2014 ADA Guidelines, My Perspective

This is an analysis from a patient's perspective. I am not saying I am right, but this is the way I read the 2014 ADA guidelines.

Even though I have read the summary of changes, I still see little difference between the 2013 and 2014 guidelines. At least this year there are no claims that testing has changed and apparently all the hoopla raised last year that resulted in no change in testing supply needs by insurance will get no more support. This just shows how much support people with diabetes will receive from the ADA.

Some minor changes were made for gestational diabetes diagnosis and more precise language was put in place for retinopathy exams from 2 to 3 years down to every two years. This is still too general for people above the age of 60. It ought to be every year and more often if any retinopathy is detected.

Other than this, you may read the summary of changes here. I would urge people to read the Medscape article by Dr. Anne Peters here and she covers the evolution of the ADA guidelines in more detail and while I can agree with her, I wish she would have pointed out more weaknesses.

I will quote her response to blood glucose testing for those of us on insulin. “Once you have diagnosed a patient with diabetes, you need to set treatment goals and make a treatment plan. That is fairly standard and is outlined in the standards of care. Somewhat different in the new guidelines is how often patients with diabetes should be monitoring their blood sugar levels.

Patients who are on multiple daily insulin injections or an insulin pump should be monitoring their blood sugar levels as frequently as they need to; in general, this is before meals and snacks, at bedtime, if they are going to drive, if they feel hypoglycemic, and from time to time after eating to get a sense of their postprandial glucose levels. The total is somewhere in the range of 4-10 times (typically 6-8 times) daily.

This frequency is often at variance with what patients are allowed in terms of test strips. I spend a great deal of time trying to get my brittle, older patients with type 1 diabetes the coverage for enough strips. It is important to fight for this because as they get older, people often develop more episodes of hypoglycemia, and we want our patients to have enough strips for testing.”

No one seems supportive of patients on oral diabetes medications and for him or her to be able to self-monitor their blood glucose levels. All anyone wants is to move them over to stronger medications and then to insulin if they HbA1c's trend upward. This may be the best course of treatment if they will not change the blood glucose testing requirements and recommend reduction of carbohydrates to a reasonable level.

Doctors Don't Always Explain Everything

This article in the Mayo Clinic website is good, but there is an opportunity lost. Doctor Maria Collazo-Clavell answers a question posed with a good answer, but stops too soon. The question is, “Sometimes my blood glucose monitor seems to give incorrect readings. What can I do to make sure the measurement is accurate?”

The doctor says, “When you start a new container of test strips, occasionally perform these quality control tests as you use them and when your results seem unusual.

To perform a quality control test, do one or both of the following:

• Test using a control solution. Follow your normal blood-testing procedure, but use a liquid control solution instead of blood. These solutions usually come with your monitor and are available at most drugstores and pharmacies. Follow package directions.
• Match your reading with lab results. Take the blood glucose monitor along when you visit your doctor or have an appointment for lab work. Check your blood glucose with your meter at the same time that blood is drawn for lab tests. Then compare your meter's reading with the lab results. Your meter's result is considered accurate if it falls within 15 percent of the lab test result.”

These are both great points and something many patients forget to do. The first one should be performed more often than many people want to do. It is a fact that most people never use the control solution. If the pharmacy does not have the control solution, they will order it for you. I have found one bad container of test strips in the 10 years of testing and that was about three months ago. I almost expected to find another bad container in this cold snap we had, but so far, all have been right on. The test strips are shipped in the mail and set in the mailbox too long.

I always check my test strips with the lab, and I have always been within five percent or less of the lab results. Several times, I have received the same result.

Now for the points I think the doctor should have talked about and did not:

#1. Is the person actually talking about a monitor or a meter? If the person is talking about a continuous glucose monitor (CGM), then the answer given by the doctor is completely off base. She does answer the question for a blood glucose meter and test strips; therefore, I will continue for the meter as well.

#2. Were the test strips stored properly? This should have been a point in the answer. Too often, the test strip container is stored in the bathroom or kitchen where excessive humidity can overload the container, which is manufactured to keep the test strips dry within limits. Also keeping the container in an area that is above the proper temperature or below will give erroneous readings.

#3. Were your hands properly washed and dried?

I could make this an extremely long blog, but I have covered this and much more in my blog here. I urge you to read it if you haven't and follow the links to other blogs. This is a topic that is very important and we can easily forget to be proper users of this delicate equipment.

My Perspective On Reasons Doctors Say We Are Noncompliant

This Medscape article has me riled. Doctors are complaining about a noncompliance epidemic and how to solve it. There are seven articles of several pages each and all are attempting to solve the epidemic.

I have an easy answer for them and I don't need over 30 pages to tell doctors the problem. Learn how to communicate with patients rather than ram medications down our throat. Most of the time these doctors just hand the patient a fist full of prescriptions with no explanation and expect the patient to fill each prescription and take the medication as directed. A small number of patients will comply with no questions asked. However, more patients are pushing back, want an explanation of what the medication is for, an explanation of the side effects, a benefits to harm analysis, and want a discussion of why they need it. Then even more patients desire to have some input in the decision of what may be best for them and openly rebel at being excluded by the paternalistic attitude of the doctor. Today's patient also wants more transparency on the part of the doctor and if he receives incentives for each prescription.

Most doctors refuse to take the time for any explanation and are upset with the patients when prescriptions are not filled and the patients refuse to take any medications. Their own lack of communication causes the majority of noncompliance as they deem to call it. These paternalistic doctors need a swift kick in the backside and be required to take and pass a communications course. It is the lack of communication not the miscommunication as they try to say in #7 below,

Doctors do not seem to care whether the patient can afford the medication as long as their bill is paid. They seem to forget that a little communication can do wonders for their practice and the confidence their patients have in them. I therefore say that the patient rebellion is mostly of their own causing. Yet, it is full speed ahead at blaming the patient, instead of looking at what they are doing.

David Mendosa is a bit more forceful in his blog from October 30, 2009. This was when more people were afraid to walk away from these doctors; however, today the doctors are forcing us to walk away more because of the over paternalistic attitude. With more people using the internet, we are able to understand the problems of pharmaceutical overreach and lack of communication about side effects that cause more harm than benefits for some people. I like a quote David used at the bottom of his blog by an endocrinologist friend, “The ‘noncompliant’ label always grated on me — it’s assuming a model of health care delivery that the doctor is the captain of the ship and the patients are chained to the oars.”

The following links will take you to each article: NOTE: These are written by doctors and for doctors – sort of an insight in the way we, as patients, are viewed.

#1. http://www.medscape.com/viewarticle/818850

Title - Why Are So Many Patients Noncompliant? - 9 pages

#2. http://www.medscape.com/viewarticle/819317

Title - Can We Get Patients to Be More Compliant? - 9 pages

#3. http://www.medscape.com/viewarticle/773918

Title - Documenting Noncompliance Won't Protect You Anymore – 4 pages

#4. http://www.medscape.com/viewarticle/703674

Title - Best Ways to Deal With Noncompliant Patients – 6 pages

#5. http://www.medscape.com/viewarticle/774271

Title - Noncompliance With Schizophrenia Therapy Usually Persists – 1 page

#6. http://www.medscape.com/viewarticle/781036

Title - Patients: 'Difficult,' 'Tough,' or Just Misunderstood? - 3 pages

#7. http://www.medscape.com/viewarticle/804739

Title - Why Some Patients Aren't Following Your Instructions – 4 pages

#8. http://www.medscape.com/viewcollection/33015

This is the master collection of the above articles

Can a Certified Diabetes Educator Help You?

This question has many sides and depends on many variables. If you live in heavily populated areas of the United States, your chances are above average that you may find a certified diabetes educator (CDE) that may be willing to help you. If you reside in many of the rural areas, you can bet that you will not find one near you. If you are willing to travel hundreds of miles, maybe, just maybe, you will find one. Whether you have type 1 diabetes or type 2 diabetes will also make a difference as to their willingness to provide help.

I will not hide the fact that I have a bias. I even have a cousin that is a CDE, but I don't talk to her anymore because she has attempted to have me reduce my criticism of the profession. A nurse (CDE) friend of my first wife does still talk to me, but we have agreed not to discuss CDEs and the topics related to the profession. The latest discussion with a CDE was anything but a discussion and became very contentious. She had recommended a certain medication, which is manufactured, by one of their industry allies and I questioned the usefulness since I do take a competing product. Then I commented that she was showing a conflict of interest and the contentiousness escalated.

The endocrinologist asked what the problem was and when I brought up the conflict of interest, he asked if I could prove it. I asked for permission to use the internet and showed him the Industry Allies Council page in the American Association of Diabetes Educators (AADE) site. Since this was not a diabetes medication which the CDE wanted me to change to, I had told the CDE that she had a conflict of interest.

Now I know that CDEs are a great help for many people with type 1 diabetes, but in general prefer not to work with people with type 2 diabetes. The myth even exists that CDEs are for people with type 1 diabetes only. I know that people with type 2 diabetes are seen by CDEs, but not in great numbers. Much of this is because there are not enough CDEs to go around. The other factor against them is that so few have either type 1 diabetes or type 2 diabetes that they have more difficulty relating to us.

The new writer about type 2 diabetes at About dot Com is a registered dietitian, certified diabetes educator. She says, “There are about 18,000 Certified Diabetes Educators accredited by the National Certification Board for Diabetes Educators.” At least this is a distinction from the membership numbers the AADE has on their website; and helps explain that not all CDEs are members of the AADE. In her biographical information, she does not claim to be a member, does work as an Advanced Nutrition Coordinator for the Mount Sinai Diabetes and Cardiovascular Alliance, and served as past editor and board member of the Long Island Dietetic Association. She is certified in Adult Weight Management.

It will be interesting to follow her and see how often whole grains becomes the topic and how often they are promoted.

Internal Medicine Claims Elderly Veterans Over Treated

Internal medicine doctors must be jealous because of all the veterans receiving excellent care from the Veterans Health Administration. So, they go and claim that the elderly veterans are being over treated because so many are on sulfonylureas or insulin. If ever I saw something to be less concerned about, it is something like this. I just know that veterans in general can take better care of themselves and are driven to do so by their determination and the military training they have experienced.

I know what the VA members of our support group are doing and all of them are under 6.5% when A1c is the comparison factor.

Patients at the Veterans Integrated Service Network facility demonstrated varying rates:

• 8.5% to 14.3% for HbA1c less than 6%;
• 24.7% to 32.7% for HbA1c less than 6.5%; and
• 46.2% to 53.4% for HbA1c less than 7%.

However, over treatment rates were more significant, researchers wrote; with rates ranging from:

• 6.1% to 23.0% for HbA1c less than 6%;
• 20.4% to 45.9% for HbA1c less than 6.5%; and
• 39.7% to 65.0% for HbA1c less than 7%.

What the report fails to tell us is how the over treated rates were determined, what the comorbid conditions were for those that were considered over treated, and what the age ranges were for those participants analyzed. This is the reason for the claim I make that internal medicine is jealous and can't stand that the veterans have better A1c's than their patients do.

If these veterans are in Veterans care facilities and they are being properly cared for, then the caregivers deserve credit for managing the patients very well. If this statement is correct - “The primary outcome was an HbA1c less than 7% in patients aged 75 years or older with a serum creatinine value greater than 2 mg/dL or a diagnosis of cognitive impairment or dementia,” then they are being cared for in a range to prevent the complications from becoming a serious factor.

Internal medicine prefers that the Veterans develop complications to have these serious conditions to treat. This is standard for many nursing homes where internal medicine doctors are in charge. In one nursing home, two diabetes patients each had amputations because they were not kept below an A1c of 12%. Another patient was due for an amputation and was legally blind because of retinopathy. His A1c was above 13%.

Do You Support A Loved One with Diabetes?

Diabetes is a self-managed disease. This is the start of the last paragraph and to me says more than the rest of the blog. Whether you have a supportive family or even supportive friends, you still have to manage diabetes to the best of your ability. They cannot and should not manage your diabetes, unless you are incapacitated or have a form of dementia. Even many adults with type 2 diabetes expect their doctor to manage their diabetes.

When you have diabetes, you have it 24/7 with no vacations. It is not an easy task and it takes a real task manager to stay on top of diabetes. Supporting someone you love is natural, but it can be difficult if he/she shuts you out or won't take charge of his/her diabetes. Finding the right ways to help is a key. You must work with them, but at the same time help them to accept their diabetes and manage it.

Because the chances are you are not knowledgeable about the disease, you will need to learn starting with the basics and carefully manage the terminology. Unless it is your child that has diabetes, you will still want to go to the doctor appointments, if the spouse will allow this. You should be able to ask questions during the doctor visit and because diabetes is different for everyone, knowing about their diabetes will make helping them easier.

For some people, diabetes education classes may be the answer and many hospitals offer them nationwide. Use the search help here. Be concerned if those in charge are more interested in pushing carbohydrates than teaching about diabetes.

Another thing to consider is when dealing with a spouse, assisting them with their diabetes requires more than marital trust. Some couples find this easy and for others this special trust comes slowly and needs to be worked at over time. Nagging can stop this trust and even negate marital trust.

Type 2 diabetes can often be managed with proper nutrition and exercise. By planning to exercise together, you are making it easier for your loved one to work toward a healthier lifestyle. If you are the cook in the family, learn what is necessary for healthy nutrition and start cooking accordingly. This may require some education on your part and learn how to count carbohydrates.

One of the most important aspects that a spouse needs to learn is the symptoms that can happen with diabetes. If your spouse, or child, is on insulin or a sulfonylurea or The DPP-4 inhibitors, they may be at risk for hypoglycemia (low blood glucose). I can only urge you to know the symptoms of a hypoglycemic attack and what to do if it happens.

This Joslin blog has other suggestions and I suggest following the links for additional information. A review of a few of my prior blogs may also be of help.

Yes, every family is different and needs thought in the method used to discuss a diagnosis with them. This blog discusses a study and what the people with diabetes feels his or her family thinks about their diabetes. This blog covers some useful tips for the person with diabetes and how to manage some situations. The final blog I offer is about some of the reasons loving family members can be the worst at assisting good diabetes management.

Eye Disease – Diabetic Macular Edema

It is interesting reading some of the topics at DiaTribe dot Com. Diabetic macular edema (DME) is a form of diabetic retinopathy. This happens when high blood glucose levels cause blood leakage in the small blood vessels and the resulting swelling of the macula can cause blurry vision.

Diabetic macular edema affects people with type 1 and type 2 diabetes. About 75,000 new cases of DME develop each year. This makes DME the leading cause of blindness in working-age Americans. If people with diabetes would manage their blood glucose levels and have an annual dilated eye exam, there are several treatment options available to help prevent or delay DME.

In the past 25 years, the standard for treating DME has been laser surgery. This seals up the leaking blood vessels to reduce the fluid around the macula. This procedure can stop the progression of vision loss, but cannot reverse the damage that has already been done.

Today, we have an alternative. The FDA approved in August 2012 a drug named Lucentis (ranibizumab), as the first drug for treatment of diabetic macular edema. Lucentis is a once monthly microinjection into the eye. Clinical trials show that in two years, individuals are able to read two additional lines on average on the eye chart. This is a great improvement and Lucentis is generally safe and well tolerated. Laser surgery and Lucentis are sometimes used in parallel to maximize outcome.

I will mention that Avastin, a drug approved for cancer treatment, is sometimes used “off-label” to treat DME if Lucentis is not available. It is a similar drug to Lucentis, but has not been approved for treatment of DME.

As a last resort, steroids are used “off-label” to treat DME. Steroids can cause additional cataracts and glaucoma.

Additional information can be read here and here. I feel they are worth the time reading if you have concerns in this area.