July 2, 2016

Epsom Salts, Safe for People with Diabetes? - Part 1

Foot problems are a complication of diabetes. Too much glucose in the bloodstream can lead to nerve damage and poor blood flow, which can result in serious foot problems. Nerve damage can cause tingling, painful burning, or stinging in the feet. It is important that people with diabetes take good care of their feet and are gentle with them.

The tools and products that people use on their feet can significantly affect the overall health of their feet. This is especially true if they have nerve damage or the blood flow to their feet is greatly reduced. Many people commonly soak their feet in Epsom salt to soothe aches. For people with diabetes, however, soaking feet in Epsom salt is not ideal.

The scientific name for Epsom salt is magnesium sulfate. It is a mineral compound that has many different uses.

Epsom salt has become a common home remedy for various problems and has several claimed health and beauty benefits. For many years, people have recommended soaking the feet or taking a bath in Epsom salt for various reasons. Potential reasons for doing so include:
  • To soothe muscle aches and pain
  • To provide relief from itches caused by sunburn and poison ivy
  • To help remove splinters
  • To decrease swelling in the body
  • To boost the body's levels of magnesium and sulfate

The theory behind this product is that the body absorbs the magnesium from the Epsom salt through the skin. However, there are no studies that support this claim. While there is no evidence to support the benefits of Epsom salt, simply soaking in warm water can help with many of the issues listed above.

To understand why people with diabetes should not soak in Epsom salt, it is important to know how diabetes can affect the feet.

High blood sugar levels can cause damage to the nerves of the body. This is commonly referred to as neuropathy. The most common type of neuropathy for people with diabetes is peripheral neuropathy. Peripheral neuropathy is damage to the nerves that serve the legs and arms.

As a result, people with diabetes may lose feeling in their feet. It is not uncommon for people with diabetes to be unable to feel pain, heat, or cold in their legs or feet. Some may not notice when they have a sore on their foot or have developed a blister.

Open sores on the feet can easily become infected. Raised blood sugar levels help to feed the infection in open wounds making it worse. Poor circulation makes healing these sores difficult.

Common foot problems that can cause infections in people with diabetes include:
  • Corns and calluses
  • Blisters
  • Ingrown toenails
  • Bunions
  • Plantar warts
  • Hammertoe
  • Dry and cracked skin
  • Athlete's foot
  • Fungal infection

Continued in next blog.

July 1, 2016

Scientists May Have Secret of Diabetes Alert Dogs

A chemical that is found in our breath could provide a flag to warn of dangerously low blood sugar levels in patients with type 1 diabetes, according to new research the University of Cambridge. The finding, published in the journal Diabetes Care, could explain why some dogs can be trained to spot the warning signs in patients.

Important terminology - Volatile organic compounds (VOCs) – term used in Diabetes Care report.

Claire Pesterfield, a pediatric diabetes specialist nurse at Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust has type 1 diabetes, which requires insulin injections to manage blood sugar levels. She also has a golden Labrador dog that has been trained by the charity Medical Detection Dogs to detect when her blood sugar levels are falling to potentially dangerous levels.

Claire had a diabetes service dog and she says her golden Labrador alerts her when she is at risk for hypoglycemia. She says he jumps up and puts his paws on her shoulders to let her know.

Hypoglycemia (low blood glucose) can cause problems such as shakiness, disorientation and fatigue; if the patient does not receive a sugar boost in time, it can cause seizures and lead to unconsciousness. In some people with diabetes, these episodes can occur suddenly with little warning.

Given the reports of dogs alerting owners to blood glucose changes, researchers at the Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, believed that certain naturally occurring chemicals in exhaled breath might change when glucose levels were low. In a preliminary study to test this hypothesis, the scientists gradually lowered blood sugar levels under controlled conditions in 8 women, all around their forties, and all with type 1 diabetes. They then used mass spectrometry, which look for chemical signatures, to detect the presence of these chemicals.

The researchers found that levels of the chemical isoprene rose significantly at hypoglycemia, in some cases almost doubling. They believe that dogs may be sensitive to the presence of isoprene, and suggest that it may be possible to develop new detectors that can identify elevated levels of isoprene in patients at risk.

Another group in Ireland had also tried to discover what the dogs were smelling, but had no success. In the USA, several companies have researched this and have been left wanting.

"Isoprene is one of the most common natural chemicals that we find in human breath, but we know surprisingly little about where it comes from," says Dr Mark Evans, Honorary Consultant Physician at Addenbrooke's Hospital, University of Cambridge. "We suspect it's a by-product of the production of cholesterol, but it isn't clear why levels of the chemical rise when patients get very low blood glucose.”

"Humans aren't sensitive to the presence of isoprene, but dogs with their incredible sense of smell, find it easy to identify and can be trained to alert their owners about dangerously low blood sugar levels. It provides a 'scent' that could help us develop new tests for detecting hypoglycemia and reducing the risk of potentially life-threatening complications for patients living with diabetes."

The research was funded by the National Institute for Health Research (NIHR) Cambridge Biomedical Research Centre with support from the Cambridge NIHR Wellcome Trust Clinical Research Facility.

The one thing not mentioned in all the articles or Diabetes Care, it that this has been proven to be what the dogs smell. It all sounds good, but no positive statement has been made saying a discovery has been made. This may be what they are looking for, but I will wait until an actual piece of equipment is available and working.

June 30, 2016

Guidelines on How to Treat Young Patients

This really surprised me and I had to call friends living in Maryland and asked them about this. One of my friends called me back and said he had asked a neighbor who had a 16-year old son in Johns Hopkins and had given him a printout of the article. The neighbor was happy to have the information and said this isn't being practiced as the doctor had the parents leave the room and then he talked to them about their son's condition.

When they went back into the son's room, the doctor did not wash his hands or sanitize the instruments he used. The father said his wife asked the doctor why he was not using sterile instruments and washing his hands or wearing latex gloves when examining the burns on their son. That father told my friend that the doctor just ignored her question and his wife whispered to him that she was going to find someone in charge.

When she came back, the doctor had moved on and she said she had asked for the doctor to be removed from their son's care and replaced with a doctor that would:
  • Wash his hands
  • Use sterile instruments
  • Talk with their son and not ignore him
  • Communicate like you care
This is only a few items off both lists and sterile instruments wasn't even on either list. My friend said her wish had been granted and another doctor was assigned to their son. The mother was happy even though he didn't wash his hands, but put on latex gloves as soon as he entered the room. Both the father and mother expressed that the doctor had examined his burns and then he talked with all three and said that they should be able to start work on the burns the following week and would possibly need to do some skin grafts. When the doctor saw some concern on the parent's faces, he said they will start with plastic surgery and the skin grafts would only be the last resort if needed.

The next day he had some skin graft pictures to show them and they could hardly recognize that they were skin grafts. The son said they don't look that bad and he had looked up plastic surgery and skin grafts the prior evening and felt that he should have whatever the doctor's felt was best. The doctor asked the parents and they said okay. He said on following Tuesday, the plastic surgeon would be in to look at the burns and if he was satisfied, he would set the date to start.

With that, the parents said they would be available and ready to support whatever the decision became. The son told his parents to go home and rest and he was going to do the same in the hospital. The doctor said he would be in on Monday to reinspect the burns and the nurses would be changing the dressing on a daily basis.

This is the last of the three part series.

June 29, 2016

Parent Guidelines on How to Treat Young Patients

This is something you don't often see in print. I will give the Armstrong Institute of Johns Hopkins Medicine credit for being this bold, but I have reservations that a lot of this is still not happening. This is quoted from their newsletter. I will have my comments in the last of three blogs.

The Parent Wish ListJohns Hopkins Children’s Center
Pediatric Family Advisory Council
  1. Meet my basic needs. Once I have adjusted to the shock of my child being admitted to the hospital, orient me. These are the things I need to know: Where can I get food? How can I make parking more affordable? When can people visit? Where do I sleep? Where do I shower? What other resources do you provide? Is there anyone else that can support me through this stressful time?
  1. Let me see you wash your hands. I worry about germs. I know how many germs are in the hospital. Watching you wash your hands is the first step that lets me know you are going to keep my child safe.
  1. Before you start speaking, introduce yourself. I want to know who you are. I want you to know who I am. I expect this from anyone who enters my child’s room. I want to know how you are going to be involved in my child’s care. It also really helps when you are friendly. This is stressful, and kindness goes a long way.
  1. Communicate, communicate, communicate. I am waiting for updates, any updates. Sometimes I wait hours just to hear what you have to say. So when you do come, give me as much information as you know. If you get delayed, let me know. I plan the day around the times I get to communicate with the care providers. It’s also OK to say you don’t have the answer but that you are going to find out and get back to me. Communicate.
  1. Know my child’s whole history. Read about my child. Read the notes from other people who know my child. If you don’t have access to my child’s history, ask me. I am my child’s best historian. Be sensitive to my child’s complexities. I appreciate when you are willing to talk to others involved in my child’s care.
  1. When you are with me, be present. I know you are busy and time is precious, but please take time when you can to answer my questions and outline the plan for the day. I want to be included in formulating that plan, discussing goals big and small. Let me know what I can do to help move things forward. Sharing the next steps with me is helpful. The unknown is scary, so the more information I have, the better.
  1. Tell me when there is downtime. I don’t want to leave and miss something important. I appreciate when you tell me this is a good time to take a nap, grab something to eat, take a shower, have visitors or maybe even get in a few hours of work.
  1. Answer the call bell. Please answer when I call. And once you answer, please come to my room as soon as you can. Minutes can seem like hours when my child is in pain or I am stressed and worried about something. Let me know you will do your best to be there. If I am unable to be there when my child calls, it makes me feel better to know someone is going to check on my child quickly. It’s hard to leave, but sometimes I have to.
  1. Clean my child’s room. Keeping my space clean is important to me. This becomes my home, especially when we have extended stays. It is helpful to have the trash emptied, the food trays removed and a clean bathroom. It is also helpful when common areas are clean.
  1. Sleep is precious. I know I am not going to get the same amount of sleep that I am going to get at home, but whenever possible, please let me sleep. Group tasks together, if medically possible, especially overnight. The little things you do to meet my basic needs go a long way in showing you care.

June 28, 2016

Teen Guidelines on How to Treat Young Patients

This is something you don't often see in print. I will give the Armstrong Institute of Johns Hopkins Medicine credit for being this bold, but I have reservations that a lot of this is still not happening. This is quoted from their newsletter. I will have my comments in the last of three blogs.

The Teenage Patient Wish ListJohns Hopkins Children’s Center
Teen and Youth Advisory Council
  1. Smile, introduce yourself and call me by the name I wish to be called. A smile goes a long way. It is much easier to talk to you when you smile at me. It helps put me at ease. I like to be called by my first name. Many teens may have nicknames that make them feel more comfortable. We want the hospital to have a more personal feel and not be so formal. Calling me by my last name makes me feel old. A simple ask goes a long way. It will start our relationship on the right foot.
  1. Be on time. Whether I’m inpatient or outpatient, waiting is hard. It is hard enough to come here, and to know that I may have to be here twice as long makes me dread it more. It also makes me not want to share things because it will make my stay longer.
  1. Communicate with me. Yes, me. I am here in the room too. I may not be an adult yet, but I want you to explain things to me in a way I understand as well. It is OK to talk to my parents; sometimes it is OK for you to even talk to them first. Just remember that I also want you to give me information in a way I can understand and encourage me to ask questions.
  1. Know my whole medical history if able. Just because I am here for one thing doesn’t mean there are no other things that you should know about me. It is important to me that you are thoughtful about all things about me. If you are treating my belly, it doesn’t mean my lung problems are not important. Just remember the “whole” me.
  1. Give me frequent updates. Waiting for answers is really hard. I may not tell you that I am worried, but I am. I even sometimes will make up my own answers. When giving the updates, it is helpful when they are detailed. I want as much information as you know. When you are vague, I tend to make up my own answers and think you are just trying not to tell me something. It is better to say you don’t know then to say nothing at all.
  1. Take a walk in my shoes. If even for just a brief moment, consider what it must be like for me sitting in your clinic or in my hospital bed. I would much rather be playing soccer, performing in my high school musical, attending my prom. I am missing “normal things in my teenage life.” I don’t expect you to fully understand or remember, but knowing for that brief moment you are going to consider it is helpful.
  1. Don’t rush. I know you are busy. I know you have many other important places to be and things to do, but when you take your time and hide how busy you are it makes me feel more comfortable. I also worry if you are rushing that you are going to forget something or miss something. Thank you for the time you are willing to give me.
  1. Distractions are helpful. All the things you offer, like Xbox, movies, games and Bingo, help me feel like I am not in the hospital. They make me feel more normal. I will probably turn you down sometimes, but please don’t stop offering. Knowing that you are trying also lets me know that you care.
  1. Keep my space clean. When things are clean and organized around me, it makes me feel better. I don’t want to worry about getting an infection. I always hear people say that hospitals have germs, so anything you do to show me you are trying to protect me makes me feel at ease — for example, cleaning my room every day and washing your hands.
  2. It helps when you comfort me and my whole family. We are not always going to be able to smile in return. Sometimes we are going to have a bad day. Sometimes we may even cry. It is OK to comfort us and acknowledge our feelings, even if it is uncomfortable. Sometimes we need our space, but also comfort us when it looks like we need it.

June 27, 2016

SGLT2 Inhibitors Heavily Promoted at ADA

The 2016 ADA conference in New Orleans was the showcase for the latest research on SGLT2 Inhibitors. The Diabetes-in-Control team was at the conference and state the SGLT2Inhibitors had over 150 poster presentations on this class alone. The article says they will cover the new research in depth over the coming weeks.

For now, here’s a taste of some of the breaking news from the sessions:
  1. Research pertaining to the kidneys was a major topic. Researchers concluded that canagliflozin slows the progression of kidney function decline compared to glimepirde at almost equal glycemic control. This suggests that canagliflozin’s beneficial effect on kidney function is independent of its glycemic effects.
  2. Janssen presented results from a Phase 2, randomized study showing glycemic improvements in adults with type 1 diabetes mellitus (T1DM), when treated with canagliflozin (Invokana) plus insulin.
  3. Two study results pertaining to AstraZeneca’s Farxiga were presented. In one study, Farxiga was shown to decrease body weight and blood pressure among patients with kidney problems,
  4. In the other study, Farxiga was used in combination with a potassium-sparing diuretic. A1C, body weight and blood pressure were reduced, with no significant increase in potassium levels. This reduces the risk for hyperkalemia.
In other news, the results of the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results—A Long Term Evaluation (LEADER) trial was major news at the conference on Monday, June 13. The results showed that liraglutide (Victoza), in patients identified with cardiovascular disease, lowered the combined risk of heart attack, stroke and death from cardiovascular causes by 13%. While a reduction in CV risk with a GLP-1 treatment is an exciting development, there’s not a yet any real evidence of a class effect.

Meanwhile, multiple SGLT-2 drugs are undergoing further testing to explore the possibility that SGLT-2 inhibitors as a class can reduce cardiovascular risk.

June 26, 2016

Amputation Risk Up for Canagliflozin Users

The FDA had continued to issue new warnings for the sodium-glucose cotransporter 2 (SGLT2) inhibitor class of drugs. This last warning for the diabetes drug canagliflozin which has been linked to an increase in leg and foot amputations. Canagliflozin is marketed as a stand-alone drug therapy under the name of Invokana and as part of a combo therapy under the name of Invokamet.

The Canagliflozin Cardiovascular Assessment Study (CANVAS), a 4.5-year research project which will finish up in 2017 is the basis for the latest warning.
Researchers have found a slightly elevated amputation risk among those who took the drug. The rate of amputation was seven for every 1000 patients taking 100 mg of canagliflozin and five for 1000 patients for those taking 300 mg of the drug. Those in the placebo group saw an amputation risk of three per 1000 patients.

There are many 'what if's' missing from the above analysis. What if the amputations were for people that had the highest A1cs? What is the comparison of A1cs between those patients taking 100 mg and those taking 300 mg. I am talking about those that needed amputations and not the 1000 patients in each group.

The article does say there are many questions raised by this study that still need to be answered. For example, a follow-up study did not yield the same increased rate of amputations for those taking the drug. I have to wonder how a follow-up study can be completed before the CANVAS study is complete. Also, FDA regulators are not certain if the drug was what caused the increased amputation risk. Still, out of an abundance of caution, they are warning doctors to watch for possible foot issues with patients taking canagliflozin and for other SGLT2 drugs.

I am writing about several other issues with the sodium-glucose cotransporter 2 (SGLT2) inhibitor class of drugs. Never assume that oral diabetes drugs are safe and many of the latest drugs are still being found to have serious side effects.