In our ninth episode, we interrupt our regularly scheduled podcast to talk about the recently released ACCORD and ADVANCE trials which focus on intensive glucose control (reduction) in diabetes. We discuss the patient-oriented outcomes and harms, ranging from mortality to hypoglycemia, as well as the potential benefits such as preventing microalbuminuria. Evidence regarding patient blood sugar monitoring is reviewed while reminding listeners how much fun monitoring is for our patients.

Show Notes

1) A synopsis of what was reported in the ACCORD and ADVANCE studies.

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N Engl J Med 2008 358:2545-2559

N Engl J Med 2008 358:2560-2572

2) Studies of monitoring blood sugar in type 2 diabetics showing no benefit and increased depression scores

BMJ. 2007 Jul 21;335(7611):105-6

BMJ. 2008 May 24;336(7654):1174-7

In our eighth installment, we discuss the initiation of hypertensive drug therapy. In recommending thiazide diuretics, we outline the evidence (e.g. ALLHAT trial) showing equivalence and the significantly lower yearly cost. We debate (politely this time) dosing and attempt to dispel the smokescreen of thiazide metabolic issues (e.g. blood glucose). The usual banter ensues around the challenges of monitoring therapeutic effect and the pseudo-logic of initiating combination drugs.

Show Notes

1) ALLHAT – no difference in CVD outcomes between thiazides, ACEI or CCBs in hypertensive patients treated for 4.9 years

2) Additional benefits of ACEIs/ARBs on renal outcomes in diabetic patients is unproven

Lancet 2005;366:2026-33

3) No evidence of superiority of CCBs or ACEs over thiazides for hypertenison in type 2 diabetics

Arch Intern Med 2005;165:1401-9

In our seventh installment, we discuss the options for blood pressure reduction before adding medications. We first talk about medicines, drug use and dietary factors that may increase blood pressure. We review the approach and potential benefits of varying lifestyle interventions like Exercise (e.g. pedometers), Diet (e.g. DASH) and Salt Reduction. The ever elusive balance between nagging and encouragement is debated (James and Mike pick sides).

Show Notes

1) Using a Pedometer

• Ask the patient to wear the pedometer for one week
• Have them calculate their “steps/day”
• Next add 1000 steps to the day average and that will be their daily goal for each day next week.
• They repeat this every week.
• Once at 10,000 steps/day. They can stay stable (and come to see you to brag about their success)

NOTE: This is only one way. There are many and you should feel free to use any safe approach to help you patients increase their activity.

2) Approximately 35% of patients who reduced their salt intake either

had no change in blood pressure (20%)

or an increase in blood pressure (15%)

Hypertension 2003;42:459-67

In our sixth installment, we begin to discuss hypertension. We review the principles of making the diagnosis of hypertension and confounders in the office. Although the identification of an elevated blood pressure for a certain patient may be new, the hypertension itself is likely not and rarely an emergency. The risks of hypertension are put in context of global cardiovascular risk while we wax poetically around evolving hypertension guidelines.

Show Notes

1) Our 45 y/o 10-year risk

2) Treating a Blood Pressure of 160 /100 mmHg for 5 years –

CVD ? 1% (4% to 3%)

• TI Letter # 62.
• Episode 2: Evidence does not equal decision-making

3) Diagnosis of high blood pressure

• CMAJ 2005,173: 480-83