Wil Dubois

Happy Saturday, and welcome back to our weekly advice column, Ask D'Mine, hosted by veteran type 1, diabetes author and educator Wil Dubois. This week, Wil examines a recent mainstream media news story that told us people with diabetes (PWDs) need to be taking a certain medication just because we have diabetes, and there's no questioning that medical wisdom.

Hmmm... well, it probably won't surprise you that Wil sees things differently. Read on!

{Got your own questions? Email us at AskDMine@diabetesmine.com}

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Our very own Mike Hoskins, type 1 from Indiana, writes: New heart guidelines issued on Nov. 12 say: Anyone with Type 1 or 2 diabetes should be on cholesterol-lowering statins -- No. Matter. What. Uh... what if my cholesterol isn't high and I don't want to add another prescription to the ones I'm already taking? I don't know what to think about these new guidelines... I'm gonna Ask Wil.

Wil@Ask D'Mine answers: New, shmoo, Mike. The latest guidelines from American Heart and the American College of Cardiology should be old hat for PWDs. The take-it-because-we-said-so (and because you have diabetes) mantra has been part and parcel of the diabetologist's tool kit for years.

And for good reason.

What kills PWDs?

Not diabetes. Not by a long shot.

Heart attacks are the number one killer of our sweet kind. In fact, I heard the other day that the grim reaper assigned to heart attacks had to hire 50 new employees just to keep up with the extra workload from the diabetes epidemic, which now claims over three million souls globally every year. That being the case, it behooves our doctors to do everything in their power to minimize our heart attack risk.

That's where statins come into the picture.

Statins lower cholesterol, and they do a damn fine job of it. And the lower your cholesterol, the less likely it is that you'll have a heart attack. How low does it need to be? Well, when you were born, your "bad cholesterol" was around 50. Those with diabetes should be around 70. If you're not a PWD, it can be as high as 100 (double what you were born with). Where do these numbers come from? From hard science, right?

Uhhhh... No. They come from expert consensus panels. {Insert snicker here}. When we lack real knowledge about anything in medicine, a straw poll is taken of various experts, and if they agree then whatever it is becomes law of the land. In reality, this is not as fly-by-night as it sounds. Of course, map experts maintained from the Dark Ages right on up to Christopher Columbus that the world was flat.

So there's that.TheWorldIsNotFlat

Still, vividly imprinted on my mind's eye is a power point slide that showed the 20-year cardiac outcomes of PWDs on statins and not on statins. Year after year the gap widened, looking like a funnel. Not much difference out of the gate, but take a statin for a decade or two and you cut your risk of a heart attack in half. I scoured the Internet to try to find the image for you, but failed to locate it.

Still, with those kinds of numbers, it was quickly accepted in medical circles that an ounce of statin yielded a pound of cure, and the sooner it was started, the better.

And the statin is hardly the only med to take no-matter-what just because you've got diabetes. The same is true of ACE inhibitors to shield kidneys; a baby aspirin to protect the heart, and in some playbooks an anti-depressant because if you aren't a depressed diabetic yet, you probably will be soon.

Wait a sec. A baby aspirin?

Didn't we drop the baby aspirin requirement a while back? Why, yes. Yes we did. And that's when the Standards of Care started to unravel for me.

It went down like this: Aspirin is a safe, mild blood thinner. Well, safe in small doses anyway. Thinner blood is less likely to clot than thicker blood so, at some point in the past, a group of experts came out with a consensus statement that said all D-folk should take a baby aspirin a day. On the surface, it made perfect sense. Little harm was likely to come of it and great good might. It was also cheap, so no harm done there, either.

But guess what? Once enough of us were aspirined up, it turned out it didn't do a damn bit of good for most PWDs. Now the recommendation for universal consumption of low-dose aspirin by PWDs has been abandoned, and the advice today is that only high-risk PWDs take it. High risk, in this case, is defined as a Framingham risk score of having a heart attack in the next decaDoctor Prescribingde of 10% or greater. You can check your risk here, but for God's sake don't stop taking any med because of something I wrote. Talk to your doc and your wife first. If those two come to an expert consensus about you, you'll be wise to follow it.

Now, when I first joined the medical corps on the frontlines, I was fully indoctrinated into the trio of aspirin, ACE inhibitors, and statins. Control the blood sugar, then control the cardiovascular risk factors. It all made perfect sense. It didn't bother me that we asked people to take meds they didn't need today if it helped prevent a disease tomorrow. Really, it was just another kind of vaccine. Being a faithful servant, I not only peddled the trio of standard meds to our patients, I also pushed them in my books and took them myself.

But the dropping of the long-standing aspirin a day because you are diabetic was the first crack in the armor of my faith in the Religion of Diabetology. It let in a heretical thought: Maybe... maybe the Experts aren't so smart after all. Maybe there's nothing but snow and ice and wind on top of Mount Olympus, instead of Gods.

Recently, I've been reading up on the ACE inhibitors. This is a class of blood-pressure lowering meds that, as an unintended side effect, seem to be good at protecting the kidneys of PWDs from the ravaging effects of high blood sugar. As many PWDs also have elevated blood pressure it only makes sense to kill two birds with one stone: Use an anti-hypertensive that also shields the kidneys.

But the experts went a step further and decided that we should all take ACEs, regardless of our blood pressure. What's the harm in that? Well, we know the ACEs can cause an odd metallic taste in your mouth, elevate potassium levels, cause birth defects, and—as it turns out—give a lot of people, maybe as many as 20%, a persistent dry cough. I began to wonder... What else might the ACEs be doing to our bodies?

Then, my studies revealed that the kidney-protective effect is dose-dependent—it takes a high dose to really be a good shield. So does it still make sense to make someone with normal blood pressure take a med with a lengthy list of potential side effects, when it may not really help all that much? As more and more new evidence materialized, did the experts change the mantra?

No.

Instead, they suggested maximizing the dose to help the kidneys, and advised patients to take it at bedtime so if their blood pressure went too low it would happen when they were already lying down. That way no one would faint, fall down, and bump their heads. At this point, I began to question my pill-peddling faith.

I wasn't a heretic yet, but I dropped the hard-sell with patients who offered resistance to taking yet another med for something that might happen to them sometime in the future.

Bringing this back statins, it's the same issue. The evidence for the life-saving curve is still there, but there's aDoctorShakingFinger problem. Statins are actually pretty damn toxic on their own. Waaaaay worse than ACEs. Statins are hard on the liver. They cause deep painful muscle aches in as many as 10% of people who take them. They can cause negative gastrointestinal, dermatological, and psychiatric side effects. They may raise cancer risk, and, oh, yes, they can raise your blood sugar! Statins are getting such a bad rep the more they are studied that many Lipidologists (and Primary Care Docs) have stopped using them to treat cholesterol—the purpose they were designed for!

So where am I, the loyal soldier, now? Have I crossed over and joined Benedict Arnold and Judas when it comes to statin-prescribing? Ummmmmm..... No. But I won't be getting any recruiting medals anytime soon.

I used to regard myself as a Diabetes Treatment Specialist. That included the whole gambit of trying to treat every part of the body and soul that diabetes touches. But now, my faith in the "experts" is pretty well shattered, so I'm holding on to the One True God of diabetes that we can prove exists: Sugar is toxic. It's a proven scientific fact, not the opinions of experts, that high levels of blood sugar kill cells and devastate bodies. So now, I view myself more as a Blood Sugar Control Technician. My job is to do everything in my power to help my patients get their blood sugar in control and keep it there. And the statins, the ACEs, the aspirins, and the anti-depressants? I'll say, "Many experts feel that you ought to take this because you have diabetes."

Then I download their meters and focus on what I can see.

 

Disclaimer: This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

 

 
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This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.