July 21, 2012

Just Thoughts from the Last Few Months

Having computer failure and moving to a backup computer is not fun, but it is doable. Having lost many of my favorites and bookmarks is difficult to rebuild and I still have a quite few I have not recovered. I have noticed that many of my favorites are seldom posting blogs. Yes, they post, but not as frequently as they had in the past. I have found some activity on Facebook and Google+; so much of the activity may have gone where they get more immediate response, which can be more rewarding. I say good for them, I will miss them.

I do have accounts with both, but cannot find time for participating. I admit I am tired of receiving invites to play the games on Facebook. I would much rather play one game of solitaire which will be over shortly, and not waste a lot of time I see wasted on Facebook games. I enjoy researching and reading more than playing these games. There are so many good sources of information, some very interesting, and a lot of garbage is published trying to pass itself off as something important.

Part of what irritates me is the small studies done that mean nothing more than a call for more money to do larger and even less meaningful studies. Yes, I am venting. Then I get tired of all the rodent studies that herald a breakthrough. Yet we seldom see much beyond these rodent studies. Why? Because so much just won’t translate to the human body. Then there is the type of studies blogged about very accurately by Tom Ross here. This alone has me wondering how these get by peer review and how they are funded in the first place. It also raises questions about data committees and who else passed the buck. These researchers need to have criminal penalties imposed and do some prison time for their fraudulent use of research funds.

Now back to bloggers. I know bloggers come and go. Some I do miss and wonder what I could have done to encourage them. Others, well I hope you learned something while you were here and nothing serious has caused you to leave. I know from experience that sometimes a thick skin is needed and at other times, you can get emails for help that you cannot answer. Blogging can be very rewarding and at other times, you wonder if you are reaching anyone with something informative.

Then there are times when you receive both good comments (I receive mostly emails) and negative emails. I have been very surprised by what blogs get responses. I have had several over the last couple of months. Were the blogs that good? No, I can honestly say for a couple, I missed a lot and will write more later for some of them. At the same time, I at least opened the door for further discussion and I am learning a lot from one doctor, and for that, I am very thankful. I am also thankful for some of the contacts I have been making. Being a patient does have some advantages and at other times garners some sharp criticism. If I can continue to learn from some of the criticism, then I will have gained.

Several professionals have answered emails and we have started good discussions. A couple have contacted me and their discussions have been even more productive. I have been surprised at the questions and information they have requested and the responses to the information. You never know when something you blog about can open avenues for conversation.

Another activity that has been brought to my attention in the last few months is the use of peer mentors. I was a little shocked when I learned this, but after talking with a doctor using peer mentors and two of the peer mentors, I have learned a lot. The doctor stated that the nearest certified diabetes educator was over 150 miles distant and the closest registered dietitian was over 200 miles distant. The doctor had attempted to use the computer for video conferencing, but could not work around their schedules.

The doctor said he had two patients that he knew spent time researching on the Internet about diabetes and decided to have them in for a session of questions and answers just with him. He was pleased with the interaction with both, but one was not interested in peer mentoring. Therefore, he started with just one person and the first few sessions with patients went very well. In the meantime, both he and his peer mentor looked for others that would be capable. Over the next six months, they found and interviewed six more people, ending up with four peer mentors.

How did I end up being in contact with them? One of the peer mentors had read one of my blogs about shared medical appointments (SMAs) and made the doctor aware of this. The doctor was not sure if this would work for him, but was interested in exploring the topic. Over the last four weeks, we have corresponded about this. The doctors admits he does not like my stance on the American Diabetes Association, but is pleasantly surprised about the alternatives I do present.

My opposition to a one-size-fits-all mantra also got his attention, as did the discussion he had with his mentors about this. He knows that many people do not have the ability to afford the extra test strips to eat to your meter, or to discover how the different foods affect their bodies at diagnosis or at different times afterward. After discussing programs that a few of the test strip manufacturers have, he is now on a mission to see what can be done for his patients. Two of his mentors are writing on his behalf to see what can be accomplished. The office has gathered the numbers of each different meter used by his patients so that they can use this for volume.

He has asked about having SMAs with 5 to 9 people only as this about all his office can hold in the reception area. We have talked about having them at 4:00 PM to avoid interruptions. He does feel this would be workable, and if necessary he can see them going past 5:00 PM. Since he has the computers and equipment from attempting to set up with the CDEs and RDs, he seems willing to try this. His office is now surveying his patients with type 2 diabetes to find out how many would be interested. He is aware from reading my blog that secrecy for some may be an issue. He is investigating the frequency of having the SMAs, but in the beginning will start with quarterly.

He has used the video conferencing with me and has said he hopes I am not disappointed by not being asked to mentor for him. I said no, as I was writing my blogs and would be starting with two other doctors in the coming weeks as a peer mentor for them. I did email him copies of my twelve-blog series and the dates to be published and that if parts of them were useful then I had served as well in supplying education topics. He has forwarded them to his mentors and one has thanked me for them.

I have supplied him with the names of several people with nutrition degrees in his area and he said he was not aware of them, but would be in contact with a couple to see if schedules could be worked out. I have to thank my contacts for the names I sent to him.

Even if I have no other contacts like this, the last few weeks have been very rewarding for me. Complaints aside, I have learned a lot and even one that was especially critical has given me a valuable lesson in how to approach a couple of topics.

July 20, 2012

Summary of 'Back to Diabetes Basics' Series

This is a summary of the 12 blogs and a link to the blog to assist if you need to review any of the topics.

Back to Diabetes Basics – Part 1
What You May Experience After Diagnosis
The First Stage – Shock!
The Second Stage – Denial!
The Third Stage – Acceptance!
A Possible Fourth Stage – Depression!
An interesting blog and another way of looking at this by Gretchen Becker

Back to Diabetes Basics – Part 2
Why Keep Diabetes A Secret?
Presently There Is No Cure
Acronyms and Their Use
Some of the Testing Basics

Back to Diabetes Basics – Part 3
Hypoglycemia and Hyperglycemia
Doctors and the Different Types of Practice

Back to Diabetes Basics – Part 4
Proper Hand Care for Blood Glucose Testing
Importance of Self-monitored Blood Glucose (SMBG), and Type 2 Bloggers

Back to Diabetes Basics – Part 5
Diabetes Complications
Diabetes Myths
Diabetes Scams and Scammers
Food for Diabetes Patients and Introduction to Glycemic Index

Back to Diabetes Basics – Part 6
Exercise Is a Key in Diabetes Management
Lifestyle Changes

Back to Diabetes Basics – Part 7
Medical Alert Jewelry
Diabetes Management and Doctors
Suggestions for Doctors

Back to Diabetes Basics – Part 8
Learn to Count Carbohydrates
Diabetes Burnout

Back to Diabetes Basics – Part 9
Oral Medications

Back to Diabetes Basics – Part 10
Introduction to Insulins

Back to Diabetes Basics – Part 11

Back to Diabetes Basics – Part 12
Amylin Mimetic (Symlin)
Incretin Mimetic (Byetta)
Liraglutide Injection (Victoza)

There may be other topics that should be included, but at this time, I have only a few thoughts and decided to end this series of blogs. I may pick up some topics later and start another series in the future.

I am a firm believer that each person has to learn about how their body reacts to diabetes, how much exercise they are capable of doing, and finding out what works for them. There are no firm rules other than what works for me, may not work for you. Much of what is taught is on a one-size-fits-all basis. which can be misleading for many and does not work for everyone. This is the reason for giving people other information so that they may try different approaches in finding what works for them.

I have no objections if what I say does not work for you. My objective is to present ideas that you can adapt and make them over to work for you. Yes, I often make references to people saying the doctor did not mention or talk about this, as if this gives them a free pass. Just because your doctor did not mention or talk about something, does not mean that you are free to avoid it. Your diabetes health is too important and you should be working to constantly maintain excellent management of your diabetes.

Several points need to be emphasized before leaving this series. Do not, repeat do not consider insulin as a medication of last resort. Some people are capable of managing diabetes for many years without medication while others have trouble with oral medication and find it difficult to manage their diabetes with oral medication. Insulin should always be considered to prevent diabetes gaining the upper hand and causing complications.

Age is often not considered by ADA and other medical support organizations when they give out information. One-size-fits-all is the preferred mantra of most to avoid problems. This works fine for the average person, but if you are not the average person, know that you will need to adjust for age and abilities that you possess. I am working on a blog or possibly more about the consideration of age in managing diabetes.

July 19, 2012

Back to Diabetes Basics – Part 12

If I had not for looking for something else, I may have passed over these medications.

Amylin Mimetic (Symlin)

This medication is not for people with type 2 diabetes taking oral medications. It is only for people already taking insulin. There are several warnings you must take seriously. Symlin cannot be used in place of insulin. You must use a separate syringe to inject Symlin. Symlin may reduce the amount of insulin you need to use. Non-compliance is a problem for those taking Symlin.

Symlin does help keep your blood glucose at lower levels after you eat by helping your liver not put glucose into your blood stream. It may also prevent hunger, causing you to eat less and has the potential to assist in losing weight.

You should not take Symlin and need to talk with your doctor if you can't tell when you are having low blood glucose, a condition called hypoglycemia unawareness, you have recently had severe low blood glucose, you have stomach problems caused by diabetes-related nerve damage, and the standard if you are pregnant, planning to get pregnant, or breastfeeding. Symlin has not been studied for use in children. There may be times when you should not take your usual dose of Symlin and this includes: if you're having surgery and you’re sick and can’t eat. Also, discuss with your doctor about other times not to take Symlin.

Symlin can cause the following side effects and you should be prepared for them. They include - nausea and vomiting-most often when you first start taking Symlin, swelling, redness, or itching of the skin where Symlin is injected, headache, decreased appetite, stomach pain and indigestion, tiredness, and dizziness. Symlin does not cause low blood glucose by itself; however, your risk of having low blood glucose is higher because Symlin is always taken along with insulin.

Incretin Mimetic (Byetta)

Byetta is very much like Symlin, but you need to add that Byetta helps slow digestion by moving the food slowly through your stomach. Byetta is not used in place of insulin; however, people on oral medications or not on any medications may use it if appropriate.

You should not take Byetta and need to talk with your doctor if you have severe stomach or digestive problems, you have any symptoms of kidney disease or are on dialysis, you are pregnant, planning to get pregnant, or breastfeeding, and you have type 1 diabetes. Byetta has not been studied for use in children.

The possible side effects Byetta can cause are - nausea and vomiting-most often when you first start taking Byetta, headache, diarrhea, and dizziness. Byetta also can cause an acid stomach or make you feel nervous.

If you are planning to take Byetta, you need to know about problems with your kidneys
and talk with your doctor right away if you notice any of the following - changes in the color of your urine, how often you urinate, or the amount you urinate. swelling of your hands or feet, tiredness, changes in your appetite or digestion, and a dull ache in your mid to lower back. Byetta does not cause low blood glucose by itself, but your risk of having low blood glucose goes up if you also take diabetes pills that cause low blood glucose, or insulin. Your doctor may advise you to take a lower dose of your other diabetes medicines while you are taking Byetta.

Liraglutide Injection (Victoza)

I dislike starting this with a warning, but it is necessary and valid for this medication. Just because a celebrity chef (Paula Deen) promotes this medication does not make it safe and I suspect there will be more warnings in the future.

Warning Liraglutide injection may increase the risk that you will develop tumors of the thyroid gland, including medullary thyroid carcinoma (MTC; a type of thyroid cancer), which may cause death if it is not treated at an early stage. If you develop thyroid cancer, your thyroid gland may need to be surgically removed. Tell your doctor if you or anyone in your family has or has ever had thyroid cancer, medullary thyroid carcinoma, or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2; condition that causes tumors in more than one gland in the body). If so, your doctor will probably tell you not to use Liraglutide injection. If you experience any of the following symptoms, call your doctor immediately: lump or swelling in the neck; hoarseness; difficulty swallowing; or shortness of breath.

Keep all appointments with your doctor and the laboratory. Your doctor may order certain tests to check your body's response to Liraglutide injection.

Your doctor or pharmacist will give you the manufacturer's patient information sheet (Medication Guide) when you begin treatment with Liraglutide injection and each time you refill your prescription. Read the information carefully and ask your doctor or pharmacist if you have any questions. You can also visit the Food and Drug Administration (FDA) website (http://www.fda.gov/Drugs/DrugSafety/ucm085729.htm) or the manufacturer's website to obtain the Medication Guide.

Talk to your doctor about the risks of using Liraglutide injection.

I strongly urge you to read this link or the suggested links above in the warning so that you can familiarize yourself about Victoza. There are many special instructions that need to followed for proper use and avoiding problems with Victoza.

Series 12 of 12

July 18, 2012

Back to Diabetes Basics – Part 11


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 on the Joslin site and I will add other terms that I have been taught from various sources.

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 - 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 in NIDDK, 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 monitor carefully your results to determine if you are in the average group, or if you fit another area.

I never 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.

Two excellent insulin charts are available here and here. I will not reproduce them and urge you to bookmark them or print them out. The times shown in the chart are estimates. Your onset, peak, and duration times may be different. You should work with your health care professionals to come up with an insulin plan that works best for you. Learn the principles of insulin use and how they affect your body. Like oral medications, learn how you manage insulin and know that if you skip a meal, do not inject any of the rapid-acting or short-acting insulins as you are just asking for an episode of hypoglycemia.

Your doctor should work with you to prescribe the type of insulin that is best for you and your diabetes. Deciding what type of insulin might be best for you will depend on many factors, including:

Your body's individualized response to insulin. How long it takes insulin to be absorbed in the body and remain active in the body varies slightly from person to person. Here again, one-size-does-not-fit-all.

Your own lifestyle choices -- for instance, the type of food you eat, if or how much alcohol you drink, or how much exercise you get -- are all factors that influence your body's processing of insulin. Also taken into consideration should be the insulin resistance factor. If your doctor does not talk about this before prescribing, try to discuss this. This could make adjusting to insulin easier.

How willing you are to give yourself multiple injections per day. Many people with type 1 diabetes prefer insulin pumps and use them almost exclusively. That is their choice and I personally prefer the multiple daily injections and not having to worry about tubing or extra equipment being attached to my body.

How frequently you are willing to check your blood sugar level? I have been considering a continuous glucose monitor (CGM), but it is another piece of equipment to deal with. I will leave these decisions to each individual. If you choose to use a CGM, know that most readings are approximately 20 minutes behind what is actually happening. You should be looking at trends and acting on them. Always use your blood glucose meter to verify what the CGM is telling you.

Your age, and your blood sugar management goals are important considerations.

Follow your health care provider's guidelines on when to take your insulin. The time span between your insulin shot and meals will vary depending on the type of insulin you are taking.

In general, however, you should coordinate your insulin injection with when you want to eat. From the charts, the "onset" column provides useful information. Again, the "onset" refers to when the insulin will begin to work in your body. You want the insulin to begin working in your body at the same time your food is being absorbed. This timing will help avoid low blood sugar levels. I suggest printing out the chart you prefer and have it handy until you learn the timing.

One instruction I have not seen, but have learned over time, is a correction calculation when your blood glucose level is higher than planned either at the end of the duration, or prior to your next meal. Since this will vary for each person, I will only urge you to discuss this with your doctor and then work on refining from that point. I have my correction ratio figured out for myself, but you need to work with your doctor to refine how you arrive at your correction dosage of insulin.

For more information about when to take insulin, read the "dosing and administration" section of the insulin product package insert that came with your insulin product or talk with your doctor. Sometimes a doctor can think one thing and say another unintentionally, so please do not be afraid to ask. This is also a method of reinforcing what you need to do for best diabetes management.

On July 5, 2012, David Mendosa posted an excellent article about the value of being aggressive at the beginning with insulin and preserving the function of the pancreas for many years. This is worth reading even if you were just diagnosed with prediabetes or diabetes.

One WARNING is in order. If you are taking insulin with an oral medication, you are more susceptible for having hypoglycemia. Make sure you understand the symptoms and be prepared to test more frequently.

Series 11 of 12

July 17, 2012

Back to Diabetes Basics – Part 10


No, I did not leave this for near the last because it is the treatment of last resort for most doctors. I wanted to do my research and leave this series with what I feel is a great topic that needs attention. And, being near the last topic, you may remember more about it.

We know that people with type 1 diabetes can't live without insulin, but the medical community (especially the American Diabetes Association (ADA)) seems to think that people with type 2 diabetes can. In this light, they promote oral medications and if the first one they prescribe does not take care of the problem, they keep stacking oral medications. They will not prescribe insulin until they deplete the oral medications or have no other choice. I say they are causing more harm with this method of treatment than they doing patients good. From the preceding blog, you can see some of the side effects caused by oral medications.

That is not to say that insulin has no side effects, as insulins can. Some people are allergic to the insulins not produced by their own body, and for them insulin can be very toxic. Fortunately, their number is small and sometimes can be overcome with the right introduction and treatment regimen. For an even smaller number some insulins (not analogue insulins) approved and still on the market outside the USA will work for them. The remaining people will never be able to tolerate insulin that they do not produce in their own bodies.

For many years, the insulin used by people with diabetes was produced from the pancreases of pigs and cows. Synthetic human insulin derived from genetically engineered bacteria first became available in the 1980s, and now all insulin available in the United States is manufactured in a laboratory. Although the development of synthetic human insulin was a boon for most people, especially those who were allergic to the animal insulins, a few people find that they can manage their diabetes better using animal insulins.

Although animal insulins are no longer produced in the United States, the FDA allows individuals to import animal insulins for their own personal use. See their Policy on Importation of Drugs (1998) for more information. The Insulin Dependent Diabetes Trust, a nonprofit group in the United Kingdom, has additional information on animal insulins, including contact information for a company in the U.K. that still manufactures them. Explore the site if you need more information.

The major side effect of insulin can be a dangerously low blood sugar level (severe hypoglycemia). A very low blood sugar level can develop within 10 to 15 minutes with rapid-acting insulins. Always have glucose tablets, 6 oz or 8 oz juice drinks, or other suitable fast acting carbohydrates available to treat hypoglycemia. Glucose tablets are the fastest acting and most reliable.

Insulin can contribute to weight gain, especially in people with type 2 diabetes who already are overweight. The myth about weight gain on insulin happens to be fact, although in reality it is muddied up by people. For people with type 2 diabetes, taking insulin can cause weight gain. There are several reasons for this. The one factor that comes to the front is people use insulin as the medication of last resort. Normally this is fought until there is no longer any choice, insulin cannot be postponed as blood glucose levels are out of control and oral medications cannot keep blood glucose levels down.

Because insulin is often the medication of last resort, two factors can cause weight gain. The first is inactivity or sedentary lifestyle. This may be caused by diabetic neuropathy, which makes it difficult to walk more than short distances. The second is people do not reduce the intake of carbohydrates when going on insulin.

Why is the second necessary? Because insulin is necessary, when first started, insulin makes management of blood glucose levels easier. Instead of losing some of your carbohydrates in your urine when your blood glucose exceeded your urinary limits, these carbohydrates are now put to work or stored as fat. This new efficiency in blood glucose management generally causes initial weight gain.

This is the main reason that people starting on insulin should consider reducing the total carbohydrate intake for a period of time while your body adjusts to the efficiency. However, if you are a person that is able to exercise on a regular basis and you do this, your carbohydrate intake may not need to be reduced greatly and may be resumed shortly after starting insulin.

Weight gain is always a possibility for some body types and these people must learn to manage their carbohydrate intake to avoid weight gain. The article did say that you should limit your insulin dosage, which is only possible, if you reduce your intake of carbohydrates. I will also reemphasize their statement of using exercise to aid in insulin use to burn calories and help keep insulin use low. This will aid in preventing weight gain.

Other possible side effects of long-term insulin use include the loss of fatty tissue (lipodystrophy) where the insulin is injected and, in rare cases, allergic reactions that include swelling, or edema.

What can affect insulin? Some factors that affect how fast and how well an insulin dose works are:
  • Where the dose is given. If you give insulin into your abdomen (especially above and to the side of your belly button), the medicine will get into your system more consistently from day to day. If the medicine is given into a muscle or a small blood vessel instead of fatty tissue, the medicine will get into your system faster. This is generally not recommended by most doctors.
  • How much insulin is given. Higher doses of insulin reduce the blood sugar level more than lower doses. Do not overdose!
  • Whether you have exercised before or just after taking insulin. If you have just exercised the muscles in the area where you give your insulin injection, the medicine will get into your system faster.
  • If you apply heat to the area. The medicine will get into your system faster if you take a hot bath or shower, put on a heat pack, or massage the area where you have just given your insulin injection.
  • If you do not drink enough water and you are dehydrated, you will not have as much blood flow to your skin, so insulin will not be absorbed as well as it would be otherwise.

Things to do
  • Label each insulin bottle when it is used for the first time, and discard unused medicine after 30 days. A bottle of insulin may lose its potency after 30 days of use. Most inserts accompanying your insulin will state 28 days.
  • Store insulin properly so that its effectiveness is protected. Storing it in the refrigerator is the ideal place, but preferably not in the door to avoid vibrations when the refrigerator door is opened and closed.
  • When you buy insulin, check the generic or brand names to make sure you are buying the correct type. For example, if you have been using Humulin-R (insulin regular), make sure you buy Humulin-R instead of Humulin-N (insulin NPH).
  • Know when your prescribed types of insulin start working (onset), when they work most (peak), and how long they work (duration).
  • Know how to give an insulin injection.
  • Once you have started using the vial of insulin, it generally is not necessary to return it to the refrigerator. Only return it to the refrigerator if the temperature in the house or apartment will be above 85 degrees Fahrenheit for an extended period of time as this will shorten the life of the insulin or make it unusable.
  • Keep insulin out of direct sunlight and in Frio packs or a cooler with cold packs if it is in a vehicle for any length of time or while traveling or hiking.
The Internet does have some good tips here and if you search, you may find more.

One word of encouragement you should take away is that a move to insulin does not mean you have failed in your diabetes management. Just the fact that you are reading this should mean that you are doing you homework and learning about insulin. True, most doctors use insulin as the medication of last resort and this should not be the rule. Once one or two of the oral medications have not worked, instead of letting your doctor stack on more oral medications, give insulin serious consideration.

Series 10 of 12

July 16, 2012

Back to Diabetes Basics – Part 9

Oral Medications

Without a medical degree and not taking oral medication for over eight years, I am not sure I will cover this as well as I should. There are six classes of oral medications, pills if you will. For some people who do well with being able to stay on schedules and can avoid timing problems, these may work very well for you. The six classes are -Biguanides, Sulfonylureas, Alpha-glucosidase inhibitors, Thiazolidinediones, (glitazones), Glitinides, and DPP-4 inhibitors.

The one thing about oral diabetes medications that makes me happy and not to be taking them is the side effects. Some of them are not too severe. It is the new side effects that happen with some classes that frighten me. Most may cause weight gain and one is weight neutral, and may help with minor weight loss.

No, the oral medications do not have insulin in them. This is what some people believe and are astounded when they learn that there is no insulin. This may be one of the myths of why people feel so strongly about taking oral medications over insulin shots. No, I am not forgetting that many people have an unhealthy fear of needles. Others have had a fear of needles and have learned to conquer this fear.

To learn more, let's take a brief look at the classes of oral medications – pills:

These medications work on your pancreas to produce more insulin. When they overwork the pancreas, you will not be able to produce your own insulin.

Who should not take Sulfonylureas - talk with your doctor about whether to take this type of pill if you are allergic to sulfa drugs and you are pregnant, planning to get pregnant, or breastfeeding.

This class has the most numerous medications and causes hypoglycemia by itself or in combination with other medications. These pills are known to cause upset stomach, skin rash, and weight gain.

This medicine, which comes in pill or liquid form, lowers the amount of glucose made by your liver. Then your blood glucose levels don’t go too high. This medicine also helps treat insulin resistance. With insulin resistance, your body doesn’t use insulin the way it should. When your insulin works properly, your blood glucose levels tend to stay on target and your cells get the energy they need. This medication also works to improve your cholesterol levels.

It also may help you lose weight or can be weight neutral. Do not expect this medication to work immediately as this will depend on your body and the dosage prescribed. Because of the immediate side effects often, your doctor will start you out slowly and gradually increase the dosage. For some, results will happen in one week and for others, the benefits will not become effective for two to three weeks. It is strongly suggested that this medication be taken with food.

You should not take this medication and need to talk to your doctor if you have advanced kidney or liver disease, you drink large amounts of alcoholic beverages, or you are pregnant, planning to get pregnant, or breastfeeding. Sometimes you'll need to stop taking this medication for a short time so you can avoid developing lactic acidosis. If you have severe vomiting, diarrhea, or a fever, or if you can't keep fluids down, call your doctor immediately. You should also talk with your doctor well ahead of time about stopping this type of medicine if you will be having special x rays that require an injection of dye, you will be having surgery, or you will have having a colonoscopy. Your doctor will tell you when it is safe to start taking your medicine again.

This medication will not cause hypoglycemia by itself; however, they will increase your risk if taken with diabetes medications that cause low blood glucose, insulin, or certain other medications. Your doctor should advise you to lower your other diabetes medications while you take this medication.

The side effects are nausea, diarrhea, or an upset stomach when you first start taking this medication. These side effects normally go away or subside after a while. Rarely, a serious condition called lactic acidosis occurs as a side effect of taking this medicine. Call your doctor immediately if you become weak and tired. become dizzy, feel very cold. have trouble breathing, have unusual muscle pain and stomach problems, or have a sudden change in the speed or steadiness of your heartbeat

Alpha-glucosidase inhibitors
This medication helps keep your blood glucose from going too high after you eat, a common problem in people with diabetes. It works by slowing down the digestion of foods high in carbohydrate, such as rice, potatoes, bread, milk, and fruit. These are foods that you should not be eating or at least limiting in quantity.

You should not take this medication and need to talk to your doctor if you have bowel disease or other intestinal conditions, you have advanced kidney or liver disease, or you are pregnant, planning to get pregnant, or breastfeeding.

The side effects are risky if you do not follow careful guidelines. While it is said that this medication does not cause low blood glucose by itself, risks go up dramatically if combined with medications that cause hypoglycemia or insulin. Here again your doctor should advise you to lower your other diabetes medications while you take this medication. These medications may cause stomach pain, gas, bloating, or diarrhea. These symptoms usually go away after you have taken these pills for a while.

WARNING If you take Glyset or Precose, only glucose tablets or glucose gel will bring your blood glucose level back to normal quickly. Other quick-fix foods and drinks won't raise your blood glucose as quickly because Glyset and Precose slow the digestion of other quick-fix foods and drinks.

Thiazolidinediones (glitazones)
I do not want to discuss this class as one medication has been pulled from the market and the other should be. Actos has been shown to cause bladder cancer and now another study shows it raises diabetic macular edema. Read this link for all the warnings and the Food and Drug Administration advice. This is all I will say on this class.  Added Aug 17, 2012 - read this by Gretchen Becker.

Glitinides (Meglitinides)
Confusing isn't it? Yes, and it took me some time to decipher that both terms refer to the same class of medications. This is the medication needed to replace Sulfonylureas if you are allergic to sulfa. These are medications used to make your pancreas product more insulin for a short period following meals.

You should not take this medication (Prandin) and need to talk to your doctor if you are pregnant, planning to get pregnant, or breastfeeding, or you have liver disease. The side effects of Prandin include low blood glucose (hypoglycemia), weight gain, upset stomach, and back pain or a headache.

DPP-4 inhibitors
These are medications also used to make your pancreas product more insulin for a short period following meals. These medications also work to prevent stored glucose from being dumped from the liver into your blood stream.

You should not take this medication (Januvia) and need to talk to your doctor if you are pregnant, planning to get pregnant, or breastfeeding, you have kidney disease, you have type 1 diabetes and if you have a condition called diabetic ketoacidosis. The side effects while not causing low blood glucose by itself, do increase if you take medications that cause low blood glucose, or insulin. Here also your doctor may advise you to take a lower dose of other diabetes medications while on Januvia. Other possible side effects include a cold, a runny nose, sore throat, or headache. If you take Januvia and have kidney problems, your doctor should order blood tests to see how well your kidneys are working.

Combination Medications
I have chosen not to discuss this group of medications, but instead refer you to the charts. I would also suggest printing out the charts and keeping them handy for reference. They may be found here and here.

With all oral medications, you should communicate with your doctor and may sure you understand the answers to the following questions and keep this for your records as well:

1. What are the names of my medicine? Class Name:
Brand name: Generic name:
2. What does my medicine do?
3. When should I start this medicine?
4. This medicine is prescribed by:
5. How long will it take this medicine to work?
6. What is the strength (for example, how many milligrams, written as mg)?
7. How much should I take for each dose?
8. How many times a day should I take my medicine?
9. At what times should I take my medicine?
10. Should I take it before, with, or after a meal?
11. Should I avoid any foods or medicines when I take it?
12. Should I avoid alcoholic beverages when I take it?
13. Are there any times when I should change the amount of medicine I take?
14. What should I do if I forget to take it?
15. If I'm sick and can't keep food down, should I still take my medicine?
16. Can my diabetes medicine cause low blood glucose?
17. What should I do if my blood glucose is too low?
18. What side effects can this medicine cause?
19. What should I do if I have side effects?
20. How should I store this medicine?

These are important to your health and you need to understand the answers. I would even suggest printing out the list and covering them with your doctor. Also have an extra list to give the doctor to answer and mail to you if you are short on time. Most doctors will do this because they understand the importance. If your doctor says read the inserts that come with the medication, then keep the list and discuss the questions with the pharmacist. Some of the answers may also be found in the charts or in this discussion. You may wish to find your medication(s) in these inserts and print out the information relevant to each.

A study that may be of interest to you can be read here. It discusses the points about oral medications and claims it clarifies drug choices for people with type 2 diabetes.

Series 9 of 12

July 15, 2012

This Study Says - White Rice Joins White Bread

Normally I have respect for MedPage Today reports and read them with interest. Soon July 12, 2012 was no different when I received a special report titled Diabetes Risk: White Rice Joins White Bread.” Then after reading the report, I looked at the publication date and did a double take. The report was published on March 15, 2012, almost four months ago! How does this rate a special report?

So, I decided to reread the report to see what was so special four months ago. Yes, we have known that white rice increases the risk of diabetes, especially among Asian populations. Nothing new there. The only thing new is the discussion of the transition to more sedentary lifestyles, which may have become a factor. Then they launch into the more readily available food supply, which includes increased availability of refined carbohydrates, such as pastries, white bread, and sugar sweetened beverages.  So, is it the white rice or the white bread causing the diabetes?  Then they try to cover this up by stating that the glycemic index (GI) of white rice is higher than other whole grains - what about the white non-whole grain bread. They then say that the white rice GI is the result of processing and continue by stating that the primary contributor is the dietary glycemic load (GL) for populations that consume white rice as a staple food.

Now my curiosity is up and I wonder what other information they are going to try to blame on the white rice. No, they now start listing statistics about the size of the studies, as if this lends credence to the validity. Finally, we get to the fallacies. First, all the studies in the meta-analysis were observational studies and only one study included any information on brown rice. They also relied on food frequency questionnaires to assess dietary intake. Okay, the studies are faulty to begin with and should not lead to earlier statements. Then the authors really mute the value of this meta-analysis by stating, “even for Western populations with typically low intake levels, relatively high white rice consumption may still modestly increase risk of diabetes."

Then the last icing on the deathblow to the meta-analysis is in the editorial to the study by Bruce Neal, MD, of the University of Sydney in Australia. He cautioned that the "interpretation of the observed association, and, in particular, determination of the likelihood of causality, are problematic." He continued that there are "few immediate clinical implications," since "further research is needed to develop and substantiate the research hypothesis" -- even though funding is likely a challenge.

So much for a “special report.” No real science involved here. Now I would add a few thoughts of my own. First, this report is pure hype and means little. Second, is white rice like wheat that has been so genetically modified for increased production that it is causing the weight gain and increased incidence of diabetes? This is a question I doubt these hucksters will want to include in any true scientific research.

My last thoughts are mainly how I am going to be more cautious of what I read when something is included and hyped as a special report. The other concern is the increased availability of refined carbohydrates, such as pastries, white bread, and sugar sweetened beverages in Asian countries. Is this mentioned to make rice seem the culprit, when in fact it may be the adoption of a more western-style of living?