Issue: 69

October: Halloween and the Goblins of Fear!
I have yet to meet a patient who is completely carefree.  Cares lead to anxieties, anxieties to fear, and fears occasionally lead to panic and paralysis.  Have you ever been so afraid you were unable to move?  I have. 

There are rational fears and irrational fears. The former we understand, the latter less so.  Either way, it is useful to probe the cause.  For instance, some of my patients have witnessed the suffering of a relative or dear friend and live in fear that the same terrible outcome will befall them (Guilt enters in here. Why should I be so lucky?). People who know and care for you can help you identify your fears and support you. The solution begins with introspection, seeking help from close friends, and then dealing with those goblins in a supportive environment.  

Fear can lead to bad behaviors.  For example, patients sometimes deal with fear by expressing anger, rage, and foul language. Rather than admitting their fear and receiving empathy from loved ones, they lash out and antagonize their caregivers. Reflection can help fearful patients engage those around them, thereby avoiding alienation of those they need most.

Another fear-driven phenomenon is the somatization syndrome . A patient may have, for example, heartburn, convince him/herself it's a heart attack and, fast forward, double their heart rate and blood pressure. Analyzing the steps that led to this downward spiral can help patients avoid fruitless trips to the ER. 

Alcohol, tobacco, and narcotics are maladaptive approaches to dealing with fear. Exercise, yoga, prayer, and mindfulness exercises are healthier approaches to anxiolysis . Prescription medicines can be helpful but are best used in conjunction with these measures and/or psychotherapy. The two classes of medicines that work best are benzodiazepines and selective serotonin reuptake inhibitors (SSRIs). Benzodiazepines work quickly whereas SSRIs take time. I prescribe these medicines in combination, relying on benzodiazepines to buy time for SSRIs. Once the SSRI has reached full effect, typically three weeks, many patients no longer need benzodiazepines or only need them for breakthrough anxiety . The fast-acting benzodiazepine, alprazolam ( Xanax® ), has addictive potential so I reserve it for patients with authentic panic disorder . The benzodiazepines with longer duration of action, clonazepam ( Klonopin® ) and lorazepam ( Ativan® ), are usually the best choice and, if dosed properly, allow patients to function without sedation.
John A. Schmidt, MD 
Nobel Prize in Medicine or Physiology: What's Your Chronotype?
The Nobel Prize in Medicine or Physiology for 2017 has been awarded to three American scientists who discovered the " clock genes ," the genes which regulate sleep-wake cycles , core body temperature , cortisol , food intake, cognitive performance , mood and other critically important bodily functions, known collectively as circadian rhythms . The clock genes function as an oscillator . As the clock gene known as Period accumulates, it turns off its own synthesis. The degradation of Period starts the cycle over again to match the 24-hour cycle resulting from the earth spinning on its axis as it rotates around the sun. Most of the cells in the body have clock mechanisms. They obey signals generated by the "master clock," a group of about 20,000 nerve cells called the suprachiasmatic nucleus  (SCN). The SCN is located in a part of the brain called the hypothalamus that receives direct input from the eyes.  

The purpose of the clock is to prepare us for the start of the day. Jet lag results when we land in an eastern time zone before the clock genes turn on. We feel terrible and are unable to face the day.  There are data suggesting that seasonal affective disorder (SAD) is related to genetic variation in the genes encoding clock proteins . 

The most important circadian rhythm in my practice is blood pressure.  For most of us, blood pressure peaks in the morning and declines in the evening. This is why I encourage my patients to focus on their morning blood pressure and take their blood pressure medicines first thing in the morning.  Respect the clock in your brain, not the one on your wrist!

Chronotype refers to your preference for morning (early bird or lark) or night (night owl).  To determine your chronotype, complete the Munich Chronotype Questionnaire.

The chronotype of your surgeon may be important or so a study published online in The Lancet on October 26 would suggest!  Elective surgery is best because your surgeon and his/her team are fully awake!
Selecting the Best Medications for the Treatment of Type 2 Diabetes
As discussed in previous issues of this newsletter, the treatment of type 2 diabetes is changing dramatically for the better. The older, cheaper medicines do not have the same cardiovascular , kidney, and weight loss benefits provided by the newer medicines.  Among the newer medicines there are two standouts. 

The first is Jardiance® ( empagliflozin ), a SGLT2 inhibitor , that works by releasing excess glucose (approximately 600 calories per day) into the urine. According to UpToDate , "Empagliflozin is the first antidiabetic agent with an additional indication to reduce the risk of cardiovascular death ."  Jardiance® is a once daily pill.  It is well tolerated.  Invokana® is a similar medicine which also showed reduction in cardiovascular complications in the Canagliflozin Cardiovascular Assessment Study (CANVAS) trial, but FDA has not yet granted Invokana® the same label as Jardiance®, perhaps because of the slight but real increase in amputations observed for Invokana®. I like both medicines and recommend the one that is best covered by your insurance. Patients who have peripheral vascular disease should use Jardiance®.

The second is a once daily injectable, Victoza® . Victoza is a GLP-1 agonist , completely different from Jardiance and Invokana®. According to UpToDate , "Victoza reduces the risk of major cardiovascular events including death, nonfatal myocardial infarction , and nonfatal stroke in adults with type 2 diabetes and established cardiovascular disease." 

As reported in the August 31 issue of the New England Journal of Medicine , Victoza® also resulted in lower rates and progression of diabetic kidney disease ."  This is an important added benefit because diabetes is the leading cause of chronic renal failure and hemodialysis in the United States. There is a competing once-a-week product called Trulicity® , but it has not yet demonstrated the same benefits as daily Victoza.  Likewise, Bydureon® , a once weekly GLP-1 agonist, as reported in the September 28 issue of the New England Journal of Medicine , failed to show a cardiovascular benefit.  Thus, until proven otherwise, Vicotoza® is the only injectable with a cardiovascular and renal benefit in patients with type 2 DM .  Note that none of the insulins used in the treatment of type 2 diabetes ( Lantus® , Levemir® , Toujeo® , Tresiba® , Basaglar®have been demonstrated to have the same benefits.  Thus, among injectables, insulin is no longer preferred!  Take Victoza® instead.
Word to the Wise!
If you have type 2 diabetes, exercise vigorously, reduce intake of concentrated carbs , and check if your medication plan covers Jardiance®, Invokana®, and/or Victoza®. If not, change plans!!!  Avoid donut-holes !  If you are a Medicare patient, visit Medicare.gov , pull down the part D tab , and enter your current meds and zip code.  Then enter Victoza® and Jardiance® and select the lowest cost plan for you without donut-holes!
Strategy to Reduce Your Health Care Insurance Premiums in 2018!
If you are not a Medicare or Medicaid patient, your 2018 medical insurance premiums will probably be higher.  But there is a good strategy to keep a lid on your out-of-pocket costs. Purchase a high-deductible policy and contribute to a Health Savings Account (HSA)!  Your contributions to the HSA are tax deductible, your contributions stay with you and can be invested for growth, and any withdrawals are tax free. Call your bank and set up a HSA. If they don't offer one, find one that does.  Horizon is offering a high-deductible policy with a built-in HSA. Check it out!
Now Hear This!
It gives me great pleasure to welcome Ms. Amanda (Mandy) Sivits to my practice.  Mandy will be working with Valerie to serve you as Morgan prepares to begin her nursing career at Hackensack-Meridian's Riverview campus. Please give her a warm welcome! Thank you!

Valerie, Morgan, Mandy, Ms. Clark and I wish you a Happy Halloween, reverent All Saints Day, hopeful All Souls Day, and joyous beginning to the Holiday Season!
In This Issue
October: Halloween and the Goblins of Fear!
Nobel Prize in Medicine or Physiology: What's Your Chronotype?
Selecting the Best Medications for the Treatment of Type 2 Diabetes
Word to the Wise!
Strategy to Reduce Your Health Care Insurance Premiums in 2018!
Now Hear This!
John A. Schmidt Jr., M.D.
Board Certified Internist
Dr. Schmidt is one of the leading internists in Monmouth County offering  Medical Home  services.  
He is an attending physician at Jersey Shore University Medical Center.
Dr. Schmidt is enrolled in the Maintenance of Certification Program of the American Board of Internal Medicine
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"Health is the greatest gift, contentment the greatest wealth, faithfulness the best relationship."

- Buddha


Dr. Schmidt's New Office in Spring Lake Heights
John A. Schmidt Jr., MD
Meaningful Medicine in Your Medical Home
2006 Highway 71, Ste. 3, Spring Lake Heights, NJ 07762
Phone:  732-282-8166  
Fax:  732-280-0147 
Disclaimer: The articles in Healthy Living are for general information only and are not medical advice.
Discuss all medical concerns and treatment options with your physician.