July 6, 2015

SGLT2 Dangerous for Causing Diabetic Ketoacidosis

Allen and I were talking to a person with type 1 diabetes this last weekend and he was bragging about being on an oral medication for type 2 people with diabetes. I said that the doctor was prescribing it “off label” and there were some serious side effects to the SGLT2 medication. He asked what the side effects could be. Allen said that DKA (diabetic ketoacidosis) was the side effect and that it was not the same as that experienced generally by people with type 1 diabetes.

The person laughed and said he was not aware of any problems. Fortunately, I had just read this and had my wife's laptop with me. I pulled up the article and the definition for euglycemic, which is a condition or state in which the blood glucose level is within the normal range. See also glycemia. As reported…the presence of euglycemia appeared to delay correct diagnosis in some of the patients in their series.
  • Euglycemic DKA may be associated with the use of a SGLT2-inhibitor in type 1's.
  • Volume depletion associated with SGLT2-inhibitor use could exacerbate the problem by further increasing glucagon, cortisol, and epinephrine.
  • If insulin levels are low and glucagon and other counterregulatory hormones are high, a perfect storm exists.
Now we had his attention and he asked to read the article. When he finished, he said that then he could be in trouble as he was scheduled to a surgery on Monday, June 29. He said that it is recommended that he be off the medication for three days before any surgery.

Then I opened the Medscape article and had him read that article. His first question was how he could get access to either article, as he was not aware of either source. I said he would have to join both sites to have access to them and that they were free. Allen said it would be good to be a journalist when applying, but that there was good information, he would email him some of the links for diabetes and other information, and then he could explore for his favorite topics.

He called his doctor at his home and informed the doctor of what he had read and that he needed to postpone this surgery at least two days if possible. He asked the doctor for his email address and sent the doctor the two links and his phone number and then the doctor called him and said he would see that the surgery was set back for at least two days. He went back to talking with us.

Next, he thanked both of us and said he was sorry he had acted so badly when we started the conversation. He explained that he had always felt that people type 2 diabetes had no interest in helping people with type 1 diabetes. I said that type 1 takes enough grief from people ignorant of the difference and accused them of many of the problems that type 2 people face on a regular basis. I said we need to work together to end the ignorance and help each other at every opportunity. He agreed and thanked us again.

I said that I had sent him the links for the two articles and would send him any more that I found. I said I was aware of at least one more, but I would need to get on my home computer to find it.

Then he asked to read the first article again. He said that he had not been counseled by his doctor when he started the medication as was recommended and was happy we could show him information. He was going to have a long discussion with his doctor and consider not taking the medication. He said that it was helping in the management of his daily blood glucose levels so the decision would be difficult without the doctor understanding what could happen.

He asked if anyone we knew was using the SGLT2 medication. Allen said no, as the members of our support group only used metformin or insulin. I added that we have a few members that have been able to stop all medications after lifestyle changes. They continue the monitor their blood glucose levels and have been successful so far.

He said he needed to head home and repeated his thanks and said he would stay in touch.

July 3, 2015

Doctors Ignore Guidelines for Prediabetes Patients

Many of the diabetes news sources are carrying this news item. The titles vary by what each source wants to emphasize. Basically, the consensus is disparaging about doctors that are under using metformin to treat prediabetes. Considering that the drug is generic and cheap, I can agree that this is an inexpensive therapy to help manage and possibly prevent the full onset of type 2 diabetes.

Before I continue, I will make some observations. First, I am not surprised at the lack of prescriptions for metformin because many doctors are not screening for prediabetes. Second, many doctors believe prediabetes and diabetes are a lifestyle disease and want patients to suffer and will not prescribe any medications until full diabetes is present and sometimes even then will delay medications. These doctors want to see improvement in weight and other lifestyle changes that prove the patient will follow a medication regimen. Many patients often surprise these doctors by making the lifestyle changes and not needing the medications the doctors were planning to make them take because the doctors believe that prediabetes and diabetes are progressive and people will not be able to manage their prediabetes or diabetes.

Metformin was prescribed for only 3.7% of patients with prediabetes, even though it can help prevent the onset of type 2 diabetes, according to a new retrospective cohort analysis. Lead author Tannaz Moin, MD, from the David Geffen School of Medicine at University of California, Los Angeles, says, “We were surprised to see just how low the [prescription] rates were, particularly among the highest-risk individuals, where evidence for metformin use is strongest."

"Despite inclusion in national guidelines for more than 6 years and proven long-term tolerability, safety, and cost-effectiveness, the prescription of metformin in the real-world clinical approach to diabetes prevention remains unclear," Dr Moin and colleagues write.

Their findings are published in the April 21 issue of the Annals of Internal Medicine.

Among those with a BMI equal to or greater than 35 kg/m2 (n= 391) or gestational diabetes (n = 121) the prevalence of metformin prescription was 7.8%. This is "the group for which the ADA guideline places the most emphasis on treating prediabetes with metformin," the authors write.

In their study, Dr Moin and colleagues analyzed data from a national sample of 17,352 adults aged 19 to 58 years with prediabetes between 2010 and 2012 who were insured for 3 continuous years to determine the percentage who were prescribed metformin.

In 2008, the American Diabetes Association (ADA) updated its "Standards for Medical Care in Diabetes" guidelines to include metformin use in patients aged less than 60 years who are at very high risk [of diabetes], are very obese (body mass index [BMI] greater than 35 kg/m2), or have a history of gestational diabetes.

The guidelines also say clinicians can consider metformin in those with impaired glucose tolerance, impaired fasting glucose, or an HbA1c of 5.7% to 6.4%.

Again, this study is interesting and would be more valuable if doctors were taking prediabetes seriously and screening for it.

Two other articles can be read. The first is from Science Daily, titled “Drug that can prevent onset of diabetes is rarely used.” The second is from Diabetes-in-Control and is titled “Metformin Reported in Use with Only 3.7% of Those with Prediabetes.”

July 2, 2015

ACDE Promoting IDF

This is most interesting and in a way unusual for a Certified Diabetes Educator organization to be promoting the International Diabetes Federation. Could it be that their membership goals are not being met and they are contemplating expanding to other countries? While I doubt this, it could be interesting. This time I made sure I captured the information beingpromoted by the Academy.

The link in the ad is 'D-Net.' I followed it as far as I was allowed, but there was little information available.

As of today, the ACDE has avoided showing any conflicts of interest. Maybe there are none, but from a few sources, I am hearing different information, but in contacting two of the companies (one a food company and the other a pharmaceutical company), I was stonewalled and my questions not answered.

I am most disappointed in the exclusive attitude the ACDE has displayed. The Academy does not want people with diabetes knowledge and some training to be able to use their information and the statement by the ACDE that only people with formal training and passing the CDE examination are to be allowed to work with diabetes patients.

I am thankful that in some rural states that have very few CDEs that doctors are working with willing patients to prepare them to be peer-to-peer workers or peer mentors. In one state the ACDE has written the State Medical Board to discourage this from happening. One of the doctors has received some questions from the medical board, but they have taken no action as the closest CDE is over 250 miles distant and works for a hospital and does not travel.