Afrezza, Is It the Answer for People with Type 2 Diabetes?

I had not expected to write this, but after seeing this on another blog by Scott Strumello and a comment to it, I felt it was time to open a dialog about it and hopefully see other bloggers write about it.

Several of our support group members have been talking about Afrezza and how they want to see if they will be allowed to use it. Brenda, Allen, and I have decided against it because there is still a big question about determining the correct dose. Tim and Jason are still considering it. Barry has taken a wait and see and warns that it may not even be available to those of us receiving VA benefits. He also wonders if Medicare will allow it.

After reading Scott's blog, we have to wonder from the early hype, will Afrezza even become a product for use in the United States. As of February 3, it supposedly is available in the US, but will every pharmacy carry it.  Currently one local pharmacy has it, but doctors are only prescribing for type 1 diabetes, but not for type 2.  The other pharmacy currently is not carrying Afrezza and offered no reason.  When I first wrote about Afrezza, I had some concerns which are still valid. This has caused me to start listing the pros and cons:

Pros -

• May help many type 2's that have needle phobia
• May help type 2's that are afraid of other insulins
• May be prescribed earlier and not as a medication of last resort

Cons -

• Acute bronchospasm has been observed in patients with asthma and chronic obstructive pulmonary disease (COPD)
• No testing has been done for the elderly and health illiterate
• No testing on people with diabetes that develop pneumonia
• No testing on people with other respiratory problems that often necessitate oxygen use.
• Hypoglycemia may become an even greater concern with Afrezza

Afrezza is not recommended for the treatment of diabetic ketoacidosis, or in patients who smoke. Even with the hype, there are too many unanswered questions about Afrezza that we have not been provided answers to, as of yet. Many of these questions may be answered after it has been on the market for a period of time.

If you are a person that is using Afrezza, please consider responding to this request at Diabetes Update, as this is one place to put the information to use and spread the word about your results.

Help in Diabetes Management Education – Part 8

Part 8 of 12

Developing a food plan (not a diet) and counting carbohydrates is the topic for this blog. Lately the buzz has been about the DASH diet and most of us with diabetes find that it is often too high in carbohydrates and low in the fats. I have found that some diets promote great ideas, but end up not being something that can be followed for the long term. This is the reason that I suggest that each person with type 2 diabetes develop the food plan (not a diet) that fits their way of living.

Some can eat very few carbohydrates while other can consume larger amounts. I do encourage people to limit the amount of whole grains they consume. Beyond this the food plan needs to be what your testing shows is best for you.

The following links will help you in determining the number of carbohydrates in your meal. This site if free and all you need to do is sign up at this link. There is several things that are explained at the link and there is a mobile app that you can download.

This link is the one I use when my wife uses her own recipe and I can enter the ingredients. The following image is what you will find.

 

What I also like is that you can use a link to recipes on the internet. Some recipes have the nutritional information and this will provide a check of the nutritional information provided. The next thing that you need to do is determine the number of servings you will be using for the recipe. This can even be done after the food is prepared and you have a better idea of how much you may want to consume. If you like it and your meter tells you that it raised your blood glucose more than you wanted, you now can get a better idea of the serving size you need to consume.

Having this information can go a long way in counting carbohydrates. Many of us count carbohydrates the hard way but reading the number of carbohydrates from the labels on the products we use for recipes and then determining the serving size and dividing the total carbohydrates by the number of servings. This is also when a scale becomes a tool to help determine carbohydrates. I have used a scale for about 10 years and in the last five years, I have used it less and this is because when using the same recipes, the carb counting has been easier. I highly recommend using one to help in the accuracy of counting carbohydrates.

I am no longer surprised by variances in the number of carbohydrates. Manufacturers and processors are allowed to vary by up to 20 percent also. And the USDA tables used by most calculators are only an average and have a variance. So if you are wondering why those of us that have had diabetes for more than a decade get up tight about all the variances we have to take into account, you would be right, as we do have to wonder ourselves. This won't change anytime soon, so we need to go with the flow.

Help in Diabetes Management Education – Part 7

Part 7 of 12

This is a difficult topic to explain to people and at the same time not confuse them. I have talked about testing in pairs and how important this is. Again, I will advise people to set their own goals based on what they are willing to tolerate for blood glucose numbers. I would urge everyone to manage their goals below or near those promoted by the American Association of Clinical Endocrinologists (AACE).

The medication you are taking will also affect your goals. This means that you should discuss this with your doctor for ideas – if your doctor will allow this. Many doctors are not knowledgeable about the diabetes medications and their effects on the body. Most doctors refuse to allow patients to use insulin and make insulin the medication of last resort. This means that many doctors will harm patients by prescribing insulin only when the complications are happening and oral medications are no longer effective. If your doctor has stacked (prescribed) three or more oral medications, it is time to become knowledgeable about insulin and seriously consider using it before the complications set in.

This blogger uses the AACE guidelines and has some well thought out blogs about the ranges and why they are important. Again, many doctors only follow the ADA guidelines and become extremely anxious when patients obtain lower readings. This is because of their fear of hypoglycemia and they have not taken time to read many of the follow-ups to the ACCORD study. Studies are good, but when they are using targeted participants and not a range of different medications, they are not reliable.

I also suggest reading my blogs from January 23, 2015 and January 24, 2015. Testing in pairs is important if you can afford the test strips. The before meal test and the test at your best time after meals will tell you how your blood glucose level is based on the two tests. If your preprandial is 83 mg/dl and at 90 minutes, your postprandial is 153 mg/dl, this means that you had a total increase in blood glucose of 70 mg/dl. This says you ate too much food or grams of carbohydrates. This will vary by individual and how each body reacts to carbohydrates and the medication the person is taking.

I try to eat between 20 and 25 grams of carbohydrates at each meal so I would expect to have an increase of 24 to 30 mg/dl in my blood glucose level. Again this would depend on the food, the type of carbohydrates, and how I was feeling. Always remember to wash your hands and fingers with soap and warm water and dry before testing.

The other factor to remember is your health and recording this in a health log. This can have an effect on your blood glucose. A fever can increase your blood glucose reading and can even extra pain or stress. These are all factors that must be resolved to know what your blood glucose increase is and how best to treat it.

In the 70 mg/dl increase, was the count really 70 grams of carbohydrates, or were your wife and you have a verbal battle of some not so nice words? Were the carbohydrates the kind that really spike your blood glucose? There is always a variable that needs to be resolved. Sometimes it can be two or more variables. Read my blog here for some of the variables.

Blogger Bad Habits

I know I have some bad habits in writing about diabetes, as a reader reminds me of them. I make occasionally mistakes in medical terminology, but I have to be concerned when group like this one fails to follow editorial policy or at least enforce a good policy. With the errors appearing lately, the editor may be on vacation.

I am referring to this blog from January 27, 2015. I know the author should have used blood glucose meter for most of the blog in place of glucose monitor and uses the term monitor correctly when talking about continuous glucose monitor. A monitor does not use test strips.

The only thing I can figure out from this -Quote - “It will be easier on your pocketbook if the monitor you chose is popular. You will find the test strips everywhere with no trouble, often at lower cost because they are widely available.” - Unquote is that the author has unlimited funds and can purchase any test strips desired.

Most of type 2 diabetes and type 1 need to stay with the meter and test strips that are what the insurance provider will reasonably reimburse or pay. Each insurance company is different in their formulary and therefore what is popular may not be the brand that the insurance company will allow.

Quote - “Blood glucose monitor test strips are sealed in packs and vials. Keep the ones you are not using in their original packages.” - Unquote. The author may desire the containers to be sealed, but I have not found any that are sealed and I have never needed to break a seal to use them. I have had to open the box, then open the container lid, and carefully remove the first test strip.

Quote - “Make sure your hands are freshly washed before handling test strips, and be careful not to get the strips wet with water or alcohol. After using an alcohol wipe, let your finger dry before pricking it to get the drop of blood.” - Unquote. Yes, it advised by most test strip manufacturers to wash your hands and dry thoroughly and this is in the instructions that come with each box containing the container of test strips. Alcohol pads or wipes should only be used when water and soap in unavailable. Never rely on alcohol pads when you have been handling or cutting fruit or certain foods and you will receive very elevated readings. Only washing with soap and warm water will remove the sugar of fruit from your hands.

Using alcohol pads on your fingers during late fall to early spring is asking for cracked fingers and very painful testing. Alcohol dries out the skin and this is a serious problem.

This is the type of information we don't need. I have had several emails asking me what the information meant as they had not heard of glucose monitors requiring test strips. It is blood glucose meters that require test strips.

Continuous glucose monitors (CGMs) are very expensive and very few people with type 2 diabetes can have them approved for use, but a few do. Mostly they are used by people with type 1 diabetes.

Help in Diabetes Management Education – Part 6

Part 6 of 12

Learning to interpret your blood glucose readings and how they should guide your food intake is part of self-monitoring of blood glucose (SMBG). A few certified diabetes educators (CDEs) will actually teach this, but most will only use mandates and mantras. If you are fortunate to have one that is teaching this, learn from them. Those of you in the rural areas will most likely need to learn this on your own. Some rural doctors are working with diabetes patients that want to learn and training them to be peer-to-peer workers or peer mentors. In turn, they work with the doctor to help educate other patients.

I will state before I go further, each patient needs to discuss with their doctor what reasonable goals they should consider. Then you will need to decide what you are willing to tolerate for diabetes management. The numbers I will use are reasonable, but you should still select your own goals. This is not a topic that can be neatly wrapped in a bow. It needs to be individualized to the person and their goals and abilities. I would urge you to read the many links I will provide as it will give you ideas for goals.

The first link is this with tables and a discussion on managing blood glucose. There are suggestions that need to be considered. The second link is a blog of mine that I wrote about from a book published by Joslin. This surprised me and Joslin is not always talking about this and often discouraging to people with type 2 diabetes.

One factor where most authors fail is talking about “testing in pairs.” Dr. William Polonsky of the Behavioral Diabetes Institute is the person that coined this and promotes this as the best method for determining how food affects you body. This is important because by taking only one blood glucose reading either before or after eating will not give you any meaning and just a reading that tells you nothing except what the reading was at that time. This does not help in determining how the food you consumed affects your blood glucose.

This also tells the doctor nothing toward finding the correct amount of medication. Granted the doctor uses your A1c to determine how well you are managing your diabetes, but more doctors are using the readings from either your testing or from your meter to help them do this. I will cover counting carbohydrates in a future blog.

While I do not like the numbers used in this blog at DiabetesMine, this will give you more of an idea why testing in pairs is important.

The last blog I refer you to is this one where CDEs think about us a round pegs and they want to put us in square holes. I wrote this with tongue in cheek, but it is very applicable today because CDEs teach to the lowest level and don't want to work with people with type 2 diabetes when they can avoid it.

Help in Diabetes Management Education – Part 5

Part 5 of 12

Self-examination of our legs and feet for sores and areas that are not healing has scared, finally, the newest members of our group. Our meeting with the podiatrists showed them how serious we were and how they were not taking care of their health as great as they thought. They now understand how important it is to see a podiatrist on a regular basis.

Brenda called me two days after our meeting and was wondering if we would be losing a member or two because of our meeting. I asked why and she responded that two members had approached her since the meeting and asked why we needed to know the doctor they were seeing and why we held the meeting and brought in the two podiatrists.

She said one of them was on insulin and the other was on metformin. The one was one with a minor cracked heel and the other was a good friend of her's. Brenda said that we felt that their health was important and we had always been this way even when we were a group of six. She said that the one on insulin had gone along with the call-in program, but was having second thoughts about this.

Then the following day, Tim was called by the same person, she said was out of the call-in program and would no longer be attending our meetings, and hung up. A few minutes later Tim said, he had a second call and the same message from another member.

With that, Tim called for a group of us to get together on Thursday and discuss this. When the ten, A.J, Jerry, Ben, Barry, Sue, Brenda, Allen, Jason, Tim, and I were together, Tim asked if we were pushing the members too hard. Only Allen thought so, but said if the free foot exam had led to this, then we could be better off without them. Brenda felt secrecy was behind some of this and the free foot exam was more than they wanted. Tim said that brings the membership to 30 members then.

Sue said that two others had called her and were very thankful for the foot examination and having discovered the problems early. Tim said he had received the same calls. Allen said this shows that we did the right thing and we should just ignore the two that want secrecy. I said that the two individuals were ones that did not want me to use their names in my meeting blogs. This would make secrecy consistent with their life.

Jerry said if anyone could have wanted secrecy, it would have been him, but he was glad that he had been helped and that everyone knew why. He said that the free foot examination was a plus as far as he was concerned and these people should be thankful that we cared enough. Sue said that the person she had been helping was asking her about the meeting after receiving the meeting email and wished she could have been caught earlier, but she had not been paying attention to her feet until she had blood in her slipper. Sue said she has ordered a mirror so she could see her feet better and is just glad that she had someone willing to help.

Brenda spoke then and said, with all the battles we face with diabetes every day, we should be thankful when others can help us and make life easier. She said at first she was just happy that there was a group that cared about each other, but when members are refusing this help, I don't like it and in a way, I am not sorry to see them leave the group. The call-in is no guarantee that you will not die, but can help get you to the hospital if needed. Hypoglycemia is not something to be laughed at, but if they are arrogant enough to think we are being nosy, then they don't belong.

That concluded our meeting about the members leaving.

Options After Insulin

This is one confusing article in Diabetes Self-Management magazine. First, there is an error in the byline, as when I contacted Will Dubois, his answer back was there is a misprint in the byline because he didn't write it. In an email to Gary Scheiner, he confirmed to me that he is the author and the article is written for people with type 1 diabetes.  The byline has now been corrected.

I have needed to reread the article several times and slowly to determine that it was written for people with type 1 diabetes. I do wish he had clearly stated that the article was written for type 1 diabetes. This can be inferred, but is far from clear in the overall context of the article. With the number of people with type 2 diabetes using insulin, this could have been written for both types. However, I should have known this as most CDEs do not deal with type 2

With the conflicts of interest that the American Association of Diabetes Educators has, I am also wondering how much of a conflict of interest is represented by the article and the medications he is promoting. The “off label” use that is being promoted is heavy and questionable at best.

Since I am a person with type 2 diabetes, none of the medications is “off label” use for me. This is the only clear reason for this being written for those with type 1 diabetes. I cannot agree with some of the medications as the potential side effects far out weigh the benefits and this is true for type 2 and type 1.

In looking at the medications recommended for type 1 there are only two that I could consider as being valid and only one that is truly “off label” and that would be metformin as it is used “off label” for prediabetes as well and has many studies to confirm its benefits. The one contraindication would be kidney problems which is true even for type 2 diabetes.

The first injectable drug other than insulin to hit the market was pramlintide (brand name Symlin), a replacement for the hormone Amylin. Amylin is normally secreted by the pancreas along with insulin. People with type 1 diabetes secrete no Amylin at all, and people with type 2 diabetes usually secrete far too little. Yet people with type 2 diabetes that use insulin therapy early often preserve their ability to produce enough Amylin to avoid needing Symlin. When insulin is the medication of last resort, then often Symlin may be needed, but is seldom prescribed.

The only drug that the author gave a warning for is the Thiazolidinediones. Both pioglitazone (Actos) and rosiglitazone (Avandia) have been linked to increased risk of congestive heart failure in people already at high risk for heart disease.

Even the newest class of type 2 oral drugs, sodium-glucose cotransporter 2 (SGLT2) inhibitors are not listed with the warning for people with kidney problems as they are for people with type 2 diabetes.

There are several DPP-4 inhibitors on the market today, as well as a few under development. The currently available drugs include sitagliptin (Januvia), linagliptin (Tradjenta), saxagliptin (Onglyza), and alogliptin (Nesina). No warning is given about causing hypoglycemia when these drugs are used with insulin.

With the lack of warnings and the overall promotion of drugs that are generally for type 2 diabetes, I would be concerned about unstated conflicts of interest.