May 3, 2012

Finally, With Eyes Wide Open

This is an odd title, but an even odder message from an unexpected source. I guess if you believe in something long enough it may just happen. I have been saying that others should be promoting insulin earlier for the treatment of type 2 diabetes and not be the medication of last resort. Finally, Jonathan Marquess, PharmD, from the Institute for Wellness and Education Inc in Atlanta, Georgia is saying it.

I do not mind that it is a pharmacist saying this as long as this happens more frequently. He does not criticize the American Diabetes Association (ADA) for setting the A1c level at 7.0%, but at least he is saying, “We know that diabetic complications happen at a more prevalent rate when the A1c is above 7. Those diabetic complications are where we're really spending big, big money in this disease state.”

I agree, but would say that we need to ignore the ADA and adopt the American Association of Clinical Endocrinologists (AACE) level of 6.5%. At least then, there would be some room for error although even this could or should be lower. I also appreciate this statement by him, “All too often, physicians, nurses, and pharmacists, will advise patients to take oral agent #1, then oral agent #2, then oral agent #3, and then say, "Wow, I guess it's time to start insulin."”

He does cite some statistics that are alarming, but believable. Of the approximately 43 percent of people having A1c levels above 7% he does not make any statement about how important blood glucose testing should be. This I think is where he misspoke or possibly was misquoted as these people with diabetes need to be testing more and moved over to insulin to prevent or delay the development of complications.

It is true that people with diabetes need to be concerned with morning fasting blood glucose levels and their two-hour postprandial glucose levels. This should be important whether their A1c is above or below 7%.

When he answers the question about insulins, he is correct that we have some great basal insulins and rapid-acting mealtime insulins. His answer about misconceptions about insulin is a little outdated and he missed a great opportunity to dispel a few more of the insulin myths. He concentrated more on fear of needles and people being afraid of the past big needle size. He did mention that people think of insulin as inconvenient and many have the fear of hypoglycemia. I will give him credit for attacking the perception that going on insulin means you did something wrong and had been a bad patient. Sometimes this cannot be helped so it is not their fault.

He did mention insulin pens, which are not available to everyone, but are becoming more popular and available. These will be easier to teach and should help by reducing medication and dosing errors. Insulin pens may also help patients overcome dexterity problems.

Dr. Marquess did shine when talking about education and that it takes time. He talks about patients needing to watch what they eat, learn what the numbers mean in blood glucose monitoring. He talks about physical activity and the potential for problems of hypoglycemia and how to treat with glucose tablets. He did an excellent presentation about needing to go back and reinforce many ideas on a continuous basis and ask the patient how they are doing.

For such a short interview, he covered a lot of material fairly well and I commend him for that. I have heard doctors fumble and make a mess of less material. Read the interview here.

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