Preventing an Insulin Overdose – Part 1

No, this is not just for those of us type 2's and all type 1's that inject insulin, but it certainly applies to us. This also applies the type 2's that take certain oral medications that force the pancreas to produce more insulin and to any person with diabetes that takes oral medications and uses insulin.

Cold sweats, trembling hands, intense anxiety, a general sense of confusion are some of the warning signs. These are signs of low blood glucose (hypoglycemia), and it often happens when you take too much insulin or your pancreas is forced into producing more insulin than the food you consumed required. Hypoglycemia happens to many people with diabetes. And it can sometimes be serious. Thankfully, most episodes related to insulin can be avoided if you follow a few simple rules.

You might have too much insulin in your system and get a drop in your blood glucose for several reasons. It most often happens when you:

Misread the syringes or vials. This is easy to do if you’re unfamiliar with a new product.

Use the wrong type of insulin. Let's say you normally take 30 units of long-acting and 10 units of short-acting insulin. It's easy to get them mixed up.

Take insulin or oral medication, but don't eat. Rapid-acting and short-acting insulin injections should be taken just before or with meals. Blood glucose level rises after meals. Taking rapid-acting or short-acting insulin without eating could lower sugar levels to a potentially dangerous level. Some oral medications force the pancreas to produce insulin that is not needed if you don't eat.

Inject insulin in an arm or leg just before exercise. Physical activity can lower blood glucose levels and also affect how your body absorbs insulin. Inject in an area that isn’t affected by the exercise.

Everyone on insulin needs to talk to the doctor about hypoglycemia. Those on oral medication should talk to the doctor about taking the medication when they are not feeling like eating. The oral medications that can cause hypoglycemia include these classes – Sulfonylureas, DPP-4 Inhibitors, and D-Phenylalanine Derivative are the three classes of oral medications that can cause hypoglycemia.

Low blood glucose can make you feel

• hungry
• dizzy
• nervous
• shaky
• sweaty
• sleepy
• confused
• anxious
• weak

Low blood glucose can also happen while you sleep. You might cry out or have nightmares, sweat a lot, feel tired or confused when you wake up, or have a headache when you wake up. If your blood glucose levels continue to fall, you can have serious complications, like seizures or passing out. Hopefully you will have family or a significant other that can make a 911 call if your have no other remedies available.

Don’t panic. Most insulin overdoses can be treated at home. Follow these steps if you're able to do so:

• Check your blood glucose.

• Drink one-half cup of regular soda or sweetened fruit juice, and eat a hard candy or glucose paste, tablets, or gel.

• If you skipped a meal, eat something now. Something with 15 to 20 grams of carbohydrates should raise your blood glucose.

• Rest. Get off your feet and take a break.

• Recheck your blood glucose after 15 or 20 minutes. If it's still low, take another 15 to 20 grams of a quick-acting sugar, and eat something if you can.

• Pay attention to how you feel for the next few hours. If you still have symptoms, check your glucose again an hour after eating. Keep snacking if your blood glucose is low.

• If your glucose level stays low after 2 hours, or if your symptoms don’t get better, seek medical help immediately.

Continued on next blog.

Doctors Instill Fear of Insulin

The word insulin for most doctors is not a word they want to hear. They threaten patients with it to convince patients to stay on oral medications. They, the doctors make it sound like insulin is a punishment for failing on oral medications. Then they stack oral medication on top of oral medication. This causes many patients to conclude that when they are required to use insulin that they have failed and this is their punishment.

I am not totally sure why these doctors have to bully patients this way, but they do. Is it because of their lack of knowledge, or their fear of hypoglycemia that drives these actions? I have known two doctors that have been this way and thankfully, they were not my doctors. One has passed recently and the other retired recently, but they both cringed when anyone mentions insulin to them. I finally told the one just to think of me as a person that required insulin.

And many people listen to these inept doctors when they should know better. Insulin is just another tool in the arsenal for managing diabetes. Two weeks ago, I finally had a doctor, who is not my doctor fortunately; ask if I had failed in my efforts to manage diabetes. My hackles went up and I asked him what he meant by the statement. He said obviously I could not manage my diabetes on oral medications and so needed insulin.

I know he was not prepared for the tongue-lashing I put on him, but I would do it again and probably do it more forcefully. I did tell him that only doctors fail, as they do not understand diabetes and are so afraid of hypoglycemia that they forget about the oral medications that can cause it. Doctors also fail because they are afraid to acknowledge their lack of information about insulin. Insulin is an important tool in the management of diabetes and because doctors leave insulin as the medication of last resort, they often do immeasurable harm to patients.

Things went from bad to worse and the doctor reminded me that he was the doctor and I should not talk to him that way. I said he should not admit he was a doctor when he uses statements like he did. I told him that his pedestal was broken and he had better step off it before it broke under him. I ended the conversation by stating I put my pants on the same way he did and I did not respect doctors that were bullies.

I had not noticed Sue come up behind me until she suggested that we keep our voices down. Then she turned to the doctor and asked him why he needed to be a bully and always put patients down when they were on insulin. She said that was very unprofessional and he should be ashamed for acting that way. She continued that most of our support group used insulin and they are doing well.

Then she took my arm and moved me away as she told me to ignore the bully. When she had me out of range and around a corner, she explained that she knew the doctor and was happy that I had stood up to him, but too many people were trying to listen and she felt that I should be moved away from him. I thanked her and we went our separate ways.

Have Type 2 Diabetes – Stop Some “Good” Habits

Go ahead, laugh, but I am serious. You would be surprised how many people new to type 2 diabetes keep these habits.

Habit #1 Stop buying "sugar-free" foods. Grocery stores and supermarkets have shelf after shelf of packaged items that appear to be diabetes-friendly because they don't have added sugar. This does not mean that they are healthy for you, as many have carb-containing sugar substitutes and may send you blood glucose levels into the stratosphere. Always be skeptical and check the nutrition facts to see how many grams of carbs are in each serving before you consider putting it in the cart.

Habit #2 Stop swapping meals for meal replacement bars. Often it is wise to shed some weight to improve your health, but is relying on meal replacement bars the right way to go? Most meal replacement products are for athletes, which allow them to be high in carbohydrates. Some contain sugar alcohols, such as sorbitol and mannitol, which can cause stomach problems.

Having written the above, occasionally eating a bar for breakfast when you are pressed for time can be better than skipping breakfast. If you pay attention to the nutrition label, you may be okay, but it is still wiser to have a real breakfast.

Habit #3 Stop loading up on vitamins and supplements. Most people that have diabetes do not need extra vitamins and supplements. A food plan that includes fruit and vegetables should provide most of the nutrients you need. Taking a multivitamin may help fill in nutritional gaps. Two vitamins that should be tested for deficiency are Vitamin B12 and Vitamin D. As you age, your body may have difficulty in making use of them in from the foods consumed.

Some people take supplements like cinnamon or chromium to try to keep their blood sugar levels stable, but it's unclear whether these work. These may work for a short period, but generally not in the long term. If you choose to try them, or any supplement, tell your doctor, to make sure it's safe for you, and won't interact with any medication you’re taking.

Habit #4 Stop drinking juice. Yes, it's made from fruit; but natural doesn't always equal healthy. One cup of apple juice, for example, has 25 grams of sugar and only 0.5 grams of fiber. An apple, on the other hand, has less sugar (19 grams) and more fiber (4.5 grams). Therefore, it will satisfy you longer and help stabilize your blood glucose. A study found that drinking juice every day increases the risk of developing diabetes, but regularly eating whole fruit lowers it.

Habit #5 Stop drinking diet soda. It may be calorie-free, carbohydrate-free, and sugar-free, but you can still overdo it. One study found that overweight people who rely on diet soda end up taking in more calories from food. Why? Diet-drink lovers may think they're "saving" calories on drinks and can afford to splurge on food. Another possible reason is that artificial sweeteners confuse your body because they taste sweet but don't provide calories. If you're craving a cola occasionally, it's fine to treat yourself. But you should usually fill your glass with water and other unsweetened beverages, like plain iced tea.

Habit #6 Stop avoiding all high-fat foods. I know that many doctors still preach the low-fat food plan, but research is showing that this is not bad and is actually good for us if we don't consume excessive amounts of fat. Of course, trans fats are still off the menu, but the other fats are good for us in moderation, even saturated fats.

You may also be surprised to learn that certain high-fat foods seem to have benefits for people with diabetes. Eating nuts in combination with higher-carbohydrate foods may help prevent blood sugar levels from rising too sharply. Other studies have shown that people who eat avocados are less likely to get metabolic syndrome (a cluster of symptoms that includes high glucose levels). Just remember to keep portion sizes small, because the carbohydrates can add up quickly.

Habit #7 Stop nibbling on 100-calorie snack packs. Many people open pack after pack because each one seems so tiny. They end up eating more than if they had started with a "regular" container. In one study, people who were given nine small bags of chips ended up eating almost twice as much those who were given two large bags. The biggest truth is being honest with yourself. If you have trouble eating more than one, please leave the box on the shelf.

PWD Have Low Medication Adherence

I would almost say that the low adherence by people with diabetes (PWD) of medication is a diabetes complication. It certainly makes the complications of diabetes easier to develop when PWD do not take their medications.

There are several reasons that make people with diabetes not take their medications and these include:

• The doctor goes paternalistic or maternalistic, and ignores patient questions about side effects in the medications.
• The doctor just hands the patient a prescription(s) with no explanation or directions.
• The doctor refuses to explain the purpose of the medication(s).
• The doctor refuses to include the patient in the selection of the medication(s).
• The doctor refuses to take into consideration the cost and financial implications for the patient.
• The doctor does not check allergies.
• The patient goes into denial.
• The patient develops depression.
• The patient does not understand polypharmacy and the pharmacist does not explain each medication.

A large cohort study of patients with diabetes, data on 19,962 patients with diabetes aged older than 55 years who had hypertension or dyslipidemia and had initiated treatment with a statin and ACE inhibitor. They found that 5,645 patients (28%) were nonadherent, 7,571 patients (38%) were partially adherent, and 6,746 patients (34%) were fully adherent.

The findings were very much in line with the hypotheses. The fact that only 34% of the high risk diabetic participants were adherent to medications is alarming. The fact that more than 80% adherence is associated with a 28% lower risk for major cardiovascular events compared to nonadherence is significant.

Diabetes is as much a cardiovascular disease as an endocrine one. Endocrinology will appreciate the troubling issue of polypharmacy and poor medication adherence in their patients. The physician community is interested in improving the outcomes of diabetic patients; this study drives home the need to employ innovative strategies such as emerging technologies, nonphysician care models, and polypills to get patients beyond the 80% adherence line to reduce cardiovascular risks.

Kim Eagle, MD, who is a professor of internal medicine and director of the Cardiovascular Center at the University of Michigan Health System in Ann Arbor, stated, “I am not surprised at all. Study after study show that in conditions that don't hurt every day, such as diabetes and hypertension, people think, ‘Why should I take this?' It might be cost; it might be side effects; it might be a sense of not having control over the disease.”

He said this study is very important because noncompliance is such a widespread problem in the treatment of diabetes, and it is very common for patients to say they are taking their prescribed medicines when they are not. Another problem in this area is the difficulty with documenting adherence, according to Dr. Eagle.

Dr. Eagle said, “We go over the medications every time we see them. Patients can be passive aggressive and wait until their next visit in 6 months when they have run out of medicine. “We need the whole care team, the pharmacists, extended providers and the insurance companies. It is a systems problem. Patients have different availability to caregivers and insurance.”

Some good doctors work with patients to avoid nonadherence, but many doctors are too busy to be bothered with the reasons listed above to take the time to talk with the patient. Instead they talk at the patient and just expect the patient to take the medication(s) prescribed because he/she is the doctor and knows what is best for the patient.

Are Patients Customers or Not?

I thought I knew the answer and had settled for myself that a patient is a patient, is a patient. However, some that are also declaring that patients are not customers are doing an excellent task of making me doubt myself.

The definition used for customer is a person or entity that obtains a service or product from another person or entity in exchange for money. Customers can buy either goods or services. The stickler (any puzzling or difficult problem) is that health care is classified by the government as a service industry because is provides an intangible thing rather than an actual thing.

Here is why the patient shouldn’t be considered a customer, at least not in the business sense.

#1. Patients are not on vacation. They are not in the mindset that they are sitting in the doctor's office or the hospital to have a good time. They are not relaxed; they have not left their troubles temporarily behind them. They have not bought room service and a massage. They are not in the mood to be happy. They would rather not be requiring the service they are requesting.

#2. Patients have not chosen to buy the service. Patients have been forced to seek the service, in most cases. Whether the quality of service is excellent or poor, often the patient has to accept what is provided.

#3. Patients are not paying for the service. At least not directly. And they have no idea what the price is anyway. This is where the insurance industry and the health care industry are in collusion to hide information from patients.

#4. Patients are not buying a product from which they can demand a positive outcome. Sometimes the result of the service is still illness and/or death. This does not mean the service provided was not a good one. Yet many doctors and hospitals insist that they did nothing wrong, when in fact, the service was loaded with errors and adverse events.

#5. The patient is not always right. A patient cannot, or should not, go to a doctor or hospital demanding certain things. They should demand good care, but that care might mean denying the patient what the patient thinks he or she needs. The doctor is not a servant, the doctor or hospital does not have to do everything the patient wants. The doctor or hospital is only obligated to do everything the patient needs.

#6. Patient satisfaction does not always correlate with the quality of the product or the quality of care. A patient who is given antibiotics for a cold is very satisfied, but has gotten poor quality care. A patient who gets a knee scope for knee pain might also be very satisfied, despite the fact that such surgery has been shown to have little actual benefit in many types of knee pain.

Hospitals are presently promoting (not focusing) what they call “patient centered” care. Some doctors are doing the same and the result is anything but patient centered. It is profit centered and promotes what the hospital and the doctors want, not what the patient needs in most cases. It involves unnecessary tests and procedures which often results in harm to patients. The hospitals and doctors make everything sound rosy and great, but everything is done to satisfy hospital dollar needs.

This is one reason not to use the term customer but keep the term patient, as the patient needs the service. They don't need the service often demanded by many doctors and hospitals, but they still need health care. While health care workers and providers are exposed to all the human foibles of temperament, background, values, and expectations, the patient needs health care, but does so under duress and health needs, often to remain alive.

If doctors and hospitals would treat patients with care and respect instead of with dollar signs the patient represents, doctors and hospitals would not need to constantly be inventing new terms to describe patients and confuse issues.

Type 2, Use Insulin as Another Medication Tool

When I wrote this blog, I knew then that more would be said on the topic. Insulin for most doctors is not a word they want to hear. They threaten patients with it to convince patients to stay on oral medications. Then they stack oral medication on top of oral medication. This causes many patients to conclude that when they are required to use insulin that they have failed and this is their punishment.

And many people listen to these inept doctors when they should know better. Insulin is just another tool in the arsenal for managing diabetes. Many people with type 2 diabetes do use insulin. Others feel that using insulin makes them a failure. This should never be the case, but our doctors have been behind promoting this to keep patients on oral medications and because of the fact that doctors fear hypoglycemia to the point it clouds their thinking.

Insulin is simply a necessary and beneficial addition to diabetes management. There are a few reasons why people that have not needed insulin to require it (and possibly on a temporary basis). Gestational diabetes, surgery, broken bones, cancer, and taking steroidal medicines (prednisone for example) can require some people to take insulin for a temporary period. Then some people end up needing insulin on a permanent basis as they age because the pancreas becomes unable to produce enough insulin. Sometimes they have been on oral medications that force the pancreas to produce insulin and the pancreas can no longer produce sufficient insulin.

Now back to feeling as a failure because of needing insulin. When we age, the functioning of our pancreas often decreases and becomes unable to produce the quantity of insulin necessary for our cells to function and provide the energy we need. Because we are human, we don't always maintain a healthy food plan and exercise regimen and our blood glucose levels rise dramatically to a level only insulin can control.

When the dose of insulin is discussed, I urge you to read this about the three methods of dosing. It has been the experience of our support group that most doctors, CDEs, and dietitians all prefer the fixed dose of insulin. This in turn forces us, as patients, to eat a fixed number of carbs which may not be the best solution.

Yes, we need to learn how to count carbs and know what foods are safe in a food plan. This we can use when we are not feeling like eating but a snack, are under stress, have an infection, cannot exercise, or need to avoid food. This will help in managing our blood glucose levels and prevent having an episode of hypoglycemia. The amount of insulin needed will also depend on a patient’s weight, eating habits, exercise levels, other illnesses, and level of insulin resistance.

I prefer the third dosing method and use it because I have learned how with a little help from the endocrinologist. Having insulin resistance does make the adjusting more complicated at times as the level of insulin resistance has varied for me. Just when I think I have it down, it changes. I would encourage you to read this on blood glucose variables and this on more variables.

I am happy that I am on insulin and one 500 mg dose of metformin ER. I am better able to manage my diabetes, even with all the variables. I moved from oral medications to insulin about 3 months after diagnosis. Therefore, I had none of the feelings of failure, as I was able to embrace insulin and a better tool for the management of my diabetes.

Elderly Discrimination Harms Elderly Patients

I am happy at least one doctor is on our side. I knew this would happen one day, but Stephanie E. Rogers, MD states that, “For the first time in human history, adults older than age 65 will outnumber children younger than age 5.” Then she continues, “In medical school, we receive training in treating young patients during the pediatrics lecture series and later in an extended clinical rotation, yet the training we receive for treating geriatric patients is significantly lacking.”

This is sad, but it helps explain why our doctors know so little about treating the people above 60 or 65 years of age. Despite recommendations of international regulatory agencies, exclusion of older individuals from ongoing trials regarding type 2 diabetes mellitus is frequent, higher than reported for other age-related diseases. This exclusion limits the value of the evidence that clinicians use when treating old, frail, and complex patients with diabetes mellitus.

“Pediatric units are common at most hospitals, where multidisciplinary teams including nurses and pharmacists are specialized in treating children and most children have access to an outpatient pediatrician. In contrast, few health systems have adopted the specialized models that exist to provide cost-effective care for older adults in hospitals, clinics, and at home. Furthermore, plenty of research literature exists regarding the care and treatment of children, while it is commonplace to exclude older adults from clinical trials due to age or multiple comorbidities, despite the fact that they are likely to benefit from the study interventions.”

The presence of ageism (age discrimination) is a glaring deficiency in our current health care system. Ageism is the “systematic stereotyping of and discrimination against people because they are old, in the way that racism and sexism discriminate against skin color and gender.” Dr. Rogers said. “In our study published online today in the Journal of General Internal Medicine, we report that this systematic discrimination by doctors and hospitals leads to earlier functional decline in patients. Using the Health and Retirement Study, a nationally-represented sample of 6,017 adults older than age 50, we found that 1 in 5 older adults reported experiencing discrimination in the healthcare setting. Those who reported the most frequent discrimination were more likely to have developed new or worsened disability over the next 4 years. The most common reason reported for this discrimination was age.”

Promoting health and well being for our diverse population cannot be achieved without paying attention to the precise needs of our aging nation. As a healthcare system, the U.S. has neglected our future selves long enough. Our older patients deserve devotion, in particular because of their age. Their long life experience and contribution to society should allow them the same attention and quality of care we offer to our children.

Clinical practice guidelines rarely address the treatment of patients with three or more chronic diseases, and such patients make up half of the population greater than 65 years of age in the United States. When other aspects of chronic disease management (e.g., dietary or other lifestyle modifications, attending regular office visits, and laboratory monitoring) are added, the burden on elderly patients and their caregivers becomes onerous and, in many cases, unsustainable over time.

Guidelines and quality assurance initiatives largely ignore the issue of marginal benefits of multiple medications as recommended by various sets of treatment guidelines. The guidelines are all set up for people under 60 years of age with only one chronic condition. The elderly are discriminated because no research has been done to determine how to treat people with multiple chronic conditions. Yet, the so-called “experts” could care less about treating the elderly.

By not including the elderly in diabetes trials, our doctors have clinical practice guidelines that rarely address the treatment of patients with three or more chronic diseases, and such patients make up half of the population greater than 65 years of age in the United States. When other aspects of chronic disease management (e.g., dietary or other lifestyle modifications, attending regular office visits, and laboratory monitoring) are added, the burden on elderly patients and their caregivers becomes onerous and, in many cases, unsustainable over time. Guidelines and quality assurance initiatives largely ignore the issue of marginal benefits of multiple medications as recommended by various sets of treatment guidelines.

The guidelines are all set up for people under 60 years of age with only one chronic condition. The elderly are discriminated because no research has been done to determine how to treat people with multiple chronic conditions. Yet, the so-called “diabetes experts” and researchers could care less about treating the elderly.