Medications – Take As Directed

Are you taking your medications as directed? If you are not, you may be putting your health at risk. Many people are doing just that and wonder why they are having reactions to the medication. Yes, the elderly have more problems because of age, the medications have not been tested in most cases for the elderly, and therefore the side effects and potential reactions are unknown. Yet doctors prescribe the medications without this information.

Others areas doctors do not consider is the size of the pill or capsule and if the patient may have problems in swallowing it. This is a dangerous area where the elderly often have problems and crush, cut, or chew the tablet or pull the capsule apart and swallow the contents. For many medications, this is not a good idea and can create unwanted side effects.

When a patient is prescribed a timed release medication such as Glucotrol XL or Glucophage XR, doctors need to ensure that the patients understand that they should not crush, chew, or cut these pills. The medications must be swallowed whole. Many of the long-acting medications have drug names that end with a two-letter suffix. For example, CD (controlled dosing), SR (sustained release), LA (long-acting), XR (extended release) or ER (extended release).

A chart prepared by the Institute for Safe Medication Practices (ISMP) is in a PDF file that lists most of the drugs that patients need to swallow whole and not crush, chew, or cut.

The following example is cited in Diabetes in Control of what can happen if one of the sulfonylureas (Glucotrol XL) is chewed. “In one case an elderly patient was prescribed Glucotrol XL to treat elevated blood sugars. This is a specially formulated medication that releases an entire day's supply of the medication slowly over a 24-hour period. The pill was too large for the woman to swallow, so she chewed it. She soon complained of feeling dizzy, weak, listless, and lethargic. Chewing the drug caused it to be released all at once, causing dangerously low blood glucose levels, which could have been fatal.”

Some pills are coated so the medication won't be released in the stomach where it may cause irritation. Other pills have special coatings or other properties to slow the delivery of the medication into the body so that the drug is delivered over a period of time. This is done to make the medication more convenient than taking a drug several times a day. If these pills are crushed or chewed, this delivery action is destroyed and the medication may enter the body too fast. When this happens, then a large amount of the drug will be released all at once, which could cause side effects or serious harm.

When People with Type 2 Know More Than the Doctor

No, I am not saying in general, but just about type 2 diabetes. This is becoming more the rule than the exception for many doctors. Patients are fast learning that their doctor just doesn't know much about diabetes. Yes, they can make a diagnosis, but often they can't make an accurate diagnosis. What is harder to understand is that many make a diagnosis based on stereotypes and then later the patient finds out that they have a different type of diabetes.

Seldom do doctors do the full series of tests, blood glucose, plasma glucose, C-peptide, GAD, and A1c to determine the type of diabetes. If you are under a certain age, you have type 1, if you are over a certain age, you have type 2, and if you are in the middle, they often guess you have type 2. Some of the formal names for Diabetes-related Autoantibodies include Islet Cell Cytoplasmic Autoantibodies; ICA; Insulin Autoantibodies; IAA; Glutamic Acid Decarboxylase Autoantibodies; GADA; GAD65 Autoantibodies; Insulinoma-Associated-2 Autoantibodies; IA-2A; ICA512 Autoantibodies.

Now an endocrinologist specializing in diabetes will know the tests, and what they are telling him/her. Expect a proper diagnosis from an endocrinologist. They will determine if you have type 1, type 2, LADA, or MODY and which genetic type of MODY (presently there are 7 types).

If after a few months of dealing with the doctor, you find out that the doctor is unable to answer some of your questions, you will know that you are in charge of you own diabetes. Some doctors will refer you to a certified diabetes educator if they have one available. You may be referred to a registered dietitian, but don't expect to have much nutrition taught. You may learn quickly that the number of carbohydrates they suggest will spike your blood glucose numbers. They will push whole grains and other carbohydrates that will make it difficult to keep your blood glucose in the range you desire and your A1c below even 7.0.

Some things I have found in my journey with diabetes include:

#1. Doctors do not know everything and you can't expect them to have complete knowledge on every disease. They are not trained to know everything. (We can certainly wish they knew more about type 2 diabetes.) Endocrinologists who specialize in diabetes really know their specialty. The nurse practitioner I see is very knowledgeable and except for a few things has always answered my questions.

#2. Don't believe everything you read about diabetes. Sound advice. Even I have to reread some things to figure out that what I am reading is false. With all the different diets published and claiming to be for diabetes, I become very frustrated. I know what works for me and I follow it. The important thing to remember is what works for you may not work for others.

#3. Understand that everybody who has something to say about diabetes has both an emotional and a monetary stake in it. Most of us may not have much of a monetary stake, but what we pay for medications is still a stake. Some say that the monetary stake needs to be an income, but I say either will work and when you earn or pay for something, it is a stake.

Whatever your opinion is of pharmaceutical companies, certain medical professions, and some occupations, supposedly they all do things legally and above board – I wish!

Then we come to the openly dishonest advertisers on the internet and in the Sunday papers that offer a free meal in a hotel ballroom, but you must attend and listen to a presentation about how to reverse your diabetes. Have no doubt, the speaker will be very dynamic, and he/she will be very convincing. The question is did he have or the person they have portraying a diabetic, did they actually have diabetes. The speaker will have a series of books, DVDs, and personal therapy sessions available for a very steep price if you decide to sign up. Please don't be gullible.

On the internet, the tactics will be similar, but the prices will be slightly lower, but still high. The site will be very convincing or you may need to sign up for a webinar. They will use many tactics to separate you from your money.

The Difference - A1C and Blood Glucose Monitoring

I do not like doctors and other medical professions that tell people with type 2 diabetes that they don't need to test and that a quarterly A1c test is sufficient. In attempting to find a doctor, I could relate to, I have run the gambit or gauntlet of bad doctors. Two have said they were taking me off insulin and would not give me a reason for doing this. They just stated that I should be on oral medications as a person with type 2 diabetes. One even told me the first statement and that he would not prescribe testing supplies. Needless to say, they obviously were not up to date about diabetes.

This is one reason the blog from the Mayo Clinic really hit home. The author asked, “A1C or blood glucose monitoring: Which one is better? Neither. You need both measurements to ensure you have good diabetes management.” The author discusses both and importantly their differences.

The A1c test: For doctors, this is their bread and butter. It tells them how you are managing your diabetes. Most doctors want this test every 3 to 6 months. How often will often depend on how well you manage your blood glucose levels as a person with type 2 diabetes.

“The goal standard set by the American Diabetes Association is for you to keep your A1c percentage at 7.0 or below. The American Association of Clinical Endocrinologists prefers the percentage to be 6.5 or below. The American Geriatrics Society recommends A1c levels of 7 percent or lower for healthy adults and less stringent levels for less healthy adults of 8 percent or lower.”

Now I don't agree with the upper limits that doctors recommend, but I do work to keep mine under the level set by the American Association of Clinical Endocrinologists. I will now get more technical by quoting from a blog by David Mendosa. “How much glycated hemoglobin we have in our blood depends first on the lifespan of our red blood cells. The “average lifespan is 120 days,” the book says, which is of course four months.

But the glycated hemoglobin in our blood is also “directly proportional to the concentration of glucose in our blood” and “represents integrated values for glucose over the preceding 8 to 12 weeks.” Most people seem to think that our levels at any time during this two to three month period are equal. But they aren’t.

“More recent values,” the book continues, “provide a larger contribution than earlier values.” How much more? “The plasma glucose in the preceding 1 month determines 50% of the HbA1C, whereas days 60 to 120 determine only 25%.” This is the key statement and the one that prompted me to change my testing strategy.” Note: David tests his A1c on a monthly basis.” If you missed reading his blog, you may want to read it. I did leave out some page references that were not adding meaning.

Blood glucose metering: There are several terms that may be used - “blood glucose testing” or “BG testing.” Yes, metering is not a generally used term for blood glucose meter and test strips. Checking your blood glucose level helps you immediately and gives you information to aid in diabetes management decisions.

If you are not on insulin, blood glucose testing several times per week can tell you how well you are managing your diabetes. It will let you know if you need to make lifestyle changes or if you need to contact your doctor.

The two tests together can tell your doctor how well the long-range management has been for the last 120 days. Consider the A1c as a movie for the last 120 days and the blood glucose meter readings as a snap shot in time.

FDA approved medicines, Off-label uses

When you have the American College of Cardiology (ACC) for cardiovascular diseases and the American Association of Clinical Endocrinologists (AACE) for endocrine related disorders holding classes for pharmaceutical sales people, is it any surprise that these drug reps are heavily promoting 'off-label' prescriptions. I quite imagine that some of these sales reps have then started classes for the companies they are employed by for more sales reps.

The blog here is written for medical professionals, but patients should learn from this and how their medical professionals may be promoting drugs 'off-label' for other than good medical reasons. The term 'off-label' means that the FDA has not approved the medicine for these uses.

The problem confronting us as patients is two-fold. Many physicians are receiving money to promote drugs and pharmaceutical drugs reps are promoting 'off-label' uses and dosages of many drugs. Then add to this that fact that many medical care providers do not stay current with the drugs entering the market or even many already on the market, and you have real problems because the doctors do not know what is approved or not approved for use by the FDA.

For 160 drugs tracked that are prescribed to U.S. adults and children, 21 percent were for off-label prescriptions totaling 150 million prescriptions. It is not surprising that 73 percent had little to no scientific backing. Psychoactive drugs had the highest level of off-label use. We should not be surprised that sales representatives are misrepresenting their companies' products. They systematically overemphasize the positive aspects and downplay or completely omit the negative features of their drugs.

This information is worth quoting. “The most recent study examined the quantity and quality of safety information that a random sample of primary care doctors in Montreal and Vancouver, Canada, Toulouse, France, and Sacramento, U.S. received from sales representatives. Serious adverse events were mentioned in just 5-6 percent of promotions, although 45 percent of promotions were for drugs with FDA “black box” warnings.”

To have a better understanding of the scope, pharmaceutical companies in Canada and the United States spend about $16.7 billion in 2009 on sales representatives (no wonder our medicines are so expensive!). These representatives come into doctors' offices with detailed information about their individual prescribing practices as well as free samples of their medicines. They use their personal relationships to promote the medicines of the company they represent, promote 'off-label' use of medications, and promote different dosages for the medications their company manufacturers.

“Restricting access needs to be accompanied by a multipronged education effort. Mansfield and colleagues have outlined an educational campaign based on studies of psychology students’ responses to persuasion, and medical students’ and physicians’ responses to pharmaceutical promotion that should be pursued throughout all levels of training and continued once doctors are in practice.

The fourfold objectives of this campaign are: explicitly educating doctors about decision making and how to evaluate evidence and promotion; helping doctors to understand that there is no proven method to enable them to have an overall positive benefit from promotion; helping doctors to understand their responsibility to avoid pharmaceutical and device promotion; and explicitly educating doctors about the most reliable sources of information.”

Hopefully, some of the last two paragraphs will come to fruition, doctors can get back to being doctors, and use FDA approved medications of the correct dosage and less 'off-label' use. There are some 'off-label' uses that are appropriate, but even then, the FDA should approve the use.

FDA Gives 4 Medication Tips to Older Adults

What is your age? I don't expect an answer, but I do wish to point out some problems as you age. I was surprised that the Food and Drug Administration (FDA) would put something out about medications for the elderly or older adults. I am especially surprised because they don't approve drugs for the elderly and most trials leading up to approval do not include the elderly.

Speaking from experience, the older one becomes, the more likely you will need additional medications. This is the worry because each addition can increase the risk of harmful drug interactions. Our bodies change and this can affect the way medicines are absorbed, leading to potential drug complications. Think about it, your liver and kidneys may not work as well, and this affects how a drug breaks down and leaves your body. Then consider changes in your digestive system and this can determine how fast drugs get into your bloodstream.

These are the four tips FDA advises for medications:

Take Medicine as Prescribed

Take your medications according to your health care provider's instructions. Do not skip doses or stop taking a medication until you have consulted your provider. I have know fellow patients who say they have talked to their doctor and stopped a medications, but in fact did talk to their doctor, but about something completely unrelated.

This does not mean that just because you are feeling better you can stop taking a medication. If you are experiencing side effects, also talk to your doctor about the side effects. You doctor may wish to change to another medication or reduce the dosage.

For chronic conditions, such as high blood pressure and diabetes, it is important that you take them as directed and continuously to maintain management of your condition. The dosage your doctor prescribes in based on tested and it is never wise to change the dose yourself.

Keep a Medication List

Keep a list of the medications you are taking. List the name of the medication, the dose, what it is for, and when you take it. Many leave important information of the list. If you take a medication three times per day, indicate this by time or meal if eaten with food. If it is AM or PM or both, indicate this.

Consider giving a copy to a trusted friend or family member is you live alone. Keep the list up-to-date if you add medications or the dose changes.

Be Aware of Potential Interactions

As you age, remember, you’re at higher risk for drug interactions.

Interactions can occur when:

• One drug affects how another drug works;
• A medical condition you have makes a certain drug potentially harmful;
• A food or non-alcoholic drink reacts with a drug;
• A medicine interacts with an alcoholic drink.
  

“Learn which interactions are possible. You can do this by carefully reading drug facts labels on over-the-counter drugs and the information that comes with your prescription medications, and by reviewing any special instructions with your health care provider. For instance nitroglycerin, which treats angina (chest pain related to heart disease), should not be taken with many erectile dysfunction drugs, including Viagra and Cialis, because serious interactions can occur. And some drugs should not be taken with alcohol, as symptoms such as loss of coordination and memory loss can result.”

“If you’re seeing multiple health care providers, tell each one about all of your medications and supplements. You also can ask your pharmacist about potential interactions.”

Review Medications with Your Health Care Provider

Schedule at least one annual review of your medications with your health care provider to confirm which medications are still necessary and which you can stop taking (if any). This may not be necessary if each doctor records you medications at each visit. In my case, they do and the doctor's assistant does this and he reviews it.

If a certain medication is out of your budget, ask your health care provider whether there is a cheaper, and still effective, alternative. It is important to remember that there is not a stupid question pertaining to medications. Consider asking questions of your pharmacist if your doctor does not answer the question.

Carb Ranges for Meal Planning

The range of carbohydrates for the different categories, very low carb, low carb, moderate carb, high carb, and extreme high carb varies greatly and there is no consensus or official ranges. Still some blog authors have done their research and spelled out ranges to consider.

Jimmy Moore who blogs at Livin La Vida Low-Carb has the following to say, “What is a low-carb diet? That seems like such an elementary question to ask, especially to people who are already following Atkins, Protein Power, or any of the many other respected and proven carbohydrate-restricted nutritional approaches that have emerged over the years. And yet defining what “low-carb” means is an important distinction since there is debate over how low you should go and at what point carb intake is no longer considered low.

Organizing a virtual who’s who of low-carb diet research and practice, a review article published in the journal Nutrition and Metabolism last year attempted to come to a consensus on what constitutes a low-carb diet. You may recognize a few of the names featured on the expert panel shaping this definition: Dr. Richard Bernstein, Dr. Annika Dahlqvist, Dr. Richard Feinman, Uffe Ravnskov, Dr. Jeff Volek, Dr. Eric Westman, Dr. Jay Wortman and Dr. Mary Vernon, among many others. The collective wisdom of this group of highly-qualified experts came up with the following:

So, we have three distinct and practical terms and definitions to use now:

Low-carb ketogenic diet (LCKD): less than 50g carbs and 10% calories dailyLow-carb diet (LCD): 50-130g carbs daily and between 10-26% of caloriesModerate-carb diet (MCD): 130-225g carbs daily and between 26-45% of calories

This is the first time we’ve seen actual numbers and percentages applied to what defines a low-carb diet.”

Then I did some more searching and the blog Mark's Daily Apple on January 14, 2009 had a listing that I found interesting.

“300 or more grams/day - Danger Zone! Extreme high carb

Easy to reach with the “normal” American diet (cereals, pasta, rice, bread, waffles, pancakes, muffins, soft drinks, packaged snacks, sweets, desserts). High risk of excess fat storage, inflammation, increased disease markers including Metabolic Syndrome or diabetes. Sharp reduction of grains and other processed carbs is critical unless you are on the “chronic cardio” treadmill (which has its own major drawbacks).

150-300 grams/day – Steady, Insidious Weight Gain High carb

Continued higher insulin-stimulating effect prevents efficient fat burning and contributes to widespread chronic disease conditions. This range – irresponsibly recommended by the USDA and other diet authorities – can lead to the statistical US average gain of 1.5 pounds of fat per year for forty years.

100-150 grams/day – Primal Blueprint Maintenance Range Moderate carb

This range based on body weight and activity level. When combined with Primal exercises, allows for genetically optimal fat burning and muscle development. Range derived from Grok’s (ancestors’) example of enjoying abundant vegetables and fruits and avoiding grains and sugars.

50-100 grams/day – Primal Sweet Spot for Effortless Weight Loss Low carb

Minimizes insulin production and ramps up fat metabolism. By meeting average daily protein requirements (.7 – 1 gram per pound of lean bodyweight formula), eating nutritious vegetables and fruits (easy to stay in 50-100 gram range, even with generous servings), and staying satisfied with delicious high fat foods (meat, fish, eggs, nuts, seeds), you can lose one to two pounds of body fat per week and then keep it off forever by eating in the maintenance range.

0-50 grams/day – Ketosis and Accelerated Fat Burning Very low carb

Acceptable for a day or two of Intermittent Fasting towards aggressive weight loss efforts, provided adequate protein, fat and supplements are consumed otherwise. May be ideal for many diabetics. Not necessarily recommended as a long-term practice for otherwise healthy people due to resultant deprivation of high nutrient value vegetables and fruits.”

I quoted much of the above because I felt they were important and something we could all benefit by learning from these two individuals. I am especially appreciative of the information from Mark's Daily Apple.

I had my own thoughts for ranges, but I can live with the thoughts of the second blog.

The explanations (not in red) are my classifications of the carbohydrate ranges.

What Are the Old Curmudgeons Up to Today?

A curmudgeon generally refers to an elderly person that is bad-tempered, difficult, and cantankerous. I can be one of these people at times, especially when I am in the company of another person with diabetes that is doing little to manage his/her diabetes.

In general, there are at least two types of curmudgeons. There are those that have life's experiences that they are being difficult about, or those that have knowledge and/or wisdom that they are imparting to the rest of us. Whether the person is bad-tempered or cantankerous will often depend on the listener and if they can agree or find a way to sooth the feelings of the elder person.

I don't enjoy being bad-tempered or difficult, but there are times when this is the only way I can capture the attention of the person not managing his or her diabetes.

Now I am doing something that I don't like doing or very often, but feel that what I have been reading and learning over the last few years is very indicative of what will happen over the next few years. Yes, I am taking a chance and a risky one, but someone needs to make people aware that this is not that far away.

#1. Under the current medical laws, people with diabetes reaching a certain age (mostly 65 and up) will no longer be able to obtain organ transplants of any kind even if they have a proven record of excellent diabetes management.

#2. People with HbA1c levels above certain levels will no longer be able to obtain certain medications to manage their diabetes. Equipment to help them manage diabetes will not be available. The CMS is also making it more difficult to obtain reliable testing supplies for diabetes.

#3. Many people with certain diseases and cancer will not be able to receive treatment and will be denied lifesaving medications or treatments. They will be given pain medications and allowed to die.

#4. Many hospitals will refuse treatments to people that don't have living wills and do not resuscitate orders on file. A few hospitals are already enforcing this.  More hospitals will be practicing medical blackmail when parents of children ask to get a second opinion.  This blackmail involves calling in childrens' social services and taking control of the children.  Increasingly, hospitals are accusing caretakers of medical child abuse, also known as Munchausen Syndrome by Proxy, in order to seize control of a child’s medical fate. 

Doctors at the Boston Children’s did just that in 2013.  Read more about how hospitals are treating our children here.

#5. More people will file bankruptcies under the current Affordable Care Act than ever before in all generations.

#6. More money will be wasted on studies of no clinical value than is already being wasted. More people will want to prove their values and will spend the money to do just that. Valuable studies of clinical value will cease to happen as Big Pharma, Big Food, Big Chemical, and Big Agriculture are going to find their profits shrinking in the face of Big Government forcing costs down.

#7. The war on patients will make patients' lives more difficult and make #5 accelerate at an even faster pace.

Life for the elderly will be returned to the days when they were dependent on the handouts from others. For those unable to afford medical care and the necessities of daily living, life will become a battle unlike this country has ever seen.

Although this link is not about any one disease in particular, it is still interesting and has a powerful message.