Issue: 47

Christmas, No Time for Scrooge!
The classic Dickens's story still holds meaning today! Kindness, not selfishness, leads to transformation and redemption. The life of Jesus was launched by acts of selflessness. A maiden willing to take a risk, a carpenter willing to swallow his pride, an inn-keeper willing to give shelter, together led to the miraculous birth of a child who would become the model of generosity and love.
An act of kindness is an expression of optimism in our collective future. When we put a bill in the Salvation Army red kettle, take a tag and place a gift under the tree, or drop off a Toy for a Tot, we hope that somehow our random acts of kindness will create a better future for someone we will unfortunately never meet. This is the meaning of Christmas!
You may recall that Scrooge's transformation began with the ringing of a bell at midnight. Can you still hear the bell?

John A. Schmidt, MD 
Paris Accord: A Breath of Fresh Air!
Just when the world appeared to be going up in smoke, we hear that one hundred and eighty three nations have signed an accord that will hopefully reduce greenhouse emissions and slow the rate of global warming in the future. The mere fact that nations, rich and poor, worked so tirelessly together to reach a compromise is cause for joy! Pope Francis' moral leadership on this issue is also to be admired.
We, the residents of the Jersey Shore, know the havoc caused by a rising sea. All the more reason to understand how we individually contribute to carbon emissions and what steps we, individually and collectively, can take to reduce them. According to the Environmental Protection Agency (EPA), a single two person household emits more than 40,000 pounds of carbon dioxide annually! Use the EPA's Carbon Footprint Calculator to tally your household's greenhouse emissions and identify ways to reduce your carbon plume.
Sprint Shows How to Reduce Blood Pressure and Save Lives!
The anxiously awaited results of taxpayer-funded SPRINT (Systolic Blood Pressure Intervention Trial) have now been published in the November 26 issue of the New England Journal of Medicine. The study showed that targeting a systolic blood pressure (top number) of less than 120 mm Hg, typically with a diuretic (e.g., hydrochlorothiazide), angiotensin receptor blocker (ARB, e.g. losartan), and/or a calcium channel blocker (e.g. amlodipine), reduced cardiovascular mortality and all-cause mortality by about 25 percent in less than 4 years among those at increased risk. The study used a widely available, battery operated blood pressure cuff (made by Omron) and required medication changes on a monthly basis. The previous guideline of 140 mm Hg is now outdated. Put a blood pressure cuff in the stocking of someone you love and call me if your blood pressure is too high!
SGLT2 Inhibitor Improves Cardiovascular Outcomes in Patients with Type 2 Diabetes!
Just like high blood pressure, type 2 diabetes dramatically increases cardiovascular risk. Prevention of diabetes with diet, exercise, and weight loss is still the best approach. In patients who already have type 2 diabetes (hemoglobin A1C > 6.4, know your A1C!), I recommend low dose aspirin, a statin, and an ACE inhibitor to reduce your cardiovascular risk. I also prescribe medications such as metformin (e.g. Glucophage�), a DPP-4 inhibitor (e.g. Januvia�), and sulfonylureas (glipizide, glyburide, and Prandin�/rapaglinide) to lower your blood glucose and A1C. Unfortunately, while lowering blood glucose is known to reduce the microvascular complications of diabetes (retinopathy, neuropathy, and renal disease), there has been little data showing that lowering blood glucose in diabetics reduces cardiovascular risk, until now.

As published in the November 26 issue of the New England Journal of Medicine, one of a new class of glucose lowering agents known as SGLT2 inhibitors (Jardiance�/empagliflozin), significantly reduced death from cardiovascular causes, hospitalization for heart failure, and all-cause mortality. The study focused on patients who already had cardiovascular disease (coronary disease, angina, stroke, and/or occlusive peripheral vascular disease). SGLT2 is a transporter used by the kidney to reabsorb glucose into the blood stream. Inhibit SGLT2 and the excess glucose goes out into the urine, about 600 calories a day! The class also has favorable effects on blood pressure and abdominal girth (see last month's newsletter for a discussion of the importance of waist-to-hip ratio!). The upshot is that this new class of medications should now be considered first line treatment for type 2 diabetes. Similar studies with two other SGLT2 inhibitors, Invokana�/canigliflozin and Farxiga�/dapagliflozin, are ongoing. While urinary tract infections may occur in patients taking SGLT2 inhibitors, this has not been a significant problem in my experience and, should they occur, are quite manageable.
Putting these findings into sharp relief is a study published in the December 3 issue of the New England Journal of Medicine showing that one of the injectable GLP-1 agonists used to treat type 2 diabetes, Lyxumia�/lixisenatide, failed to improve cardiovascular outcomes!
Epidural Steroid Injections-Patient's Beware!
As published in the December 10 issue of the New England Journal of Medicine, the FDA has chosen to stand by its 2014 guidance that "serous neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids" and that the "safety and effectiveness of epidural administration of corticosteroids have not been established and corticosteroids are not approved for this use." Given that the effectiveness of these highly profitable procedures has never been conclusively demonstrated, I caution my patients to think twice before submitting themselves to these injections.

New Antidote for Factor Xa Anticoagulants!
Most of my patients with atrial fibrillation know that I prefer the newer agents (Pradaxa�/dabigatran, Xarelto�/rivaroxaban, and Eliquis�/apixaban) over Coumadin�/warfarin for the simple reasons that these medicines are effective and convenient and do not require periodic blood tests. Food interactions are also a major problem with Coumadin� but not with Pradaxa�, Xarelto�, and Eliquis�. All anticoagulants raise the risk of bleeding, especially when used in combination with aspirin or clopidogrel, as is sometimes required in patients with known coronary disease or TIA/stroke. Coumadin hold-outs have argued that Coumadin� is safer because it can be (slowly) reversed with vitamin K. Now comes welcome news in the December 17 issue of the New England Journal of Medicine that an antidote for Xarelto� and Eliquis� (as well as the low molecular weight heparin, Lovenox�/enoxaparin) is on the way! The injectable antidote is known as andexanet and it works as a decoy to bind and inactivate Factor Xa inhibitors on a time scale that is far faster than vitamin K. In the meantime, a specific antibody based inhibitor of Pradaxa� known as Praxbind�/idarucizumab was approved by FDA in October. Hopefully, these developments will help convince the holdouts that in most (not all) cases, the newer agents are preferable to Coumadin�.

Penalties Will Increase for the Medically Uninsured

The Affordable Care Act requires those without insurance to pay a stiff penalty at income tax filing (Bah-Humbug!). Visit to find out more. 

Now Hear This!
The office will close for the Christmas holiday beginning Tuesday, December 22, and reopen on Monday, December 28. The office will also be closed on New Year's Day. Please send your refill requests at your earliest convenience. As always, you may reach me during the holiday period via your Follow My Health patient portal account, email or text messaging.
Morgan has been accepted to nursing school!! Please send her your congratulations! She is very excited, as are we!
Valerie, Morgan, and I wish you and yours the happiest of holidays! Listen for the bell!
In This Issue
Christmas, No Time for Scrooge
Paris Accord
Sprint Shows How to Reduce Blood Pressure
SGLT2 Inhibitor Improves Cardiovascular Outcomes
Epidural Steroid Injections-Patient's Beware
New Antidote for Factor Xa Anticoagulants
Penalties Will Increase for the Medically Uninsured
Now Hear This
John A. Schmidt Jr., M.D.
Dr. Schmidt is one of the leading internists in Monmouth County offeringMedical Home services.  

He is an Associate Attending in the Department of Medicine, Jersey Shore University Medical Center, and  Clinical Assistant Professor in the Department of Medicine, Rutgers Robert Wood Johnson Medical School.

Feel free to share this newsletter with your family and friends.
Register to receive our monthly newsletter

"Christmas doesn't come from a store, maybe Christmas perhaps means a little bit more...."  

Stole Christmas!

John A. Schmidt Jr., MD
Meaningful Medicine in Your Medical Home
709 Seventh Avenue
Belmar, NJ 07719
Phone:  732-282-8166  
Fax:  732-280-0147 
E-Mail:  [email protected] 
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.