Monday, September 9, 2013

Why did my sugar increase?


Why did my blood sugar increase after starting glipizide?

Todays post is a continuation of a discussion from a question ask in July.

Case discussion - intolerance to metformin and gli...


The answer to your question about  glipizide is  a good question that is difficult to answer without more specific  data. 
It was not clear to me  from the the information provided exactly when you were testing  your blood sugars. 
Please read chapter 3  and 4 in my book , Diabetes Office visit , for more details on record keeping that will help you and your physician deal with the sometimes confusing ups and downs in  home glucose test. 
Fasting glucose test
 A persistent increase in fasting glucose could mean that your diabetes has progressed to a new level of insulin deficiency  and  intermittent increases in the fasting sugar could mean that your sugar was to low at  2 to 3 AM . Did you check a 3 am glucose?
 Glipizide could increase your sugar if there was a preceding  low sugar.

Persistent high sugars before meals and bedtime suggest that you are no longer able to make enough insulin to handle the glucose from the previous meal or snack. 

Testing after meals
Increases in after meal sugars can depend on where your glucose was before the meal and how much carbohydrate you had with the meal . if your glucose test was high before the meal then it will be higher after the meal. 
 Read the Feb. post discussing glucagon and it's effect on your blood sugar levels.
Generally after meal glucose test are of limited value for diabetics taking oral medications. Some of the new medication for type 2 diabetes help  reduce after meal test by reducing glucagon levels and stimulating something called " glucose sensitive insulin release " 

After meal sugar test are more useful for people taking insulin before each meal or snacks . The after meal glucose test helps them develop something called insulin / carbohydrate ratios. This ratio allows them vary  the carbohydrates in a meal and to the adjust the dose of rapid acting insulin needed for that meal.

Read some of my Feb. post that deal with oral medications. 

Let me know if this  does or does not answers your question. Continuing this discussion on my web site may help other people with the same questions.  Thanks for your input. Dr. Calder

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Your comments and questions are appreciated. David Calder,MD

Thursday, August 15, 2013

"Don'ts" in life

I am in the process of learning one of the "don'ts" in life. It is not a good idea to buy and start remodeling one house before selling an existing home while starting a new starting a new job.
This web site quickly moved to 4th place in my daily list of things to do. I hope to get back to my almost daily blog soon.
Have fun , be smart and chose to be happy
David Calder,M.D.

Tuesday, June 25, 2013

Diabetes- Insulin Resistance and U 500 Insulin

Question from anonymous:

I am on 275 units of insulin a day and still my BS do not fall below 260. I am worried about taking so much insulin and not seeing any results. I would like to try this U500 insulin but I am also leary about taking something new. There is not much info on this insulin that I can read that is put into laymens terms. Is there a web sight that I can go to that will put it into words that I can understand? on severe insulin resistance and U 500 insulin

My thoughts:
   My personal experience with U 500 insulin was limited to 3 patients. They did achieve some slight improvement in their A1c but did not reach the target goal of 7 . all gained weight gained weight and the U 500 insulin is very expensive. My experience is not to much different than the results obtained in a study published a few years ago.

Clinical experience with U-500 insulin
risk and benefits
Angela Boldo, MD and Richard J. Comi , MD
Endocrine Practice 2012; 18(1):56-61

    66% decreased A1c by .5 or more
     8% achieved An A1c goal of of 7
     Weight gain- 61 to 74 pounds  ( 28 to 34 kg )

 They referenced another study for a definition of severe insulin resistance . 
     1.9 U/2.2 pounds ( 1.97 units/ kg )
 They also mentioned that U 500 insulin onset and duration of action is similar to NPH insulin.
      onset of effect about 45 minutes  
      peak effect 7 to 8.5 hours
      injection frequency 2 to 3 per day with it acting as a basal insulin and also using a rapid acting before meals.

I generally tried to help my patients avoid U 500 insulin for all of the above reasons. Most people with severe insulin resistance are over weight and many have polycystic ovary disease.
Suggested conversation with your doctor
    #1  Weight loss - increase your food management skills by working with a dietitian.
            Ask your dietitian about the Dash diet ( see reference to previous post below)
    # 2  increase exercise with your doctors approval
    # 3 medications to discuss with your physician. ( multiple medications are needed )
         -   Glucophage ( metformin ) is the first choice of medication for treating type 2 diabetes
         -     Byetta or the newer once a week injection of Bydureon
         -     Lantus insulin at bedtime to control your fasting glucose
         -     A rapid acting insulin such as Humalog or Novolog  regulated by insulin / carb.
               ratios may have to be added.

None of the above suggestion are easy and requires a lot of work with diabetes educators and dietitians. Your physician may want to refer you to an endocrinologist to help you work out the details of dealing with insulin resistance. My last consideration is a gastric bypass because of the risk  involved with any surgery.The newer procedures have corrected many of the problems we used to see with this procedure and I have to admit that some of the results have been very good.

Have fun , Be smart and just do what every is necessary to manage your diabetes and preserve your good health.
David Calder,MD

References to previous post on the above topic. Just click on the topic to review the discussion.


Monday, June 24, 2013

Thyroid Hormone replacement

I apologize for getting behind in my almost daily blog. My excuse is work is cutting into my blogging time. I enjoy writing on this website and I especially enjoy your comments. Yesterday, there were 6 comments.  I will do my best to respond to your questions or comments within 24 hours.   We all benefit from your input.

I  recommend reading the comment made by one of former endocrinology partners , Bryon
Musa, MD ,  on 3/19/13 . I have always thought of Bryon as one of the smartest persons I have every know and I had the pleasure of  sharing our endocrine practice for many years. Byron focused on the more complex endocrine problems allowing to focus my attention to diabetes .

Have fun ,Be smart and think about your thyroid hormone replacement
David Calder,

Your comments and questions are always welcome.

Saturday, June 8, 2013

Fainting , Diabetes , High blood pressure Sleep Apnea and the Vagus nerve

 Vagus nerve 
The vagus nerve is the longest most wide spread nerve in our body. This nerve supplies fibers to every organ except the adrenal gland.  Most of these fibers (80 % ) carry information towards the brain and some of these fibers are very sensitive to low blood glucose  and low oxygen levels resulting in a variety of symptoms .

 Common symptoms often associated with the vagus nerve.
   Heart rate - stimulation of the vagus nerve causes slowing of the heart rate and
                        severe stimulation can cause conduction blocks in the heart.
                               The patient discussed in a previous post had transient blocks in the electrical connection between the
                                upper and lower parts of his heart. 
    Sweating  -  especially facial sweating
   Gastrointestinal - Nausea

The patient discussed in a previous post had all of the above symptoms and testing revealed low oxygen levels of 78 %.  Click on the link below to review the case.

The patient above also had hypertension and pre-diabetes and his cardiology work up revealed episodes of slow heart rates including transient heart blocks occuring at night. Blood oxygen levels revealed 98 episodes of anoxia ( oxygen levels dropping to 78 %)  on the night tested. Normal oxygen levels are 95 to 99 % and values below 90% are considered abnormal.

He was diagnosed and treated for Obstructive Sleep Apnea and his oxygen levels and his symptoms have almost completely resolved with CPAP treatment.  He still has occasional mild symptoms of transient nausea and sweating that can be traced back to  an increased number of  night time episodes of apnea  3 to 4 /hour . ( normal is less than 5 ) the night before. The cause for the periodic increase in apnea ( usually for 2 nights ) has not yet been determined.  In addition , his BP is usually increased for 3 to 4 days during and after these periodic episodes.  His BP is nomally controlled  to 130 +- / 75 + - with a diuretic every other day. His Pre- diabetes has not progressed. .

Have Fun , Be Smart and do not overlook sleep apnea 
David Calder,MD


Friday, May 31, 2013

Why is my finger stick glucose often different that a laboratory glucose test ?

Why is my finger stick often different that the laboratory glucose test?

Is there a difference between whole blood and plasma glucose test results ?

   We all put a lot of faith in our home glucose testing equipment and feel comfortable making management decisions based on the test results.  However, have you ever wondered why your finger stick capillary test is often different than the venous glucose test done in a laboratory. There are a number of variables effecting your glucose test results.
   The source of the blood sample ( arterial , capillary  or venous ) and how the blood was processed all make a difference .  Whole blood is usually removed from a vein in our arm and then put into a centrifuge and separated into plasma and red blood cells. The glucose test is then done on the plasma component of the blood. Whole blood can also be allowed to clot which separates the blood into red blood cells and serum.  Your finger stick test is measuring whole blood glucose taken from capillaries in your finger and done on a machine with it's own built in error rate. The last time I checked, meters  are  required to have an error rate of < 20% at glucose levels of 30 to 400 mg/dl.

 From my own personal experience in the hospital and office , where I frequently compared finger stick results with hospital lab. results , I believe the error rate on most meters is small and not a major issue.
The source of the blood effects the results. Arterial blood is about 5% higher than capillary blood and 10% higher than venous blood. You are not likely to be using arterial blood but you will be comparing capillary blood ( finger stick sample) to venous blood that is usually taken from your arm by a lab. Tech. This means ,that if you did a fingerstick test( capillary blood )at the same time as a laboratory test( venous blood) , your result may be a little higher than the lab result by about 5%
Their is another interesting variable to be aware of. Your glucose meter reads” whole blood ” which is about 10 to 15 % lower than “plasma ” used by the lab .. I believed that this was a good thing when I was following hospital patients on continuous intravenous insulin infusion because the hourly finger stick test were a little higher ( capillary whole blood) and made the lab ( venous plasma )and bedside test have a little better correlation .Then the meter builders decide to convert the whole blood results into a plasma-calibrated result. For the doctor this change resulted in higher bedside result and more concern that we may miss low test results.. I had to adapt to the change.
So this is probable a lot more than you wanted to know but it may help you understand why your home test may not match the lab. results. In general our home meter are wonderful machines that have dramatically improve our lives..

Have fun , Be smart and test your blood glucose frequently and learn how to use the results to make decisions in in your daily diabetes management decisions.
David Calder, MD

Wednesday, May 29, 2013

Tips for converting A1c reading to average plasma glucose

 Answer to yesterdays question - 
        An A1c test result of 8  is equivalent to a mean glucose of 183 mg/dl or 10.2 mm/l 

  A1c interpretation tip -
       A 1 point change in your A1c equals a 29 mg/dl or 1.6 mm/l  change in your average glucose.  I
       personally remember the desirable target goal for A1c is 7 which equals 154 Mg /dl ( 8.6 mm/l )
       and the add or subtract  from there. There are calculators that are useful if you happen to have
       it with you at the time. The attached link is to the ADA calculator.
   I have attached a link to an article with more details on this 
   subject.   ull.pdf


    What are the Benefits of A1c testing ?  Glucose in blood binds to  hemoglobin in  red blood cells  and remains attached for the life of the  cell which is about  3 months.  Higher glucose levels are associated with more glucose attachment . The chart below will give you an idea of how A1c results correlate with mean glucose test results.. The chart below was copied from the American Diabetes Association Standards of care         A1C (%)                  Average plasma glucose
                                          mg/dl               mmol/l
        6                                  126                     7.0
        7                                  154                     8.6
        8                                  183                    10.2
        9                                  212                    11.8
       10                                 240                    13.4
       11                                 269                    14.9
       12                                 298                    16.5
    The A1c test is a predictor of the risk for developing diabetes complications. Two classic studies, the DCCT study in Type 1 Diabetes and  the UKPDS  done with Type 2 Diabetes demonstrated a significant   reduction in eye , nerve and kidney damage by reducing  the A1c  to 7. There was about a 30 % reduction in risk for  a 1 % point drop in A1c. There was also a nonsignificant 16% reduction in cardiovascular risk  by reducing The A1c from 8 to 7 in the UKPDS .
 These two large studies  and another one called the Kumamoto study provided the evidence for establishing an A1c result of < 7 as the recommended target goal
Have fun , Be smart and know your numbers
David calder,MD
Question - What is the difference between whole blood and plasma glucose test results ?

Tuesday, May 28, 2013

Question - Define glucose sensitive insulin release .


    Yesterdays questions:
    Define glucose sensitive insulin release. 
       Non- Diabetic:

           Beta cells in the pancreas normally respond to any increase in blood glucose levels with an 

           initial burst of insulin( first phase insulin release that begins with in 2 minutes of food intake) 

           followed by more sustained insulin release ( second phase insulin release ) as needed to
          maintain glucose levels in a normal range.    
       Type 2 Diabetes: 

           The decline of insulin sensitivity to increasing glucose levels occurs very early in the 

           development of type 2 diabetes and is an early marker of Beta cell dysfunction. 

        Significance :

             Sulfonylureas drugs and meglitinides* stimulate beta cells to release insulin with no 

             regard for blood glucose levels which increases the risk of hypoglycemia.

             Some of the newer medications such as GLP-agonist and DPP-4 inhibitors ** restore

             and preserve beta cells ability to release insulin when stimulated by a meal time

             increase in glucose levels. This reduces the risk of hypoglycemia.


             Sulfonylurea type medications produce a continuous unregulated insulin release

             irrespective of a person glucose level and increases the risk of low blood sugars.

             GLP-Agonist and DPP-4 inhibitors produce meal stimulated insulin release and 
             reduce the risk of hypoglycemia               
            *Amaryl ( glimepiride ) , Glucatrol ( glipizide ) , Diabeta ( glyburide ) and others.
             Meglitinides - Starlex (nateglinides ) , Prandin (repaglinide )

          ** Byetta ( exenatide ) , Victroza ( liraglutide )
             Januvia ( sitagliptin ) ,Onglyza ( saxagliptin ) , Tradjenta ( linagliptin ) , Nesina ( alogliptin )

        Where is glucagon made and what does it do ? Hint . Click on the link below.
        Glucagon effects your life every day
    New question -  An A1c test result of 8  is equivalent to a mean glucose of_____ . 
        A little tip for  interpreting your A1c results will be revealed tomorrow.
Have fun , Be Smart and reduce your risk of hypoglycemia
David Calder,MD

Monday, May 27, 2013

Lantus insulin and Byetta is a good combination

                                      Lantus insulin (glargine ) and Byetta ( exenatide ) 

                     This is a very useful combination for people with Type 2 Diabetes

 Lantus is very effective for providing basal insulin and controlling fasting glucose levels.
 Byetta is an excellent choice for controlling the daytime glucose levels

  Byetta allows for glucose sensitive insulin release which reduces the risk  of hypoglycemia
    Byetta slow gastric emptying
    Byetta helps regulate dysfunctional glucagon secretion
    Byetta often helps with weight loss

 Two very good medicines  made better in combination.
  Have fun, Be Smart and talk to your doctor about treatment options

  David Calder,MD 

Questions for tomorrow
     Define glucose sensitive insulin release.  
     Where is glucagon made and what does it do ? Hint . Click on the link below.
     Glucagon effects your life every day




Sunday, May 26, 2013

Type 2 Diabetes , pills not working.Is there option other than insulin ? Maybe

This is an interesting article that opens the door to another treatment option for patients with type 2 diabetes who are considering starting insulin. This study compared the effectiveness of once weekly exenitide 2mg ( GLP-1 Agonist , Bydureon ) to once daily Lantus insulin (Glargine).

Baseline patient characteristic :
                 Bydureon ( exenitide ) 2mg                   Glargine ( Lantus insulin  starting dose 4 units )
 Number              215  patients                                         212 patients          
 Mean age             57                                                          56
 Mean weight       69.9 kg                                                   71 kg
 Mean A1c             8.5                                                           8.5

Results at 26 weeks of treatment :
A1c < 7                 89 of 211 patients ( 42% )                        44 of 210 patients  ( 21% )
A1c <6.5               44 of 214 patients (20.6% )                        9 of 212  patients (4.2 %) 
Weight reduced     yes                                                               no             

 2012 Sep;34(9):1892-908.e1. doi: 10.1016/j.clinthera.2012.07.007. Epub 2012 Aug 9
Efficacy and safety profile of exenatide once weekly compared with insulin once daily in Japanese patients with type 2 diabetes treated with oral antidiabetes drug(s): results from a 26-week, randomized, open-label, parallel-group, multicenter, noninferiority study.


Department of Diabetes and Clinical Nutrition, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
Have fun , Be  Smart and discuss all options with your doctor
David Calder, MD

Friday, May 24, 2013

The ideal patient. Is there one?

On May 17th Doctor Calder wrote about a study that was done and he outlines the findings for you with one caveat.

He states..."Looking at the data in studies like this does does not show the full picture of the long term diabetes management . It is easy to set and achieve ideal target goals for A1c , blood pressure and the other 7 risk factors in the ideal patient. Unfortunately many of us do not fall into that category . Age , general life situation and medication cost play an important role in trying to achieve ideal diabetes management. One size  certainly does not fit all . It is important to remember , test result that are perfect for your neighbor may not be the best one for you."

Now I can tell you from my own perspective I am far from the ideal patient. I believe the Doc will agree with me knowing me the way I am. I have a hard time sticking to a diet. I have a hard time dealing with stress and to be honest all of these factors create and control my blood glucose and my heart. 

One minute I am perfect and then a little stress hits and BOOM my blood glucose flies high or low, just depending.

I use to post a picture of the DNA of diabetes and ask people, "when you do to your Doctor does he or she see this picture or your face?" I asked this because many Doctors, but of course not all look at us as books. They hear us, they try to listen and then they go to the book and they prescribe. The thing is they really don't hear us, they hear words and see numbers and then make a decision. No consultation no nothing.

Then on the other side once they begin to speak to us, how many of us actually understand what they are saying? They have a language all their own just like we are not a book. They speak to us we listen but do we truly understand? Do we really know what they have planned or do we just go out the door take the meds prescribed and go on with life till we see them again?

This scenario is more real than one may think. I happen to have an Internist who believes in listening to me and I do to her. We argue, we discuss, we develop a plan of attack when my numbers, like my A1C are out of whack and then we go to it. The thing is we understand each other and we listen to each other.

Doctor Calder wrote a book "The Diabetes Office Visit" ( get a copy if you haven't) that really help you to understand what your Doctor is saying and how you can speak to your Doctor so they can help you. Amazing book. The perfect guide for both Doctor and patient. In fact I gave a copy to my Internist and maybe that's why we have a great relationship. 

In closing what must be remembered is there is no ideal patient. I don't care what someone says. At some point in their life they were not ideal. So don't let people or Doctors intimidate you by telling you your not ideal. No one is! 

Be well

Friday, May 17, 2013

I believe , the key to success in a persons diabetes care is ____?____ .

I will review some of the abstracts from the recent American Association of Clinical Endocrinologists annual meeting over the next week.

Kelly Khai Li Yap, M.D., Yiyi Yan, Aruna Chelliah
York Hospital

The study included 1226 patients with Type 2 Diabetes with 273 with  A1c results  greater than 8.5%. Among these 273 patients , 119 were not on insulin. A survey was conducted among the primary care physicians treating these patients to investigate the barriers insulin initiation .

 45 % of the physicians responded
 80 % of the responding physicians believed insulin was efficacious
 90 % disagreed that insulin should be started by a endocrinologist
 66 % chose to delay insulin therapy because it was to burdensome for their patients
 60 % said that insulin therapy was to complicated for their patients and more than 50% said the variety
          of insulin products lead to confusion.

" Our study suggests that education is the key to improving glycemic control and insulin usage among
   patients managed by their PCPs."

My opinion:
   Type 2 diabetes is a progressive disease leading to insulin deficiency and the need for insulin replacement . The convenience of oral diabetes medication and the increase complexity and risk of hypoglycemia with insulin is certainly a big factor  in delaying insulin use . Also , many people on insulin still do not  reach recommended target goals . A good example is , this study, 56%  of  patients  were on insulin and  still had  an A1c greater than 8.5 % in order to qualify for this survey.

   Looking at the data in studies like this does does not show the full picture of the long term diabetes management . It is easy to set and achieve ideal target goals for A1c , blood pressure and the other 7 risk factors in the ideal patient. Unfortunately many of us do not fall into that category . Age , general life situation and medication cost play an important role in trying to achieve ideal diabetes management. One size  certainly does not fit all . It is important to remember , test result that are perfect for your neighbor may not be the best one for you.

   The  above problems in diabetes management  was one of the main reason for me writing ,  Diabetes Office Visit  and developing this web site . I believe , the key to success in a persons diabetes care is a well informed patient wanting to preserve their good health  blended with the knowledge and wisdom of their health care provider .  Setting , reaching and maintaining target goals in diabetes care is the secret to maintaining good health.

Know your treatment goals:
  The informed patient knows the American Diabetes Association  recommended goals and their 
  health care provider has the wisdom to help fit those goals into his / her individual life situation.

Ask for a copy of your laboratory test results.

Knowing your treatment goals simplifies your health care
    If your laboratory or exam result is not at  the mutually agreed goal .

  Ask a simple question.
    Doc. ( or other health provider ) , my test is not at our mutually agreed upon goal .

  Can you help me fix it ?

Have fun , Be Smart and Check out the Diabetes Office Visit video above.
David Calder , MD

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