Monthly Archives: March 2011

Can Actos Really Prevent Type 2 Diabetes?


Diagnosing diabetes is simple. If the blood sugar is found to be elevated you are diabetic. Increasing or decreasing the cut off level between normal and diabetic will dramatically change the number of people diagnosed with diabetes. In 1997 the American Diabetes Association lowered the criterion of diabetes (type 2) to a fasting blood sugar above 126 mg/dl instead of 140 mg/dl. Suddenly 1.7 million Americans became “diabetic” under the new definition.

In the latest issue (March 24, 2011) of the New England Journal of Medicine research was published stating that Actos (pioglitazone), a popular medication used to treat type 2 diabetes, could substantially reduce the percentage of people at high risk for developing diabetes who progress to actual diabetes. 600 people with a form of pre-diabetes known as impaired fasting blood sugar (fasting blood sugar levels between 95 and 125), were divided into one group given placebo and the other group given Actos. After 2.5 years Actos reduced the incidence of developing type 2 diabetes by 72% compared to placebo. Initially, I was very impressed with these results.

Actos is the sister drug to Avandia and Rezulin. All of these drugs show similar ability to reduce blood sugar in diabetics. Rezulin and Avandia fell into disfavor due to the potential for side effects. Actos is considered safer.

It seems almost a little too obvious that if diabetes is defined as elevated blood sugar that if the test medication reduces blood sugar, diabetes can be “prevented”. Since Actos lowers blood sugar, the conclusion that Actos reduces the progression of pre-diabetes to actual diabetes seems inevitable. A substance that does not already lower blood sugar which prevented elevated blood sugar from developing would be far more impressive.

Side-effects of taking Actos need to be considered, as well. In this research study (New England J of Medicine 364; 12, 2011) the group taking Actos gained an average of about 9 pounds. That doesn’t include the 3% of test subjects who dropped out of the study because they gained too much weight. Edema (puffy ankles) was also more common in those taking Actos. We know that weight gain, particularly in pre-diabetics, is not a good thing. What are we hoping to accomplish by using Actos to prevent diabetes when at the same time, we make people chunkier and puffier?

To be fair, the family of medications known as “glitazones” which contain Actos, Avandia and Rezulin, have some intriguing properties. Years ago, the Triad Study, showed that women with gestational diabetes who received Rezulin, did not go on to develop type 2 diabetes nearly as often, even years after stopping this medication. This does seem like a true preventive benefit.

I am dubious about using Actos to prevent diabetes at this time. My patients, I suspect, will agree with that decision. I don’t think I would survive very long in practice, if my patients gain 10 or more pounds as I try to “prevent” their progression to diabetes.

This information is for educational purposes only and is not intended as medical advise or treatment. Always consult with your physician when deciding whether to use a prescription drug.

Gary Pepper, M.D.

Editor-in-Chief, Metabolism.com

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More Toxic Thyroid Supplements


During 2 decades of practicing endocrinology I had not encountered an instance of an over the counter product containing enough active thyroid hormone to make a difference in thyroid levels. In the last month I consulted on two new patients who appear to have developed toxic thyroid levels due to non-prescription products. The first involved a “Metabolic Complex” obtained from New Zealand. This seemed like a fairly random event in which a non-prescribing health practitioner was able to obtain an unregulated product which was passed on to the patient. Not likely to become a common issue. This second instance is more worrisome since it involves a product purchased directly by the patient from the internet, and supposedly “vegetarian” in nature.

Here is the story. A woman with a history of hypothyroidism for about one year taking synthetic prescription thyroid hormone decided to find a more natural solution to thyroid hormone replacement. She stopped the thyroid hormone replacement prescribed by her local physician and purchased a product via the internet advertised to improve thyroid gland “health”. Prior to starting the OTC product her thyroid blood tests indicated low thyroid levels, as expected. About a month after starting the thyroid supplement her thyroid levels were clearly above normal, entering the thyrotoxic range. Fortunately she returned to her physician who alerted her to the problem and asked her to stop the thyroid supplement and one month later she was back to being hypothyroid again. It was at this time I first consulted with her and found her to have the expected symptoms of fatigue, weight gain, poor memory, dry skin and water retention (edema). I restarted her on prescription thyroid hormone replacement.

I wanted to see the product bottle myself but was unable to obtain it. Instead I went on-line and tried to track down the product’s manufacturer and list of ingredients. It was a frustrating exercise since the names of the products and the manufacturers and distributors changed from one website to another. I narrowed my search to one product manufactured in California and another in Canada. Perhaps I will be able to get the original pill container and nail this product down but for now it remains a bit mysterious.

Members of metabolism.com have asked me to pass on the name of these products. Now come on…do you think I want to make this situation worse by giving the information away to juvenile delinquents? I am hoping government regulators will become more vigilante to what appears to be a growing problem. In the mean time I advise everyone to be on the alert to similar products being marketed to an unsuspecting public.

Gary Pepper, M.D.
Editor-in-Chief, Metabolism.com

Some of the details of this report have been changed to protect the identity of my patient. This information is for educational purposes only and is not intended as medical advice or therapy.

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Dangerous Metabolic Supplements


A few weeks ago a new patient arrived at my office to discuss treatment for her thyroid disease. She was diagnosed with an under active thyroid several years prior but treatment with Synthroid was unsuccessful. She stopped using the medication on her own, at least a year ago. Blood tests obtained by another doctor a month before her visit with me, were diagnostic of hypothyroidism (low thyroid levels with elevated TSH) . During our session she described typical symptoms of hypothyroidism including fatigue, feeling unusually cold, dryness of the skin, brittle nails and puffiness around the eyes. On exam her thyroid was enlarged and had a gritty texture typical of Hashimoto’s Thyroiditis. Her sister and mother also had thyroid disease, increasing the likelihood of the diagnosis of Hashimoto’s. Since her latest thyroid blood tests were only a few weeks old I felt comfortable beginning her on thyroid hormone replacement, in this case, Armour Thyroid, which I prefer due to its excellent clinical effectiveness.

My new patient was also on a number of supplements and vitamins including a non-prescription “metabolic complex” given to her recently by her chiropractor. By law in the U.S. supplements like these do not possess thyroid hormone and, in my experience, have no impact on thyroid hormone levels, either to increase or decrease them. As a precaution, we obtained a new set of thyroid hormone levels along with the test for Hashimoto’s Thyroiditis (anti-thyroid antibody panel).

Several days later, the patient called complaining she was “allergic” to the Armour Thyroid, developing jitteriness, anxiety, feeling flushed and a rapid heart rate. My first thought was she received the wrong dose of medication but a quick check of her records indicated this was not the issue. I called the lab and was surprised to learn the TSH at the time of her visit was already low, indicating excess thyroid levels or hyperthyroidism. What could have caused the sudden switch from hypo to hyper thyroidism? Rarely, patients with Hashimoto’s Thyroiditis can convert to hyperthyroidism, an event I call the Zombie Thyroid because the thyroid comes back from the dead. More likely was that one of her supplements contained actual thyroid hormone, so I asked the patient to get me the labels from these products. In the meantime, I instructed her to stop the Armour Thyroid and the supplements until I could figure out what was happening. Her allergic symptoms resolved in a few days.

Examination of the supplements’ labels indicated that one manufactured in New Zealand did in fact have thyroid extract in it. It had so much thyroid hormone in it that the patient was already becoming hyperthyroid at the time she first came to the office. Signs and symptoms of hyperthyroidism didn’t develop until she started taking Armour Thyroid along with the supplement. The mystery was solved but I am left feeling much less secure that my patients will not injure themselves with products obtained from outside the country either via the internet or from practitioners who provide it, perhaps unwittingly.

As I have in the past, I urge everyone to avoid medications and supplements produced outside the country which can contain active ingredients with potential health hazards. Always check with a physician before beginning a supplement which is obtained from the internet or mail order.

Gary Pepper, M.D.
Editor-in-Chief, metabolism.com

This information is for educational purposes only and is not intended as medical advice or treatment. Some details of this case have been altered to protect the patient’s identity.

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