November 26, 2016

Parkinson's Risk Increases with Statin Use

New findings from a large national claims database show the use of cholesterol-lowering statin drugs to be associated with an increased risk for Parkinson's disease (PD), contrary to previous research suggesting the drugs have a protective effect for PD.

"We identified 20,000 Parkinson's disease patients and looked at whether using statins was associated with a higher or lower risk, and we found people using statins have a higher risk of the disease, so this is the opposite of what has been hypothesized," senior author Xuemei Huang, MD, PhD, vice chair for research at Penn State College of Medicine, Hershey, Pennsylvania, told Medscape Medical News.

While high cholesterol has been shown to have a protective effect on the risk for PD, the role of statin use has been the subject of debate.

In looking at the issue in a previous study of their own, Dr Huang and colleagues in fact found an increased risk associated with statin use, and they sought in the new study to further explore the association in a much larger cohort.

For the new study, presented here at the American Neurological Association (ANA) 2016 Annual Meeting, the researchers turned to data from the MarketScan Commercial Claims and Encounters database, including information on 30,343,035 persons aged 40 to 65 years between January 1, 2008, and December 31, 2012.

In the cross-sectional analysis, the use of cholesterol-lowering drugs, including statins or nonstatins, was associated with a significantly higher prevalence of Parkinson's disease (odds ratio [OR], 1.61 - 1.67; P less than .0001) after adjustment for age, sex, and other comorbidities, such as hyperlipidemia, diabetes, hypertension, and coronary artery disease.

For a comparative neurodegenerative group, the researchers also looked at the association of statin with diagnosis of Alzheimer's disease but found only a minimal association (OR, 1.01 - 1.12; P = .055).

The associations of cholesterol-lowering medications with PD were strongest among patients with hyperlipidemia, and there were no significant differences between lipophilic or hydrophilic statins, as well as the other nonstatin cholesterol-lowering drugs, in their effect on PD risk.

"We know that overall weight of the literature favors that higher cholesterol is associated with beneficial outcomes in Parkinson's disease, so it's possible that statins take away that protection by treating the high cholesterol," Dr Huang explained.

"Another possibility is that statins can block not only the cholesterol synthesis but also synthesis of coenzyme Q10 that is essential for cell function."

The researchers also stratified persons according to how long they had been receiving treatment by using a lagged matched case-control analysis of 2458 pairs of PD cases and controls.

In the cross-sectional analysis, both statins and nonstatin cholesterol-lowering drugs were associated with PD, but in the lagged case-control analysis of treatment duration, only statins remained significantly associated with PD risk.

"The increased risk of Parkinson's is more likely when statins are first used, so we think it could be that the statins 'unmasked' Parkinson's," Dr. Huang said. "Namely, people may be already on the way to Parkinson's and when they use statins to control the high cholesterol, it gives Parkinson's a push to reveal its clinical symptoms.

"Based on this data, we think caution should be taken before advancing statins to be protective of Parkinson's disease," she added. "The data are not clear yet."

A meta-analysis published earlier this year in the journal Pharmacoepidemiology and Drug Safety suggests that one reason for the inconsistencies in evidence of the role of statins is that many studies fail to adjust for cholesterol levels.

November 25, 2016

Guidelines for Prediabetes Screening not Followed

On November 9, Brenda called and asked if I had read about physicians not following the guidelines forprediabetes screening. I told her that I had not, but it was on the list to read. She said that Dr. Tom had called her and felt this would be a good topic for a group meeting.

I said I did not agree, but I would go along with the majority. I suggested she send out an email to our group and ask for their approval or reasons against it. I also suggested she send a similar email to Glen and Dr. Tom to discuss with their members to find out how many would attend. She agreed and I asked her if she could read Medscape articles. She answered no and I said I would send her a copy of one and instructions on how to join. I stated that I felt this could be more valuable for a group meeting, but I would not oppose what Dr. Tom had proposed.

The identification and treatment of prediabetes is one of the most effective ways to prevent patients from developing diabetes, but a new University of Florida study finds that only about half of family physicians report following national guidelines for screening patients for prediabetes.

Physicians also said that patient factors, such as sustaining a patient's motivation to make lifestyle changes, were significant barriers to diabetes prevention. The findings were published November 8 in the Journal of the American Board of Family Medicine.

More than a third of U.S. adults have prediabetes and most don't know it. Prediabetes, which is characterized by having blood glucose concentrations higher than normal, but not high enough for a diabetes diagnosis, can lead to vascular problems, kidney disease, and nerve and retinal damage. It is one of the greatest risk factors for the development of diabetes.

A previous study led by Arch G. Mainous III, Ph.D., chair of the department of health services research, management and policy in the UF College of Public Health and Health Professions, part of UF Health, found that very few patients who met the criteria for prediabetes were told by their doctors they had the condition. Less than one-quarter of those patients received drug or lifestyle modification treatment.

"For our next study we wanted to find out why the detection and treatment of prediabetes is so low when we know what the guidelines say about diagnosis and treatment and that many millions of Americans have this condition," said Mainous, the Florida Blue endowed chair of health administration. "We know from the literature that there are some different points of view on prediabetes. Some physicians think that a prediabetes diagnosis 'over medicalizes' patients, and some believe it is best to focus on providing general advice on healthy lifestyle."

The American Diabetes Association recommends that all adults who are overweight or obese or over the age of 45 should be screened for prediabetes. The U.S. Preventive Services Task Force recommends prediabetes screening for adults age 40 to 70 who are overweight or obese. Prediabetes treatment plans include drug therapy or intensive lifestyle modification.

The new UF study surveyed more than 1,200 family physicians working in an academic medical setting, asking them to rate the strength of the current evidence for prediabetes screening and treatment, the costs and benefits of formally diagnosing patients with prediabetes and the value in focusing on prediabetes as a way to prevent diabetes.

The researchers found that physicians who have a positive attitude toward prediabetes as a clinical condition were more likely to follow national guidelines for prediabetes screening and to offer treatment for their patients. Physicians who hold a negative attitude toward prediabetes were more likely to recommend to their patients general lifestyle changes that may reduce cardiovascular disease risk, but are not associated with lowering blood glucose levels.

"I'm hoping that we can change physician attitudes so that they follow and trust the screening and treatment guidelines, which are evidence-based, and view it as a worthwhile way to prevent diabetes," Mainous said.

Another key finding is that regardless of whether they hold a positive or negative attitude toward prediabetes, the majority of physicians surveyed indicated there are several patient barriers to diabetes prevention, including a patient's economic resources, sustaining patient motivation, a patient's ability to modify his or her lifestyle and time to educate patients.

"This suggests we need to provide new resources for physicians to support them in helping patients make lifestyle changes," Mainous said.

November 24, 2016

New Diabetes Group Is Now a Fact

On November 19, the potential members for the suggested new group had a meeting. Sue interviewed all of them individually and determined that three would not be a benefit for any group and Brenda agreed. Glen and Allen were present for all the interviews. After the meeting formally started, Brenda explained why they were suggested for a new group. Glen explained that both his group and the group Brenda leads have capped their membership at 25 members. This means that until someone dies or moves out of the area, no new members will be accepted.

Brenda continued that three of the potential new members were rejected for reasons you may not understand, but we felt that they would not be acceptable to any group. The reasons will be given to the leader you elect and then you will be told. You will be able to select how you want your group to operate and the positions you desire. She continued that we will tell you the positions we have and then the decision is yours and does not need to be set in stone at this meeting.

Glen called Allen to talk about the VA and said that four of the members of Brenda's group were present for this only and would not be at future meetings. Allen then asked Barry to come to the front with him and the two discussed the benefits of the VA and answered questions from the members. After a half and hour of questions and answers, and wrote Barry's and his name and phone numbers on a card and passed this around for all to have the information.

At that point, all non-members for the group except Brenda and Glen left. Several questions about positions were discussed and then the duties of the leader were discussed. Both Brenda and Glen carefully laid out their duties and what they do. They explained what their groups' had for policy and where they disagreed the with group that Brenda's group split from. They were told that there were other groups around and that our city would now have four groups and they listed several of the other groups in nearby cities.

Brenda then showed them the equipment and programs she uses to aid speakers during programs. Glen said his group does not have this equipment, but it is something we are investigating. He said that the leaders collect email addresses, phone numbers, and other information the group wants.

Brenda said the new group was not charging dues for the first year, and asked about the best meeting place. They liked the room where the meeting was held and both Glen and Brenda said that as long as the room was kept clean, they would be able to use this and the phone number was given to one member to reserve the room for use. Glen said that his group tried to use the same day each month and Brenda said we move our date as needed and Dr. Tom's group tries to use the same day each month and they have priority because he is a doctor.

Brenda suggested that since our group is all retired and most of Glen's group is retired that was the reason for the needs of each group. You will need to communicate among the members to determine when to meet, which right now are 17 members.

Brenda asked if they were ready to elect and leader. Two individuals said they would like to be the leader, and they both agreed to abide with the vote. Glen had both individuals talk to the members and then he had them vote for each member. An individual named JoAnne was elected and everyone settled in and elected a secretary, program manager, historian, and a treasurer. They each gave JoAnne, their phone number and email address and decided to start discussing matters via email before the next meeting.

They ended the meeting and cleaned the room. Glen and Brenda also added their name, phone number, and email address to also receive the list of members and said they would also receive the two lists. Brenda said she would talk to Dr. Tom about giving his email address for notice of group meetings.

November 23, 2016

Insurance Companies Now Writing Prescriptions

Don't believe this? Just wait until you receive a prescription for one medication that you and your doctor have agreed would be the best for your medical condition and you present it to your pharmacist. While you are waiting or when you return, the pharmacist tells you that your insurance no longer will cover your prescription and will only cover another medication.

Hypertension medications are a common problem. The doctor feels that because your blood pressure (BP) is quite elevated, you should be using an angiotensin receptor blocker (ARB) to control your BP and sends this to the pharmacy. However, when you arrive at the pharmacy, the pharmacist tells you that there may be a change and until the doctor replies, your prescription cannot be filled. The pharmacist tells you the your insurance will not cover the medication prescribed and the doctor is calling the insurance company as the medication the insurance will cover may require you to use a pacemaker as it lowers your heart rate to a lower rate than you may be able to handle. These decisions are made solely based on cost considerations and not sound medicine. Yet, this is what happens every day in most medical practices in the United States.

In our current health care system, doctors should get to decide what medication is prescribed. Typically, the patient and doctor decide what is the best, then the prescription is sent to the pharmacy. When the patient goes to pick up the prescription, often they find a different one instead or are told that their health insurance coverage is not covering that prescription. Instead of receiving the best medication for themselves, they are often told to just take this medicine instead. Insurance formularies have gone mad and not in a good way.

Insurance companies will tell you that they send copies to physicians and patients on an annual basis. However, those formularies change and those lists are not always kept up-to-date. Even when we chose a medication that may be listed on a formulary, there is no guarantee that it will actually be covered when a patient goes to the pharmacy. The pharmacist then usually calls to ask to change to a different medication based on the patient’s insurance coverage. I know many people get mad at the pharmacist, but this is not his/her fault — it is entirely on the insurance plan. And patients sometimes get angry with their doctor as well, but the doctor does not possess a magic wand that will make the insurance company pay for whatever medication we wish.

While no one can argue that health care spending in our country has gotten out of hand, there is need to curb those costs in the right fashion. Putting patients in danger to cut costs is not the answer. Insurance company representatives who never received any medical training should never make medical decisions. It is time to end this formulary madness.

November 22, 2016

High Cholesterol May Be Good

People with high cholesterol live the longest.

This statement seems so incredible that it takes a long time to clear one´s mind to fully understand its importance. Yet, the fact that people with high cholesterol live the longest emerges clearly from many scientific papers. But let us take a look at heart mortality, the risk of dying from a heart attack if cholesterol is high.

Consider the finding by Dr. Harlan Krumholz of the Department of Cardiovascular Medicine at Yale University, who reported that old people with low cholesterol died twice as often from a heart attack as did old people with high cholesterol. Supporters of the cholesterol campaign consistently ignore his observation, or consider it as a rare exception, the result of chance among a huge number of studies finding the opposite.

But it is not an exception; there are now a large number of findings that contradict the lipid hypothesis. To be more specific, almost all studies of old people have shown that high cholesterol is not a risk fact for coronary heart disease. This was the result of a search in the Medline database for studies addressing that question. Eleven studies of old people came up with that result, and a further seven found that high cholesterol did not predict all-cause mortality either, and more such studies have been published since then.

It has been mentioned before, but it is worth repeating, that more than 90 percent of those who die from a heart attack or a stroke have passed the age of 65. You may also recall that high cholesterol is not a risk factor for women, or for a number of other population groups.

But there is more comfort for those who have high cholesterol. At least fifteen studies found that total mortality was inversely associated with either total or LDL-cholesterol, or both. This means that it is actually much better to have high than to have low cholesterol if you want to live to be very old.

Many studies have found that low cholesterol in certain respects is worse than high cholesterol. For instance, in nineteen large studies of more than 68,000 deaths, reviewed by David R. Jacobs and his co-workers from the Division of Epidemiology at the University of Minnesota, low cholesterol predicted an increased risk of dying from gastrointestinal and respiratory diseases. Most gastrointestinal and respiratory diseases have an infectious origin. Therefore, a relevant question is whether it is the infection that lowers cholesterol or the low cholesterol that predisposes to infection. You have probably already guessed what the directors of the cholesterol campaign have said, but is it true?

To answer that question David Jacobs´ group followed more than 100,000 healthy individuals in the San Francisco area for fifteen years. At the end of the study, those who had low cholesterol at the start of the study had been admitted more often to hospital because of an infectious disease of the respiratory system or because of another type of infection. This finding cannot be explained away with the argument that the infection had caused cholesterol to go down, because how could low cholesterol, recorded when these people had no evidence of infection, be caused by a disease they had not yet encountered? Isn´t it much more likely that low cholesterol in some way made them more vulnerable to infection, or that high cholesterol protected those who did not become infected. Much evidence exists to support that interpretation.

Heart disease may lead to a weakening of the heart muscle. A weak heart means that less blood and therefore less oxygen is delivered to the arteries. To compensate for the decreased power, the heart beat goes up, but in severe heart failure, this is not sufficient. Such patients become short of breath because too little oxygen is delivered to the tissues, the pressure in their veins increases because the heart cannot deliver the blood away from the heart with sufficient power, and they become edematous, meaning that fluid accumulates in the legs and in serious cases also in the lungs and other parts of the body. This condition is called congestive or chronic heart failure.

There are many indications that bacteria or other microorganisms play an important role in chronic heart failure, and also that the risk of heart failure is much greater in people with low cholesterol.

November 21, 2016

Diabetes-Related Distress

Diabetes-related distress (DRD) is the worry and concern that many of you with diabetes experience related to management of the disease, fear of complications, and perceived lack of support from healthcare providers and your social network. It's been associated with poor self-care, high blood sugars, increased risk of diabetes related complications and lower survival rates.

The Mayo Clinic recently posed four questions to some of the patients in their diabetes clinic. Here are the questions and some of the responses.

#1. Have you experienced diabetes-related distress and, if so, how does it affect your health and management of your diabetes? How does it affect your life in general?
    • "Most definitely! I get depressed at times and very frustrated … asking 'why me'? Low self-esteem."
    • "Yes. It affects my health in regards to the need to be more vigilant with dietary intake, times to eat and trying to eat 3 meals a day. In general it affects my life in regards to thinking how this chronic disease is affecting my overall life and lifespan."
    • "Yes I would say I have experienced DRD. I have found with medications being adjusted I have felt as though I have to learn what the medications do so I can adjust my eating to help my numbers turn out good, (not that I always do).
    • "Taking a test 4 times a day has been a little bit of a hassle cause you can't eat for 4 hours before the test, and sometimes it would be very nice to just be able to grab a carrot or something cause you're hungry, but you can't because of the test, which tends to make me overeat when I can eat.
    • "Fear of having the blood sugar drop and the feeling I get with it, it seems to take a while afterwards to just feel better, and it feels like it just hits real fast no warning, it has been kind of scary. Dietary restrictions are kind of 'not fun', but that is because I have mastered eating quite well, and should address this whether I am diabetic or not, it does sometimes not make sense to me what makes my sugars go high and other times some things that don’t make it go high.
    • "Exercising is a real struggle for me, working full time, being a mother of very active son, being tired; it just makes it very undesirable to add more on.
    • "Challenging myself to keep accurate records, record them, see how many days in a row I can keep blood sugar levels below a certain level. Not foolproof, but it is keeping me motivated."

#2. What do you find helpful in reducing your level of diabetes-related distress?
    • "Exercising helps me a lot. Especially walking with my friend or also interacting with other friends socially and family. "
    • "Regular visits with health care providers. Consistent monitoring of blood sugars and of course having blood sugar reading at or near your goal level."
    • "I guess for me reducing the DRD, prayer should be my key, but having accessibility to contact health care providers when I have questions is very helpful. Learning to discipline myself would be a key, not that I have, but I am working on it."

#3. What have your healthcare providers done in the past to help you combat diabetes-related distress? How could healthcare providers or others do a better job of helping you deal with DRD?
    • "I think networking with other diabetics would be great! I can honestly say I have not heard of a 'Diabetic Club' or organization."
    • "I really believe the consistent contact I had with the diabetes service here was valuable in reducing my stress levels. From offering reassurance, trying different treatment regimens and having the ability to meet the patient at 'their level' of acceptance/denial/fear of the disease was paramount in helping with my DRD."
    • "My healthcare providers have encouraged me to exercise more, lose weight, always in a positive way. Also suggested that if I lose some weight, I could possibly reduce the amount of insulin used. They have made themselves available if I have questions, and provided training and information. I really don’t have any suggestions as far as helping deal with DRD."

#4. If you have other chronic health conditions, how does diabetes related distress compare to distress from other conditions? Is it different? If so, how is it different?
    • "I think for me it is different than my other medical co-morbidities. The fact you need more close monitoring and the fact of being IDDM (insulin-dependent diabetes mellitus) you are reminded on a daily basis the seriousness of the disease."
    • "Diabetes just has to be monitored so much more throughout your entire waking day, it seems to be much more of a constant chore than any other I have experienced."

Please read the full article and the comments following it as some are very interesting and to the point.

November 20, 2016

Two Articles on Legal Drugs

The first article is - 'Legal Drugs:Time to “Just Say No”' and the second article is - 'Not Diabetic? Take a Diabetes Drug Anyway!' These are both controversial articles and a shame to our medical establishment.

I have written previously about deprescribing which most doctors are not trained to do, and polypharmacy, which is the bane of many patients, especially the elderly. Yet, the medical profession continues to harm patients with their actions of adding one prescription on top of many prescriptions. The American Association of Clinical Endocrinologists is now advocating prescribing diabetes medications other than metformin to prediabetes patients.

Big Pharma is very much in favor of this and is licking their chops for the profit potential. The American Association of Clinical Endocrinologists (AACE) has obliged by recommending diabetes drugs for “prediabetes.” It should come as no surprise that the list of the AACE’s corporate sponsors includes the largest pharmaceutical companies in the world: Novo Nordisk, Merck, Sanofi, AstraZeneca, GlaxoSmithKline, Pfizer, and many others.

When is involves legal prescription drugs, many are dangerous, even deadly, but hugely profitable. Big Pharma has bought politicians and doctors. Only the American public can stop it by refusing the product.

Most people are understandably afraid to say no. They don’t know enough about medicine. That I can understand. I am not a doctor and never offer medical advice. But the Internet has put most medical research at your doorstep, including information about drug side effects and risks. And there are integrative doctors who can offer sound advice on the subject.

Are we as a society addicted to legal drugs? Are we also wasting huge amounts of money on substances that all too often offer more harm than benefit? Let’s consider these numbers:
  • 60% of Americans take one or more prescription drugs.
  • 15% of Americans take five or more prescription drugs. Some, many more. There are no studies on the interaction of all these drugs.
  • 10% of Americans take an antidepressant medication; for women in their 40s and 50s, it’s 25%.
  • 25% of Americans over the age of 45 take a statin drug, despite much evidence of harm, including promoting diabetes.
  • Doctors write about 6 million prescriptions for proton-pump inhibitors (a class of acid blocking drugs) each year, making these drugs the third highest selling class of drugs on the market. This is happening although logic and evidence suggest that most people, especially older people, suffer from too little stomach acid, not too much.

Statins and acid blockers only begin to describe the problems.

A recent study found that elderly patients were able to reduce their risk of death by 38%. How? By “deprescribing”—reducing the number of prescription drugs they were taking.

Properly prescribed prescription drugs are the fourth leading cause of death in the country; they cause an estimated 1.9 million hospitalizations a year and 128,000 deaths. Another 840,000 hospitalized patients are given drugs that cause serious adverse reactions. These are just hospital numbers. And even in hospitals, there is reason to believe that most of the injury from drugs is hard to isolate and therefore not reported.

Another risk to taking prescription drugs: they often deplete the body of nutrients. This is a serious issue. The blog on November 17 reported that the US Department of Agriculture estimates that 90% of the American public is deficient in at least one nutrient; it is common to be severely deficient in many. Magnesium is an essential co-factor with more than 300 different enzymes regulating different processes throughout the body. If magnesium is scarce, it may be routed to the heart, where it is especially needed, and other parts of the body suffer over time. Or it may even be inadequate in the heart.

The irony is that many doctors prescribing multiple drugs to their patients will advise them not to take a vitamin or mineral supplement while on the drug, when in fact the need for supplements is increased.