Diabetes Office Visit

The Dash Diet - My first 2 month Experience

2012-05-19T09:29:00.001-07:00

My 2 months experience with the DASH diet . My 3 month trial period is about to expire and I will need to decide about my renewal.

Am I really following the DASH diet ? " Kind of "

My excuse;
I really want to blame my wife because she never really accepted the idea of the extra effort that would be required by her. I liked the idea of the shopping list and the exact menu to follow. We did go shopping one time but I cannot recall seeing any of meals as presented on the menu.
It is not really all her fault because have a pet peave about diets made up by dietitians that will include unusual foods that require special purchase and is used only one time during the week and then leftovers rot in the refrigerator.

Patient -Centered care
I still believe the best diet is one that is made by you and a dietitian using your written food diary and then adjusted by you and the dietitian to best meet your specific medical needs. This approach is not a one shot fix all deal. Individualizing patent care is hard work that requires multiple visit with your dietitian and physician. I have had the good fortune to have always had outstanding dietitians working with my patients.

The part that I like best about the DASH diet
I have been a fan of the Mediterranean style diet for years. I believe the Dash diet is one of the variations of the Mediterranean diet ideas. The one thing that initially got my attention was the "Daily Serving Goals". I liked this idea because it is simple and would best fit my eating habits and life style. Even with this simple approach their are some rough spots that still require attention and measurement.
Portion size and daily consistency requires require almost daily thought.
The easy part for me is 4 fruit servings, hand a full of nuts and dairy. I eat very little meat and try to make up for that with beans. I like 4 bean salad that I can buy in a jar. I am still struggling with getting 7 grains and 4 vegetable in my diet each day. I am using a can of V8 juice to work down my vegetable requirement. Changing food habits is alway a work in progress.

Daily Serving Goals
I think this is the best part of the diet.
This is the take home message that I can remember and apply most of the time . I chose an 1800 calorie diet because my initial goal is to weigh 178 to 180 pounds.

My serving goals:

fruit vegetables dairy grains meat/ fish/poultry nuts/beans fats sweets
4 4 3 7 1.5 0. 5 2 0.5

I am going to continue using the concepts of this diet and my wife and me are going to start working their actual diet plan into our daily routine. I believe this will help with my grain and vegetable deficiency.

Have fun, Be smart , changing food habits is a life time project
David Calder, MD

PS - Watch my Diabetes Office Video . It is focus on Patient - Centered Care. I think the goal setting and risk management sections may help in reducing your risk of heart disease. Thanks
http://www.youtube.com/watch?v=kfuSnepozS8

Diabetes management- " any target could (should ) reflect an agreement between patient and physician"

2012-05-18T10:55:00.000-07:00

Management of Hyperglycemia in Type 2 Diabetes : A Patient Centered Approach

Position Statement of the American Diabetes Association (ADA) and

the European Association for the Study of Diabetes (EASD)

This position statement was published on line April19, 2012 by the American diabetes Association. I am not sure when the printed version will become available. I recommend that every patient with type 2 diabetes read all 12 pages of this paper. It is full of charts graphs and information that will improve your understanding of this complex disease . This paper will enhance your ability to become a full partner in your diabetes care.

I took this one little section, Antihyperglycemic Therapy , and started high lighting the areas that I felt were worth emphasis. You will notice almost every thing is highlighted. It is worth reading every line. I have added my brief comments on the right side.

ANTIHYPERGLYCEMIC comments

THERAPY

Glycemic targets Correcting your A1c to <7 has the most impact in reducing the risk of eye,
Nerve and kidney damage.

The ADA’s “Standards of Medical Care in

Diabetes” recommends lowering HbA1c

to ,7.0% in most patients to reduce the

incidence of microvascular disease (42).

This can be achieved with a mean plasma This is a good answer to a common question. What is my goal for before and after meal glucose ?

glucose of ;8.3–8.9 mmol/L (;150–160

mg/dL); ideally, fasting and premeal glucose

should bemaintained at,7.2mmol/L

(,130 mg/dL) and the postprandial glucose

at ,10 mmol/L (,180 mg/dL).

More stringent HbA1c targets (e.g., 6.0 This is good information to know when setting your target goals

6.5%) might be considered in selected

patients (with short disease duration, long

life expectancy, no significant CVD) if this

can be achieved without significant hypoglycemia

or other adverse effects of treatment

(20,43). Conversely, less stringent This is more good information to know when you are setting your target goals.

HbA1c goalsde.g., 7.5–8.0% or even

slightly higherdare appropriate for patients

with a history of severe hypoglycemia,

limited life expectancy, advanced complications,

extensive comorbid conditions and

those inwhomthe target is difficult to attain

despite intensive self-management education,

repeated counseling, and effective

doses of multiple glucose-lowering agents,

including insulin (20,44).

The accumulated results from the One size does not fit all!

aforementioned type 2 diabetes cardiovascular

trials suggest that not everyone

benefits from aggressive glucose management.

It follows that it is important to

individualize treatment targets (5,34–36).

The elements that may guide the clinician

in choosing an HbA1c target for a specific

patient are shown in Fig. 1. As mentioned

earlier, the desires and values of the

patient should also be considered, since

the achievement of any degree of glucose

control requires active participation and

commitment (19,23,45,46).

Indeed, any This is the headline . I did change could to should

target could reflect an agreement between

patient and clinician.

An important related

concept is that the ease with which more

intensive targets are reached influences

treatment decisions; logically, lower targets

are attractive if they can be achieved

with less complex regimens and no or

minimal adverse effects.

Importantly, utilizing This happens and needs to be changed.

the percentage of diabetic patients

who are achieving an HbA1c ,7.0% as a

quality indicator, as promulgated by various

health care organizations, is inconsistent

with the emphasis on individualization

Have fun , Be Smart and read very line of this position statement by The ADA and ESDA. It is worth your time.
David Calder,MD

" Importantly. islet cell dysfunction is not necessarily irreversible

2012-05-16T09:48:00.000-07:00

Management of Hyperglycemia in Type 2 Diabetes: A Patient Centered Approach
Position statement of the American Diabetes Association and the European Association for the study of Diabetes
April 2012

Page 2
"Overview of the pathogenesis of type 2 diabetes"
The first paragraph points out that a rise in blood sugar is the result of glucose influx exceeding glucose outflow.
They point out that abnormal islet cell function is a feature of the 2 diabetes.
"The functional islet cell incompetence is the main quantitative determinant of hyperglycemia and
progresses over time "

" Importantly , islet cell dysfunction is not necessarily irreversible "

They recognize the value of weight loss , including bariatric surgery , in decreasing insulin resistance
and relieving the secretory burden of the Beta cells.

They also mention the role of the dysfunctional Alpha cells hyper-secreting glucagon resulting in
increased inappropriate glucose release from the liver

Reading page 2 reminds me of one of the best things physicians can offer their patients is , Hope.

" Importantly , islet cell dysfunction is not necessarily irreversible " , provides that little glimmer of hope.

Have fun , Be Smart and thank God for the wonderful medical research

David Calder,MD

Check out 2 related post from the past

Oct 8,2011 Lessons from my first patient , Hope

Feb 12 , 2012 Glucagon effects your everyday life

You are officially recognized as a full partner in your health care

2012-05-15T08:35:00.000-07:00

Management of Hyperglycemia in Type 2 Diabetes: A Patient Centered Approach
Position statement of the American Diabetes Association and the European Association for the study of Diabetes
April 2012

I recommend that you read the full document available from the American Diabetes Association. I plan to review and comment on 2 to 3 pages a day. These guidelines have done an excellent job of putting into words the activities that are occurring every day in physicians , diabetes educations and dietitians offices around the world .

Page 1 summary
You are officially recognized as a full partner in your health care

People with Type 2 diabetes are at increased risk of heart disease
The introduction points out " this document refers to glycemic control; yet this needs to be pursued within a multifactorial risk reduction framework". Preventing heart disease requires aggressive management of multiple risk factors, Blood pressure, lipids , aspirin use and smoking cessation also.

Patient - centered approach
Patient-centered care is defined as an approach to " providing care that is respectful of and responsive to individual patients preferences , needs, and values and ensuring that patient values guide all clinical decisions."

" in a shared decision -making approach, clinicians and patients act as partners, mutually exchanging information and deliberating on option , in order to reach a consensus on the therapeutic course of action "

Page 2 summary
younger people with shorter duration of diabetes who achieve A1c targets of <6.5 without significant hypoglycemia may have a lower risk of developing cardiovascular disease

This page reminds us of the reality of Type 2 diabetes being a leading cause of cardiovascular disorders , blindness , end- stage kidney failure , amputations , and hospitalizations.

They also review the hope and benefits of our current treatment by reviewing four studies results :
* UKPDS( UK prospective study )
- results from reducing A1c from 7.9 to 7 ( treated with sulfonylurea or insulin )
a signficant reduction in the risk for developing eye , nerve and kidney damage
a non- signficant reduction in risk for cardiovascu;ar disease
-results from treatment with metformin :
fewer patients experienced heart attacks and had an overall
-10 year followup of the intensive treatment group:
A1c had increased slightly but all intensive treatment groups had a reduction in heart attacks and
overall mortality
* Three other studies in 2008 ,ACCORD and VADT had treatment goals of A1c <6 and ADVANCE
with treatment goals of A1c of <6.5. None of these studies showed any significant reduction in
cardiovascular risk in the treatment groups.

They did demonstrate a significant increase in the risk of hypoglycemia in the treatment groups.

The ACCORD study had a 22 % increase in total mortality in the patients in the intensive treatment
group. ( goal A1c <6 ) The increased mortality in this group seem to occur in older patients
struggling to achieve an A1c of < 6 .
There were suggestions that younger people with shorter duration of diabetes and without
cardiovascular disease benefited from the more intensive therapy.
* finally a meta-analysis of these trials suggest that for every 1 % decrease in A1c may be associated
with a 15 % relative risk reduction in non fatal myocardial infarction, but without any benefits on
stroke are all-cause mortality

Tomorrow- Treatment decisions

Have Fun , Be Smart and become a full informed partner in your health care
David Calder, MD

Hyperglycemia- New treatment guidelines , Patient-Centered care

2012-05-14T08:22:00.000-07:00

Yesterday , I mentioned the "New Treatment Guidelines for managing hyperglycemia in patients with Type 2 Diabetes " published in April 2012. A committee of 6 American and 6 European Diabetes Specialist spent over 3 years developing these guidelines. They produced a 12 page document That I will review with you over the next few days.

Patient Centered approach
I believe this is the most important concept of this document. They focus on the idea of individualized treatment goals . Please review my quote from Ann Peters, MD ( one of the guideline developers) in yesterdays blog.

I will also ask you to review two other blogs in preparation for our review.
Jan.19, 2012 You fail to achieve 100% of the goals you don't set
Feb. 9 , 2012 Glucophage failed , now what should I do

I plan to review 3 pages of this document each day.

Have Fun, Be Smart and set diabetes management goals with the help of your physician
David Calder, MD

Sad News ! setting treatment goals is easier than achieving treatment goals.

2012-05-13T11:04:00.001-07:00

Heart Disease is the # 1 killer of people with Diabetes. Numerous studies have have shown the benefit of controlling individual risk factors in preventing and slowing heart disease. An article published in Diabetes Care 2011;34:1337-1343 discussed the evidence , showing that the 10 year coronary risk has improved significantly . I will review the risk factors and my failure to reach my goals. I am also offering you a little challenge from someone who is better at giving advice than taking advice.

Individualizing Targets
If you have my book , iPhone or iPad app, Diabetes Office visit, please go to the goal setting section and review your goals as we review these risk factors.Another point I would like to make is ,as I pointed out in my book , treatment goals are very individual , one size does not fit all . My recommendation is that you and your physician discuss each goal and make adjustments as needed . With the iPhone and iPad app it is very easy to adjust the goals to your specific life circumstances.

New Position statement by the American Diabetes Association
I was very happy to see Ann Peters, MD comments in Medscape 4/20/12 , on the new position statement on managing of hyperglycemia to be published by the American Diabetes Association and the European Association for the study of Diabetes essentially focused on patient-centered guidelines.. I think it is good to now have a name for what doctors have been doing in their offices for years. A good example is A1c hemoglobin. I will quote Ann Peters remarks to emphasize the point. "I think each of us can think of patients in our practices who can achieve an A1c that is even below 6.5, as close to normal as possible. Then their are others who are older, have comorbidities, and are not able to safely get their A1c down that low, so we raise the targets. I think the notion of adjusting targets, individualizing targets, is the key to this position statement ".

Target goals
* A1c < 7
* Blood Pressure <130/80
* LDL cholesterol < 100 mg/dl for low risk individuals Apo B < 90
< 70 mg/dl for higher risk individuals ApoB < 80
* Total cholesterol <200 mg/dl ( 96mm/l)
* Triglycerides <150 mg/dl (1.7mm/l)
* HDL cholesterol > 40 mg/dl for men (1 mm/l)
> 50 mg/dl for females (1.3mm/l )
* Albumin / Creatinine ratio < 30 mg/24 hours (3.4 mm/l )
* abdominal girth < 38 inches for males (96 cm )
< 35 inches for females ( 88.9 cm )

Home work - I am sad to report that ! Achieving goals involves more than just setting goals
For those of you with Diabetes Office visit App or with the book go to the risk management section and make to make sure your lab reports are up to date and that you have achieved your targets. I just looked at my target goals and reviewed my success in the risk management section. I am proud to announce that have reached all of the goals except the most difficult ones , my weight and waist size.My goal was to have my weight down to 187 pounds and my waist to < 38 by July 2012. It is May 13 and my weight is 191 pounds and my waist is 40 inches. Yipes I will have to lose 4 pounds and shrink my waist by 2 inches by July to meet my goals. It is amazing how fast this year has passed. I think achieving goals requires more than just setting goals. One of my other goals was to be doing 100 pushups /day using the 100 pushups App. I did very well for about 2 months and actually got up to 80 . Then I missed a day or 2 or 3 or month and did not continue . This same thing happens with food intake and other forms of exercise.
Does any one want to join me in losing 4 pounds in the next 2 months?
Make a comment and a commitment and lets discuss our plans.
use the comment section or email me at: info@diabetesofficevisit.com

Have fun , Be smart , Set treatment goals and then find the hidden inner strength to achieve those goals.

David Calder, MD

ps. Mark Clifford recommended trying The Live Strong diet tracking app. I am trying the free version and it looks good after my first day look. I must admit that it also requires some commitment. I neglected to put my lunch and Dinner in yesterday.

A better way to evaluate LDL cholesterol

2012-05-11T10:16:00.002-07:00

This is a follow up of yesterday post and request that you calculate your LDL cholesterol from your own test results. My reason for asking you to do the math exercise was to put attention on the fickle nature of the LDL test result used to evaluate our risk for Cardiovascular disease.

Some of the points to keep in mind are:
* LDL is usually a calculated number
* any increase in triglycerides results in a lower appearing LDL and a false sense of security
* any increase in triglycerides actually starting at about 100mg/dl is associated with an increase in small
dense LDL and increased risk of cardiovascular disease.

Is there a better way of evaluating LDL cholesterol ? Yes
* Measuring ApoB is the the easiest, least expensive most consistent way to evaluate LDL Cholesterol.
* there is one ApoB for each LDL particle regardless of the LDL parcel size.

Treatment guidelines goals
* American college of clinical endocrinologist ( AACE )

ACCE LIPID and Athersclerosis Guidelines

Endocr.Pract. 2012 ; 18 ( supplement 11: 1-78

Apo B - < 90 mg /dl in people at risk for cardiovascular disease
< 80 mg/dl for people with "established" cardiovascular disease
< 80 mg/dl for patients with diabetes plus one or more " risk factors "

* American Diabetes Association consensus statement on lipid management

ApoB < 90 mg/dl - for people with diabetes and no other risk factors
- for people without diabetes without cardiovascular disease but with 2
"risk factors "
< 80 mg/dl - people with "known" cardiovascular disease
people with diabetes plus one or more additional risk factors

Comment:
The official guidelines are catching up with what doctors have been doing for some time , using ApoB test to validate the the accuracy of LDL measurements in predicting risk for cardiovascular disease.

Who are those "people at risk for cardiovascular disease " and what are those "risk factors" ?
more tomorrow

Have Fun , Be smart and ask for an ApoB test with your next Lab. evaluation. You do not have to fast for this test.

David Calder, MD
email me at info@diabetesofficevisit.com with questions or comments

Have you checked your APO-b lately ?

2012-05-10T08:46:00.000-07:00

What is Apo -b ?

Apo-b is an integral part of each LDL cholesterol particle made in the liver . LDL is responsible for carrying cholesterol to tissues in our body. Apo -b is the key opening the door to various cells in those tissues.

LDL cholesterol is the primary tool used to evaluate risk for heart disease. I have discussed some of the problems with LDL measurements in previous post. Dec,11,2011

Basically LDL Cholesterol is produced in our liver in a spectrum of sizes, from small dense particles to large fatty particles. The size of the LDL particle is effected by Triglyceride levels . Triglyceride levels above 150 mg/dl is associated with an increase in small dense LDL putting a person at higher risk of cardiovascular disease .

I will ask you now to find your last lipid panel and do a little math.

* calculate your LDL by subtracting your HDL and 1/5 of your triglycerides from your total cholesterol

* Now add 200 to your triglyceride test result and repeat the calculation. What effect did that have on

your LDL cholesterol result ?

contact me at info@diabetesofficevisit.com if you have a question

Have Fun , be Smart , do your math

David Calder,MD

Preventing colon cancer is more fun than having colon cancer

2012-05-09T09:37:00.001-07:00

Colorectal cancer
early detection is the key to survival that many of us overlook

Recommended screening for early cancer detection 2012
American Cancer Society

Beginning at age 50, both men and women should follow one of these testing schedules

Test to find polyps and cancer
* flexible sigmoidoscopy every 5 years , or
* colonoscopy every 10 years ,or
* double - contrast barium enema every 5 years , or
* CT colonography ( virtual colonoscopy ) every 5 years

Test that primarily find cancer
* yearly 3 card fecal occult blood test( FOBT) , or
*yearly fecal immunochemcal test ( FIT ) every year, or
* stool DNA test (sDNA) , interval uncertain

Colonoscopy and fecal blood test are probable the most common test done.

Comment and selection of the most user friendly look at a colon
After years of medical practice , with analysis of my patients experience and my own personal experience with these test, I have selected the "most beneficial " and "user friendly " of the above test.

Colonoscopy is the winner based on my experience
The prep was a small very effective vial of liquid the evening before. My visit to the colonoscopy center at our hospital was a very pleasant experience . I exchanged my cloths for theirs and was ask to lie down on a gurney. The gastroenterologist walked by and said , without breaking his stride , Dave , I will do a good job. Another doctor walked by and said , I am your bartender.
My next awareness was a nurse telling me the test was ok and that I could get dressed. She made sure that I had a ride home

Reality
A study published in the Archives of Internal Medicine 2012;172 (7) : 575 - 582 reported on 997 patients; 58% agreed to have colorectal cancer screening .They could chose between colonoscopy or fecal blood test to be completed within 12 months.

38% of those selected to have colonoscopy actually completed the test within 12 months
67% of those selected to do a fecal blood test actually completed the test within 12 months

Why not do both .
A study , published in the " The Journal of Family Practice Nov. 2005. vol. 54 #11 compared studies using 3 card fecal blood test and colonoscopy , found no specific comparison . They did find that the odds of dying from colorectal cancer were lower for patients who had had a colonoscopy compared to people who did not have a colonscopy.They also found in multiple trials that people with a positive 3-card test for blood followed by a colonoscopy had a significant reduction in mortality from colon cancer.

Who is ultimately responsible for maintaining your good health ?
Don't look around , it is you. Ask your doctor about doing yearly 3 card occult blood test and a colonoscopy every 10 years.

Have fun , Be Smart and take care of your body
David Calder,MD

ACTOS side effects by MARK

2012-05-07T10:05:00.002-07:00

I have attached a copy of something written by my friend Mark Clifford and posted on his web Page. His short blog does a great job describing the primary side effects of of glitazones , ACTOS( pioglitazone) and Avandia ( rosiglitazone) .

http://www.1diaseaseworldvoice.org

Click on his title below and it will link you to his web site.

Have You Taken Actos? Are You Still On Actos?

I was on Actos and after Patti my Wife read an article about the side effects we talked with my then Cardiologist who said to stay on Actos. Later when I decided to take myself off Actos, approved of course from my Internist, I immediately lost 20 pounds of water weight and the pressure around my heart went away as well as my raspy voice that seemed to prove I had lots of fluid within my lungs.

Read this and learn more.

http://www.virtual-strategy.com/2012/05/02/resource-center-offering-help-victims-actos-lawsuit-questions

Have fun , Be smart and read the package insert that comes with each of your medicines.

David Calder,MD

ACTOS , the efficiency expert, involved in a bladder cancer problem ?

2012-05-05T09:24:00.000-07:00

Glitazones - Actos (pioglitazone ) Avandia ( rosiglitazone )
Hint - it is time to retire and join sulfonylureas in the" has been" room

I loved the mechanism of action and hated the side effects. I will outline the mechanism of action below for anyone other than me who may be interested. I was shocked to learn that ACTOS is one of the most commonly prescribed drugs in the world for treatment of Type 2 Diabetes .

I never prescribed Avandi because I did not like its effect on lipids but I did use ACTOS in a limited manor. The side effects of edema (swelling ) , weight gain and the tendency be associated with congestive heart failure in older people limited its usefulness in my patients.

Both drugs now have FDA warnings
AVANDIA for it's association with increase risk of heart disease
ACTOS with a possible like to bladder cancer.

Comment:
We have better safer medications .

Mechanism of Action with " light "((embellishment to make a better story
One good thing about these two drugs is this mechanism of action that caught my attention a few years ago.A researcher using sophisticated imaging techniques was able to demonstrate the process discussed below.I am not sure if this research was confirmed by others.

NORMAL
Insulin connects to a insulin receptor on a cell . This signals the nucleus ( the business office ) in the cell to send a message to the Glut 4 transporters ( the Teamsters ) to go out to the surface of the cell and pick up a glucose molecule and return it to the office ( nucleus) to be used for fuel .

Type 2 diabetes
The business office in the cell ( the nucleus ) is not efficient and fails to send a memo to the Teamsters to make the trip. This results in glucose piling up on the loading dock outside the cell and an increase in blood glucose levels.

ACTOS is hired as an efficiency expert
ACTOS quickly correct the" office inefficiencies " , the correct memo gets to the "Teamsters", and
the glucose is pickup and delivered to the right address in the cell .

Have Fun , Be Smart and chose your medications carefully.
Enjoy your week end, the sun is actually visible in western Oregon.

David Calder, MD

Tiredness- a little history of B12 treatment

2012-05-04T09:56:00.000-07:00

Vitamin B 12 (cyanocobalamin ) Has been available for many years. The early treatment of pernicious anemia was a little tough to swallow- large quantities of raw liver had to be eaten daily in 1934. Fortunately cobalamin(vitamin B12 ) was isolated from liver in 1948 making treatment a little more palatable .

A little history of the treatment of tiredness.
The use of B12 injections was a common treatment in older people complaining of tiredness. It apparently worked in some people because B12 injections was common practice for many years . My medical training labeled this use of B 12 as something just a little short of witch craft and I recommended that patients stop the B12 injections . It turns out that I may have been right about 80 % of the time . Recent studies have shown that about 20% of elderly people are at risk of B12 deficiency.
Another little bit of history about the treatment of tiredness in years past involved thyroid hormone use. The diagnosis of hypothyroidism was not as easy as it is now. I recall one older OBGYN doctor who decided that all women were tired so they must all be deficient in thyroid hormone. He started all of his patients on thyroid hormone. He used desiccated thyroid hormone which contained the active ingredient T3. This resulted in an initial buzz of energy until their own thyroid gland turned off. The availability of accurate laboratory test ended the above treatments.

The treatment of B12 deficiency is very easy now.

Vitamin B12( cyanocobalamin )

Vitamin B12 is available by injection ( least expensive )
oral ( moderate cost )
intranasal spray ( most expensive )

Most multivitamins contain B12 and folic acid
many cereals are fortified with B12 and folic

Pernicious anemia
The injection of B12 is recommend for the treatment of Pernicious Anemia .

Metformin users
The treatment for Metformin induced B12 deficiency can be done with oral B12 supplements . Calcium supplements also improve B12 absorption in this situation.

Senior citizens
one study reported in J.AM Geriatr Soc. 2002 Aug; volume 50(8) pp. 1401-4 reported that the amount of B 12 found is multiple vitamins ( 2 - 35.5 microg/day ) may be sufficient to correct the deficiency . The dose can be adjusted based on laboratory test

Have fun Be Smart and Defeat Diabetes and the Pills we use to treat it.
David Calder,MD

Tomorrow : what about those Glitazones ( ACTOS and Avandia )

tingling feet, shiny tongue,diabetes and Bell telephone

2012-05-03T09:45:00.003-07:00

*Diabetic peripheral sensory neuropathy is the most common complication of Type 1 and Type 2
Diabetes.
*The early symptoms of diabetic peripheral sensory neuropathy and B12 deficiency are similar.
* Metformin ( Glucophage ) is the most commonly used medicine for treating Type 2 Diabetes
(see yesterdays post, metformin may interfere with the absorption of Vitamin B12)
* Don't overlook B12 deficiency as a cause or contributor to your symptoms.

Symptoms of B12 deficiency
The symptoms of B12 deficiency are vague and non specific.
Feelings of fatigue , tiredness ,poor memory are common.

The symptoms of neurological dysfunction are similar to the neurological symptoms associated with diabetes
Bilateral numbness and tingling in a persons legs and arms, usually more noticeable in the lower legs
Clumsiness and lack of coordination can occur. If left untreated the symptoms can progress to more
severe weakness .

Another physical finding can be a shiny smooth tongue .
Heart murmurs may be found in the patients with anemia.

Answer to yesterdays question:

Which vitamin can mask some of the laboratory finding of Vitamin B 12 deficiency ?

Folic Acid

Anemia ( megaloblastic anemia ) is one of the classical findings of B12 deficiency. This is characterized by a decreased number and larger size of red blood cells due to faulty DNA synthesis in the red blood cells. Folic acid will correct this problem and essentially hide this clue of B12 deficiency. Vitamin B12 and/or folic acid is needed for red blood cell development.

History note.

Alexander Graham Bell invented the telephone. He also had diabetes and died from pernicious

anemia.

Treatment of B-12 deficiency tomorrow.

Have fun and out smart diabetes

David Calder, MD

Diabetic neuropathy and Vitamin B12

2012-05-02T08:49:00.000-07:00

Vitamin B12 deficiency is commonly thought of as an uncommon autoimmune disease , Pernicious anemia.

Vitamin B12 is commonly found in eggs , meat and dairy products . The absorption of B12 in our small intestine requires the presence of acid and something called Intrinsic factor from parietal cells in our stomach.

There are multiple causes of B12 deficiency that are easily overlooked when we deal with the multiple issues associated with Diabetes , especially diabetic neuropathy .

common problems associated with B12 deficiency

# 1 any problem involving a persons stomach or intestine such as ;

* gastric bypass surgery an increasingly popular treatment for obesity and type 2 Diabetes
* diseases of the small intestine such as Celiac disease
* gastric atrophy occurs in 5 to 20 % of the elderly population

# 2 Medications
* proton pump inhibitors - long term use
Prilosec , Losec ( omeprazole )
Nexium ( esomeprazole )
Prevacid ( lansoprozole )
Dexilant ( dexlansoprazole )
Protonics ( pantroprazole )
AcipHex, Pariet (rabeprazole )
Zegerid
* Metformin ( glucophage )

#3 Severe illness such as sepsis , AIDS , subarachnoid hemorrhage

Tomorrow. Symptoms of B12 deficiency
Can you name another vitamin that will hide one of the diagnostic clues of B12 deficiency ?

Have fun , Be Smart and learn more about the the little details that hide under the name ,Diabetes
David Calder, MD

Diabetes medication increases the risk of Vitamin B12 deficiency

2012-05-01T08:24:00.001-07:00

Metformin ( glucophage) use increases the risk of Vitamin B12 deficiency.

Metformin reduces the absorption of vitamin B12 from our intestinal track.

The effect seems to be dose related.
About 22% of the patients taking metformin developed B12 deficiency. There have been multiple studies with similar results.

The occurrence of B12 deficiency was less in people who took a multivitamin containing B12.

Recommendation for people taking metformin:
#1 Consider routine assessment of B12 levels during long term treatment with metformin
#2 Taking a multiple vitamin containing B12 may reduce the risk of developing B12 deficiency

Have fun , be smart and look up the side effects of every medication you are taking
David calder,MD

Tomorrow . Discussion of B12 deficiency

Metformin ( glucophage) effects Thyroid test

2012-04-30T09:53:00.001-07:00

Diabetes , Metformin effects Thyroid Test

Definitions :
Low thyroid (hypothyroidism ) from various causes is diagnosed from symptoms and confirmed by laboratory test The TSH ( Thyroid stimulating Hormone ) test is usually elevated
and the T4 ( thyroid hormone ) level is decreased.

Subclinical hypothyroidism ( someone with no symptoms are physical findings of hypothyroidism with an elevated TSH and low T4 )

Metformin effect
Metformin has an effect on TSH and T4 levels in people with hypothyroidism. Metformin decreases TSH levels and may increase T4 levels making it more difficult to diagnosis and monitor treatment of hypothyroidism.

Complicates Thyroid replacement therapy
Doctors follow TSH levels and adjust thyroid hormone replacement therapy to correct the TSH into the normal range. Metformin may complicate this process by making the TSH level appear lower than it is .
The mechanism of this effect is not known but one theory suggest that metformin may increase the absorption of thyroid hormone from the intestinal tract making a lower replacement dose adequate. This is an interesting unconfirmed idea . Finding the correct replacement dose for someone on metformin will require some thought by your physician.

Complicates the diagnosis of subclinical hypothyroidism
The effects of Metformin on lowering TSH may also interfere with the diagnosis of subclinical hypothyroidism

People with normal thyroids do not seem to be effected by metformin.

Have fun , be smart and understand your lab test.
David calder,MD

Metformin and Vitamin B12 tomorrow

Diabetes Cancer risk and " Drugs of Interest "

2012-04-27T10:31:00.000-07:00

Diabetes medications that may be associated with cancer risk features 2 medications groups as "drugs of interest " , sulfonylureas and Insulin.

I have attached a few abstracts , copied from Medscape articles, and high lighted statements of interest to our discussion today. Most of the articles I have reviewed seem to agree that there is some slight increase in cancer risk for people with Type 2 Diabetes.
Metformin ( glucophage ) is generally associated with lower risk of cancer but attaching the higher risk of cancer label to other diabetes medications such as Insulin and Sulfonylureas remains in the category of "drugs of interest ". There seem to be a lot of " may be associated " in the discussions.
Research into this area is an ongoing process and we may have a definite answer in the future.

What should we do while waiting for a definite answer?
Some of the newer medications , GLP-1 agonist and DPP-4 inhibitors , have given us tools that will allow full retirement of sulfonylurea medications and delay or even prevent the need for insulin in many people with Type 2 Diabetes. This does not mean that we should delay moving to insulin quickly when other medications have failed to control blood glucose levels. The benefits of insulin are much greater than the unproven risk of insulin.

Please review my Feb 9 and 10 Blogs for more on GLP-1 agonist and DPP-4 inhibitors.

Have fun , be Smart , Ask your doctor specific questions and you will be amazed at the amount of wisdom and knowledge available to you today in your doctors office .

David Calder,MD

Mortality After Incident Cancer in People With and Without Type 2 Diabetes

Impact of metformin on survival

Craig J. Currie, PHD1⇓, Chris D. Poole, PHD2, Sara Jenkins-Jones, MSC2, Edwin A.M. Gale, MD3, Jeffrey A. Johnson, PHD4 and Christopher Ll. Morgan, MSC2

Author Affiliations

1Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, U.K.
2Global Epidemiology, Pharmatelligence, Cardiff, U.K.
3Diabetes and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, U.K.
4School of Public Health, University of Alberta, Edmonton, Alberta, Canada

Corresponding author: Craig J. Currie, currie@cardiff.ac.uk.

Abstract

OBJECTIVE Type 2 diabetes is associated with an increased risk of several types of cancer and with reduced survival after cancer diagnosis. We examined the hypotheses that survival after a diagnosis of solid-tumor cancer is reduced in those with diabetes when compared with those without diabetes, and that treatment with metformin influences survival after cancer diagnosis.

RESEARCH DESIGN AND METHODS Data were obtained from >350 U.K. primary care practices in a retrospective cohort study. All individuals with or without diabetes who developed a first tumor after January 1990 were identified and records were followed to December 2009. Diabetes was further stratified by treatment regimen. Cox proportional hazards models were used to compare all-cause mortality from all cancers and from specific cancers.

RESULTS Of 112,408 eligible individuals, 8,392 (7.5%) had type 2 diabetes. Cancer mortality was increased in those with diabetes, compared with those without (hazard ratio 1.09 [95% CI 1.06–1.13]). Mortality was increased in those with breast (1.32 [1.17–1.49]) and prostate cancer (1.19 [1.08–1.31]) but decreased in lung cancer (0.84 [0.77–0.92]). When analyzed by diabetes therapy, mortality was increased relative to nondiabetes in those on monotherapy with sulfonylureas (1.13 [1.05–1.21]) or insulin (1.13 [1.01–1.27]) but reduced in those on metformin monotherapy (0.85 [0.78–0.93]).

CONCLUSIONS This study confirmed that type 2 diabetes was associated with poorer prognosis after incident cancer, but that the association varied according to diabetes therapy and cancer site. Metformin was associated with survival benefit both in comparison with other treatments for diabetes and in comparison with a nondiabetic population.

Metformin Associated With Lower Cancer Risk

Allan S. Brett, MD

Authors and Disclosures

Abstract and Introduction
Comment

References

Abstract and Introduction

Abstract

Compared with sulfonylurea users, metformin users had a 10% lower incidence of cancer.

Introduction

During the past decade, observational studies have suggested associations between cancer and type 2 diabetes (or insulin therapy). Although several plausible mechanisms exist (e.g., cancer cells express insulin receptors that when activated could promote cell proliferation in type 2 diabetic patients with hyperinsulinemia), the association remains controversial (CA Cancer J Clin 2010; 60:207). In some studies, metformin has been associated with decreased cancer risk.

In a population-based retrospective study, Dutch researchers recorded the incidence of cancer in 85,000 type 2 diabetic patients who initiated metformin or sulfonylurea monotherapy. During up to 10 years of follow-up, metformin users were less likely to receive cancer diagnoses than sulfonylurea users (hazard ratio, 0.9; 95% confidence interval, 0.88–0.91) after adjustment for age, sex, and several other variables. This 10% reduction was modest in relative terms but highly statistically significant. Metformin-associated lower risks were noted for cancers of the esophagus, stomach, colon, liver, pancreas, lung, breast, and prostate.

Section 1 of 2

Insulin Analogues and Cancer Risk: Cause for Concern or Cause Célèbre?

M. Pollak; D. Russell-Jones

Authors and Disclosures

Abstract and Introduction

The Biological Plausibility of a Link between Diabetes, Diabetes Therapies and Cancer

Investigating the Possible Mechanisms: Insulin-like Receptors, Insulin Analogues and Mitogenicity

What is the Clinical Evidence Linking Insulins and Cancer?

Is a Difference in the Incidence of Cancer Plausible in Less than 2 Years of Follow-up?

What Next?

References

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Abstract and Introduction

Abstract

People with diabetes, particularly those with type 2 diabetes, may be at an increased risk of cancer. Furthermore, their cancer risk may be modified by treatment choices. In this respect, metformin may be protective, whereas insulin and insulin analogues can function as growth factors and therefore have theoretical potential to promote tumour proliferation. Analogues causing inappropriate prolonged stimulation of the insulin receptor, or excess stimulation of the IGF-1 receptor, are the most likely to show mitogenic properties in laboratory studies. Some recent epidemiological studies appear to be consistent with these experimental findings, suggesting that there could be different relative risks for cancer associated with different insulins, although these studies have attracted some methodological criticism. However, it is biologically plausible that hormonal factors that influence neoplasia could begin to manifest their effects in surprisingly short timescales (within 2 years) and hence these epidemiological studies justify further research. Even if future research were to document an increase in cancer risk among insulin users, this would be unlikely to significantly diminish the favourable benefit-risk ratio for patients requiring insulin therapy. There is a need for further population studies and for the development of new laboratory models that are more sophisticated than previous experimental methods employed to assess potential tumour growth-promoting properties of insulins.

Metformin reduces cancer risk

2012-04-25T10:21:00.000-07:00

Question . What other diabetes medication also reduces our risk of cancer ?

Answer . Metformin ( Glucophage )

A review in Medscape by Megan Brooks reviewed a study of women with ovarian cancer.

The the study team reported in Obstetrics and Gynecology, five-year progression-free survival rates were 51% in diabetic patients who used metformin, 8% in diabetic patients who did not use metformin, and 23% in nondiabetics (p=0.03).

Overall survival at five years was 63% in metformin users, 23% in non-metformin users and 37% in the nondiabetic group (p=0.03).

Obstet Gynecol 2012;119:61-

Footnotes

From Reuters Health Information

There are numerous studies reporting the anti - cancer effects of metformin in various type of cancers. Medscape has over 200 articles reporting on metformin and cancer. Almost all of the articles are reporting on the benefits of metformin in reducing the risk associated with cancer and some animal studies discussing the preventive aspects of metformin in cancer prevention. One article discussed the lack of effectiveness of metformin in reducing the mortality rate in women with advanced breast cancer . However they did not a trend in the reduction of distant metastasis in the women with diabetes taking metformin.

This is an exciting area of research that holds great promise in reducing all of the risk associated with cancer. I like the statement made by Dr. Romero in the Medscape article.

Dr. Iris L. Romero and colleagues from the University of Chicago, Illinois say their observations add to a "growing body of evidence" from epidemiologic and preclinical studies indicating that metformin has anti tumor effects.

Have fun, be Smart and be your doctors best assistant in your own health care

David Calder, MD

Question.

Can you name 2 diabetes medications that may be associated with increased risk of cancer ?

Reporting an error. A few days ago I reported a price reduction in Diabetes Office Visit App. for iPhones and iPads.the change did not occur due to my error . I have corrected the problem. the new price is now .99 cents.

" daily aspirin reduces the long -term risk of cancer "

2012-04-24T09:28:00.003-07:00

"Daily aspirin reduces the long-term risk of cancer"

This quote was taken from an article article published in The Lancet , March 21 2012 and reviewed in Internal Medicine News 4/1/12

They study data from 51 randomized studies comparing daily aspirin use vs. no aspirin and adults who take a daily aspirin have a 15 % reduction in death from cancer compared to the non-aspirin control group. Cancer death reduction was 37 % in the groups taking aspirin for over 5 years

If you look at the numbers :

the overall 15 % reductions in deaths in the 51 studies reviewed ( 79,549 patients )

562 aspirin users compared to 664 non- aspirin users.

In the 34 studies following patients for over 5 years ( 69,000 patients )

92 deaths in the aspirin users compared to 145 deaths in the non -aspirin users

In 6 studies of patients (35,500 patients ) taking low dose aspirin 72 mg/day for longer than 3 years

deaths in female aspirin users - 324 compared to 421 in non-aspirin users

deaths in male aspirin users - 192 compared to 245 in non - aspirin users

Daily aspirin has an absolute cancer risk reduction of 3.13 per 1000 patient per year.

This is more good news for us aspirin takers.

Question . What other diabetes medication also reduces our risk of cancer ?

Have fun , be smart and take your aspirin

David Calder,MD

Persistent cough . Is your blood medication the cause ?

2012-04-23T09:07:00.000-07:00

Todays brief discussion is a continuation of our discussion of ACE inhibitors and ARBS . Please review the last few posts for more details.

A persistent dry cough that develops while taking an ACE Inhibitor ( angiotensin converting enzyme inhibitor) is a reason to talk to your doctor. Dry cough is one of the common side effects of taking ACE inhibitors . Your doctor can change you to a different blood pressure medication and the cough should go away. If the cough continues after stopping the ACE inhibitor further evaluation may be needed.

Switching to a ARB ( angiotensin receptor blocker) is probable not a good idea. The medications in each of these drug classes effect the same systems in our body by different mechanism. Your doctor can chose from a variety of other blood pressure medications .

Have fun , Be smart and know the names and function of each of your medications.

David Calder ,MD

Blood Pressure Medication alert for Diabetics

2012-04-21T08:29:00.000-07:00

News alert from Medscape 4/20/2012

The U.S. Food and Drug Administration ( FDA ) is warning of possible risk when using blood pressure medications containing aliskirin with ACE Inhibitors and ARBS in patients with Diabetes or kidney impairment.

Aliskiren Is often combined with other medications. Check your Blood Pressure medications and contact your doctor if aliskiren is present in any of your medications. I have listed some of the combinations below.

Aliskiren ( Tekturna )
aliskiren, amlodipine ,hydrochlorothiazide combination ( Amternide )
aliskiren ,amlodipine (Tekamlo )
aliskiren ,valsartan ( Valturna)

Have fun , be Smart , be safe and know the name , contents and why you are taking any
medication.

David Calder,MD

Angioedema with an ACE inhibitor. How about an ARB ?

2012-04-21T08:24:00.002-07:00

More on the ins and outs of ACE inhibitors ( angiotensin converting enzyme inhibitor ) and
ARBS ( angiotensin receptor blocker ) .

ACE inhibitor associated angioedema is not common and occurs in about 0.1 to 0.68 % of people taking ACE inhibitors

Yesterdays question .
Can a person who developed angioedema from a ACE Inhibitor take an ARB ?

Answer .
My short answer is no. I would not personally prescribe an ARB for someone who had angioedema
with an ACE inhibitor. One study found that about half of patients with ARB associated angioedema
had previously developed angioedema taking ACE Inhibitors.
( Angiotensin 2 receptor blocker associated angioedema: on the heels of ACE inhibitor angioedem
Pharmacotherapy 2002; 25:1173-75 Abdi R,Dong VM ,Lee CJ, Ntosso KA)

The etiology of ACE Inhibitor associated angioedema is thought to be associated with Bradykinin. Bradykinin is a potent blood vessel dilator. ACE Inhibitors slow down the clearance of bradykinin from our body. This is generally a good thing and helps lower blood pressure and a bad thing when it causes angioedema.
.
Todays question :

Can a person with a history of angioedema from any cause known or unknown take a ACE
Inhibitor or ARB ?

Answer :
My short answer is no. There are plenty of other Blood Pressure medications with lower risk.

Tomorrow - Persistent cough ? Could it be your ACE Inhibitor ?

News alert from Medscape 4/20/2012

The U.S. Food and Drug Administration ( FDA ) is warning of possible risk when using blood pressure medications containing aliskirin with ACE Inhibitors and ARBS in patients with Diabetes or kidney impairment. Aliskiren Is often combined with other medications. check your Blood Pressure medication and contact your doctor if aliskiren is present in any of your medications. I have listed some of the combinations below.

Aliskiren ( Tekturna )
aliskiren, amlodipine ,hydrochlorothiazide combination ( Amternide )
aliskiren ,amlodipine (Tekamlo )
aliskiren ,valsartan ( Valturna)

Have fun , be Smart , be safe and know the name , contents and why you are taking any
medication.

David calder,MD

Your Blood Pressure - Angioedema - ACES and ARBS

2012-04-20T08:53:00.001-07:00

What are ACE inhibitors and ARBS . These medications work in different ways to reduce the effect of angiotension 2 on our blood pressure.

The enzymes and the receptor blockers

ACE ( angiotension converting enzyme ) - converts Angiotensin 1 to Angiotension 2

Angiotensin- 2 - a very potent constrictor of small arteries increasing blood pressure

ACE inhibitors - partially blocks angiotension converting enzyme and allows dilation of small arteries
lowering blood pressure . (see yesterdays blog for a list of ACE Inhibitors)

Angiotensin -2 Receptor   - angiotensin 2 has to connect into a receptor on our arteries
to effectively raise blood pressure


ARBS ( angiotensin receptor blockers ) - lowers blood pressure by interfering with the ability of
angiotensin 2 to connect to small arteries .

List of Angiotensin receptor blockers

losartan ( Cozaar )
valasartan ( Diovan)
irbesartan ( Avapro )
candesartan ( Atacand )
azilsartan ( Edarbi )
eprostartan ( Teveten )
olmesartan ( Benicar )
telmisartan ( Micardis )

We started this conversation discussing 2 cases of an unusual complication of ACE inhibitors , Angioedema.

Can a person who has had angioedema with ACE inhibitors take a ARB ?

The answer tomorrow.

Have fun, be Smart , be Safe - understand more about your blood pressure pills
David Calder, MD

Diabetes Office Visit App. on sale .99 cents

2012-04-19T10:18:00.000-07:00

Diabetes Office Visit- Helps you prevent Heart Disease

Diabetes Office Visit iPhone and iPad App. is on sale $0.99 for a limited time.

The sale is to celebrate a new update that will be available soon .
Look for improvements in the the Risk Management section and Lab. test reports can be followed in either mg/dl or mm/l.

click on the Training Video link above for better understanding of goal setting , cardiovascular risk management and data that is always at your finger tips.

Have Fun , Be Smart and use the tools in Diabetes Office Visit to prevent heart disease

David Calder,MD

Diabetes office visit

" fixing the 9 "

*CREATED BY David Calder MD to provide an always at your finger tips comprehensive diabetes management tool , that will simplify your diabetes care and help you preserve your good health.

Diabetes control is more than just controlling blood glucose levels.

Heart disease and stroke risk is increased for people with diabetes and is the number one cause of disability and death for people with and without diabetes.
This does not have to happen, It is your choice. Chose wisely.

Over 36 million people in the United States with diabetes have 9 primary risk factors to manage. ( just numbers )

One study found that only 7% of people with diabetes achieve target goals for A1c, Cholesterol and blood pressure. (JAMA 2004; 291:335-342, a recent update in 2010 showed an improvement to 11%)

Diabetes Office Visit can significantly improve those numbers by simplifying risk management to managing 9 numbers.

How do we do it?

Simple and Specific Goals Empower each of us to do better

Start Simple, Set Goals

Initially, you don’t have to know what the numbers mean to affect them.You just need to learn the targets and what levers to pull to move your numbers toward the target. The first lever to pull is learning how to discuss the Lab values with your doctor. The Diabetes Office visit suite empowers you to have that conversation.
Remember : “ You fail to achieve 100% of the goals you don’t set “

Be Specific

Diabetes Office Visit provides the goals and a patient-focused template for a conversation with your doctor about your goals. The point is to focus each conversation on the specific goals where you are not hitting the target.

Repeat, Repeat, Repeat.

Over time, repeated conversations about your lab values create opportunities for you to learn how to better manage this disease.

Our goal is to empower you to gain understanding of this disease over time and actively partner with your health care provider to manage it.

Fixing the Nine, Why it Works

Correcting just one risk factor is already proven effective !

The Heart Protection Study,focused on LDL cholesterol over a 5 year period and prevented a major vascular event in 70 to 100 people per 1000. A key finding was that regardless of whether you do or don’t have diabetes, and whether you do or don’t have heart disease, you benefit from treating one risk factor for heart disease.

Correcting a few more cardiovascular risk factors saves lives...

Blood pressure control reduces the risk of heat disease and stroke among people with diabetes by 33 to 50 percent.

Diabetes office visit provides you with the tools to make this happen

Visit my web site daily, www.diabetesofficevisit.com for more references and more studies and discussions on how you can better manage 9 known risk factors and preserve your good health. “Fixing the nine” will work for you.

email me - info@diabetesofficevisit.com with comments , questions , ideas and complaints

Regular mail- Diabetes Office visit PO Box 1170 Creswell, Oregon

Diabetes Office is available in paperback , ebook and iphone ipad App versions and all are supported by my web site,www.diabetesofficevisit.com .I will soon have an App version for MAC's and PC's

Check out the DiabetesOffice Visit training video tab on the home page

If you are unhappy with this app Ebook or paper back book for any reason , I will return your money.

Thank you David Calder,MD

Blood pressure pills and a numb tongue ( left side only)

2012-04-19T08:56:00.000-07:00

The two patients presented yesterday have the same diagnosis , angioedema.
The cause of the angioedema was lisinopril.

Angioedema

Angioedema is a transient swelling of subcutaneous tissue with multiple triggers that can be;

Allergies - such as food allergies ( nuts , shell fish , eggs ) , medications (penicillin sulfa and others )
insect bites and latex are common
Hereditary angioedema

Non - Allergic Drug Reaction - ACE Inhibitors

I would like to focus our attention on the Non- Allergic drug reactions seen with medications called
ACE Inhibitors . Lisinopril is a ACE inhibitor and was taken by both of the patients discussed
yesterday.

ACE inhibitors are excellent safe medications used by millions of people with diabetes to treat high
blood pressure and to help protect their kidneys from the damage caused by diabetes.

The Symptoms , are unusual atypical mimics

The symptoms of ACE Inhibitor induced angioedema are atypical and mimic other more common problems such insect bites , hives , heart and gall bladder disease.

There are a few symptoms are more specific to angioedema.
#1 the symptoms usually occur on one side of our body and resolve in hours to days with no residual
Our patient number 2 had recurrent swelling and itching of either the top of his right or left foot
and numbness swelling and tingling of the left side of his tongue

#2 atypical chest or upper abdominal pain with abnormal liver test that return to normal within a few
days

#3 Angioedema can occur with the first dose or after years of being on the medication.
A physician friend of mine had one patient develop severe angiedema of her throat after taking
her first pill . Our patients # 1 and 2 developed symptoms after years of taking lisinopril.

#4 There may be a family history of allergies to medications.
Our patients #1 is allergic to Dilantin,and has a son and daughter allergic to penicillin.
Our patient #2 is allergic to penicillin , has hay fever and mild asthma and has a son allergic to
latex and penicillinA.

ACE Inhibitors are common very useful medications
Lisinopril ( prinivil , Zesteril )
Captopril (capiton )
Ramipril (Altase )
Enalapril ( Vasotec enalaprilat )
Quinipril ( Accupril )
Benazepril ( Lotensin )
cilazapril (Inhibace )
fosinopril ( monopril )
moexipril (Univasc )
perindopril ( Aceon , Coversyl )
Trandolapril ( Mavik )

It is hard to remember all of these different brands . Did you notice the generic names all end in "pril "

Have fun , be smart and understand the medication the medicines you are taking

David Calder , MD

Tomorrow! What about them ARBS and are they related to ACE.