April 19, 2013

Hyperglycemia – No Pain, No Harm Done – Right?

My email inbox had a very interesting question recently. The person said, “If I don't feel sick, how will high blood sugars hurt me?” I have answered the question in several emails, but felt the topic was important for a blog of the experiences this person went through. Too many doctors do not explain high blood glucose and the damage it will cause over time. They most generally just tell people to watch what they eat and leave it at that. This may have been what happened to this person as she was recently diagnosed with type 2 diabetes. Metformin was a good start, but she gave no other information.

A query about blood glucose readings yielded a question mark and her dosage was only 500 mg at the evening meal. I was afraid I had been too blunt about having another visit with her doctor and asking for a blood glucose meter, test strips, and the rest of the equipment, as I did not hear from her for another two weeks. She said the doctor had told her not to be using that and she did not need to know what anything was and that he would tell her everything from her quarterly tests (I assumed A1c from that statement, but I will disclose the actual test later) and would increase her medications if needed. By this time, she was complaining about the problems metformin was causing. She was being sick almost every day.

My immediate email back to her was which type of metformin was she taking and when was she taking it? It was the metformin tablet and not the extended release. The doctor has told her to take it one hour before the evening meal and the pharmacist had said with her evening meal. She had mentioned this to the doctor and he had really chewed her out for not following his instructions. I suggested that she have a talk with the pharmacist and explain what was happening and what the doctor had said.

She had gone to the pharmacy, but passed out on arrival and was rushed to a hospital where she was given tests and a recheck for diabetes. Yes, her reading was over 600 mg/dl and she met with the hospital diabetes educator. The CDE had given her a blood glucose meter and showed her how to use it. She was on insulin while in the hospital and then given a prescription for metformin XR (extended release) and told to find another doctor after discussing what had happened. She also had prescriptions for the test strips and lancets, alcohol pads, and a few other non-diabetes medications.

As soon as she was released from the hospital, she went back to the pharmacy and they were happy to see her. The pharmacist suggested two other doctors and said this was a wise move on her part. The pharmacist was happy to see the prescriptions and said that the metformin XR could be taken most anytime, but the hospital had wisely recommended at meal time. Her dose now was 1500 mg at breakfast, and 1000 mg with dinner.

What her email said then really makes me happy that she has this pharmacist. This pharmacist discussed and explained each medication in terms she could understand and then took a highlighter pen and highlighted the important parts of the instructions. Then when it came to the diabetes supplies, the pharmacist asked if she would afford xxx dollars for the strips. She was told yes and the pharmacist said then she would put five containers in her bag and explained that if the insurance did not cover them, she would be billed. The pharmacist then took time to tell her about testing, approximately when to test pre-meal, post-meal, and before bed time. Then she said it was not a bad idea to have one box of alcohol pads around, but not to use them on the fingers for testing, but instead to wash her hands with warm water and soap and dry thoroughly. Not to handle the test strips with wet hands was her next instruction and then she explained what the alcohol would do to her fingers in the winter time. Bravo pharmacist!!!

She had called the first doctor, but he was not taking new patients at this time, but the second doctor was and she had a next day appointment. She took all her prescriptions and meter with her and the telephone number for the pharmacist. The nurse asked for her meter so that it could be downloaded even if it was only a few results. She was surprised when she was called for a blood draw, but did not say anything. After the nurse had gathered all her information and given her meter back, she said she got a big shock when a woman doctor entered and then she realized that her doctor was a niece that she did not even know was in the area. The last communication was when she was in Denver, Co.

The email said that the doctor spent about an hour with her discussing testing and nutrition, and what foods she should avoid and lots of good information. Her A1c was still high as the doctor had expected. Turns out the previous doctor only used the oral glucose tolerance test for everything. I think he is behind the times. She is to bring her meter in for downloading every fourth Monday of the month so the doctor could review it. She is to have another appointment on the next time she brings in her meter. Future appointments will depend on what the meter readings show for diabetes management. She even said the new doctor had discussed hypoglycemia and hyperglycemia and given her a few sheets of facts so she did not need my answer any longer. She said she was happy that I asked so many questions as this had given her the confidence when she was talking to the CDE and to understand how important the information was that she was receiving.

After this, she said the communication from the previous doctor was very unpleasant and between the new doctor and her, they asked the local sheriff if he would pick up her records. For a small fee, he would, but even the deputy reported he was happy that both had provided letters of authorization for the transfer. Her new doctor even had to take time to unseal the box and confirm to the deputy that they were her records and that the box had been received unopened. She would not say that the records were complete, just that she had received what was in the package. She then stated the doctor had sent her a bill for the time and packaging, which she talked over with her new doctor. Both felt it was unethical, but agreed that it should be paid since charges were being filed by other patients for malpractice and this could be added to the charges. She concluded by saying that her new doctor had found several areas of problems and she is to go in tomorrow to review whether these would be added to the complaints since queries had been sent to all doctors receiving patients of his.  She is very happy with her niece as her doctor. 

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