Saturday, March 23, 2013

" Avoid dessicated thyroid hormone displacement" comments and discussion

I wrote a short post Nov. 28,2011 - Avoid desiccated Thyroid Hormone replacement. This post  continues to draw comments with we doctors on one side and frustrated patients on the other.  The frustrated patients need their voice heard.

   My personal opinion is ;
      * The great majority of people with hypothyroidism are well treated with T4.
      * There rare individuals who are unable to convert T4 into the active form of thyroid hormone T3.
      *  It is our job as physicians to sort out and diagnose those rare individuals and offer them
          replacement T3.

Please review the post  and comments listed below for more information on this topic.

Avoid Desiccated Thyroid Hormone Replacement

Have fun , Be smart and see your doctor if you are having problems with your thyroid replacement
David Calder, MD

Monday, March 18, 2013

Amazing Type 2 Diabetes Medications - Your choice

                           The  better choice is easy 

Glucophage is usually the first medication used used in people with type 2 diabetes allowing the limited insulin production to function more efficiently by reducing insulin resistance.

Choosing a second diabetes medications that deals with  three other dysfunctional  hormones associated with Type 2 Diabetes is a good idea.

There are now 2 classes of medications , DPP-4 Inhibitors and GLP-1 agonist  now available.

                                    DPP-4 inhibitors    
         Januvia ( sitagliptin) , Onglyza (saxagliptin) or Tradjenta (linagliptin)

          These medication inhibit an enzyme that destroys GLP-1 

# 1 allowing the limited amount of GLP-1 found in patients with type 2 diabetes to last longer , 
# 2 stimulating  beta cells in the pancreas to haveglucose sensitive insulin release

# 3 and to also suppresses glucagon  decreasing inappropriate glucose release from the liver

                                     GLP-1 agonist
           Byetta and Bydureon ( exenatide ) and Victroza ( Liraglutide )

    These medications help replace the deficiency of GLP-1 with a twice daily injection ( Byetta ) , once daily injection ( Victroza ) or once weekly injection of Bydureon. These medications provide glucose sensitive insulin release and suppress inappropriate glucagon secretion.  These medications have the added benefit of weight loss allowing existing insulin to work more efficiently.

What is glucose sensitive insulin release ?

Have fun , Be smart and talk to your doctor about these medication
David Calder, MD

I have included some of my previous post on the above subject for your review.

 Glucophage "failed " Now what should I do ?

Saturday, March 16, 2013

Frustrated with varying fasting glucose . What is going on ?

A 65 y/o man ,with type 2 diabetes , is frustrated with variations in his home fasting glucose test results .

 He takes glucophage 1000 mg twice daily and recently stopped diabeta 5 mg twice daily and started Januvia 25 mg/day. His fasting glucose increased initially to 180 mg/dl + - and now is back down to 120 to 160 mg/dl after increasing the Januvia to 50 mg/dl .  This up and down pattern of his fasting glucose is about the same as it was when taking Diabeta.

 " I know this is not much of a change , but it is irritating."

 "What is going on ? "

" I can eat the same meal at dinner for 3 or more days with no snacking except for 1 glass of wine with or after dinner and my fasting glucose can be 110 one day and 160 the next with no changes in  exercise or my dinner  meal. I have check a few 3 am glucose readings to rule out silent  nocturnal hypoglycemia as a cause for the variation in my fasting glucose."

                               
 --------------------------  Discussion ---------------------------

            Ruling out silent nocturnal hypoglycemia is always a good idea ,
             although it is not likely to occur with the glucophage and Januvia combination. 

                                  The Dysfunctional Family

 Remember managing type 2 diabetes is  basically an effort to replace or stimulate a dysfunctional  combination of at least 3 hormones  to reach  a specific glucose  target .

                              
 Meet the dysfunctional family members 

                    #1 insulin deficiency due to poorly functional beta cells 
                    #2 the inappropriate glucagon secretion from alpha cells in the pancreas . 
                    #3 a deficiency of GLP-1 ( Glucagon like peptide 1) from the intestinal tract.


         The combination of glucophage and Diabeta is not the best choice
                          (but it is the least expensive choice)

The initial combination of  glucophage  and diabeta did not effectively deal with all of the dysfunctional family members. Glucophage ,  almost everyone first choice of a medication for type 2 diabetes , allows a persons limited amount of insulin to function more efficiently. Diabeta stimulates beta cells to produce an unregulated release of insulin irrespective of of glucose levels.  The unregulated insulin release increases the risk of low blood sugars.

                                   A better choice discussion tomorrow

Have Fun , be Smart and discuss medication choices with your doctor
David Calder, MD


Saturday, March 9, 2013

A new glucose meter with Pattern Alert Techniology

Looking for patterns of high or low glucose test results is difficult and time consuming !

Using home glucose test results to find patterns of high or low glucose test results is one of the keys to successful glucose managenent. Adjusting insulin and oral medications based on patterns found on home glucose test results has always been difficult for patients and their physicians. This process has just become easier thanks to a new One Touch  glucose meter

Finding patterns just became easier

The new One Touch Verio IQ meter has pattern alert techniology. 

This meter looks for and finds patterns of high and low glucose results and reports the results to you.
 It reports and saves a pattern of 3 highs (within a 3 hour window of time ) or 2 lows ( within a 3 hour window of time ).
 It also has a tagging icon on the screen with your glucose test allowing you to appropriately tag before or after meal test results

Have fun , Be Smart .This meter is another step forward , in improving your life and making your doctor a little happier.
David Calder, MD

ps. you can go to the One Touch website and get a voucher for a free  One Touch Verio IQ

www.onetouch.com/onetouch-diabetes-testing-supplies


Previous post related to this topic

Unexplainable glucose elevations? Look for Pattern...

Friday, March 8, 2013

The benefits of Omega 3's may be dose related



The benefits of  taking omega 3 Fatty acids to reduce the risk of cardiovascular disease and death is still unsettled.  

A recent study , the* ORGIN Study , suggest that there is no benefit.
                   
This study was part of a larger study  evaluating the use of Lantus insulin and cardiovascular disease. They used a 1 gram dose of omega 3 's containing 465mg of EPA and 375 mg of of DHA and 1 gm of olive oil.
The study demonstrated an average 14mg/dl ( .16 mm/l )  decrease in triglycerides.
 2012 Jul 26;367(4):309-18. doi: 10.1056/NEJMoa1203859. Epub 2012 Jun 11.n-3 fatty acids and cardiovascular outcomes in patients with dysglycemia.

Comment. The Orgin study has some deficiencies .
    #1 There was no measure of inflammatory markers such as hs-CRP or others
    #2  There was no test of omega 3 blood levels to confirm compliance
    #3  other intake of omega 3's from diet or other sources was done by using a questionare
    #4   The dose may not have been adequate . What is the minimum effective dose ?


The benefits of Omega 3's may be dose related

 My personal experience supports the idea that the benefits are dose related.

 The Jellis study referred to a few days ago used 1.8 gms of purified EPA and did demonstrate a
 reduction in cardiovascular risk.

** The Anchor study , comparing  2 gm vs 4 gm of EPA  , demonstrated a difference in the beneficial
 effects of EPA on known cardiovascular risk factors.

                                        4 gram dose  EPA                    2 gram dose EPA
Triglycerides                     21 % reduction                         10.1 % reduction
 LDL                                 6.2 % reduction                        3.6% % reduction
Apo-b                                9.3 % reduction                        3.8 % reduction
hs-CRP                              22 %  reduction                        6.8 % reduction

Have fun , Be smart  check your dose of Omega 3's and talk to your doctor
David Calder ,MD

reference


 *  2012 Jul 26;367(4):309-18. doi: 10.1056/NEJMoa1203859. Epub 2012 Jun 11.n-3 fatty acids and cardiovascular outcomes in patients with dysglycemia.
ORIGIN Trial InvestigatorsBosch JGerstein HCDagenais GRDíaz RDyal LJung HMaggiono APProbstfield JRamachandran ARiddle MCRydén LE,Yusuf S.

 **Jelis Study (Japan EPA Lipid intervention Study) reported in Lancet 2007;369: 1090-8
***American Journal of Cardiology
      Volume 110, Issue 7 , Pages 984-992, 1 October 2012

(from    the ANCHOR Study    Efficacy and Safety of Eicosapentaenoic Acid Ethyl Ester (AMR101) Therapy in Statin-Treated Patients With Persistent High Triglycerides

      








Thursday, March 7, 2013

Triglyceride levels above 150mg/dl may effect your LDL test result


Question from a few days ago- 
    Can you name one test , available in your doctors office , that may help you better 
    understand your LDL test results ?
    Remember your LDL test result is a calculated number most of the time.
    LDL = total cholesterol - HDL - 1/5 of the triglycerides

 Answer-    
    Apo b -   
 Please review the two previous post's for details.


Have fun , Be Smart and don't overlook your triglyceride test results
David Calder,MD

ps. What about the Orgin study fish oil fans ? more tomorrow.
______________________________________________________

Wednesday, March 6, 2013

Anti-inflammatory benefits of Omega 3 fatty acids may be the most important benefit .


I received this excellent comment yesterday focused on the anti-inflammatory benefits  of Omega 3 fatty acids. Anonymous attached a link  to a brochure with more details on this topic. 


----
Anonymous has left a new comment on your post "Vascepa the latest option for lowering elevated tr...": 

Thank you for recognizing Vascepa...I am also an MD with a special interest in chronic inflammation..(not and employee or representative of AMRN).

You may not be aware that EPA plays a crucial role as a moderator of inflammation..acting at the cellular level..it slows down the conversion of Omega6 Linoleic Acid derived DGLA into Arachidonic Acid (AA).AA is known to be the principal pro inflammatory signalling molecule in the inflammatory cascade...

Diabetes, like other "degenerative diseases is an inflammatory disease..Insulin is known to activate the conversion of DGLA into AA thus increasing inflammation...EPA (and glucagon) are known to suppress the reaction..The most important benefit of EPA in diabetics, may be the anti inflammatory (diet controlled) action of EPA in combination with insulin control, rather than viewing it as simply a Trig reducing drug...Check out this reference...



AMW

Thanks again 
David Calder, MD

Yesterdays question and my comments on the ORGIN Study tomorrow.  Could the benefits of omega 3 fatty acids may be dose dependent?

Tuesday, March 5, 2013

Vascepa the latest option for lowering elevated triglycerides

  I think that you can tell from my previous post that I have had a long term interest and use of fish oil ( omega 3 fatty acids) for my patients with diabetes and elevated triglycerides. The development of highly purified forms of omega 3 fatty acids has been a major step forward in providing safe effective medications for all of us.
Vascepa just approved by the FDA in Janurary 2013 is a highly purified form of EPA.  My interest in Vascepa peaked after reading Jelis Study last year.

 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.


 Two other studies , Marine Trial and Anchor Trial , 
demonstrated Vascepa's effectiveness in lowering triglycerides and inflammatory risk markers such as hsCRP  levels. 

   The Marine trial was done in patients with triglyceride levels 500 mg/dl or higher
   The Anchor trial was done in patients with triglycerides between 200 and 500 mg/dl



These studies pointed out one interesting difference between Vascepa and Lovaza ( highly purified EPA and DHA ) is, Vascepa lowers LDL cholesterol ( the bad cholesterol) while Lovza slightly increases LDL cholesterol.I have not seen an analysis of this difference but it could be as simple as LDL particle size. Lowering triglycerides has been shown to increase LDL size which is a good thing . Small dense LDL particles increase the risk of heart disease.

Question- Can you name one test available in your doctors office that may help understand LDL particle size ?

A third trial is in progress , Reduce It ,
designed to evaluate the effectiveness of Vascepa in reducing cardiovascular risk.


Have fun , Be Smart and think about the fish oil your taking
David Calder,MD

ps. What about the Orgin study fish oil fans ? more tomorrow.
_______________________________________________________________________

I have attached information from the Amarin web site because they did a good job outlining the existing  studies mentioned above.
The efficacy and safety of Vascepa were studied in two Phase 3 clinical trials, the MARINE trial and the ANCHOR trial. Both studies were conducted under Special Protocol Assessment (SPA) agreements with the U.S. Food and Drug Administration (FDA). Amarin is also enrolling patients in a cardiovascular outcomes study designed to evaluate the efficacy of Vascepa in reducing major cardiovascular events in a high-risk patient population on statin therapy called REDUCE-IT. REDUCE-IT is also being conducted under a Special Protocol Assessment, or SPA, with FDA.
The MARINE study: A Phase 3, multi-center, placebo-controlled, randomized, double-blind, 12-week study that treated patients with severe (≥500 mg/dL) hypertriglyceridemia (very high triglycerides) with 229 patients enrolled. The primary endpoint in the trial was the percentage change in triglyceride level from baseline compared to placebo after 12 weeks of treatment. In November, 2010, Amarin reported top-line data for the MARINE trial which met its primary endpoints.
The MARINE trial demonstrated that Vascepa significantly lowered triglyercides without increasing LDL-C (non-significant decrease of -2%). In addition, MARINE demonstrated a statistically significant decrease in multiple other important lipid biomarkers including non-HDL-C, apolipoprotein B (apo B), lipoprotein-phospholipase A2 (Lp-PLA2), very low-density lipoprotein cholesterol (VLDL-C), Total Cholesterol (TC) and high-sensitivity C-reactive protein (hsCRP).
Vascepa® (icosapent ethyl) capsules, a therapy approved by the U.S. Food and Drug Administration (FDA) as an adjunct to diet to reduce triglyceride (TG) levels in adult patients with severe (≥500 mg/dL) hypertriglyceridemia (patient population studied in the MARINE trial), more commonly known as very high triglycerides, or VHTG, is now available by prescription.
In the MARINE study, the only reported adverse reaction with an incidence >2% and greater than placebo in Vascepa treated patients was arthralgia (2.3% for Vascepa vs. 1.0% for placebo).*

*based on pooled data across two clinical studies (MARINE and ANCHOR) that included patients with triglycerides values of 200 to 2000 mg/dL

For more information see www.vascepa.com.
The ANCHOR trial: A multi-center, placebo-controlled, randomized, double-blind, 12-week pivotal Phase 3 study in patients with high triglycerides (≥200 mg/dL and <500 mg/dL) who were also on statin therapy. 702 patients were enrolled in this trial. The primary endpoint in the trial was the percentage change in triglyceride level from baseline of Vascepa-treated subjects compared to placebo after 12 weeks of treatment. In April 2011, Amarin reported top-line results from the ANCHOR trial. The ANCHOR trial met its primary and secondary endpoints.
One of the ANCHOR trial's key secondary endpoints was to demonstrate a lack of elevation in LDL-C in order to avoid offset to the target of cholesterol lowering therapy. The trial's non-inferiority criterion for LDL-C was met at both Vascepa doses. For the 4 grams per day Vascepa group, LDL-C decreased significantly (-6.2%, P=0.0067) from baseline versus placebo, demonstrating superiority over placebo.
Other secondary efficacy endpoints included the median placebo-adjusted percent change in non-high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (apo B), and lipoprotein-associated phospholipase A2 (Lp-PLA2) and very-low-density lipoprotein cholesterol (VLDL-C).
In this trial, the safety profile of Vascepa was comparable to placebo and there were no treatment-related serious adverse events.
The FDA has not completed its review of the ANCHOR trial. Vascepa is not approved for use in this patient population.
The REDUCE-IT (Reduction of Cardiovascular Events Outcomes trial): A multi-center, prospective, randomized, double-blind, placebo-controlled, parallel-group study to evaluate the effectiveness of Vascepa as an add-on to statin therapy, in reducing the first major cardiovascular event in an high-risk patient population compared to statin therapy alone. Patients enrolled in the study have elevated triglyceride levels (>150 mg/dL) and at least one other defined cardiovascular risk factor. The control arm of the study is comprised of patients on optimized statin therapy. The active arm of the study is comprised of patients on optimized statin therapy plus Vascepa. Entry requirements for participants in this study include elevated triglyceride levels and either coronary heart disease or risk factors for coronary heart disease. This study is being conducted internationally and Amarin anticipates utilizing more than 300 clinical sites in connection with the trial, the largest number of which will be in the United States. In December 2011, Amarin announced that the first patient was dosed in the REDUCE-IT study. The study is scheduled to be completed in approximately six years and is anticipated to include approximately 8,000 patients.
This page was last updated on January 25, 2013.

 

3 ANCHOR Study Results Presented at American Heart Association's Scientific Sessions 2011

BEDMINSTER, N.J., and DUBLIN, IrelandNov. 16, 2011 (GLOBE NEWSWIRE) -- Amarin Corporation plc (Nasdaq:AMRN), a late-stage biopharmaceutical company with a focus on cardiovascular disease, announced today the first presentation in a scientific session of data from Amarin's Phase 3 clinical trial, the ANCHOR study, in which patients with high triglycerides who were also on statin therapy experienced a significant reduction in triglyceride levels and other lipid parameters, as well as important inflammatory biomarkers. The data, from Amarin's ANCHOR Phase 3 pivotal trial, were presented by Christie M. Ballantyne, M.D., at the American Heart Association's Scientific Sessions 2011.
As reported in April 2011, the ANCHOR trial met its primary endpoint, which was defined as themedian placebo-adjusted percentage change in triglyceride levels from baseline after 12 weeks of treatment. This endpoint was achieved at doses of 4 grams and 2 grams per day with median placebo-adjusted reductions in triglyceride levels of 21.5% (P<0.0001 value) for 4 grams and 10.1% (P=0.0005) for 2 grams. The median baseline triglyceride levels were 259 mg/dL, 265 mg/dL and 254 mg/dL for the patient groups treated with placebo, 4 grams and 2 grams of AMR101 per day, respectively. The analysis of subgroups by baseline triglyceride tertiles showed that higher baseline triglycerides resulted in greater triglyceride reductions.
Secondary efficacy endpoints included the median placebo-adjusted percent change in non-high-density lipoprotein cholesterol (non-HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein B (apo B), and lipoprotein-associated phospholipase A2 (Lp-PLA2). The 4 gram dose was associated with statistically significant reductions in non-HDL-C (13.6%), LDL-C (6.2%), apo B (9.3%), Lp-PLA2 (19%) and high-sensitivity C-reactive protein (hsCRP )(22%) at week 12 compared to placebo. The 2 gram dose was associated with statistically significant reductions in non-HDL-C (5.5%), apo B (3.8%), Lp-PLA2 (8.0%) and a non-statistically significant reduction in LDL-C (3.6%) and high-sensitivity C-reactive protein (hsCRP) (6.8%) at week 12 compared to placebo. 
Importantly, neither the 2 gram or 4 gram dose showed any significant increase in LDL-C compared to placebo; this was a pre-specified endpoint in this study using a non-inferiority test and, at the 4 gram dose, demonstrated not only non-inferiority but a statistically significant 6.2% reduction for patients who were optimally treated with atorvastatin, simvastatin, or rosuvastatin.
In the trial, AMR101 appeared to be safe and well tolerated, with incidence of treatment-emergent adverse events similar to placebo. No significant changes in fasting blood glucose, hemoglobin A1C, vital signs, electrocardiograms, or liver or kidney function with either AMR101 dose.
"The positive data from the ANCHOR study show that AMR101 may be an important therapeutic option for mixed dyslipidemia patients with persistent high triglyceride levels on statin-therapy," said Dr. Ballantyne. "One of the potential explanations for the continued elevation of cardiovascular risk in patients with persistent high triglyceride elevations despite statin therapy may be due to increased inflammation. Patients in the ANCHOR study who received AMR101 at 4 grams/day experienced a significant reduction in median placebo-adjusted inflammation biomarkers, specifically hsCRP and Lp-PLA2. The REDUCE-IT cardiovascular outcomes study will investigate the extent to which lipid and other biomarker changes observed by AMR101 will translate into a reduction in cardiovascular events."
The ANCHOR trial was a Phase 3, multi-center, placebo-controlled, randomized, double-blind, 12-week pivotal study. The ANCHOR trial investigated AMR101 as a treatment for high triglycerides (≥200 and <500mg/dL) in 702 patients with mixed dyslipidemia (two or more lipid disorders) on background statin therapy at LDL-C (low-density lipoprotein cholesterol) goal who were at high risk of cardiovascular disease. The majority of these patients were diabetic (73%). This is the largest trial with omega-3 therapy conducted in this important patient population. All patients were on background statin therapy with simvastatin, atorvastatin or rosuvastatin. Despite the benefits of statin therapy, patients in this population have significant residual risk for cardiovascular events. The trial was conducted under a Special Protocol Assessment (SPA) agreement with the FDA.
About AMR101
AMR101 is a prescription-grade omega-3 fatty acid, comprising not less than 96% ultra pure EPA (icosapent ethyl), that Amarin is developing for the treatment of patients with very high triglyceride levels (≥500 mg/dL) and as a potentially first-in-class therapy for patients with high triglyceride levels (≥200 and <500mg/dL) who are also on statin therapy for elevated LDL-cholesterol levels (which we refer to as mixed dyslipidemia). Triglycerides are fats in the blood. Significant scientific and clinical evidence support the efficacy and safety of ethyl-EPA in reducing triglyceride levels and other important lipid and inflammation biomarkers, including Apo-B, non-HDL-C, Total-Cholesterol, VLDL-C, Lp-PLA2, and hs-CRP. AMR101 demonstrated a safety profile comparable to placebo in two completed Phase 3 clinical trials.
About Amarin
Amarin Corporation plc is a late-stage biopharmaceutical company with expertise in lipid science focused on the treatment of cardiovascular disease. The Company's lead product candidate is AMR101 (icosapent ethyl). Amarin reported positive, statistically significant top-line results for both of its two pivotal Phase 3 clinical trials, the MARINE trial (investigation of AMR101 as a treatment for patients with very high triglycerides [≥500 mg/dL]), as reported in November 2010, and the ANCHOR trial (investigation of AMR101 for the treatment of patients on statin therapy with high triglycerides [≥200 and <500mg/dL] with mixed dyslipidemia), as reported in April 2011. Both the MARINE and ANCHOR trials were conducted under Special Protocol Assessment (SPA) agreements with the U.S. Food and Drug Administration (FDA). Amarin also has next-generation lipid candidates under evaluation for preclinical development. In September 2011Amarin submitted a New Drug Application (NDA) to the U.S. Food and Drug Administration (FDA) seeking approval for the marketing and sale of AMR101 for treatment of the patient population studied in the MARINE trial. Amarin plans to separately seek approval for the population studied in the ANCHOR trial after its REDUCE-IT cardiovascular outcomes trial is substantially underway. In August 2011, an SPA agreement with the FDAwas reached for the REDUCE-IT cardiovascular outcomes study. The Company seeks to have this study substantially underway before the end of 2012. 

         Sen

Monday, March 4, 2013

Triglycerides , residual risk -fish oil and your heart


Triglycerides- Fish Oil and your Heart

Cardiovascular disease is the primary risk associated with Type 2 diabetes . Statin medications ( such as,  simvastatin , atorvastatin ,  resuvastatin and others ) have significantly reduced the risk of heart disease. Unfortunately, statins do not completely eliminate the risk and leave something called residual risk .  Elevated triglyceride levels contribute to this residual risk . 
 click on the link below for more information on residual risk



Finding effective safe medications to lower triglycerides has improved over the last few years. Many  doctors recommended  increased fatty fish consumption and over the counter fish oil capsules .  However , eating a pound of salmon a day and trusting the contents of over the counter fish oil was a significant barrier for most of us.

The first FDA approved a form of a purified form of omega 3 fatty acids , Lovaza  (EPA and DHA was approved fot triglyceride levels above 500 mg/dl ) .

 The FDA recently approved another medication , Vascepa (a purified form of EPA )  for treatment of Triglycerides above 500 mg/dl.

Most people with type 2 diabetes have elevated triglycerides between 150 and 500 mg/dl

Unfortunately most people with type 2 diabetes have triglyceride levels above 150 mg/dl but below 500 mg/dl. A recent study has demonstrated the effectiveness of Vascepa for lowering triglyceride levels and reducing inflammatory markers of cardiovascular disease in this group. They have applied for FDA approval for treatment of elevated triglyceride levels below 500 mg/dl.

More on Vascepa tomorrow

Have fun . Be smart and lower your residual cardiovascular risk
David Calder, MD

Click on the links below for previous post on this topic
Diabetes, Residual Risk and Dysfunctional triglyce...


Other related previous post on this topic


I HAVE COLLECTED  4 0F MY POST  FROM JAN. AND FEB. THAT DEAL WITH OMEGA 3 FATTY ACIDS. THIS SEEMED LIKE A GOOD TIME TO PUT THEM ALL TOGETHER  TO COMPLIMENT THE FDA'S RECENT APPROVAL OF A NEW HIGHLY PURIFIED OMEGA - 3- FATTY ACIDS DISCUSSED YESTERDAY. 


You may find the Feb. 4 post " shopping for Omega 3's "and the Feb. 6  ,  "The  other Omega 3's " useful the next time you go shopping for Fish oil. The other 2 post will help with your understanding of Omega 3's and heart disease.
Have Fun, Be Smart and take your fish oil
David Calder,MD



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
.

1 comment:

  1. Having a great healthy post on disease, its very easy to read and understand for anyone, This is great effort made by you,
    Thank you for great support
    Rachel garcia
    ReplyDelete

    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

    SATURDAY, FEBRUARY 4, 2012


    Shopping for Omega -3 Fatty Acids can be confusing


     HINT-  Save 45.6 seconds of your day by just reading the bold print

    Shopping for Omega- 3- Acids can sometimes be confusing. I was in a store yesterday that had at least 6 different brands of Omega -3 - fatty acids on their shelves.

    My wife has elevated triglycerides and takes 4 to 5 grams of " Omega -3- FA" /day and I have normal triglycerides and take close to 2 gms/day.  The American Heart Association recommends 1 gm/day for someone without elevated triglycerides or heart disease. I have attached a copy of the American Heart Association recommendations below. The Jelis study , that we discussed on Jan. 30 , found a 19% relative risk reduction for a cardiovascular event by taking 1.8 gms of purified EPA for people with and without known heart disease or triglyceride problems.

    I feel like a well informed consumer and had a simple goal of finding the smallest capsule with the highest amount of Omega -3 Fatty acids. My wife and I spent about 20 minutes reading labels using our calculator to find the pill that best met our goals. I have 3 different bottle setting in front of me now.

    # 1 1200 mg of natural fish oil concentrate with 684 mg Omega -3 -Fatty acids
                                  smaller print   EPA 410 mg
                                                         DHA 274 m
                   Total amount /capsule---------  684
         

    # 2   Fish oil 1400mg/980 omega-3
                                    smaller print  EPA  647 mg
                                                         DHA 253 mg
                                                         other *****
                   Total amount /capsule---------- 900 mg 

    # 3   Cod Liver Oil    high in EPA and DHA /   Omega - 3 - Fatty acid 1100 mg
                                     smaller print EPA   400 mg
                                                          DHA  500 mg
                                                          Other *****
                   Total amount per teaspoon          900 mg

    I am not sure which omega -3 fatty acid is named  "other ".  I personally prefer to use EPA and DHA because they have been shown to be effective. We chose #2 because it  had a little more Mg / capsule than #1 and also had more EPA and less "other" than #3.  

    I plan to take 2 capsules /day and my wife will take 5 capsules /day. We have lipid panels scheduled for next month.

    What is in  that "Other " category ?   What is alpha  linolenic acid ?  Find out tomorrow.

                                                                                                              Happy shopping,
                                                                                                              David Calder, MD
    My friend , a  fellow blogger and founder of 1 diseaseworldvoice.org  and Laffing at Life is shopping for Omega 3's today and  may have a comment  about his experience.


    AMERICAN HEART ASSOCIATION RECOMMENDATIONS

    Fish is a good source of protein and, unlike fatty meat products, it’s not high in saturated fat. Fish is also a good source of omega-3 fatty acids.  Omega-3 fatty acids benefit the heart of healthy people and those at high risk of — or who have — cardiovascular disease.  Research has shown that omega-3 fatty acids decrease risk of arrhythmias (abnormal heartbeats), which can lead to sudden cardiac death. Omega-3 fatty acids also decrease triglyceride levels, slow the growth rate of atherosclerotic plaque and lower blood pressure (slightly).
    AHA Recommendation
    We recommend eating fish (particularly fatty fish) at least two times (two servings) a week. Each serving is 3.5 oz. cooked, or about ¾ cup of flaked fish.  Enjoy fish baked or grilled, not fried.  Choose low-sodium, low-fat seasonings such as spices, herbs, lemon juice and other flavorings in cooking and at the table. 
    Fatty fish like salmon, mackerel, herring, lake trout, sardines and albacore tuna are high in two kinds of omega-3 fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which have demonstrated benefits at reducing heart disease.
    We also recommend eating tofu and other forms of soybeans, canola, walnut and flaxseed, and their oils. These foods contain alpha-linolenic acid (ALA), another omega-3 fatty acid. Large-scale epidemiologic studies suggest that people at risk for coronary heart disease benefit from consuming omega-3 fatty acids from marine and plant sources. However, more studies are needed to show a cause-and-effect beneficial relationship between ALA and heart disease.
    Increasing omega-3 fatty acid consumption through foods is preferable.  However, coronary artery disease patients may not be able to get enough omega-3 by diet alone.  These people may want to talk to their doctor about taking a supplement.  Supplements also could help people with high triglycerides, who need even larger doses. 
    Population
    Recommendation
    Patients without documented coronary heart disease (CHD)
    Eat a variety of (preferably fatty) fish at least twice a week. Include oils and foods rich in alpha-linolenic acid (flaxseed, canola and soybean oils; flaxseed and walnuts).
    Patients with documented CHD
    Consume about 1 g of EPA+DHA per day, preferably from fatty fish.  EPA+DHA in capsule form could be considered in consultation with the physician. 
    Patients who need to lower triglycerides 
    2 to 4 grams of EPA+DHA per day provided as capsules under a physician’s care. 
    Patients taking more than 3 grams of omega-3 fatty acids from capsules should only do so under a physician’s care.  High intakes could cause excessive bleeding in some people.
    Benefits vs. Risks of Eating FishSome types of fish may contain high levels of mercury, PCBs (polychlorinated biphenyls), dioxins and other environmental contaminants. Levels of these substances are generally highest in older, larger predatory fish and marine mammals.
    The benefits and risks of eating fish vary depending on a person’s stage of life.
    • Children and pregnant women are advised by the U.S. Food and Drug Administration (FDA) to avoid eating those fish with the potential for the highest level of mercury contamination (e.g., shark, swordfish, king mackerel or tilefish); to eat up to 12 ounces (two average meals) per week of a variety of fish and shellfish that are lower in mercury (e.g., canned light tuna, salmon, pollock, catfish); and to check local advisories about the safety of fish caught by family and friends in local lakes, rivers and coastal areas.
    • For middle-aged and older men and postmenopausal women, the benefits of eating fish far outweigh the potential risks when the amount of fish are eaten is within the recommendations established by the FDA and Environmental Protection Agency.
    • Eating a variety of fish will help minimize any potentially adverse effects due to environmental pollutants.
    Potential exposure to some contaminants can be reduced by removing the skin and surface fat from these fish before cooking. Consumers should also check with local and state authorities about types of fish and watersheds that may be contaminated and visit the FDA Web site for the most up-to-date information on recommendations for specific subgroups of the U.S. population (e.g., children, pregnant women).
    Top 10 Fish and Shellfish in the United States Based on Consumption – Omega-3 and Mercury Levels:

    Omega-3 fatty acids
    (grams per 3-oz. serving)
    Mean mercury level in parts per million (ppm)
    Canned tuna (light)
    0.17–0.24
    0.12
    Shrimp
    0.29
    ND*
    Pollock
    0.45
    0.06
    Salmon (fresh, frozen)
    1.1–1.9
    0.01
    Cod
    0.15–0.24
    0.11
    Catfish
    0.22–0.3
    0.05
    Clams
    0.25
    ND*
    Flounder or sole   
    0.48
    0.05
    Crabs
    0.27–0.40
    0.06
    Scallops
    0.18–0.34
    0.05
    * ND – mercury concentration below the Level of Detection (LOD=0.01ppm)
    Fish with the Highest Levels of Mercury (about 1 ppm):

    Omega-3 fatty acids
    (grams per 3-oz. serving)
    Mean mercury level in parts per million (ppm)
    Tilefish (golden bass or golden snapper)
    0.90
    1.45
    Shark
    0.83
    0.99
    Swordfish
    0.97
    0.97
    King mackerel
    0.36
    0.73
    Five of the most commonly eaten fish or shellfish that are low in mercury are shrimp, canned light tuna, salmon, pollock, and catfish.    Avoid eating shark, swordfish, king Mackerel, or tilefish because they contain high levels of mercury.

    MONDAY, FEBRUARY 6, 2012


    The 'Other" Omega -3- Fatty acids

    According to Wikipedia there are  11 forms of Omega- 3 -Fatty acids. 

    Three of those have received the most attention as being beneficial to our health. These include Alpha- Linolenic Acid (ALA),  EPA and  DHA.

    I did not see ALA ( alpha - linolenic acid) listed as a primary ingredient on the packages I looked at , so it must fall into the "other" category.

    ALA  cannot be over looked because it is the parent fatty acid to EPA and DHA.

    Alpha -linolenic acid is found in vegetables such as rape seed used to produce canola oil, flax seed, walnuts, TOFU , spinach, Romaine lettuce ,soybeans, turnip greens, brussels sprouts, raspberries green beans and others. I generally think of the sources of ALA as Beans, Greens and Nuts.

    Our bodies can convert Alpha- Linolenic Acid to EPA and DHA,however;
     This conversion process is not efficient so we tend to delegate this job to fatty cold water fish , such as  Sardines , salmon , Cod , Tuna ,Herring ,shrimp and scollops .

    In summary eating greens,beans,nuts (especially walnuts) and cold water fish is not a bad idea. It reminds me of something called the Mediterranean diet.

                                                                       Have fun eat healthy and defeat diabetes
                                                                       David Calder,MD





2 comments:

  1. The main reason why triglycerides levels increases is due to poor diet and excessive intake of sugar and alcohol, and foods that are rich in carbohydrates. Triglycerides, along with cholesterol, are the lipids or fatty acids deposited in the body. These are developed from the excess calories that are consumed and not able to burn during physical activity.


    what are triglycerides ?
    ReplyDelete
  2. 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.

    https://www.carlmontpharmacy.com
    ReplyDelete