August 30, 2013

Information From Barry's Friend

This was a pleasant reminder of what can happen when you help someone. In addition to thanking everyone at our meeting and doing it profusely, this week everyone involved received a personal email of thanks. Thank you George for being very thoughtful!

Then I received a second email telling me what he appreciated reading in my blogs and where they are helping him. Now I need to thank Barry for organizing them in an order for him. I then asked Barry if he had sent a second list. He said that he and Ben have worked on and sent two more lists and will wait to send a forth when George asks for more reading.

George has stated that he and insulin are getting along just find and he is now getting blood glucose readings already in the mid 80's for morning fasting. He needs to adjust his correction ratio next and his new doctor is helping him. He let us know that he had a meeting with a certified diabetes educator and learned how to count carbs and adjust his insulin to the number of carbs for each meal. I am impressed because he was told what to do if he did not feel good and was not sure he could eat. He was actually told to not inject his rapid acting insulin until he was finished eating and knew how many carbs he had consumed. Then at that time he could add his amount of correction insulin and insulin for carbs consumed together for one shot.

He did state that this was good to know, because this had happened before the CDE appointment and he had given his correction shot and nothing for eating as he had not felt like eating. He said this had caused a low of 63 mg/dl and since Barry had explained the symptoms to him, he knew he needed to test and then chew on a few glucose tablets. He had obtained the 4 gram tablets and is now looking for a 5 or 15 gram tablets to have them on hand. He did assure me that he had tested fifteen minutes later and then in another 15 minutes to confirm that he was not going lower, but also that he was above 80 mg/dl.

George told everyone that since the doctor here had faxed the A1c results to his new doctor, he had not had another test, but would at his six week's appointment. Barry told him this was not unusual and to keep track of his lab results. George let us know that with Tim's help he already had his database up and is using it.

George has met with the VA office in his area and has completed and filed his application. He is very happy to have found out about this. Now he will wait for the determination letter.

With his appointment now about four weeks away, George indicated that if he improved like the Doctor says he might, he will be coming back to Iowa after that appointment. Be sure to check your blood glucose before you drive and to continue to monitor while you are at a rest stop or naturally before you eat. Barry says he and Ben have been able to answer his questions, but he will call on us when they are unable.

Brenda and Jason are now back and thanking us for the emails about George's escapades.

August 29, 2013

Proper Insulin Storage and Handling

Guidelines for Insulin Storage and Handling Courtesy of Novo Nordisk, this handout covers what every patient and medical professional needs to know about the proper storage and handling of insulin products. Novo Storage/Handling Guidelines for Insulin Clicking on the link will download a PDF file for Australia and New Zealand.  I strongly urge you to read the information that comes with your insulin vials or pens.

#1. Store your insulin in the refrigerator (2º- 8ºC) (36º- 46ºF), away from the freezer or freezing coils. In my Novolog box the pamphlet states that unopened vials that have not been frozen, may be used until the expiration date on the Novolog label.

#2. You can keep the insulin you are using out of the refrigerator for up to one month if kept below 25º C (77º F). This avoids stinging when injecting cold insulin. Note: The pamphlet in my box of Novolog states room temperature below 86ºF (30ºC). It also advised throwing away opened vials after 28 days of use, even if there is insulin left in the vial.

#3. Before storing your cloudy insulin in the refrigerator, gently shake the vial, cartridge or prefilled device to resuspend any settled insulin. Clear insulins do not need to be shaken before storage. Store the cartons on their side.

#4. Do not expose your insulin to excessive heat or sunlight.

#5. Do not freeze your insulin. Never use insulin that has been frozen.

#6. Never use an insulin vial that has had the cap remove, except by you. The 28 days of use starts when you remove the insulin vial cap.

#1. Prior to use, your cloudy insulin vials should be resuspended by gently rolling the vial between the palms of the hands and/or moving the insulin up and down 10 times to make sure the insulin is well mixed. Always refer to the instructions provided with the insulin and injection device.

#2. If you draw up more than the required amount of insulin from a vial, do not squirt the excess insulin back into the vial, as this may contaminate the vial with syringe lubricant.

#1. When traveling keep your insulin cartons in as cool a place as possible. Check out these Frio packs at Amazon  and this site for Frio packs.

#2. Storage of insulin in a small insulated container is advisable to protect the insulin from extremes of temperature.

#3. Carry at least twice your calculated insulin requirements to allow for breakages etc. during your trip.

#4. Do not keep insulin vials or cartridges in the glove box of a car, as the high temperatures, which may occur especially in summer, may damage insulin. In the winter, you should also protect your insulin from freezing.

#5. Any supplies should be divided and transported in different pieces of hand luggage, so that if one piece of luggage is mislaid, supplies are still available.

#6. Remember that insulin should not be stored in luggage that will enter the hold of an aircraft as the insulin may freeze during the flight and its action may be altered.

#7. Contact Novo Nordisk Customer Care Centre regarding the availability of your insulin overseas, since exact equivalents are not always available. In the US the telephone number is 1-800-727-6500. They should be able to answer most questions and give you telephone numbers for the areas outside the US you will be traveling.

Do not use any vial or cartridge if:
#1. The clear soluble insulin has turned cloudy.

#2. The expiry date has been reached as shown on the vial, cartridge or prefilled device label and carton.

#3. The insulin has been frozen or exposed to high temperatures.

#4. Lumps or flakes are seen in the insulin.

#5. The insulin is discolored.

#6. Deposits of insulin are seen on the inside of the vial, which remains after initial shaking.

The above are sound pointers of advice. I did add a few items from my own pamphlet and if you are using insulin from other companies, please read the pamphlet contained in their insulin box. In the US, currently the designation for our insulin is U-100. Some pharmacies also carry U-500 so be careful as this is about five times more potent. Do not substitute U-500 for U-100 except under directions of a doctor. Outside the US you may encounter U-200, U-300, or even U-400, in addition to U-100 and U-500.

August 28, 2013

Is There a Best Way, Part 2

Part 2 of 2 parts

I hope that the last blog did not scare you. Many of the items are a must and not doing them may create future problems. Baselines of information related to diabetes is important. I purposely left out one item and that is seeing a cardiologist (heart doctor) as most primary care physicians (PCPs) or family physicians (FPs) will check the heart and refer you if they feel it is necessary. Yes, a few will ignore warning signs and you will probably end up in the emergency department.

Others will prescribe statins, often over prescribe is more like it. Then they will look at your blood pressure and prescribe drugs to bring it down. I don't know which is worse, having the PCP do this or the cardiologist do this. If a doctor insists on prescribing statins, ask that they not prescribe the maximum dosage. Even FDA has cautions about doing this.

This is unfair any way you cut it, but there is a test to determine if you have a need for statins. The test is not cheap and as of yet Medicare and medical insurance will not pay for the test because it is not a diagnostic test, but strictly informational. The test is explained here and helps determine if you have the KIF6 carriers. If you do not, then you don't need statins. If you have the carriers then the statin may prevent the heart attack or heart disease. I checked with my insurance carrier and they will not cover the test.

Blood pressure medications are not that large of a problem, but some people don't need them and can use alternative therapies to lower their blood pressure. Be careful as some people are not successful with alternative therapies. This article in Science Daily can be a reference.

The more of the items you accomplish from the last blog, the easier it will be to know if something is headed in the wrong direction and to what degree. This is why having a baseline is so important. Many will ignore the suggestions and later when diabetes complications set in, there is no reference point to know how long this has been going on and whether the progression is serious or not. I met an individual recently that is nearly blind because of diabetes. He has had diabetes for over 15 years and has not managed his diabetes nor his eyesight. When I asked when he had found out about his eyesight, he said about a month prior and he had not been to an eye doctor ever that he could remember until then. I asked why he had not gone and he said, what will happen will happen, and in addition to retinopathy he had advanced cataracts as well. I had wanted to ask more questions, but his guide was wanting to continue on.

August 27, 2013

Is There a Best Way?

Part 1 of 2 parts

There are days when a topic says write about me and there are days when the thoughts just won't come together. I have about a dozen or more topics I want to write about if I could just put some thoughts on paper. Normally I start out on a yellow tablet and start outlining ideas for a blog, but sometimes it is easier to use the word processor and put ideas down and outline. Using either route, I put the points in the order I want and then start writing.

The last week was difficult in organizing anything and my last weeks blogs may reflect some of that. I sometimes force myself to write. While I have had a few excellent (in my mind) topics that I can outline, organize, and write about, it is often not wise to finalize them, but put them aside for some time and go back later and reread them. Then I sometimes rewrite much of the blog and schedule it for posting.. Some have surpassed my expectations for readership while some that I really liked and felt they were important, were rewarded with a poor number of reads, but this happens.

This is a blog that I had started back in 2010 and it has been in my hold file all this time. When I opened it this evening, the idea came to me that I have not written about what might be the best way to manage diabetes. Yes, I have skirted the edges and made some good points here and there, but I am hoping this gives some readers an idea to latch onto and possibly make it work for them. I have no idea of how many blogs this may encompass.

So I will start at diagnosis and work my way through what may work. Yes, I will use some of my previous blogs as they cover some of the points that should be important for everyone to learn. This is the first one covering the ideas and points everyone newly diagnosed should learn. The support group has tried to add other items to the list and after discussing them, we have set them aside as they did not fit the way we thought they would..

Now for some points to make sure you consider at diagnosis or shortly after diagnosis.

#1. Attempt to obtain your lab results at each doctor appointment. It is much easier to ask for them at each appointment than later when you may need them. Plus the doctor may make you wait 30 days which presently they can do legally. Plus this will help you track your health and provide good information if you need to change doctors,. Hopefully this won't be needed. The lab results will let you know if your doctor is checking the vitamins and mineral levels, thyroid condition, and many other vital tests. Blogs about some of the important tests are here and here.

#2. See your eye doctor for an eye examination. This is important to establish a baseline for the condition of you eyes. When most eye doctors are told you are newly diagnosed with type 2 diabetes, they will normally do a thorough eye exam and make many notes. This provides a base for future eye exams and they will check for retinopathy, cataracts, and other eye diseases.

#3. Set up that dental appointment! I know many people avoid this, but it is important so the dentist can check for periodontal disease which often can accompany diabetes. Better to establish a baseline here as well and have your teeth and gums taken care of to prevent future problems.

#4. Make sure you have a good pharmacist. A pharmacist can be a great asset for questions about medications. They can prevent medication conflicts. It is a good idea to ask the pharmacy if they would like a list of supplements you are taking as some supplements can have deadly conflicts with some medications. Most pharmacist are an excellent resource for knowledge on diabetes supplies and if not overly busy may be able to answer many questions about them. Some pharmacists are working into primary care.

#5. Check your insurance for supplies covered. Laugh if you want, but many people are not familiar with what supplies their insurance will reimburse. With the changes being made by the Centers for Medicare and Medicaid Services (CMS) changes have and are being limited. If you have the funds to buy what you chose, great. Otherwise you will need to consider what is reimbursed by your insurance, not great in many cases.

#6. Start reading and looking for material (books and newsletters) for self-education. Chances are as a type 2, that you will not have a certified diabetes educator available help educate you. Self-education may be your only option. Don't forget about some types of social media. Also see number 4 above.

#7. Do not be afraid to ask questions, of your doctor, and anyone with diabetes. Normally those of us that blog are able to answer some questions and if we are unable, we will refer you back to your doctor, or a source that should be able to answer your question. We will not answer certain questions that should be answered by your doctor. Only your doctor can answer some questions based on your tests and personal history. We may ask more questions to determine how best to suggest a solution based on our experiences.

#8. Another exam that needs to happen is a hearing test. This will also develop a baseline for future tests to determine if there is hearing loss happening. Small blood vessels in your inner ear can be damaged by high blood glucose levels and over time will rupture and cause hearing loss. It is important to maintain excellent blood glucose levels and blood pressure readings.

#9. Get an examination by a podiatrist. As a person with diabetes, this is important as atherosclerosis, problems with the large arteries in your legs need to be avoided and you need to be sure that you have someone to treat wounds, cuts, and other foot problems to avoid infections that may prevent healing and causing a need for an amputation of a toe or part of your foot or leg.

#10. Consider getting an appointment with an urologist or doctor specializing in kidney diseases. If you primary doctor is doing the necessary tests, this may not be necessary, but you may need a referral later to handle kidney disease, or nephropathy which is a complication of poorly managed diabetes.

#11. If you develop neuropathy, another complication of diabetes, you may need to see a neurologist. They can help with the pain and prescribe medications that can ease the pain. Only excellent diabetes management will prevent this from happening and outside of heart problems, is the most prevalent complication of diabetes. An important article appeared on August 15 about the risk of peripheral neuropathy occurs only with fluoroquinolones that are taken by mouth or by injection. This answered many questions for myself and another member of our group because we had neuropathy before we were diagnosed with diabetes. Now we understand the medicines that caused it. I would suggest that if you have neuropathy, and are diagnosed with pneumonia, do not let the doctor prescribe Levaquin as you will be put in extreme neuropathy pain. This is what happened to me about a year ago and the pain put me back in the emergency room.

There are always more tests and things to do, but this will provide items for thought and be a starting point.

August 26, 2013

Reasons Behind Varying Blood Glucose Readings

We should be happy that Joslin has highlighted some of the less talked about variables in our blood glucose readings. When they have a blog that many people read, I am concerned that they are not including information that many bloggers do cover and complain about incessantly. Surely, Joslin has a larger reading base and could reach more people, but time after time, much information is totally ignored. Back to why blood glucose readings can vary dramatically even eating the same meal day after day.

#1. Food consumption can be a large component of blood glucose reading variability. Then when we remember that food labels, meaning carbohydrate count, can vary by 20 percent and sometimes more. And, we wonder why we get readings that vary.

#2. Meter accuracy can be a factor. With the exception of a few meters that are accurate within 15 percent on the low side in their test strips, all meters are supposed to be within 20 percent of actual blood glucose. Now we are learning that many test strips, once they have received FDA approval, do not meet that requirement in their test strips and yet the FDA is doing nothing about it. There is even greater questions about the test strips being brought into the US from other countries by CMS.

#3. Exercise and physical activity is another variable. The amount of exercise or other physical activity can draw glucose from our liver and put it to work in our bodies, shorting us later when we take our readings. Being sedentary can also affect our blood glucose levels when we are normally physically active and they can affect our readings.

#4. Insulin is also a variable. Yes, even our insulins are not that dependable. I quote what Joslin wrote. “One of these is the insulins we have available. NPH insulin is notorious for having large intra-individual variability (meaning you can get widely different results each time you use it), but even the newer insulins, Lantus® and Levemir®, are not anywhere near 100 percent reproducible every time. One study by Heise et al published in Diabetes found that the serum concentrations of insulin Lantus® and insulin Levemir® varied by 24 percent and 18 percent when participants received four same- quantity doses of the medication.” This is even more dramatic than I had thought.

#5. Liver output of glucose is a variable. Our liver puts out glucose when it is called upon by our bodies. When we have lost some of our pancreas capability, this can become a larger variable than we realize. This is especially true for those of us with type 2 diabetes.

#6. Emotions and stress are variables. Some people try to ignore this, but these are factors in our blood glucose production. It also can become a larger variable if you become stressed before taking a reading.

#7. Illness and injury is a variable. When you are on the verge of an illness, your liver can be called upon to supply more blood glucose to help in the battle of an illness. A severe injury can affect blood glucose readings as well, while a minor injury will have a smaller effect.

#8. Hormones are variables. In addition to a woman's normal monthly cycle, other things in our daily lives can increase or decrease our level of hormone activity and this will affect our blood glucose readings.

#9. Food consumed at other meals and snacks are variables. People are forgetful and often do not remember the extra carbohydrates they consumed the previous meal. It is that second small serving they had or the small 15-gram carbohydrate snack that turned into 25 grams of carbohydrates. Or maybe you had less to eat that anticipated. It is little things like this that can cause variances in our blood glucose readings.

If you think about it, whether you are a type 1 or a type 2 on insulin, calculating a dosage is a crap shoot. It is surprising that we are as close as we are most of the time. Knowing this also confirms why doctors are so nervous about hypoglycemia. Is it any wonder that when people forget to inject insulin or take their oral medication, we sometimes have very high spikes in blood glucose? Or when we take our medicine and then don't eat what we anticipated that we can have hypoglycemia.

Doctors will very seldom remind patients to not take a medication if they are not feeling like eating unless there is a blood glucose reading above a certain level. Doctors also forget to review the correction ratio for insulin to assist people for injections when they are ill or don't feel they can eat.

The above are not intended to be all inclusive of all variables, but should point out why people with diabetes have burnout from all the calculations and variables to keep track of on a daily basis. Our diabetes health is dependent on these considerations and our calculations. Sorry folks, the doctor can't do this for you.