Why Is Everyone Worried about A1c Overtesting?

Disclosure for me – I am a person with type 2 diabetes and am managing my diabetes with insulin. I only have two HbA1c tests per year and I do not feel this is often enough. Admittedly, I discontinued seeing an endocrinologist because I was consistently being asked to raise my A1c to level above 7.5%. When my A1c was under 6.5%, I was told rather sternly to let my A1c rise. I, of course do not believe this and believe I should manage my glucose levels to the best of my ability.

Fortunately, my VA nurse practitioner believes this also and with the other tests they run, she can determine that my meal plan is not affecting my health and the tests clearly show this. So I will continue to follow the low carb, high fat, moderate protein food plan and hopefully my next A1c test will be better and I won't have a couple of infections and another problem that will keep it as high.

It seems that certain doctors feel that for persons with well-managed diabetes, that they only need at most two HbA1c tests per year. Fortunately, some doctors disagree and feel that their patients need four tests per year. And some individuals buy their own kits to test on a monthly basis. This must drive these doctors into a tizzy.

Dr. Rozalina McCoy, a professor of medicine at the Mayo Clinic, in Rochester, Minn. is one of these doctors and a lead researcher that states - "I think part of the problem is that we often think more testing is better."

Her research showed that over 60% of adults in the United States with well-controlled type 2 diabetes receive more than the recommended number of tests for HbA1c. And excessive testing increases the risk of treatment being intensified despite a patient having normal HbA1c levels, a new retrospective analysis of an administrative claims database demonstrates.

The test, which gauges a person's average blood sugar control over the past three months, is routinely used to diagnose and monitor type 2 diabetes. But guidelines say it should be done only once or twice a year if a patient has been showing good blood sugar control, according to the study.

First, the HbA1c test reflects the prior four months and this is from David Mendosa's blog. I think this is a common mistake that the article author made, as the author of the second article did not even mention this.

"I think the most important drivers of HbA1c overtesting in the US are multifactorial," Dr McCoy told Medscape Medical News.

She and her colleague identified some factors that seem to play a role in how frequently patients are tested, including the number of different healthcare providers each patient sees and whether their endocrinologist also treats type 1 diabetes patients, who do require more frequent monitoring. Also, there was a wide geographic variation in frequency of testing.

Current guidelines recommend patients with stable glycemic control receive HbA1c tests once or twice a year. While this is true, often once a year is insufficient and because the American Diabetes Association only recommends A1c tests, patients often need to pay for their own test strips or completely operate in the dark. Dr. Robert Ratner, chief scientific and medical officer for the ADA that says, “Many people with type 2 diabetes who are on medications don't need to do home glucose monitoring at all," in talking about oral medications.

With all this stacked against diabetes patients, it is small wonder, many patients see several doctors to be HbA1c tested several times per year. Unlike the following statement, with the ADA against you, I believe that overtesting of HbA1c is over researched. This is just another way the medical community is working to harm patients with well managed type 2 diabetes.  The researchers also use a value of A1c greater that 7 percent for increased A1c testing.  When will they learn that A1c values above 6.5 percent can lead to complications.  It is no small wonder that this is why doctors consider type 2 diabetes progressive.  They want to limit testing and give no education.

“And in an accompanying editorial, Rodney Hayward, MD, University of Michigan, Ann Arbor, says the current study "probably greatly underestimates" the size of the overtreatment problem among US patients with type 2 diabetes. This common belief that there is "no harm in looking" continues to result in not just waste in the healthcare system but palpable patient harm, he stresses.”

For an HbA1c test the cost is very reasonable and a few extra tests are minimal cost and often great security for type 2 patients and generally create little harm.

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! 

I must apologize, as before my computer crashes in August and September, I had a blog written for gifts for people with diabetes, but it did not survive the crashes.  I had intended to publish it right after Thanksgiving, but I completely forgot about it since I no longer had it.

Doctors Now Advocating Statins for Children

It seems that endocrinologists, cardiologists, and several other medical groups in the medical world are promoting statins like never before. Not only are they now promoting them for children above the age of five years of age, but the also have flooded the medical journals with information that many (almost 50 percent) of eligible adults are not taking statins.

I cannot prove this, but it seems that there must be a lot of money to be made from promoting statins and many medical groups are thus promoting statins. This statement is beginning to have more significance - “Statin use has become what appears to us to be a kind of religion, an unchallengeable article of faith among some doctors.”

One in five children and adolescents had at least one abnormal cholesterol measure, according to new data from the CDC. "While the authors do not focus on this, some of the very high total cholesterol and non-HDL-cholesterol values are likely due to genetic causes such as familial hypercholesterolemia," wrote Daniels, who was not involved with the study. "The heterozygous form of familial hypercholesterolemia occurs in approximately one in 250 individuals."

Obesity is also listed as a potential risk factor, as nearly half (44.3%) of obese children and adolescents had some form of abnormal cholesterol, more than three times that of their normal weight peers (13.8%). Obese children and adolescents also saw statistically significant differences in high total cholesterol (11.6%) compared with those who were normal weight (6.3%) and overweight (6.9%).

Switching to the adults, nearly half of American adults who should be taking cholesterol-lowering drugs do not, according to research published in the U.S. Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report. The CDC study team analyzed national data from 2005 to 2014 and found that 36.7% of U.S. adults — 78.1 million people aged 21 and older — were eligible to take cholesterol-lowering medications or was already taking them.

Many of the medical groups now believe that with statins now being generic, the benefits now favor statins and are pushing them very aggressively. There are few doctors that warn about the side effects and most never even consider that most statins deplete the levels of CoQ10 or Coenzyme Q10 made by our bodies. Most doctors do not even test for this and some people will develop problems because of this.

According to the University of Maryland Medical Center (UMMC), statins lower your body’s levels of coenzyme Q10. As your levels go down, the side effects of statins increase. Taking CoQ10 supplements might help increase the levels in the body and reduce problems.

Learning to Manage Diabetes

For people that want a different source for diabetes information, I would like to refer you to the site – BD Diabetes Education Center (the link is not always dependable). While it is not the most comprehensive site, they have a great overview of certain topics and can give us topics to research.

The first area is for those injecting medications to help manage diabetes and reduce discomfort. Do take the time to view the links they put in blue. If you are injecting insulin or another medication, BD lists some things to keep in mind:

1) Consistent delivery into fat layer

• Injections should consistently enter the fat just underneath the skin and should avoid the muscle.
  Watch demonstration: how to inject with a syringe
  Watch demonstration: how to inject with a pen
• Injections into the muscle are more common with longer needles, leading to quicker insulin action and greater risk of low blood sugar.
  Learn how to recognize and treat low blood sugar
  
  
• A 4mm x 32G pen needle rarely enters the muscle as compared with longer 6mm-12mm pen needles.
  Learn which pen needles do not require a pinch up.

2) Injection site location and rotation

• Common injection sites include the stomach, thigh, buttocks and upper arm.
• Rotating among these sites may reduce the risk of lypodystrophy, lumps of fat that develop under the skin from injecting in the same spot repeatedly.
  More discussion at bottom.

• A 4mm pen needle length allows for a “straight in” no pinch injection technique at all injection sites. This allows you to inject with one hand into harder to reach areas like the upper arm or the buttocks.

3) Choices of needle type, length and gauge

• Factors to consider when choosing a needle are the thickness (gauge) and the length of the needle.
• People who have participated in studies seem to prefer the 4mm x 32G pen needle over other longer pen needle lengths.

4) Additional tips

• How to improve your injection technique
  
  
• A reused needle does not enter the skin as easily or as cleanly because it has become dulled by use and the lubricant that lets the needle enter the skin has been rubbed off. Use pen needles and syringes only once.
• All used sharps should be contained and disposed of in a sealed sharps container according to local municipality regulations.

Number is 2 above is probably the most important to me and what I have been reading about lately. Rotating among these sites may reduce the risk of lypodystrophy, lumps of fat that develop under the skin from injecting in the same spot repeatedly. I am not sure that the term lypodystrophy is correct, as I have always been told that the area that is used for injections day after day develops scar tissue in the fatty area. This traps the medication and does not allow, generally insulin, to be dispersed for use in the blood stream.

There is much more to the site and I will suggest that you explore the site.

CKD May Result from Proton Pump Inhibitors

This article caused me to ask my pharmacist some questions about the medication I was taking for acid reflux. She said that because of the gall bladder removal they were careful to give me an acid reflux medication that was not a proton pump inhibitor.

The article is this one and discusses that certain medications often used to treat heartburn and acid reflux may have damaging effects on the kidneys. The drugs, called proton pump inhibitors (PPIs), are among the top 10 class of prescribed medications in the United States.

With all the problems of chronic kidney disease (CKD) on the increase, apparently physicians are not properly assessing patients and keeping the patients on the medication for too long. Three studies indicate that PPIs may be contributing to the CKD epidemic.

In one study, Benjamin Lazarus, MBBS (Johns Hopkins University) and his colleagues followed 10,482 adults with normal kidney function from 1996 to 2011. They found that PPI users were between 20% and 50% more likely to develop CKD than non-PPI users, even after accounting for baseline differences between users and non-users. This discovery was replicated in a second study, in which over 240,000 patients were followed from 1997 to 2014. “In both studies, people who used a different class of medications to suppress stomach acid, known as H2-blockers, did not have a higher risk of developing kidney disease,” said Dr. Lazarus. “If we know the potential adverse effects of PPI medications we can design better interventions to reduce overuse.”

In the third study, Pradeep Arora, MD (SUNY, Buffalo) and his team found that among 24,149 patients who developed CKD between 2001 and 2008 (out of a total of 71,516 patients), 25.7% were treated with PPIs. Among the total group of patients, those who took PPIs were less likely to have vascular disease, cancer, diabetes, hypertension, and chronic obstructive pulmonary disease. However, PPI use was linked with a 10% increased risk of CKD and a 76% increased risk of dying prematurely.

“As a large number of patients are being treated with PPIs, health care providers need to be better educated about the potential side effects of these drugs, such as CKD,” said Dr. Arora. “PPIs are often prescribed outside of their approved uses, and it has been estimated that up to two-thirds of all people on PPIs do not have a verified indication for the drug.”

This warning was issued - Please consult your doctor or other qualified health care provider if you have any questions about a medical condition, or before taking any drug, changing your diet or commencing or discontinuing any course of treatment. Do not ignore or delay obtaining professional medical advice because of information accessed through ASN. Call 911 or your doctor for all medical emergencies.

The proton pump inhibitors include:

• Omeprazole (Prilosec), also available over-the-counter (without a prescription)
• Esomeprazole (Nexium)
• Lansoprazole (Prevacid)
• Rabeprazole (AcipHex)
• Pantoprazole (Protonix)
• Dexlansoprazole (Kapidex)
  

Bringing Everyone Up to Date

I am very surprised and yet very happy. This fall has been one of ups and downs for many of the support group. Most of us are happy that most of the dual title (RD and CDE) people have moved out of the area. We know that two CDEs are still around and one RD is still preaching high carb, but for the most part, many of the new members have been given permission to see Brenda's daughter or my cousin for nutrition advice.

Tim is very happy as he has been approved for using my cousin for nutrition and Bonnie has worked with a CDE and asked Tim to use her if his insurance will approve. Tim agreed after meeting her and asking several questions, and has told Bonnie that as soon as she can practice, she had better plan on being busy.

Allen, Barry, and Ben have found a doctor that believes them and it wasn't Dr. Tom. Even Sue has changed to the same doctor. Allen, Jerry, and I all had our VA appointments the same day and Allen and Jerry had excellent A1c's. Because of a couple of infections the prior month, and another problem, my A1c was higher than I anticipated. I have other doctor appointments now and may need to see a VA specialist next year.

Beverly is away for some classes and our December meeting could not happen. We did try and other activities seemed to conflict. So, Sue and Jason are planning a program for January. We did have a brief meeting on December 16, since most could attend that evening. There were a few questions that Allen, I needed to answer about insulin, and A.J had quite a few questions about exercise. Sue's husband, Bob said that his fall schedule had forced him to go on metformin and that presently he was taking it two times per day for a total of 1,000 mg.

A.J emphasized that a YMCA membership was not necessary, but could help for those that could afford it. A.J said that with the open fall we have had, he has not needed to use a swimming pool and has been able to exercise outside most days. He asked how many could jump rope and was surprised at the lack of response. A.J said that he is using this for some of his exercise and his incline tread mill at other times on days that it has rained enough to keep him from running.

Then A.J showed the group the jacket he wore when running. With the florescent stripes, we could appreciate why he showed us. Sue commented that she has almost hit other runners and walkers that wear dark clothing in the evenings now that it turns dark early. Several of the new members asked where they could find the florescent material. A.J listed several places and where it was the least expensive and where to find the widest stripes. Then he displayed the pants he uses with their stripes. He said that he has two sets and uses both and is happy he has them. He estimated that his total cost was about $35 and he said that he probably has more stripes than needed, but it was up to each person how visible they wanted to be in the evenings.

This generated quite a bit of discussion and then Tim said the meeting was adjourned and people could talk among themselves if needed. Half an hour later the cleanup was done and everyone left. Tim wanted to talk to me, we went to my car, and Tim said that with Bonnie and my cousin taking classes for several months, we needed to have Brenda's daughter and members of our group have programs for a few months. I agreed and said I would be looking for topics and Tim said he had several topics in mind and he would put them in an email and ask for volunteers. I thanked Tim and said I would wait for the email.

People with Diabetes and HBP May Not Donate Kidneys

Yes, you read this right! The reason is most people with diabetes and high blood pressure (HBP) may have kidney damage that would not support living on one kidney.

Researchers are saying that donors with those conditions face a high risk of developing kidney problems themselves, and may need both kidneys in the long term. The advisory is part of a set of new metrics, based on a donor’s health prior to donation, that can predict the lifetime incidence of kidney failure or end-stage renal disease (ESRD).

Dr. Hassan Ibrahim, a nephrologist at the University of Minnesota Medical Center, led the team that looked at the health impacts from diabetes and high blood pressure, or hypertension, in living kidney donors. They found that people who have diabetes or high blood pressure have a two to four times higher chance of experiencing reduced kidney function compared to those who do not.

Dr. Darla Granger, director of the St. John Transplant Specialty Center in Michigan, and a transplant surgeon, said that people with diabetes are ruled out as donors at her facility. If a person has high blood pressure and wishes to donate a kidney, they may be considered on a case-by-case basis. Both conditions are top causes of kidney failure. “You don’t want to create end-stage renal disease in someone because you took their kidney,” she said. However, both hypertension and diabetes can be reversed with lifestyle and diet changes. Donors who can reform their lifestyles may be reconsidered, she said.

Both conditions, diabetes and high blood pressure are the top causes of kidney failure. Granger said, “If a person has high blood pressure and wishes to donate a kidney, they may be considered on a case-by-case basis. Obesity is affecting the donor kidney pool and type 2 diabetes is a disease related to obesity. ”

There are so many more people waiting for kidneys than there are available donors. People with diabetes or hypertension who want to help another person by donating a kidney may not realize that they could wind up hurting themselves in the long run. “You don’t want to create end-stage renal disease in someone because you took their kidney,” she said. “But both hypertension and diabetes can be reversed with lifestyle and diet changes. Donors who can reform their lifestyles may be reconsidered,” she said.

Group or Shared Medical Appointments

Group (GMA) or shared medical appointments (SMA) seem to have taken on a life of their own in the last few years. I have been involved with two doctors that have asked me about SMAs and they both were surprised that a lay person (patient) would be promoting them. I have put both in contact with the doctors that have trained their own peer mentors to help them and received their thanks.

Now I am beginning to see some research on group medical appointments. I see little difference between them and they can vary by how a doctor wants to call them.

Medical management delivered via group medical appointments appears to be effective for glycemic control in patients with type 2 diabetes, according to research published in Diabetes Spectrum. It is a shame that this research has to be behind a pay wall, but at least I can use this to give to doctors that ask questions.

Cora A. Caballero, NP, from Loma Linda Healthcare System in California, and colleagues conducted an electronic chart review comparing group medical appointments care for 52 male patients with usual primary care for 52 male patients, all with type 2 diabetes. Demographic and health-related variables were analyzed.

The researchers found that the target HbA1c goals were reached by a greater proportion of group medical appointment patients (50%) than usual primary care patients (19.2%). The rate of decline of HbA1c over time was significantly faster for group medical appointment participants vs usual primary care participants.

"This study demonstrated that the concept of medical management delivered in a group approach had a positive effect on glycemic control in patients with type 2 diabetes," the researchers wrote. "GMAs were found to be an effective approach to achieving patient-centered goals for improving the glycemic control of patients with type 2 diabetes."

No mention is made about secrecy and any problems encountered. I think this is great and hopefully opens the door to more GMAs or SMAs.