Statin Use and Diabetes in Older Women

Older women who take statins may be at an increased risk of developing Type 2 Diabetes Mellitus (adult onset). In a study published in the Archives of Internal Medicine, Dr Ma, of the University of Massachusetts School of Medicine, looked at the 154,000 women in the Women’s Health Initiative who did not have Diabetes when the study began in 1993.  Seven percent (7%) of them were on statins at the time through follow-up, 12 years later.  At that point, 10,242 cases of new cases of diabetes were reported. They theorize that this computes to an almost 50% increase in becoming a Diabetic if you are on a statin as compared to women who are not. Surprisingly, this occurred far more frequently in thin women taking a statin than in heavy or obese women.

The salient points taken out of this research are that women on statins need their liver enzymes monitored frequently they need their blood sugars monitored as well. The overriding message is that as physicians and patients we need to make a monumental effort to control elevated lipids by diet , exercise and weight loss without statins if humanly possible.

This also raises the question of whether we should be measuring HDL and LDL subtypes an Lpa levels on all patients before instituting statin therapy?  While this raises doubt about a popular class of drugs that are a crucial part of the prevention of cardiovascular disease, it does not yet make it clear what the clinical implications are for postmenopausal women on statins.

I will reevaluate all my female patients on statins as I see them for follow-up visits.

Bariatric Surgery Reverses Diabetes – But What About Seniors?

A recent well written article in the Fort Lauderdale Sun Sentinel discussed how bariatric surgery to treat extreme obesity was also now a formidable weapon against Type II Diabetes Mellitus.   Type II Diabetes Mellitus or adult onset diabetes occurs in older individuals and is closely related to weight gain, high blood pressure, elevated cholesterol, triglycerides and accelerated narrowing of arteries. The accelerated artery-narrowing results in premature and advanced coronary artery disease and peripheral arterial vascular disease.  A study published in the American Journal of Medicine in 2009 looked at 3,188 obese Type 2 diabetics who had bariatric surgery and lost weight.  Amazingly, 78% of them no longer met the criteria to be called diabetics.

Bariatric surgery includes minimally invasive surgery such as laparoscopic adjusted gastric banding to the more invasive re-routing of the intestines and reduction of stomach volume in the classic Roux-en-Y gastric bypass. Other procedures include open duodenal switch and vertical banded gastroplasty.  These types of procedures are only performed in the morbidly obese defined as those with a Body Mass Index (BMI) of 40 or greater.  The results in reversing Type II diabetes have been so impressive that experts are now considering reducing the BMI to 35 for consideration of candidacy to have these procedures.

Why these procedure reverse diabetes is a matter of debate. Weight loss is a traditional successful treatment for Type II diabetes. Some believe that the actual surgery on the gut stimulates hormones that help control the blood sugar. The positive result has led insurance companies to now start approving payment for these procedures because the $18,000- $30,000 cost is cheap compared to the $300,000 lifetime cost of treating a Type II diabetic.

With so many elderly obese patients with Type II Diabetes, and other metabolic and cardiovascular complications of obesity in the health system, is the procedure safe for the elderly?  A recent study by Robert B. Dorman M.D., at the University of Minnesota seemed to indicate that the surgery is safe.  He looked at 48,378 patients with a BMI above 35 who had bariatric surgery between 2005 and 2009.  He found that the mortality rate for seniors over 65 was higher than for younger patients but was still extremely low and rare for a death to occur. Longer hospital stays were noted for the elderly and were related to how heavy the patient was prior to surgery.  This study gives bariatric surgeons excellent figures on the risk of complications when performing bariatric surgery in the elderly.

As a primary care physician working with elderly Type II Diabetics, I will continue to stress lifestyle improvement with dietary improvement, weight reduction, increased exercise and activity as first line therapy.  Medication when necessary will be next. Bariatric surgery, now proven to be safe is a new weapon available to the proper patient.  Finding an experienced surgeon in performing the procedures (more than 200 of that procedure) will be paramount in reducing complications and mortality.