NSAIDS and Heart Failure in Type II Diabetics

The European Society of Cardiology is receiving a presentation on the increased risk of heart failure occurring in Type II Diabetics over the age of 65 years with an elevated HgbA1C level. The mechanism of the heart failure is still under discussion and being researched and it is believed to be beyond the accepted increased retention of fluid that occurs when you take an oral NSAID. The risk of developing heart failure was increased by almost 50% in Type II Diabetics 65 years of age or older. It was clearly not seen in patients with a normal HgbA1C younger than 65 years of age.

The study was led by Anders Halt, MD, a cardiologist and epidemiologist, who accessed the Danish National Health Registry to obtain his raw data. In his study it was clear that older age and elevated HgbA1C were present in those patients developing heart failure and requiring treatment and/or hospitalization. In Denmark patients were using Diclofenac Sodium and Ibuprofen primarily with few using celexocab or naproxen products.

As we age, we develop joint inflammation and aches and pains that make us reach for an over-the-counter anti-inflammatory medication frequently. This study raises the question clearly “If you are a Type II diabetic over sixty-five years of age with poorly controlled sugars should you be looking elsewhere than NSAIDs for relief”. Diclofenac sodium is no longer in oral form in the USA, but ibuprofen certainly is. The study clearly outlines the need for exploration of the mechanism of the heart failure. I believe the reason heart failure occurs must be clarified but until that occurs older Type II diabetics should be wary of reaching for an NSAID for relief of aches and pains.

Prediabetes & Exercise

Prediabetes is a condition that identifies individuals who have an increased risk of becoming Type II diabetics. It is diagnosed with either a fasting blood glucose measurement of 100-125 or an elevated Hemoglobin A1C level. The Hemoglobin A1C level provides a look at the average blood sugar level over the previous 8-12 weeks and is fairly independent of the previous few meals.

Gone are the days of the physician saying to his patient, “your blood sugar was elevated at 120” and the patient responding, “Well it was my birthday this week and I had some cake and alcoholic drinks causing the elevation.” The hemoglobin A1C removes that reason.

When physicians diagnose patients with “prediabetes” we try and educate the patient and family encouraging dietary education on a healthy eating lifestyle, weight reduction if they are overweight and regular exercise. Fortunately, in the senior citizen age group, newly diagnosed prediabetics usually don’t end up developing full blown diabetes if they watch their weight and get active.

A recent study published in BMC Endocrine Disorders found that aerobic exercise was best at controlling Hemoglobin A1C levels but resistance training was not far behind. Those individuals who engaged in both aerobic training plus resistance training showed better weight control and fasting blood glucose levels than the control groups or aerobic training alone. When evaluating the data both aerobic training and resistance training helped. The message to me for my patients is, if you are a prediabetic, start exercising doing what you enjoy doing. Make it fun, not work. Couple that with a dietary education from a trained dietitian or diabetes peer educator and you will do well.

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.