Is Precision Medicine for the Masses?

Since the President's “State of the Union” address, the medical community, including the drug industry has been licking their chops in anticipation of the money to be gleaned in the process. Even patients are wondering how quickly this will be available.

I admit it sounds exciting until more information comes to light and there are many variables that may not have been considered. With each individual being so different, how will doctors be able to know which medication is applicable. Precision medicine is still a buzzword at present and it will be at least a decade, if not longer, before there will be a practical application. Medications will need to be developed to cover the different types of individuals and since there will be less needed; the costs will be significantly higher.

Doctors writing about precision medicine at this time, like Dr. Pelzman, are creating pie-in-the-sky scenarios that may never happen. For this to be successful, new specialists will be needed that understand the relationships involved in the individual genomes. Add to this, ethnical variances and other factors, and who will be able to determine what will be best for the individual patient. Doctors presently have problems with people with different ethnicities.

This will tend to exclude the elderly as few clinical trials are done to determine the effectiveness of medicines for the elderly.

Precision medicine cannot be precise if the implications/malfunctions of specific DNAs/RNAs/Proteins identified in an individual patient are unknown. With more than 20.000 genes, many of them with allelomorphs (alleles) in every human being, the number or permutations are astronomical and do not with our current limited molecular biology/physiology/pathology understanding allow doctors to select the information most relevant to a particular patient. An overload with chaotic information will make the doctor just as ill as the patient he/she is trying to help.

Then when the doctor prescribes one medication and sees no improvement, will they continue as they do today, of prescribing another medication in addition to (stacking) the current medication in hopes that the combination will solve the problem. With the cost of the two medications, or even more, the patient will not be able to afford the treatment.

There may be a place for precision medicine, but too little is known at this time about the under pinnings of how some medicines react positively for some individuals and negatively for others. Add to this allergies and the world of medicine may not be as precise as some are hoping.

Hypoglycemia and You

With hypoglycemia, remember testing is the most reliable and not your feelings. However, if you do not trust one meter reading, it is often wise to rewash your hands, paying attention to the finger you will be using for the test and then retest. Keep in mind that insufficient blood on the test strip can give a false reading on your blood glucose meter. The correct technique of testing is especially during hypoglycemia is important.

If you find that you develop hypoglycemia during or after exercise, contact your doctor to decide if a lower medication dose may be necessary. Remember, low blood glucose is any reading below 70 mg/dl (3.9 mmol/L). Treat it and do not suffer the complications of not treating low blood glucose.

Remember, very low blood glucose levels may require more than 15 grams of carbohydrates to correct back to safe levels of blood glucose. To do this, consider your blood glucose reading, the amount of medication in your system, the amount and timing of your last meal, and the effects of any recent exercise. All of these can affect the amount of carbohydrates needed to correct low blood glucose readings.

Appropriate carbohydrate choices to treat hypoglycemia include:

3 or more glucose tablets

½ cup orange, apple, or pineapple juice

1/3 cup prune, grape, or cranberry juice

½ cup of regular soda (not diet)

1 small apple, orange, pear, peach, or banana

2 tablespoons of raisins

1 cup of nonfat milk

1 tablespoon of sugar, honey, or syrup (can mix in water if desired)

Don't consider donuts, ice cream, candy bars, pie, cookies. These all contain fat in quantities that will slow digestion and availability of the carbohydrates. With hypoglycemia, fast digestion and absorption into the blood stream is required. If you take any medication that can cause hypoglycemia, you should always carry an appropriate source of carbohydrates with you in case you need it.

Keep glucose tablets in the car's glove box, your purse, your desk at work, or your pocket. It is also wise to wear form of identification that states that you have type 2 diabetes. This is where medical alert jewelry comes in handy.

It is important to follow up or talk with your doctor regularly. You may be needing a different medication or your dose of your current medication may need to be adjusted. Medication doses often need to be reduced when you start an exercise program, improve your food choices, or lose some weight. Continue to do your blood glucose testing and write down the results. The doctor may only use your A1c results, but you may need to show your testing results to prove you need a change in dose.

Be prepared to show the doctor blood glucose readings below 70 mg/dl if they happen. If they don't happen, you are fortunate and probably not on a medication that will cause hypoglycemia. The best idea is to research or look up your medication and I suggest on WebMD, or on this website, or this discussion of oral diabetes medications that may cause hypoglycemia.

Part 4 of 4

More Information on Hypoglycemia

If you haven't figured it out yet, your body does not like low blood glucose and does its best to correct the condition. The body does store some glucose in the muscles and the liver in the form of glycogen. When the body needs glucose, the liver breaks down glycogen stores and releases glucose into the blood. When the liver or you body is short of glycogen, gluconeogenesis can occur. Gluconeogenesis is the term for making new sugar in the body.

The liver and even the kidneys, to some extent, can take the building blocks from proteins (amino acids) and convert them into glucose. This is why drinking alcohol is discouraged for people with diabetes. The liver is prevented from making new glucose when it is processing alcohol. This is the reason alcohol can cause hypoglycemia. Insulin is the hormone that lowers blood glucose. Just about all of the other hormones (adrenaline, glucagon, cortisol, and growth hormone) can raise blood glucose levels.

When prescribed correctly and taken correctly, both insulin and oral diabetes pills can work well at controlling blood glucose levels without causing hypoglycemia. It is when you take too much medication or eat less food that you can cause hypoglycemia. If the body's defenses are down or not a match for the amount of medication taken, then hypoglycemia will result.

The following are the symptoms of mild hypoglycemia and include, hunger, trembling, rapid heartbeat, increased pulse, sweating, heavy breathing, tingling, nausea, weakness, and nightmares., If you think these are bad, here are the symptoms of moderate to severe hypoglycemia. They include, headache, slow thinking, lack of coordination, trouble concentrating, blurred vision, anger, dizziness, slurred speech, seizure, coma, and potential death.

With the above symptoms, don't count on being able to predict your blood glucose levels by the way your feel. The only sure way of knowing is by testing. Newly diagnosed patients often have some of the symptoms when they are still above 100 mg/dl. This is because their body has adapted to a higher blood glucose level and when the medication acts, some medications do bring the blood glucose level down rapidly. This can cause false hypoglycemia. This is the reason for testing to prevent over reacting and eating carbs because you body is giving you a false alarm. As your body adapts to the lower blood glucose levels, the false alarms will stop.

The official level for hypoglycemia is 70 mg/dl. Readings above this and below 100 mg/dl are considered normal. This is a reason to keep blood glucose tablets and if your blood glucose test is less than 70 mg/dl then you need to follow the rule of 15.

The rule of 15:

Treat low blood glucose with 15 grams of carbohydrates/

Wait 15 minutes, then test again.

If your blood glucose had not risen 15 to 20 points, repeat the procedure.

Remember that if your blood glucose is below 50 mg/dl, then it is better to take 30 grams of carbohydrates and then test in 15 minutes. Low blood glucose can happen if you eat too few carbohydrates, and especially if you skip a meal. Learn that once you start feeling of any of the symptoms, your body can continue the symptoms for 15 to 25 minutes after eating glucose tablets. This is because of the hormones released by your body to combat hypoglycemia and it takes time for these hormones to settle down.

If you continue to eat until your felt better, you will likely eat too much. This would then result in raising your blood glucose level to a higher level than needed. Then you would need to possibly take more medication and the roller coaster ride begins.

Part 3 of 4

Information on Hypoglycemia

The technical term for low blood glucose (or as most writers say – low blood sugar) is hypoglycemia. Many people that have type 2 diabetes seldom experience hypoglycemia. It all depends on the medication they are using to manage diabetes. Example – metformin taken by itself generally will not cause hypoglycemia. On the other end, insulin is very apt to cause hypoglycemia if the person using it is not careful.

People with type 2 diabetes that use exercise and diet to manage their diabetes are not at risk for hypoglycemia. The type 2 people taking the oral medications below are at risk for hypoglycemia -

1. D-Phenylalanine Derivative There is only one drug in this class, Starlix or nateglinede.
2. Sulfonylureas This is a multi-drug class. The medications are Amaryl or glimepiride, DiaBeta or glyburide, Diabinese or chlorpamide, Glucotrol or glipizide, Glucogtrol XL or glipizide long acting, Glynase or glyburide, and Micronase or glyburide. The two generic only are tolazamide and tolbutamide.
3. Meglitinide This has one drug in its class, Prandin or repaglinide.

Note of concern – several of the sulfonylureas are combined with other oral medications, but this does not mean they will not cause hypoglycemia.

Then there is insulin which affects everyone using this medication. More care needs to be used with insulin. Don't get me wrong, care needs to be used for all diabetes medications, but insulin creates it own special care.

The causes of hypoglycemia include:

1. Too much injected insulin
2. Too much or too strong a dose of an oral medication
3. Improper period of time between medication and meals
4. Skipped or delayed meals
5. Not eating enough carbohydrates
6. More exercise than usual
7. Drinking alcohol on an empty stomach

#1. Be sure you are reasonably accurate in your carbohydrate count. Until you understand the correction ratio, be careful in not over injecting insulin.

#2. Too strong a dose of an oral medication can be dangerous. Always ask the doctor how much food is required for the prescribed dose. Always ask the doctor what to do if you only eat two meals per day. Don't forget to ask the doctor what to do if you don't feel good and may not eat a meal.

#3. This is an important point and you should not inject insulin or take an oral medication if you will not be eating within the necessary time frame. Accidents do happen and what do you do when someone arrives as you are ready to eat,

#4. Skipping or delaying meals and taking medication is a dangerous way to bring on hypoglycemia.

#5. This is important. The oral medication dose size can determine the amount of carbohydrates you must eat. This is why you must discuss this with your doctor to decrease or increase the size of your oral medication. Those using insulin can adjust the units of insulin injected based on the number of carbohydrates you will be consuming or even wait until you have finished eating to know how many carbohydrates you consumed.

#6. Not testing before exercise can create problems if you over exercise and do not have high enough blood glucose levels. Yes, over exercising can cause hypoglycemia.

#7. If you insist on having your alcohol, be aware that this can cause hypoglycemia, especially if you drink on an empty stomach. Make sure that you have an adequate amount of carbohydrates on board. Drinking excessive amounts of alcohol can result can result oh hypoglycemia problems.

As a person using insulin as a type 2, hypoglycemia needs to be taken seriously. I can speak from experience and while one doctor of mine keeps telling me to let my A1c rise, I have found that if I am more careful and eat less carbohydrates, I don't need as much insulin and my concern about hypoglycemia also has become less of a concern. My problem lately has been making sure that before I test, I have properly washed my hands and paying attention the finger I would be testing on.

Part 2 of 4

PWD Seem Not to Understand Hypoglycemia

Do you know the symptoms of hypoglycemia? According to the survey conducted by the American Association of Diabetes Educators (AADE) many people with diabetes (type 1 and type 2) are unsure of how to manage hypoglycemia. An online survey showed that many patients with diabetes are concerned about experiencing hypoglycemia but are unsure of how to prevent and manage the condition.

The online survey, which polled more than 1000 adults with type 1 and type 2 diabetes resulted in the following:

1. 60 percent of respondents have experienced hypoglycemia.
2. 19 percent of these have visited the emergency room for treatment.
3. 40 percent experienced nighttime hypoglycemia.
4. 84 percent felt anxiety.
5. 68 percent felt frustration.
6. 60 percent felt fear of nighttime hypoglycemia.

Then the next important data showed (from the 1000):

1. 62 percent expressed concern about experiencing hypoglycemia.
2. 81 percent perceived hypoglycemia as a significant health concern.
3. 98 percent reported understanding the importance of controlling hypoglycemia.
4. 81 percent acknowledged the health consequences if not treated appropriately.

The findings showcase a need for further education about hypoglycemia. People living with diabetes may be unaware of the causes, symptoms as well as the methods of preventing and managing hypoglycemia as evidenced by the following survey findings:

• Of respondents who had not experienced hypoglycemia, approximately 42 percent were unable to define it correctly
• Less than one third (30 percent) of respondents cited avoiding alcohol as a way to prevent hypoglycemia
• Nearly half (49 percent) were not aware that taking glucose tablets could help treat an episode

Hypoglycemia can be a debilitating complication for people with diabetes, but it is often under recognized. This means that people with diabetes should be taught the warning signs and symptoms of hypoglycemia. Then these same people need to be taught how to effectively manage and prevent hypoglycemia from happening.  Hypoglycemia occurs when blood sugars reach a low level, usually 70mg/dl (3.9 mmol/L) or below. Hypoglycemia can affect people living with type 1 or type 2 diabetes, who are on insulin or multiple therapies for diabetes. Symptoms of hypoglycemia include shakiness, dizziness, fatigue, confusion and  lack of coordination. In severe cases, hypoglycemia can lead to unconciousness, seizures, or death.

To treat hypoglycemia, those living with diabetes should regularly check their blood sugar levels. If levels are 70mg/dl or lower, it is recommended to consume 15-20 grams of carbohydrates and check levels again 15 minutes following consumption. If low blood sugar levels continue, repeat. Once blood sugar returns to normal, the individual should consume a small snack if the next planned meal or snack is more than an hour or two away to prevent recurrence of hypoglycemia.

Part 1 of 4

Investors in Afrezza Don't Appreciate Questions

A person that says he is a researcher is calling me out for my recent blog on Afrezza. If he is indeed a researcher, why does he need to hide under a user name? Oh, probably because he may be afraid of exposing his true investing nature in Afrezza.

I do appreciate him for promoting my blog. I am not confused as he tries to portray me, but I will not use Afrezza. I think until many other issues are put to rest, many people will wait and make sure that Afrezza will not end up as Exubera did – being pulled from the market for lack of use. Many of the people posting are investors and are forcing issues like joining diabetes forum websites and in essence advertising Afrezza. Most of the good forums are deleting these posts and when they republish them, they are banned as a participant from the forum. All forums will accept paid advertising, but will delete advertising that is free in this manner.

Some people with diabetes that I have talked to are afraid of what it will do to their lungs and some are afraid of lung cancer. I just tell them that if they are afraid, then wait until Afrezza has been on the market for five to seven years and this will confirm or deny their fear. Others have said the acute bronchospasm that has been observed will cause them not to use it. One said this applies to him as he has been recently diagnosed with COPD and therefore he would not consider using it.

Others in our support group are now saying that the research into smart insulin may be worth waiting for, as rodent testing has been very positive. The researchers are now developing the smart insulin into a therapy for human use. The sad part of this is that it will not be ready for clinical trials for another 2 to 5 years. Presently, this is being targeted for people with type 1 diabetes, but maybe it will become available “off label” for type 2.

Either way, I have to wonder if inhaled insulin will be that popular. It may be among the younger people with diabetes, but without testing in the elderly, many may avoid using it.

Still Learning about Sleep Apnea

I thought I had learned a lot about sleep apnea, but the lessons keep coming. I am now on my third CPAP machine and I am happy that I still ask questions. It seems that sometimes I ask too many questions as I am still searching for the right combination of machine, mask, and supplies to give me a great night's sleep. A question I asked recently has resulted in more problems as I believe an incorrect adjustment was made instead of the one I asked for.

I have had to change from a nasal mask to a full-face mask because of problems of breathing through my mouth. This will require some getting used to for me. Another problem that will require adapting is from a machine with an easy fill humidifier to one that cannot be filled beyond a certain level. Overfill slightly and then the air hose from the machine to the mask needs to be removed and the water drained out of the air hose. Then, while the machine is off, the humidifier needs to be drained to the right level. Fun, fun, and more fun for me.

I am happy that this CPAP machine runs more quietly than the previous machines, but I do miss the large capacity water container of my first CPAP for humidity. The last two have had small containers that only last for a day.

I have received questions from other readers and friends that wonder how I can tolerate wearing a mask of any type and sleep. I can only say that with the rest I am receiving by wearing the mask and using my CPAP, I would not want to sleep without it. I can remember how tired and sleepy I was before the CPAP machine that as long as I need it, I will use it.

A friend of Allen and me, who also has diabetes, refuses to wear a mask because he is so claustrophobic. He has even refused to use an oral device. He will not shut the bathroom door when he is using it and refuses to have a curtain for his shower. To play a joke on him one day, as he was getting his coat out of the closet, Allen pushed him in and shut the door. Allen will not do that again as he now has removed the door and refuses to put it back. Other closet doors are now missing in his home. Allen recently said he had been shown the results of the last sleep study by our friend and the apneas were almost normal. Our friend is happy about this as he has lost weight and had also refused surgery and another treatment.

While my CPAP machine is a true BiPAP or as others call it, an AutoPAP, I do like it as it is set with two settings, one for the lowest pressure, and one for the highest pressure. Then the machine self adjusts as I sleep to keep me breathing and not having apneas. I used a different source for my machine than previously because I felt I was not obtaining reliable service or even caring service. The number of problems just kept multiplying.