Under Pressure: IIH - A lesser Known CoMorbidity of Obesity

From Ultimateclasssicrock.com

I bet you can hear the bass guitar lead-in to the classic song now in your head...

A classic vintage rock duet, with David Bowie and Queen.   

(click the above link for some mood music for your listening pleasure as you read this post...)

Very appropriate, or perhaps very inappropriate depending on your perspective, as an intro for our topic today.

This obesity-related comorbidity is far less common than many of the others we have discussed in this Blog over the past year, but nonetheless not so benign as its name might imply.  If not diagnosed and treated effectively, disability, persistent severe headache, and blindness can result.

I had a few patients clustered together in the past few weeks that have had very good effects from their weight loss surgery in regard to this process that accompanied their morbid obesity, and I wanted to highlight the issue.

Let's talk about Idiopathic Intracranial Hypertension (IIH), better known as Pseudotumor Cerebri.

IIH is a not-so-common issue.  Its annual incidence is 1-2 per 100,000 population, however there is much higher incidence in obese women between the ages of 15 and 44 years (4 - 21 per 100,000).  There is some evidence to suggest that central obesity can increase intra-abdominal pressure, pleural pressure, cardiac filling pressure, and central venous pressure, which then can lead to increased intracranial venous pressure, and IIH.

Sleep apnea, much more commonly seen in association with obesity, may also play an additional causative role.

Common manifestations of this disorder include usually severe and recalcitrant headaches, transient visual obscurations, intracranial noises (pulsatile tinnitus), photopsia, and perhaps some retrobulbar pain.

Headache is most common complaint, and may have some features of both tension and migraine HAs, but their refractory, persistent, and severe character often leads to further workup.

That workup would include, among other diagnostics,  a lumbar puncture that shows elevated CSF pressure with normal fluid composition, and a correspondingly negative MRI for any space occupying lesion that could be causing the increased CSF pressure.

Treatment is centered on accomplishing significant weight loss as a way to diminish the headache frequency and severity, as well as preserve vision by reducing pappiledema and intracranial pressure. Medicines are utilized as well by Neurology, ranging from Carbonic Anhydrase Inhibitors to Loop Diuretics to steroids; Pain meds are also necessary and frequently narcotics and NSAIDs are prescribed.

Surgical options are occasionally needed, and are usually aimed at CSF shunting.  In fact, we had a patient who was very successful with her weight loss after Gastric Bypass 7/12 (250# / BMI 44 to a recent weight of 158# / BMI 28), and a previous history of IIH.  She was excited to tell me at her last visit that she was recently to her Neuro for follow up, had a trial of shunt clamping that she passed, and had her shunt removed with no significant further headaches!

I can recall 2 other patients I have seen recently, one that was an RN that was able to get back to full time work after she was disabled previously (she actually was a Band removal to Sleeve Gastrectomy), and another patient who had a Bypass and was on much less meds,  with reduced headache frequency and severity.

So, even though we don't see this as frequently as other more common comorbidities, the effect from weight loss can be quality-of-life-saving, as well as quite dramatic.  Keep Pseudotumor Cerebri in mind if you see that obese female patient with a challenging headache pattern that is refractory to your standard care, requiring a further workup or neuro referral.  Keep us in mind!

                                    (That was a lame play on words, sorry)

Exhibit I: A Simpler Solution

From NESN.com

In my baseball playing days, I heard a Coach’s comment that stuck with me.  

And as with most aspects of Baseball, and sport in general, truth often transcends their original context.

"People that don’t know what they are doing can make something easy look difficult".  The converse is also true - those that have a higher level of skill can make something difficult look easy.

A parallel here, and certainly not a judgement on the management team of the patient being highlighted, is that it took a very challenging insulin pump regimen to keep this overweight Type 2 Diabetic in control.  In fact, to the Endocrinologist's credit, his regimen of both U-500 insulin in the pump, as well as 5 different daily basal settings, kept him well controlled with a decent Hemoglobin A1C.

Thankfully, after his Bariatric surgery, things got quite a bit easier.

Demographics:  47 y/o WM

Start Weight: 386   BMI: 49

Date of Surgery:  5/13  Gastric Bypass

DM2 History:  10 + years having a Diabetes diagnosis.  He was seeing Endo at the time of his entry H&P for management of his DM2.  Control was quite good with last glyco prior to surgery at 7.3, and management was with U-500 insulin in his insulin pump and 5 different basal settings throughout a 24 hour day. He was also taking Metformin 2G per day total.  No diabetic complications thus far.  He works as a truck driver and requires a waiver for his DOT  driver’s license with his Hx of DM and on Insulin. C Peptide on intake with us was 2.7.

Also with comorbidities of HTN, Hyperlipidemia, GERD, chronic LE edema,  OSA on CPap, and fatty liver changes.

Current DM Hx:  Last seen in June at his 3 month follow-up.  He was happy, doing well with no complaints.  His Pump regimen was able to be locked in at a basal rate of 0.25 U/Hr of his U-500 insulin, with his total daily dose of his insulin (in standard concentration dosing from greater than 120 units daily before surgery to now around 30 units per day), and his CHO: insulin regimen also similarly reduced for mealtimes.

He has had no substantial lows since his surgery, and is happier with his control and the more simplistic regimen that the surgery now affords him.

On his last visit at 3 mos post op, his weight is down to 279 now, BMI of 36.8, and he remains on his pravastatin and losartan, but is off Lasix, Metformin, and taking only 1/2 of his Atenolol dose as per previous.

Take Home Points:  Some of the interesting aspects of this case can be divided up into the perioperative Diabetic care, and then the longer term impact of the metabolic change after the surgery – which is still somewhat in evolution.

In the hospital, we took an “educated guess” approach to this patient’s post op insulin needs, taking into consideration his duration of DM, Glyco preop, insulin dosing, and his age.  I added up all of his total insulin for the day (basal + bolus/meal time dosing) which was then converted to U-100 dosing (multiplied by a factor of 5).  In this case he was well above 120 units per day of U-100 equivalent.  We then took roughly a quarter of the total daily dose and gave it to him in basal dosing (Levmir) and monitored his BGs QID. He did fairly well, averaging in the 120’s to 160’s perioperatively on that regimen.

Turns out that he was able to go home on that same dose of Levmir at 30 units per day which equillabrated to restaring his pump at 0.25 u / hr of U-500 insulin (therefore 6 units per day x 5 =30 units total of U-100 strength), until such time  he was to see his Endo for followup a few days post op.

He continues to see Endocrinology, and they are monitoring him to potentially further reduce his insulin needs as he continues to lose weight.  He is happy with his success thus far, and is fully aware that he likely will not completely get off insulin, but with its greatly reduced dose, and ease of administration (pumpless in the future with a fixed dose of Levmir and some metformin?)of his currently efficacious DM / insulin regimen, the future looks bright. 

He is ecstatic about his associated weight loss as well, already his improved quality of life, as well as the shedding of a number of his other meds, and is looking forward to his next visit in 3 mos with us in follow up.

Again, making the difficult look easy is usually the more difficult thing to do, but I am sure this patient is very grateful to live more 'simply' now vs. his life before he had his Bypass.

Gastric Banding Update

You may wonder if I suffer from a little slow-motion Attention Deficit Disorder, as I keep promising that Case Study, and it will come, but not yet.  Soon!

After the last post with some new info on our experiences with Sleeve, I thought I'd follow through on an update for the Band as well.  Things have changed in a similar but different way for this procedure of late.

As mentioned earlier, our Band numbers have dropped from a high of around 25% of our case load 4 or 5 years ago, to currently less than 5% of new procedures being done.  The Sleeve's emergence as a procedure that has Bypass-like legitimate impact on both weight and metabolic disease is likely the biggest reason for that change.

A secondary aspect is the increase in some complications that appear to be related to duration of the how long the Band is in place.  This has occurred nationally with other Band programs, as well as internationally in Europe in the past decade.  The longer the time, and it is designed to be a lifelong implant, the higher the likelihood of some complications for some folks.

While there still is a significant segment of our Band population that is experiencing good results, "Loves" their Band (and how it helps them eat more appropriately and lose / control their weight), and has had their life changed from having the procedure - some aren't so happy these days.

Unhappiness with their Band is usually in large part from behavioral indiscretion, leading to recurrent emesis, and possible a Band slip (Gastric Prolapse).  It may take the form of lack of follow up, insufficient adherence to the quality/quantity of dietary intake to facilitate meaningful weight loss, or lack of consistent exercise as also required to lose weight.

It does seem that time may not be on a patient's side that does not adhere to the above behavioral requirements, as not achieving and maintaining meaningful weight loss is the end result of all these issues that could be cited as truly the biggest complication from unsuccessful Banding-Patient lifestyle.

Resultantly, we have seen an increase in patients needing their Band out due to chronic dysphagia, odynophagia, or lack of substantial weight loss.  Occasionally we see esophageal issues with atypical chest pain that needs to be remedied be fluid removal from the Band.

With more frequency now, we have been converting those interested patients that qualify in a revisional procedure such as converting to a Bypass or a Sleeve at the time of Band removal.  Moreover, early experience with these Revisional procedures have a substantial weight loss benefit over the more traditional revisional procedure in a patient with weight gain after a Bypass with some mild mechanical issue that may or may not (likely not) be the culprit in the weight regain.


So, the take home message- "Should we even be doing the Band", or, "Should I even refer a patient who wants to have a gastric Band performed?"

Yes, to both.

 If a patient is only interested in a Band and needs a weight loss procedure, it still is superior, and worth the 'risk' vs. taking your chances with medical models of weight loss, and the likelihood of success for the majority of patients who try lifestyle modification alone that need to lose more than 10% of their excess weight and keep it off.

Gastric Banding still has its place in our armamentarium, and we will continue both to place Bands and service our Band population with expert after care as we do now.

Having them come in to see us as a potential new patient, after you have referred them with their letter of medical necessity, allows them to come to an orientation first and find out which procedure is best for them.

 Their surgeon will then work with them to decide:  Band,  Bypass or Sleeve?

Sleeve Gastrectomy Update

From Bariatric.templehealth.org

Before I get to that promised case presentation, I wanted to give a quick update on our experience with the Sleeve Gastrectomy as a metabolic and weight loss procedure.  I saw an article from a December  2012 Summit on Sleeve Gastrectomy in New York, NY, and I thought there would be interest in giving our recent history and impressions as well.

Firstly, and paralleling a presentation on a 6 year study on involving 547 patients in Florida, we have seen a dramatic increase in the number of patients requesting a Sleeve, and following through to have them done. Earlier in this blog, essentially within the past year, I reported our case mix (of our 700+ surgeries per year) as roughly 75% Bypass, 20% Band, and 5% Sleeve.  Now, the mix is more like 70% Bypass and nearly 25-30% Sleeve with a rare Band being done currently.

Additionally, the Metabolic benefits of the Sleeve Gastrectomy are nearly comparable to the Bypass, which is great news for Diabetic or pre-Diabetic patients.  I was just speaking with one of our Surgeons the other day, about how this has shown to be even better than was originally expected, which has been savored by both patients and Endocrinologists alike!

Weight loss amounts have also been very good, again a little more than we had expected, vs. the known track record of the Bypass which is and has been the Gold Standard.  Weight losses over 100 pounds have been common, I even saw a patient today who had lost 180#, now down to a BMI of 29.  The aforementioned study showed average weight loss of just over 60% Excess Weight Lost, with the mean of 137 pounds.  The EWL at 48 months and 60 months post op was 47% and 31% respectively.

Our initial concerns with the Sleeve were mainly centered around it's apparent unimodal mechanism of action : Restriction, and the decreased size of the Gastric reservoir..  We had thought it was more Band-like than Bypass-like in that regard.  We honestly expected relatively easy weight regain from maladaptive eating behaviors just after the 9-12 month time frame.  We have been doing Sleeve Gastrectomies now for over 2 years, and we haven't really seen that as a common theme yet.  This study seemed to support that notion, making it similar to Bypass in rates and degree of weight regain, but no worse.

So with the Sleeve's preservation of the more native GI anatomy, the added metabolic effect from alteration in gut hormones, and the reduction in micronutrient deficiencies from minimized malabsorption, it appears that the Sleeve Gastrectomy is a durable and effective Bariatric and Metabolic procedure that is here to stay.

Judge Not, Lest Ye Be Judged

I came across this TED talk the other day, one to do with a Surgeon's story about his initial judgement of an obese, Diabetic woman in need of an amputation of her foot.

At the time he saw that patient, he felt justified in his "contempt" for this patient that 'deserved' this complication of not paying attention to herself, not caring enough to eat right or exercise or even try to put some effort forth to keep her weight in check.

When the shoe was literally on his foot when he later developed metabolic syndrome and diabetes, he really did some soul searching as to how this could happen to him; and maybe how it could happen to anyone else- including that patient he saw in the ER years ago.


What if our current understanding, and our working model of obesity, from suspected behavioral indiscretion to overweightedness to insulin resistance to disease ... is wrong?

Could it be reverse from what it actually is?  Do we suffer from "Idea Resistance"? Is diabetes possibly just a proxy for metabolic illness?

Why do some patients NOT have diabetes when they have extremely high BMIs?  Why do some patients have severe metabolic syndrome with a much lower BMI?  Is today's diet the real trigger for this whole cascade of metabolic events that is leading to one of the most common causes of death in Americans today?

Dr. Peter Attia has started a non-profit company that is looking at this very issue in a multidisciplinary, research-oriented way, aiming to get to the truth.

Take a look at this talk.  It is well delivered, has a great message, as well as some real honesty that is not heard all that often in the main stream medical publications of today.  I believe the 15 minutes will open your mind, and is well spent.

What if......?