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I saw my pcp yesterday and he recommended that I go off of insulin altogether. I have been tapering off for a few weeks (since I went VERY low carb) and was going to give it a bit longer before ending it all together, but he thought it was not necessary any more. And he said to lower the amount of glucophage I am taking.

Three months ago he said I should consider taking an ACE inhibitor and a statin, but this time he said things were looking like I could put those off for a while. I am very happy about that.

Susan
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Woo Hoo!!!

CONGRATULATIONS, Susan!!! That's great news!!! I'm really hoping that it goes well with you.

Apathy4All
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Outstanding, Susan! Doing whatever you've done to get this far is great..and will pay great dividends. Insulin that has to be piped in (via needles) or or more forced out (via, for example, orals like I used to take) is 'bad'; increases insulin resistance (not the direction we want to go!), increases weight (same comment), and guarantees more too-low lows.
WELL DONE!!!

>>Three months ago he said I should consider taking an ACE inhibitor and a statin, but this time he said things were looking like I could put those off for a while. I am very happy about that.<<

Errr.....not sure about that; though I don't know your age and other stats et al. If you were a Type-II, obese male in his 40s or more (not that I know any of those, understand), I would, all things considered, Disagree with that conclusion. Especially the statin; but even the ACE inhibitor.
Look, not a 6-month period goes by without someone, somewhere, finding out that statins, in general, seem to have yet another positive effect on the over 40 crowd (and definitely the over 50 crowd. The British National Health Service, for example, is seriously considering making taking a statin over 50 as 'standard'). Anyone who is a Type II diabetic...especially males...are, BY DEFINITION, at-risk individuals. As my own PCP put it, 'you're male, type 2...you already have heart disease; you've already had your first heart attack. And we base everything else on that'. (I haven't had a 'real' heart attack, per se, yet. If/when it comes, it will come against a heart that's already 'suffered', is what he....and the Diabetes Association...are saying).

My spouse has MS; there are even indications that a small dose of statin...'particularly in women over 50 with MS'-- will end up being 'indicated', according to the head of the UMich MS Program at a seminar he gave last week. He said he has a low threshold, therefore, in putting his female patients on low-dosage statin even with 'ok' cholesterol (meaning he has no problems putting them on it unless contraindicated by something else). (Also keep in mind: 'ok' levels of cholesterol generally need to be even stricter with Type-II diabetics, anyway). And, while all drugs have side effects of some sort, so does NOT taking them, sometimes. Keep in mind, before 1900, the word most commonly used to describe the 'average' Joe like me (i.e., male, 48), was 'dead'. We're living longer; but we've got to live smarter, too.

Statins are now the most prescribed drug in human history; and it looks like they will continue to grow in usage. Small-dose usage by people who clearly already have a risk factor...and Type-II diabetes is one of the biggest ones....is erring on the safer side, in my view (all things considered of course).

Regards,

JP
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Errr.....not sure about that; though I don't know your age and other stats et al. If you were a Type-II, obese male in his 40s or more (not that I know any of those, understand), I would, all things considered, Disagree with that conclusion. Especially the statin; but even the ACE inhibitor.
Look, not a 6-month period goes by without someone, somewhere, finding out that statins, in general, seem to have yet another positive effect on the over 40 crowd (and definitely the over 50 crowd. The British National Health Service, for example, is seriously considering making taking a statin over 50 as 'standard'). Anyone who is a Type II diabetic...especially males...are, BY DEFINITION, at-risk individuals. As my own PCP put it, 'you're male, type 2...you already have heart disease; you've already had your first heart attack. And we base everything else on that'. (I haven't had a 'real' heart attack, per se, yet. If/when it comes, it will come against a heart that's already 'suffered', is what he....and the Diabetes Association...are saying).


Generally true.

Diabetics suffer damage to kidneys on a microscopic level (at the tiny tubules that connect the "filter" and the filter itself - the glomerulus). This leads to loss of protein in the urine (proteinuria), and gradually accelerating kidney damage. This protein can be measured even at an early stage with a test called urine microalbumin. Angiotensin-converting-enzyme inhibitors, "ACE-I", by their effect on the tubules connected to the glomerulus can greatly slow this phenomenon and are said to be "renal protective" (the word renal referring to kidney). If you have microalbuminuria, you should be on ACE-I, though ask your doctor about the potential side-effects (usually minor and reversible). An alternative to an ACE-I is a simlar class of drugs called angiotensin receptor blockers or "ARB"'s which also provide this renal protection. Ask your doc if you might benefit from one.

By the way, the Joint National Committee on Hypertension (JNC), in its latest recommendations, have suggested that a diabetic's blood pressure should be 120/70 (or close) to greatly reduce stroke, renal and cardiac problems - this has been borne out by quite a few studies. ACE-I's and ARB's are anti-hypertensives and are considered first-line BP meds for diabetics (some restrictions apply which your doc can tell you about).



Statins are now the most prescribed drug in human history; and it looks like they will continue to grow in usage. Small-dose usage by people who clearly already have a risk factor...and Type-II diabetes is one of the biggest ones....is erring on the safer side, in my view (all things considered of course).


Absolutely true to this point. I've discussed statins here several times and prescribe them extensively, including to myself. I think I mentioned previously that a recent study strongly suggested that the statin Zocor, made by Merck, was successful in lowering the risk of 1st heart attack in diabetics even without elevated cholesterol at baseline (it was the only statin in the study and will probably be a class-effect). Ask your doc about a statin and the monitoring and possible side-effects that may go with it.

ab - am I being helpful to the board?

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I read every post you write. And, will talk to my physician about statins.

Thanks,

WC
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ab - am I being helpful to the board?

Absolutely! Much appreciate the info.
Ted
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Statins are now the most prescribed drug in human history; and it looks like they will continue to grow in usage. Small-dose usage by people who clearly already have a risk factor...and Type-II diabetes is one of the biggest ones....is erring on the safer side, in my view (all things considered of course).


And, probably, rightly so. The Pravastatin studies indicated a 50% reduction in heart attacks for patients taking Pravastatin vs controls. That's phenomenal! Although the results are not in, hopefully the more potent analogs (Lipitor et al.) will show even better numbers.

We may be looking at a situation where beta-blockers plus statins controls 75% or more of prospective heart attacks. That's phenomenal!!!


OleDoc
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Yikes, folks! Susan said she was on a very low carb diet which is no doubt the reason for her doctor no longer wanting to put her on statins. Low carbing is the only way of eating to date that has been shown to improve one's cholesterol and lipid profile based on studies that were actually constructed to show the opposite. Perhaps I am reading your replies wrong, but why the cheerleading for taking drugs when modifying your diet does the trick just as well with out any side effects or budgetary calamities of popping very expensive pills?

InParadise,
who would much rather tackle the root cause than simply hide the effect with medecines.
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>>Perhaps I am reading your replies wrong, but why the cheerleading for taking drugs when modifying your diet does the trick just as well with out any side effects or budgetary calamities of popping very expensive pills?<<

I feel you're reading them wrong! If you don't mind a little repetition:

And, while all drugs have side effects of some sort; so can NOT taking them, sometimes. Keep in mind, before 1900, the word most commonly used to describe the 'average' Joe like me (i.e., male, 48), was 'dead'. We're living longer; but we've got to live smarter, too.

I'm on a medically-supervised, very low-carb diet, too. Down 103 pounds so far (13 months). As you said, it had a dramatic effect on all of my numbers (though I continued taking the statin; in this case, lipitor). Total cholesterol got down into the 90s from the 200s; LDL got down into the 40s; HDL, from 29 to into the 40s. (I was later able to raise up the HDL into the 50s by adding no-flush niacin, and increasing my exercise to daily).

Now, after all of this, both my weight-loss MD, as well as my PCP, ended up agreeing:
1) that I should stay on a statin (i.e., lipitor); though they disagreed whether I should stay at 20 mg, or lower it to 10mg. and,
2) that I needed to stay on my bp medication.

Their reasoning was as I've indicated before: I'm no longer 'ok'; I'm a Type II diabetic---for life. (That could probably have been avoided if I had taken care of myself in previous years; but, once you've tipped yourself over....you're there). That automatically means I'm AT RISK for the rest of my life. (Not automatically dead, mind you; but permanently on the edge in many ways). As I mentioned before, my PCP said that that essentially already means I now have heart disease; when my (permanently?) high bp is added to that....... it means I just can't eat well from now on and call it even. As previously mentioned, every year some statin ends up indicating it probably has another side benefit; and all things being equal, the safety profile is pretty darn good. Conclusion: keep going on the weight AND exercise AND niacin AND lipitor AND bp medication.

That's just me, of course; but that's why I was giving an example of a diabetic, obese, late 40s male. Your mileage may vary.

jp
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As previously mentioned, every year some statin ends up indicating it probably has another side benefit; and all things being equal, the safety profile is pretty darn good.

THAT'S THE POINT!!! The bottom line is that the current results indicate that statins REDUCE HEART ATTACKS by 50%. That's a phenomenal result!!!

Yeah, they reduce cholesterol levels. But statins affect a number of other metabolic pathways. It is quite possible that the dramatic effects of statin protection against heart attacks are a result of these other pathways and not due to the effects on cholesterol levels.


OleDoc
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Total cholesterol got down into the 90s from the 200s;...

Jim,

Congrats on getting your cholesterol under control, but are you aware that it can be too low? Cholesterol is a very important part of our body chemistry and IMO way too villainized by todays society, including many doctors.

I recently picked up this great book called The Protein Power Lifeplan, by Drs Eades. They spend a whole chapter going over cholesterol and lipids in great detail. One very interesting graph is on page 100 in the paperback version showing Total Mortality vs Serum Cholesterol. By looking at "deaths from all causes" rather than just "deaths from heart disease", the data shows that the best place to be is right around 200:

Look at how the mortality curve shoots sharply up as cholesterol falls below 160 mg/dl. It climbs even more steeply at the low end of cholesterol levels than at the high end, meaning that having a cholesterol reading below 140 mg/dl is as bad as or worse than having one above 240 as far as risk of dying goes. At the lower end of the scale, deaths don't occur from heart disease and stroke, rather people in that group die from cancer, suicide, homicide, and vehicular trauma (which quite often is disguised suicide.) .... Just a quick glance at this U-shaped line shows where you want to be--down there in the flat part of the bottom where the incidence of deaths of all kinds is lowest. This means your best bet would be to keep your cholesterol in the 160 to 220 range...

They go into great depth on all the different types of cholesterol, including the different kinds of LDLs which are not reported on our typical cholesterol profile where LDLs are approximated by subtracting HDLs and triglicerides from total cholesterol. They state that there are at least two types of LDLs, the bb type and a "fluffy" type, (for lack of a more scientific word.) It appears that the "fluffy" LDLs are heavily resistant to oxidation and some researchers believe they may even play an antioxidant role in your system. There is a very expensive test that can be done to determine the types of LDLs you have, but there is also a direct correlation with lowering your triglicerides resulting in an increase in the "fluffy cottonball" type LDLs. Basically, their point is that lowering your total cholesterol as low as you can is not a healthy goal.

They also go into some of the side effects of statins, some of which are not mentioned in the drug pamphlets. In addition to the better known liver dammage, skeletal muscle depletion and kidney failure, one of their primary concerns is that statins deplete the body of coenzyme Q-10, a critical antioxidant for the heart, thereby seriously increasing the risk of oxidative damage to tissues body wide. Dr. Andrew Weil is a strong proponent of taking as much Co Q-10 as you can afford on a daily basis. If you take statins, as some people must, the Eades suggest you take at least 300mg of an oil-based coQ10 every day as long as you take these drugs. They do suggest taking the niacin if your levels remain over 250 or LDLs over 190.

I realize they are not targeting diabetics specifically in their book, but they are dealing with cardiac patients, some of whom are diabetic. The book is a great read, and their statements are backed up by data and footnoted studies. Well worth the $9.99 I paid for it at Books-a-Million.


Food for thought,
InParadise


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THAT'S THE POINT!!! The bottom line is that the current results indicate that statins REDUCE HEART ATTACKS by 50%. That's a phenomenal result!!!


Doc,

Your point is an interesting one, but surely you admit that cholesterol serves an important function in the body and that one's cholesterol levels can get too low. I wonder if the studies that produced these impressive results looked at total mortality as well as cardiac events. Very low cholesterol can do a number on depression, and has been indicated in an increased risk of suicide, as well as other physical issues.

I often find it interesting to read the actual study report. They have to explain any "outliers" to the data they threw out, and how the study was designed, which can sometimes give insight into the validity of the study.

InParadise,

In God we trust, all others show data.
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In God we trust, all others show data.

Good advice, if you can follow it. Try PubMed...

http://www.ncbi.nlm.nih.gov/

Search for < pravastatin heart attacks >. A lot of the results have full text publications online free.

My PCP told me it was 50%; the articles I looked at pegged it at 25-30% over a six year study. The trend lines were still diverging at the end of 6 years so one might expect the risk reduction to increase after 6 years of therapy.

I don't know if these studies are still considered ethical in light of the dramatic reduction in death for those taking pravastatin.


OleDoc
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In addition to the better known liver dammage, skeletal muscle depletion and kidney failure, one of their primary concerns is that statins deplete the body of coenzyme Q-10, a critical antioxidant for the heart, thereby seriously increasing the risk of oxidative damage to tissues body wide.

I've heard this argument but I haven't checked it out to see how valid it is. I take CoQ-10 supplements anyway.

Actually, CoQ-10 is a cofactor for the oxidation reactions of the oxidative phosphorylation pathway in mitochondria. The mitochondria of both heart muscle and skeletal muscle use the ox-phos to generate lots of energy for muscle work as they "burn" the pyruvate produced by glycolysis to lactic acid (Cori cycle).

Here's a nice little biochemistry site...

http://web.indstate.edu/thcme/mwking/


OleDoc


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But statins affect a number of other metabolic pathways. It is quite possible that the dramatic effects of statin protection against heart attacks are a result of these other pathways and not due to the effects on cholesterol levels.


However, it is proposed that statins have cardiovascular effects beyond their ability to lower cholesterol, possibly via recruitment of phosphatidyl inositol 3-kinase (PI3K) and the serine/threonine kinase, Akt. This signaling pathway has recently been linked to growth factor-mediated reperfusion salvage.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12575984&dopt=Abstract


OleDoc
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Your point is an interesting one, but surely you admit that cholesterol serves an important function in the body and that one's cholesterol levels can get too low.

Absolutely. My thoughts are that levels of total cholesterol below 130 are "abnormal", i.e. they represent less than 5% of the population. It is a phallacy to assume that less is better; at some point less becomes a biochemical liability. Where this point is for cholesterol levels is unknown, but certainly if one is at the lower extreme, one is subject to cholesterol metabolism disorders just as much as one who is at the higher extremes.


OleDoc
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I've heard this argument but I haven't checked it out to see how valid it is. I take CoQ-10 supplements anyway.

I read several abstracts (about 20) of journal articles about this (search = < statins ubiquinone >). The consensus seems to be that statins do lower SERUM levels of ubiquinone (CoQ-10) and that supplements of CoQ-10 increase SERUM levels.

None of the studies that I found actually looked at ubiquinone levels in mitochondria isolated from animals treated with statins and/or ubiquinone supplements.

None of the studies addressed the correlation of serum levels of ubiquinone with levels in the mitochondrial membranes.

Until these studies are done properly, the jury is still out and I will continue to take the CoQ-10 supplements just in case...


OleDoc
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Where this point is for cholesterol levels is unknown, but certainly if one is at the lower extreme, one is subject to cholesterol metabolism disorders just as much as one who is at the higher extremes.

This causes me some concern since my total cholesterol level is 110. What are some of the cholesterol metabolism disorders that I should be on the lookout for? Any ideas on how to push up the cholesterol level without giving up giving up the statins? I'm currently taking 20 mg of lipitor. Would it help to reduce it to 10?
Thanks in advance.
Ted
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Ted,

I started a thread on cholesterol on the low carb board. Some of the replies have very interesting links, though I'm afraid a bit of a pissing contest is in there too.


http://boards.fool.com/Message.asp?mid=19469869&sort=whole#19470321

I would definitely discuss these issues with your doctor(s). I don't understand why they feel you are at increased cardiac risk as a diabetic over say a non-diabetic with cardiac issues. I've never seen this lower cholesterol at any cost approach before, but I admit I'm no doctor, (even though we sure do see enough of them in my family.) My dad, who had a tripple bypass 20+ years ago and my mom who suffered from a major stroke a few years back have not had this approach prescribed by any number of doctors visited, nor by the once over given by the Mayo clinic. Is one of your doctors an endocrinologist? If not, may be time to get one.

Best,

InParadise
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InParadise I would definitely discuss these issues with your doctor(s). I don't understand why they feel you are at increased cardiac risk as a diabetic over say a non-diabetic with cardiac issues.

I didn't provide enough information in my post. I'm at increased cardiac risk because I have had one heart attack. It was about 5 years ago. We (cardiologist and I) have been aggressively working to get the "good" cholesterol up and the "bad cholesterol" down since that time. Being a type II diabetic just complicates things.

Thanks for the idea of the endocrinolologist. I'll mention that to my GP when I go in for my annual physical in about three weeks.
Ted
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This causes me some concern since my total cholesterol level is 110. What are some of the cholesterol metabolism disorders that I should be on the lookout for?

I can't answer the what to look out for question. But, like IP said, cholesterol plays a central role in lipid metabolism and tissue structure. Total serum cholesterol <130 mg/dL is considered "hypocholesterolemia." There are a number of inherited disorders of cholesterol and lipoprotein metabolism but these do not apply to you but do indicate the importance of this metabolism in normals as well. Severe hypocholesterolemia correlates with increased mortality during hospital care (trauma, surgery, severe infections, etc).

With a level of 110 for TC, I would be concerned that your HDL levels are probably too low (<35-40 mg/DL). I don't know your overall profile; you'll have to discuss it with your MD, but certainly lowering the Lipitor to 10 mg would appear to be reasonable. If your TG's are still too high on 20 mg, it might be that your low TC might be causing a longer postprandial metabolism of dietary fat (elevated VLDL).


OleDoc
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With a level of 110 for TC, I would be concerned that your HDL levels are probably too low (<35-40 mg/DL). I don't know your overall profile; you'll have to discuss it with your MD

Just for completeness.
Triglycerides 55
cholesterol total 110
HDL cholesterol 50
LDL cholesterol 49
T-3 Uptake 27
Hemoglobin A1C 4.7
Creatine Kinase Total 67
Ck-BB 0
Ck-MM 0
CK-mm 100

Both my GP and cardiologist are pleased, but finding that I am in the bottom 5% causes me to start looking further afield for more information. I'm aware that no Doctor can keep up with everything. The other thing that concerns me is that I have been having quite a few PVC's lately. B.P. resting normally runs about 118/60.

I think the earlier suggestion to talk to an endocrinologist is something I need to do.
Ted
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Just for completeness.
Triglycerides 55
cholesterol total 110
HDL cholesterol 50
LDL cholesterol 49
T-3 Uptake 27
Hemoglobin A1C 4.7
Creatine Kinase Total 67
Ck-BB 0
Ck-MM 0
CK-mm 100

Both my GP and cardiologist are pleased, but finding that I am in the bottom 5% causes me to start looking further afield for more information.


Wow! That's impressive! My personal opinion is that there is no reason to keep you on 20 mg Lipitor; 10 mg Lipitor is all you need. You must be a "complier." (i.e. doing all the right things).

Don't let what I said scare you. "Severe hypocholesterolemia" generally refers to patients with TC levels <100 mg/dL. My opinion is that the ideal range for TC is 130 to 150.


OleDoc
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