Dr. Keith Roach: Lower-leg swelling may be due to venous insufficiency
DEAR DR. ROACH: I am an 84-year-old man in reasonably good health. I have taken blood pressure medicine for about 30 years. For the past six months, I have been taking trospium tablets to treat frequent urination. I have prostate cancer treated with radioactive seeds, not surgery. About two months ago, I began noticing swelling in my lower legs and feet. Do you have any advice on how to reduce or eliminate the swelling? — H.S.
ANSWER: The first thing to consider with a new diagnosis of swelling, also called edema, in the legs is what might be causing it. Medications are one common cause. Of the blood pressure medicines, the calcium blockers that end in “-pine,” such as amlodipine (Norvasc) and nifedipine (Procardia), commonly cause this side effect, but with a new issue after 30 years, I wouldn’t expect that to be the only cause. Trospium is a bladder anti-spasmodic, and swelling is not commonly reported with that.
The three main worrisome causes of lower-extremity swelling are heart failure, kidney disease (especially protein loss) and liver disease. Your doctor should be able to evaluate these three very quickly through an exam and simple blood and urine tests.
When no cause is identified, by far the most likely cause is “venous insufficiency,” meaning that the veins in the legs aren’t doing their job properly, often because of poor valves, which can wear out after working perfectly for 84 years. The most appropriate initial treatment is support stockings put on every morning and taken off at night, combined with leg elevation (above your heart, 30 minutes, three times a day). That works well for most people, and if it doesn’t, then further testing and treatment can be considered by an expert, such as a vascular surgeon.
However, in your case, your doctor also should be thinking about your cancer and its treatment. Uncomplicated prostate cancer treated with radiation seeds is not usually associated with leg swelling. However, blood clots are a known complication of prostate cancer, and a blood clot in the deep veins of the pelvis in the inferior vena cava (the largest vein in the lower part of the body) can lead to swelling. This would be a rare cause but one worth considering.
DEAR DR. ROACH: When I had gestational diabetes, my internist always told me my goal A1C level was between 5 and 6 percent and that 7 percent was too high. Is there a difference between the A1C goal in a gestational diabetic versus a Type 2 diabetic? — N.E.
ANSWER: There is a difference. The issue with Type 2 diabetes is that many people are at high risk for heart disease. So, older people with diabetes, especially those with additional risk factors for heart disease, usually are advised to have an A1C goal near 7 percent.
This is due to a study that showed people at high risk for heart disease were more likely to have a heart attack or death when the A1C goal was below 6 percent compared with around 7 percent.
Pregnant women have a different goal, since high levels of insulin during pregnancy cause the developing baby to get large, sometimes so large that there is an increased risk of trauma during birth. Since an increased risk of heart attack is a very small risk in pregnant women, it’s best to have as normal a blood sugar as possible (a normal A1C level in a person without diabetes is 4 percent to 5.6 percent).