Category: General

When it comes to weight gain, nothing beats the thought that thyroid is the first culprit. It is a well-known fact that overactive thyroid can drive weight loss and underactive thyroid can drive weight gain. When you have an underactive thyroid, the metabolic rate of the body slows down. Further due to inadequate thyroid hormone in the body, the person tends to add more water to his body. If low thyroid persists for a long time, weight gain can go on.

But the weight that can be attributed to thyroid is in the range of 2-5 kg. This extra fluid may disappear once the thyroid function is brought to normal. However since hypothyroidism develops slowly, most patients don’t lose substantial weight even after thyroid is normalized.

Sometimes thyroxine in higher doses is used to achieve weight loss. However this is not advisable as high levels of thyroxine may cause fast heart beats (palpitation) and bone loss (osteoporosis) especially in older persons.
To sum up, underactive thyroid contributes partly to weight gain, but is not the sole reason. This weight attributed to underactive thyroid can be lost once thyroid is normalized with thyroxine.

Insulin pump is possibly the best method for delivering insulin. It is very helpful for patients with type 1 diabetes and selected patients with type 2 diabetes who want precise and timely delivery of insulin along with the flexibility of leading an active lifestyle.

Most type 1 diabetes patients if not all would benefit from using an insulin pump. Especially when we are trying to achieve very good glycemic control (HbA1c < 7 %) with minimum of hypoglycemia. For subjects with type 2 diabetes on insulin, it is not very clear who will benefit from insulin pump. But if the patient and the care giver is motivated to achieve a good blood sugar control, insulin pump would be a good option.

If you have type 2 diabetes, this chart would help you know if you are the right candidate for INSULIN PUMP

If you have marked YES to more than 3 of these questions (or one each in each of the colors), insulin pump is an option for you. Especially if you marked YES to 1, 3 and 6 you should be discussing with your doctor seriously about using an insulin pump.

PCOS or Polycystic Ovary Syndrome is a common medical problem. I have heard my patients say casually that they have PCOS in the family. The causes of PCOS is still not fully understood. It is true that the entire spectrum of PCOD is not very clear and it is still evolving. But every ultrasound that reports polycystic ovaries is not really PCOD.

We are concerned about PCOD since it causes irregular periods, excessive hair growth in women, infertility, risk of diabetes, metabolic diseases and possibly cancer. But before you label someone as PCOD, it is important to exclude other medical conditions that can possibly cause some or most of these symptoms. It may be something simple like a hypothyroidism or something more complex like an adrenal tumor or Cushing’s disease.

Treating PCOD is to target the specific reason why the patient approaches the doctor. This would mean addressing hirsutism (excess hair growth), irregular menstrual periods or infertility. But at the core of treating PCOD is the need to take care of metabolic syndrome and obesity and prevent diabetes, heart disease and cancer in the longer term.

Young people with hypertension are not the same as older people with hypertension. Older persons with hypertension have something that we doctors label as essential hypertension. This basically means that the hypertension is due to a list of causes that we poorly understand in full. It is however important that we check these individuals for reasons like kidney disease, heart disease etc.

But in younger individuals, the reasons may be entirely different. Disease of the kidney, adrenal hormone overproduction, diseases involving the blood vessels of the kidney or aorta (large blood vessel arising from the heart), pituitary hormone overproduction etc. can lead on to high blood pressures. These are called “secondary hypertension “and may be curable.

If you have hypertension and any of the following features, you need to exclude a potential curable cause of hypertension

1. If you have hypertension onset less than 40 years of age

2. If you ever had a kidney disease in the past

3. If you ever had a low potassium on blood tests

4. If you have rapid weight gain, rounding of face , leg muscle weakness or pink stripes (striae) on your abdomen or irregular menstrual periods

5. Episodes of sweating, palpitations or fainting spells

After all, your blood pressure may be “CURABLE”

The recent outcry in the media on the reports of “ketoacidosis “with the use of a new class of diabetes medications, SGLT-2 inhibitors ( Canagliflozin, Dapagliflozin, Empagliflozin) lead to a flurry of phone calls to physicians asking if the drug can be safely continued. This has led to discussions on how qualified are the so called “health news journalists “in reporting medical news and interpreting medical studies. This new information given by the FDA (Food and Drug Administration) was considered as a “WARNING “. In fact most other diabetes medicines used also have more serious warnings. (see table given below) It is good for everyone to understand what these terms mean before jumping into conclusions.

FDA gives approval to a new drug based on its efficacy and safety profile in clinical studies done on individuals with a disease randomly divided into 2 groups; one receiving the drug and one not receiving it. (Randomized controlled studies). A few thousand patients are studied in these trials. Side effects are the unintended effects occurring at normal dose related to the pharmacological properties of the drug.

Adverse events are any untoward medical occurrence that may present during treatment with a pharmaceutical product but which does not necessarily have a causal relationship with this treatment. Serious Adverse Effects (SAE) are those that can cause disability, are life-threatening, result in hospitalization or death, or are birth defects. Most of these are identified in clinical trials before the drugs are approved by FDA and are included in the DRUG LABEL.

Once the drug is approved and used, then the post marketing surveillance comes in where the adverse effects of drugs are monitored in the real world. These effects can be reported to FDA by patients, doctors, pharmacists, and drug manufacturers. These reports are collected in the Adverse Event Reporting System (AERS). If sufficient safety concerns evolve from the clinical studies or through AERS, the FDA decides whether to continue monitoring, put a boxed warning on product labelling, or withdraw a drug from the market. Less serious safety concerns are simply added to the “Warnings and Precautions” section of the package insert.

A BOXED WARNING (or black box warning) appears in the package insert of the drug in a black box format and signifies that studies indicate the drug carries significant risk of serious adverse effects. Sometimes the FDA asks for a DRUG LABELLING CHANGE to reflect the new safety concerns.When FDA believes that a drug’s benefits no longer outweigh its risks, the agency will ask the manufacturer to withdraw the drug. (DRUG WITHDRAWAL). Sometimes black box warnings may be given on a strong possibility of side effect e.g. Metformin given boxed warning of lactic acidosis. These may be revised subsequently if there is not enough evidence. These warnings and change in drug labelling and prescribing information are informed to doctors with a “Dear healthcare professional “letter.

Following table provides the ‘Warning and Precautions’, ‘Boxed Warning’ and ‘Labelling’ for the following drugs – Pioglitazone, Rosiglitazone, Sitagliptin, Saxagliptin, Alogliptin, SGLT-2 inhibitors, Sulphonylurea, Metformin, Exenatide

Treating physicians may or may not be aware of the warnings and labelling and its implications. This information should be analyzed by physicians and ultimately decide whether the benefits of drug outweighs the risk of side effects. Healthcare journalists should report this information keeping in mind that the drug has been extensively studied before approval. Recently, FDA Adverse Event Reporting System (AERS) database identified 20 cases of acidosis reported as diabetic ketoacidosis (DKA), ketoacidosis, or ketosis in patients treated with SGLT2 inhibitors from March 2013 to June 6, 2014. Only temporal association of DKA with SGLT-2 inhibitors was noted by FDA. FDA has clearly mentioned that they are continuing to investigate this safety issue and no changes in labeling of SGLT-2 inhibitors are advised as of now.The warnings are based on post marketing data which may not suggest causality and the drug is used by millions of patients worldwide. Healthcare reporting should not amount to sensationalism but sensitivity to all stake holders.

Regulatory bodies like FDA gives us the confidence that the drugs may continue to be monitored even after the initial trials are over.
Healthcare reporting should not amount to sensationalism but sensitivity to all stake holders.

Over the years in practicing Endocrinology, one of the most common questions I get asked is the role of diet in thyroid diseases. It is well known that iodine is required for the normal thyroid gland to make thyroxine. And if you have significant iodine deficiency, the thyroid gland can reduce the function. But being supplemented with iodine in the salt, there are less and less of patients who are labelled as iodine deficiency goitre.

But more patients now have autoimmune thyroid disease, hyperthyroidism (autoimmune or due to a nodule) and thyroid nodules with normal thyroid function. Certain food like cassava, millets and vegetables of Brassica family (cabbage, cauliflower, broccoli) etc contains natural goiterogens. Studies in rabbits and rats have shown that these animals develop goitre when they are fed with diet containing cabbage. In one of the studies in man, uncooked Rutabaga (a type of turnip) was found to interfere with certain thyroid tests, but not when it was cooked.

Isoflavones (in soya beans) can interfere with thyroid hormone synthesis and so does high dose flavanoids in supplements. Beware of using calcium, iron and fibres (for constipation) along with thyroid supplements. If used, they should be spaced 4 hours apart. Chromium picolonate in vitamin supplements may interfere with thyroid function.

Iodine will serve as building block for thyroid hormones. So, it would be wise to restrict iodine containing food in subjects with increased thyroid hormone synthesis (hyperthyroidism). However in practice, seldom do we restrict patients of any iodine except if they are planning to undergo radioactive iodine whole body scan or ablation.

In short, there is no scientific proof to advice people with thyroid problems to avoid any vegetables. However, patients should discuss.

Invokana (Canagliflozin) and Forxiga (Dapagliflozin) belong to a new class of drugs used for managing diabetes. It works in the kidney to prevent absorption of glucose and in turn helps to lower blood glucose. It literally flushes the glucose out of the body and thus reduces blood glucose.

What are the advantages of these drugs?
These drugs reduce the blood glucose by a mechanism independent of insulin. So, it can work whether your body is producing insulin or not. It reduces HbA1c by around 1-2%. It further reduces weight unlike some drugs and insulin which increases weight. It may further help to reduce blood pressure.

What are the side effects of these drugs?
Patients using these drugs may have certain side effects different from other drugs. Your doctor would have enquired about your previous history of having urinary tract infections or genital infections before prescribing the medicine.

Women: 1 in 10 women using these medicines may have vaginal thrush when you may have vaginal discharge or irritation.

Men: Men may develop balanoposthitis or balanitis (redness and pain of glans penis).
There is a mild increased risk of urinary tract infection (pain during urination, fever, frequency of passing urine etc) while using these drugs. Since it may reduce blood pressure, some patients may rarely develop dizziness. Report to your doctor if you experience drowsiness, dizziness, tiredness or weakness when you are taking the medicine. So mention to your doctor all the medications that you are using. You may experience mild increase in urination and thirst especially during the initial weeks of using the medicine.
Low blood sugars: you are unlikely to develop low blood sugars if you are taking these medicines with Metformin, Pioglitazone or Gliptins. But you may develop hypoglycemia if using with certain groups of diabetes medications (Glimiperide, Gliclazide, Glipizide, Glibenclamide) or with insulin.

What are the doses?
Invokana (Canagliflozin) comes as 100 mg tablets
Forxiga (Dapagliflozin) comes as 10 mg tablets.
These tablets can be taken before or after food at breakfast time. If you forget the tablet, take it when you remember but not 2 tablets together.

What precautions should I take while using these medications?
1. Drink an extra glass of water every day; you may urinate one extra time daily
2. Washing your genital area after passing urine would help reduce the risk of infections
3. Report to your doctor if you have signs of genital/urinary infection

Thyroxine is one of the most common medications in practice. It is used and misused in a variety of circumstances. The tablet is the synthetic form of L-thyroxine which is chemically similar to the thyroxine produced in the body from the thyroid gland.

Thyroxine is preferably consumed in the morning in empty stomach. Many patients follow this as a routine and ensures good compliance with medications. If missed in the morning, it can be taken at any time of the day. The blood is tested for thyroid function tests at 3 months to 1 year interval to adjust the doses of medications. More stable patients require less frequent testing.

Some medicines can have interactions with thyroxine. Iron supplements, calcium supplements and certain herbal products can interfere with thyroxine absorption. Certain medicines like oral contraceptives, rifampicin and anti-epileptic drugs can have effects on thyroxine metabolism. So you need to tell your doctor if you are on any new medications including over the counter drugs.

It is important to have your doses modified only after checking the thyroid function tests. Over replacement and under replacements of thyroxine can lead to health problems. The target of thyroid function tests may be different for different patients.

Dose: the dose is decided by the doctor according to the patient’s symptoms and the biochemical tests. The tablet strength from 12.5 to 150 mcg is available.

Diabetic Retinopathy is one of the most important causes of visual loss worldwide. In individuals with diabetes, eyes can get affected in various ways including having retinopathy, cataract and glaucoma. High blood sugars along with high blood pressure will damage the blood vessels of retina and lead to retinopathy. This is often a silent complication with no symptoms at initial stages. When symptoms appear the disease will be generally advanced and the treatment is difficult and the outcome will be poor. Hence screening for retinopathy forms the cornerstone of proper diabetes management. Do get your eyes tested today for diabetes eye disease.

For more detailed opinion, read https://www.providence.co.in/faq/diabetes-eye/

Bariatric surgery (weight loss surgery) is a boon for overweight individuals. Been around for more than 15 years, the safety of this procedure is well established. It has been helping overweight people lose weight and improve their longevity, reduce risk of diabetes , blood pressure, cholesterol problems and risk of heart disease and cancers.

But bariatric surgery is just the start of the journey as you would know. Unless taken care of well with proper diet and exercise, weight gain can occur over a period of time. Depending on the procedure, you are bound to have nutritional problems and gastrointestinal problems. Some of these deficiencies may not have any symptoms at the start but can later cause major health problems. There can be reduced nutritional intake of micronutrients and macronutrients without your knowledge. Blood sugars may bounce back after few months to years after the procedure and so can cholesterol levels. Poor Vitamin D and calcium can cause bone problems. Fluctuation in blood sugars with occasional low sugars can happen.

So all is not well after bariatric surgery unless you have a good regular follow up with your endocrinologist and dietician. It is recommended that you undergo a pre-bariatric check and counselling and at least an annual post bariatric metabolic evaluation

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