Monday, October 29, 2012

Is our case a victim of "Treatment Inertia"

Diabetes is just a game of numbers

 It is a game that allows you to be less than perfect and still win unless you become a victim of " treatment inertia". Todays post is a continuation of  the case initially discussed Oct 17 and Oct. 22 . Please review the previous post for details.

Quick Review
middle age male with uncontrolled Type 2 diabetes. His fasting glucose is over 300 mg/dl and associated with markedly elevated LDL cholesterol  and Triglyceride level. I  have discussed the problems associated with trying to correct his LDL cholesterol and Triglyceride without first correcting his glucose levels on previous post.

 Today we will discuss " treatment inertia" and insulin options.

"Treatment inertia"
 is common and is basically a failure of diabetes patients and their doctors to adjust treatment regimens to  keep up with with the progressive development of insulin deficiency in people with Type 2 Diabetes

Remember insulin works for people with Type 2 and Type 1 Diabetes . 
Unfortunately insulin it is ofter thought of as the dreaded medication of last resort for people with type 2 diabetes.

Adequate aggressive insulin use will allow  a person with type 2 Diabetes to gain control of their blood sugar and then possible  wean off of / or reduce their dose of the insulin and be able to have a better response to *oral medications or other injectable medications such as Byetta ,Bydureon or Victoza . 

I recall a discussion with a well known Diabetes specialist who started all of his new patients with type 2 diabetes on insulin and taught them how to control their blood sugars. He then waited until their blood sugars were under control and they were feeling well before discussing other treatment options. That approach seems a little extreme but is much better than the more common approach that happens every day in doctors offices around the world, Treatment Inertia.  Treatment inertia is generated by patients and doctors reluctance to move to a medicine that works ,adequate insulin replacement .

Our patient is a self inflicted victim of treatment inertia . He is taking taking insulin but his technique  and doses are inadequate doses to get the job done. As you may recall he has a fasting glucose of over 300mg/dl and takes  inadequate doses of Lantus  and a short acting insulin  and plans to try Bydureon.

 Remember it takes more insulin to bring glucose levels down than it does to maintain them in a lower risk range. 80 to 130 mg/dl

Successful use of insulin requires training and persistance 

 Correct the fasting glucose with adequate doses of Lantus insulin 
 See an endocrinologist if necessary to get and learn how to use  a Lantus insulin adjustment protocol  that will allow you to safely adjust lantus insulin to keep your fasting glucose in the target range .

Correct before meal glucose levels with with a rapid acting insulin such as Novolog or Humalog before the preceding meal. 
Use insulin / carbohydrate ratios plus additional rapid acting insulin before Breakfast , lunch and dinner to correct the glucose before the meal and to cover the carbohydrate to be eaten. This will require work and a few visits with your doctor and /or Diabetes educator.

You will need  2 calculations:
    -Insulin / Carbohydrate ratios
           units of insulin needed / grams of carbohydrate to be eaten 
    -Corrective dose for elevated glucose before the meal
          Insulin Units /  to correct mg./dl ( mm/l )increase in glucose levels

This is easier than it sounds , for example;
   My glucose before lunch is  200 mg/dl ( 11.1 mm/l)
    I plan to eat 60 grams of carbohydrate for lunch
                my insulin carbohyrate ratio is
       1 unit of novolog/ 20 grams of carbohydrate = 3 units
                 my corrective dose is 
        1 unit of Novolog for each 50 mg(2.8 mm/l) increase in glucose  over 100 mg/dl = 2 units

      My total dose of Novolog before lunch = 5 units      

This will allow him to gain control of his glucose levels , feel good again and may

 allow his other diabetes medications to be more effective .He may be able to wean the insulin down slowly and control his glucose levels  glucophage ( metformin) with one injection of Lantus insulin a day and one injection of Bydureon a week ( Byetta twice daily or victoza once daily) or a DPP-4 inhibitor 

*DPP-4 inhibitors                  *GLP-1 Agonist                           *Glucophage
Januvia ( sitigliptin)                         Byetta  or Bydureon (exenatide )          metformin
Onglyzia ( saxagliptin )                   Victorza (liraglutide )
Tragentia (linaglipitin )

Insulin / Carbohydrate ratios
   The amount of rapid acting insulin needed to cover a amount of carbohydrate to be eaten

Insulin / glucose  ratio
Additional rapid acting insulin need to correct an elevated glucose before a meal. This is a very individual number that needs to be developed with help from your doctor or diabetes educator.
 For example  a thin insulin sensitive person may require 1 unit of insulin to correct each 50 mg/dl ( 2.8 mm/L) increase in before meal glucose to their target goal and a heavier person who is more insulin resistent may require 1 unit of insulin/ 5 mg/dl (.3mm/L) to correct a  elevated before meal glucose 

Have fun Be Smart and remember managing diabetes is not easy but the rewards of management are great. Do not become a victim of treatment inertia .

David Calder, MD

Wednesday, October 24, 2012

Triglyceride lowering medication may cause a false positive drug screen

This will be interesting to anyone taking fenofibrate ( Tricor ,Fenoglide ,Lipofen ,Lipidil) . 

This is one of the medications used to help lower triglyceride levels . It may cause a false positive test for amphetamines (Street name  "bennies ")  and Ecstasy  on the routine urine test for drugs.

Have fun , be smart and know your medications side effects. It may keep you out of the slammer.
David Calder,MD

 2012 Oct;34(5):493-5.

False-Positive Amphetamine/Ecstasy (MDMA/3,4-Methylenedioxymethamphetamine) (CEDIA) and Ecstasy (MDMA/3,4-Methylenedioxymethamphetamine) (DRI) Test Results With Fenofibrate.


*Department of Pharmacology, Clinical Pharmacology, and Toxicology Unit, Izmir Katip Celebi University Faculty of Medicine, Ataturk Training and Research Hospital, Izmir, Turkey †Clinic of Psychiatry, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey ‡Clinical Pharmacology and Toxicology Unit, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir Turkey.


ABSTRACT:: This case report describes a false-positive amphetamine/ecstasy [3,4-methylenedioxymethamphetamine (MDMA)] and ecstasy (MDMA) screen after therapeutic use of antihyperlipidemic drug, fenofibrate. A 60-year-old male patient was admitted to inpatient psychiatry unit with the diagnosis of alcohol dependency. He was prescribed diazepam 30 mg/day, thiamine 300 mg/day, and naltrexone 50 mg/day. He had also been using fenofibrate 267 mg/day for 3 years for hyperlipidemia and trazodone 100 mg/day for 5 months for insomnia. On routine, urine drugs-of-abuse screening amphetamine/MDMA (CEDIA) test was positive for 4 different occasions and MDMA (DRI) test was positive on 5 different occasions. Gas chromatography/mass spectrometry confirmation of the first positive 3 samples were negative for amphetamine and MDMA. After discontinuation of fenofibrate, amphetamine/MDMA, and MDMA immunoassay results turned out to be negative. Caution should be given to interpretation of amphetamine/MDMA (CEDIA) and MDMA (DRI) tests in patients taking fenofibrate. Specific confirmation with a suitable method should be used to prevent erroneous interpretations.

Tuesday, October 23, 2012

FDA approves a new continuous glucose monitor

October 8, 2012

U.S. FDA Approves the Dexcom G4™ PLATINUM Continuous Glucose Monitor (CGM)

New Device for Diabetes Management is Most-Advanced CGM Available with up to 30% Improvement in Hypoglycemic Accuracy
SAN DIEGO--(BUSINESS WIRE)-- Dexcom (NASDAQ: DXCM), a leader in continuous glucose monitoring, announced today that the U.S. Food and Drug Administration has approved its eagerly anticipated new continuous glucose monitoring system, the Dexcom G4™ PLATINUM.
Clinical trials report up to approximately 19 percent improvement in overall accuracy for the Dexcom G4 PLATINUM compared to the Seven Plus, and approximately a 30 percent improvement in accuracy in the hypoglycemia range (i.e., when blood glucose is less than 70mg/dl). The overall accuracy and ease of use for the Dexcom G4 PLATINUM sets a new standard for commercially available CGMs, making the Dexcom G4 PLATINUM the most-advanced CGM system available.
"Improved accuracy in the critical hypoglycemic range is most important from a life-saving point of view," said Terrance H. GreggDexcomCEO. "The Dexcom G4 PLATINUM fulfills the promise of CGM for people with diabetes by providing accurate and reliable real-time performance."
Continuous glucose monitoring is considered the most significant breakthrough in diabetes management in the past 40 years. The traditional standard-of-care for glucose (blood sugar) measurement has been a finger stick meter. Although they remain an essential part of a comprehensive diabetes management program, finger stick meters are inherently limited by the fact that, like a photograph, it only provides data for the specific moment in which the measurement is completed; it doesn't show whether glucose is going up or down — or how fast.
By contrast, CGM provides an in-motion picture that shows not only glucose levels, but also the speed and direction in which it is moving, and alerts the user to sudden changes so they can take action.
The Dexcom G4 PLATINUM offers not only outstanding accuracy and performance, but many new capabilities, including:
  • Longest transmission range, enabling improved patient flexibility and convenience
  • A smaller, discrete profile that fits busy lifestyles
  • A first-of-its-kind color LCD display for easy viewing
  • Customizable alerts with specific tones
  • "Hypo alert" setting at 55 mg/dl that provides an increased level of safety — a feature that no other device has.
An ideal and convenient tool for diabetes management
The Dexcom G4 PLATINUM CGM system consists of just three parts: a sensor, transmitter, and monitor.
The tiny sensor - about the diameter of a human hair —is inserted by the user under the skin on the abdomen. A small transmitter sends data wirelessly to a sleek and small monitor, which easily fits in a purse or pocket. It provides data every 5 minutes for up to 7 consecutive days, quickly and easily showing the body's response to medication, food and exercise. If users are outside their target zones, configurable alarms alert them so that they can take action.
The Dexcom G4 PLATINUM is prescribed by a physician and covered by most insurance plans for people taking insulin, and is indicated for use as an adjunctive device to complement, not replace, information obtained from standard home glucose monitoring devices. The company plans to begin taking orders for the Dexcom G4 PLATINUM immediately and expects to begin shipping to patients within the next several weeks. For more information, visit
About Dexcom, Inc.
DexCom, Inc., headquartered in San Diego, California, is developing and marketing continuous glucose monitoring systems for ambulatory use by patients with diabetes and by healthcare providers in the hospital.
Cautionary Statement Regarding Forward Looking Statements
DexCom is a medical device company with a limited operating history. Successful commercialization of the company's products is subject to numerous risks and uncertainties, including a lack of acceptance in the marketplace by physicians and patients, the inability to manufacture products in commercial quantities at an acceptable cost, possible delays in the company's development programs, the inability of patients to receive reimbursement from third-party payors and inadequate financial and other resources. Certain of these risks and uncertainties, in addition to other risks, are more fully described in the company's quarterly report on Form 10-Q for the period ended June 30, 2012, as filed with the Securities and Exchange Commission on August 6, 2012.
Dexcom, Inc.
John Lister, 858-875-5369
Source: Dexcom, Inc.

Monday, October 22, 2012

Treating Insulin deficiency is a game that allows you to be less than perfect and still win

Diabetes is just a game of numbers.  

                   It is a game that allows you to be less than perfect and still win

Todays post is a continuation of post from 10/17 and 10/19. On 10/17 I discussed the idea above and on 10/19 reviewed the  effects of doubling the dose of Crestor on his LDL. Today the discussion will center overall management of this problem.

Case review
I have a friend who shared his recent laboratory results with me . He has had a coronary bypass and was diagnosed with diabetes at the time of surgery. He currently is taking Lantus insulin ? dose, Novolog about once daily if his sugar is high before a meal, and Januvia. His glucose test result are higher than usual , he does not feel well and has lost weight without trying.
Lab test results
      FBS 321  mg/dl
      A1c 10.4
     Cholesterol 271       mg/dl
     LDL Cholesterol 160 mg/dl
     Triglycerides 383    mg/dl
      HDL  34
He does not like the idea of multiple injection and will be starting Bydureon if it is approved by his insurance company and his doctor doubled his dose of *Crestor.
He and his wife are concerned about his test results, especially the LDL of 160 mg/dl while taking Crestor.

Insulin deficiency is the  primary problem for people with type 2 diabetes

 - Doubling the dose of Crestor  and trying Bydureon will be of some benefit but it will not fix the  primary problem ,insulin deficiency. In the absence of any other occult medical problem such as infection , he  needs to take enough insulin to meet his daily needs.  
- He demonstrates the typical progressive loss of  adequate insulin production and this  has to be corrected before an accurate evaluation of his cholesterol and triglyceride can be made.

 - Adequate insulin is needed to effectively use and store glucose and triglycerides as fuel for our bodies . Without enough insulin both glucose and triglycerides will back up in the blood. 

 -You may remember, one fifth of Triglycerides is cholesterol. With a little math , Triglyceride 383/5 = 76.6 mg of cholesterol, we can move his total cholesterol to over 300 mg/dl.

- This man has severe insulin deficiency and this deficiency must be corrected before anything else can be  effectively managed.

Management ideas
#1 Physical exam and lab to rule out reasons other than insulin deficiency as a cause
     for his elevated glucose levels

#2 reevaluate his life style and move towards a vegetarian style of eating . The Dash
     diet is a good place to start .I have attached my thoughts on the Dash diet below.
      He can start applying the basic food management ideas needed to control his blood
               Chapter 5 page 21 of Diabetes office visit   and

           a) recognize foods that contain carbohydrates , fruits, grains , milk and 
           b ) control portion size and start counting carbohydrates
           c ) work on being consistent with daily carbohydrate intake.

 #3 Start thinking about insulin / carbohydrate ratios 

 #4 make the mental decision to do what ever is necessary to control and just do it

Tomorrow---- injectable options

Have fun be smart and remember , applying the basic ideas of glucose control really does work
David Calder, MD

A few previous post to review
My favorite diet ideas including the DASH diet

Dash Diet, Simple Ideas That Work


Friday, October 19, 2012

LDL cholesterol , You can be less than perfect and still win

Diabetes is just a game of numbers.  

                   It is a game that allows you to be less than perfect and still win

I have a friend who shared his recent laboratory results with me . He has had a coronary bypass and was diagnosed with diabetes at the time of surgery. He currently is taking Lantus insulin ? dose, Novolog about once daily if his sugar is high before a meal, and Januvia. His glucose test result are higher than usual , he does not feel well and has lost weight without trying.
Lab test results
      FBS 321  mg/dl
      A1c 10.4
     Cholesterol 271       mg/dl
     LDL Cholesterol 160 mg/dl
     Triglycerides 383    mg/dl
      HDL  34
He does not like the idea of multiple injection and will be starting Bydureon if it is approved by his insurance company and his doctor doubled his dose of *Crestor.
He and his wife are concerned about his test results, especially the LDL of 160 mg/dl while taking Crestor.

Questions -

#1 Will doubling the dose of Crestor have a significant impact on his efforts to get his LDL cholesterol down to 70 mg/dl ? 

 Answer- doubling the does of Crestor will have minimal effect on his LDL cholesterol.
Have you heard of the rule of 7 ? 
Generally the initial dose of a "statin "will lower LDL cholesterol about 30 to 40 %  and doubling the statin dose will only add another 7 %. This makes it unlikely that he will reach his target goal of LDL  of 70 with Crestor alone. 

However he does not have to be perfect to win 
           He will  still have a significant benefit just by taking a "statin".

This was best demonstrated by the Heart Protection Study. This study was done using simvastatin ( Zocor ) in patients with known heart disease or elevated risk of heart disease

    In the study  40 mg of Zocor lowered the average LDL cholesterol by 42mg/dl ( 1.1 mm/l  ) and reduced the  rates of myocardial infarction, of stroke and coronary bypass surgery by about 25% regardless of age , sex or initial LDL level .  

 The CARDS study was done using Atorvastatin ( Lipitor ) 10 mg in people with type 2 diabetes with at least 1 risk factor for heart disease . Their average baseline  LDL was 129  mg/dl  and Lipitor 10 mg/day helped 75% of the study group achieve an LDL cholesterol of 93 mg% (2.4 mm/l) and 25% achieved LDL 's of 64 mg/dl (1.6 mm/L ).

 The people taking Lipitor benefited with   strokes reduced 48% , coronary Bypass graft  reduced 31% and acute Myocardial infarcts reduced 36%
 Just taking lipitor 10 mg/day Prevented 1 Cardiovascular event /37 pts./1000 treated for 4 years even though 75% of the people in the study failed to achieve the recomended target goal of 70 mg/DL (1.8 mm/L )

Good studies demonstrate that our friend will benefiting by just taking  Crestor . However he will  probable not gain much from doubling the dose  .

What else can he do?
Will controlling his blood sugars help control his abnormal lipid problem ?

This discussion will continue tomorrow.

Have fun , be smart , follow your doctors advise and take your Statin
David calder,MD

 commonly used "Statins"
atorvastatin (Lipitor )
simvastatin (Zocor)
rosuvastatin ( Crestor)
pravastatin ( Pravachol )
lovastatin  (mevacor )

When the data was corrected
           for other variables , zocor reduced the risk compared to controls  by about 1/3 rd. treatment for 5
           years will prevent 70 to 100/1000 from having a CV event

Wednesday, October 17, 2012

Diabetes is a game that allows you to be less than perfect and still win

Diabetes is just a game of numbers.  

                   It is a game that allows you to be less than perfect and still win

 There are a lot of " to does "  that don't always get done in our daily lives with diabetes
I have discussed the idea of " fixing the nine" in previous post and it is also a page on this web site . Many of us will not be able to consistently reach the" recommended goals". 

I believe the "recommended  goals" evolved from averages results of less than perfect people in research study's. This means ,there was a range of perfect , better than perfect and worse than perfect results that produced the average results we call "goals". 

So how close do we need to get to the recommended goal to still benefit? I will start the discussion with LDL " goals " tomorrow.

Please review , Risk factor management can Prevent Heart attacks and strokes , at the top of site. I have also attached links to previous post dealing with this subject .

Type 2 Diabetes. Are you focused on the wrong prob..

.Recommended goals for LDL cholesterol. Is there a .. 

Goals for LDL cholesterol. Is there a level of opt...

Diabetes management- " any target could (should ) ...

Have fun, be smart and remember any improvement is better than no improvement
David calder,MD

ps. Google changed Blogger a little bit and interfered with my blogs. Everything is OK now.

Sunday, October 7, 2012

"life with diabetes sucks" is not true ! Diabetes is your body's early warning system

I saw a comment on twitter this morning ," life with diabetes sucks".
This is a common understandable feeling that I do not agree with.    My thoughts.

Diabetes as your body's early warning system
 I will ask you think of Diabetes as your body's early warning system  providing you with the opportunity to defend your good health. 

 Life after a stroke, massive heart attack , vision loss , kidney failure or amputation really sucks. Many people without diabetes just wake up with a sudden stroke or heart attack and immediately, without warning or mercy, their lives dramatically change forever.

 My approached to managing diabetes has been framed by years of observation of people in my medical practice, my friends and family. My dad and my good friend Tony died in their 50's of sudden massive heart attacks without being given the privilege of a early warning system like diabetes. I am sure they would have loved to have been giving the opportunity to fight for their lives.

The diagnosis of diabetes is a opportunity 
 Consider the diagnosis of diabetes ( especially Type 2 ) as an opportunity , a early warning system , picked up by your body's radar giving you an opportunity to fight and defend the home your soul lives in. 

 The technology and tools are available to defeat diabetes.
 The increased glucose, slight increase in blood pressure , LDL cholesterol and triglycerides is the early warning providing you with the time and opportunity to look the enemy in the face and declare that you will never yield. The technology and the tools are available to defeat diabetes.

Pick up the Tools
You have  the privilege and the option to pick up and use the existing tools .

Make the right choice

Have fun , Be smart and pick up the tools ad review the the link below.

Diabetes- knowing the risk is our advantage"
David Calder,MD

Wednesday, October 3, 2012

Diabetes Office Visit Update is still not complete

Diabetes office visit.

We are still working on the update. The problems are in the risk management section. Please avoid this section until we have corrected the problem . Every thing else is working and I think the ability to view lab. test in mg/dl or mm/L , will make tracking lab result  easier for everyone out side the United States.

Have you updated your iphone and/or ipad to IOS 6.0?

I apologize for the update problems. Thanks for using Diabetes Office Visit.     Dr. Calder