Nutrients - Magnesium

Magnesium

Overview

Magnesium is an important mineral for everyone. The RDA varies for everyone depending on sex and age. Read about magnesium in this blog by David Mendosa. Most research indicates that only about half of American adults reach the RDA.

Magnesium is used for more than 300 biochemical reactions in the body. It helps maintain normal muscle and nerve function, it keeps heart rhythm steady, it supports a healthy immune system, and it keeps bones strong. It also helps the body digest, absorb, and utilize proteins, fats, and carbohydrates. It also contributes to the makeup of teeth and bones. Most important, it activates enzymes, contributes to energy production, and helps regulate calcium levels, as well as copper, zinc, potassium, vitamin D, and other important nutrients in the body.

Researchers are studying the role magnesium plays in preventing and managing disorders such as diabetes. They have found that it is an essential mineral in the regulation of blood sugar, playing a part in the secretion and function of insulin by opening cell membranes for glucose. Low blood levels of magnesium are frequently seen in people with type 2 diabetes. A deficiency can cause insulin resistance, so that they require greater amounts of insulin to maintain their blood sugar within normal levels.

People with diabetes are always at risk for wounds and slow healing, but with proper medical management and nutrition, these hurdles can be overcome. Certain medical conditions; however, can upset the body's magnesium balance. For example, an intestinal virus that causes vomiting or diarrhea can cause temporary magnesium deficiencies. Some gastrointestinal diseases (such as irritable bowel syndrome or IBS and ulcerative colitis), diabetes, pancreatitis, hyperthyroidism (high thyroid hormone levels), kidney disease, and taking diuretics can lead to deficiencies. Too much coffee, soda, salt, or alcohol, as well as heavy menstrual periods, excessive sweating, and prolonged stress can also lower magnesium levels.

Tests

A magnesium test is used to measure the level of magnesium in the blood. Abnormal levels of magnesium are most frequently seen in conditions or diseases that cause impaired or excessive excretion of magnesium by the kidneys or that cause impaired absorption in the intestines. Magnesium levels may be checked as part of an evaluation of the severity of kidney problems and/or of uncontrolled diabetes and may help in the diagnosis of gastrointestinal disorders.

Since a low magnesium level can, over time, cause persistently low calcium and potassium levels, it may be checked to help diagnose problems with calcium, potassium, phosphorus, and/or parathyroid hormone – another component of calcium regulation.

Recommended Daily Allowance

Dosages are based on the dietary reference intakes (DRIs) issued from the Food and Nutrition Board of the United States Government's Office of Dietary Supplements, part of the National Institutes of Health.

Pediatric

Do not give magnesium supplements to a child without a doctor's supervision.

• Children 1 - 3 years of age: 40 - 80 mg daily
• Children 4 - 8 years of age: 130 mg daily
• Children 9 - 13 years of age: 240 mg daily
• Males 14 - 18 years of age: 410 mg daily
• Females 14 - 18 years of age: 360 mg daily
• Pregnant females 14 - 18 years of age: 400 mg daily
• Breastfeeding females 14 - 18 years of age: 360 mg daily

Adult

• Males 19 - 30 years of age: 400 mg daily
• Females 19 - 30 years of age: 310 mg daily
• Males 31 years of age and over: 420 mg daily
• Females 31 years of age and over: 320 mg daily
• Pregnant females 19 - 30 years of age: 350 mg daily
• Pregnant females 31 and over: 360 mg daily
• Breastfeeding females 19 - 30 years of age: 310 mg daily
• Breastfeeding females 31 years of age and over: 320 mg daily

A person's need for magnesium increases during pregnancy, recovery from surgery and illnesses, and athletic training. Always consult with your physician.

Food Sources

Rich sources of magnesium include tofu, legumes, whole grains, green leafy vegetables, wheat bran, Brazil nuts, soybean flour, almonds, cashews, blackstrap molasses, pumpkin and squash seeds, pine nuts, and black walnuts. Other good dietary sources of this mineral include peanuts, whole wheat flour, oat flour, beet greens, spinach, pistachio nuts, shredded wheat, bran cereals, oatmeal, bananas, and baked potatoes (with skin), chocolate, and cocoa powder. Many herbs, spices, and seaweeds supply magnesium, such as agar seaweed, coriander, dill weed, celery seed, sage, dried mustard, basil, cocoa powder, fennel seed, savory, cumin seed, tarragon, marjoram, and poppy seed.

Precautions 

Because of the potential for side effects and interactions with medications, dietary supplements should be taken only under the supervision of a knowledgeable health care provider. Since magnesium is excreted by the kidneys, people with heart or kidney disease should not take magnesium supplements except under their doctor's supervision.

It is rare to overdose on magnesium from food. However, people who ingest large amounts of milk of magnesia (as a laxative or antacid), epsom salts (as a laxative or tonic), or magnesium supplements may overdose, especially if they have kidney problems. Too much magnesium can cause serious health problems, including nausea, vomiting, severely lowered blood pressure, confusion, slowed heart rate, respiratory paralysis, deficiencies of other minerals, coma, cardiac arrhythmias, cardiac arrest, and death.

The common side effects from magnesium include upset stomach and diarrhea.

Magnesium competes with calcium for absorption and can cause a calcium deficiency if calcium levels are already low. Some medications may lower magnesium levels in the body. These include chemotherapy drugs, diuretics, digoxin (Lanoxin), steroids, and certain antibiotics.

Possible Interactions

If you are currently being treated with any of the following medications, you should not use magnesium without first talking to your health care provider. Because the list is long, I felt it would be better to quote it from this source.

Aminoglycosides -- Concomitant use with magnesium may cause neuromuscular weakness and paralysis.

Antibiotics -- Taking magnesium supplements may reduce the absorption of quinolone antibiotics, tetracycline antibiotics, and nitrofurantoin (Macrodandin). Magnesium should be taken 1 hour before or 2 hours after taking these medications. Quinolone and tetracycline antibiotics include:

 Ciprofloxacin (Cipro)

 Moxifloxacin (Avelox)

 Tetracycline (Sumycin)

 Doxycycline (Vibramycin)

 Minocycline (Minocin)

Blood Pressure Medications, Calcium Channel Blockers -- Magnesium may increase the risk of negative side effects (such as dizziness, nausea, and fluid retention) from calcium channel blockers (particularly nifedipine or Procardia) in pregnant women. Other calcium channel blockers include:

 Aamlodipine (Norvasc)

 Diltiazem (Cardizem)

 Felodipine (Plendil)

 Verapamil (Calan)

Medications for diabetes -- Magnesium hydroxide, commonly found in antacids such as Alternagel, may increase the absorption of some medications used to control blood sugar levels (particularly glipizide or Glucatrol and glyburide or Micronase). If you take these medications to control blood sugar, your doctor may need to adjust your dose.

Digoxin (Lanoxin) -- Low blood levels of magnesium can increase negative effects from digoxin, including heart palpitations and nausea. In addition, digoxin can cause more magnesium to be lost in the urine. A doctor will monitor magnesium levels in people taking digoxin to see whether they need a magnesium supplement.

Diuretics -- Diuretics known as loop (such as furosemide or Lasix) and thiazide (including hydrochlorothiazide) can lower magnesium levels. For this reason, doctors who prescribe diuretics may recommend magnesium supplements as well.

Fluoroquinones -- Concomitant use with magnesium may decrease absorption and effectiveness. Flouroquinones should be taken a minimum of 4 hours before any products containing magnesium.

Hormone Replacement Therapy -- Magnesium levels tend to decrease during menopause. Clinical studies suggest, however, that hormone replacement therapy may help prevent the loss of this mineral. Postmenopausal women, or those taking hormone replacement therapy, should talk with a health care provider about the risks and benefits of magnesium supplementation.

Labetol -- Concomitant use with magnesium can slow heart beat abnormally and reduce cardiac output.

Levomethadyl -- Concomitant use with magnesium may precipitate a heart condition called QT prolongation.

Levothyroxine -- There have been case reports of magnesium containing antacids reducing the effectiveness of levothyroxine, a medication that treats underactive thyroid.

Penicillamine -- Penicillamine, a medication used to treat Wilson's disease (a condition characterized by high levels of copper in the body) and rheumatoid arthritis, can inactivate magnesium, particularly when high doses of the drug are used over a long period of time. Supplementation with magnesium and other nutrients may reduce side effects associated with penicillamine. If you take penicillamine, a health care provider can determine whether magnesium supplements are right for you.

Tiludronate (Skelid) and Alendronate (Fosamax) -- Magnesium may interfere with absorption of medications used in osteoporosis, including alendronate (Fosamax). Magnesium or antacids containing magnesium should be taken 1 hour before or 2 hours after taking these medications.

Others -- Aminoglycoside antibiotics (such as gentamicin and tobramycin), thiazide diuretics (such as hydrochlorothiazide), loop diuretics (such as furosemide and bumetanide), amphotericin B, corticosteroids (prednisone or Deltasone), antacids, and insulin may lower magnesium levels. Please refer to the depletions monographs on some of these medications for more information.

The Various Terms for Types of Patients

I have blogged about patients before, but I had not really researched the types of patients on the Internet. I approached my analysis from what I read on mostly diabetes sites and a few other web sites. Now it is time to discuss how some in the medical profession view patients and from some other sources. Even our doctors have different classes for us as patients. Most are very understandable and fit many patients. Most do not list us as compliant or noncompliant, although some may wish they could just label us that way.

The list I have been familiar with and that I use starts with patient, passive patient, proactive patient, empowered patient, and e-patient. I have also listed patient advocate to the list. I have listed the first three in this blog and the second three in this blog.

A doctor lists the following type of patients - passive-dependent, independent-skeptical, intellectual-researcher, expedient-flexible, and open-minded-exploring. I like that this list is a little more descriptive. Rather than duplicate his work, read his descriptions here.  This is spread out over five short pages.

The next list is different. I can understand the expansive list, but it seems a little too expanded. The list includes pleasant, courageous, angry, manipulative, demanding, drug-seeking, direct, all-knowing, noncompliant, anxious, psychosomatic, depressed, suffering patients, chronic pain, dying patients, and geriatric patients. The last type is one that needs to be listed and often is not on any list. For the author's explanations, read about the list here.

There are many other classifications for patients and this depends on the field of medicine and on the location of the patient. Fact is, I wonder if some of the patient types are designed to confuse people. Dentist have their list of patient types. Hospitals have several lists of patients types they use and some are even coded to prevent others from having an idea for the reason they are in the hospital. I am only listing one link although there are many such lists depending on the type of hospital and the patients each serves.

Neurology has a list of patient types. This is the last list I will link to as it raises many valid concerns when dealing with people that have no control of the condition they often find themselves. Nursing homes have a set of terms they use for their clients or residents. It seems many of the medical professions have their preferred list for patient types.

Psychologists and the related professions have a separate list of terms for their office patients, and those admitted to hospitals, and patients in mental facilities. There seems to be separate patient lists for records and another list of types for insurance purposes. I am still researching, but as of yet I can find no linking evidence.

In doing my reading, there seems to be different types of patients for everything and there is little crossover of patient types. Only once did I see both compliant and noncompliant listed on the same list. Three times I saw noncompliant in a list of patients. It is discouraging that patients are viewed so differently across the medical professions. I honestly feel this is to confuse us as patients and doctors in each specialty have their own code to describe us. After reading over 40 sources of patient lists, I admit I don't have a grasp on the reasons for so many different lists of patient types.

Could these lists be standardized? This is highly doubtful as I can see the need for some of the patient types in very specialized medical fields. As patients, we could generalize patient types, but it would never be accepted. We can only agree that there is a need for many patients types.

The one discussion I had with two doctors (a husband and wife practice) probably had the greatest impact on me and at the same time was the most rewarding. I ask the question of did they use the term noncompliant to describe patients. Both answered almost no immediately and stated the term was an insult to the doctor and to the patient. Each went on to explain that if the doctor did not take the time to explain a course of treatment and the reasons for the particular treatment and the patient did not understand the importance, then the doctor would be at fault if the patient did not find it important to follow the advice.

Both doctors felt that much of what others label a patient as noncompliant is the fault of the doctor. Both expressed the belief that there are some patients who will start out willingly, but dislike the routine and stop taking a medication or look to alternative medicine for answers. This is why they have developed a standard set of questions to ask any patient to assess whether the patient understands the reason for the treatment, if the patient agrees with the plan, and if there is a high indication the patient will not follow the treatment plan, or will seek alternative medicine advice.

One doctor said they had such a patient and termed this patient as an alternative medicine patient. When the doctor pressed the patient about why he even came to them, the patient answered that a correct diagnosis was being sought and if alternative medicine had a treatment, that would be the treatment of choice. If alternative medicine did not have a treatment, he would follow their treatment. Further discussion uncovered that the patient owned his alternative medicine/health food store and was very knowledgeable. The patient said that both doctors had never used the word noncompliant with him and that was the reason he would continue to have them as his doctors.

They admitted that this was an unusual doctor-patient relationship, but that they would make the diagnosis, discuss the treatment and the reasons, and the patient would go on his way. If the patient determined that the alternative treatment would not work, he would come back for the prescription and ask any questions needed. Only once has he come back for the prescription and a renewal in the two years of being a patient.

Occupations That Can Assist People with Diabetes

For this blog, I will start with the people that may have the least training. This is not to say that many do not have college degrees or have not learned from experience or the college of hard knocks. Some will do excellent work and be able to translate information into understandable meaning for people new to diabetes or people still learning about diabetes. Most will not be afraid to tell patients that now is the time to learn when they hear someone say, “It could not have been important as my doctor did not mention this,” or “I did not hear anything about this.”

Yes, many doctors do not cover everything because of time constraints. This is where peer-to-peer workers and peer mentors will become a valuable asset in working with other diabetes patients. They can use experiences to excellent advantage and gently challenge other patients to learn.

Peer-to-peer workers will generally be working on a one on one basis and will report to a doctor at some point. Some patients will do better in a peer-to-peer setting and this should be taken full advantage of, as education is so important. The informal setting is often more relaxing and makes the giving and receiving of information easier. If the person giving the information is given proper training, she/he can become a powerful tool in getting information to other patients.

Peer mentors may or may not work with groups of people. They can work in either an informal setting or a formal setting. When working in a group setting, they need to be open to taking the discussion in a direction that will teach the most people. Having just had my first session as a volunteer peer mentor by video conferencing (telemedicine if you will permit), there are many areas to be concerned about. With no formal training or certification to point to, a peer mentor must not make medical recommendations about medications or when to take medications. This is the function of doctors and other medically qualified individuals. This does not mean that you are prohibited from talking about different medications as long as you make comparisons and discuss all sides of any issues. There are areas where you have experiences that you may share, and many subjects that may be presented for discussion.

If you are working with patients of a particular doctor(s) like I am, you must set the ground rules before hand to not conflict with a doctor's instructions. I am fortunate that wife of this husband-wife team earned a degree in nutrition before her medical degree, so I don't need to answer most nutrition questions. I have been given permission to discuss pros and cons of different diets, suggesting what works best for one individual may not be the best for another, and then passing them to her for further discussion. Since I am a blogger, the two doctors knew my position on many issues and only asked me to tone down my position on a few issues. Because they have no certified diabetes educators that will work with them, they were looking for other means to cover many areas. We had discussed many issues in the weeks leading up to the shared medical appointment (SMA) and they had one SMA before this where they discussed doing this, but this still did not prevent a couple of the questions.

They knew areas where I could be aggressive in nature and that I normally would not tell readers to use a particular medication. We had a long discussion about the many times I would suggest to patients that they may need to consider finding another doctor. They explained their position on many of these issues and were surprised when I stated that their position was what I was looking for and expressed agreement. The wife did ask that I not get too expressive about some areas of nutrition, but that I was welcome to encourage people to find their own level for carbohydrates, protein, and fat. She felt this could be an area of concern for many patients as they only had one person on a low carb diet. She as a dietitian was not concerned about fat levels other than avoiding anything over 60%. She would prefer people stayed under 50%, but would allow people to experiment. She also stated she would prefer working with people at their dietary preference and if needed encourage them to eat certain foods the help balance their nutrients. This did not come up in the first session, but they will be doing more testing to determine certain deficiencies and suggesting supplements for those who cannot or will not eat certain foods. They both said my blogs had alerted them to the vitamin B12 deficiency for patients who had been on metformin for extended periods and they had one patient with a deficiency.

Nutritionists need to step forward and be recognized. I am talking about those that have a four-year degree or an advanced degree in nutrition. The field of diabetes is in need of people that are more concerned with the nutritional value of food consumed by people with diabetes that how many carbohydrates are in each meal. Nutrition for people with diabetes is not a one-size-fits-all proposition and we need guidance on an individual basis. We have had enough of the mandates, mantras, and dogma. This may work for some, but not the many.

One group that I have also had conflicts with is people that call themselves diabetes coaches. These people seldom have diabetes and come from a variety of professional pursuits. Of the four I have dealt with, all have come from the nursing profession. I know a few that have a dietitian background, and another that was a certified diabetes educator. I am not saying that there are not possibly good diabetes coaches, but I personally disagree with many of their positions and visions of how people with diabetes must eat, live, and sleep. I have only seen one that recognized the value of exercise. Most diabetes coaches promote the same mantras, mandates, and dogma as certified diabetes educators and dietitians that are members of the Academy of Nutrition and Dietetics (AND). This means whole grains and low fat and no compromises. Disagree with them or question them, and they will not keep you as a customer or client. Unfortunately, my experience has been – it is their way, or the highway. Considering the following paragraph, I may have had experiences with the bad apples in diabetes coaching.

On July 30, 2012, Allison B has an excellent blog on the Diabetes Coaches. This presented in a different light than I have encountered. Apparently, this category has some people that know what they are doing and can be an excellent addition to your healthcare team. They have an international  professional organization and do work across many chronic illnesses and diseases. Some of these coaches do have diabetes and speaks well for what they are accomplishing. Take time to read the blog as this may help you decide that this is a group you need. Many use the telemedicine type of communication, which means that can be successful to wide geographical locations.

Until the lawsuit is settled and there will be more, I will attempt to leave the registered dietitians and AND out of discussions. If there is more news that surfaces about them, yes, I will write about it.

Like any profession, the certified diabetes educators (CDEs) have their bad apples. Their numbers are not keeping pace with the need and increase of people diagnosed with diabetes. It would be interesting to know what the actual numbers of CDEs are and whether they are in practice as CDEs, whether they work full-time or only part-time, or whether they are writing books and doing speaking tours, and not actually serving patients.

If these people would do the education that their title says, we might not have the epidemic we are facing today. Lack of diabetes education is just that, little is actually being taught.

Patients Trust Doctors but Consult the Internet

This is one study that does not reveal anything new to me. Members of our informal group have been talking about this for some time. We all were disappointed when one of the group had an appointment with a doctor for something other than diabetes. The doctor informed him that if he went on the Internet to search about his condition, he did not want him as a patient. Since he knew that he would, no matter what the doctor stated, he did think to ask a few questions.

Why would any doctor today make this statement? What was he trying to hide? The last question was why he would chase patients away? The doctor did say that for this condition there was not much good information on the Internet. Our friend did think to say why did the doctor not have a list of reliable websites to hand out rather than drive patients away. Doctor asked if he was intending to use the Internet and our friend said most definitely as he used it for other medical problems, among them diabetes, and that with a group of friends would be searching the Internet. The doctor just stated that he did not want him back as a patient. At least our friend stated that with this attitude, he would not be back to a doctor that was against technology.

We have had quite a bit of fun with this experience. A couple of phone calls were made to the office to see if this was indeed true. The person answering the phone just says yes, if you are a person that will search the Internet, the doctor does not want you as a patient. This has raised other activities like a doctor search and name search. Apparently this doctor has succeeded in maintaining an almost zero presence on the Internet, except for an address and office location.

In our research, we did discover that very little was available on the Internet. What was available was from studies that did not give out much information. The member did get another appointment with a different doctor. This doctor did a different series of tests and determined that the first diagnosis was not a complete diagnosis and that two important steps had been bypassed. The doctor asked if he was going to research for more information on the Internet and when our friend answered yes, the doctor handed him a list of URLs that could help. The doctor stated that there was other information, but he did not consider much of it as reliable. The doctor was right and had done his research. We found several other sites, but the information was not as complete.

Back to the study which found no evidence that the users of online health information had less trust in their doctors than patients who did not seek information through the Internet. Xinyi Hu, who co-authored the study as part of her master's thesis in communication was somewhat surprised and suggested that doctors need not be defensive when their patients come to their appointments armed with information taken from the Internet.

“"As a practicing physician, these results provide some degree of reassurance," said co-author Richard L. Kravitz, a UC Davis Health System professor of internal medicine and study co-author. "The results mean that patients are not turning to the Internet out of mistrust; more likely, Internet users are curious information seekers who are just trying to learn as much as they can before their visit."”

“Almost 70 percent of the study subjects reported they were planning to ask their doctor questions about the information they found, and about 40 percent said they had printed out information to take with them to discuss with their doctors. More than 50 percent of subjects said they intended to make at least one request of their doctor on the basis of Internet information.”

This says a lot about what people do with the information they glean from the Internet and that they would not be asking questions if they thought the information was not worthy of discussion. Doctors that are afraid of patients looking for information on the Internet, either are afraid of their lack of skills, or their knowledge of the topic. It is a good doctor that says he is not up on the information for the disease or illness of the patient and says we can learn together. This also says that the doctor is appreciative of a patient that is proactive in their care.

While many doctors hesitate to say that their education about an illness or a disease is not as recent as it should be, there are some that are confident in their skills to learn that they will challenge most patients to learn with them. These doctors should be valued as they want what is best for their patients and will spend the time learning so they can answer questions their patient asks. I have even seen doctors admit they are not current in their knowledge and refer a patient to a doctor that is current. This says that the doctor is a caring person and realizes that they do not have the time, or possibly even the interest at that time in their career and are confident in knowing what is best for the patient.

Type 2 Diabetes May Be Diagnosed Late

This physician has it right and knows what he is saying. Type 2 diabetes is often diagnosed late. Timothy Lyons, MD, does not point the finger at patients like many doctors are prone to do, but also points an equal responsibility at the doctors. Dr. Lyons is presently Director of Research of the Harold Hamm Diabetes Center in Oklahoma City and has experience as a researcher and a clinician.

Dr. Lyons has some strong suggestions for earlier detection, and I am in complete agreement with his suggestions. His suggestions will not be popular with the medical insurance industry that does not believe in prevention, just illness treatment.

His first suggestion is that routine screening should occur after age 45, or at younger ages for those that are overweight, have a family history of diabetes, and those who are not Caucasians. He then states, "I personally think that everyone by age 30 should know what their fasting glucose is." This is an aggressive proposal, but could help prevent many cases of diabetes. This could be the wake-up call many people need.

I sincerely wish that Dr. Lyons had been available to me in the years before my diagnosis and that I had been routinely tested after age 45 as I might have been able to prevent diabetes. I do have diabetes history on my mother's side of the family, but not a lot of her side of the family ended up with diabetes. My brother was able to manage with diet and exercise until cancer forced the issue.

Dr. Lyons also states that even when diabetes is diagnosed, many primary care physicians may not have the time to adequately examine patients. He also emphasized that prevention, early detection, and good long-term management are keys to defeating the diabetes epidemic.

The point that most doctors fail to cover is the availability of testing supplies for the fasting blood glucose that they talk about wanting. To-date Medicare and the medical insurance companies will not cover meters and test strips for people without diabetes. Then after diagnosis, testing supplies are limited because of many studies funded by the National Institutes of Health and Medicare. Medicare followed by the medical insurance industry in lock step has continuously reduced to number of test strips available to people with type 2 diabetes. Anyone with prediabetes or that does not have diabetes is not eligible for insurance reimbursement for meters and test strips.

This is the problem with Dr. Lyons suggestion of everyone by age 30 and over knowing what their fasting blood glucose reading is, as many people will not be able to obtain testing supplies with the Centers for Medicare and Medicaid Services (CMS) standing in the way. Until we can push the medical associations and other professional groups working with people with type 2 diabetes to object to the studies, it will continue to be an uphill struggle. By encouraging the manufactures of meters and test strips to up the amount of education and do scientific studies for people to obtain the correct amount of testing supplies, suggestions like those from Dr. Lyons will not become a reality.

Sulfonylureas Cause Higher Mortality Risk

Alvin Powers, MD, of Vanderbilt University in Nashville, TN, who was not involved in the study, was brave enough to make this statement, "We don't know enough about those drugs [sulfonylureas]." I thought as long as these had been around, they should have had more than enough information, but when it comes to oral diabetes medications, apparently there is still a lot to learn even when they are now in generic.

The study compared data from a large retrospective cohort study of metformin to three commonly prescribed sulfonylurea drugs. The three drugs were glipizide, glyburide, and glimepiride. The discovery was a little shocking when diabetes patients had a 50 percent higher risk of death compared to patients on metformin. The study, which was funded by drug company Astra Zeneca shows that apparently the sulfonylureas are more a cause for concern.

This is speculation on my part, but I feel that doctors just don't cover the side effects in sufficient detail. They don't emphasize the warning that these drugs cause low blood glucose by themselves (hypoglycemia) and if you skip a meal, skip the medication. This alone could be causing part if not much of the increase in mortality. Patients that do not understand the dangers of hypoglycemia will not take the care that needs to be taken. This is also an area that the certified diabetes educators seem to gloss over.

I also hope this will give researchers cause for concern and not to stack so many oral medications. Many researchers that think the larger the oral diabetes medications cocktail, the greater glycemic control there should be. Some researchers may continue to stack oral medications and fail to report adverse medication events until the adverse events become so great like they did on the ACCORD study.

Findings, like this study, presented at medical meetings are typically considered preliminary until published in a peer-reviewed journal. However, this could still cause "enormous clinical implications." Apparently, sulfonylureas have been considered safe and effective. Now we will need to see if the FDA will require a label warning.

Cost cannot be a distinguishing factor, as all three sulfonylurea drugs are available in inexpensive generic forms. Metformin offers an alternative to sulfonylureas as first-line oral therapy for diabetes and also is available as a generic.

An enterprise-wide electronic health record (EHR) system was used to conduct the retrospective study of diabetic patients who started treatment with one of the sulfonylureas or metformin from Oct. 24, 1998 to Oct. 12, 2006. The search produced records for 23,915 patients. About half (12,774) started treatment with metformin, followed by glipizide (4,325), glyburide (4,279), and glimepiride (2,537). All patients were adults treated in outpatient clinics. Investigators excluded patients using insulin, other injectable diabetes medications, or multiple oral drugs for diabetes.

The patients had a median follow-up of 2.2 years and 2,546 patients died. This was verified by the EHR or Social Security Death Index. This is how patients treated with a sulfonylurea had a mortality hazard ratio of 1.50 compared with metformin.

Because recent reports suggested sulfonylurea risk varied in patients with coronary artery disease (CAD), investigators conducted a separate analysis of 2,721 patients with a history of CAD. As compared with metformin, patients who started treatment with glyburide had a 38% increase in the mortality hazard (HR 1.38), and there was a 41% increased risk in patients started on glipizide (HR 1.41). Only glimepiride was not associated with an increased mortality hazard versus metformin.

Dr. Minisha Sood, also an endocrinologist at Lenox Hill, said that sulfonylureas may fare worse than metformin because they may "interfere" with cardiovascular processes that strengthen and protect heart tissue making it more resilient should a cardiac event occur.

"What's interesting about this study is that all three sulfonylureas examined led to increased mortality rates vs. metformin in the entire cohort study, which included patients without coronary artery disease," Sood added. "Does this mean that we shouldn't be prescribing sulfonylureas at all? I think prospective trials are needed to answer that question, so the jury is still out."