From the office of Robert S. Grimshaw Jr MD FACP Internal Medicine 3535 Hill Blvd Yorktown Hts NY 914 962-3180 NEWS Recognized Provider  “With Distinction” by the American Diabetes Association/National Committee for Quality Assurance 2/99-2/02

102-103                         June  2001

 

New Cholesterol Goals: the National Cholesterol Education Program (a program of the National Institutes of Health) has tightened the recommendations for cholesterol control in adults. Citing steadily increasing evidence - which readers of these pages are very familiar with - that lowering cholesterol saves lives, NCEP has challenged all of us to get cholesterols lower:

    HDL goal higher: the "good" High Density Lipoprotein should be over 40.

    Triglycerides (another way you carry fat in your blood) should be lower - preferably under 150.

The guidelines urge drug therapy when there are severe risks, such as:

    diabetes

    heavy smoking

    poorly controlled high blood pressure

    strong family history of heart disease at a young age

    10-year heart risk over 20%.

We can calculate your heart attack risk in the office, or you can do so yourself with a model developed by Dr. Jon Keevil at the University of Wisconsin, that you can get to through the "Assess Your Risk" section of our website.

The drug treatment of congestive heart failure (CHF) continues to advance. Regular readers (April 2001) know that beta-blockers, which block the effects of adrenaline-like compounds, help patients whose hearts are not keeping up with the demand put on them. Now Columbia’s Dr Milton Packer and colleagues write in The New England Journal of Medicine that carvedilol (Coreg) markedly improves patients with severe CHF. The studied 2289 patients with symptoms at rest or with minimal exertion. In an average of 10 months, the death rate was 35% lower with carvedilol. Earlier studies had shown benefit in less affected patients.

Synthroid Trouble? A report from the Wall Street Journal 6/1/01 on-line edition says that the FDA has told Abbott Laboratories that its Synthroid thyroid medication may be in trouble. There is an August 14 deadline for the company to submit paperwork to the agency on the drug’s safety and effectiveness. The drug, which has been around 40 years, could be withdrawn from the market. Abbott bought the maker of Synthroid earlier this year. The FDA set a deadline 4 years ago for all thyroid drugs to meet current standards, which were not in force when they were first released. We’ll watch this carefully.

A study at Johns Hopkins University shows that older people who are more fit and have less body fat tend to have a better outlook on life. Dr. Kerry Stewart and colleagues presented at last month’s American College of Sports Medicine in Baltimore. They studied people 55-75 with mild hypertension who signed up for an exercise program. Those who were more fit were less tired, tense, depressed and angry.

Pravachol Saves Seniors: A report in The Annals of Internal Medicine studied 3500 heart patients 65-75 treated with pravastatin (Pravachol) or placebo. Royal Melbourne Hospital’s Dr. David Hunt and colleague found that after 6 years, 45 deaths and 133 coronary events were prevented.

Another Winner: Joan Canavan is our last winner of 2 tickets to the movies for getting her colon cancer (guaiac) cards in promptly. Everyone who submits the cards is a winner in our fight to reduce this preventable cancer. Next month, we’re switching to Hollywood Video coupons for our winners!

On a Personal Note: I want to thank all of you who expressed your condolences on the death of my mother. I am very grateful for your good wishes in this difficult time.

Update 2001:  Alzheimer’s Disease

Dr Alois Alzheimer described the disease which carries his name in 1906. It is now the most common cause of memory loss in the U.S.:

4 million have it now

14 million are expected to have it by 2050

1 in 10 people over 65 has it

half of those over 85 have it

US costs are estimated to be at least $100 billion yearly

average lifetime cost per patient is $174,000

What is Alzheimer’s? It is not yet clear what the cause or causes of AD are. Autopsy studies show dense "neurofibrillary tangles"and "senile plaques" in brain specimens. Beta-amyloid and tau proteins are strongly implicated, as are some nerve transmitter deficiencies. At least 4 genes are suspected.

Memory loss at work

Problems with familiar tasks such as forgetting you made a meal

Problems with simple words

Getting lost in your own neighborhood or home

Poor judgement such as not dressing properly

Abstract thinking issues such as inability to work numbers

Misplacing things bizarrely such putting an iron in the freezer

Unexplained mood swings

Changes in personality

                    Profound loss of initiative

How is Alzheimer’s Diagnosed? No one test (except brain biopsy!) is diagnostic. History & physical exam, a brief memory test and lab tests to rule out other diagnoses (such as low thyroid and vitamin B-12 deficiency) are done. MRI or CT scan of the brain may be needed to rule out multiple small strokes.

Non-Drug Treatments: Mental Activity: A study by Dr. Robert Friedland and colleagues at Case Western Reserve in Cleveland found that the more you do (mentally), the more you can do. Those who were more active mentally in early and midlife had 1/4th the chance of AD.

Exercise reduced the risk of AD in senior women in 1 study by 13% for every extra mile walked daily.

Antioxidants: Vitamin E (2000 units daily) was shown to reduce the risk of AD in the Alzheimer Prevention Study; in the Rotterdam Study beta-carotene and vitamins C & E reduced AD, especially in smokers.

Alcohol: in a Boston study, 1-2 daily drinks led to less AD.

Low-fat Diet: Another Cleveland study showed high-fat diet increased AD 5-6 fold in susceptible patients.

Diabetes: control of type 2 diabetes reduced dementia in a Dutch study.

Blood Pressure: control of blood pressure also reduced dementia in several studies.

Statins: anti-cholesterol drugs (lovastatin, etc). Reduce AD

Anti-inflammatories: Aspirin, ibuprofen and similar drugs have been associated with reduced AD in several observational studies.

Anti-Alzheimer Drugs: Tacrine (Cognex) was the first; little used now due to liver risks.

Donepezil (Aricept) is now the most used, working by increasing the neurotransmitter acetylcholine.

Rivastigmine (Exelon) is a similar drug, with perhaps a bit more improvement in memory, but with higher rates of stomach trouble here.

Galantamine (Reminyl) is the newest drug (derived from the daffodils), acting similarly, but with a 16% drop out rate due to side effects.

There are no head-to-head studies. On these drugs, avoid Ditropan, Levsin, Atrohist, Bentyl; they counter the effect.

Future Vaccine? Elan Pharmaceutical has a vaccine trial underway against one of the proteins in the amyloid plaques.