The Arrow #263 Polypharmacy

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Greetings from water-logged California, where it’s rained non-stop for days and is expected to continue to do so for several more. Somewhere surely an ark is being constructed.

Sorry for the delay in getting this edition of the Arrow out to you, but in addition to the endless rain, we’ve been out of pocket with Christmas travel and its attendant delays and disruptions.

There wasn’t much in the way of questions in emails or comments this week, so we can just get right on with the show. It’s a bit of a rant, but only in the way of the unfathomable state of Standard of Care nowadays. Because it’s important to point it up when you see it.

The Perils of Polypharmacy!

The Bride was making her morning perusal of incoming news material (aka emails from various entities) a day or two ago and stopped to read aloud a headline in an email from Medscape (a daily news feed that goes to physicians) that beggars belief. It said:

Beyond Triple Therapy: Next Steps for Resistant Hypertension

She did a double take and after scanning the thing she read it aloud to me. It was the introduction to a quiz concerning proper care of a hypertensive patient (Thelma) describing her recent medical history and current state of health as follows:

Let’s look at what we have here. For starters, take the line ‘she remains asymptomatic’; that’s a pretty telling one. And we could read it as meaning ‘she didn’t come to the doctor because she was suffering a symptom of some sort, her condition was presumably uncovered on just taking her blood pressure routinely. (We don’t know this for sure but it makes sense that this was the course of events.)

And while a blood pressure of 138/84 isn’t quite 130/80 (which is the new cut off the US medical authorities currently settled on for claiming ‘control’ of high blood pressure) it’s not far off it. And it bears mention that in the 1980s, when MD and I were in the early years of our practice, a pressure of 140/90 was considered normal. That trend is analogous to what’s happened with normals for so many other lab values (blood sugar, cholesterol, LDL) over the years; the goal posts have moved inexorably downward. A reasonable case can be made that this ever-lowered normal is designed (by Pharma via financial capture of media, research funding, and medical journal content) to make an ever-growing market for their products. So many more people need to be medicated when you keep lowering the ideal targets.

When I looked into what the medical rationale for making this recommended drop in normal blood pressure might be, it turns out one of the two main supports listed for it was a Chinese study. And per this study, over half of Chinese researchers admit they have committed research fraud. Ergo, are their conclusions even valid?

Notably, our medical colleagues in Europe and Japan still adhere to the 140/90 is normal blood pressure — and they live longer than those of us in the US on average. But in the US today, a reading that was considered normal not so very long ago is considered abnormal enough to require putting a patient on three (and if they have their way, four) medications to corral it.

They mention Thelma is adhering to the medication regimen she’s on, and they even say she’s ‘trying to eat a more plant-based diet’. And in 5 months of trying, she’d lost a whole kilogram of weight. Which is tantamount to saying she was the same weight as when she began. Very effective treatment.

This history and physical detail was the set-up for a quiz question about what you (as the doctor) should do next to help her. And the four possible therapeutic options, per the American College of Cardiology and American Heart Association standards, are laid out below:

You’ll note that there is no mention of going onto a therapeutic low-carb/ketogenic diet. Nor is there any mention of adding exercise or other lifestyle modifications, such as meditation or yoga. (And, FYI, the green highlighted answer, adding spironolactone, a potassium-sparing diuretic, was their preferred answer.)

The poor woman is already taking three prescription medications for blood pressure and trying to follow their misguided dietary recommendation to ‘eat a more plant-based diet’. And not seeing much improvement. (They don’t tell us what her blood pressure was initially when they intervened with their pharmaceuticals. That would have been helpful to know. Perhaps it was astronomically elevated — a real BP crisis — but somehow her story doesn’t read like that to me.)

Regardless, she is where she is now, stuck with an average BP hovering just over what they consider ‘controlled’ on three meds, and the best and brightest of these ‘medical authorities’ want to either add a fourth medication or choice #4 – and this truly does boggle the mind – refer her for evaluation for renal denervation! By which they mean to ablate the sympathetic nerves going to and from her kidneys to hamper their normal physiologic function of controlling blood pressure and fluid balance and a plethora of other things they do.

These people wear such opaque blinders it’s a wonder they can get around without a guide dog.

I think Jesus just reached for a new box of Kleenex! And so did I.

Why not a decent diet proven to address Metabolic Syndrome (MetS)?

While it’s well-documented in an extensive library of medical literature that most of the crowded constellation of symptoms that make up MetS predictably and promptly improve or resolve with adoption of a well-constructed, whole food, protein-and-good-fat-rich, low-carb/ketogenic diet, hypertension is the one that might not be fully handled just by going keto.

In our many clinical years of dealing with this issue (and not just in our own experience but that of many other clinicians and researchers) I’d estimate that about 80-85% of cases of hypertension will respond well to the correct nutritional therapy (by which I don’t mean ‘trying to eat a more plant-based diet’), and the other 15% have causes outside MetS that might need drug therapies.

Our clinical stance, almost regardless of what MetS symptoms were in play for a particular patient, was first to level the playing field by getting the patient stabilized on a low-carb diet and then backing up to see if there was anything left to deal with. The vast majority of the time that was all it took. (I should add here, the patients must get on it to correct the problem and then stay on it to keep it corrected!) And to be honest some cases of hypertension fall into that ‘still something left to do’ category.

But the Medscape quizters tell us in the intro that they’ve evaluated Thelma for and found no causes of secondary hypertension, which includes numerous possible conditions, ranging from structural anomalies in the kidney’s vascular system that can increase pressure to inappropriate secretion of ‘pressor’ substances (hormones and neurotransmitters of one kind and another that raise pressure) to endocrine tumors secreting substances that raise pressure to sleep apnea to something as simple as a medication or a food (licorice is a common one) that can raise blood pressure.

So in my view, with all that ruled out, her hypertension is most probably a consequence of insulin resistance – a feature of her expression of the Metabolic Syndrome — and her persistent ‘resistance’ to drug treatment of the hypertension is the child of medical mismanagement. She is likely overweight, insulin resistant, storing excess sodium and fluid because of it, probably has stored visceral fat, might have fatty liver, may be trapped in ‘fat storage mode’ by her elevated insulin and (likely) seed oil and carb diet, and ‘eating more plant based foods’ means more carbs, which just further fuels the underlying dysfunction.

Thelma at least deserves a trial of a low-carb/keto nutritional metabolic reset.

One definition of the metabolic syndrome—I think posited either by Jeff Volek or maybe it was Steve Phinney at a conference we attended once (I confess I can’t now recall who it was)—is that any condition resolved by the low-carb diet is by definition a component of the Metabolic Syndrome. And a pretty good working definition it is, when you think about it. Predictably these responses occur with switching the diet from high-carb low-fat to low-carb high-fat:

• Elevated insulin falls. Insulin resistance markers improve (per HOMA-IR measures.)

• Elevated glucose falls and stabilizes.

• Elevated triglycerides drop like a stone (one of the quickest resolutions.)

• HDL levels rise usually back to a normal range.

• Waist circumference (reflective of visceral fat) declines progressively and noticeably.

• Body weight and BMI numbers drop more impressively than her 1 kg loss in 5 months. And more from fat loss than lean loss.

• Blood pressure declines (average 5-10mm Hg in published trials) but not in all cases. And this is better than what they predict will occur with the addition of the fourth med.

• Even leptin (the fatness signaling hormone) reaches more normal, healthier levels.

Tell me what physician wouldn’t want these outcomes for their patient? Tell me what’s not addressed here? And yet, ‘Put her on a sound low-carb/ketogenic diet’ wasn’t among the choices in the quiz.

So I had to ask myself why on God’s green earth the standard of care (SOC) promoted by these medical authorities would be to add a fourth prescription medication, unless the main goal is to enrich Big Pharma, and maybe that’s behind it, though I don’t think overtly with malice, just from constant brainwashing and corporate capture of research and medical consensus thought.

Or even worse they might opt to send Thelma to surgery to denervate her kidneys rather than to put her on a low-carb/ketogenic diet. The ‘medical experts’ don’t believe in that nutritional therapy, of course, but they could at least try it for a month and see. The woman has to eat anyway, so just flip the macronutrient structure of what she eats to fewer carbs, more fat and protein … and be prepared for the dramatic response! (I can virtually guarantee her docs will need to monitor her closely and instead of speculating on what other med to add, they’ll need to reduce the meds pretty quickly.)

Maybe that’s what they fear. That they’ll see exactly what we saw in our years of clinical practice: the reversal of her relentless progression to more and more medications and possibly surgery. That they’ll need to peel her off the three medications she’s now on rather than add another. And how would Big Pharma feel about that?

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Odds and Ends

There's something hypnotic and calming about surreptitiously watching birds go about their quotidian avian lives. So I was intrigued to find this link. Watch wild birds feast on Cornell U's live bird cam. It's very calming.

The skies are going to be pretty busy in 2026 according to this list of 10 'don't miss' celestial events set to occur this year. Clear skies willing, MD, I assure you, will be watching! 

What makes a word beautiful? What do you think is the most beautiful English language word in the world? Beauty certainly must be in the ear of the be-hearer (I know that's not a word, but you get the drift). But here's what a group of linguists settled on. Not sure I agree. Do you? Or what would you add? I might add ‘Melifluous’.

Sick ant pupae emit a scent that calls the nearby workers to destroy them, sacrificing themselves for the good of the colony. Or so says research published in Nature Communications. There may be a bit of anthropomorphizing going on, but it's interesting nonetheless. 

Predictions made about 2025 from a century ago. Some landed eerily on point and others wildly off the mark. Interesting to see it from their perspective.

Do you write grocery lists by hand, and if so what does that reveal about your personality? I confess that the Bride does all (most anyway) of the grocery shopping, so I turned to her. She says she used to write them by hand, as her mother did, but in this digital age, she uses the 'Notes' app on her phone and writes them there now. But she agrees with the article (being a world class note taker herself) that writing it down with a pen on paper sticks in your head better. What does your choice reveal about your personality?

Where did the notion of 'dry January' begin? And why?

An epic 5,000 mile trek from northernmost Norway to southernmost Sicily. It would take a year or more, but what a challenge that would be for those who have the time to hike it. 

Simple test to assess how well you're aging. How are you doing?

Scientist captures lightning in a bottle. Amazing.

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Video of the Week

As so many of us of a ‘certain age’ I grew up on Saturday morning cartoons. It was most kids’ first introduction to classical music or jazz, and I can still see Bugs Bunny sweeping his long ears back like the mane of an orchestra conductor or using those ears to hit the high notes on a boogie woogie piano performance.

And I was captivated by animation. I was a kid who loved to draw, given to making my own ‘moving pictures’ by sketching serial pictures on tablets that I could then flip through to watch my character move.

So when I ran across this behind the scenes view of how the Disney sound effects get created juxtaposed side by side with some of my old favorite cartoon sequences, it was truly catnip to me. Enjoy the Disney magic.

Time for the poll, so you can grade my performance this week.

That’s about it for this edition. Keep in good cheer, and I’ll be back soon.

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This newsletter is for informational and educational purposes only. It is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice.

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