September 27, 2013

Neuropathy Warning for Fluoroquinolones

Before getting into this, I will list the approved fluoroquinolones. The list shows the name and the (brand name): levofloxacin – (Levaquin); ciprofloxacin – (Cipro); moxifloxacin – (Avelox); norfloxacin – (Noroxin); ofloxacin – (Floxin); and gemifloxacin – (Factive). Have you memorized them yet? No, I haven't either.

I do have one of them down pretty well and that is Levaquin as that put me back in the emergency room after one pill. Since I already have neuropathy, I suspect that it did not take long to put me in severe pain of all joints and especially my feet and lower legs. Some doctors use Levaquin for pneumonia which is what I had, but I will never knowingly take another pill of Levaquin. The pain is unbearable and I would advise anyone with neuropathy to avoid Levaquin. Probably is wise for the rest of the group if you already have neuropathy.

At least there have been enough adverse events reported with the above drugs that the labels have to be changed to reflect this. However, topical formulations applied to the ears or eyes are presently not known to carry the risk.

As of August 15, 2013, the US Food and Drug Administration (FDA) requires the drug labels and Medication Guides for all fluoroquinolone antibacterial drugs be updated to describe better the serious side effect of peripheral neuropathy. The nerve damage may occur soon after these drugs are taken. The sad part is that for many this condition may become permanent.

If you, as the patient, develop symptoms of peripheral neuropathy, the fluoroquinolone should be stopped. The FDA advises that the patient be switched another non-fluoroquinolone antibacterial drug. Then we see the almost mandatory risk statement of “unless the benefit of continued treatment with a fluoroquinolone outweighs the risk.” If it was me, the pain would prevent me from more of this drug.

Peripheral neuropathy is a nerve disorder occurring in the arms or legs. Symptoms include pain, burning, tingling, numbness, weakness, or a change in sensation to light touch, pain or temperature, or the sense of body position. It can occur at any time during treatment with fluoroquinolones and can last for months to years after the drug is stopped or be permanent. Patients using fluoroquinolones who develop any symptoms of peripheral neuropathy should tell their health care professionals right away.”

September 26, 2013

Caregiver Care Done Right

Most people enter caregiving as amateurs and forget about what they may need to be quality caregivers. Some continue and become embroiled in the fight for their own health and often develop major depression. The better caregivers have realized that things happen beyond their control, consult with others early, accept help from friends and neighbors, and develop a relaxed but vigilant style of caregiving. These are the people that make great caregivers.

This article in WebMD covers caregiver stress and depression, both of which are real problems for caregivers. If you are providing near end of life care, or care for someone with a chronic painful condition, be aware that the rewards for this caregiving are real and can vary greatly.

Stephen Zarit, PhD, professor of human development at Pennsylvania State University, has been studying caregivers for more than 30 years. He finds that 40% to 70% of caregivers are significantly stressed. Zarit also says that about half of these seriously stressed caregivers “meet the diagnostic criteria for major depression.”

Psychologist Michael Williams, senior program associate at Wellness House, a caregiver support center in the Chicago area says caregivers seldom realize they are becoming depressed. He also states, "Depression builds over time due to the physical and emotional symptoms the caregiver experiences,"

I appreciate what Philip Higgins, MSW, director of palliative care outreach at Boston's Dana Farber Cancer Center has to say. He says, "You don't become depressed because of the symptoms; you become depressed because they are extreme and persistent,"

Symptoms of major depression include:
  • Sad, anxious, or "empty" feelings
  • Feelings of hopelessness or pessimism
  • Irritability, restlessness, and anxiety
  • Feelings of guilt, worthlessness, or helplessness
  • Loss of interest in once pleasurable hobbies or activities, including sex
  • Fatigue and decreased energy
  • Difficulty concentrating, remembering details, and making decisions
  • Insomnia, waking up during the night, or excessive sleeping
  • Overeating or appetite loss
  • Persistent aches or pains, headaches, cramps, or digestive problems that do not ease, even with treatment
  • Thoughts of suicide or suicide attempts

People caring for a loved one with a terminal illness should add "feelings of anticipatory grief" related to a sense of impending loss to the list, says Ruth Steinman, a psychiatrist at the Abramson Cancer Center at the University of Pennsylvania in Philadelphia. "This is a symptom where a palliative care service can be especially helpful," Steinman says.”

It is important to recognize that the stress you are experiencing can sometimes lead to depression. This is the first step to preventing it and burnout from happening. Then take the second step and find a palliative care team's social worker or mental health professional. Talk about your feelings, frustrations, and fears. This talking will help you understand what is happening to you and the person in your care. When caregivers understand that they are not in total control of the situation, this alone can bring on a great sense of relief. This will also allow the caregiver to have goals that are more realistic.

I will quote this as it contains important information.
In addition, to keep depression at bay:
  • Maintain a life outside of caregiving. Stay connected to friends. Don't give up your daily routines.
  • Maintain your health. Get regular check-ups, eat a balanced diet, and exercise. "It wasn't until I was hospitalized that I started thinking about my own health. That was a real wake-up call," says Nancy Knitter, who is caring for her husband with Parkinson's disease in their Rochester Hills, Mich., home.
  • Exercise. It un-kinks tense muscles, revs up the cardiovascular system, and floods the brain with feel-good chemicals, such as endorphins.
  • Use simple de-stressing techniques: deep breathing, muscle relaxation, meditation, and self-massage. And laugh. "People don't think of humor as a way to cope with stress, but they should," says Irv Ginsburg, of Ooltewah, Tenn., who cared for his wife, Nada, while she had brain cancer.
  • Join a support group. In support groups, you validate your role as caregiver, voice your fears, vent your frustrations, and learn coping strategies and techniques. Hospitals and most disease-specific organizations sponsor groups. If you can't get out to a group, many organizations sponsor online support groups, and the Veterans Administration has a free caregiver support line (855-260-3274).
  • Ask for help from the palliative care team, family, and friends. Delegating lessens stress and provides ways for others to show they care. "People want to help, they just don't know what needs doing," says Helene Morgan, MSW, clinical social worker in the pediatric palliative care program at Children's Hospital Los Angeles.
  • Use respite care. Organizations -- home health agencies, adult day care programs, nursing homes, faith groups, Area Agencies on Aging, the Veterans Administration -- and friends can provide short breaks that lessen stress and allow batteries to recharge. "Using respite care didn't just help me with the caregiving, it helped my wife and me have a social life."

Some of the above points are covered in three prior blogs - here, here, and here.

September 25, 2013

Do You Know the HbA1c Test?

Many of my peers have written on this topic, but now is my attempt. I do receive emails asking me “what is the best HbA1c?” I answer that if you do not have diabetes, normal HbA1c should be between 4.2% and 5.6%, meaning the person is healthy and at minimum risk of diabetes. I have seen others say it should be between 4.2% and 4.8% for normal healthy individuals, and generally, these indicate no risk for diabetes. In all of this, I advise you to read this by David Mendosa. He did his research and speaks to the subject of normal being 4.7% to 5.7%.

These same people say that there is minimal risk for diabetes between 4.9% and 5.6%; however, they advise paying closer attention if this starts to creep up toward 5.7%. The range from 5.7% to 6.4% is ignored by most doctors and treated in a cavalier way. In reality, this range is for diagnosis of pre-diabetes, but don't rely on most doctors doing anything about it. If you have a history of diabetes in your family, are overweight, or having any of the symptoms of diabetes, make sure that your doctor is aware of this. Your risk for diabetes is higher than it should be.

Once your HbA1c crosses into the 6.5% or higher level, you have diabetes. Forget about arguing that you don't have diabetes. Your pancreas is having trouble producing enough insulin or your insulin resistance is preventing the insulin your pancreas is producing from being utilized. Now that I have said this, many doctors can't get away from the teachings of the American Diabetes Association (ADA), which declares diabetes starts at 7.0%. Even this is outdated, but in the recent past this was the crossing point for diabetes and many doctors cling to this.

I will advise people who have diabetes in their family history and their doctor will not test for diabetes to find an endocrinologist that will test them for diabetes and to do this a minimum of once per year. No I did not say fire your current doctor as with the changes happening under the Affordable Care Act (ACA), this may not be a good time to be without a doctor.

Patients with anemia, those taking vitamin C and E, patients with high blood cholesterol levels, and people with liver or kidney diseases need to be aware that they may have abnormal HbA1c tests. Be prepared to discuss this with your doctor and especially if you are taking supplements. Be careful and manage your diabetes as those who do not manage their diabetes have a much higher risk of developing the complications.

How often you should have the HbA1c test is another area for concern. I don't say this lightly as doctors vary considerably in how often they wish to test you. Some of this depends on how well you are managing your diabetes. If you are self-motivated and are always below 6.0% most doctors may wish to only test your HbA1c every six months. Some doctors will still insist on testing your quarterly. You should always strive to have HbA1c tests below 6.5% although some will say less than 7% - again this is the recommendation of the ADA.

I do appreciate what David Mendosa recommends in his blog. I will admit that being able to have the test strips for checking my blood glucose as frequently as I need has kept me from following his advice. Read the complete blog as he points out the importance of monthly HbA1c testing.

September 24, 2013

Insulin Resistance versus B-Cell Dysfunction

When I wrote this blog about the possibilities of type 2 diabetes having sub classes, I had not expected another article this quickly. And this article says, “Identifying the profound differences in risk factors for diabetes in the subpopulations of this study is a step in the right direction.” Subpopulations is not sub-classes, but definitely raises the odds or may just a way of downplaying this.

At least adults older that 65 were the study subjects. Granted this was a multi-site cohort study and included about 4400 adults. The mean age of participants was 73 years, and 59% of them were women. The study followed 4384 participants who were free of diabetes at the start in 1992 through 2007 for the development of diabetes. Based on beginning data, the authors evaluated degrees of insulin resistance and beta-cell dysfunction, which was calculated from fasting glucose and insulin levels. This distinction is important.

In the median follow-up of 11.7 years, seven percent of the patients developed diabetes. And if you didn't guess, higher body mass index, hypertension, low HDL-C levels, elevated triglyceride levels, and elevated glucose levels were all independently associated with a higher risk for diabetes.

If insulin resistance (IR) was present (with or without beta-cell dysfunction), these same risk factors were similarly associated with incident diabetes. This was not the case when diabetes was preceded by only beta-call dysfunction. With these individuals, being overweight or obese were associated with a lower risk, and hypertension and low HDK-C also trended toward a lower risk. In comparing patients who had diabetes, those preceded predominately by IR differed significantly from those preceded by beta-cell dysfunction.

While it is known that hyperglycemia that characterizes type 2 diabetes is caused by both IR and beta-cell failure, it is generally assumed that both causes are present in a typical diabetes patient and the relative contribution of each could have important factors for both prevention and treatment. Prescribing weight loss in patients who are at the appropriate weight, but have little or no beta-cell function would not be an effective prevention measure.

This in turn creates the problem in selecting the most effective anti-hyperglycemic medication. We need to know precisely what is driving the hyperglycemia. Identifying the differences in risk factors for diabetes in the subpopulations of this study is a step in the right direction. This raises the interest that the differential contributions of beta-cell dysfunction and IR might help explain findings such as the apparent u-shaped relationship between glycated hemoglobin (A1c) and cardiovascular disease and mortality.

The important caveat is that the current study was conducted in older individuals who do not represent the vast majority of incident diabetes cases. Without further study with younger patients, this is an important open question. I feel that the concluding statement is worth quoting and bold is my emphasis. “In any case, as convenient as A1c is for diagnosing diabetes, one of its big detractions is that it tells us little about the underlying pathophysiologic abnormalities of diabetes.”

September 23, 2013

Diet As Effective As Surgery For Obese Diabetes Patients

For all those considering bariatric surgery, stop, don't. If you wish to find out what you will be able to eat, just get hold of a menu for what they are required to eat for the rest of their life and follow it for a month or more and this will tell you how diet restricted you will be. If you think you can follow this diet for the rest of your life, then the surgery may be for you. However, consider that you can obtain the same results as surgery by using the diet.

This is now proven in a study conducted by researchers at the University of Texas Southwestern Medical Center and published in the journal Diabetes Care. Dr. Ildiko Lingvay, assistant professor of internal medicine and first author of the research, said:  "For years, the question has been whether it is the bariatric surgery or a change in diet that causes the diabetes to improve so rapidly after surgery. We found that the reduction of patients' caloric intake following bariatric surgery is what leads to the major improvements in diabetes, not the surgery itself."

Why people would undergo the Roux-en-Y gastric bypass bariatric surgery to achieve the same results is a puzzle for me. At least with the diet, you will have the opportunity to change lifestyles, especially exercise to help maintain weight loss instead of dealing with the restricted diet for the remainder of your life.

If you are considering gastric bypass bariatric surgery, be careful and do your homework as the surgeons are so anxious to take your money, they often do not tell you about the problems you may experience following surgery and sometimes for the rest of your life. Above all else, do your homework and find out for yourself what the problems may be as each person may react differently.

Because the surgery makes your stomach smaller, you will get full more quickly. This is the good part. The problems start occurring as the food may empty into the small intestine quickly and lead to dumping syndrome. This may cause diarrhea and make you feel faint, shaky, and nauseated. This can also make it difficult for your body to get enough nutrition.

This is where the surgeons and doctors often drop the ball and do not explain that the part of the intestine where many minerals and vitamins are easily absorbed is bypassed. With this, you may have a deficiency in iron, calcium, magnesium, or vitamins and this in turn can lead to osteoporosis. To prevent vitamin and mineral deficiencies, every source recommends working with a dietitian – not always the best as they will be promoting “big food”. I urge people to talk with a nutritionist or someone specializing in nutrition for bariatric surgery for best results as they will cover things more completely and also advise you which supplements are necessary since often you will not be able to consume enough food to make up for the loss of vitamins and minerals. Plus they will work to see that your doctor does test you for the vitamins and minerals to determine what needs to be supplemented. Vitamin B12 is often on the list as well.

Your doctor should, but often does not, give you specific instructions about what to eat after surgery. For the first month or longer, most doctors do not tell you it is necessary to avoid drinking liquids approximately 30 minutes before and after eating. You will of necessity need to eat slowly and chew your food very thoroughly as it will not have the stomach to depend on for breaking down your food. Also for about the first month you will be limited to soft foods and small amounts of food. Then you will need to sip water between meals to avoid dehydration.

It is common to not have regular bowel movements, but try to avoid constipation and straining with bowel movements. Very slowly, solid foods may be added back into your diet. It is very important to chew all foods well and stop eating when you feel full. Not doing this may cause discomfort or nausea and sometimes you will vomit. If you drink a lot of high calorie liquids such as soda or fruit juice, you will not lose weight. If you continually overeat, your stomach will stretch and you will not receive the benefit from your surgery.

As you can see, there are many things to consider and many pitfalls to surgery. I believe it is advisable to develop the mind-set to use the diet approach and work to a low carbohydrate diet that you can stick to and avoid surgery.