I’m sorry to write about the same topic on two consecutive weeks, but this really deserves the attention.  Last week I wrote about how we’re still not past the peak of this flu season and how the flu shot this year has been less effective, and I linked to a few authoritative web sites that I thought would be useful.

This week, allow me some personal observations.

This year’s flu is hellish.  I’ve had young healthy patients who’ve been in bed for two weeks with it.  The important thing to know for those of you who don’t have it (yet) is that there is an antiviral medicine, Tamiflu, which shortens the duration of the flu if it’s started in the first 48 hours of symptoms.  So if you develop a high fever, aches, and a cough call your doctor that day.  I’ve seen several people who had already been ill for a week, and didn’t call sooner because they were sure they were about to improve.  I had nothing to offer them but medicines for their symptoms and sympathy.  This isn’t the year to postpone getting attention for the flu.

Next week, I promise to educate you about something else.

Tangential Miscellany:

If you know someone with some experience with website design, preferably with the WordPress publishing platform, please ask her to contact me.  I have a little project with which I need help.  Thank you.

The recent news about this flu season has all been bad.  As reported in this Reuters article, the match between the strains in this year’s flu vaccine and the strains that are actually making people sick in North America are not as close as in previous years, meaning the flu vaccine this year is giving patients less protection than it has in the past.  There are documented cases of vaccinated patients still coming down with confirmed flu infections.  Still, experts think that the vaccine may decrease the severity of the illness.

To make matters worse, it looks like we’re not nearly done with the flu season yet.  According to the weekly flu surveillance by the Centers for Disease Control and the California Department of Health Services incidence of flu both nationally and in California is still on the rise.

So where does that leave us?  Well, if you’re in a high risk group (pregnant women, people with chronic health conditions like asthma, diabetes or heart disease, and people 65 and older) getting the vaccine still makes sense.  It’s also a good time to reinforce good general germ-avoidance habits like frequent hand-washing and avoiding people who are sick.

Finally, since there is an antiviral medicine that shortens the duration of the flu but that only works if it’s taken within 48 hours of symptom onset, please take the time to read about the symptoms of flu and call your doctor promptly if you get sick.

Like the interminable primaries and the rainy weather, I hope this is over soon.

Last month BusinessWeek had a fascinating article about cholesterol-lowering medications.  The article also teaches us how we should calculate a specific medication’s benefit and harm, and how pharmaceutical companies manipulate our opinions by reporting benefits in percentages but side effects in absolute numbers.  If you want an interesting lesson in evidence-based medicine, or just in cholesterol treatment, take the time to read it.  (My only major objection to the article is the headline, “Do Cholesterol Drugs Do Any Good?”  Of course they do, and the article doesn’t even argue that they don’t.  A more accurate headline would have been “How Much Good Do Cholesterol Drugs Do?”)

Here are the take-home points.

• Statins definitely prevent strokes and heart attacks in people at high risk for strokes and heart attacks.
• Statins also lower cholesterol, but no one knows if that’s how they prevent strokes and heart attacks, or if they prevent strokes and heart attacks through some other mechanism.
• The greater a patient’s risk for stroke and heart attacks, the greater the benefit she derives from a statin.
• Patients who have no heart disease and no risk factors for heart disease (these are non-smoking men under 45 or women under 55 without high blood pressure, diabetes, or first-degree relatives with heart disease) are at such low risk from heart disease (regardless of their cholesterol) that their benefit from taking a statin is likely to be very small, and only realized after taking a statin for many years.  At that point the side effects of a statin, even if mild and rare, may actually be more significant than the tiny benefits.

(Thanks to Harriet E. for pointing me to the BusinessWeek article.)

Tangential Miscellany:

At the risk of horrible immodesty, I just have to brag for a second about electronic medical records (EMR).  After my post a few weeks ago about the bad news about Zetia and Vytorin I wanted to review all of my patients who were taking the medications to make sure that they were on it for appropriate reasons.  With our EMR I was able to generate a list of every patient on Zetia or Vitorin in a few minutes.  Try that with paper charts.

This week we learned something very important about diabetes.  We learned that we don’t know something we thought we knew.  (Regular readers will note that this keeps happening in medicine.  For a generation everyone assumes something.  Then we check and discover it isn’t so.)

We’ve always assumed that in type 2 diabetes, the closer to normal that blood sugar is lowered the fewer complications of diabetes patients would have.  Why?  Because diabetes is known to be a major cause of kidney disease, blindness, strokes and heart attacks, and we always assumed these complications are caused by the abnormally high blood sugars in diabetes.

We also have good studies in type 1 diabetes which prove that keeping sugar levels close to normal prevents complications.  So we assumed that this also applied to type 2 diabetes, even though type 1 and type 2 are completely different diseases.

With me so far?  We had lots of good reasons to assume that better sugar control in type 2 diabetes leads to fewer complications, and this assumption has guided diabetes management.  Finally a trial was undertaken to test this belief.  The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial enrolled over 10,000 people with type 2 diabetes who either already had cardiovascular disease or were at high risk for it.  The patients were randomized to one group which received conventional treatment which lowered sugars but not to normal levels, and another group which received intensive treatment which reduced blood sugars to non-diabetic levels.

This week the ACCORD trial was stopped early because of excess deaths in one group.  What stunned experts and will confuse diabetes management for some time is that the group with excess deaths was the group receiving intensive treatment.  This received a lot of media attention, including this NY Times article and this LA Times article.

So intensive lowering of sugars in type 2 diabetes is worse than more lax control of sugars, at least in patients with multiple risk factors for cardiovascular disease.  The burning questions now are:  What should our goal for blood sugars be?  How low is too low?  Do medicines that lower blood sugar in type 2 diabetes do any good?  No one knows.

For now the experts are calming the public by urging them not to change any of their medicines before discussing it with their doctor, but this reassurance simply covers up the ignorance in which we find ourselves mired.  The scary truth is that as of this week, and until more studies help us, we’re not really sure how we should be treating diabetes.

(I am grateful to Judy F. and Victoria W. for pointing me to the articles.)

The scientific evidence for treatment of obesity is trending in a very interesting direction.  For years a safe and effective medication for weight loss has been sought, with only modest results.  (I wrote about orlistat, the medication in Xenical and Alli, a year ago.)  Surprisingly, for obese patients evidence is increasingly mounting in favor of surgery for weight loss, rather than medications or even diet and exercise.

In 2006 a randomized study demonstrated that patients with mild to moderate obesity lost more weight and had a better quality of life than patients randomized to diet, exercise and weight loss medications.  Last week, the evidence got even better.  A study published in the Journal of the American Medical Association examined the effect of laparoscopic gastric banding on obese patients with diabetes.  The study randomized patients with recently diagnosed type II diabetes with body mass indexes between 30 and 40 (20 to 25 is normal) into two groups.  Both groups received conventional diabetes care with medications, but only one group underwent laparoscopic gastric banding.  The difference between the groups was very impressive.  73% of the surgical group had their diabetes entirely resolve, compared to 13% in the conventional therapy group.  The surgical group lost an average of 20% of their body weight, compared to 1.7% in the conventional therapy group.  Importantly, there were no serious complications in either group.  The study generated a lot of media coverage, including this article in the LA Times.

So if you have diabetes and are very overweight, surgery is no longer the most radical option.  It’s becoming the most conservative evidence-based option.  If this trend continues, diet and exercise for obesity will be considered the radical fringe option.

(I’m grateful to Jay F. for pointing me to the LA Times article.)

Tangential Miscellany:

My 15 minutes of fame is extended slightly by this article on concierge medicine.