May 4, 2013

Medicare Enforcing Healthcare Rationing

Yes, a very drastic statement, but this is what you need to bring attention to the recent actions of Medicare. Two articles recently are highlighting what Medicare is doing at the behest of Congress and the President. The most recent example of the numerous cancer patients being turned away from treatment because of sequestration and the President's desire to make it painful for Americans.

Rather than suffer a financial collapse, most cancer clinics are turning away cancer patients on Medicare. This is especially true for those cancer patients requiring the most expensive of cancer drugs. However, even if cancer is the one disease highlighted by the media, other diseases, and even routine Medicare visits will take a hit and the senior citizens will be the ones on the short end of medical care.

Call it rationing, healthcare restrictions, the people affected will be the seniors, and they will be the ones suffering. All because we have a crybaby President that whines when he doesn't get his way.

The second article is about Medicare quietly killing seniors. This started with the Balanced Budget Act of 1997 (BBA). This like the sequestration was done by Congress to reduce the federal deficit. The sequestration is part of the deal worked out by our President to appease Congress and he did not expect that it would be allowed to happen. Now that it has happened, our President is whining and trying to blame Congress for his part in this.

When the BBA went into effect, many predicted that hospitals would make deep cuts by becoming more efficient. Instead, researchers found that the heart attack death rate spiked because hospitals only reduced staff to cut operating costs. What the researchers left unexplained, but very important in a policy context, is what happened as a result to Medicare patients being treated for all medical problems, not just heart attacks. This is called rationing of healthcare for seniors.

May 3, 2013

Is Your Doctor Listening to You – Part 2

Part 2 of 2 Parts

In this part I will cover a blog from Dr. Rob Lamberts. I have followed his blog regularly for several years and enjoy his writing style. I also like his outlook on doctor-patient relationships. Occasionally he will cross into doctor-speak, but he generally says what needs to be said in patient terms for everyone to understand. He has a knack for bringing out the best in communications from the patient and from following him on Facebook I can understand why his patients want him as their doctor.

Doctor Lamberts tries to follow this list as a doctor when seeing patients: (Bold are his headings and comments are mine). Read his blog for his analysis.

  1. Listen – He finds a lot of keys by listening.
  2. Direct the dialog – Here he means not just asking the right questions, but keeping the patient on track. He will not accept a patient's self-diagnosis, but he wants to hear the patient's story and see if he comes to the same conclusion.
  3. Believe the patient – He does not want to be considered ignoring a patient. He realizes patients can be self-conscious about what they are saying. He wants the patient to tell him what the problem is and will help by asking questions.
  4. Examine – Dr. Lamberts uses the examination to get more pieces of the puzzle and develop a more complete picture of the problem.
  5. Get more data Family members can often provide other data and it is important to listen to them when an incomplete picture is present. Dr. Lamberts feels that this sometimes prevents additional visits for the same problem. Sometimes more visits are necessary to get more facts or until he asks the right question.
  6. Make a list – This is not just the list that the patient may have which can often provide keys, but Dr. Lamberts makes lists also. He wants to know what are the things he can rule out, and what other possibilities are still in play. This is used to aid in determining which test may or not be needed.
  7. Address the fear Many times this is what brought the patient to the doctor. This fear needs to determined and confirmed as this will help the patient understand what is happening and know that their concerns are being addressed. It is also important to know when the patient does not have fear and may only need an excuse for work or school.
  8. Order the right tests More tests if often not better and can confuse the issue. Dr. Lamberts is correct here and only orders the test to rule out important bad diagnoses or strengthen the case for others. I like his thoughts of tests are not meant to change what I know, but to change what I do.
  9. Look for patterns It is often the pattern that makes the diagnosis, not the symptom. Getting a good, factual narrative from the patient, often eliminates many of the symptoms and creates the pattern.
  10. When all else fails, do nothing – This is difficult for most doctors. The key here is ruling out serious problems. Communication is the next key so the patient understands to call back or get another appointment if the symptoms or a pattern develops. When the patient understands the plan and knows they will have follow-up, patients will cooperate with doctors that communicate.

Dr. Lamberts concludes his blog by giving advice to patients and is worth quoting.
Let me end with a bit of advice for patients:
  1. Tell your story first. If you have theories, tell them only after you’ve told the story, otherwise you may cause the doc to jump to conclusions.
  2. Don’t be ashamed if it sounds silly. You feel what you feel, and sometimes the strangest symptoms are the key to the diagnosis.
  3. Say why you came to be seen. What is the worst symptom and what do you fear the most?
  4. Don’t insist on tests or medications. More is often less. The best doctors, in my opinion, order less tests and give less medication than the worst ones.
  5. Get a plan. Understand what the plan of action is, and when you should call or come back in.
  6. Don’t ever assume. If you don’t get results, never ever ever ever assume “no news is good news.” Never. You got that? Never.
  7. Try not to be an interesting patient. It’s bad when you are a puzzle to your doctor. Words like, “man, that’s interesting,” or, “I’ve never seen anything like this before,” are usually bad signs. It’s even worse when you are presented in front of a group of doctors or are published in a journal. Don’t seek fame in this way. Stay boring.
P.S. That last one is tongue-in-cheek.” Emphasis in bold is mine.

Don't get me wrong, both doctors have good things to say, but I personally feel that Dr. Lamberts is a doctor I would enjoy seeing more than I would Dr. Wen. This is contrary to what I would normally think or do. Both blogs are worth the time reading on a regular basis.

I will mention another blog of mine using lessons doctors have learned by listening to patients.

May 2, 2013

Is Your Doctor Listening to You – Part 1

Part 1 of 2 Parts

How doctors blog does say a lot about them. Some are very caring and understanding, while others are brisk and matter-of-fact in their approach to patients. This is evident in their writing as well. Communication is the topic of these two blogs and express both of the above approaches.

The first blog is by Dr. Leana Wen and I will take time to list her points and give my thoughts as a patient. I will encourage you to read each doctors blog and then read my response.

Tip #1: Answer the doctor’s pressing questions first. This requires a very concerted effort on your part to be polite. You must restrain yourself when doctors behave this way. This is how many doctors are and they are easily upset when things are not accomplished in their order.

Tip #2: Attach a narrative response at the end of these close-ended questions.
This will often tax your diplomacy, but it can work. If the doctor asks more questions to follow-up, you know that you are getting his/her attention. Don't over dramatize the point as a simple statement of the facts will generally work the best.

Tip #3: Ask your own questions. This can serve you well if properly done. Some doctors are running on autopilot and this can bring them out of it. Be careful if the doctor just repeats the question and then it may be important. Then if you fumble because you don't understand, often then the doctor will know to reword the question. Always respond to the best of your ability.

Tip #4: Interrupt when interrupted. This will work for some doctors, but be polite and use diplomacy. For those doctors that refuse to let you interrupt, follow their lead even though you may be irritated. If this technique works, keep the narrative brief and state the facts.

Tip #5: Focus on your concerns.
Yes, if you feel like the doctor is ignoring your concerns or not listening, use your best diplomacy and politely interrupt. Express your concerns and Dr. Wen's example is appropriate, “Excuse me, doctor, I have tried to answer all your questions, but I am still not certain my concerns have been addressed. Can you please help me understand why it is that I have been feeling fatigued and short of breath for the last two weeks?” (insert your health concerns) or what the problem is. Do not over state the problem, just give the facts as you know them. If this does not bring the doctor into the discussion of your problem, then you may need to consider more drastic action. Depending on the seriousness of the problem or medical issue, ask the doctor if you need to see the emergency department. Don't use this if you really wish to keep your doctor.

Tip #6: Make sure you are courteous and respectful to your doctor.
Yes, your doctor is supposed to be a professional and is probably doing their best to help you, but don't let them bully you into totally doing things their way and ignoring your medical problem. If at all possible use diplomacy and be respectful. This will normally build a solid doctor-patient relationship.

When I was much younger, as a teenager, I was kicked in the groin by a cow and the doctor was very careful and when he was done with his examination, he said that I had a tear in the bladder and this could likely affect me for the rest of my life. After leaving the military, I had a rough time and the doctor I had did many of the same procedures. He said basically the same thing, and gave me a new antibiotic to help with the healing again as it had somehow torn slightly.

After moving to another part of the state, the trouble flared up again, and it was not six months later. I could tell the new doctor had dollar signs in his eyes, as he would not call the previous doctor, so I ended the conversation and appointment and went home. There I called my previous doctor, and he was kind enough to call in a prescription to my pharmacy. In the meantime I had my previous doctor locate another doctor and forward my records to him. He asked me to come in for an appointment and he also gave me a prescription and said if I had more problems to call and he could prescribe the antibiotic again. I went another 28 years before I had any more problems.

The above tips will generally serve you well in most situations. I have had doctors be on autopilot and I have been able politely to bring them back to the present. One doctor had to think a long time about what I had done. At the next appointment, he did apologize and we even discussed how to bring him back to the now. He had asked his nurse if she had seen him go on autopilot and she had to admit this was a problem for him.

Dr. Wen does describe a trend happening because of the pressure more doctors are facing to see more and more patients. She says that today doctors spend less and less time listening. “Cookbook medicine” (I like this term) is prevalent, with doctors resorting to checklists of yes/no questions rather than really listening to what’s going on with the patient.

May 1, 2013

AAFP and Their Professional Website – Part 3

Part 3 of 3 parts

Some information that can prevent problems is found in the supplies area of this part. It is good to have a few alcohol pads around but not for what they describe doing with them. Using alcohol pad to clean the finger area for testing is not advisable. In the colder areas, this will dry out your fingers and lead to cracking of the skin. If you want very painful pricking of your fingers for testing, go ahead and use the alcohol pads. If you have been handling several fruits, alcohol will not remove the fruit sugar from your fingers, so washing your hands with soap and warm water is the recommended treatment. Use the alcohol pads in emergencies when you cannot get to a bathroom or other hand washing area. Also use the alcohol pads to clean the lancet device when testing on other people. Change the lancets and clean the area around the hole to remove blood from the lancet device.

You are welcome to use their (AAFP) unscientific food plan. The American Diabetes Association (ADA) has changed their advice and you may read about it here (go to section E (MNT)) or my blog here. I do encourage you to read and learn about food plans, as there is not a specific diabetes diet or food plan. The American Academy of Family Physicians (AAFP) does recommend a high carbohydrate – low fat food plan. This may work for some individuals, but for a majority of people with type 2 diabetes, forget this and consider other food plans. I personally follow a low to mid carbohydrate – high fat food plan. Many people with type 2 diabetes follow a low carbohydrate, moderate fat, moderate protein food plan. Others follow a paleolithic food plan, still others use South Beach or Atkins diet plans. You will need to use your meter to determine what works for you by testing postprandial to see how high the blood glucose level has spiked. A good reference is this site.

They almost blew this section on oral medications, but they did list them in the first paragraph, but then only discussed three of the six classes or oral medications. There is a seventh, but this is a mixed class of the other six oral medications. Read my blog here and follow the links or go directly to the main page for a discussion of diabetes medications here (inserts D through K).

If you are interested in the different classes of insulin not discussed in the insulin section on the AAFP site, go to insert C in the link above.

There are other items that may be missing or have errors, but in my opinion, I could not consider them now.

This concludes my discussion of the AAFP website. I am very disappointed in the site and especially the discussion of diabetes. Until they correct their critical errors and update the information annually, I cannot recommend the site for people serious in learning about diabetes.

April 30, 2013

AAFP and Their Professional Website – Part 2

Part 2 of 2 parts

When I started reading this I had some very mixed thoughts. In rereading the site, I do think there is much information missing, but some of it may be intentional because they have so few patients needing this information. I do strongly disagree with some statements. The first statement is this one here. The statement sets a tone that I dislike when they say, “Your A1C goal will be determined by your doctor, but it is generally less than 7%.” The doctor is not the person to set the goal; it is the responsibility of you, the patient. Yes, your doctor should help and maybe guide you, but it is not for the doctor to be dictating this goal. The doctor does not live with you 24/7 to help you reach the goal, unless you are married to one.

And why would a doctor recommend an A1c goal above 7%? At this level, the risk of complications is already elevated and complications become very likely. Even a A1c goal of 6.5% is increasing the risk of complications. In rare cases where the person with diabetes is in extremely poor health and consequently unlikely to be able to manage their diabetes, if they are near the end of life, a goal above 7% may be advisable. Still, this is doing harm which goes against doctors not doing any harm. The caregiver may be able to maintain an A1c level below 7%, but many do not consider this possible.

I am reading more and more about how when doctors set goals for patients; this is destructive to the incentive of the patient for working for better diabetes management. This is also what some doctors will do to set you up for failure. By setting your goal, then the doctor can tell you that you are not following directions and that if you continue to fail, the doctor will threaten you with insulin. I will walk away from a doctor doing this and not think twice about it.

If you set a reasonable goal and the doctor does not like it, he should be able to tell you why it is unreasonable and maybe suggest a different goal. To dictate a goal is unethical in my opinion. I also think nothing is wrong, if you have just been diagnosed, of not setting any goals until you have had time to learn, and maybe, talk to others with diabetes. This will give you time to do some reading and find information with which to set good and reasonable goals. A doctor that is not educating you or setting up education classes for you should be happy that you are not setting goals until the second appointment.

Now if you are willing to let the doctor set your goal, then you have only yourself to blame when the doctor chews you out for not making the goal. A good doctor should know better than to set goals for patients and should be willing to guide the patient with a little education to assist the patient arriving at realistic and reasonable goals.

The following discussion from the causes and risk factors is not well thought out and needs more discussion.

Weight and Risk Here is one place I feel simplicity needs to take a back seat. There is no discussion of ideal weight for a particular type of body frame size. This often invalidates much of this discussion. An example should highlight the need for additional discussion. I urge you to consider opening this blog in one tab, the AAFP page is another tab, and the ideal body weight calculator in a third tab.

Using the woman's chart, I chose a 5' 4” women and the 157 pounds from their chart.
For a small frame - the ideal weight is 120 to 132 lbs – or 25 lbs over weight.
For a medium frame – the ideal weight is 130 to 143 lbs – or 14 lbs over weight.
For a large frame – the ideal weight is 140 to 154 lbs – or 3 lbs over weight.
The one factor that I have not found a calculator for is mixing the age into the calculations. I don't know if it would make this great a difference, but it is a variable.

Using the men's, I chose a 5' 10” man and the weight of 186 pounds from the chart.
A small frame – the ideal weight is 156 to 171.6 lbs – or 14.4 lbs over weight.
A medium frame – the ideal weight is 166 to 182.6 lbs – or 3.4 lbs over weight.
A large frame – the ideal weight is 176 to 193.6 lbs – ideal weight.
Again, the one variable is the man's age.

This shows how different charts can mislead people and create false goals and realities. There may be different weight to height charts for the different body frame sizes, but it comes fairly close from memory with what my doctor discussed. Another variable that needs consideration is ethnic background.

Everyday there seems to be studies about diabetes. Many articles do their best to highlight something. The American Academy of Family Physicians (AAFP) decided to start the diagnosis and tests section with some of the complications caused by diabetes. If they want readers to read this, they would not be interested in the bad things first. They would likely want to know how diabetes is diagnosed which is what the topic heading suggests. The diagnosis and tests area is a poor place to discuss the diabetes complications. This discussion should have been left for the diabetes complication area where they are again discussed.

One indication of how much their information needs updating comes when they discuss how they diagnose diabetes. Granted, the three discussed tests are very valid, but the American Diabetes Association (ADA) had declared the A1c as a valid test also, but this is not given any consideration by the AAFP. I know some groups do not accept the ADA and what they designate, but I had not thought the A1c test would be rejected by the AAFP.

The fasting blood glucose test (FGT), the oral glucose tolerance test (OGTT), and random blood glucose test are just three of the tests. To this you also need to add the plasma blood glucose test (PGT) and the A1c test. Then there are several additional tests to assist in the determination of the type of diabetes including several of the symptoms which might help in the determination.

April 29, 2013

AAFP and Their Professional Website – Part 1

Part 1 of 3 parts

When I started reading this, I had some very mixed thoughts. Normally I would not even refer you to this, but I feel some education is in order. You need to understand why sites like this can be loaded with poor or incomplete information. This website is the example of incomplete information. Some of the information is good, but in my opinion, it does not out weight the incomplete information. I even had to do a double take when I really looked at the site for an address. It is on the American Academy of Family Physicians (AAFP) website. And yes, I stand by my statement. Some information I consider critically incomplete and some is just in the way a patient views it, or has learned it. This can happen in any medical information.

Yes, I do not like it when a professional organization chooses to ignore good policy when it is available and leave out important information. It would have been wiser of the AAFP to refer readers to other sites instead of leaving information out. They also do not update the information on a yearly basis. In some instances, this creates what I would term a fatal lack of information. Information changes rapidly and to not update the website is not a good promotion of their profession. Even the ADA issues new guidelines every year, faulty as they are.

At first I was attempting to do a blog for each topic or in some cases two or more blogs, but this would result in too many blogs. Therefore, I will try to limit the number of blogs and just highlight the incomplete areas and the areas I find that are critical errors. I will start with the critical errors.

I do not understand the reasoning when they say, “The other test is called SMBG, or self-monitoring of blood glucose.” This is stated here and here. Yes, I can understand how some people may think this is the test, but this is not the way I was taught.  Many people are just told to test and to consider this SMBG, but are told nothing more about SMBG.   I admit I know a fair amount about SMBG and have blogged about this quite frequently. To me SMBG is the process of using the blood glucose test results (not just one test) to monitor how well, or not, you are managing your blood glucose levels on a daily, weekly, and continuous basis. The test is done with the blood glucose meter and test strip. Then the meter translates the results from the test strip to a reading on your meter that we can all understand.

SMBG is the process of using the data from the different tests to look for trends and other relationships. SMBG should teach you the when, where, why, and how of testing for you to manage your diabetes more effectively and efficiently. We look to the food we have consumed from our food logs, how we feel from a health standpoint (our health logs), and the time of day. Then we analyze the test information to see if we are on target, or need to reevaluate what we eat and adjust to be on target for the next test. This will help us determine if we need to do more exercise, or if it gives us clues about our health care we may have missed.

This is the second critical error. And yes, I am being technical here, but the doctors or writing staff of the AAFP does not seem to want to use the correct terms. There are blood glucose monitors, but this is for having a device (canula) inserted under your skin and this reads the interstitial fluid glucose levels. This device is called a continuous glucose monitor (CGM). Even they cannot be relied on for obtaining blood glucose readings that are current. They have a lag time or time difference when compared to a blood glucose meter. They are excellent tools for determining trends and giving you an idea of where you were about 15 to 20 minutes ago. CGM devices measure glucose levels in interstitial fluid in 1- or 5-min increments (depending on the system used) on a continuous basis.

For most testing, we as type 2 patients use a blood glucose meter. Now if we have a glucometer, then we know the brand of our meter and that it is a registered trademark of Bayer. If you think the doctor is prescribing a blood glucose monitor, make sure that it is a CGM and that your insurance will cover it. Most insurance will not cover a CGM for patients with type 2 diabetes, as they are expensive. It may be easier today than a few years ago, because some doctors are more persuasive in their writing ability and doctors generally prescribe these only for type 2 diabetes patients that are unable to manage their blood glucose levels. Chances are that it is a blood glucose meter he may prescribe, but if the doctor is an owner of Bayer stock, it could be a glucometer.

The third critical error is here (at How can I deal with an insulin reaction?)  The AAFP says people who have diabetes should carry at least 15 grams of fast-acting carbohydrates with them at all times in case of hypoglycemia or an insulin reaction. The list is far from complete, the fastest carbohydrate tablet is about 4 grams each, and 5 grams are very uncommon, although some may exist and it may depend on the area of the country. Many people that have hypoglycemia problems have bottles of them. In checking with my local pharmacy, they carry tubes of 10 tablets of 4 grams of glucose in the various fruit flavors. They can get the 15-gram glucose gel tubes and bottles of 50 each of the 4-gram glucose tablets. I still have two strips of three each of the 15-gram glucose tablets. A person with type 2 diabetes on most oral medications may not need more than a tube or 40 grams. Anyone on insulin needs to have more glucose tablets available. Apparently, this is another area where they need to update to reflect what is available and specify the instructions for type 1 or type 2 (for oral medications and insulin) patients.

If you are a person with type 2 diabetes having problems managing your blood glucose levels and have been prescribed a CGM, then you will also need a meter for times when you are experiencing hypoglycemia. You will need the now factor for blood glucose testing. The lag time on a CGM may cause you real problems, which you do not need during a hypoglycemic episode. Not being able to adjust quickly enough can put you into a coma. If no one is around or you live alone, people have died.

The next critical error I feel needs mentioning is the list of quick energy sources for correcting hypoglycemia. The AAFP just listed some of the sources of quick energy. Then they list milk without specifying non-fat milk. Fat will slow down the speed needed to bring blood glucose levels back to near normal. I would encourage you to compare the AAFP list to this list from as well as the information with it.

The last critical error is the mixing of information for type 1 and type 2 diabetes. There is much information that can apply to both, but also a lot of information that needs to specify whether they are writing for type 1 or for type 2 patients.

April 28, 2013

Diabetes Guidelines You Can't Avoid

In diabetes it is not what the patient wants, but what the doctor can command and bully his way into making the patient do. Now the American Association of Clinical Endocrinologists (AACE) has developed another way, an algorithm this time, to force, where possible, patients into submission. Much of what is shown in the layout of the algorithm is aimed at convincing the patient to follow their doctor's wishes and desires. How else will they, the doctors, meet their goals? I wonder how soon this will be put into effect. The algorithm is available here in PDF format.

Following the Table of Contents, the first page is – Complications-Centric Model for Care of the Overweight/Obese Patient. They start the information off with Step 1 - evaluation for complications and staging. This is not a nice way of saying how we are to be treated. Step 2 is treatment options where only three options are allowed – lifestyle modification, medical therapy, and surgical therapy (a must if body mass index is equal to or greater than 35) They will push medication on top of medication in the medical therapy and insulin is one of those mentioned when we exhausted our options with the oral medications. They leave no doubt that surgical procedures will be sought for BMI's over the limit.

Step 3 is where they may actually dismiss us as patients as they state, “If therapeutic targets for improvements in complications not met, intensify lifestyle and/or medical and/or surgical treatment modalities for greater weight loss.” Apparently, diabetes patients will no longer have a choice and must be made compliant.

The next page is the Prediabetes Algorithm. In searching the page, they do not allow patients to stay off of medications or start and then wean themselves off medications. The assumption is that prediabetes will progress to diabetes. There is one improvement and that is the use of metformin for those at low risk. Maybe now we will see some action by Medicare and insurance. The counter to this is multiple medications when fasting plasma glucose is greater than 100 mg/dl with two-hour plasma glucose greater than 140 mg/dl.

The next page covers - Goals for Glycemic Control. They leave no doubt about where they are coming from and what they will be setting for their patients. If you are a compliant healthy patient without concurrent illness and at low hypoglycemic risk, you will be allowed to have an A1c of 6.5% or lower. If on the other side (greater than 6.5%), they will individualize goals for patients with concurrent illness and at risk for hypoglycemia.

On the next page, we come to what should make anyone with diabetes nervous. The page is titled Glycemic Control Algorithm. It is further subtitled Lifestyle Modification (Including Medically Assisted Weight Loss). So not to forget, they are supposedly talking about a couple of the weight loss medications approved by the FDA. Still in my mind, this should be classified as medication weight loss therapy and not medically assisted weight loss. This sounds more like surgery than medication therapy.

There are three entry A1c listings - 1) A1c that is less than 7.5%, 2) A1c that is equal to or greater than 7.5%, and 3) A1c greater than 9.0%. 1) above starts out as Monotherapy. Metformin is listed first, but they also list several others and even some that should be used with caution because of studies lately that show problems affecting the heart and other side effects. The bottom should raise alarm bells as you are only given three (only three) months to show improvement, or you will be moved to Dual therapy. Here basal (long acting insulin) may be part of the therapy, but this is supposed to be done with caution.

If you don't show improvement in dual therapy by the end of three months, you are to be moved to Triple therapy. This means three oral medications and with the order of suggested usage, they are going with oral medications that should be used with caution or basal insulin. If you don't succeed in three months here, you are to be moved to insulin therapy and oral medications.

Now look at 2) above. Here you will start on Dual therapy and if no improvement in three months, you move to Triple therapy. If you don't succeed on triple therapy in three months, insulin therapy is up next. If you started at 3) above, then if you have no symptoms (probably meaning no complications or concurrent illness) you may start at Dual therapy if your A1c is under 8.0%, otherwise you may start at Triple therapy and this is when basal insulin is recommended in Dual or Triple therapy. Now if you have symptoms, then you are to start on basal insulin and other oral medications as necessary.

The page following this is – Algorithm for Adding/Intensifying Insulin. The left side of the page is for basal (long-acting insulin) and not using sulfonylureas but other oral medications. I will not get into the titration part. That is between you and your doctor. On the right side is more intensifying of oral medications and adding prandial (mealtime) insulin (or short- or rapid- acting insulin).

The last three pages discuss cardiovascular disease (CVD) risk factor modifications algorithm, profiles of antidiabetes medications. I was surprised that for the most part, the page is right on. For comparison on most, use the different inserts here for each medication. The cardiovascular page discusses statins and blood pressure lowing medications.

The last page summarizes the guiding principles for the algorithms. I some ways this is difficult to swallow as it explains the importance of a lifestyle modification, the individualization of treatments, and their targets. The minimization of weight gain and hypoglycemia are worthy discussions.

I summary, I am surprised at what is not included. This would be exercise (covered in a blog by Tom Ross) and allowing patients to start without medications or using medications for bringing prediabetes and diabetes under excellent management and then weaning off medications as lifestyle goals are met. No mention is made of working at the prediabetes level of lifestyle changes to prevent the onset of type 2 diabetes.  Also missing is the option for those patients wanting off oral medications and onto the full insulin therapy.  Apparently this is not allowed under the algorithm.   For these reasons, I feel strongly that the algorithm is shortsighted and presents a defeatist attitude.

As a patient, I am very concerned about how they feel that diabetes is progressive and they offer no hope of people preventing this. One article about the algorithm may be read here and another here.