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Month: January 2024

Aw, Nuts! By: Sasha Klemawesch, MD

Aw, Nuts! By: Sasha Klemawesch, MD

Conventional wisdom for decades has been to avoid nuts and seeds if you have diverticulosis; however official Gastroenterology literature now says otherwise. Actually, it has for some time, but old habits die hard, and anecdotal rumors still heavily cloud the discussion both in the medical community and among lay people. While it’s not surprising that patients’ impressions may be skewed by rampant Reddit forums on the subject, doctors should be aware of the change in recs, seeing that literally hundreds of studies (more than 300 in the past decade) exist evaluating a variety of dietary effects on diverticular disease. Many of those specifically focused on seed and nuts, and none of them showed any increased harm or risk. The one diet that was affiliated with diverticulitis bouts? No surprise here: “Standard American Fare.” (fried foods, red/processed meats, heavily refined grains, sweets and high fat dairy products). I personally think a big reason why those are correlated with worse outcomes in diverticulosis is that they are all so constipating; and avoiding straining and incorporating fiber and hydration into your diet has long been known to be beneficial (both for diverticulosis as well as in people w/o it).

Now speaking of trying to turn the cruise liner that is diverticulitis management…. Antibiotics. The American Gastroenterology Association has had data out for years showing that we only started treating diverticulitis with antibiotics because “that’s what they always did.” When docs first started doling out Cipro/Flagyl to everyone, it wasn’t based on any scientific trials or evidence, it came more from a logical, hypothetical theory and resultant trial and error approach, and then got passed down from generation to generation. But we now have actual research data showing that uncomplicated diverticulitis in an otherwise healthy patient is more of an InFLAMMatory process, not an InFECTious one, and therefore treatment should include anti-inflammatories, not antimicrobials. Myself being a huge proponent of antibiotic stewardship, I love this change in practice, but it has been pulling teeth to get patients to accept it, and even to change the minds of my fellow colleagues; many of whom say “yeah, I heard about that literature, but I still cover them.” (meaning they prescribe them antibiotics) …  Cut to 4 days later when I see the patient back for their even worse diarrhea due to the antibiotic side effect. Now certain patients and certain cases (i.e. those w abscesses or perforations), still do need antibiotics, but your run-of-the-mill mild case, those do not.

I know many of you will have a hard time *stomaching* this news, so here is a high-quality source for you to check out and verify that I’m not blowing smoke up your behind (sorry couldn’t resist two GI tract puns) just copy this into your search bar:  10.1053/j.gastro.2020.09.059

Tincture of Time By: Sasha Klemawesh, MD

Tincture of Time By: Sasha Klemawesh, MD

In the preceding article I mentioned how antibiotics became accepted as standard treatment for diverticulitis; doctors considered which pathogenic bacteria would typically invade the gut, and drew a logical conclusion that if the colon was infected, then Cipro/Flagyl would treat it. The practice had staying power because patients seemed to get better while on said treatment. However, like many other entities commonly “treated” with antibiotics, it is not the antibiotic that is making the patient better, it is so-called Tincture of Time; the issue either has an inherently discrete duration and/or the patient’s body heals itself. It just seems like the antibiotics are helping because those two things coincide. This same phenomenon is the reason that so many people swear they MUST be prescribed a Zpack for their mild URI, or some Amoxil for their sinusitis. Both of those illnesses are far more commonly due to a viral trigger than bacterial, but because lazy doctors write for Zpacks at the drop of a hat, patients come to expect it. This is not good medical practice and is the reason for so much of the antibiotic resistance we have accrued in the US. While just like in diverticulitis, there is a role for antibiotics in certain cases of sinusitis or bronchitis, withholding them should be the rule for 90% plus of the cases, not the exception. So next time a doctor “refuses” to give you your precious Zpack, please know that it is more work for them to not simply acquiesce to your request, and thank them for actually having your best interest in mind.

O O O….Oh no! By: Sasha Klemawesch, MD

O O O….Oh no! By: Sasha Klemawesch, MD

If you are a non-streaming luddite like me who still watches cable, then I’m sure you could not only sing the Ozempic jingle on command, but probably do the Jardiance-Lady’s dance as well. There’s been so much hype around the novel diabetic agents, I thought it worth discussing some of their downsides, since otherwise mainly what you hear are social media-ites & bravo-lebrities lauding them as quick & easy weight loss hacks.

While it’s true (especially for the Ozempics/Mounjaro’s of the bunch), that they do help you lose weight, it’s also true that along w that desired benefit comes the potential for many adverse effects. 

Let’s look at Jardiance – aka – Empagliflozin first. This is an SGLT-2 Inhibitor, which is a different class from the others. It essentially makes your kidneys pee out boatloads of glucose, which in turn causes you to pee out high volumes of urine. The medical term for this is “osmotic diuresis.” If you remember from high school science, when you have two containers of water connected by a semi-permeable-membrane, one side w salt water, the other w tap, the tap water will selectively flow through to the side with the salt, in attempts to balance the ratio of salt: water on both sides. The kidneys do the same thing when you have excessive sugar in the urine; they send excessive water/fluid after it; which is why Jardiance not only lowers Blood Sugar, but also (partially) why it has a proven benefit in Heart Failure patients. (a key component of treating heart failure is keeping body fluid low, keeping patients ‘dry’). However, Glucosuria (glucose in urine) is also the reason for the main adverse effects I see time & time again in the ED; the 3 main ones being UTIs, Dehydration/Acute kidney failure, and Euglycemic Ketoacidosis.

UTI is simple enough. Bacteria love sugar, they need it to live and thrive. When you have too much sugar coursing through your genitourinary tract, bacteria show up to party, increasing the likelihood of infections throughout it.

Dehydration and Kidney Failure. Sounds scary, but Dehydration IS (in medical terms at least) the mild form of         “Pre-Renal Acute Kidney Failure.” It simply means that you’re so dehydrated that your creatinine level (aka “kidney number”) goes up a little when you run lab work. Treatment is very simple. IV fluids (or oral), and your labs go back to normal and everything is fine. Occasionally though, the degree of renal dysfunction can get severe enough to necessitate admission to the hospital for ongoing fluid resuscitation and lab monitoring.

Euglycemic Ketoacidosis. This is the most severe of the adverse sequalae that I have personally seen come through the ED. Most people have heard of DKA, Diabetic Ketoacidosis. This is similar in that it involves the pH level of your body becoming dangerously low, and requires treatment in the ICU w an insulin infusion. The difference here is that your glucose level is normal, and because of that, many times this condition can be overlooked and underrecognized, especially if you happen to be seen by a provider who is not aware of what it is or how it presents. Unfortunately, that is not uncommon, and it doesn’t help that its symptoms are quite vague; nausea, stomach upset, fatigue, weakness, etc. 

Now to the other family of meds which includes Ozempic, Victoza, Wegovy, Saxenda, Rybelsus, and Mounjaro. All but Mounjaro are GLP-1 Agonists. Mounjaro is both a GLP-1 and GIP Agonist. GLP-1 Agonism exerts several effects. It slows gastric emptying, so food stays in your stomach longer, you feel fuller longer and therefore naturally start eating smaller portions.  It also increases insulin production, decreases glucagon release (a hormone that raises blood sugar), and has direct effects in brain centers involved in both physiologic appetite and psychologic food cravings. It also affects acid secretion in the stomach (which can cause some nausea/ queasiness), and that, combined w the effects in the brain and the slowed gastric emptying all combine to severely curb appetite and food consumption. The GIP in Mounjaro does all the same things since GIP and GLP-1 are closely related hormones, but the addition of it leads to synergism such that all the effects are compounded and weight loss is augmented.

The most common complaint I see in these medicines is the nausea and stomach upset. The worst effect I have seen (and I have personally had 4 patients so far with it) is pancreatitis. Pancreatitis can range from painful but not dangerous to potentially life-threatening. Two of my 4 patients went to the ICU, one went to Med-Surg, and one went home.

Another increasingly common issue coming to light w these meds is that they are forcing surgeons and anesthesiologists to adjust their OR scheduling. While “nothing after midnight” has been the pre-op mantra for decades, nowadays 6 hours NPO is becoming woefully inadequate; patients are regurgitating and sometimes aspirating when they start to get put under, since food is staying in their stomachs for so much longer. They are having to either come off their meds briefly or try and not eat for prohibitively long times before the OR.

But probably the biggest drawback of these medicines is their cost and availability, since they are all quite expensive, and right now the demand is still eclipsing supply.

What is the bottom line of all this? All of these meds are wonderful additions to the diabetes and obesity medicine arsenals, but they are by no means miracle cures. If you are taking one or considering one, just be aware of and be prepared for possible side effects. You can help to avoid many of the common adverse effects of Jardiance by keeping up your fluid intake. Unfortunately, there is not much you can do to avoid being the unlucky one who gets pancreatitis.

But DO feel reassured that my POV is skewed, since I only see bad outcomes in the ED. There are millions of other people out there doing great on them….   And if you need proof, just turn on your TV!