ( Reduction of Cardiovascular Events with EPA intervention trial ) that will specifically look at the effects of Triglyceride reduction  and cardiovascular risk. Hopefully this study , to be completed in 6 years ,will provide us with a more definitive answer .

For now , Omega 3 fatty acids , are still my first choice.

Have fun , Be Smart and Defeat Diabetes
David Calder,MD

Click on the link below to learn more about ," Fixing The 9 " and preventing heart disease.

Diabetes Office Visits- Helps You Prevent Heart Disease

Sunday, January 29, 2012

Diabetes ,Triglycerides, Fish Oil and Heart Disease

Yesterday we discussed why the ACCORD study failed to demonstrate a reduction in the risk of heart disease with combination of simvastatin and fenofibrate .

For those of you who just want a quick summary of todays blog , just read the bold print.

Lowering Triglyceride levels and raising HDL Cholesterol is a continuing challenge. 
Life style changes with weight loss and increased exercise and correcting high glucose levels work to a certain degree .  Our choices of medications have been limited primarily to fibrates such as fenofibrate  , Niacin and Omega -3 -fatty acids ( fish oil ) .

 I was always reluctant to use fibrates because of the increased risk of Rhabdomylosis when combined with a Statin and Niacin was difficult to use because of site effects.   This left me with Omega -3-fatty acids that had its on set of problems. It was only recently that we had an FDA approved source of purified fish oil with each capsule  containing 840 mg of EPA =DHA. ( Lovaza). Cost became a factor because of the number of pills required to be effective.  All of the above resulted in my having patients use over the counter  brands of fish oil. Using over the counter medications made me uncomfortable but I did find that the results were good . I was encourage by a  recent article in Consumer Report  ( January 2012 page11) verifying that most of the over the counter brands did actually contain the amounts of EPA ad DHA found on the label.

 There is an article in the January 2012 Internal Medicine News that  is reviews more good news for us Fish Oil lovers. There may be another FDA approved source of fish oil available soon.

Fish Oil Works to lower Triglycerides
 AMR101 is pure EPA. There initial study (ANCHOR Trial ) was in a group of patients with high cardiovascular risk on Statins with LDL cholesterols of 100 mg/dl  or less and Triglyceride levels between 200 and 500 mg/dlAMR 101 2 gms/day and 4 gms/ day reduced triglycerides 10.1% and 
22 % respectively. 

 Another study  using the same medication was done in patients with fasting triglyceride levels of at least 500mg/dl .This study , MARINE Study, reported in the American J. Of Cardiology 2011;108:682-90 found that 2 and 4 gms/day of AMR101 reduced Triglyceride levels 20 % and 33 % respectively. 

These two studies provide more evidence that Omega 3 fatty acids work and seem to be more effective in patients with higher triglyceride levels.

Will Fish oil reduce my risk of developing heart disease ?
        stay tuned
                                                                       Have Fun , be Smart and Defeat Diabetes
                                                                       David Calder,MD

Saturday, January 28, 2012

News report " Diabetes treatments Deemed Harmful " The rest of the story

Diabetes Treatments Deemed Harmful

By MAYS Submitted At January 8 Views 201 Likes A major diabetes study has found that common treatments don't reduce heart trouble and some may actually cause harm. Elaine Quijano speaks with Russ Mitchell about this revealing study.

This was reported on CBS news Jan 8, 2012 and the video was shown again on Diabetes Connect  today.

I could not let this pass without telling you the rest of the story. They reported that heart disease and strokes are a major cause of death and disability for people with type 2 diabetes which is correct. They also reported that lowering blood pressure from 140 to 120 systolic or that combining simvastatin ( Zocor ) and fenofibrate (tricor)  did not reduce cardiovascular risk.

I believe they are referring to the ACCORD study.

The ACCORD trial, sponsored by the National Heart, Lung and Blood Institute (NHLBI), was set up to test the efficacy of 3 medical treatment strategies (blood glucose lowering, blood pressure lowering, and lipid altering) in reducing cardiovascular events in middle-aged and older people with type 2 diabetes plus established cardiovascular disease (CVD) or additional (≥ 2) cardiovascular risk factors.[1,2] The multicenter, double 2×2 factorial design ACCORD trial recruited 10,251 patients in the United States and Canada.

I have read a number of articles about the pros and cons of this study and came away with the idea that this study did make some good points;

     #1 " if it ain't broke don't fix it "
     #2   Ours current guides lines for the treatment of Lipids , Blood pressure and blood sugar are pretty  good
     #3   The treatment of diabetes is not a one size fit all disease. The treatment recommendations that we make
            as physicians and other health care providers has to be  tailored to fit the life situations of the person 
            setting in front of us at that moment in time.
I would like to discuss the  " if ain't broke don't fix it " idea today. 

This refers to the treatment of elevated triglycerides and low HDL  as a cause for something called "residual risk ".
We have some very good tools ( primarily Statins ) for lowering LDL Cholesterol and lowering but not removing the  risk of heart disease and stroke. This residual risk is thought to be related to the problems of low HDL  ( <40 in men and < 50 mg/dl in women )and high triglycerides ( >150 mg/dl ).

The ACCORD trail hoped to clarify some of the issues around this problem of residual risk .The study did prove one thing " if it ain't broke don't fix it" . The use of simvastatin  was so effective at lowering LDL cholesterol to an average of 78mg/dl  and decreasing Triglycerides and raising HDL  that only 17 % of the group receiving fenofibrate met the criteria for it's use. This means that in real life  , in your doctors office ,83 % of the people would not have been treated with any thing other than simvastatin . It is unfortunate that that the study design got in the way of more helping us resolve the question of residual risk. It is no real surprise that they were unable to demonstrate any benefit from the use of fenofibrate.

Tomorrow . More on triglycerides , HDL and risk 

Have fun , be smart and defeat diabetes 
David Calder,MD

 The idea of "if it ain't broke don't fix it " idea came from the article below.

Cardiovasc Diabetol. 2010 Jun 15;9:24.

"If it ain't broke, don't fix it": a commentary on the positive-negative results of the ACCORD Lipid study.
Tenenbaum A, Fisman EZ.

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study investigated whether combination therapy with a statin plus a fibrate, as compared with statin monotherapy, would reduce the risk of cardiovascular disease in patients with type 2 diabetes mellitus. However, relevant patients with atherogenic dyslipidemia represented less than 17 percent of the ACCORD Lipid population (941 out of 5518 patients). 

This means that 83 % of the people treated with the combination of Simvastatin/ fenofibrate would not have been treated with fenofibrate according to the recommendation for using the drug. Low HDL and elevated triglycerides

Friday, January 27, 2012

CPAP , Hearing Aids and Diabetes- New is better !

My old experience as a physician seeing patients dealing with the various sleep apnea treatments including CPAP was not that good. It seemed that most  sleep apnea equipment was similar to  the use of hearing aids , a lot of people owned the equipment but few consistently used it.

Advances in technology has changed both  hearing aids and sleep apnea equipment into comfortable useful tools that are a pleasure to use.

 My new experience as a physician and a patient using new hearing aids and CPAP for for my obstructive sleep apnea is "Oh my goodness ! Why did I wait so long ? "

The diagnosis of sleep apnea and compliance to treatment recommendations have improved significantly in recent years. The new quite comfortable simple to use equipment coupled the expertise of doctors and respiratory therapist have had a big impact on the management of this problem.

There are various surgical procedures and different oral appliances that have had limited success .

I believe that the use of  CPAP  "continuous positive airway pressure" continues to be the most effective. These machines are quite and automatically adjust to deliver just the right amount of pressure needed to over come the airway obstruction. The humidity of the delivered air can be adjusted to your comfort.  The face masks have improved along with the machines to deliver warmed humidified air comfortable to your nose and mouth. The delivery of air  directly into a person's nose with something called Nasals Pillows has been a step in the right direction. 

If you have been diagnosed with sleep apnea , I suggest that you Google CPAP and also Nasal Pillows. Read and learn much as you can about the available equipment before your doctors visit . Decide on the features you would prefer to have with your equipment  and if possible  talk to someone who has sleep apnea and get their opinion on their pros and cons on the equipment they are using . It is possible to talk with some one ,ME . You can use the comment section below.

Your doctor will make recommendations based on his or her experience and  your test results . There is a lot of CPAP equipment with multiple options
If you have done your home work then you will be a better participant in the decision process .

Have fun, Take advantage  of the new wonderful advances in medical care.
  David Calder, MD

Wednesday, January 25, 2012

Sleep Apnea,You can't diagnosis it if you don't think of it

                                                    Sleep Apnea
                                 You can't diagnosis it if you don't  think of it 

Obstructive Sleep Apnea is a contributor to :
            * the development  of Diabetes and hypertension
            * to some of the management problems associated with diabetes and hypertension
                     ( including hypoglycemia )
            * To a variety of vague common every day symptoms discussed yesterday

The Diagnosis is easy and painless .
            *  Talk to your doctor about Sleep Apnea
            *  Ask for a consult to a sleep center and sleep specialist

Testing is easy and painless . No blood test involved.

            *  There is a simple unattended screening sleep study . This involves picking up a device  that
                measure pulse and oxygen saturation and a few other things at a sleep center.
                This device is small and attaches to the tip of your ring finger  You wear this all night
                and return it to the sleep center the next morning. The results and recommendations on how to                    
                proceed are reported  to you in a few days.

                Our 72 y/o patient , discussed a few days ago , had this test done. He slept  7 hours and had 99
                episodes of  oxygen desaturations with his oxygen (sp o2 levels)  levels dropping down to
                78%. ( normal is about 100 %). His study was reported as definitely abnormal and compatible
                 with having, Obstructive Sleep apnea. He was asked to return for a more complete study that
                 involved spending the night in the sleep center. The primary reason for this test was to
                 determine the pressure needed to overcome the obstruction to air flowing into his lungs.

                CPAP  was ordered  and within 2 months his blood pressure was normal (<130/80 ) with no
                medications, His nasal congestion and morning cough is gone and there is no snoring .  His
                wife is happier because she is now able to have a good nights sleep .
                His A1c and lipid panel are pending.

 More on CPAP and other treatments tomorrow.

                                                                               Have fun , be smart and defeat Diabetes

                                                                                                 David Calder,MD

Tuesday, January 24, 2012

Two sneaky diseases, Diabetes and Sleep apnea

                       Obstructive Sleep Apnea

 Who is at risk of having sleep apnea ?

* Almost everyone regardless of age however it is more common as we mature and get thicker.
*  It is estimated that  2% of women and 4% of men over the age of 50 have sleep apnea
*  Loud snorers , 17% of men and15% of women have obstructive sleep apnea
* Adolescents with high blood pressure are at risk of sleep apnea
* 30 % of adults with hypertension may have sleep apnea
* two thirds of people with difficult to control blood pressure had sleep apnea in one study
* Obstructive sleep apnea is associated with a 2.7 fold increased risk of having diabetes
* anyone ignoring the vague symptoms listed below

What are the symptoms ?
The symptoms are often considered  as normal every day problems that we all deal with from time to time in our lives.

The symptoms and findings may or may not include;

Snoring , snoring and lapses in breathing noticed by a spouse , large neck , daytime sleepiness,  fatigue , nasal congestion , morning cough , high blood pressure , having the metabolic syndrome or diabetes , spells of nausea ,sweating and light headedness, sweating at night , unrefreshing sleep , impaired concentration , personality changes and more.

              Making a diagnosis of sleep apnea is easy,

 Not thinking of Sleep Apnea as a possible  correctable cause for our symptoms is the difficult part.

Diagnosis and treatment tomorrow
 Have fun , be smart and defeat diabetes.   
 David Calder,MD

Monday, January 23, 2012

For those of you who read  the Jan. 19  discussion .
 " You fail to achieve 100% of the goals you don't set "

Please click on the link below or the tab above for the continued discussion of :
         "Simple and Specific Goals Empower each of us to do better "

  Diabetes Office Visits- Simple and Specific Goals Empower each of us to do better

    Have Fun , Be Smart and Defeat Diabetes.      David Calder, MD

Bra-size , Snoring , Diabetes and hypertension

 I saw an article the other day suggesting that larger Bra sizes increased the risk of developing diabetes. I immediately thought of news paper adds " Get your breast reduction TODAY and cure diabetes ". There may be more to this than meets the eye. We will just have to wait for more research to get the answer.

Snoring with intermittent lapses in breathing is no laughing matter . The National Commission on Sleep -
Disdisorder Research estimate that 7 to 18 million people in the United State have sleep disordered breathing .

Obstructive sleep apnea ( a condition in which the back of the throat collapses during sleep blocking the airway ) is the most common form of this condition. One study found , in a group of 379 women and 262 men between the ages 65 and 70 , that  57 %  had obstructive sleep apnea . This condition becomes more common as we age but is not limited to older people.

Sleep Apnea is associated with an increased risk of Metabolic syndrome , Hypertension , Heart disease and Diabetes. 

The symptoms of sleep apnea are often  common vague things that occur in our every day life such as snoring, insomnia , falling asleep reading the newspaper , tiredness , anxiety  and depression. 
Making a diagnosis first requires thinking about sleep apnea as a cause for a group of vague symptoms.

I will present a case that outlines the problems and delays in making a diagnosis.
    A 72 y/o male  with pre-diabetes ,hypertension and a stout build  ( 5ft 8 in and 186 # )developed vague symptoms of sudden strange nausea followed by mild forehead sweating and an intense desire to sit down.The symptoms lasted less than a minute and continued to occur in groups of 3 about once a month.  The symptoms occurred sitting standing or even lying down. Initially they were mild  and ignored until one day the symptoms occurred and he found himself on the ground. He saw his doctor and had an evaluation including blood test , chest X-ray and ECG.  His medications included glucaphage , amlodipine , a diuretic, L- Arginine and aspirin. There was no clear cause for the symptoms and glucophage,L-arginine and the diuretic were stopped. The symptoms were milder until one day he had the symptoms while driving and went off of the road. This episode  resulted in a cardiology visit and testing that revealed a mild transient electrical conduction problem during the episodes. A diagnosis of Vasovagal syndrome( basically fainting ) was made and amlodipine was discontinued. Exercises and better hydration was recommended and the symptoms improved but did not go away and his BP was staying elevated above 140 mmhg systolic.
     The concerns about driving persisted and prompted another visit with his doctor. The doctor ask about snoring, looked at his neck and throat , and suggested seeing a sleep specialist. A diagnosis of obstructive sleep apnea was made and CPAP  treatment was started resulting in completes resolution of all of the symptoms. His blood pressure is 123 -130 / 70 to 80 mmhg with no medications and his wife is now able to sleep through the night without the snoring serenade.

The time from the onset of symptoms and a diagnosis was about 18 months.

 Remember : 

Thinking of sleep apnea as a cause for your vague symptoms is the first step to making a diagnosis.

 AnotheHint , If your spouse can't sleep because of your snoring , think of sleep apnea.

 More on symptoms , screening test , effects on diabetes and blood pressure  . Stay tuned.  
   David Calder,MD

Saturday, January 21, 2012

Terminal illness to one doctor may be a moment to excel by another.

I will put a hold on my goal setting ideas for today to discuss the article below. I am also still having trouble moving charts and graphs from Pages to my blog page. They transfer initially and then disappear leaving a ? mark. Any ideas ?

I read an article  and comments  in Medscape Connect today discussing "How doctors die". After reading the article and many of the comments , I came away with the feeling that most of the doctors responding would chose to accept the diagnosis of terminal illness and slip comfortable into the beyond without a fight.

    I would like to offer a different perspective based on my over 48 years experience as a physician.
   The first lecture on my first day of medical school was given by an old family doctor. His best advise for us as hopeful new doctors was to " never tell someone when they going to die because that person will probable be kicking dirt in your face" . I have lived long enough to know that he was right. I have had the pleasure of watching people make amazing come backs from what seemed like hopeless circumstances. I have also learned that we doctors are not that good at defining terminal illness. Terminal illness to one doctor may be a moment to excel by another. 

   I have had a very personal experience that high lights my thoughts. In my wife's will she signed a form stating that she wanted no life support. I recall asking her at the time if she really meant that and she said yes. Fortunately I had forgotten about our wills when my wife became ill . About 8 years ago she developed flu like symptoms and within 36 hours was hospitalized with septic shock. Over the next 24 hours she was on total life support , unconscious, bleeding from every orifice , acute renal failure on dialysis, gangrene of both lower extremities ,requiring respiratory and BP support . She had multiple surgeries including bilateral below the knee amputations and was in ICU for 2 months.
   I refused request to talk about end of life care. Thanks to the doctors who chose to excel rather than yield to the easy choice of death, my wife now is healthy and enjoying life ,walking up to 2 miles each day on her new titanium legs. She has sense told me that dying would have been easy because the has no recall of anything after getting in the ambulance. She also has a better understanding of "do not resuscitate "and has now changed her choice to; allowing family and her doctor to make the decision if she is unable do do so on her own. 

She is thankful for being given the opportunity to spit in deaths face. 

 David Calder,MD 

Thursday, January 19, 2012

"You Fail to Achieve 100% of the Goals you don't set"

                                                  Chapter 2  Diabetes Office Visit

 Setting Goals and talking to your doctor

Diabetes is a chronic disease with known correctable risk factors. 
Preventing diabetes complication,
especially heart disease, is possible  and it depends on you.You are your doctors number one assistant and correcting  these risk is up to you. 
"Fixing the nine" is a term I like and setting 9 treatment goals with your doctor is your first step to preserving your good health.
"You fail to achieve 100% of the goals you don't set"
My A1c goal is < 6 because I have pre- diabetes and do not want to progress to diabetes. What is your  A1c goal?
How you achieve those goals is the next question.
                                                           Have fun, be smart and defeat diabetes.       
                                                            David Calder,

Wednesday, January 18, 2012

Hypoglycemic unawareness and continuous glucose monitoring

Doctors and people with diabetes are all aware of the amazing benefits of achieving an A1c hemoglobin levels of < 7 .  Something that we do not discuss as often is the risk associated with achieving that goal. 
 Recently the ACCORD  study , designed to demonstrate the benefits of near normal A1c's , was stopped early because of the increased mortality in the treatment group related to hypoglycemia.

Low blood glucose levels ( less than 70 mg/dl ) are usually associated with some early warning signals , such as a feeling of anxiety, sweating and shaking shaking. The duration of diabetes and the number of hypoglycemic events over time blunt a persons awareness of these early warning signals . The loss of the early warning signals result in a condition know as hypoglycemic unawareness. 

Hypoglycemic unawareness  means that a person first awareness of a low glucose is cognitive impairment. This may result in the loss of a persons ability to take corrective measure to treat the low glucose levels and  then progress to severe hypoglycemia.

Severe Hypoglycemia  is defined as" hypoglycemia requiring the assistance of another person"  "This is one good reason for not living alone and having a up to date Glucagon emergency kit."

The occurrence of hypoglycemia mild or severe is a reason to see your doctor to discuss treatment options.

Preparation for the visit

   # 1 Good home glucose records with before meal , bedtime and 3 am test are important. 
   # 2 food records for 2 to 3 days  paying close attention to consistency of carbohydrate intake
   # 3 exercise records with the time of day and duration
  ( hint - Diabetes Office Visit App keeps these tools and the ability to share your results always at your finger tips)

Things to discuss with your doctor

#1  Discuss your current diabetes management and ways to improve your skills especially with food and  insulin. Discuss the use of insulin /carbohydrate ratios , timing of your insulin doses and switching  to a  different basal  insulin such as Lantus .
#2 Discuss medications that have a lower risk of hypoglycemia such as glucophage (metformin ), exentide (byetta ), liraglutide (victors) , sitagliptin (januvia) , saxagliptin ( onglyza) and older drugs such as acarbose
 #3  Discuss the use of temporary or permanent continuous glucose monitoring .  I personally feel that continuous glucose monitoring may be one of the best tools available in our efforts to reduce the risk  associated with hypoglycemia.

 I have attached a copy of a Medscape article  discussing guidelines for  using continuous   glucose monitoring. 

                             Have fun , be smart and defeat diabetes        David Calder, MD

Guidelines Address Continuous Glucose Monitoring
Laurie Barclay, MD

October 12, 2011 — Continuous glucose monitoring (CGM) assists people with diabetes in maintaining target blood glucose levels, according to an Endocrine Society clinical practice guideline published in the October issue of the Journal of Clinical Endocrinology and Metabolism.
"There are some caveats to consider before accepting continuous monitoring of glucose as a routine measure to improve glycemic control in diabetes," guidelines task force chair David C. Klonoff, MD, from Mills-Peninsula Health Services in San Mateo, California, said in a news release. "There are still concerns about the high costs of CGM and the accuracy of the various systems available. However, the new [clinical practice guideline] shows that CGM can be a beneficial tool to help maintain target levels of glycemia and limit the risk of hypoglycemia."
CGM, using various devices, measures glucose in the interstitial fluid; the intended use is for patients with type 1 or type 2 diabetes to make decisions about food, medicines, and exercise. A task force of experts, a methodologist, and a medical writer set out to develop evidence-based practice guidelines for identifying clinical scenarios in which CGM would be most beneficial to patients with diabetes. The goals of CGM are to maintain target levels of glycemia and to limit the risk for hypoglycemia in 3 potential settings: real-time (RT) CGM in hospitalized adults, RT-CGM in children and adolescent outpatients, and RT-CGM in adult outpatients.
The strength of the recommendations and the quality of the evidence were described using the Grading of Recommendations, Assessment, Development, and Evaluation system. Consensus was established in a group meeting, conference calls, and emails. The Diabetes Technology Society and the European Society of Endocrinology also reviewed and commented on preliminary drafts of these guidelines.
Specific recommendations for CGM are as follows:
  • While awaiting further evidence, RT-CGM alone should not be used for glucose management of adults in the intensive care unit or operating room.
  • Children and adolescent outpatients with type 1 diabetes mellitus (T1DM) and glycosylated hemoglobin (HbA1c) levels less than 7.0% should use RT-CGM with currently approved devices.
  • Pediatric, adolescent, and adult outpatients with T1DM and HbA1c levels of 7.0% or more should use RT-CGM if they are able to use these devices on a nearly daily basis.
  • The guidelines do not recommend for or against the use of RT-CGM by children younger than 8 years with T1DM.
  • Patients should be given treatment guidelines so that they can safely and effectively use the information obtained from RT-CGM.
  • Intermittent use of CGM systems capable of short-term retrospective analysis is recommended in children and adults with diabetes and possible nocturnal hypoglycemia, dawn phenomenon, and postprandial hyperglycemia; in patients with hypoglycemic unawareness; and in patients undergoing significant changes to their diabetes regimen.
  • Adults with T1DM and HbA1c levels less than 7.0% should use RT-CGM devices if they can use them on a nearly daily basis.
"CGM can be beneficial in maintaining target levels of glycemia and limiting the risk of hypoglycemia," the guidelines authors write.
All Endocrine Society clinical practice guidelines are supported entirely by society funds. Some members report various financial relationships with Bayer, C8 MediSensors, Insuline, LifeScan, Medtronic Diabetes, Roche, Diabetes Technology Society, MedTronic MiniMed, LifeScan, NovoNordisk, JDRF, UnoMedical, European Society of Endocrinology. KER Unit (Mayo Clinic), Abbott Diabetes, Eli Lilly, Macrogenics, Dexcom, the Endocrine Society, and/or Insulet.
J Clin Endocrinol Metabol. 2011;96:2968-2979. Abstract

and don't forget to visit Laughing at LIfe by Mark to gain a little insight into the lows from a personal point of view...


Monday, January 16, 2012

More on hypoglycemia and " lizard spit "

Answer to yesterdays question about lizard spit. 
Byetta ( exenatide ) is a synthetic  version of a hormone found in saliva of Gila Monsters  
 I have another question for you .

 What currently available diabetes medicine has all of the benefits listed below ?  ( hint- look up )
 #1 improves glycemic control and provides glucose sensitive insulin release

 #2 decrease systolic BP

 #3 decreases body weight

 #4 decreases LDL Cholesterol  

 #5 decreases fasting triglycerides

 #6 decreases hsCRP ( an inflammatory marker )

 #7 decreases insulin resistance

#8  preserves Beta cell function  and increases insulin levels . 

#9  no significant risk of hypoglycemia

Mark and I had planned to move on to a discussion of goal setting and then living life stepped in with technical problems and my computer skills while Mark ( my partner in this blog ) was having a real life adventure with hypoglycemic unawareness last weekend.  Our goal with this blog is discuss  diabetes from the  clean , clinical , It is all clear in my mind doc's perspective  and from Mark's down in the dirt daily dealing with diabetes.

The ACCORD  study we discussed a few days ago discusses some of the risk of hypoglycemia.

We also know that it is possible to recover some of the early warning signals of hypoglycemia by carefully avoiding hypoglycemia . So, what is wrong with Mark ? Why doesn't he just fix the problem ?  It is easy for me to say " avoid having hypoglycemia ". What is his problem ?
Read about Marks  weekend adventure 

More tomorrow
 David Calder,MD

Saturday, January 14, 2012

NPH insulin at dinner - low glucose at 3 am

Night time hypoglycemia is no fun , and is one of the main concerns for mothers of children with diabetes and the elderly.

Normal physiology - Low glucose levels at 2 to 3 am is partially related to the normal physiology of our bodies allowing us to be more sensitive to insulin in the early morning hours. Bedtime snacks are used to helps avoid the problem.

 Insulin type and when it is injected is also a contributor to this problem. In my experience NPH insulin with dinner was one cause of this problem. NPH insulin has its peak effect about 6 to 8 hours after injection ,which is about 2 to 3 am if it is taken with the evening meal .

Oral medications  such as glicazide, glimepiride ( Amaryl) , glipizide ( Glucatrol ) and glyburide
( Diabeta, Glynase ) can be associated with hypoglycemia especially in frail elderly people

If you are using NPH with your evening meal or taking the oral medications listed above and having middle of the night lows it is time to talk with your doctor about other options.

Other options
Switching to Lantus (glargine ) or Levemir (detemir ) insulins or adjusting injection time and/ or dose of your NPH  can help solve this problem. Some of the oral medications less likely to be associated with
hypoglycemia include  Metformin (glucophage ) , Onglyza (saxagliptin ), Januvia (sitagliptin ) ,Tradjenta (linagliptin ) and Byetta (exenatide ).

 Which of the above medications has a nick name of " lizard spit " ?

 Have fun, be smart and defeat diabetes .     David Calder,MD

Friday, January 13, 2012

Hypoglycemia risk may sometimes out weigh the advantage of having a " normal A1c result "

 We have very good data supporting the reduced risk of eye , nerve and kidney damage by achieving an A1c of  7.  We have some data supporting the idea of reduced reduced cardiovascular risk with achieving the same target. I have attached part of  a discussion that outlines more of the risk associated with our efforts to reach normal glucose levels in everyone with diabetes. The risk of hypoglycemia may sometimes out weigh the advantage of having normal blood glucose test.  I have highlighted the area that you may want to read.  This is something you and your doctor need to discuss.                                                                                            David Calder,MD

and don't forget to visit Laughing at LIfe by Mark to gain a little insight into the lows from a personal point of view...

Thursday, January 12, 2012

The Sneaky Devil - Hypoglycemic unawareness

Hypoglycemic unawareness ,  is a common treatable problem most commonly seen in people with type 1 diabetes . It involves the loss of the early warning signals of hypoglycemia and allows glucose levels to slowly and silently decrease to the point of of mental impairment , poor judgement  and even coma. This is especially important for someone driving a car, working around dangerous equipment , Caring for young children or living alone. This is important to recognize in older people because it increases their risk of falls and injury. 
 The treatment is easy to talk about but hard to do. Basically it involves accepting a little higher glucose levels and carefully avoiding low glucose levels.  This will allow recovery of those early warning indicators.  
 Have fun, be smart and defeat diabetes.       David Calder
By the way stop by Marks blog Laffing at Life to get a little more about Hypoglycemic Unawareness

Tuesday, January 10, 2012

The Devil Is In The Details or Welcome To Our New Blog!

Lots to accomplish in this blog post and I want to keep it as short as possible so away we go...

This is our new blog, Laughing at Life as you can tell. We will be cross posting our blog posts between the Dr.s blog right here and also Laughing at Life. It's all a lighter look on life and all it offers us. It will be a look at the past, present and the future of what life has to offer and has offered in the past. Of course as you can figure from this statement it will mostly about my success and failures in getting to where I am at now and where I want to be in the future with Patti, my wife, the kids and Dr. Calder. The attempt is to not give you the hows of life, but the who, what, when, where and why of life and  living healthy.

I couldn't do this without Dr. David Calder who I met through the internet and from that have grown a great friendship over the past year. Not only is he a friend but now a partner in changing my life for the better and hopefully helping you change yours. Throughout the next few months you will be included and invited, if you want to join us on this quest to get healthier and live a great life and totally laugh at life!. That's my goal. I did it in the past and now I want to do it again for the future.

Now along with myself writing and the Doc, Patti my wife, caregiver, best friend and partner will be giving you her take on moi. This should help you to laugh at life a great deal.

As for the title of this post, "The Devil Is In The Details" it is based on Dr. Calder's book The Diabetes Office Visits first chapter. He talks about the Two Devils- The Lows and the Highs. You bet the devil can really get into technical details when as a diabetic we deal with the highs and the lows. Now if you throw in heart disease and the fact that I am slightly hampered by polio from  my youth, that takes the details to a higher ground. Makes for some laughable times, not really.

I suggest you all read this chapter. If you do not have the book you can purchase it through the Doc's web site at The Diabetes Office Visit or on our main site 1 Disease World Voice. You can do and while you are at it purchase the iPhone app if you have an iPhone. If not no worries we can help you work around that as we go along. I promise we are not going to spend a great deal of time selling you stuff. We don't really have too. Are posts, our lives, our success and failures all relate to what I have learned from Dr. Calder in the past few months and what I will learn in the future months as I progress. The best part is you are welcome to join us and get the advantages of watching me succeed or fail so you can succeed where I fail.

Okay getting a little long here on this supposed short post but heck that's what Laughing at Life is going to be about. 

Get ready for a roller coaster ride that you will never forget. Not only of what we have planned now for the future but what has happened in the past to get me to where I am at today, Laughing at Life endlessly.

I am happy and proud to say that I could not have picked a better mentor than Dr. Calder who I know you will find to be a mentor to you all. 

Be Well and 
Laugh at Life!

Diabetes Office Visit- review from different perspectives

In 2011 our website was hacked and essentially destroyed .This event was initially upsetting to everyone involved yet overall the hacker opened a door of opportunity for us. We have looked at and are in the process of  better defining our goals. I see Mark as a man of a million ideas who has diabetes and has experienced some of its complications. He has a more global look at diabetes with a goal of developing communities of people to help improve the lives of every one with diabetes . He has discovered that this process is as complex and difficult as diabetes is itself. My vision of diabetes care comes from a different perspective.
I am a physician , with pre-diabetes, who has had the privilege of being an endocrinologist with partners that have allowed me to focus my attention on diabetes for over 35 years. I have always been fascinated by  the physiology of this disease, how it effects our lives each each day, with it's silent capacity to steal our good health. I have been even more impressed  by my patients ability to rise up and face this enemy of our health. I marveled at the good sense, strengths and determined will of of my frailest patients to stand  alone with their faith and make very tough decisions.  I believe that these moments with my patients,  often in the early morning or late night hours, is a very special privilege that doctors share with their patients . I have always hoped that possess that same courage. I have certainly had some very good teachers.
As a result of my experience , my approach to diabetes is more local and focused on one person at a time. I believe that I have developed, over time, a simpler approach to this complex disease that I discussed in my book ,Diabetes Office visit. I  believe that your best diabetes care comes from the wisdom and care provided by your personal physician.My goal with “Diabetes Office Visit “ is to improve the  communication between you and your physician to reduce your risk of complications.
My son in law, Vince, was helping me write a grant proposal  recently. After listening to my ideas he coined a term “ Managing The nine “ referring to the risk factors associated with our increased risk of heart disease. That one term explains the whole concept of this book. My other goal is to sell enough books and Apps. to recoup my development cost.
With the above background; Mark and I plan to discuss diabetes from our different perspectives. We will start with a review of each chapter of my book with a goal of getting your comments combined with our perspectives and develop a better second edition. 

 Chapter 1 Two Devils- The Lows and the highs

My summary of this chapter is that everyone with diabetes walks a path each day between the immediate some times silent consequences of the Devil of low blood sugar and the mostly silent long term consequences of high sugars. The other message in this chapter is that as we get older Long Term gets shorter and short term becomes more important in our treatment decisions. The last paragraph “ Just do your best “ is my over 35 years observation of people with diabetes      

Have fun, be smart and “Fix the Nine”         David Calder, MD

"Statins worsen glucose control" The evening news

Statins worsen glucose control in people with diabetes was the message I heard on the evening news last night.
How about the rest of the story.

     I think they were referring to an article in Diabetes Med. Dec.12:dol: 10.1111/j.1464-5491x
     The effects of rosuvasatin and atorvastin on glycemic control in type 2 diabetes- The Corall study Results: ( copied from an article in Medscape )

Treatment with the highest dose of statins, i.e. atorvastatin 80 mg and rosuvastatin 40 mg at 18 weeks from baseline, was associated with increase in HbA(1c) levels; baseline 57 ± XX mmol/l (7.4 ± 1.0%) to 61 ± XX mmol/mol (7.7 ± 1.3%) (range 5.0-11.9) for atorvastatin (P = 0.003) and from baseline 60 ± XX mmol/mol (7.6 ± 1.0%) to 63 ± XX mmol/mol (7.9 ± 1.2%) (range 5.7-12.3) for rosuvastatin (P < 0.001). Mean fasting plasma glucose increased from baseline 8.7 ± 2.4 mmol/l to 9.5 ± 3.0 mmol/l upon treatment with atorvastatin 20 mg (P = 0.002) and 9.0 ± 3.0 mmol/l after treatment with 80 mg (not significant compared with baseline). The mean fasting plasma glucose did not change after treatment with rosuvastatin (9.1 ± 2.7 mmol/l at baseline, 8.9 ± 2.7 mmol/l with 10 mg, 9.4 ± 2.9 mmol/l with 40 mg).
Closer look:  Atorvastatin 80 mg and Rosuvastatin 40 mg increase A1c by 0.3 which is about a 9 mg/dl ( or 0.5 mm/l ) increase in average glucose and about a 6 mg/dl( 0.3 mm/l ) increase in Fasting glucose. These are minimal changes when you consider that the accuracy of your glucose meter may be plus or minus 20 %.The benefit from taking a small dose of statin for out ways any potential slight increase in glucose. See the CARDS
study below.  

 My comments ;
    This Corall study was done with the highest dose of statins that most people with type 2 diabetes will never need .
   Most people with type 2 diabetes have minimal increases in their LDL cholesterol , Triglycerides associated with lower HDL .
    My friend John Nelson, PA and I did a small observational type study on people with diabetes admitted  to Sacred Heart Hospital in Eugene , Oregon for a coronary bypass . We did this study to document our observation that most of the patients with diabetes admitted for a coronary bypass were not on a statin. We looked at 121 patients and found that only 37 ( 30 % ) were on a statin. Many of these people were just started on the statin after developing chest pain. 
The average lab values for all of the patients was;     A1c     7.58
                                                                             Cholesterol  190.6 mg/dl ( 5 mm/l )
                                                                              Triglycerides 256.6  mg/dl  ( 2.9 mm/l )
                                                                               HDL             34.9 mg/dl ( .91 mm/l )
                                                                               LDL              110 mg/dl ( 2.9 mm/l )
The take home message is that most of us will not need the high doses of statins used in The Corell study to reach our target goal.

 For example 10 mg of lipitor will reduce LDL cholesterol by about 38 mg/dl ( 1mm/l ) in most people.That dose is more than enough to get the average person with type 2 diabetes below 100 mg/dl (2.6 mm/l )and close to 70 mg/dl. (1.8 mm/l )

The CARDS ( Collaborative Atorvasatin  Diabetes Study ) demonstrated that 10 mg of lipitor (atorvastatin) in people with type 2 diabetes without know heart disease but with at least 1 risk factor could prevent  37 major vascular events (Heart attack and strokes) for each 1000 people treated for 4 years.
My favorite line from The CARDS study is, “The debate about whether all patients with type 2 diabetes warrant statin treatment should now focus on whether any patient can reliably be identified as sufficiently low risk for this safe, efficacious treatment to be withheld.” 

Calder, David (2010). The diabetes Office Visit (Kindle Locations 621-623). David Calder, MD. Kindle Edition. 
Have fun be smart and defeat diabetes .   David Calder,MD


Friday, January 6, 2012

More on the idea of "fixing the 9 " Statins effect on glucose

"Fixing  the 9 " is a phrase I like . Fixing, is a common term in my home state of Texas .for example, I am fixing to go to town.The nine are the 9 risk factors those of us with diabetes and pre diabetes need to correct to recommended target goals to reduce our risk of heart disease and stroke. For the people without diabetes the number decreases to 6. What are those risk factors ? ( hint ,look at the last few days post).

The study below is good news for those of us concerned about the impact of Statins such as lipitor ( atovastatin)  and Crestor ( rosuvastatin ) on glucose control. The bottom line , if my math is correct ,is that there were very minimal increases  in  average A1c  .3  and Fasting blood glucose  6 mg/dl for atorvastatin and rosuvastatin . I think we can handle this when we compare that small correctable increase to the tremendous  benefit we gain by taking a statin.
                                Have fun , be smart ,  be healthy ," Fix the 9 "    David Calder, MD 

Diabet Med. 2011 Dec 12. doi: 10.1111/j.1464-5491.2011.03553.x. [Epub ahead of print]

Effects of rosuvastatin and atorvastatin on glycaemic control in Type 2 diabetes-the CORALL study.


Department of Internal Medicine/Diabetes Centre, Medical Centre Alkmaar, Alkmaar Internal Medicine, Maastricht University Hospital, Maastricht Department of Endocrinology and Metabolism, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.


Aims:  To examine whether high-dose statin therapy in Dutch European patients with Type 2 diabetes and dyslipidaemia influenced variables of glycaemic control. Methods:  The CORALL study, which was a 24-week, open-label, randomized, parallel-group, phase IIIb, multi-centre study, was designed to compare the cholesterol-lowering effects of rosuvastatin compared with atorvastatin in patients with Type 2 diabetes. Fasting plasma glucose levels and HbA(1c) levels were collected at baseline and at 6 and 18 weeks. Results:  Treatment with the highest dose of statins, i.e. atorvastatin 80 mg and rosuvastatin 40 mg at 18 weeks from baseline, was associated with increase in HbA(1c) levels; baseline 57 ± XX mmol/l (7.4 ± 1.0%) to 61 ± XX mmol/mol (7.7 ± 1.3%) (range 5.0-11.9) for atorvastatin (P = 0.003) and from baseline 60 ± XX mmol/mol (7.6 ± 1.0%) to 63 ± XX mmol/mol (7.9 ± 1.2%) (range 5.7-12.3) for rosuvastatin (P < 0.001). Mean fasting plasma glucose increased from baseline 8.7 ± 2.4 mmol/l to 9.5 ± 3.0 mmol/l upon treatment with atorvastatin 20 mg (P = 0.002) and 9.0 ± 3.0 mmol/l after treatment with 80 mg (not significant compared with baseline). The mean fasting plasma glucose did not change after treatment with rosuvastatin (9.1 ± 2.7 mmol/l at baseline, 8.9 ± 2.7 mmol/l with 10 mg, 9.4 ± 2.9 mmol/l with 40 mg). Conclusions:  Glycaemic control deteriorated in patients with diabetes following high-dose statin therapy. Future controlled studies are needed to verify these findings and, if confirmed, determine whether such changes represent a true decline in glycaemic control. Presently, it appears that, based on the overwhelming prospective trial data available, the preventive effect of statin therapy supersedes that of the slight increase in HbA(1c) . © 2011 The Authors. Diabetic Medicine© 2011 Diabetes UK.
© 2011 The Authors. Diabetic Medicine © 2011 Diabetes UK.