Dr Mark Cucuzella: Online resources for low carbing for patients and doctors

Adapting Medication for Type 2 Diabetes to a Low Carbohydrate Diet- Frontiers 2021

https://www.frontiersin.org/articles/10.3389/fnut.2021.688540/full

The above link gives the full paper from Dr Cucuzella about the medication adaptations, including insulin adaptations that need to be done if you are transitioning to a low carb diet. There is a helpful traffic light summary. Some medications do not need altered and these are discussed too.

Diet Doctor video on article “Why deprescription should be your new favorite word”

What your new diet will consist of and how to avoid unnecessary expense or complicated recipes is fully discussed in the following links. They are the same booklet but in different formats.

Our new “Low Carb on any Budget  – A Low-carb Shopping and Recipe Starter Begin a Life Free of Dieting and Indulge Yourself in Health” patient guide- Print and share with your patients

Pdf version

www.tinyurl.com/lowcarbanybudget

online flipbook

www.tinyurl.com/lowcarbanybudgetebook

For clinicians through guideline central

These booklets are quite complex and are for doctors who want to know more about low carb diets and fine tuning of medication and insulin. The first is in USA units and the second is the UK format. It does no harm for any diabetic or their carers to read these too but bear in mind that they do go into some depth.

-Guideline Central: Low-Carbohydrate Nutrition Approaches in Patients with Obesity, Prediabetes and  Type 2 Diabetes

http://eguideline.guidelinecentral.com/i/1180534-low-carb-nutritional-approaches-guidelines-advisory/0?

UK version – http://eguideline.guidelinecentral.com/i/1183584-low-carb-nutrition-queens-units/0? 

Vitamin D supplementation has been shown to reduce the development of autoimmune disease

Photo by Pavel Danilyuk on Pexels.com

Adapted from BMJ 29 Jan 2022

This USA study looked at what happened after 5 years of vitamin D 3, omega 3 fatty acids and placebo to a group of over 12 thousand men and 13 thousand women. The men were at least 50 and the women 55 at the time of the start of the trial.

The groups were randomised to test out different combinations on the incidence of autoimmune diseases including rheumatoid arthritis, polymyalgia rheumatica, autoimmune thyroid disease, and psoriasis.

The results show that the vitamin D supplement group had the only statistically significant finding. This was a 22% reduction in autoimmune disease whether or not they took the vitamin D with omega three fatty acids or a placebo.

Although the doses are probably stated in the main paper, the summary from the BMJ did not contain this information.

Statin “deniers” take the Mail on Sunday to court for defamation

Photo by EKATERINA BOLOVTSOVA on Pexels.com

Adapted from BMJ 26 March 2022.

Dr Malcolm Kendrick who is a GP, and Zoe Harcombe who is a PhD researcher, have raised a court action against the Mail on Sunday, because they think that their reputations have been damaged by being called “statin deniers whose deadly propaganda has endangered lives.” Their influence was described as “being worse than the MMR scare.”

Mr Justice Nicklin describes the case as a most significant piece of defamation litigation. The claimants assert that they have been accused of putting many thousands if not millions of people at a greater risk of a deadly or debilitating heart attack or stroke by misleading them into the false belief that statins do not work and/or have debilitating side effects.

Both Malcolm and Zoe write blog articles, have given lectures and written books. Malcolm writes, “Readers will know there is not one cause of heart disease. Equally, you are not going to protect yourself against heart disease doing one thing. You need to do many.”

Associated Newspapers who own the Mail on Sunday, say that their articles are substantially true, express an honest opinion and also say that they are protected by qualified privilege or by the defence of publication on a matter of public interest.

My comment: I was most concerned when I read about this case. There is a lot of controversy over the use of statins and the public should be able to hear both positive and negative information on health matters, so as to help them make up their own minds, or to stimulate further personal research. Dr Kendrick and Zoe Harcombe are both highly intelligent, well informed and well meaning people. They both support low- carbing for health care, and we have corresponded and met up personally and online at discussions and conferences of common interest. I am concerned that there is financial resource asymmetry here and that this case will be potentially ruinous for them. I await the court’s findings with interest and trepidation.

NICE: Semiglutide is the cavalry coming over the hill in the obesity battle

Photo by SHVETS production on Pexels.com

Adapted from BMJ 12 Feb 2022

NICE are recommending that the anti diabetes drug Semiglutide is used for its anorexic properties in non diabetics who meet certain criteria.

Trials have found that patients given diet and exercise advice plus Semiglutide lost 12% more weight than lifestyle advice alone.

The drug is given in a weekly, self administered injection. My comment: I have used similar drugs with my type two patients and they were all surprised at how easy this was to do and how effective the drug was as an appetite suppressant.

To be considered for the treatment you have to have a BMI of at least 35 and have a related co-morbidity.

If you have a BMI between 30 and 34.9 you may be eligible for the drug if you are of South Asian, Chinese, black African or Caribbean family background or if you have been referred to a tier 3 weight loss service. This is because the drug is cheaper and safer than bariatric surgery and also because certain ethnic groups are more at risk of co-morbidity at lower BMIs than those of white European ancestry.

My comment: I can envisage that there will be huge market for this drug. One issue is that patients tend to regain weight on stopping and I understand that newcomers are expected to stay on the drug for two years.

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.”