Pharmacists Could Be Health Care Providers

This is a great article and everyone should read this. Will it work? This will depend on many factors and largest problem is the patients themselves. Why, you ask? Because many patients fill one prescription at one pharmacy and then go to another pharmacy to fill a second prescription. This is so common it is scary. I see it all the time. I asked a couple not too long ago, why they would do this. I was not surprised by the answer as I have heard it before.

They said it was not the business of the pharmacist to know all their medications. The husband goes to several doctors and goes to the three pharmacies in town to fill prescriptions from different doctors. The wife sees four different doctors and does the same. Each takes more than five different medications. I asked if they had time to talk, but they were in a hurry to get the next pharmacy.

As they walked away, I could not help but think that they are living very dangerously. They are the ones putting their health and lives in jeopardy. I wonder if they had the same attitude about keeping the supplements they take from their doctors. They were both older than me, and the wife was using a walker, but they were as unconcerned about my question and more concerned about keep information away from the pharmacist.

I am concerned about my privacy as much as the next person, but when it comes to my health, I want to make sure my doctors know and that my pharmacist knows. Granted I do business with two pharmacies, one a military pharmacy and the other a local pharmacy. You bet I make sure the local pharmacy has a list of all medications I am taking plus any supplements. I try to update the list at least quarterly with the local pharmacy.

Only once has the local pharmacy asked me to stop taking a supplement and one prescription when the two would have conflicted with the new medication I needed for ten days. I was asked several questions and the reason for the new prescription and then she told me which supplement and prescription to stop and for how long. This was most reassuring to me and let me know that I was doing the right thing by having my list of medications and supplements on file with the pharmacy.

This interview with Rear Admiral Scott F. Giberson, RPh, PhC, MPH, US Assistant Surgeon General and chief professional officer of pharmacy at the US Public Health Service in Rockville, Maryland is very interesting about moving pharmacists into the healthcare profession legislatively.

The model Dr. Giberson is proposing would compensate pharmacists (as healthcare providers) based on the level of service they provide. Much like other health professionals, as the complexity of care increases, so too would the compensation. It may include both Medicaid Part D and Medicare Part B. Currently, pharmacists receive compensation within Medicare Part D for services provided through Medication Therapy Management (MTM). However, this is limited by considerable restrictions, including the number of medications (at least seven) the patient takes and the number of chronic conditions (two or three).

This subject I am sure will continue to be put before professionals and congress.
There are even greater ramifications not mentioned here. First, most doctors are being required to submit prescriptions electronically which should help eliminate some of the pharmacy hopping done by many people. As they get closer to issuing all prescriptions electronically, it will become evident to the doctors what patients are doing and may help the doctors to avoid conflicts in medications and even supplements.

This country still has a long way to go in this arena, but progress is being made. More doctors as beginning to ask the right questions about prescriptions and supplements and some are beginning to insist on a complete list from their patients. Some even are requiring that patients bring the actual medications with them to the appointments. A few doctors are even asking to see the supplement bottles as well. Patient medication safety is on the move and will be slowly implemented. Now is the time and next the clinics in many communities will be brought into this.

Know Your Keywords for Insulin Medication

It is often difficult to know which is the official term for the different types of insulin. One author will use one set of terms and a different author uses another set of terms. Then when you get out the magnifying glass and decipher the text on the materials supplied with the insulin, you will occasionally see a third set of terms. For someone new or even experienced with using insulin, this can be a little confusing.

Since I do not have but two types of insulin that I use, I cannot find the terms best used in the materials supplied with many of the insulins so if you have other types, do not hesitate to add comments with the terms used. The best chart I have found to-date for the terminology is this in WebMD. An incomplete listing of terms can be found here and I will add other terms that I have been taught from various sources and some “off-label” terms.

The medically correct terms listed here are from many sources and the most often used. I have added other terms I have been taught or that I have learned over the years.

• Onset refers to when the insulin starts to work. I was taught Begins or Activates.
• Peak refers to when the insulin works hardest. I was taught Effective Period and Period of Maximum Effectiveness.
• Duration refers to how long the insulin works. I was taught Length of Usefulness.
• Official sources list nothing about when insulin ends and I was taught End.

Next, we need to consider the types of insulin:

• Rapid-acting - I learned fast-acting insulin.
• Short-acting - This was never explained to me and I lumped it with fast-acting,
• Intermediate-acting - I learned this as 12-hour insulin.
• Long-acting - I learned this as 24-hour insulin.
• Pre-mixed - All I learned was mixed insulin.
  

Now that you have an idea of the different terms used, understand that this applies to the average person with diabetes. All the directions and times used are for the average person. I take Lantus, which is a 24-hour insulin. I cannot count on this as through experience and my body chemistry, I have learned that I have an 18 to 20 hour effective period of insulin use. Others have no problem of Lantus lasting for 22 to 24 hours. I believe your own body chemistry has some effect on the effective period insulin will last.

After discussing this with my endocrinologist after changing times for injection and always having problems at the end of the 24-hour period, we decided to split my Lantus injection and take half the dosage twelve hours apart. To many this is stacking insulin; however, this has eliminated the dawn phenomenon for me and leveled out the total day for me. For some people this does not work.

If you look at this chart, you will see that Novolog duration is 3 to 5 hours. I normally get the 3 1/2 hours and no further benefits. For every person, you will need to carefully monitor your results to determine if you are in the average group, or if you fit another area.

I never really thought that being my own lab rat would be any fun, but over the years, I have learned otherwise. More than once my own experiments have proven beneficial in managing my diabetes more effectively. This does not mean that I have not needed to repeat experiments, as I have. Sometimes, I need to make adjustments and other times they become temporary. Each person has to find his or her own level of comfort and tolerance.

Some weeks are great and sometimes days can become a nightmare trying to discover what needs to be adjusted. Keeping a positive attitude and realizing that some times an answer will not be discerned is important. Do not be taken aback when later you realize what happened. Just remember for the next time.

Are People With Type 2 Lazy and Undisciplined?

This is the curse of having type 2 diabetes. Even people with type 1 diabetes are affected by this from people that are ignorant about type 2 diabetes. Unfortunately, even people in the medical profession seem ignorant about type 2 diabetes and insult their patients.

Of the group of people that I get together on a regular basis, only two of us have weight problems. Of the six that are on insulin, we are the two with constant battles to shed some weight. Yet even the rest of the group receives insults when people find out that that we have type 2 diabetes.

We receive comments about our inability to exercise, lack of will to leave the table, eating too much sugar, and not having the will power to prevent diabetes. Not only do we hear these insults, but also when we are together, people are constantly inspecting our table to see what we are eating. It will vary among us, but most have unsweetened tea or diet beverages, some will have a salad with vinegar and oil, and a few of us may have a meat without a bun or bread, or another protein.

Depending on the time of day, some of us may have fried eggs or even poached eggs, yet we have people that insist that we have sweetened tea and make not so pleasant comments about what we are eating. Yet there they sit with their donuts and sweetened drinks like regular colas, coffee with cream and sugar. Or they have a plate of pasta and few vegetables, and they are blaming us for our diabetes.

Oh, yes, when one of them is diagnosed with diabetes, we would like to return the favor, but our group has chosen to take the high road and not the road they have chosen. Even the member (Sue) of our group who had been a pain in our side as the diabetes police has more than once commented that if only she knew then what she knows now, she would have thought twice before making insulting remarks.

Even her husband (an informal member) is surprised we have not rubbed her face in it. We just answer, “what would we gain” - except a very negative attitude. We promote as positive an attitude as we can even in the face of most insults. We feel that this is the reason we get along so well when we are together – whether this includes three of us or all eight of us. We are a confident group that generally ignores the insulting comments directed at us.

Isn't it great to have an invisible disease? At least among the members in our group, we enjoy the company of each other and the interests we have in reading and comparing notes about what we read.

Our last addition to our group (Allen) has asked to stay in our group so that he can learn and carry information to another group of his friends that have type 2 diabetes. He stated he likes the informal nature of the group and the way in which we support each other. He stated that he likes to read, but the rest of his type 2 friends are not into computers and research or reading.

All of those that he gets together with are on oral medications and do little testing. This bothers him (Allen) and he has been asking a lot of questions about testing which we answer. Last Thursday we got into depression as he was having a downer, as was another in his group. Since there were only five of us, we told him to get the member in so we could possibly answer some of his questions.

Well, the two others from his group accompanied the friend he called as they were already there with him. Our group members knew something was indeed wrong just as soon as they arrived. Our member, Tim, asked a few questions and said we had better get him to the emergency room or if a doctor could see him, he would prefer that. Several calls were made and we were able to get him to his doctor that knows diabetes. The doctor was waiting on their arrival and took him immediately and Tim accompanied him.

Later after the appointment, Tim explained that they were admitting him to the hospital and putting a watch on him as he was suicidal and very deeply depressed. Tim said that the other two friends of his were both going to visit him when allowed and well as a couple of our group. For now, that is where we left it.

We did get together with Allen to see what his mood was, but Allen said seeing his friend in that shape had scared him deeply and he was not down now. He expressed his feelings as more of concern for his friend than worry about himself and this was the reason for his downer, as he did not know what to do for his friend. He thanked Tim for knowing what to do.

We discussed asking the doctor to speak to both groups about depression and how to recognize the symptoms he had. Tim said he would talk to the doctor and see what could be arranged.

We discovered that the person Tim had helped was the eldest brother of our member (Sue) and she had not been aware that he had been admitted to the hospital until she received the email from us about the day's events. After she had been to the hospital and seen her brother, she had her husband stop by Tim's house and thanked him. Tim told her we were not aware of their relationship or we would have let her know immediately.

Our group has decided to use this example to discuss with the members of both groups about the problems of keeping diabetes a secret.

You may enjoy reading this blog by Elizabeth Woolley.

Statin Risks Outweighed by Statin Benefits?

Statin drugs are at a crossroads. Some are promoting statins very heavily, which includes Big Pharma. At the same time the Food and Drug Administration (FDA) is issuing warnings about statins. These warnings must be part of the written materials included with every prescription.

As more risks are deemed hazardous and more people are experiencing them, it is right that the FDA has taken their action. Now we have an article in WebMD that ups the anti and says “Statin Risks Outweighed by Statin Benefits.” This has to be weighed carefully. Even though the article clearly states the favoritism for statins, as you read the article, I was surprised by the toned down approach taken.

Statin drugs are used to block an enzyme the body needs to create cholesterol and this in turn lowers the amount of LDL cholesterol (the bad cholesterol) in the body. The article lists the following statin drugs: Altocor, Altoprev, Mevacor (lovastatin), Crestor (rosuvastatin), Lescol (fluvastatin), Lipitor (atorvastatin), Livalo (pitavastatin),

Pravachol (pravastatin), and Zocor (simvastatin). Then the person interviewed - Steven Nissen, MD, chair of cardiovascular medicine at the Cleveland Clinic stated, “Clinical trials show that all of these cholesterol-lowering drugs cut the risk of heart disease by 25% to 30%.”

Dr. Nissen does use some common sense, but is still in favor of statins. He states that if you have heart disease, or have a very high risk of heart disease with high cholesterol; statins are one of the best classes of drugs for treating this. He goes on to state, "When used thoughtfully and with good monitoring, they are safe and effective. We all need to watch our cholesterol levels. But statin treatment is not for everyone.”

His last statement is very good and needs to be considered on an individual basis. Nissen says. "Statins should be coupled with good diet and exercise. They are not a substitute for a healthy lifestyle."

The article continues with who should and should not take statin drugs. It covers the risks, many common side effects and the latest warnings from the FDA. Please read as this may answer some of your questions about statins. This will also give you information to have a more informed discussion with your doctor.

In addition, this video needs to be watched. This is a cardiologist from the New York School of Medicine presenting his views on the FDA warnings. Unless I totally misunderstood him, it is full speed ahead with acknowledgment that the warnings exist, but that statins are best for the patient.

Will CDEs Really Help PWDs With Depression?

With the exception of a few CDEs working for physicians that are concerned about their patients and make sure that their CDEs are knowledgeable about depression, apparently the American Association of Diabetes Educators is still mired in the past and could care less about the patients. All they seem concerned about is their certification standing and their paycheck. Sad, but true. Read this blog for more confirmation.

Many of us were hoping that with a new leader that is trying (according to her) to improve the profession, we might see some changes. But, apparently those in the trenches are not buying into the changes and we as patients are getting more of the same BS they have been dishing out for years.

After reading the above-mentioned blog, I called my relative that is a CDE in a large practice and asked her about the webinar. She said that one of their CDEs was to have monitored the webinar and she would have a talk with her and get back to me by Monday evening.

I have now had a return call from her. The only statement I am allowed to use is this - “thank goodness the practice we work for gives and sends us to good continuing education classes.” I ask if this applied to the webinar. No, was the answer. We talked about some other topics of interest like self-monitoring of blood glucose and she would only state that she liked some of my blogs on SMBG.

As long as I do not quote her or mention specifics, she will talk openly about many topics as long as they remain just between us. So do not ask for quotes has been good for me. When it comes to her honesty about most topics, she has very good for advice to me and does not spout the mantras of ADA or other professional groups. I have to respect her for this and staying as a relative I can consult.

Based on my own observations, I would conclude that Wil Dubois is probably very much on target with his analysis of the CDE webinar.

The Individual Symptoms of Hypoglycemia

Yes, symptoms of hypoglycemia are very individual. One individual may have one feeling and another person may have different sensations. Some of the more common symptoms include extreme hunger, nervousness (shakiness or tremors), excessive perspiration (sweating), rapid heartbeat (tachycardia), headache, fatigue, mood changes, blurred vision and difficulty concentration and completing mental tasks.

Some of the less common ones are a cold feeling, seizures, loss of consciousness and a few others. What the symptoms are telling you is that your brain is not receiving enough blood glucose (sugar), and it is signaling your body for more. Now be aware that these symptoms are not specific to hypoglycemia. There may other causes and the only way to be sure is to use your blood glucose meter and test. If the meter says you are below 70 mg/dl (3.9 mmol/L) then you need to be concerned about hypoglycemia and take corrective action.

People with type 2 diabetes do need to be concerned about hypoglycemia. I often see people complaining about having some of the symptoms shortly after they are diagnosed with diabetes. They are wondering why they have these feelings but their blood glucose readings are still in the 100's. This is generally because they have had a rapid drop from a higher reading that their body has been accustomed to and their brain is telling them it needs more glucose. This should still be of concern, tested for, and not ignored.

I can remember this shortly after I was diagnosed and I would test every half hour for several hours until I knew that I had not gone below 70 mg/dl. Many people with type 2 diabetes never experience true hypoglycemia, but this false hypoglycemia can still become serious if ignored. Those of us with type 2 on insulin even need to be more careful. A small percentage of people with type 2 diabetes can become hypoglycemia unaware. It is more of a concern for people with type 1 diabetes.

Hypoglycemia unaware is the term used to describe the complete lack of symptoms when blood glucose is going low. This does happen to some people with type 2, but not that frequently. Once it does happen, much care needs to be taken. A continuous glucose monitor should be necessary. If your insurance will not allow one, then take time to learn BGAT (blood glucose awareness training), it just may save your life. You will need to learn this on your own as the CDEs refuse to waste time on it. Too much to learn and it will not improve their paycheck.

If you are on oral medications, this web site should be one that you read. It discusses the oral medications and how they can affect your blood glucose and cause hypoglycemia.

Researchers Now Advising Against Red Meat

We really need to read carefully some of the studies about red meat that are being reported lately. Observational studies prove little, but these studies are getting press. Recently one of the studies was done by a doctor associated with the Harvard School of Public Health, Boston, MA, it is looks like 22 years of observational looking fits the agenda of the lead investigator.

Now I am not saying that this is not possible, and with all of the growth hormones and antibiotics fed to cattle, it may be that they are right. I do know that less meat is being certified as heart healthy, and the majority of this is grass fed beef.

This is getting a lot of attention in the news media and even in some of the medical journals. It is also being hyped in the medical press. There are even some bloggers hyping the study as being the last nail in the red meat coffin.  I do not believe them.  

At least Tom Naughton has shown the truth about the study and I urge you to read his blog here. Another blog worth reading is this one at Mark's Daily Apple. It is written by a guest blogger and worth the time to read.

For those wanting to read Gary Taubes, I urge you to read his blog about the red meat studies which he calls by other terms.

Since I am behind the times on this topic, reading what others more versed on this is only proper and I hope I have given you something worth your time.  Two other articles about the same study are here and here.

Are OTC Diabetes Drugs - a Good Idea?

What do you feel about medications for diabetes, cholesterol, high blood pressure, asthma and migraines becoming over-the-counter (OTC) medications? The current Food and Drug Administration (FDA) is seriously floating this idea. No decision has been made yet, but we need to be prepared should this become submitted for comments.

This came to light in an article by the Associated Press on March 7 and was reproduced in the Washington Post dot com, business section. Another article is here.

In the past, the FDA has approved this action for many drugs only if studies show that patients can safely take the drug after reading the package labeling. There are reasons the FDA is considering this, but I will let you read the reasons on the link above.

Quinn Phillips, writing for DiabetesSelf Management dot com presents other ideas to consider. Both emphasized that this could relieve the patient per doctor load and free up doctor time for patients needing to see the doctor. It is true that we now have the home use A1c test kits. We could use these to check our quarterly blood glucose levels. This self treating of diabetes is bound to create health problems and increase the number of deaths from over medication.

Patients left to their own initiatives have a bad habit of over medication because they think more has to be better. They do this now with supplements, so why would they not do this with medications they are able to get over-the-counter? Yes, many patients will properly use the medications. There will also be patients that will under-medicate themselves thinking they can always increase the dosage later.

Someone has proposed self-serve medical Kiosks where information would be entered in a computer to assist patients in calculating the medication and the dosage required. Others are proposing that pharmacists would be able to keep the medications behind the counter and after the initial doctor's prescription, they would be able to give out the medications upon the patient updating the data via computer. This would be the self-monitoring of blood glucose data entered by the patient.

All of this leaves open the possibility of fabricating data to obtain more medications or decreasing the amount of the medications. Even if the pharmacist could perform the A1c test, people would still be potentially able to skew the results.

Since this is not yet a fact of life, we need to be aware of the potential and how we would react to this happening. The FDA emphasized that consideration of any over-the-counter change is still in the initial stages. If you have thoughts on this topic, please leave a comment below.