Two Masters

A friend of mine, the one I mentioned when I wrote about renal sally ports, recently has had a relapse. Yep, he neglected to take his medications at the proper times. That can cause havoc for mental illness, especially bipolar disorder. It got me to thinking. What if my friend had Chronic Kidney Disease AND bipolar disease? How could he handle both diagnoses at the same time?

Let’s start at the beginning. There are certain drugs I take in the hopes of delaying dialysis as long as possible. One of those is the ACE Inhibitor I’d been taking for hypertension for about two decades before I was even diagnosed with CKD. Here’s the definition from What Is It and How Did I Get It? Early Stage Chronic Kidney Disease: “ACE Inhibitor: A blood pressure medication that lowers protein in the urine if you have CKD.”

It works by both relaxing the blood vessels and reducing the blood volume. This, in turn, lowers your blood pressure which, in turn, lowers your heart’s oxygen needs. And the problem for my friend would be? Well, maybe just remembering to take the medication each day.

However, according to MedicineNet.com at http://www.medicinenet.com/ace_inhibitors/page2.htm,
The most common side effects are:
• Cough
• Elevated blood potassium levels
• Low blood pressure
• Dizziness
• Headache
• Drowsiness
• Weakness
• Abnormal taste (metallic or salty taste)
• Rash
• Chest pain
• Increased uric acid levels
• Sun sensitivity
• Increased BUN and creatinine levels

Did you notice increased uric acid levels, and increased BUN and creatinine levels? This could be a dicey medication for CKD patients if they did not heed their doctor’s advice once (s)he has evaluated the patient’s labs. That’s the problem here: not having the ability to be a compliant patient during a bipolar episode.

I was also prescribed a drug for cholesterol, a statin. This drug inhibits (the word of the day) an enzyme in the liver that produces lipids. As reported in The Book of Blogs: Moderate Stage Chronic Kidney Disease, Part 1:
According to Dr. Dr. Robert Provenzano, chief of nephrology at St. John Hospital and Medical Center in Detroit, “…LDL, bad cholesterol, directly impacts acceleration of Chronic Kidney Disease.” One of the possible side effects is of this drug is Type 2 Diabetes. All I can say about that is thank goodness these side effects are not the norm.

Here’s the problem: statins have to be taken at night. That’s when the body produces cholesterol. Again, can my friend be compliant during an episode? What about the drugs he already takes? Are they going to somehow interfere with these common drugs for CKD?

Lithium is the usual drug for him. This is from The Book of Blogs: Moderate Stage Chronic Kidney Disease, Part 2:
“There were two Plenary Sessions I attended at the Southwest Nephrology Conference I attended last weekend. It was at the second one, ‘Psychiatric issues in kidney patients’ that I suddenly sprang to attention. What was this man saying? Something about lithium doubling the risk for Chronic Kidney Disease? And I was off… how many psychiatric patients knew that fact? How many of their caretakers knew that just in case the patient was not responsible at the time of treatment? What about children? Did their parents know? Was a screening for CKD performed BEFORE lithium was prescribed?”

Kidney.org at https://www.kidney.org/atoz/content/lithium has me downright frightened for my friend:

“What is lithium?
Lithium is a common medicine used to help calm mood for treating people with mental disorders. Since such disorders need lifelong treatment, long-term use of lithium may be harmful to organs, such as the kidneys.

How does lithium cause kidney damage?
Lithium may cause problems with kidney health. Kidney damage due to lithium may include acute (sudden) or chronic (long-term) kidney disease and kidney cysts. The amount of kidney damage depends on how long you have been taking lithium. It is possible to reverse kidney damage caused by lithium early in treatment, but the damage may become permanent over time.

What is nephrogenic diabetes insipidus?
The most common problem from taking lithium is a form of diabetes due to kidney damage called nephrogenic diabetes insipidus. This type of diabetes is different than diabetes mellitus caused by high blood sugar. In nephrogenic diabetes insipidus, the kidneys cannot respond to anti-diuretic hormone (ADH), a chemical messenger that controls fluid balance. This results in greater than normal urine out-put and excessive thirst. It can be hard to treat nephrogenic diabetes insipidus.”

I keep reminding myself that the word “may” appears over and over again. Yet, since my friend either wasn’t taking his medication at all or not taking it as prescribed, it wasn’t working…and he is still at risk for CKD.

I found this tidbit on Drugs.com at https://www.drugs.com/interactions-check.php?drug_list=1477-0,1489-0, ACE Inhibitors: “…may increase the blood levels and effects of lithium. You may need a dose adjustment or more frequent monitoring by your doctor to safely use both medications.” Wait. So you need an ACE Inhibitor if you have CKD, but it can interfere with the lithium you take if you’re bi-polar. And statins? While I couldn’t find any interactions, I did find the caution that there may be some and to check with your doctor. I am aware he takes an anti-depressant, but in researching, have discovered there are many that are safe to take with CKD.

My friend usually goes to his medical appointments, but he neglects to mention certain symptoms and sometimes has trouble telling reality from non-reality. Does he know whether his doctor has warned him about the higher risk of CKD or not? Does he know that he may develop a form of diabetes from long term use of lithium? Does he know that if even one of his parents has CKD, his risk is doubled yet again?

Tomorrow is July 4th, the day the United States celebrates its independence from the tyranny of England. Where is my friend’s independence from the tyranny of his mental illness? The English and the United States have learned to peacefully share our existences (right, English readers?). Here’s hoping my friend can learn to peacefully share his existence with bipolar disorder… and CKD should he develop it. Heaven forbid.

Until next week,
Keep living your life!

Statins: No Easy Decision Here

A reader asked me to write about this topic.  Like me, she is a woman in her middle sixties who takes statins.  Unlike me, she has had adverse side effects.  Who even remembered about these?

Of course, I read the information handout the pharmacy attaches to the bag containing your prescription.  Of course, I researched this drug on the internet when it was first prescribed for me. But that was years ago and, while I periodically re-read the pharmacy’s handout, the dangers of this drug never quite resonated with me.

Dangers?  With statins?  That’s most people’s reaction.statins

Let’s go back to the beginning with an explanation of what statins are and what they do. According to MedicineNet.com at http://www.medicinenet.com/statins/article.htm,

“’Statins’ is a class of drugs that lowers the level of cholesterol in the blood by reducing the production of cholesterol by the liver. (The other source of cholesterol in the blood is dietary cholesterol.) Statins block the enzyme in the liver that is responsible for making cholesterol.”

Makes sense.  But what’s cholesterol? Medical News Today at http://www.medicalnewstoday.com/articles/9152.php tells us,

“Cholesterol is a lipid (fat) which is produced by the liver. Cholesterol is vital for normal body function. Every cell in our body has cholesterol in its outer layer.”

Okay, so we need this particular lipid but sometimes – between the foods we eat and our body’s functioning – we produce too much of it. Then it may stick to our arteries as plaque, possibly narrowing or even blocking them.  This could lead to CAD or coronary artery disease (heart problems).

liverHere’s the important part for Chronic Kidney Disease sufferers: it’s the liver – the organ that produces cholesterol – that is affected by the statins. That’s the only other filtering system your body has and your kidneys are already compromised.  TWO compromised filtering systems seems like a really poor idea to me.  Yet, sometimes, we need to take statins.

I went to my favorite, The Mayo Clinic, at http://www.mayoclinic.com/health/statins/CL00010 for information about when you need to be on a statin:

“If you have high cholesterol, meaning your total cholesterol level is 240 milligrams per deciliter (mg/dL) (6.22 millimoles per liter, or mmol/L) or higher, or your low-density lipoprotein cholesterol (LDL, or “bad” cholesterol) level is 130 mg/dL (3.37 mmol/L) or higher, your doctor may recommend you begin to take a statin. But the numbers alone won’t tell you or your doctor the whole story.

If the only risk factor you have is high cholesterol, you may not need medication because your risk of heart attack and stroke could otherwise be low. High cholesterol is only one of a number of risk factors for heart attack and stroke. “

As CKD patients, we already have another risk factor.  If, like me, those numbers mystify you, you can find them on your quarterly blood test reports which will usually have an “H” to indicate high or “L” to indicate low (You won’t find that if you’re on statins.) next to the numbers for your total cholesterol and your low-density lipoprotein levels.

As for how hyperlipidemia (high cholesterol) can affect your body and why statins are prescribed, I took a look at a non-technical explanation at  http://heartdisease.about.com/cs/cholesterol/a/statins.htm:

“Clinical studies have shown that statins significantly reduce the risk of heart attack and death in patients with proven coronary artery disease (CAD), and can also reduce cardiac events in patients with high cholesterol levels who are at increased risk for heart disease. While best known as drugs that lower cholesterol, statins have several other beneficial effects that may also improve cardiac risk, and that may turn out to be even more important than their cholesterol-reducing properties.”

Well, that all sounds good so what’s the problem?  It’s the side effects, ladies and gentlemen.  It’s all the ‘may cause’ that you find on the websites and in your pharmacy handout information.confused

I went to a new site for me, http://statinseffects.org/, and was staggered by the side effects:

“The risk of liver & kidney damage, muscle damage, increased risk of cancer & other side effects of cholesterol lowering drugs are good reason why exercise & diet should be patient’s first resort for controlling cholesterol levels. For people who must take cholesterol lowering medications, the dose needs to be reduced to minimum by again exercise & diet. The main concern seems to be the overuse or underuse of the medication, despite of the evidence that high cholesterol level itself is not the most important factor of heart disease. It is, however, the ratio between total & HDL cholesterol levels.”

You KNOW what popped out at me: kidney damage.  We already have kidney damage.  Each of these side effects deserves a blog of its own.  But, it is important to remember that these are possible, not definite, side effects.

Am I endorsing statin use for hyperlipidemia? No, I’m not.  I’m not a doctor.  You need to discuss this with your doctor. Mine at the time of my diagnose with hyperlipidemia was amenable to my desire not to take the drugs for a while.

Dr. Susan Bennett, agreed to this in an attempt to demonstrate to me that I needed the medication.  This was about six years before I was diagnosed with CKD.  For three months – the acknowledged honeymoon period – my numbers were great.  And then they started to climb… and climb, despite the dietary changes and exercise.  I am just one of those unlucky ones with naturally high cholesterol. Try this for yourself if your doctor agrees, but keep your health foremost in your mind.exercising silhouette

Talking about that, SlowItDown held our first of ten monthly Chronic Kidney Disease education classes on The Salt River Pima – Maricopa Indian Community last Thursday. Talk about a gratifying experience!  In addition, the book is now being used by a spiritual healing and medical care group in the community.

Many thanks to Annette Folmer of DaVita for the ever higher quality of her teaching and to MaryAnn Bennett, the brand new Clinical Services Manager at Salt River Pima-Maricopa Indian Community. Our classroom was even more electronically modern than the ones I’ve taught in here in Arizona’s community colleges!

Until next week,

Keep living your life!Book Cover

Exercising My Options

According to a study published in Diabetes Care this past July, “Weight control through diet and exercise can prevent most cases of type 2 diabetes in American women over age 50…”  I am a woman.  I am an American. I am over the age of 50.  And I have chronic kidney disease which can be a cause of diabetes.  Therefore, I am also confused.  (One place to read about this study is http://www.drugs.com/news/weight-control-can-cut-women-s-diabetes-risk-study-shows-39516.html.)exercising

Why, you ask?  Easy, I’ve just finished reading Dr.Wes Fisher’s November 30th essay in Physician. In this essay, he makes a point in the form of a question: “What if, believe it or not, when it comes to people with Type II diabetes, diet and exercise don’t affect the incidence of heart attack, stroke, or hospital admission for angina or even the incidence of death?” Of course, the quote is taken out of context so you need to read the essay for yourself at: http://www.kevinmd.com/blog/2012/11/reconsider-benefits-exercise-weight-loss.html?utm_medium=twitter&utm_source=twitterfeed.

Okay, so my wildest dream of not having to exercise to avoid illness has finally come true.  Or has it?  I looked over the articles I’d saved about my nemesis. It was a lot easier to force myself to exercise four years ago than it is now.  My knees troubled me a bit then, but that was it. Now it’s the knees, right hip, feet, and shoulders.  I honestly do exercise, but it’s not half as much fun as it used to be. Sure enough, in the articles I’d saved, I ran right into a bunch of reasons to keep up the exercise.

“Statin therapy and physical fitness amounted to a one-two punch for lowering mortality risk in a large cohort of middle-age and older patients with dyslipidemia followed for 10 years.” Damn!  I have dyslipidemia (high cholesterol) and periodically need to pay closer attention to it.  According to this study originally printed in The Lancet, I need to keep exercising – if not to prevent myself from developing the horrors of Type II Diabetes possible outcomes, then to keep the dyslipidemia under control… and I need to keep watching my diet.  You can read the article via Medpage at: http://www.medpagetoday.com/PrimaryCare/GeneralPrimaryCare/36134?utm_source=share&utm_medium=mobile&utm_campaign=medpage%2Biphone%20app.

sore kneeWell, what about my knees and my other hurting parts that make me NOT want to exercise?  The best quote I found came from Dr. Candice Johnstone at the Radiological Society of North America’s press briefing this year when she spoke about exercising in moderation,

“I was not surprised by these results. This is more like common sense,” added Johnstone,

who is from the Medical College of Wisconsin in Milwaukee. “This adds to information

people have to use to design their own exercise program.”

The url for this article is: http://www.medpagetoday.com/MeetingCoverage/RSNA/36117?utm_source=share&utm_medium=mobile&utm_campaign=medpage%2Biphone%20app

Dr. Johnstone’s reference to common sense seems like… well, common sense.  If it hurts, don’t do it.  If you can do it with modification so that no pain is incurred, do it.  You try not to poke at a tooth that hurts, don’t you?  So why poke at a joint that hurts?

All right now, just one more article.  This one just about convinced me I should be happy about exercising. “Most weight loss occurs because of decreased caloric intake. However, evidence shows the only way to maintain weight loss is to be engaged in regular physical activity.” I can accept that.  But what was the convincing part of the article is this:

“Physical activity also helps to–

  • Maintain weight.
  • Reduce high blood pressure.
  • Reduce risk for type 2 diabetes, heart attack,      stroke, and several forms of cancer.
  • Reduce arthritis pain and associated disability.
  • Reduce risk for osteoporosis and falls.
  • Reduce symptoms of depression and anxiety. “

And this from my old friend, Centers for Disease Control and Prevention.  Read it for yourself at: http://www.cdc.gov/healthyweight/physical_activity/index.html?s_cid=tw_ob254

Now I remember why I started exercising.  I love life.  I love avoiding extra medication for ailments I could have handled with life style changes (sorry, Dr. Fisher). I love moving and feeling alive.dogandcatmainpage

Of course today’s blog leaves me thinking that I must continue to exercise.  Am I happy about that?  No, I can’t honestly say I am, but I will do so.  Who knows, maybe it’ll keep me healthy enough that I’ll live long enough to see grand-children instead of just grand-animals.

Announcing the winners of last week’s contest to find the most creative use of the useless garden tub in my master bathroom:

Advocator Peruza – a copy of the book is on its way to her now and it’s personally inscribed to her

Mimi Smiley – all I need is her information to send her a personally inscribed poster for the book

Nima Beckie – who entered just for the fun of it.

Thank you all!  Unfortunately, no one could come up with an answer to the question, “Why is this called a garden tub if it’s in the house?” so I’ll research that myself.

Until next week,

Keep living your life.

So Is It A Good Thing Or Not?

I cannot begin to tell you how eager I am for the second cataract surgery.  The repaired eye sees so well that the other one seems worse than it really is.

In my big ten minutes of reading at a time while the repaired eye continues to heal, I’ve seen the same word over and over again. It isn’t a word I usually expect to see: statin.  According to Macmillandictionary.com, it means “a drug that is used to reduce the amount of cholesterol in the blood.”

 This class of drugs can have a different name in other countries. It preforms its miracle by inhibiting a key enzyme while encouraging the receptor binding of LDL-cholesterol (Low-density lipoprotein which causes health problems and cardiovascular disease), resulting in decreased levels of serum cholesterol (that’s cholesterol in the blood stream) and LDL-cholesterol and increased levels of HDL-cholesterol.

I don’t know about you, but I went running back to What Is It And How Did I Get It? Early Stage Chronic Kidney Disease to remind myself what that all means. From the glossary, I understood that dyslipidemia means abnormal levels of cholesterol, triglycerides or both. Well then, what does HDL-cholesterol do? What else? This so called good cholesterol fights LDL-cholesterol.  This is important because what we call the bad cholesterol (LDL-cholesterol) can build up in your arties and may even block them eventually. Look at page 97 in the book for a clear diagram of just how this affects your blood pressure.

Let’s get to the articles now. One from this past June suggests that statins may cause fatigue and that women may experience this more than men. Notice the mention of vitamin D production in the article at:  http://www.ama-assn.org/amednews/2012/06/25/hlsb0626.htm

Study links statin use to fatigue

One possible reason is that reducing cholesterol levels can lead to the production of less vitamin D.

All right, I’m a woman.  I take statins. I’m fatigued, but I take vitamin D supplements.  Back to the sleep apnea exploration for me.

Then in July, only one month later, this article appeared in The New York Times:

 Women May Benefit Less From Statins

Many studies have found that statins reduce the risk for recurring cardiac problems, but not the risk for death. Now an analysis suggests that the drugs may reduce mortality significantly only in men.

You can read more about this at: http://well.blogs.nytimes.com/2012/07/02/women-may-benefit-less-from-statins/?partner=rss&emc=rss

Back in February of this year, The New York Times was warning us about the possible side effects of statins, albeit rare ones:

Safety Alerts Cite Cholesterol Drugs’ Side Effects

Federal health officials on Tuesday added new safety alerts to the prescribing information for statins, the cholesterol-reducing medications that are among the most widely prescribed drugs in the world, citing rare risks of memory loss, diabetes and muscle pain.

The entire article is located at: http://www.nytimes.com/2012/02/29/health/fda-warns-of-cholesterol-drugs-side-effects.html?_r=3

Hmmm, my primary care doctor has been monitoring me for muscle pain since we met.  She has already changed my statins three times in the last five years.  As for the memory loss, who can tell?  I’m at that age, you know. Diabetes can be a problem.  You take statins to reduce your LDL cholesterol so that you don’t end up with high blood pressure, but it may cause diabetes. Which is the lesser of the two evils? Read on for help from USA Today this month to make that decision.

Benefits of cholesterol-cutting drugs outweigh diabetes risk

The benefits of taking cholesterol-lowering medications outweigh the increased risk some patients have of developing diabetes from using the drugs, a report out Thursday says.

Patients who were at higher risk for diabetes were 39% less likely to develop a cardiovascular illness on statins and 17% less likely to die. Patients who were not already at risk for diabetes and were taking statins had a 52% reduction in cardiovascular illness, and no increase in diabetes risk.

“When we focus only on the risk (of diabetes) we may be doing a disservice to our patients,” says lead author Paul Ridker of Brigham and Women’s Hospital in Boston. “As it turns out for this data, the hazard of being on a statin is limited almost entirely to those well on their way to getting diabetes.”

Here’s where you can find that article: http://www.usatoday.com/news/health/story/2012-08-09/statins-diabetes/56920686/1?csp=34news&utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+UsatodaycomHealth-TopStories+%28News+-+Health+-+Top+Stories%29

Also this month, there was good news about statins:

 Statins reduce pancreatitis risk

Statins reduce the risk for pancreatitis in patients with normal or mildly elevated triglyceride levels, say the authors of a large meta-analysis.

The address?  It’s: http://www.news-medical.net/news/20120824/Statins-reduce-pancreatitis-risk.aspx

My all time favorite appeared in The New York Times as a blog in March of this year.

Do Statins Make It Tough to Exercise?

For years, physicians and scientists have been aware that statins, the most widely prescribed drugs in the world, can cause muscle aches and fatigue in some patients. What many people don’t know is that these side effects are especially pronounced in people who exercise.

Do read the rest of it at: http://well.blogs.nytimes.com/2012/03/14/do-statins-make-it-tough-to-exercise/?smid=tw-nytimeswell&seid=auto

I got this smug sense of satisfaction at a hit against exercise… until I realized I still had to exercise so I could keep my organs healthy.  Damned if you do, damned if you don’t.

Being in the midst of cataract surgeries, I could not help myself.  I had to include this month’s article from Medical News Today even though it doesn’t mention ckd. The article’s address is: http://www.medicalnewstoday.com/articles/248785.php

Cataracts Risk Associated With Statins    
     
     

A new study, appearing in the August issue of Optometry and Vision Science , has found that patients might have an increased risk of developing age-related cataracts if they use cholesterol-lowering statin drugs.

We know I’m older and I use cholesterol lowering statins.  But I am getting better eye sight than I ever had (I think).

Note: I may have been too quick to condemn Medical ID Fashions.  The rhodium replacement bracelet they sent when I complained the first bracelet of brass, copper and silver both tarnished and wasn’t waterproof seems to be doing well.  It’s too shiny for me, but it is waterproof and hasn’t tarnished.  I also discovered this company donates $2.00 of every purchase to one of six charities. Maybe they just didn’t receive my first and second emails.

Before I forget, the book is not only available in Europe now, but it’s on sale in India too. Amazing.

I’ve given you enough homework to last more than a week!  Uh-oh, getting back into teacher mode.

Until next week,

Keep living your life!