With Chronic Kidney Disease, Stop Metformin

A recent study reported a significant increase in all-cause mortality associated with the use of metformin in patients with type 2 diabetes. Yes, I can believe this as I have been taken off metformin recently because my kidney disease was moving closer to stage 3 and my doctor said to stop immediately. It will be interesting to see if there is improvement at my next appointment in late October.

Metformin is currently recommended as first line treatment for type 2 diabetes. However, its use is often limited in patients with chronic kidney disease stage 3 or higher due to the risk of lactic acidosis. I have not had any symptoms of lactic acidosis and feel fortunate for that. Since I will only use metformin and insulin, I was disappointed in having metformin removed as it had been helping me maintain and lose some weight.

The study took place in Taiwan, which allows metformin to be used in all stages of chronic kidney disease. Other countries in the world vary to greater extent and this allowed for this study to be more accurate. The finding of this study confirmed that metformin is associated with higher death rate among type 2 diabetes patient with higher stage of chronic kidney diseases.

My doctor did ask if I would consider using another oral medication or an injectable medication along with my insulin. I was very firm that I would not and going forward, I would rely on insulin only. She said that would be best and agreed with me. What I did not say is that I would not until it was proven that some of the side effects have been proven not to be harmful.

For metformin, the increased mortality risk was associated with higher dose and remained consistent across all subgroups. Finally, metformin users did not differ significantly from non-metformin users group in regard to risk of metabolic acidosis.

This study did confirm that metformin is associated with a higher death rate among type 2 diabetes patient with higher stage of chronic kidney diseases.

The study findings have therapeutic implications, supporting the current recommendations that metformin should not be used in patients with stage 5 chronic kidney disease.

In addition, the researchers also recommended future study evaluating the use of metformin in patients with less severe chronic kidney disease.

Who Is On Your Diabetes Care Team? - Part 2

A Podiatrist: This health professional is trained to treat feet and problems of the lower legs. For anyone with diabetes, which can cause nerve damage in the extremities, foot care is important. Podiatrists have a Doctor of Podiatric Medicine (DPM) degree from a college of podiatry. They have also done a residency (hospital training) in podiatry. This doctor is important for care of your feet and lower legs and to help you prevent problems with foot ulcers and other cuts or bruises that don't heal as fast as they should.

The last two individuals are often optional and sometimes not available in largely rural areas. If you are taking insulin then this doctor could be important if available:

An Endocrinologist: An endocrinologist should also be seen regularly. An endocrinologist is a doctor who has special training and experience in treating people with diabetes and is important for people on insulin.

Exercise trainer:  This person is totally optional and unless you can afford this person, ignore this specialist:   Exercise plays a major role in your diabetes care, no matter what kind of diabetes you have. The best person to plan your fitness program -- along with your doctor -- is someone trained in the scientific basis of exercise and in safe conditioning methods.

People with diabetes who are treated with insulin shots generally should see their doctor at least every three to four months. Those who are treated with pills or who are managing diabetes through diet should be seen at least every four to six months. Visits that are more frequent may be necessary if your blood glucose is not well managed, or if complications of diabetes are becoming worse.

Generally, your doctor needs to know how well your diabetes is managed and whether diabetic complications are starting or getting worse. Therefore, at each visit, provide your doctor with your home blood sugar monitoring record and report any symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Your doctor also should be informed of any changes in your diet, exercise, or medicines and of any new illnesses you may have developed. Tell your doctor if you have experienced any symptoms of eye, nerve, kidney, or cardiovascular problems such as:

• Blurred vision
• Numbness or tingling in your feet
• Persistent hand, feet, face, or leg swelling
• Cramping or pain in the legs
• Chest pain
• Shortness of breath
• Numbness or weakness on one side of your body
• Unusual weight gain

If you have diabetes, your lab tests should include:

• Hemoglobin A1c
• Urine and blood tests for kidney function
• Lipid testing, which includes cholesterol, triglycerides, HDL, and LDL
• Thyroid and liver tests as needed

 

Who Is On Your Diabetes Care Team? - Part 1

Many people do not have a diabetes care team, yet when I ask them if they have an eye doctor and a dentist, most admit they do have these doctors. Then I have to ask if they have even told the eye doctor and dentist that they have type 2 diabetes. Some admit they have not and some say why should they let these doctors even know this. This attitude I do not understand as they should have informed them after diagnosis to enable the eye doctor to have a baseline for measuring changes in eye sight and possible eye diseases.

The eye doctor will be either an ophthalmologist (a doctor who can treat eye problems both medically and surgically) or an optometrist (someone who is trained to examine the eye for certain problems, such as how well the eye focuses; optometrists are not medical doctors).

The dentist should know to have a baseline to keep alert for signs of peridontal disease and other teeth problems. The more these two doctors know, the better they will be able to watch for diabetes problems. I know that I have these two people as part of my diabetes care team. It did take dismissing the original two and replacing them, but it was needed. Keep in mind, though, that you are the most important member of your diabetes care team. Your health care team is available to help you manage your diabetes and maintain your good health.

Always remember that you are number one, you are the most important member of your diabetes care team. Only you know how you feel. Your diabetes care team will depend on you to talk to them honestly and supply information about your body. Monitoring your blood glucose is an important part of effective therapy. This will tell your doctors whether your current treatment is effective or not.

Other members of your diabetes care team will depend on the medication or medications you are taking and how important you feel they can help you with your diabetes care and health.

A Primary doctor: Your primary care doctor is the doctor you see for general checkups and when you get sick. This person is usually an internist or family medicine doctor who has experience treating people with diabetes. Because your primary care doctor is your main source of care, he or she will probably coordinate your care. Many people living in rural areas may only have this doctor plus the two above and none of those below.

Dietitian or Nutritionist: A dietitian or nutritionist is trained in the field of nutrition for people with diabetes. Because food is a key part of your diabetes treatment, this person is very important. This specialist will help you figure out your food needs based on your weight, lifestyle, medication, and other health goals (such as lowering blood glucose levels and blood pressure). Note: Whole grains, especially wheat and rice, should not be part of the food recommended as these will generally increase your blood glucose more than desirable. This person should not recommend a food plan that is high in carbohydrates and low in fat. If this happens, find a different person.

Nurse educator: A nurse/educator or a diabetes nurse practitioner is a registered nurse (RN) with special training and background in caring for and teaching people with diabetes. Nurse educators often help you learn the day-to-day aspects of diabetes self-care. If you live in an area without this specialist, know that you will need to spend time on the internet learning about diabetes on your own.

Many Psychiatric Drugs Cause Weight Gain

I have been fortunate in my life to have never needed any psychiatric drugs. While I have had two periods of minor depression during my battle with diabetes, and a few weeks after my first wife passed from cancer, I was fortunate that I had some people around me that pushed me into a positive attitude after my wife passed and told me to find the positive in her passing.

Now that I know what the drugs do to people taking them, I will need to refuse them if a doctor attempts to prescribe them for me in the future. In the medical community, antipsychotics are well known to cause significant weight gain. Gains of 20 to 35 pounds or more over the course of a year or two are not unusual. Doctors seldom warn patients about this side effect. The situation is not uncommon, according to psychiatrist Matthew Rudorfer, chief of the somatic treatments program at the National Institute of Mental Health, who points out that although the U.S. Food and Drug Administration carefully tracks acute side effects such as seizures, it pays less attention to longer-term complications such as weight change. Perhaps taking their cue from the FDA, doctors tend to downplay weight-related risks that accompany many psychiatric drugs, Rudorfer says. For many, the weight gain is not trivial.

Antipsychotics

According to a 2014 review of eight studies, as many as 55 percent of patients who take modern antipsychotics experienced weight gain. This is a side effect that appears to be caused by a disruption of the chemical signals controlling appetite. Olanzapine (Zyprexa) and clozapine (Clozaril) are the top two offenders, as studies have shown that on average these drugs cause patients to gain more than eight pounds in just 10 weeks. These two drugs also bear the highest risk of metabolic syndrome, which encompasses weight gain and other related disorders, including type 2 diabetes, according to a 2011 study of 90 people with schizophrenia.

Antidepressants

A 2014 study of 22,610 people revealed that antidepressants generally cause more modest weight gain than antipsychotics, although the outcome varies greatly from one drug to the next. Of the 11 antidepressants analyzed, mirtazapine (Remeron) caused the greatest weight gain, followed by paroxetine (Paxil). A quarter of those who took mirtazapine for a year gained more than 7 percent of their initial weight. Only one antidepressant, bupropion (Wellbutrin and other brands), was associated with a small degree of weight loss.

Depression itself, however, is linked with an increased risk of becoming obese, according to a 2010 analysis that included more than 58,000 people. The reverse holds true as well, the study found; obese people are more likely to suffer from depression. As a result, “it is easy to misattribute the weight gain to a medicine when, in fact, it may largely be related to the illness being treated,” cautions Richard Shelton, a professor of psychiatry at the University of Alabama at Birmingham.

Stimulants

Typically used to treat attention-deficit disorders, stimulants such as Ritalin are consistently associated with weight loss. Many stimulants are specifically marketed as antiobesity drugs, including phentermine and lisdexamfetamine dimesylate (Vyvanse), which earlier this year became the first drug approved for the treatment of binge-eating disorder. Although the evidence is limited, early studies have shown that some young adults abuse prescription stimulants for weight-loss purposes. About 12 percent of the 705 undergraduate participants in a 2013 study reported that they had attempted to lose weight by taking a stimulant without a doctor's prescription.

What Is Your Stress Level?

Stress levels can vary from individual to individual; however, everyone can have stress and for people with type 2 diabetes, this can happen. Stress is not a “one-size-fits-all” case.

Stress can hamper your diabetes management. For instance, if you have so much on your mind that you skip meals or forget to take your medicines, that will affect your blood glucose level. Life can always present challenges and setbacks, but you do have the power to choose how you respond to these.

Here are a few ways to start.

#1. Keep a positive attitude. When things seem to be going wrong, it is easier to see the negative instead of the positive. Find something to appreciate in each important area of your life, such as your family, friends, work, and health. That perspective can help you get through tough times.

#2. Be kind to yourself. Do you expect too much from yourself? It's okay to say "no" to things that you don't really want or need to do. Don't let others overload you with things and ideas that are not productive in the management of your diabetes.

#3. Accept what you can't change. Ask yourself these three questions:

1. "Will this be important 2 years from now?"
2. "Do I have control over these circumstances?"
3. "Can I change my situation?"

If you can make things better, go for it. If not, is there a different way to handle it that would be better for you?

#4. Talk to someone. You could confide in a trusted family member or close friend. There are also professionals who can listen and help you find solutions. Ask your doctor for recommendations if you'd like to see a psychologist or counselor.

#5. Tap the power of exercise. You can blow off steam with hard exercise, recharge on a hike, or do a relaxing mind-body activity like yoga or tai chi. You'll feel better.

#6. Take time to unwind. Practice muscle relaxation, deep breathing, meditation, or visualization. Your doctor may know of classes or programs that teach these skills. You can also check for apps that do that.

#7. Laugh it off. Sometimes things just suck, and you simply need to laugh it off. Humor goes a long way. You can always laugh, even when you don't feel like it. I much prefer a laughing person to a person that always whines!

#8. Stop Self-Defeating Behaviors. If you are feeling overwhelmed by the challenges of your battles with diabetes, you may find yourself overeating or skipping your exercise. Many of us encounter mild depression and burnout from our daily diabetes duties.

#9. Avoid Perfectionism. This is my worst enemy and I do get very frustrated when I don't achieve my goals as fast as I want. According to the article, this can contribute very easily to self-sabotaging behaviors. A team of experts at Joslin Diabetes Center claim the best strategy is to have long-term goals so realistic that failure is erased. Biting off bigger goals that are difficult to achieve is not realistic.

#10. Your Handy Stress Reducer. If you have a stress reducer that works for you that is not listed here, make use of it. There are many ways people reduce stress. If meditation, walking, or anything else works for you – make use of it to reduce or eliminate stress in your life.