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Home glucose measuring and the availability of Glucose Strips.

At the Diabetes Control Center, we use home blood glucose levels to alter therapy.  It is not necessary to repeat here the proven health and economic advantages of diabetes control.  To adequately treat uncontrolled diabetes, it is necessary to evaluate blood glucose levels at different times of the day.  It is very difficult and time consuming to do this with (an oft unreliable) written glucose log and virtually impossible by scrolling through the memory of a glucose meter. We therefore download glucose meters whenever possible.

New challenges for us and our patients appeared at the start of 2014 with changes in insurance “formularies”. Insurers now insist that patients switch from standard brand testing meters and strips to something cheaper. This is especially vexing after we have established a pattern for blood glucose control in difficult diabetes by periodically downloading glucose meter data and making therapeutic changes based on pattern analysis. The often stated rationale is the Affordable Care Act. I’m convinced the changes are to improve the insurer’s financial health as opposed to the patient’s well-being. It seems like a simple excuse to line their coffers and blame a healthcare program designed to cover most people in need. I am not so naive to think that our financial system doesn’t need a profit motivation for growth and innovation. However, a balance between good practices/societal well-being and profit must be struck (or enforced? [John Boehner please don’t exterminate me, I’m a "Conservative" in my circles]).

We find that most of the newer, “approved” cheaper meters are downloadable but have software designed to retrieve data for a single patient, simply not usable in a diabetology office. The great majority of our patients don’t have the resources to collect glucose meter data and bring to the office.

Enough on that. Here’s is what I found when attempting to see what alternatives my patients have when it comes to glucose strips.
A recent Internet search for prices of glucose test strips was revealing. What I report is not a fair because the search was limited to Amazon because of their return policies. There are likely other reputable companies with similar or better prices. Also I only searched meters recommended at the Diabetes Control Center because of software and download capabilities.
Bayer Contour Next Strips
100 strips $32.01 - $43.99 (Amazon Prime)
One Touch Ultra Test Strips
100 strips $59.86 – 63.89
FreeStyle Lite Test Strips
100 strips $53.77 - $56.42
Accu-Check Aviva Test Plus Strips
100 strips $37.99 - $45.83

These are retail prices with no insurance involvement and can be ordered by anyone. Our patients report insurance co-pay greater than this.  I ordered the Bayer Contour Next 100 strips for $43.99. I was suspicious of the cheaper price, suspecting the strips were about to expire (glucose strips are dated).  The ones I received had an expiration date of 2015 – 05.  This is about as good as you can get anywhere.  We also looked closely at the strips, examined them for faults and found none.  We compared these with strips from our pharmacy, they were identical.  We did back-to-back tests and found our blood glucose 135 on the recently ordered strips and 139 from the ones from the pharmacy.  This is about as close as one can expect.

The Medicare basic utilization guideline for glucose strips is to allow 100 strips every 3 months for non-insulin treated patients and 300 test strips for an insulin treated patient.

As far as I can determine, the Medicare allowable amount for glucose strips ranges between $10.41 and $20.82 for 50 strips. I have no idea what a local pharmacy or chain or managed care insurer can get them for.

One hundred strips for 3 months allows for once a day testing for the patient not taking insulin.  In my opinion, this is probably adequate for most.  There is a need to have pre-meal and post-meal data for analysis in non-insulin treated patients.  The easy work around is to have the patient alternate between 1st morning testing and post meal tests.  With this information provided by a glucose log or download from a reasonably accurate meter, we are able to assess glucose control quite adequately.

Charles H. Raine, III,M.D Disclosure: Research and speaking engagements paid for by Bayer Diabetes.


Strut to OKRA for diabetes cure. strut what an Okra Strut!

When I first heard of the “cure” for diabetes with Okra, I was about to dismiss it out of hand, but thought it deserved a little research. After all, diabetes is predicted to touch 1 in every 3 Americans by 2050, a cure would be greater than great!  

First the Okra Strut. It is a festival event of Irmo, South Carolina (a burb just west of Columbia), started in 1973 as a fund raiser. The festival, generallyIrmo in September, includes the Okra Strut street dance featuring beach bands, a 10k run, parade and food, food, food. After all this is South Carolina.

Back to Okra and diabetes.  The official plant name is Abelmoschus esculentus (syn. Hibiscus esculentus) It is grown in many tropical areas of the world and is known by as many names (Bamia, Bendi, Bhindee, Bhindi, Bindi, Cantarela, Gombaut, Gombo, Bumbo, Lady-finger, Mesta, Ochro, Okra, Okro, Quiabo, Quimbambo, Quingombo, Rosenapfel, Vendakai).

Even if individual accounts of improvement in diabetes from nontraditional items appear plausible, these do not account for other variables which could be producing the result.  For instance, what medication is the person taking, have there been dietary, exercise or other lifestyle changes to name a few.  It is probably a good idea to look at these claims with a high level of skepticism.  Certainly, do not alter any prescribed therapy based on stuff from social media or the internet.

The scientific information related to the diabetes cure chatter stems from several articles in medical literature.  The most prominent of these comes from the Journal of Pharmacy and Bio-allied Sciences (J Pharm Bioallied Sci. 2011 Jul-Sep; 3(3): 397–402).  It is primarily a Journal of India, the editor-in-chief is of the Faculty of Pharmacy, Jamia Hamdard, New Delhi, India.  There are a number of other editors from all over the world including the USA. The article is titled “Antidiabetic and antihyperlipidemic potential of Abelmoschus esculentus (L.) Moench. in streptozotocin-induced diabetic rats”.  Department of Bioinformatics, Karunya University, Coimbatore, Tamil Nadu, India and  Department of Pharmacology, KMCH College of Pharmacy, Coimbatore, Tamil Nadu, India. Lead author: V. Sabitha

Essentially an extract from okra (peel and seed powder) was used to treat diabetic rats (the insulin producing portion of the rat pancreases were poisoned by a compound, streptozotocin, producing artificial diabetes).  The experiment was conducted on 7 groups of Wistar albino rats.  There were 6 rats in each group.  A control group received placebo, 30 rats received varying doses of the okra compound.
At the end of the study, all of the treated rats had improvement in blood sugars.  The control group did not. At the start of the study, the range of blood sugar of treated rats was 318 – 331 MG/DL and at the end of 4 weeks blood sugar ranged between 89 and 109 MG/DL.  

A quote about okra from the discussion portion of the study: “The plant has a wide range of medicinal value and has been used to control various diseases and disorders. The fiber in okra helps to stabilize blood sugar by regulating the rate at which sugar is absorbed from the intestinal tract. It is a good vegetable for those feeling weak, exhausted, and suffering from depression and it is also used in ulcers, lung inflammation, sore throat as well as irritable bowel. Okra is good for asthma patients and it also normalizes blood sugar and cholesterol levels.” This kind of “cure all” statement raises concern about the validity of the experiment.

This study, if valid, shows promise.  It could be that a compound within okra can be isolated and utilized in a standardized, purified form.  So far, several things are needed.  The study needs to be repeated by different labs with similar results. The precice compound in okra producing the effect must be identified. The exact mechanism of action need to be described (what are the details of how it works?).  If the process passes these and other tests, controlled human experimentation might be started.

In the meantime if you are a white rat in India with artificially produced diabetes from poisoning the beta cells of your pancreas, there is pretty good evidence that powder from seeds and peels of okra collected from Indian farms might help your diabetes.  If you don’t meet these criteria, it is best to continue your prescribed diabetes therapy. LOL 

At the same time, we’re not aware of anything in okra that is harmful.  A cup of okra contains 0.2 g of fat, no cholesterol, 7 mg sodium, 299 mg of potassium and 7 g of total carbohydrate.


Diabetes Drugs and Cancer.
What's all the fuss about?  There have been repeated concerns about an increased risk of pancreatitis and to a lesser extent cancer related to some drugs used to treat diabetes.  As early as 2011, an article in the Journal GASTROENTEROLOGY reviewed published data and indicated there was a six fold increased risk of pancreatitis in people with diabetes taking sitagliptin (Januvia™) or exenatide (Byetta™) compared to other therapy.  They concluded: "These data are consistent with case reports and animal studies indicating an increased risk of pancreatitis with glucagon – like peptide 1 based therapy.  These findings also raise caution about the potential long-term actions of these drugs to promote pancreatic cancer."

Since that time there have been reports to the FDA of autopsy findings of precancerous cells in the pancreas of people taking these drugs.  As a result, the American Diabetes Association and the American Association of Clinical Endocrinologists have reviewed the problem extensively.
Several factors have emerged.

  1. There is an increased risk of pancreatitis in people with diabetes.
  2. There is an increased risk of cancer (including pancreatic cancer) in people with diabetes.
  3. There appears to be an increased risk of pancreatitis in people with diabetes taking certain drugs.
  4. There are some suggestions on an increased risk of some cancers in some patients taking some drugs.

The American Association of Clinical Endocrinologists published a review of cancer risk in the Journal ENDOCRINE PRACTICE, 2013; 19 (number 4) and indicated the following relating to diabetes medications and cancer risk.
Metformin – no discernible cancer risk, possible protective benefits on cancer outcomes.

  1. TZDs
    1. Rosiglitazone (Avandia™) – no evidence of cancer risk.
    2. Pioglitazone (Actos™) - possible risk of bladder cancer at high doses (greater than 24 months and greater than 28,000 mg cumulative dose).
  2. SGLT2 Inhibitors (Invokana™) – no evidence of cancer risk.
  3. Incretins
    1. GLP-1 agonists (Byeta™, Bydueron™, Victoza™) – no evidence of MTC (thyroid cancer) or pancreatic cancer in humans.
    2. DPP – 4 inhibitors (Januvia, Onglyza™, Tradjenta™, Nesina™) – no evidence of MTC or pancreatic cancer in humans.
  4. Insulins – concern of cancer at very high doses.

My opinion.
The risks of uncontrolled diabetes to life and limb are well-established.  Those of us with diabetes are at higher risk of many maladies including cancer, various infections and inflammatory problems.  Any medications that we take for any reason has a potential for side effects.  If it doesn't have a potential for side effect, it has no beneficial effect.  We therefore have a choice.  We can attempt to control diabetes that is known to cause major problems with drugs that have the potential of causing some problems or we can leave the diabetes uncontrolled and be certain that something bad will happen.

July 29, 2012

Travel with Diabetes


It’s important to remember that you will need everything for your diabetes management when you travel as you do at home.  This places an extra burden on packing requirements.  You will want to think ahead and plan for contingencies. Take twice the supplies and medicine you think you will need. It is a good idea to have a letter from your health care provider indicating that you have diabetes and a list of medications you need.  The medication list should indicate both generic and non-generic names.  Therefore, if you must go through an extensive search, the official information from your medical record will reflect the medication in your baggage. This list and letter are a MUST for overseas travel.


PILLS.  Traveling with pills is generally no problem.  Take you pills in carry-on luggage.  Airlines are getting better but they still lose baggage.  If your medication is in checked baggage and it is delayed, you are up the creek without a paddle.  You will generally not have a problem from airport security relating to pills in your carry-on baggage.
INSULIN.  The metal on the insulin bottle cap will generally not cause a problem in airport security.  It will need to go through the x-ray machine.  This will not harm the insulin.  If you use insulin syringes or insulin pens you will not have a problem with airport security. Keep the insulin and the syringes in the same place.  Again, they must go through the x-ray machine.  Insulin must be kept cool.
A notice from the Food and Drug administration indicates: “According to the product labels from all three U.S. insulin manufacturers, it is recommended that insulin be stored in a refrigerator at approximately 36 to 46 degrees F.  Unopened and stored in this manner, these products maintain potency until the expiration date on the package.  However, all of the available insulin products may be left unrefrigerated (between 59 and 86 degrees F) for up to 28 days and still maintain potency.” http://www.fda.gov/Drugs/EmergencyPreparedness/ucm085213.htm
I usually place a vial or 2 of insulin in my carry-on bag if only traveling across the country.  Upon arrival at the hotel, I request a refrigerator for the room.  This works quite well.  If traveling overseas, it might not be a bad idea to ask the flight attendants to provide a small amount of ice for a Ziploc bag you have brought on board.  I would not attempt to bring a freezer pack on board an airplane.  It might look suspiciously like a solid explosive.
INSULIN PUMPS.  Generally, insulin pumps do not trigger the metal detector when going through airport.  The TSA officials will want to see it. Recently, they have required me to remove the pump from the clip (not disconnect), they then require me to rub both hands over the pump which they then swab and check for evidence of explosives. This is nonintrusive and only takes a few minutes.  Ladies, it is not a good idea to go through airport security with your pump in your bra. In my travels, the security officials have been efficient and very courteous through this process. Only in Paris (Charles de Gaulle Airport) did they insist that I disconnect the pump and run it through the x-ray machine. After an initial refusal, I became very cooperative after several armed officials surrounded me. My feeble attempt at the French language was futile, they refused to speak English, I’m convinced they could. The experience was not comfortable.


Alzheimer's disease and diabetes

Almost everyone has a relative or knows someone with symptoms of Alzheimer’s disease.

Actually Alzheimer's disease is only one form of a group of brain altering or dementia causing diseases. Dementia is defined as a loss of brain function that affects memory, thinking, language and behavior. Alzheimer s' disease accounts for 60-80% of dementia. Other causes are vascular dementia, Lewey Body dementia, Parkinson’s' and others.


So, what's the connection between Alzheimer's disease and diabetes?  The Salk institute points to recent epidemiological studies that show diabetic patients have a 30 to 65 percent higher risk of developing Alzheimer's disease compared to non-diabetic individuals. The increased risk applies to both type 1 and type 2 diabetes. Elevated blood sugar is the common thread between type 2 and type 1 diabetes.  According to the Mayo Clinic, diabetes and Alzheimer's disease are connected in ways that are not completely understood.  The dementia or brain dysfunction associated with Alzheimer's disease seems to be caused by an excess of something called beta-amyloid protein.  

Amyloid is found in the brains and spinal fluid of patients with Alzheimer's disease but is also found in the pancreas of patients with type 2 diabetes.  Is there a connection?  Not known.  It is known that amyloid seems to destroy the insulin producing cells in the pancreas as well as brain cells.

Does control of diabetes prevent dementia?
It is well-established that control of diabetes prevents blood vessel disease.  Blood vessel disease is directly responsible for vascular dementia. There is at least one study suggesting that insulin resistance is related to the buildup of beta-amyloid protein.  

What if you have diabetes and are concerned about early signs of Alzheimer's disease?


What if you are dealing with a loved one with Alzheimer’s or another form of dementia?

Things to understand:
The disease causes behavior problems as well as memory and language dysfunction.

Here is why, look at the difference in the brain images between the normal and Alzheimer’s patient. There is shrinkage in the latter. Click to see the source of the images on WebMD and learn more.

  • Check with the Alzheimer’s association
  • What of Alzheimer’s treatment?
    Check with your physician regarding early treatment.

    There is controversy regarding early treatment with medications currently available.  In our experience, early treatment with donepezil (Aricept ™) and Memantine (Namenda ™) seems to prevent the progression of dementia. Some of our patients indicate they're actually better after taking these drugs for several months.  They are relatively safe.  Donepezil (Aricept™) and Rivastigmine (Exelon ™) are in a class of drugs that inhibit the production of cholinesterase.  Cholinesterase breaks down acetylcholine in the brain; the result is decreased cognitive function.
    Memantine (Namenda™; Axura™ in Europe) seems to be protective of brain cells according to UpToDate. It may work by protecting the brain against glutamate.  Cells damaged by Alzheimer's disease release excess amounts of glutamate. Glutamate binds with another substance causing excess calcium to flow into brain cells. Excess calcium causes brain cell degeneration.

    February 8, 2014

    New Insulin Pumps for type 2 diabetes.

    You don't have to have type 1 diabetes or smart guybe a genius to use an insulin pump. You also don't have to have a cute movie star belly. Pump

    We know that optimal control of diabetes prevents or delays the onset of serious complications. The easier we can get that control, the better. If it takes a pump or a slick gadget to get control, then let’s have at it. No matter if one is fat or slim, afflicted by type 1 or type 2 diabetes, we need control by any means necessary.

    There are several questions to be asked when considering an insulin pump.

    Questions to ask of yourself:

    1. Am I sensitive about others seeing me wearing a medical device?
    2. Am I concerned about being "attached" to a gadget?
    3. Do I really want better control of my diabetes?
    4. Am I willing to stick my finger 3 – 6 times a day to monitor blood sugar?
    5. Am I willing to keep regular appointments with my diabetes team?
    6. Am I willing to stick to a prescribed diet and exercise program?

    Questions to ask of the pump manufacturer and medical team:

    1. Does the pump supplier have a likelihood of being around over the next several years?
    2. What level of support does the manufacturing company have for you?
    3. Are pump supplies readily available?
    4. Does your healthcare team have experience in insulin pumps?
    5. Does your healthcare team have practitioners available after hours in case of an emergency?

    Questions to ask of your insurance company:

    1. How much of the cost of the pump will I have to pay up front?
    2. What will be my monthly out of pocket expenses related to the pump, pump supplies, glucose strips and insulin?

    So, where do insulin pumps fit in the control of type 2 diabetes? There is no need to even think about a pump for patient with type 2 diabetes if it can be managed with pills. First of all, no insurance will pay for it. Secondly insulin pump therapy requires a significant amount of attention. On the other hand, there is no better way to control blood glucose than with insulin in a continuous insulin infusion device (pump). We believe that a person with type 2 diabetes is a candidate for an insulin pump if blood glucose cannot be controlled without two types of insulin basal insulin (Lantus™, Levemir™, others to come) plus mealtime insulin (Humalog, NovoLog, Apidra, etc.).

    What’s out there?
    Traditional pumps using tube delivery systems.
    Click here for a review of these pumps. There are several new ones approved by FDA, will try to review these after getting some experience.

    Tubeless Pumps
    The first pump delivering insulin without tubes was the Omnipod™. It was reviewed previously. Click here for notes. Others are under review by FDA.

    The V-GO™ Disposable Insulin Delivery Device – now approved by the FDA. VGoThis pump has an interesting design. It has no electronics, no batteries no tubes and does not require a controlling unit like the Omnipod™ and some others. It is what one might call your "basic" pump. There are three device choices. They are prescribed based on a preset basal rate. Mealtime bolus insulin is given in increments of two units per "click". It has to be changed daily; the entire unit is then thrown away. A sales representative for this product left a note in my office indicating it is available on Medicare part D and for those with private insurance, it is covered with a patient co-pay of $25. We have a number of patients using this device.  The great majority prefer it to multiple injections.  Diabetes control has been improved with nearly all users.

    Several factors to consider.

    1. The basal rate for this pump cannot be changed.  One will either continuously get 20 units, 30 units or 40 units over a 24-hour period.
    2. It must be worn on a part of the body that is accessible at mealtime so that insulin for the meal can be given.
    3. It must be changed daily.

    Diabetic Shoes

    Diabetic therapeutic shoes are designed for this:

    foot_DiabeticAccording to Medicare Carriers Manual section 2134, Medicare covers therapeutic footwear for vulnerable beneficiaries who meet certain requirements. Medicare coverage for therapeutic footwear became effective May 1, 1993. To meet the eligibility requirements, beneficiaries must be receiving treatment for diabetes. They must also have one or more of the following conditions:
    1. Peripheral neuropathy with evidence of callus formation.
    2. A history of pre-ulcerative calluses.
    3. A history of previous foot ulceration.
    4. Foot deformity.
    5. Previous amputation of a foot or part of a foot.
    6. Poor circulation.
    According to HCFA’s documentation guidelines, a doctor of medicine or a doctor of osteopathy who is treating the beneficiary's systemic diabetic condition under a comprehensive plan of care must certify the need for therapeutic footwear. This physician must also certify that the beneficiary suffers from one or more of the six qualifying conditions cited above.

    If a person qualifies, no problem. If not, I tell my patients you don’t WANT to qualify for shoes under Medicare. You are being treated at the Diabetes Control Center to PREVENT qualifying for shoes under Medicare.

    Want to know what Medicare covers in your state? Click here.

    Diet Pill pill

    Belviq™ (Lorcaserin) works in the same manner as fenfluramine and Fen/Phen but is far more selective. Fen/Phen caused severe heart problems particularly scarring and valve problems. In clinical tests, the company indicates that none of the heart problems noted with Fen/Phen have been seen in clinical trials with Belvig. It reduces appetite by working on the selective serotonin 2C receptor in the brain. In a study published in the Journal of Clinical Endocrinology and Metabolism, Belvig was shown to reduce body weight by decreasing calorie intake without influencing energy expenditure.

    According to the FDA, Belviq™ (Lorcaserin) can be used like this:

    1. As part of an on-going weight management program.
    2. As an adjunct to a low calorie diet.
    3. If a person has a body mass index (BMI) of 30 kg/m² or greater (see below).
    4. If a person has a BMI of 27 kg/m² or greater and a condition associated with being overweight, e.g.
      1. Type 2 diabetes.
      2. High blood pressure
      3. Abnormal blood fats (cholesterol, LDL, triglycerides, etc.)

    If a person is 5'7" tall and weighs 195 pounds the BMI is approximately 30 kg/m².

    Click here to calculate your BMI.
    The three question test we like to apply to every new pharmaceutical product is: 1. Does it work? 2. Is it safe? 3. Is it available at a reasonable price?

    In a study of people with type 2 diabetes, about 38 percent of patients treated with Belvig lost at least 5 percent of their body weight, compared to 16 percent in patients treated with placebo. By extrapolation if you weighed 230 pounds and took this product for year, you would be expected to lose about 11.5 pounds. Several studies have shown that a 5% weight loss improves diabetes as well as blood pressure.

    It is similar but more selective than Fen/Phen which caused major heart/lung problems. FDA delayed approval on this concern. It was deemed safe after further review.

    Warnings and precautions regarding this drug include the following:
    Serotonin syndrome or neuroleptic malignant syndrome (NMS). Serotonin syndrome generally causes nausea, vomiting and diarrhea. NMS causes fever, muscle rigidity, nervous system instability with various psychiatric reactions.

    In clinical trials of at least 1-year duration, adverse reactions related to cognitive impairment (e.g., difficulty with concentration/attention, difficulty with memory, and confusion) occurred in 2.3% of patients taking BELVIQ and 0.7% of patients taking placebo.

    The relative risk of developing a heart valve problem while taking Belvig was 1.13 times greater than if taking placebo and studies.

    Drug interactions. There is the potential for interaction with a number of medications, particularly those used for depression. Also cough medicines such as dextromethorphan, tricyclic antidepressants(amitriptyline, Sinequan™, etc), lithium, bupropion (Wellbutrin™) and the supplements tryptophan and St. John's Wort.

    Other warnings and precautions from prescribing information:
    Cognitive Impairment: May cause disturbances in attention or memory. Caution with use of hazardous machinery when starting BELVIQ treatment.

    Psychiatric Disorders, including euphoria and dissociation: Do not exceed recommended dose of 10 mg twice daily.

    Monitor for depression or suicidal thoughts. Discontinue if symptoms develop.

    Use of Anti diabetic Medications: weight loss may cause hypoglycemia. Monitor blood glucose. BELVIQ has not been studied in patients taking insulin.

    Priapism (sustained painful penile erection): Patients should seek emergency treatment if an erection lasts >4 hours. Use BELVIQ with caution in patients predisposed to priapism.

    I was unable to locate a price. You can bet your boots that it won't be cheap. Some estimate the price at about $5.50 per capsule. At twice a day that's about $330/month. Will insurance companies look at it as something to prevent major problems in the long run, who knows?

    RECOMMENDATION: my BMI places me in the obese category. Would I take this medication? NO!!! I believe that it is prudent wait until there's more experience with this product. I do not intend to start prescribing it right away.




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