Diabetes control: what if my sugars are too high?

So, having posted a few days ago on good blood sugar goals, an obvious good question is what about if they are higher than goal?

Pills are used to improve blood sugar control and to prevent eventual and inevitable failure of insulin production by your pancreas.

However, diet and exercise are 2-8 times more effective than pills in maintaining normal blood sugars and body weight. A major reason to use pills is that diet and exercise cannot keep your pancreas from eventually needing insulin, and pills can prevent this.

Insulins are used where your body has simply become unable to make insulin for itself.

If sugars first thing in the morning or before meals are over 125, it usually means the meal before this was high in carbohydrates and or that you were not very physically active (such as sleeping or sitting at a desk all day). If you take fast insulins (such as Humalog) before meals, it may mean that the amount you took was too small.

You can get lower sugars in these settings by eating less, being more active or exercising, or by increasing the dose of pills that help to maintain greater insulin responsiveness (such as metformin). If you use insulins and you fasting morning sugars are under 125, but later pre-meal sugars are higher, then increase your fast insulin dose by 1-2 units for the meal before this. For example if your pre-dinner sugar is 155 and you took 5 units of fast insulin before lunch, next time try 6-7 units before the same kind of lunch.

If you are seeing higher than goal sugars after your meals, then try reducing the size of your meals. You may need to increase the dose on pills that help your pancreas to put out more insulin (such as glimiperide, Glyburide, or Precose) or increase your before meal doses of fast insulins.

If you are using long-acting insulins (such as Lantus), then your fasting morning blood sugars are telling you how well your dose is working out for you. The sugar goals for this time are the same as everyone else's: 80-125 is good to go.

If they run over this for over 3 days in a row, then increase the Lantus dose by 2-3 units every 2-3 days until it falls back into this zone and then stay at that dose.

If they are under 80 for 3 days in a row, then go the other direction. Decrease the Lantus dose by 2-3 units every 2-3 days until your morning sugars come back up into the zone, and then stay at that dose.

Rules of thumb:

• Fasting AM sugars reflect overall steady basal insulin activity which maintains normal baseline sugars.
• Pre-meal sugars show how your body is doing with your last meal and activity level since then.
• After-meal sugars are telling you about how much and what you just ate and how well medicines that help with this are working for you.
• Feel free to call or see me if you are concerned about your blood sugar control, medicines, or what to do next!
  

Diabetic Labs: what are those every 3 month tests for?

Every 3 months, you should have a test done called a glycohemoglobin A1c, or glyco for short.

This is a test that tells us what your average (mean, actually, if you are savvy about statistics) blood sugar has been over the prior 2-3 months.

What it actually is is a measurement of glucose (blood sugar) molecules that have become stuck to hemoglobin molecules in your bloodstream. Hemoglobin is the large molecule in your red blood cells that helps to pick up and deliver oxygen to your organs.

Naturally, the normal number is not zero since you'd have to have no blood sugar or no hemoglobin!

People without diabetes have a glyco between 4.0 and 6.0, where 5.0 is an average blood sugar of 100.

If you have diabetes, this test result would be higher because your blood sugar is higher than it should be.

The glycohemoglobin test is useful because it tells us how well controlled your blood sugars have been over a 2-3 month period around the clock and not just at times you check it or the morning you go to the lab. Here is a table that shows how high your average sugar is depending on your glyco test result. A rule of thumb is add 40 points for every 1.0 above a test result of 5.0.

The American Diabetes Association recommends a glyco of under 7.0, however endocrinologists (specialists in gland disorders, including diabetes) recommend under 6.5.

I recommend this lower goal of under 6.5, too.

Under 7.0 does reduce your chances of diabetes causing damage to small blood vessels and causing blindness, nerve pain, kidney failure, erectile dysfunction (male impotence) and circulation problems to your feet.

However, getting the glyco under 6.5 accomplishes this and also prevents damage to larger blood vessels and thereby reduces your chances of having a cardiac arrest, heart attack or stroke. I think it's worthwhile going for the brass ring here, as long as efforts to do so are not causing problems with hypoglycemia or medication side-effects.

As to that computer print-out you get at the lab, do not worry about it!

• It is not a bill, and signing it does not mean MediCare or your insurance will bill you. (If you don't believe this, read the fine print carefully and think like a contract lawyer while you're doing it.)
  
• MediCare covers glyco tests every 90 days for stable well-controlled diabetes. When they say 90 days, they mean it so do know when was the last one so you can avoid this problem. Feel free to ask, too.
• If your diabetes is not well-controlled as your doctor defines it, then MediCare will pay for glyco tests more frequently than every 90 days.
• We are very careful to make sure that your lab forms reflect this, so that if we instruct you to get tests done more frequently, this will not result in a billing problem for you.
• Bear in mind that the lab simply generates a form any time they are asked to do any test for any reason where MediCare may have a time limit! THIS IS NOT THE SAME THING AS BEING TOLD YOU WILL BE BILLED. THIS IS COMPUTER-GENERATED PAPERWORK!

End of rant ; . )

Diabetic Blood Sugar Goals: where should my blood sugars be?

If you have diabetes, checking your blood sugar is a great way of being able to instantly tell how your body is responding to your diet, exercise habits and medications (whether pills, insulins, or both).

The latest generation of glucometers (finger-stick blood sugar monitors) are easier to use than older ones as they need such a small amount of blood you can test easy and less painful sites such as the forearm or sides of the fingers.

As for how low your sugars should be, the answer is basically as close to normal as possible without going so low that hypoglycemia (low blood sugar) occurs.

Fasting (first thing in the morning and pre-meal sugars should be low enough to reflect good overall blood sugars. After eating, sugars will of course be higher since your body is breaking down your food and absorbing vital nutrients into your blood for use and storage. This includes glucose, or blood sugar.

Good goals to meet are:

Fasting or pre-meal: 70-130
1 hour after eating: under 280
2 hours after eating: under 180
3 hours after eating: under 150

Notice that these goals may vary somewhat depending on the recommendations of various medical organizations (such as here, and here).

Where these recommendations all agree is that the goal is to keep your sugars as close to normal as is possible and safe, so that your are reducing as much as possible the risks of diabetes harming your body.

More coming up on what to do if your sugars are too high, and what are those every 3 month lab tests for?

Generic medicines: just as good as the brand name

When a drug company researchs, develops and then markets a new drug, the law provides a period of time in which it is illegal for anyone else to copy it and then sell it. This is intended to give drug companies an incentive to research and sell new drugs.

After a period of several years, it becomes legal for other manufactures to copy it and sell it under other brand names or generic labels.

The FDA requires that generic versions are within 5% margin of error of the brand name drug in terms of how it is released into your bloodstream over time. In other words, generics have to be the same chemical as the brand name drug with very similar action in your body.

On the other hand, it is possible for one generic to be 5% "above the curve" and for another to be 5% "below the curve" which means that the two generics might be 10% different in how they get in and out of your system.

For the most part, this difference does not seem to result in clinical differences or outcomes in a variety of medicines including blood pressure, cholesterol and hormonal medicines.

Mind you, it is possible that reactions to inert ingredients that are in one generic but not another may account for side-effects such as rashes or stomach upset.

Serevent and Foradil

Recent news coverage raises concerns on the part of the FDA (Food and Drug Administration) of these two long-acting medicines.

Both are taken twice a day, and both are bronchodilators which work by relaxing your breathing tubes and allowing them to open up.

If you are supposed to use these daily for emphysema, that's perfectly safe to do.

The safety issue on these medicines is around asthma. Asthma involves unusual sensitivity of your lungs to allergens or irritants and needs to be treated with inhaled steroids (such as Advair, Flovent, Beclovent, AzmaCort, etc.) which prevent sensitivity reactions from occurring.

The problem, then, is that if you just use the bronchodilators without the steroids (treatment without prevention), inflammation in your lungs can progressively worsen and cause potentially fatal asthma flare-ups. Using bronchodilators alone is a bit like hiding the smoke without putting out the fire.

We'll be away over the holidays!

The office will be closed on Wednesday the 24th and open as usual on Monday the 29th for the Christmas holidays. Phone calls to the office will connect you to the doctor on call.

Also, we will be out on Thursday and Friday January 1st and 2nd of the New Year to celebrate the New Year holidays. Again, phone calls will put you in touch with the doc on call. We'll be back as usual on Monday the 5th.

Plan if you have specific needs such as prescriptions or other concerns.

Have a wonderful, happy and healthy holiday season!

Keeping away the colds and flus

Colds are certainly going around, and influenza (the flu) has been cropping up in a few states such as Florida and Washington. The flu that has been seen so far is not unusual, and if you have received a flu shot this should help.

The most important and effective ways to not get colds and flus are avoidance and hygiene.

• Wash your hands frequently with soap and warm water, or waterless hand cleanser. Anti-bacterial soaps are more expensive, but are not better. It's the scrubbing action that rids your hands of bacteria and viruses. A thorough hand washing should take as long as it takes to sing the Happy Birthday To You song twice (to yourself in your head, if you prefer : .).
• Avoid rubbing your eyes, and touching your nose and mouth. This is how bacteria and viruses enter your body!
• Avoid being around people who are obviously ill. This is tricky with Christmas coming up, but if you or your children are ill it's polite to inform family and other guests in advance.
• Masks are useful in preventing the spread of colds and flus.
• Surgical masks like those worn in operating rooms are disposable and made of thin paper-like material. These are worn by the sick person to prevent coughs and sneezes from throwing cold and flu viruses into the air, where they can float for up to several hours afterwards. They do not keep you from inhaling bacteria and viruses into your mouth and lungs!
  
• N95 respirator masks are reusable and are worn by well persons to filter out bacteria and viruses when you breath. This link shows several places you can buy them. They can often be found in hardware stores (for workers around fine dusts), and in medical supply stores (for allergy sufferers).
• N95 masks are so called because they are certified by NIOSH (National Institute of Occupational Safety and Health) as filtering out 95% of workplace dusts and particles. Because of the material used, they actually filter out 99% of bacteria and viruses including TB, pneumonia, colds and avian flu ("bird flu").
• Get the kind that have a valve for breathing out because they are much more comfortable to wear.

Hopefully, these steps will help you to stay well during the cold and flu season!

Things that should concern you that you may have something more serious could include chest pain, shortness of breath or wheezing. Please feel free to call us to be seen as soon as possible to make sure that you don't have a more serious condition such as asthma or pneumonia.

Nosebleeds

'Tis the season for nosebleeds; the air is drier, indoor heating is in use and colds and flus abound.

Most nosebleeds occur because each nostril has a network of small, delicate blood vessels right at the opening of the nostril (Keiselbach's plexus, for those who like to know these things).

Problem is, this plexus in in reach of your hand meaning that sneezing, rubbing or wiping your nose (or picking your nose) can physically damage them and result in bleeding.

Most remedies for nosebleeds seem like remedies for hiccups- mainly designed for the amusement of bystanders.

Direct pressure stops bleeding in the nose just like it stops bleeding from other places such as a cut on your hand.

So, treat nosebleeds as follows:

1. Press firmly but gently along the side of your nose with your finger.
2. Do not tilt your head back (tasting your own blood is off-putting), do not pack your nose with Kleenex (you remove blood clots are renew the bleeding when you take it out).
3. DO THIS FOR 15 MINUTES WITHOUT LETTING UP THE PRESSSURE!
4. It takes 15 minutes to not only form a blood clot, but for it to be hard enough so that when you let up on the pressure it doesn't just fall apart.
5. This cannot be over-emphasized; 15 minutes is a long time in our hurry, hurry, hurry society. If you need to watch TV and wait through two entire sets of commercial breaks, do it.
6. If necessary, repeat again.
7. If this doesn't work, spray 3-4 puffs of an over-the-counter nasal decongestant spray (Afrin, Neo-Synephrine, 4-Way, etc.) into the bleeding nostril to shrink down the blood vessels and try 15 minutes of direct pressure again.
8. If this still hasn't work, you should call to be seen or go to the emergency department.

Nosebleeds are generally not a sign of high blood pressure. It takes an exceedingly high pressure to cause this to occur, such as 170-240 on your blood pressure cuff. Mind, if your blood pressure is that high you should be seen urgently about this.

Medicare Part D

You still have time to add prescription drug coverage to your Medicare!

Open enrollment ends at the end of this month.

Until then, you can go on-line or call 1-800-MEDICARE to get help adding this to your Medicare Part A and B (these cover hospital and outpatient medical care).

Basically, these are commercial insurance plans that meet or exceed standards set by the federal government. They are used for covering the costs of you medications.

There are lots of choices, and lots of differences in cost. The last time I looked, there were over 50 plans in California and the average premium was about $45/month.

DO. NOT. PANIC.

First of all, if you have very little money (make less than $14,355/year yourself, or less than $19,245/year as a couple at last count) you may be entitled to Plan D at no cost to you at all as long as you pick a plan that does not exceed the average premium cost for California.

Second, use the available resources to narrow your search:

• You live in California. Only look for plans offered in California.
• Most generic drugs are not a real issue. The ones that aren't generic are the ones that will cost you (such as Actos and Avandia for diabetes, brand name insulins like Lantus and Humalog and ARB's for blood pressure and heart failure like Diovan, Cozaar and Atacand). Generate a list of your expensive drugs, and then look for plans that cover them.
• If you already have Part D and always end up having to pay full cost on you pills before the end of the calendar year, this does not mean that your insurance no longer covers it! This means you've hit the "donut hole" for the year.
• This means Part D has covered $2,250 for the year and that you are on the hook for the next $2,850. If you go past that for the year, then Part D picks up for the rest of the year.
• If this keeps happening to you, pay a bit more for a plan with "donut hole" coverage!

This link shows all the plans available for 2009 in El Dorado county in nice neat columns showing what they are called, how much they cost, whether they are free to low income folks and whether they have gap (donut hole) coverage or not.

It also provides links to the plans so you can see all the details, and toll-free numbers for folks who prefer telephoning.

Use it or lose it!

Diabetes control: low blood sugars

Having addressed blood sugar goals, and treatment of high sugars, what about lows?

Developing low blood sugar (hypoglycemia) can be frightening, since most people find that they suddenly feel very shakey, weak "like someone just pulled the plug on me". If your blood sugar reading is under 70 (which means a lab would find that it is under 55- 60) or has dropped quickly over a short period of time to low-normal levels, then you may find your self feeling this way all of a sudden. If you do, DO. NOT. PANIC.

If it is convenient and safe to do so, go ahead and check your blood sugar. Certainly, if your were in a hospital or ER and said this was how you felt, we'd stick your finger immediately and find out if that was the trouble.

If it is indeed low, then have something to eat or drink. Orange juice is fine, but really anything with a few carbs is okay. A piece of bread, a few crackers a piece of candy, a piece of fruit will do just fine. You should feel back to normal in a few minutes. If you don't, then re-check your blood sugar.

It is generally not necessary to eat large amounts of food or drink over the few minutes until the hypoglycemic symptoms resolve. This can result in weight gain and very high blood sugars for hours afterwards.

The goal is to get low sugars back up into a normal range of less than 125 quickly and safely without feeling compelled to over-do it.

Certainly, frequent episodes of low sugars are something we should discuss to determine whether any of your medications doses are too high.

Low sugars that don't respond to eating, keep dropping back or are causing fainting or near-fainting are a serious emergency for which you should call 911 or be taken to an emergency department.