Some good news about a non statin cholesterol drug

Finally, after being on the market for over 20 years, researchers have shown that adding a non-statin drug called ZETIA to a statin (Lipitor, Crestor) actually helps lower the risks of ALL cardiovascular events in high risk patients. The IMPROVE-IT trial took six years and involved 18,000 patients.

This is an important study because, prior to this there was no evidence that the extra lowering of LDL cholesterol actually had any benefits and the medication is very expensive.

It should be noted, that by itself, ZETIA is not a very good cholesterol medication-only when used with a statin do we see the extra benefits. Also, it should only be used for HIGH RISK patients.




New cure for diabetes?

It is known that diabetes causes an overproduction of a protein called TXNIP which can damage the pancreas. Researchers have found that an old high blood pressure pilled called VERAPAMIL could reverse diabetes in the lab by decreasing TXNIP levels.

All that’s left now is to perform human trials, and if successful will revolutionize the way we treat diabetes in the future.

More on the aspirin controversy

JAMA NOVEMBER 17 (online)

Researchers found no benefit in primary prevention of strokes and heart attacks in patients taking aspirin prophylactively to prevent cardiovascular diseases. This study did not look at aspirin use in patients who already had cardiovascular problems. This has been controversial for several years as the risk of bleeding may outweigh any positive benefits and for the past several years I have been telling my patients to stop taking aspirin. However, nothing in the world of medicine is black or white. Recent studies have also shown a 35% reduction in certain cancers, like colon cancer are associated WITH taking aspirin and I now recommend that all my adult patients take a daily aspirin unless they are at risk for internal (GI) bleeding.

As always, research is ongoing and recommendations could be changed again!

Treatment options for neuropathies

Ann Intern Med. 2014;161:639-649, 674-675

There are many different causes of a painful condition called peripheral neuropathy. Symptoms can range from mild to severe and consist of pain, burning and numbness. If addition, the lack of feeling in the feet can also increase the risk of falling.

Whereas we don’t know the cause of many neuropathies, many times they are associated with diabetes, alcoholism, bariatric surgery, smoking and celiac disease.

Treating neuropathies can be frustrating for both the patient and physician. This study compared several deferent FDA approved drugs to see which one worked the best. They looked at anti-seizure medications like Neurontin and Lyrica,  SRNI anti-depressants like Cymbalta and Effexor, Tricyclic antidepressants like amitriptyline and pain killers including narcotics. Whereas all of the treatments helped, there was not one that particularly stood out from the others. Costs and side effects were also taken into account.

It is also clear that micronutrient deficiencies are also often present with neuropathies and correcting deficiencies should also be considered when treating symptoms. Functional deficiencies (this means that even though the vitamins may be present in the blood, the body may not be able to utilize them) should be corrected and an exercise program should be started.

We not only offer micronutrient testing now in the office, but have offered  both physical therapy and nutritional programs for years through  our Kaizen Total Wellness programs



Cologuard and colon cancer

American College of Gastroenterology guidelines

Recently a patient requested a prescription for the new COLOGUARD colon cancer screen.

Cologuard®, a stool DNA test manufactured by Exact Sciences (Madison, Wisconsin) has just been approved by the US Food and Drug Administration (FDA). I think the main reason that patients are intrigued by this is because there is no “Prep” and there is no need to be put to sleep and lose a day of work. The American College of Gastroenterology recommends that, if used, this should be done every 3 years.

There is only 1 big problem: Colonoscopies are still the gold standard for preventing and detecting colon cancer and the COLOGUARD is being recommended only as an alternative for those people that absolutely refuse to get a colonoscopy.

It also costs $590.

Another benefit of colonoscopies is that if there is no history of colon cancer in your family and your initial colonoscopy (age 50) is negative, then you only need it done every 10 years.

According to the researchers, any screening is better than no screening, but I doubt you will find many gastroenterologists advising their families to stop getting colonoscopies.


Another erectile dysfunction drug

The FDA has recently approved AVANAFIL (brand name:STENDRA) to be taken by patients with erectile dysfunction. Basically, it is no different than the big 3 (Viagra, Cialis and Levitra). There are also several other similar ED meds on the market. For years, the biggest problem with these medication were that they had to be taken either 1 hour before meals or 2 hours after and then 1 hour prior to sex. This product is approved to be used 15-30 minutes prior to sex.

There are 2 problems with these medications:

1.       Very expensive

2.       No insurance company that I am aware of will pay for it. Viagra, Cialis and Levitra will not become generic until at least 2020 and may cost as much as $20-$25/dose.


A better option that I have found is the use of VIAGRA TROCHES (lozenges). These products are compounded for my patients by a lab in St. Petersburg and only costs $4.00-$4.50. Because it is absorbed in the mouth, it can be taken without regards to meals and is recommended to be used 15-30 minutes prior to sex. Please note that you cannot buy these at any commercial pharmacies and will be shipped to your home.

So far, my patients have been very happy using these lozenges.

For more information, call our office to make an appointment.

Harvey S. Mishner MD


Two(?) new weight loss medications

The FDA was busy last week as they have approved 2 new products for weight loss.

The first is called CONTRAVE and it is a combination of 2 older medications: WELLBUTRIN (anti-depressant) and NALTREXONE (anti-addiction). 40% of patients lost about 5% of their weight. BELVIQ patients lost on average 3.5% and QYSMIA (Phentermine/Topamax) lost almost 9%.

The second drug has also been around for a few years. VICTOZA is an injectable medication used for treating diabetes ( this is NOT insulin). Because it may slow gastric emptying, it can lead to decreased appetite and therefore weight loss. The “new” name of the medicine will be called SAXENDA and will be dosed higher than Victoza. Potential side effects include nausea and pancreatitis. If used in diabetics, SAXENDA may also cause hypoglycemia if used in combination with other diabetes drugs.

I think the best weight loss medication is phentermine and is enhanced when combined with Topamax. I have seen mixed results with Belviq and Wellbutrin/Naltrexone. Adding VICTOZA/SAXENDA to Phentermine and Topamax may be the best combination to achieve your weight loss goals.

Here are 3 important facts to keep in mind:

1.       Just 2% of people who are candidates for drug treatment are using a drug at this time.

2.       Insurers are increasingly paying for the medications, with 60% of privately insured patients now getting some coverage.

3.       There is no generic for BELVIQ or VICTOZA but both QYSMIA and CONTRAVE can both be written as inexpensive generics which should work just as well as the brand names


New thoughts about daily aspirin

Annals of Oncology

For years we had been asking our patients to take aspirin to help prevent heart disease. But studies then showed that daily aspirin may not be appropriate if the risks of gastrointestinal bleeding outweighed the risks of preventing heart attacks. This study shows that taking aspirin can reduce the risks of some types of cancer. They claim that taking aspirin is the first thing we should do to reduce cancer after quitting smoking and losing weight.

They proposed that if everyone between ages 50-65 started taking aspirin daily for 10 years, that there would be a 9% reduction in cancer, strokes and heart attacks in men (7% in women).

So, maybe it’s time again for all adults to start an aspirin regimen again. Of course this does not apply to anyone who is allergic to aspirin and anyone who has stomach problems should consult their physician first. Also, this study did not look at those people who take both aspirin and Advil/Aleve but we know that combining them will cancel the cardioprotective benefits of aspirin.



Tramadol (Ulram) to become controlled drug

Beginning August 18,2014, TRAMADOL will become a schedule IV controlled substance. We have used tramadol for years as moderate pain killer that is better than Tylenol but not as good as codeine.

Please be aware that Tramadol refills will become restricted and we probably will no longer be able to prescribe electronically over the computer. Patients needing refills will have to be seen face to face in the office or be referred to a pain specialist for chronic use.

What happens after women stop taking osteoporosis medications?

JAMA Internal Medicine, 05/07/2014


This study looked at  women treated with Fosamax for 4-5 years to see what their risks of fracturing bones were after the medication was stopped. Please note that taking bisphosphonates (Fosamax, Boniva, Actonel) for more than 5 years is not recommended and may be associated with increased fracture risk. The researchers looked at yearly bone density scans as well as 2 biological markers of bone turnover and found that neither were predictive of fracture risk in either the drug or placebo group.

What they did find was that women who took placebo vs the drug had a much higher incidence of fractures.

They also discovered  that the older you were and the worse your bone density score was at the time of stopping the medicine was significantly related to higher fracture risk.

Most women do not like taking medication for osteoporosis for various reasons and many have been on them for too long. In our practice we try to encourage our patients to do weight bearing exercises on a regular basis.

Over the past 5 years, patients who worked with our staff on our bioDENSITY machine ALL achieved measurably higher muscle and  strength scores (in just 15 minutes once a week). I also cannot think of one patient who has had a fracture who has exercised with us!

Insurance may or may not cover the costs, but our fees are usually less than what you would pay to have your hair styled!


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