Current 'risk reduction' standard of care reduces the chance of heart attack and stroke by 30-50%. That still leaves a huge number of people at risk for one of these events. Heart attacks (myocardial infarction) is the number one killer in the U.S. and stroke (CVA- cerebrovascular accident) is number three.
The Bale-Doneen method proposes that risk can be close to zero with proper evaluation and treatment. The method goes far beyond the 'consensus' recommendations for blood pressure and cholesterol and goes as far as genetic studies to further evaluate risk and best treatments. There are short videos discussing the program here and there.
Dr. Lardinois and I attended the preceptor course in Las Vegas on Feb 25-26. We will be instituting a heart attack and stroke prevention program in the near future. Stay tuned to this blog for further information.
Monday, February 28, 2011
Wednesday, February 16, 2011
If you are going to see your car mechanic...
because your car was making a funny noise; you describe what it sounds like, when it happens etc. The mechanic says 'I have some ideas about what may be wrong. Let me take a look'. You are shocked that he might actually want to look at the car itself to figure out what needs fixing.
Sounds silly, doesn't it? It happens every day at my office. People come in for diabetes care, they tell me what the blood sugars are running but they don't bring in the log book or meter. For some they remember only the highest blood sugars and are surprised that the A1c is so good. Others remember only the good blood sugars and are surprised when the A1c comes back high. Some remember testing frequently when the meter has only 1-2 tests per month.
I like helping people with diabetes. I can't help much if I don't have enough information. If the A1c is above target range and I don't have any home glucose values to guide my treatment decision then I take an educated guess on what will work best.
Some people are fortunate enough to have amazingly stable blood sugars with A1c consistently under 7% without having hypoglycemia. These people don't need to test every day. If you are one of these people, congratulations on doing so well and disregard the next comments. If you are not one of these fortunate people, please consider these recommendations.
Help yourself out the folowing ways:
1. The best data is a log book with space for date, time, glucose values, medication doses and food. One commercial product is called 'my other checkbook'.
2. If you think that level of effort will not provide equivalent benefit, then record the date, time and blood sugars. The manufacturer of your meter will provide/sell such log books that fit nicely in the meter carrying case. Call the toll free number on the back of your meter to order them.
3. If writing down information is not your style, bring in you meter. Please have the correct date and time in it. If the date and time are incorrect, call the toll-free number on the back of the meter to get instructions on correcting the date and time.
4. If you are in to digital data, get a download cord and software to generate some data for your visit. Don't forget to print it and bring the results with you.
If none of this matters to you, ask yourself why you are seeing a specialist for your diabetes.
Sounds silly, doesn't it? It happens every day at my office. People come in for diabetes care, they tell me what the blood sugars are running but they don't bring in the log book or meter. For some they remember only the highest blood sugars and are surprised that the A1c is so good. Others remember only the good blood sugars and are surprised when the A1c comes back high. Some remember testing frequently when the meter has only 1-2 tests per month.
I like helping people with diabetes. I can't help much if I don't have enough information. If the A1c is above target range and I don't have any home glucose values to guide my treatment decision then I take an educated guess on what will work best.
Some people are fortunate enough to have amazingly stable blood sugars with A1c consistently under 7% without having hypoglycemia. These people don't need to test every day. If you are one of these people, congratulations on doing so well and disregard the next comments. If you are not one of these fortunate people, please consider these recommendations.
Help yourself out the folowing ways:
1. The best data is a log book with space for date, time, glucose values, medication doses and food. One commercial product is called 'my other checkbook'.
2. If you think that level of effort will not provide equivalent benefit, then record the date, time and blood sugars. The manufacturer of your meter will provide/sell such log books that fit nicely in the meter carrying case. Call the toll free number on the back of your meter to order them.
3. If writing down information is not your style, bring in you meter. Please have the correct date and time in it. If the date and time are incorrect, call the toll-free number on the back of the meter to get instructions on correcting the date and time.
4. If you are in to digital data, get a download cord and software to generate some data for your visit. Don't forget to print it and bring the results with you.
If none of this matters to you, ask yourself why you are seeing a specialist for your diabetes.
Wednesday, February 9, 2011
Glucagon excess in diabetes- what to do?
Gucagon is a hormone produced in the pancreatic islet alpha cell. glucagon stimulates the liver to release sugar into the blood. Glucagon is normally produced as blood sugar drops in an effort to prevent hypoglycemia. In people without diabetes glucagon drops to zero when eating. However, in diabetes glucagon is increased when the person eats. The blood sugar goes up not only from the food but also from abnormal glucagon increase causing the liver to release glucose. Treatment for this abnormal glucagon is limited.
Symlin is a medication for people on insulin to take at meal time to reduce glucagon. It is only available by injection. It is effective but can be difficult to adjust to since it lowers mealtime insulin requirements. I have used Symlin when it originally came out as a vial-and-syringe treatment. I used it again when it was released in a pen device. It curbed my after-meal blood sugars and also reduced my appetite. However when it wore off in 3 hr I was hungry again. A physician suggested I try it in a pump. I absolutely loved it! I had a basal rate of Symlin as well as bolusing at meals. Blood sugars were very even and I didn't have rebound hunger. My daily insulin dropped form 28 to 24 units. When I was on a long bike ride I would suspend the Symlin so I could maintain hydration and nutrition without feeling full. The downside was keeping track of two pumps, when each one was due for a change, different alarms for batteries, low reservoir, etc. I considered using an Omnipod for the Symlin. I decided against it because the Omnipod requires 80 units minimum fill. I was using less than 20 'units' of Symlin in 3 1/2 days. I suppose I could run insulin in the 'pod and Symlin in a tubed pump but the overall hassle is huge regardless.
Byetta and Victoza are glucagon-like peptide 1 (GLP-1) replacements that increase GLP-1 by 6-10x the normal blood level. These are both approved for treating T2DM but not with insulin. They are potent in keeping glucagon low after meals. In clinical trials about 75% of patients lose weight on these products. I chose to try Victoza because it is once daily compared to Byetta twice daily.
Victoza hit hard at the beginning. On the lowest dose I felt full most of the time. It was hard for me to stay hydrated I felt so full. My mouth was dry most of the time. After a few weeks the side effects eased up dramatically. I could eat little and not be excessively hungry. Blood sugars after meals have generally been under 170. Insulin dose is around 25 units daily, down from 28-30. I've yet to take it during hot weather so I don't know how well hydrated I can stay on long bike rides.
I have prescribed Byetta and Victoza for T2DM patients on insulin and they generally work well. I've tried both in a few T1DM patients with variable effectiveness. One of the greatest difficulties is cost. Because neither product has FDA approval for use with insulin the insurance companies use this as an excuse to not pay for the product. Please keep in mind that this 'off-label' use is not forbidden; it means that there has not been sufficient data submitted to the FDA for that use to be 'indicated'.
What is next? I am hoping that Byetta or Victoza seek approval for use with insulin. I don't know if either company will go to the trouble of performing necessary studies to gain approval. It would be ideal if Symlin could be mixed with insulin but the current formulation is not stable with insulin. Maybe Amylin Pharmaceuticals will cook up an alternative recipe that is stable with insulin in a pump. There are many new GLP-1 agonists in development. Maybe one of them will start with insulin compatibility.
Symlin is a medication for people on insulin to take at meal time to reduce glucagon. It is only available by injection. It is effective but can be difficult to adjust to since it lowers mealtime insulin requirements. I have used Symlin when it originally came out as a vial-and-syringe treatment. I used it again when it was released in a pen device. It curbed my after-meal blood sugars and also reduced my appetite. However when it wore off in 3 hr I was hungry again. A physician suggested I try it in a pump. I absolutely loved it! I had a basal rate of Symlin as well as bolusing at meals. Blood sugars were very even and I didn't have rebound hunger. My daily insulin dropped form 28 to 24 units. When I was on a long bike ride I would suspend the Symlin so I could maintain hydration and nutrition without feeling full. The downside was keeping track of two pumps, when each one was due for a change, different alarms for batteries, low reservoir, etc. I considered using an Omnipod for the Symlin. I decided against it because the Omnipod requires 80 units minimum fill. I was using less than 20 'units' of Symlin in 3 1/2 days. I suppose I could run insulin in the 'pod and Symlin in a tubed pump but the overall hassle is huge regardless.
Byetta and Victoza are glucagon-like peptide 1 (GLP-1) replacements that increase GLP-1 by 6-10x the normal blood level. These are both approved for treating T2DM but not with insulin. They are potent in keeping glucagon low after meals. In clinical trials about 75% of patients lose weight on these products. I chose to try Victoza because it is once daily compared to Byetta twice daily.
Victoza hit hard at the beginning. On the lowest dose I felt full most of the time. It was hard for me to stay hydrated I felt so full. My mouth was dry most of the time. After a few weeks the side effects eased up dramatically. I could eat little and not be excessively hungry. Blood sugars after meals have generally been under 170. Insulin dose is around 25 units daily, down from 28-30. I've yet to take it during hot weather so I don't know how well hydrated I can stay on long bike rides.
I have prescribed Byetta and Victoza for T2DM patients on insulin and they generally work well. I've tried both in a few T1DM patients with variable effectiveness. One of the greatest difficulties is cost. Because neither product has FDA approval for use with insulin the insurance companies use this as an excuse to not pay for the product. Please keep in mind that this 'off-label' use is not forbidden; it means that there has not been sufficient data submitted to the FDA for that use to be 'indicated'.
What is next? I am hoping that Byetta or Victoza seek approval for use with insulin. I don't know if either company will go to the trouble of performing necessary studies to gain approval. It would be ideal if Symlin could be mixed with insulin but the current formulation is not stable with insulin. Maybe Amylin Pharmaceuticals will cook up an alternative recipe that is stable with insulin in a pump. There are many new GLP-1 agonists in development. Maybe one of them will start with insulin compatibility.
Friday, February 4, 2011
Osteoporosis treatment extends life
A study published in the Journal of Clinical Endocrinology and Metabolism (and summarized in the LA Times Booster Shots ) reports that bisphosphonate therapy reduces mortality in women and men. Mortality was not reduced by vitamin D + calcium therapy compared to no treatment. Bisphosphonates include Fosamax, Actonel, Atelvia, Boniva and Reclast. Even though these medications can cause a rare condition called osteonecrosis of the jaw the benefits of fewer fractures and longer life would appear to outweigh the risk of side effects.
Wednesday, February 2, 2011
Sprinting to prevent hypoglycemia
I found some interesting articles during a literature search on interval training. The most interesting was controlled observations that in type 1 diabetes, a 10 second all-out sprint either at the beginning or end of 20 min moderate exercise reduced hypoglycemia after exercise. The sprint did not prevent blood glucose from dropping during exercise.
Additional tidbits: (1) High intensity interval exercise (HIIE) releases more weight than prolonged low intensity exercise. This may be due to increased adrenaline and its tendency to burn fat. (2) HIIE improves aerobic performance as much as intermediate intensity exercise performed for a much longer time. (3) HIIE improves anaerobic capacity and this does not occur with intermediate intensity exercise.
If you are interested in adding HIIE to your exercise program it would be prudent to work with a trainer who has familiarity with this type of exercise. There are many web sites promoting various HIIE protocols. You want to pick one that has research data to demonstrate its efficacy.
Additional tidbits: (1) High intensity interval exercise (HIIE) releases more weight than prolonged low intensity exercise. This may be due to increased adrenaline and its tendency to burn fat. (2) HIIE improves aerobic performance as much as intermediate intensity exercise performed for a much longer time. (3) HIIE improves anaerobic capacity and this does not occur with intermediate intensity exercise.
If you are interested in adding HIIE to your exercise program it would be prudent to work with a trainer who has familiarity with this type of exercise. There are many web sites promoting various HIIE protocols. You want to pick one that has research data to demonstrate its efficacy.
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