February 1, 2015

Options After Insulin

This is one confusing article in Diabetes Self-Management magazine. First, there is an error in the byline, as when I contacted Will Dubois, his answer back was there is a misprint in the byline because he didn't write it. In an email to Gary Scheiner, he confirmed to me that he is the author and the article is written for people with type 1 diabetes.  The byline has now been corrected.

I have needed to reread the article several times and slowly to determine that it was written for people with type 1 diabetes. I do wish he had clearly stated that the article was written for type 1 diabetes. This can be inferred, but is far from clear in the overall context of the article. With the number of people with type 2 diabetes using insulin, this could have been written for both types. However, I should have known this as most CDEs do not deal with type 2

With the conflicts of interest that the American Association of Diabetes Educators has, I am also wondering how much of a conflict of interest is represented by the article and the medications he is promoting. The “off label” use that is being promoted is heavy and questionable at best.

Since I am a person with type 2 diabetes, none of the medications is “off label” use for me. This is the only clear reason for this being written for those with type 1 diabetes. I cannot agree with some of the medications as the potential side effects far out weigh the benefits and this is true for type 2 and type 1.

In looking at the medications recommended for type 1 there are only two that I could consider as being valid and only one that is truly “off label” and that would be metformin as it is used “off label” for prediabetes as well and has many studies to confirm its benefits. The one contraindication would be kidney problems which is true even for type 2 diabetes.

The first injectable drug other than insulin to hit the market was pramlintide (brand name Symlin), a replacement for the hormone Amylin. Amylin is normally secreted by the pancreas along with insulin. People with type 1 diabetes secrete no Amylin at all, and people with type 2 diabetes usually secrete far too little. Yet people with type 2 diabetes that use insulin therapy early often preserve their ability to produce enough Amylin to avoid needing Symlin. When insulin is the medication of last resort, then often Symlin may be needed, but is seldom prescribed.

The only drug that the author gave a warning for is the Thiazolidinediones. Both pioglitazone (Actos) and rosiglitazone (Avandia) have been linked to increased risk of congestive heart failure in people already at high risk for heart disease.

Even the newest class of type 2 oral drugs, sodium-glucose cotransporter 2 (SGLT2) inhibitors are not listed with the warning for people with kidney problems as they are for people with type 2 diabetes.

There are several DPP-4 inhibitors on the market today, as well as a few under development. The currently available drugs include sitagliptin (Januvia), linagliptin (Tradjenta), saxagliptin (Onglyza), and alogliptin (Nesina). No warning is given about causing hypoglycemia when these drugs are used with insulin.

With the lack of warnings and the overall promotion of drugs that are generally for type 2 diabetes, I would be concerned about unstated conflicts of interest.

January 31, 2015

Young People with Type 1 Diabetes

This video in the NY Times is somewhat frightening and I have viewed it several times to get that out of my mind, but I can't. The young girl, Grace, at 15 has type 1 diabetes and is having wild swings in her blood glucose levels. As with most parents, Mr. and Mrs. Chamberlain are all over her and her testing schedule. They set alarms to check her blood glucose at midnight, three AM, and six AM. She tests the rest of the day.

They may have good reason for concern as apparently she is on a high carbohydrate/low-fat food plan and also seems hypoglycemia unaware. She does have a diabetes service dog and this has eased the concern some. The dog does go with her to school and anyplace she goes away from her parents.

David Mendosa says she and her family have apparently never heard of Dr. Richard K. Bernstein and the law of small numbers. For the brief time when her blood glucose numbers flashed across the screen, I would have to agree with David and say she and her family need to read Dr. Bernstein's book, “Diabetes Solutions.”

Hopefully, the link above will allow you to see the video. It is not the best video and jumps from point to point without any narrative or controls to allow you to pause the video, which I could get to work.

She has had three or four friends or acquaintances that have died from type 1 diabetes. This does concern the entire family and has left a lasting impression on the daughter.

Below the video is a brief write-up about the Chamberlain family in Fort Worth, Texas. Grace was diagnosed with type 1 diabetes in 2006. Grace’s experience with the disease has been particularly volatile. Her blood glucose levels must be checked and managed constantly; if they get too low, she could die within minutes. Grace’s parents have devoted their lives to keeping their daughter healthy. Their kitchen has been transformed into an arsenal of diabetes-regulating equipment and food. Because she often can’t feel the fluctuations in her blood sugar levels, they got her a diabetes service dog, Jackie, who can sense when Grace’s glucose levels may be getting too low, and urge her to go check and correct them.

Grace’s main hope is for an artificial pancreas, which would mimic the biological function of the organ by regulating insulin and other hormone delivery and helping maintain healthy blood glucose levels. Research for this technology is ongoing in the United States, but a 4-year-old in Australia has received the world’s first artificial pancreas last week; Grace has a fund-raising campaign of her own. Once the artificial pancreas is perfected and approved for use by the FDA, Jackie the dog can focus on being a dog, and Patricia and her husband can sleep. More important, Grace will have the best shot possible at the pursuit of a stable, independent, and almost normal life.

January 30, 2015

Help in Diabetes Management Education – Part 4

Part 4 of 12

I have a difficult time understanding people with type 2 diabetes that have never heard of hypoglycemia or hyperglycemia. This last fall, I had two people say they had not heard these terms and because their doctor had not mentioned them, they did want to talk about them. They were quick to separate from A.J and me when we were talking to them and I had to wonder if this was a topic that the doctor had mentioned and they had selective hearing loss at the time.

Many men do this regularly and some women, then they use the excuse that the doctor did not mention or talk about this. In our support group, we do get in the face of a person that says this and ask them point blank why they think they can get away with this. We have lost one member over this, but the rest realize that we are trying to teach them something and we don't hear this phrase again.

Hypoglycemia is the fear of all doctors and they are very careful to avoid insulin for this reason. Patients  need to learn about both hypoglycemia and hyperglycemia to be able to manage their diabetes. Yet this is something many patients do not want to learn about, especially the older type 2 diabetes people.

What many forget is that both conditions can result in a coma and even death and that is one reason the members of our support group learn about these and why we have a call tree for single people that don't call in every morning. This was discussed by all the members and while only two of the single people opted out at the beginning, everyone is now part of this. Yes, our deceased member was one of the two. Those that are still working have a procedure with their boss if they are over 15 minutes late for work. The boss has a list of phone numbers by day to call and a member will check on them.

Hypoglycemia is considered for blood glucose (BG) readings below 70 mg/dl (3.9 mmol/L). Most people get noticeable symptoms when BG goes below 80 mg/dl (4.4 mmol/L), but others do not until BG gets lower. Readings of 70 mg/dl and above are normal for most people and generally of no concern. Trends below 80 mg/dl need to be watched carefully if they get near the 70 mg/dl level. Why do I use the mg/dl behind the numbers? This is what the meters are set to read in the USA. All other countries use the mmol/L.

Symptoms of hypoglycemia vary by individual, but may include extreme hunger, nervousness, excessive perspiration, rapid heartbeat (tachycardia), headache, fatigue, mood changes, blurred vision and difficulty concentration and completing mental tasks. Extremely low glucose levels can lead to disorientation and convulsions, even coma and death

Hyperglycemia is difficult to detect for most individuals. There is much disagreement as to where hyperglycemia starts. Irrespective of what number you choose to believe, the American Diabetes Association (ADA) has set the upper limit for A1c's at 7.0 percent. This equates to 154 mg/dl (8.6 mmol/L). I have also seen ADA use the number of 180 mg/dl (10.0 mmol/L). It is known that complication damage occurs at an A1c value of 7.0% and higher. Some will argue that damage occurs above 140 mg/dl (7.8 mmol/L). I prefer using the 140 mg/dl as the starting point for complication damage and as the starting point for hyperglycemia.

Most people can only detect hyperglycemia by testing. When your blood glucose levels are above 200 mg/dl (11.1 mmol/L) it may be several days before you may notice any signs. Some people do not notice frequent urination and increased thirst, even then. This is another reason to test regularly. If you are a person that exercises regularly, a blood glucose reading of 240 mg/dl (13.3 mmol/L) means you must not exercise until your BG is below 200 mg/dl. It is always advisable to talk to your doctor about the amount of medication to use to bring high BG numbers down. Unless you have previously discussed this with your doctor and know what to do, it is always wise to talk with the doctor.

January 29, 2015

Help in Diabetes Management Education – Part 3

Part 3 of 12

I don't expect everyone to keep all the records that I keep, but these are offered to give you ideas. A few of my fellow support group members are good with databases and keep more information than I keep. I use spreadsheets in my system. A few members keep it all on paper from tablet paper to fairly large accounting paper.

Now that I have patted myself on the back, I find that there is always more that I could record. Journaling is not something I had even thought about, but David Mendosa writes about it here. Not only does he journal about the positive things that happen, but also the worst things that happen to us with diabetes. Journaling is personal for your own use and not shared generally and as David says, he uses a diary format.

Since I have blogged about the spreadsheet format before, I will just refer you to those blogs. The first is my food log and the information I keep. I keep more than most people would, as I am on insulin. The second is my daily blood glucose testing log and related notes. The third blog and other logs are my daily health log, lab test log, and other logs. Yes, they do take time and effort, but this is my health and I treat this with respect.

This is mentioned in the third blog, but I do think it needs some clarification. This log is my medications log and I do print this out in two copies and one I give to the doctor for adding to my medical records. This is also something that I give to my local pharmacist at least once a year or anything there is a change in my medications. Since I use the Veteran Affairs pharmacy, I also give the VA nurse a printout which they check against their records and change accordingly. A change made at the VA office is available to all offices that need it.

The medications log has my name and address centered across the top and includes my telephone number. After I print out the report, I hand write my social security number on a blank also in the heading and my date of birth.

After the heading, the first column is just the number starting at one through the number of medications. This also includes all non-prescription drugs (like aspirin) and
dietary supplements (like vitamin D3 and B12). The second column is for the name (like Lantus - Insulin Glargine) of the medication. The third column is for the daily dosage. Column four is the description or purpose of the medication. Column five is the daily usage or when taken (AM, PM, or AM/PM).

Then for my usage are the columns to the right after two blank columns. The first column is the RX number which comes in very handy when the print on the vial holding the medication becomes unreadable. The next column is the expiration date of the prescription. The next column is the last purchase date which comes in handy when the next purchase date will be after to expiration date. This reminds me to ask for a new prescription. I have other columns that I use, such the number of pills or capsules in the bottle of non-prescription drugs and dietary supplements and this I use to determine when to repurchase and whether the count is correct.

You will need to determine what works for you and what you want to keep in the way of records. I will say that many of us that keep detailed records recover from mistakes faster and are able to discern the cause of problems easier.

January 28, 2015

Help in Diabetes Management Education – Part 2

Part 2 of 12

Blood glucose testing will depend on how many test strips your insurance company will pay for and then on your budget. I don't expect everyone to able to test for what is ideal, but I will list the ideal first to give you a basis. This is also one reason I urge people to ask their doctor for extra test strips at the beginning to help them determine what works for their food plan and which foods to limit or eliminate. This will also allow you to determine the time from first bite or last bite to the peak in your blood glucose. This varies for each individual and you should determine what your peak is for each meal. Many have their peak at one hour and others at two hours. Some like me peak at about 90 minutes and others a two hours and thirty minutes. This is a variable that you must determine for your body. This can change as you age, so be aware of this.

The first time for testing is when you wake. This is also your before breakfast blood glucose test (termed preprandial). Then you should test about one or two hours after breakfast. Do this for each of your meals and then before going to bed. Then you should always test before and after exercise unless you are on oral medications that do not cause lows (hypoglycemia). Read my blog on blood glucose levels that are safe for exercising. Some people with type 2 diabetes do exercise with blood glucose levels that are too low or too high.

If you are on insulin, you should test before and after exercise. With the position of the ADA and actions by some states on people driving with low blood glucose levels, it is also wise to test before starting to drive and stop and test if you feel low. Some states are suspending driver's licenses when it can be determined that an accident happens that is caused by hypoglycemia. Other causes include if you are stopped while driving during an episode of hypoglycemia. In other words, know the law in your state. The above link is to a prior blog on driving, and this is the link for the 2105 guidelines for diabetes and driving – actually a use of the 2014 guidelines which was not changed for 2015.

Most people on oral medications are limited to one or two test strips per day depending on the medication. Those using insulin are generally limited to three test strips per day. This means that you are limited in the testing you can do and what you can do for experimenting. I know quite a few people on oral medications and on insulin that purchase the extra test strips to be able to experiment and determine the best postprandial time to test. They also used the extra test strips at the beginning that their doctors were able to have approved to determine what foods they could eat, what needed to be limited, and the foods they needed to eliminate.

Developing their meal plan was also a priority for them and a few that needed to spend their own money for extra test strips to do this experimenting. When I meet someone that has done this or even receive an email about the success from doing this, I always feel good for the person. This is management at its best and means to me that the person wants to learn how best to manage his or her diabetes. Oh, yes, we all make mistakes or errors, we are human, but if we learn from these, we are better for these mistakes.

January 27, 2015

Help in Diabetes Management Education – Part 1

Part 1 of 12

How many parts this will evolve into is a big question, but by the above you know that this will be in twelve parts. The first part is about knowing your equipment, how to use it, and the temperatures at which it can be operated. Yes, I have written about this before, but I still receive emails asking me where to find this information. Unfortunately, some of the emails tell me they could care less about proper storage or even using their meter at the proper temperature or even the test strips, as the doctor does not look at their logs even though he is the one telling them to test.

Sadly, this involves many patients and too many think they are testing for their doctor. Many of these are the same people that take the prescription for the pills (oral medication) and keep on the same destructive lifestyle. Yes, they take the medication or medications, but nothing else is changed. It is when they have the second or third appointment and the doctor tells them that their A1c is getting worse and really chews them out, that some wake up and decide to change, but again they don't know what to do or even how to make the changes necessary.

Knowing and learning about your diabetes equipment is saving the instructions that came with the equipment. Yes, the print is often smaller than many people my age enjoy reading, but that is why I keep a magnifier on my desk. The instructions for the meter are important and should be read. Learn the operating temperature range and the same for the test strips. Always keep the test strips in the container they are in and know the places not to store them.

A few summers ago, I had to wrap a cold pack in a towel and place it in a cooler and put my test strips in a large cooler when the air conditioner quit working. The temperature in the apartment was over 100 degrees and fans did help, but not enough for the test strips. I did not have any problems by storing them using this method.

In many rural or less populated areas of the United States, certified diabetes educators are not available so hopefully your doctor will give your some help or have a nurse that can help you. Diabetes support groups are also a good resource provided they share information and teach.

In the area I live in, I am aware of two certified diabetes educators; however, they have the title of registered dietitian (RD) listed before the CDE title. We have discovered they do more to preach high carbohydrate – low fat than they talk about managing diabetes or even how to test. We have determined that they don't want us to test to discover how their food plans spike our blood glucose levels. The emphasis is very heavy on whole grains and we all have found that this does not work for most of us with type 2 diabetes.

We are happy that my cousin, Suzanne, has been working with the members of our support group. Even the new members have been appreciative of her help and are asking when we will have her back. I have said that they may contact her when they have questions and that is why she gave them a business card with her telephone number on it. Most say that they don't want to abuse this as she can only charge their insurance or Medicare for two hours and they don't want to use up their time immediately. I tell them to ask questions the next time she will be present, as we are planning that for February.

January 26, 2015

Gift Ideas for a Person with Diabetes During the Year

We are all aware of getting gifts for people with diabetes during the holidays, but do we think of gifts for birthdays, anniversaries, and other special days. With that in mind, here are a few ideas that are not just for Christmas, but also for anytime.

Medical alert jewelry is always a great gift; however, make sure that the recipient will wear it. I have been shocked at the number of people with diabetes that will not wear anything that identifies them as having diabetes. In conversations with several emergency medical technicians (EMTs) over the last few months all commented how few people actually wear medical alert jewelry of any type.

All agreed that too often people are given medication that they are allergic to or have bad reactions after a few minutes. Several commented that the police that often arrive at a person's residence do a search for medications and check the refrigerators looking for medications requiring refrigeration. One of the EMTs stated that he likes people that have medical alert information where it can be found as this often means better treatment and a phone call will alert them to medications that could be life saving for the person.

Another commented that in many cases where the husband and wife are both alive, sometimes one spouse will not be aware of what medications the other spouse is taking. He has also seen one spouse refuse to give information that could be critical to the treatment of the spouse in trouble. Often they have brain freeze and cannot think when a loved one is in trouble.

Fresh food is always appreciated. Avoid 'food of the month clubs,' as you will often pay more than at the local grocery store and for poorer quality. If your friend lives in a cold climate, warm gloves, thermal socks, cashmere scarves (even the wool variety), and warm hats are often much appreciated. These will help in the cold winds and help reduce the stress on the organs.

If you have the funds, exercise machines can be a great exercise aid. Before spending the money, be sure that there is space available and that the person has the ability to use the equipment. If the person is one that likes massages, facials, or other pampering sort of things, then consider these. Be sure to avoid tanning beds, as these are not safe. The tanning bed manufacturers will claim otherwise, but they are still not safe.

If you have youngsters on your list, how about lessons in Karate, dancing, fencing, basketball, or other sport they may have an interest? Always be sure that the parents will support the youngster in this. Some children and even teens enjoy reading and will love books. Check to be sure if they have an interest in a series or particular author.

If a person with diabetes works, buy them a slow cooker. They can leave for work in the morning and come home to a cooked meal at night. If necessary, consider adding a slow cooker cookbook.

If the person with diabetes needs to be in contact with others because of health issues, think of a cell phone. This might help allay anxiety when they are alone. Be sure that you can afford or the person can afford the monthly bill.

For an elderly parent, an alert necklace with a button that can be pushed to summon help by the police can help after falls or other events where the person is threatened or fears outsiders can be of help. Even web cameras if the parent will allow them can help and make the elderly parent more comfortable. Then you can keep tabs on them from your computer at home and in some cases from work. Be sure your employer will allow this first.

January 25, 2015

Our Second January Meeting and a Surprise

As soon as Tim said we would have our second meeting this month, Brenda and Jason have been busy, and both Brenda and Sue have been in contact with me about images to use. I pulled up several images like the ones below and emailed them to both.
 

Brenda said she was forwarding both to Tim and she said the top picture was close to the one she saw. She was not sure she could get the name of the antibiotics used, but she knew the place where the member received her prescriptions and maybe the member would let her see them.

When the date arrived, January 24, we were ready. Only one member was absent and that was the one that Sue was working with to heal the foot ulcer. Sue said the doctor had ordered her to stay off her feet for a week or more and she did have crutches. Tim called the meeting to order and stated that we have told you we are interested in helping each and every one of you and for you to ask questions. He said we have one member absent because of a foot ulcer and another person that is here while still recovering from a cracked heel. The doctor has also ordered her on crutches. So before we start this evening, everyone sit down, take off your shoes and socks or stockings, and have your feet ready for inspection.

There was a lot of grumbling, but everyone complied. Allen brought out the two stools for the people to rest their feet on during the inspections. Tim had not told us he had two podiatrists coming, and he went to the door and invited them in. Tim introduced them and said he had arranged for everyone to obtain a free foot inspection. The one podiatrist that knew me came to me first while the other went to Allen first. When they had finished with us they explained what they had seen and the podiatrist that examined me asked me to sit on the rolling stool and pushed me around the group to show them the big toe that he knew about and he announced that it had not changed much since he had last seen me. He did say that the damage was under the toenail and not the toenail as he had originally thought as the toenail was growing. He said I had notified him at my last checkup and he would keep watching it. With that he asked me to notify his office if there were more changes, but for now he was not concerned. He asked me to put my socks and shoes back on and assist him.

The podiatrist that had examined Allen said he found nothing and that Allen's feet were in good condition and to get ready to help him. With that we moved the stools while the doctor took the chairs they would use. They checked the older members first and found nothing other than one scratch on Rob's ankle which Rob said he was using Neosporin on it before bed each evening. The podiatrist said it looked like it was healing. Next they started with the member with the cracked heel and the podiatrist said it was healing well and if she continued to follow the treatments she should be okay in another two or three weeks.

Next, my podiatrist examined Jerry and said that the foot ulcer was healing nicely and as long as he continued the treatment the doctor has prescribed, it should be okay in another month. Jerry said that was what the doctor had told him. We continued with the rest of the new members and found two more members with minor cracked heels and another member with the start of a foot ulcer.  One in-grown toenail was also found. They were advised to see their doctor as quickly as possible or to make an appointment with one of them the following week. The three were told if they wanted prescriptions to help them start the healing, they would be given one.

Tim said that this evening was done for their benefit and the rest of the members wanted what was best for them. But with the problems happening the prior two weeks, this was what brought this meeting about. Then he asked if anyone did not have insurance. When no hands were raised, he asked why people were not taking care of their health. He apologized to the doctors for interrupting and asked them to finish their talk about proper shoes.

The doctors said most of the cracked heels were probably caused by wearing the incorrect shoes or foot support around the house or apartment. During the winter, wearing shoes without proper heel protection helps aggravate dry and cracked heels, and he was not talking about high or spike heels for women. If they wanted to wear elevated heels with proper foot support, those could work.

For the foot ulcers, they strongly recommended wearing foot support in the shoes and these needed to be custom fit by a specialist and they could give them at least three that the person could chose from. They had seen the supports that Max had and asked him. Max gave the name and they agreed that the person was good. Jerry asked how soon he should consider getting fit for them and they said not until the ulcer had healed, but that he could get one for the other foot anytime.

Tim asked if anyone else had any questions and there were a lot of questions from the newer members and a few from the older members. In the meantime he told Brenda and Jason that he had taken over the program when he got acceptance from the two podiatrists as he felt that this was best. Brenda and Jason agreed that this was more effective and had been well received. Tim thanked them and said he would not do this again without notification, but he had only received confirmation about an hour before the meeting.

I went to thank the podiatrists and they admitted they had hesitated, but after seeing the number and the interest, they admitted that it was worth the trip. I commented that they should pick up a few patients as well. They both agreed and Tim said the meeting is over. About another half hour was spent with many asking questions and then the two doctors needed to leave. Many of the members said thank you to us as they left.