Sunday, May 29, 2011

Metformin is first, but what diabetes medicine is #2?

Most experts seem to agree that for type 2 diabetes, metformin should be the first line therapy for most patients, but there is significant disagreement for which agent holds the #2 spot.  Recently, the NY Times wrote a piece "For Those With Diabetes, Older Drugs Are Often Best." claiming that docs should stick with the older, cheaper drugs.  This may be true for metformin, but likely not for sulfonylureas which cause hypoglycemia, weight gain and do not sustain glycemic control. This means the next agent will need to be a branded drug.  DPP4's likely Januvia and Onglyza and TZD's like Actos are but possibilities, and each has advantages and disadvantages over the other.  The DPP4's are the newest agents and therefore have the shortest track record.  We don't know whether they can sustain glycemic control, but 2 year data looks promising.  However, they are very clean with essentially no side effects.  The TZD's have been the best studied, and really the only drugs that have shown sustained glycemic control.  However, they have more side effects including edema, weight gain, a very small risk of non-vertebral fractures, a very small risk of heart failure in those at risk, and of course the FDA's concern about myocardial ischemia with Avandia (though not a concern with Actos per the FDA).   Both classes also come in combination with metformin.

For a more complete discussion, see my Medscape blog post "Metformin is first, but what diabetes medicine should be your second choice?" (You will need to create a log in and password for Medscape in order to see this).

Sunday, May 15, 2011

Time to Get Together on Reducing Health Care Costs

As reported in the Wall Street Journal Reports Show Strain of Health Costs, two reports just came out showing that out of control health care spending are about the crush the entire system and our country along with it.  The first report is from the Medicare Board of Trustees which stated that unless something radically changes, Medicare will go bankrupt in 2024. The second report regards what we pay for health care.  Per the WSJ Health Blog:

"The latest Milliman Medical Index, which measures the total cost of health care for a typical family of four covered by a preferred provider plan (PPO), rose 7.3% to $19,393 in 2011. The per-employee cost more than doubled between 2002 and 2011. And the employee’s share of that cost now stands at 39.7%."

In other words, escalating health care costs are destroying business in America making an economic recovery almost impossible and the health safety net for our senior citizens (which working non-seniors currently pay for) will shortly disappear.

We can argue whether or not heath care in America should be entirely government run or completely private.  We can argue whether health care is a right for our citizens or an entitlement we can't afford.  However, reducing the escalating cost of health care should be something both sides can come together on.

An editorial in today's Washington Post looks to where President Obama and Mr. Ryan could possibly come together:

"The current debate has an ideological incoherence on both sides. Republicans endorse a premium support model for Medicare even as they work to undo the new insurance exchanges in the health-care law. Democrats distrust premium support when it comes to Medicare but support the exchanges, with sliding scale subsidies that amount to premium support, in the health-care plan. The problem of getting health-care costs under control is complicated enough without knee-jerk opposition being the default reaction to any proposal from the other side."

Given that the 2012 elections are not far away, it is unlikely that there will be any common ground seeking in the near future.  However, our country can not wait much longer for politicians to put away their partisanship and come together on the one thing that both sides can and should agree on: we are spending too much money on health care and it is bankrupting the country.

Monday, May 9, 2011

May is National Women's Health Week

Happy Mother's Day! Hopefully, you sent your mom flowers, cards, etc. (or at least gave a phone call).  In thinking about mom (and all the women in our lives), it's important to remember their health. And, what better way to honor and celebrate the women in our lives than to support their health during National Women’s Health Week. Last week, the Kaiser Family Foundation issued a new report on Women’s Health and it’s clear that many women put their family obligations and friends ahead of their health.  Here are five suggestions for women (or the women in your lives) to take control of their health:
5 Ways to Take Control of Your Health During May Women’s Health Week

1. There’s a Doctor in the House. This month, schedule an appointment with your health care professional to receive your regular checkups and preventive screenings.  The new health care reform legislation requires new health plans to cover recommended preventive services, including mammograms, colonoscopies, immunizations, and well-baby and well-child screenings without charging deductibles, co-payments, or co-insurance. It also assures women the right to see an OB/GYN without having to obtain a referral first. To learn more about the new benefits and cost savings available, please visit

2. Move! Exercise is critical to staying healthy and managing chronic diseases such as diabetes, hypertension and arthritis pain. And, exercise can help prevent more serious complications, such as diabetic peripheral neuropathy (DPN) in diabetics.  With the responsibilities of work and family, it’s understandable that it might seem impossible to find the time and motivation to get moving. But physical activity can be as simple as taking the stairs, taking a walk at lunch with coworkers, setting a good example for your family by playing with your children outside, or going dancing with friends or family.
3. "Winning" by unwinding. Many women feel heavy stress from health, economic, and family issues, including health problems of their family members, financial concerns, and career challenges. Mental health is an often overlooked but critical aspect of women’s health care. Pay attention to your mental health, including getting enough sleep and managing stress to help prevent chronic disease. Take some “me time” to relax and meditate. Give yourself a pat on the back for taking steps to better health.

4. Food for Thought. An important factor in preventing chronic diseases is to maintain a healthy weight. Eating a balanced diet high in fruits and vegetables, whole grains, lean protein and dairy, and “good fat” is easier than think. Eating right for you also sets a good example for your family.

5. No Smoking! Avoid risky behaviors, such as smoking. Speak with your health care provider and your employer about benefits and resources available to help you quit like the one available to Federal Employees and retirees