January 24, 2020 · 9:00 AM

Paul Ingraham Cured My PFPS: Patello-Femoral Pain Syndrome

…and Paul’s not even a physician or physical therapist. But he’s a smart guy, writer, and former massage therapist. Click for his article on patello-femoral pain syndrome if interested. I paid about $20 USD for the full article, and it was well worth it. Full disclosure: I don’t know Paul and earn no commission or other compensation for this endorsement.

Photo credit: Steven Paul Parker II

The key to my cure was probably radical rest, or what Paul calls profound rest.

If you have PFPS, I hope you find something useful here.

Regular readers here know I’m a huge proponent of exercise. Unfortunately, exercise can be risky. You can injure yourself. I did that a few years ago when I was getting in shape to climb Humphreys Peak. I accelerated my training program too rapidly and developed patell0-femoral pain syndrome (PFPS).

This is how my right knee felt in 2017:

I’ve developed over the last month some bothersome pain in my right knee. It’s not interfered much with my actual hiking, but I pay for it over the subsequent day or two. I’m starting to think this may put the kibosh on my Humphries Peak trek next month.

The pain is mostly anterior (front part of the knee) and is most noticeable after I’ve been sitting for a while with the bent knee, then get up to walk. The pain improves greatly after walking for a minute or less. It also hurts a bit when I step up on something using my right leg. If I sit with my knee straight (in full extension), it doesn’t hurt when I get up. The joint is neither unusually warm nor swollen. Ibuprofen doesn’t seem to help it.

That episode resolved after I stopped hiking for 3-4 months. But in 2018 I had recurrence of similar pains in my left knee, with no clear precipitant this time. I continued my usual weight-training program and expected another spontaneous resolution. Six months passed…no improvement. That’s when I found Paul Ingraham’s article.

By the way, I’m the one who diagnosed my PFPS. It’s been said that a doctor who diagnoses and treats himself has a fool for a patient. He can’t be adequately objective.

Alternative diagnoses would include patello-femoral osteoarthritis and degenerative meniscus, due to my age (over 60). Diagnosis of the osteoarthritis could be facilitated by knee X-rays: weight-bearing posterior-anterior imaging, weight-bearing lateral view, and sunrise view.

This was my treatment plan for PFPS in early Feb 2019, based on Paul Ingraham’s recommendations. Paul explains how to do various specific exercises below in his article.

  1. Avoid all activities that stress the patella-femoral joint or aggravate pain for at least two weeks, if not longer (2–3 months). Paul calls it “profound rest.” I started this Feb 17. No knee-loading exercise (e.g., leg presses, any kind of squat, deep knee bends) until pain is truly in remission from rest. I quit my usual squats, Bulgarian split-squats, and single-leg Romanian deadlifts.
  2. Consider Motrin (ibuprofen) 400-600 mg three times daily for two weeks (I did 600 mg 3x/day) but usually no help
  3. Consider cold-packs (10–20 mins) when it flares up but usually no help. (I never did this because I couldn’t find my WalMart cold-pack.)
  4. Find a substitute for the squats? E.g., stationary bike? No bike for now: too much stress on patello-femoral joint at this time
  5. Paul’s not big on stretching (quadriceps and hamstring stretches routinely recommended by others). I didn’t stretch.
  6. While recovering, keep leg straight most of the time, even when sitting. Sit less. (I didn’t sit less but did make a huge effort to keep my  affected led fully extended, or at least not bent more that 20 degrees at any time. This necessitated sitting on the edge of my seat at work, and/or lowering the height of the seat. At home relaxing, I’d keep my leg fully extended. I think this was extremely important for my healing. I considered getting a standing desk for home or work but didn’t.)
  7. Start with exercises that keep knees straight. Exercise both lower extremities. As condition improves, can start to add other exercises, very slowly, that allow bent knees. Single-leg RDLs may be a good start (started in Sept 2019). Restart squats, deep knee bends, and leg presses (cycling?) only very late into recovery. Rehab must progress VERY SLOWLY. If an exercise causes more knee pain, back off and work the hips first. Exercise 2–3 times/week. Walking on the flat in moderation is usually OK. Strengthening hip abductors may be helpful.
  8. Hamstring curls via machine or therabands. Curl to 60 degrees, not 120. (I curled to 90 degrees using therabands).
  9. Quadricep setting. (I didn’t do this. Straight-leg raises on your back seem to be similar, which I did.)
  10. Straight-leg raises, on back and side-lying. (Done: 3 sets of 10 reps each side.)
  11. Clam shells. (Done: 3 sets of 10 reps each side.)
  12. Knee lifts? (don’t know what that is; not done).
  13. Consider the following although not from Paul: Hip abductor strengthening: “monster walks” (lateral steps with elastic band around (just proximal to) knees: 1 min x 3 sets. Hip hikes (what’s this?): 2 sets of 20 reps each side.
  14. Consider the following although not from Paul: Quad strengthening: terminal knee extensions with elastic band, 3 sets of 15 reps; leg presses?; semi squat, 3 sets of 10 reps (also recumbent bike?). Also consider stork stance TKE (terminal knee extensions) as alternative to standard TKE.
  15. Paul likes trekking poles for hikers. (I’ve been using these for years; Leki brand.)
  16. Not from Paul: Home physical therapy for six weeks
  17. Not from Paul: Turkish get-ups now or later? Much further into recovery!

Update of Progress on April 4, 2019:

Knee definitely feeling better, probably due to profound rest as above.  On Feb 23, I aggravated knee mildly by sledding in snow with Paul in Care Free – no regrets! Around Feb 26, Sunny got me started on Platinum’s Ortho-Chon Plus, 3 caps twice daily. Per 3 caps: glucosamine sulfate 800 mg, turmeric 380 mg, methylsulfonylmethane 350 mg, berberine HCL 145 mg, Boswellia serrata extract 140 mg, hyaluronic acid 50 mg, cat’s claw 10 mg, total cetylated fatty acids 3 mg. Not sure if these did any good at all; I’m skeptical. Started feeling less pain around Feb 29.

I am not healed or in remission yet. Doing hip exercises twice or once/wk with Therabands: clamshells, straight leg raises, side-lying straight leg raises, hamstring curls.

I had to put hip exercises on hold temporarily on March 28 due to a right low back muscle strain either from the exercises or weed pulling.

Update on Nov 25, 2019:

The PFPS is in remission and has been since July or so. For the last couple months I’ve been doing single-leg Romanian deadlifts and “walking” on elliptical-type aerobic machines at Anytime Fitness—some machines also work the upper limbs, others don’t—which are very easy on my knees. Avoiding treadmill since I have a palpable click in one knee, and treadmill aggravates my degenerative joint disease (DJD in both knees but predominantly left knee).

Next step is to slowly re-introduce exercises that load the knees (particularly the patell0-femoral joint). This is scary but must be done. My quads have atrophied somewhat. Squats? Lunges? Bulgarian split squats?

Steve Parker, M.D.

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com

1 Comment

Filed under Knee Pain

January 23, 2020 · 7:00 AM

Both Low- and High-Carb Diets May Kill You

In the research at hand, low-carb was defined as under 40% of calories from carbohydrate, and high-carb was over 70% of calories.

Garlic Naan, a type of flat bread, definitely high-carb

The longevity sweet spot was 50-55% of calories from carbs. You know what? That’s the typical carb percentage in the traditional Mediterranean diet.

If you want to eat low-carb, read more below to identify the possibly healthier substitutions for carbs. Tl;dr version: Eat plant-derived protein and fats.

From a 2018 study in The Lancet Public Health:

Background

Low carbohydrate diets, which restrict carbohydrate in favour of increased protein or fat intake, or both, are a popular weight-loss strategy. However, the long-term effect of carbohydrate restriction on mortality is controversial and could depend on whether dietary carbohydrate is replaced by plant-based or animal-based fat and protein. We aimed to investigate the association between carbohydrate intake and mortality.

Methods

We studied 15 428 adults aged 45–64 years, in four US communities, who completed a dietary questionnaire at enrolment in the Atherosclerosis Risk in Communities (ARIC) study (between 1987 and 1989), and who did not report extreme caloric intake (4200 kcal per day for men and 3600 kcal per day for women). The primary outcome was all-cause mortality. We investigated the association between the percentage of energy from carbohydrate intake and all-cause mortality, accounting for possible non-linear relationships in this cohort. We further examined this association, combining ARIC data with data for carbohydrate intake reported from seven multinational prospective studies in a meta-analysis. Finally, we assessed whether the substitution of animal or plant sources of fat and protein for carbohydrate affected mortality.

Findings

During a median follow-up of 25 years there were 6283 deaths in the ARIC cohort, and there were 40 181 deaths across all cohort studies. In the ARIC cohort, after multivariable adjustment, there was a U-shaped association between the percentage of energy consumed from carbohydrate (mean 48·9%, SD 9·4) and mortality: a percentage of 50–55% energy from carbohydrate was associated with the lowest risk of mortality. In the meta-analysis of all cohorts (432 179 participants), both low carbohydrate consumption (70%) conferred greater mortality risk than did moderate intake, which was consistent with a U-shaped association (pooled hazard ratio 1·20, 95% CI 1·09–1·32 for low carbohydrate consumption; 1·23, 1·11–1·36 for high carbohydrate consumption). However, results varied by the source of macronutrients: mortality increased when carbohydrates were exchanged for animal-derived fat or protein (1·18, 1·08–1·29) and mortality decreased when the substitutions were plant-based (0·82, 0·78–0·87).

Interpretation

Both high and low percentages of carbohydrate diets were associated with increased mortality, with minimal risk observed at 50–55% carbohydrate intake. Low carbohydrate dietary patterns favouring animal-derived protein and fat sources, from sources such as lamb, beef, pork, and chicken, were associated with higher mortality, whereas those that favoured plant-derived protein and fat intake, from sources such as vegetables, nuts, peanut butter, and whole-grain breads, were associated with lower mortality, suggesting that the source of food notably modifies the association between carbohydrate intake and mortality.

Source: Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis – The Lancet Public Health

Steve Parker, M.D.

PS: These types of studies are often unreliable.

 

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com

 

2 Comments

Filed under Carbohydrate, Longevity

January 22, 2020 · 7:00 AM

Diabetes Drug Dapagliflozin Prevents Worsening Heart Failure and Cardiovascular Deaths

Pulmonary artery arrow is wrong

The amazing thing about this research is that dapagliflozin 10 mg/day seemed to benefit patient who didn’t even have diabetes. Unfortunately, the abstract doesn’t mention how many non-diabetic patients were in the study. As always, you should take news like this with a grain of salt.

Conclusion from the abstract:

Among patients with heart failure and a reduced [left ventricular] ejection fraction [under 40%], the risk of worsening heart failure or death from cardiovascular causes was lower among those who received dapagliflozin than among those who received placebo, regardless of the presence or absence of diabetes.

Source: Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction | NEJM

Steve Parker, M.D.

PS: Your doctor isn’t going to prescribe dapagliflozin for you if you don’t have diabetes. Guess what else helps prevent heart failure and premature cardiac death. The Mediterranean diet.

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com

1 Comment

Filed under Heart Disease

January 21, 2020 · 7:00 AM

Dr David Unwin Explains Why He Favors Low-Carb Eating as Best Diet for Type 2 Diabetes

 

diabetic diet, Paleobetic diet, diabetes,

Sunny’s Super Salad

The Diet Doctor website posted a video interview of Dr David Unwin (in the U.K.) discussing his experience with low-carb diets in folks with diabetes (type 2, I assume). If  you’re short on time, just read the transcript. Thanks, Diet Doctor!

I took note of Dr Unwin’s transformation from a run-of-the mill follow-the-herd practitioner to a low-carb advocate. This happened around 2012 when Dr Unwin was 55 years old and on the threshold of retirement. Here it is:

Dr David Unwin speaking: ….There was one particular case I’ve talked about before where there was a patient who – so in 25 years I’d never seen a single person put their [type 2] diabetes into remission, I had not seen it once. I didn’t even really know it was possible.

Dr Bret Scher speaking:  We were not [taught] that it’s possible.

Dr Unwin:  No, my model was that the people with diabetes… It was a chronic deteriorating condition and I could expect that they would deteriorate and I would add drugs and that’s what would be normally going to happen. And then one particular patient wasn’t taking her drugs and she actually went on the low-carb diet and put her diabetes into remission.

But she confronted me with, you know, “Dr. Unwin, surely you know that actually sugar is not a good thing for diabetes.” “Yes, I do.” But then she said, “But you’ve never once in all the years mentioned that really bread was sugar, did you.” And, you know, I never did. I don’t know what my excuse was. So this this lady had done this wonderful thing and she’d also changed her husband’s life as well.

She’d sorted his diabetes out and she’d done it with a low-carb diet and that really made me think I didn’t know much about it. I didn’t know much about it. So I found out what she’d been on… on the low-carb forum of diabetes.co.uk and to my amazement there was 40,000 people on there, all doing this amazing thing. And I was blown away but then I was very sad because the stories of the people online were full of doctors who are critical of these people’s achievements.

***

Dr Unwin: And that original case that showed me you could put into remission; if you could repeat that, how wonderful for people… And when I now – because I think we’ve done 60 patients who put their type 2 diabetes into remission. So I’m able to say with confidence to people, you know, you stand a good chance. In fact I can say that of my patients who take up low-carb, about 45% of them will put their diabetes into remission which is amazing.

At no point does the transcript indicate they’re talking about type 2 diabetes rather than type 1, but that must be the case. Nor does it mention the amount of required carbohydrate restriction. I figure it’s between 20 and 100 grams/day of digestible carbohydrate, depending on one’s metabolic health and how many years of diabetes.

I’ve mentioned Dr Unwin before.

Source: Diet Doctor Podcast #33 – Dr. David Unwin – Diet Doctor

Steve Parker, M.D.

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com

2 Comments

Filed under Carbohydrate

January 13, 2020 · 7:00 AM

Think Twice Before Heart Artery Stenting or Bypass

Heart attacks and chest pains are linked to blocked arteries in the heart

Doctors are often criticised for over-using coronary artery angioplasty/stenting and coronary artery bypass grafting.

From Stanford Medicine:

Patients with severe but stable heart disease who are treated with medications and lifestyle advice alone are no more at risk of a heart attack or death than those who undergo invasive surgical procedures, according to a large, federally-funded clinical trial led by researchers at the Stanford School of Medicine and New York University’s medical school.

The trial did show, however, that among patients with coronary artery disease who also had symptoms of angina — chest pain caused by restricted blood flow to the heart — treatment with invasive procedures, such as stents or bypass surgery, was more effective at relieving symptoms and improving quality of life. “For patients with severe but stable heart disease who don’t want to undergo these invasive procedures, these results are very reassuring,” said David Maron, MD, clinical professor of medicine and director of preventive cardiology at the Stanford School of Medicine, and co-chair of the trial, called ISCHEMIA, for International Study of Comparative Health Effectiveness with Medical and Invasive Approaches.

***

“Based on our results, we recommend that all patients take medications proven to reduce risk of heart attack, be physically active, eat a healthy diet and quit smoking,” Maron said. “Patients without angina will not see an improvement, but those with angina of any severity will tend to have a greater, lasting improvement in quality of life if they have an invasive heart procedure. They should talk with their physicians to decide whether to undergo revascularization.”

Source: Stents, bypass surgery show no benefit in heart disease mortality rates among stable patients | News Center | Stanford Medicine

Steve Parker, M.D.

PS: The Mediterranean diet is a healthy diet, reduces the risk of heart disease, and you can even lose weight with it!

low-carb mediterranean diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords.com.

1 Comment

Filed under coronary heart disease, Heart Disease

January 12, 2020 · 10:10 PM

Not Into Salads? Try This!

Salad and cheese

Jan over at Low Carb Diabetic has a great post on building a salad from the ground up.

“Salads make a nutritious and satisfying meal, whether it’s for lunch or dinner. The best part is that no two salads are exactly the same. There are limitless ways to make salad unique and flavourful. Get some tips for what to add to your next salad….”

Source: The Low Carb Diabetic: Super Salads – Some Tips for Building A Better Salad

Click for my nutritional assessment of various salad greens. Variety is also important.

Steve Parker, M.D.

1 Comment

Filed under Uncategorized

January 12, 2020 · 7:00 AM

One Expert’s Anti-Aging Program

dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

“Darling, think about upping your NMN dose.”

The goal isn’t simply to live longer, but to be vigorous and functional for longer.

David Sinclair is a PhD professor and researcher at Harvard. Harriet Hall, M.D., reviewed his 2019 anti-aging book at Science-Based Medicine. Here’s his current anti-aging regimen as outlined by Dr Hall:

He makes no recommendations for others except “Eat fewer calories”, “Don’t sweat the small stuff”, and “Exercise”.

But he argues that if he does nothing, he will age and die, so he has nothing to lose by trying unproven treatments, and he has personally chosen to do these things:

    • He takes a gram each of NMN [nicotinamide mononucleotide] resveratrol, and metformin daily.
    • He takes vitamin D, vitamin K2, and 83 mg. aspirin.
    • He limits sugar, bread, and pasta intake, doesn’t eat desserts, and avoids eating meat from animals.
    • He skips one meal a day.
    • He gets frequent blood tests to monitor biomarkers; if not optimal, he tries to moderate them with food and exercise.
    • He stays active, goes to the gym, jogs, lifts weights, uses the sauna and then dunks in an ice-cold pool.
    • He doesn’t smoke.
    • He avoids microwaved plastic, excessive UV exposure, X-rays, and CT scans.
    • He tries to keep environmental temperatures on the cool side.
    • He maintains a BMI of 23-25 [click to calculate your BMI].

He plans to fine-tune his regimen as research evolves. He acknowledges “It’s impossible to say if my regimen is working…but it doesn’t seem to be hurting.” He says he feels the same at 50 as he did at 30.

Source: Aging: Is It a Preventable Disease? – Science-Based Medicine

For additional science-based info on anti-aging, see P.D. Mangan’s blog.

Steve Parker, M.D.

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com

1 Comment

Filed under Longevity

January 11, 2020 · 7:00 AM

Takine BP Meds at Bedtime Prevents Cardiovascular Events

High blood pressure is linked to heart attacks

Very recently I have noticed hypertension patients taking their medications at bedtime. Now I know why.

From Medscape:

Taking antihypertensive medication at bedtime led to an almost halving of cardiovascular events in a new study.

The Hygia Chronotherapy Trial is the largest ever study to investigate the effect of the time of day when people take their antihypertensive medication on the risk of cardiovascular events.

The trial randomly assigned 19,084 patients to take their medication on waking or at bedtime and followed them for an average of 6 years.Results showed that patients who took their pills at bedtime had a 45% reduction in overall cardiovascular events. This included a 56% reduction in cardiovascular death, a 34% reduction in myocardial infarction (MI), a 40% reduction in coronary revascularization [bypass surgery and angioplasty/stenting], a 42% reduction in heart failure, and a 49% reduction in stroke, all of which were statistically significant.

***

“We showed that if blood pressure is elevated during sleep then patients have increased cardiovascular risk regardless of daytime pressure, and if blood pressure during sleep is normal then cardiovascular risk is low even if the [doctor’s] office pressure is elevated,” Hermida said.

***

Results showed that during the 6.3-year median patient follow-up, 1752 participants experienced the primary cardiovascular disease (CVD) outcome (a composite of CVD death, MI, coronary revascularization, heart failure, or stroke).

Drug classes at physicians’ disposal were ARBs (angiotensin receptor blockers), calcium channel blockers, ACE inhibitors, and diuretics. Preventative effects were most pronounced for ARBs and ACE inhibitors.

Don’t change your BP medication dosing until you check with your personal physician.

Source: Bedtime Dosing of Hypertension Meds Reduces CV Events

Did you know most heart attacks occur in the morning, and those tend to be the most serious?

Steve Parker, M.D.

PS: Exercise and loss of excess weight help control blood pressure and prevent cardiovascular disease. I can help you with those…

low-carb mediterranean diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords.com.

 

 

1 Comment

Filed under coronary heart disease, Heart Disease, Stroke

January 10, 2020 · 6:43 AM

Science Skepticism

 

“You can’t tell whether I’m lying, delusional, ignorant, or simply incompetent. Sometimes even I don’t know!”

I ran across a 2016 article by Callie Joubert that summarizes skeptical ideas I’ve read about for years, but most people and physicians don’t know about. Bottom line: scientific research and medical studies aren’t nearly as reliable as you think.

Read the whole thing, but here are some excerpts:

We tend to think of science as a dispassionate (impartial, neutral) search for truth and certainty. But is it possible that we are facing a situation in which there is a massive production of wrong information or distortion of information? Is it possible that certain scientific disciplines are facing a crisis of credibility? Mounting evidence suggests this is indeed the case, which raises two questions: How serious is the problem? And what could explain this?

***

The title of an editorial in the prestigious medical journal The Lancet, dated April 6, 2002, asks the question, “Just How Tainted Has Medicine Become?”4 The article states, “Heavily, and damagingly so, is the answer.” Among other things, in 2001, researchers completed experiments with biotechnology products in which they had a direct financial interest and doctors did not tell their patients that others had died using these products when safer alternatives were available. In the same journal, dated April 11, 2015, Dr. Richard Horton stated the gravity of the problem as follows: “The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue . . . science has taken a turn towards darkness.”

In 2004, under the heading of “Depressing Research,” the editor of The Lancet had this to say about antidepressants for children: “The story of research into selective serotonin reuptake inhibitor (SSRI) use in childhood depression is one of confusion, manipulation, and institutional failure. . . . In a global medical culture where evidence-based practice is seen as the gold standard for care, these failings [i.e., of the USA Food and Drug Administration to act on information provided to them about the harmful effects of these drugs on children] are a disaster.”6 After being editor of the New England Journal of Medicine for 20 years, Dr. Marcia Angell stated that “physicians can no longer rely on the medical literature for valid and reliable information.”7 She referred to a study of 74 clinical trials of antidepressants that indicates that 37 of 38 positive studies were published. In contrast, 33 of the 36 negative studies were either not published or published in a form that conveyed a positive outcome. She also mentions the fact that drug companies are financing “most clinical research on the prescription drugs, and there is mounting evidence that they often skew the research they sponsor to make their drugs look better and safer.”

In 2011, researchers at Bayer decided to test 67 recent drug discoveries on preclinical cancer biology research. In more than 75 percent of cases, the published data did not match their attempts to replicate them.8 In 2012, a study published in Nature announced that only 11 percent of the sampled preclinical cancer studies coming out of the academic pipeline were replicable.9

In the prestigious Science journal, in 2015, the Open Science Collaboration10 presented a study of 100 psychological research studies that 270 contributing authors tried to replicate. An astonishing 65 percent failed to show any statistical significance on replication, and many of the remainder showed greatly reduced effect sizes. In plain terms, evidence for original findings is weak.

***

A discovery in physics, the hardest of all hard sciences, is usually thought of as the most reliable in the world of science. However, two of the most vaunted physics results of the past few years—“cosmic inflation and gravitational waves at the BICEP2 experiment in Antarctica, and the supposed discovery of superluminal neutrinos at the Swiss-Italian border—have now been retracted, with far less fanfare than when they were first published.”

***

Parker here again….

The science skeptic best known to physicians is John P.A. Ioannidis:

Empirical evidence from diverse fields suggests that when efforts are made to repeat or reproduce published research, the repeatability and reproducibility is dismal.

Another quote form Ioannidis:

There is increasing concern that most current published research findings are false. The probability that a research claim is true may depend on study power and bias, the number of other studies on the same question, and, importantly, the ratio of true to no relationships among the relationships probed in each scientific field. In this framework, a research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser preselection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance. Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias.

Ioannidis again:

Most physicians and other healthcare professionals are unaware of the pervasiveness of poor quality clinical evidence that contributes considerably to overuse, underuse, avoidable adverse events, missed opportunities for right care and wasted healthcare resources. The Medical Misinformation Mess comprises four key problems. First, much published medical research is not reliable or is of uncertain reliability, offers no benefit to patients, or is not useful to decision makers. Second, most healthcare professionals are not aware of this problem. Third, they also lack the skills necessary to evaluate the reliability and usefulness of medical evidence. Finally, patients and families frequently lack relevant, accurate medical evidence and skilled guidance at the time of medical decision‐making.

If you like videos, here’s Ioannidis on YouTube.

Staying skeptical,

Steve Parker, M.D.

h/t Vox Day

 

1 Comment

Filed under Uncategorized

January 9, 2020 · 7:00 AM

Do Certain Diabetes Drugs Protect the Heart and Kidneys?

 

Blood pressure control is also extremely important for protection of heart and kidneys

I’ve been reticent to tout the putative heart-protective effects of diabetes drugs in the classes called SGLT2 inhibitors and GLP-1 receptor agonists. Frankly, their supposed kidney-protective effects haven’t even been on my radar. My hesitation to report on these matters stems from:

Maybe if Big Pharma sent me a nice check….

The GLP-1 receptor agonists seem to have beneficial effects on both heart and kidney. With SGLT2 inhibitors, renal benefits may be more prominent than cardiac. Also note that any beneficial heart or renal effects may be attributable only to certain drug within the class, and not a class effect.

For what it’s worth, the American Diabetes Association recently hosted a conference on these issues. I assume the ADA endorses the report written by three experts, two of whom have received some sort of compensation from pharmaceutical companies. This doesn’t necessarily mean they are biased. Some excerpts:

Since patients with diabetes are at increased risk for CV [cardiovascular] and renal events, reducing the risk of these events is of primary interest to improve outcomes in the long-term. [Cardiovascular events usually refers to heart attacks, strokes, and death from those. Renal events would be high loss of protein through the kidneys, impaired kidney function or chronic kidney disease, or the need for dialysis.]

SGLT2 inhibitors and GLP-1 RAs have dramatically changed the treatment landscape of type 2 diabetes due to their established CV benefits, and the observed improvements in renal function seen with these classes of agents are currently undergoing intense investigation.

***

It is now apparent that both SGLT2 inhibitors and GLP-1 RAs show consistent reductions in major adverse cardiovascular events for patients with established cardiovascular (CV) disease, and both appear to have renal benefits as well.

***

The nephron is the microscopic structural and functional unit of the kidney.

Renal effects of GLP-1 receptor agonists

These drugs may exert their beneficial actions on the kidneys through their effects on lowering blood glucose and blood pressure and by reducing the levels of insulin.

For GLP-1RAs, these [studies] include ELIXA with lixisenatide, LEADER with liraglutide, SUSTAIN-6 with semaglutide, EXCSEL with exenatide once-weekly, HARMONY with albiglutide, and REWIND with dulaglutide.

All these studies indicate that albuminuria [protein loss through urine] is reduced during treatment with GLP-1 RAs, and eGFR [estimated glomerular filtration rate, a measure of kidney function] appears to be stabilized.

These benefits are seen independently of HbA1c, weight, and blood pressure variations.

***

Heart attack is only one type of cardiovascular event

Cardiovascular effects of GLP-1 receptor agonists

Large CV outcomes trials with GLP-1 RAs have shown that these agents can reduce the risk of major adverse CV events, CV mortality, and all-cause mortality.

These CV benefits appear to be related to four distinct mechanisms:

    • Improve myocardial [heart muscle] performance in ischemic heart failure [caused by poor blood flow to heart]
    • Improve myocardial survival in ischemic heart disease
    • Ameliorate endothelial dysfunction [endothelium is the lining of arteries]
    • Decrease markers of CV risk.

***

Renal effects of SGLT2 inhibitors

  • However, many potential mechanisms have been linked to the renoprotective effects of SGLT2 inhibitors.
  • These include reduction of blood pressure, improved metabolic parameters, reduced volume overload, reduction in albuminuria, and glomerular pressure.
  • For the latter, SGLT2 inhibition appears to reduce hyperfiltration via a tubuloglomerular feedback mechanism.
  • Clinical data from CV outcomes trials have shown consistent variations in eGFR and reduction in death from renal causes with empagliflozin, canagliflozin, and dapagliflozin.
  • However, to gain more information about the renal effects of these agents, dedicated renal outcomes trials are needed to study reductions in albuminuria, changes in eGFR, number of patients reaching end-stage renal disease, need for dialysis, and deaths due to kidney failure.

***

Key Messages from the authors

Large CV outcomes trials have shown that both SGLT2 inhibitors and GLP-1 RAs are associated with significant reductions in CV events in patients with elevated CV risk.

From CV outcomes trials both classes of agents also appear to have renal benefits, although large dedicated studies are needed to establish the magnitude of this potential benefit

The mechanism of action at the basis of CV and renal benefits of SGLT2 inhibitors and GLP-1 RAs is complex, multifactorial, and still not completely understood.

 

I’m still skeptical but will keep an open mind.

Steve Parker, M.D.

PS: Bold emphasis above is mine.

low-carb mediterranean diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords.com.

 

 

3 Comments

Filed under coronary heart disease, Drugs for Diabetes, Heart Disease, kidney disease, Stroke