TEC: Evidence Based Therapeutics
Therapeutics Education Collaboration
Medication Mythbusters – Home of the Best Science (BS) Medicine Podcast

The BS Medicine Podcast episodes are presented by James McCormack and Michael Allan. We try to promote healthy skepticism and critical thinking and most of the podcasts are presented in a case-based approach. We also try to inject some humour into the whole process to make the learning more interesting. Occasionally we have great guests like Mike Kolber, Tina Korownyk and Bruce Arroll help us out.

Most podcast episodes are available for free until they become archived after about 1-2 months. Every 4th episode or so is a “New Studies You Need to Know About” podcast and these will only be available to our Premium Podcast members. Premium members will also be able to listen to all archived episodes since episode #1.

Episode 60: Type 2 Diabetes – how sweet it isn’t – Part VI

In episode 60, the sixth podcast in our saga on type-2 diabetes, we talk about what to do when metformin is not enough and get to the evidence surrounding other blood glucose lowering treatments. We fumble around in a pretty much evidence-free zone. James develops a bad case of hypoglycemia during the podcast because he hasn’t eaten since the start of the diabetes section of these podcasts; Mike comes to his aid by prescribing a low dose of a chocolate bar and eats the rest of it himself.

Show Notes

1) UKPDS (recent results)

NEJM 2008;359:1577-89

Table of results

2) Fluoxetine, orlistat, sibutramine for weight loss in type-2 diabetics

Arch Intern Med 2004;164:1395–404

3) Acarbose for impaired glucose tolerance

JAMA 2003;290:486-94

4) Glitazones meta-analyses

JAMA 2007;298:1180-8

JAMA 2007;298:1189-95

Table of results

5) Risks of an elevated A1c

Link to table

6) Long acting insulin analogues – no advantage

CMAJ 2009;180:385-97

Episode 59: Type 2 Diabetes – how sweet it isn’t – Part V

In episode 59, the fifth podcast in our diatribe on type-2 diabetes, we finally get to the evidence surrounding specific treatments. The importance of lifestyle is discussed and then the rest of the time is spent talking about the who, what, why, where, and when’s of metformin. James asks lots of rhetorical questions and Mike tries to answer them in a grandiloquent way.

Show Notes

1) UKPDS (original trial)

Lancet 1998;352:854-65

2) UKPDS (recent results)

NEJM 2008;359:1577-89

3) Metformin’s contraindications should be contraindicated

CMAJ 2005;173:502-4

Episode 58: Type 2 Diabetes – how sweet it isn’t – Part IV

In episode 58, the fourth in our installment of podcasts on diabetes, we briefly talk about the evidence surrounding intensive glucose lowering (ACCORD, ADVANCE, VADT and UKPDS trials) – podcasts #9 and #38 did this in more detail. At the end of the podcast, Mike identifies many of James’ flaws, but does it with compassion and kindness; at least he says he does.

Show Notes

1) Does tight glycemic control burden patients with complex treatment programs, hypoglycemia, weight gain, and costs and offers uncertain benefits in return?

Ann Int Med 2009;150:803-8

2) ACCORD and ADVANCE studies

Click here for a synopsis of the results

N Engl J Med 2008 358:2545-2559

N Engl J Med 2008 358:2560-2572

Also listen to Episode 9: News Flash: Aggressive Blood Sugar Control Not All Sweet

3) VADT trial N Engl J Med 2009;360:129-39

Also listen to Episode 38: New trials you need to know about

4) Glucose lowering meta-analysis – do the results support the conclusions?

Lancet 2009; 373:1765-72

5) UKPDS data

BMJ 2000;320:1720-3

6)UKPDS – 10 year update (recent results)

NEJM 2008;359:1577-89

Episode 57: Type 2 Diabetes – how sweet it isn’t – Part III

In episode 57, we continue yet again with the topic of type 2 diabetes. In this podcast, we talk about monitoring HbA1C, self-monitoring of blood glucose and, diabetes education in general. We hear Jillian Popel suggest not only is self-monitoring of glucose not really useful when it comes to overall glucose control, it in fact might be harmful. We also discuss what we think diabetes education should really focus upon. Finally, after 56 episodes, Mike and James actually agree on an issue, but it was just that all complaints about any of the content in the podcasts should be sent directly to Jillian.

Show Notes

1) Self-monitoring of blood glucose ESMON

BMJ 2008;336:1174-7

DiGEM

BMJ 2008;336:1177-80

2) Calculating cardiovascular risk for type 2 diabetics

UKPDS risk engine

3) Diabetes education – Cochrane reviews

Individual patient education for people with type 2 diabetes mellitus

Group based training for self-management strategies in people with type 2 diabetes mellitus

Episode 56: Type 2 Diabetes – how sweet it isn’t – Part II

Episode 56 continues from where we left off last time with type 2 diabetes. In this podcast, we bring out the numbers and put the risks of diabetes into context by discussing the absolute cardiovascular risks associated with different levels of HbA1c. In addition, we talk about other things to look at in the evaluation of type 2 diabetes and Jillian Popel again joins us for the ride. She is quite shocked by what she hears about how “absolutely low” the renal risks associated with type 2 diabetics really are. She is also quite shocked by most of what Mike and James have to say in general, but that’s a whole other issue for another time.

Show Notes

1) Diabetes is NOT a CHD risk equivalent

Diabet Med 2009;26:142–8

2) Calculating cardiovascular risk for type 2 diabetics<

UKPDS risk engine

3) The risks associated with diabetes

Diabetes Care 2003;26:2353-8

Episode 55: Type 2 Diabetes – how sweet it isn't

Episode 55 starts off a “sweet” new topic – type 2 diabetes. In the first podcast on this topic we talk about the whole issue of the diagnosis of diabetes, how to make the diagnosis and to some degree what the diagnosis means.

Episode 54: CRP – An important part of a Comprehensive Risk Profile or a Completely Ridiculous Practice- Part III

Episode 54 finishes off the whole issue of CRP measurement by looking at the evidence we have about what happens to patients when they take drugs that lower CRP – glitazones, COX-2s, fibrates, vitamin E, niacin, ezetimibe, and statins. Other than statins and maybe niacin, it doesn’t look good – in contrast to Mike and James of course that is.

Show Notes

1) Drugs that lower CRP

Cardiovasc Drug Rev 2006;24:33-50

Chest 2004;125:1610-5

Atherosclerosis 2005;179:361-7

2)Drugs that lower CRP and their effect on outcome

Glitazones

JAMA 2007;298:1189-95

COX-2s

CMAJ 2002;166:1649-50

Fenofibrate

Lancet 2005;366;1849-61

Bezafibrate

Circulation 2000;102:21-7

Vitamin E

Lancet 2003;361:2017-23

JAMA 2007;297:842-57

Niacin

JAMA 1975;231:360-81

Ezetimibe

N Engl J Med 2008;358:1431-43

Statins

Lancet 2008;371:117-25

High dose statins – not treating to target

CMAJ2008;178(5):576-84

Episode 53: CRP – An important part of a Comprehensive Risk Profile or a Completely Ridiculous Practice- Part II

Episode 53 continues where we left with the whole CRP measurement or no measurement discussion. James and Mike start with the Reynolds Risk Score and show how even at the extremes of CRP, absolute risks only change by around +/- 2% or so. Far more interesting is that there are now 2 studies showing clearly that good estimates of cardiovascular risk can be made without knowing lab values like cholesterol and CRP. All you have to basically do is look at the patient. Mike looks at James and declares that James is at very high risk of annoying Mike – so he does, just to show the evidence is solid.

Show Notes

1) Reynolds Risk Score

www.reynoldsriskscore.org

2) CRP goes up as weight goes up

Diabetes Metab 2003;29:133-8

JAMA 1999;282:2131-5

3) Estimating cardiovascular risk estimates without knowing cholesterol or CRP

Lancet 2008;371:923–31

Eur J Card Prev RehabMay 2009

Episode 52: CRP – An important part of a Comprehensive Risk Profile or a Completely Ridiculous Practice

Episode 52 goes back in time to look in more detail at what we talked about in episode 30; the whole issue of CRP measurement. Mike and James start at the “large” issue of intra-subject variability, then focus on the “small” impact CRP has on absolute risk assessment, and briefly discuss how “accurate” risk assessments are in the first place. Finally they come to the conclusion that, as with most of the podcasts, they are very accurately vague and there is huge intra-podcaster variability.

Show Notes

1) Issues of intra-subject CRP measurement variability

Clinical Chemistry 2001;47:444–50

2) Need for repeat and multiple values

Clinical Chemistry 1997;43:52–8

Ann Clin Biochem 2002;39:85-8

3) Impact on risk assessment of adding CRP to other risk factors

“Our findings suggest that routine measurement of these novel markers [CRP] is not warranted for risk assessment”

Arch Intern Med 2006;166:1368-73

“the addition of multimarker scores [CRP] to conventional risk factors resulted in only small increases in the ability to classify risk” 

NEJM 2006;355;2631-9

“CRP does not perform better than the Framingham risk equation for discrimination. The improvement in risk stratification or reclassification …is small and inconsistent”

Int J Epidem 2009;38:217–31

4) Reclassification in risk level when using CRP

Women

Ann Int Med 2006;145:21-9

Men

Circulation 2008;118:2243-51

Net reclassification less than that seen in the above studies

Circ Cardiovasc Qual Outcomes 2008;1:92-7

5) Issue of confidence intervals around risk assessments

J Cardiovasc Risk 2002;9:183-90

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