Good idea, elixer of Metformin

Tolerating metformin

Metformin along with lifestyle change is a cornerstone in the treatment of type 2 diabetes, unfortunately many people have trouble tolerating the gastrointestinal side effects associated with metformin.

My usual approach is to start with a low dose , 250 mg daily, and then increase by 250 mg /d every 2 weeks until the recommended dose is reached. If nausea occurs with a dose increase , the person can go back to previous dose and wait 2 more weeks and then try increasing it again. This approach is usually effective .

Good idea , elixer of metformin

I was listening to a diabetes medication discussion by Ann Peters,MD recently.  She has added a useful idea that may be useful for some one unable tolerate  the 250 mg dose.

She has them go to a compounding pharmacy and get an elixer of metformin 50 mg/teaspoon. This allows a person to start the metformin dose titration at 50 mg and then adjust every 2 weeks as discussed above.

Have fun , Be Smart and find a way to take your metformin

David Calder,MD

I have attached links to my other discussion about metformin. Metformin is a safe effective medication that lowers blood sugar levels and helps reduces cardiovascular and cancer risk

.Metformin( glucophage) - better understanding of a.

. Pre-Diabetes treatment with Glucophage ? Statins ?...

Diabetes medication , the first choice is easy, th...

 Metformin reduces cancer risk

Cancer survival, another reason to take glucophage...

Metformin ( glucophage) effects Thyroid test

Metformin ( glucophage) effects Thyroid test

Glucophage "failed " Now what should I do ?

Framingham Heart study

The Framingham Heart study started in 1948 and continues today. This is one of the classic studies forming a base for  understanding  the benefits of controlling known heart disease risk factors and preserving our good health.
 The initial study started with 5,209 men and women between the ages of 30 and 62 and have followed exams and known cardiovascular risk factors on a regular basis. They are now following the 3rd. generation of these original participants.  The cardiovascular risk evaluator charts that we used a few days ago are just one of the benefits of this on going research,
I suggest that you click on the link below and go to their home page.  I enjoyed the history  and risk score profile sections .

http://www.framinghamheartstudy.org/index.html

The answer to question #2 .
 What 3 letter word best describes our  greatest risk ?                  age


Have Fun , Be Smart and live a healthy life style and enjoy the freedom of getting a little older.
David Calder,MD

NEW Diabetes office visit update is still in progress

The new updates on Diabetes Office visit app. is still in a "bug Chasing mode ".  We are LOCATING still having problems with the Risk Management Section. Rudy Aramayo , with Orbitus Robotics LLC ,  a very talented innovative app developer is working on the problem and it will be resolved soon. Everything Rudy does always exceeds my expectations.

We are still trying to resolve some issues in the Risk management section.

The Risk Management section    is one of the most important sections of  the Diabetes Office Visit app. This portion of the app allows a person  to always have their medical history and lab data at their finger tips. Having your health history and medication always available is important for every one with and without diabetes. In fact about 50 % of Diabetes Office Visit  app applies to non-diabetics ,The risk management and Goal Setting sections .

I WILL COMPLETE THE FRAMINGHAM DISCUSSION TOMORROW.

Diabetes Office Visit app . Repairs in progress

Sorry , I have been busy working on correcting Diabetes Office visit app bugs today. I will complete the Framingham  discussion tomorrow. Dr Calder

That is close to a 50 % reduction in Heart attack risk!!

A recent CME ( Continuing Medical education) program ( OpenCME) reviewed some interesting information about smoking and and heart disease. They used something called The Framingham Risk Calculator to evaluate the benefits of not smoking.

They used a 50 y/o overweight male smoker with mild hypertension and elevated LDL as an example. 

He could reduce his risk of having a heart attack in the next 10 years from 25% to 11% if he just stopped smoking.

 That is close to a 50% reductions in risk, according to The Framingham Risk calculator .

Home Work
 #1 Check out the link below and estimate your own risk .  Sleep well.
        http://www.nhlbi.nih.gov/guidelines/cholesterol/risk_tbl.htm#men

 #2 What 3 letter word best describes our greatest risk ?

               More Framingham discussion tomorrow 


 #3 What happens if a person corrects a few more  known risk  factors for heart disease?
     click on  here

            Treating multiple risk factors is additive


Be Smart Stop smoking, preserve your good health and enjoy your wonderful life a little longer.
David Calder,MD

Avoiding Dissicated Thyroid Hormone Replacement is still a good idea .

Avoiding Dissicated Thyroid Hormone Replacement is still a good idea . Please see my November discussion and comments below from people who felt that there is benefit in taking  a little T3 . I still agree with the FDA that desiccated thyroid is obsolete.  There is a FDA approved product with reliable content of T4 and T3, Thyrolar .

 #1 Question ?
                    What is  the structural difference between T4 and T3 ?
     Answer -
                     One iodine molecule ( T4 has 4 iodine molecules and T3 has 3 )

#2 Question True/ false
                     T3 is the  active metabolic form of thyroid hormone.

     Answer -  True,
                      T4 is the inactive primary form of thyroid hormone produced in the thyroid gland. The
                      T4 is then slowly converted to T3 by enzymes in our tissues by removing 1 iodine
                       molecule.
#3  Question ?
                     Why not cut out the  "middle man , T4 " and just take the active form of the hormone T3 ?

       Answer ? The short answer is that it is just not safe for every one.  T3 is almost 100%  absorbed
                        and produces an elevated T3 level with every dose. This can produce extra demands on
                        a persons heart.
                       T4 is a longer lasting hormone that slowly converts to the metabolically active , T3 ,
                        delivering a steady stable supply of T3 to our tissues. There is a small percent of
                        people who genetically are unable to convert T4 to T3  , and will benefit from taking a
                        medication containing T4 and T3 such as Thyrolar .

#4 Question?
                    Is there any reason for ever using pure T3 ?
     
     Answer -
                     Yes. I used Cytomel ( T3 )  , because of its short half life , as part of the process in
                      evaluation of patients with thyroid cancer.


 There is some evidence that some people may need to take a little bit of T3 to get the full benefit from thyroid replacement. I have attached an abstract of an article supporting the idea below.

J Clin Endocrinol Metab. 2009 May;94(5):1623-9. Epub 2009 Feb 3.

Common variation in the DIO2 gene predicts baseline psychological well-being and response to combination thyroxine plus triiodothyronine therapy in hypothyroid patients.

Panicker V, Saravanan P, Vaidya B, Evans J, Hattersley AT, Frayling TM, Dayan CM.

Source

Henry Wellcome Laboratories for Integrative Neurosciences and Endocrinology, University of Bristol, Dorothy Hodgkin Building, Whitson Street, Bristol BS1 3NY, United Kingdom.

Abstract

INTRODUCTION:

Animal studies suggest that up to 80% of intracellular T(3) in the brain is derived from circulating T(4) by local deiodination. We hypothesized that in patients on T(4) common variants in the deiodinase genes might influence baseline psychological well-being and any improvement on combined T(4)/T(3) without necessarily affecting serum thyroid hormone levels.

METHODS:

We analyzed common variants in the three deiodinase genes vs. baseline psychological morbidity and response to T(4)/T(3) in 552 subjects on T(4) from the Weston Area T(4) T(3) Study (WATTS). Primary outcome was improvement in psychological well-being assessed by the General Health Questionnaire 12 (GHQ-12).

RESULTS:

The rarer CC genotype of the rs225014 polymorphism in the deiodinase 2 gene (DIO2) was present in 16% of the study population and was associated with worse baseline GHQ scores in patients on T(4) (CC vs. TT genotype: 14.1 vs. 12.8, P = 0.03). In addition, this genotype showed greater improvement on T(4)/T(3) therapy compared with T(4) only by 2.3 GHQ points at 3 months and 1.4 at 12 months (P = 0.03 for repeated measures ANOVA). This polymorphism had no impact on circulating thyroid hormone levels.

CONCLUSIONS:

Our results require replication but suggest that commonly inherited variation in the DIO2 gene is associated both with impaired baseline psychological well-being on T(4) and enhanced response to combination T(4)/T(3) therapy, but did not affect serum thyroid hormone levels.

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

Diabetes Office visit iphone and ipad app still has a few bugs

The recent update on Diabetes Office visit had a few bugs.  I think we have found and corrected the problems. The bug fixes on the update are still in the itunes review process.  I think you will be pleased with the result.  I apologize for inconvenience.   Dr. Calder

Omega 3 Fatty acids in the news, The rest of the story.

• Omega 3 fatty acids had their moment in the news yesterday .
• 
  
•  The headline , omega 3's have no effect in reducing the risk of cardiovascular disease. 
• 
  
• I believe they were referring to the ORIGIN study. This was a large study, 12,537 people with high risk for cardio vascular disease who had impaired fasting glucose , impaired glucose tolerance ,or recent onset of type 2 diabetes. 
•  The ORIGIN Trial Investigators. N-3 fatty acids and cardiovascular outcomes in patients with dysglycemia. N Engl J Med. 2012; Jun 11. Epub ahead of print.
• 
  
• End points
•  Primary end points cardiovascular death , secondary end points 
• Secondary end points , nonfatal heart attack or stroke ,all cause mortality or arrhythmic death
• 
  
• The purpose was to answer 2 questions
• 
  
•  #1 Question -
•       To investigate wether insulin replacement with Glargine ( Lantus insulin ) and
•       maintaining a fasting glucose below 95mg/dl (5.3 mm/l) would reduce the risk 
•       of cardiovascular disease.
• 
  
•      Answer - 
•                       No , there was no significant reduction in cardiovascular outcome in
•                       the insulin group
•                   
•     The rest of the story   
•                       There was no increase in the risk of developing cancer.
•                       There was a decrease in the progression to type 2 diabetes with
•                       maintaining a normal fasting glucose.
•                   
• 
  
•   # 2 Question
•        To evaluate cardiovascular risk in patients taking  1 capsule  containing 
•         900 mg of  omega 3 fatty acid
•       
•             
•        Answer - there was no reduction in cardiovascular risk  over the 6.2 years of 
•                         the study.
• 
  
•       The rest of the story and comment
•                      baseline Triglycerides 152 mg/dl 
•                                       LDL cholesterol 112 mg/dl
•                     The treatment group  had a 23.5 mg/dl decrease in triglycerides 
•                     compared to a 9% decrease in the placebo group. 
•                     and  no significant  decrease in LDL  or increase in HDL. They did 
•                     demonstrate that a small dose has a small effect on lipids.
•                  .

                   Comment. 

                        The good news in the rest of this story is that early aggressive correction

                        of glucose can slow the progression of type 2 diabetes . 

                        

                        The finding of no increase in the risk of cancer in patients using glargine 

                         (Lantus )relieves some of the early concerns about glargine and cancer.

                        

                        Omega 3 fatty acids are effective for reducing abnormally elevated

                        triglyceride. The average baseline  triglyceride level in the study was 152 

                        mg/dl( normal < 150 mg/dl ) .

                       

                        This was a research study, in patients with no clinical indication for using

                        omega 3 fatty acids , and they successfully demonstrated that there was 

                        no benefit in  taking low dose ( < 1 gram ) of omega -3 - fatty acid.

                       

                       The therapeutic dose for elevated triglycerides is 4 to 6 grams of fatty 

                        acids EPA and DHA. Most of the patients would not have received
                        omega -3 -Fatty acid in their doctors office and would have instead
                        received a recommendation to adjust their statins  to correct their LDL 
                        cholesterol to < 70 mg/dl.

                      

             I have attached some of my previous blogs for your review on this topic.

Have fun , Be Smart and read the details
David calder,MD

Omega -3 - fatty acids and Heart Disease

 Diabetes ,Triglycerides, Fish Oil and Heart Diseas.. .

 The 'Other" Omega -3- Fatty acids

Shopping for Omega -3 Fatty Acids can be confusing...

• Niacin " Aims High " and Missed         

New update for Diabetes Office visit App, a few problems

Problems with the recent update released yesterday.
    Ipad Diabetes office visit will not open
    Iphone clicking the plus sign in the Risk management section  turns the app off.

Sorry for the inconvenience . We will correct these problems as soon as possible.

The good news about the update is that it  will allow lab data to be seen in metric or US customary units.

Dr. Calder

Sleep Apnea , A mix of seemingly unrelated symptoms

 A mix of seemingly unrelated symptoms ! one Diagnosis
                                   Obstructive Sleep Apnea a Case study

72 y/o male with a recent problem of syncope and near syncope.
The symptoms started about 1 year ago  with the occasional sudden onset of nausea and a feeling that he needed to sit down. The sensations lasted about 2 minutes and would pass without any residual symptoms. There was no pain or shortness of breath.The symptoms became more frequent occurring about once a month in groups of about 3 to 4 within a 24 hours time span. The symptoms occurred when sitting , walking , eating dinner and doing hard work. One episode occurred while using a weed eater and he fell down.

 His physician ordered a  24 hour  heart monitor test  revealing an electrical conduction problem , junctional rhythm. He was referred to a cardiologist and a diagnosis of vasovagal  attacks ( fainting ) was made. He was given some exercises to do and told to discontinue his blood pressure medications amlodipine and HCTZ .


The symptoms continued . 

His wife observed one episode while they were on a daily walk. He complained of the unusual nausea sensation and the urge to sit down. She observed that he was pale, sweating and unsteady on his feet . The symptoms lasted less than a minute  and they continued their walk.

The next episode occurred while driving causing him to hit a small road sign . He did have the nausea but nothing else with this episode. He felt that he just dropped of to sleep.
They discussed his long history of sleepiness when driving , some times having to stop and take a nap in less than 100 miles into a trip. The desire to sleep when driving has been very intense for many years.  Driving became a hard unpleasant chore  for years because of his struggle with drowsiness.  He always just attributed this symptoms to fatigue and long hours working. He recalled similar sleepiness dating back to his first year in college.

He saw his physician again to discuss the more severe symptoms and to discuss the question of driving safety.His physician listened to the history again , examined his neck , mouth ,weight , and suggested the idea of sleep apnea. 


    He was referred to a sleep specialist who agreed with the diagnosis and ordered a home overnight sleep test.The test was positive and confirmed the diagnosis of Obstructive Sleep Apnea. A more comprehensive in hospital overnight test was done again confirming the diagnosis.

CPAP treatment was ordered and started . The patient was amazed at how easy and comfortable  the CPAP machine was to use. He now looks forward to going to bed and sleeping soundly all night.

This was a big previously unrecognized change for him and his wife .
 He no longer keeps her awake with his snoring  . The sweating , restlessness and having to get up at 3 or 4 in the morning is also gone. He now sleeps 6 to 7 hours each night.

 His other medical problems , include mild high blood pressure and Pre-Diabetes, which started about 10 to 15 years ago.


Results of  8 months of CPAP treatment
  
     * No further vasovagal  symptoms 
     *No syncopal episodes
     * No sleepiness when driving. He and his wife have taken two road trips , totaling over 5000
        miles.  He actually enjoyed driving again.
     * His blood pressure has averaged below 140 systolic without medication. He recently restarted 
       a mild diuretic to help keep his BP below his target  goal of 130. He will  recheck his A1c test
       with his wellness exam in June.


Comment:
This case demonstrates the long unintentional delay in diagnosing sleep apnea starting with the early onset of a common everyday things such as snoring . This can be followed by a mix and gradual  addition of seeming  more unrelated things such as sleepiness while driving , mild hypertension , vasovagal symptoms , heart rhythm disturbances and Pre-Diabetes. 


Family history also needs to be considered. The above patient recalls, as a child , listening to his dads loud snoring and pauses in breathing  that seem to echo through the house. I know of another family with the father and 2 sons with obstructive sleep apnea.


I suspect that the above patients symptoms started over 20 years ago. 


Earlier Diagnosis
I believe that earlier diagnosis is possible if we pay closer attention;
         #1 to the first clue , Snoring


         #2 Make better more frequent use of the overnight home test for sleep apnea 
              and sleep specialists. 


         #3 consider family history of sleep apnea as another clue


Have fun , Be Smart-   stop snoring , live longer
David Calder, MD

treating high blood pressure without medication side effects

High blood pressure is common and is associated with a higher risk of heart attacks and strokes.

Sleep apnea is common and contributes to the development of high blood pressure.

The  diagnosis and treatment of  obstructive sleep is simple , effective with less side effects than any blood pressure lowering medication .

 Plus , you wake up feeling better

I looked up Obstructive sleep apnea in PUBMED and found a list of 24,784 articles . I reviewed the first 100 looking for more information on the metabolic effects of Obstructive Sleep Apnea. One well constructed sentence high lighted in the article below does a good job explaining the underlying correctable problems of sleep apnea.

"Some of the mechanisms by which sleep apnea contributes to the development of hypertension are intermittent hypoxia and/or increased upper airway resistance associated with sleep apnea that induces a sustained increase in sympathetic nervous system activity."

In fact almost every sentence is worth reading . 
 "The prevalence of sleep apnea syndrome is relatively high in population (5%)."

"There is an increased rate of car accidents in the subjects with OSA compared to those who don't have this syndrome (31% versus 6%)." 

"The association between OSA and hypertension has been much debated. The prevalence of hypertension among patients with OSA varies between 50-58%, while the prevalence of OSA in hypertensive patients is 30%. 
A particular association is OSA and resistant hypertension, i.e. blood pressure that remains above goal in spite of the concurrent use of three antihypertensive agents of different classes, one to be a diuretic and all pharmacological agents being prescribed at recommended doses."

"The impact of OSA on mortality is also given by its association with a significant number of cardiovascular diseases".

*

Pneumologia. 2011 Oct-Dec; vol. 60(4) pp. 202-7

[Sleep apnea syndrome -- cause of resistance to treatment of arterial hypertension].

Frenţ S, Tudorache V, Ardelean C, Dimitriu D, Lighezan D, Gaiţă D, Mihăicuţă S

The prevalence of sleep apnea syndrome is relatively high in population (5%). The mortality is significantly higher in those with apnea-hypopnea index >20. There is an increased rate of car accidents in the subjects with OSA compared to those who don't have this syndrome (31% versus 6%). The impact of OSA on mortality is also given by its association with a significant number of cardiovascular diseases. The association between OSA and hypertension has been much debated. The prevalence of hypertension among patients with OSA varies between 50-58%, while the prevalence of OSA in hypertensive patients is 30%. A particular association is OSA and resistant hypertension, i.e. blood pressure that remains above goal in spite of the concurrent use of three antihypertensive agents of different classes, one to be a diuretic and all pharmacological agents being prescribed at recommended doses. Secondary causes of hypertension are common in patients with resistant hypertension. Among these causes, one of the most frequent is sleep apnea syndrome. Some of the mechanisms by which sleep apnea contributes to the development of hypertension are intermittent hypoxia and/or increased upper airway resistance associated with sleep apnea that induces a sustained increase in sympathetic nervous system activity. Treatment of sleep apnea with continuous positive airway pressure devices (CPAP) improves blood pressure control, although the benefit of CPAP evaluated in clinical trials is variable.

Comment. 

I was impressed by the number of articles discussing the various effect of Obstructive Sleep Apnea on the heart. It is listed as an independent risk factor for cardiovascular impairment .It is associated with structural and functional changes in the heart. Electrical conduction problems  with Rhythm disturbances such as Atrial fibrillation and heart block.  

Pre-diabetes, Type 2 Diabetes and elements of the Metabolic Syndrome are associated with this disorder.

I personally believe that the diagnosis of obstructive Sleep Apnea is delayed for years because almost everyone snores and the other vague symptoms of tiredness , daytime sleepiness especially when driving a car are just overlooked by patients and doctors . The association with multiple  other serious disease states are often just not linked to this disorder. 

I will present a case tomorrow that exhibits bits and pieces of all of the above.

Have fun , Be Smart and Think of Sleep Apnea

David Calder,MD

• Unlikely fixable connections , Snoring and Type 2 ...
• Sleep apnea explained in one good sentence
• Is sleep apnea a correctable cause of Pre-diabete...
• Home sleep apnea test. The method of choice?

Subtle symptoms of uncommon serious medication side effects

 Reviewing the side effect of ACE inhibitors and ARB's is important because the side effects are often subtle and overlooked as a possible cause of seemingly unrelated problems.The list of symptoms include ;

     #1  persistent dry cough

     #2  recurrent transient episodes of sudden onset unexplained lower chest or abdominal pain often 

           associated transient elevations  liver enzyme test. More common causes of these symptoms such 

           as heart attack , gall bladder and other gastrointestinal diseases have to be considered and

           ruled out before considering  ACE inhibitor caused visceral angioedema . However discussing 

           angioedema  with your doctor and switching to a different blood pressure medication while the

           evaluation of symptoms is in progress is a good idea. The symptoms stop when ACE inhibitors

          are discontinued.

    #3  Recurrent localized bee sting like swelling and itching on one part of your body. 

          These symptoms are often mistaken for insect bites and months can pass between episodes. The

          hint that it is not an insect bite  is that it occurs in the same spot , such as the top of your foot or 

          hand.

   #4    Transient swelling and tingling of one side of your tongue or throat. 

           These symptoms can become an emergency.  Contact your doctor or go to  an emergency

           room . It is ok to remind your doctor of ACE or ARB caused angioedema.

I suggest that you read attached copies of some of my previous post on this topic

_________________________________________________________________________________

Angioedema with an ACE inhibitor. How about an ARB ?

More on the ins and outs of ACE inhibitors ( angiotensin converting enzyme inhibitor ) and
 ARBS ( angiotensin receptor blocker ) .

ACE inhibitor associated angioedema is not common and occurs in about 0.1 to 0.68  % of people taking ACE inhibitors

 Yesterdays question .
   Can a person who developed angioedema from a ACE Inhibitor take an ARB ?

 Answer . 
    My short answer is no. I would not personally prescribe an ARB for someone who had angioedema
    with an ACE inhibitor.  One study found that about half of patients with ARB associated angioedema
    had previously  developed angioedema  taking ACE Inhibitors.
   ( Angiotensin 2 receptor blocker  associated angioedema: on the heels of ACE inhibitor angioedem 
   Pharmacotherapy 2002; 25:1173-75   Abdi R,Dong VM ,Lee CJ, Ntosso KA)

  The etiology of ACE Inhibitor associated angioedema is thought to be associated with Bradykinin. Bradykinin is a potent blood vessel dilator. ACE Inhibitors slow down the clearance of bradykinin from our body. This is generally a good thing and helps lower blood pressure and a bad thing when it causes angioedema.
 .
Todays question :

   Can a person with a history of angioedema from any cause known or unknown take a ACE
   Inhibitor or ARB ?

 Answer : 
     My short answer is no. There are plenty of other Blood Pressure medications with lower risk.
__________________________________________________________________________________

MONDAY, APRIL 23, 2012

Persistent cough . Is your blood medication the cause ?

Todays brief discussion is a continuation of our discussion of ACE inhibitors and ARBS . Please review the last few posts for more details.


 A persistent dry cough that develops while taking an ACE Inhibitor ( angiotensin converting enzyme  inhibitor) is a reason  to talk to your doctor. Dry cough is one of the common side effects of taking ACE inhibitors . Your doctor can change you to a different blood pressure medication and the cough should go away. If the cough continues after stopping the ACE inhibitor further evaluation may be needed.

Switching to a ARB ( angiotensin receptor blocker) is probable not a good idea.  The medications in each of these drug classes  effect the same systems in our body by different mechanism. Your doctor can chose from a variety of other blood pressure medications .

Have fun , Be smart and know the names and function of each of your medications
David Calder ,MD

WEDNESDAY, APRIL 18, 2012

Different symptoms with the same diagnosis. This could happen to you?

I will present 2 cases of patients with pre-diabetes , mild hypertension , dyslipidemia who have very different symptoms of the same medical problem.

Case #1 72 y/o male with a  Fasting blood glucose of 116 mg/dl, A1c of 6.1,
                                              Blood Pressure 126/78
                                              Cholesterol 116
                                              LDL             57
                                              triglyceride 114
                                              HDL            36

Medications  zocor  ( simvastatin )           20 mg/day for  2 years
                      lisinopril                              20 mg/day  for 3 years
                      metformin                          500 mg twice daily
                      aspirin                                  85mg/day
                      omega -3 FA                     960 mg twice daily

Symptoms .  recurrent episodes , separated by weeks or months , of a stinging sensation followed by itching and swelling of the top of his right or left foot . The swelling and itching would subside over the next 4 to 5 days and he would be asymptomatic until the next episode. He attributed the symptoms to  insect bites.
One afternoon while watching TV he developed a numb tingling swelling sensation in the left half of his tongue that lasted about 1 hour. The tongue symptoms prompted a doctor visit .

A diagnosis was made , treatment was started with complete resolution of all symptoms.

What is your diagnosis ?

Case #2  71 y/o female with a : Fasting glucose of  112
                                                  Blood Pressure       132/86
                                                  Cholesterol             168 mg/dl
                                                  LDL                         66 mg/dl
                                                  HDL                         52 mg/dl
                                                  Triglycerides           249 mg/dl
  Medications        Zocor  (simvastatin )                     40 mg/day for years
                              Omega -3 -Fatty Acid               4000 mg/day for years
                               Lisinopril                                      40 mg/day for years
                               coumadin                                        5 mg/day for 3 years

Symptoms;

     The sudden onset of  severe chest pain , nausea , sweating and difficulty breathing. The symptoms subsided in the emergency room. Her physical exam , EKG, chest x ray and test for heart damage was normal. They did find 3 abnormal liver test.  She had similar symptoms about 15 years ago which resulted in a diagnosis of gall bladder disease and surgery.She had repeat liver test the next week that were normal.She saw a cardiologist who could not find any evidence of heart disease. She continued to have the same recurrent symptoms , multiple Emergency room visits. Abnormal liver test that quickly returned to normal were present with each episode of pain . She was referred to a gastroenterologist to for further evaluation and to rule out a retained gall stone. After the visit and plans for further invasive studies  were discussed . A doctor friend suggested a unusual  possible diagnosis.  Treatment was initiated  with complete resolution of her symptoms.

What is your diagnosis ? 
Are these 2 cases the result of the same problem?
The clue to the diagnosis of both cases is discussed above.

Have Fun  Be Smart and make a diagnosis and don't overlook these symptoms.
This could happen to you

The answer and discussion tomorrow.

David Calder, MD

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Have fun , Be Smart . Unusual symptoms ? think about medication side effects , especially angioedema.

This topic reminds me of my internship and residency and a familiar quote . " when you hear hoof beats don't look for zebras".  With all of the fantastic useful medications we use, it is worth considering the possibility of at least one zebra in the herd .
David Calder,MD