Category: health

Metformin improves surgery results in type 2 patients

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From Diabetes in Control

Improved Post-Surgical Outcomes in Patients Using Metformin 

Feb 13, 2021 Editor: Steve Freed, R.PH., CDE
Author: Abdullah Al-Ajmi, PharmD Candidate, Skaggs School of Pharmacy and Pharmaceutical Sciences

Metformin use was associated with lower inflammatory markers before surgery, leading to improved outcomes post-surgery. 

Around a third of patients >65 years in the U.S. have type 2 diabetes (T2DM). Due to diabetes complications, renal and cardiac comorbidities are common in many patients, leading to impaired inflammatory responses and reduced time to recovery. Also, around half of this patient population undergoes surgical treatment during their lifetime. Therefore, these effects may lead to increased morbidity and mortality post-surgery.

Patients with T2DM have commonly been prescribed metformin as first-line therapy. In addition to its impact on blood glucose control, it has been shown to reduce chronic inflammation. These effects have been studied in diseases linked with the aging process, such as cardiovascular and renal diseases. Previous literature regarding the use of metformin has shown that it reduces all-cause mortality and cardiovascular and renal complications. However, whether metformin use pre-surgery can improve patients’ outcomes post-surgery was not studied before.  

A new study aimed to assess the effect of metformin on post-surgical outcomes in patients with T2DM. The study design was retrospective, including patients with T2DM who underwent surgery and were eligible for metformin use. It excluded patients with type 1 diabetes or impaired renal function, since metformin is not indicated in those cases. The investigators compared the patients’ outcomes based on whether they received metformin before surgery or not. Since metformin’s effect on inflammation is based on its use over time, patients’ glycemic control was not considered in the enrollment process. They included patients with an increased risk of mortality or readmission.  

The study data was collected from January 2010 to January 2016, and the follow-up continued to December 2018. 

Metformin exposure was considered if the patient received at least one prescription within six months before surgery and prescribed the last doctor’s prescription before surgery. Patients who did not meet these criteria were considered not exposed to metformin and fell in the comparison group. Those who are not indicated to use metformin were excluded from the study. The study identified the primary outcome to be 90 days mortality post-surgery. Additionally, secondary outcomes were identified, including 30-day mortality, readmission within three months post-surgery, 5-year survival rate, and the level of the inflammatory marker neutrophil to leukocyte ratio (NLR) pre-surgery. 

The study included 5,460 patients who were matched at a 1:1 ratio between the study groups. Patient characteristics were similar between the groups. In the metformin group, around 2% of deaths were reported within a month of surgery. Also, 3% of deaths were reported after three months and 13% in the 5th year. On the other hand, the non-metformin group showed a similar 2% death rate in the first month, but the rates increased to 5% and 17% by three months and five years, respectively. The risk reduction associated with metformin use is considered statistically significant (1.28%; 95% CI, 0.26–2.31). The results also indicate that metformin use was associated with a statically significant reduction in 90-day and 5-year mortality. These outcomes were similar to most surgical interventions except in neurosurgery, which did not show a significant risk reduction with the use of metformin. When comparing hospital readmissions, metformin use was associated with significantly lower readmission rates from 1 to 3 months after discharge than patients who did not receive metformin. Moreover, patients in the metformin group had lower NLR levels before surgery.  

The study findings suggest that metformin has additional mechanisms of action to its known means for glycemic control. The reduction of the NLR before surgery is associated with a decrease in morbidity and mortality post-surgery. The study has several limitations, one of which the possibility of confounding variables due to its design. One reason is that the type of surgery was evenly distributed between cohorts. Different surgeries can cause additional surgical stress to the patients, which may affect the study’s outcome. Also, the retrospective nature may introduce selection bias during the data collection phase. Furthermore, the author indicated that the mortality and admission rate might have been misrepresented.  

Practice Pearls: 

  • Metformin use in patients with T2DM is associated with a reduced mortality risk post-surgery. 
  • Readmission post-discharge is reduced with metformin use before surgery in patients with T2DM. 
  • Patients with T2DM on metformin have lower inflammatory markers before surgery, leading to improved outcomes post-surgery. 

Reitz, Katherine M. et al. “Association Between Preoperative Metformin Exposure And Postoperative Outcomes In Adults With Type 2 Diabetes”. JAMA Surgery, vol 155, no. 6, 2020, p. e200416. American Medical Association (AMA), doi:10.1001/jamasurg.2020.0416.  

Campbell, Jared M. et al. “Metformin Reduces All-Cause Mortality And Diseases Of Ageing Independent Of Its Effect On Diabetes Control: A Systematic Review And Meta-Analysis.” Ageing Research Reviews, vol 40, 2017, pp. 31-44. Elsevier BV, doi:10.1016/j.arr.2017.08.003.  

Abdullah Al-Ajmi, PharmD Candidate, Skaggs School of Pharmacy and Pharmaceutical Sciences    

Kriss Kresser: What to eat instead of the fat hidden in processed foods

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If you think these are the healthy option, you must read this post

Industrial seed oils are sold in big plastic containers of bright gold liquid, and although some of us will buy these to deep and shallow fry foods at home, most of the seed oils we eat will be hidden in processed foods, often marketed as convenient and healthy.

When ingested, these oils cause a low grade inflammatory process that can aggravate and sometimes cause such diverse conditions as: diabetes, obesity, cardiovascular disease, macular degeneration of the eyes, osteoarthritis, gut pain, asthma, autoimmune illnesses, dementia and mental health problems.

Kriss Kresser explains why these oils should be avoided and what fats to eat instead. Of course, this largely means ditching processed foods, if you haven’t already.

https://chriskresser.com/how-industrial-seed-oils-are-making-us-sick/

ADA cut target HbAIC for children to 7%

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Adapted from Diabetes in Control

More Stringent HbA1C Targets for Children and Adolescents with Type 1 Diabetes

Mar 2, 2021 Editor: David L. Joffe, BSPharm, CDE, FACA
Author: Adrian Gavre, PharmD Candidate, Philadelphia College of Osteopathic Medicine

What do the new ADA guidelines for HbA1C have to say about treating children and adolescents with type 1 diabetes? 

Recently, the American Diabetes Association (ADA) recommended lowering the target hemoglobin A1C (HbA1C) guidelines for children with type 1 diabetes (T1D).

A study conducted by Redondo et al. has shown that stricter controls of HbA1C within this population resulted in improved patient outcomes. Specifically, it was revealed that chronically elevated blood glucose levels in children could lead to increased rates of several serious effects, such as abnormal brain development; cardiac issues including stroke, coronary, peripheral heart disease; and other diabetic complications, nephropathy, neuropathy, and retinopathy. Better control of blood glucose levels lowered these events’ incidence and improved mortality rates in children and adolescents with T1D.  http://imasdk.googleapis.com/js/core/bridge3.476.0_en.html#goog_25686799Volume 0% 

Regarding abnormal brain development, one meta-analysis (n=1619) showed that patients with T1D had lower inhibition, working memory, and executive function compared to control subjects. In a study regarding microvascular diseases, patients with lower HbA1C had a significantly lower risk of microvascular diseases than patients with higher HbA1C (mean Hba1C 8.06% vs. 9.76%). A study conducted by the Swedish National Diabetes Register found a risk over fourfold for all-cause mortality, over sevenfold for cardiovascular mortality, and elevenfold for cardiovascular disease in patients diagnosed with T1D under age ten compared to the control group. 

Due to this study’s results, the ADA 2020 Standards of Medical Care recommends that children and adolescents with T1D target an HbA1C goal of less than 7%. This is a change from their 2019 guidelines, which had a target HbA1C goal of less than 7.5%. 

The study suggests that more intensive insulin therapy is the preferred strategy to treat children and adolescents with T1D. Instead of simply treating a patient’s hyperglycemia with insulin, it would be more beneficial to more aggressively bring blood glucose levels to a normal range. More aggressive blood glucose treatment seems to be the best strategy that results in a lower incidence of diabetes-related complications and long-term organ damage.  

However, caution should be used in this approach as more aggressive insulin therapy and lower HbA1C targets often result in a higher incidence of hypoglycemia. Symptoms of hypoglycemia are severe and can include dizziness, seizures, coma, and death. Despite this, the study has found that the incidence of hypoglycemia in children and adolescents with T1D has been steadily declining over the past three decades. The Danish Adult Diabetes Database (DADD) found an annual decrease of 8.4% in hypoglycemia incidence in children under 15 with type 1 diabetes from 1995-2016. Another similar study showed no significant difference in hypoglycemia rates in children who had an A1C <7% compared to children who had an A1C between 8-9% (n=1,770). Over this time, the lowered hypoglycemia rates coincide with innovations in drug therapies and technologies, such as insulin analogs, insulin pumps, and continuous glucose monitoring.  

These innovative technologies make it easier than ever to keep a patient’s HbA1C within a prespecified range and reduce the risk of hypoglycemia. The ADA still recommends a target of 7.5% for patients too young to properly articulate hypoglycemic symptoms, or patients who do not have access to these innovative technologies. An HbA1C score of less than 8% is acceptable for patients with a severe history of hypoglycemia or a shortened life expectancy due to other pre-existing conditions.  

Practice Pearls: 

  • The ADA recently recommended lowering the target HbA1C from 7.5% to 7% for children with type 1 diabetes. 
  • Lowering the target HbA1C in children and adolescents with type 1 diabetes reduces the risks of developing diabetic complications such as nephropathy, neuropathy, and retinopathy, abnormal brain development, and cardiac disorders, and improves mortality. 
  • Although more aggressive insulin regimens can result in hypoglycemia, hypoglycemia rates in children and adolescents with type 1 diabetes have decreased over the past three decades due to innovative new technologies and therapies such as insulin analogs, insulin pumps, and continuous glucose monitoring. 

Redondo, M, et al. “The Evolution of Hemoglobin A1c Targets for Youth With Type 1 Diabetes: Rationale and Supporting Evidence.“ 

Adrian Gavre, PharmD Candidate, Philadelphia College of Osteopathic Medicine   

Dr Gil Wilshire: Resource for women with polycystic ovary syndrome

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Dr Gil Wilshire has treated thousands of women with polycystic ovary syndrome over 30 years

Dr Wilshire is a USA gynaecologist who recommends low carbing, also known as a reduced carbohydrate therapeutic diet, for his patients who wish to improve their weight, symptoms and fertility.

His You Tube Videos are collected here for your interest. Please feel free to recommend them to women you know who are afflicted. This is thought to be about one in ten women.

Don’t over treat blood pressure in the over 75s

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Adapted from BMJ Oct 10 2020

The lowest mortality in people over the age of 75 occurred in those with a systolic blood pressure of 140-160 and a diastolic pressure of 80-90.

These figures are different than for the middle aged, young retirees and those with diabetes, who are often told to shoot for systolic BPs of 130 to 140.

It was reported Age and Ageing that an analysis of a primary care database that strict blood pressure control can actually be detrimental. Frail older adults do particularly poorly when their blood pressures are too low.

My comment: I remember doing four house calls in a row one warm summer’s day to see older adults, all at different addresses, who had collapsed from over treated blood pressure. None came to serious harm but they could have had fractures, sustained head injuries or collapsed in the street. I have read that a higher blood pressure in older life helps to perfuse the kidneys better. For many patients, they see nurses at nurse led clinics and lower blood pressures are not remarked on. They are told “good, come back in six months or a year”. They only see GPs when the blood pressure is considered to be too high. Instead, patients may be better to have realistic targets set by their GP depending on their age and ongoing health issues and check their blood pressure at home where it is less likely to be artificially raised by anxiety that is common in the health care setting.

Saving lives from cardiac arrest in young athletes

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Adapted from BMJ Oct 10 2020

Ventricular fibrillation with cardiac arrest is the most common cause of death in young athletes.

Unless there has just been physical contact with another player it is best to assume that someone who collapses on a playing field should be considered to have had a cardiac arrest until proven otherwise.

Breathing can continue for half a minute after cardiac arrest and jerking of the limbs is common.

In this situation, begin chest compressions immediately and send for an automated defibrillator and ambulance crew.

My comments: Chest compressions are done to the Bee Gees “Staying Alive”. Don’t waste your time with rescue breaths as these don’t improve survival. Defibrillation is the key and survival reduces by 10% per minute post collapse.

From British Journal of Sports Medicine.

Omega 3 fatty acids are an easy way improve life expectancy

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Adapted from BMJ Aug 7 21

A study reported in the American Journal of Clinical Nutrition has found that the highest levels of omega 3 fatty acids found in red blood cells were strongly associated with corresponding increased life expectancy.

This was a longitudinal study over 11 years. People in the top 5th of the erythrocyte fatty acid group had a life expectancy of 5 years more than the people in the bottom 5th.

This is actually as strong an association with mortality and cardiovascular events as traditional factors such as blood pressure, serum lipids and diabetes.

It is never too late to stop smoking

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Adapted from BMJ Aug 7 21

There are far fewer smokers now and many have transferred from cigarettes to the more benign vaping devices. Everyone knows not to start or stop if they possibly can, particularly people with diabetes, cardiovascular and lung disease. But is there a point when stopping becomes pointless?

Researchers performed a prospective cohort study with 517 Russian smokers who had been diagnosed with early stage, non small cell lung cancer.

Life lasted a whopping 21.6 months longer in those who stopped smoking soon after diagnosis.

Don’t blame your metabolism for middle age spread!

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Pontzer H et al. Daily energy expenditure through the human life course. Science. 2021 Aug 13.

A large scale study about energy expenditure has surprisingly showed that human metabolism peaks at about age one and only declines after the age of 60. There are no related changes at either puberty or the menopause, or after childbirth, which as many of us recognise, are key life stages when we all tend to put on weight, or more precisely for many of us, body fat.

The researchers measured the calories burned by 6,600 people aged from one week to 95 years old. They used the state of the art doubly labelled water technique to measure energy expenditure as they went around their daily lives in 29 countries.

Energy expenditure is highest in the first year of life compared to body mass. Then metabolism slows by about 3 per cent per year until you reach around 30. It then levels off. It only starts to decline after the age of 60. Even then this is only at a rate of 0.7 per cent per year.

This study suggests that the drivers of changes in metabolism are cellular changes unrelated to different stages of life.

My comment: So, for the most part we can’t blame our metabolisms for slowing down for our weight gain at various stages of life. The big gain times seem to me to be puberty, moving to university, pregnancy and after having a baby, the mid-forties and peri-menopause years, and retirement.

So what are the causes? I would say these are hormonal and lifestyle related.

Puberty is characterised by hormonal surges, appetite stimulation, and for girls in particular a reduction in active games and sport in preference to socialising. In pregnancy the appetite is stimulated and in my case, if I didn’t eat solid food every 3 hours day and night between weeks 10 to 20, I would vomit for hours. I had to set my alarm through the night and ate loads of breakfast cereal and milk, even keeping it in my car!

When students go to university and when they become exhausted new parents the lure of the quick fix carry out meal and sugary/alcoholic drinks becomes stronger.

The onset of the menopause reduces oestrogen and this leads to cortisol being less inhibited. Chronic stress and sleep deprivation, also enhance cortisol excretion and this stimulates the appetite and belly fat accumulation.

Retirement for many can prompt a resurgence of walking, golf and keep fit activities but also may lead to less activity if the job or commute involved a lot of walking or stair climbing.

Since we can’t just blame our metabolisms any more, we do need to consider what lifestyle changes we can make that will keep us slim and fit.

Eggs really are good for you!

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For any lingering controversy regarding eggs and cholesterol and heart disease, this new study reveals a considerable association between egg eating and a reduction in cardiovascular disease.

Meta-Analysis Am J Med

. 2021 Jan;134(1):76-83.e2. doi: 10.1016/j.amjmed.2020.05.046. Epub 2020 Jul 10.

Association Between Egg Consumption and Risk of Cardiovascular Outcomes: A Systematic Review and Meta-Analysis

Chayakrit Krittanawong 1, Bharat Narasimhan 2, Zhen Wang 3, Hafeez Ul Hassan Virk 4, Ann M Farrell 5, HongJu Zhang 5, W H Wilson Tang 6Affiliations expand

Abstract

Introduction: Considerable controversy remains on the relationship between egg consumption and cardiovascular disease risk. The objective of this systematic review and meta-analysis was to explore the association between egg consumption and overall cardiovascular disease events.

Methods: We systematically searched Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception in 1966 through January 2020 for observational studies that reported the association between egg consumption and cardiovascular disease events. Two investigators independently reviewed data. Conflicts were resolved through consensus. Random-effects meta-analyses were used. Sources of heterogeneity were analyzed.

Results: We identified 23 prospective studies with a median follow-up of 12.28 years. A total of 1,415,839 individuals with a total of 123,660 cases and 157,324 cardiovascular disease events were included. Compared with the consumption of no or 1 egg/day, higher egg consumption (more than 1 egg/day) was not associated with significantly increased risk of overall cardiovascular disease events (pooled hazard ratios, 0.99; 95% confidence interval, 0.93-1.06; P < .001; I² = 72.1%). Higher egg consumption (more than 1 egg/day) was associated with a significantly decreased risk of coronary artery disease (pooled hazard ratios, 0.89; 95% confidence interval, 0.86-0.93; P < .001; I² = 0%), compared with consumption of no or 1 egg/day.

Conclusions: Our analysis suggests that higher consumption of eggs (more than 1 egg/day) was not associated with increased risk of cardiovascular disease, but was associated with a significant reduction in risk of coronary artery disease.

Keywords: Acute myocardial infarction; Cardiovascular disease; Egg consumption; Meta-analysis; Stroke; Systematic review.