Saturday, April 27, 2013

Are the uncertainties of cancer repressing the certainties of reducing the risk of damage caused by uncontrolled diabetes

I have attached a comment from a recent post "Diabetes, Januvia and Cancer". This ladies comments accentuate some of the frustrations and concerns that many of us have with our diabetes medications . The daily TV adds by lawyers hoping to cash in on the uncertainties of cancer and diabetes medications is not providing us with much comfort.   I am concerned that the uncertainties of cancer are repressing the certainties of reducing the risk of damage caused by uncontrolled diabetes . I have attached my thoughts on dealing with her immediate problem, hyperglycemia .  

"Well here I am...the one that got the cancer while on Januvia. Was it chance? I don't know. First came shingles and then came the cancer. I had good blood sugar results on the Januvia. Mine was breast cancer. They caught it early not that means anything in the end. But ........ which is your lesser evil. I don't know.
I guess I would take Januvia again, and I might. because now the cancer is gone, the diabetes is high and we all know the risks that can entail and I have been over 225 for almost a year. No side effects yet. but no balance. I am on metformin and glipizide. Because they were cheap. Januvia is over 800 now for 90 days. That is so expensive.

What is our life worth? "

My Response:  Insulin works  and Metformin reduces cancer risk

Congratulations ,you have already successfully faced  and defeated two difficult problems , shingles and breast cancer. You have done a good job and now it is time to do battle with with your old enemy, diabetes.
I understand your reluctance to restart Januvia . There are other  excellent choices that will allow you to again gain control of your glucose levels .   Insulin works. Lantus insulin is a once a day injection that can be adjusted to control your fasting glucose. Controlling your fasting blood glucose may allow you to control your other before meal sugars with diet , exercise and metformin . Your doctor may taper or discontinue glipizide to reduce your risk of hypoglycemia.

Have fun , be smart and talk to your doctor about your options.
David Calder, MD

Tomorrow - more on cancer and diabetes.

Monday, April 22, 2013

A new diabetes medication ,Canaglifloxin ( Invokana ) To take or not to take is a question

My opinion
 New diabetes medications are generally welcome tools for our patients with diabetes. This new medication , Canaglifloxin ( Invokana ) , will not be added to my tool box until more safety data is available . It just has to many real and potential problems . I have added two quotes for you to consider.

 "So, this is not a drug I'd be enthusiastic about," 
     Dr David M Nathan ,Endocrinologist  ( Harvard Medical School ) 

" I'm not sure yet it's 100% okay, so I voted no," 
            Dr William R Hiatt  , cardiologist currently on the FDA panel

I have added a link below for more information . Read the side effects and precautions. Choosing the right patient for this medications and following patients , especially over age 65, will not be easy.

How does Invokana work ?
  It blocks the reabsorption of glucose in the kidney allowing glucose and fluids to spill into the urine.

Things to consider

Yeast infections
 The increase loss of glucose in the urine increases the frequency of urinary tract infection and a 4 to 7 fold increase in mycotic infection ( yeast infection ) in men and women .

 Increased fluid loss
   Increases postural hypotension ( low BP when standing ) and syncope especially in  older people
   ( age 65 + - ) .
   The normal process of aging is often associated with a  mild , often undetected , decrease in kidney  
   function . This medication may contribute to the problem . 

 Cardio vascular risk is still not determined
     - 46 % increase in strokes in one study within the first 30 days of use
     - increase LDL cholesterol 
     - increase non -HDL  cholesterol
     - increase serum potassium that could effect heart rhythm . This is dose dependent and is worse in
       patients  taking ACE Inhibitors  ( Angiotensin converting enzyme inhibitors ) and ARB 
      ( angiotension receptor blockers ) . These two medications are commonly used to lower BP and 
       protect kidneys for patients with diabetes .
     - increase digoxin levels for patients on digoxin ( digoxin is  cardio-toxic at  high levels )
 None of the above problems are good and the regular consistent followup of patients kidney function , potassium  and digoxin levels will add another level of difficulty to an already complex management problem .

Have Fun , Be smart and be sure you have reviewed and discussed all of the side effects of the medication with your doctor before adding it to your treatment program.
  David Calder , MD

Thursday, April 18, 2013

Welcome back Mark .

I am happy to announce that a friend of mine , Mark - John Clifford  , will begin writing on this web site . Mark , his wife and other family members are responsible for the original website development and I welcome them back. Mark is now in charge of the " What Did He Just Say Department ". Mark is dedicated to helping people with diabetes and other chronic diseases deal with the twists and turns of life with one of his main tools , laughter .

 Have you ever had trouble really understanding what your doctor is talking about ?  Tell Mark and we will try our best to help.

Mark will have some of his own posts and will also look at what I have written from a patients perspective and , in his own way , ask and answer two simple questions .
"What did he just say?"  
" Why  should I  care ? "
We also have the pleasure of commenting on his thoughts .

Have Fun , Be Smart and remember it is Ok to Laugh. Relax a little , have fun , enjoy each other  and realize  that we are all in the same boat.
David Calder,MD

Tuesday, April 16, 2013

Recall , One touch Verio IQ , Verio Pro and Verio pro+ / My opinion

One touch verio IQ  , Verio pro , verio pro + ,meters have been voluntarily recalled  by Life Scan and Johnson & Johnson !!!!!!!!!!

Reason- "At extremely high glucose reading of 1024 mg/dl and above, the units have failed to provide a warning of dangerously high blood sugar and will shut off, potentially delaying proper treatment ." There have been no reported injuries in the United States .

Discussion-  I applaud these companies for finding the problem and putting the interest of our patients  as their primary goal. I am sure they will find and correct the problem. 

My opinion -  Be responsible for your own care . 
A blood sugar of 1024 mg/dl is usually not a sudden finding , except in some very unstable patients with type 1 diabetes .

We as patients are responsible for monitoring our blood glucose, looking for patterns and  then correcting glucose levels out side our recommended goals.

The problems of extremely high blood sugars and Diabetic Keto acidosis is preventable by each of us, as patients and parents of children with diabetes, by just doing our job. Teens with diabetes often present their parents and health care providers with a few additional challenges.

I hope these meters gets back in every one hands as soon as possible because they provides the tools , when used , to guide the user to a pattern of abnormal glucose results that can result in corrective actions preventing  extremely high reading.

Have fun , Be Smart and use the tools now available to help you  and your heath care provider manage this disease . Good health is a wonderful gift that is preserved by our own efforts .
David Calder , MD
I have attached my post from last month with more discussion of  the above meters.

A new glucose meter with Pattern Alert Technoilogy

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

Previous post related to this topic

Unexplainable glucose elevations? Look for Pattern...

Friday, April 12, 2013

Preventing Iodine Deficiency

American Thyroid Association
June 4,2012

Preventing iodine deficiency:
Back ground information 
from the 2nd national report on biochemical indicators of Diet and Nutrition in the U.S. population
    sources of iodine world wide - iodize salt  and sea food
    sources in the United States - dairy products and grains . Iodized salt is not mandatory and 
                                             about 50 to 60 % of the U.S. population chose iodized salt

  Food sources of iodine
     use iodized table salt  ( contains 400 micrograms per teaspoon )
     Eat other foods high in iodine such as dairy products , sea food , meat , some breads and eggs

  Take a multivitamin containing 150 micrograms of iodine daily

United States recommendations / The institute of medicine 
    adult men and women  - 150 micrograms per day
    for pregnant women     - 220  micrograms per day
    Breast feeding women  - 290 micrograms per day 
    Children age 1  to   8    -   90 micrograms /day
                  age 9 to  13     - 120 micrograms/day
                  age 14 to18     -150 micrograms/ day

Have Fun , Be Smart and add a little iodine to your diet
David Calder,MD

ps. " Most ingested salt ( about 70 %) , which is typically not iodized ,  comes from processed foods in
         the United states and Canada "
         (The Public health committee of the American thyroid Association 2006)

Thursday, April 11, 2013

Buying salt is more than just a container of sodium chloride

CDC " Iodine deficiency is the most preventable cause of mental retardation in the world."

Sea salt  is  sodium chloride - with varying amounts of trace minerals  depending on the source.
Table salt is sodium chloride -without the trace minerals but has one chemical element added that can improve your health.
 What  chemical element is added to table salt ?  
 Answer   - Iodine    *( be sure to read the label and check Yipes below)                                               
 Iodine may also be present in sea salt but in varying amounts depending on the source .
Adequate iodine in our diet allows the thyroid gland to do its job , produce thyroid hormone

Thyroid hormone ( T4 ) is produced , using iodine , in the thyroid gland and has 4 iodine molecules attached to two benzene rings.

T4 has one iodine molecule removed to produce T3 the metabolically active form of thyroid hormone.

The thyroid gland cannot produce thyroid hormone without iodine . Diets deficient in iodine cause enlargement of the thyroid gland ( goiters ) and hypothyroidism.

         CDC ( Center for Disease Control ) 
                                             nutrition report. April 2012

" Iodine deficiency is the most preventable cause of mental retardation in the world. Iodine deficiency can also cause hypothyroidism , goiter , cretinism and other growth and developmental abnormalities "

" Women 20 to 29 years of age had the lowest iodine levels compared to all other age groups.Iodine intake in young women merits special attention to ensure the best possible brain development of the fetus during pregnancy "

" The American Thyroid associations recommends all prenatal vitamins contain 150 micrograms of iodine and that all north american women receive daily dietary supplements containing 150 micrograms iodine during pregnancy and while nursing."

                        News flash!!!!!
************ All table salt does not have iodine ******************* 
Yipes, I checked our home salt supply and discover that our Mortons salt did not contain iodine . I found a large container of sea salt with no mention of iodine. I finally checked our multivitamin and it did contain 150 micrograms of iodine .
My wife claims she already knew this and just picked the one without iodine.

Have Fun , Be smart and make sure your family is getting adequate iodine in their diet or at least in their multivitamin.
David Calder,MD

Wednesday, April 10, 2013

little changes in BP and A1c can have Big a impact on our lives

little changes in BP and A1c can have Big a impact on our lives

little changes in BP and A1c can have Big a impact on our lives

Todays Question
   * Table salt is composed of sodium and chloride ions. What is sea salt composed of ? *

 Today I would like to review a study done by Dr. Heintjes and presented at the European Society for the Study of Diabetes and reviewed in ,Internal Medicine news by Michele G. Sullivan

LISBON – Even small changes in hemoglobin A1c and blood pressure could significantly reduce the risk of heart attack, stroke, and other cardiovascular complications in people with type 2 diabetes, according to the findings of a population-based observational study.
A 0.5% decrease in HbA1c and a 10 Hg/mm decrease in systolic blood pressure could avert 10% of such events over 5 years,
Those patients with the greatest risk factors – elevated HbA1c, high blood pressure, and higher body mass index – stand to gain the most when they improve those factors, she said.
Dr. Heintjes’ analysis included 5,841 Dutch patients with a diagnosis of type 2 diabetes for at least 2 years. The patients were all taking some form of treatment – oral medications, insulin, or both – for at least 6 months to be included in the study. After examining both baseline data and 5-year outcomes, she was able to extrapolate how improvements in the three risk factors might impact the expected number of cardiovascular events.A multivariable analysis allowed her to extrapolate that 796 cardiovascular events (heart attack, ischemic heart disease, stroke, and chronic heart failure) would occur if all of the patients were followed for 5 years
My interest in this study faded quickly after I realized that she did not actually follow the patients for 5 years . It appears to me the results are the result of a mathematical calculation. This is interesting data but I prefer studies done by researchers following patients in clinics and analyzing actual collected data.
Wait a minute . don't give up on the idea.
I recall one classic study completed in 1998, THe UKPDS study( the United Kingdom Prospective Study. This was a study done on patients with Type 2 diabetes. They found that a small reduction in BP 154/87 to 144/82 resulted in a 34 % reduction in death related to diabetes , a 34% reduction in small vessel disease (eye and kidney damage) , a 44% reduction in strokes and a 56% reduction in heart failure.
This same study also revealed that a 1 point drop in A1c from 8 to 7 reduced the development of eye damage 17 to 21 % ,kidney damage 24 to 33 % and cardiovascular disease 16%. If you were taking metformin the result were even better with a 29% reduction in eye and kidney damage , 39% reduction in heart attacks and a 36% reduction in all cause mortality
Little changes do have a big impact. You can beat this disease with little steps. Celebrate a victory with ever little improvement in this game of numbers.
Have fun , be smart and remember , a few little steps every day lead to success.

* Sea salt  is also sodium chloride  with varying amounts of trace minerals  depending on the source.
   Table salt is sodium chloride without the trace minerals but has one chemical element added that can improve
   your health. What is chemical element and what does it do ?

Friday, April 5, 2013

DPP-4 inhibitors vs sulfonylureas

Two good news articles of interest today.

    DPP-4 inhibitors ( vildagliptin ) vs sulfonylyureas ( glimepiride)

#1 Vildagliptin helped patients achieve an A1c of < 7  with less weight gain and without hypoglycemia 
      compared to glimepiride
        -  click below to read the abstract
            2013 Mar 25. pii: S0168-8227(13)00089-2. doi: 
           10.1016/j.diabres.2013.03.011. [Epub ahead of print]

 # 2 Data suggests that chronic treatment with DPP-4i may have cardioprotective effects
       - The patients were admitted with acute coronary syndrome on oral diabetes medications
       - DPP-4 inhibitors with or without metformin  had less in-hospital and 30 day posthospital  complication than
         patients on other oral diabetes medication 

       - My opinion : The study has a possible flaw.
         The DPP-4 group were younger with less history of  heart and kidney disease  which could also put 
         them at lower risk of cardiovascular disease complication. Click below to read the abstract.
          2013 Mar 28;12(1):53. [Epub ahead of print]
Have fun , Be smart , learn more about your diabetes medications  
David Calder,MD