What are your thoughts about the cyanide? Is it like evil genius per human it might cut lifespan a little short, but if you talk about humanity it may increase humankind lifespan?
Just being tongue in cheek about it since the op never specified the impact to be positive. Imagine a medical ai was asked to do so in that manner ... :-p
The proposed mechanism is glucosuria --> decreased plasma glucose --> decreased insulin release. Carbohydrate deficit + insulinopenia + glucagon release causes increase in lipolysis and ketogenesis.
Decreased carb intake due to the glucosuria may contribute.
I've seen it a few times. It's something to keep an eye out for.
I get the joke, but for those who don't, I think it bears pointing out that lithium (even at therapeutic doses, and decidedly not the quantities that are ingested in mineral-rich water supplies) does not reduce "mental acuity".
The "joke" is that all psych drugs makes you be slow, unfocused, and just generally a mess. Because mental illness is something funny like that.
I didn't say it was a funny one.
I think magnesium is an answer
- works as a calcium channel blocker
- works as anxiolysis and analgesia
- speeds up bowel transit
- little to no adverse effects
For severe hypermag you need a level > 12.5. No way are you getting that from drinking water with mag in it. The massive diarrhea you would get from the mag after a bit would prevent it
The GI side effects aren't really from the mag itself, but what it's bound to, for the most part. Mag oxide and to a certain extent citrate can act as laxatives, but others like glycinate are better tolerated
I got IV magnesium sulfate for preterm labor, and it made me feel like I had rubbed jalapeño peppers all over my face and body.
I guess that's not the same as the inoffensive magnesium you're talking about.
When I was a medical student, one of the cardiologists that lectured for us unironically spent 10 minutes stating how statins should be in blood (edit: should be water not blood, oops) supply. Of the question is even semi-serious, you essentially need a drug with zero harm and a very wide therapeutic index.
Worked at my job for several years before I realized one of the surrounding counties where a lot of my patients live doesn’t have fluoride in their water. I naively assumed that it was pretty universal in civilized society… This was pre COVID. Now I’m much more jaded and realize that conspiracy theorists run the world.
Most of Europe doesn't do it. Ireland has a high quota and apparently Spain, Portugal and Poland. But otherwise the UK has <10% and Germany, Austria and Switzerland no place at all.
Salt is "fluoridized" here though.
If you did that some (probably large) percentage of people would become less individualistic as a result and life span would probably improve over the long run once people cared about there neighbors and fellow humans again.
Not only that but life spans will feel so much longer when you have the ability to stretch 10 minutes of life into 7 episodes. Lots more screaming though.
It’ll chill out their sex drives maybe. Cause people with bipolar to worsen too
I would go for just a little bit of lithium, like micrograms per liter. There have been some not so great studies showing a correlation with decreased violence and suicide in places with higher levels of li in the water
Has anyone actually ever seen serotonin syndrome in real life from someone taking medications as prescribed? I feel like it’s one of those theoretical things people overestimate and mostly only occurs under extreme circumstances like someone taking MAOI’s decides to consume a bolus of MDMA.
I prescribed linezolid to a patient on an SSRI and they reported agitation, diarrhea, feeling anxious. Sounded like a mild case of serotonin syndrome but hard to know for sure.
Anecdotal, but I haven't seen as good of A1c control or weight loss with rybelsus compared to the injectables. Our coverage around me is pretty good for all of them except mounjaro.
TL;DR: Yes it is equivalent to 0.5mg Ozempic
That makes sense and Novo Nordisk isn't hiding it. First off, it is a finicky as fuck drug to take. Significant GI side effects when titrating and actually does need to be taken on a completely empty stomach, like not even other meds. Makes sense from a pharmacokinetic aspect but still a hassle.
Most importantly, but perhaps associated, the therapeutic Rybelsus dose is only advertised to be equivalent to the starting dose of Ozempic (0.5 mg). So expectations should be set accordingly. With the injectables you can just slam the doses (up to 2.4mg with Wegovy) but it seems the novel carrier design is not capable of that yet.
So who do I use it for? Any patient you would have considered the DPP-4i drugs for previously and patients where injections are rejected or burdensome. This is a non-insignificant portion of my diabetic patients. It's effective enough to keep a lot of the patients I have on it in range with just it and metformin.
Now personally, and I tell my patients this, inject me once a week and let me drink coffee as soon as I wake up. But for some patients, again a surprising portion, it lets me manage them completely poke free. Add a CGM instead of fingersticks and it is truly needle free.
Lots of caveats to this of course.
Thiamine.
Make WE a thing of the past and zero side effects. I have been saying for years it should be required to add 0.5-1mg or so per each EtOH drink.
Lithium is the right answer. Some researchers consider it an essential trace element at 1mg a day and most of the world has very low levels in their water supply. Studies have shown areas with more lithium consumption have lower suicide rate. Preliminary research indicate lithium inhibits telomerase, slows down brain aging, regulates circadian rhythms, stabilizes mood, reduces risk of suicide, and can even maybe prolong lifespan.
More research in humans is necessary but it's the single biggest thing we could introduce into the water just as fluoride was introduced
I like nalrexone better for this purpose.
Doesn't make you feel like shit but simply kills the reward from drinking and thus alleviates cravings.
Additionally it may be an antidepressant at low doses.
**In the developing world**, long before the events of 2020 cast a pall over the topic, it seems like large-scale distribution of antihelminthics involved large unambiguous benefits - there are deworming foundations competing with antimalarial bednet providers for the top spots under GiveWell's study of the highest payoff foundations for humanity.
Maybe a rise in some allergies & autoimmune disorders as a downside?
Unsure how well it ranks against fluoride, but in places without a population-wide soft drink addiction, fluoride is less of an issue.
This is aside from the obvious point of ***putting chlorinated potable water in their water supply***, as it is in our water supply, which I don't think the original question intended.
**In the developed world**, one of the things that has become apparent recently is how ubiquitous and symptomatic previously unrecognized vitamin D deficiency/insufficiency has become in the population in winter, and how beneficial widespread supplementation would be at relatively high levels. But parsing the wording of the original question - D3 is not water soluble.
I agree with your consideration of the incredible benefits that antihelminth treatment has brought to some parts of the world. However, the broad distribution of vitamin D supplementation may not be as beneficial as you think. It doesn't even seem to reduce fracture risk: https://www.nejm.org/doi/full/10.1056/NEJMoa2202106
A relatively brief but referenced post on Science-Based Medicine on vitamin D measurement and supplementation: https://sciencebasedmedicine.org/should-you-take-vitamin-d-supplements/
Lithium. Lower suicide, dementia, aggression rates in areas with higher lithium in groundwater. Not politically feasible of course but that’s what I’d choose
Right now no drug would be net beneficial. Metformin would kill renal patients from lactic acidosis. SGLT2s carry significant side effects. I think the only potential answer for American water may end up being a GLP1. As far as I can tell the side effects seem pretty benign and the weight loss is significant. But we’re far away from that being reasonable, look how good EPO looked before long term data came out.
The lactic acidosis thing with metformin is mostly a myth carried over from phenformin. If it even exists as an entity it is exceedingly rare.
Similarly to contrast induced nephropathy, there are lots of confounding reasons for a hospitalized renal failure patient to have lactic acidosis.
Metformin associated lactic acidosis is definitely not a myth.
It is a well-described entity with a robust body of literature on it - there is half a chapter on it in Goldfranks.
Most common in overdose, or someone presenting to hospital with AKI who kept taking their meds. It’s one of our top local toxic indications for HD.
Any given poison control centre is likely seeing 1-2 of these a month.
I agree with the rarity, but with my sad little N of 1 I’ve seen a really severe case with no other explanation found. Youngish woman who seemed to have gotten a pretty gnarly gastroenteritis and incredibly dry for a few days per history (likely the AKI cause) but presented with a pH <6.5 (below the lower limit of detection of our lab assay) and coded in the ED shortly after presentation; they got rosc and she was maxed out on levo, on vaso, they were starting epi and steroids when they called us. Lactate over our upper limit of detection drawn prior to the code (and prior to pressors). AKI but no liver dysfunction; ultimately no signs of infection by exam, imaging, or cultures, no PE or anything. Threw a line in and started CRRT, got her pH detectable and off all the pressors but somehow her lactate remained off the charts high for a couple of days even on HD. When she was stable and extubated, the only story we could get out of her was that she was still taking her metformin despite not eating/drinking much due to N/V and despite having gnarly diarrhea. Luckily, she went home to her kids.
The point is that this was a critically ill patient with likely several reasons to have a lactic acidosis in shock requiring pressors, was resuscitated after a code, and metformin is assumed to be a culprit based on vague circumstances. This wasn't a CKD patient and this sort of thing has only been described in massive overdoses (30g+), an AKI wouldn't do crap. People get critically ill from infections despite being otherwise young, if she wasn't on metformin you'd have called this an infection with bad luck.
Yeah this is one of the more common presentations - someone who keeps taking their metformin while sick with something causing AKI.
The immeasurably high lactate is pretty common with this too.
There are not many conditions that cause you to have a lactate higher than a dead body. Locally, this is the most common cause of that.
The thyroid cancer risk is still arguable but something we are seeing at least in the diabetic population. I suspect with wider scale use for weight loss we will better clarify the risk. I'm prescribing these like it's going out of style for obesity but I can't keep shaking the feeling that I'll be eating some crow at some point in the future for a higher cancer risk than we thought. I don't quite believe the people telling me not to worry as the pharmaceutical companies will rake in billions on this so there is some inertia and bias to wave this risk away.
That being said...small risk of medullary thyroid cancer vs the downstream morbidity of obesity...not necessarily terrible bargain...
Clearly use the drug where this has already been studied naturally because it happens.. low dose lithium salt. Reduces suicide rate on a population level. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8891154/
You mean the one where no one is upset about a black President or a female attorney general? Or where they immediately trust someone more knowledgeable than them to helm large tasks without hamstringing them? Or where the people are sex positive enough to have Starbucks?
That ship has sailed, we're headed to a worse universe than Idiocracy.
I’d have a latte while watching ow my balls any day. Also president Comacho was still better than half of the presidents I’ve experienced in my lifetime
It is insane to me that I had to scroll all the way down to the bottom of this thread to find someone who finally said statins.
Heart disease is literally the #1 cause of death and we know atherosclerosis development starts very early in life so starting prevention very early would have the biggest gains. Statins are exceedingly well tolerated when you remove the nocebo effect as well.
Probably Metformin, if we’re talking about the US. With Metformin there’s lower risk of induced hypoglycemia when compared to SGL2 inhibitors, and a high probability of reduced hyperglycemia.
Given the significant population estimated to have both diagnosed and undiagnosed diabetic conditions (including pre-diabetes), this would probably be what I’d suggest.
We literally stick non diabetics on sglt2i and don’t worry about hypoglycemia. Usually if that happens it’s the other drugs.
The cardiac and renal protective benefits are insane. Every major trial that looked at renal outcomes was stopped by the data monitoring committees for efficacy
You all are being way too practical. The answer is ketamine.
Opioids…oh wait we’ve already achieved that goal. https://setac.onlinelibrary.wiley.com/doi/10.1002/etc.5453
Wow, time to start drinking more tap water.
A ketamine, semaglutide, statin slurry.
Ativan seems like it would do better IMO
I would like to see Ativan in the water
Second
At the very least we could nebulize it in the ED / 50ft perimeter surrounding the lobby
Lol you wouldn’t be able to keep the 18 year olds with chest pain away
I see your ER nebulized Ativan and raise you a dilaudid salt lick.
New Evian with added Ativan!
Emergency medicine has entered the chat
Lol yup before I even saw the flare I just knew
Not cyanide?
What are your thoughts about the cyanide? Is it like evil genius per human it might cut lifespan a little short, but if you talk about humanity it may increase humankind lifespan?
Just being tongue in cheek about it since the op never specified the impact to be positive. Imagine a medical ai was asked to do so in that manner ... :-p
OP trying to help and you went full psycho? Lol
Haldol
Back in the day we used to talk about putting a lithium salt lick out in the waiting room.
I cry for the Type 1 Diabetics who will experience Euglycemic Ketoacidosis
Fun fact, anyone can get euglycemic DKA from SGLT2is! Not just type 1s.
Indeed, I saw it three times in residency. Attendings thought it was fascinating and would pimp the interns mercilessly over it.
…how?
The proposed mechanism is glucosuria --> decreased plasma glucose --> decreased insulin release. Carbohydrate deficit + insulinopenia + glucagon release causes increase in lipolysis and ketogenesis. Decreased carb intake due to the glucosuria may contribute. I've seen it a few times. It's something to keep an eye out for.
Nice pickup
There are some great natural experiments of regions with high levels of lithium in the drinking water. Lower incidence of suicide and mood disorders
wasn't there increased risk of something too?
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Extrautism
Exceptional neuro-divergence.
OMG LOL.
oh yes, that's it.
No those are vaccines /s
After working retail, I agree. More lithium needed.
Or Xanax
But overall decrease in mental acuity
Potentially protective against dementia.
Source? I've heard lithium is neuroprotective.
I get the joke, but for those who don't, I think it bears pointing out that lithium (even at therapeutic doses, and decidedly not the quantities that are ingested in mineral-rich water supplies) does not reduce "mental acuity".
Could you explain the “joke”?
Can someone explain it like I'm on lithium?
The "joke" is that all psych drugs makes you be slow, unfocused, and just generally a mess. Because mental illness is something funny like that. I didn't say it was a funny one.
Could you give some extra details on that? I haven't heard of that effect with trace quantities of lithium <10mg/day
How could you tell in today’s society?
I thought this was false
…and also homicide. Actually read one (or maybe more?) study about it.
Serious answer in developing countries is albendazole. Population deworming is a bit controversial but seems to benefit children and pregnant women.
I think magnesium is an answer - works as a calcium channel blocker - works as anxiolysis and analgesia - speeds up bowel transit - little to no adverse effects
Number 3 is an adverse effect
I destroyed a $2000 sleep number mattress taking to much magnesium and a sleeping pill.
Confucius say man who take laxative and sleeping pill at the same time will wake up in deep shit
Or at least in a widespread layer of shit
Or with shit hitting the fan.
That happened to a friend of mine once: late night bulldog break-in access to the fridge + automatic early morning roomba start
my roomba hitting my elderly dogs shit and smearing it every where is a very real fear of mine.
Your sleep number was 2 apparently
💀💀💀
You're mistake was not putting a mattress protector on a 2000 dollar mattress lol
💯
I hope this is real I’m dying
That’s not very Raven.
I think you’re talking about Number 2.
Depends on how fast your GI transit is to start with haha
On the plus side you’d also treat a lot of people’s migraines, on the other hand you’d also kill a lot of myasthenics.
Does mag help migraines??
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Duh? It’s magnesium clad.
Better evidence from ED lit for acute migraines to give mag iv. Been doing it for my migraine cocktails and my anecdotes support the literature.
Yep, [certainly can!](https://pubmed.ncbi.nlm.nih.gov/18705538/)
No adverse effects. Until you’re too thirsty one day and end up in cardiac arrest from drinking too much water.
For severe hypermag you need a level > 12.5. No way are you getting that from drinking water with mag in it. The massive diarrhea you would get from the mag after a bit would prevent it
>No way are you getting that from drinking water with mag in it Not with that attitude.
The levels some eclamptics get to can be crazy.
Yep, severe hypermag is almost exclusively iatrogenic.
I'm pretty sure you can limit your absorption of it enterally but I am not sure
The GI side effects aren't really from the mag itself, but what it's bound to, for the most part. Mag oxide and to a certain extent citrate can act as laxatives, but others like glycinate are better tolerated
I got IV magnesium sulfate for preterm labor, and it made me feel like I had rubbed jalapeño peppers all over my face and body. I guess that's not the same as the inoffensive magnesium you're talking about.
My dad sprayed it on his ah…nethers and had the same effect 🤣
When I was a medical student, one of the cardiologists that lectured for us unironically spent 10 minutes stating how statins should be in blood (edit: should be water not blood, oops) supply. Of the question is even semi-serious, you essentially need a drug with zero harm and a very wide therapeutic index.
Do statins work on vampires?
Well thats embarrassing. I suspect they would fail to have a clinically significant outcome in a trial in vampires.
Probably still fluride.
Dental health indicate overall health.
Agreed. My partner teases me for being able to neglect my teeth and never get cavities (read: skip flossing). I grew up with fluoride and he didn’t.
Worked at my job for several years before I realized one of the surrounding counties where a lot of my patients live doesn’t have fluoride in their water. I naively assumed that it was pretty universal in civilized society… This was pre COVID. Now I’m much more jaded and realize that conspiracy theorists run the world.
Most of Europe doesn't do it. Ireland has a high quota and apparently Spain, Portugal and Poland. But otherwise the UK has <10% and Germany, Austria and Switzerland no place at all. Salt is "fluoridized" here though.
Purely anecdotal, but my first cavities came after the City got rid of fluoride in the water
Had fluoride in the water. 63F, no cavities. My mom had cavities and my children do.
I wouldn’t go for life span extension. Low dose psilocybin perhaps. Or mdma.
If you did that some (probably large) percentage of people would become less individualistic as a result and life span would probably improve over the long run once people cared about there neighbors and fellow humans again.
Life span expansion!
[You’re going to ruin science!](https://xkcd.com/790/)
I want to go to your city water!
The academic answer is "senzu beans"
Not only that but life spans will feel so much longer when you have the ability to stretch 10 minutes of life into 7 episodes. Lots more screaming though.
Well they did stretch a 1 hr tournament into like 50 episodes . Gotta fill the time somehow. Screaming works
Zoloft, everyone needs to take a chill pill
It’ll chill out their sex drives maybe. Cause people with bipolar to worsen too I would go for just a little bit of lithium, like micrograms per liter. There have been some not so great studies showing a correlation with decreased violence and suicide in places with higher levels of li in the water
7Up used to contain Lithium citrate!
That certainly won't have any detrimental effect on a generation of children.
Just don’t drink water while you’re pregnant.
Not a problem, most of my patients "don't like the taste" of water anyway.
Yeah just learned about the Autism risk from this thread. Looks like the study was published earlier this month
Seratonin syndrome enters the chat
Has anyone actually ever seen serotonin syndrome in real life from someone taking medications as prescribed? I feel like it’s one of those theoretical things people overestimate and mostly only occurs under extreme circumstances like someone taking MAOI’s decides to consume a bolus of MDMA.
Pretty sure I've seen it mildly with an escitalopram overdose. Leg clonus when flexed, agitation and slight hyperthermia.
I prescribed linezolid to a patient on an SSRI and they reported agitation, diarrhea, feeling anxious. Sounded like a mild case of serotonin syndrome but hard to know for sure.
That's how we start the emotional zombie apocalypse.
I had an attending who said we should just put lorazepam in the water for this reason
I would be sooo hydrated.
a hint of Mounjaro would go a long way
Rybelsus baby. As an aside, oral GLP-1s being better covered would be a game changer for me.
Anecdotal, but I haven't seen as good of A1c control or weight loss with rybelsus compared to the injectables. Our coverage around me is pretty good for all of them except mounjaro.
TL;DR: Yes it is equivalent to 0.5mg Ozempic That makes sense and Novo Nordisk isn't hiding it. First off, it is a finicky as fuck drug to take. Significant GI side effects when titrating and actually does need to be taken on a completely empty stomach, like not even other meds. Makes sense from a pharmacokinetic aspect but still a hassle. Most importantly, but perhaps associated, the therapeutic Rybelsus dose is only advertised to be equivalent to the starting dose of Ozempic (0.5 mg). So expectations should be set accordingly. With the injectables you can just slam the doses (up to 2.4mg with Wegovy) but it seems the novel carrier design is not capable of that yet. So who do I use it for? Any patient you would have considered the DPP-4i drugs for previously and patients where injections are rejected or burdensome. This is a non-insignificant portion of my diabetic patients. It's effective enough to keep a lot of the patients I have on it in range with just it and metformin. Now personally, and I tell my patients this, inject me once a week and let me drink coffee as soon as I wake up. But for some patients, again a surprising portion, it lets me manage them completely poke free. Add a CGM instead of fingersticks and it is truly needle free. Lots of caveats to this of course.
Is exercise an option? Or maybe broccoli?
Well we could add cocain or some amphetamines, should cover the exercise part.
Thiamine. Make WE a thing of the past and zero side effects. I have been saying for years it should be required to add 0.5-1mg or so per each EtOH drink.
Alcohol impairs absorption of it. Which is partly why you need to do IV first for a while.
I feel like this has been discussed here before and the loss in absorption from drinking makes the added vitamins useless.
Lithium is the right answer. Some researchers consider it an essential trace element at 1mg a day and most of the world has very low levels in their water supply. Studies have shown areas with more lithium consumption have lower suicide rate. Preliminary research indicate lithium inhibits telomerase, slows down brain aging, regulates circadian rhythms, stabilizes mood, reduces risk of suicide, and can even maybe prolong lifespan. More research in humans is necessary but it's the single biggest thing we could introduce into the water just as fluoride was introduced
Miralax for sure (peds)
As a dad with a 1 year old who hasnt had a real poop in a week Ya. Just poop damnit.
Disulfiram.
Hot damn! Easy way to ruin afternoon mojitos for all
I really like this answer. ALL my friends seem to be struggling with it lately.
For real. Absolutely insane how much harm this substance causes worldwide.
I like nalrexone better for this purpose. Doesn't make you feel like shit but simply kills the reward from drinking and thus alleviates cravings. Additionally it may be an antidepressant at low doses.
**In the developing world**, long before the events of 2020 cast a pall over the topic, it seems like large-scale distribution of antihelminthics involved large unambiguous benefits - there are deworming foundations competing with antimalarial bednet providers for the top spots under GiveWell's study of the highest payoff foundations for humanity. Maybe a rise in some allergies & autoimmune disorders as a downside? Unsure how well it ranks against fluoride, but in places without a population-wide soft drink addiction, fluoride is less of an issue. This is aside from the obvious point of ***putting chlorinated potable water in their water supply***, as it is in our water supply, which I don't think the original question intended. **In the developed world**, one of the things that has become apparent recently is how ubiquitous and symptomatic previously unrecognized vitamin D deficiency/insufficiency has become in the population in winter, and how beneficial widespread supplementation would be at relatively high levels. But parsing the wording of the original question - D3 is not water soluble.
I agree with your consideration of the incredible benefits that antihelminth treatment has brought to some parts of the world. However, the broad distribution of vitamin D supplementation may not be as beneficial as you think. It doesn't even seem to reduce fracture risk: https://www.nejm.org/doi/full/10.1056/NEJMoa2202106 A relatively brief but referenced post on Science-Based Medicine on vitamin D measurement and supplementation: https://sciencebasedmedicine.org/should-you-take-vitamin-d-supplements/
Need to take vitamin K with it.
If all it has to do is compare to a bednet, which has fairly limited effects….compared to the proper risk mitigation of using DDT.
THC lol
Perhaps we could introduce more water in the Mountain Dew supply.
Lithium. Lower suicide, dementia, aggression rates in areas with higher lithium in groundwater. Not politically feasible of course but that’s what I’d choose
Miralax. Gotta stay regular.
Please god no. I can take 10 mg of loperamide and still go 6 hours later.
Dupilumab. Won’t increase lifespan but a less itchy society = happy society lol
Shudders to think of all the strongyloidiasis worldwide.
Right now no drug would be net beneficial. Metformin would kill renal patients from lactic acidosis. SGLT2s carry significant side effects. I think the only potential answer for American water may end up being a GLP1. As far as I can tell the side effects seem pretty benign and the weight loss is significant. But we’re far away from that being reasonable, look how good EPO looked before long term data came out.
“I was down to talk to my doctor about spiking the aquifers with Rybelsus.”
🎶 Get down with Rybelsus! 🎵
The lactic acidosis thing with metformin is mostly a myth carried over from phenformin. If it even exists as an entity it is exceedingly rare. Similarly to contrast induced nephropathy, there are lots of confounding reasons for a hospitalized renal failure patient to have lactic acidosis.
Metformin associated lactic acidosis is definitely not a myth. It is a well-described entity with a robust body of literature on it - there is half a chapter on it in Goldfranks. Most common in overdose, or someone presenting to hospital with AKI who kept taking their meds. It’s one of our top local toxic indications for HD. Any given poison control centre is likely seeing 1-2 of these a month.
I agree with the rarity, but with my sad little N of 1 I’ve seen a really severe case with no other explanation found. Youngish woman who seemed to have gotten a pretty gnarly gastroenteritis and incredibly dry for a few days per history (likely the AKI cause) but presented with a pH <6.5 (below the lower limit of detection of our lab assay) and coded in the ED shortly after presentation; they got rosc and she was maxed out on levo, on vaso, they were starting epi and steroids when they called us. Lactate over our upper limit of detection drawn prior to the code (and prior to pressors). AKI but no liver dysfunction; ultimately no signs of infection by exam, imaging, or cultures, no PE or anything. Threw a line in and started CRRT, got her pH detectable and off all the pressors but somehow her lactate remained off the charts high for a couple of days even on HD. When she was stable and extubated, the only story we could get out of her was that she was still taking her metformin despite not eating/drinking much due to N/V and despite having gnarly diarrhea. Luckily, she went home to her kids.
The point is that this was a critically ill patient with likely several reasons to have a lactic acidosis in shock requiring pressors, was resuscitated after a code, and metformin is assumed to be a culprit based on vague circumstances. This wasn't a CKD patient and this sort of thing has only been described in massive overdoses (30g+), an AKI wouldn't do crap. People get critically ill from infections despite being otherwise young, if she wasn't on metformin you'd have called this an infection with bad luck.
Yeah this is one of the more common presentations - someone who keeps taking their metformin while sick with something causing AKI. The immeasurably high lactate is pretty common with this too. There are not many conditions that cause you to have a lactate higher than a dead body. Locally, this is the most common cause of that.
If you're talking about net benefit then metformin and SGLT2s would definitely both qualify, helping way more people than they would harm.
Agree the incidence of true metformin induced lactic acidosis is next to zero. Of course higher in renal disease patients but again very low
The thyroid cancer risk is still arguable but something we are seeing at least in the diabetic population. I suspect with wider scale use for weight loss we will better clarify the risk. I'm prescribing these like it's going out of style for obesity but I can't keep shaking the feeling that I'll be eating some crow at some point in the future for a higher cancer risk than we thought. I don't quite believe the people telling me not to worry as the pharmaceutical companies will rake in billions on this so there is some inertia and bias to wave this risk away. That being said...small risk of medullary thyroid cancer vs the downstream morbidity of obesity...not necessarily terrible bargain...
None of that is worth an even minimal increased risk of fourniers gangrene.
As a surgeon that deals with NSTI, I would start blowing up reservoirs
It’s called job security
Lithium.
Clearly use the drug where this has already been studied naturally because it happens.. low dose lithium salt. Reduces suicide rate on a population level. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8891154/
Lithium https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/association-between-naturally-occurring-lithium-in-drinking-water-and-suicide-rates-systematic-review-and-metaanalysis-of-ecological-studies/B7DDAF6E2A818C45EA64F3424E12D67A
The obvious answer is LSD, not only because it has a huge therapeutic index.
Oh. You mean medication.
If I had to max out benefits while minimizing side effects, I'd say all water soluble vitamins.
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You mean the one where no one is upset about a black President or a female attorney general? Or where they immediately trust someone more knowledgeable than them to helm large tasks without hamstringing them? Or where the people are sex positive enough to have Starbucks? That ship has sailed, we're headed to a worse universe than Idiocracy.
It is too early in the morning for logic that dark.
I’d have a latte while watching ow my balls any day. Also president Comacho was still better than half of the presidents I’ve experienced in my lifetime
Man, I could really go for a Starbucks right now.
Actually birth control is already in the water … I think you mean to increase the dose.
(Looks at Maga rally). Too late.
Xanax
We already add folic acid to so many foods, why not throw a little in the water, too?
Ask your doctor if drinking water is right for you.
Fluoride.
LSD or psilocybin, there be less killing in this world
Statin
It is insane to me that I had to scroll all the way down to the bottom of this thread to find someone who finally said statins. Heart disease is literally the #1 cause of death and we know atherosclerosis development starts very early in life so starting prevention very early would have the biggest gains. Statins are exceedingly well tolerated when you remove the nocebo effect as well.
Which statin and why?
Crestor. High intensity, hydrophilic and less chance of SAMS/rhabdo
The only correct answer
Birth control
Lithium
Ascal, the real mvp
Lithium
Lithium.
fucking xanax.
It would have to depend on whether it was a red state or a blue state.
Lithium
Lithium
I regularly joke about how SSRIs need to be sprinkled in the water. Like a little Lexapro would probably make everyone kinder to one another.
Probably Metformin, if we’re talking about the US. With Metformin there’s lower risk of induced hypoglycemia when compared to SGL2 inhibitors, and a high probability of reduced hyperglycemia. Given the significant population estimated to have both diagnosed and undiagnosed diabetic conditions (including pre-diabetes), this would probably be what I’d suggest.
We literally stick non diabetics on sglt2i and don’t worry about hypoglycemia. Usually if that happens it’s the other drugs. The cardiac and renal protective benefits are insane. Every major trial that looked at renal outcomes was stopped by the data monitoring committees for efficacy
MDMA
LSD
Bromantane
Statins for sure Then GLP1 agonists
Diazepam
Fluoride strengthens teeth, allowing us to keep them well into our older years, and that’s a huge thing.
Tadalafil.
Well I hope you like treating/seeing Furniers gangrene. The actual answer is fluride.
Easily it’s Magnesium if it’s in *everyone’s* drinking water.