Tag Archives: guideline

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On line weight loss drugs

Don’t buy it. Apparently a company call Him is selling a compounded GLP-1 like drug, have worked around the DEA for the moment, but people are getting really sick and there have been some deaths. Article here.

The workaround is that the DEA will let compounding pharmacies make a drug if there is a shortage. Unfortunately, online companies are doing 734,000 prescriptions a month. People can get them on line without a doctor visit or labs, though there may be a doctor signing off. Remember that they are selling an untested GLP-1, and the side effects of the tested ones can include gall bladder disease, pancreatitis and gastroparesis, where the food sits in the stomach and doesn’t leave. And yes, there have been deaths. This may be the salt of the drug, so that it doesn’t have the slow absorption when injected, and hits all at once. Is weight loss that important?

The guidelines for weight loss drugs are here: https://www.aafp.org/pubs/afp/issues/2023/1000/practice-guidelines-medications-weight-loss.html. This article is from October 2023, so doesn’t have the latest offering. I recently saw a person who did not fall into those guidelines. I refused to prescribe. The person responded, “I’ll go to Mexico and get it.” I reply, “Be sure that they do laboratory work and talk to you about the potential side effects.” I am also reading that now there are faked weight loss injector pens circulating. I don’t know what is in them. Fentanyl? Floor sweepings? Who knows.

Meanwhile I am still working on a little weight loss myself. I don’t know if I’ve lost much but clothes are fitting better. The climbing gym and hiking are having an effect. Muscle burns 9 kcal per gram and fat only 4 kcal per gram, so building muscle slims one even if the weight stays the same. My endurance is rising. That feels so good after being on oxygen for a year and a half. I am still trying to eat 1/2 green/yellow or orange vegetables at each meal and I think that is helping too. All this discipline stuff, eeyuk. Oh well.

Anyhow, be careful out there. I do not recommend getting weight loss drugs off the internet or buying it from “friends of friends”. Bad news.

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Diabetes update

Friday I attended a Zoom diabetes update all day. Sigh. We are really doing diabetes wrong.

Diabetes affected every system in the body and so the guidelines want us to check everything. They made the point that controlled diabetes does NOT lead to blindness, kidney failure, and amputations. Only uncontrolled diabetes. There, do we feel better now?

There are three NEW things to check for. One is CHF, aka Congestive Heart Failure. Heart Failure is pump failure. It makes a lot more sense if you think of the heart as a pump. Diabetes doubles the risk of heart failure in men and increases it by five times in women. We are now to do a yearly BNP (Brain Natriuretic Peptide, got that?) except that it is useless if the person is in renal failure, because that raises it artificially.

The second NEW thing is liver problems. Liver failure is back in the top ten causes of death, having fallen off that list for a while. People drank more alcohol during COVID, there was more drug abuse adding to hepatitis B and C, but the biggest cause is NASH and NAFLD. More acronyms: NASH is Nonalchoholic Steatohepatitis and NAFLD is Nonalcoholic Fatty Liver Disease. This is related to overweight and obesity. Being overweight or obese messes up fat storage and over time this inflames the liver and then cells die, leading to cirrhosis. We are to watch liver tests, think about an ultrasound, and then there are two specific tests for cirrhosis.

Third NEW thing is Diabetes Distress. This is not depression. People score “depressed” on the PHQ-9 test, but don’t respond to anti-depressants. The lecturer said that we have to talk to the patient and find out why they are distressed, or what part of diabetes is getting them down. I thought that we should have been talking to the patient all along. There is a convenient 30 question tool we can use for this, if we have time. Will we?

Now, the old guidelines said that we are to check these things:

HgbA1C every 6 months if not on insulin, every 3 months on insulin and even more in pregnant patients.

Microalbumin/creatinine ratio: a urine test that tells us if the kidneys are starting to leak albumin. They shouldn’t.

Yearly eye test to check for diabetes damage.

Specific blood pressure ranges.

Keep everyone’s LDL cholesterol under 70. So nearly every person with diabetes gets a statin drug.

Do a foot check yearly for neuropathy.

So six things plus the new three. Can’t explain that in one visit and can’t do it in one visit either. I think we should revamp the Diabetes Distress tool and check if physicians and nurses have Guideline Distress. Diabetes is the most complicated set of guidelines other than pregnancy.

Diabetes also takes a lot of time for the person who has it. To check things “correctly”, it takes a minimum of two hours a day for Type II not on insulin and more like three or more for Type I and II on insulin. Think if you have to take two or three or more hours away from your current daily activities and devote it to diabetes. No wonder people are distressed.

The medicines are also confusing. Wegovy is in the same class as Ozempic, but is FDA approved only for weight loss in people who are overweight and have a complication, or people who are obese. Ozempic is for diabetes but people often lose weight so think about it if the person is overweight. Some of the medicines in that class also are approved to reduce the risk of heart disease, which goes up with diabetes. Another class has medicines some of which have approval for diabetes and others for diabetes and renal problems, BUT don’t use it if the eGFR is under 20, got that? The lecturer on medicines said that we’ll see less in each of those classes after they fight it out for dominance of the market. He’s been an endocrinologist for 30 years and remembers when the very first non-insulin medicine was approved. Cool! He is not discouraged, but another lecturer said that we have one endocrinologist for 5000 people with diabetes, which is not enough. We were encouraged to do more continuing medical education.

There is one guideline that I disagree with and would like to see changed. I will write about that next. After I memorize all of the different things the new medicines do, which is changing every month as new research comes out! Stay tuned!

I think I will put the clutch in and coast a bit. Or perhaps clutch handfuls of hair and pull at them, I don’t know.

For the Ragtag Daily Prompt: clutch.

I hiked again yesterday and had a very cooperative bunny stop for a snack in camera range.

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A yarn about paper

On Friday in the morning I took notes on paper. I was attending a conference on diabetes on Zoom. There are three new things added to the diabetes guidelines. It is now impossible to do a visit about diabetes and actually talk to the human being who has diabetes. We’ll be too busy doing the stupid checklists.

The personnel person stopped by. I said I was taking notes. “On PAPER? You are killing me!”

“Ok. I will use yarn this afternoon.” I drove home and got my knitting and worked on a sock in the afternoon. All the clinics were having a slow day. I guess the kids are getting out of school and everyone is feeling good. Or panicked.

I retain as much information knitting as I do taking notes. Tactile-auditory learner and the controlled fidgeting of knitting helps me stay awake, retain information, and produce socks and others items. I wear the socks more than I reread the notes.

I still like paper. I keep a paper journal. I wanted notes from the most complex lecture. The new medicines are jockeying for position but right now there are different indications for each one, so it’s rather confusing. They said that Type II Diabetes takes two hours daily to manage “correctly”. And that Type I and Type II on insulin take 3 or more. We are supposed to check for Diabetes Distress, which is not depression, exactly. I think I need to be checked for Guideline Distress and Contact Diabetes Distress, sigh. At least the Diabetes Distress speaker thought we should talk to the patient, though I think the talking should have been long before that. Medicine in the US is a mess.

I used the back of the clinic schedules for notes. I do print it out daily. It’s to try to run on time. What time am I supposed to see the patient, but they can be up to 7 minutes late and then the medical assistant still has to “room” them (yes, room has been verbed). Then I can go see them. So the theoretical starting time and the actual starting time can vary quite a bit. I don’t feel bad about being twenty minutes late if I didn’t get to go in the room with the last patient until twenty minutes late. Maybe a no show will let me catch up. Or not.

Anyhow, I still like paper.

For the Ragtag Daily Prompt: paper.

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Keep it simple

Sometimes I just despair as I read new guidelines. Don’t you? Maybe you are not a physician and don’t try to keep all of this impossible stuff in your head. Mine is full. Tilt.

Diabetes alone: if someone has type II diabetes, there are specific blood pressure guidelines, cholesterol guidelines, we are to do a hgbA1C lab test every six months minimum and more often if they are out of control, and a urine microalbumin/creatinine ratio yearly. If that starts being abnormal we are to start one of two classes of blood pressure medicines even if they have normal blood pressure.

Oh, and don’t forget: a yearly eye test and we are supposed to check their feet at EVERY visit to make sure they are not getting diabetic ulcers.

Got that? And that is just type II diabetes. And there are a whole raft of medicines, about forty right now. Some are weekly shots, some are daily tablets, some are twice a day or with every meal and they all have their own side effects, how fun. Check drug interactions, are their kidneys ok? Is their liver ok? Diabetes increases the risk of heart attack and stroke and don’t forget those feet.

Diabetes is one of the most complicated sets of guidelines, but there are a rather appalling number of guidelines. Maybe we should sic an AI on that job: Mr. Smith has type II diabetes poorly controlled, hypertension, erectile dysfunction, feels a little short of breath and has a bruise on his left shin after tripping yesterday. Please, AI, organize a twenty minute visit to cover as many things as possible efficiently and have the note finished and followup arranged by the end of it. Then it turns out that what Mr. Smith really wants to talk about is his niece who has just overdosed and nearly died from heroin, so everything else goes out the window. Maybe I should see him weekly for the next month.

Do you want to keep it simple and stay out of the doctor’s office and more importantly out of the hospital? If you are 25 and healthy, you don’t much care because old is unimaginable.

But there is a very nice study that looked at just five things regarding health, over 28 years for men and 34 for women: “The researchers looked at NHS and HPFS data on diet, physical activity, body weight, smoking, and alcohol consumption that had been collected from regularly administered, validated questionnaires.”

Here is an article about the study: https://www.health.harvard.edu/blog/healthy-lifestyle-5-keys-to-a-longer-life-2018070514186

Here is the study: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.032047

So let’s break the five things down. Here are the more formal definitions: “Using data from the Nurses’ Health Study (1980–2014; n=78 865) and the Health Professionals Follow-up Study (1986–2014, n=44 354), we defined 5 low-risk lifestyle factors as never smoking, body mass index of 18.5 to 24.9 kg/m2, ≥30 min/d of moderate to vigorous physical activity, moderate alcohol intake, and a high diet quality score (upper 40%), and estimated hazard ratios for the association of total lifestyle score (0–5 scale) with mortality.”

First: never smoking. I would add never vaping and not living in a cave and burning wood and hopefully not living right next to a 12 lane superhighway, all of which are bad for the lungs. Ok, while we are at it, don’t use methamphetamines or heroin or cocaine or krocodil, right? They didn’t even include those in the study.

Second: Body mass index 18.5-25. If you aren’t there, it is diet and exercise that need to change.

Third: Thirty minutes or more per day of moderate to vigorous physical activity. That can be ten minute intervals. Three can have an enormous effect on number two.

Fourth: moderate alcohol intake. Ok, alcohol is bad for the heart, period. So is tobacco. They defined moderate as less than or equal to “5 to 15 g/d for women and 5 to 30 g/d for men”. Let’s do the math: a 12 ounce beer that is 5% has 14gm of alcohol. Here: https://www.niaaa.nih.gov/alcohols-effects-health/overview-alcohol-consumption/what-standard-drink. The 8.9% 16 ounce beer at our local pub has quite a bit more. Here is a website where you can calculate how much alcohol is in a drink: https://www.rethinkingdrinking.niaaa.nih.gov/Tools/Calculators/Cocktail-Calculator.aspx.

Fifth: Diet. There is an overwhelming amount of confusing information on the internet and some of it is not only confusing but wrong. “Diet quality in the NHS, HPFS, and NHANES was assessed with the Alternate Healthy Eating Index score (Methods in the online-only Data Supplement), which is strongly associated with the onset of cardiometabolic disease in the general population.” I have not assessed my own Alternate Healthy Eating Index score. However, there are a couple very straightforward things that help with diet. First: No sweetened drinks. That means that sugary coffee with the syrup should go. I quit drinking mochas when I read that a 12 ounce one has 62 grams of carbohydrate. I would rather have a small dark chocolate. And sodas are just evil and juice not much better. Eat the fruit instead. Second: eat vegetables, every meal. A fruit is not a vegetable and no, potato chips don’t count. I mean a green or yellow or red vegetable. You can saute any vegetable, or any that I can think of. I am not counting grains as a vegetable, so pasta, pizza, potato chips and so forth do not count. Beans do count. Third: the DASH diet recommends only a tablespoon of sweetener per day. That is not very much. You can make that cheesecake slice last a week! A small piece of dark chocolate daily or tablespoon size chunk of that cheesecake.

I had a diabetic patient who would be fine, fine, fine, then out of control. “WHAT are you eating? And drinking?” The first time it was two 16 ounce Mochas a day. Then he was fine for a year and a half. Then labs went haywire again. “What are you drinking?” “Well,” he said, not wanting to admit it, “Ok, I decided to try Caramel Machiattos.” “No, no, no! You can’t do that! You’ll end up on insulin!” “Ok, ok, got it, got it.”

And what is the difference if I try to do those five things, you ask, skeptical. “We estimated that the life expectancy at age 50 years was 29.0 years (95% CI, 28.3–29.8) for women and 25.5 years (95% CI, 24.7–26.2) for men who adopted zero low-risk lifestyle factors. In contrast, for those who adopted all 5 low-risk factors, we projected a life expectancy at age 50 years of 43.1 years (95% CI, 41.3–44.9) for women and 37.6 years (95% CI, 35.8–39.4) for men.The projected life expectancy at age 50 years was on average 14.0 years (95% CI, 11.8–16.2) longer among female Americans with 5 low-risk factors compared with those with zero low-risk factors; for men, the difference was 12.2 years (95% CI, 10.1–14.2).”

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I took the photograph from Marrowstone Island. What does a healthy seal diet look like? I am so lucky to have miles of beach to hike, as long as I watch the tides and don’t mind rain.