Sleep Apnea – Gout Flares, Tied

I have sleep apnea and use a type of CPAP machine when I sleep. I apparently am doing all the right things, as I have never had any problems with gout. However, this study says that sleep apnea may increase the risk of developing gout and experiencing flare-ups.

I know from friends that the pain can be intense and make walking very difficult. Gout causes swelling of a joint, normally in the big toe. Gout is caused by the accumulation of uric acid crystals in joints and tissue. Sleep apnea causes periods of oxygen deprivation during the night when people stop breathing, and this triggers the overproduction of uric acid in the blood stream. The study team states that little in known about the relationship between the two conditions.

The study, in Arthritis and Rheumatology, states that in 2007-2008, almost six percent of men and two percent of women in the U.S. Experienced gout, according to the Centers for Disease Control and Prevention. Sleep apnea, which is more common and if untreated can increase the risk of high blood pressure, heart attack, stroke, and heart failure.

Lead author, Yuqing Zhang of Boston University Clinical Epidemiology Research and Training Unit says obesity plays a role in both sleep apnea and gout. He continued that sleep apnea still increased the risk of gout even when weight was taken into account.

The researchers in the United Kingdom used data on almost 10,000 people newly diagnosed with sleep apnea and compared them to more than 40,000 people of similar sex, age, and body composition, but without sleep apnea. In a one-year period, there were 270 cases of gout with 76 in the sleep apnea group and 194 in the larger comparison group. Gout was diagnosed at an average age of 60. Gout was almost twice as common in the sleep apnea group as in the comparison group, according to the analysis.

Obesity increases the risk for sleep apnea, but some thin people have sleep apnea, too, and even in these people, the risk of gout was increased by 80 percent.

The next step is to test whether treating sleep apnea also reduces the risk for gout. Some studies show that if you get treatment, your uric acid may go down. Sleep apnea can be treated with lifestyle changes, such as losing weight, wearing mouthpieces, breathing devices at night, or with surgery.

“It takes years for uric acid crystals to accumulate in the joints and lead to an eventual gout flare, so sleep apnea may not “cause” the gout, but may create a more ideal environment for a flare up, said Dr. Robert Thomas Keenan of Duke University School of Medicine in Durham, North Carolina, who was not part of the new study.”

“Gout is the most common inflammatory arthritis in the western world,” he told Reuters Health by email. “Sleep apnea and gout risks can be reduced in many people by losing weight if they are overweight, eating healthy and indulging in alcohol and red meats in moderation,” he said.

A Misdiagnosis, the Disease Waiting a Cure

A report in the BMJ Quality and Safety Journal states, each year in the U.S. approximately 12 million adults or 1 out of 20 patients who seek outpatient medical care, are misdiagnosed in a way that could cause severe harm.

A new study from the Institute of Medicine (IOM) published in September 2015,

confirms these statistics. Doctors apparently are not as careful as they should be. I know this for a fact and fortunately, the error the doctor made was not critical. I had a severe gall bladder attack and all the doctor could think was heart problems.

When I had the second severe gall bladder attack, I went to another hospital and the two doctors had it correctly diagnosed within minutes. They gave me medicine to ease the pain and the following morning, I was given a scan, which showed that they were correct. A month later, I was operated on and my gall bladder removed.

Other patients are often not as lucky and the doctor misdiagnosis results in death.

What does this say about the current level of patient care in the United States? #1. It says that we patients are tolerating a healthcare system where we too often do not experience full disclosure from our clinicians.

#2. It says that our system does not encourage collaboration and communication between healthcare clinicians and patients.

#3. It tells us that us that misdiagnosis is raising the cost of care for all of us.

#4. It says that each of us will face a potentially life threatening situation over the course of our healthcare that could be addressed and reversed if we pay attention.

#5. It says that providers who are in a position to make a diagnosis for a patient, along with the patients and their caretakers or family, need to pay more attention to what is going on.

#6. It tells us that we live with a system that is ill designed to support the diagnostic process because our clinicians are limited by the time they are allowed to spend with each patient.

#7. It tells us that some doctors do not always follow-up with tests and procedures that they have ordered. Even if they follow-up, they are often not provided with adequate feedback about the accuracy of a diagnosis.

#8. It says ours is a culture of care that discourages transparency and disclosure of diagnostic errors, which impedes attempts to correct these problems.

Diagnostic errors are often incredibly harmful to patients, as they may lead to:

• delays in treatment,
• lack of treatment,
• inappropriate, or unnecessary treatment,

These can have physical, psychological, and financial consequences.

Because of the magnitude of the misdiagnosis disease, I urge you to read the full post by Nancy Finn here

Have Type 2 Diabetes, See a Nurse Practitioner

If you live in a state that allows nurse practitioners to practice unsupervised or even in a state that allows them to be supervised, and you have type 2 diabetes, you may be better treated by seeing a nurse practitioner.

“Nurse practitioners' patients had a 10% lower risk of hospitalization for a potentially preventable condition (odds ratio [OR], 0.90) and a 6% lower risk of hospitalization for poor diabetes control, such as hypoglycemia or hyperglycemia (OR, 0.94), compared with patients of physicians. Similarly, the odds for hospitalization for other conditions were slightly lower among nurse practitioners' patients than among physicians' patients (OR, 0.96).”

“The researchers compared potentially preventable hospitalizations from 2007 to 2010 among 345,819 Medicare patients with any diagnosis of diabetes. Of these, 93,443 patients had received all their primary care from nurse practitioners (a total of 136,348 person-years), and 252,376 patients had received all their care from a generalist physician (553,890 person-years).”

The all-cause mortality between the two groups was statistically the same in the four years of the study.

Coauthor Mukaila A. Raji, MD, told Medscape Medical News, "We find it surprising that the findings of lower rate of potentially avoidable hospitalization among nurse practitioners patients still hold true, despite use of multiple advanced analyses to adjust for complexity and severity of illnesses between diabetes patients cared for by nurse practitioners vs MDs."

The researchers explain that primary care provided by nurse practitioners has been promoted as necessary to lessen the shortage of primary-care physicians.

A 15-fold increase in the number of patients receiving care from nurse practitioners from 1998 to 2010, and 22 US states have changed their policies to allow nurse practitioners to practice and prescribe without physician supervision.

Some medical groups have raised concerns about primary care delivered solely by nurse practitioners, arguing that outcomes might not be comparable, particularly in complex patients. A number of trials in controlled settings have found comparable outcomes between the two groups, but there have been no population-based studies of outcomes of primary care delivered by nurse practitioners and MDs.

“The current results show that patients of nurse practitioners were more likely to live in rural areas and be younger, female, and white and have lower income, possibly because individuals with these demographics may be more open to receiving care from nurse practitioners, Dr Raji suggested.” “And yet the findings reveal that nurse practitioners provide the same quality of clinical care as MDs, he added.”

"Reducing unnecessary hospital admissions and readmissions is a key benchmark of quality and the basis for financial reimbursement for the healthcare system."

"Our finding of the association of nurse practitioners' diabetes primary care with lower risk of avoidable hospitalizations likely reflects the unique skills of nurse practitioners in care coordination, transitional care management, advance care planning, and preventive care," he concluded.

The research was funded by the Agency for Healthcare Research and Quality and the National Institutes of Health. The authors reported no relevant financial relationships.

Low-fat Diet Not Most Effective for Weight Loss

It is great to see headlines like this, “Low-fat diet not most effective in long-term weight loss.” Researchers conducted a systematic review of randomized clinical trials comparing the long-term effectiveness of low-fat and higher-fat dietary interventions on weight loss. The effectiveness of low-fat diet on weight-loss has been debated for decades, and hundreds of randomized clinical trials aimed at evaluating this issue have been conducted with mixed results. Mixed results because of setting up the studies for short periods of time and often using individuals that could easily lose weight.

Researchers from Brigham and Women's Hospital (BWH) and the Harvard T.H. Chan School of Public Health (HSPH) conducted a comprehensive review of the data generated from randomized clinical trials that explored the efficacy of a low-fat diet and found that low-fat interventions were no more successful than higher-fat interventions in achieving and maintaining weight loss for periods longer than one year. These results are published in The Lancet Diabetes & Endocrinology on October 30, 2015.

"Despite the pervasive dogma that one needs to cut fat from their diet in order to lose weight, the existing scientific evidence does not support low-fat diets over other dietary interventions for long-term weight loss," said Deirdre Tobias, ScD, a researcher in the Division of Preventive Medicine at BWH.

"In fact, we did not find evidence that is particularly supportive of any specific proportion of calories from fat for meaningful long-term weight loss. We need to look beyond the ratios of calories from fat, carbs, and protein to a discussion of healthy eating patterns, whole foods, and portion sizes. Finding new ways to improve diet adherence for the long-term and preventing weight gain in the first place are important strategies for maintaining a healthy weight."

According to the researchers, "The key is to improve long-term compliance and cardiometabolic health. Therefore, weight loss diets should be tailored to cultural and food preferences and health conditions of the individual and should also consider long-term health consequences of the diets."

While I can agree with part of this, we need to get away from the word diet, which always leads to failure, and consider this a lifestyle change and a way of eating to have success. Normally, a low carbohydrate and high fat (LCHF) way of eating should achieve weight loss and help maintain this loss of weight.

Yet, most dietitians and the organizations they belong to, insist on whole grains and high carbohydrate diets that can't be sustained because of the weight gain that results.

The members of our diabetes support group are happy that we have two nutritionists that are not members of the Academy of Nutrition and Dietetics (AND) or the American Society of Nutrition (ASN), which are the tools of Big Food. We are learning about LCHF and balancing the daily nutrition. They also encourage each of us to be careful not to increase the amount of protein in our meal plan unless the doctor approves this.

Eight Reasons for Drug Non Adherence

Drug non adherence (or non compliance) is a topic few people want to talk about, except doctors who rail about patients that do not take their medications. In my blog here, I summarized it this way - I have an easy answer for them and I don't need over 30 pages to tell doctors the problem. Learn how to communicate with patients rather than ram medications down our throat. Most of the time, these doctors just hand the patient a fist full of prescriptions with no explanation and expect the patient to fill each prescription and take the medication as directed.

Now we have an article by the American Medical Association listing eight reasons patients don't take their medications. Data show about one-quarter of new prescriptions are never filled, and patients do not take their medications about 50 percent of the time. Most non adherence is intentional: patients make a rational decision not to take their medicine based on their knowledge, experience and beliefs.

The top eight reasons for intentional non adherence are:

1. Fear. Patients may be frightened of potential side effects. They may have witnessed side effects experienced by someone else that was taking the same or a similar medication and believe the medication caused the problems.
   
   
2. Cost. Patients may not fill medications in the first place or ration what they do fill to extend their supply.
   
3. Misunderstanding. Patients may not understand the need for the medicine, the nature of the side effects or the time it will take to see results. This is particularly true for patients with chronic illness, because taking a medication every day to reduce the risk of something bad happening can be confusing. Failure to see immediate improvement may lead to premature discontinuation.
   
4. Too many medications. The greater the number of different medicines prescribed and the higher the dosing frequency, the more likely a patient is to be non adherent.
   
5. Lack of symptoms. Patients who don’t feel any differently when they start or stop their medicine might see no reason to take it.
   
6. Worry. Concerns about becoming dependent on a medicine also lead to non adherence.
   
7. Depression. Patients who are depressed are less likely to take their medications as prescribed.
   
   
8. Mistrust. Patients may be suspicious of their doctor’s motives for prescribing certain medications because of recent news coverage of marketing efforts by pharmaceutical companies influencing physician prescribing patterns.

Unfortunately, the AMA is not concerned about communication with the patients and only interested in improving medication adherence. They have a free online module that includes practical strategies and tools that doctors can implement. The module also includes information about how to get support for intervention implementation, and it offers continuing medical education credit.

Many Elderly Need Less Medications

Many studies are finding that the elderly are over medicated. Two studies recently pushed the numbers at us and how few doctors will decrease medications.

1. Based on Veterans Affairs primary care data on older adults with longstanding diabetes, deintensification of hypertension therapy, not including angiotensin converting enzyme inhibitors (ACE-I) amongst patients with moderately low and very low blood pressures (BP) occurred less than 20% of the time.

2. Similarly, deintensification of diabetes therapy, not including metformin, amongst the same population with moderately low (HgbA1c 6-6.4%) and very low (HgbA1c less than 6%) blood sugars occurred less than 20% of the time.

This does not speak well for our doctors and may mean that they are more interested in piling on medications to the harm of patients. I will say that patients need to be proactive in their medications. I have been able to have the VA reduce my medications and after looking at the test results, they had no trouble lowering the dose I am taking. Fact is the physician thanked me for bringing this up.

With the shortage of studies that include testing for the elderly, it seems that for many people over 70 years of age, it might be safer to consider reducing medications. I like the word deprescribing that was first brought to my attention in a blog by David Mendosa on September 08, 2015. His blog has a different challenge, but it still needs to be said.

The two new studies published in JAMA Internal Medicine suggest doctors and patients should work together to deprescribe such treatment more often. In people 70 and older, very low blood pressures and blood glucose levels can actually raise the risk of dizzy spells, confusion, falls and even death. The consequences can be dangerous.

In recent years, the experts have started to suggest that doctors ease up on how aggressively they treat such patients for high blood pressure or diabetes, especially if they have other conditions that limit their life expectancy. What needs to be added is when older patients have decreasing cognitive abilities, this should be when medication needs a complete review with the goal of reducing medications.

Jeremy Sussman, M.D., M.S., lead author of the study that used medical records, stated, “Every guideline for physicians has detailed guidance for prescribing and stepping up or adding drugs to control these risk factors, and somewhere toward the end it says 'personalize treatment for older people'."

It may be hard for an older person to recognize the signs of too-low blood sugar, such as confusion and combativeness, or of too-low blood pressure, such as dizziness. Meanwhile, keeping up with taking multiple medications, and checking blood sugar daily or even more often, can be a struggle for the oldest patients. De-intensifying or deprescribing their treatment can often be a relief, if their treatment is personalized.

Would You Give Up Your Privacy for Free PCSK9 Copay Card?

This is what Amgen is asking people to do and for a very few, this might be something to consider. For the rest of the people, privacy should be carefully guarded. Amgen feels that its extremely expensive new cholesterol drug, Repatha, is worth surrendering your privacy.

“Doctors, pharmacists, patients, and others are now starting to learn that in order to receive financial assistance from Amgen for its expensive new cholesterol drug Repatha, patients are being required to surrender rights to their personal information, including their personal health information. The information will be freely available, with few restrictions, not only to the company, but to unspecified third parties.”

Marilyn Mann, a respected patient advocate who has family members who have familial hypercholesterolemia, suggests the policy be revised so that patients in financial need can receive assistance without having to agree to such a wholesale waiver of their privacy rights.

The Repatha copay program is part of the larger Repatha Ready program, which supplies "support services to help you start and stay on Repatha." They don't want to lose their lucrative profits. The supposedly most important part of the program is a copay card which gives patients access to the drug for only $5 a month. The program includes email reminders and a free needle-disposal (sharps) container. For patients to receive this, they must first sign over their rights to privacy to Amgen to use their personal information.

Some of the language should scare you. “I understand that Amgen may use my personal information, including my personal health information, for 10 years once I accept this Authorization or for a shorter time period if required by state law.” The agreement specifically states that by agreeing to the terms, patients may lose federal HIPAA protection. Further, the company specifically warns that there is nothing to prevent it from sharing your information with third parties:

Copay cards are normally used by patients to offset their out of pocket costs, and the companies used them as promotions to gain and maintain market share for the long term to maintain profitability.

The Amgen plan seems to be taking a different approach. They are seeking market domination and a novel data source. The use of patient data might well be part of the broader strategy to find more patients by mining new sources of data. This move by Amgen represents the next step in the merger of digital technology and biotechnology, i.e., if you' re not paying for the product, you are the product.

With your personal information, they can sell this to other companies looking at patient data-mining and you, as the patient will be bombarded with information to convince you that you need their products.

To this, I say – NO THANKS!

You may want to pass this information on to friends who may be at risk for diabetes.

Doctors Desperately Seeking PCSK9 Eligible Patients

This is one drug that may be more dangerous than all the statins. Although the two drug companies will deny it, it is expected that type 2 diabetes will become more prevalent for those using this drug.

Amgen and Sanofi/Regeneron are expected to rake in many billions (yes, a B), but they need to find the patients who will take the drug. None of the current members of our support group has been contacted or has had the suggestion to consider this drug. I don't think any are considering it, but I could be wrong. Several of us have stated we will not.

To help find these patients, a central strategy of the companies involves giving hundreds of millions of dollars to a whole host of non-profit medical groups, commercial companies, and individual physician experts.

Amgen and Sanofi/Regeneron make the two newly approved cholesterol drugs -- evolocumab (Repatha) and alirocumab (Praluent). These companies are fueling an explosion of new programs, some of which utilize innovative data-mining techniques to gather massive amounts of data from new sources. If these programs work as intended, they will likely identify large numbers of new patients who are candidates for the expensive drugs. How many will be marginal patients remains to be determined, but with money as stake, the numbers will probably be more than expected.

“The sheer size and scope of these programs are not generally known. The activities funded by industry fall across the entire spectrum of basic and clinical research, continuing medical education for physicians, patient education, and support for not-for-profit groups and patient advocacy groups. Of course, the companies are also spending millions of dollars on all the more traditional sales and marketing avenues. The financial tsunami will undoubtedly help secure the close bond between the medical establishment, patients, and industry.”

People with familial hypercholesterolemia (FH) are the best early candidates for the new drugs. The vast majority of people with FH have never been diagnosed, and FH has not been on the radar screen of most physicians. Many of the new initiatives are designed to find these currently hidden patients.

Remember that the long-term clinical benefits with these drugs will not be known for another few years. Also not mentioned are the harmful side effects. These are not complete as of yet and some of them may be severe, especially in the elderly. There could be many problems from overuse of the drugs, the mistaken diagnosis of FH, an inflated perception of risk in some patients, or a lowered threshold for treatment.

There is talk about statin intolerance and once the PCSK9 inhibitors were approved, statin intolerance became a hot topic. Among people in the medical community the manufactured explosion of interest in the statin intolerance is widely known. Most in the medical community do not consider this controversial and it is something everyone knows and talks about, but seldom in public.

“In 2014, Amgen gave money to the American College of Cardiology (ACC) to support a new program called LDL: Address the Risk. An unusual and unique product of the program is the ACC Statin Intolerance App, for iPhone and Android, that "uses clinical guidelines and best practices to help" doctors evaluate, manage, and treat statin intolerance.”

For the new drugs, all you need to do is follow the money. This will show you what is happening in the medical community where everyone is reaching for their unearned share of the largess.

Read the full article here and a commentary by Dr. Malcolm Kendrick here.