July 6, 2012

Back to Diabetes Basics – Part 3

Hypoglycemia and Hyperglycemia

Hypoglycemia and hyperglycemia are two terms to get to know and remember. Knowing how to treat low blood glucose episodes (hypoglycemia) and high blood glucose episodes (hyperglycemia) is important in your management of diabetes. In my last blog, some numbers were given for goals in blood glucose management and they are important.

Hypoglycemia is considered for 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

People with type 2 diabetes still need to be concerned about readings heading downward from 80 mg/dl and especially if on insulin or Sulfonylureas as they can cause hypoglycemia very easily. Although Metformin will not cause hypoglycemia, in combination with Sulfonylureas, hypoglycemia can become a problem. Many doctors are not aware of oral medications causing hypoglycemia and this may lead to problems. Be especially aware of this if you skip a meal or if you are becoming ill. Test and if you are below 70 mg/dl, then take a glucose tablet, wait 15 minutes and test again. If you are below 60 mg/dl (3.3 mmol/L) take two glucose tablets and repeat. If you are below 45 mg/dl (2.5 mmol/L), and having a hard time thinking, have someone call 911 as you need treatment immediately unless you have a glycogen pen and can have someone inject you. Most people with type 2 seldom have these available unless they are on insulin and have had serious hypoglycemia previously.

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.

Both hypoglycemia and hyperglycemia can cause death and it is important to know what to do and how to treat both. Many people with type 2 diabetes don't think this will happen and ignore the signs for hypoglycemia or think it is not important to test regularly for hyperglycemia. People with type 1 diabetes know the value of testing because they are on insulin, but people with type 2 diabetes are often not even told about this until they are prescribed insulin. I lay this problem at the feet of doctors because they do not stay current with oral medications and often do not understand what the combined side effects are for multiple oral medications. I also believe the ADA is responsible because they promote stacking (using more than one oral medication) of oral medications and do not give appropriate warning of the dangers.  Read this article on the Joslin website for a chart of oral medications and the side-effects. It does not cover the problems when using combinations or stacking. More on this in another blog.

Doctors and the Different Types of Practice

Doctors and those in the medical profession are mostly like you and I. The one difference is the amount of education they have and the type of experiences is what sets them apart. Some excellent doctors always work for the patient and strive to give the highest quality service. Like any profession, there are the “bad apples” and we need to avoid them as they give medicine a bad reputation. In between there is all types and variations. Do not forget the physician practitioners and physician assistants. We must also include the nurse practitioners. When I use the term medical profession I mean to include all of them. Doctors work with the other medical professionals, but many do not like them as part of their practice while other doctors welcome them.

Read a blog I wrote in May 2010 on patients and doctors. Also follow the links provided, as the information is still applicable and appropriate for this discussion. I do need to add a few new types of medical operations that exist today and are very important. For diabetes these can add value to the appointment and save many problems from developing. A few practices are beginning to see the value also. I am talking about shared medical appointments (SMAs). If you are a patient that insists on keeping your diagnosis a secret, they are not for you. You must be ready to talk and listen to others and have them know you. How many people participate in SMAs? This will vary by how much room a doctor has, how many patients are willing to attend, the size of the staff available, and how much preparation is needed. Doctors that are old hands at this and have the room have been known to have 25 or more patients. Others limit it to 10 to 15 patients. In my limited discussions with a few doctors using SMAs, they only have room for the smaller numbers. They utilize private rooms to talk with those patients unwilling to have the doctor tell them test results in the group setting or for someone receiving information that the doctor wants to share in private.

Most doctors use SMAs to dispense the same information to everyone at the same time. Examples include importance of testing, medication side effects, goal setting, lifestyle changes, foot care, and other information. Questions are answered and discussions on some points do happen. One endocrinologist uses this to mix new to diabetes patients with old hands with diabetes to breakdown the panic the new patients are experiencing. Other groups include people by experience, and some are with groups that want to stay together. Some doctors have registered dietitians (RDs) and certified diabetes educators (CDEs) assisting. Others use physician assistants and nurses. Other combinations also exist for the medical staff.

Concierge medicine is also gaining in popularity and doctors can spend varying time with the patients. Appointments can vary from a half hour to an hour and a half depending on the need. Some will have a secretary/receptionist and others will have no one but themselves. Some practices may be two or more doctors. For more information I suggest reading my blog here and follow the links to more on the topic. Investigate this site, which also is about concierge practices. I am aware of one husband and wife team in concierge practice that is investigating the use of shared medical appointments (SMAs) for different diseases, diabetes, cancer, multiple sclerosis, and one other disease.

Something being talked about and possibly happening is telemedicine. This study is the first I had read about it, but I think this will have a place in rural areas. By using nurses or nurse practitioners in the field, telemedicine may reach patients that otherwise would not have access to doctors because of the distance to be traveled and especially those no longer able to drive. It will be interesting to see this develop over the next few years.

An area of medical practice that is operating is retail clinics and pharmacy medicine. They are not quite as sophisticated as neighborhood or a few other inner city clinics that are staffed by doctors on a voluntary or small fee basis. The retail clinics are normally staffed by nurse practitioners, physician assistants, or pharmacists. There is opposition to these clinics, but they may have their place because of the coming shortage of primary care physicians. They may have a place to serve to take the pressure off primary care and emergency room medicine and they are more economical when compared to emergency room services. Patients rate most very high for service and satisfaction. Read about these services here and here.

In some states, actions are underway to regulate heavily many of the above practices and the state of California wants to force all doctors back into the practices or hospitals. The state hospital association is lobbying hard for this.

Series 3 of 12

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