Many Type 2s On Oral Medications Stop

Apparently no one thought this was important enough to talk about it earlier during or after the American Diabetes Association Scientific Sessions in Chicago. I am surprised that it even received a mention now.

A new study conducted by Carol E. Koro, Ph.D., “shows that a majority of people taking drugs to treat type 2 diabetes stop taking their medications within six months, while almost all of them stop taking them within a year. The rate of drug discontinuation among type 2 diabetes patients was 89 percent for those taking a GLP-1 agonist to lower blood sugar levels, 82 percent for those who took a DPP-4 inhibitor to stimulate the release of insulin by the pancreas, and 84 percent for those taking other diabetes medications.”

“Carol E. Koro, Ph.D., who along with colleagues looked at 134,696 type 2 diabetes patients placed on a GLP-1 agonist, 202,269 who were taking a DPP-4 inhibitor, and 1,014,630 who were prescribed another diabetes drug. All patients were commercially insured.” These are alarming statistics, but with the alarms about the GLP-1 agonists and DPP-4 inhibitors, we probably should not be surprised. I am concerned that the patients did not talk to their doctors' about this to prevent diabetes from becoming unmanaged.

Now an even more concerning factor is that Koro, “An epidemiologist at GlaxoSmithKline in Research Triangle Park, N.C., based her research on data from the Truven Health Analytics MarketScan database between 2005 and 2011, and tracked refill rate patterns to determine how much of their medications patients were taking.”

"These results demonstrate the need for improved persistence with GLP-1 agonist treatment," Koro said, “adding that estimates suggest that improving compliance with diabetes drug protocol could prevent 700,000 emergency room visits and 341,000 hospitalizations each year, saving $4.7 billion in health care costs.” The study was funded by the pharmaceutical company GlaxoSmithKline.

You have to know that the company drug reps will be pushing hard to reverse this. GlaxoSmithKline does not want a loss in revenue. This also points out problems in the confidentially of data when a pharmaceutical company like this can identify patients by doctor and what weight and sex the patients were.

It is sad that this happened, but to allow a pharmaceutical company access to this information is not good. It is understandable now why this was probably not reported earlier and for Diabetes Health to be reporting this now speaks volumes in their lack of concern for ethics and is just another point they have broken in patient trust.

Diabetes Equipment Information

Are you seeking information about equipment for diabetes? I have one source that I depend upon that is fairly reliable. There may be other sources that are easier to read, but I am not aware of them. There are many blood glucose meter comparison charts and I will list two of them later.

First, you will need a PDF reader like Adobe Reader or Foxit Reader. Both are free and can be downloaded. I use both for different reasons. The files that I show next in the second image below are all PDF files.

This link should take you to Diabetes Health magazine. Then about one fourth of the way down the right column you will find this - 

 

You are welcome to explore, but I suggest going to the last line above and by clicking on it, you will be taken to the following image.

These are the five choices and you are welcome to explore. I have saved the first two items and the last item. I am not sure, but I believe the new charts for 2014 will be available sometime in January 2014, as they usually are.

The following are links to other blood glucose meter comparisons: I am not sure they will be updated each year; however, the first is generally updated whenever a new meter is available on the market and is carried by them.

http://www.walgreens.com/marketing/library/centers/diabetes/bgmcc.jsp

http://www.diabetesdaily.com/voices/2013/07/blood-glucose-meter-accuracy-comparison-chart/

The following link covers a wide variety of diabetes equipment:

http://www.diabetesforecast.org/landing-pages/lp-consumer-guide.html

Most is in discussion about the items with some good pointers on use and advantages and disadvantages of some of the equipment. There are almost no charts for comparison purposes.

Fitting SGLT2 Inhibitors in Diabetes Care

This is yet another doctor that believes diabetes is progressive and talks about it in that way. He does not acknowledge that the progression can be halted, but that the complications can be mitigated to some degree with the right medication. How deflating this must be for his patients.

He is talking about SGLT2 and how this medication is needed to lessen to severity of the complications. He states, “We need different treatments and different combinations of treatments to focus on these different factors at different times as the disease progresses.”

Clifford J. Bailey, PhD, Professor of Clinical Science at Aston University in Birmingham, United Kingdom says, “We now have very good evidence that good glycemic control, especially at the very beginning of type 2 diabetes, after diagnosis, is also very important in the long term to reduce the onset and severity of the complications of type 2 diabetes and to reduce macrovascular risk. Therefore, there is very good rationale for using as many therapies as we need at different times to control hyperglycemia.”

Now, if he would just read what he said, he might just realize that the onset of complications can be managed and diabetes can be non-progressive. Here again, I would be inclined to believe that this doctor is not big on diabetes education and lets his patients wallow in ignorance; therefore insuring that he has patients to treat for the complications.

At least we can know that he has conflicts of interest in his promotion of SGLT2 medications. Disclosure: Clifford J. Bailey, PhD, has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Abbott Cardiovascular Systems, Inc. (formerly Advanced Cardiovascular Systems, Inc.) ; AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; Boehringer Ingelheim; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Eli Lilly and Company; Merck Sharp Dohme; Novo Nordisk; Takeda Pharmaceuticals North America, Inc.; sanofi-aventis

Serve(d) as a speaker or a member of a speakers bureau for: AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; Boehringer Ingelheim; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Eli Lilly and Company; Merck Sharp Dohme; Novo Nordisk; sanofi-aventis

Received research grant from: AstraZeneca Pharmaceuticals LP; sanofi-aventis

At least he does list the problem areas for the class SGLT2 medications, but even then he couches it very carefully by promoting the drug while listing the urinary track infections and stating that the patients need adequate renal function before taking the drug. He does state the following - “Chronic kidney disease is an issue in advancing years in patients with type 2 diabetes, and so that is one of the precautions that needs to be seriously considered when choosing to use this type of therapy. That said, because this type of therapy is non-insulin dependent, it can be used early in the progression of type 2 diabetes as an add-on to the monotherapies that we have available at the moment.”

I would be very cautious if renal function may be impaired and I would demand to be tested for this before allowing this medication to be prescribed to me. This is a subject that needs to be raised with your doctor.

Again, a Doctor Refuses to Test for Vitamin B12 Deficiency

Allen called Friday morning in a panic. He said that a friend of his could not get tested for vitamin B12 deficiency. He was seeing the same doctor Allen had his trouble with. Allen wondered if he should take his friend to the endocrinologist we see or take this up with the local doctor. He said his friend had been taking metformin longer than he had.

I suggested that he try the local doctor and see if he was sincere in the concern he had expressed earlier. Allen said this was what he was thinking and said he would call me back later. That afternoon he called and said the doctor had taken him immediately and did several tests like the endocrinologist had done on him. Allen said that his vitamin B12 level was even lower than his had been. His vitamin D level had been slightly higher than Allen remembered his had been. Then Allen said the doctor had also checked the potassium and magnesium levels and they were low.

Once the doctor had the test results and found out why he had not been tested by his doctor, Allen said he had called the doctor and made his results known and told the doctor to be in his office that evening. Allen said he then called the pharmacy to see what they had for potassium and magnesium supplements and wrote a note for him to purchase the supplements and take one a day for 30 days and he would be retested then.

Then Allen was asked to leave the room while he gave vitamin B12 and D shots. In the discussion when Allen was back in the room, the doctor asked his friend not to drive until his levels were back in the normal range. He then asked Allen to let him know if he did drive and he would ask for his license. He was scheduled for shots in the next two weeks and then he would be tested again the third week before they decided whether he needed more shots. He would be started on vitamin B12 and D supplements at that time if no more shots were required.

Allen said that he was asked to stay while his friend checked out. The doctor had thanked him for bringing his friend and said that this would go a long way in helping him convince this doctor that many people could not eat their way to good health and levels of vitamin B12 on metformin. I told Allen that I had sent the URLs for this article and this article to the doctor and received a thank you for sending them. Allen asked me to send them to him as well.

Allen said his friend wanted to drive, but Allen said the doctor was serious and recounted what had happened to him. Allen said he had also alerted his friend's daughter about the situation and she had agreed to help her father until this was over.  I asked Allen how old his friend was and Allen said only a year younger than he was.

Allen anticipated my next question and stated that he was on VA assistance and that he had been warned about his vitamin B12 levels, but had ignored them. I said he may not have been very low or they would have given him a shot then.

Allen said his friend had asked him to drive for his tests the following week at the VA and then for his appointment the week after. I said that he may be taking them serious now, but at least he knows. I commented to Allen that he could send out an email to everyone now and emphasize to people the importance of being tested for vitamin B12 especially if they had friends or relatives on metformin. Allen thanked me for allowing him to do this and he would have Tim send it on to people in the other groups.

Allen concluded by saying he had asked his friend to consider joining our support group, but his friend was not sure he wanted to. Allen said he was not going to pressure him, but would continue to promote the idea with him.

Can We Trust WebMD for Reliable Info?

At least one of my Senators is speaking out about transparency. “The contract has raised concerns for one senator. Sen. Chuck Grassley, R-Iowa, told the Times that "disclosure and transparency would be a good practice for any recipient of federal funding to promote the administration's health care plan."”

“Even if certain content is not produced with federal funding, but the same company takes federal government money to produce other materials, consumers would be better-informed by knowing the financial relationships.” Senator Grassley is an influential member of the Senate Finance and Budget committees.

WebMD has received a $4.8 million deal with the government, through the Centers for Medicare and Medicaid Services, to educate health care workers about parts of the health care law.

“WebMD says it doesn’t believe it had an obligation to disclose to its broad consumer base its $4.8 million contract with the government. The company says the contract, while awarded to WebMD, went through its Medscape platform, which provides continuing education to doctors in a password-protected portal and is run independently from WebMD’s news operation.”

CMS (Centers for Medicare and Medicaid Services) officials defended the contract.  “As part of our broad outreach and education efforts that we have conducted across CMS programs for years, we are working with Medscape, which is owned by WebMD, to inform Americans about the new opportunity to enroll, many for the very first time, in quality affordable health care coverage,” the CMS statement read.

Anyway you slice this, a conflict exists and the intent harms readers because they do not know who or what entity is behind the articles. All I can say is thank you to the Washington Times for their investigating and bringing this to the attention of all.

Then we are able to hear from a doctor that does not appreciate medical content providers that go political. It is refreshing to see this happen and realize that patients are not the only people that wonder when this happens.

Holiday Greetings

To all my readers

May you have a happy holiday season

Have a Merry Christmas!

and

A Happy New Year!

The blog will continue during the holidays. I wanted to take this opportunity to greet everyone and wish you happy holidays!

Diabetes Management Relying on Pharmacists

Pharmacists are being relied on more and more to play a key role in diabetes management, especially for type 2 patients. With certified diabetes educators not adding membership at a pace to keep up with the increase in numbers of new type 2 patients, this is a welcome help for type 2 patients.

I will not include a single case study from Washington, but will use the national program Project IMPACT: Diabetes, a program launched in 25 communities across the United States with disproportionately high numbers of cases of diabetes.  This study found that many participants saw improved levels of A1c levels, cholesterol, blood pressure, and body mass index. The data was compiled by the American Pharmacists Association Foundation.

This data found that because patients had one-on-one consultations with their pharmacists, medications could be adjusted to better meet patients' needs, allowing for improved results. The study also had the pharmacists provide counseling on exercise, nutrition, and lifestyle changes while collaborating with physicians, diabetes educators, and other healthcare providers to ensure that patients receive comprehensive care.

"Working together with pharmacists empowers all types of patients, rich and poor, insured and uninsured, anywhere in America, to take the steps they need to understand and manage their diabetes while living healthier lives."

"Everyone with diabetes faces challenges such as adhering to prescribed medications, monitoring blood glucose levels, staying current with vaccines and foot and eye exams, and maintaining a healthy diet and lifestyle," Lindsay Watson, RPh, director of applied innovation for the American Pharmacists Association Foundation, said in a press release.

I don't expect that all pharmacists are participating or anticipate being this involved in the needs of people with diabetes, but many are working to improve the lives of people with diabetes. Much of this is possible because people are more willing to talk to pharmacists than they are to doctors on a time schedule. Then think about the doctors belittling their patients and using threats to keep patients on oral medications and it is easy to understand why many patients are more willing to discuss medical problems with a non-judgmental pharmacist.

Another factor in favor of the pharmacists is across the United States in the smaller rural communities; the pharmacists are part of this community and receive the respect of the community. Helping their pharmacy customers is part of a natural outreach to their community.

If you haven't read my previous blog about a five state pharmacy group and how they are helping patients with diabetes, please do so as this could be what is needed to stop the diabetes epidemic.

User Errors in Blood Glucose Testing

User errors are very common for people with diabetes. The equipment that helps us measure our blood glucose and manage our diabetes is delicate and deserves our care to function as intended. Yet, I see people doing the wrong things and wonder why the readings they receive from their meters are unreliable.

This is not a comprehensive list, because when I think it might be, I always discover another error or watch people abuse their testing equipment in a new way. I do wish people would read the instructions that are contained in the box with the container of test strips and read the instruction manual that comes with their meter.

The list of user errors that I have seen to-date:

#1. Not keeping the test strips in the container they came in. I have seen people take them out of purses, wallets, zip-lock bags, and other containers. Some even have them in tea bags holders or folded paper towels to protect them from the light, but this is not the correct way to carry them. The container you receive them in is the only proper container to carry them in as this container is manufactured to protect them from light and moisture. If you will be spending the day on the water, then you may wish to put the container and your testing equipment in a zip-lock bag.

#2. Not carrying the meter in its case. Using the case that came with the meter is best, but will not prevent lint and dust from getting in the meter if the case is left open when not using the meter. Lint and dust are often the culprits that cause a meter to not read the test strip properly. I have seen people carry the meter in purses, pockets, and backpacks or fanny packs and not in the intended carrying case. I have even watched people search through their purses, backpacks, and other places for the different parts to the lancet device while dust was blowing onto their meter. One of our support group members commented about people handling their test strips and meters with wet hands after getting out of the swimming pool to test their blood glucose levels. If you want accuracy in testing, this is not a good practice.

#3. Keeping the container of test strips and meters on the car dashboard, in the car glove box, or even the seat of the car in the summer or winter. This delicate equipment has temperature guidelines for storage and use. Baking them in the car or freezing them will not produce accurate test results. Yet this seems to be a favorite place for people to carry them.

#4. Using test strips in direct sunlight. This is a big no no, but I see people do this quite frequently. Not too many days ago, my wife and I were in a restaurant, and a couple was sitting in the sunlight. I watched the wife take her meter out of the purse and sit it in direct sunlight, then dump out a few test strips, pick one up, and insert in her meter. Then she needed to hunt up the parts of the lancing device from her handbag, assemble it, and then prick her finger and wick the blood into the test strip. I could see her pull out the test strip, insert another from the pile on the table, and repeat the process. This happened two more times before she gave up. The first error was not having the lancet device ready for use. Then she should have only taken one strip from the container and kept the meter and inserted test strip behind something to prevent the direct sun from shining on it while pricking her finger.

#5. Most people do not take time to read the instructions that come in the box with the test strip container. I admit I did this for a few years until instructions started to change. Until about four years ago, instructions seldom changed. Now they change at least once a year if not more often. Maybe not much of a change, but changes nonetheless. Some have been important, such as the change from using alcohol pads to wipe the finger to using warm water and soap to clean your fingers and then drying your hands thoroughly.

#6. Many people are not aware of using the second drop of blood or when this should be used. Read my blog here for when to use the second drop of blood.

We as patients can make many more errors in testing our blood glucose levels. For the errors David Mendosa covers, read his blog here. David has a better grasp of some of the mistakes we can make when we don't respect the delicate equipment we have to use.

I have also written other blogs about errors we make. The first is about the importance in hand washing that is here and the second is about the needless ways we find to waste test strips and this blog is here.

For those that have problems getting a single test strip out of the container, my suggestion is obtaining a plastic tweezers for use. I have two that I use when I open a new container. I have taken both and glued a quarter of an inch length of a three eighth inch wide rubber band on the outside of the tip of one side of the tweezers and then wrap it slightly around the tip.  The second tip as a quarter in of a thin rubber band glued to the inside of the tip.  To pull out a test strip, I insert outside of the first part into the container very carefully and once I have it far enough in to pull out a test strip. I have the container tilted enough to pull one strip out and then when it is far enough out to rotate the tweezers to grasp with both tips, I lightly squeeze and extract the test strip. Still holding the test strip with the tweezers, I set the container down and close the lid. Then I grasp the test strip with my fingers and set the tweezers down. I then pick up the meter and carefully insert the test strip in the slot in the meter.

Granted, this did take some practice to do this without damaging a test strip. It is better than dumping a few test strips out and then risk damaging them when putting them back into the container. I don't know that the manufacturers of the test strips would approve of this, but it works for me. Never, I repeat, never use a metal tweezers. The metal will damage the test strip and some have been magnetized and this will damage the test strip.

And with many of the errors I witness, I ask myself why these people are even testing. They create a climate that wastes test strips and do not receive readings that are reliable. It is bad enough that there is a built in margin of error, but to needlessly add more error margin with the mistakes many people add to the built in error margin really is a waste of money for the results they receive.  If you are using insulin, these errors can create hypoglycemia that you don't want.