Metformin improves side effects of steroid treatment

From Pernicova I et al. Lancet Diabetes Endocrinol 25 Feb 2020

Long-term glucocorticoids, most often prednisolone, are prescribed for about 3% of European adults. The long term exposure can raise metabolic, infectious and cardiovascular risks.

This was a trial of 53 adults who had inflammatory disease treated with prednisolone but did not have diabetes, who were given either 12 weeks of metformin or a placebo.

The dose of prednisolone was 20mg or more for the first month and then 10mg or more for the next 12 weeks. The dose of metformin given was up to 850mg three times a day.

What improved:

Facial fatness was in seen in 52% of the placebo group but only 10% in the metformin group.

Increased blood sugar was seen in 33% of the placebo group and none of the metformin group.

There was improvement in insulin resistance, beta cell function, liver function, fibrinolysis, carotid intima media thickness, inflammatory parameters and disease activity severity markers in the metformin group.

There were fewer cases of pneumonia, moderate to severe infections and all causes of hospitalisation for adverse events in the metformin group.

What got worse:

Diarrhea was worse in the metformin group.

What didn’t get better:

Visceral to subcutaneous fat ratio was unchanged between the groups.

My comment: Looks like a clear winner for adding metformin to long term prednisolone treatments.

Statin study shows no memory loss

From BMJ 18 Jan 2020

An Australian study looked at how 1,000 community living Australians aged between 70 and 90 got on with memory and cognition tests over a six year period.

It found no differences between people who took statins and those who had never taken them. If anything, statin use reduced decline in memory especially in those with heart disease or who were carriers of apolipoprotein E4.

Magnetic resonance imaging of some of the group detected no effects of statins on total brain volume or on hippocampal or para-hippocampal volumes.

BMJ 2020; 368:m52

Younger women more likely to get urine infections with Flozins

From Univadis Nakhleh A et al. Journal of Diabetes Complications 18th April 2020

It is well known that patients on Flozins are much more prone to urine infections and thrush due to the extra sugar in the urine which is excreted by taking these drugs, also known as SGLT2 inhibitors.

An Israeli study of over 6 thousand women with type two diabetes sought to clarify who was more or less likely to be affected by this very annoying problem.

They found that those most likely to get urine infections were:

Women who had existing gastro intestinal problems

Pre-menopausal women

Women who had been taking oral oestrogen in the form of the contraceptive pill or HRT

Women less likely to be affected:

were older (over 70)

had prior existing chronic kidney disease

My comment: From my GP experience I found that these drugs were highly effective and generally well tolerated. A few patients were indeed badly affected by recurrent urine infections and thrush and had to discontinue the drugs.

 

 

NICE: Hydrogen peroxide for impetigo

 Adapted from :NICE issues antimicrobial prescribing guidance for impetigo

curated by Pavankumar Kamat UK Medical News 28 Feb 2020

National Institute for Health and Care Excellence (NICE) recently published antimicrobial prescribing guidance which describes the antimicrobial strategy for adults, young people and children aged ≥72 hours with impetigo.

According to the new NICE guidance, GPs should prescribe topical hydrogen peroxide 1% instead of topical antibiotics for patients with localised non-bullous impetigo.
The guidance states that hydrogen peroxide 1% cream is as effective as topical antibiotics in patients with localised, non-bullous impetigo, provided they are not systemically unwell or at risk for complications.

If hydrogen peroxide 1% cream is not suitable or if symptoms have worsened or not improved, a short course of a topical antibiotic may be considered.
A topical or oral antibiotic is recommended for patients with widespread non-bullous impetigo, provided they are not systemically unwell or at risk for complications. Oral antibiotic treatment is recommended for patients who have bullous impetigo or if they are systemically unwell or at high risk for complications.
NICE does not recommend a combination of topical and oral antibiotic. There is no evidence that the combination works more effectively than a topical treatment alone.
The primary choice of topical antibiotic is fusidic acid 2%, and the secondary option is mupirocin 2%. The drug of choice for first-line oral antibiotic therapy is flucloxacillin, with clarithromycin and erythromycin (for pregnant women) as secondary choices.

References
Impetigo: antimicrobial prescribing: NICE guideline [NG153]. National Institute for Health and Care Excellence. 2020 February.

My comment: Impetigo is a common skin infection caused by staphloccus which tends to colonise up people’s noses. It spreads rapidly in the nursery and primary school environments. Previously it was treated with oral penicillin. Children are advised to stay off school to reduce spread. Any effective topical, non antibiotic treatment, is welcome as this will help reduce antibiotic resistance.

NICE: Blood Pressure Update

From Diagnosis and management of hypertension in adults. NICE guideline update 2019

BJGP Feb 2020 by Nicholas R Jones et al.

The last update by NICE was in 2011. The key changes are explained in this article.

High blood pressure is blood pressure over 140/90 if measured in the clinic.

Home measurements can be more reliable due to a natural rise in blood pressure in the clinic setting. Ambulatory monitoring can be done, but it is not always available or tolerated. My comment: The machine can be very uncomfortable and disrupts sleep. 

To take your blood pressure at home, take two readings, one minute apart, twice a day for 4 to 7 days.  Don’t count the first days readings. Then take the average of the others.

Hypertension is diagnosed if the average of home or ambulatory monitoring is over 135/85.

The BP should be taken standing for those people over 80, who have type two diabetes and if you have postural hypotension. You need to stand for at least a minute before taking the blood pressure and it is best to avoid talking. 

A blood pressure difference between the arms of over 15 mmHg is a marker for vascular disease. Thereafter the arm with the highest measurements should be chosen for monitoring.

Urgent admission is needed if the bp is over 180/110.

Target organ damage is assessed with looking at the retina, urine testing, U and E and eGFR, ECG and a cardiovascular risk score such as QRISK. Check up should be annually.

Lifestyle advice should be emphasised as this can result in taking fewer drugs.

People with blood pressures over 140/90 at the clinic or 135/85 who are aged 60 to 80 are currently advised to have treatment for their blood pressure. People over the age of 80 are fine with blood pressure targets lower than 150 systolic.

The treatment target for people with diabetes is now 140 systolic which is now the same as the general population.

The drugs to treat hypertension are:

ACE or ARB if type 2 diabetes, age under 55 or African or Caribbean origin.

The next step is to add a calcium channel blocker or thiazide like diuretic.

The next step is a combination of ACE or ARB, CCB and Thiazide.

If the potassium is less than 4.5, Spironolactone can be added as a next step.

If the potassium is over 4.5 then an alpha or beta blocker.

For all other patients the first step is a CCB or Thiazide. 

The next step is an ACE, ARB or Thiazide.

Then any combination of these.

If the potassium is under 4.5 then spironolactone can be added.

If the potassium is over 4.5 then an alpha or beta blocker can be added.

 

Take your blood pressure pills at night

Adapted from BMJ Take anti-hypertensives at night says study. Susan Major 2 Nov 19

Taking your blood pressure medication at night gives you better blood pressure control and nearly halves cardiovascular events and deaths compared to taking them in the morning.

This study was done on nearly 20 thousand patients with an average age of 60 for six years. The reductions in events included cardiovascular death, heart attacks, coronary artery revascularisation, heart failure and stroke.

Professor of cardiovascular medicine at Sheffield, Tim Chico said, ” As taking medications at bedtime poses little risk there is enough evidence to recommend that patients consider taking their medication at bedtime.”

Dr Chris Palmer: Ketogenic diet now being used in mental health

Dr Chris Palmer from Harvard has been using the low-carbohydrate and ketogenic diets in practice for over 15 years now mostly for weight loss. Recently, he has found an anti-psychotic and mood stabilizing effect from specific types of the ketogenic diet. Now he is pursuing clinical research in this area to better understand the topic. As a result, he has also been speaking at national and international conferences.

Here area few of his podcasts/interviews:

http://lowcarbmd.com/episode-49-dr-chris-palmer-treating-schizophrenia-with-lifestyle

https://www.chrispalmermd.com/ketogenic-diet-psychology…/ and keto putting schizophrenia into remission.

https://www.chrispalmermd.com/ketogenic-diet-remission…/

https://www.chrispalmermd.com/keto-naturopath-by-karl-goldcamp-interview-christopher-palmer/

My comment: It is a very good idea for those people with schizophrenia to be on a low carb diet, mainly due to the side effects of the anti-psychotics which give people metabolic syndrome and diabetes. It is even better to hear that there conditions are improved so they are less reliant on these drugs.

HRT risks need to balanced with benefits

Adapted from Editorial BMJ 19 October 19 by Janice Rymer et al.

In the UK most women go through the menopause aged between 45 and 55. About half of them will get symptoms such as flushes, sweats, low mood, anxiety, joint and muscle pain, vaginal dryness, reduced sex drive, and hip fractures in later life. Hormone replacement therapy can turn these symptoms around.

Women’s health specialists are concerned that a meta-analysis published in the Lancet does not evenly show the benefits of HRT compared to the risks and think that the NICE guidance in 2015 looked more comprehensively at all the available evidence. They don’t want either women or doctors to stop HRT unnecessarily.

The Lancet showed that in the UK one in 16 women who have never taken HRT will develop breast cancer between the ages of 50 and 69.  If a woman of normal body mass index (under 25) starts HRT in her 40s or 50s the additional risk of getting breast cancer is one in 200 for oestrogen only HRT, one in 70 for daily oestrogen and progestogen for part of the month, and one in 50 for preparations with a mix of oestrogen and progesterone daily.  But body weight and alcohol have a greater effect on getting breast cancer than HRT. For instance, being overweight or obese will increase the rate of breast cancer six times compared to combined HRT.

The Lancet study looked at how many cases of breast cancer started but did not look at the mortality rate. A recent systematic review did. This showed that if a woman started HRT close to the menopause there was an apparent reduction in all cause mortality and cardiac death with no evidence of an increase in deaths from breast cancer.

The womens’ health specialists are concerned that the bone benefits and cardiac benefits, especially for women going through an early menopause, will be ignored if undue weight is put on the small increase in breast cancer diagnosis, over the symptomatic benefits and improvement in total mortality.

BMJ 2019;367:15928

 

Self caring during illness

Adapted from online presentation by Beverly Bostock ANP 7 May 2020

If you have diabetes you are more at risk of serious complications from Covid-19 and should seek medical advice early in the illness.

Any febrile illness can raise your blood sugars, including the prodromal phase when you don’t otherwise have symptoms. Once you are aware that you are coming down with something there are some useful ways of remembering how to monitor yourself.

Particularly for insulin users:

S – SUGAR – check your blood sugar more frequently than usual. For instance, if you would normally check your blood sugar every 5 hours during the day, double this to every 2.5 hours.

I – INSULIN – Adjust your insulin according to your blood sugars to keep within your target blood sugar level.

C – CARBOHYDRATE – If your blood sugar is low eat or drink more glucose or sugar/starch food items. If your blood sugar is high, drink plain water or more diet drinks.

K – KETONES – Use blood ketone stix or urine ketone stix to monitor your ketones if you are a type one diabetic every 4 hours or so. This is particularly important if you feel very ill, are nauseated, vomiting or have abdominal pain. If your ketones are high consider extra insulin, keep well hydrated and alert medical staff sooner rather than later.

Particularly for type twos:

It is important to keep well hydrated when you experience any illness but particularly an illness where you are febrile, or have  vomiting, limited oral intake, or severe diarrhea.

Some drugs can worsen your response to dehydrating illness and you may need to seek advice from a doctor, nurse or pharmacist about stopping certain drugs and when it is appropriate to restart them.

You can remember what they are with the mnemonic: SADMAN

SGLT2 inhibitors, ACE inhibitors, Diuretics, Metformin, ARBs, and Non- steroidal anti-inflammatory drugs.

 

 

 

Metformin reduces oesophageal cancer

Adapted from Wang QL et al. American Journal of Gastroenterology 1st January 2020

Metformin users were at a lower risk of developing oesophageal squamous carcinoma than non metformin users.

A growing number of observational studies have shown that metformin reduces overall cancer risk and a few specific cancer types such as colon, rectal, breast and stomach.

A population based cohort study included over 400,000 metformin and an equal number of non metformin users who were matched by age and sex.

There were 3.5 cases of oesophageal cancer in the metformin group per 100,000 person/years and 5.3 in the non metformin group. This finding was true for men, women and those in their sixties.  The odds ratio was 0.68 for metformin use.