Metformin Has Link to Neuropathy, B12 Deficiency

Called me puzzled! I have never understood why the American Diabetes Association had never called for testing of vitamin B12 deficiency for people taking metformin for any length of time. Even this article shows a lack of this testing and only calls for more research. This is why I am reversing the situation and listing what Diabetes-in-Control lists as practice pearls first.

Practice Pearls:

1. Metformin has been linked with vitamin B12 deficiency.
2. A randomized placebo-controlled trial showed that metformin use is associated with an increase in neuropathy scores for patients.
3. Current guidelines do not offer specific instructions on metformin and B12 deficiency, but future research is warranted.

Yes, one of the most common and beneficial T2DM drugs may contribute to neuropathy and vitamin deficiency – metformin.

The link between metformin and vitamin B12 lowering is well-known and mentioned in American Diabetes Association guidelines as a disadvantage of the drug. However, the ADA gives no recommendations for monitoring and prevention of vitamin B12 deficiency for patients taking metformin. Vitamin B12 deficiency is associated with adverse effects such as anemia, fatigue, mental status changes, and neuropathy. Given the prevalence of neuropathy in diabetic patients, metformin-induced vitamin B12 deficiency is clinically relevant.

The relationship between vitamin B12 deficiency and metformin was studied in a recent randomized placebo-controlled trial. The trial lasted 52 months and included 390 type 2 diabetes patients. They were treated with 850 mg metformin at doses up to three times a day or a placebo. Patients with baseline vitamin B12 deficiency or patients taking vitamin B12 supplements were excluded from the trial.

Metformin is prescribed around the world, so this relationship warrants more investigation according to the study authors. Future studies may clarify the relationship and will help the authors of guidelines decide whether to recommend testing or supplementation.

Be Concerned About What CDEs Teach You

I am happy that I don't currently use insulin pens. Hopefully, I will not make the mistakes some of these people did. My blog here explains one mistake a patient made and I am writing about another.

Yes, I admit I do not understand why patients are not properly taught how to use insulin pens, or for that matter any diabetes equipment. This time I am surprised as the instructor has RN (registered nurse) as her first title and CDE is the last one listed. It is apparent that assumptions were made about using insulin pens that should not have been assumed. When this happens, patients can often receive bad results.

I would have thought the patient would have thought to ask more questions and would have noticed earlier that things weren't right, but apparently, some patients blindly go about treating themselves and think nothing is wrong. Please readers don't let this happen to you.

“Lessons Learned:

• It’s not always clear to patients that they need to change pen needles. As part of insulin pen teaching, include safe ways of removing, and disposing of, the needle. Always remove the needle, so the patient sees that step.
• When I receive reports of high carb intake, I won’t always rely on what I’m told on the phone. I will request the patient come in to see me sooner so I can assess technique.
• Don’t always blame high carbs for the high glucose levels. There are many reasons for high glucose levels.”

Comments to lessons learned above – why is the patient not required to show that he/she understands by removing the needle. Some patients do require doing this several times before they fully comprehend the procedure. Apparently, there is more than one type of pen needle and all types should be taught.

The second point above is common sense and should done if proper procedures were not taught in the first place. The last statement is also common sense and should not be overlooked.

If you have questions about what the CDE tells or mandates that you do, always ask for a re-explanation or if there are other types of that same equipment that may operate differently.

Always learn as much as possible and read any instructions that come with the equipment to find out if you have more questions and if necessary call the CDE if possible to have these questions answered.

How Many Pharmacies Do You Need?

After years of complaining about people using multiple pharmacies to prevent tracking of duplicate prescriptions and preventing one pharmacy from having all the information on a patient or family, I come across an article recommending two pharmacies. I admit I have some learning to do. Most of the time people using many pharmacies think they are hiding their narcotic or opiate usage.

Apparently, with the prevalence of mail-order pharmacies and Medicare pushing them and many insurance companies forcing patients to them, there is concern for emergencies.

The author of the Diabetes-in-Control article (article no longer available) does cover an interesting point. He has always recommended that his patients use their local pharmacy for at least one prescription. This is in case an emergency arises and they need a medication or supplies right away, they can get great service locally because they have established a relationship.

This makes good sense as mail order pharmacies are not the most prompt in sending supplies or medications and a four to 10 day wait may not be practical or the most healthy.

“Lessons Learned:

• Recommend that your patients have at least one local pharmacy. If one is a small pharmacy, that’s fine, but also establish a relationship with a national chain. The national chain can be very helpful when traveling.
• Always discuss the importance of having long- and short-acting insulin available for patients who are on pumps.”

The lessons learned can be important when traveling and an emergency arises. Since I am a person with type 2 diabetes on insulin, I always travel with a sufficient quantity of insulin and use a cooler if necessary to keep extra vials cool enough. Normally for other prescriptions, I can get extra to cover me while traveling and if needed a partial prescription and have the rest filled when I return home.

Medical ID Importance

I don't understand people that email me and tell me that medical identification is not necessary or needed. I even had one fellow say that he has not told anyone that he has diabetes, not even his family. I asked what medication he was using and the answer came back that he was not using any medication and managed his diabetes with diet and exercise.

In this instance, I told him that I still recommend that he wear some sort of medical identification on his person. I told him that if he was involved in an auto accident and was unconscious, he could be fed with IVs that had glucose that could cause his blood glucose levels to rise rapidly. If he could not tell the hospital who his doctor is, his treatment could push him into dangers that they might not catch in time and he could die.

Even this did not convince him as he said he wanted to keep it a secret that only his doctor and he knew. I emailed him that this is something he should reconsider as accidents do happen. Then six days later, I received another email from the fellow. It turns out that the day I sent the last email, he did have an accident and was unconscious for four hours. When he asked to have his blood glucose checked, the reading was 389. He said the hospital used insulin and rechecked in five hours and he had only decreased to 245. This meant a second shot and another check in five hours. This time the reading was 102 and they did not give him another shot.

At the end, he said he would be getting a medical ID necklace with the needed information to prevent this from happening in the future. He said that the four days in the hospital had shown him how important this could be. He thanked me for pushing on the medical identification. For the present until he would be able to exercise (in about four months), he would be on two insulins, Lantus and Novolog. He asked me if it would be difficult to get off insulin. I responded that if he was determined, he should be able, if too much damage had not been done by the accident.

I suggested that he get back into the habit of exercising slowly until things felt right, watch his blood glucose readings until that happened; talk with his doctor about reducing his doses of insulin when his exercise showed improvement in blood glucose readings, and not get anxious if he needed insulin for a while longer.

He promised that would happen and he asked if he should obtain Dr. Bernstein's book, “Diabetes Solution” and consider a low carb, high fat way of eating. I said that would be a good thing and I sent him several of the URLs from this blog. I did suggest that he take it slow as his injuries could make it difficult for a while and he should not become impatient with his recovery.

His return email stated that he would as his doctor had made this clear to him and he was to be careful the first few months. It sounds like I have made a friend and he is opening up about his diabetes. 

Previous blogs about medical identification:

http://bobsdiabetes.blogspot.com/2010/09/to-wear-or-not-to-wear-medic-alert-id.html

http://bobsdiabetes.blogspot.com/2010/09/medic-alert-jewelry-pros-and-cons.html

http://bobsdiabetes.blogspot.com/2011/05/why-are-you-not-wearing-medic-alert.html

http://bobsdiabetes.blogspot.com/2012/05/should-we-standardize-diabetic-medical.html

http://bobsdiabetes.blogspot.com/2013/11/importance-of-medical-alert-jewelry.html

Sleep Apnea – Gout Flares, Tied

I have sleep apnea and use a type of CPAP machine when I sleep. I apparently am doing all the right things, as I have never had any problems with gout. However, this study says that sleep apnea may increase the risk of developing gout and experiencing flare-ups.

I know from friends that the pain can be intense and make walking very difficult. Gout causes swelling of a joint, normally in the big toe. Gout is caused by the accumulation of uric acid crystals in joints and tissue. Sleep apnea causes periods of oxygen deprivation during the night when people stop breathing, and this triggers the overproduction of uric acid in the blood stream. The study team states that little in known about the relationship between the two conditions.

The study, in Arthritis and Rheumatology, states that in 2007-2008, almost six percent of men and two percent of women in the U.S. Experienced gout, according to the Centers for Disease Control and Prevention. Sleep apnea, which is more common and if untreated can increase the risk of high blood pressure, heart attack, stroke, and heart failure.

Lead author, Yuqing Zhang of Boston University Clinical Epidemiology Research and Training Unit says obesity plays a role in both sleep apnea and gout. He continued that sleep apnea still increased the risk of gout even when weight was taken into account.

The researchers in the United Kingdom used data on almost 10,000 people newly diagnosed with sleep apnea and compared them to more than 40,000 people of similar sex, age, and body composition, but without sleep apnea. In a one-year period, there were 270 cases of gout with 76 in the sleep apnea group and 194 in the larger comparison group. Gout was diagnosed at an average age of 60. Gout was almost twice as common in the sleep apnea group as in the comparison group, according to the analysis.

Obesity increases the risk for sleep apnea, but some thin people have sleep apnea, too, and even in these people, the risk of gout was increased by 80 percent.

The next step is to test whether treating sleep apnea also reduces the risk for gout. Some studies show that if you get treatment, your uric acid may go down. Sleep apnea can be treated with lifestyle changes, such as losing weight, wearing mouthpieces, breathing devices at night, or with surgery.

“It takes years for uric acid crystals to accumulate in the joints and lead to an eventual gout flare, so sleep apnea may not “cause” the gout, but may create a more ideal environment for a flare up, said Dr. Robert Thomas Keenan of Duke University School of Medicine in Durham, North Carolina, who was not part of the new study.”

“Gout is the most common inflammatory arthritis in the western world,” he told Reuters Health by email. “Sleep apnea and gout risks can be reduced in many people by losing weight if they are overweight, eating healthy and indulging in alcohol and red meats in moderation,” he said.

A Misdiagnosis, the Disease Waiting a Cure

A report in the BMJ Quality and Safety Journal states, each year in the U.S. approximately 12 million adults or 1 out of 20 patients who seek outpatient medical care, are misdiagnosed in a way that could cause severe harm.

A new study from the Institute of Medicine (IOM) published in September 2015,

confirms these statistics. Doctors apparently are not as careful as they should be. I know this for a fact and fortunately, the error the doctor made was not critical. I had a severe gall bladder attack and all the doctor could think was heart problems.

When I had the second severe gall bladder attack, I went to another hospital and the two doctors had it correctly diagnosed within minutes. They gave me medicine to ease the pain and the following morning, I was given a scan, which showed that they were correct. A month later, I was operated on and my gall bladder removed.

Other patients are often not as lucky and the doctor misdiagnosis results in death.

What does this say about the current level of patient care in the United States? #1. It says that we patients are tolerating a healthcare system where we too often do not experience full disclosure from our clinicians.

#2. It says that our system does not encourage collaboration and communication between healthcare clinicians and patients.

#3. It tells us that us that misdiagnosis is raising the cost of care for all of us.

#4. It says that each of us will face a potentially life threatening situation over the course of our healthcare that could be addressed and reversed if we pay attention.

#5. It says that providers who are in a position to make a diagnosis for a patient, along with the patients and their caretakers or family, need to pay more attention to what is going on.

#6. It tells us that we live with a system that is ill designed to support the diagnostic process because our clinicians are limited by the time they are allowed to spend with each patient.

#7. It tells us that some doctors do not always follow-up with tests and procedures that they have ordered. Even if they follow-up, they are often not provided with adequate feedback about the accuracy of a diagnosis.

#8. It says ours is a culture of care that discourages transparency and disclosure of diagnostic errors, which impedes attempts to correct these problems.

Diagnostic errors are often incredibly harmful to patients, as they may lead to:

• delays in treatment,
• lack of treatment,
• inappropriate, or unnecessary treatment,

These can have physical, psychological, and financial consequences.

Because of the magnitude of the misdiagnosis disease, I urge you to read the full post by Nancy Finn here

Have Type 2 Diabetes, See a Nurse Practitioner

If you live in a state that allows nurse practitioners to practice unsupervised or even in a state that allows them to be supervised, and you have type 2 diabetes, you may be better treated by seeing a nurse practitioner.

“Nurse practitioners' patients had a 10% lower risk of hospitalization for a potentially preventable condition (odds ratio [OR], 0.90) and a 6% lower risk of hospitalization for poor diabetes control, such as hypoglycemia or hyperglycemia (OR, 0.94), compared with patients of physicians. Similarly, the odds for hospitalization for other conditions were slightly lower among nurse practitioners' patients than among physicians' patients (OR, 0.96).”

“The researchers compared potentially preventable hospitalizations from 2007 to 2010 among 345,819 Medicare patients with any diagnosis of diabetes. Of these, 93,443 patients had received all their primary care from nurse practitioners (a total of 136,348 person-years), and 252,376 patients had received all their care from a generalist physician (553,890 person-years).”

The all-cause mortality between the two groups was statistically the same in the four years of the study.

Coauthor Mukaila A. Raji, MD, told Medscape Medical News, "We find it surprising that the findings of lower rate of potentially avoidable hospitalization among nurse practitioners patients still hold true, despite use of multiple advanced analyses to adjust for complexity and severity of illnesses between diabetes patients cared for by nurse practitioners vs MDs."

The researchers explain that primary care provided by nurse practitioners has been promoted as necessary to lessen the shortage of primary-care physicians.

A 15-fold increase in the number of patients receiving care from nurse practitioners from 1998 to 2010, and 22 US states have changed their policies to allow nurse practitioners to practice and prescribe without physician supervision.

Some medical groups have raised concerns about primary care delivered solely by nurse practitioners, arguing that outcomes might not be comparable, particularly in complex patients. A number of trials in controlled settings have found comparable outcomes between the two groups, but there have been no population-based studies of outcomes of primary care delivered by nurse practitioners and MDs.

“The current results show that patients of nurse practitioners were more likely to live in rural areas and be younger, female, and white and have lower income, possibly because individuals with these demographics may be more open to receiving care from nurse practitioners, Dr Raji suggested.” “And yet the findings reveal that nurse practitioners provide the same quality of clinical care as MDs, he added.”

"Reducing unnecessary hospital admissions and readmissions is a key benchmark of quality and the basis for financial reimbursement for the healthcare system."

"Our finding of the association of nurse practitioners' diabetes primary care with lower risk of avoidable hospitalizations likely reflects the unique skills of nurse practitioners in care coordination, transitional care management, advance care planning, and preventive care," he concluded.

The research was funded by the Agency for Healthcare Research and Quality and the National Institutes of Health. The authors reported no relevant financial relationships.