Letters to the Editor - September 2013
Dear Editor,
I very much appreciated Dr Ronald Rubin’s article on naloxone in the June 2013 issue of Consultant ("Obtundation, Miosis, and Hypoventilation in a Young Man," What’s Your “Take Home”?®, page 462). However, I was puzzled by the following wording: "Naloxone is generally effective in reversing essentially any opioid causative agent and has an overwhelmingly positive risk-benefit ratio in suspected cases of drug-related respiratory depression."
If one interprets this as a mathematic ratio, this would mean naloxone is extremely risky. If one interprets the word “positive” as a non-mathematical adjective, naloxone appears very beneficial. In other words, one can interpret this in two entirely opposite ways. (I chose the latter interpretation.)
Can you clarify?
Ashok Nimgade, MD
Brookline, MA
Dr Rubin responds:
He's correct as a semantics expert. The sentence, “Naloxone is generally effective in reversing essentially any opioid causative agent and has an overwhelmingly positive risk-benefit ratio in suspected cases of drug-related respiratory depression” was intended to mean that the benefits of Naloxone far outweigh any risks. Therefore, he is accurate in his interpretation.
Dear Editor,
I should like to expand on the article by Edward Shahady, MD, on the treatment of diabetics and prediabetics.1 My comments are based on data that I presented at the 2009 symposium of the International Atherosclerosis Society in Boston, at the symposium of the National Lipid Association in Chicago, and the 2010 symposium of the European Atherosclerosis Society in Hamburg.
In brief, the prediction of the population at risk of atherothrombotic disease (ATD)—defined as atherosclerotic disease with emphasis on the thrombosis that so often precipitates the acute event such as heart attack, stroke, etc.—is independent of the blood sugar level, defined by the two-hour postprandial blood sugar level (2 hr pp BSL) or a known history of diabetes. The prediction of the population at risk of ATD is precisely the same, whether the 2 hr pp BSL is less than 99 mg/dl or greater than 200 mg/dl, or anywhere in between—or even if the BSL is unknown. The predictive tool has been presented in Consultant before.2
Any therapy that brings the CRF-SBP plot below the threshold line results in angiographic stabilization/regression of coronary plaque in a minimum average of 75% of cases.3 The illustrated threshold line is based on lipid values obtained when the indirect method of HDL measurement is utilized; if the direct method of HDL measurement is used, then the line coordinates must be lowered to (0.62, 100) and (0.40, 140). The validation of the predictive tool is available.4
ATD remains the leading cause of death in diabetics. Even in my practice, diabetics who have sustained an ATD event in the past die of a subsequent ATD event in 57% of cases—but those diabetic ATD patients of mine who have never smoked cigarettes don’t die till an average age of 80 years.5
I treat to bring the 2 hr pp BSL below 200 mg/dl. This prevents retinopathy, in my experience (since 1974). Although some of my elderly diabetic patients develop renal insufficiency, no patient of mine whose BSL control has been fully under my control has required dialysis.
In summary, diabetic and prediabetic patients should be treated to prevent ATD by modification of the three main ATD risk factors: cigarette smoking, dyslipidemia, and hypertension—and I offer my graph as a valuable tool.4 Only one of my treated diabetic patients has suffered a fatal AMI so far this century. Diabetic patients should be treated bring their 2 hr pp BSL below 200 mg/dl to prevent microangiopathy.
W.E. Feeman, Jr, MD
Bowling Green, OH
References:
1.Shahady EJ. Diabetes and prediabetes: new guidelines for diagnosis and controversy over treatment goals. Consultant. 2011;51(8):521-526.
2.Feeman WE Jr. Lipid ratios and the prediction of atherothrombotic risk. Consultant. 2008;48(1):12-14.
3.Feeman WE Jr. Prediction of angiographic stabilization/regression of coronary atherosclerosis by a risk factor graph. J Cardio Risk. 2000;7(6):415-423.
4.Freeman WE Jr. The Bowling Green study. Available at: www.bowlinggreenstudy.org. Accessed August 2013.
5.Feeman WE Jr. Decreasing cardiovascular deaths in diabetics with cardiovascular disease. Poster presented at the 2003 AAFP Symposium; New Orleans, La.
Dr Shahady responds:
Dr Feeman has provided additional tools that can be used by clinicians in the care of diabetes and/or cardiovascular risk in diabetes.
